Sleep Disorders

1. LEEP DISORDERS

2. Sleep Architecture and Sleep Stages divided into two independent states: NREM and REM sleep NREM - further divided into three stages ie N1, N2, N3 After sleep onset, progresses through NREM stages N1–N3 sleep within 45–60 min NREM and REM sleep alternate, with each cycle lasting for approximately 90 to 100 minutes

3. Four to six such cycles are noted during a normal sleep period N3 predominates in the first third of the night and comprises 15–25% of total nocturnal sleep REM sleep dominates the last third Overall, REM sleep constitutes 20–25% of total sleep, and NREM stages N1 and N2 are 50–60 %

4. Sleep Requirements and Quantity of Sleep Sleep requirement is defined as the optimal amount of sleep required to remain alert and fully awake and to function adequately throughout the day for an average adult is approximately 7.5 to 8 hours

5. Classification of Sleep Disorders International Classification of Sleep Disorders latest edition of the International Classification of Sleep Disorders (ICSD-2) (AASM, 2005 ) eight broad categories of disordered sleep, along with several subcategories

6. I. Insomnia II. Sleep-related breathing disorders III. Hypersomnias of central origin not due to a circadian rhythm sleep disorder, sleep-related breathing disorder, or other cause IV. Circadian rhythm sleep disorders

7. V. Parasomnias VI. Sleep-related movement disorders VII . Isolated symptoms, apparently normal variants, and unresolved issues VIII. Other sleep disorders

8. Approach to the Patient: Sleep Disorders an acute or chronic inability to initiate or maintain sleep adequately at night (insomnia ) chronic fatigue, sleepiness, or tiredness during the day (EDS) Inability to sleep at the right time Abnormal movements and behavioural manifestation associated with sleep itself

9. SUBJECTIVE MEASURES OF SLEEPINESS

10. Narcolepsy characterized by recurrent "sleep attacks" that the patient cannot fight Irresistible desire to fall asleep in inappropriate circumstances and at inappropriate places

11. e.g., while talking, driving, eating, playing, walking , running, working, sitting, listening to lectures , watching television or movies The sleep attacks are about 20-30 minutes long. The patient feels refreshed by the sleep, but typically feels sleepy again several hours later

12. Narcolepsy Symptoms of narcolepsy typically begin in the second decade Once established, the disease is chronic without remissions Men and women are equally affected affects about 1 in 4000 people in the United States

13. ICSD-2 (AASM, 2005) narcolepsy withcataplexy narcolepsy without cataplexy secondary narcolepsy

14. Narcolepsy Tetrad EDS plus 3 specific symptoms : Cataplexy sudden weakness or loss of muscle tone without loss of consciousness, often elicited by emotion Hallucinations at sleep onset (hypnagogic hallucinations) or upon awakening(hypnopompic hallucinations )- visual Sleep paralysis occurs during the transition from being asleep to waking up.

15. GENETICS Most are sporadic, some are AD 10 to 40 times greater prevalence in families hypothalamic neuropeptide hypocretin ( orexin ) is involved in the pathogenesis narcoleptics with cataplexy are positive for HLA DQB1*0602, suggesting that an autoimmune process

16. CURRENT THEORY Results from a depletion ( degeneration or autoimmune) of hypocretin neurons in lateral and perifornical regions of hypothalamus

17. Symptomatic or secondary narcolepsy-cataplexy diencephalic and midbrain tumors , MS, strokes, cysts, vascular malformations, encephalitis, cerebral trauma, and paraneoplastic syndrome with anti-Ma2 antibodies

18. Treatment of Narcolepsy-Cataplexy Syndrome Nonpharmacological measures include scheduled short daytime naps, sleep hygiene measures attendance at narcolepsy support groups

19. Breathing-related Sleep Disorders syndromes in which the patient's sleep is interrupted by problems with his or her breathing

20. types of breathing-related sleep disorders: Obstructive sleep apnea syndrome. most common form, marked by episodes of blockage in the upper airway during sleep. It is found primarily in obese people. Central sleep apnea syndrome. primarily found in elderly patients with heart or neurological conditions that affect their ability to breathe properly.Problem lies in the ventilator control mechanisms in CNS.

