Sleep Disorders and Health Conditions: Focus on Insomnia - Episode 5

Approaching Diagnosis and Treatment of Sleep Disorders and Co-occurring Health Conditions

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Experts in sleep medicine stress the importance of early diagnosis of sleep disorders and how they approach treatment in their clinics.

C. Michael Gibson, MD: Let’s talk about making the diagnosis earlier. My father was diagnosed with borderline narcolepsy. This isn’t just a disease of old people, right? There are some young people who also have some sleep disorders, right?

Ashgan A. Elshinawy, DO: Absolutely. Whether we’ve talked about insomnia, sleep apnea, or narcolepsy, it definitely spans all ages. Especially with narcolepsy and genetic disorders like that, it can start at a very young age; however, it’s often misdiagnosed, unfortunately. Maybe the kid is not getting enough sleep at night or is up watching TV. We blame it on a lot of different things. In my practice, I’ve noticed a lot of people with narcolepsy who don’t get diagnosed until age of 30 or 40, after they lost so much quality of life—maybe they lost jobs or were kicked out of school. There have been a lot of complications from that diagnosis, and the problem is that sleep disorders aren’t screened for and thought of as often as they should be. They have such an impact on our lives, and they should be addressed a lot more.

This ties back to what you were asking about being a cardiologist and trying to screen for sleep disorders. I share a practice with a bunch of cardiologists, and it took me a little while to get them to buy into the strong link between sleep disorders and cardiovascular diseases, which they’re challenged with every day. It could be uncontrolled hypertension, congestive heart failure, or rapid A-Fib [atrial fibrillation]. They can’t seem to get into sinus rhythm and keep in sinus rhythm. I tell them that it’s a very simple screening tool that your medical assistant can use. It should be your extra vital sign. You’re checking blood pressure; heart rate; pulse; Epworth Sleepiness Scale score; STOP-Bang score, which takes 10 to 15 seconds to do. If that score is high, you can do nothing else and refer them to a sleep doctor.

If you have time, you can ask them a few more questions during your cardiac evaluation. What I’m finding with my cardiology colleagues is that they’re excellent at screening and spotting significant sleep disorders, whether it’s insomnia or sleep apnea, and they’re having a lot more success controlling hypertension, A-Fib, and sinus bradycardia. Some people are now getting pacemakers because they have severe sleep apnea that may be causing bradycardia at night. Because it’s only happening at night, it took them a little time to realize that they’re strongly associated and that it’s worth it to invest an extra 2 to 3 minutes in the visit to get that information.

C. Michael Gibson, MD: Our patients can have both central problems with their drive to breathe and obstructive problems because they’re often obese or have diabetes, and both of those are risk factors. Cardiology is a high-risk group. Are there any other specialties that need to be paying attention to this?

Nathaniel F. Watson, MD: Patients with pulmonary diseases—as COPD [chronic obstructive pulmonary disease] in particular—can have an overlap syndrome with OSA [obstructive sleep apnea], and that can lead to problems with sleep continuity, which can be an issue. We talked about affective disorders, in particular depression. We know that depression and insomnia are tightly linked. Insomnia is a symptom of depression and can precede a depression diagnosis, or it can be a trigger for depression. We know that if we treat both simultaneously, we have a greater opportunity for success in improving these patients’ problems.

Stroke is a big 1. After patients have strokes, a very high percentage will have some sleep-disordered breathing, central apneas, and obstructive apneas. Typically, the central apneas will improve as the stroke symptoms improve, but the obstructive apneas persist. Most of us in the field believe that the obstructive apnea was likely present prior to the stroke and a contributing factor or an independent risk factor for the stroke. Certainly, it causes high blood pressure, which is a stroke risk factor. Sleep apnea is very common following stroke, with a 70% to 80% occurrence. Almost any patient who has had a stroke should be referred to a sleep center to get the issue addressed.

You have neuroimmunology and multiple sclerosis, and fatigue can be a big problem. Certainly, you can have problems with insomnia—either sleep onset, sleep maintenance, or early morning awakening. You can have sleep-disordered breathing co-occur with multiple sclerosis, which is another area. With neurodegenerative diseases like Parkinson disease and Alzheimer disease, sleep is very disturbed in those individuals and can be a real challenge to improve. To the extent that you can get a solid amount of continuous sleep to occur in a 24-hour period, behaviors can improve in Alzheimer disease, or a late stage of it. In Parkinson disease, sleep can help with some of that symptomatology during the day concerning healthy sleep. There’s a lot of overlap with many disease processes.

