2. ⚫Sleep disorders are common
⚫Sleep disorders are serious
⚫Sleep disorders are treatable
⚫Sleep disorders are under diagnosed
Introduction
•2
3. ⚫Sleep complaints are usually not due to
psychiatric conditions.
⚫Most sleep disorders are readily
diagnosable and treatable
⚫The studies include
⚫Polysomnography (PSG)
⚫Multiple sleep latency test (MSLT)
⚫Actigraphy (It is a relatively non-invasive
method of monitoring human rest/activity
Introduction …
•3
cycles)
4. ⚫All-night recording of:
⚫Eye movement
⚫Electroencephalogram( EEG)
⚫Electrocardiogram(ECG)
⚫Electromyogram (EMG) [technique for evaluating
and recording the activation signal of muscles]
⚫Ear Oximetry (non-invasive method allowing the
monitoring of the oxygenation of a patient's
hemoglobin), air flow at nose and mouth
⚫Thoracic and abdominal wall motion
⚫Physiological assessment: Esophageal pH
•4
Common Diagnostic Tests
Polysomnography
5. Test(MSLT)
•5
⚫Is a measure of daytime sleepiness:
⚫five brief naps at 2hrs interval
⚫the time necessary to fall asleep is measured for
each of the naps
⚫EEG, EMG, eye movement are monitored.
Multiple Sleep LC
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yDiagnosticTests
10. Sleep
Cycle
•10
•Stage 1: Very light sleep
•Stage 2: Light sleep
•Stage 3: Deeper sleep
•Stage 4: Very deep sleep, most restorative
•Stage 5: REM sleep, when we dream
NREM
12. Insomnia - Definition
⚫ Insomnia and excessive daytime sleepiness are primary complaints
regardless of the stage of the disease
⚫ Insomnia includes difficulty falling asleep, difficulty staying asleep, and
early morning awakening
⚫ Insomnia is not defined by the number of hours of sleep, but rather, by
an individual‘s ability to sleep long enough to feel healthy and alert
during the day.
⚫ The normal requirement for sleep ranges between 4 and 10 hours.
⚫ Insomnia is a symptom, not a disorder by itself
•12
13. Insomnia - Assessment
⚫ Determine the pattern of sleep problem
(frequency, associated events, how long it takes to go
to sleep, and how long the patient can stay asleep)
⚫ Include a full history of alcohol and caffeine intake and
other factors that might affect sleep
⚫ Review current medications that patient is taking to
eliminate these as possible causes
⚫ Take a history to rule out physical cause and/or
psychosocial cause
•13
14. Headache
Bad or vivid dreams
Problems of breathing
Chest pain/heartburn
Need to pass urine or
move bowels
Abdominal pains
Fever/night sweats
Leg cramps
Fear/anxiety
Depression
Possible Causes of Insomnia
•14
15. Insomnia – Associated Problems
At least one (or more) of the following
⚫ Malaise (feeling of general discomfort or uneasiness)
⚫ Attention, concentration impairment
⚫ Social/ vocational dysfunction/ poor work
⚫ Mood disturbance or irritability
⚫ Daytime sleepiness
⚫ Proneness for errors or accidents at work or while
driving
⚫ Tension, headaches or gastrointestinal symptoms in
response to sleep loss
⚫ Concerns or worries about sleep
•15
16. Medications that causes Insomnia
Type of medication Example
CNS stimulants D-amphetamine, Methyphenindrate
Blood pressure drugs - blockers, - blockers
Respiratory medicines Albuterol, Theophylline
Decongestants Phenylephine, Pseudoephedrine
Hormones Thyroxin, Corticosteroids
Other substances Alcohol, Nicotine, Caffeine
•16
17. Types of Insomnia
⚫ Transient insomnia
⚫< 4 weeks triggered by excitement or stress, occurs
when away from home
⚫ Short-term
⚫4 wks to 6 months , ongoing stress at home or work,
medical problems, psychiatric illness
⚫ Chronic
⚫Poor sleep every night or most nights for > 6
months, psychological factors (prevalence 9%)
•17
18. Management of Insomnia
⚫Treat underlying causes whenever possible
•18
⚫Advise
meals,
patient
alcohol,
to avoid exercise, heavy
or conflict situations just
before bed
⚫Plain aspirin or paracetamol in low doses
short-acting
may be helpful; or give
hypnotics or a sedative
⚫Treat underlying depression
19. Non-Pharmacologic Management
⚫ Go to bed when sleepy
⚫ Get up the same time every morning
⚫ Get up when sleep onset does not occur in
20 min, and go to another room
⚫ No daytime napping
⚫ Reduce or stop Caffeine, Alcohol, Nicotine
⚫ Exercise < 4hrs before bed
⚫ Meditation, Yoga
⚫ Hypnosis to ↓ anxiety & tension at bedtime
⚫ Progressive muscle relaxation
•19
22. BzRAs – side effects and safety
⚫Amnesia
⚫Residual sedation – longer acting BzRAs
⚫Abuse and dependence
⚫Prolonged use can lead to withdrawal symptoms:
headache, irritability, dizziness, abnormal sleep
⚫Rebound insomnia - triazolam
⚫Increased fall risk, cognitive effects in the elderly
•22
23. Benzodiazepine use
⚫ Benzodiazepines are the drugs of choice for the
treatment of insomnia.
