Diagnostic & Treatment Challenges in the

Adolescent Patient:

Sleep….. Why Bother?

Helene A. Emsellem, MD

November 6, 2015

MoKan 2015 Sleep Conference

Objectives• Brief overview of sleep & sleep needs• What makes adolescent sleep special

– sleep requirements– circadian delay

• Adolescent consequences of insufficient sleep

• Treatment & coping strategies• Politics of school start times• Sleep & the college student/ post-grads• Identifying sleep disorders in teens

Sleep is mandatory… eventually

SURVIVAL: water, food, air & SLEEP

What is sleep & what does it do?

• Restores us physically• Resets us

psychologically• We learn during sleep• We grow during sleep• Caloric management is

sleep dependent

Sleep? .... What happens when we don’t get enough?

• Impaired cognitive function– difficulty with FOCUS, ATTENTION &

CONCENTRATION– irritability– impaired memory– Impaired inhibitory control– subjective sleepiness

- prolonged auditory reaction time- prolonged visual reaction time

Impaired motor function

– Prolonged motor reaction time

– Tremor – Poor coordination– Blurred vision

Crashes• Drowsiness or fatigue

is a factor in at least 72,000 crashes each year, killing more than 830 and injuring many others, (NHTSA, 2009).

• Young drivers age 25 or under are involved in more than one-half of fall-asleep crashes.

Teen driving risks related to:

• Inexperience• Risk taking – limit testing• Maturational changes increasing sleep

needs• Changes in sleep patterns reducing

nocturnal sleep time & circadian disruption• Homework demands, part-time jobs,

extracurricular activities, late night socializing– Brightest and hardest working teens at highest

risk ( M. Carskadon 1990)

School Start Times & MVAs

• A 1 hour delay in school start times in 1 large county in Kentucky resulted in a 16.5% drop in crash rates for teen drivers over 2 years

• During the same time, the state teen crash rate increased 7.8%

• There was a significant increase in the percentage of students that got at least 8 hours of sleep each night (from 35.7% to 50.0%)

Danner, F. & Phillips, B. (2008) Adolescent Sleep, School Start Times and Teen Motor Vehicle Crashes. Journal of Clinical Sleep. 4(6): 533-535.

Social Implications of Insufficient Sleep

• Poor school performance• Reduced school “engagement”• Difficulty with interpersonal relationships• Crashes • Impaired judgment• Risk taking behaviors - Substance abuse:

alcohol, nicotine, stimulants• Poor sports performance• Lack of creativity & humor

Medical Implications:Impaired: immune function → infections

(acne) weight control → obesity BP control → hypertension blood sugar control → diabetes mood → depression

HEADACHES

REM Pressure →

Micro sleeps intruding into the day → Impaired learning!

Sleep & Metabolism

Purpose of fat: energy storage for survival ~ insulation

Prolonged wakefulness

in primitive days

meant DANGER

The longer I’m awake the more calories I burn…. Right?

• Prolonged wakefulness →

– Impaired cellular LEPTIN metabolism – appetite (via Ghrelin) Weight gain

Obesity: 20.5% teens (2011-2012, CDC)

linked to: insufficient sleep

24/7 society

Overlapping Symptoms: Sleepiness & ADHD

• Sleepy children more likely to manifest sleepiness as hyperactivity

• Sleepy teens --- just look sleepy• Cardinal symptoms overlap:

– Difficulty with:• FOCUS• ATTENTION• CONCENTRATION

• Cannot diagnose ADD when sleepy!

Use of stimulants in sleepy teens misdiagnosed with

ADD/ADHD:

Prolonged wakefulness →Increasing sleep restriction →Increasing irritability &

exhaustion →Worsening school performance

Sleep RequirementsAges 5 – 12: 10-11 hrsTeenagers: 9.25 hrs! (8.5-9.5)Adults: 7-9 hrs

What is sleep?

Synaptic Homeostasis Hypothesis:During the day we are building connections ---strengthening synapses

At night we downscale ---restore synaptic homeostasis

---enhance learning

“Sleep is the price we pay for plasticity”

G. Tononi & C. Cirelli, Sleep Medicine Reviews, Vol. 10, no 1:49-62, 2006

Glial Washing

• Glial supportive cells in the brain• Form the GLYMPHATIC system• Enhanced removal of toxic waste

– Including amyloid proteins assoc with Alzheimer’s

• During slow wave sleep

REM Sleep• Dreaming• No memories of the dream

process formed• Cognitive cortex off line• Muscle paralysis (atonia)• REM bursts

• LEARNING

Positive effect of sleep on learning does not occur if sleep restricted!!!!

