This document provides information about sleep medicine and sleep disorders. It discusses topics such as insomnia, restless leg syndrome, narcolepsy, obstructive sleep apnea, and other common sleep disorders. It notes that obstructive sleep apnea is a common and dangerous sleep disorder characterized by recurrent collapse of the pharyngeal airway during sleep, and lists risk factors such as obesity, age, sex, and craniofacial anatomy.

1. Athaya CommercialAthaya Commercial
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2. Senthil Ramasamy, M.DSenthil Ramasamy, M.D..
Board Certified in Neurology & Sleep MedicineBoard Certified in Neurology & Sleep Medicine
 Clinical ConsultationClinical Consultation
 Sleep Studies – PSGSleep Studies – PSG
 Nerve Conduction/ EMGNerve Conduction/ EMG
 EEGEEG
 ALL INSURANCES ACCEPTEDALL INSURANCES ACCEPTED
 Pres, Lovelace, BCBS, UHC, AETNA, CIGNAPres, Lovelace, BCBS, UHC, AETNA, CIGNA
 MedicareMedicare
 MedicaidMedicaid

3. SLEEP MEDICINESLEEP MEDICINE
 Inter-disciplinary subspecialty; ABMS first board exam inInter-disciplinary subspecialty; ABMS first board exam in
20072007
 The International Classification of Sleep Disorders, Second
Edition documents 81 official sleep disorders.
 Healthful Sleep is more influential in predictingHealthful Sleep is more influential in predicting
longevity than diet, exercise or hereditylongevity than diet, exercise or heredity
William Dement, M.D., Ph.D. – Promise of SleepWilliam Dement, M.D., Ph.D. – Promise of Sleep

4. Sleep Disorders ClassificationsSleep Disorders Classifications
Sleep disorders
Hypersomnias
Circadian
dysrhythmias
InsomniasParasomnias
Sleep breathing
disorders
Sleep movement
disorders
4

5. Common Sleep ComplaintsCommon Sleep Complaints
By PatientBy Patient
 Difficulty falling asleep
 Difficulty staying asleep
 Feeling headache, tired on
waking up
 Day time sleepiness
 Concentration/ memory
trouble
By Patient’s FamilyBy Patient’s Family
 Snoring
 Gasping/ stopping to
breathe
 Repeated Leg Jerking
 Sleep Walking
 Violent Movements -
grabbing, punching,grabbing, punching,
kicking, jumping, runningkicking, jumping, running
out of the bed orout of the bed or yelling,yelling,
swearing,swearing,

6. Chronic InsomniaChronic Insomnia
Psychiatric conditions – Depression/ AnxietyPsychiatric conditions – Depression/ Anxiety
Drug and Alcohol AbuseDrug and Alcohol Abuse
Neurological Disorders – Headache, Stroke,Neurological Disorders – Headache, Stroke,
Dementia, TBI, Parkinson’s syndromeDementia, TBI, Parkinson’s syndrome
Medical Conditions – CAD, CHF, Asthma, COPD,Medical Conditions – CAD, CHF, Asthma, COPD,
GERD, Fibromyalgia, Rheumatologic disordersGERD, Fibromyalgia, Rheumatologic disorders
Primary or Psychophysiologic InsomniaPrimary or Psychophysiologic Insomnia

7. Insomnia RxInsomnia Rx
Cognitive Behavioral TherapyCognitive Behavioral Therapy
• Sleep restriction consolidationSleep restriction consolidation
• Stimulus control therapyStimulus control therapy
• Sleep hygiene educationSleep hygiene education
• Relaxation therapyRelaxation therapy
7

8. Insomnia RxInsomnia Rx
Pharmacological management:
Benzodiazepines (BDZ) and benzodiazepine receptor agonists (BZRA)
 GABAGABAAA receptors arereceptors are
comprised of a centralcomprised of a central
chloride channel surroundedchloride channel surrounded
by five protein subunits.by five protein subunits.
 Nineteen subunits from 7Nineteen subunits from 7
gene familiesgene families

