Pub Date : 2019-08-01DOI: 10.1093/med/9780190671099.003.0010
Charles J. Bae, A. Roy, Li Ling Lim
This chapter covers the diagnostic criteria and epidemiology of restless legs syndrome (RLS) and pharmacotherapy for this highly prevalent disorder. Specifically, the case illustrates a patient with RLS treated with dopaminergic medication and the phenomenon of augmentation. The diagnosis of RLS with augmentation due to dopaminergic medication was based on the history of worsening symptoms in relation to upward titration of a dopaminergic agent that was initially effective, with symptom improvement after the agent was discontinued. The differentiation of augmentation and rebound is discussed. Familial and secondary forms of RLS are viewed. Pharmacotherapy for RLS includes dopaminergic agents, alpha-2-delta ligands, benzodiazepines, and opioids; these are detailed and indications, approval by the U.S. Food and Drug Administration, dosing, and adverse effects are discussed.
{"title":"Too Much of a Good Thing","authors":"Charles J. Bae, A. Roy, Li Ling Lim","doi":"10.1093/med/9780190671099.003.0010","DOIUrl":"https://doi.org/10.1093/med/9780190671099.003.0010","url":null,"abstract":"This chapter covers the diagnostic criteria and epidemiology of restless legs syndrome (RLS) and pharmacotherapy for this highly prevalent disorder. Specifically, the case illustrates a patient with RLS treated with dopaminergic medication and the phenomenon of augmentation. The diagnosis of RLS with augmentation due to dopaminergic medication was based on the history of worsening symptoms in relation to upward titration of a dopaminergic agent that was initially effective, with symptom improvement after the agent was discontinued. The differentiation of augmentation and rebound is discussed. Familial and secondary forms of RLS are viewed. Pharmacotherapy for RLS includes dopaminergic agents, alpha-2-delta ligands, benzodiazepines, and opioids; these are detailed and indications, approval by the U.S. Food and Drug Administration, dosing, and adverse effects are discussed.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82626876","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0033
R. Siriwat, M. Grigg-Damberger, V. Shah
The most common sleep disorder in pre-adolescents and adolescents is insufficient sleep syndrome. The use of screen-based activities (e.g., cellphones, tablets, and video games) is a major contributor to insufficient and poor-quality sleep. The authors discuss changes in the sleep/wake pattern at the transition from pre-adolescent to adolescent age and various factors affecting these changes. They explain how self-imposed poor sleep hygiene practices and behaviors at bedtime affect sleep latency. Sleep logs or actigraphy can be useful tools in the confirmation of ISS. Strategies to avoid wake-promoting late evening activities and a consistent sleep/wake schedule are the keys to optimal daytime functioning. Treating insufficient sleep in adolescents with education and behavioral modification is effective in most cases.
{"title":"Digital in Her DNA","authors":"R. Siriwat, M. Grigg-Damberger, V. Shah","doi":"10.1093/MED/9780190671099.003.0033","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0033","url":null,"abstract":"The most common sleep disorder in pre-adolescents and adolescents is insufficient sleep syndrome. The use of screen-based activities (e.g., cellphones, tablets, and video games) is a major contributor to insufficient and poor-quality sleep. The authors discuss changes in the sleep/wake pattern at the transition from pre-adolescent to adolescent age and various factors affecting these changes. They explain how self-imposed poor sleep hygiene practices and behaviors at bedtime affect sleep latency. Sleep logs or actigraphy can be useful tools in the confirmation of ISS. Strategies to avoid wake-promoting late evening activities and a consistent sleep/wake schedule are the keys to optimal daytime functioning. Treating insufficient sleep in adolescents with education and behavioral modification is effective in most cases.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"184 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82753514","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0054
Todd Coy, R. Mehra, C. Bae
This chapter discusses the role of oral appliance (OA) therapy for treating obstructive sleep apnea (OSA). Positive airway pressure (PAP) therapy is often the first-line treatment for OSA, but the average PAP adherence is approximately 50%. OA is a good alternative to PAP therapy that can be combined with other conservative options, such as weight loss and positional therapy. Many patients with OSA who cannot tolerate PAP therapy may be able to be managed by OA. Short-term side effects of OA device usage for OSA include tooth pain, gum soreness/gingival irritation, muscle soreness, myofascial pain, excessive salivation, dryness, and abnormal occlusion. OA adherence for OSA treatment is greater than that observed for PAP and shows comparable improvement in subjective sleepiness. PAP therapy continues to show greater improvement in the apnea/hypopnea and hypoxia index.
