Published: Feb. 21, 2008
Updated: June 1, 2010
Meet the caretakers of that forgotten third of our lives -- the portion we spend asleep.
By Kathleen Yount
Move over, Manhattan. It used to be that, outside of the world's most urban areas, the night belonged only to stoics like doctors on call, cops, and truck drivers.
But now that so much of modern culture and commerce aspires to 24/5/365, the sleepless most anywhere in America can pass the night from the 24-hour Wal-Mart to the 24-hour Kinko's to their 300-channel cable TV and the World Wide Web, where it's always daylight somewhere.
Want to wake up in a city that never sleeps? You probably already do.
Perhaps that’s why sleep medicine, once something of a backwater specialty, is now experiencing an unprecedented heyday. In a clear sign that the specialty has arrived, the American Board of Medical Specialties began offering physicians board certification in sleep medicine in 2007.
“I think sleep is in the public consciousness,” says psychiatrist Andrew Krystal, MD, who directs the sleep research program at Duke. “It’s hard for me to believe that people are sleeping worse now than they were a few decades ago, but it seems that people are talking about it more. Ambien is a household word now, like Prozac.”
In the Triangle, while growing ranks of insomniacs fill clinicians’ offices, sleep labs are running ever-more recordings of the squiggles and lines that describe the landscape of nightly repose -- or the fitful lack thereof. The Duke Sleep Disorders Center -- one of the country’s oldest, and one of the few in the nation that offer faculty expertise in neurology, pulmonology, psychology, and psychiatry -- moved its clinical sleep laboratory to Durham’s Millennium Hotel in November 2005.
The setting not only provides patients with a less hospitalized and more amenitized way to undergo a sleep study, but also upped the number of beds, in order to accommodate increasing referrals from physicians and patients themselves. It seems that the long-sung refrain of sleep medicine experts is finally catching on: How can we ignore any chronic disruption in something that all of us are wired to spend a third of our lives doing?
By far, the number-one disorder of sleep is its painful absence. We live in a sleep-deprived culture, but beyond our self-imposed sleep debt, on any given night at least a fifth of our populace is watching the alarm clock in waking misery. There is good news for those with chronic insomnia: There’s a well-proven, drug-free treatment that works well for the majority of patients. The bad news? Only about 100 psychologists in the country are trained and board-certified to provide it.
One of them -- Duke sleep psychologist Jack Edinger, PhD -- pulls a dust-covered briefcase from the corner of his office in the Durham VA Medical Center, opening it to display a tool from the early days of this now-proven prescription for insomnia, cognitive behavioral therapy (CBT).
“It’s a timer with an alarm on it, and a tape recorder,” Edinger says of the circa-1970s machine. “It was set up to beep, very softly, several times throughout the night; when it beeped it would turn on the tape recorder, and the patient had 10 seconds to say ‘I’m awake.’ Then in the morning you could reconstruct the night of sleep or wakefulness.” The device was among the tools used by a small group of researchers, including Edinger, to develop and prove the effectiveness of CBT for insomnia.
“It’s not rocket science,” says Edinger of his craft, but it is one that was painstakingly designed to target and disengage the behaviors and anxieties that can perpetuate sleeplessness.
Most people with chronic insomnia are stuck in a self-perpetuating loop: Their anxiety about not getting enough sleep keeps them hyper-aroused at night, both mentally and physically. Meanwhile, they’ve altered their sleeping habits -- napping, fiddling with their bedtimes, and so forth -- in an effort to coax more sleep out of their days. This sort of sleep-chasing ultimately interrupts the homeostatic drive of the body’s sleep system.
“CBT helps them right the ship again,” Edinger says. “And once they are in treatment, it’s easy for the patients to see what they need to change. Conceptually, it’s not a tough disorder to treat.” A recent study at the Durham VA Medical Center showed that people with primary insomnia who undergo cognitive behavioral therapy have excellent success rates -- 75 percent experience remission.
The caveat is that sleep research to date -- and this goes for both CBT and pharmacologic research, notes Edinger -- has focused almost exclusively on primary insomnia, meaning insomnia that occurs in the absence of other illnesses, chronic pain, and substance abuse. While people with this type of insomnia number large, they comprise only about 20 percent of all insomnia sufferers.
Edinger and other sleep psychologists at Duke are working to tweak the CBT model for patients whose insomnia is confounded by other conditions. According to current research, including three studies at Duke, the management of one hinges on the other. “If you look at people with depression, those with prominent comorbid insomnia problems are generally more difficult to manage and treat,” Edinger says.
“They also have a greater propensity toward suicide, and if you treat the depression effectively but there is residual insomnia, they’re more likely to relapse.” Conversely, treating insomnia along with depression seems to vault a patient’s progress forward. Research shows that both anxiety disorders and chronic pain are also linked with insomnia in this way: To treat any of the conditions effectively, you must treat them all.
