2. SLEEP
• Sleep is a naturally recurring state of mind and body, characterized by
altered consciousness, relatively inhibited sensory activity, inhibition of
nearly all voluntary muscles, and reduced interactions with
surroundings
• USES
• Improve memory
• Live longer?
• Lower stress
• Steer clear of depression
• build muscle more easily.
3.
4. ASSESSMENT
• Sleep questionnaire
• Sleep history
• Sleep diary
• History from bed patner
• Investigation
1. Video recording
2. EEG
3. EMG
4. Polysomnography
5. HISTORY
• 1913, Henri Pieron wrote “Le probleme physiologique du sommeil”
• Nathaniel Kleitman regarded as the father of American sleep research
• His crucial work included studies of sleep characteristics in different
populations and the effects of sleep deprivation
• In 1953, along with one of his students, Eugene Aserinsky, discovered REM
during sleep
• William C. Dement, another of Kleitman’s students, described the cyclical
nature of sleep in 1955
• Published a paper in 1958 that created an explosion of fundamental research
that led Michel Jouvet to identify REM sleep as an independent state of
alertness
6.
7. NORMAL SLEEP
• Stage 1
• Transition to sleep/slow eye movements
• AlphaTheta on EEG
• Dreaminess, beginning to fall asleep
• Hypnogogic hallucinations
• Approx 7 mins to fall asleep, lasts 5-10 mins
• About 5% of our time asleep
8. • Stage 2
• Unconscious, but awakened easily
• Heart rate and temp begin to drop
• No eye movements
• Theta Waves on EEG
• Lasts about 20 mins
• About 50% of our time asleep
9. • Stage 3
• Transition from light to deep sleep
• Deep, slow Delta waves emerge
• 4-6 % of sleep
10. • Stage 4
• Deepest stage of sleep
• Lasts 30 mins
• May be dreaming
• Parasomnias occur
11. • Stage 5
• Rapid eye movement (REM) sleep
• Paradoxical- brain most active/muscles paralyzed
• Brain activity most similar to wakefulness
• Dreaming due to increased brain activity
• 4 or 5 episodes per night – 20% of total sleep
• Typically enter REM 90 mins after falling asleep
12.
13. • Cycles
• Stages do not progress in sequence:
• NREM 1, 2, 3, 4, 3, 2 then REM, back to 2
• Sleep cycles through these stages 4-5 times nightly
• Each cycle 90-120 min
• Each cycle becomes longer
• Long dreams? REM can last up to 1 hr
14. • Circadian Rhythm
• Natural clock is about 25 hrs
• Biological clock based on environmental cues
• Sleep “Requirements”:
• Infants: 15-16 hours/day
• Teens: 8-10 hours/day
• Adults: 6-9 hours/day (including elderly
15.
16. SLEEP DISORDER
A sleep disorder, or somnipathy, is a medical
disorder of the sleep patterns of a person or
animal. Some sleep disorders are serious
enough to interfere with normal physical,
mental, social and emotional functioning.
EPIDEMIOLOGY
10.2% - insomnia
3.2% hypersomnia
17. CAUSES
• Physical disturbances (for example, pain from ulcers)
• Medical issues (for example, asthma)
• Psychiatric disorders (for example, depression and anxiety
disorders)
• Environmental issues (for example, alcohol use)
• Genetics:
• Night shift work:
• Medications: (antidepressants, blood pressure )
• Aging
19. CLASSIFICATION
• DYSSOMNIA
is a broad type of sleep disorders involving difficulty falling or
remaining asleep, which can lead to excessive sleepiness
during the day due to the reduced quantity, quality or timing of
sleep.
20. PARASOMNIAS
• are a category of sleep disorders that involve abnormal
movements, behaviors, emotions, perceptions, and dreams that
occur while falling asleep, sleeping, between sleep stages, or
during arousal from sleep.
21. INSOMNIA
• difficulty falling asleep or staying asleep, even when a person
has the chance to do so. People with insomnia can feel
dissatisfied with their sleep and usually experience one or more
of the following
• symptoms:
• fatigue, low energy, difficulty concentrating, mood disturbances,
and decreased performance in work or at school.
29. HYPERSOMNIA
• or excessive sleepiness, is a condition in which a person has
trouble staying awake during the day. People who
have hypersomnia can fall asleep at any time; for instance, at
work or while they are driving.
