Making Your Sleep Healthy and

Happy: Sleep Disorders

Dr. Barbara C. FisherDr. Barbara C. FisherClinic DirectorClinic Director

47818 Van Dyke Ave47818 Van Dyke AveShelby Twp., MI 48317Shelby Twp., MI 48317Phone # 586-323-3620Phone # 586-323-3620

Fax # 586-323-3568Fax # 586-323-3568Brainevaluation.comBrainevaluation.com

Seminar Objectives

1. Defining sleep2. Sleep parameters: Process C and S,

sleep stages 3. Developmental changes in sleep:

changes in sleep requirements with age

4. Sleep Disorders5. Good sleep hygiene6. Behavioral therapies

Factors that Impact Sleep

• Developmental• Circadian• Ultradian• Prior sleep

deprivation• Neurological• Cardiopulmonary• Gastrointestinal • Sleep Hygiene

• Endocrine• Dermatologic• Pain• Upper respiratory• Allergies• Drugs• Psychiatric• Infections

Fundamental Processes of Sleep

• Circadian• Homeostatic• Ultradian• Physiological

Hyperarousal – muscle tension– Agitation– Reactivity– Cardiac– Anxiety

• Cardiorespiratory• Upper airway• Neurological• Psychiatric• Behavioral• Drugs and Alcohol• Other medical

conditions• Developmental

Sleep Dysfunction in Children: Conceptual Framework

Excessive Daytime Sleepiness (EDS)

Primary Disorders of EDS

Insufficient Sleep(Sleep is Deprived)

Fragmented Sleep(Sleep is Disrupted)

Daytime Sleepiness in Children:Conceptual Framework

Daytime Sleepiness

Behavioral Problems: Irritability, Low Frustration

Tolerance

Mood Disturbance:Emotional Lability

Performance Deficits:Difficulties in schoolDifficulties in schoolShort term memory Attention and Concentration

Poor sleep at night leads to:

• Mood and emotional changes• Behavioral problems: • aggressiveness, hyperactivity, poor

impulse control• Cognitive deficits: attention, memory,

confusion, not thinking clearly• Performance deficits: academic and social• Affects whole family if child awake at night

Sleep in Infants

• Development NREM sleep by 6 months; decreased REM amounts

• At 6 months: total sleep time 13-14 hrs; sleep episodes 6-8 hrs

• “Sleeping through the night”: 70-80% at 9 months

Sleep in Toddlers

• Total sleep time 12 - 14 hours• Most give up 2nd nap at about one year• Developmental issues: separation anxiety,

night time fears, independent sleeping, ability to self-soothe

• Awakenings, sleep terrors: Sleep problems common (20-40%)

• Importance of bedtime routines

Sleep in Pre-Schoolers

• Sleep cycles: REM/Non-REM 90 minutes

• Total sleep time: 11-12 hours

• By age 4-5, many children give up regular daytime naps

• Sleep problems that are present are at risk to become chronic

Middle Childhood (6-12 years old)

• Total sleep time: 9-11 hours (10 - 11 hours in 6-7 year olds; 9 - 9 1/2 hours in early adolescence)

• Sleep pattern more stable, night-to-night consistency

• Naps rare, not sleep in the daytime• School and lifestyle influences, bedtimes,

insufficient sleep

Sleep Changes in Adolescence

• Delayed sleep onset

• Circadian: relative phase delay emerges at puberty

• Advanced wake times (sleep offset)

• Earlier school start times

• Sleep Deprivation

• Decreased sleep / wake regularity

Sleep Changes in Adolescence

• Sleep deprivation during the week with makeup sleep on the weekend

• Sleep deprivation leads to decreased attention and focus as well as depression, emotionality lability, decreased attention and concentration.

Normal Adult Sleep• Average amount of sleep per night: range of 6.5 to 8.3

hours• Normal sleep latency: 10 minutes• Normal sleep structure

– 5% stage 1– 50% stage 2– 15-25% stages 3 and 4 (slow wave sleep)– 25% REM

• Napping occurs at the beginning and the end of life (in our culture)

Sleep Changes with Age

• Increased awakenings and arousals

• Decreased REM sleep

• (Probably) decreased SWS

• Increased stage shifts

• Fewer “cycles”

• Reduced sleep efficiency

• Phase advancement

Sleep Disorders

• Two factors influence how sleepy or alert anyone is during a 24 hour period of time.

