Sleep, sleep disorders Professor Yasser Metwally
<ul><li>Each of us will spend about  27 years  of our lifetime sleeping…..  </li></ul><ul><li>… ..And  1/3 part  of the po...
„ Why we sleep remains one of nature’s greatest mysteries” <ul><li>(MG Frank, The function of sleep, 2006) </li></ul><ul><...
Regulation of sleep <ul><li>Cirkadian timing:  lasts about 24 hours </li></ul><ul><li>Hypothalamus </li></ul><ul><ul><ul><...
Normal human sleep <ul><li>Sleep cycle  – occurs about every 90 minutes,  </li></ul><ul><li>approximately 4-6 cycles occur...
NREM <ul><li>stage (3-8%) ~  drowsiness, sleepiness  EEG:  α -activity, muscle tone, eye movement ↓, myoclonus!  </li></ul...
<ul><ul><li>Tonic   stage (desyncronized EEG ~ low voltage, frequency  ↑ , muscle atonia)  </li></ul></ul><ul><ul><li>Phas...
Sleep disorders
Polysomnography <ul><li>multiparametric monitoring during 1 sleep period (1 night)  </li></ul><ul><li>EEG </li></ul><ul><l...
More than 80 sleep disorders are known   (International Classification of Sleep Disorders, 2 nd  Edition American Academy ...
Traditional classification of sleep disorders <ul><li>Dyssomnias :  abnormalities in the quantity, quality or timing of sl...
I. Insomnias <ul><li>Difficulty in initiating sleep or in staying asleep or waking up earlier </li></ul><ul><li>Nonrefresh...
I. Insomnias <ul><li>Prevalence: 33% </li></ul><ul><li>Accompanied with daytime consequences: 10% </li></ul><ul><li>Last l...
I. Insomnias <ul><li>Primary (idiopathic) </li></ul><ul><li>Secunder </li></ul><ul><ul><li>Inadequate sleep hygiene (10%) ...
Treatment <ul><li>Treating the medical or psychiatric conditions (sec. insomnias) </li></ul><ul><li>Nonpharmacologic:  </l...
Pharmacologic treatment <ul><li>Benzodiazepines </li></ul><ul><ul><li>midazolam, triazolam  ~  rebound insomnia </li></ul>...
Pharmacologic treatment <ul><li>Selective GABA A  agonists: nonbenzodiazepines </li></ul><ul><ul><li>no rebound insomnia <...
II. Sleep related breathing disorders   (International Classification of Sleep Disorders, 2 nd  Edition American Academy o...
Apnea-hypopnea index (AHI) <ul><li>Numbers of apneas and hypopneas/ 1 sleeping hour </li></ul><ul><li>Severity of sleep re...
OSAHS: symptoms <ul><li>Daily </li></ul><ul><li>Excessive daytime sleepiness </li></ul><ul><li>Unrefreshing sleep </li></u...
OSAHS: diagnostic criteria <ul><li>(1. or 2.) and 3. </li></ul>AASM, Sleep, 1999:22:667-89.
Risk factors of OSAHS <ul><li>Obesitas </li></ul><ul><li>Age </li></ul><ul><li>Male gender </li></ul><ul><li>Pozitive fami...
Treatment of bening snoring <ul><li>Weight loss, alcohol withdrawal  </li></ul><ul><li>Position training </li></ul><ul><li...
IV. Cirkadian rhythm sleep disorders <ul><li>Primary </li></ul><ul><ul><li>Delayed sleep phase type  </li></ul></ul><ul><u...
V. Parasomnias <ul><li>In NREM </li></ul><ul><ul><li>Myoclonus </li></ul></ul><ul><ul><li>Enuresis nocturna </li></ul></ul...
VI. Sleep related movement disorders <ul><li>Restless legs syndroma </li></ul><ul><ul><li>Therapy: dopamin agonists </li><...
