This document discusses various sleep and wake disorders including insomnia, hypersomnia, parasomnia, sleep apnea, narcolepsy, and restless legs syndrome. It covers the classification, clinical manifestations, causes, diagnosis, and treatment options for each disorder. Key points include that insomnia is characterized by issues initiating or maintaining sleep, hypersomnia involves excessive sleepiness, and parasomnia involves abnormal behaviors during sleep stages. Disorders are classified as intrinsic, extrinsic, or circadian rhythm related. Treatment involves lifestyle changes, medications, CPAP, surgery, or oral appliances depending on the underlying cause.

1. SLEEP AND WAKE DISORDERS

2. • Tense wake
• Wake
• Relaxed wake
• Drowse
• Light sleep
• Deep slow sleep
• Rapid-eye-movement sleep
(REM sleep)
Human functional conditions

3. Regulation of sleep and wake
THALAMUS
Cortex activation
Synchronisation of EEG
HYPOTHALAMUS
Shift sleep/wake
SUPRACHIASMATIC NUCLEUS
Biological hours
MEDULLA
Cortex activation
Shift “REM/slow" sleep

5. Functions of sleep
• Functions of non-REM sleep
– anabolic
– Optimization of visceral organs regulation
• Functions of REM-sleep
– Psychological adaptation
– Formation of behavioral program

6. • Insomnia
– primary disorders of initiating or maintaining sleep,
characterized by a disturbance in the amount, quality, or
timing of sleep
• Hypersomnia
– disorder characterized by excessive sleepiness
• Parasomnia
– 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 during arousal from sleep
Classification of sleep disorders

7. Insomnias
• Intrinsic sleep disorders
– idiopathic insomnia
– psychophysiological insomnia
– distorted perception of sleep
– restless legs syndrome
– periodic limb movement disorder
• Extrinsic sleep disorders
• Circadian rhythm sleep disorders

8. Sleep hygiene
• Waking up at the same time
• Eliminate naps, especially in the second half of the day
• Allowing enough time for sleep. Most people need 7-9 hours of sleep each day
• Avoiding heavy meals and alcohol before sleep and reducing intake of caffeine and
other stimulants several hours before bedtime
• Arranging a sleep environment that is very dark, comfortable, quiet, and cool to
facilitate falling asleep quickly and staying asleep
• Avoiding TV beds and other media-furniture
• Following an exercise routine (but not within 3 hours before bedtime), as daily physical
activity improves sleep, helps with stress management, and promotes general health
• Seeking assistance from healthcare providers for continuing difficulties with sleep,
since specific sleep disorders may require particular treatments

9. Principles for hypnotics purpose
• Preferable to start treatment of insomnia with herbal sleeping pills or
melatonin
• Predominant use of short half-life drugs
• Duration of use sleeping pills as possible should not exceed 3 weeks. This
period does not form addiction and dependence
• For elderly patients should be given half the daily dose of sleeping pills, and
take account of their interactions with other drugs
• You can assign the sleeping pills “on demand“ not more than 3 times a week
(or 10 days in a month)

10. Hypnotics
Group od drugs Drug Duration of
action (hours)
Dependence
Benzodiazepines Phenazepam 12 +
Nitrazepam
(Raderodorm)
8
+
Midazolam (Dormicum) 6 +
Triazolam (Halcion) 6 +
Nonbenzodiazepines,
agonists of benzodiazepine
receptors
Zopiclon
(Imovan, Somnol,
Piclodorm)
6-8
-
Zolpidem
(Ivadal, Sanval)
5-6
-
Zaleplon
(Andante)
2-3
-
Antidepressants with
sedative effect
Amitriptylin 12
-
Miamserin (Lerivon) 12 -
Trazodon (Trittico) 8 -
Barbiturates as hypnotics unacceptable!

11. • Narcolepsy
• Sleep apnea
Principal forms of hypersomnia

12. Clinical manifestations of narcolepsy
• Excessive daytime sleepiness (EDS)
• Cataplexy
• Hypnagogic hallucinations
• Automatic behavior (a person continues to function (talking, putting
things away, etc.) During sleep episodes)
• Sleep paralysis
Simultaneously, all these manifestations are rare.
For clinical diagnostics it is enough combination of daily falling
asleep with one or two of additional clinical symptoms see
above).

