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Adventures in Sleep

Self Medicating
October 6, 2014 12:49 PM by Penny Mehaffey

New research shows alarming but not surprising data that teens the world over self -medicate with over-the counter and prescription drugs. The statistics are:

  • young people age 13 to 18 routinely self-medicate with over-the-counter and prescription medications for various health concerns;
  • 22 percent of U.S. teens indicated that they overmedicated with painkillers; and 
  • around 14 to 28 percent of teens reported that they gave away, loaned or sold their prescription medications. 

The risky practice often continues into adulthood. Teenagers are highly impressionable and affected by their environment. They often have a tendency to adopt the habits of their parents. Peer pressure can also be a big influence. The fact that teens adopt the habits of their parents and peers comes really as no surprise though. 

Parents, whether they realize it or not, have a huge impact on the behavior of their teens. We are constantly under their microscope and they desperately need our guidance.  They need to be shown how to develop good sleep habits and routines, going to bed at a set time & waking at a set time, refraining from electronic devices 30 minutes before bed and developing a relaxing bedtime routine. But they most likely won't do this without parental monitoring and pressure. 

Left to their own devices, teens will stay up all night on the cell phone and sleep with the television playing. They will nap half the day and their circadian rhythm will get disrupted. This is the lament of many a sleep professional.

A study of U.S. teens further found 22 percent overmedicated with painkillers and 14 percent did not inform their parents about their use. The prevalence of self-medication was higher in females in most countries. Around 14 to 28 percent of teens gave away, loaned or sold their prescription medication, particularly pain killers, stimulants and sleep medication.

This is particularly disturbing to me because of the number of teens and young adults we see with daytime sleepiness, ADD & ADHD who are being treated. I know at our facility it is common practice to obtain urine samples for testing to make sure the expected drugs/levels are present. 

It's not hopeless though. Parents must use their influence over their teens for good in this area and be proactive instead of reactive.  The prevalence of self-medication in the studies ranged from 2 percent to 92 percent, with some of the highest use in Germany, the U.S., India, and Kuwait. "The good news is that federal data (from the National Survey on Drug Use and Health) show that initiation of prescription drug abuse is now actually declining among adolescents-even as it continues to grow among older demographics."

For Additional Reading:                                                                                                                                                 

  • Reach the Health Behavior News Service, part of the Center for Advancing Health, at (202) 387-2829, hbns-editor@cfah.org
  • Journal of Adolescent Health: Contact Tor Berg at (415) 502-1373 or tor.berg@ucsf.edu or visit http://www.jahonline.org/
  • Shehnaz SI, Agarwal AK, Khan N. A systematic review of self-medication practices among adolescents. Journal of Adolescent Health. 2014.
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Sleep Improves Learning
September 18, 2014 11:38 AM by Penny Mehaffey

I read with great interest the study results suggesting that sleeping after learning (studying) enhances our memory and ability to recall information. This is good news for students everywhere. The article was released in June by researchers at NYU Langone Medical Center.  The research, done in mice (I'm sorry but I can't help picturing Jerry the mouse sitting in his little mouse hole reading the newspaper), supports the theory that sleep helps consolidate and strengthen new memories and how sleep and learning cause actual physical changes in the brain. Very interesting.      

It seems that sleeping after learning (napping after studying) promotes the growth of tiny protrusions in our brain cells that make connections with other brain cells and helps the information pass across the synapses.  I'm telling you this is so exciting to me.

"We've known for a long time that sleep plays an important role in learning and memory. If you don't sleep well you won't learn well," says senior investigator Wen-Biao Gan, PhD, professor of neuroscience and physiology and a member of the Skirball Institute of Biomolecular Medicine at NYU Langone Medical Center. "But what's the underlying physical mechanism responsible for this phenomenon? Here we've shown how sleep helps neurons form very specific connections on dendritic branches that may facilitate long-term memory. We also show how different types of learning form synapses on different branches of the same neurons, suggesting that learning causes very specific structural changes in the brain."  On the cellular level, sleep is anything but restful: Brain cells that spark as we digest new information during waking hours replay during deep sleep, also known as slow-wave sleep, when brain waves slow down and rapid-eye movement, as well as dreaming, stops. Scientists have long believed that this nocturnal replay helps us form and recall new memories, yet the structural changes underpinning this process have remained poorly understood.

