SLEEP , TYPES OF SLEEP AND ITS MANAGEMENT PPT..

SLEEP AND ITS MANAGEMENT

1. Sleep Disorders and Their Management

2. Epidemiology of sleep-related disorders A considerable number of studies have demonstrated that sleep-related problems are rampant in the general populations throughout the world. A study conducted in south India reported a prevalence of sleep disorders to be around 20% in the general population They also commented on the low perception of sleep-related problems in the general population. A major study was conducted by JC Suri et al (2008) (2009) in Delhi by questionnaire followed with PSG on sleep problems in adult and elderly. They reported it to be the highest (59%) for disorders of initiation and maintenance of sleep and lowest for sleep waking (6.9%) in the elderly. They also reported that none of the individuals they included in the study were undergoing any form of treatment.

3. Classification of sleep-related disorders One of the earliest classifications available were provided by the Diagnostic Classification of Sleep and Arousal Disorders , published in 1979. Later in the year 1990, the International Classification of Sleep Disorders (ICSD) was published through the efforts a few major international sleep societies at that time, like the American Sleep Disorders Association (ASDA), European Sleep Research Society etc. The ICSD classification was developed primarily for diagnostic, epidemiologic, and at the time, research purposes. Later in 2005, the International Classification of Sleep Disorders was revised and the second version of ICSD was introduced. According to the ICSD-2 classification, there are majorly 81 sleep disorders which fall in eight diagnostic categories. The International Classification of Sleep Disorders (ICSD-3) produced by the American Academy of Sleep Medicine is a major revision of the prior classification and was published in 2014.

4. According to the ICSD-2 classification, there are majorly 81 sleep disorders which fall in eight diagnostic categories. These categories are: 1. Insomnia 2. Sleep-related breathing disorders 3. Hypersomnias of central origin 4. Circadian rhythm sleep disorders 5. Parasomnias 6. Sleep-related movement disorder 7. Isolated symptoms, apparently normal variants and unresolved issues 8. Other sleep disorders

5. Insomnia have heterogeneous complaints of difficulty in initiating and maintenance of sleep, waking too early, or non-restorative sleep. In addition to the mentioned complaints, day time difficulties are also associated like fatigue, attention and memory problems, irritability, and worrying about not being able to sleep A commonly used cognitive and behavioural model of insomnia, referred to as the 3P mode helps in distinguishing three types of factors that are responsible for the sleep difficulties which the patient experiences: Predisposing, Precipitating, and Perpetuating Factors According to the physiological model, hyper arousal, circadian rhythm, dysrhythmia and disturbed homeostasis are responsible for the development of insomnia. These patients have been shown to have physiological symptoms like heart rate increase and variability, hyper activity of hypothalamic-pituitary-adrenal axis activity, increased EEG frequency at sleep onset and REM sleep.

6. According to ICSD-2, insomnia can be primary (psycho-physiological, paradoxical, idiopathic adjustment and that caused due to mental disorder insomnia.) or secondary Clinical examination Management of insomnia can broadly be classified into pharmacological and apharmacological.

7. S leep hygiene Sleep restriction increases this sleep efficiency by reducing this gap by increasing sleep onset latency and improving total sleep Cognitive therapy works on helping the patient to deal with faulty thoughts related to sleep and modifying them accordingly. It is the mainstay of psychological treatment and is dealt with by a clinical psychologist sleep time Relaxation therapy

8. Sleep hygiene

9. Sleep-related breathing disorders Sleep-related breathing disorders were characterized by disordered breathing during respiration. It was broadly classified by ICSD-2 Central Sleep Apnea Disorders Obstructive Sleep Apnea Syndromes Sleep-related hypoventilation/Hypoxemic syndromes

10. C entral apnea D iminished or absent respiration in a cyclic or intermittent fashion is because of central nervous system By definition, primary central sleep apnea is a disorder of unknown origin and is characterized by repeated periods of loss of breathing during sleep without associated ventilatory effort. The episodes can go up to five or more, which is visible on a full night PSG. It is usually associated with frequent awakenings with complaints of insomnia or awakening with shortness of breath, and in the absence of another concurrent sleep disorder, medical or neurological disorders or medication/substance use and day-time sleepiness syndrome

11. Gender: Males are more prone to developing central sleep apnea as compared to females. Age: Central sleep apnea is more common among older adults after 65. It could be because they may have other associated medical conditions or sleep patterns that predispose them to central sleep apnea. Heart disorders: Sleep disordered breathing, such as Cheyne-Stokes breathing and obstructive sleep apnea, may be present in up to 50 per cent of people with congestive heart failure. Stroke or brain tumor: These conditions lead to the inability of the brain to work efficiently and regulate breathing. High altitude: Sleeping at higher altitudes predispose individuals towards central sleep apnea but the condition reverses back when lower altitudes are achieved. Opioid use: Opioid medications may increase the risk of central sleep apnea.