Matt Walker, personal communication.

Brain Plasticity associated with Learning during Sleep

How does your brain know

when to turn sleep on?• How many hours you’ve been awake: (Process S)

• Day – night cycle (Process C)

• Body temperature• Circadian rhythm of hormones• Genetics (HLA D1)– are you a night

owl?

•Habit

Entrainment of Sleep Behaviors

• Regulated bed time

• Bedtime routine• Controlled

environment• Positive

reinforcement

Loss of Environmental Sleep Cues

Adolescence

Process S – Building sleep debt

TEENS

Later onset of alertness

Slower build-up of sleepiness

Longer internal day

(>24 hours)Emsellem & Whitely, Joseph Henry Press

Homeostatic sleep drive

6 pm midnight 6 am 6 pmnoon

Normal sleep phase

10 pm - 7am

Process S (Homeostatic sleep drive)

* Brain thinks forward calculates bedtime from time you wake up + 15-16 hours, then makes you sleepy again

Process C: clock dependent alertness

Emsellem & Whitely, Joseph Henry Press

Suppression of perception of sleepiness during the day

Retino-hypothalamic Pathway

• Documented in rat• Receptor = retinal

ganglion cells• Secretes melatonin• Connects to

Suprachiasmatic nucleus

• Aligns brain clock to day-night cycle

• (Process C = clock dependent alertness)

CLOCK BIOLOGY

Controllable variables: sleep habits

“Light is a DRUG that promotes WAKEFULNESS”

Charles A. Czeisler, PhD, MD Director of Sleep Medicine Harvard Medical School

Dim Light Melatonin Onset

4-6 hours before bedtime melatonin

secretion begins and gradually suppresses the

SCN and clock dependent alertness

allowing us to manifest our sleep debt and fall

asleep

Changes in Sleep with Adolescence Coincide with

Tanner Stages & Progress thru Puberty

Longer internal clock time (24.3 hrs)

Slower accumulation of sleepiness during the day later bedtime & wake-up time

Reduced potency of light as a sleep-wake cue in the morning

Emsellem & Whitely, Joseph Henry Press

6 pm6 am

6 pmnoon

Normal sleep phase

Delayed sleep phase

10 pm – 7 am

12 am – 9 am

Net result: can’t fall asleep on time have to get up too early insufficient sleep

Evils of Puberty: Predominant Process S

Delayed Sleep Phase of Adolescence

Mammalian models

of adolescent phase delay

Why is This Such a Big Issue in 2015?

• Early school start times

• 24-7 “Lit” Society (electronics in bedroom)

• AP Classes & college stress

Late Bedtime

LessSleep

WeekendSleep-in

Tired duringschool week

TeenWorld

Adolescent Vicious Cycle

Consequence of Weekend Sleep-ins

6 pm6 am

6 pmnoon

IDEAL sleep time

Weekend catch up sleep

Brain thinks forward calculates bedtime from time you wake up + 15-16 hours,

then makes you sleepy again

Late sleep-ins reset the circadian clock LATER

Teen Coping Strategies:

Education: understand forces at play

Control your surroundings: Reduce late-night exposure to

•Light -(orange lens sun glasses)•Sound•Food

Limit caffeine & chocolate intake

Be organized• Don’t leave homework for late at night

– Or the last minute

• Lay out clothes the night before• Make a “to-do” list & structure after school

time• Keep a diary or journal to clear your head• Charge phone in the kitchen

• Establish a REGULAR sleep-wake schedule

• Make the bedroom a comfortable, calm place• Have an internet & cell phone sign-off time• Do some yoga / relaxation exercise• Move the TV out of the bedroom• Don’t go to bed hungry

• If sleep doesn’t happen then stay in a “sleep conducive” position in bed with lights out and listen to music/book – set a 15 minute sleep timer

• Keep a sleep log and confess your sleep schedule!

(www.snoozeorlose.com)

Evening Routine

Reinforce your own sleep scheduleset a reasonable lights out time

limit late weekend sleep-ins arise by 9 AM on weekends

Controlled nappingshort nap after school (20-30 min)

weekend mid-afternoon longer nap

Enhance Morning Wakefulness

with

• LIGHT, FOOD, Exercise

Daily Exercise enhances sleep

2014 NSF Sleep in America Poll

Sleep in the Modern Family• Teens don’t meet minimum sleep

requirements• Electronics in the bedroom less sleep• Parents’ poor sleep habits kids’ poor

sleep habits– 26% of parents text during the night

• 45% school aged kids have TV in bedroom• Kids who drink caffeine sleep less• More rules = more sleep

– Older kids less rules

PARENTS

Set a GOOD EXAMPLE

Treatment Intervention

Melatonin 200 micrograms at 5 PM to simulate dim light melatonin onset

? ChronotherapyLight therapy

Light visor – 10,000 lux of lightWeekday morningsAt necessary wake up timeLight may make things worse if

used incorrectly!

