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QUARTER TWO 2019 / VOLUME 28 / NUMBER 02
Alzheimer’s
Disease
Biomarkers
in Children With OSA
WHAT’S INSIDE
Sleep Disturbances Associated
With Post-Traumatic Stress Disorder
The Start School Later Movement:
Putting Sleep Health on the National Radar
How to Survive a BRPT Audit
Support Groups in Sleep Disorders Medicine
FULL PAGE AD
Table of Contents
QUARTER TWO 2019
VOLUME 28 / NUMBER 02
Alzheimer’s Disease Biomarkers in
Children With OSA
By Regina Patrick, RPSGT, RST
Various studies have indicated that obstructive sleep apnea (OSA) is
associated with an increased risk of developing Alzheimer’s disease
and that people with OSA have increased levels of certain biomarkers
(e.g., amyloid beta protein) associated with Alzheimer’s disease.
Scientists have recently noted increased levels of biomarkers
associated with Alzheimer’s disease in young children with OSA.
09
Sleep Disturbances Associated With Post-Traumatic Stress Disorder 14
By Shana Hansen, Lt. Col., USAF, MC, and Shannon N. Foster, Major, USA, MC
The Start School Later Movement: Putting Sleep Health on the National Radar 17
By Terra Ziporyn Snider, Ph.D.
How to Survive a BRPT Audit 19
By Jessica Schmidt, MA, FACHE, RPSGT, CCSH, and Rita Brooks, MEd, RPSGT, REEG/EPT, FAAST
Support Groups in Sleep Disorders Medicine 22
By Kimberly Trotter, MA, RPSGT
DEPARTMENTS
President & Editor’s Message – 07
Trends – 24
Compliance Corner – 26
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QUARTER TWO 2019
VOLUME 28 / NUMBER 02
THE OFFICIAL PUBLICATION OF AAST
ABOUT A 2Zzz CONTRIBUTORS
A2Zzz is published quarterly by AAST. DISCLAIMER EDITOR
The statements and opinions contained Rita Brooks. MEd, RPSGT, REEG/
SUBMISSIONS
in articles and editorials in this magazine EPT, FAAST
Original articles submitted by AAST are solely those of the authors thereof
members and by invited authors will be and not of AAST. The appearance of MANAGING EDITOR
considered for publication. Published products and services, and statements Alexa Schlosser
articles become the permanent property contained in advertisements, are the sole
of AAST. responsibility of the advertisers, including SENIOR WRITER
any descriptions of effectiveness, quality or Regina Patrick, RPSGT, RST
PERMISSION TO USE AND REPRODUCE
safety. The editor, managing editor, AAST,
A2Zzz is published quarterly by AAST, CONTRIBUTING WRITERS
and the organization’s officers, regents,
all rights reserved. Permission to copy Shana Hansen, Lt. Col., USAF, MC
members and employees disclaim all
or republish. A2Zzz material is limited Shannon N. Foster, Major, USA, MC
responsibility for any injury to persons or
by restrictions. Jessica Schmidt, MA, FACHE,
property resulting from any ideas, products
or services referred to in articles or RPSGT, CCSH
ADVERTISING
advertisements in this magazine. Kimberly Trotter, MA, RPSGT
Advertising is available in A2Zzz. Please Matthew Anastasi, BS, RST, RPSGT
contact the AAST national office for SUBMIT AN ARTICLE TO A 2ZZZ
information concerning A2Zzz rates and ART DIRECTOR
Share your expertise with colleagues in Bill Wargo
policies, or find more details online at
the profession of sleep technology by
www.aastweb.org.
submitting an original article to A2Zzz. GRAPHIC DESIGNER
Read the A2Zzz Writer’s Guidelines at Alaina Kornfeld
www.aastweb.org/publication-info. To
propose an article topic or to get more
information, send an email to
A2Zzz@aastweb.org.
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A2Zzz@aastweb.org | www.aastweb.org
© 2019 AAST
AAST THANKS ITS PRESTIGE PARTNERS
Quarter Two 2019 A2Zzz 5
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President & Editor’s Message
Roles and Responsibilities
By Rita Brooks, MEd, RPSGT, REEG/EPT, FAAST
As I look back over my career in sleep organization does what or the rules. a popular feature that provides practical
medicine and technology, I realize just We strive to always provide accurate and thought-provoking information. Our
how far we have come in the past 30 information that supports our profession, Compliance Corner feature, authored
years, as well as how far we have to go and, as such, Jessica Schmidt, BRPT by Laura Linley, CRT, RPSGT, FAAST,
to define who we are and our roles as president, and I revised that article to continues to provide valuable regulatory
sleep professionals. As interest in sleep assure that accurate information on an information that is focused on providing
and availability of information expand, important topic for our members and
timely information applicable to our field.
our roles as educators and providers of credential holders is available. I hope you
These features and our articles highlight
information also expand. Along with this will review this article and learn from it, as
the changes that have been occurring
come responsibilities. Research into why well as pass on accurate information to
and that will continue to occur as our field
we sleep and the health consequences those you interact or work with.
of insufficient or disordered sleep is grows and our roles in the sleep medicine
AAST has always focused on education —
providing new avenues for our exploration arena grow and change. Keep abreast of
bringing you high quality current
and learning. As professionals, we are the changes!
educational offerings to assist you to
responsible for remaining current in our further your knowledge and flourish in The AAST Program Committee is hard at
knowledge and providing education that is your profession. Many new educational work on preparing our 2019 AAST Annual
current and useful — in all of our roles. initiatives are underway at AAST, fueled Meeting program. This year’s meeting in
It is also our responsibility, as by new and essential knowledge that St. Louis is scheduled for Sept. 6-8, and
professionals, to know the players and the supports our professionals and addresses registration is open. The committee has
rules in our field. There is, unfortunately, expanding educational needs. As editor, prepared an exciting program that includes
much misinformation available, I am pleased to see that each new issue a variety of topics that are sure to interest
particularly regarding the rules in our of A2Zzz addresses some aspect of new attendees, along with some workshops
field and the processes that surround our findings in sleep research. This issue is
and a special offering for those who are
credentialing and licensing. We pulled the no exception, with fascinating articles
interested in qualifying to sit for the CCSH
original article entitled “How to Survive on a possible connection between OSA
credential examination under a new
a BRPT Audit” from the last issue of in children and Alzheimer’s disease and
RPSGT eligibility pathway.