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Sleep disorders

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Sleep disorders

  1. 1. Sleep, sleep disorders Professor Yasser Metwally
  2. 2. <ul><li>Each of us will spend about 27 years of our lifetime sleeping….. </li></ul><ul><li>… ..And 1/3 part of the population has sleep disorder </li></ul>About the sleep…
  3. 3. „ Why we sleep remains one of nature’s greatest mysteries” <ul><li>(MG Frank, The function of sleep, 2006) </li></ul><ul><li>Somatic theories of sleep function </li></ul><ul><li>Neural metabolic theories: detoxification and regeneration </li></ul><ul><li>Cognitive theories of sleep function: learning and brain development </li></ul>
  4. 4. Regulation of sleep <ul><li>Cirkadian timing: lasts about 24 hours </li></ul><ul><li>Hypothalamus </li></ul><ul><ul><ul><li>Suprachiasmatic nucleus </li></ul></ul></ul><ul><li>Pituitary gland: melatonin </li></ul><ul><li>Ultradian timing : lasts less than 24 hours </li></ul><ul><li>Prepontin nuclei </li></ul><ul><li>Raphe nuclei </li></ul><ul><li>L. coeruleus </li></ul>
  5. 5. Normal human sleep <ul><li>Sleep cycle – occurs about every 90 minutes, </li></ul><ul><li>approximately 4-6 cycles occur per major sleep episode </li></ul><ul><li>Microarousal </li></ul><ul><li>NREM (70-80%) </li></ul><ul><ul><ul><li>slow wave sleep </li></ul></ul></ul><ul><ul><ul><li>heart rate, BP, breathing ↓ </li></ul></ul></ul><ul><ul><ul><li>body temperature, muscle tone ↓ </li></ul></ul></ul><ul><li>REM (20-25%) </li></ul><ul><ul><ul><li>rapid eye movement, paradox, fast wave sleep </li></ul></ul></ul><ul><ul><ul><li>heart rate, BP, breathing ↑ , metabolic rate ↑ </li></ul></ul></ul><ul><ul><ul><li>dreaming, erection </li></ul></ul></ul><ul><ul><ul><li>muscleatonia, BUT: myoclonus! </li></ul></ul></ul>
  6. 6. NREM <ul><li>stage (3-8%) ~ drowsiness, sleepiness EEG: α -activity, muscle tone, eye movement ↓, myoclonus! </li></ul><ul><li>stage (45-55%) ~ EEG: K-complexes, sleep spindles, no eye movement </li></ul><ul><li>stage (5-10%) EEG: delta waves </li></ul><ul><li>stage (15-20%) slow wave sleep </li></ul>
  7. 7. <ul><ul><li>Tonic stage (desyncronized EEG ~ low voltage, frequency ↑ , muscle atonia) </li></ul></ul><ul><ul><li>Phasic stage (rapid eye movements ~ fast, saccadic eye movements ~, irregular breathing, heart rate ↑ , myoclonus, apnea, hyperpnea, dreaming!!!) </li></ul></ul>REM
  8. 8. Sleep disorders
  9. 9. Polysomnography <ul><li>multiparametric monitoring during 1 sleep period (1 night) </li></ul><ul><li>EEG </li></ul><ul><li>Electrooculogram </li></ul><ul><li>EMG </li></ul><ul><li>ECG </li></ul><ul><li>Respiratory effort </li></ul><ul><li>SpO 2 </li></ul><ul><li>Body position </li></ul><ul><li>Snoring </li></ul>
  10. 10. More than 80 sleep disorders are known (International Classification of Sleep Disorders, 2 nd Edition American Academy of Sleep Medicine, 2005) <ul><li>Insomnias (33%) </li></ul><ul><li>Sleep related breathing disorders (1,4-40%) </li></ul><ul><li>Hypersomnias (0,3-16,3%) </li></ul><ul><li>Cirkadian rhythm sleep disorders </li></ul><ul><li>Parasomnia </li></ul><ul><li>Sleep related movement disorders </li></ul><ul><li>Isolated symptoms, normal variants </li></ul><ul><li>Other sleep disorders </li></ul>
  11. 11. Traditional classification of sleep disorders <ul><li>Dyssomnias : abnormalities in the quantity, quality or timing of sleep. They are associated with difficulty initiating or maintaining the sleep or daytime sleepiness. </li></ul><ul><li>Parasomnias : abnormal behavioral or physiological events occurring during sleep but don’t involve the sleep mechanisms per se. </li></ul>
  12. 12. I. Insomnias <ul><li>Difficulty in initiating sleep or in staying asleep or waking up earlier </li></ul><ul><li>Nonrefreshing, nonrestorative sleep </li></ul><ul><li>Fatigue, concentration or memory impairment </li></ul><ul><li>Mood disturbances, motivation, initiative reduction </li></ul><ul><li>Daytime sleepiness </li></ul><ul><li>Tension headache </li></ul>
  13. 13. I. Insomnias <ul><li>Prevalence: 33% </li></ul><ul><li>Accompanied with daytime consequences: 10% </li></ul><ul><li>Last less than 1 month: 4% (transient insomnia) </li></ul><ul><li>Last more than 1 year: 85% (persistent insomnia) </li></ul><ul><li>Male:female = 1:1.4 </li></ul><ul><li>Increase with age: above 65 years: 50% </li></ul>
  14. 14. I. Insomnias <ul><li>Primary (idiopathic) </li></ul><ul><li>Secunder </li></ul><ul><ul><li>Inadequate sleep hygiene (10%) </li></ul></ul><ul><ul><li>Paradoxical insomnia (10%) </li></ul></ul><ul><ul><li>Insomnia due to mental disorder (30-40%) </li></ul></ul><ul><ul><li>Psychophysiological insomnia (15%) </li></ul></ul><ul><ul><li>Insomnia due to drug or substance </li></ul></ul><ul><ul><li>Insomnia due to medical conditions </li></ul></ul><ul><ul><li>Sunday night insomnia </li></ul></ul>
  15. 15. Treatment <ul><li>Treating the medical or psychiatric conditions (sec. insomnias) </li></ul><ul><li>Nonpharmacologic: </li></ul><ul><ul><li>behavioral treatments: normalizing the circadian rhythm </li></ul></ul><ul><ul><li>sleep hygiene </li></ul></ul><ul><ul><li>cognitive behavior therapy </li></ul></ul><ul><ul><li>sleep restriction therapy </li></ul></ul><ul><li>Pharmacologic treatment </li></ul>
  16. 16. Pharmacologic treatment <ul><li>Benzodiazepines </li></ul><ul><ul><li>midazolam, triazolam ~ rebound insomnia </li></ul></ul><ul><ul><li>cinolazepam, quazepam </li></ul></ul><ul><ul><li>brotizolam, temazepam </li></ul></ul><ul><ul><li>nitrazepam ~ drowsiness </li></ul></ul>
  17. 17. Pharmacologic treatment <ul><li>Selective GABA A agonists: nonbenzodiazepines </li></ul><ul><ul><li>no rebound insomnia </li></ul></ul><ul><ul><li>zolpidem, zopiclon </li></ul></ul><ul><li>Melatonin receptor agonist </li></ul><ul><ul><li>ramelteon </li></ul></ul>
  18. 18. II. Sleep related breathing disorders (International Classification of Sleep Disorders, 2 nd Edition American Academy of Sleep Medicine, 2005) 3. Sleep related hypoventilation/hypoxemia 1. 2.