But there are times, says Duke neurologist Aatif Husain, MD, when a patient complaining of insomnia may actually have an entirely different sleep disorder. Husain is one of the physicians who read sleep studies at Duke’s lab at the Millennium Hotel -- one of the few in the area staffed entirely by physicians who are board-certified in sleep medicine.
In many cases, he says, the real culprit is another of the wide range of sleep-disrupting problems patients present with. Some suffer from REM behavior disorders, in which sleepers act out fearful, violent dreams at great peril to themselves and their bed partners (and which has now been linked to a subsequent onset of Parkinson’s disease).
Others have narcolepsy, which often plagues patients for 10 years before they get a proper diagnosis. That’s because most of the time its main symptoms -- fatigue and daytime sleepiness -- start in the teenage years, when fatigue and sleepiness are likely to be glossed over as the throes of adolescence or treated as symptoms of depression.
“Unless a diagnosis is made early on, it can have long-lasting consequences for these patients’ lives,” says Husain, “since they may underachieve during important academic years in high school and college.” He says that a physician can spot signs of narcolepsy in the patient history: If someone says she doesn’t sleep well at night and reports having dreams during short naps (15 to 30 minutes), she may need further evaluation.
A more common cause of sleep disruption is restless leg syndrome (RLS). Hallmarked by nighttime movement of the legs and a creepy-crawly sensation that can torment patients trying to sleep, RLS may be a disorder of dopamine levels in the brain -- much like Parkinson’s disease. In fact, Husain notes that many Parkinson’s disease patients have restless leg syndrome -- though the converse is far from true.
Husain participated in the international testing of the two medications currently approved for the treatment of restless leg syndrome, both of which are also prescribed for many Parkinson’s disease patients, although at a much higher strength. In some cases, the treatment can be as simple as an iron supplement, because there is a high incidence of low iron levels among patients with RLS. “Patients really see a significant day-to-day benefit from these treatments,” says Husain.
Even more common than RLS in patients visiting sleep labs is obstructive sleep apnea, says neurologist Rodney Radtke, MD, medical director of the Duke Sleep Disorders Center. Sleep apnea affects about one out of every 10 people, and because obesity often triggers the condition, that number could be on the rise. But Radtke emphasizes that it is not strictly a disorder of obesity: “One 300-pound man may have it while another doesn’t. And a 170-pound man may have it while a 300-pound person doesn’t.”
The toll obstructive sleep apnea takes on a sufferer of any weight can be extreme, and sleep-study footage of the condition is almost painful to watch: Over and over, the sleeping patient stops breathing; then, as the oxygen levels in his blood drop, he rouses from sleep with a jarring gasp, his heart rate leaping high as he hyperventilates. The same episode repeats and repeats, eerie quiet followed by frantic gasping.
What’s unseen on film, says Duke pulmonologist Ambrose Chiang, MD, is how this grim cycle triggers the body’s sympathetic system and increases oxidative stress, leading to endothelial cell dysfunction and systemic inflammation. This is why sleep apnea not only strains the heart but also can play a role in atherosclerosis, insulin resistance, and glucose intolerance, as well as a host of cardiovascular complications from refractory hypertension to atrial fibrillation.
“It’s such an important disease, and it affects so many organ systems,” Chiang says, noting that it’s also among the most common causes of motor vehicle accidents in which drivers fall asleep at the wheel.
The condition also brings with it a buffet of unpleasant complications that can raze the sufferer’s quality of life, from headaches and acid reflux to erectile dysfunction and nocturia (frequent nighttime urination), which is triggered by the heart’s chemical release when the body strains to breathe against a closed airway.
But because it is usually these accompanying complaints that drive patients to the practitioner, most of the time, Chiang says, the sleep apnea is not picked up. “Nocturia in particular is often misattributed to fluid intake, diuretics, or bladder or prostate problems,” he says. “Many physicians don’t know that it can be a sign of sleep apnea.”
In many cases, people who seek treatment specifically for sleep apnea are those whose bed partners have lain awake beside them, listening for their absent breathing. Chiang believes that certain patients should be screened for sleep apnea as a routine.
“Though we don’t have the studies to support this yet, it’s my opinion that every cardiac inpatient should be evaluated for sleep apnea before they are discharged,” he says. “When folks come in for an acute cardiac event and we send them home without catching their sleep apnea, they may wind up coming back.”
Likewise, he says, every hypertensive patient, every obese patient, and every insomnia patient should be screened. “ It makes good clinical sense to assess the possibility of sleep apnea in these patients -- because there are a lot of patients that we could be treating that we’re not.”
But all of these patients can’t just grab a sleep study on their way home, so Chiang hopes to improve in-office diagnostic tactics. He is working to devise an easy-to-use scoring system that could flag possible obstructive sleep apnea patients, based on the patient’s history, symptoms, craniofacial profile, and a good physical exam of the upper airway.
