"Sleep Disorders in the Military; PTSD and OSA" Jacob F Collen (01.27.2021)

February 08, 2021

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00:00Few brief announcements.
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00:44So this afternoon I have the pleasure
00:47of introducing Doctor Jacob Colin.
00:49Doctor Colin is a Pro is program
00:51director for the Sleep Medicine
00:53Fellowship at the Walter Reed
00:55National Military Medical Center in
00:57Bethesda and completed his medical
00:59degree from the Uniformed Services
01:01University Anas pulmonary critical
01:02Care and Sleep Medicine Fellowships.
01:04At Walter Reed.
01:06His areas of research interest include
01:09the relationship between sleep
01:11disordered breathing and PTSD sleep,
01:13disordered breathing, and CPAP adherence.
01:15An respiratory symptoms and disorders
01:18that are related to deployment.
01:20He's an active clinical educator
01:22for trainees at all levels.
01:24He spoken widely on and published
01:27widely as well on various topics
01:30across Sleep Medicine,
01:31ranging from emerging sleep
01:33technologies to sleep disordered
01:35breathing to forensic Sleep Medicine.
01:38He serves as associate editor for the
01:40Journal of Clinical Sleep Medicine.
01:42Ann is on the editorial board for
01:45Behavioral Sleep Medicine this past year.
01:47In 2020,
01:48he was honored with a distinguished
01:50Chest Educator Award,
01:51and he's also received the Stuart
01:54Quan Award for Editorial Excellence
01:56from the JC SM.
01:58And so it's a real pleasure to have
02:00Doctor Colin here to share his
02:02expertise about the unique aspects
02:03of managing sleep disordered sleep
02:05disorders in military and veteran
02:08populations. With us this afternoon.
02:10And with that, I'll turn it over to him.
02:13Thanks again for joining us, Jacob.
02:16Thanks for having me Lauren.
02:17I've been looking forward to
02:19speaking with all of you and.
02:22And it's a complicated topic,
02:24but hopefully I can shed some
02:25light on kind of the different
02:27sleep disorders and sleep issues
02:29that we encounter in the military,
02:31and I think their relevance to
02:33everybody because I'm as these
02:35folks filter out of the military
02:37and they separate from service.
02:39They'll be treated not only at the
02:41through the Veterans Administration,
02:43their Veterans Affairs hospitals,
02:44but also in private practice and kind of
02:47in multiple different healthcare settings.
02:48So it's important that sleep physicians
02:51know about this population in general.
02:55So here's some of the details for the CME.
02:57I have no disclosures.
03:00And my objectives to really understand the
03:02culture of sleep deprivation in the military,
03:05and there's certainly we're learning more
03:07and more about understanding the culture
03:09of sleep deprivation in society at large.
03:12And there are some interesting
03:13differences that come up with the
03:15history of sleep deprivation in the
03:17military and the complicated relationship
03:19between sleep and combat operations,
03:22and how this then leads into the sleep
03:25disorders that we see in the military.
03:28And and specifically in patients
03:30who have PTSD and TBI.
03:32And it's important to appreciate that in
03:35in a lot of the literature you'll see.
03:39They'll oftentimes sort of breakdown
03:41populations as obstructive sleep
03:43apnea and CPAP adherence in patients
03:45with PTSD or sleep disorders.
03:47Among veterans with TBI and usually
03:49this is a messy population,
03:51and that's part of what limits the
03:53quality of the research, is it?
03:56Most of these patients have both
03:59PTSD and TBI.
04:01And they're on a number of medications
04:03that can affect sleep architecture
04:05and then make it difficult to have
04:07sort of clean populations for
04:09randomized clinical trials.
04:13So, First off, we've there's so many
04:16examples throughout society where we sort
04:19of see this notion of sleep as a weakness,
04:22and being able to sort of
04:25stay engaged and stay alert.
04:27You know, in spite of sleep deprivation
04:31is a sign of stamina and even manliness.
04:35And when people fall asleep,
04:37you know their their teas.
04:39Who made fun of an and or viewed as
04:42may be weaker or not quite not as
04:45resilient or as solid of an employee.
04:48It is definitely different specialties
04:50of medicine where the culture you know
04:52really really pushes that I remember
04:54in medical school you know pulling
04:56all nighters to study and having
04:58friends tease me if I fell asleep or
05:02bang pots over my head to wake me up.
05:05You know to play joke on me if I
05:07fall asleep while studying and I had
05:09given a talk on sleeping performance
05:12to the special Operations Medical
05:14Community and they were really
05:16interested in knowing about you.
05:18What's the history of sleep in the
05:21military in terms of when did the
05:23military start becoming aware of sleep as
05:25a weapon and as a weakness or vulnerability,
05:28and what did they do about it?
05:30And I had gotten in touch with.
05:34A few different military historians.
05:35I knew that you know.
05:37We've had the same.
05:38A military historian who's been at useless
05:40at the Med school for a few decades and
05:43he didn't answer my emails at first.
05:45But when I finally finally,
05:46he responded.
05:47He said there's really no,
05:48no,
05:48no good history or no one that really
05:50writes about this topic and I also
05:53contacted the military historian at
05:54the Command General Staff College.
05:56It's a professional school.
05:57We have to go through and as we move up
06:00the ranks in the Army and that military
06:02historian also had no new insights.
06:04But our medical librarian at the hospital,
06:07who's incredibly resourceful found
06:08a nice article by this author.
06:10Alan Derickson,
06:12who's a social scientist at Penn State
06:15and he wrote this book dangerously sleepy.
06:18And he's also written a great
06:21article about sleep in the military.
06:25And so when we think about how
06:27are we doing in the military,
06:29we have a very sleep deprived population.
06:32An if you make this sort of rough
06:35correlation between how much do
06:37people sleep on average in general,
06:39you know this is variable,
06:40but probably about 2/3 of the population
06:43is getting 7-8 hours of sleep a night
06:46or certainly more than six habitually,
06:48and by contrast,
06:49in the military,
06:50probably 3/4 of the militaries
06:52getting is habitually getting less
06:54than six hours of sleep a night.
06:56And a substantial portion,
06:58you know,
06:59a little bit less than 50% are constantly
07:02getting less than five hours a night,
07:05and there's been interesting performance
07:07research that looks at sleep deprivation.
07:10And which is a whole other lecture.
07:12You know,
07:13the impact of sleep deprivation and
07:15performance and what they found
07:17is we're sort of rote tasks like
07:19breaking down a weapon and putting it
07:21back together and loading and aiming a
07:24firearm and and marksmanship inaccuracy.
07:25That sleep doesn't have a huge
07:27effect on performance in these areas,
07:30but where you do see an
07:32effect is decision-making,
07:33so when they've done sleep deprivation,
07:35work with the Navy seals,
07:36for instance during hell week,
07:38where they have 72 hours of.
07:40Of sleep deprivation,
07:41they found that that these trainees
07:43are in live fire exercises or
07:46simulated combat exercises.
07:47Their accuracy doesn't really diminish
07:49with progressive sleep deprivation,
07:50but their choice of target does,
07:52so they start picking the
07:54wrong target more often,
07:56hitting the friendly target you know,
07:58shooting the wrong person,
07:59which is a big deal,
08:01obviously,
08:01and their insight about
08:03what they're doing is loss,
08:05so they'll their perception
08:06as they go through 72 hours
08:08of sleep deprivation is that.
