Cardinal Sleep Newsletter, Summer 2009

WHAT’S INSIDE: CPAP and Mortality in Stroke Patients with OSA

Cardinal Chirp

Treating sleep loss with good sleep hygiene. Is your patient compliant with their nPAP therapy?

Headlines in Sleep—Recent Research and Discovery At Cardinal Sleep Centers, we take initiative in providing up-to-date information on the science of sleep to physicians of all specialties. The following headlines and latest research conclusions illustrate how sleep disorders may be affecting your patients: Obstructive Sleep Apnea Syndrome Is Associated with Overactive Bladder and Urgency Incontinence in Men “Increasing severity of OSAS appears to be associated with an increasing occurrence of overactive bladder and urgency incontinence in men. This relationship may have clinical implications for the treatment of affected patients.” Kemmer H; Mathes AM; Dilk O; Gröschel A; Grass C; Stöckle M. SLEEP 2009;32(2):271-275. Insomnia with Objective Short Sleep Duration is Associated with a High Risk for Hypertension “Insomnia with short sleep duration is associated with increased risk of hypertension, to a degree comparable to that of other common sleep disorders, e.g., SDB. Objective sleep duration may predict the severity of chronic insomnia a prevalent condition whose medical impact has been apparently underestimated.” Vgontzas AN; Liao D; Bixler EO; Chrousos GP; Vela-Bueno A. SLEEP 2009;32(4):491-497. Sleep Apnea in Early and Advanced Chronic Kidney Disease “This study demonstrated an increased risk of SA in patients with early CKD. Further evidence of a causal relationship should be sought in the hope that the detection and management of SA may improve the course of CKD.” Sim J; Rasgon S; Kujubu D; Kumar V; Liu IL; Shi T; Pham T; Derose S. Chest 2009;135:710-716. Obstructive Sleep Apnea Among Obese Patients With Type 2 Diabetes “Physicians should be particularly cognizant of the likelihood of OSA in obese patients with type 2 diabetes, especially among individuals with higher waist circumference and BMI.” Foster G, Sanders M, Millman R, Zammit G. Diabetes Care, published online May 21, 2009.

, RPSGT Clinical Administrator, Kramer Management Expert Leadership in Patient Care: With over 9 years of experience at Kramer Management, Marsha Cronkrite provides the overall direction of clinical operations at both Cardinal Sleep Disorder Centers and Kramer DME. Cronkrite leads and oversees sleep technologists and sleep equipment and compliance specialists, while herself maintaining certification as a registered polysmomographic technologist.

A Passion for Sleep Medicine: Cronkrite began her career in sleep medicine by working part-time at the scheduling office at Cardinal Sleep Centers. She quickly began educating herself in the science of sleep, and developed a strong interest in sleep and sleep disorders. Within a few months, Cronkrite launched into training as a sleep technologist, and began to recognize many of the symptoms of sleep apnea in a family member who passed away at an early age from a massive heart attack. “I have a strong belief that had my brother been treated for sleep apnea, he might not have died,” says Cronkrite.

Cardinal Sleep Centers and Kramer DME: Cronkrite feels that the quality of the sleep studies provided, and the passion for patient education demonstrated by the staff are what separate Cardinal from competing centers. At Kramer DME, Cronkrite upholds a standard for individualized care that includes a compliance department, with trained specialists proven to improve patient compliance with nPAP treatment to over 85 percent. “I have had patients say that being treated has saved their lives—it is not just whether or not you are tired, it is your overall health and quality of life that is affected by a sleep disorder,” says Cronkrite. “Because I have firsthand proof of the dangers of sleep disorders, it is what drives me.”

What Cardinal patients are saying… “It was my first study and I did not know what to expect. The tech was great. She made me feel relaxed in a stressful situation. She perfectly balanced her professionalism with her human nature. I am very satisfied with the way I was treated.” Go to www.bbb.org/chicago to view Cardinal Sleep Center’s Reliability Report.

— Edward Mitchell, New Lenox

Cardinal Chirp

Summer 2009 Vol. 6 No. 3

From the Medical Director’s Desk: CPAP and Mortality in Stroke Patients with OSA Robert Aronson MD, ABSM Medical Director, Cardinal Sleep Disorder Centers of America Obstructive sleep apnea (OSA) has been shown to be an independent risk factor for cardiovascular events and mortality. For example, long term follow-up from the Wisconsin Cohort study recently showed that subjects with severe OSA vs. no OSA had a roughly 3 fold increased mortality risk, even after accounting for confounding factors. Separating out subjects who had never received CPAP, the mortality risk was roughly 4 fold increased. Furthermore, when looking at specific cardiovascular mortality in untreated subjects, the risk was roughly 5 fold increased. The increased mortality risk was furthermore unaffected by the presence or absence of sleepiness, suggesting that treating asymptomatic severe OSA patients is appropriate to mitigate cardiovascular risk. Studies are emerging examining OSA and specific types of cardiovascular risks. Regarding OSA and stroke, that OSA decreases CNS autoregulation and is associated with swings in intracranial pressure, and intermittent hypoxemia predisposes to endothelial injury, creates biologic plausibility for OSA as a stoke risk. Epidemiologic data confirms that OSA is a specific CVA risk factor. The Wisconsin Cohort Study noted above, looking specifically at stroke, showed over 4 years follow-up an adjusted incident CVA odds ratio of about 3.1 if the AHI is over 20. The Yale Cohort (Yaggi et. al., NEJM 2005;353: 2034-41) prospectively over 3.4 years average follow-up showed a dose response relation between OSA and CVA & death; the odds ratio, adjusted for other stroke risk factors including hypertension, was about 2.0. Now, Martinez-Garcia and colleagues (Am J Respir Crit Care Med Vol 180. pp 36–41, 2009) have just published 5 year follow up of a prospective observational study of patients with ischemic stroke. Sleep studies were performed in 166 patients with ischemic stroke. Those proving to have moderate to severe OSA (AHI >= 20) were offered CPAP. Those patients with moderate to severe OSA who did not use CPAP had a mortality risk 1.6 higher than those with moderate to severe OSA who did use CPAP, and 2.7 higher than those with no OSA or mild OSA. These results suggest that the presence of moderate to severe OSA in patients presenting with ischemic stroke have increased long term mortality, and that CPAP therapy is associated with reduction of such risk. One major challenge in the management is finding measures to facilitate CPAP compliance in stroke patients, which tends to be low (30%). For more information on this article please contact Community Relations at [email protected] or (815) 773-9090 ext. 300. In no way are the suggestions in this newsletter to be taken as medical advice, please seek proper medical attention from a medical professional.