So, how did they do it? To shed light on this process, Gan and colleagues employed mice genetically engineered to express a fluorescent protein in neurons. Using a special laser-scanning microscope that illuminates the glowing fluorescent proteins in the motor cortex, the scientists were then able to track and image the growth of dendritic spines along individual branches of dendrites before and after mice learned to balance on a spin rod. Over time mice learned how to balance on the rod as it gradually spun faster. "It's like learning to ride a bike," says Gan. "Once you learn it, you never forget."

After documenting that mice, in fact, sprout new spines along dendritic branches, within six hours after training on the spinning rod, the researchers set out to understand how sleep would impact this physical growth. They trained two sets of mice: one trained on the spinning rod for an hour and then slept for 7 hours; the second trained for the same period of time on the rod but stayed awake for 7 hours. The scientists found that the sleep-deprived mice experienced significantly less dendritic spine growth than the well-rested mice. Furthermore, they found that the type of task learned determined which dendritic branches spines would grow.

Running forward on the spinning rod, for instance, produced spine growth on different dendritic branches than running backward on the rod, suggesting that learning specific tasks causes specific structural changes in the brain.

"Now we know that when we learn something new, a neuron will grow new connections on a specific branch," says Gan. "Imagine a tree that grows leaves (spines) on one branch but not another branch. When we learn something new, it's like we're sprouting leaves on a specific branch."

Finally, the scientists showed that brain cells in the motor cortex that activate when mice learn a task reactivate during slow-wave deep sleep. Disrupting this process, they found, prevents dendritic spine growth. Their findings offer an important insight into the functional role of neuronal replay-the process by which the sleeping brain rehearses tasks learned during the day-observed in the motor cortex.

"Our data suggest that neuronal reactivation during sleep is quite important for growing specific connections within the motor cortex," Gan adds.   

To reasd about the study see: www.nyulmc.org/,

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COPD in the Sleep Lab
August 28, 2014 10:50 AM by Penny Mehaffey

We had a COPD patient in the lab this week. This is not an unusual occurrence, but it was an exclamation point for me, given that CMS adds COPD to the list of targeted and tracked diseases this October. I thought our patient was a prime example of why COPD is so difficult to treat and why it made the list.

Upon arrival to the lab all was well, but an hour and a half later he begins to complain of SOB; he can get air in but can't move it out well. He said it was painful to breathe and he could take only short breaths. His oxygen saturation remained in the 90s. We did not make it past hook-up. Due to worsening symptoms, we called our RAT (rapid assessment team). He was assessed and taken to the ED for treatment. According to the RAT, the patient was tiring and would have gone into respiratory arrest. Fortunately for us, the MD on call with the RAT was also the patient's pulmonologist.

Interestingly, earlier the sleep tech tried to get the patient to go to the ED but he refused. He did not want to have a blood gas drawn. He thought he would be okay if he rested. Once he was in the ED, he refused the jet neb treatments. This is part of what makes COPD so difficult. These patients are hard to manage and have a host of reasons why not to comply. He was well known to the ED and had multiple admissions. His doctor stated that he really needs CPAP. He was kept in the ED's observation area for about 16 hours and then discharged home with a sleep study rescheduled.

This is a typical scenario that is played out on nursing wards all the time. I see it coming to a sleep lab near you soon, as we take on our roles with the CPAP action plans. I am glad that our tech was alert, diligent and used good assessment skills. I am glad that we had a plan in place and that she followed it. I hope we are ready for October.

