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  1. 1. Introduction to Sleep and Sleep Disorders Steven M. Scharf MD, PhD
  2. 2. Sleep Disorders - Socioeconomic Consequences <ul><li>40 million Americans suffer from chronic disorders of sleep and wakefulness. </li></ul><ul><li>95% of these remain unidentified and undiagnosed. </li></ul><ul><li>The annual direct cost of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs (accidents, litigation, property destruction, hospitalization, and death). </li></ul>
  3. 3. What else about sleep? <ul><li>Sleep disorders are common </li></ul><ul><li>Sleep disorders are serious </li></ul><ul><li>Sleep disorders are treatable </li></ul><ul><li>Sleep disorders are underdiagnosed </li></ul>
  4. 4. Sleep - Definition <ul><li>A very complex orchestration of physiological and behavioral processes. </li></ul><ul><li>Unlike coma: physiologic, recurrent, and reversible. </li></ul>
  5. 5. Sleep is NOT the absence of wakefulness <ul><li>Active </li></ul><ul><li>Complex </li></ul><ul><li>Highly Regulated </li></ul><ul><li>Involves different areas in the brain </li></ul><ul><li>Purpose is not understood </li></ul><ul><li>Essential to life </li></ul><ul><ul><li>We all do it </li></ul></ul>
  6. 6. Sleep Positions
  7. 7. State Generators
  8. 8. Sleep States of Being (adults) REM Sleep ~20% of night NREM Sleep ~80% of night Wake 2/3 of life
  9. 9. Wake / Sleep Pattern Development
  10. 10. <ul><li>The Cyclic alteration of wakefulness, NREM and REM defines two rhythms </li></ul><ul><ul><li>CIRCADIAN RHYTHM - daily (24 hour) biorhythms </li></ul></ul><ul><ul><ul><li>hormonal (almost all) </li></ul></ul></ul><ul><ul><ul><li>temperature </li></ul></ul></ul><ul><ul><ul><li>BP </li></ul></ul></ul><ul><ul><ul><li>drug metabolism </li></ul></ul></ul><ul><ul><ul><li>sleep state </li></ul></ul></ul><ul><ul><li>SLEEP STATE ASSOCIATED RHYTHMS </li></ul></ul>
  11. 12. Sleep Academic Award Circadian Rhythms Suprachiasmatic Nuclei (SCN) Output Rhythms Physiology Behavior Light
  12. 14. Disruption of Circadian Rhythms <ul><li>Aging </li></ul><ul><li>Many physiological and behavioral circadian rhythms are altered with advanced age: </li></ul><ul><li>The most notable are changes in sleep, such as earlier onset of sleepiness, early morning awakening and increased daytime napping ( 33% of older people). </li></ul><ul><li>Decrease in the amplitude of various circadian rhythms, including hormonal rhythms, are associated with advanced age. </li></ul>
  13. 15. Jet Lag <ul><li>Temporary desynchronization between internal circadian rhythms and external time cues </li></ul><ul><li>Symptoms: Malaise; Insomnia / hypersomnia; Fatigue; Poor performance </li></ul>
  14. 16. Shift Work <ul><li>Chronic desynchronization of internal circadian and external time cues </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Insomnia / hypersomnia; Fatigue; Poor performance; Medical / psychiatric illness; Drug abuse; Social impact </li></ul></ul>
  15. 17. Sleep structure
  16. 18. State Determination <ul><li>Behavioral </li></ul><ul><li>Electrographic </li></ul><ul><li>Neuronal state Within each state, there is ongoing variability and fluctuation of brain/neural activity. </li></ul>
  17. 19. Polygraphic Monitoring
  18. 21. 75mn 1 sec. Stage 3 EYES Brain waves Muscle tone EKG
  19. 22. Stage REM EYES Brain waves Muscle tone EKG
  20. 23. Sleep Medicine Introduction <ul><li>88 recognized sleep disorders </li></ul><ul><ul><li>Breathing disorders </li></ul></ul><ul><ul><ul><li>Sleep Apnea </li></ul></ul></ul><ul><ul><li>Neurological </li></ul></ul><ul><ul><ul><li>Restless legs syndrome </li></ul></ul></ul><ul><ul><li>Psychiatric </li></ul></ul><ul><ul><ul><li>Depression </li></ul></ul></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><li>Drug associated </li></ul></ul><ul><ul><ul><li>Alcohol, hypnotics, stimulants </li></ul></ul></ul><ul><ul><li>Circadian Rhythms </li></ul></ul><ul><ul><ul><li>Phase shift syndromes </li></ul></ul></ul><ul><ul><li>Abnormal Behaviors </li></ul></ul><ul><ul><ul><li>Sleep walking </li></ul></ul></ul><ul><ul><ul><li>Night terrors </li></ul></ul></ul>
  21. 24. A 27 year-old nurse is referred for evaluation of excessive daytime sleepiness. She carries a diagnosis of “narcolepsy.” In spite of having to struggle every day, she finished nursing school and works as a research nurse in a prestigious institution. She has tried stimulant with no help. She was diagnosed with depression and is taking an antidepressant with no change in symptoms. She notes that in the early evening she experiences a “funny feeling” in her calves, best described as a drawing or pulling. She thinks this improves with movement, and does try walking around. Her mother and an aunt all have the same symptoms.   A sleep study was performed: Here it is: CASE
  22. 25. Arousals following limb movements Limb movements Periodic Limb Movement disorder EEG1 EOG EMG Chin Airflow Resp Effort EMG Leg EEG2 EEG3 EEG4 Arousals following limb movements Limb Movements
  23. 26. Diagnosis : Restless Legs Syndrome/Periodic Limb movement disorder Treatment : pramapaxole (anti-parkinson’s drug) Outcome : Terrific. She feels refreshed in the morning and functions well all day (you didn’t think I would write about any treatment failures, did you?)