08:10Their performance hasn't changed
08:12and they're doing fine when in
08:14actuality you know the an observer
08:16running the experiment can see that
08:18there's a progressive decrement in
08:19performance with regards to these
08:21complex decisions that can lead to
08:23friendly fire incidents and shooting
08:26civilians and things like this.
08:28So it's decision making that's
08:30really impacted,
08:30and generally you know when we
08:32think about the patients we see in
08:35our sleep clinic at Walter Reed,
08:37I would say many of them,
08:39especially officers and senior
08:40enlisted folks in leadership position,
08:42are getting around five hours
08:43of sleep a night habitually and
08:45sometimes catching up on the
08:47weekends and sometimes not.
08:48And there's literature,
08:49both in GME and in the military,
08:52showing that you know anything
08:53if you're getting less than four
08:55hours of sleep habitually.
08:57Not a huge difference from.
08:59Zero hours of sleep,
09:00kind of on a one night,
09:02a single night basis,
09:03and then when you start looking at
09:05that habitually of getting less than
09:07four hours of sleep over a number of days,
09:09you see a steep decline in cognitive
09:11performance and mood and irritability.
09:13Ability to stay awake,
09:14and those sorts of things when
09:16you're at that 5-6 hour mark.
09:18We know that there's definitely
09:19safety issues with folks that are,
09:21you know, driving for instance,
09:23with habitually less than six hours of sleep.
09:25Those folks are almost
09:27like an impaired driver.
09:29And but you kind of see a decline in
09:32performance in that five to six hour window,
09:35which is where much of our military is.
09:37But it's not as steep.
09:39Is that less than 4 marks?
09:41So people are kind of able to
09:43muddle through with this, you know,
09:455-6 hours of sleep a night.
09:47I would argue there's no free lunch,
09:49and so you tend to see in these
09:51these patient populations,
09:52other health problems,
09:53or they're coming to the sleep clinic
09:56because they're not able to do well
09:58with this anymore or professionalism.
10:00Issues.
10:00Work,
10:00and so a number of you know
10:02issues may be issues with their
10:05marriage or with their children.
10:07So quality of life and and
10:08work quality issues that
10:10start to suffer with progressive
10:12sleep deprivation in the military.
10:14Since the combat operations in the
10:16Middle East sort of took off in 2001,
10:19we've added progressive steep rise
10:20and insomnia sleep apnea and really
10:22all sleep disorders across the
10:24different branches of the military.
10:28And so I had said a little bit earlier.
10:31I was interested in this author Alan
10:34Derickson, and he had published an article
10:36called no Such Thing as a Night Sleep.
10:38That sort of looked looked at the
10:40origins of sleep deprivation in this
10:42culture of sleepless in the military,
10:44going back to World War Two.
10:46And when we think about some changes
10:48that happened in combat operations.
10:50If we think about the blitzkrieg
10:52in in Europe, that the German,
10:54the German army rolled into Poland very fast,
10:57you know less than 72 hours.
10:59They covered,
10:59they covered an amount of ground
11:02that wasn't previously possible.
11:04And it was such a fast paced assault
11:07that it took Poland by surprise and it
11:09was just a very quick take over and
11:12later people realize that the German
11:15army was amped up on methamphetamine,
11:17were known as providing,
11:18which had been kind of was used in the
11:21military and also throughout German society.
11:23There's a little bit of debate about
11:26to what extent this was utilized,
11:28but there's been.
11:29It's been kind of widely documented
11:31that heavy use of stimulants to help
11:34kind of further 24/7 combat operations.
11:37The Japanese in their kamikaze pilots
11:39would use cocaine suppositories with
11:41haggis are actually mentioned in this
11:43article as well as drinking saki.
11:45So for some of these for kamikaze pilots,
11:48for instance,
11:49the idea of drugs and alcohol to enable
11:52them to get into a state where they
11:55could go forward with their mission.
11:58So a lot of fear and terror in this
12:01population in relation to kind of these
12:03issues and the United States and Great
12:06Britain used amphetamines for their pilots.
12:08And we saw that, you know,
12:10with the attack on Pearl Harbor was early
12:12in the morning before folks were awake,
12:15or just as they're getting started with
12:17their day and the devastating effects
12:19had so people realize they combats.
12:21There's there's no like good
12:23manners in combat.
12:24It's a 24/7 operation.
12:25This was probably always the case,
12:27but it kind of became a
12:30little more pronounced.
12:31In World War Two and the Soviet Union and
12:33the United States and some other countries
12:36started publishing field manuals for
12:38their military about nighttime operations,
12:40and there was a lot of fear with sleep.
12:43So if you were in the Pacific Theater and you
12:46fall asleep in trench Warfare Island hopping,
12:49you could be hacked to
12:51death by Japanese scouts,
12:52so there's a lot of fear surrounding sleep.
12:57And as a matter of fact,
12:59an Congress you know prior to even
13:01the Civil War had made falling asleep
13:03on guard duty a capital offense.
13:05So you could be publicly executed.
13:09Admitted in addition to being just
13:11disgraced for falling asleep on duty
13:13because it was a big big safety issue of
13:16that could put all your colleagues at risk.
13:19When I was deployed to Iraq in 2000 and
13:21four 2005 we had this issue transpired
13:24where we had a mortar platoon.
13:26It was 28 US service members
13:28at a small patrol
13:29base that we had set up in this town in
13:32Iraq guarded by Iraqi Army who allowed
13:35a suicide truck bomber to drive through
13:37the gate and blow up the sleeping.
13:40Orders and so we had about 10 casualties in
13:44the deaths in addition to a lot of wounded.
13:47So this is, you know,
13:49this notion of using sleep as a weapon
13:51an recognizing that people are vulnerable
13:53when they're asleep is widely used.
13:55If I go back to this and these
13:57two books on the bottom,
13:59the greatest generation and never was so
14:01much owed by so many to so few you know,
14:04we get the idea that in the military
14:06sleeps a weakness folks were able to
14:08kind of pound through and succeed
14:10in spite of sleep deprivation,
14:12and in spite of fatigue they could.
14:14They could get through with a
14:16strong Cup of coffee.
14:17And then use of tobacco,
14:19other stimulants and make it an
14:21that succeeding in combat in spite
14:22of sleep deprivation or in spite of
14:24the cold in the European theater,
14:26was a sign of strength and manliness.
14:28And then these folks came home,
14:30and they were known as the
14:32greatest generation.
14:33These are folks that were strong,
14:34they could kind of get through any situation.
14:38And it sort of basically kind of carries
14:40forth this mythology that you don't
14:42need sleep to function effectively,
14:44and that that sleep is a weakness,
14:46and this is a an idea that kind
14:49of comes up repeatedly.
14:50There's a whole series of cartoons and just
14:54blanking at the moment on the authors name.
14:57Depicting kind of the sleepy GI,
14:59you know the baggy eyes and and
15:02sleep deprived soldier in World
15:03War Two and equating sleep with,
15:05you know, a fatal outcome being
15:07neglectful or being irresponsible.
15:09So over and over,
15:10there's almost this morally Laden
15:12messaging of sleeping, a weakness.
15:14And now in our Military United States,
15:16another kind of 1st World Nations have
15:18the advantage of night vision technology,
15:21so it's in the current conflicts
15:23in the Middle East.