C. Michael Gibson, MD: Another 1 I want to point out is that a lot of my patients are older men who have to go to the bathroom 5 times a night. That’s very disruptive to not just their sleep but their partner’s sleep. That’s another population that you must treat as well.

Let’s talk a little about insomnia in depression. When you talk about treating depression in co-occurrence with insomnia, are there any drugs that you feel are very helpful? I’ve seen SSRIs [selective serotonin reuptake inhibitors] to be helpful when they bring down some of that agitated depression, and then people tend to sleep a little better. Ashgan, what are your thoughts?

Ashgan A. Elshinawy, DO: That was definitely the popular thought. It continues to be, especially among primary care physicians. A lot of patients who come to me from primary care with depression and insomnia are very often started on an SSRI, or a sleep aid that isn’t necessarily FDA approved but will treat depression and, hopefully, insomnia as well. With regard to treating separate entities separately and exclusively, if it’s done in a combined fashion—meaning we’re giving an antidepressant to treat the insomnia and the depression—then it will improve the sleep if the anxiety and depression are so significant that they’re interfering with a person’s sleep.

However, I rarely find that their sleep gets much better automatically. There’s always something missing, almost like a primary thing going on that’s driving their insomnia. Very often they do need a supplemental sleep aid. Having said that, as a sleep physician, I always start with 1 thing before I take out the prescription pad: cognitive behavioral therapy. That’s always the secondary treatment. Sometimes I do it at the same time if the person’s quality of life is so severely impaired and there isn’t enough time to wait for cognitive behavioral therapy to be executed consistently and for it to kick it in; it can take weeks or months. That’s the standard of care, which is very effective care, but a lot of people won’t do it or don’t want to do it. A lot of practitioners are not well versed on cognitive behavioral therapy for insomnia. That’s another challenge for the treatment of insomnia. If you’re going to choose pharmacological therapy, you should treat the depression with an antidepressant, and you should treat insomnia with an FDA-approved sleep aid.

Nathaniel F. Watson, MD: I totally agree. We have a “3-P” model for insomnia. We have predisposing factors, which could be somebody who has some depression. We have precipitating factors, which could be a major negative life event occurrence, like a divorce or a death in the family, that triggers insomnia. Then we have perpetuating factors, which may be bad sleep hygiene that began following that major life event. This is a helpful way for us to think about insomnia as we unravel the best way to treat it.

In that particular patient, you’d obviously want to treat the depression. You’d want to explain to them that some short-term insomnia is not unusual. It affects about 30% of the population, [so we’d need to explain that] we expect it to get better and it’s not the new normal. Then you’d counsel them on proper sleep hygiene, but take that a step further toward cognitive behavioral therapy for insomnia.

Ultimately, you could get that patient managed and get their sleep issues addressed without an additional medication. When it comes to insomnia, we like to focus on cognitive behavioral therapy because it’s so effective. The challenge is that a limited number of providers know how to do it, so there’s an access issue. Despite that, it continues to be a highly recommended treatment option for patients with insomnia, as far as clinical guidelines are concerned.

C. Michael Gibson, MD: I want to ask about restless legs syndrome. It’s unnerving when you’re on the couch at night and your legs start going crazy. What can you do about that?

Nathaniel F. Watson, MD: It can be a real problem, and it can be a major cause of insomnia—sleep onset or sleep maintenance insomnia. It’s highly prevalent, probably an underappreciated problem. You get that uncomfortable, creepy-crawly feeling in your legs, usually at night. That’s relieved by movement, so it’s a clinical diagnosis.

First, we want to assess your iron status. Oftentimes, iron replacement therapy can be quite beneficial, or an intravenous iron infusion can be very beneficial. This is related to how iron interacts in various neurological pathways in the brain. Beyond that, there are FDA-approved medications to treat restless legs, or dopamine agonist medications, so there are other options at your disposal. A number of treatments are effective in addressing this. It can be a challenge, but we have ways to make it better.

Transcript edited for clarity