  19. 19. Apnea-hypopnea index (AHI) <ul><li>Numbers of apneas and hypopneas/ 1 sleeping hour </li></ul><ul><li>Severity of sleep related breathing disorders: </li></ul><ul><li>Normal: AHI<5/h </li></ul><ul><li>Mild: AHI: 5-15/h </li></ul><ul><li>Moderate: AHI:16-30/h </li></ul><ul><li>Sever: AHI>30/h </li></ul>Sleep, 1999:22:667-89.
  20. 20. OSAHS: symptoms <ul><li>Daily </li></ul><ul><li>Excessive daytime sleepiness </li></ul><ul><li>Unrefreshing sleep </li></ul><ul><li>Memory disturbances </li></ul><ul><li>Morning headache </li></ul><ul><li>Depression </li></ul><ul><li>Decreased libido </li></ul><ul><li>Stomach ache </li></ul><ul><li>Nightly </li></ul><ul><li>snoring </li></ul><ul><li>apneas </li></ul><ul><li>choking, gasping </li></ul><ul><li>arousals </li></ul><ul><li>sweating </li></ul><ul><li>dry mouth </li></ul><ul><li>palpitation </li></ul><ul><li>nycturia </li></ul>
  21. 21. OSAHS: diagnostic criteria <ul><li>(1. or 2.) and 3. </li></ul>AASM, Sleep, 1999:22:667-89.
  22. 22. Risk factors of OSAHS <ul><li>Obesitas </li></ul><ul><li>Age </li></ul><ul><li>Male gender </li></ul><ul><li>Pozitive family history of OSAHS </li></ul><ul><li>Alcohol consumption before bedtime </li></ul><ul><li>Race </li></ul><ul><li>Smoking </li></ul><ul><li>Sedatives </li></ul><ul><li>Craniofacial anomalies </li></ul><ul><li>Hypothyroidism, acromegaly </li></ul>
  23. 23. Treatment of bening snoring <ul><li>Weight loss, alcohol withdrawal </li></ul><ul><li>Position training </li></ul><ul><li>Nasal, pharyngeal surgery (UPPP) </li></ul><ul><li>Oral appliances </li></ul>Treatment of OSAHS : nasal CPAP
  24. 24. IV. Cirkadian rhythm sleep disorders <ul><li>Primary </li></ul><ul><ul><li>Delayed sleep phase type </li></ul></ul><ul><ul><li>Advanced sleep phase type </li></ul></ul><ul><ul><li>Irregular sleep phase type </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Jet lag type </li></ul></ul><ul><ul><li>Shift work type </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Sleep hygiena </li></ul></ul><ul><ul><li>Cronotherapy </li></ul></ul><ul><ul><li>Light therapy </li></ul></ul><ul><ul><li>Melatonin, zolpidem </li></ul></ul>
  25. 25. V. Parasomnias <ul><li>In NREM </li></ul><ul><ul><li>Myoclonus </li></ul></ul><ul><ul><li>Enuresis nocturna </li></ul></ul><ul><ul><li>Pavor nocturnus, night terrors </li></ul></ul><ul><ul><li>Sleep walking - somnambulism </li></ul></ul><ul><ul><li>Bruxism </li></ul></ul><ul><li>In REM </li></ul><ul><ul><li>Nightmares </li></ul></ul><ul><ul><li>REM sleep behavior disorder </li></ul></ul>
  26. 26. VI. Sleep related movement disorders <ul><li>Restless legs syndroma </li></ul><ul><ul><li>Therapy: dopamin agonists </li></ul></ul><ul><li>Periodic limb movement disorder </li></ul><ul><li>Sleep related leg cramps </li></ul><ul><li>Sleep related rhythmic movement disorder </li></ul>
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