⚫ Flurazepam can be used for up to one month with
little tolerance.
⚫ Temazepam can be used for up to three months with
little tolerance.
⚫ Intermittent use recommended (every three days).
Use for no longer than 3 – 6 months.
⚫ Benzodiazepines with short half lives may be best for
patients with difficulty falling asleep, but can produce
rebound insomnia
•23
25. Hypersomnia: Narcolepsy
•25
Extreme daytime sleepiness
Frequent brief naps
Rare, familial, presents in 20s and 30s
Requires sleep study and daytime
Main Symptoms
⚫Cataplexy (sudden, usually brief loss of muscle tone
induced by emotions.)
⚫Sleep paralysis: A symptom of narcolepsy; paralysis
occurring just before a person falls asleep.
⚫Hypnagogic hallucinations - REM sleep while
conscious
28. Parasomnias
•28
⚫ Parasomnias are a category of sleep disorders that
involve abnormal and unnatural movements,
behaviors, emotions, perceptions, and dreams that
occur while falling asleep, sleeping, between sleep
stages, or arousal from sleep. Most parasomnias are
dissociated sleep states which are partial arousals
during the transitions between wakefulness and
NREM sleep, or wakefulness and REM sleep.
⚫ Types:
Restless Leg Syndrome
Night Terror
Sleepwalking (Somnambulism)
Sleep Enuresis
REM Sleep behaviour
29. Parasomnias: Restless Leg Syndrome
•29
⚫ Intense dysesthesias (unpleasant abnormal
sensation), repetitive jerking
- Worse at bedtime
- Often awakens patient
- Often familial, progresses with age
⚫ Etiology unknown
⚫ May be caused by uremia, Iron deficiency anemia or
alcohol abuse.
⚫ Treatment
-Carbidopa-Levodopa 25mg/100mg qhs (70%
respond)
- Clonazepam 0.5-2 mg qhs
30. Parasomnias: Night Terror
•30
⚫Sleep Terrors
⚫Emerge from Stage 3-4 sleep
⚫Autonomic arousal is interpreted as fear
⚫Arousal is abrupt
⚫ Occurs primarily in children
⚫ Sudden arousal from slow wave sleep :
⚫cry
⚫automatic and behavioral manifestation of intense
fear(marked tachycardia, mydriasis sweating).The
child is agitated and confused.
⚫lasts for few minutes, sleep resumes. Amnesia +
⚫Treatment: reassurance, diazepam, imipramine
31. Parasomnias: Sleepwalking (Somnambulism)
•31
⚫Emerge out of Stage 3 and 4 sleep
⚫May overlap with night terror
⚫Involves complex behavior
⚫sitting up in bed, walking, dressing, eating and
even driving a car.
⚫lasts few minutes
⚫mostly in children
⚫Treatment: reassurance, safety restraints and if
frequent consider diazepam
32. Parasomnias: Sleep Enuresis
•32
⚫Involuntary micturation during sleep following
attainment of control while awake
⚫usually idiopathic
⚫may be caused by urogenital disease, or other
medical problem
⚫it may represent delayed micturation
⚫Treatment: bladder training, Imipramine
33. Parasomnias: REM Sleep behavior
⚫REM Behavior Disorder
⚫A rare neurological disorder in which a person
does not become paralyzed during REM sleep,
and thus acts out dreams.
⚫Experiments with cats. Lesions to cellular nucleus
in the medial medulla near LC. Form inhibitory
synapses with motor neurons.
⚫ Lack of REM atonia allows patient to enact his
dreams.