21. Sleep-Disordered Breathing Terminology Apnea - three types: obstructive, central, and mixed central apnea - Cessation of airflow with no respiratory effort, both diaphragmatic and intercostal muscle activities as well as gas exchange through the nose or mouth are absent obstructive apnea - airflow stops while the effort continues

22. mixed apnea - there is an initial cessation of airflow with no respiratory effort (central apnea ) followed by a period of upper airway obstructive sleep apnea Apneas are defined in adults as breathing pauses lasting > 10 s hypopneas as events > 10 s in which there is continued breathing but ventilation is reduced by at least 50% from the previous baseline during sleep

23. OBSTRUCTIVE SLEEP APNEA defined as the coexistence of unexplained EDS with at least five obstructed breathing events ( apnea or hypopnea) per hour of sleep Factors contributing to the pathogenesis include local anatomical, neurological, and vascular factors, as well as familial predisposition

24. Pathogenesis Collapse of the pharyngeal airway is the fundamental factor During sleep, muscle tone decreases - causes these muscles to relax - increasing upper airway resistance and narrowing the upper airway space

25. Epidemiology prevalence is 4% in men and 2% in women between the ages of 30 and 60 also occurs in childhood—usually associated with tonsil or adenoid enlargement

26. Factors predisposing to OSAS obesity—in Western populations around 50% of OSAHS patients have a body mass index (BMI) >30 kg/m2 Hypothyroidism and acromegaly - narrowing the upper airway with tissue infiltration male sex, middle age (40–65 years )

27. Symptoms and Signs

28. sleep attacks lasting 0.5 to 2 hours and occurring mostly when the patient is relaxing. The prolonged duration and the nonrefreshing nature of these sleep attacks in OSAS differentiate these from narcoleptic sleep attacks

29. Consequences increased morbidity and mortality short-term consequences (impairment of quality of life and increasing traffic- and work-related accidents ) long-term consequences from associated and comorbid conditions such as hypertension, heart failure, MI, cardiac arrhythmias, stroke, transient ischemic attacks, cognitive dysfunction, depression , and insomnia

30. Mallampati classification

31. General Measures Avoid alcohol and sedative-hypnotics, especially in the evening Reduce body weight if overweight Avoid sleep deprivation Participate in regular exercise program Avoid supine sleeping position

32. Mechanical Devices Continuous positive airway pressure (CPAP) titration - treatment of choice Bilevel positive airway pressure ( BiPAP ) titration Auto-CPAP Oral appliances, including mandibular advancement device Tongue-retaining device

33. Surgical Techniques Uvulopalatopharyngoplasty (UPP) Laser-assisted UPP (LAUP) Radiofrequency UPP ( somnoplasty ) Palatal implants Nasal surgery Maxillomandibular advancement Anterior hyoid advancement Tonsillectomy and adenoidectomy

34. Insomnia most common sleep disorder Inability to initiate or maintain sleep, early awakening, inadequate sleep time, or poor sleep quality associated with a lack of feeling restored and refreshed in the morning, leading to poor daytime functioning - AASM (2005)

35. Primary Insomnia onset occurs in early childhood lifelong difficulty with initiating or maintaining sleep exclusion of concomitant comorbid medical, neurological, psychiatric, or psychological disturbances .

36. Medical Disorders Comorbid with Insomnia Ischemic heart disease Congestive cardiac failure Chronic obstructive pulmonary disease Bronchial asthma Peptic ulcer disease Gastroesophageal reflux disease Rheumatic disorders

37. Treatment of Insomnia most commonly used hypnotics are the benzodiazepine receptor agonists – zolpidem , zaleplon , and eszopiclone Melatonin receptor agonists( ramelteon ) - sleep-onset insomnia

38. PARASOMNIAS abnormal movements or behaviours that occur in sleep or during arousals from sleep may be intermittent or episodic, and sleep architecture may not be disturbed

39. ICSD-2 (AASM, 2005) Disorders of arousal (from NREM sleep), which include confusional arousals , sleepwalking, and sleep terror Parasomnias associated with REM sleep, which include RBD, recurrent isolated sleep paralysis, and nightmare disorder other parasomnias including sleep-related dissociative disorders, sleep enuresis, sleep-related groaning ( catathrenia )

40. Sleepwalking Somnambulism Onset: common between ages 5 and 12 yr High incidence of positive family history Abrupt onset of motor activity arising out of slow-wave sleep (NREM stage N3 sleep), during first one-third of the night

41. Duration: less than 10 min Injuries and violent activity occasionally reported Precipitating factors: sleep deprivation, fatigue, concurrent illness, sedatives Treatment: precaution, benzodiazepines, imipramine