15:24It's really the first time where you have
15:27widespread use of night vision technology to.
15:30You know,
15:30especially in this special
15:32operations community,
15:32to capture and kill high value
15:34targets by sneaking up on them.
15:36You know when they're asleep and for
15:38folks in the special operations community.
15:41When they deploy,
15:42many will deploy for several months
15:43at a time where they're completely
15:46shifted to nighttime operation,
15:47so everything is happening at
15:49night and they get what they what
15:51they call reverse cycle.
15:53So you're basically training someone
15:54to be in an incredibly intense high
15:57adrenaline situations at night time,
15:59life or death,
16:00you know fight or flight situations
16:02every night for months and months on end.
16:05And not surprisingly,
16:06these folks have trouble when they
16:08come back home and back to their family
16:11independence and are trying to sleep.
16:13Normal hours in bed with their wife.
16:17In the military we were.
16:18We've been trying to look at
16:20what's the operational relevance
16:22of sleep disorders on our active duty forces.
16:24If we just look at in our
16:27electronic medical record,
16:28how many of the roughly 500,000
16:30service members in the Army
16:32active duty folks in the army,
16:34how many of these 500 soldiers
16:35have a sleep disorder documented
16:37or asleep complaint documented?
16:39This doesn't necessarily mean we have a PSTN.
16:41All these folks are perfect diagnosis,
16:43but where a diagnosis of snoring,
16:45daytime sleepiness, shift work disorder.
16:47Insomnia and so on and so forth.
16:50Half of them were saying and that
16:52half of our soldiers have have gone
16:54to their doctor with some sort of
16:57asleep complaint and around 10,000
16:59that are actually on a profile,
17:01meaning duty restrictions that limit their
17:04ability to deploy or to be stationed
17:07overseas because of their sleep disorder.
17:10In 2018 these were on the top 20
17:12list of medications prescribed in
17:14the military in terms of costs and
17:17what's being paid out by Tricare.
17:20So a lot of ambient and trazadone so clearly
17:23sleep is a huge issue in our population.
17:26Unfortunately not enough sleep
17:28centers within the military health
17:30care system to see all these folks.
17:35I'm not sure that red line came out with C.
17:39Ever Red Lion on my screen and I
17:41don't know how it got there, but.
17:44Interesting anyway.
17:47This is sort of top 10.
17:49This is a graph showing the
17:50top 20 causes of reasons why
17:52folks are non deployable sleep.
17:54A sleep disorder is number 10.
17:56These are usually folks with so
17:58anybody that is requiring use of
18:01a sedative hypnotics like Ambien
18:02or Lunesta for more than 30 days,
18:04or a stimulant like PROVIGIL for
18:06more than 30 days where it's a
18:09habitual something that using
18:10habitually or they have moderate
18:12or severe sleep apnea on CPAP,
18:14they actually get a profile
18:16with duty limitations.
18:17And they can affect the
18:18playability and even affect
18:20their retention in the service.
18:24So an who suffers so probably the folks in
18:27our population that have kind of the greatest
18:30amount of where this is having the most
18:32impact are kind of senior level leaders.
18:35So in the military it's a younger cohort, and
18:38when you're looking at folks in their 40s,
18:40that's that's your sort of senior leadership.
18:43So senior enlisted senior officer ranks.
18:44I'm in my 40s and I'm a kernel and,
18:47you know, be retiring out of
18:50the military before I turn 50.
18:53And so sort of a younger population overall,
18:55but this is the group where you start
18:58to see them really being challenged
19:01by the impact of sleep disorders.
19:04And sort of, what sorts of factors
19:06play a role in sleep disorders in the
19:08military an you know one is chronic,
19:11insufficient sleep.
19:11We've talked about how most of the
19:14military is not getting enough sleep.
19:17A lot of shift work that's utilized
19:19in the intelligence community,
19:20for instance at Fort Fort Meade,
19:22Maryland, where the.
19:24The NSA is located.
19:25There's a lot of shift work and
19:27kind of monitoring intelligence
19:28feeds where folks are doing shift
19:30work with mixed cycles throughout.
19:32The re can.
19:33Oftentimes these are younger
19:34kind of junior personnel that are
19:36involved in very important work,
19:37but they're doing all sorts of
19:39different shifts throughout the week.
19:41You know they may have night shifts,
19:43day shifts and swing shifts,
19:45and a day off you know all in one week,
19:48rather than you know more of what we
19:50would all recommend in Sleep Medicine
19:52of usually several weeks to months.
19:54Kind of on the same shift pattern
19:56with the gradual.
19:57Transition is as you change it.
20:00For sleep environments on deployment,
20:02so you'll have infantrymen on a
20:03base in Iraq or Afghanistan where
20:05they're oftentimes sleeping in a
20:07like a shipping container that's
20:09been divided up with plywood,
20:10so that four different people
20:12can share the space.
20:13Usually the only thing good about
20:15it is high powered air conditioning,
20:17but otherwise you'll have service members
20:19that are on different shift schedules,
20:21so you may have two folks that are
20:23trying to sleep during the day while you
20:26know other folks are coming in and out,
20:28and so just a very bad sleep
20:30environment in addition to.
20:32Kennedy,
20:32other things that come up in
20:34a combat environment.
20:34You know if there's mortar or combat
20:36operations or things that are,
20:37you know where there's safety issues
20:40and people may have to wake up from
20:42sleep and put on their gear and things.
20:45And then operational contributors,
20:46constant threat of harm,
20:48unpredictable operations,
20:49tempo, long duty days.
20:50It's just sort of taken for granted in
20:53the military that people will kind of
20:56do more with less is a common mantra,
20:59and you know,
21:00for many of our leaders working you know,
21:0316 hour days becomes the norm
21:05and there's a lot of issues with
21:07family separation which creates
21:09emotional trauma and stress.
21:11Chronic anxiety,
21:12alot of issues with alcohol and tobacco.
21:14Use heavy use of caffeine and energy
21:17drinks and other supplements throughout
21:18all age groups in the military,
21:21and then folks that suffer from
21:23PTSD and traumatic brain injury.
21:25And in the case of TBI,
21:27most of what you see in the
21:29military is mild TBI concussions.
21:31More analogous to what you'd
21:33see in sports injuries.
21:34And oftentimes folks that have been in
21:37proximity to blast trauma on deployment.
21:42If you think about sort of the
21:44Speelman model of insomnia,
21:46or that 3P model of sort of factors that
21:48lead to the development of of insomnia,
21:51kind of a predisposition,
21:53some sort of a precipitating event and
21:55then factors that perpetuate the insomnia
21:57cause it to turn into this chronic issue,
22:00we can sort of replicate this model
22:02in the military where we have a a
22:05population that's younger and tends
22:07to be a little bit more phase delayed
22:10with regards to circadian timing.
22:11So most most younger folks,
22:13as we all know it, would probably
22:15prefer to be staying up later at night.
22:17You know 11 or midnight or even later.
22:19And sleeping in a little later
22:21than in the morning.
22:22So a 9 to 5 schedule for most people.
22:25Most adults tends to workout OK,
22:26but in the military many folks are
22:28starting their work day, you know.
22:30Well before 6:00 in the morning.
22:33Whether it's due to long commutes or
22:36just a long training day or setting
22:39up a training environment by 7:00 AM.
