Sleep Medicine: An Overview

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Fraser Willsey, Sleep Specialist at The Royal shares facts on sleep, what they do at the Sleep Lab, and how to treat sleep disorders.

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Sleep Medicine: An Overview

  1. 1. SLEEP MEDICINE: An Overview Fraser Willsey, BA, RPSGT Sleep Lab Technologist Sleep Disorders Service, The Royal
  2. 2. Why Study Sleep? • We spend 1/3 of our lives sleeping • 1 in 7 Canadians are not getting enough sleep (Statistics Canada, 2002) • Severe health consequences - DEATH! • Sleep deprivation costs $150 BILLION/yr in lost productivity (Nat’l Commission on Sleep Disorders, 2003)
  3. 3. THE IMPACT OF SLEEP DEPRIVATION
  4. 4. • Challenger Disaster • 3 Mile Island • Chernobyl
  5. 5. Purpose of Sleep • Restorative Function • Energy Conservation • Immune Function Regulation • Memory Consolidation • Mood Regulation and depression • Protective Mechanism
  6. 6. WHAT WE DO AT THE SLEEP LAB….
  7. 7. What Happens at the Sleep Lab… • ROMHC: 6 bed clinical lab, 4 bed research lab STEPS: 1) → Referral 2) → Consultation with a Sleep Specialist 3) → Overnight Sleep Study 4) → Data is Analyzed by RPSGTs 5) → Results Appt with a Sleep Specialist
  8. 8. How Do We Measure Sleep in the Laboratory? • EEG – brainwaves (Central & Occipital Leads) • EOG – eye movements • EMG – muscle tone • EKG/ECG – heart • Breathing: 1)Airflow & 2) Effort: Thoracic & Abdominal • Blood oxygen saturation (SaO2) • Snore mic. • Digital AV recording
  9. 9. STAGES OF SLEEP • NREM & REM • NREM = N1, N2, N3 • Sleep Cycle • REM increases as the night progresses • Changes across the lifespan
  10. 10. NREM SLEEP • N1: lightest stage of sleep (hypnic jerks/sleep starts), dozing • N2: Sleep spindles & K complexes • N3 (formerly stages 3 & 4): deepest most physically restorative stage of sleep. More difficult to awaken from this stage. Decreases with age. • Breathing regular, heart rate decreases
  11. 11. AWAKE
  12. 12. STAGE N1
  13. 13. STAGE N2
  14. 14. STAGE N3
  15. 15. STAGE N3
  16. 16. REM Sleep • Rapid Eye Movements • Muscle atonia (paralysis) • Dream recall • 90 minute latency • “Paradoxical Sleep” – EEG mimics wakefulness • Breathing irregular, heart rate fluctuates
  17. 17. REM
  18. 18. TRANSITION INTO REM
  19. 19. SLEEP APNEA
  20. 20. SLEEP APNEA • Two Types: Obstructive & Central • Pauses in breathing > 10 seconds in length • Respiratory Disturbance Index: >5 hr =clinically significant • Symptoms: ▪ Excessive daytime sleepiness (EDS) ▪ morning headaches ▪ SNORING***** ▪ pauses in breathing ▪ waking with a dry mouth ▪ nocturia ▪ Gastroesophageal reflux disease ZZZZzzzzzzZZZZzzzzzz
  21. 21. OBSTRUCTIVE SLEEP APNEA (OSA) • Causes ▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx • Exacerbated by: ▪ Rx ▪ Alcohol Consumption ▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep
  22. 22. Normal vs. Collapsed Airway
  23. 23. “Kissing” Tonsils
  24. 24. OBSTRUCTIVE APNEA
  25. 25. OBSTRUCTIVE APNEA, 2MIN
  26. 26. OBSTRUCTIVE APNEA 5MIN
  27. 27. TREATMENTS FOR OSA • **CPAP – Continuous Positive Airway Pressure • **Weight Loss - ↓ BMI = ↓ RDI • Avoid Alcohol Consumption • Avoid Sedative Medications • “Snoreball” Technique / Positional Therapy • Oral Appliance • Upper Airway Surgery – Tonsilectomy – Laser Surgery – Tracheostomy – Uvulopalatopharyngoplasty (UPPP)
  28. 28. CPAP
  29. 29. CPAP
  30. 30. Consequences of Untreated OSA • Memory Problems • Depression • Cardiovascular disease –High blood pressure –Stroke –Cardiac arrhythmias
  31. 31. FASTEN YOUR SEATBELTS… THERE’S ANOTHER CONSEQUENCE OF UNTREATED OSA & SLEEPINESS ANY GUESSES WHAT IT IS?
  32. 32. PARASOMNIAS
  33. 33. PARASOMNIAS • NREM Sleepwalking (Somnambulism) Sleep Terrors (aka Night Terrors) Others examples: Sleep Related Eating Disorders, Confusional Arousals, Somniloquy ■ REM REM Behaviour Disorder (RBD) Measured in the sleep lab with full EEG to rule out seizure activity