A2Zzz because of just this; it contained research surrounding post-traumatic
misinformation provided by those in stress disorder (PTSD) that led to a AAST is pleased to present out first CCSH-
the field who do not understand which proposal for a new parasomnia with focused education program as a full-day
unique features called trauma-associated program on Sept. 6 in St. Louis.
sleep disorder (TSD). Offerings such as
I hope you will review the offerings at this
these provide opportunity for continued
year’s meeting and join us in St. Louis. The
It is also our learning that assists us to grow and to
keep up with the latest information in
CCSH program is offered as a separate,
all-day certificate program; however, it can
our field.
responsibility, as This issue of A2Zzz contains a new
be bundled with meeting registration at a
discounted rate. If you attend the meeting
feature called Trends. This column,
professionals, to authored by Matthew Anastasi, BS,
and/or the CCSH program, you will be
well prepared for the challenges of the
RST, RPSGT, will focus on leading-edge
know the players developments in the field and offer
practical advice that you can use in
continued advances in the profession. I
look forward to seeing you at the meeting
and the rules in your own sleep center or practice. This
issue, the column provides information
this year!
Wishing you all a wondrous spring!
useful to those who are seeing higher-
our field. acuity patients in the sleep laboratory,
Sleep well!
which is most of us. I expect this to be Rita
Quarter Two 2019 A2Zzz 7
Instructions for Earning Credit
AAST members who read A2Zzz and claim their credits online by STATEMENT OF EDUCATIONAL PURPOSE & OVERALL
the deadline can earn 2.00 AAST Continuing Education Credits EDUCATIONAL OBJECTIVES
(CECs) per issue, for up to 8.00 AAST CECs per year. AAST CECs A2Zzz provides current sleep-related information that is relevant
are accepted by the Board of Registered Polysomnographic to sleep technologists. The magazine also informs readers about
Technologists (BRPT) and the American Board of Sleep recent and upcoming activities of the AAST. CEC articles should
Medicine (ABSM). benefit readers in their practice of sleep technology or in their
To earn AAST CECs, carefully read the four designated CEC management and administration of a sleep disorders center.
articles listed below and claim your credits online. You must go
READERS OF A 2ZZZ SHOULD BE ABLE TO DO
online to claim your credits by the deadline of Aug. 15, 2019.
THE FOLLOWING:
After the successful completion of this educational activity, your
• Analyze articles for information that improves their
certificates will be available in the My CEC Portal acknowledging
understanding of sleep, sleep disorders, sleep studies and
the credits earned.
treatment options
COST • Interpret this information to determine how it relates to the
The A2Zzz continuing education credit offering is an exclusive practice of sleep technology
learning opportunity for AAST members only and is a free benefit • Decide how this information can improve the techniques and
of membership. procedures that are used to evaluate sleep disorders patients
STATEMENT OF APPROVAL and treatments
This activity has been planned and implemented by the AAST • Apply this knowledge in the practice of sleep technology
Board of Directors to meet the educational needs of sleep You must go online to claim your CECs by the deadline of
technologists. AAST CECs are accepted by the Board of Aug. 15, 2019.
Registered Polysomnographic Technologists (BRPT) and the
American Board of Sleep Medicine (ABSM). Individuals should only
claim credit for the articles that they actually read and evaluate for
this educational activity.
READ AND EVALUATE THE FOUR FOLLOWING ARTICLES TO EARN 2.0 AAST CECS:
Alzheimer’s Disease Sleep Disturbances The Start School Later How to Survive a
Biomarkers in Children Associated With Movement: Putting BRPT Audit
With OSA Post-Traumatic Sleep Health on the Objective: Readers
Objective: Readers Stress Disorder National Radar should understand
should understand the Objective: Readers should Objective: Readers should their recertification
factors that contribute understand the sleep understand the current responsibilities and the
to neuronal damage and patterns that correlate science behind adolescent recertification audit.
destruction as it relates to with combat veterans who sleep needs and the trend
Alzheimer’s disease. have PTSD. toward pushing start-time
policies that align with
those needs.
Quarter Two 2019 A2Zzz 8
Alzheimer’s Disease Biomarkers
IN CHILDREN WITH OSA
By Regina Patrick, RPSGT, RST
Read more
T
he neurocognitive disorder Alzheimer’s disease affects an estimated 5 Alzheimer’s disease, tau proteins detach
million Americans.1 Its prevalence is expected to triple by 2060.1,2 People from microtubules and instead stick to other
affected by Alzheimer’s disease have increasing problems with memory, tau molecules, thereby forming threads
judgment and daily tasks of living as the disease progresses. Various that eventually join to form tangles within
studies have indicated that obstructive sleep apnea (OSA) is associated a neuron. These tangles hinder neuronal
with an increased risk of developing Alzheimer’s disease and people processes (e.g., the transport of nutrients),
with OSA have increased levels of certain biomarkers (e.g., amyloid beta protein) linked which damages the neurons and contributes
to Alzheimer’s disease.3-5 Scientists have recently noted increased levels of biomarkers to neuronal death. Exactly what causes
associated with Alzheimer’s disease in young children with OSA. plaque and neurofibrillary tangles to form in
Alzheimer’s disease is named after psychiatrist and neuropathologist Alois Alzheimer.6 In the Alzheimer’s brain remains unknown. A
1906, Dr. Alzheimer reported his experience with a 51-year-old woman, “Auguste D,” who possibility is that these changes may result
had what he called “presenile dementia.” Over a five-year period, Dr. Alzheimer recorded from a complex interplay between abnormal
forms of tau proteins and amyloid beta
her symptoms of progressive cognitive impairment, reduced comprehension and memory,
protein or other factors.13
aphasia, disorientation, unpredictable behavior, paranoia, auditory hallucinations and
psychosocial impairment.7 An autopsy of her brain revealed plaques and neurofibrillary
tangles, which Alzheimer described as follows:
“In the center of an otherwise almost normal cell there stands out one or several fibrils
due to their characteristic thickness and peculiar impregnability ... Numerous small miliary
Approximately
foci [now called plaques] are found in the superior layers. They are determined by the
storage of a peculiar material in the cortex [now called amyloid beta protein].”7
200,000
He later reported three more cases of patients with presenile dementia whose brains
showed similar findings at autopsy. After Alzheimer’s 1906 report, other physicians began
Americans under
reporting similar brain changes in patients with dementia similar to that of Auguste D.7,8
In 1909, Emil Kraepelin, who was a colleague of Alzheimer, first used the term “Alzheimer
the age of 65
disease” in a psychiatry textbook.
