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OVERVIEW OF SLEEP DISORDERS
Gina S. de los Reyes, MD, FPCP, FPCCP, FPSSM
Objective:
to give a general overview of the evaluation and management of common sleep disorders
Overview of Sleep Disorders
Sleep related breathing disorders
ex . Obstructive sleep apnea
Sleep Related Movement disorders
ex. Restless legs syndrome & Periodic limb movement disorder
Insomnia
Hypersomnias of central origin
ex. Narcolepsy
Circadian Rhythm sleep disorders
Parasomnias
International Classification of Sleep Disorder (ICSD-2)
3 Cardinal Clinical presentations of sleep disorders
Insomnia
Excessive daytime sleepiness
Abnormal movements or behaviors in sleep
Obstructive Sleep Apnea
Characterized by repetitive episodes of upper airway obstruction that occur during sleep
usually associated with a reduction in blood oxygen saturation
Pathophysiology of OSA
Reduced cross-sectional area of the upper airway lumen due to either: excessive bulk of soft tissue (tongue, soft
palate, lateral pharyngeal walls) OR
craniofacial anatomy or both
Upper airway patency is dependent on pharyngeal dilating muscles; activity of which decreases during sleep onset
AWAKE
SLEEP
Inadequate Anatomy
Compensatory Pressure Reflexes
Activity of Pharyngeal Dilators
Upper Airway Patency Maintained
UA Muscle tone Lung Volume Central Resp.Drive
Endothelin Vagus
Cardiovascular Sequelae
Sympathetic Activation
AROUSAL Respiratory Effort
Airway Collapse
O2 CO2
Clinical Presentation
Loud snoring
Witnessed obstructive events during sleep in a habitual snorer
Observed apnea
Interrupted snoring pattern
Nocturnal gasping or choking
Severe sleepiness
Obstructive sleep apnea
Complications of OSA
Loss of alertness
Cardiovascular complications Systemic hypertension
Pulmonary artery HPN
Myocardial infarction
Cerebrovascular disease
Cardiac arrhythmias
Metabolic syndrome
Treatment options: CPAP
Gold standard for treatment of moderate-severe OSA
may be given trial basis-for milder cases; when contribution to symptoms not clear
65-90%compliance rate
Treatment options
Overview of Sleep Disorders
Obstructi ve sleep apnea
Restless legs syndrome & Periodic limb movement disorder
Psychophysiologic insomnia
Narcolepsy
Circadian disorders
Parasomnias
Restless Legs Syndrome
a sensorimotor disorder in which patients experience an irresistible desire to move the legs (akathisia)
uncomfortable or frankly painful sensation within the legs
brought on by rest, relieved with moving or walking
occur primarily at night or in the evening
Pathophysiology of RLS
Genetic basis
Dopamine imbalance dopamine (affects movement) naturally falls at
night
symptoms worse late in the day & at night
Iron deficiency Iron is important to the production of dopamine
low iron levels are often linked to RLS symptoms
Restless Legs Syndrome & Periodic Limb Movement Disorder
RLS is a symptom - awake
PLMD is an EMG finding – asleep
RLS & PLMD frequently overlap
Neither is necessary nor sufficient to make the diagnosis of the other
Periodic Limb Movement Disorder
Predisposing Conditions-RLS/PLMD Anemia (iron deficiency)
Folate /B12 deficiency
Chronic renal failure
Pregnancy
Peripheral nerve disease
Hypothyroidism
Medications (SSRIs, TCAs, caffeine)
Treatment RLS/PLMD
Regular sleep-wake schedule
Avoid caffeine, alcohol, smoking
Treat secondary causes – iron deficiency, folate deficiency, renal failure
L-Dopa, dopamine agonists, gabapentin, benzodiazepines, opioids
Overview of Sleep Disorders
Obstructi ve sleep apnea