9. ZolpidemZolpidem
AmbienAmbien
ZaleplonZaleplon
SonataSonata
EszopicloneEszopiclone
LunestaLunesta
Zolpidem CRZolpidem CR
Half lifeHalf life 2.5 hours2.5 hours 1 hour1 hour 5-9 hrs5-9 hrs
dependingdepending
on ageon age
2.8-2.9 hrs2.8-2.9 hrs
TmaxTmax 1.5 hours1.5 hours 1 hour1 hour 1 hour1 hour 1.5-2 hours1.5-2 hours
IndicationIndication SleepSleep
onset.onset.
Short termShort term
useuse
SleepSleep
onset.onset.
short termshort term
useuse
Sleep onsetSleep onset
maintenancemaintenance
Long termLong term
useuse
Sleep onsetSleep onset
maintenancemaintenance
Long termLong term
useuse
9
BZRA

10. RLSRLS –– Restless Leg SyndromeRestless Leg Syndrome
A neurological movement disorderA neurological movement disorder
characterized by an irresistible urgecharacterized by an irresistible urge
to move the legs accompaniedto move the legs accompanied
by uncomfortable sensationsby uncomfortable sensations
that often occurthat often occur
in the evening/ at rest or nightin the evening/ at rest or night

11. RLSRLS
Key diagnostic criteriaKey diagnostic criteria Supportive featuresSupportive features
Urge to move the legs – usuallyUrge to move the legs – usually
accompanied or caused byaccompanied or caused by
uncomfortable leg sensationsuncomfortable leg sensations
Sleep disturbancesSleep disturbances
Involuntary leg movementsInvoluntary leg movements
Positive family history forPositive family history for
RLSRLS
Temporary relief with movementTemporary relief with movement
Onset or worsening of symptomsOnset or worsening of symptoms
at rest or inactivity - in theat rest or inactivity - in the
evening or at nightevening or at night

12. RLS RXRLS RX
DopamineDopamine
agonistsagonists OpiatesOpiates AnticonvulsantsAnticonvulsants OthersOthers
Ropinorol*Ropinorol* TramadolTramadol Gabapentin Enacarbil*Gabapentin Enacarbil* BaclofenBaclofen
Pramipexol*Pramipexol* MethadoneMethadone TopiramateTopiramate ClonazepamClonazepam
Carbidopa/Carbidopa/
levodopalevodopa
CodeineCodeine PregabalinPregabalin ClonidineClonidine
Replace iron in patients with serum Ferritin levels below 50 mcg/L

13. SomnambulismSomnambulism
 Sleepwalking – common in childrenSleepwalking – common in children
 Complex purposeless tasks and wandering episodes of variableComplex purposeless tasks and wandering episodes of variable
duration, with memory impairment for the eventduration, with memory impairment for the event
 Starts in the deep stages of N-REM sleep in first third of nightStarts in the deep stages of N-REM sleep in first third of night
 Runs in family and often associated with Sleep TerrorsRuns in family and often associated with Sleep Terrors
 If starts in an adultIf starts in an adult
• OSAOSA
• DementiaDementia

14. Night TerrorsNight Terrors
• Sleep disorder characterized by high arousal
and appearance of being terrified
• Happens during stage 4 sleep; mostly children
• The children seldom remember the event.

15. Narcolepsy
• A sleep disorder characterized by uncontrollable
sleep attacks
• REM sleep occurs earlier than normal
• Narcolepsy with and without Cataplexy
• Cataplexy – momentary loss of muscle tone
triggered by emotional excitement

16. NarcolepsyNarcolepsy
 Neuropeptide hypocretin II,Neuropeptide hypocretin II,
(orexin B) producing cells(orexin B) producing cells
 reduced by 85%reduced by 85%––95% in the95% in the
posterior and lateralposterior and lateral
hypothalamushypothalamus
 Reduced CSF hypocretinReduced CSF hypocretin
HypothalamusHypothalamus
16

17. RBDRBD –– REM Sleep Behavior D/OREM Sleep Behavior D/O
 RBD is a REM sleep parasomnia with emergenceRBD is a REM sleep parasomnia with emergence
of complex and vigorous behaviors.of complex and vigorous behaviors.
 More common in >50 years of age, but can occurMore common in >50 years of age, but can occur
at any ageat any age
 More prevalent in men and often a precursor ofMore prevalent in men and often a precursor of
ParkinsonParkinson’’s Diseases Disease