• 1. Sleep-wake Balance: how long it has been since you last slept- the longer you stay awake the sleepier you become

• 2. Circadian Rhythm: your body’s biological clock, the natural timing system which tells you when to sleep and when to be awake. Responsible for the feeling of a mild need to sleep during the afternoon and a strong need to sleep in the evening-the urge is pre-set to occur at specific times. When these times are changed by staying up too late or by a sleeping disorder the result is daytime sleepiness.

Circadian Rhythm Sleep Disorders

• Delayed Sleep Phase type

• Advanced Sleep Phase type

• Irregular sleep-wake type

• Free Running Type

• Jet Lag type

• Shift Work type

• Due to medical condition or substance abuse

Sleep Related Breathing Disorders

• Central Sleep Apnea (Cheyne Stokes, High altitude, Medical condition, Substance abuse, Infancy)

• OSA (arrthymia 58%)• Sleep related Hypoventilation/Hypoxemic

Syndrome• Sleep related Hypoventilation/Hypoxemic due

to medical condition• Sleep Related Breathing Disorder/ Upper

Airway Resistance Syndrome (UARS)

Sleep Apnea

• Decreased REM sleep, sleep not refreshing• Chronic, loud snoring, Gasping or choking

episodes • Excessive daytime sleepiness (drowsy when

driving)Automobile or work related accidents due to

fatigue• Personality changes or cognitive difficulties:

Neuropsychological evaluation reveals memory deficits and frontal deficits

Causes of Sleep Apnea

Age (tonicity decreases) Smaller-than-normal jaw Enlarged tonsils Lateral pharyngeal walls close in Large tongue Tongue moves posterior which displaces

the soft palate Tissues that partially block the entrance to

the airway

Symptoms of Sleep Disordered Breathing-Adult

• Snoring How loudly How often In all sleeping positions

• Apnea Does breathing stop in the night Snorting, choking, gasping, waking up to breathe?

• Daytime Tiredness/Sleepiness Do you awaken feeling refreshed or relaxed and ready to go? Do you awaken with a headache, tiredness & fatigue or

confusion? Daytime sleepiness, in the car? At the work setting? In a

business meeting? Anytime you sit down? When reading? Watch TV?

• Sleep How long to get to sleep? Hours sleeping? Awakenings during the night?

Symptoms of Sleep Disordered Breathing-Children

• Breathing during sleep Mouth breathing Choking, snorting, and snoring Increased breathing effort Apnea-breathing stops

• Restless sleep Frequent awakening at night Unusual sleep patterns Sweating or perspiration

• Enuresis• Behavioral problems

Hyperactivity Poor school performance Refusal to go to bed at night (toddlers)

• Growth changes Weight gain Failure to thrive-poor appetitive (possible consequence of sleep apnea)

Sleep Disordered Breathing in Children

• Snoring

• Sleep apnoea

• In children >1 apneic event per hour is abnormal

• May be present from birth

Relationship between ADHD and Sleep Disorders

• School performance improved inattentive, hyperactive and disruptive behavior improved when sleep disorder treated

• Relationship between sleep apnea and ADHD symptoms

• 25% of diagnosed ADHD no longer showed symptoms following treatment

Hypersomnias of Central Origin (not due to Circadian Rhythm, SRBD, or other

• Narcolepsy with Cataplexy• Narcolepsy without Cataplexy• Narcolepsy due to a medical condition• Narcolepsy unspecified• Recurrent Hypersomnia (Kleine-Levin Syndrome,

Menstrual related hypersomnia)• Ideopathic Hypersomnia with Long sleep time• Ideopathic Hypersomnia without Long sleep time• Behaviorally induced insufficient sleep syndrome• Hypersomnia due to medical condition or substance

abuse

Narcolepsy

• Excessive daytime sleepiness– Not uniform across patients– May be caused by other conditions

• Cataplexy –More common for facial muscles than for leg weakness-complete loss of motor tone, usually less than two minutes, range of weakness (full attack less common) loss of motor tone precipitated by strong emotions (anger or laughter)

• Sleep Paralysis-Cannot move just as awakening, feel like cannot breathe

• Hypnogogic Hallucinations-Armchair talking in evil ways, faces on the bed, green men

Parasomnias• Disorders of arousal from NREM sleep

– Confusional arousals– Sleepwalking– Sleep Terrors

• Parasomnias usually associated with REM sleep– REM Sleep behavior disorder– Recurrent isolated sleep paralysis– Nightmare disorder