{"title":"Moving Forward When CPAP Fails","authors":"Todd Coy, R. Mehra, C. Bae","doi":"10.1093/MED/9780190671099.003.0054","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0054","url":null,"abstract":"This chapter discusses the role of oral appliance (OA) therapy for treating obstructive sleep apnea (OSA). Positive airway pressure (PAP) therapy is often the first-line treatment for OSA, but the average PAP adherence is approximately 50%. OA is a good alternative to PAP therapy that can be combined with other conservative options, such as weight loss and positional therapy. Many patients with OSA who cannot tolerate PAP therapy may be able to be managed by OA. Short-term side effects of OA device usage for OSA include tooth pain, gum soreness/gingival irritation, muscle soreness, myofascial pain, excessive salivation, dryness, and abnormal occlusion. OA adherence for OSA treatment is greater than that observed for PAP and shows comparable improvement in subjective sleepiness. PAP therapy continues to show greater improvement in the apnea/hypopnea and hypoxia index.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"67 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89918373","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0005
Harneet K. Walia, M. Mansukhani
Obstructive sleep apnea (OSA) is highly prevalent in patients with hypertension, particularly in the resistant hypertension population. A large body of evidence supports the association between OSA and incident hypertension independent of confounding risk factors. This chapter discusses the relationship between OSA and hypertension and resistant hypertension, including the prevalence, epidemiology, and pathophysiologic mechanisms linking these conditions. Treatment of OSA has been shown to reduce blood pressure in patients with hypertension, and the reduction is more marked in those with resistant hypertension. Given the high prevalence of OSA in patients with resistant hypertension, clinicians should be cognizant about screening and evaluating for OSA in patients with resistant hypertension, as treatment of OSA can improve blood-pressure control.
{"title":"Is Resistance Futile?","authors":"Harneet K. Walia, M. Mansukhani","doi":"10.1093/MED/9780190671099.003.0005","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0005","url":null,"abstract":"Obstructive sleep apnea (OSA) is highly prevalent in patients with hypertension, particularly in the resistant hypertension population. A large body of evidence supports the association between OSA and incident hypertension independent of confounding risk factors. This chapter discusses the relationship between OSA and hypertension and resistant hypertension, including the prevalence, epidemiology, and pathophysiologic mechanisms linking these conditions. Treatment of OSA has been shown to reduce blood pressure in patients with hypertension, and the reduction is more marked in those with resistant hypertension. Given the high prevalence of OSA in patients with resistant hypertension, clinicians should be cognizant about screening and evaluating for OSA in patients with resistant hypertension, as treatment of OSA can improve blood-pressure control.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"22 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75527930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0006
R. Downey, M. Grigg-Damberger, C. Bae
Sleep loss may impair athletic performance. Sleep extension may improve performance in sleep-deprived athletes. In elite sports, where the slightest edge can make a difference in individual and team success, ways to improve performance are of great interest to athletes and teams. In the presented case, a male basketball player sought to improve his free throw shooting accuracy. With a disciplined approach to sleeping longer periods of time each night over a 12-week period, there was a substantial improvement in free throw percentage, sleepiness, and self-reported confidence in making free throws. This result is consistent with an extensive literature showing that improving sleep can improve athletic performance.
{"title":"More Sleep Is a Slam Dunk","authors":"R. Downey, M. Grigg-Damberger, C. Bae","doi":"10.1093/MED/9780190671099.003.0006","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0006","url":null,"abstract":"Sleep loss may impair athletic performance. Sleep extension may improve performance in sleep-deprived athletes. In elite sports, where the slightest edge can make a difference in individual and team success, ways to improve performance are of great interest to athletes and teams. In the presented case, a male basketball player sought to improve his free throw shooting accuracy. With a disciplined approach to sleeping longer periods of time each night over a 12-week period, there was a substantial improvement in free throw percentage, sleepiness, and self-reported confidence in making free throws. This result is consistent with an extensive literature showing that improving sleep can improve athletic performance.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85525031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0035
H. Mar, R. Mehra
This chapter reviews the “overlap syndrome” between obstructive sleep apnea and chronic obstructive pulmonary disease. The authors discuss the potential mechanisms implicated in these interactions and the bidirectional influences that the entities exert on one another. Overlap syndrome is a highly prevalent condition associated with increased morbidity and mortality. It has been associated with a high recurrence of acute exacerbations of COPD compared to isolated COPD. The chapter also reviews the interactions of overlap syndrome during sleep and the clinical consequences of untreated overlap syndrome. Therapeutic options and the benefits of continuous positive airway pressure are also reviewed. The mortality benefits of treating overlap syndrome with CPAP have been extensively demonstrated but the role of noninvasive positive-pressure ventilation in the treatment of overlap syndrome remains poorly established.