Alzheimer’s disease accounts for most cases of dementia. Dementia (i.e., a dysfunction
have early-onset
in mental processes caused by brain disease or injury) manifests as memory problems,
personality changes and impaired reasoning. Symptoms of Alzheimer’s disease typically
Alzheimer’s
begin with mild memory loss or impaired judgement. As it progresses, a person loses
the ability to carry on a conversation, to respond to the environment and to perform daily
disease.
activities. It typically occurs in elderly people, but it can begin in people younger than 65
years old (i.e., early-onset Alzheimer’s disease),6 and has even been diagnosed in people
as young as in their 30s9 and 40s.10 Approximately 200,000 Americans under the age of 65 Inflammation
have early-onset Alzheimer’s disease.11 Inflammation is associated with an
In Alzheimer’s disease, neurons and their connections are increasingly destroyed because increased number of glial cells in the
of the presence of plaques (composed mostly of amyloid proteins), neurofibrillary tangles brain.4,5 In the healthy brain, glial cells
and inflammation. Each of these factors contributes to neuronal damage and destruction, normally remove waste and toxins. For
as follows. example, one type of glial cell, called a
microglia, engulfs and destroys waste and
Plaques toxins. In the Alzheimer’s brain, microglia
collect around neurons but do not clear
Plaques in the brains of people with Alzheimer’s disease contain amyloid proteins. debris such as amyloid beta plaques. The
(The term “amyloid” is based on the Greek word amylo, meaning “starch”; they were so cells instead release chemicals that cause
named because the substances were mistaken as being a type of starch rather than chronic inflammation and further damage
protein.) Alterations in the molecular shape of amyloid proteins — in particular, amyloid the neurons they would normally protect.
beta proteins — have been associated with Alzheimer’s disease.1,12,13 An amyloid plaque Why the microglial cells do not remove
consists of several strands, called “beta strands.” The binding of two or more beta strands waste is unclear.13
form a beta sheet (i.e., plaque). Amyloid plaque collects outside neurons and disrupts cell
Neurodegenerative and inflammatory
function. The two most common forms of amyloid beta protein involved in Alzheimer’s
changes noted in Alzheimer’s disease have
disease are amyloid beta 40 and amyloid beta 42. The latter is especially toxic to neurons.
also been noted in people who have OSA,
In the Alzheimer’s brain, strands of beta-amyloid 42 clump together to form plaques.
a sleep disorder in which a person stops
breathing (i.e., has apnea) intermittently
Neurofibrillary tangles during sleep. The cessation in sleep occurs
Neurofibrillary tangles result from an abnormal accumulation of a protein, called tau, within because upper airway structures collapse
a neuron. In healthy neurons, tau normally binds to and stabilizes microtubules, which are into the airway and block airflow. The
tubular structures that help transport nutrients and other molecules throughout a neuron. In blood oxygen level consequently falls. The
Quarter Two 2019 A2Zzz 10respiratory center in the brain ultimately induces a brief arousal during which a person takes The pathophysiological processes that
a few deep breaths to restore the blood oxygen level. Once the oxygen level is restored, contribute to Alzheimer’s disease begin
the person resumes sleep. In people with OSA, disrupted sleep caused by respiratory- long before the disease manifests. Once
related arousals and hypoxia have both been associated with cognitive impairment and symptoms are apparent, the disease has
neurodegenerative changes in brain regions involved in learning and memory.14 no cure. Reducing the risk factors for
In children, obesity is associated with an increased risk of having OSA.15 Obesity and OSA Alzheimer’s disease could theoretically
are both associated with an increased risk of developing Alzheimer’s disease.4,5 With this in reduce its prevalence. The findings that
mind, Keirandish-Gozal and colleagues14 examined whether obese children with OSA would pathophysiological changes associated
have increased plasma levels of two biomarkers for Alzheimer’s disease: amyloid beta 42 with Alzheimer’s disease can occur
and presenilin 1. The mean age of the children in the study was approximately 7 years. in young children with OSA and that
Plasma samples were obtained from healthy children who had obesity only, OSA only, OSA treating OSA reduces these changes are
and obesity (OSA + OB), or no OSA or obesity (i.e., the control group). Plasma samples were interesting. These findings could potentially
also obtained from children with OSA who had undergone adenotonsillectomy. The amyloid be important in preventing or delaying
beta 42 and presenilin levels were similar between the obese children and the control group. the development of Alzheimer’s disease.
Compared to these two groups, children with OSA only, but more so children with OSA + For example, treating OSA in children or
OB, had significantly higher levels of the two biomarkers. In the subgroup of children that
reducing childhood obesity may help to
had undergone adenotonsillectomy, the levels of amyloid beta 42 and presenilin 1 were
maintain or restore normal biochemical
significantly reduced. The researchers concluded that OSA — in particular, OSA + OB —
processes in the brain (e.g., the interaction
increased the plasma levels of the biomarkers, whereas weight did not seem to increase the
between tau protein and amyloid beta
level of the biomarkers, and that OSA treatment reduced the levels of the biomarkers.
protein) and thereby prevent or delay the
However, some research indicates weight may have an impact on the levels of biomarkers development of Alzheimer’s disease. Future
of Alzheimer’s disease. In a study of preschoolers and adolescents of various weights (i.e.,
research may determine the extent that
normal, overweight, obese), Luciano et al.16 demonstrated a correlation existed between
treating OSA in children and/or reducing
weight and amyloid beta 42 and presenilin levels in the total sample: the highest levels of
childhood obesity can prevent or delay the
amyloid beta 42 and presenilin 1 were in the obese children, followed by (in decreasing
development of Alzheimer’s disease.
order) overweight children and normal weight children. When evaluating the preschooler
and adolescent groups separately, the trend of increasing levels of the biomarkers with
increasing weight was more pronounced in the adolescents than in the preschoolers. References
However, because of certain methodological problems in the study (e.g., the use of 1. Centers for Disease Control and Prevention.
preschoolers and adolescents but not children between these age ranges, which may Alzheimer’s Disease and Healthy Aging.
have impacted the results), Luciano is uncertain of the clinical importance of the findings https://www.cdc.gov/aging/aginginfo/
and encourages more research. alzheimers.htm. Accessed March 11, 2019.