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Difficult Patients in the Sleep Lab
August 21, 2014 11:15 AM by Penny Mehaffey

Difficult patients in the sleep lab are no surprise, nor are they a new phenomenon. What is new is the frequency with which they are showing up. Sometimes it feels as if the doctors are in a contest to see who can refer in the most difficult patient. 

I come from a nursing background and so I can usually handle whatever comes through the door but now I am guided by a different set of standards. The safety net is different. For instance, sleep labs traditionally do not deliver bedside nursing care. Patient's requiring this type of care or help must be accompanied by a caregiver during testing. The paradigm we practice under is difficult for those outside of sleep to understand. They think we need a nurse for everything and -- to the other extreme -- that no patient should ever be one-to-one. (What is this selective blindness that some of us in healthcare seem to get when looking at other disciplines? But I digress...) 

My point is that sleep techs will encounter difficult patients and we should be able to complete our testing while ensuring patient safety in our lab. Just this week we had a patient who was the victim of a gunshot wound in the past. She was blind and wheelchair-bound. She had a professional caregiver in the home, plus family, yet no one thought she would need any help during the sleep study or the MSLT.  

I had a hard time convincing them, too. Fortunately, I was successful and she came with her aide. I believe this is the way it is going to be. The patients we see in the lab are going to be the more difficult to care for, sicker patients. We need to keep our skills sharp, be prepared for anything and have a plan for how to care for these people. I have a partner who works with me during the day ... I think we are lucky. 

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Mask Fit Savvy
August 7, 2014 11:56 AM by Penny Mehaffey

I wish, oh how I wish, that my lab dispensed our own CPAP equipment. And not so much the CPAP machines but the masks. We do as much as we can by giving the patient the mask they are titrated with, but that's as far as it goes. Once they leave us, it's out to the big bad world of DMEs. 

Part of the life of a day tech is to perform mask fit clinics; mine are usually the one-to-one basis/trickle-in types. The person who trickled in this morning actually was a VIP who did not have his sleep study with us, but is now seeing our sleep doctor. He was seen by one of the "better" DMEs in town and was told "they could not fit him." I am shocked. He has no facial hair, nothing going on that I could see that would make him hard to fit. He prefers a full-face mask and is compliant. 

I only had to go through two masks; the second one fit most comfortably to him. It was a pretty standard model, one of the two major manufacturers and one of the top full-face models, essentially something that you should find on everyone's shelf. 

It seems as though this scenario occurs more often than it should. Mask fit is the most important component of CPAP therapy. It's the delivery system. It has to work and work well or you have nothing.

Failure is not an option. I for one would prefer to have total control over that part of the process. 

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Ultimate responsibility?
August 1, 2014 8:52 AM by Penny Mehaffey

Problem: A patient was diagnosed with sleep apnea 5 years ago and has been treated with CPAP since. At his office visit this year he complains of poor sleep and a return of symptoms of OSA. He has gained 60 pounds and has other lung problems as well. 

His doctor orders a new sleep study since it's been 5 years. Said sleep study is promptly denied by the strategically aimed, absolute and total no-care comprehensive major government services coverage plan he has. Default request of HST denied promptly as well.  

It seems that all approvals for this scenario hinge on the download data over the last 5 years. No problem, it's a reasonable request. Patient can't locate the smart card, thinks it was lost a while back during home renovations, but, that he has not been using it for a while since "it got mold in it ." Ok, let's check with the DME, who is unable to provide documentation, and says that's most likely because patient did not keep their follow up appointments.

This is a nightmare.  You have a patient who legitimately needs something but can't prove they were ever compliant, an equipment provider who can offer no evidence either way and a hardline payor who absolutely will not approve any testing without the requested information. 

There are missing links here all along the way and it's very difficult for the person stuck in the middle who is trying to obtain what is now needed for the patient.  Did ultimate responsibility lie with the patient?  Were the rules this strict 5 years ago? Did the DME do all they should to follow up? And should it even matter? If you consider just the new symptoms only wouldn't he qualify for at the least an HST? 

