sleeping with the enemy” link to cognitive and ... · dm, a fib, heart failure nocturia,...
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"Sleeping with the Enemy” Link to Cognitive and
Cardiovascular Disease
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Bill Davies PAC BS RRT
Confluence Health
Division of Pulmonary
Sleep Medicine
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‘Don’t ever go to sleep, Too many people die there” •
Mark Twain
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The Temporal Lobe mainly revolves around hearing and selective
listening.
It receives sensory information such as sounds and speech from
the ears.
It is also key to being able to comprehend, or understand
meaningful speech.
This lobe is special because it makes sense of the all the different
sounds and pitches (different types of sound) being transmitted
from the sensory receptors of the ears.
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Engage 6
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OUR Mission is:
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Sleep function, regulation and dysfunction
Review Cognition: executive function/ performance and
sleep issues
Correlate the complex bidirectional relationships of Sleep Disorders and Cardiovascular Disease
Offered Insight for Clinical Practice
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What is Sleep
• a periodic, rapidly reversible neuro-
behavioral state
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What is Sleep
a periodic,
rapidly
reversible
neuro-
behavioral
state
• characterized by
almost simultaneous
changes in activity
patterns and mode of
firing of central
nervous system
neurons and circuits
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•Dopamine
•Norepinephrine
•Histamine
•Acetylcholine
•Serotonin
•Interleukin-1
•Adenosine
•Prostaglandins
•Melatonin
•Neuropeptides
•GABA
•Acetylcholine Receptors
•Muscanaric Receptors
•Nicotinic Receptors
•Adrenergic Receptors
•Orexin Receptors
•Serotoenegeric Receptors
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Sleep Wake Cycle
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Sleep Flip/Flop Switch
• A periodic, rapidly reversible neuro-
behavioral state
• Brain circuitry & neurotransmitter
• Key is in hypothalamus shuts off arousal
• Hypothalamic stabilize the switch
• Ventrolateral preoptic nucleus
• Serotonin, dopamine, noradrenaline, orexin,
GABA 14
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Wake System
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Sleep System
___________________________
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Sleep –Wake Regulation
Nightime sleep • First part of night- sleep because we have been awake
all day (homeostatic drive high)
• Second part of night- sleep because circadian alertness is
low
• Daytime wakefulness • First part of day- awake because We slept at night
(homeostatic drive low)
• Second part of day/evening- awake because circadian
alertness is high (although sleep drive is building)
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REM vs. nREM Sleep?
• Physiologic Variable
• Heart rate
• Respiratory rate
• Blood pressure
• Skeletal muscle tone
• Brain 02 consumption
• Ventilatory response
• Temperature
• Sexual changes
• NREM REM
• Regular Irregular
• Regular Irregular
• Regular Variable
• Preserved Absent
• Reduced Increased
• Normal Reduced
• Normal Poikilothermic
• Rare Frequent
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Meet Your Brain Waves
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Beta
• With normal waking
conscious, alertness,
logic, critical
reasoning
• Majority of adults
operate on it
Alpha
• In deep relaxation with
eyes closed
• Heightens imagination,
visualization, memory
learning, concentration
• Gateway to your
subconscious
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Theta
• In light sleep
• Realm of sub
consciousness
• Brief as one drifts to
Alpha and awake from
Delta
• Vivid visualization and
creativity
Delta
• In deep sleep with eyes
closed
• Awareness is fully
detached
• Process information
from unconscious
• Deep healing and
regeneration
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Sleep the Great Regulator of the Body
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What are Sleep Functions
• Regulates Organ functions
• synchronizes hormonal regulation
• Orchestrates repairs
• Maintains cognition executive functions
• Decreases: metabolic rate, sympathetic nervous
activity, blood pressure, heart rate
• Increase in cardiac vagal tone
• Growth, detox and repair
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Presenting Symptoms that would suggest need for
a deeper probe investigation
• Related to sleep
• Unrefreshing or restorative
sleep
• Disturbing snoring
• Breathing pauses
• Restless sleep
• Nocturia
• Nocturnal sweating
• Gasping sound
• Wake suffocating
• Related to wakefulness
• Tiredness
• Lack of energy
• Sleepiness
• Memory impairment
• Depression
• Lost interest
• Sexual dysfunction
• Headaches
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Sleep complaints tee up a clinical evaluation
• Sleep Questionnaire
• Sleep Log or Sleep
Diary
• Drug and Alcohol
History
• Psychiatric History
• Medical, Cardiac and
Neurologic History
• History of Illnesses
(admissions)
• Family History
• Psychical Examination
• Medical Test (echo,
heart cath)
• Sleep Testing
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Sleep dysfunction conditions and issues