22:42The day's work days in the military
22:45are slanted more towards like a 7:00
22:48AM to 4:00 PM rather than a 9 to 5.
22:51So you're taking a population that's
22:53naturally kind of has more of a
22:55phase delay tendency and forcing.
22:56You know the round peg into a square hole,
22:59so to speak.
23:00And this right off the bat can
23:03lead to issues with.
23:06With. I'm just getting a
23:10notification on here with Zoom.
23:15So this can, I'm sorry again about
23:16this red streak on the screen.
23:18I've no idea where that came from.
23:19I don't know if it's showing up on
23:21your end, but it could be worse.
23:23It could be like covering
23:24the whole screen I suppose.
23:27And I think Lauren tried to jump
23:29in to take control to maybe
23:30help me with that, but it's it.
23:32When this happens it makes me go in
23:34and change all my settings for zuman
23:35like log out of the meeting and so
23:37it may not be worth it or possible
23:39and I'm not tech savvy enough.
23:41Um hi Jacob it's
23:42Lauren sorry yeah that was going
23:44to try to get in to do that.
23:46I think if you want to get rid of it,
23:49you if you go to the very top of zoom
23:51and you go to view options there's
23:53a little thing that says annotate.
23:56I don't know if you can see that and
23:58then there's like an eraser, so undo.
24:02And maybe undo or maybe just
24:03hit the eraser and erase it.
24:05I tried to remotely do that for you,
24:07but it wouldn't let me.
24:09OK got it, you got
24:10it. Bingo, you're a miracle worker.
24:12Thank you. I learned
24:14something new about Zoom now.
24:16So I think I was mentioning this
24:17idea of sort of social jetlag that
24:19you have this younger population
24:20and they kind of end up burning
24:22the candle at both ends there.
24:23Getting up very early in the morning,
24:24but it's hard for them to fall
24:27asleep until quite late at night.
24:29And so they they sort of struggle
24:31with chronic insufficient sleep.
24:33So sometimes,
24:33when these folks are coming into
24:35our clinic and they're having
24:37sleep related symptoms, no,
24:38it's not obstructive sleep apnea.
24:40These are usually young,
24:42thinner, healthier folks without
24:43a lot of risk factors.
24:45There just profoundly sleep deprived,
24:46and sometimes it's hard to reverse that we
24:50can't really change their work schedule.
24:53What also creates,
24:54you know,
24:54confusion in the in the military
24:56are kind of the premium placed on
24:58having obstructive sleep apnea,
25:00so there's actually a VA disability
25:02rating for obstructive sleep apnea,
25:03so you'll have a lot of folks coming in
25:06wanting to be tested with sleep apnea,
25:08or maybe sort of telling you
25:10what they think you want to hear
25:12in terms of symptoms so they
25:14can get tested for sleep apnea,
25:16but where maybe the big issue is
25:18insomnia or chronic insufficient sleep.
25:22See.
25:29OK, So what are the specific sleep
25:32disorders we see in the military?
25:36It said I stop sharing.
25:38I'm hopefully you guys can still see me.
25:40Let me know if not sorry that
25:41was my fault. I was trying to turn
25:43things off 'cause I didn't know
25:44if it when I took over control.
25:46If you had control you
25:47could re share your power.
25:50No, no, no is this good now.
25:52Yeah, I just wanted to make
25:54sure you're able to advance
25:56it yourself. Is that possible?
25:57So yeah, no, it's good. Thank you.
25:59OK, so if you look at sort of
26:01diagnostic coding in the military
26:03and like what we see in our clinic,
26:06so Walter Reed in our we have a 12
26:08bed sleep lab and a fellowship.
26:10We have 5 sleep physicians
26:12and one sleep asleep.
26:13Clinical psychologists were
26:14getting 700 to 1000 referrals
26:15per month for our sleep clinic.
26:17So you know over half of these
26:19folks end up getting leaked to
26:21the civilian network and seeing.
26:23Physicians on the sleep clinics
26:24on the outside 'cause we just
26:26don't have space for all of them.
26:28At our sleep center,
26:29just too much of a volume of
26:31patients and not enough providers,
26:33but the most common diagnosis that's
26:35coded in our clinic is obstructive
26:37sleep apnea and the reason for this
26:39is there is a VA disability for
26:42having obstructive sleep apnea,
26:43whereas service members separate
26:44from the military,
26:45they have to go to a whole series of
26:48events where they are given counseling
26:50on sort of how to transition out
26:52of the military to civilian life.
26:54Whether it's job fairs but a big
26:56part of that is getting making sure
26:59you have your disability ratings.
27:00That and there's a big veterans lobby,
27:03so there's a lot of emphasis put in on
27:05making sure veterans are getting their fair.
27:08Do you know rightfully so?
27:11The but the disability piece for
27:13sleep apnea is a little bit odd.
27:15There's no nothing that would really
27:17link obstructive sleep apnea to
27:19military service other than kind
27:21of a maybe questionable sort of
27:23argument related to insufficient
27:24sleep and airway tone,
27:26but it's if you have obstructive
27:28sleep apnea and daytime sleepiness,
27:30regardless of severity,
27:31it's a 30% disability rating
27:3350% if you require CPAP,
27:34and 100% if you have to get a tracheostomy,
27:38and so clearly these are these were
27:40guidelines or disability ratings.
27:42That were constructed around older
27:43ideas about sleep apnea more as
27:45a pulmonary overlap syndrome and
27:46hypoventilation or pickwickian patients.
27:48We all know how easy it is to get a
27:50diagnosis of mild sleep sleep apnea,
27:52and that's the majority of what we see
27:55in the military is a lot of mild OSA.
27:57This doesn't diminish the importance
27:59of sleep apnea in general.
28:00Could sleep apnea is quite
28:02common even in our population,
28:03but it just really makes in monies the
28:06waters 'cause it makes it hard to,
28:08you know,
28:08get a good estimate of pretest
28:10probability and know how much of
28:12a factor sleep apnea is playing.
28:14You know in your population.
28:17Insomnia is the second most likely,
28:19and this is because you know,
28:22we see circadian rhythm disorders
28:25and anxiety.
28:26And maybe even untreated OSA all
28:27kind of get lumped into insomnia
28:29or somebody is having trouble
28:31sleeping and a high you know high
28:33rate of use of sedative hypnotics.
28:35So insomnia would be kind of the
28:37second most build sort of thing,
28:39but I think if we look at what's
28:41the number
28:42one problem in the military,
28:43it's insufficient sleep,
28:44just grossly insufficient sleep.
28:45We also have a lot of parasomnias,
28:48so we do have service members with PTSD.
28:52In a number of psychoactive
28:54medications to treat their depression,
28:56PTSD and anxiety and sleep,
28:58who end up with who have nightmare
29:01disorder that is trying to be treated,
29:04chronic insomnia and kind of a
29:07variable presentation of both
29:09non REM and REM parasomnias.
29:11Especially kind of issues with
29:13combative behaviors in bed,
29:14which can be a big problem in a
29:16marriage and a big problem in a
29:18population where we see a high rate
29:20of service members and veterans that
29:22sleep with weapons in the bedroom.
29:24So I think this is a you'll be
29:26surprised when you meet with a veteran
29:28or an active duty service member.
