The Current State of Sleep Apnea with Rachel Salas, MD

Rachel Salas, MD, Associate Professor of Neurology, Johns Hopkins Medicine

Rachel Salas, MD

Rachel Salas, MD, Associate Professor, Neurology and Nursing at Johns Hopkins Medicine, spoke to NeurologyLive about a number of topics, one of which included further insight on how Salas and her colleagues have been working to address the shortage of sleep specialists. With the shortage, there’s been a push for educating primary care providers, advanced practice providers, medical students, residents as well as other health care team members to ensure there’s a united front when it comes to diagnosing, treating and managing sleep problems.

Additionally, Salas also spoke to the current state of sleep apnea stating that while 80% of individuals meet the diagnostic criteria, they are not diagnosed. Salas stresses that everyone can and should be improving their sleeping habits, whether it’s the sleep environment or getting diagnosed and treatment, people need to know there are treatment strategies available.

NeurologyLive: How are you and your colleagues working to address the shortage of sleep specialists?

Rachel Salas, MD: In terms of sleep broadly, there is more sleep awareness not only from the medical community but from patients and the public. I think people are finally realizing that sleep is obviously important and it’s important not just for health, but our well-being, and it just crosses many boundaries in our health and well-being. With that, there is actually a shortage of sleep specialists and, so one of the goals for me and my colleagues is to really get out there and try to educate our peers, particularly primary care providers, advanced practice providers, and then the trainees coming up not only in medical school and residency programs but also nursing, and other health care team members to really have a united front when it comes to sleep.

One of the studies I often refer to says that the average clinical visit for a primary care provider is about 18 minutes and that study was a few years ago, so it may even be less now, and when primary care providers are busy taking care of acute things or chronic things, like diabetes and blood pressure, things like that regardless if the patient is suffering from sleep disruption or has an undiagnosed, untreated sleep disorder, there’s just not a lot of time in the clinic to get at that, so it often gets unasked and unchecked.

With that we’ve really tried to focus on ways to address the shortage, the need, and also to help our peers in clinics so that they can identify patients that need further evaluation or even therapy, but not take their time from their practice. One of the things that I can say is that we’ve developed kind of a twofer app combination that we’re still piloting with studies and different clinics, but it’s 2 apps and 1 of them is to educate our health care providers and trainees on the common sleep disorders in short lectures and hopefully we can combine it with CME credit, credit we all need to maintain.¹ And then, offer a second clinical tool that potential patients could fill out in the clinic while they’re waiting for blood draws, and while it doesn’t diagnose the patient, it assesses risk factors and symptoms. The app can then alert the provider saying this is someone that has some risk factors, but really no symptoms. What it does is it generates customized reports for patients that can be printed or emailed to the patient saying there’s a concern you have sleep apnea, you have risk factors and there’s some things to look for and this is why it’s important, so we give the patients homework. Then for patients who are more serious where we are like ok this patient has shown risk factors and has been exhibiting symptoms, this is somebody that has to get further evaluated. We kind of help the provider determine who needs to be seen by a sleep specialist, who’s at risk, what are these risk factors, and what can the patient do. We’re really trying to put the patient in a more active role in health.

Can you discuss the current state of sleep apnea?

RS: Sleep apnea is a very common sleep disorder, in fact, 80% of people that actually meet the diagnostic criteria for apnea are not diagnosed, and you could say that’s obviously high, but how does that affect me? In reality, it affects all of us. These people are driving on the road, people with untreated apnea are 5 times more likely to get in a car accident and have microsleeps, and when you’re on the road with them or your family member has sleep apnea that’s not treated there’s a higher risk of heart attacks or strokes. In fact, they’re even putting sleep apnea as a cause of death on death certificates now, so that’s how far we’ve come in terms of apnea. There’s a lot of other risk factors not just for apnea, but several disorders on cognition and not getting good quality sleep. There’re more and more studies coming out showing the relationship with poor sleep, regardless if it’s just because you’re not getting enough or because you have an undiagnosed, untreated sleep disorder, you’re going to have problems with memory and concentration and maybe there’s a higher risk for certain dementia, if that’s already a risk for you. Apnea is pretty straightforward, patients can come in, they can have a sleep study either in the lab, depending on their other medical issues or they even have a home sleep apnea test; we then diagnose patients and there are treatments.