Where do you think the ultimate responsibility lies?

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Being a Sleep Educator
July 24, 2014 10:32 AM by Penny Mehaffey

I want to blog today about an experience I had related to sleep in industry. I know it's been done but it is pertinent still. I took the sleep educator workshop at FOCUS this summer and thank God I passed the exam. It was a toughy. Then, as if right on cue, I was contacted by a company in our area asking for me to attend their annual employee health and safety training. I went yesterday to tour the plant and learn about what they actually do and see the work sites of their employees. This was all at the company's invitation. 

I must admit that I am very impressed by this company's approach to sleep-related issues on the job. I will be the only healthcare professional present on training day and focusing just on sleep. Safety is of upmost importance at this plant and they recognize that shift workers face a unique set of problems when it comes to being able to remain alert on the job. I toured the facility giving an eye to the work space and looking for areas where they could make changes that would make staying alert easier? I guess that's how I want to say that. This companys willingness to be proactive represents to me a novel approach. They don't just say they are concerned about safety among shift workers, but they are putting a plan into action. I am so excited to be a part of this process and to have my first official task as a sleep educator lined up. 

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Medical Marijuana
July 17, 2014 11:10 AM by Penny Mehaffey

I am curious about the opinions of my peers regarding medical marijuana. It's a hot topic lately and especially so in my area. Our governor was in for a visit last week to underscore his support of continuing research in the use of marijuana to help treat seizures in children. Our pediatric neurologist is very interested in researching cannabidiol with his severe patients. He has one child who has upwards of 60 seizures a day.  

I live in the Bible Belt and change does not always come easily or quickly here. I am in support of the research. I think the stigma attached to marijuana research is legitimate, but I also believe we shouldn't let that stop us from investigating the benefits to be derived from cannabidiol. 

Marijuana is not the first drug of ill repute to be harnessed for medicinal purposes. I think in this day and age we should be open to finding the facts or seeking the truth about this drug and how we can use it to our patients' benefit. It is, after all, a chemical just as the rest of our medications are.

The potential for, and history of, misuse for this drug is a fact, but that is true in many instances -- consider the myriad of narcotic pain medications we have today. 

There are 20 or so states that have legalized medical marijuana. It has been demonstrated to have medical benefits for AIDS/HIV, Alzheimer's disease, arthritis, asthma  and breathing disorders, Crohn's disease, epilepsy/seizures, glaucoma, hepatitis C, migraines, multiple sclerosis/muscle spasms, nausea/ chemotherapy side effects, pain, psychological conditions and Tourette syndrome. Let's try and think clearly and objectively about this research and not limit it based on the stigma it currently carries.
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Challenged by BRPT Exam
July 10, 2014 11:34 AM by Penny Mehaffey

I mentioned before that I attended the FOCUS spring conference in Florida. My main goal for that event was to attend the sleep educator workshop presented by the BRPT. I must say I thoroughly enjoyed the workshop and I did learn a lot; it was worth every penny spent. 

Now, I am tasked with passing the associated exam. I attempted it a day or so ago and am disappointed to say that I did not pass on my first try. I had heard that this was the case with a lot of students, but you never think it will be you.  Fortunately, the BRPT has extended the deadline for testing and has allowed a third attempt at the exam...

I guess I fell into the trap of thinking that since I've been in sleep long enough, I should know this stuff; I did not expect to have any trouble with the test. I mean, I'm a smart girl. Boy, was that notion a mistake. The exam is very challenging.  And since I am not handling stress very well right now, I wanted to sit down and cry and have a big ol' hissy fit when I saw my score. But I didn't. 

I'm taking a deep breath and planning to retest this weekend. In retrospect it was probably a bad idea to try to do the test while I was at work even though my boss promised not to bother me. Still, I was interrupted about 25 times. That's my fault. I am really glad now for the extra time to test and for the third attempt. Looks like I may need it too. Good luck to everybody taking this exam, and remember, nothing worth having ever really comes easy. 

