The Business of Sleep: Rise of sleep disorders sparks new treatments, technology

Dr. Martha Frankowski in the Munson Sleep Disorders Center.

Dr. Martha Frankowski’s prescription is simple: “Sleep, sex, or sickness,” says the Traverse City physician who is board certified in both neurology and sleep medicine and works at the Munson Sleep Disorders Center. “If you’re not doing one of those things, you don’t belong lying in bed.”

Sleep medicine is on the rise in both the United States and in northwest Michigan. Between 2005 and 2016, the number of American Academy of Sleep Medicine (AASM)-accredited sleep centers almost doubled, growing from 915 to 2,539. According to the Center for Disease Control, almost 40 percent of Michiganders aren’t getting enough sleep. Doctors and sleep technicians at Munson’s Sleep Disorders Center in Traverse City and McLaren Sleep Center in Petoskey are working to lower those numbers for residents of northwest Michigan.

“Our field is relatively young,” said Michelle Davis, the clinical coordinator at the Munson Sleep Disorders Center. In fact, the American Board of Internal Medicine didn’t begin issuing board certifications in sleep medicine until the early eighties. “The growth spurt has been good, but it’s still an under-recognized comorbid condition.”

A comorbid condition is something like type two diabetes or high blood pressure: a condition that comes about as the result of a current condition. Obstructive sleep apnea (OSA) is an extremely common comorbid sleep condition where the airway is obstructed and an individual experiences episodes of not being able to breathe while asleep. While OSA is commonly associated with obesity (a comorbidity of OSA), an individual can be of normal weight and still exhibit symptoms because of their anatomy.

Sleep apnea is not the only chronic sleep disorder. The National Institute of Health reports that about 70 million Americans suffer from sleep problems. Nearly 60 percent have a chronic sleep disorder like restless leg syndrome, narcolepsy or insomnia. Many disorders are undiagnosed. For example, of the estimated 500,000 Americans with narcolepsy, less than 50,000 are diagnosed.

What is the difference between having trouble sleeping and a full-blown sleep disorder? It all comes down to the symptoms. Needing to watch a 30-minute show in bed to wind down before falling asleep isn’t a sleep disorder. Turning off the screen and staring at the ceiling for several hours very well could be.

A few common symptoms for sleep disorders include:

  • Daytime sleepiness
  • Snoring
  • Involuntary leg and arm movements during sleep
  • Unpleasant sensations in the legs
  • Difficulty falling/staying asleep
  • Waking up frequently in the night
  • Choking or gasping sounds
  • Irritability
  • Nocturia (frequent trips to the bathroom in the night)
  • Memory loss

In a culture that glorifies busy, it’s hard to prioritize good sleep, said Dr. Frankowski. “The patient blows off their tiredness because that’s their norm,” she said. “They don’t know what normal is and unless they complain to their primary care doctor, we’re not going to see them.”

In her experience, people with sleep disorders won’t take the time to investigate this potential health risk until something dramatic happens, such as falling asleep at the wheel or in the middle of a meeting at work. “It’s not an old wives’ tale,” she said. “The average adult between 18 and 65 needs seven to nine hours of sleep for healthy sleep, and that’s if we’re sleeping well!”

An increased awareness and focus on sleep medicine has sparked new technology. In 2007, the AASM released its first guidelines on home sleep tests (HST). But it wasn’t until 2015 when they released HST scoring criteria that insurance companies began requiring HSTs as a first line of defense in sleep disorder diagnostics. According to Dr. Frankowski, the HST is now one of the most influential pieces of technology in sleep medicine today. It’s less expensive, more comfortable, and gives the patient a sense of autonomy.

On the flip side, they are less sensitive and produce more frequent false negatives than the in-lab testing. “It’s an evolution,” said Dr. Frankowski of the HST. “Sleep centers are evolving. Insurance requirements are evolving,”

Both Munson and McLaren hospitals say they have felt the effects of the HST. “The home sleep testing was a big change for us,” Davis said.

Munson’s business is now an almost even split. In 2018, they tested 887 patients in the lab and 902 took the home sleep test. McLaren reports that only about 20 percent of their patients take the home sleep test.
“A lot of different variables would come into play the more serious your health issues are,” Davis said.

Generally, a more dire health issue or a large number of comorbidities would indicate that the patient would require an in-lab test, which involves significantly more sensors than the at-home variety.

The overnight lab test involves a lot of wires and sometimes masks. As Davis explains the process, the underlying message is, “I know this won’t be comfortable, but we try.” Patients arrive at quarter to nine in the evening. Technicians place wires all over the body. Fifteen sensors are attached to the head and even more to the rest of the body. Cardiac patches are attached to the legs and sensors are placed in the nose to detect breathing.

Sometimes a mask is worn, depending on the study. An oxygen sensor is clipped to the end of the patient’s finger and a live video feed connects to a long rectangular room where the techs monitor the visual and numerical data. The techs observing brain waves on the monitor are able to monitor sleep and wake patterns.

Davis has worked at the sleep center for 24 years and says she has seen most everything in the realm of sleep disorders. “We’ve had patients who have acted out their dreams in the night with arm movements and leg movements, kicking, running in bed, calling out…” she said.

Sometimes people even try to get up out of bed in an attempt to sleepwalk or sleep eat. The techs are able to interfere before they get very far; the wire leads attached to the patient are only about five feet long and are anchored to larger monitors, hampering a long trip by the patient.

Depending on the severity of the disorder, the next step is to investigate possible lines of treatment. For example, the majority of patients with sleep apnea choose to use a CPAP machine. A small number of patients choose either surgery or to use a mandibular advancement device (pictured left) which is a mold the patient places in their mouth at night like a retainer. It pushes the lower jaw forward and creates more space for the patient to breathe.

There are a few likely reasons behind the increasing number of patients, studies report. Several major studies like the Wisconsin Sleep Cohort Study at the University of Wisconsin-Madison, which is an ongoing examination of the effects of sleep apnea, are bringing focus to sleep disorders. Due to these studies, primary care physicians are more likely to ask the right questions when symptoms linked to sleep disorders arise in their patients. Another prevailing theory is that a ballooning obesity epidemic has caused a drastic increase in OSA sufferers.

“There is a multitude of layers of sleep disorders and how other disorders affect sleep,” said Dr. Frankowski.
Sleep medicine allows doctors to view the body from an all-encompassing and more holistic lens. Sleep drastically affects cardiovascular, neurological and mental health. Problems with sleep only compound other preexisting issues. In fact, Munson Sleep Disorders Center’s Clinical Director, Cindy Nichols, who is board certified in behavioral sleep medicine, is starting to conduct a group therapy session for those who suffer from insomnia.

Chronic sleepiness or wakefulness can mean life or death. AAA reports an annual average of 328,000 car crashes, including 6,400 fatal crashes, due to drowsy driving. Treatment will also lower your risk of developing further comorbidities, says Davis.

“If you catch sleep apnea in its early stages and you treat it, you’re going to live longer,” she said.

Tips for a Healthful Sleep Environment

  1. No vigorous exercise or caffeine for at least six hours before bedtime
  2. Maintain regular bedtime and waking time
  3. Avoid nicotine before bed
  4. Maintain a comfortable bed in a dark quiet room (if not easily attainable, try blackout curtains or an app for white noise)
  5. Use your bedroom only for sleep, sickness and sex
  6. Engage in regular exercise
  7. A light snack may be helpful before bed, but no large meals
  8. Avoid napping during the day as much as possible
  9. Write a to-do list for the next day
  10. Minimize extremes of temperature in the bedroom

Source: American Academy of Sleep Medicine