Newsletters 2008

Special Sleep Issue

Contents
Adolescent Sleep by David Daniel, MD
Sleep Apnea and Cardiovascular Issues by Craig R. Kunz, MD
Women and Sleep by Carolina See, MD
Common Sleep Disturbances in Women by Carolina See, MD
Sleep and Depression by Susan Marney, ARNP 
Welcome New Physicians and Midlevels

Adolescent Sleep
by Dave Daniel, MD, Pulmonary Medicine

In 1997 the National Institutes of Health identified adolescents as a population at high risk for problem sleepiness. Despite this there has been little research into this area when compared to sleep problems in adults.

Poor quality sleep either in terms of length of time or interruptions can have significant consequences.

Adolescents and young adults are four times more likely to be involved in a sleep-related car crash than adults. In fact two-thirds of such accidents occur in teens and young adults. Lack of good sleep can lead to struggles in school and mood or behavior problems.

The first question to ask as a parent is “Is my teen getting enough sleep?” One of the most common problems affecting an adolescent’s sleep is just getting enough sleep. The biologic clock that determines our feeling of sleepiness and wakefulness undergoes changes in adolescence. Many teens don’t feel sleepy until 11 pm or later. However, if they aren’t falling asleep until 2 or 3 in the morning, they may have a problem with sleep cycles. Teens frequently need at least eight hours of sleep, so if they are going to sleep late their brain may not be ready to wake up 8 a.m. or later.

Another problem causing teens to have trouble falling asleep can be ‘electronic.’ Televisions, computers and cell phones in your teen’s bedroom can be a problem if left on. While your teen may not be texting or emailing or instant messaging, one of their friends may be a night owl who tries to communicate late at night.

If your teenager is getting enough sleep, but is still having problems staying awake during school or in the evening, the problem may be disrupted sleep. Problems such as sleep apnea (characterized by loud snoring and changes in breathing patterns) and restless leg syndrome (characterized by a need to move your legs to relieve uncomfortable sensations in the legs) can decrease how much time your teen is actually sleeping.

Unfortunately getting up and going to school is seldom a spontaneous or voluntary event in the life of a teenager and lack of sleep makes it worse.

Here are four questions you and your teen can discuss to see if they have a sleep problem:

• 1. Do you fall asleep in school frequently?
  2. Do you feel wide awake all day long at school?
  3. Do you fall asleep at home in the evening doing schoolwork?
  4. Do you feel sleepy riding in a car or bus?

If your teen is having trouble staying awake during the day and it is affecting their driving or schoolwork or attitudes, then a discussion with your pediatrician or family practitioner may be in order.

Sleep Apnea and Cardiovascular Issues
By Craig R. Kunz, M.D., Pulmonary Medicine

Could you be sleeping your heart to death? Obstructive sleep apnea (OSA) is a very common sleep disorder that not only has debilitating effects on sleep, but it is also detrimental to overall health and quality of life. Data show that obstructive sleep apnea affects approximately 15 to 20 million Americans, and a majority of individuals suffering from the disorder remain undiagnosed and untreated. But if my initial question is not enough to grab your attention, then the untimely and tragic death at the age of 43 of National Football League legend Reggie White in 2004 can serve as a warning of the grave consequences of untreated sleep apnea, which is reported to have contributed in part to Mr. White’s death.

Obstructive sleep apnea consists of repeated episodes of partial or complete upper airway obstruction in sleep, due to relaxation of the muscles that support the upper airway. These episodes of obstruction are associated with repeated arousals from sleep (of which the sleeper is typically unaware) and declines in blood oxygen levels. The pauses in breathing are brief and usually last 10 to 30 seconds; an individual can cease breathing hundreds of times in one night. Obstructive sleep apnea is most easily recognized by cardinal symptoms of loud snoring and daytime sleepiness, manifest primarily by drowsiness and involuntary dozing in sedentary situations. This disorder is also predicted by an individual’s body mass index and neck size. In addition to the potentially devastating effects on daytime alertness, mood, memory and performance, obstructive sleep apnea is associated with cardiovascular complications.

When a person stops their breathing, they no longer exchange the oxygen with carbon dioxide. A 10 to 20 second pause can cause significant drops in oxygen levels and rises in carbon dioxide levels. These repetitive oscillations in blood gas levels of oxygen and carbon dioxide can lead to changes in heart rate and blood pressure. Sometimes these changes can be dramatic with the post-apnea systolic blood pressure reaching 300 mmHg in patients who have normal blood pressures during the day. Combining the increased strain on the heart and thereby increasing the oxygen demand of the heart muscle itself, with the loss of oxygen supply from breath holding, you have a recipe for potentially serious cardiovascular problems.