Restless legs syndrome & Periodic limb movement disorder
Psychophysiologic insomnia
Narcolepsy
Circadian disorders
Parasomnias
Insomnia & decreased functioning
during wakefulness
Learned sleep preventing associations – “trying too hard to sleep”
Increased somatized tension (agitation)
sleep latency, number & duration of awakenings, sleep efficiency
Psychophysiologic Insomnia
Psychophysiologic insomnia
Predisposing factors
Perpetuating factors
Precipitating factors
Insomnia – Cognitive Behavioral Therapy
Technique Patient symptoms
Stimulus control Delayed sleep onset
Sleep restriction Excessive time spent in bed; fragmented or poor sleep quality
Relaxation High physiologic, cognitive, or emotional arousal
Cognitive Racing or obsessive thoughts around bedtime
Sleep hygiene education
Any of the above or general poor sleep hygiene
Insomnia - Rx
Elimination Half lives (hrs)
Overview of Sleep Disorders
Obstructi ve sleep apnea
Restless legs syndrome & Periodic limb movement disorder
Psychophysiologic insomnia
Narcolepsy
Circadian disorders
Parasomnias
Pathologic Sleepiness-Narcolepsy
Sudden intrusion of REM sleep during wakefulness
Excessive daytime sleepiness
REM Dysregulation
Cataplexy – sleep attacks
Sleep paralysis
Hypnagogic hallucinations
Absent hypocretin/orexin in CSF
Narcolepsy
Narcolepsy Treatment
Sleepiness
Alerting agents – ex. Provigil
Stimulants – ex. Dexedrine
Naps – 20 mins
Hydroxybutyrate
Cataplexy
REM suppressing drugs – Ex. Effexor
SWS promoting drugs – Ex. Hydroxybutyrate
Overview of Sleep Disorders
Obstructi ve sleep apnea
Restless legs syndrome & Periodic limb movement disorder
Psychophysiologic insomnia
Narcolepsy
Circadian Rhythm sleep disorders
Parasomnias
Circadian Rhythm Disorders
Advanced sleep phase
Delayed Sleep phase
Irregular sleep wake type
Free-running type
Shift work sleep disorder
Time Zone Change (Jet lag) Syndrome
Circadian Rhythm Disorders
Advanced Sleep Phase Delayed Sleep Phase
“Early bird”
earlier sleep onset & earlier awakening than desired
Common with aging (>50 yo)
Sometimes confused with depression, OSA, narcolepsy
“Night owl “
later sleep onset & later awakening than desired
Common in teenagers
complaint of insomnia
May develop chemical dependency, viewed as lazy
CRSD-Treatment
melatonin
Light exposure
CRSD-Treatment
Advanced Sleep Phase Delayed Sleep Phase
Fix bed time
Exposure to bright light in late-afternoon or evening
Melatonin in am
Exercise in afternoon
Fixed wake-up time
Avoid light exposure in the evening
Exposure to am light
Melatonin in early evening
No more than 1 hr shift in wake-up time on weekend
Shift work disorder
diagnosed by the presence of excessive sleepiness (ES) and/or insomnia for ≥1 month during which the individual is performing shift work
Michael J. Thorpy, MD, Supp Jour of Family Practice n Vol 59, No 1 / January 2010
Sleep/wake patterns of day & night-shift workers
Michael J. Thorpy, MD, Supp Jour of Family Practice n Vol 59, No 1 / January 2010
Shift work disorder treatment
Avoid > 4 consecutive 12-hour night shifts
planned napping before, or on the job
bright light during work
stimulant medication- ex. Caffeine, modafinil, methamphetamine
sunglasses for the morning commute
melatonin prior to daytime sleep
hypnotic medication-
ex. zolpidem
Jet Lag
temporary mismatch between the timing of the sleep & wake cycle generated by the endogenous circadian clock & that of the sleep-wake pattern required by the change in time zone
Jet Lag symptoms
Disturbed sleep
Impaired daytime alertness & performance