29:31How often you'll get an answer
29:32of yes if you ask them if they
29:35have weapons in the bedroom,
29:36particularly even in the bed.
29:38So we've had service members that sleep
29:40with a combat knife under the pillow.
29:42Or they have a handgun in the bedside table,
29:45or even multiple weapons in the bedroom.
29:47It's really astounding,
29:47and it did.
29:48It doesn't really come out in
29:50less you specifically ask.
29:54We know that sleep is a risk for psychiatric
29:57disorders and that psychiatric diagnosis.
30:00Occur more frequently in folks that
30:02have pre existing sleep disorders,
30:04and we know that insomnia or objectively
30:07diagnose sleep disorders like insomnia,
30:08OSA, insufficient sleep are all
30:10independent risk factors for developing
30:12behavioral health disorders and over
30:14the ensuing three to five years.
30:16And they tend to pretend
30:18a much worse outcome.
30:19In particular, risk of suicide.
30:21So there's been an increasing
30:23body of literature,
30:24both in the military and
30:25outside the military,
30:26that then we'll get into this a
30:29little bit more later that looks at.
30:32Kind of the impact of sleep disorders
30:35on increasing your risk for suicide
30:37and suicide's been a huge issue in
30:39the military for a number of reasons,
30:42but we've seen spikes in cases
30:44of suicides in the army,
30:46especially with the frequent deployments
30:48and separation from family and
30:49inadequate behavioral health resources.
30:53Sleep complaints notably worse outcomes
30:55in post traumatic stress disorder,
30:57so we have a you know probably 30%
31:00of service members who have had a
31:03combat deployment will come back
31:05and get a diagnosis and evidence
31:08based diagnosis of PTSD nearby.
31:09A doctoral level behavioral health provider,
31:12whether it's a clinical psychologist
31:14or psychiatrist, but using kind of an
31:16evidence based metric for diagnosing PTSD,
31:19say 30% of deployed service members.
31:21And we know that sleep disorders,
31:24whether it's insufficient.
31:25Sleep fragmented sleep daytime sleepiness
31:28that sleep complaints are a Cardinal
31:31feature or diagnostic criteria of
31:33PTSD and that they they make it much
31:36more challenging to treat an already
31:38difficult population to manage.
31:40We know that patients with PTSD have
31:43lower compliance across the board
31:45with really all health interventions,
31:47so you know worse compliance with
31:50taking into hypertensives worse
31:52compliance with going to outpatient
31:54mental health care visits.
31:57Worst compliance with taking
31:58psychoactive medications.
31:59Works compliance if you're looking
32:02at HIV patients with PTSD,
32:04lower lower usage of heart therapy,
32:07and higher risk dramatically
32:08higher risk of suicide either.
32:11Suicidality, suicidal thoughts,
32:12or behaviors in addition
32:14to completed suicides.
32:15Among patients who have PTSD
32:18with a concurrent sleep disorder.
32:20So this is a big issue.
32:23High stakes for a vulnerable population.
32:27And we know that clearly there's
32:30this this interplay.
32:31You know that sleep disorders
32:32and PTSD feed off of 1 another.
32:35So as as folks are not getting enough sleep,
32:38if they are,
32:39you know will have service
32:41members who are hypervigilant,
32:43especially special operations folks
32:45who returned from deployment and
32:47they have a lot of trouble sleeping
32:50at home or sleeping in bed and
32:52they sometimes find themselves.
32:54Sort of perceiving themselves as the
32:56Guardian of the house and watching
32:57over the safety of their household,
32:59and that that's what they're responsible for.
33:01And they have a lot of trouble
33:03sleeping at night.
33:04And then you know,
33:05they're sleeping in,
33:06like sleeping on the couch or in
33:08other places during the day and kind
33:11of cat napping around the Clock and.
33:13And so this can then lead to if you're
33:16getting chronic insufficient sleep,
33:19there's some literature from the 90s
33:21showing you can actually have worsened
33:24airway tone enough to where you can
33:27increase your RDI into the mild OSA range.
33:30So there is maybe a mechanism,
33:32although kind of weak,
33:34chronic insufficiently,
33:35maybe reducing airway tone or
33:37responsiveness and leading to
33:39sleep disordered breathing.
33:41With with these patients that have
33:43PTSD and that are on an ice depressants
33:46which can suppress REM in some cases.
33:48And when we do sleep studies on
33:50our folks with PTSD will usually
33:52see very fragmented sleep most of
33:54the night is spending like 40% of
33:56the night spent in N1.
33:58It's hard to know how much of this is
34:00sort of first night effect in the sleep lab,
34:04and how much is kind of their
34:06day-to-day but very poor quality sleep,
34:08and not enough of our deeper stages of sleep,
34:11which. Yeah, there's increasing
34:12literature looking at the role of RAM
34:15and emotional memory consolidation,
34:17so your ability to kind of recover and
34:19process emotionally traumatic events,
34:21which is really important
34:23in PTSD and mental illness,
34:25and is covered nicely in this
34:27article by Ali El Sol.
34:29I think he's from Suni Buffalo,
34:31and he's done a lot of great
34:34work on PTSD and sleep apnea.
34:37And this was a nice review article
34:39that he did in Annals ATS and 2015.
34:42This vanlent is an author with a
34:45sleep researcher that works for
34:46the Dutch military and has done
34:48some really nice review papers
34:50and studies putting together.
34:52Kind of illustrating the link between
34:54PTSD and sleep disorders over here.
34:56There's a lot of work by Barry Krakow
34:59looking at different populations,
35:01natural disaster victims,
35:02sexual assault victims and the risk of OSA.
35:05The quality is a little.
35:07Questionable in some cases.
35:09Usually cohort studies,
35:10smaller populations and and
35:11oftentimes not using PSG.
35:12So sometimes these are folks
35:14with sleep disorder breathing
35:15based on subjective complaints,
35:17but that may you know where they're
35:19giving an estimate of 52% of rape.
35:22Survivors have sleep apnea,
35:23which is probably not accurate,
35:25but it's based more on questionnaire data,
35:27so you have to you have to sort of
35:30look at the literature with PTSD and
35:32OSA in terms of you know where these
35:35patients studied with the PSG or serve aid.
35:38And for subjective complaints.
35:41Then more traumatic your deployment,
35:43the higher risk you are for
35:45having PTSD and there is a high
35:47prevalence of obstructive sleep
35:49apnea among those with PTSD.
35:51Getting into the mechanism behind that
35:53can be a little more controversial.
35:56This is a study Chris Lettieri did.
35:58We did this together in 2016 and
36:00we had 200 service members that
36:02had come through our clinics.
36:04It's a cohort of people.
36:05We could kind of pull from our
36:07own data 50 in each group.
36:09You know, PTSD plus sleep apnea,
36:11PTSD without sleep apnea,
36:12sleep apnea without PTSD and
36:14then quote unquote, normal.
36:15Or really just people that didn't have,
36:17didn't have sleep apnea,
36:19didn't have PTSD and didn't really
36:21end up with a formal sleep diagnosis.
36:23So again,
36:23this is important when you think about that.
36:26Quality of this study.
36:27This is interesting,
36:29but it's not necessarily a clean,
36:31true controlled population,
36:32but we found where that folks
36:34with sleep apnea PTSD have
36:36dramatically worse fatigue mood,
36:37lower sleep related, quality of life,
36:40and worse function.