  24. 27. Restless legs syndrome and periodic limb movements of sleep <ul><li>RLS </li></ul><ul><li>Characterized by an almost irresistible urge to move, usually associated with disagreeable leg sensations , worse during inactivity, and often interfering with sleep (akisthesia). </li></ul><ul><li>Symptoms worse at rest, partially relieved by activity </li></ul><ul><li>Symptoms worse in the evening or at night </li></ul><ul><li>Periodic limb movements: found on polysomnography </li></ul><ul><li>Stereotypic movements of legs (or arms) during sleep </li></ul><ul><li>90% pts with RLS </li></ul><ul><li>May be independent </li></ul><ul><li>May disturb sleep </li></ul><ul><li>Both of these may be “Primary” or secondary to a variety of medical conditions or drug therapies. </li></ul>
  25. 28. Posted by sleepless Sam on April 19, 2002 at 09:07:23: In Reply to: Sorry to keep bothering everyone..... posted by Melanie on April 19, 2002 at 07:31:23: Hi Melanie, … . I suffer from chronic insomnia, this has been going on for 2 years now. I am also desperate . I stayed awake the whole of last night and have had zero sleep. My muscles also ache with pain, I have no energy or enthusiasm to do anything. I just feel like no-one can help me, I've done the whole doctors thing, herbal thing, sleeping pills thing, alternative medicine eg. acupunture, hypnotherapy, etc. I JUST WANT MY LIFE BACK. ...I've seen so many doctors, all they've tried to do is put me on sleeping pills or anti-depressants, they are such a joke! Why can't somebody find a cure for insomnia that doesn't involve sleeping pills?? The funny thing is that insomnia makes you depressed, we all know if we could just get some decent deep sleep, we would all be back to our normal selves! … before I got insomnia I had a real love for life and had boundless energy, I am only 27 but feel like a 60 year old. …Its terrible, just remember that there are the rest of us out here also and we're all going through it together. Lets try to not let us defeat us or our spirits!! Good luck with everything, INSOMNIA: From an Internet posting
  26. 29. Insomnia <ul><li>Affecting up to 30% of the adult population at one time </li></ul><ul><li>Chronic insomnia </li></ul><ul><ul><ul><li>8% of men; 12% women </li></ul></ul></ul><ul><li>Usually a symptom and not a disorder in and of itself </li></ul><ul><li>Often the symptom of many underlying medical, psychiatric (particularly depression) and psychological conditions. </li></ul><ul><li>Insomnia may be the presenting symptom of primary </li></ul><ul><li>sleep disorders </li></ul><ul><li>15 – 20% of insomniacs are “primary” meaning have no organic or psychologic cause </li></ul>
  27. 30. Insomnia Treatment <ul><li>Treat underlying medical or psychiatric condition if there is one </li></ul><ul><li>Pharmacologic: sleeping pills </li></ul><ul><ul><li>For transient insomnia </li></ul></ul><ul><ul><li>Less useful for chronic insomnia – but used in selected cases </li></ul></ul><ul><li>Cognitive – Behavioral therapy: </li></ul><ul><ul><li>Most useful for chronic insomnia </li></ul></ul><ul><ul><li>Sleep Habits and behavioral modification </li></ul></ul>
  28. 31. Inadequate Sleep Hygiene Extremely common – we go 24/7 <ul><li>Fix a bedtime and fix an awakening time </li></ul><ul><li>Avoid napping during the day </li></ul><ul><li>Avoid alcohol before bed </li></ul><ul><li>Avoid caffeine containing beverages 4 – 6 hours before bedtime </li></ul><ul><li>Avoid heavy, spicy, or sugary foods before bed </li></ul><ul><li>Regular exercise is good, not before bedtime </li></ul><ul><li>Comfortable bedding </li></ul><ul><li>Bedroom cool, dark, quiet </li></ul><ul><li>Bedroom reserved for sleep and sex – NOT a work room </li></ul><ul><li>  </li></ul>