Effect of AM Light on Sleep Phase

6 pm midnight 6 am 6 pmnoon 3 AM – 11 AM

11 PM – 7 AM

Core body temp minimum

Light BEFORE Core Body Temperature Minimum will

aggravate phase delay

Why not use hypnotics to force sleep at the correct

time?

It doesn’t work!

Must try to initiate sleep within the patient’s circadian “window of

opportunity” for sleep

It is critical to “move” the window

Advocate for CHANGE

• Educate teens and parents• Incorporate sleep education

into health curricula• National Sleep Foundation

School Start Time initiative toolkit

• Politic your school system

Relationships between hours of sleep & health-risk

behaviors in US adolescent students

• 70% of HS students do not get recommended hours of sleep

• Insufficient sleep in teens associated with:– Physical fighting -- Not exercising– Cigarette use -- Feeling sad or

hopeless– Marijuana use -- Seriously considering– Sexual activity suicide

Recommendation of CDC

“Public health intervention is greatly needed, and the consideration of delayed school start times may hold promise as one effective step in a comprehensive approach to address this problem.”

McKnight-Eily LR, et al "Relationships between hours of sleep and health-risk behaviors in US adolescent students" Prev Med 2011;

DOI:10.1016/j.ymed.2011.06.020.

Sleep on Campus

• Split sleep schedule• Delayed sleep phase syndrome

6 pm midnight6 am

6 pmnoon

Normal sleep phase

Delayed sleep phaseDelayed sleep phase

11pm-7am

3am-11am

Reinforced by late weekend sleep-ins

Flexibility to nap – better coping

Sleep Disorders in Teens

• Obstructive sleep apnea• Narcolepsy• Restless Legs Syndrome• Parasomnias• Insomnia

Sleepy Teens Differential Dx

Insufficient sleepMedication side effects

Medical disorders

Narcolepsy & primary disorders of alertness

Obstructive sleep apnea

RLS/PLSM

Depression

Substance Abuse

NARCOLEPSY• Peak age of onset teens thru

20s• Pentad of symptoms

– Sleepiness– Hypnogogic hallucinations– Sleep Paralysis– Cataplexy– Fragmented nighttime sleep

• Must be well-rested for valid diagnostic testing

Same

patient

@ age

16 & 17

8/11/2014Poly TST 380 minutes

8/12/2014MSLT Sleep Latency REM Latency

7:59 1 1.5 2.59:46 2 17 18.5

12:05 3 6.5 71:46 4 5 24.5

Mean Sleep Latency 7.5Mean REM Latency 13.1Naps with REM 4

8/16/2015Poly TST 472 minutes

8/17/2015MSLT Sleep Latency REM Latency

10:06 1 20 N/A12:00 2 15.35 N/A

2:05 3 9.5 N/A4:04 4 20 N/A6:03 5 20 N/A

Mean Sleep Latency 17Mean REM Latency N/ANaps with REM 0

Sleep & Mood Disorders

risk of mood disorder in sleep deprived teens

• Mood disorder may disturb sleep onset/maintenance

• Precipitation of RLS/PLMS by SSRIs• Sleepiness as medication

complication frequency of Delayed phase with

Bipolar disorder

Sleep Apnea in Teens

RISK FACTORS• Overweight / obesity• Tonsil/adenoid enlargement• Retrognathia• Prader Willi syndrome• Neuromuscular diseases• + Family history

Sleep Apnea in Teens

SYMPTOMS• +/- snoring• Restless sleep• Daytime sleepiness• ADD / ADHD• Depression

EVALUATION• Overnight sleep study (not portable)

End tidal CO2 & special scoring rules

Sleep Apnea in Teens

TREATMENT• Weight loss• Tonsillectomy • CPAP

• ? Mandibular appliance• ? Mandibular advancement

surgery• ? Apnicure WINX system

Parasomnias

• Night terrors• Sleep talking• Sleep walking

• Decreased frequency with age

• Recur with stress• Familial predisposition

Differential diagnosis: seizures

BRUXISM

• May be sufficiently severe to:– Disturb sleep– Cause tooth wear

• Increased frequency with:– Apnea– Medication induced

May require RX

Restless Leg Syndrome

• Familial occurrence• Childhood/teen onset in some• Check iron levels• Remove offending drugs

Sleep is as important to health as diet & exercise

The National Sleep Foundation