Sleep DownUnder 2018 – meeting highlights
Highlights from the Sleep Down Under 2018 meeting in Brisbane. Topics highlighted are narcolepsy, insomnia, sleep health, obstructive sleep apnea and the effects of caffeine on sleep.
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00:00 – 01:30 Caffeine and sleep
- 01:30 – 03:26 Narcolepsy
- 03:26 – 06:29 Insomnia
- 06:29 – 08:39 Sleep health
- 08:39 – 10:12 Obstructive sleep apnea
- 10:12 – 11:02 Subscribe to Sleep Talk podcast and attend Sleep DownUnder 2019
Links mentioned in the podcast:
- Sleep DownUnder meeting – Brisbane October 2018
- Recent paper on T-cells in narcolepsy
- CBTi Coach
- Shuti program
- Using polysomnographic measures to physiologically phenotype obstructive sleep apnea
- Sleep Talk podcast on iTunes
- Sleep Talk app on iOS
- Sleep DownUnder 2019, Oct 17-19 Sydney
Dr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is certified as both an International Sleep Medicine Specialist and International Behavioural Sleep Medicine Specialist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep. David is a regular media commentator on sleep, both in traditional media and social media. David’s recent research has been in the area of non-drug, psychologically-based treatments such as cognitive behavioral therapy and mindfulness in managing insomnia, restless legs syndrome and other sleep disorders.
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Hi I’m David Cunnington a specialist sleep physician and I hope you enjoy these highlights from the Sleep DownUnder 2018 meeting in Brisbane.
The first topic that opened the meeting was caffeine. Caffeine is the most widely used socially acceptable stimulant in modern societies and data was presented that Australians average between 100 and 200 milligrams per day which is equivalent of one to two espresso shots per day of caffeine. The question was does that actually help in reducing the sleepiness associated with sleep loss as we maintain sustained wakefulness. From this adenosine increases and caffeine acts as an adenosine antagonist which can mitigate the cognitive performance impairment that is seen due to sleep loss. Now that’s been shown in a number of acute sleep deprivation experiments where particularly on night one if people take doses of caffeine and varying doses that performance lapses or the ability to maintain vigilance those effects can largely be mitigated by caffeine. But then on the second night of total sleep deprivation those effects are still there. Then people begin to become impaired. There was some talk about whether caffeine can be used for shift workers or people that need to maintain sustained operations. Again the data suggested that on night one of using caffeine you can maintain performance moving on to other things.
Ron Grunstein presented a great breakfast session on contemporary management of narcolepsy. A couple of points for me from that breakfast session was that although narcolepsy is often described as a rare disorder and in fact there was a poster at the meeting describing it as a rare neurological disorder, in fact it’s actually not that rare. Between 1 in 2000 and 1 in 3000 individuals which makes it the fourth most common neurodegenerative disorder behind only multiple sclerosis, Parkinson’s and Alzheimer’s disease. Of all these conditions it’s the one with the most localized and specific defect. So not as rare as sometimes we make out. Ron highlighted a recent paper that’s important in how narcolepsy with cataplexy may develop as part of an auto-immune response. A lovely paper published by Latorre in Nature showing that people with narcolepsy have unusually high levels of T cells directed towards hypocretin / orexin, supporting the notion that narcolepsy with cataplexy is an autoimmune disorder mediated by auto immune destruction of orexin producing nerve cells. In terms of treatment for narcolepsy some of the new things that are on the horizon is solreamfitol and the phase 3 clinical trial results were presented to the Sleep 2018 meeting back in June showing improved maintenance of wakefulness test and reduction in the Epworth sleep in a score of 4.5 points. This is a similar magnitude to what seen with either modafinil or dexamfetamine. Ron also talked about a clinical trial that’s about to start in Australia of a once nightly formulation of sodium oxybate which would be a step forward for patients with narcolepsy both as it would mean people don’t need to take a second dose during the night. Also if we have data showing effectiveness in a phase three clinical trial in testing in Australia, this data could be used as part of an application to our TGA for it to become a registered product.