⚫ Motor activity may be harmful
⚫ most patients are elderly
⚫ The condition usually idiopathic
⚫ Neurological cause in 1/3rd.
⚫ Treatment: sleep study, clonazepam
•33
34. Sleep-Disordered Breathing
(Sleep Apnea)
⚫Symptoms include loud snoring, choking,
gasping during sleep
⚫Associated with daytime sleepiness
⚫Risk factors include:
⚫Older age
⚫Male sex
⚫CVD risk factors such as obesity
Sleep apnea’s are divided into two:
⚫ Central sleep apnea: (CSA) causes fragmented sleep
and consequent daytime somnolence.
⚫ Obstructive sleep apnea:(OSA) is characterized by
partial or complete closure of the upper airway, posterior
from the nasal septum to the epiglottis, during inspiration
•34
35. Pathogenesis
⚫ Occlusion of the oropharyngeal airway results in progressive
asphyxia (condition of severely deficient supply of oxygen to the
body that arises from being unable to breathe normally) until
there is a brief arousal from sleep, whereupon airway patency
is restored and airflow resumes.
⚫ The patient then returns to sleep and the process is repeated,
up to 300 - 400 times per night & sleep becomes fragmented.
⚫ During wakefulness upper airway muscle activity is greater than
normal to compensate for airway narrowing and high airway
resistance
• Normal Snoring Sleep Apnea
•35
36. Etiology
⚫Obesity as a risk factor
⚫Anatomical abnormalities like neck obesity,
narrow airway, and fixed upper airway lesions
(e.g., polyps, enlarged tonsils)
⚫Alcohol
•36
37. Diagnostic Tests of Sleep Apnea
•37
⚫Polysomnography is a detailed overnight
sleep study with recordings of:
⚫ECG (arrhythmias), EEG (brain waves – level
of sleep )
⚫Ventilatory variables: movement of chest wall
and airflow at the mouth and nose
⚫Arterial O2 saturation (finger/ear-oximetry)
⚫Heart rate
38. Management
tone: mild OSA – avoid alcohol and
⚫ upper airway muscle
sedatives
⚫ upper airway lumen size: 1.Mild to moderate OSA –weight
reduction, avoid supine position and use oral prosthesis to keep
airway patent
2.Severe OSA: Surgery (uvulopalatopharyngoplasty)
⚫ Bypass occlusion: severe OSA – tracheotomy
⚫ – Weight Loss
⚫ – Continuous Positive Airway Pressure (CPAP)
⚫ – Medication
The most important pharmacologic intervention is the avoidance
of all CNS depressants (e.g., alcohol, hypnotics) and drugs that
promote weight gain. There is no drug therapy for OSA.
⚫ Tricyclic antidepressants (TCAs) (i.e., imipramine, protriptyline),
and clonidine have effects on sleep architecture or upper airway
patency but do not clinically improve severity of OSA.
•38
39. CIRCADIAN RHYTHM DISORDER
•39
⚫The sleep-wake cycle is under the circadian
control of oscillators and can be disrupted by
misalignment between an individual’s biologic
clock and external demands on the sleep cycle.
⚫Circadian rhythm sleep disorders usually present
with either insomnia or hypersomnia, depending
on the individual’s performance requirements.
⚫Two commonly occurring circadian rhythm sleep
disorders are jet lag and shift work sleep
problems.
40. Jet Lag
•40
•Jet lag occurs when a person travels across time
zones, and the external environmental time is
mismatched with the internal circadian clock.
•Symptoms: malaise, insomnia /
fatigue, poor performance,
hypersomnia,
gastrointestinal
disturbance.
•Treatment: Short-acting benzodiazepine receptor
agonists or 0.5 to 5 mg melatonin taken at
appropriate target bedtimes
41. Shift Work
• Night shift work causes a misalignment in the
sleep-wake
associated
cycle
with
and circadian rhythm that is
a decrease in alertness,
performance, and quality of daytime sleep.
•Treatment: Short-acting benzodiazepine receptor
agonists or 0.5 to 5 mg melatonin taken at
appropriate target bedtimes
•41
42. Principles of Sleep Hygiene
•42
⚫Sleep in cool, quiet, comfortable place.
⚫Keep regular sleep-wake schedule.
⚫When having trouble sleeping at night, avoid daytime
naps.
⚫Exercise < 4hrs before bed.
⚫Avoid caffeine, food close to bedtime.
⚫Make bed a restful heaven for sleep.
⚫Don’t worry about not getting enough sleep .
⚫Change sleeping place, if unable to sleep.