There is increasing evidence supporting the link between untreated obstructive sleep apnea and cardiovascular mortality. In one study following patients with OSA for 3 years, researchers found that they were twice as likely to have a stroke or death from any cause even when confounding variables like smoking status, age, weight, and presence or absence of diabetes, hypertension, and high cholesterol were factored out. Another study over 10 years, patients with untreated severe obstructive sleep apnea had 2.8 times increased risk of fatal and non-fatal cardiovascular events compared to those with untreated milder sleep apnea, simple snorers, OSA patients treated with CPAP (continuous positive airway pressure), or healthy people. Other studies have demonstrated an increased risk of angina, myocardial infarction, and stroke in patients with OSA. The disorder has also been associated with heart rhythm problems. In one study, the incidence of cardiac arrhythmias including atrial fibrillation and sudden cardiac asystole were significantly higher.

Obstructive sleep apnea can affect many chronic conditions that can increase your risk of cardiovascular problems. Studies have shown that patients with OSA had significantly higher blood pressures than patients without the disorder, both during wakefulness and sleep. Trials examining the impact of treatment with CPAP or surgery have demonstrated improvements in blood pressure control. There is growing evidence for the association with OSA to disturbances in metabolic pathways affecting insulin resistance, worsening diabetes mellitus control and impaired cholesterol management. Obstructive sleep apnea may also be associated with abnormalities in metabolism that could predispose to weight gain. Leptin is a fat-cell derived hormone regulating body weight through appetite control and calorie burning. Some studies have shown that there are increased levels of leptin in patients with OSA and the leptin levels reduced with CPAP therapy.

So if making your sleep and heart healthier are not sufficient motivators to being evaluated for sleep apnea, then helping you shed a few extra pounds could be reason enough.

Women and Sleep
By Carolina See, MD, Pulmonary Medicine

Sleep is not merely a “time out” from our busy routines. A full night's rest is as vital to good health as eating or breathing. Although most people need 7 to 9 hours of sleep each night to function well the next day, the National Sleep Foundation 1998 Women and Sleep Poll found that the average woman aged 30-60 sleeps only 6 hours and 41 minutes during the workweek. Many of these women have to juggle the various demands of motherhood, work, marriage, and social relationships, limiting their time for sleep. For some, the bedroom becomes an "invisible workplace" where they stay on constant call.

As many as 30 million people are subject to sleep-related problems. Most of those complaints are from women. Yet many women may not understand the seriousness of perpetual tiredness. Every biological function unique to women including menstruation, pregnancy and menopause frequently disrupts a woman’s road to Dreamland. The changing levels of hormones that a woman experiences throughout the month and over her lifetime, like estrogen and progesterone, including oral contraceptive use and hormone replacement therapy, have impact on sleep. Sleep complaints across the menstrual cycle often occur in tandem with pre-menstrual exacerbations of migraine, epilepsy, asthma, mood disorders, and other illnesses. An estimated 1 in 4 pregnant women develops restless legs syndrome, chiefly in the second and third trimester. In pregnancy, low back pain, fetal movement, and frequent urination also frequently trigger sleep disturbance.
Understanding the effects of these hormones, environmental factors and lifestyle habits can help women enjoy a good night’s sleep.

Common Sleep Disturbances in Women

1. Insomnia is the most common sleep problem among women. A more recent 2005 National Sleep Foundation Sleep in America poll of all adults revealed that women are 50% more likely than men to suffer from insomnia (difficulty falling and staying asleep) and to experience more daytime sleepiness at least a few nights/days a week. They begin to have sleepless nights associated with menstruation, pregnancy or menopause and find it difficult to break poor sleep habits. Nocturnal hot flashes, mood disorders, and sleep apnea may also contribute to insomnia during the menopause and postmenopausal years.

2. Obstructive sleep apnea is another serious sleep disorder that is characterized by snoring, interrupted breathing during sleep and excessive daytime sleepiness. While apnea is more common in men, it increases in women after age 50. Some risk factors identified in menopausal women included overweight and obesity, increase in abdominal fat during menopause, as well as hormonal changes with decrease in progesterone.
Obstructive sleep apnea is associated with high blood pressure, a risk for cardiovascular disease and stroke. But a number of effective treatment approaches are available.

3. Restless Leg Syndrome is a neurological movement disorder that affects as many as 10% of adult Americans. As much as 18% of the female adult population reported RLS symptoms a few nights a week or more. Its symptoms are characterized by an irresistible urge to move the arms or legs, precipitated by rest and relieved by movement. Due to difficulties sleeping, restless leg syndrome can lead to daytime sleepiness, mood swings, anxiety and depression. One study found that 42% of those with restless leg syndrome stated that it affected their relationship with their partner.
The exact cause for restless leg syndrome still eludes us but recent research indicates that iron deficiency may be a risk factor. Treatment may include iron or vitamin supplements, lifestyle changes and medications.