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Independence Day
July 3, 2014 10:36 AM by Penny Mehaffey

I hope you all have a safe and fun time as our nation celebrates another birthday. I'd like to suggest that we take time to think of freedom as it relates to our health today. We have open access to doctors in our country and readily available medications, equipment and medical supplies. We have volumes of information streaming in from multiple media. We have hospitals, urgent care centers, primary care centers and retail walk-in care centers on almost every corner.

Yet, we don't take care of ourselves. This frustrates me to no end. We have for the most part access to safe places to walk or exercise ... gyms and parks and school playgrounds, church programs and support groups that lag by the wayside. And let's just skip the endless access we have to food.

Are we so rich that we don't see it? Are we so overloaded with information that we are unable to sort through the fodder and pull out what's right for us? What can we do?  I say exercise your independence. You have the right and responsibility to be in charge of your healthcare and your body.

Exercise your rights: exercise and take your medicines every day, check your blood sugar and blood pressure and bombard your physician with those numbers. Dust off that CPAP machine and liberate the treadmill from the pile of clothes that now oppresses it. Put on your tenny shoes (southern speak for sneakers) and take a little walk. Turn off the television and go to bed, you owe it to yourself to get a good night of sleep every night. Encourage your patients to do the same. 

I believe motivation -- or the lack of it -- is the main culprit. And I know it's hard to stay motivated day after day; sometimes it feels almost impossible. But it's worth it.  There's only one you and we have only one shot at this life. Let's do it right!!

Enjoy your Fourth of July and be careful not to get carried away while celebrating.
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Cancer and Sleep Woes
June 26, 2014 10:10 AM by Penny Mehaffey

I was thinking about an article I saw a while back about cancer patients and the sleep disturbances and cognitive loss that they experience. I have read before that CPAP was helping to improve memory and function during the day for some patients. I have a wonderful sister-in-law, who is a breast cancer survivor. I remember talking with her about this very thing when she was going through chemo and radiation. 

She said that at times it felt like her brain was on fire. She was fortunate that she happened to live in a village where there was a major cancer research and treatment center. She received excellent care and it was very inclusive in that they treated mind, body and soul with traditional medicine and holistic therapies. 

Cancer patients have a host of sleep issues, pain, insomnia, anxiety, respiratory disturbances, hot flashes.  The article I read reported that some improvements in response to therapy and alleviation of some symptoms was achieved when CPAP was used. I totally believe this. I am a proponent of CPAP. I love mine and my husband's. I think the majority of us could benefit from a little CPAP. 

I  believe the cancer patients were being treated with behavior modification and sleep aids. But I wonder how they would respond to mild CPAP. I'm thinking about the soothing hum of the device as it gently delivers the low pressure and the rhythmic sound of their breaths as they breathe in and out. CPAP could be incorporated as part of the breathing exercises for relaxation.

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Expanding Sleep Resources
June 19, 2014 10:08 AM by Penny Mehaffey

There are a lot of good resources available to us today that even 10 years ago we did not have.  I encourage you to read the various e-magazines and periodicals and keep up with what's happening in sleep. There is constantly new and exciting research being published and changes going on in government that greatly affect us. 

I have some very saavy people attending our  AWAKE  support group who show up with a lot of good questions and suggestions. I am proud of them for investing in learning about their sleep problems in this way and for bringing what they've learned to the group. (This must be how teachers feel when the light goes on in the student's brain.)  It's a good thing. 

This week of interest to me was an article comparing CPAP to oxygen and CPAP to exercise. The benefits of regular use of CPAP come as no surprise to those of us who work in sleep, but it is nice to see it in black and white and now almost on a daily basis. The report said that in patients with OSA who have a cardiovascular risk, CPAP proved more beneficial than giving oxygen at night. The same held true of CPAP versus exercise. Obese people with elevated CRP levels who wore CPAP at night had results that were similar to a weight-loss intervention in reducing the inflammatory maker -- very interesting.  Check it out on MedPage Today; it's full of research  and continuing education information.

