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Sleep disorders

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Sleep disorders

Sleep disorders


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