1. Insomnia.
2. Sleep Disorders Breathing. (SDB)
3. Hypersomnia.
4. Sleep related movement disorders
5. Parasomnias.
6. Circadian Rhythm Sleep Disorder
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Headache
Bad or vivid dreams
Problems of breathing
Chest pain/heartburn
Need to pass urine or
move bowels
Abdominal pains
Fever/night sweats
Leg cramps
Fear/anxiety
Depression
Possible causes of insomnia
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Sleep Disorder Breathing
• Umbrella term:
– partial or complete cessation of breathing
occurs throughout the night resulting in :
1. daytime sleepiness or
2. Fatigue
3. snoring, pauses in breathing described by
bed partners, and disturbed sleep
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Signs and Symptoms of Sleep Disorder Breathing
(SDB)
DEPRESSION
EXCESSIVE DAYTIME
SLEEPINESS
GASPING, CHOKING
DURING SLEEP
IMPAIRED
CONCENTRATION
IRRITABILITY
MEMORY
LOSS/DETERIORATION
MORNING HEADACHE OR
HEADACHE DISORDERS
NIGHTTIME CHEST PAIN
FREQUENT NIGHT TIME
URINATION
OBESITY
POOR JUDGMENT
RESTLESS SLEEP
SEXUAL DYSFUNCTION,
LOW DRIVE OR INTEREST
SNORING, APNEA
DIFFICULT TO CONTROL
BLOOD SUGAR
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The clinical conditions includes:
•obstructive apnea
•obstructed hypopnea
• central sleep apnea
•complex sleep apnea
•upper airway resistance syndrome
•nocturnal hypoventilation syndrome
Sleep Disorder Breathing (SDB):
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Sleep related movement disorders
____________________________
1. Restless Leg Syndrome
2. Periodic Limb Movement Disorder
3. Sleep Related Leg Cramps
4. Sleep Related Bruxism
5. PD, MS, ALS, Seizure
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Cough
COPD
Obesity
CVA
CHF
A Fib
Wife or Husband
Pets
Other possible causes of Sleep
Fragmentation
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Next we will review cognition, executive
function/ performance.
And the impact on it by sleep issues
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Cognition is: What make us Human
• It is memory and executive function
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Cognition is: What make us Human
• Interwoven layers of knowledge allow us to:
recognize similarities,
see new and old patterns,
different perspectives,
resolve problems
become empathetic
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Cognition Changes
• As we age the brain (mind) literally acts
differently
• We think differently
• Our brain dries
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The Brain needs Neurogenesis - Plasticity
1. Improve rapid visual
processing
2. Enhanced learning
3. Regain spatial
recognition
4. Cognitive energy
1. Correct executive
problems
2. Arrest memory
decline
3. De spam the brain
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What are the types of Memory?
• Episodic:
• specific past events
involve the person
• Implicit:
• un-conscious part of
memory uses past
experience to shape
current behavior (loss of
inhibition)
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What are the types of Memory?
• Semantic:
• store of facts and
general knowledge
• Executive function:
• goal directed behavior
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Why is Executive Function Important?
• Behavioral inhibition
• Set shifting
• Self regulation &
arousal
• Perseveration
• Analysis synthesis
• Working memory
• Abstract thinking
• Conceptualization
• Attention
• Mental flexibility
• Problem solving
• ID Fake News
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What happens with Loss Cognition?
(ability to reason and remember)
1. MCI: » Altered brain speed
» Altered Neurogenesis (Potholes)
» Altered hormone regulation
• Memory disorder
• Dementia
• Alzheimer
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What does Sleep Dysfunction do to the Brain?
• Fragmentation alters metabolism
• Fatigue alters brain speed and reasoning
• Arousals disrupt brain waves
• Alters neurogenesis and energy
• Cognitive memory impairment
• Increase risk for cerebral microvascular
disease
• Alters Toxin removal
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Hormonal Regulation with Sleep
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Do Sleep Disruptions alter Hormonal
Regulation?
Insomnia.
Sleep Disorders
Breathing. (SDB)
Hypersomnia.
• Sleep related
movement disorders
• Parasomnias.