12. Obstructive Sleep Apnea Obstructive sleep apnea syndrome(OSAS) is a common chronic disorder that often requires lifelong care. Upper airway obstruction results in a series of clinical features associated with sleep-disordered breathing that varies from mild snoring to limited airflow, resulting in reduced airflow and tidal volume or hypopnea , to cessation of airflow or  apnea , associated symptoms like excessive daytime sleepiness and/or insomnia. This is usually seen in patient’s narrowed oropharynx, such as a low-lying palate or redundant soft palate tissue, a thickened tongue base, or a narrow hypopharynx, although nasal anatomy with septal deviation or chronic congestion can also aggravate the problem . The episodes should be at least 5 per hour to be diagnosed as apnea

13. The diagnosis of obstructive sleep apnea should start with a sleep history that has to be obtained in any one of three clinical settings: R outine health examination Examination of a patient complaining of symptoms of apnea E xamination of patients who are at a high risk for obstructive sleep apnea like obese, type 2 diabetes, stroke etc. The clinician taking the history should include typical questions regarding the patient’s history like snoring, gasping/choking episodes, excessive sleepiness not explained by other factors, total sleep amount, morning headaches etc. An assessment of associated conditions is also warranted. After examination, the patients are classified according to their obstructive sleep apnea risk The two most objective methods for the confirmation of apnea are home PSG and laboratory PSG

14. Treatment options can be broadly divided into: Behavioural interventions. Overweight should be strictly advised to lose weight as weight reduction improves obstructive sleep apnea symptoms and other excess weight-related disorders which can be leading to obstructive sleep apnea. Alcohol should not be taken in the evenings and sedatives and sleeping tablets avoided as all of these decrease airway dilator function and worsen. Smokers should be advised to lose the habit as it is a proven risk factor Non-surgical options include options like CPAP, bi-level positive airway pressure, intra oral devices etc. Surgical options for the patients include uvulopalato-pharyngoplasty , tracheostomy, mandibular advancements, bariatric surgeries to decrease weight, nasal surgery for any anomalies People with poorly treated sleep apnea often have problems like an increase in anxiety and depression, poor performance at .work or school because of daytime sleepiness or fragmented sleep etc. They are prone to having motor vehicle accidents because of daytime sleepiness, industrial accidents, poor quality of life etc. With treatment, the symptoms and problems of sleep apnea should be totally corrected.

15. Hypersomnias of Central Origin Hypersomnia, or excessive sleepiness, is a condition in which a person has trouble staying awake during the day. It usually affects individuals between 15-30 years of age. It was described by DSM IV as the prolonged sleep amounts for more than 9 hours during a day There are two main categories of hypersomnia - primary or idiopathic and recurrent hypersomnia. The only difference between them is the frequency and regularity of occurrence of the symptoms.

16. Circadian Rhythm Disorders Circadian rhythm disorders are sleep disorders where there is a mismatch between circadian rhythms and the required sleep–wake cycle. Thus there can be sleeplessness when trying to sleep at a time which is not appropriate. Some of these disorders can be attributed to lifestyle, like shift work disorders and they are exogenous in nature . Each circadian rhythm sleep disorder must include atleast two of the mentioned clinical features. The patient might complain of difficulty in sleep initiation, sleep fragmentation, frequent awakenings, non-restorative and poor quality of sleep (AASM) . There can be a few types of circadian rhythm disorders like shift work disorder, irregular sleep-wake cycle, jet lag disorder, delayed sleep phase disorder, advanced sleep phase disorder and free running type of disorder.

17. Parasomnias Parasomnias can be defined as a group of undesirable behaviour or experiential phenomena occurring during sleep or in the transition to, and from, sleep. They can be divided into three subgroups dependent on the stages in which they are exhibited: disorders of arousal disorders of REM sleep other parasomnias. These occur due to abnormal transitions between the three primary states of being wake, REM sleep, and NREM sleep It consists of abnormal behaviours , movements, emotions, perceptions, dreams and autonomic nervous system functions. Clinical features include skeletal muscles and autonomic nervous system activity . Commonly seen parasomnias in clinical practice include night terrors, sleep walking, REM sleep behavioural disorders etc. The risks for parasomnia include age, genetic predisposition, stress, post traumatic stress disorder, alcohol abuse, substance abuse etc. Management of the condition includes behavioural changes like sleep on ground floor, putting alarms at various places etc. The patient is also advised to take certain precaution like sleep well, have regular sleep cycles, follow the sleep hygiene well etc.

18. Sleep-Related Movement Disorders This category of ICSD-2 includes restless legs syndrome (RLS), periodic limb movement disorders (PLMD), sleep-related Bruxism, sleep-related leg cramps and sleep-related rhythmic disorder (RMD) Pharmacological intervention is initiated only when patient inflicts injury or complains of poor sleep

19. Physiotherapy intervention P hysical agents should bring about a change or play a role in the improvement of sleep quality. Some of them are: Physical agents bring about a muscle relaxation and muscle relaxation has a positive relationship with the sleep quality Some neurotransmitters like serotonin, histamine play a role in sleep wakefulness cycle. These peptides are closely related with the physical agents too. They are decreased by the applications as certain modalities because of the increased blood flow etc Physical agents activate the sympathetic nervous system which is related with sleep too. Cholinergic activity is also related to sleep as well as physical agents