2. Matthews KA, Xu W, Gaglioti AH, et al. Racial
and ethnic estimates of Alzheimer’s disease
and related dementias in the United States
Once symptoms are apparent, the (2015-2060) in adults aged >/=65 years.
Alzheimer’s and Dementia. 2019;15:17-24.
disease has no cure. Reducing the risk 3. Ancoli-Israel S, Palmer BW, Cooke JR, et al.
Cognitive effects of treating obstructive sleep
factors for Alzheimer’s disease could apnea in Alzheimer’s disease: a randomized
controlled study. Journal of the American
Geriatric Society. 2008;56:2076-2081.
theoretically reduce its prevalence. 4. Daulatzai MA. Pathogenesis of cognitive
dysfunction in patients with obstructive
Quarter Two 2019 A2Zzz 11sleep apnea: a hypothesis with emphasis on the nucleus tractus solitarius. Sleep Disorders. 14. K
heirandish-Gozal L, Philby MF, Alonso-
2012;2012:251096. Alvarez ML, et al. Biomarkers of Alzheimer
disease in children with obstructive sleep
5. Daulatzai MA. Evidence of neurodegeneration in obstructive sleep apnea: Relationship between
apnea: effect of adenotonsillectomy. Sleep.
obstructive sleep apnea and cognitive dysfunction in the elderly. Journal of Neuroscience Research.
2016;39:1225-1232.
2015;93:1778-1794.
15. M
athew JL, Narang I. Sleeping too close
6. National Institure on Aging. Alzheimer’s disease fact sheet 2019; https://www.nia.nih.gov/health/ together: obesity and obstructive sleep
alzheimers-disease-fact-sheet. Accessed 3/29/2019. apnea in childhood and adolescence.
7. Maurer K, Volk S, Gerbaldo H. Auguste D and Alzheimer’s disease. Lancet. 1997;349:1546–1549. Paediatric Respiratory Reviews.
2014;15:211-218.
8. Hippius H, Neundorfer, G. The discovery of Alzheimer’s disease. Dialogues in Clinical
16. L
uciano R, Barraco, GM, Muraca M.
Neuroscience. 2003;5:101-108.
Biomarkers of Alzheimer disease, insulin
9. Um YH, Choi WH, Jung WS, et al. Case report of a 37-year-old Alzheimer’s disease patient with resistance, and obesity in childhood.
prominent striatum amyloid retention. Psychiatry Investigations. 2017;14:521-524. Pediatrics. 2015;135:1074-1081.
10. N
ikisch G, Hertel A, Kiessling B, et al. Three-year follow-up of a patient with early-onset
Alzheimer’s disease with presenilin-2 N141I mutation - case report and review of the literature.
European Journal of Medical Research. 2008;13:579-584. REGINA
PATRICK,
11. A
lzheimer’s Association. What is Alzheimer’s? https://www.alz.org/alzheimers-dementia/what-
RPSGT, RST, has
is-alzheimers.
been in the sleep
12. C
enters for Disease Control and Prevention (US Department of Health and Human Services). field for more than
Alzheimer’s disease and related dementias. 2019; https://www.cdc.gov/aging/aginginfo/ 20 years and
alzheimers.htm. works as a sleep
13. N
ational Institute on Aging (National Institutes of Health). Causes of Alzheimer’s disease: what technologist at the
happens to the brain in Alzheimer’s disease? 2019; https://www.nia.nih.gov/health/what- Wolverine Sleep Disorders Center in
happens-brain-alzheimers-disease. Tecumseh, Michigan.
Quarter Two 2019 A2Zzz 12AAST Learning Center Your One-Stop Shop for Online Education The AAST Learning Center is accessible 24/7 and provides you with on-demand videos, advanced learning modules that you can start and stop on your schedule, conference recordings and more! Discover relevant educational content by searching by content type or topic area and access the Case of the Month, Journal Club and A2Zzz CECs all through the AAST Learning Center. Get started by checking out the latest offerings, including the AAST 2018 Annual Meeting Recordings.
Sleep Disturbances Associated With
Post-Traumatic Stress Disorder
By Shana Hansen, Lt. Col., USAF, MC, and Shannon N. Foster, Major, USA, MC
Post-traumatic stress disorder (PTSD) in this population are often resistant to first-line PTSD treatment.12 Sleep-specific
is a trauma and stress-related disorder interventions are commonly employed to alleviate insomnia and nightmares. Effective
characterized by re-experiencing, treatment has been associated with improved daytime PTSD symptoms, depression,
avoidance, hyperarousal and negative quality of life and subjective physical health.13,14,15
alterations in cognition or mood.1 Events
that involve threat to integrity of self or Nightmares
others such as rape, physical assault,
Nightmares are characterized by disturbing, well-remembered dreams that cause
natural disasters and combat exposure
distress or daytime impairment (ICSD). Nightmares in the general population are not
are commonly associated with the
uncommon, with up to 85% of adults reporting at least one nightmare per year.16 In
development of PTSD.1 The lifetime
patients with PTSD and psychiatric disorders, occurrence of nightmares is much more
prevalence of PTSD among adults in the
common.17 Additionally, nightmares are associated with an increased risk of suicidal
United States ranges from 6-10%,2,3 with
ideation.18,19 Despite this, nightmares are frequently under-reported by patients and thus
women being more than twice as likely
under-recognized by clinicians.17 The high prevalence of PTSD and psychiatric disorders
to have PTSD at some point. Significantly
in military personnel leads to an even higher rate of nightmares. In military personnel
higher estimates have been reported in
referred for a sleep evaluation, nightmares at least weekly were reported in 31%, which
combat veterans (15-30%).4 Rates of
is significantly higher than the general population of 0.9-6.8%.17 Treatment options
PTSD in veterans are higher if they were
for nightmares include a combination of behavioral techniques and medical therapy.