• Circadian Rhythm
Sleep Disorder
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Altered Hormonal Regulation
• Central neurotransmitter
• HPA
• Peripheral endocrine
gland
• Renin
• Hypothyroidism
• Adrenocorticotrophic
• Corticosteroids
• Aldosterone
• Vasopressin
• Leptin (Satiety +)
• Growth hormone
deficiency (sws)
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Altered Hormonal Regulation
Leptin (Satiety +)
• powerful respiratory
stimulant,
• Elevated with SDB:
adaptive mech, leads to
resistance
• Hunger
• OBESITY, CHD
• Insulin resistance
• Impaired fibrinolysis
Growth hormone deficiency
(sws)
• Pulse secreted mostly in
sleep in slow wave,
• Low IGF has vascular
endothelial cell recepters,
• Dec nitric oxide = dec
vasodilatation
• Impede vascular smooth
muscle cell growth
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So if sleep impact so much, how about
Cardiovascular Diseases.
Is there a Bidirectional
Relationship between sleep
disorders and CVD?
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Does SDB predispose, those at risk for
HTN, CAD, stroke and or HF?
Does CVD and Stroke promote or
exacerbate lethal SDB (CSA, CSR)?
Does Tx of both reduce mortality and
morbidity?
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Some Common Cardiovascular Dysregulations
• Hypertension
• Arrhythmias, A fib
• CAD
• Autonomic dysregulation
• Oxidative stress, endothelial dysfunction
• Pulmonary hypertension
• Congestive heart failure
• Platelet activation, hypercoag, Stroke, TIA 51
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CVD associated with Sleep Apnea
Risk Factors
• Hypertension
• Obesity
• Diabetes
• Depression
• Metabolic syndrome
• Sleep Disorder
Breathing
Diseases
• Arrhythmias
• A fib
• CAD/MI
• CHF :
• Systolic
• Diastolic
• Sudden death
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Sleep Heart Health Study
Sleep disorder breathing and CVD
• Elevated RDI = inc triglyceride + dec HDL
• HTN (diastolic dysfunction)
– nocturnal HTN more resistant to Tx
• In CHF: 37% with diastolic have OSA
• 30% with systolic have OSA
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Circulation 2012/Wisconsin Sleep Cohort
CVD and Sleep Apnea
In primary HTN 35%
In CAD 30%
In HF up to 58%
With Stroke 42% (risk post CVA
high for 6 months)
Mortality risk 3.8 x all cause,
CV x 5.2 Higher
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What are some Vascular effects of OSA
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• Intermittent hypoxia O2 free radical activation
of inflammatory pathways impaired endothelial fx
& inc BP independent of sympathetic activation
• Hypercoagulability from inc expression of
adhesion molecules & vascular smooth muscle
proliferation
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Figure 1. Pathophysiological effects of OSA on the cardiovascular system.
T. Douglas Bradley, and John S. Floras Circulation. 2003;107:1671-1678
Copyright © American Heart Association, Inc. All rights reserved.
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Pathophysiological effects of OSA on the cardiovascular system.
Obstructive apneas increase left ventricular (LV) transmural pressure (ie, afterload)
through the generation of negative intrathoracic pressure (Pit) and elevations in
systemic blood pressure (BP) secondary to hypoxia, arousals from sleep, and
increased sympathetic nervous system activity (SNA).
Apnea also suppresses the sympathetic inhibitory effects of lung stretch receptors,
further enhancing SNA.
The combination of increased LV afterload and increased heart rate (HR) secondary
to increased SNA increases myocardial O2 demand in the face of a reduced
myocardial O2 supply.
These conditions predispose a patient acutely to cardiac ischemia and arrhythmias,
and chronically could contribute to LV hypertrophy and, ultimately, failure. The
resultant fall in stroke volume will further augment SNA.
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Does CVD and Stroke promote or
exacerbate lethal SDB (CSA, CSR)?
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Does CVD and Stroke promote or exacerbate
lethal SDB (CSA, CSR)?
• Yes they are bidirectional insults
• Chances of having sleep apnea post
CVA is 42% for next 6 months
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. Pathophysiology of central sleep apnea in heart failure
(HF).
T. Douglas Bradley, and John S. Floras Circulation.
2003;107:1822-1826
Copyright © American Heart Association, Inc. All rights reserved.
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Pathophysiology of central sleep apnea in heart failure (HF).
HF leads to increased left ventricular (LV) filling pressure. The resulting pulmonary
congestion activates lung vagal irritant receptors, which stimulate hyperventilation
and hypocapnia.
Superimposed arousals cause further abrupt increases in ventilation and drive
PaCO2 below the threshold for ventilation, triggering a central apnea. Central sleep
apneas are sustained by recurrent arousals resulting from apnea-induced hypoxia
and the increased effort to breathe during the ventilatory phase because of
pulmonary congestion and reduced lung compliance.
