The Sleep Disorders Toolkit

While the pathophysiology of idiopathic hypersomnia is unknown, emerging science suggests that nighttime sleep dysfunction may contribute to daytime sleepiness in patients with idiopathic hypersomnia. A systematic review and meta-analysis that included 10 studies found that, on average, several sleep architecture hallmarks were different in patients with idiopathic hypersomnia relative to controls.

• Total sleep time and percent of REM sleep were increased in patients with idiopathic hypersomnia compared with controls.
• Sleep-onset latency and percent of slow-wave sleep were decreased in patients with idiopathic hypersomnia compared with controls.
• Sleep efficiency and REM latency were similar between patients with IH and controls.

In addition to nighttime sleep dysfunction, other physiological changes have been observed in some patients with idiopathic hypersomnia and theorized as possible contributors to its pathophysiology including:

• Dysfunction of the GABAergic system
• Autonomic system dysfunction
• Altered functional or regional connectivity in the brain
• Circadian system dysfunction
• Dysfunction of energy metabolism

This episode is produced by Sleep Review and is episode 5 of a 5-part series sponsored by Jazz Pharmaceuticals. Visit Jazzpharma.com and SleepCountsHCP.com for more information. In episode 5, listen as Sleep Review’s Sree Roy and neurologist-sleep specialist Isabelle Arnulf, MD, PhD, discuss:

• Science doesn’t fully understand the pathophysiology of idiopathic hypersomnia. Research has revealed potential clues, however. For example, idiopathic hypersomnia is associated with changes in sleep staging and architecture. What does emerging science suggest are differences in nighttime sleep?
• How might the arousal index differ in idiopathic hypersomnia versus in people without it, and why might that matter?
• In addition to nighttime sleep dysfunction, other physiological changes have been observed in some patients with idiopathic hypersomnia and theorized as possible contributors to its pathophysiology. What is the GABAergic system and its possible role?
• What are some emerging findings surrounding idiopathic hypersomnia and autonomic system dysfunction?
• What is the evidence that supports the idea of altered functional or regional connectivity in the brain in people with idiopathic hypersomnia?
• There were fascinating studies done on skin fibroblasts, suggesting that circadian period length may be different in people with idiopathic hypersomnia versus in people without it. What role might circadian rhythm dysfunction have in idiopathic hypersomnia?
• What has science discovered about the possible role of dysfunction of energy metabolism in idiopathic hypersomnia?
• What further research would you like to see conducted on the pathophysiology of idiopathic hypersomnia?

Listen to Episode 1: Symptoms of Idiopathic Hypersomnia

Listen to Episode 2: Diagnosis of Idiopathic Hypersomnia

Listen to Episode 3: Differential Diagnosis of Idiopathic Hypersomnia

Listen to Episode 4: Burden of Idiopathic Hypersomnia

People with idiopathic hypersomnia face a significant disease burden. Idiopathic hypersomnia is associated with challenges that impact daily living activities, such as limitations at school, work, interpersonal relationships, and social activities. Various impairments include 

• • Impacts on attention and cognition, which can be characterized as “brain fog”
  • The burden of memory problems and a feeling of the mind going blank or making a mistake in a habitual activity

Public health and safety are also impacted, as more severe causes of sleepiness can be cause for accidents. Management strategies may not address the underlying sleep dysfunction associated, resulting in suboptimal symptom management. Patient survey and registry data suggest patients continue to experience symptoms of idiopathic hypersomnia and residual disease burden. This episode is produced by Sleep Review and is episode 4 of a 5-part series sponsored by Jazz Pharmaceuticals. Visit Jazzpharma.com and SleepCountsHCP.com for more information. In episode 4, listen as Sleep Review’s Sree Roy and pulmonologist-sleep specialist Richard K. Bogan, MD, discuss: 

• • What are some limits that people with idiopathic hypersomnia can experience in their daily living activities?
  • How do people with idiopathic hypersomnia commonly describe "brain fog," and what are some of the real-life consequences it?
  • How does prolonged sleep inertia place a burden on the people with idiopathic hypersomnia who experience this symptom?
  • What do you see as the burden of idiopathic hypersomnia on public health and safety?
  • Beyond medications, how is idiopathic hypersomnia typically managed to control for symptoms as much as possible?
  • How do you determine when therapy for idiopathic hypersomnia has been optimized, and what symptoms may remain at this point?