18. RBD: Diagnostic CriteriaRBD: Diagnostic Criteria
 History of problematic sleep behavior (orHistory of problematic sleep behavior (or
videotaped documentation of such behaviors)videotaped documentation of such behaviors)
 PSG evidence of excessive augmentation ofPSG evidence of excessive augmentation of
chin EMG tone or of excessive limb twitchingchin EMG tone or of excessive limb twitching
in REM sleepin REM sleep

19. RBD RiskRBD Risk
RBD is associated with neurological
disorders in 38%–75% of cases –
Neurodegenerative conditions.
Particularly common are:
Parkinson disease
Multiple System Atrophy and
Lewy body dementia

20. RBD D/DRBD D/D
Severe OSASevere OSA
Drug InducedDrug Induced –– Sedatives, TCA, AnticholinergicsSedatives, TCA, Anticholinergics
AlcoholismAlcoholism
Structural Brain Stem LesionsStructural Brain Stem Lesions

22. OSA – Obstructive Sleep ApneaOSA – Obstructive Sleep Apnea

23. OSA IS :
 CommonCommon
 DangerousDangerous
 Easily recognizedEasily recognized
 TreatableTreatable

24. What is OSA?What is OSA?
 Sleep disorder characterized by recurrent episodes ofSleep disorder characterized by recurrent episodes of
narrowing or collapse of pharyngeal airway during sleepnarrowing or collapse of pharyngeal airway during sleep
despite ongoing breathing efforts.despite ongoing breathing efforts.
 These often lead toThese often lead to
• Acute derangements in blood gas disturbancesAcute derangements in blood gas disturbances
• Surges of sympathetic activationSurges of sympathetic activation
• Periodic arousal from sleep (fragmented sleep)Periodic arousal from sleep (fragmented sleep)

25. PATENT Vs COLLAPSED AIRWAYPATENT Vs COLLAPSED AIRWAY

26. WHAT IS OSA?WHAT IS OSA?
 Episodes of complete or partial collapse of airwayEpisodes of complete or partial collapse of airway
are translated to # of apnea and hypopneaare translated to # of apnea and hypopnea
events (AHI).events (AHI).
• Apnea = cessation of airflowApnea = cessation of airflow >> 10 seconds10 seconds
• Hypopnea = Decreased airflowHypopnea = Decreased airflow >> 10 seconds10 seconds
associated with:associated with:
 ArousalArousal
 Oxyhemoglobin desaturationOxyhemoglobin desaturation

27. WHY DOES THIS MATTER?WHY DOES THIS MATTER?
 Excessive daytime somnolenceExcessive daytime somnolence
 Impaired cognitive performanceImpaired cognitive performance
 DM/metabolic syndromeDM/metabolic syndrome
 Poor quality of lifePoor quality of life
 Increased risk of MVAIncreased risk of MVA
 Adverse cardiovascular outcomesAdverse cardiovascular outcomes
 Pulmonary hypertensionPulmonary hypertension

28. Prevalence of OSAPrevalence of OSA
 3-7 % in general US adult population3-7 % in general US adult population
 Higher in population subsetsHigher in population subsets
Ancoli-Israel and colleagues reported that 70% of men and 56%Ancoli-Israel and colleagues reported that 70% of men and 56%
of women between 65 and 99 years of age had obstructiveof women between 65 and 99 years of age had obstructive
sleep apnea defined as an AHI of at least 10 events per hoursleep apnea defined as an AHI of at least 10 events per hour..
Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing inAncoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing in
community-dwelling elderly. Sleep 1991;14:486–495community-dwelling elderly. Sleep 1991;14:486–495

29. ObesityObesity
 Alters upper airway mechanics duringAlters upper airway mechanics during
sleepsleep
1.1. Increased parapharyngeal fatIncreased parapharyngeal fat
deposition:deposition:
neck circumference:neck circumference: >> 17” males17” males
>> 16” females16” females
With subsequent:With subsequent:
 smaller upper airwaysmaller upper airway
 increase the collapsibility of theincrease the collapsibility of the
pharyngeal airwaypharyngeal airway