  29. 32. Sleep Hygiene - 2 <ul><li>Bedtime rituals </li></ul><ul><li>Relaxation techniques </li></ul><ul><li>What to do if you wake up in the middle of the night </li></ul><ul><li>Television : Bad; Reading , music: good </li></ul><ul><li>Med problems upsetting sleep: arthritis, acid reflux with heartburn, menstruation, headache, and hot flashes. </li></ul><ul><li>Psyche problems upsetting sleep: Poor sleep maintenance may be only presentation of major depression </li></ul><ul><li>Medication effects: </li></ul><ul><ul><li>Hypnotic dependent sleep disorders </li></ul></ul><ul><ul><li>Stimulant dependent sleep disorders </li></ul></ul><ul><ul><li>Meds leading to insomnia </li></ul></ul>
  30. 33. Burwell et al: Extreme Obesity associated with alveolar hypoventilation: A pickwickian syndrome. Am J Med 1956;21: 811- 818 <ul><li>An obese patient came to the emergency room of the Peter Bent Brigham Hospital </li></ul><ul><li>CC: Fell asleep at Poker with a full house and a large pot </li></ul><ul><li>PE: Obese, hypersomnolance, hypoventilation, cor pulmonale </li></ul>This reminded Burwell of Joe, the fat boy From the Dickens novel, “ The posthumous papers of the Pickwick Club .” To be fair: The term was initially coined by Osler (1918)
  31. 34. Fat Here And here
  32. 35. Sleep Apnea Syndrome Is characterized by repetitive episodes of decreased airflow that occur during sleep. Decreased airflow may be associated with a reduction in blood oxygen saturation, and enhanced autonomic activity. Apneic events may terminate in arousals with resultant sleep fragmentation.
  33. 36. Classic Obstructive Apneas Airflow Airflow Ceases Chest wall motion continues Arousal
  34. 37. Repetitive Obstructive Apneas
  35. 38. Quantification in terms of “events” <ul><li>Apneas = airflow stops </li></ul><ul><li>Hypopneas = airflow decreases </li></ul><ul><li>Respiratory Disturbance index (RDI) = the number of events for each hour of sleep </li></ul><ul><ul><li>More than 20 is often considered “severe” </li></ul></ul>
  36. 39. Prevalence of Sleep Apnea Syndrome In young to middle aged men: 3 - 9 % In young to middle aged women: 1 - 3%
  37. 40. Sleep Apnea-Hypopnea Syndrome <ul><li>Excessive daytime sleepiness </li></ul><ul><li>Snoring </li></ul><ul><li>Obesity is a risk </li></ul><ul><ul><li>Only 50% are obese, means 50% NOT obese </li></ul></ul><ul><li>Poor cognition/memory </li></ul><ul><li>Social/sexual/psychologic problems </li></ul>
  38. 41. Cardiovascular Disease <ul><li>The association with hypertension is striking </li></ul><ul><li>Increased risk for Heart Attack </li></ul><ul><li>Increased risk for Stroke </li></ul><ul><li>Increased incidence of Sudden Death </li></ul><ul><li>Many cardiac rhythm disturbances </li></ul>
  39. 42. SNA RESP BP Sympathetic Nerve Recordeings During Sleep In OSA
  40. 43. Loss of vigilence Car Accidents in SAHS ACCIDENTS single/5yr multiple/5yr POPULATION SNORERS RDI>15 ODDS 3.4 7.3 Young T. SLEEP 1997;20(8):608-13 n=913
  41. 44. Physical Examination Normal SAHS Patient
  42. 45. Treatment <ul><li>Medical Treatment </li></ul><ul><ul><li>Lose weight if obese </li></ul></ul><ul><ul><li>Eliminate alcohol, sedatives </li></ul></ul><ul><ul><li>Improved sleep hygiene </li></ul></ul><ul><ul><li>Smoking Cessation </li></ul></ul><ul><li>Continuous Positive Airway Pressure (CPAP) </li></ul><ul><li>Upper airway surgery </li></ul><ul><li>Dental orthotic or mandibular positioning devices </li></ul>Note: Treatment recommendations are individualized for each patient: No “one size fits all”
  43. 46. Continuous Positive Airway Pressure (CPAP) 95% effective – usually first line treatment for severe disease
  44. 47. Surgical approaches Uvulopalatopharyngoplasty
  45. 48. Dental orthotic or mandibular repositioning devices: surprisingly effective in many cases
  46. 49. Often used devices which don’t treat sleep apnea This one treats the partner ->                                 Separate balls slightly and place onto septum.
  47. 50. University of Maryland Sleep Disorders Center Sleep Laboratory Sleep specialists Referrals (MD’s, Patients) ENT Psyche Neuro Peds Other OP facility PFT lab Blood lab X-ray Secretarial BILLER Dental Michelle Lynn 410-706-4771