This episode also provides valuable advice for sleep techs dealing with patients wanting to use mouth tape during in-lab sleep studies. DeNike underlines the importance of ensuring patients have a healthy nasal passageway and clarifies the role of mouth tape as a supportive accessory, not a standalone treatment. This episode is sure to provide you with a deeper understanding of mouth taping during sleep, armed with expert advice and valuable insights, whether you're a sleep professional or someone simply interested in optimizing your sleep health. In this episode, we answer the questions:

• What exactly is mouth taping during sleep?
• How has the practice of mouth taping during sleep evolved in popularity over the years?
• Is there any evidence that mouth taping is useful for healthy sleepers, that is, people without any sleep disorders?
• Is there any evidence that mouth taping is useful for people with any sleep disorders, perhaps as an add-on to a device such as an oral appliance for sleep apnea?
• What dangers are associated with mouth taping during sleep?
• What is your advice to sleep techs for how to handle the situation of an in-lab sleep study patient who wants to use mouth taping during an in-lab sleep study?
• What is your evidence to sleep medicine professionals if their patients confide in them that they using mouth tape, either with or without their prescribed device, to treat a sleep disorder?

The differential diagnosis of idiopathic hypersomnia is challenging for several reasons. Its hallmark symptom, excessive daytime sleepiness, is a common symptom of many disorders, and ts ancillary symptoms also overlap with other disorders. A lack of validated biomarkers adds to the challenge. Assessing for key symptoms and medical history is a first step to help identify patients presenting with excessive daytime sleepiness who may have idiopathic hypersomnia. From there, there are several symptoms that can differentiate the diagnosis of idiopathic hypersomnia from other disorders such as sleep apnea or narcolepsy. These include:

• • Sleep inertia: sleep inertia is common in patients with idiopathic hypersomnia but can also be reported by individuals with mood disorders
  • Patients with idiopathic hypersomnia often find naps to be long and unrefreshing, while patients with narcolepsy generally find short naps to be restorative
  • If a patient has prolonged nighttime sleep, long sleeper syndrome should be considered; in contrast to patients with idiopathic hypersomnia, long sleepers feel refreshed and do not have daytime sleepiness and difficulty awakening if they are allowed to sleep as long as they need
  • Cognitive complaints, often described as "brain fog" are common symptoms of idiopathic hypersomnia but also can occur in patients with various sleep-wake disorders (including narcolepsy type 1 and insufficient sleep syndrome)

This episode is produced by Sleep Review and is episode 3 of a 5-part series sponsored by Jazz Pharmaceuticals. Visit Jazzpharma.com and SleepCountsHCP.com for more information. In episode 3, listen as Sleep Review’s Sree Roy and neurologist-sleep specialist Yves Dauvilliers, MD, PhD, discuss:

• • Idiopathic hypersomnia can be particularly challenging to diagnose because of its lack of specific biomarkers, as well as its symptoms resembling those of other disorders. How do you differentiate idiopathic hypersomnia from hypersomnias of a specific cause, such as narcolepsy type 1 and type 2, insufficient sleep syndrome, or hypersomnia due to a neurodegenerative disease?
  • A minority of people simply need to sleep longer than most, even 10 hours or more, to feel refreshed. How do you determine if that applies to a given person, who may not have a sleep disorder at all?
  • How do you differentiate idiopathic hypersomnia from hypersomnia comorbid to psychiatric disorders, such as prolonged sleep time tied to depression?
  • At what point in ruling out other disorders should objective sleep testing, such as polysomnography and multiple sleep latency testing, be done?
  • Why is idiopathic hypersomnia sometimes confused with sleep-breathing disorders? When would you recommend a CPAP trial to address possible apneas, hypopneas, or respiratory-event related arousals?
  • How do you distinguish chronic fatigue syndrome from idiopathic hypersomnia?