36:41In terms of the functional outcomes
36:43of sleep questionnaire you know,
36:45then with either condition alone and that.
36:49Symptoms among those with PTSD in OSA
36:52are closer to those with obstructive
36:54sleep apnea as opposed to PTSD alone.
36:58So sleep apnea definitely makes
37:00things dramatically worse.
37:02And this was a paper in 2010.
37:04They kind of started my interest
37:06in the topic again by Doctor El Sol
37:09from from Sony that showed this
37:11was an older veterans population,
37:14around 148 or 150 older veterans,
37:16so more comorbidities were like Vietnam era
37:18veterans with more obesity, heart disease,
37:21metabolic syndrome, hypertension.
37:22These are more of your kind of typical OSA
37:25patients having moderate and severe OSA,
37:27and then this population had
37:29much lower compliance with CPAP,
37:31and so that was the point of this.
37:34Study was showing that in your
37:36patients with OSA and PTSD,
37:37that adherence is markedly lower.
37:40And that that folks that
37:42were excessively sleepy.
37:44Or maybe I'd better perception in
37:46terms of sleep related symptoms,
37:48had better CPAP adherence,
37:50which makes sense,
37:51and that improved Pap adherence lowered
37:53nightmare frequency and severity,
37:55which has been found in other studies.
37:59We did kind of a follow up study with fewer
38:02patients an and somehow still got published.
38:05So he had like half the number of patients
38:07is then we had but a different population.
38:11So younger veterans.
38:12These are people within six months to a year
38:15of coming back from Iraq or Afghanistan.
38:17So younger, thinner, healthier,
38:19so to speak 45 with PTSD and
38:21OSA and 45 kind of without.
38:23Not not a real control,
38:25but folks that did not have sleep
38:28apnea and did not have PTSD.
38:30We found much more comorbid
38:32insomnia in the folks with PTSD.
38:34Not surprisingly,
38:35and insomnia,
38:36you know separate from PTSD
38:38in mood disorders.
38:39Insomnia is a big confounder
38:41in CPAP adherence.
38:42We found a market reduction
38:44in CPAP compliance across all
38:46metrics based on a data downloads.
38:48We use mostly Phillips Respironics devices,
38:50so from the Encore anywhere at that time.
38:55When we think about comorbid PTSD,
38:57OSA and insomnia.
39:00We know that among this patient,
39:02insomnia can be almost universal,
39:04likely due to this hypervigilant state.
39:06Not surprising when we think back
39:08to some of the literature from
39:09World War Two about like this
39:12notion of being hacked to death
39:14in trenches in the South Pacific.
39:16If you fell asleep or sort of the
39:18realization that a service member
39:20may come to that they they go after
39:22high value targets in their sleep,
39:25then not surprisingly makes it harder
39:27for people to feel comfortable
39:28sleeping when they come home.
39:31So we see kind of that these sleep
39:34complaints together just have a
39:36significantly bad impact on whether
39:39it's rates of major depressive disorder,
39:42suicidality need for antidepressive therapy,
39:45and certainly worsened puppet hearings.
39:48Another issue that's come up else always
39:51talked about this and so of other authors.
39:53And is this idea of low arousal threshold
39:56so we know that patients with obstructive
39:58sleep apnea have different fees.
40:00Types and we we all it makes sense
40:02to all of us that there are folks
40:04that are obese and have metabolic
40:06syndrome and hypertension.
40:08Anna huge neck with a High Peak
40:10written a collapsible airway and
40:12those folks are a little more
40:14straightforward for most of us,
40:15and many of those folks are going
40:17to be more here with Pap and be
40:19just more straightforward.
40:20More benefit from CPAP to begin with.
40:22What we find in our folks with PTSD is many
40:25of them have really bad insomnia,
40:27their younger, so you don't see much
40:29hypoxemia on their sleep studies.
40:31You'll see a lot of high pop,
40:34Mia's and depending on the score you know
40:36you could debate many of those high pop news.
40:40If you're picking apart the hi,
40:42especially if you're in a system
40:44unit using their era or an RDI,
40:46it's very easy for someone to end up
40:49you know who has bad PTSD and insomnia,
40:52and hyper vigilance.
40:53Getting a diagnosis of mild OSA because it's
40:56so easy to get that diagnosis of mild OSA,
40:59especially someone that has
41:00light kind of fragmented sleep.
41:02And so Danny Ecker has done some
41:05research with Oesophageal Manometry
41:06where they sort of defined this low
41:08arousal threshold phenotype in OSA.
41:10Or folks that with kind of you know,
41:13a minimal reduction in airflow
41:14having arousal from sleep.
41:16And it prevents you from getting
41:17into deeper stages of sleep and
41:19having as refreshing sleep.
41:21And he did a nice study in 2014 in the Blue
41:24Journal sort of showing that you know,
41:27because it's not feasible to do
41:29oesophageal manometry on everybody that
41:31you can make kind of a non invasive
41:33definition of low arousal threshold and.
41:35And what that's defined is as
41:38folks that you know,
41:39their oxygen saturation nadir is
41:41above 83% more than half of their
41:44sleep disordered breathing events
41:46are obstructed by Papias.
41:48And kind of mild moderate
41:50severity in terms of the HI,
41:52so it's so this is really kind of
41:55fits in with what we see in PTSD.
41:58That it's a hypervigilant
42:00group with a lot of insomnia.
42:02A lot of psycho pharmacy,
42:04and.
42:05Some questionable hypocapnia is enough
42:07to put them into the mild range for OSA,
42:10not a lot of hypoxemia,
42:12and not surprisingly,
42:13these people don't use their CPAP,
42:15so it's it is almost a little more
42:17of a concern that you sort of
42:19confound things and cause a little
42:22bit of harm for this population,
42:24or muddy the waters.
42:25Iatrogenic Lee by giving them
42:27this diagnosis of mild OSA,
42:28which probably isn't,
42:29you know,
42:30a big piece of what's causing
42:33their disability in terms of sleep.
42:35Anne Anne Anne where they're not going
42:37to have a response to seep out in some cases,
42:39kind of to be more concrete about that.
42:41These patients may see their
42:43psychiatrist who and complained
42:44that they're not getting better with
42:45regards to their PTSD and nightmares,
42:47and the psychiatrist or psychologist
42:48might say, well, you know,
42:50your sleep doctor noted that you
42:51have sleep apnea and you're not
42:53using your CPAP and so you really
42:55need to start using your CPAP.
42:56And that's the problem when really
42:58this is someone who has mild or
43:00borderline OSA who's not going to
43:02get much benefit from C pap therapy.
43:04And who really needs more help from
43:07a mood disorder standpoint so it
43:10can create a lot of confusion.
43:13So benefits of treatment in OSA and PTSD.
43:16We know that there have been a
43:19number of studies
43:20showing that you can get a significant
43:23improvement in PTSD symptoms based on this
43:27PTSD questionnaire called the PCL S&P CLM.
43:30So less sleepiness improves sleep quality,
43:32better daytime functioning, less depression.
43:35Can get big improvements in symptoms
43:37when folks with OSA and PTSD are
43:38compliant with CPAP and this is
43:40from Kathleen Sarmiento's Group.
43:42I think you see San Diego.
43:43She's another kind of big author
43:46in this field and a real leader.
