Sleep disorders

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Sleep disorders

  1. 1. Sleep disorders
  2. 2. Main Topics <ul><li>Insomnia </li></ul><ul><li>Obstructive sleep apnea </li></ul><ul><li>Central sleep apnea </li></ul><ul><li>Periodic limb movement </li></ul><ul><li>Narcolepsy </li></ul>
  3. 3. Secondary causes of insomnia <ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Pain </li></ul><ul><li>GORD </li></ul><ul><li>Dyspnea </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Drugs </li></ul><ul><li>Environmental factors-”learned insomnia” </li></ul>
  4. 4. Drugs that can cause insomnia <ul><li>Theophylline </li></ul><ul><li>Beta blockers </li></ul><ul><li>Caffeine </li></ul><ul><li>Amphetamine </li></ul><ul><li>Dopamine agonist </li></ul><ul><li>Nasal decongestant </li></ul><ul><li>Anti-depressants. </li></ul><ul><li>Corticosteroids </li></ul>
  5. 5. Management of insomnia <ul><li>Cognitive behavioural therapy . </li></ul><ul><li>Types of CBT: </li></ul><ul><li>Stimulus control </li></ul><ul><li>Sleep restriction </li></ul><ul><li>Sleep habits and education </li></ul><ul><li>Relaxation techniques </li></ul><ul><li>Bright light therapy </li></ul><ul><li>Cognitive therapy </li></ul>
  6. 6. Drugs that causes reduce REM sleep <ul><li>Amitriptylline (TCA) </li></ul><ul><li>Moclobemide (MAOI) </li></ul><ul><li>Citalopram (SSRI) </li></ul><ul><li>Venlafaxine (Selective serotonin and NorAd reuptake inhibitor) </li></ul><ul><li>Antipsychotics </li></ul>
  7. 7. Drugs that increase REM sleep <ul><li>Bupropion (NorAd and dopamine reuptake inhibitor) </li></ul><ul><li>Trazodone (Serotonin antagonist and reuptake inhibitor) </li></ul>
  8. 8. Obstructive sleep apnea <ul><li>Increasing prevalence with obesity . </li></ul><ul><li>Factors leading to increased airway narrowing: </li></ul><ul><li>Obesity </li></ul><ul><li>Genetics-micrognathia, retrognathia </li></ul><ul><li>Alcohol </li></ul>
  9. 9. Signs of OSA <ul><li>Sleepiness </li></ul><ul><li>Obesity </li></ul><ul><li>Crowded pharynx </li></ul><ul><li>Retrognathia </li></ul><ul><li>Congested nose </li></ul><ul><li>HT </li></ul>
  10. 10. Associated conditions with OSA <ul><li>Hypothyroidism </li></ul><ul><li>Acromegaly </li></ul><ul><li>Marfan’s syndrome </li></ul><ul><li>Cor Pulmonale </li></ul>
  11. 11. The reason why a person would be compliant with his CPAP for OSA <ul><li>Daytime sleepiness </li></ul><ul><li>Quality of life </li></ul>
  12. 12. Other consequences of OSA <ul><li>HT </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Road trauma </li></ul><ul><li>Cognitive function </li></ul>
  13. 13. Management of OSA <ul><li>Weight loss </li></ul><ul><li>CPAP (mainstay of Rx) </li></ul><ul><li>Upper airway surgery-does not work for adults. </li></ul><ul><li>Mandibular advancement splint-must have own teeth. </li></ul>
  14. 14. Central sleep Apnea <ul><li>Associated with LVF </li></ul><ul><li>Treat CSA by treating the LVF </li></ul>
  15. 15. Periodic limb movement <ul><li>Sudden jerking leg movements that commonly accompany RLS. </li></ul><ul><li>The patient is usually unaware of these movements. </li></ul><ul><li>Associated with iron deficiency and renal failure . </li></ul><ul><li>ALWAYS Check ferritin!! </li></ul><ul><li>Start oral iron therapy if ferritin levels are low. </li></ul>
  16. 16. Polysomnography in PLM <ul><li>repetitive, highly stereotyped limb movements. </li></ul><ul><li>0.5 to 5 seconds in duration. </li></ul><ul><li>amplitude >25% of toe dorsiflexion during calibration </li></ul><ul><li>in a sequence of four or more movements </li></ul><ul><li>separated by an interval of 5-90 secs. </li></ul>
  17. 17. Levodopa in PLM <ul><li>Reduces PLMs, Excess Daytime Sleepiness (EDS) and improves QOL but… </li></ul><ul><li>Issues with Levodopa: (If used continuously) </li></ul><ul><li>Augmentation . Worsening of RLS symptoms earlier in the day after an evening dose of medication, including earlier onset of symptoms, increased intensity of symptoms, or spread of symptoms to the arms. </li></ul><ul><li>Rebound is the recurrence of RLS early in the morning </li></ul><ul><li>Recurrence of symptoms in the second half of the night may occur. </li></ul>
  18. 18. Levodopa in PLM <ul><li>How to avoid this effect? </li></ul><ul><li>Don’t use it everyday, only use it intermittently. (“Drug holiday”) </li></ul><ul><li>Beware of retroperitoneal, mediastinal and pulmonary fibrosis. </li></ul>
  19. 19. Narcolepsy <ul><li>Pathology: loss of hypocretin producing cells. </li></ul><ul><li>Very low prevalence 0.03%. </li></ul><ul><li>Characterized by: </li></ul><ul><li>Excessive daytime sleepiness </li></ul><ul><li>Cataplexy </li></ul><ul><li>Sleep paralysis </li></ul><ul><li>Hypnogogic and hypnapompic hallucinations. </li></ul><ul><li>100% will have HLA DQB1*0602 (HLA DR2) </li></ul>
  20. 20. Management of narcolepsy <ul><li>Scheduled naps </li></ul><ul><li>Reduce heavy carbo meals </li></ul><ul><li>Good night’s sleep </li></ul><ul><li>Psychosocial support </li></ul><ul><li>Avoid prazosin- may induce cataplexy. </li></ul><ul><li>Drugs to use: dexamphetamine, methylphenidate, caffeine, antidepressants. </li></ul>
  21. 21. Drop in SaO2 with attempt to breath “ Breathing-not breathing-breathing”
  22. 22. Drop in Sats but NO attempt to breath
  23. 23. Low sats, High CO2.
  24. 24. Repetitive leg movement No change in respiratory signals

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