Listen to Episode 1: Symptoms of Idiopathic Hypersomnia Listen to Episode 2: Diagnosis of Idiopathic Hypersomnia

Sleep specialist Indira Gurubhagavatula, MD, MPH, is our guest and chair of the Count on Sleep Tool Development and Surveillance Workgroup for The Obstructive Sleep Apnea: Indicator Report, which provides an in-depth analysis of the symptoms, risk factors, prevalence, and burden of obstructive sleep apnea and serves as a resource for both the public and the health care communities on the importance of diagnosis and long-term treatment. Gurubhagavatula and Sleep Review editor Sree Roy discuss the hidden risks of obstructive sleep apnea—the mortality and morbidity that makes obstructive sleep apnea (OSA, for short) particularly insidious. We discuss obstructive sleep apnea’s links to vehicle crashes, treatment-resistant hypertension, impaired brain function, erectile dysfunction and female sexual dysfunction, type 2 diabetes, and early death. We also discuss treatments for obstructive sleep apnea and how healthcare providers can screen patients to intervene early for patients at risk of obstructive sleep apnea. Specifically, this episode about the hidden risks of obstructive sleep apnea provides answers to: 

• What is obstructive sleep apnea, also known as OSA for short?
• What do you think is the most troubling risk of not treating obstructive sleep apnea?
• How has treatment-resistant hypertension been linked to OSA?
• How can the impaired brain function linked to OSA manifest in patients?
• What evidence is out there that erectile dysfunction and female sexual dysfunction can be tied to OSA?
• How has obstructive sleep apnea been linked to diabetes?
• The worst link in my view is that obstructive sleep apnea has been linked to an earlier death. Why is that?
• Treatment of sleep apnea typically involves a device, such as a CPAP machine or an oral appliance, though surgery can be an option for some patients. Is there any evidence that treating OSA can alleviate some of sleep apnea morbidities or mortality?
• With all of this evidence in mind, what should healthcare providers do to help identify patients who are likely to have obstructive sleep apnea?
• What should any patients listening to this podcast do if they think they have symptoms of obstructive sleep apnea?

The International Classification of Sleep Disorders, 3rd ed, lists the criteria needed for a diagnosis idiopathic hypersomnia.

For a diagnosis of idiopathic hypersomnia, the following must be met:
o excessive daytime sleepiness daily for at least 3 months
o cataplexy is not present
o multiple sleep latency test (MSLT) shows <2 or no sleep-onset REM periods (SOREMPs) if the rapid eye movement (REM) latency on the preceding polysomnogram (PSG) was ≤15 minutes
o insufficient sleep syndrome is ruled out

And at least one of the following:
o MSLT shows a mean sleep latency of ≤8 minutes
o Total 24-hour sleep time is ≥660 minutes (typically 12-14 hours) on 24-hour PSG monitoring (performed after correction of chronic sleep deprivation), or by wrist actigraphy in association with a sleep log (averaged over at least 7 days with unrestricted sleep)
o Hypersomnolence and/or MSLT findings are not better explained by another sleep disorder, other medical or psychiatric disorders, or use of drugs or medication

Additional supportive features can include:
o Severe and prolonged sleep inertia
o High sleep efficiency (>90%)
o Long, unrefreshing naps (>1 hour)

This episode is produced by Sleep Review. It is episode 2 of a 5-part series sponsored by Jazz Pharmaceuticals. Visit Jazzpharma.com and SleepCountsHCP.com for more information.