43:49We know this is from Tim on in 2014.
43:52Another great paper showing
43:53market reduction in nightmares,
43:55frequency and nightmare severity,
43:56and folks with the use of C pap,
43:59and I remember citing this in a review
44:01paper we wrote an actually I had
44:04inadvertently like put my personal email
44:06on the author information and I got an
44:08email from an angry veteran saying that
44:11CPAP actually made his nightmares worse.
44:13So you will sometimes hear from
44:15folks with PTSD and nightmares that
44:18they get this worsening of their
44:20nightmares when they go on C pap.
44:22I haven't found it to be terribly common,
44:25but the thought is,
44:26if treating their sleep apnea facilitates
44:28more RAM or more deep sleep that they
44:30may then have more dreams or more
44:32opportunities for nightmares with other
44:33folks on the call may have a little
44:36more expertise in this realm than me.
44:39We did a study.
44:40This is that same population.
44:42Chris Litarion I did with our 200 patients.
44:45Kind of broken into those four
44:47categories and we showed that.
44:49The use of C pap in this population
44:51definitely improved symptoms,
44:52but a really diminished response to see path
44:55when you look at those with PTSD and OSA.
44:58So you get benefit,
44:59but it's it's not nearly what
45:02you would get in someone who
45:04has sleep apnea without PTSD.
45:06What are some alternative treatments?
45:08Because the PTSD population is
45:10notoriously non adherent in general
45:12and weather of any kind of medical
45:15intervention and very non adherent
45:17with CPAP unit which is what we found.
45:20So oral appliances have been studied,
45:22I think.
45:23Also by Kathleen Sarmiento's Group,
45:24and they've done some randomized
45:26clinical trials and I think.
45:31Doctor El Sol from Sony as well,
45:33so randomized control trials looking
45:35at the treatment of use of oral
45:37appliance in patients with PTSD and OSA,
45:40and in general what you find are
45:42subjectively pretty similar.
45:43Improvements with oral appliance or CPAP you
45:45you definitely don't get the same degree.
45:48You don't get a significant reduction in age.
45:50I with an oral appliance compared
45:52to path that were an improvement in
45:55hypoxemia to the same degree with
45:57an oral appliance as opposed to PAP.
45:59But the patients tend to feel like
46:02they're getting the same amount of
46:04benefit with regards to daytime
46:06sleepiness and compliance with an
46:08oral appliance tends to be better,
46:10so we've really tried to push more
46:13oral appliances with with our folks.
46:15Unfortunately, words gotten around that,
46:17you know, using an oral appliance
46:19to treat your sleep apnea does not
46:22yield the same disability rating
46:24as treating your sleep apnea with.
46:26With CPAP,
46:27the difference between a 30% and
46:2950% disability rating.
46:30Is when you hit 50% a certain portion of it,
46:34or the way your retirement comes
46:36to you becomes tax free.
46:38So if it so someone like a CPAP
46:40person with OSA on CPAP,
46:42that's like a 50% disability rating which
46:44is essentially $1000 tax free per month.
46:46The rest of your life.
46:48Once you have a 50% disability rating,
46:50it's not that hard to get up to 100%,
46:53and once you're 100% disabled it
46:55gets you about 3500 a month tax free.
46:58The rest of your life as well as
47:00preferential hiring and federal institutions.
47:02So there is a lot that goes into this,
47:05and it's not surprising that veterans are
47:07aware of this and that it factors into
47:09kind of interferes with our sleep treatment.
47:11Um?
47:12Let's see here.
47:13Sedative hypnotic use.
47:14So some people have said, well,
47:16maybe for these folks with low arousal
47:18threshold and there has been some literature.
47:21One study looking at Trazadone and failing
47:23to find kind of a benefit with Trazadone,
47:25but Lunesta there was a study done with
47:28his upper clone showing a reduction
47:30in the hi in folks that had a low
47:33arousal threshold that was significant.
47:36Chris Lettieri and I did some of this
47:38work with him and some with some of
47:41our other fellows showing kind of a
47:43benefit of using both Zolpidem in his
47:46upper clone and improving the quality
47:47of CPAP titrations and CPAP adherence.
47:50So there are some thoughts
47:51that maybe you know,
47:53for some patients we definitely
47:54use sedative hypnotics to to
47:56help with concurrent insomnia,
47:57but it's it's always a little bit
47:59of risk if you have a population
48:02that as weapons in the bedroom and
48:04as may be prone to parasomnia's.
48:07And you know,
48:07and and that are already on a number
48:09of Psycho Pharma pharmacologic agents.
48:11So I tend to try to be careful with that.
48:13Or at least IG knowledge that this is
48:15a different population where there are
48:17some other safety concerns that have
48:19to be thought about, like counseling the
48:21patient to not have weapons in the bedroom,
48:23or that they have to sort of agree that
48:25any weapons in the bedroom or in a safe.
48:30And so take away message.
48:32Sleep apnea is common
48:33PTSD and worsen symptoms.
48:34Treatment of OSA improves symptoms,
48:36but these but this really is limited
48:37by lack of adherence to PAP in this
48:40population and that there are some or
48:42all other therapies we can consider,
48:44especially oral appliances,
48:45and maybe send it,
48:46if not excpet some unique challenges in
48:48this population that we have to consider.
48:50I know I need to speed up a little
48:53bit of a little bit more to go if we
48:56switch gears and talk a little bit
48:58about TBI we see a high prevalence or
49:01high rates of traumatic brain injury.
49:02In our service members over the years,
49:05rising and probably kind of dropping
49:07down now that we're not having as many
49:10active combat operations in the Middle East,
49:12most of these are mild TBI
49:14cases like concussion.
49:15These are folks that drove by an ID
49:18and there was blast trauma to varying
49:20degrees and experienced concussive force.
49:24That we've seen in our,
49:26there's been a number of authors.
49:28Doctor castrated, I think is at USC now.
49:30Has written some really great papers
49:32about the impact of TBI on sleep.
49:34When you think about moderate and
49:36severe TBI and what you might see in
49:38folks with penetrating brain injury,
49:40there's definitely an impact of
49:42sleep disordered breathing and
49:43other sleep disorders on neuro
49:44recovery in patients with more severe
49:46forms of TBI in our population,
49:48what we found,
49:49you know in mostly in a population that
49:51has mild TBI and hence well enough to
49:54make it into a sleep clinic visit.
49:56Is a ton of insomnia and it's hard to
49:58study at this population in terms of.
50:00Control trial or making comparisons
50:03because they're universally on a ton
50:05of psychoactive medications that
50:07make it really challenging too.
50:09I'm.
50:10Do a better job assessing the sleep
50:12complaint in how much TV is playing a
50:15role as opposed to medication side effects.
50:18There's been a little bit of theoretical
50:20work on what the pathophysiology is
50:23of sleep disorders in folks with TBI.
50:25Certainly there's a potential for
50:27direct and indirect brain trauma
50:29and a reduction in weight promoting
50:32neurotransmitters.
50:33This isn't really my area of expertise.
50:35I do know that in folks with penetrating
50:37head trauma that blood in the cerebral space,
50:40if they've had a surgery where
50:42there was a lot of bleeding and
50:44aneurysmal repair that you can see
50:46folks that come out of that.
50:48With hypersomnia you can get a
50:49narcolepsy or a central hypersomnolence
50:51condition in relation to TBI
50:53for folks post operatively.