  34. 34. SLEEPWALKING • Stage N3 (slow wave sleep) • Common in children • Do not awaken. Secure the environment • No recall of a dream or of the episode • Aggravated by sleep deprivation, stress, alcohol • Positive family history • Perform complex behaviours with heightened pain threshold
  35. 35. JAROD ALLGOOD Feb. 2, 1973 – Feb. 9, 1993
  36. 36. REM Behaviour Disorder (RBD) • No muscle atonia during REM sleep • Ability to act out complex dream behaviour • Bedpartner often the “victim” • Age of onset: 50 – 60yrs. Males • Usually opposite of waking personality • Case study: “baseball player” at ROMHC
  37. 37. RBD
  38. 38. REM BEHAVIOUR DISORDER
  39. 39. Treatments for RBD • Full EEG montage during PSG • CT Scan, MRI – r/o lesions • Securing the environment (mattress on floor, bed rails, restraints) • Bedpartner sleeps in another room • Rx
  40. 40. SLEEPWALKING vs. RBD SleepwalkingSleepwalking ▪▪ Stage N3 (NREM)Stage N3 (NREM) ▪▪ No dream recallNo dream recall ▪▪ ChildrenChildren ▪▪ Not easily awakenedNot easily awakened REM BehaviourREM Behaviour DisorderDisorder ▪▪ REM sleepREM sleep ▪▪ Dream recallDream recall ▪▪ Adults (elderly)Adults (elderly) ▪▪ Easily awakenedEasily awakened
  41. 41. PLMs 2 MIN
  42. 42. PLMS Treatment • Rx • Iron supplementation • CPAP if PLMs secondary to apnea
  43. 43. Restless Legs Syndrome (RLS) • Disorder of WAKEFULNESS (PLMs = sleep) • Subjective report of an uncomfortable sensation in the legs while at rest • Irresistible urge to move the legs • Symptoms subside with movement • “Creeping”, “itching”, “creepy-crawly”, “pulling”, “tugging”, “gnawing”, “toothache in my legs”, “bugs or worms crawling under my skin” • Symptoms worse in the evening • Almost all patients with RLS display PLMs during sleep
  44. 44. RLS Treatments • Pharmacological (dopamine agonists) • Non-Pharmacological: – Iron supplementation – Warm bath – Exercise – Massage, acupuncture, relaxation techniques – Keeping mind engaged when having to stay seated – Eliminate caffeine and alcohol – Bar of soap under the sheets!
  45. 45. SLEEP & MEDICAL ILLNESS
  46. 46. Normal Fibromyalgia
  47. 47. SLEEP & MENTAL ILLNESS • Depression – Early morning awakenings – Short REM latency – Increased time in REM sleep – May mimic narcolepsy on the MSLT
  48. 48. SLEEP & MENTAL ILLNESS • Anxiety – Increased sleep onset – Prolonged awakenings – Panic attacks (with/without sleep apnea)
  49. 49. SLEEP & MENTAL ILLNESS • Psychiatric Populations and Sleep – Schizophrenia (apnea, sleep spindles) – PTSD (nightmares) – Geriatrics – Mood disorders
  50. 50. INSOMNIA
  51. 51. INSOMNIA • Difficulty initiating and maintaining sleep • Early morning awakenings • Complaint of poor, insufficient or nonrefreshing sleep • Impact on waking behaviour • Sleep Efficiency < 85% • Longer SOL (> 30 minutes), short total sleep time (TST)
  52. 52. Insomnia Treatments • Cognitive Behavioural Therapy • Sleep Restriction Therapy • Relaxation Techniques • Sleep Hygiene • Prescription medications
  53. 53. GOOD SLEEP HABITS • Get up at the same time each morning. Even if you fall asleep very late, you should still get up at the same time each morning • To avoid “Sunday night insomnia, Monday morning blues”, don’t stay up late on weekends and then sleep in • Go to bed only when sleepy • Develop a relaxing pre-sleep ritual such as reading, taking a bath, brushing your teeth, etc
  54. 54. GOOD SLEEP HABITS • Use the bed only for sleep and intimacy • Nicotine is a stimulant. Try not to smoke near bedtime • Hunger may disturb sleep. Perhaps try to have a light snack before bed. A glass of warm milk contains a natural sleep aid • Exercise regularly. Get vigorous exercise either in the morning or the afternoon and do only mild exercise two to three hours before bed
  55. 55. GOOD SLEEP HABITS • Don’t stay in bed if you can’t fall asleep within 15 minutes. Tossing and turning will just make you more frustrated • Get as much sleep as you need, but no more • If you find yourself worrying at bedtime, set aside a “worry time” – perhaps 30 minutes in the early evening to write down both problems and solutions
  56. 56. Zzzzzz QUESTIONS?? Zzzzzz fraser.willsey@theroyal.ca

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