• Other parasomnias– Sleep related dissociative disorders– Sleep enuresis– Sleep related groaning– Exploding head syndrome– Sleep related hallucinations– Sleep related eating disorder (SRED)– Parasomnia, unspecificied, related to medical or substance

abuse

Things that go bump in the Night

Parasomnias:

Episodic nocturnal behaviors, often involve disorientation, autonomic, skeletal muscle disturbances; related CNS immaturity

Somnambulism: Sleep Walking

• Prevalence: up to 15% of population; most between 6 and 16 years

• Age onset: usually 4 - 6 years

• Duration: one third for 5 years; 12% for 10

• Quiet vs. agitated; displacement from bed, often complex behaviors; SAFETY issues

Pavor Nocturus: Night Terrors

A few strangled words or cries precede bloodcurdling shrieks; the child sits up and stares wide-eyed. He may stumble out of bed or by movement, words, and expression reveal how he would seek to avoid some horror. Oblivious of his parents or soothing words he does not see their alarmed faces. Within minutes he is again sleeping soundly and in the morning remembers nothing untoward.

Sleep / Night Terrors

• Arousal from slow wave sleep first or second episode

• Incidence: 1-3%; 10% of sleepwalkers; peaks at age 5-7 years

• Male > female• Age onset: 4-12 years• Frequency: often highest at onset; often

higher ( > once a week) with younger onset• Usual disappearance by adolescence

Insomnia• Adjustment Insomnia• Psychophysiological Insomnia• Paradoxical Insomnia• Idiopathic Insomnia• Inadequate Sleep Hygiene• Behavioral Insomnia of Childhood• Insomnia due to substance abuse• Insomnia due to a medical condition

Factors Affecting the Development of Insomnia

Perpetuating factors

Perpetuating factors

Precipitating factors

Precipitating factors Predisposing

factors

Predisposing factors

InsomniaInsomnia

Personality Sleep-Wake cycleCircadian RhythmCoping Mechanisms

Conditioning Substance Abuse Performance Anxiety Poor sleep hygiene

Situational Environmental Medical Psychiatric Prescription Medication

Sleep Related Movement Disorders

• RLS Restless Legs Syndrome• PLMD: Periodic Limb Movement Disorder• Sleep related leg cramps• Sleep related bruxism• Sleep Related Rhythmic Movement

disorder• Sleep Related Rhythmic Movement

disorder due to medical condition or substance abuse

Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder

(PLMD)

• RLS is a symptom

• PLMS is an EMG finding

• RLS and PLMS frequently overlap

• Neither is necessary nor sufficient to make the diagnosis of the other

Restless Legs Syndrome (RLS)

• Uncomfortable leg sensations

• Worse at night

• Worse with inactivity / relieved with activity

• Associated motor hyperactivity

Periodic Limb Movement Disorder (PLMD)

• Stereotypic, repetitive movements of the legs (or arms)

• During sleep / inactivity

• Every 20-40 seconds

• May be associated with arousals from sleep

• Occur in minimum clusters of 4

Patient Complaints with RLS

• Sleep disturbances

• Difficulty falling asleep and staying

asleep

• Need to walk around (“nightwalkers”)

• Daytime sleepiness

Associated Conditions

• Neuropathies, myelopathies, and radiculopathies• Pregnancy• Anemia (iron deficiency)• Chronic renal failure• Folate / B12 deficiency• Medications (tricyclics, SSRI’s, caffeine)• Obesity• Hypothyroidism

RLS and ADHD

• RLS were greater in patients who had ADHD versus those who did not-(p<0.001)

• Recommendation if patient diagnosed with ADHD need to screen for RLS

• Recommendation if patient diagnosed with RLS need to screen for ADHD

• Consider medication such as dopamine agonists

Reported Clinical Signs of Seizure

• Motionless Stare, drop attacks, nausea, funny smell, Deja Vu• Obsessive rituals, compulsive order • Automatisms (lip smacking, chewing, facial grimacing,

rocking, noises)• Blatant personality change, mood shift• Emotionally reactive , overly focused, negative, dark, gloomy,

pessimistic• Spontaneous, undirected violence, rage• Sleep is fearful, tired in morning

Reported Night-time Symptoms

• Nocturnal wandering• Sleepwalking• Thrashing, restless sleep• Unintelligible talking, moaning• Continual movement vs. RLS or PLMS