42. Sleep Terror pavor nocturnus Onset: peak is between ages 5 and 7 yr High incidence of familial occurrences Abrupt arousal from slow-wave sleep during first one-third of the night , with a loud piercing scream Intense autonomic and motor components

43. Precipitating factors: stress, sleep deprivation, fever Treatment: psychotherapy, benzodiazepines, tricyclic antidepressants

44. Rapid Eye Movement Sleep Behavior Disorder (RBD) Onset: middle-aged or elderly men Presents with violent dream-enacting behavior during sleep, causing injury to self or bed partner Often misdiagnosed as a psychiatric disorder or nocturnal seizure (partial complex seizure)

45. Etiology : 40% idiopathic, 60% causal association with structural central nervous system lesion or related to alcohol or drugs (sedative-hypnotics , tricyclic antidepressants, anticholinergics ) Polysomnography : rapid eye movement sleep without muscle atonia Treatment: 90% response to clonazepam, melatonin

46. Nightmare Disorder Dream anxiety attacks fearful, vivid, often frightening dreams, mostly visual but sometimes auditory, and seen during REM sleep most commonly occur during the middle to late part of sleep at night

47. mostly a normal phenomenon, up to 50% of children have nightmares beginning at age 3 to 5 years side effects of certain medications such as antiparkinsonian drugs ( pergolide , levodopa), anticholinergics , and antihypertensive drugs , particularly beta-blockers generally do not require any treatment except reassurance

48. Sleep-Related Movement Disorders

49. Restless Legs Syndrome (RLS) most common movement disorder but is uncommonly recognized and treated irresistible urge to move their legs while at rest. experience a vague, uncomfortable feeling while at rest that is only relieved by moving the legs. mostly diagnosed in the middle or later years

50. Clinical Diagnostic Criteria Essential Criteria An urge to move the legs, usually accompanied by or caused by uncomfortable sensations in the legs begins or worsens during periods of rest or inactivity, such as lying or sitting partially or totally relieved by movement such as walking or stretching worse in the evening or night

51. Supportive Features Dopaminergic responsiveness Presence of periodic limb movements in sleep or wakefulness – 80% Positive family history

52. Associated Features Usually progressive clinical course Normal neurological examination in the idiopathic form Sleep disturbance

53. Secondary - Medical Disorders Anemia : iron and folate deficiency Diabetes mellitus Amyloidosis Uremia Chronic obstructive pulmonary disease Peripheral vascular (arterial or venous) disorder Rheumatoid arthritis Hypothyroidism

54. Pathophysiology iron-dopamine dysfunction abnormalities in the body’s use and storage of iron dopamine dysfunction - changes in dopamine receptors or dopamine uptake

55. Drug Treatment of Restless Legs Syndrome Dopaminergic agents: Pramipexole Ropinirole Benzodiazepines: Clonazepam Temazepam Antiepileptic agents: Gabapentin Pregabalin

56. Circadian Rhythm Sleep Disorders Mismatch between the body’s internal clock and geophysical environment either as a result of malfunction of the biological clock or a shift in the environment causing this to be out of phase Most common are jet lag and shift-work sleep disorder

57. Types of Circadian Rhythm Sleep Disorders

58. Jet lag sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone 

59. Shift work insomnia during the major sleep period or excessive sleepiness during the major awake period associated with night shift work or frequently changing shift work 

60. Modafinil (200 mg, taken 30–60 min before the start of each night shift) is approved by the U.S. Food and Drug Administration as a treatment for the excessive sleepiness during night work in patients with SWD

61. Laboratory Assessment of Sleep Disorders The two most important laboratory tests for diagnosis of sleep disturbance are PSG and the MSLT overnight PSG study is the single most important laboratory test for the diagnosis and treatment of patients with sleep disorders

62. Multiple Sleep Latency Test important test to effectively document EDS Narcolepsy is the single most important indication presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggest a diagnosis of narcolepsy circadian rhythm sleep disturbance - REM sleep abnormalities

63. Sleep Education "Sleep hygiene" or sleep education for sleep disorders often includes instructing the patient in methods to enhance sleep. Patients are advised to: wait until he or she is sleepy before going to bed avoid using the bedroom for work, reading, or watching television get up at the same time every morning no matter how much or how little he or she slept avoid smoking and avoid drinking liquids with caffeine get some physical exercise early in the day every day limit fluid intake after dinner; in particular, avoid alcohol because it frequently causes interrupted sleep learn to meditate or practice relaxation techniques avoid tossing and turning in bed; instead, he or she should get up and listen to relaxing music or read