2. What is sleep?
• Complex physiological state that occurs
periodically and is characterised by relative
quiescence, immobility and greatly decreased
responsiveness to external stimuli
3. Sleep Stages
• based on EEG, EOG, EMG divided into two
independent states: NREM and REM sleep
• NREM - further divided into three stages ie
N1, N2, N3 – based on EEG
4. Sleep Requirements
• Sleep requirement is defined as the optimal
amount of sleep required to remain alert and
fully awake and to function adequately
throughout the day
• for an average adult is approximately 7.5 to 8
hours
5. Classification of Sleep Disorders
• I. Insomnia
• II. Sleep-related breathing disorders
• III. Hypersomnias of central origin
• IV. Circadian rhythm sleep disorders
• V. Parasomnias
• VI. Sleep-related movement disorders
6. Approach to the Patient
Common sleep complaints
• Insomnia - inability to initiate or maintain
sleep adequately at night
• EDS - chronic fatigue, sleepiness, or tiredness
during the day
• Inability to sleep at the right time
• Abnormal movements and behavioural
manifestation associated with sleep
8. Narcolepsy
• characterized by recurrent "sleep attacks"
• Irresistible desire to fall asleep in inappropriate
circumstances and at inappropriate places
• last for a few minutes to as long as 20 to 30
minutes
9. Narcolepsy Tetrad
Sleep Attacks plus 3 specific symptoms:
1. Cataplexy sudden weakness or
paralysis without loss of
consciousness, often precipitated by
emotional changes
2. Hallucinations at sleep onset
(hypnagogic hallucinations) or upon
awakening(hypnopompic
hallucinations)- most common is visual
3. Sleep paralysis occurs near sleep onset
or during arousal. Consciousness is
maintained.
10. Narcolepsy
• Symptoms of narcolepsy typically begin in the
second decade
• Once established, the disease is chronic
without remissions
• Men and women are equally affected
• affects about 1 in 4000 people in the United
States
11.
12. GENETICS & PATHOGENESIS
• Most are sporadic, some are AD
• positivity for HLA DQB1*0602 – most specific
marker
• Dysfunction of hypothalamic hypocretin
(orexin) peptidergic system is involved in the
pathogenesis
• decreased hypocretin 1 in CSF < 110pg/ml
16. OBSTRUCTIVE SLEEP APNEA
• MC medical condition @ EDS
• defined as the coexistence of unexplained EDS
with at least five obstructed breathing events
(apnea or hypopnea) per hour of sleep
• repetitive episodes of complete (apnea) or
partial (hypopnea) upper airway obstruction
during sleep
• arterial oxygen desaturation and arousal from
sleep
17. Apnea-Hypopnea Index (AHI)
• number of apneas and hypopneas per hour of
sleep
• AHI score of 5 or below is considered normal
• 5 to 15 - mild OSAS
• 16 to 29 - moderate OSAS
• 30 or more - severe OSAS
18. Pathogenesis
• Collapse of the pharyngeal airway is the
fundamental factor
• During sleep, muscle tone decreases-
increasing upper airway resistance and
narrowing the upper airway space
19. Epidemiology
• prevalence is 4% in men and 2% in women
between the ages of 30 and 60
• also occurs in childhood—usually associated
with tonsil or adenoid enlargement
23. Consequences
• increased morbidity and mortality
• short-term consequences (impairment of
quality of life and increasing traffic- and work-
related accidents)
• long-term consequences from associated and
comorbid conditions such as systemic
hypertension, pulmonary hypertension, heart
failure, cardiac arrhythmias
24. General Measures
• Avoid alcohol and sedative-hypnotics,
especially in the evening
• Reduce body weight if overweight
• Avoid sleep deprivation
• Participate in regular exercise program
• Avoid supine sleeping position
29. ICSD-2 (AASM, 2005)
Disorders of arousal (from NREM sleep),
• Confusional arousals
• Sleepwalking
• Sleep terror
Parasomnias associated with REM sleep
• RBD
• Recurrent isolated sleep paralysis
• Nightmare disorder
Other Parasomnias
30. Sleepwalking
• Onset: common between ages 5
and 12 yr
• Abrupt onset of motor activity
arising out of slow-wave sleep
during first one-third of the night
• Duration: less than 10 min
• Injuries and violent activity
occasionally reported
• Treatment: benzodiazepines,
imipramine
31. Sleep Terror
• pavor nocturnus
• Onset: peak is between ages
5 and 7 yr
• Abrupt arousal from slow-
wave sleep during first one-
third of the night, with a loud
piercing scream
• Treatment: psychotherapy,
benzodiazepines, tricyclic
antidepressants
32. Rapid Eye Movement Sleep
Behavior Disorder (RBD)
• Onset: middle-aged or elderly men
• Presents with violent dream-enacting
behavior during sleep, causing injury to self or
bed partner
• 40% idiopathic, 60% associated
neurodegenerative diseases - PD, MSA, CBD,
DLBD, PSP
• Treatment: clonazepam, melatonin
33. Nightmare
Disorder• Dream anxiety attacks
• fearful, vivid, often
frightening dreams,
mostly visual but
sometimes auditory
• most commonly occur
during the middle to
late part of sleep at
night
34. • mostly a normal phenomenon, up to 50% of
children have nightmares
• side effects of certain medications such as
antiparkinsonian drugs (pergolide, levodopa),
anticholinergics, and antihypertensive drugs,
particularly beta-blockers
• generally do not require any treatment except
reassurance
36. Restless Legs Syndrome (RLS)
• also known as Ekbom’s syndrome
• Unpleasant sensations in the legs when the
patient is tired in the evenings and at the
onset of sleep
• ameliorated by moving the legs
• mostly diagnosed in the middle or later years
• strong familial tendency
• can present with daytime somnolence due to
disturbed night-time sleep
37. Secondary - Medical Disorders
• Anemia: iron and folate deficiency
• Diabetes mellitus
• Amyloidosis
• Uremia
• Chronic obstructive pulmonary disease
• Peripheral vascular (arterial or venous)
disorder
• Rheumatoid arthritis
• Hypothyroidism
39. Drug Treatment of Restless
Legs Syndrome
Dopaminergic agents:
• Pramipexole
• Ropinirole
Benzodiazepines:
• Clonazepam
• Temazepam
Antiepileptic agents:
• Gabapentin
• Pregabalin
40. Insomnia
• most common sleep disorder
• Inability to initiate or maintain sleep, early
awakening, inadequate sleep time, or poor
sleep quality associated with a lack of feeling
restored and refreshed in the morning,
leading to poor daytime functioning - AASM
(2005)
42. Treatment of Insomnia
• most commonly used hypnotics are the
benzodiazepine receptor agonists – zolpidem,
zaleplon, and eszopiclone
• Melatonin receptor agonists(ramelteon) -
sleep-onset insomnia
43.
44. Laboratory Assessment of
Sleep Disorders
• The two most important laboratory tests for
diagnosis of sleep disturbance are PSG and the
MSLT
• overnight PSG study is the single most
important laboratory test for the diagnosis
and treatment of patients with sleep disorders
• EEG, EMG, EOG, ECG, SaO2, Nasal and oral
airflow, Respiratory effort (chest and
abdomen)
45.
46.
47. Multiple Sleep Latency Test
• important test to effectively document EDS
• Narcolepsy is the single most important
indication
• presence of two sleep-onset REMs on four or
five nap studies and sleep-onset latency of
less than 8 minutes strongly suggest a
diagnosis of narcolepsy
• circadian rhythm sleep disturbance - REM
sleep abnormalities
