Sleep Disorders: A Physician’s Perspective

DR. PETER A. Fotinakes first encountered sleep medicine in 1977 during his first year at UC Irvine Medical School, when his mentor, Dr. Jon Sassin, lectured on a newly described medical condition called sleep apnea. Five sleep apnea patients attended that lecture to discuss how they were “cured” by having a tracheostomy, the only known treatment at the time. Their miraculous response to treatment prompted Dr. Fotinakes to make sleep medicine his life’s commitment. Sleep medicine has evolved since those early days, and today, Dr. Fotinakes serves as the medical director at St. Joseph Hospital Sleep Disorders Center in Orange, Calif., and as a diplomate of the American Board of Neurology.

BSTQ: You’ve described sleep as a “new frontier” in medicine. What do you mean?

Dr. Fotinakes: Until about 50 years ago, most physicians viewed sleep as a period of inactivity with little impact upon general health. With the discovery of narcolepsy, sleep apnea, circadian rhythm disorders and insomnia, we now understand that sleep has a profound impact on life and health. Narcolepsy is now understood to be a neurodegenerative disorder of hypocretin cells in the hypothalamus of the brain that may be related to an autoimmune reaction or exposure to exogenous toxins. Sleep apnea produces nonrestorative sleep and excessive daytime sleepiness and increases the risk of hypertension, cardiovascular disease and cerebrovascular disease. Recent prevalence studies indicate that 26 percent of adults between 30 years and 70 years old require treatment for sleep apnea. We now have better ways of treating circadian rhythm disorders with bright light exposure and wake-promoting medications. Also, the U.S. Food and Drug Administration recently approved a new medication to treat non-24-hour sleep-wake disorder, a circadian rhythm disturbance associated with ocular blindness. William Dement, MD, one of the fathers of sleep medicine, aptly said, “After 50 years of research, as far as I know, the only reason we need to sleep … is because we get sleepy.” There is still much to learn about why we sleep and what sleep does for us and to us.

BSTQ: What are the most common disorders you treat in your clinic?

Dr. Fotinakes: The most common sleep disorder seen in a general clinical practice is insomnia, but the most common sleep disorder seen within a sleep disorders center is sleep apnea. That’s because most insomnia is transient and affects people for such short periods that they don’t rise to the level of a specialty referral. Furthermore, general practitioners often treat these patients with sleeping medications that effectively treat sleeplessness but often lead to problems in chronic insomniacs. Sleep apnea requires specific testing to determine if it rises to the level to require treatment. Treatment often involves nasal continuous positive airway pressure (CPAP), which requires a certain level of expertise to improve and perpetuate compliance.

BSTQ: What are the most prevalent misconceptions about sleep disorders?

Dr. Fotinakes: Patients are often unaware of their sleep disturbance because they are asleep when their symptoms occur. The prevalence of snoring is so high in the general public that it is often viewed more as a humorous nuisance than what it truly is, a symptom of a serious condition. Insomniacs are keenly aware of their condition, because they are awake as they suffer through the night. Many insomniacs seek a quick-fix with a medication, without understanding the underlying problem and how to deal with it without medications. Insomnia is more often a symptom of another problem than a condition unto itself.

BSTQ: When should a patient be referred to a sleep disorders center?

Dr. Fotinakes: Usually this occurs when their sleep disturbance requires specialized testing that is best performed in an accredited sleep disorders center. Accreditation ensures that testing is performed within the guidelines of the American Academy of Sleep Medicine, and patients will receive evaluation by a board-certified sleep specialist and registered sleep technologists. Most people are referred for sleep testing related to the diagnosis of sleep apnea, periodic limb movements and narcolepsy. Primary care physicians also refer insomniacs who fail to improve after six months or have complicating features associated with their sleep disturbance.

BSTQ: What happens during the assessment and diagnosis process?

Dr. Fotinakes: As with most medical conditions, the medical evaluation begins with a history and physical focused upon health issues that impact sleep. Most insomniacs do not require overnight testing in the laboratory and are better served by a clinical evaluation that includes a sleep diary and a medical/ psychological assessment. People with nonrestorative sleep and daytime sleepiness often require overnight testing to screen for conditions such as sleep apnea, periodic limb movements and narcolepsy.

BSTQ: Many patients who present with sleep issues are prescribed medications. What is your opinion on this treatment tactic?

Dr. Fotinakes: Prescription sleeping pills work great, but that’s the problem. They are an easy fix for a complicated condition. More often, chronic insomnia is a symptom of an underlying medical or psychological condition, and it’s better to treat the underlying condition than it is the symptom. Prescription sleeping medication should be reserved for short periods of insomnia. If the sleep disturbance extends beyond four to six weeks, then another mode of treatment should be entertained. Most prescription sleeping medications affect the GABA receptor in the brain, which is the same receptor affected by benzodiazepine medications (Valium-type drugs). As such, even though they have a different chemical structure from benzodiazepines, they share the same potential side effects. These side effects include habituation and tolerance. Very often, insomniacs who take these medications beyond six weeks have developed a tolerance to their effects and experience rebound insomnia from the medication 24 hours after the last dose, which is when they are trying to sleep. They are, in effect, only treating medication withdrawal and not the cause of their insomnia.

BSTQ: Are there any new studies on sleep disorders or treatment options in the pipeline that show promise?

Dr. Fotinakes: The most prevalent focus in sleep medicine has been how to deal with the huge segment of the population that suffers from sleep apnea. In an attempt to reduce costs and streamline care, the industry has developed home sleep studies and automated CPAP units. While it is tempting to sidestep a large segment of the evaluation and treatment, it is difficult to fully eliminate the human element, so the automated systems may not be indicated in 30 percent of treatable sleep apnea patients who may remain undiagnosed or inappropriately treated if insurance companies relegate diagnosis and treatment to a fixed algorithm to cut costs.