stationed in combat zones, had tours
Imagery rehearsal therapy (IRT) is a technique where patients are taught to “rescript” their
of longer than one year, experienced
nightmares and thus unlearn the behavior.20 This therapy has been successful in combat
combat or were injured. Specifically,
veterans as well civilian trauma victims.13,21 A variation of IRT, called exposure, rescripting
among veterans with deployments to Iraq
and relaxation therapy (ERRT) incorporates aspects of traditional cognitive behavioral
and Afghanistan, 31-86% report multiple
therapy (CBT) with IRT.22 A combination of CBT for insomnia and IRT shows promising
traumatic combat exposures and 11-20%
short-term effects in veterans with PTSD.23 Finally, pharmacologic therapy with prazosin
endorse significant PTSD symptoms.5,6
or positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA)
can also be successful in nightmare patients.24,25
Sleep Disturbances
Associated With PTSD Trauma-Associated Sleep Disorder
Following traumatic experiences, sleep In a subset of PTSD patients, trauma-related nightmares (TRN) are accompanied by
complaints are common. Subjective parasomnias.26 Trauma-associated sleep disorder (TSD) is a recently proposed unique
and objective sleep disturbances are parasomnia that describes the clinical features of TRNs in association with disruptive
associated with an increased risk of nocturnal behaviors (DNBs).27,28 DNBs consist of abnormal vocalizations (screaming,
meeting PTSD diagnostic criteria,7 and groaning) and movements (thrashing, turning, sleepwalking) as well as combative
insomnia and nightmares are core behaviors (striking or kicking bed partner). It is not uncommon for the DNBs to mimic
diagnostic features of PTSD.1 Sleep terrors, nightmare content. Autonomic hyperarousal signs (increased heart rate, quickened
sleep avoidance, nocturnal anxiety, acting breathing, night sweats) are often linked with these behaviors. Polysomnogram (PSG)
out dreams, increased motor behaviors evaluation commonly shows dream re-enactment behavior and increased muscle activity
and vocalizations are also frequently during REM (REM without atonia). Nightmares are almost universally reported in these
reported by PTSD patients.8,9 These sleep patients.28 TSD may also present along with insomnia and OSA. Therefore, in patients
disturbances are known to exacerbate who present with symptoms of TSD, a PSG is recommended to look for sleep disordered
daytime symptoms and contribute to breathing (SDB) in addition to evaluating whether the patient has abnormal REM behavior
worsened clinical outcomes.10,11 This and/or movements. Currently, no evidenced-based guidelines for treatment of this newly
stresses the importance of monitoring for proposed sleep disorder are available. Obtaining an adequate quantity of sleep, avoiding
the development of sleep disturbances in triggers and promoting a safe sleep environment are critical. In some cases, medical
patients with trauma history and the role therapy to suppress these events may be necessary. Some patients respond well to
they may have as mediators for clinical a combined treatment with prazosin for nightmares and DNB, behavioral therapy for
outcomes in PTSD. Sleep disturbances insomnia and PAP therapy for OSA.29
Quarter Two 2019 A2Zzz 14Thus, PSG should be considered in PTSD
OSA prevalence is higher in PTSD patients with sleep disturbances, especially
if resistant to initial treatment. PAP therapy
can improve daytime functioning as well
patients than the general population. as PTSD symptoms, but compliance is
generally low. Evaluation and treatment of
sleep disorders should be an integral part
of PTSD treatment in order to limit their
Insomnia adverse effect on daytime symptoms and
Insomnia is the most common sleep complaint in civilian as well as military populations overall functioning.
(MSMR 2013). It is also the most reported symptom among service members returning from
deployment and in combat veterans with PTSD.30 Up to 74% of combat veterans with PTSD References
meet clinical criteria for insomnia.31 In addition, veterans who have experienced sexual trauma 1. American Psychiatric Association. Diagnostic
have higher rates of insomnia symptoms (61%) than veterans who did not experience trauma and statistical manual of mental disorders
(53%).32 Insomnia is associated with higher PTSD severity and does not tend to resolve (DSM-V), 5th ed. Arlington, VA: American
spontaneously over time.31 Treatment options for insomnia in patients with PTSD are similar Psychiatric Association: 2013.
to those for the general population. However, insomnia in PTSD patients can be complicated 2. Harvard Medical School, 2007. National
by their symptoms of PTSD as well as comorbid sleep disorders and unhealthy sleep Comorbidity Survey (NCS). (2017, August
practices. CBT improves sleep quality as well as daytime PTSD symptoms in this population.33 21). Retrieved from https://www.hcp.med.
In addition, combined therapy of CBT and IRT can be beneficial in those patients with harvard.edu/ncs/index.php.
comorbid nightmares.23 There are currently no evidence-based guidelines on pharmacologic 3. Kilpatrick D, Resnick H, Milanak M, et al. National
treatment of insomnia in the PTSD population due to lack of quality studies.33 While PSG is estimates of exposure to traumatic events and
not routinely recommended by the American Academy of Sleep Medicine (AASM) in chronic prevalence using DSM-IV and DSM-5 Criteria. J
of Trauma Stress. 2013;26(5):537-54.
insomnia patients, patients with PTSD have high rates of comorbid sleep disorders, such as
OSA and periodic limb movement disorders.13,34 PSG should be considered in PTSD patients 4. Weiss D, Marmar C, Schlenger W, et al. The
prevalence of lifetime and partial post-
with insomnia, especially if standard insomnia treatment fails.26
traumatic stress disorder in Vietnam theater
vetarans. J Trauma Stress 1992;5:365-76.