{"title":"Bonnie and Clyde, the Overlap Syndrome","authors":"H. Mar, R. Mehra","doi":"10.1093/MED/9780190671099.003.0035","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0035","url":null,"abstract":"This chapter reviews the “overlap syndrome” between obstructive sleep apnea and chronic obstructive pulmonary disease. The authors discuss the potential mechanisms implicated in these interactions and the bidirectional influences that the entities exert on one another. Overlap syndrome is a highly prevalent condition associated with increased morbidity and mortality. It has been associated with a high recurrence of acute exacerbations of COPD compared to isolated COPD. The chapter also reviews the interactions of overlap syndrome during sleep and the clinical consequences of untreated overlap syndrome. Therapeutic options and the benefits of continuous positive airway pressure are also reviewed. The mortality benefits of treating overlap syndrome with CPAP have been extensively demonstrated but the role of noninvasive positive-pressure ventilation in the treatment of overlap syndrome remains poorly established.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"46 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84732953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0016
S. Mashaqi, R. Mehra
The focus of this chapter is central sleep apnea with Cheyne-Stokes breathing (CSA-CSB), a hypocapnic central sleep apnea commonly observed in patients with congestive heart failure (HF). The pathophysiologic aspects of CSA-CSB are discussed, including ventilatory responsiveness and concepts of loop gain, apneic threshold, and narrowing of the carbon dioxide delta gap serving as a predisposing factor. Complexities of the clinical approach are reviewed in terms of clinically contextualizing the findings from a large randomized controlled trial demonstrating increased cardiovascular-specific mortality in patients randomized to adaptive servo ventilation versus controls in those with central-predominant sleep apnea and reduced ejection fraction HF. Potential mechanistic explanations for these findings are reviewed and placed into context with available post hoc analyses from this trial. Treatment options are discussed, including the role of other positive airway pressure (PAP) modalities, supplemental oxygen, relevant medications, and innovative non-PAP therapies such as transvenous phrenic nerve stimulation.
{"title":"To Treat or Not to Treat","authors":"S. Mashaqi, R. Mehra","doi":"10.1093/MED/9780190671099.003.0016","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0016","url":null,"abstract":"The focus of this chapter is central sleep apnea with Cheyne-Stokes breathing (CSA-CSB), a hypocapnic central sleep apnea commonly observed in patients with congestive heart failure (HF). The pathophysiologic aspects of CSA-CSB are discussed, including ventilatory responsiveness and concepts of loop gain, apneic threshold, and narrowing of the carbon dioxide delta gap serving as a predisposing factor. Complexities of the clinical approach are reviewed in terms of clinically contextualizing the findings from a large randomized controlled trial demonstrating increased cardiovascular-specific mortality in patients randomized to adaptive servo ventilation versus controls in those with central-predominant sleep apnea and reduced ejection fraction HF. Potential mechanistic explanations for these findings are reviewed and placed into context with available post hoc analyses from this trial. Treatment options are discussed, including the role of other positive airway pressure (PAP) modalities, supplemental oxygen, relevant medications, and innovative non-PAP therapies such as transvenous phrenic nerve stimulation.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85600745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0007
S. Domingo, M. Drerup
This chapter covers treatment options for individuals with chronic insomnia disorder. We describe the effectiveness of cognitive behavioral therapy for insomnia (CBT-i) and various modalities of delivery of the treatment. CBT-i is an alternative treatment for insomnia that has been demonstrated to be as successful as pharmacological therapies in the short term, and more effective in the long term. CBT-i comprises sleep restriction, stimulus control, relaxation training, sleep hygiene, and cognitive restructuring. The authors examine group CBT-i as a way to increase social support and enhance treatment adherence. Computerized CBT-i is a newer option to provide increased access to this treatment.