Often times people are not too excited about using CPAP, but the reason we keep using it is because it works, it does what it needs too, and once people get accustomed to it, they really understand why they need it to address their risk for heart attacks, strokes, car accidents, reflux, memory concentration, and so forth. We have pretty good success in our clinic with education and people buying in, but there are other treatment options like an oral dental appliance, surgery is not first line, but sometimes that can be part of a potential treatment strategy, and then there’s obviously behavioral modifications if weight is a big risk factor for some patients then that could be something that could be part of the treatment plan. I think with apnea there’s a good evaluation process, a treatment strategy, and it’s just a matter of getting people in to get evaluated. I think a lot of times not just patients or the public, but also health care providers think of apnea as being a disorder from being overweight, but I can tell you we have people underweight sometimes who have severe sleep apnea. So, while it is a big risk factor it definitely isn’t the only risk factor—part of that message is just to get the word out and really assess. Women tend not to present with horrible snoring and choking and gasping, sometimes they can actually look like they’re just low energy maybe even look a little bit like they’re depressed, and in reality, they have apnea they’re just not aware of it. Studies show that women suffer more from the consequences of sleep apnea, because it takes much longer for them to get identified.

What’s coming for apnea in terms of treatment, there’s people doing research, including at Hopkins, on stimulators, INSPIRE is out there it’s not first line, and CPAP is still the gold standard for people with moderate to severe apnea, but there is work being done in simulators and there are new medications out there. There was a study looking at MS medication and to see how there’s potential there and the small study showed that this medication this pill could be helpful for people with apnea. So, there’s definitely a lot of research going into apnea and maybe in the future there’s going to be some medications that help treat it, but at least right now there are treatments and a lot of people probably need to just get diagnosed.

Have there been any long-term studies conducted on the use of melatonin?

RS: There are some studies out there—we use melatonin not necessarily as a sleeping pill but as a circadian rhythm anchor and I think when used as part of making behavioral modifications, improving our sleep hygiene, I think it can be very helpful. Phyllis Zee, MD, PhD, at Northwestern in Chicago, has done a ton of work in circadian rhythms and so now based on some of the work she’s done when we recommend melatonin we usually tell patients to take it after dinner, because in our society our brains are constantly being stimulated with all the lights. The human brain was never meant to see blue and green lights in the evening and honestly that’s all we see—even when you drive home, the brake lights are even telling your brain it’s time to stay awake. The melatonin we start secreting in the evening is dampened in many of us, and there are some more people that are sensitive to that and this could negatively impact their circadian rhythm and sleep time even though they’re so tired, they can’t go to sleep. Taking melatonin after dinner, which is a lot earlier, can send that message a little louder to the brain, saying hey it’s evening time, bedtime will be coming soon. But that has to be coupled with behavioral changes, like not turning on all your lights, using electronic dimmers, using more lamps in the evening and improving your sleep environment and sleep practices. There’s a bunch of things we can recommend in that realm.

What's the takeaway message?

In conclusion, sleep is important and even if you’re not a patient, any person out there; athletes are turning to improve their sleep, people want to have better vigilance and memory and better concertation. So, I think sleep is something no matter who you are, whether you have other medical issues or sleep disorders, I think sleep is something that we can all do better on and improve, whether it’s the timing, our sleep environment, or getting diagnosed and treated, is really the message to send out there and that it is important and there are things we can look for, and there are options out there for treatment strategies.

Transcript edited for clarity.

REFERENCE

1. Finding Time for Sleep: Identifying Sleep Concerns in Non-Sleep Speciality Clinics Using the MySleepScript App. Doshi A, Gamaldo C, Dziedzic P, et al. Journal of Mobile Technology in Medicine. 2017;6(2):19—26. doi:10.7309/jmtm.6.2.3.