30. CAUSES
• The sleep disorders narcolepsy (daytime sleepiness) and sleep
apnea (interruptions of breathing during sleep)
• Not getting enough sleep at night (sleep deprivation)
• Being overweight
Drug or alcohol abuse
A head injury or a neurological disease, such as multiple sclerosis
Prescription drugs, such as tranquilizers
Genetics (having a relative with hypersomnia
32. NARCOLEPSY
• Narcolepsy is a sleep disorder characterized by excessive
sleepiness, sleep paralysis, hallucinations, and in some cases
episodes of cataplexy (partial or total loss of muscle control,
often triggered by a strong emotion such as laughter)
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39. BREATHING RELATED
DISORDER/OBSTRUCTIVE SLEEP APNEA
DISORDER
• The term breathing-related sleep disorder refers to a
spectrum of breathing anomalies ranging from chronic or
habitual snoring to upper airway resistancesyndrome (UARS)
to frank obstructive sleep apnea(OSA) or, in some cases,
obesity hypoventilationsyndrome (OHS)
43. TREATMENT
General treatment measures for breathing-related sleep disorders include
• behavior modification aimed at improving sleep hygiene and avoiding additional sleep
deprivation,
• avoidance of supine positioning during sleep,
• avoidance of ethanol and sedative medications.
• Treatment can require major changes in lifestyle.
• Appropriate weight management strategies and compliance with either positive airway
support or the use of a dental appliance usually represent a lifetime commitment. For
this reason, some patients have explored surgical alternatives
44. All patients should be offered nasal CPAP therapy first.
In patients with mild-to-severe obstructive sleep apnea who refuse or reject nasal CPAP therapy, BiPAP therapy should
be tried next. If this therapy fails or is rejected, OA therapy should be considered.
OAs may be considered first-line therapy for patients with mild OSA, particularly if they are unwilling to try nasal CPAP
therapy.
All interventions to improve tolerance of CPAP therapy should be attempted prior to deciding that treatment has failed
in a particular patient.
Patients in whom noninvasive medical therapy (eg, CPAP, BiPAP, OAs) fails should be offered surgical options.
Patients should be made aware of the success rates for each surgical procedure. They should be informed that they
might require more than 1 surgical procedure, some fairly extensive, to cure OSA.
Refer patients only to centers that have personnel experienced in these special surgical techniques.
45. Medications include
wakefulness-promoting drugs to help patients with daytime sleepiness such as Provigil (modafinil)
and Nuvigil (armodafinil).
Other medications to treat sleep apnea aid in sleep, including
BENZODIAZIPINES-Halcion (triazolam), Ativan (lorazepam), and Valium(diazepam);
BARBITURATES - Seconal Sodium (secobarbital sodium)
NONBENZODIAZAPINE HYPNOTICS- Edluar (zolpidem tartrate) and Ambien (zolpidem tartrate),
SEDATIVES - Xyrem (sodium oxybate), and melatonin receptor agonists such as Hetlioz (tasimelteon).
46. Over-the-counter (OTC) sleep aids should be used only on the advice of a physician if you have sleep apnea. These
include Sominex, Nytol (diphenhydramine), and Unisom (doxylamine).
In some cases, OTC nasal decongestants such as Afrin (oxymetazoline), Neo-Synephrine (phenylephrine),
and Sudafed(pseudoephedrine) may be used to treat mild cases of snoring associated with sleep apnea
47. SIDE EFFECT
• sleep apnea medicines vary depending on the type
of medication. Wakefulness-promoting medications can
cause headache, upper respiratory tract infection, nausea,
nervousness, anxiety, and insomnia.
• Benzodiazepines, barbiturates, hypnotics, and sedatives have
similar side effects including drowsiness and dizziness. Other
side effects may include stomach upset, headache, weakness,
grogginess, dreaming, and mood or behavior changes.
• Side effects of nasal decongestants include nervousness,
restlessness, or difficulty sleeping.
48. CIRCARDIAN RHYTHM DISORDER
• Circadian rhythm sleep disorders (CRSD) are a family of
sleep disorders affecting (among other bodily processes) the
timing of sleep. People withcircadian
rhythm sleep disorders are unable to go to sleep and awaken
at the times commonly required for work and school as well as
social needs.
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50.
51. THE INTERNATIONAL CLASSIFICATION
OF DISEASES
• delayed sleep phase type
• free-running type
• advanced sleep phase type
• irregular sleep-wake type
• shift work type
• jet lag type
52. DELAYED SLEEP PHASE SYNDROME
(DSPS)
is a circadian sleep disorder in which the individual's internal body clock
is delayed with respect to the external day/night cycle.
• A person with DSPS naturally falls asleep late at night, typically
between 1:00 am and 6:00 am, and awakens in the late morning or in
the afternoon.