20. Heat and its role in sleep medicine Heat loss at the skin of the hands and feet during fast sleep onset and when the core body temperature decreases during sleep this peripheral heat loss increases further. There exists an inverse relationship between peripheral skin temperature and light out as well as with latency of sleep onset Increasing cutaneous temperature is associated with an activation type typical of sleep in the hypothalamus and cerebral cortex. Hence, the cycles of core and cutaneous temperature could be one of the factors modulating the neuronal and behavioral activation state, which in turn can be associated with probability for sleep onset near the high point in cutaneous temperature in the periphery. There seems to be a relationship of negative association between core and cutaneous temperature. The fall in the core temperature is due to increased heat loss peripherally which is because of increase in peripheral temperature

21. Body temperature manipulation can be done by a number of passive methods like hot bath, heating blanket, hot packs etc. It was proposed earlier by Horne (1983) that an increase in temperature passively (by body heating) or actively (by exercise) According to this theory, an increase in body temperature would expedite the production of sleep factors which tend to accumulate in correlation with wakefulness, thus producing a change which can only be reverted back by sleep. Another theory suggests that at the onset of sleep, the core temperature decreases because of the underlying circadian rhythm and sleep accentuates this effect

22. But now it can be stated that the main force behind the decrease of core temperature is peripheral skin temperature, which has a very rich vascularity. Increased peripheral temperature is largely because of decreased activation of noradrenergic vasoconstrictor tone which facilitates heat loss. This vasodilatation is also associated with melatonin secretion. Heat exposure affects SWS and REM sleep whereas cold exposure does not have any effect over the sleep stages This is further consolidated by various studies conducted over time, which found that warm bath could enhance slow wave sleep (stages 3 and 4 sleep, deep sleep) when performed in the evening (17:30–20:00) reduce REM sleep , and also decrease sleep-onset latency and sleep arousal in healthy young adults (aged 20–33 yr) who were good sleepers. Bathing performed in the morning or afternoon had no effect on sleep .

23. Exercise therapy and sleep According to the American Sleep Disorder Association (ASDA), exercise is one of the apharmacological intervention used to promote sleep landmark survey conducted in Finland published in the year 1988. Individuals were randomly selected (n=1190) and asked an open-ended question about the factor which is the best for promotion of their sleep. Results declared found exercise as the most important factor

24. Most of the studies were conducted on normals . This can be explained on the basis of ceiling and floor effects as described by Youngstedt SD(2003). The sample sizes were generally small in interventional studies. Exercises prescribed are difficult to follow and implementation of daily routine for sedentary workers makes it a difficult and permanent apharmacological management, especially for patients who are already tight-pressed for time. Most of the work done is on slow wave sleep. Most of the studies are short-term studies. There are no studies to the best of my knowledge which have worked on long term effects and follow-up. Sleep itself is very subjective and difficult to study. There is a vast amount of interplay between numerous factors affecting it. Smaller factors like age and sex of the participant, time, duration and type of exercise have not been studied very well.

25. Possible Mechanisms of Effects of exercise On Sleep Effect On Mental Health According to a number of studies done till date, the effect of exercise on mental health is closely related to depression and anxiety. According to Daniel M Landers 57 , the benefits of exercise on anxiety and depression are similar to as reported by other treatment Number of awakenings in the night is one of the important indicators of anxiety which is effectively decreased by exercises

26. Effects on thermoregulatory mechanism Modulation in core body temperature affect the sleep parameters.This change in core body temperature can be brought about actively (by exercises etc.) or passively (by warm bath, thermosuit , electrical blankets, warm footbath etc.) These methods of increasing the temperature can be implemented at various times (before sleep or during sleep). The time of application also seems to play a role as reported in various studies positive relationship between SWS and exercise

27. Effects on restoration of the body Acute exercises have been shown to bring about an increase in cytokines which in turn can be related to regulation of sleep. This may be one of the restorative mechanisms though others like muscle repair have also been discussed along with compensation of high energy expenditure. All these factors work towards the restoration effects.

28. Effects on circadian rhythm Aerobic exercises performed late in the evening has reported to be associated with poor sleep quality as compared to exercises in the afternoon It was postulated by Driver and Taylor (2004) that exercise done in a well-lit area may improve the sleep for individuals with altered circadian rhythm. They also suggested further research to find out the relation between light, exercise and sleep. Physical activity has been suggested to decrease fatigue levels, improving the tolerance of shifts but at the same time, there is a problem of poor adherence to exercises too It has also been reported that exercise acts as a zeitgeber and it brings about a shift in the phase response curve. There are various other additional factors which are responsible for the effects.

29. Exercise is a positive behavioral modification tool for all age groups to bring about an improvement in sleep quality. Exercise can be very effective in older populations, not only for improvement in sleep but also for other ailments. Acute exercises don’t seem to be very effective in bringing about an improvement in the quality of sleep but the number of studies done is still lesser so it is not very conclusive either. Effects of aerobic and resistance training done for long durations may bring about improvement in sleep quality.