Cardinal Chirp

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Snooze News:

Treating Sleep Loss with Good Sleep Hygiene

One-third of Americans are losing sleep over the economy, according to the National Sleep Foundation. For patients having trouble getting to sleep and staying asleep, Cardinal Sleep experts suggest good sleep hygiene habits: Go to bed at a regular time each night, and get up at the same time every morning. Exercise daily, about 6 hours before bed so your body can cool down and relax before sleep. Avoid naps! Avoid products with caffeine after noontime. Avoid alcohol within 2-4 hours of bedtime. Don’t smoke!! Nicotine is a stimulant. Avoid sleeping pills; sleeping pills can actually relax the body’s muscles too much, making sleep apnea more severe. Do not watch TV in the bedroom.

Write down the things that are bothering you before you go to sleep. You will be less likely to worry about them while you are trying to fall asleep. Make a to-do list of the things that you need to accomplish for the following day. Go for a walk to clear you mind. Avoid stimulating activity or controversy before going to bed. Avoid stress of any kind. If your room seems to be noisy, try using ear plugs. If you have trouble falling asleep with even the slightest bit of light use darkening shades or wear a sleep mask. Do not go to bed until you are sleepy. If you have not fallen asleep within 20 minutes, leave the bedroom and do another quiet activity, such as reading. Soak in a warm bath or shower 15-20 minutes before bed.

Avoid or limit drinking liquids 1 hour before bedtime. Exercise the mind daily by reading the newspaper or mystery novel, do a jigsaw puzzle, or watch the History channel. Avoid stimulating the mind directly before sleep; if you are having trouble falling asleep, try reading the phone book, not something that will interest you. Other treatment options: Cognitive Behavioral Therapy Relaxation Therapy Diagnosis and treatment of an underlying sleep disorder such as sleep-disordered breathing or restless legs syndrome. Treatment of other underlying health problems such as GERD Assessment of current medications that may be interfering with sleep.

What’s New in OSA? Marsha Cronkrite, R. PSG. T. Clinical Administrator Is your Patient Compliant with their nPAP Therapy? Machines are now equipped with technology to record information on patient usage through internal data or a removable card that can be downloaded to a computer. The simple download of this information is an important step in providing your patient with optimal nPAP therapy and comfort. Stored information is designed to detect hours of machine use, mask leaks, and the Apnea Hypopnea Index (AHI is recorded by many modern nPAP machines, but not all). The information acquired from a download can be used as a tool to indicate other factors interfering with optimal therapy and to help develop an individualized treatment plan. A retitration study could be indicated if any change in AHI is displayed by the download. The AHI recorded by the machine is not comparable to the data acquired by a retitration study. Retitration studies are generally suggested if a patient experiences recurring symptoms, such as daytime sleepiness, snoring with the mask on, and/or problems controlling high blood pressure. A change in weight, nasal patency and/or medications could also necessitate a retitration study.

Kramer DME recommends a card download: Within the first 3 months of treatment After 6 months of usage After 1 year of usage Subsequently at the physician’s discretion

The downloads are important in helping the nPAP patient remain compliant with therapy. The patient has a higher chance of continued compliance if problems are detected early, especially during the critical time when they are adjusting to the machine and beginning to feel the benefits of treatment. Cardinal Chirp

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Cardinal Chirp Cardinal Sleep Disorder Centers of America 888-740-5700 www.cardinalsleep.com Newsletter Summer 2009 Vol. 6 No. 3

CPAP/Bi-level Support Group At Silver Cross Hospital in Joliet Specialty Care Pavilion, Room 1005 every fourth Tuesday, 6:30 - 8:00 p.m. At Ottawa Regional Hospital Meeting Rms. 2&3 Every last Monday, 6:30—8:00 p.m.

Community Calendar

July 3—Office Closed for Holiday Weekend

4—Independence Day 27—CPAP/Bi-level Support Group, Ottawa 28—CPAP/Bi-level Support Group, Joliet

August 3 — Joliet Chamber Golf Outing, All-day event 25—CPAP/Bi-level Support Group, Joliet 28—Arthritis Foundation Seminar, Kankakee Community College, 8am—12:30pm 31—CPAP/Bi-level Support Group, Ottawa

September 7—Labor Day 15—Bridge the Gap Seminar, Quality Inn & Suites, Bradley, 9am—3:30pm 15—Business to Business Expo, Tinley Park Convention Center, 8:00am— 4:00pm 22—CPAP/Bi-level Support Group, Joliet 28—CPAP/Bi-level Support Group, Ottawa

For updated Calendar Events visit: www.cardinalsleep.com