4. Narcolepsy is a chronic neurological disorder that affects approximately 1 in 2000 people. Symptoms frequently appear during teen years and may go undiagnosed for many years. In addition to excessive daytime sleepiness, people with narcolepsy have sudden "sleep attacks" (an over-whelming urge to sleep), suddenly lose muscle tone or strength (cataplexy) and may have disturbed sleep at night. Recent research has led to new understanding of the cause of this condition and new treatments have given doctors more ways to help manage its symptoms.

5. Nocturnal Sleep-Related Eating Disorder – This is an uncommon condition where people eat food during the night while they appear asleep. They typically do not have any recollection of the above episodes. One study indicates that over 66 percent of sufferers are women. This disorder can occur during sleepwalking. It can be caused by medications (e.g. some drugs prescribed for depression or insomnia) or by sleep disorders (e.g. sleep apnea, restless legs syndrome) that cause awakenings and trigger sleep eating.

Sleep and Depression
By Susan Marney, ARNP, Behavioral Medicine

Depression is a mood disorder that creates a feeling of being sad and hopeless. People who are depressed experience no joy and have very little energy. Depression makes people anxious and worried and can make it hard to concentrate. Sometimes people with depression do not want to live.

People who are depressed almost always have trouble sleeping. Eighty per cent of people with depression cannot sleep well. In fact, insomnia is one of the main signs of depression. Not sleeping well won’t cause depression but can certainly make it worse. Not being able to sleep for a long period of time can be an important clue that someone may be depressed.

Sometimes people with depression will sleep too much and may spend a lot of time in bed. Even with extra sleep these people will have low energy and never feel rested. Most of the time people with depression can’t fall asleep when they go to bed. Instead they lie in bed and their worried thoughts go round and round in their head. This makes them feel worse and makes it harder to sleep. It takes longer to fall asleep and people with depression sleep fewer hours. They often have little or no deep sleep and they will dream earlier in the night than usual. They also wake up during the night more frequently.

Sleep is the time when the brain recharges. Continuing to sleep poorly often makes depression worse over time. It is very important for people with depression to get help for their sleep. Depression will not get better unless sleep also gets better.

There are several actions to take to help sleep improve for people with depression.

• Create a routine with your sleep times - get up and go to bed at the same time each day.
• Don’t sleep during the day.
• Get exercise every day but don’t exercise 2 hours before bed.
• Make sure your bedroom is cool and dark.
• Get out in the daylight every day.
• Reduce caffeine.
• Avoid alcohol.
• Avoid stressful activities in the evening.
• Avoid heavy evening meals.

Taking care of your sleep will help your mood and help to heal depression. If needed, your health care practitioner can prescribe a short-term sleep medication for you. If you are feeling depressed and are not sleeping it is important to make an appointment to talk about these things. With a little work and some help you can feel better and sleep better too.

Welcome New Physicians and Midlevels

Edwin B. Carmack, MD
Hospitalist

Wenatchee Valley Medical Center

Edwin B. Carmack, MD attended the University of Washington, graduating cum laude with a Bachelor of Science in Chemical Engineering, a Master of Science in Engineering, Bioengineering, He earned his Doctor of Medicine from the University of Washington Medical School.

Dr. Carmack completed his Internal Medicine internship and residency at Scripps Mercy Hospital in San Diego and worked as a Hospitalist at St. Mary’s Hospital and Medical Center in Grand Junction, Colorado prior to coming to Wenatchee. He is board-certified in Internal Medicine.

His wife, Lara Hays, is a molecular biologist and they have a three year old son Nathan. Besides spending time with his family Dr. Carmack enjoys mountain biking, skiing and hiking.

John S. Mitchell, MD
Internal Medicine
Wenatchee Valley Medical Center

John S. Mitchell, MD graduated magna cum laude from the University of Missouri-Rolla with a B.S. degree in Chemistry, and completed three years of graduate work in Biochemistry. He earned his Medical Degree with honors from St. Louis University School of Medicine, where he was a member of alpha omega alpha, the medical honorary. H completed his internship in Internal Medicine at St. John’s Mercy Medical Center and his Internal Medicine residency at Washington University, both in St. Louis, Missouri. Prior to joining us in Wenatchee, he practiced medicine in New Hampshire. Dr. Mitchell is board-certified in Internal Medicine.

He and his wife Randy enjoy hiking, biking and golf.