50:54Whether it's from penetrating neurotrauma
50:56or a traumatic surgery where there was
50:59a lot of blood in the Inter cranial vault.
51:02Suicide is what all kind of end with.
51:05And what we've if we think about?
51:07How do all these factors come together?
51:09If we're thinking about our
51:11veteran with PTSD and TBI,
51:12these are folks that may
51:14be a little more impulsive.
51:15They're chronically sleep deprived,
51:17which makes us more impulsive.
51:18We've seen this and sleep
51:21deprivation research.
51:22And folks that may be awake
51:24in the middle of the night.
51:27Hypervigilant and and having bad
51:29memories from things they've
51:30experienced in deployment and a
51:32lot of fear surrounding sleep.
51:34Oftentimes self treated with alcohol
51:36so it is not surprising that we see
51:39this kind of interaction between
51:41sleep disorders and alcohol use
51:43and circadian timing in a military
51:45population where most of the suicides
51:47are by firearms.
51:49Most of these suicides are happening
51:51early morning hours. Or later at night.
51:53So when people are at their circadian
51:55nadir and potentially intoxicated
51:57with alcohol.
51:58So you're you know,
51:59lowest amount of resilience in
52:01terms of cognitive function.
52:02No good decisions are made at
52:04two or three in the morning.
52:06I think anyone you know,
52:08a resident after cross Country knows that,
52:10but these are kind of a bunch
52:12of factors that come together to
52:14really increase the risk of suicide
52:17in our population.
52:18With that I know I only have 5
52:21minutes left and so sorry for going
52:23over a little bit, but please let
52:25me know if you have any questions.
52:29Thank you so much.
52:30That was a wonderful talk doctor Colin
52:33and just really a great overview
52:35of all these specific disorders.
52:37I have a question and there was a
52:40question in the chat related to the
52:42disability ratings that you alluded to
52:45for military members with sleep apnea.
52:47So my question is,
52:49you want to sing a little bit about
52:52what goes into that evaluation?
52:54As far as the temporal relationship
52:56between the onset of the OSA?
52:59Um and their military time and kind
53:02of how that decision is made that
53:06we decide this is service connected.
53:09And then the question from Amit
53:11Khanna and the chat was whether
53:14compliance with CPAP therapy
53:17impact that the disability,
53:19I guess payouts or rating.
53:23Great yeah so.
53:24This is definitely a phenomenon when
53:26people are separating from the service,
53:28especially my physician colleagues
53:29when they're about to retire there,
53:31like I need to get my sleep study
53:33'cause I'm about to get out,
53:35and I went to my retirement briefing
53:37and they said you gotta get your your
53:39sleep study so there is a big push
53:41to get it done before you separate,
53:43otherwise you end up with folks
53:45that are beneficiaries or veterans.
53:46Now coming back.
53:47That will sometimes say I need
53:49you to write a memo memo for
53:50me from you as a sleep doctor.
53:52Saying that you think that my sleep apnea
53:55curd like while I was on active duty,
53:57which there's no way you can,
53:59you can say, but in some cases,
54:01if you're desperate enough to
54:02get this person away from you or
54:04or they are persistent enough.
54:06I've been pushed into it,
54:07especially as a trainee,
54:09and it's tough because we want
54:10to help our veterans,
54:12but it's kinda dicey issue
54:13in terms of compliance.
54:14I've heard mixed things I've heard
54:16from some VA folks that if they've
54:18been prescribed CPAP and there's
54:20been documentation that they were
54:21using it at some point like,
54:23then that fits the bill and others.
54:25Where they're required to demonstrate an
54:27updated like 30 months of 30 day compliance.
54:30So when I'm seeing people
54:32for they go to the VA.
54:35Really wanting documentation
54:36that they were compliant and
54:38prescribed CPAP and nobody takes
54:40an oral appliance because of this.
54:42Yeah,
54:43so I have.
54:44I have a question that was a
54:47terrific presentation.
54:48One of the things I was always
54:50impressed when when seeing female
54:52patients at the VA for insomnia is
54:55that almost all of them had been
54:58raped while they were in the military.
55:01Has that been looked at systematically?
55:05Yes,
55:06and I'm not in an expert on it,
55:08but it's a huge issue in the
55:11military that's that's been studied
55:12and we have to do online trainings
55:15about sexual harassment and sexual
55:17assault and warning signs of sexual
55:19assault an from being on deployment.
55:21I can tell you that it's it
55:24is a very big problem.
55:27And even on some of the
55:29larger bases where there are.
55:31I remember when I was deployed to
55:33Afghanistan there were some sexual
55:35assaults that occurred in the women's
55:37bathroom facilities because they
55:38were unlocked and we run a NATO bassi
55:41of service members from all over the world.
55:43So you have like from different countries.
55:47Both American troops committing these
55:49acts and and foreign services too.
55:51And it's an issue in Garrison,
55:53like on base.
55:54You know not just deployed,
55:55but it's a huge issue in the military.
55:59Thank you. It's one of those things
56:02like weapons in the bedroom if you
56:04ask about it and not just female,
56:06but also Mail service members
56:07that it's a big issue.
56:08It's a bigger issue than people
56:10realize with male service members too,
56:11unfortunately.
56:13Jacob, this is Stuart man from
56:16Pacific Sleep Medicine.
56:17Thank you so much.
56:19You know, do you have a problem?
56:22I ask patients what time they get up.
56:26This is the Marines and they'll
56:27often say like 5 in the morning,
56:30although they don't have
56:31to report until seven.
56:32I said why you getting up at 5:00
56:34and they said they get their
56:36exercise during that period of time.
56:38Is that encouraged to get exercise
56:40that early in the morning?
56:42It is. It's so counterproductive in terms
56:44of like athletic performance literature
56:46where we know that like your peak, physical
56:49performance is probably late afternoon.
56:51You know whether it's powerlifting,
56:53sprinting or whatever you think of like
56:55your best performance for any sport is
56:58late afternoon, early evening, from.
56:59From what I've read.
57:01But there's this culture in the military.
57:03Hey, we get up and we do our PT,
57:06you know before the day starts and.
57:09And if you're on any military
57:11base around the country,
57:12you'll see platoons of soldiers
57:13out running at 5-6 in the morning,
57:15and then they usually afterwards
57:16they go shower, get breakfast,
57:18and then they kind of.
57:19They actually go into the office,
57:20so to speak.
57:21It you know nine 9:30 and then
57:23even once they're out of that,
57:24and they're not required to.
57:26They kind of just got into the habit of it,
57:28where they still do it.
57:31Great, thank you I think will end there and
57:34thank you again so much for a fantastic
57:36talk take of an and then just to let
57:39everybody know our talk for next week.
57:41We're going to have a talk by Jason
57:43Ellis who's a professor of psychology
57:45and the director of the Northumbria
57:48Center for Sleep Research in the UK.
57:50He's going to be speaking about,
57:52well is talk, is titled Wind Asleep,
57:54Become the enemy and I believe
57:56he's going to speak about acute
57:58insomnia so please join us for that
58:00and I'll see you all next week.
58:02Take care.
58:05Thanks for having me.
58:06Thanks again. Take care.
58:07I'll see you on the next committee
58:09call and whenever there's a few weeks.
58:13Take care.