All of the above leads to sleep deprivation

Isolated Symptoms: Apparently Normal variants and unresolved issues

• Long sleeper• Short sleeper• Snoring• Sleep talking• Sleep starts –hypnic jerks• Benign sleep myoclonus of infancy• Hypnagogic food tremor and alternating leg

muscle activation during sleep• Propriospinal myoclonus at sleep onset• Excessive fragmentary myoclonus

Sleep disorders associated with conditions classifiable elsewhere

• Fatal familial insomnia• Fibromyalgia• Sleep related epilepsy• Sleep related headaches• Sleep related gastroesophageal reflux disease• Sleep related coronary artery ischemia• Sleep related abnormal swallowing, choking

and laryngospasm

PTSD Sleep Problems

• Universal complaints, fragmented sleep

• Inability to sleep, difficulty initiating & maintaining

• Anxiety arousals are common in PTSD

• REM and non-REM nightmares

• Repetitive nightmares are common

• Nightmares often represent a "re-living" of the original trauma and associated emotions

Menopause and Sleep

• Fragmented sleep due to hot flashes and night sweats

• Increased anxiety and panic

attacks, mood swings,

depression• Rule out sleep apnea and

sleep disordered breathing

-more common in

post-menopause

Good Sleep Habits

• Regular relaxing routine to

unwind at night just before bedtime• Avoid all products containing caffeine (soda

and chocolate)• Avoid smoking and smokeless tobacco• Avoid use of alcohols• No stimulating activities in the evening• Promote calm family atmosphere prior to

bedtime

Good Sleep Habits• Do not allow fall asleep while watching

television or video• Establish regular exercise routine and

healthy diet• Avoid late afternoon and evening bright

light• Go to bed later on weekend awaking

within two hours of usual weekday wake time

• Avoid napping-short nap only limited to 30 to 45 minutes

American Academy of Sleep Medicine, 2002 

Identify the Specifics• Sleep History• Sleep logs• Sleep diary: morning and bedtime habits• Actigraphy• PSG• Sleep schedule• Bedtime routine, bedroom environment• Sleep related cognitions• Identify the factors: daytime sleepiness,

memory

Behavioral Treatment

• Sleep hygiene

• Daytime, evening, morning habits

• Exercise-evening walk for the aged

• Limit napping

• Nocturnal activities hour

• Children: scheduled awakenings,

• Bedroom environment

• Cognitive behavioral therapy (CPT)

Problematic Sleep HabitsNight time habits:

• Irregular sleep wake schedule

• Too much Time TIB• Falling asleep to the

radio/TVs• Trying too hard to

sleep• Clock watching• Long awakenings

• Morning Habits• Lingering in bed

awake in morning• Extra sleep on

weekends• Bedroom disturbance

(noise, sun light)

Treating Techniques for childhood Insomnia

• 1. infants and children learn to fall asleep at the beginning of the night under specific conditions (teach to fall asleep independently)

• 2. An overtired child does not transition as well as when tired (increased sleep drive via sleep delay, tiredness leads to dysregulation of affective states

• 3. Finding the optimal bedtime can be difficult, varies with age, not overly tired and sleep drive high (danger zone-not easily tired)

• 4. Parent education (day and nighttime sleep patterns, explanation of multiple night time awakenings.

Address the Sleep Problem: Don’t Wait

• Daytime sleepiness is a big deal!

• Don’t try to do everything at night-schedule your day for maximum performance

• Set specific times in office or

home for paperwork vs. phone

calls on daily basis-avoid

build-up and worry

Don’t Worry-Be Happy

• Too anxious: Exercise twenty minutes on a daily basis-often running or biking are helpful

• Feeling overwhelmed: Watch the stress & feeling overwhelmed- too many things are going on at one time

• Too much to do and no time to do it: Manage time by specifically estimating each task- add up time for exact time estimates-to decrease over-planning

Don’t Worry-Be Happy

• Staying up late to complete all your goals: Issue of diminishing returns- time spent vs. being tired-examine from larger perspective- what really has to be done in the grand scheme of things- is this last task more important than health?

• Distractibility increased: – Stress & lack of food tend to increase

distractibility- increased lack of focus

Don’t Worry-Be Happy

• Easily frustrated- short fuse:

Result of too much stress, lack of food, feeling totally overwhelmed- wake up call for life

changes & “nice moments of time”

• More tired, energy loss, channel clickers

• Wake up call for life changes-check sleep, eating habits- often result of energy expended continually compensating for something else (sleep disorder, ADD..)

Sleep is a necessary function of life

Make it Healthy

Increase your happiness