30. Majority of OSA still undiagnosed
RISK FACTORSRISK FACTORS
 ObesityObesity
 AgeAge
 SexSex
 RaceRace
 Craniofacial anatomyCraniofacial anatomy
 Smoking and Alcohol consumptionSmoking and Alcohol consumption

31. OBESITYOBESITY
 Strongest risk factor for OSAStrongest risk factor for OSA
• Present in > 60% of patients referred forPresent in > 60% of patients referred for
a diagnostic sleep evaluationa diagnostic sleep evaluation
• Wisconsin Sleep Cohort StudyWisconsin Sleep Cohort Study
 A one standard deviation difference in BMIA one standard deviation difference in BMI
was associated with a 4-fold increase inwas associated with a 4-fold increase in
disease prevalencedisease prevalence

32. OBESITYOBESITY
 Alters upper airway mechanics during sleepAlters upper airway mechanics during sleep
1.1.Increased Para pharyngeal fat deposition:Increased Para pharyngeal fat deposition:
neck circumference:neck circumference: >> 17” males17” males
>> 16” females16” females
With subsequent:With subsequent:
 smaller upper airwaysmaller upper airway
 increase the collapsibility of theincrease the collapsibility of the
pharyngeal airwaypharyngeal airway

33. OBESITYOBESITY
2. Changes in neural compensatory mechanisms that2. Changes in neural compensatory mechanisms that
maintain airway patency:maintain airway patency:
 diminished protective reflexes whichdiminished protective reflexes which
otherwiseotherwise
would increase upper airway dilator musclewould increase upper airway dilator muscle
activity to maintain airway patencyactivity to maintain airway patency

34. OBESITYOBESITY
3. waist circumference3. waist circumference
Fat deposition around the abdomen producesFat deposition around the abdomen produces
 reduced lung volumes (functional residualreduced lung volumes (functional residual
capacity) which can lead to loss of caudalcapacity) which can lead to loss of caudal
traction on the upper airwaytraction on the upper airway
 low lung volumes are associated withlow lung volumes are associated with
diminished oxygen storesdiminished oxygen stores

35. AGEAGE
 Mechanisms proposed:Mechanisms proposed:
• Anatomic susceptibilityAnatomic susceptibility
• Preferential deposition of fat in thePreferential deposition of fat in the
Para pharyngeal areaPara pharyngeal area
• Changes in the body structures around theChanges in the body structures around the
pharynxpharynx
• Deterioration of protective reflex mechanismsDeterioration of protective reflex mechanisms

36. Risk Factor: AgeRisk Factor: Age
0
5
10
15
20
25
30
35
30-39 Yrs 40-49 Yrs 50-60 Yrs
Female
Male
% with
AHI > 5
Adapted from Young T et al.
N Engl J Med 1993;328. 2006 American Academy of Sleep medicine

37. CRANIOFACIAL ANATOMYCRANIOFACIAL ANATOMY
 Mandibular body lengthMandibular body length
 RetrognathiaRetrognathia
 Tonsilar hypertrophyTonsilar hypertrophy
 Enlarged tongue or soft palateEnlarged tongue or soft palate
 Inferiorly positioned hyoid boneInferiorly positioned hyoid bone
 Maxillary and mandibular retro positionMaxillary and mandibular retro position
 Decreased posterior airway spaceDecreased posterior airway space

38. SMOKINGSMOKING
0
1
2
3
4
5
Adjusted Odds Ratio for Sleep Apnea (AHI > 15)
in Former & Current Smokers vs Nonsmokers
Adapted from Wetter DW et al. Arch Intern Med 1994:154 ©1994 American Medical Association.
Former Current
Smokers Smokers
(Adjusted for age,
race, sex, BMI)
Odds Ratio
2006 American Academy of Sleep Medicine

39. Other OSA risk factorsOther OSA risk factors
 Alcohol consumptionAlcohol consumption
 Sedatives (benzodiazepines)Sedatives (benzodiazepines)
 reduce nerve output to compensatoryreduce nerve output to compensatory
dilator musclesdilator muscles
 increase OSA severity in patients withincrease OSA severity in patients with
preexisting syndrome.preexisting syndrome.