Sarah Page, MD
Physical Medicine and Rehabilitation
Wenatchee Valley Medical Center

Sarah Page, MD, earned a BA in Comparative Religion from Oberlin College in Oberlin, Ohio, and her Doctor of Medicine at the University of California, San Francisco. She completed her Internal Medicine residency at the University of Maryland in Baltimore. Dr. Page’s Physical Medicine and Rehabilitation residency was at Johns Hopkins School of Medicine in Baltimore. Her clinical interests include sports medicine, spasticity, gait disorders, and stroke and spinal cord injuries.

Dr. Page plays the fiddle and is learning to play the banjo. She’s interested in finding other old-time musicians in the area. She enjoys hiking, bike-riding, and took up cross-country skiing this winter. She is especially looking forward to spending time with her nieces and nephews, which was one of the things that prompted her to return to Washington to practice medicine.

Priscilla DeGraff, ARNP
Anticoagulation
North Valley Family Medicine

Nurse Practitioner Priscilla DeGraff earned her Bachelor of Science in Nursing from Washington State University, Pullman, where she graduated summa cum laude. She graduated from the University of Washington Seattle, with a Master of Nursing.

Priscilla and husband, Michael recently moved to Tonasket from Las Cruces, New Mexico where Priscilla was a nurse practitioner in Family Medicine at the Rio Grande Medical Group. Priscilla and Michael have three grown children. Priscilla enjoys gardening, bicycling, and watercolor painting.

Deborah A. Fisher, PA-C
Occupational Medicine
Omak Clinic

Deborah A. Fisher, PA-C (Certified Physician Assistant) earned a Bachelor of Science in Nursing from Washington State University, Pullman, and a Master in Physician Assistant Studies from the University of North Dakota, Grand Forks, North Dakota.

Deborah’s nursing experience includes long term and transitional care, inpatient oncology and surgery, emergency room, and labor and delivery. She served as camp nurse for many years at Camp IV - a camp for children and families living with hemophilia and bleeding disorders. She taught parents to start IV’s so they could treat their children at home and spend less time in the hospital and doctor’s office. Two of her own sons have severe hemophilia.

Deborah and her husband Clint, a counselor, enjoy gardening, raising chickens and horses, along with hiking, skiing, and reading. They have four grown sons, one 2-year-old grandson, four dogs and one cat.

Jonathan P. Henke, MPH, PA-C
Orthopedics
Moses Lake Clinic

Jonathan Henke, MPH, PA-C, graduated from Lawrence University in Wisconsin with a BA in Biology, then served two years as a Peace Corps volunteer in the Republic of Fiji. He taught school in El Paso, Texas before going to graduate school at the UCLA School of Medicine in Los Angeles where he completed a Master of Public Health (MPH). He earned his certification in Physician Assistant studies Oregon Health and Sciences University School of Medicine in Portland. For the past six years he has worked as a Physician Assistant in Neurosurgery and Orthopedic practices in Las Vegas.

Jonathan and his wife Karen have a two-year-old daughter, Meghan. His outside interests include horseback riding, swimming, and scuba diving.

Gregory McDonough, PA-C
Orthopedics
Wenatchee Valley Medical Center

Gregory McDonough, PA-C (Certified Physician Assistant) earned his Master of Science degree at DeSales University in Center Valley, Pennsylvania and his Master of Science in Health Administration Services from St. Mary’s College of California in Moraga, California. He also earned a Bachelor of Science degree in Physiology from the University of California, Davis.

Prior to pursuing a career as a Physician Assistant, Greg worked as the Western Regional Director of an organization providing donor and recovery services to over 60 hospitals in the Northern California and Northern Nevada. Greg is also a co-trustee for the Gertrude Stewart Charitable Trust, a non-profit organization that seeks to improve the quality of life of mentally disabled men and women.

Greg’s clinical interests include sports medicine, fractures, general orthopedics and surgery.

He and wife, Holly, have two daughters, Melissa and Paige. Greg enjoys hiking, biking, running, snowboarding and playing the guitar.

Christine Quinn, FNP-C
Hospitalist
Wenatchee Valley Medical Center

Christine earned her Bachelor of Science in Nursing at Creighton University in Omaha, Nebraska, a Master of Science in Exercise Science at the University of Utah, and a Master of Science, Family Nurse Practitioner at the University of New Mexico, where she was named outstanding Graduate Student by Sigma Theta Tau, the international honor society of nursing.

Christine has extensive experience as a certified nurse practitioner ranging from solo frontier primary care in Alaska to collaborative practice in acute care emergency, radiology and trauma services. She has also worked as a staff nurse in hospital critical care areas, including adult medical and surgical intensive care and emergency department at a Level I trauma center.