{"title":"Rewriting One Patient’s Story of Disrupted Sleep","authors":"S. Domingo, M. Drerup","doi":"10.1093/MED/9780190671099.003.0007","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0007","url":null,"abstract":"This chapter covers treatment options for individuals with chronic insomnia disorder. We describe the effectiveness of cognitive behavioral therapy for insomnia (CBT-i) and various modalities of delivery of the treatment. CBT-i is an alternative treatment for insomnia that has been demonstrated to be as successful as pharmacological therapies in the short term, and more effective in the long term. CBT-i comprises sleep restriction, stimulus control, relaxation training, sleep hygiene, and cognitive restructuring. The authors examine group CBT-i as a way to increase social support and enhance treatment adherence. Computerized CBT-i is a newer option to provide increased access to this treatment.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"120 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85848425","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0031
Ketan Deoras, Jonathan Oliver, Mita S. Deoras
This chapter covers the bidirectional relationship between depression and insomnia. Patients with insomnia are more likely to develop depression; the prevalence of depression in people with comorbid insomnia is almost 10 times greater than in those without insomnia. Conversely, depression itself has sleep disturbance as a symptom 80% of the time. Treatment of comorbid insomnia and depression should aim at treating both conditions. While cognitive-behavioral therapy for insomnia (CBT-i) should always be considered in the treatment of chronic insomnia, instances may arise when medications are required. Sedative–hypnotics derive from a wide variety of classes of medications and may need to be used in conjunction with antidepressants in the depressed insomniac.
{"title":"The Chicken and/or the Egg?","authors":"Ketan Deoras, Jonathan Oliver, Mita S. Deoras","doi":"10.1093/MED/9780190671099.003.0031","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0031","url":null,"abstract":"This chapter covers the bidirectional relationship between depression and insomnia. Patients with insomnia are more likely to develop depression; the prevalence of depression in people with comorbid insomnia is almost 10 times greater than in those without insomnia. Conversely, depression itself has sleep disturbance as a symptom 80% of the time. Treatment of comorbid insomnia and depression should aim at treating both conditions. While cognitive-behavioral therapy for insomnia (CBT-i) should always be considered in the treatment of chronic insomnia, instances may arise when medications are required. Sedative–hypnotics derive from a wide variety of classes of medications and may need to be used in conjunction with antidepressants in the depressed insomniac.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"90 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83917565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1093/MED/9780190671099.003.0027
E. Bremer, L. Trotti
Idiopathic hypersomnia is a chronic disorder of excessive daytime sleepiness that is characterized by unrefreshing sleep despite normal or long sleep times and sleep inertia. Both symptoms can interfere with normal functioning. The diagnosis requires confirmation of sleepiness or increased sleep propensity via actigraphy, polysomnography, and/or multiple sleep latency test. Clinical evaluation, sleep diagnostics, and laboratory testing must exclude other disorders of excessive sleepiness. Treatment options are limited by the lack of approval by the U.S. Food and Drug Administration of any medications for this indication, as well as the relatively small number of clinical trials including patients with this disorder. Off-label treatments may be used and new treatments are being researched.
{"title":"My Husband Tells Me I’m Lazy","authors":"E. Bremer, L. Trotti","doi":"10.1093/MED/9780190671099.003.0027","DOIUrl":"https://doi.org/10.1093/MED/9780190671099.003.0027","url":null,"abstract":"Idiopathic hypersomnia is a chronic disorder of excessive daytime sleepiness that is characterized by unrefreshing sleep despite normal or long sleep times and sleep inertia. Both symptoms can interfere with normal functioning. The diagnosis requires confirmation of sleepiness or increased sleep propensity via actigraphy, polysomnography, and/or multiple sleep latency test. Clinical evaluation, sleep diagnostics, and laboratory testing must exclude other disorders of excessive sleepiness. Treatment options are limited by the lack of approval by the U.S. Food and Drug Administration of any medications for this indication, as well as the relatively small number of clinical trials including patients with this disorder. Off-label treatments may be used and new treatments are being researched.","PeriodicalId":30275,"journal":{"name":"Sleep Disorders","volume":"5 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91033217","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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