Sleep-Disordered Breathing 5. Ramchand R, Schell TL, Karney BR, Osilla
While insomnia and nightmares have been the most frequently reported sleep symptoms in KC, Burns RM, Caldarone LB. Disparate
PTSD literature, recently, more attention has been given to the prevalence and significance prevalence estimates of PTSD among
of SDB in PTSD patients. SDB, most commonly in the form of OSA, affects 9-38% of the service members who served in Iraq and
adult population,35,36 with higher estimates among men, the elderly and obese populations. Afghanistan: possible explanations. J Trauma
Stress. 2010;23(1):59–68.
In addition, OSA rates of up to 60-85% have been reported in military samples.37,38 Further,
recent literature indicates that individuals with PTSD have a disproportionately higher 6. Hoge C, Castro C, Messer S, etc al. Combat
duty in Iraq and Afghanistan, mental health
rate of SDB than the general population,39,40 with rates of co-morbid PTSD and OSA (15-
problems, and barriers to care. N Engl J Med
90%) being reported, depending on diagnostic methodology used. Krakow et, al. proposed
2004;351(1):13-22.
a novel hypothesis involving a bidirectional pathway to explain why high rates of sleep
7. Koren D, Arnon I, Lavie P, et al. Sleep complaints
breathing disorders among PTSD patients have been observed.40 In this pathway, the
as early predictors of posttraumatic stress
sleep fragmentation (nightmares, insomnia) seen in PTSD affects the airway, causing disorder: a 1-year prospective study of injured
upper airway collapsibility and SDB events. These events further fragment sleep, leading to survivors of motor vehicle accidents. Am J
exacerbation of insomnia and nightmares, which worsens overall PTSD symptoms. This Psychiatry 2002;159(5):855-7.
may have clinical implications for a subgroup of PTSD patients who also suffer from SDB, 8. Germain A, Hall M, Krakow B, et al. A brief
and more research is needed in order to clarify best diagnostic and treatment practices. sleep scale for posttraumatic stress disorder:
Studies evaluating treatment in patients with comorbid PTSD and SDB suggest that positive Pittsburgh Sleep Quality Index Addendum for
airway pressure therapy (PAP) may improve sleep by decreasing sleep fragmentation PTSD. J Anxiety Disord 2005;19(2)233-44.
and nightmares.41,24 Unfortunately, patients with PTSD typically have suboptimal PAP 9. Krakow B, Melendrez D, Pederson B, et al.
adherence.42,43 Due to the potential adverse outcomes of comorbid mental illness and sleep Complex insomnia: insomnoia and sleep-
disorders, including suicide, interventions should begin early.44 disordered breathing in a consecutive series
of crime victims with nightmares and PTSD.
Conclusion Biol Psychiatry 2001;49(11):948-53.
10. K
rakow B, Artar A, Warner T, et al. Sleep
Sleep disturbances are prevalent in patients with PTSD and are often resistant to standard disorder, depression, and suicidality in
first-line treatments. This can lead to worsening of PTSD symptoms and poorer clinical female sexual assault survivors. Crisis
outcomes. Insomnia and nightmares are the most commonly reported sleep problems in 2000;21(4):163-70.
patients with PTSD, and treatment consists of a combination of behavioral methods and 11. K
rakow B, Melendrez D, Johnston L, et al.
pharmacologic therapy. TSD is a newly described parasomnia that can occur in some Sleep-disordered breathing, psychiatric
patients with PTSD. OSA prevalence is higher in PTSD patients than the general population. distress, and quality of life impairment in
Quarter Two 2019 A2Zzz 15sexual assault survivors. J Nerv Ment Dis 25. Raskind MA, Thompson C, Petrie EC, et al. Prazosin reduces nightmares in combat veterans with
2002;190(7):442-52. posttraumatic stress disorder. J Clin Psychiatry. 2002;63(7):565-568.
12. Z
ayfert C, DeViva J. Residual insomnia 26. Wallace DM, Shafazand S, Ramos AR, et al. Insomnia characteristics and clinical correlates in
following cognitive3 behavioral therapy for Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder
PTSD. J Trauma Stress 2004;17(1):69-73.
and mild traumatic brain injury: an exploratory study. Sleep Med. 2011;12(9):850-859.
13. K
rakow B, Hollifield M, Johnston L, et al.
27. Mysliwiec V, O’Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJ. Trauma associated sleep
Imagery rehearsal therapy for chronic
nightmares in sexual assault survivors with disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares and
posttraumatic stress disorder: a randomized rem without atonia in trauma survivors. J Clin Sleep Med 2014;10(10):1143-1148.
controlled trial. JAMA 2001;286(5)537-45. 28. Mysliwiec V, Brock M, Creamer J, et al. Trauma associated sleep disorder: A parasomnia induced
14. R
askind M, Peskind E, Kanter E, et al. by trauma. Sleep Med Reviews 2018;37:94-104.
Reduction of nightmares and other PTSD 29. Kaminer H, Lavie P. Sleep and dreaming in Holocaust survivors dramatic decrease in dream recall
symptoms in combat veterans by prazosin:
in well-adjusted survivors. J Nerv Ment Dis 1991;179(11):664-9.
a placebo-controlled trial. Am J Psychiatry
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symptom and predicts other symptoms of post-traumatic stress disorder in US service members
15. G
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related sleep disturbances: a pilot study. 31. Pigeon WR, Campbell CE, Possemato K, Ouimette P. Longitudinal relationships of insomnia,
Behav Res Ther 2007;45:627-32. nightmares, and PTSD severity in recent combat veterans. J Psych Res. 2013;75:546-550.
16. L
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distress: a review and neurocognitive model.
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intervention for sleep disturbance in
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SHANA HANSEN, LT. COL., USAF, MC, and SHANNON N. FOSTER, MAJOR, USA,
with posttraumatic stress disorder (PTSD)
and obstructive sleep apnea (OSA). J Clin MC, work at the Wilford Hall Ambulatory Surgical Center’s Sleep Disorders Center at
Sleep Med 2014;10(6):631-636. Lackland Air Force Base in San Antonio, Texas.
Quarter Two 2019 A2Zzz 16The Start School Later Movement:
Putting Sleep Health on the National Radar
By Terra Ziporyn Snider, Ph.D.
