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Sleep case #1

Sleep case #1. Case. 64 yo male smoker with hyperlipidemia BMI 28 Prev diagnosis of OSA Referred for daytime sleepiness. Prev results. 12/2006 sleep study: AHI 15.8 5/2007 PAP titration – good response to CPAP 6cm, 54 mins of sleep including REM-supine seen

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Sleep case #1

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  1. Sleep case #1

  2. Case • 64 yo male smoker with hyperlipidemia • BMI 28 • Prev diagnosis of OSA • Referred for daytime sleepiness

  3. Prev results • 12/2006 sleep study: AHI 15.8 • 5/2007 PAP titration – good response to CPAP 6cm, 54 mins of sleep including REM-supine seen • Did not get home CPAP at that time • Summer 2012: Another provider started him on CPAP based on 2006/2007 study results and ordered PSG which was performed in 10/2012

  4. Visit Jan 2013 • Started on CPAP over the summer 2012 • Using it nightly and has met compliance with 4.5h ave use • Feels he is sleeping better • No improvement in daytime sleepiness (ESS 18/24) • Irregular schedule • Difficulty falling and staying asleep • Estimates he gets 3-6 hours sleep/night • Works as a school bus driver

  5. Assessment? Next steps? Any special considerations in this patient?

  6. 10/2012 sleep study

  7. Sleep study results 10/2012 • TIB 424 min TST 344 min WASO 67 min • Sleep efficiency 81% • Sleep latency 11 mins, REM latency 17.5 mins • Sleep stages: 4.1% N1, 70.5% N2, 0% N3, 25.4% REM • Position: 65 min supine, 278 min on left • AHI 5.2 overall, supine 10.9, REM 16.5, supine REM 57 • Sat >90% entire study

  8. Impression?Next steps?

  9. PSG on CPAP/MSLT performed

  10. PSG/MSLT results • PSG: TST 382 mins, efficiency 83%, CPAP titrated from 6cm to 8cm. AHI 0. • MSLT • Nap 1: SL 1 min, REM latency 11 min • Nap 2: SL 1 min, no REM periods • Nap 3, SL 1 min, no REM periods • Nap 4: SL 4 min, no REM periods • Nap 5: SL 1 min, REM latency 5 min • Mean SL: 1.8 min, 2 SOREMs

  11. Diagnosis? Treatment?

  12. Narcolepsy • #2 cause of daytime sleepiness (#1 = OSA) • Onset typically teens and early 20’s, but can be after age 40 • NL with and without cataplexy • Pathology of NL + cataplexy (~70%): loss of neurons that produce orexin (a.k.a. hypocretin) • Wake-promoting • Stabilize wake/sleep • Inhibit REM • NL without cataplexy less well-understood • Possibly less extensive loss of orexin

  13. Symptoms of narcolepsy • EDS • Fragmented sleep • REM-related phenomena intrude into wakefulness • (Cataplexy) • Hypnagogic hallucinations • Sleep paralysis

  14. Multiple Sleep Latency Test • PSG the night before • 5 opportunities to nap, every 2 hours • 20 minutes to fall asleep • If fall asleep, allow 15 minutes of sleep • Data obtained: • Number of naps in which sleep is obtained • Mean sleep latency • If no sleep, 20 minutes for that nap • Number of SOREMs

  15. Diagnosis of Narcolepsy • EDS + cataplexy • Narcolepsy without cataplexy – definitive diagnosis • Mean SL < 8 mins • ≥ 2 SOREMs

  16. Treatment of Narcolepsy • Wake-promoting agents • Modafinil/armodafinil (provigil/nuvigil) • Likely increase dopa signaling • Amphetamines • e.g Methylphenidate • REM-suppressing drugs • Increase norepi and serotonin • Venlafaxine • Fluoxetine • Tricyclics • Sodium oxybate at bedtime (analog of GHB, GABA analog)

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