Gastrointesinal problems
Loss of appetite
Inappropriate timing of bowel movement
Excessive desire to urinate during the night
~1 day for each hour of time zone change for adaptation to be complete
Jet Lag treatment
Adequate sleep must be ensured at the destination time zone
Naps prior to, or during the flight
Avoid naps during the day at the destination
should wait for the night time of the destination before retiring
daytime rather than overnight flights
Melatonin 0.3 to 0.5 mg in evening if eastward
Overview of Sleep Disorders
Obstructi ve sleep apnea
Restless legs syndrome & Periodic limb movement disorder
Psychophysiologic insomnia
Narcolepsy
Circadian disorders
Parasomnias
Parasomnias
Non - REM related
Night terror
Sleep walking
REM related
REM sleep behavior disorder
Sleep paralysis
Other parasomnias
Sudden unexplained nocturnal death syndrome(SUNDS)
Parasomnia - Night Terror
Slow wave sleep (1st half of the night)
Initial scream
Difficult to arouse
Amnesia for episode
Peak in children age 4 to 12
Resolve around adolescence
Exacerbated by disruptions of sleep (OSA)
Sleep Terrors
Parasomnia – Sleep Walking
Passive walking during sleep
Slow wave sleep (1st half of the night)
Difficult to arouse
Peak in children age 4 to 8
Resolve in adolescence
Increased in families
Exacerbated by disruptions of sleep (OSA)
Sleep walking
REM Sleep Behaviour disorder
Complaint of violent or injurious behavior during sleep
Limb or body movement is associated with dream mentation
Look for underlying secondary causes (drugs, alcohol, neurological)
Clonazepam 0.5-1 mg initially
Advice on bedroom safety precautions
REM Sleep Behaviour disorder
Sleep paralysis
consists of a period of inability to perform voluntary movements either at
sleep onset (called hypnogogic form) or
upon awakening (called hypnopompic form)
brain awakes from a REM state, but the body paralysis persists (REM atonia)
Sleep paralysis
Sleep paralysis
Occurs at least once in a lifetime in 40%-50% of normal subjects
Isolated, familial, or symptom of narcolepsy
Predisposing factors
Irregular sleep habits
Sleep deprivation
Mental stress, overtiredness, sleeping in supine position
Excessive alcohol consumption
Sudden Unexplained Nocturnal Death syndrome (SUNDS) sudden death during sleep in healthy young
adults, particularly of Southeast Asian descent
“non-laita “ (sleep death) in Loatian
“bangungut “ (to arise & moan) in Tagalog
“pokkuri” (sudden death) in Japanese
Sudden Unexplained Nocturnal Death syndrome Male sex
Choking, gurgling, gasping, or labored breathing
occurs during habitual sleep period
history of prior sleep terrors
Cardiac studies of survivors - spontaneous ventricular fibrillation after initial resuscitation
Sudden Unexplained Nocturnal Death syndrome
Brugada syndrome -
is the major cause of SUNDS
causing sudden death by causing Vfibrillation
associated with mutation(s) in the SCN5A gene that encodes for the Na channel in the cell membranes of the myocytes
Sudden Unexplained Nocturnal Death syndrome
Genetic testing, ECG pattern
Treatment : Implantable cardioverter-defribrillator (ICD)
Cardinal Clinical presentations of sleep disorders
Insomnia :
Psychophysiologic insomnia, RLS/PLMD, CRSD
Excessive daytime sleepiness:
OSA, Narcolepsy, CRSD
Abnormal movements or behaviors in sleep
Parasomnias, PLMD
Sleep Disorders: Conceptual Framework
Insufficient Sleep (Sleep deprivation)
Fragmented Sleep (Sleep disruption)
Excessive daytime somnolence
Primary disorders of EDS
THANK YOU FOR YOUR ATTENTION!!!
