Family practitioners
waking up to sleep disorders
BY MIKE GOODKIND
Until every primary care
physician in the United States recognizes and responds to
the signs of life-depleting sleep disorders, Dr. William
C. Dement believes his work will be unfinished.
Dement, director of
Stanford's Sleep Disorders Clinic and Research Center,
took that message to Washington last month. Testifying on
March 26 before the House Subcommittee on Health and
Environment, he said sleep disorders represent one of the
nation's most serious health problems.
"The magnitude of
suffering that results from sleep disorders is so large
as to be almost incomprehensible," said Dement, who
holds the Lowell and Josephine Berry Professorship in
Psychiatry and Behavioral Sciences. He has estimated that
sleep disorders cost the U.S. economy more than $100
billion a year, including lost productivity.
Yet many physicians do not
take the time to recognize the signs of sleep disorders,
including such maladies as obstructive sleep apnea,
narcolepsy and insomnia, he said. Dement believes primary
care doctors should look for, and can successfully treat,
many sleep disorders.
He and Stanford colleagues
have worked with primary care doctors in Walla Walla,
Wash., and Moscow, Idaho, to establish pilot sleep
programs there. The Stanford physicians have been working
closely with physicians and other caregivers in the two
target cities, providing education and consultation as
needed to help local professionals gain the hands-on
experience necessary to provide care independently.
These efforts are part of
a National Primary Care Project funded by private
corporations and a variety of nonprofit foundations.
Dement is the principal investigator of the project,
which is currently expanding to a third site at Alamo
Clinic in Alamo, Calif.
"Our goals include
educating and training a group of primary care physicians
in the diagnosis and treatment of sleep disorders and
also, based on what we are learning, to devise a national
strategy to treat sleep disorders," he said. In
addition, the pilot programs are providing an important
base for much-needed research into sleep disorders, said
Dement, who in the early 1990s chaired the
congressionally appointed National Commission on Sleep
Disorders Research.
These and other studies at
the grassroots level are helping to uncover the
prevalence of sleep disorders, said Dr. Clete Kushida,
senior research scientist and Dement's associate on the
Walla Walla and Moscow projects. A Stanford collaborative
study of 975 patients in Moscow found that 32 percent
suffered from insomnia, 19 percent from sleep apnea and
25 percent from restless legs syndrome, which prevents
sufferers from lying quietly in bed. The detailed patient
surveys, completed in early March, are being compiled for
the Stanford researchers, who hope to publish their
findings in about a year, said Kushida, who also serves
as a staff physician at the Sleep Disorders Clinic.
"This was a typical
group of patients in a rather typical American community.
Relatively few of these patients probably need a referral
to a specialty clinic. Many of these patients are being
helped or cured with relatively simple measures, such as
a simple breathing device, short-term medication or even
educational counseling," said Kushida.
"Treating most
sleep-disorder patients is not difficult as long as
physicians recognize the symptoms," he added.
"Our job as sleep specialists is also basic: to help
our colleagues in family practice understand the warning
signs of sleep deprivation, apnea and more sophisticated
sleep problems."
Dement said he's gratified
with the work in Walla Walla and Moscow because "an
infrastructure of high-quality sleep medicine has taken
root there." Dr. Richard Simon at Walla Walla Clinic
is now the area's first board-certified sleep medicine
specialist and is able to treat the most complex cases.
In Moscow, Dr. John Grauke, medical director of the
nearly two-year-old sleep center there, is keeping his
colleagues informed about the need to screen for sleep
disorders. In both towns, the local hospital and clinic
have invested in equipment to evaluate conditions such as
sleep apnea.
Throughout 1997, the
Gritman Sleep Center in Moscow conducted 120 nighttime
sleep studies using a polysomnograph, which tracks
irregularities in breathing that trigger wakefulness.
Walla Walla's Kathryn Severyns Dement Sleep Disorders
Center (named after Dement's mother) has offered
treatment to more than 2,000 patients in a community of
23,000. "I'd call this the healthy sleep capital of
the world," Dement said.
The Walla Walla
relationship began in 1992 after Dement, looking for a
professional reason to spend more time in his hometown,
walked into the clinic there and "fortuitously found
a copy of my textbook on Dick Simon's office shelf."
Simon, who continues to
practice internal medicine, said he recently reviewed the
records of patients he had seen since 1983 and was
surprised to find that a significant number of those
whose initial diagnosis was fatigue or hypertension were
later found to suffer from an underlying sleep disorder.
Of the 857 patients he has
tracked since 1983, 8.5 percent have sleep apnea, he
said. "I don't take snoring [a potential sign of
sleep apnea] lightly," Simon said. "Physicians
need to ask questions." Among those questions should
be whether the patient suffers from telltale signs of
apnea, such as constant fatigue or heavy snoring often
interrupted by silence and then gasps.
"One of the most
gratifying results of my work," said Dement,
"is that patients who never knew why they were so
sick are finally getting sufficient sleep. Some patients
who simply thought they were old, fatigued and sapped of
energy are able to function successfully at work for the
first time in years and are able to enjoy their
lives."
A case in point is Moscow
patient Gloria Barker, 42, who until a few months ago
woke up an average of 111 times each night. Her snoring,
caused by an obstructed airway, was so severe that her
husband refused to sleep with her. Her apnea was
diagnosed at the Gritman Sleep Center, and she was fitted
with a continuous positive airway pressure (CPAP)
machine, which delivers a small amount of air pressure
through a mask over the nose to prevent blockage of the
airway.
The results were almost
instantaneous, Barker said. "This machine is
wonderful. ...It's been wonderful for my family." SR
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