• There is a striking inability to fall asleep at an earlier, more typical
bedtime. As a result, many people with DSPS have been labeled as
insomniacs.
• But if such a person is allowed to follow his internal body clock, he
generally has no problems with either falling asleep or waking
naturally.
54. ADVANCED SLEEP PHASE SYNDROME
(ASPS)
• Advanced Sleep Phase Syndrome (ASPS) (also called
Advanced Sleep Phase Disorder, ASPD) is characterized by
bedtime and wake-up time much earlier than normal, although
sleep quality is normal. People with ASPS may fall sleep at 6 or
8 p.m. and awaken about eight hours later.
55. IRREGULAR SLEEP-WAKE DISORDER (ISWD)
• Irregular Sleep-Wake Disorder (ISWD) is characterized by at
least three sleep episodes per 24-hour period, irregularly from
day to day.
• It most commonly occurs in elderly persons with dementia.
• It also occurs in some children with developmental disorders,
including autism spectrum disorders.
56. SHIFT WORK DISORDER
• Shift Work Disorder may occur when work schedules force people to
be awake when their circadian rhythms dictate that they should be
sleeping.
• It is classified as a Circadian Rhythm Disorder (CRD) and is extrinsic,
i.e. caused by external behavioral factors.
• A considerable amount of research has been done on shift work
disorder because of the importance of shift work in certain industries
and occupations.
57. JET LAG
• Jet Lag results from travelling across time zones.
• Nighttime begins several hours earlier (or later) in the new time zone,
than it did in the old time zone.
• As a result, the sleep/wake cycle must shift, and all the other circadian
rhythms shift also. But they don't all shift together.
• The shift in sleep hours may in itself cause significant tiredness.
58. MANAGEMENT
• Behavior therapy such as maintaining regular sleep-wake times,
avoiding naps, engaging in a regular routine of exercise, and avoiding
caffeine, nicotine, and stimulating activities within several hours of
bedtime is important in the treatment of circadian rhythm disorders
• Bright light therapy is used to advance or delay sleep. The timing of
this treatment is critical and requires guidance from a sleep specialist
• Medications such as melatonin, wake-promoting agents, and short-
term sleep aids may be used to adjust and maintain the sleep-wake
cycle to the desired schedule.
• Chronotherapy is a progressive advancement or delay (1 to 2 hours
per day) of sleep time depending on the type and the severity of the
disorder.
59. DYSSOMNIA
• is a broad type of sleep disorders involving difficulty falling or
remaining asleep, which can lead to excessive sleepiness
during the day due to the reduced quantity, quality or timing of
sleep.
63. CAUSES
• Not getting enough bright-light exposure during waking hours
• Wake-sleep pattern disturbances
• Aging
• Overactive thyroid
• Alcoholism or abruptly stopping alcohol after long-term use
• Side effect of a new medication
• Excessive physical or intellectual stimulation at bedtime
• Jet lag
• Abruptly stopping a medication
• Nicotine, alcohol, caffeine, food, or stimulants at bed
64. DIAGNOSIS
• Doctors will first obtain a detailed history of your symptoms and
the symptoms of your sleep disturbance. This will include a
sleep history including onset, frequency, and duration of sleep.
• Lifestyle habits will also be assessed to determine if substance
abuse is a causative factor. Additionally, any physical
manifestation as a result of your lack of sleep will also be
documented, like headaches or weight gain.
65. PERIODIC LEG MOVEMENT
SYNDROME(PLMS)
repetitive cramping or jerking of the legs during sleep.
It is the only movement disorder that occurs only during
sleep, and it is sometimes called periodic leg (or limb)
movements during sleep.
"Periodic" refers to the fact that the movements are
repetitive and rhythmic, occurring about every 20-40
seconds.
PLMD is also considered a sleep disorder, because the
movements often disrupt sleep and lead to daytime
sleepiness.
66. HOW ????????????
• Typically the knee, ankle, and big toe joints all bend as part of
the movements.
• The movements vary from slight to strenuous and wild kicking
and thrashing.
• The movements last about 2 seconds (and thus are much
slower than the leg jerks of myoclonus).
• The movements are rhythmic and repetitive and occur every 20-
40 seconds.