Anyone raising children expects challenges along the way, from those sleepless first with effects roughly double those in more
nights and toddler tantrums to the trauma of teaching teenagers to drive. But few are advantaged students. In addition, any
prepared for the recurring nightmare of waking a teenager for school at the crack of dawn. costs involved in moving bell times are
Getting a teenager up and off to 7 or 8 a.m. classes can feel like waking the dead — even far outweighed by lowering direct and
in homes that enforce reasonable bedtimes. If you understand sleep science, you know indirect costs of adolescent sleep loss —
why. Essentially, these early start times force families to fight biology. They fly in the face whether related to graduation rates, lifetime
of everything we know about adolescent sleep needs and patterns and create a sizable earnings, car crashes, depression, or short-
and long-term illness.
sleep debt every week.
We didn’t know all this back in the 1970s
The heart of the problem is a well-documented shift in sleep cycles (circadian rhythms)
and ’80s when U.S. school systems moved
beginning at puberty that makes it difficult for most adolescents to fall asleep as early as
traditional school start times, usually 8:30
younger children or older adults — or to wake for very early classes. The science showing
or 9 a.m., earlier — a change implemented
that early school hours are unsafe, unhealthy and counterproductive for adolescents is
primarily to make bus runs more efficient.
so compelling that many major health organizations, including the American Academy of
Back then, we didn’t fully understand the
Pediatrics, the American Medical Association, the American Academy of Sleep Medicine,
role sleep played in learning or health,
the Society of Behavioral Medicine and the Centers for Disease Control and Prevention
nor did we understand developmental
(CDC) are calling for an end to middle and high school start times before 8:30 a.m. Yet
changes in circadian rhythms. When the
according to the CDC, nearly five in six U.S. middle and high schools still start before then.
medical community began publicizing
Over 10% of high schools start regular class before 7:30 a.m., with nearly half starting
this sleep science in the mid-1990s,
before 8 a.m. Bus runs begin as early as 5 a.m. in some districts.
many school systems tried to return to
The good news is that an increasing number of communities are realizing later school
start times benefit kids and communities. Hundreds of schools have already found ways
to run classes at more developmentally appropriate times by prioritizing health and
learning. Others never moved to such insanely early hours in the first place.
A Proven Policy Solution to Teen Sleep Insufficiency
Lest you think the solution is taking away screens, consider that the same circadian
shift occurs at puberty in other mammals, who almost certainly do not have iPhones or
computers. For both biologic and cultural reasons (e.g., late-night practices, excessive
homework), teenagers often have trouble falling asleep before about 11 p.m., even if they
are “put to bed” much earlier. If they have to wake at 5 or 6 a.m. to get ready and then
commute to an early-start school, they can only get six to seven hours of sleep at
most, far less than the approximately nine they typically need. In addition, they
miss out on the bulk of critical REM sleep, which is concentrated in the last third of
the night and where most memory consolidation and emotional regulation occur.
The result is a nation of adolescents suffering from chronic sleep insufficiency
at huge — and unnecessary — costs to health and well-being. According to
the CDC, nearly three-fourths of American high school students today get
under eight hours of sleep per night, and over two-fifths get six or fewer.
While there are many factors involved, only one policy change has been proven
to make a difference in adolescent sleep insufficiency: delaying school start
times. Schools that start class at 8:30 a.m. or later not only see more students
getting more sleep but also see improved graduation and attendance rates, test
scores and mood; less depression, stimulant and illegal substance use, tardiness
and falling asleep in class; and lower teen car crash rates. When it comes to school
performance, students from disadvantaged backgrounds benefit disproportionately,
Quarter Two 2019 A2Zzz 17more traditional bell times. County boards of health supported them. So did state health Communities that understand that sleep
associations. Grassroots groups of parents arose, trying to delay start times, as well. matters will not only prioritize sleep-friendly
These efforts largely failed and continue to fail. school hours but also respect and value
sleep health more generally and the sleep
Creating the Will to Change professionals who make it possible.
The problem with returning to more traditional, healthier school hours was not science. It was, AAST strongly supports the School Start
and continues to be, politics. Contrary to popular belief, however, the politics does not involve Later initative.
logistic issues such as daycare, transportation costs, sports, after-school jobs or traffic. Fears
about these perceived obstacles are real. So is the power of those fears to block change. References
However, these fears have consistently turned out to be red herrings — or, if not, resolvable 1. Start School Later Website. www.
with creative thinking by stakeholders committed to change. The bigger challenges are more startschoollater.net.
fundamental: fear of change, failure of imagination and pervasive ignorance about sleep. 2. Wheaton AG, Ferro GA, Croft JB. School start
times for middle and high school students—
United States, 2011-12 school year. MMWR
Communities that delay start times 2015 Aug 7;64(30):809-813.
3. MMWR. Youth Risk Behavior Surveillance—
United States 2-17. June 15, 2018;67(8).
successfully prioritize sleep, health https://www.cdc.gov/healthyyouth/data/
yrbs/pdf/2017/ss6708.pdf.
and learning. 4. Adolescent Sleep Working Group, Committee
on Adolescence, Council on School Health.
School start times for adolescents. Pediatrics
2014 Sep;134(3):642-649. http://pediatrics.
The hundreds of schools that have delayed bell times have overcome these challenges. aappublications.org/content/134/3/642.
Specific solutions vary by community, depending on a budget, topography, demographics, 5. Wahlstrom, KL. Examining the impact
values, etc. However, communities that have delayed bell times successfully have certain of later high school start times on the
commonalities, including leadership from within the school district, clear communication health and academic performance of high
about reasons for change, and authentic engagement with stakeholders to facilitate school students: A multi-site study. 2014.
https://conservancy.umn.edu/bitstream/
creative solutions and build consensus. Allowing stakeholders time to plan for changes
handle/11299/162769/Impact%20of%20
may be required, together with sustained advocacy, often by sleep or health professionals, Later%20Start%20Time%20Final%20Report.
before, during and after the change. pdf?sequence=1.pdf.