40. DIAGNOSISDIAGNOSIS
 Combined assessment of clinical features andCombined assessment of clinical features and
objective sleep study dataobjective sleep study data..
 The gold standard:The gold standard: overnightovernight
polysomnogrampolysomnogram
 The Polysomnogram (PSG):The Polysomnogram (PSG):
• Provides detailed information on sleepProvides detailed information on sleep
state andstate and
respiratory and gas exchangerespiratory and gas exchange
abnormalities.abnormalities.

41. PSGPSG
 Simultaneous recordings of multipleSimultaneous recordings of multiple
physiological signals during sleep.physiological signals during sleep.
• Electroencephalogram (EEG)Electroencephalogram (EEG)
• Electrooculogram (EOG)Electrooculogram (EOG)
• Electromyogram (EMG)Electromyogram (EMG)
• Electrocardiogram (ECG)Electrocardiogram (ECG)
• Oronasal airflowOronasal airflow
• Chest/ Abdomen effortChest/ Abdomen effort
• Snore microphoneSnore microphone
• Oxyhemoglobin saturationOxyhemoglobin saturation

43. EEG
10 sec
Arousal
Airflow
Effort
(Pes)
SaO2
Effort
(Abdomen)
Effort
(Rib Cage)
2006 American Academy of Sleep Medicine
OSAOSA

44. EEG
10 sec
Arousal
Airflow
Effort
(Pes)
SaO2
Effort
(Abdomen)
Effort
(Rib Cage)
2006 American Academy of Sleep Medicine
CSACSA

45. PSGPSG
 Duration of the diagnostic studyDuration of the diagnostic study
should be at leastshould be at least
six hours.six hours.
 split-night studiessplit-night studies
• First half = diagnosisFirst half = diagnosis
• Second half = initiation of CPAP therapySecond half = initiation of CPAP therapy
((when obvious OSAS is present)when obvious OSAS is present)

48. OSA Clinical featuresOSA Clinical features
1. Excessive daytime sleepiness1. Excessive daytime sleepiness
2. fatigue2. fatigue
3. memory impairment3. memory impairment
4. personality changes4. personality changes
5. morning headaches or nausea5. morning headaches or nausea
6. depression6. depression

49. www.dentonsleepdisorderlab.com

50. SLEEP-
Apnea
Chronic
Intermittent
Hypoxia
Ventilatory
Overshoot
Hyperoxia
Increased
Sympathetic
Nervous System
Activity
Intrathoracic
Pressure Swings
Hypercapnia
Increased Arousals
Reduced Sleep
Duration
Increased
Inflammation
Increased
Oxidative Stress
Metabolic
Dysfunction/
Insulin
Resistance
Hyper-
coaguability
Endothelial
Dysfunction
Autonomic
Dysfunction
Systemic
Hypertension
Atherosclerosis
Diastolic
Dysfunction
Congestive Heart
Failure
Stroke
Increased Mortality
and Sudden Death
Cardiac Arrhythmias
PHYSIOLOGIC
PERTURBATIONS
INTERMEDIATE
MECHANISMS
CLINICAL
OUTCOMES
Mehra R Curr Resp Med Rev 2007

51. Comorbidities of OSA: MVAComorbidities of OSA: MVA
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
No Apnea Sleep Apnea All Drivers
Accident / driver / 5 yrs
Adapted from Findley LJ et al. Am Rev Respir Dis 1988;138.
2006 American Academy of Sleep Medicine

52. MEDICAL RMEDICAL Rxx
 Positive Pressure TherapyPositive Pressure Therapy
* CPAP* CPAP
* Bi-PAP* Bi-PAP
 SurgicalSurgical

53. CPAP MasksCPAP Masks
•Nasal CPAPNasal CPAP •Full Face MaskFull Face Mask •Nasal PillowsNasal Pillows

54. 2006 American Academy of Sleep Medicine
CPAP EffectCPAP Effect

55. MADMAD
56

56. Other DevicesOther Devices
 Single use deviceSingle use device
contains a mechanicalcontains a mechanical
valve with very lowvalve with very low
inspiratory but highinspiratory but high
expiratory resistanceexpiratory resistance
 The high expiratoryThe high expiratory
resistance results in +veresistance results in +ve
pressure throughoutpressure throughout
exhalation, which splintsexhalation, which splints
open the upper airway,open the upper airway,
making it more resistantmaking it more resistant
to collapse onto collapse on
subsequent inspirationsubsequent inspiration
Berry RB et al. SLEEP 2011;34(4):479-485.