In episode 2, listen as Sleep Review’s Sree Roy and neurologist-sleep specialist Margaret S. Blattner, MD, PhD discuss:
o What are some barriers to diagnosing idiopathic hypersomnia?
o Objective sleep testing is needed to diagnosis idiopathic hypersomnia. What polysomnography and multiple sleep latency test findings support a diagnosis of idiopathic hypersomnia?
o What are some best practices for conducting a PSG and MSLT for a patient with suspected idiopathic hypersomnia?
o What are some of the additional commonly seen supportive features of idiopathic hypersomnia?

Excessive daytime sleepiness is an essential feature of idiopathic hypersomnia, but other key symptoms and aspects of the medical history are crucial when evaluating patients who present with excessive daytime sleepiness. Patients with idiopathic hypersomnia commonly report the following symptoms in addition to excessive daytime sleepiness: severe and prolonged sleep inertia, long and unrefreshing naps, prolonged sleep time, and cognitive dysfunction.

Knowing the key symptoms and utilizing sleep testing can increase a healthcare professional’s confidence in his/her diagnosis of idiopathic hypersomnia.
The Idiopathic Hypersomnia Severity Scale is a 14-item questionnaire that is a clinical tool designed specifically to measure patients’ idiopathic hypersomnia symptoms and provide a touchpoint that might be useful for patient identification, follow-up visits, and idiopathic hypersomnia management.

This episode is produced by Sleep Review. It is episode 1 of a 5-part series sponsored by Jazz Pharmaceuticals. Visit Jazzpharma.com and SleepCountsHCP.com for more information.

In episode 1, listen as Sleep Review’s Sree Roy and sleep specialist Logan Schneider, MD, discuss:

• The symptom of idiopathic hypersomnia that people are most familiar with is excessive daytime sleepiness. Will you define and briefly explain this core symptom?
• But excessive daytime sleepiness is not the only symptom typically reported by people with idiopathic hypersomnia. Prolonged sleep time is another common symptom. What can this mean over the course of a 24-hour day?
• Sleep inertia, that feeling of difficulty waking up, can happen to all of us. How can sleep inertia differ in people with idiopathic hypersomnia versus in those without it?
• Are naps generally restorative for people with idiopathic hypersomnia? Does length matter?
• What ancillary cognitive symptoms are commonly reported with idiopathic hypersomnia?
• In 2019, the Idiopathic Hypersomnia Severity Scale was developed to measure the severity, frequency, and functional impact of the key symptoms of excessive daytime sleepiness, prolonged nighttime sleep, and sleep inertia. What do you think is the clinical utility of this questionnaire?

To dive even deeper:

• https://sleepreviewmag.com/sleep-disorders/hypersomnias/idiopathic-hypersomnia
• Trotti LM. Idiopathic hypersomnia. Sleep Med Clin. 2017;12(3):331-44.
• Dauvilliers Y. Idiopathic hypersomnia severity scale. 2018.
• Arnulf I, Leu-Semenescu S, Dodet P. Precision medicine for idiopathic hypersomnia. Sleep Med Clin. 2019;14(3):333-50.
• Vernet C, Leu-Semenescu S, Buzare MA, Arnulf I. Subjective symptoms in idiopathic hypersomnia: beyond excessive sleepiness. J Sleep Res. 2010;19(4):525-34.
• Dauvilliers Y, Evangelista E, Barateau L, et al. Measurement of symptoms in idiopathic hypersomnia: The Idiopathic Hypersomnia Severity Scale. Neurology. 2019;92(15):e1754-62.
• Rassu AL, Evangelista E, Barateau L, et al. Idiopathic Hypersomnia Severity Scale to better quantify symptoms severity and their consequences in idiopathic hypersomnia. J Clin Sleep Med. 2022;18(2):617-29.