Although central apneas have a different pathophysiology than obstructive apneas
and are not associated with the generation of exaggerated negative intrathoracic
pressure, they both increase sympathetic nervous system activity (SNA).
The consequent increases in blood pressure (BP) and heart rate (HR) increase
myocardial O2 demand in the face of reduced supply. This chain of events
contributes to a pathophysiological vicious cycle.
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Why worsening nocturnal dyspnea?
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Four Question to Frame Your Assessment of ?
Does the patient have HTN,
DM, A Fib, Heart Failure
Nocturia, Worsening obesity
And or are which may be
resistant to TX
• Do family members report
restless sleep, snore, apnea,
irregular breathing
• Personality changes
Is there an elevate Stop Bang or
Epworth Score
HX of snoring ,hypersomnia
Pending surgery + any
combination of any on this page
• Is there a ? of stroke, TIA,
MCI, Dementia
• Neurodegenerative disorder,
mood disorder (depression,
bipolar, or anxiety issues)
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Four Question to Frame Your Assessment of ?
Does the patient have HTN,
DM, A Fib, Heart Failure
Nocturia, Worsening obesity
And or are which may be
resistant to TX
• Do family members report
restless sleep, snore, apnea,
irregular breathing
• Personality changes
Is there an elevate Stop Bang or
Epworth Score
HX of snoring ,hypersomnia
Pending surgery + any
combination of any on this page
• Is there a ? of stroke, TIA,
MCI, Dementia
• Neurodegenerative disorder,
mood disorder (depression,
bipolar, or anxiety issues)
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Four Question to Frame Your Assessment of ?
Does the patient have HTN,
DM, A Fib, Heart Failure
Nocturia, Worsening obesity
And or are which may be
resistant to TX
• Do family members report
restless sleep, snore, apnea,
irregular breathing
• Personality changes
Is there an elevate Stop Bang or
Epworth Score
HX of snoring ,hypersomnia
Pending surgery + any
combination of any on this page
• Is there a ? of stroke, TIA,
MCI, Dementia
• Neurodegenerative disorder,
mood disorder (depression,
bipolar, or anxiety issues)
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Four Question to Frame Your Assessment of ?
Does the patient have HTN,
DM, A Fib, Heart Failure
Nocturia, Worsening obesity
And or are which may be
resistant to TX
• Do family members report
restless sleep, snore, apnea,
irregular breathing
• Personality changes
Is there an elevate Stop Bang or
Epworth Score
HX of snoring ,hypersomnia
Pending surgery + any
combination of any on this page
• Is there a ? of stroke, TIA,
MCI, Dementia
• Neurodegenerative disorder,
mood disorder (depression,
bipolar, or anxiety issues)
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This looks like a case
for Sleep Guys on deck
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This looks like he may
need a consult/sleep test.
Possible in lab or home
study. Right!
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Evaluating These Patients is Challenging
Occurrence is high as is risks
Reluctance to admit issues
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Evaluating These Patients is Challenging
Testing in now easier
Better Tx and Outcomes
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Patients are often willing to come face to face
with the facts
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Rem
SWSN2
N1
Wake
23:00 23:30 00:00 00:30 01:00 01:30 02:00 02:30 03:00 03:30 04:00 04:30 05:00 05:30 06:00
Hy
pn
og
ra
m
Hy popneas+ArAp M+ArAp O+ArAp C+Ar
Hy popneasAp MAp OAp C
Re
sp
ira
tory
80
90
100
Sa
O2
Right-Side
Left-Side
Prone
Supine
Po
sit
ion
0
10
20
CP
AP
0
10
20
BiL
ev
el
Left Leg+ArRight Leg+Ar
Both Legs+ArLeft Leg
Right LegBoth Legs
PL
Ms
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Sleeping with the enemy or sleeping with a friend
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Summary; What does this all mean for your practice?
1. Patient with HTN (resistant on more that 2 drug), CHF, A
fib + poor control + poor sleep and nocturia
2. Is there a ? of stroke, TIA, MCI, Dementia + snore, apnea
3. Neurodegenerative disorder, mood disorder (depression,
bipolar, or anxiety issues) + insomnia or hypersomnia
• Should have a brief sleep review with you or others
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Office staff tools
THE EPWORTH
SLEEPINESS SCALE
STOP-BANG Screening
Questionnaire for Sleep
Apnea
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Testing has never been easier
Treatments are at Star Trek levels
Quality of changed lives never been higher
Thanks for your time 80
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Any Questions?
Bill Davies, PAC, BS, RRT
Bill.davies
@confluencehealth.org
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