U of A's Sleep Medicine Program is a Dream Come True for Dr. Larry Pawluk

Dr. Larry Pawluk has headed the Sleep Medicine Program in the Department of Psychiatry for over 25 years, and

01 April 2019

Dr. Larry Pawluk has headed the Sleep Medicine Program in the Department of Psychiatry for over 25 years, and was instrumental in launching the Behavioural Sleep Medicine Clinic within the same program about two years ago.

As many as a hundred patients are seen by the program every week, seeking relief from Insomnia, Obstructive Sleep Apnea, Circadian Rhythm Disorders, Restless Legs Syndrome, Narcolepsy and various other common or unusual sleep disorders.

The steady parade of drowsy, heavy-eyed patients are referred by family Physicians, Psychiatrists, Neurologists, Pulmonary Specialists and even Cardiologists.

"Fortunately, most of these disorders are diagnosable and treatable, which is the most satisfying part of doing this work," says Dr. Pawluk, whose team in the Behavioural Sleep Medicine Clinic includes Psychologists Dr. Laura Le Clair and Julie Burbidge - both Clinical Lecturers in the Department of Psychiatry - and Paul McCann, who has been a Sleep Nurse Clinician for almost 20 years.

"There are other Sleep Medicine Programs in Canada, but typically they're focused on either Sleep Apnea or Insomnia. There aren't many that look at the all-encompassing aspects of sleep. That makes us somewhat unique."

After earning his Medical Degree from the University of Alberta in 1987 he went on to complete his Residency in Family Medicine.

"While I was doing that, I thought I would take an elective in Sleep Medicine. The first sleep lab in the world was started in 1973 at Stanford University, so I went to Stanford and I found that I just loved the interplay between biology and psychology in this field," he says.

"Parts of it are very biological - such as dealing with people with sleep- disordered breathing - and parts of it are psychological in nature, like when you're treating Insomnia. So I pursued a Psychiatry Residency and Dr. Bill Dewhurst, who was the Chair at the beginning of my Residency, said if I wanted to pursue a Sleep Fellowship after my training was finished, the Department would support it. They did, and that's how this all came to pass."

Dr. Pawluk completed his Clinical Fellowship in Sleep Medicine under the supervision of Drs. Mark Mahowald, Carlos Schenck and their colleagues at the multidisciplinary Minnesota Regional Sleep Disorders Center. In 1994, he became a Diplomate of the American Board of Sleep Medicine and a Fellow of the American Academy of Sleep Medicine.

"I still really enjoy working in this field all these years later," says Dr. Pawluk, who took a rare break from treating patients to grant an interview in his office at University of Alberta Hospital.

"We're really happy that we've been able to set up the Behavioural Sleep Medicine Clinic here, and we're hoping this will fast-track Insomnia referrals from family Physicians and others. We're also hoping to attract other people to this field. I've been doing this largely on my own for almost 25 years, so it would be great to have other sleep experts join us who have a background in Psychiatry or Neurology, so we can continue to build our program."

Insomnia is the most common sleep disorder Dr. Pawluk and his colleagues treat. But other sleep disorders are also common.

They include Narcolepsy - a neurological disorder that causes excessive daytime sleepiness and periodic, uncontrollable episodes of falling asleep in the daytime - as well as a disorder known as CNS (Central Nervous System) Hypersomnolence. The latter causes severe daytime sleepiness, despite normal sleep patterns at night.

"We also see a lot of Parasomnias which involve unusual behaviours during sleep, including things like night terrors, sleepwalking, sleep-related seizures, and even things like head banging, body rocking, grinding your teeth, or acting out your dreams at night," he explains.

"Sleepwalking is fairly common in children, and a child might sleepwalk a handful of times before things settle down. But I also see (adult) patients who might do this a couple times a night. Sometimes it can be quite complex. They may try to leave the house, or potentially be violent towards their bed partner. People have even been known to drive in their sleep. That may sound impossible, but when you're sleepwalking your brain is both awake and asleep simultaneously, enabling you to do complex behaviours even if you don't have full recognition of what you are doing."

Once a patient is referred to Dr. Pawluk's clinic, the diagnostic process is detailed and complex. Sleep disorders can arise from multiple causes - biological, psychological, neurological, environmental - and co-morbid conditions are common.

"If someone with, let's say, Insomnia comes to us, they first undergo a comprehensive sleep evaluation. So I'll spend at least an hour or more interviewing the patient to obtain a description of their problems, and what they perceive to be the daytime consequences of not sleeping. I also ask what they've tried, what's worked, what hasn't, or if they've been prescribed medications. Then we run through a list of other possible co-existing sleep disorders that may be impacting their Insomnia," he explains.

Once that information is compiled, Dr. Pawluk asks an extensive series of questions about the individual's sleep habits; their bedroom environment; whether they use a smartphone or tablet computer in bed; whether any household pets share the bedroom; if their bed partner snores; whether they consume alcohol, nicotine or other substances; whether they use any prescription medications; and whether they've experienced any psychiatric problems.

"The list of potential factors is lengthy, so we really need to spend the time to review all the possible contributing factors to their Insomnia. It's usually not just one thing. For a lot of people, they have what is known as Conditioned Insomnia. It's the idea that 'When my head hits the pillow my brain turns on and the more I try to sleep the worse it gets.' That is a key component in almost all cases."

Unless the patient also has a major medical condition, or an untreated psychiatric issue such as psychosis or depression, the first line of treatment is Cognitive Behavioural Therapy for Insomnia (CBTI).

"CBTI is offered in individual or group formats, and involves a series of non-medication strategies designed to break the pattern of not sleeping. It includes things like sleep consolidation - where patients are instructed to temporarily cut down the number of hours in bed to maximize their actual sleeping time in bed - and stimulus control, where the person is instructed to get out of bed, do something relaxing, and return to bed when they feel sleepier," he explains.

The Sleep Medicine Program also includes a sleep lab, where patients are observed while sleeping overnight - specifically, the Alberta Health Services (AHS) sleep lab at Edmonton General Hospital

Other sleep disorders, such as Restless Legs Syndrome, may be more challenging to treat.

"Iron is a factor that's responsible for the production of Dopamine, and some people with Restless Legs Syndrome tend to have low iron stores. So one of the first things we do is check the person's iron levels to determine whether to introduce iron supplements. If that doesn't work we look at other possible factors," he says.

"Sometimes Restless Legs is induced by medications. It can be made worse by certain medical problems like Renal Failure, and sometimes occurs in people with Peripheral Neuropathy or people with Varicose Veins. Sometimes, treating those underlying medical factors is really the key."

So how does Dr. Pawluk see the Sleep Medicine Program evolving and growing from here?

"It would be great to train other sleep experts who might join us to help build our program. We'd also like to develop more of a research component to the program. That's been lacking over the years. And then ultimately, we'd like to see if we can develop a Fellowship here that would include my sleep Physician colleagues in Pulmonary Medicine, so we'd have a comprehensive Fellowship where people could be exposed to all aspects of sleep medicine," he says.

"If we could achieve that it would be unique in many ways in Canada. There are not too many places where you have this kind of collegiality among Respirologists, Psychiatrists and Neurologists, such that you could set up a joint program together. But we have that here so I think it's just a question of time and manpower before we are able to set something like that up."