“If we do it right, a user-friendly scoring system could make it possible for a sleep apnea screening to be done by a physician’s staff, or nurses in a hospital,” says Chiang. “And if we can achieve this, then we’ll be able to pick up these sleep apnea patients early instead of 10 years down the line.”
Chiang shows a slide to illustrate how clearly some of the physical characteristics of sleep apnea can be identified. The slide, which he titled “The Evil Tongues,” shows six pinkish tongues displayed dragon-style, whose edges look nearly the shape of a piecrust. This kind of noticeable tongue scalloping suggests that the tongue may be too big for the mandible, and therefore likely to shut off the airway when that person sleeps.
Similar physical signs of apnea can be seen in the narrowness of a patient’s posterior pharynx or the size of his uvula or tonsils. Even facial features such as a small, receding chin or a pronounced overjet (overbite) can signal a potential obstructive apnea. “The upper airway examination has traditionally been ignored,” says Chiang. “A brief, focused upper-airway examination can be very enlightening, and it takes no more than two minutes to do.”
While weight is a significant contributor to obstructive sleep apnea, it usually takes major weight loss to have a significant impact, Radtke says. But like insomnia, obstructive sleep apnea already has an interventional therapy that works for most people: Nasal continuous positive airway pressure (CPAP) delivered via a soft plastic mask that fits over the nose.
“If you wear it, it works,” says Radtke. “CPAP became commercially available in 1985, and we have people who have been on it for 22 years. They’ll jokingly say things like, ‘You can have my wife, but you can’t have my machine.’ It really brings a marked benefit to their lives.”
In fact, the only patients who don’t benefit from CPAP are those who don’t wear the mask. “People who have severe apnea are remarkably compliant, because of the change in their ability to stay awake and energetic during the day,” says Radtke. “They get the immediate reinforcement of feeling great. But in the mild apnea patients, who get only a modest benefit in terms of how they feel, it can be hard to put up with the aggravation of CPAP over the long haul.”
Radtke says that in these mild cases compliance is only 70 percent at best, and sometimes as low at 30 percent. “Most 40-year-olds don’t like the vision of themselves going to bed every night with a mask on.”
Husain says that the more a patient understands about the health implications of stopping breathing 50 times an hour, the better his CPAP compliance becomes. Duke’s sleep apnea/CPAP clinic was developed in part to make sure that these patients understand the importance of what the perhaps ungainly equipment is doing for them.
“Our sleep technologist works with patients to make sure they have the best-fitting mask and to solve any issues of discomfort, as well as to provide education,” Husain says. The clinic also streamlines the CPAP process for both patient and referring physician. “We arrange for the CPAP equipment to be sent to the patient’s home, and we conduct follow-up appointments and further testing when needed,” he says -- which serves the patient and saves the primary care physician potential logistical nightmares.
“When I order CPAP I have to send a prescription to a home health company, and they get the machine to the patient. But different insurance companies deal with different home health care companies, and most physicians don’t have any cause to know which works with which. It can take a lot of navigation to sort it all out.”
For both apnea and insomnia, the greatest challenges aren’t in discovering treatment, but in getting the treatments to more patients. “Most patients who seek treatment for insomnia do so in a primary care setting,” says Edinger, “where the most they are likely to get is a sleep medication. Ultimately we want a model of CBT that would be practical for primary care physicians to use.”
He says there are now studies underway to look at different ways of providing CBT through nurse providers, physician assistants, or even Internet delivery systems. “In Holland they did behavioral interventions via TV,” he says. “That kind of delivery isn’t as effective as one-on-one CBT in a clinic setting, but for what it was they actually did fairly well -- and they reached thousands of people.”
Krystal is trying another tactic: Educating physicians online. “We know that physicians can improve how they manage their patients in general when they improve how they manage their patients’ sleep,” he says, but clinicians in the field currently don’t get much in the way of training to do so.
To remedy that, Krystal and two colleagues, Thomas Roth, PhD, at Detroit’s Henry Ford Hospital and Daniel Buysse, MD, at the University of Pittsburgh, formed the Sleep Medicine Education Institute, a non-profit organization that disseminates sleep medicine research findings and provides continuing medical education credit on insomnia, restless leg syndrome, and sleep apnea. The organization is funded in part by pharmaceutical companies, but the content of the information is not influenced by industry.
“It’s a means of education in which the educator is in no way compromised by commercial interests,” he says. “It allows physicians to hear from the people who are actually doing the research.”
Krystal hopes that this and similar education venues will help improve care for the hordes of patients still awaiting a consistent night’s rest. “Sleep medicine is still an area where we’re not getting any better at making the problems go away,” he says. “But we are getting better at treating it. There are effective methods out there to help people with sleep problems -- we just need more people who are trained to provide them.”
This article was first published in the Winter 2008 edition of DukeMed Magazine.