57. 2006 American Academy of Sleep Medicine
UVPPUVPP

58. MMA GBTMMA GBT
59

59. Circadian Rhythms OverviewCircadian Rhythms Overview
 SuprachiasmaticSuprachiasmatic
nucleus (SCN), anucleus (SCN), a
paired structure locatedpaired structure located
in the anteriorin the anterior
hypothalamus containshypothalamus contains
a circadian pacemakera circadian pacemaker
 The biological clocksThe biological clocks
work on a 24.3 hourwork on a 24.3 hour
cycle rather than a 24cycle rather than a 24
hour onehour one
6060
 Complete lesionsComplete lesions
of the SCN abolishof the SCN abolish
circadian rhythmscircadian rhythms
 SCN transplantsSCN transplants
into the thirdinto the third
ventricle andventricle and
hypothalamushypothalamus
restoresrestores
rhythmicityrhythmicity

60. Circadian Rhythms DefinitionCircadian Rhythms Definition
 The mechanism throughThe mechanism through
which light inhibitswhich light inhibits
melatonin secretion bymelatonin secretion by
the pineal gland involvingthe pineal gland involving
the neural pathwaythe neural pathway
originating in the retinaoriginating in the retina
and passing through theand passing through the
suprachiasmatic nucleussuprachiasmatic nucleus
in the brain, to reachin the brain, to reach
pinealocytes viapinealocytes via
adrenergic nerves andadrenergic nerves and
adrenergic receptors, andadrenergic receptors, and
subsequently to thesubsequently to the
peripheryperiphery

61. Circadian RhythmsCircadian Rhythms
Delayed Sleep PhaseDelayed Sleep Phase
 The most common circadian rhythm sleepThe most common circadian rhythm sleep
disorder; it usually begins in adolescence anddisorder; it usually begins in adolescence and
is manifested as habitually delayed sleep andis manifested as habitually delayed sleep and
waking timeswaking times
 May significantly impede scholastic andMay significantly impede scholastic and
occupational achievementsoccupational achievements
 Treatment with melatonin or bright lightTreatment with melatonin or bright light
augmented with behavior and lifestyleaugmented with behavior and lifestyle
modification may be effectivemodification may be effective

62. Shift WorkTreatmentShift WorkTreatment
 Sleep hygieneSleep hygiene
 Bright light exposure (continuous orBright light exposure (continuous or
intermittent) beginning early during the nightintermittent) beginning early during the night
shift and terminating 2 h before the end of theshift and terminating 2 h before the end of the
shiftshift
 Avoiding bright light by wearing dark glassesAvoiding bright light by wearing dark glasses
during the morningduring the morning
 Melatonin, hypnotics, caffeine and modafinilMelatonin, hypnotics, caffeine and modafinil
also have their usesalso have their uses

63. Other Sleep DisordersOther Sleep Disorders
• Bruxism – teeth grinding
• Enuresis – bed wetting
• Myoclonus – sudden jerk of a body part
occurring during stage 1 sleep
–Everyone has occasional episodes of
myoclonus

64. Senthil Ramasamy, M.DSenthil Ramasamy, M.D..
Board Certified in Neurology & Sleep MedicineBoard Certified in Neurology & Sleep Medicine
 Clinical ConsultationClinical Consultation
 Sleep Studies – PSGSleep Studies – PSG
 Nerve Conduction/ EMGNerve Conduction/ EMG
 EEGEEG
 ALL INSURANCES ACCEPTEDALL INSURANCES ACCEPTED
 Pres, Lovelace, BCBS, UHC, AETNA, CIGNAPres, Lovelace, BCBS, UHC, AETNA, CIGNA
 MedicareMedicare
 MedicaidMedicaid

65. AthayaAthaya
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out patient facilityout patient facility
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INVITES PRACTICES/ PROVIDERS TO STARTINVITES PRACTICES/ PROVIDERS TO START
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