Above all, communities that delay start times successfully prioritize sleep, health and 6. Marco Hafner, Martin Stepanek, Wendy M.
learning, creating a climate in which people want school hours that allow for healthy Troxel. Later School Start Times in the U.S.:
sleep. This “political will” reduces the fear of change and failure of imagination that made An Economic Analysis. RAND Corporation.
August 2017. https://www.startschoollater.
change so hard. Perceived obstacles melt away, and solutions to unsolvable problems
net/uploads/9/7/9/6/9796500/rand_later_
become readily available. school_start_times_in_the_us_083017.pdf.
7. Brian A. Jacob and Jonah E. Rockoff.
Joining Forces for Sleep Health Organizing Schools to Improve Student
Achievement: StartTimes, Grade
Building the political will to start school later for most of the nearly 14,000 school districts
Configurations, and Teacher Assignments.
in the United States will require a multipronged approach by a diversity of players
Brookings: The Hamilton Project. September
collaborating on local, state and national levels. Sleep professionals can play a critical, 2011. https://www.startschoollater.net/
even essential, role here in waking up communities to the value of sleep and healthy uploads/9/7/9/6/9796500/brookings_study_
school start times. In the clinical setting, they can do this by talking to patients or by on_later_start_times_0911.pdf.
distributing flyers and displaying posters, as well as by mentoring and modeling healthy
sleep. However, when it comes to building political will and turning science into policy,
sleep professionals will also need to step outside of traditional roles to serve as public TERRA ZIPORYN
ambassadors for sleep health and healthy school hours. SNIDER, PH.D., is
the executive
This is already starting to happen. Many sleep professionals are speaking out via social director and
media and community forums. They are also increasingly joining forces with pediatricians, co-founder of Start
superintendents, social workers, community advocates and legislators via Start School Later School Later and an
and other sleep advocacy organizations. Some sleep professionals are leading local Start award-winning
School Later chapters, and many others regularly make themselves available as resources science writer and
and sources of expert testimony. Some are playing key roles in the passage of sleep and communicator whose publications include
healthy school start time legislation. Others are encouraging their professional associations to “The New Harvard Guide to Women’s Health”
generate position statements on the need for school hours compatible with healthy sleep. and “Alternative Medicine for Dummies.”
Quarter Two 2019 A2Zzz 18How to Survive a BRPT Audit
By Jessica Schmidt, MA, FACHE, RPSGT, CCSH, BRPT President, and Rita Brooks, MEd, RPSGT,
REEG/EPT, FAAST, AAST President
Editor’s Note: An article titled “How to Courtesy recertification reminders are sent monthly during the six months leading up to
Survive a BRPT Audit” ran in the Quarter your credential expiring. However, it remains the sleep technologist’s sole responsibility
One 2019/Volume 28/Number 01 edition to be aware of the expiration of their credential and follow procedures to renew it ahead
of A2Zzz magazine. The intent of the article of that specific date. It is your responsibility as a professional to maintain your credential
was to remind sleep technologists that they and, in some states, your license.
are responsible for assuring they have the
It is critically important to track your CECs if you plan to use them for recredentialing
appropriate continuing education credits
(and/or licensing). Tracking can be as simple as keeping your certificates in a folder
to maintain their credentials and to explain
the audit process. Unfortunately, the article or scanning them to an electronic file (with a backup) for safekeeping. There are also
unintentionally contained misleading and, tracking programs (such as the one offered to AAST members) that can assist with this
in a number of cases, incorrect information, process. If you are an AAST member, CECs earned that are approved for AAST CECs are
which was confirmed by reviewing automatically tracked for you in the CEC portal as a member benefit. CECs earned outside
message history, document uploads and of AAST can also be added to your member portal for tracking.
login records that are tracked and time- Regardless of how you track your CECs, you should always keep documentation of the CECs
stamped in BRPT’s certification database. you have earned to support your credential. The BRPT portal allows you to enter and upload
That article was retracted, has been edited, CECs as they are earned; however ― and this is an important however ― the BRPT does not
and is republished here, conveying the
upload certificates sent to them and can only provide a basic transcript of what you have
important message that AAST and the
submitted. You are still responsible for maintaining your certificates, and you must also keep
BRPT continue to work together to assure
copies for a minimum of one year after your recertification date in the event of an audit.
that correct information is consistently
provided for our members and credential A word to the wise: There are many CEC tracking portals now available on the internet.
holders. The revised article and the Use extreme caution if you are tracking your CECs on a website or in a portal other than
information that follows below provide
an accurate description of recertification
responsibilities and the recertification audit
as well as tips for facilitating a smooth and Did you know that CECs must be directly
efficient audit process.
sleep or sleep-respiratory related, or prior
At some point in your career as an RPSGT
or CCSH, you may be asked to participate
in a credit audit. A credit audit is not the
approved by AAST or the BRPT?
same thing as a credential renewal.
What is a credential renewal? Every sleep one supported by your professional and/or credentialing organization. We have heard
technologist recertifies periodically to reports of CECs being lost due to a website or portal shutdown.
maintain their credential. Those holding
If you have properly maintained your CECs, when your credential comes up for renewal,
the RPSGT or the CCSH credential must
you will have all of your information in one safe place for entry into the BRPT portal.
recertify every five years. You can either
Another important bit of information to note: Don’t wait until the last minute! You can
renew by retaking the credentialing
submit up to six months before your due date, and you should submit no later than three
examination or by accumulating 50
weeks prior to your expiration date. This gives you sufficient time to address any issues
continuing education credits (CECs) —
you may encounter when entering your CECs for recertification. Also note that you must
sometimes referred to as continuing
enter each individual program for which you are presenting CECs ― by course title, date
education units (CEUs) — you’ve earned
and ID with number of credits earned ― not your transcript from a meeting.
during the five-year credential window to
maintain your credential. Most opt to collect So, what might go wrong? Did you know that CECs must be directly sleep or sleep-
CECs rather than take the boards again, and respiratory related, or prior approved by AAST or the BRPT? Are you aware that the BRPT
earning CECs fosters ongoing learning and will not accept duplicate CECs within the five-year recertification window? That means
keeps you current with changes in the field. you cannot submit a mask-fitting workshop CEC on the same mask more than once, or
Quarter Two 2019 A2Zzz 19You can also read
