2015 Fall Seminar Recap

Madhukar Kaloji,MD,FCCP.Pulmonary & Sleep Medicine Consultants,

Clinical Asst.Prof., Eastern Virginia Medical School,Norfolk-Virginia, USA.

● Definition● Epidemiology ● Significant public health problem ● Female gender, older age, medical and

family history● Psychological vulnerability: anxiety,

depressive, perfectionism, introversion etc.,

● CDC estimates: 41 million working adults in the US report sleeping 6 hours or less

● Acute or Short-term Insomnia( < 3mo )● Chronic or Long-term Insomnia( >3 mo)● Insufficient Sleep Syndrome( Volitional

Sleep Restriction)● Short Sleeper● Economic burden ( higher annual medical

costs, less productivity)

● 40% of patients in primary care settings report at least one sleep-related symptom

● Difficulty maintaining sleep-most common● Non-restorative sleep, difficulty initiating

sleep, early morning awakenings ● Overall: Mixed symptomatology is more

common

● Fatigue, Malaise & Daytime Sleepiness● Impairments in Memory, Attention,

Concentration● Impaired Academic/Social performance● Dysphoria● Behavioral problems( particularly in

children)● Errors in judgement / Accident proneness● Dissatisfaction with sleep in general

● Physical and/or Mental Fatigue play a major role in operator-related accidents

● The Exxon-Valdez oil spill: a historic environmental disaster ( fatigued crew & lack of supervision)

● The Libby Zion case( sleep-deprived interns and residents)

● Numerous airline tragedies across the globe( Pilot fatigue, swing shifts etc.,)● The Three-Mile Island Nuclear accident

● Road Traffic Accidents (due to sleepiness): major public health and occupational hazard across the world.

● Increasing trends in Asia: increased no. of automobiles and worsening congestion

● Sleep-related crashes and unintentional injuries: A very large cohort of 54,399 men and women over a 14-year period (Bjorngaard et al., Sleep 2014; 37(11):1777.

● A dose-dependent relationship between number of symptoms and risk of injuries/fatalities noted in the study

● Several studies have shown objective correlation w PVT ( a reaction time > 500 milliseconds)

Peak incidence: midnight until 6 AM

● “Allostasis”: the active process of maintaining stability ( homeostasis) through change

● A non-linear, sometimes reciprocating network● All of the systems that are modulators show

rhythms of activity over the sleep-wake cycle● Affected by circadian/sleep disruption● Circadian disrupted mice: 5 week study showed

weight gain, increased leptin, pre diabetic state● Numerous animal studies showed sleep-

deprived mice died of sepsis and septic shock

● Insomnia and sleep fragmentation very common in patients with Bronchial Asthma, COPD, OSA, Nocturnal GERD etc.,

● Could indicate poor control of the underlying pulmonary problem

● Nocturnal hypoxemia in COPD, CSA, CSR causes sleep-maintenance insomnia-hypnotic dependence

● Sleep disruption in ICU patients: prolonged Ventilator LOS, arrhythmias etc.,

● Insomnia and Sleep Deprivation: very common, disabling health problem

● Sleep disruption and non-restorative sleep linked to a variety of medical as well as neuro-psychiatric conditions

● Attention to co-morbid conditions crucial in determining insomnia prognosis

● Increased awareness among non-sleep specialists very important given wide-ranging clinical implications.