Join Sleep Review’s Sree Roy in conversation with sleep expert Russell P. Rosenberg, PhD, and primary care physician Paul Doghramji, MD, FAAFP about managing insomnia in primary care. They share insights from an expert consensus group and answer the questions:

• What are the challenges that prevent insomnia from being diagnosed in the primary care setting?
• Can you provide practical advice on how to fit in insomnia screening and diagnosis into primary care settings?
• In what circumstances should primary care physicians refer patients to sleep specialists?
• What are best practices for CBT-I in primary care settings?
• Why is trazodone so frequently prescribed and is it a good choice for insomnia patients?
• What is novel about dual orexin receptor antagonists?

For more information on insomnia in primary care, visit:

• A 2023 Update on Managing Insomnia in Primary Care: Insights From an Expert Consensus Group
• https://sleepreviewmag.com/insomnia/
• https://www.thensf.org/do-i-have-insomnia/

A large proportion of mental health professionals misunderstand the nature of sleep problems in mental health patients, according to sleep specialist Barry Krakow, MD, who has worked in the field of sleep research and clinical sleep medicine for more than 30 years. Such professionals view sleep issues as a symptom of mental health disorders, rather than as a distinct disorder that needs to be addressed.

Healthcare professionals fail to understand that treating sleep problems can help to alleviate mental health issues.

The sleep medicine community itself also struggles with how to serve the mental health community. Many sleep centers are still discounting or ignoring the significance of upper airway resistance syndrome (UARS). According to Krakow, many sleep doctors are uncomfortable treating patients with mental health conditions, such as PTSD, depression, or anxiety, and will refer them to therapists or psychiatrists rather than addressing their sleep problems. This lack of understanding and training in the connection between sleep disorders and mental health leads to patients not receiving proper treatment and being left with the impression that sleep medicine cannot help them. Sleep medicine needs to recognize that insomnia and sleep-disordered breathing are prevalent in this population and that effective treatments, such as advanced PAP machines, are available.

With regard to bureaucracy surrounding treating mental health patients, Krakow advises that sleep centers can implement efficiencies using modern technology, and offer reimbursable services, such as PAP Naps, to assist with the business aspects.

Krakow's new book Life Saving Sleep: New Horizons in Mental Health Treatment explores the link between sleep and mental health, and how the quality of sleep is often overlooked in mental health treatment. Mental health patients with sleep complaints are typically prescribed medication to help them sleep, without addressing the quality of their sleep. Many patients are unable to describe the quality of their sleep beyond the number of hours they sleep each night.

For further information:

https://barrykrakowmd.com/ https://www.lifesavingsleep.com/ https://fastasleep.substack.com/

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For #sleepawarenessweek (March 12-18, 2023), Sleep Review is joined by sleep psychologist Jade Wu, PhD, DBSM. She is the author of Hello Sleep: The Science and Art of Overcoming Insomnia Without Medications. She is also a Mattress Firm Sleep Advisor. Sleep Review’s Sree Roy and Dr. Wu discuss common #sleep myths including:

-What is the most damaging sleep myth you have heard?
-What is one sleep myth that you previously believed, but was disproven over your career?
-Have you seen other sleep physicians perpetuate certain sleep myths?
-Do those who move around in their sleep get worse rest?
-Does the brain truly “shut off” when we go to sleep?
-Do dreams only occur during REM sleep?
-Do scents, such as lavender essential oil in a diffuser, benefit sleep in any way?
-Do eye masks and/or earplugs benefit sleep?
-Is over-the-counter melatonin a good place to start if you’re having sleep problems?

Dr. Wu recommends the following resources for further information:American Academy of Sleep Medicine:
https://sleepeducation.org/sleep-disorders/obstructive-sleep-apnea/

Society of Behavioral Sleep Medicine:
https://sleepeducation.org/sleep-disorders/obstructive-sleep-apnea/

Hypersomnia Foundationhttps://www.hypersomniafoundation.org/

Pediatric Sleep Councilwww.babysleep.com

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