I had the pleasure of being involved in a symposium on insomnia where Nathaniel Marshall outlined how insomnia has been managed by the health care system in Australia over the last 15 years and over time it has been reasonably stable. At one point five percent of General Practice encounters have been for insomnia. There was a slight drop in around 2007 with some of the controversy around Stilnox and that also changed drug utilization with a reduction in the use of Stilnox or zolpidem. Around the same time melatonin became available on the Australian market so its utilization has gradually increased as has use of quetiapine an atypical antipsychotic. However the proportion of people on these medications is still quite small with around 50 percent of people in Australia treated with medications for insomnia taking temazepam. Interestingly this is completely different from any other country and really looks to be a function of our reimbursement. As part of that same symposium, Professor Sean Drummond from Monash University talked about how we should be using cognitive behavioural therapy for insomnia and his three key points were that cognitive behavioural therapy should be individualized. It’s important to incorporate particular components depending upon the precipitating and perpetuating factors in a given individual. The second point was that adherence to treatment is really the key. We know that cognitive behavioural therapy is an effective strategy and we know that medications can work for insomnia but we also know is that continuing through treatment particularly with cognitive and behavioral therapy takes a lot of work. There’s a high drop out rate unless people are motivated so we need to look at factors that might increase adherence. Sean’s group has been doing some research at having partners involved in cognitive behavioural therapy with part of the thinking behind this being that it will increase adherence. Sean’s third point was that digital forms of cognitive behavioural therapy are really expanding and these can be therapist supported apps such as CBT-I coach or a fully automated CBT programs such as Sleepio or Shuti. Whilst these automated programs have been shown to be effective in randomized clinical trials the data that we’re really interested in for these resources is adherence and attrition. So in the real world outside of a clinical trial setting how many people that actually start this type of program continue with it and get right through to the end. Janet Chung from University of Sydney also spoke as part of a panel discussion in that same symposium on her research as a pharmacist looking at people’s preferences in how they access treatment for insomnia and the very useful advice that she gave is when managing people with insomnia, think about why did they come and see you at this particular point in time. Understanding what’s important to the patient and their illness narrative will help with customizing a treatment approach for them which in turn will help with adherence. This was really reinforcing one of Sean Drummonds points about the importance of individualizing therapy for insomnia.
There were a number of sessions on sleep health and really great to see quality of research being done in Australia in this area. Amy Reynolds from the Appleton institute looked at what predicted whether people seek help from health care providers for their sleep problems. She found there were two main criteria. One was meeting the formal diagnostic criteria for insomnia. Think of that as sleep problems being sufficiently severe that they’re happening regularly for three months or more and impacting on day time functioning. The second predictor was overall poor health. Think of that as being someone with a number of co-morbidities, potentially on a range of other medications. Those two factors alone accounted for 44 to 58 percent of the variance in predicting whether people would seek help from a healthcare provider for their sleep problems. Surprisingly other factors like age and education status really didn’t impact.
Moira, my cohost on SleepTalk podcast organised a debate on the topic of are we really sleeping less today than we used to? Whilst the debate was highly entertaining it actually did a great job of summarizing the data in this area. One side argued that when you systematically review the data there really isn’t evidence to support the notion that we’re sleeping any less but that’s hampered by lack of adequate records that at most go back 100 years and are hampered by the fact that these estimates of sleep are self reported. Human beings are notoriously bad at estimating exactly how much sleep they’re getting. The group arguing that we are sleeping less, rather than necessarily having data to support this notion, pointed to evidence of increased sleepiness in the community and data showing that in pre-industrial societies still that don’t have access to electricity sleep is longer than in modern societies where electricity is freely accessible. I think this is an area that will continue to be debated but it does show that it’s not as clear cut as what we often hear in the media that we have a sleep loss epidemic. There is no doubt that people are feeling sleepier than they have done and report that in high proportions, but the question of whether that’s due to lack of minutes of sleep is something that’s still unclear.
The last subject I wanted to cover is obstructive sleep apnea. Like in insomnia there was a focus on individualizing treatment for sleep apnea and in particular using a number of assessment strategies to look at the physiological characteristics of a given individual’s causes for sleep apnea and then using that to target treatment. A beautiful summary of that was delivered by Professor David White from Harvard University who really has done a lot of this work with Australian researchers working with him to develop techniques to identify characteristics that contribute to sleep apnea, such as upper airway anatomy, muscle collapsibility, arousal threshold and loop gain. After a number of years of research, this is really now coming into the practical realm and a great paper by Scott Sands was discussed that was published this year outlining how with a good nasal pressure signal on polysomnography you can actually get a good estimate of these variables and physiologically phenotype given individuals obstructive sleep apnea. That can give then an idea about prediction of response to non-CPAP treatments such as surgery or oral appliances. Where work is going at the moment potentially the role of medications to increase muscle activity during sleep. David White also presented some interesting preliminary data on a combination of atomoxetine and oxybutinin. He is entering into phase 2 dose finding studies at the moment. He’s confident that in the next couple of years using these techniques together with medications and anatomical approaches most patients with sleep apnea will be able to be treated with a non-CPAP approach.
I’d hope you enjoyed this summary of the Sleep DownUnder 2018 meeting from Brisbane. Subscribe to our full length monthly podcast that I cohost with Dr Moira Junge. It’s available in iTunes, SleepTalk by SleepHub, or the iOS app in the iTunes store. Plan to attend next year Sleep DownUnder meeting in 2019 which will be in October in Sydney. See you there.