 

 

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Sleep Study 101
May 29, 2014 9:59 AM by Penny Mehaffey

There's a conversation going on in LinkedIn revolving around this question: Does a sleep study require a doctor's order? It's been an interesting feed to follow. You would think that this is a no-brainer, right?  It's a medical test, so it requires a physician's order.

But what's curious to me is why so many people even ask this question. I mean, they don't ask if they need an order for an x-ray  or a lab test, so what's going on here? Is it a lack of understanding about what a sleep study is, fueled by all the media information available? Is it a lack of respect for the discipline of sleep medicine and thinking that "it's just a sleep study, I don't need an order for that"?

Or is it just a simple question. I take several calls a week for this question. My feeling is that people in general have several motivations. I think the biggest is financial. Let's face it, copays aren't what they used to be and if you add up all the required visits that are now associated with having a sleep study, it could be a car payment. 

And that's only for diagnostics; we won't even talk about CPAP. I think the requirements we have to adhere to seem more like barriers to care for the patients. This was my comment to the feed.  All the new requirements imposed on us by all the insurers make us look like part of the problem. I want to be an advocate for my sleep patients, not an obstacle to overcome. 

I confess I feel very frustrated by the current environment in which we must operate and I don't trust insurers to have the best interest of my patients at heart, yet my hands are tied.

What to do?

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Hurray for FOCUS 2014
May 22, 2014 12:32 PM by Penny Mehaffey

Well, we have another FOCUS meeting behind us.  nd what a great meeting it was: action packed, star studded and uber-educational.  Hats off to everyone involved in putting this first-class event together. The meeting was held at the Coronado Springs resort at Disney World, near Orlando, Fla. It's an idyllic setting, as is everything at Disney.

I attended the Sleep Educator workshop and I am very excited about this area of practice. I was encouraged by the talks relating to insurance regulations and projections relating to where sleep is going. It was encouraging to hear positive directions for our field -- not just the usual doom and gloom. 

The CSE is actually a program of and by the BRPT. It and an Asthma Educator workshop occurred the day before the FOCUS conference started. If you have not attended an educational meeting this year, I highly recommend this one as there is typically a meeting in the fall as well.  You can find an organized listing of meetings and conferences right here at ADVANCE  as well as on the BRPT web site. It is money well spent and an investment in your professional self.

 

 

 

 

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Can Ambien Be Linked to Murder?
May 8, 2014 9:42 AM by Penny Mehaffey

I read with some horror an article, Murder: Another Ambien Side Effect?, by John Gever in MedPage Today.

Oh my goodness. I was aware of the bizarre behaviors reported with Ambien use: cooking while sleeping, having sex and not remembering... and driving while asleep. Still, I must admit this article shocked me. 

It also generated a lot of questions, like:  Isn't Ambien supposed to be a short-term drug, meaning you take it for a couple of weeks and then investigate other treatments?  Aren't Ambien users supposed to be followed closely by medical professionals?  If you take a medication differently than how it was prescribed, aren't you asking for trouble? 

And given all the press surrounding Ambien since it hit the market in the 1990s, shouldn't we be better at eliminating those who are not good candidates for this drug?  

I have spoken with people who self-report they have been taking Ambien "for years."  They usually don't report any strange behaviors though, they probably save those for the MD or may not be aware of any. I believe the drug and many drugs can cause us to do and say things we normally would not. Yet I have a hard time leaping to the conclusion that certain actions (murder, automobile accidents, violence) are not one's fault because of it.  And even if you know you are taking a drug that can potentially cause you to drive while asleep, what are you to do? Would placing the car keys in a hard to get to place be enough to prevent a sleeper from driving? 

This was a very interesting article; it also offered CME credit. Take a look, it's a quick read and I would be interested to hear your opinion. Has anyone had any experience with Ambien either personally or through patients, family or friends?

 

 

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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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