Sleep Disorders presenting with Insomnia
Insomnia
Sleep Related Movement Disorders: Restless Legs Syndrome (RLS)
Circadian Rhythm Sleep Disorders
Sleep Disorders presenting with Excessive Daytime Sleepiness
Sleep Related Breathing Disorders:OSA
Hypersomnias of Central Origin
Narcolepsy
Klein-Levin Syndrome
Idiopathic Hypersomnia
Circadian Rhythm sleep disorders
Jet Lag, Shift Work, Delayed & Advanced Sleep Phase syndromes
International Classification of Sleep Disorders
I. Dyssomnias A. Intrinsic Sleep Disorders
B. Extrinsic Sleep Disorders
C. Circadian Rhythm Sleep Disorders
II. Parasomnias A. Arousal Disorders
B. Sleep Wake Transition Disorders
C. Parasomnias usually associated with REM sleep
D. Other Parasomnias
International Classification of Sleep Disorders
III. Sleep Disorders associated with mental, neurologic, or other medical disorders
A. Associated with Mental Disorders
B. Associated with Neurologic Disorders
C. Associated with other Medical Disorders
IV. Proposed Sleep Disorders
Sleep Disorders presenting with Abnormal Movements or Behaviors in Sleep Non REM Parasomnias
Confusional arousals
Sleepwalking
Sleep terrors
• REM Parasomnias
Nightmare disorder
REM Behaviour disorder
• Sleep related movement disorders
RLS, PLMD
I. Dyssomnias
Disorders that produce either difficulty initiating or maintaining sleep or excessive sleepiness
A. Intrinsic Sleep Disorders
Psychophysiologic Insomnia
Sleep state misperception
Idiopathic insomnia
Narcolepsy
Recurrent Hypersomnia
Idiopathic Hypersomnia
Post traumatic hypersomnia
Obstructive sleep apnea
Central sleep apnea
Central alveolar hypoventilation syndrome
Periodic Limb Movement disorder
Restless legs Syndrome
B. Extrinsic Sleep Disorders
Inadequate sleep hygiene
Environmental sleep d/o
Altitude Insomnia
Adjustment Sleep d/o
Insufficient sleep syndrome
Limit-setting sleep d/o
Sleep-onset assocn d/o
Food allergy insomnia
Nocturnal Eating (Drinking) syndrome
Hypnotic-dependent sleep d/o
Stimulant-dependent sleep d/o
Alcohol-dependent sleep
Toxin-induced sleep d/o
C. Circadian-Rhythm Sleep Disorder Time Zone Change (Jet lag) Syndrome
Shift work sleep disorder
Irregular sleep-wake pattern
Delayed sleep-phase syndrome
Advanced sleep-phase syndrome
Non-24 hour sleep wake disorder
II. Parasomnias
Disorders that intrude into the sleep process and are not primarily disorders of sleep and wake states per se
Manifestations of CNS activation, usually transmitted through skeletal muscle or ANS
A. Arousal Disorders
Confusional arousals
Sleepwalking
Sleep terrors
B. Sleep-wake transition disorders Rhythmic movement d/o
Sleep starts
Sleep talking
Nocturnal leg cramps
C. Parasomnias usually associated with REM sleep Nightmares
Sleep paralysis
Impaired sleep related penile erections
Sleep related painful erections
REM sleep-related sinus arrest
REM sleep behavior d/o
D. Other parasomnias
Sleep bruxism
Sleep enuresis
Sleep related abnormal swallowing syndrome
Nocturnal paroxysmal dystonia
Sudden unexplained nocturnal death synd
Primary snoring
Infant sleep apnea
Congenital hypoventilation synd
Sudden infant death synd
Benign neonatal sleep myoclonus
III. Sleep d/o associated with mental, neurologic, or other medical d/o Are not primarily sleep d/o but are mental,
neurologic, or other medical d/o that have either sleep d/b or excessive sleepiness as a major feature of the d/o
A. Associated with Mental Disorders Psychoses
Mood disorders
Anxiety d/o
Panic d/o
alcoholism
B. Associated with Neurologic d/o Cerebral degenerative d/o
Dementia
Parkinsonism
Fatal familial insomnia
Sleep related epilepsy
Electrical status epilepticus of sleep
Sleep related headaches
C. Associated with Other Medical Disorders
Sleeping sickness
Nocturnal cardiac ischemia
COPD
Sleep related asthma
Sleep related gastroesophageal reflux
Peptic ulcer disease
fibromalgia
Parasomnias – REM Behavior disorder Injurious behavior during sleep
Acting out of dreams
Increased EMG during REM
Increased in older men
Increased with pontine lesions
Increased association with Parkinson’s disease