13. Treatment of narcolepsy
Cataplexy
• Tricyclic antidepressants (Melipramin)
• Selective serotonin reuptake inhibitors (Fluoxetine,
Venlafaxine)
Excessive daytime sleepiness
• Psychostimulants (Caffeine, Ritalin,Modafinil)
Sleep disorders
• Hypnotics (Zopiclon, Zolpidem)

14. Causes of obstructive apnea syndrome

15. Obstructive apnea syndrome -
condition, characterized by multiple episodes of upper
respiratory tract obstruction in sleep
Complaints
intermittent snoring 95%
daytime sleepiness 90%
restless sleep 40%
morning headaches 10%
nocturia 10%
episodes of shortness of breath 5%
Prevalence
M - 4% F - 0,5 %
Region of obstruction
Diagnosis
Adults - 5 and more episodes in hour
Children - 1 and more episodes in hour

16. Danger of sleep apnea
• Encephalopathy
• Dementia
• Arterial hypertension
• Pulmonary heart
• Cardiac arrhythmias
• Increased risk of stroke and heart attacks 2-7 times
• Impotence
• The increased risk of road accidents in 2-12 times
• Sudden death in sleep

17. Treatment of sleep apnea
Causative :
• weight loss program
• correction of ORL-pathology
• exception of alcohol
• exception of sedatives
• treatment of endocrine, neurological, and
systemic diseases

18. Continuous positive airway pressure (CPAP, BiPAP and other)
respiratory support in an open state
Treatment of sleep apnea

19. Treatment of sleep apnea
Pathogenetic
• Surgery
– Uvulopalatopharyngoplasty
(UPPP)
– Septoplasty
• Oral appliances
– for the tongue and lower jaw
• Pharmacotherapy (Theophylline,
Diacard, Protriptylin, Modphynil)

20. Parasomnias – adverse events related in
occurrence with sleep
• Arousal disorders
– Confusional arousals
– Sleep terrors (night terrors)
– Sleepwalking (somnambulism)
• REM parasomnias
• REM sleep behavior disorder
– frightening dreams
• Nocturnal enuresis
• Teeth grinding (bruxism)
• Restless legs syndrome & periodic limb movements

21. • An urge to move the limbs with or without sensations.
• Improvement with activity. Many patients find relief when moving and the
relief continues while they are moving.
• Worsening at rest. Patients may describe being the most affected when
sitting for a long period of time, such as when traveling in a car or
airplane, attending a meeting, or watching a performance.
• Worsening in the evening or night. Patients with mild or moderate RLS
show a clear circadian rhythm to their symptoms, with an increase in
sensory symptoms and restlessness in the evening and into the night.
The clinical signs of restless legs syndrome (RLS)

22. Etiology and pathogenesis of restless legs
syndrome
• Primary (idiopathic)
– failure of descending dopaminergic pathways
• Secondary
– pregnancy (19-26%)
– deficiency of iron (10-18%)
– uremia (12-23%)
– myelopathy, peripheral neuropathy, radiculopathy
– Parkinson disease
– smoking cessation
– venous insufficiency of the lower limbs
– amyloidosis, rheumatoid arthritis, leg injuries
– congestive heart failure
– medication (neuroleptics, lithium, tricyclic antidepressants)

23. Treatment of restless legs syndrome
• Sleep hygiene
• Correction of iron deficit
• Nonergoline dopamine agonists
• Levodopa drugs
• Benzodiazepines (Clonazepam)
• Anticonvulsants (Carbamazepine, Gabapentin)
• Opiates (Codeine, Tramadol)

24. • Differential diagnosis with epilepsy
• Organization of safe sleeping environment
• Mode of sleep
• If parasomnias do not violate social adaptation
– medical treatment is needed
• Sedative herbs
• Benzodiazepines (clonazepam, nitrazepam)
Management of parasomnias