67. CAUSES
•Diabetes mellitus
•Iron deficiency
Spinal cord injury
Sleep apnea syndrome
Narcolepsy
Uremia
Anemia
Medication - Neuroleptics and other antidopaminergic agents such as Haldol,
dopaminergic agents or tricyclic antidepressantssuch as amitriptyline (Elavil)
Withdrawal from sedative medications such as barbiturates or benzodiazepines (such
as Valium)
68. TREATMENT
• BENZODIAZEPINES: These drugs suppress
muscle contractions. They are also sedatives and help you sleep
through the movements. Clonazepam (Klonopin)
• DOPAMINERGIC AGENTS
levodopa/carbidopa combination (Sinemet) and pergolide
(Permax).
• ANTICONVULSANT AGENTS: These medications reduce
muscle contractions in some people. The most widely used
anticonvulsant in PLMD is gabapentin (Neurontin).
69. • GABA agonists: These agents inhibit release of certain
neurotransmitters that stimulate muscle contractions. The result
is relaxation of contractions. The most widely used of these
agents in PLMD is baclofen (Lioresal).
70. RESTLESS LEG SYNDROME(RLS)
Restless legs syndrome (RLS) is a disorder of the part of the nervous system that
causes an urge to move the legs.
Because it usually interferes with sleep, it also is considered a sleep disorder
71.
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74. • Dopamine agonists: These are most often the first medicines
used to treat RLS. These drugs, including pramipexole
(Mirapex), rotigotine(Neupro), and ropinirole (Requip), act like
the neurotransmitter dopamine in the brain.
• Dopaminergic agents: These drugs, including Sinemet -- a
combination of levodopa and carbidopa -- increase the level of
dopamine in the brain and may improve leg sensations in RLS.
However, they may cause a worsening of symptoms for some
people after daily use. Side effects can also include
nausea, vomiting, hallucinations, and involuntary movements
(dyskinesias).
75. • Benzodiazepines: Benzodiazepines, such
as alprazolam (Xanax), clonazepam (Klonopin),
and temazepam (Restoril), are sedatives. They do not so much
relieve symptoms as help you sleep through the symptoms.
• Alpha2 agonists: These agents stimulate alpha2 receptors in
the brain stem. This activates nerve cells (neurons) that "turn
down" the part of the nervous system that controls muscle
involuntary movements and sensations. The
drug clonidine (Catapres) is an example.
76. • Opiates: These drugs are most often used to treat pain, but they
can also relieve RLS symptoms. Because opiates are very
addictive, they are usually used only when other drugs don't
work. Hydrocodone (Vicodin, Norco) is one example.
• Anticonvulsants: These agents, such
as gabapentin (Neurontin) and gabapentin enacarbil (Horizant),
may help relieve the symptoms of RLS as well as any chronic
pain or nerve pain.
77. PARASOMNIAS
• Parasomnias are a category of sleep disorders that involve
abnormal movements, behaviors, emotions, perceptions, and
dreams that occur while falling asleep, sleeping, between sleep
stages, or during arousal from sleep
Parasomnias affect approximately 10% of Americans.
They occur in people of all ages, but are more
common in children.
78. • Here are six common parasomnias that afflict sleepers:
• Sleepwalking. More commonly seen in children, sleepwalking
(also called somnambulism) affects about 4 percent of American
adults. ...
• REM sleep behavior disorder. ...
• Nightmares. ...
• Night terrors. ...
• Nocturnal sleep-related eating disorder. ...
• Teeth grinding.
79. CAUSES
• Parasomnias often run in families and so there is probably a
genetic factor in many cases.
• Brain disorders may be responsible for some parasomnias, such
as many cases of REM sleep behavior disorder.
• Parasomnias may also be triggered by other sleep disorders
such as obstructive sleep apnea, and by various medications.
80.
81. NIGHT MARES/ DREAM ANXIETY
DISORDER
Nightmare disorder, also known as 'dream anxiety
disorder', is a sleep disorder characterized by
frequent nightmares.
The nightmares, which often portray the individual in a
situation that jeopardizes their life or personal safety,
usually occur during the REM stages of sleep.
Though such nightmares occur within many people,
those with nightmare disorder experience them with a
greater frequency.
82. caused by extreme pressure or irritation if no other mental disorder is discovered.
The death of a loved one or a stressful life event can be enough to cause a nightmare
but mental conditions like post-traumatic stress disorder and other psychiatric disorders
have been known to cause nightmares as well.
If the individual is on medication, the nightmares may be attributed to some side effects
of the drug.
Amphetamines, antidepressants, and stimulants like cocaine and caffeine can cause
nightmares.
Blood pressure medication, levodopa and medications for Parkinson's disease have
also been known to cause nightmares
84. COMPLICATIONS
• Excessive daytime sleepiness, which can lead to difficulties at
school or work, or problems with everyday tasks, such as driving
and concentrating
• Problems with mood, such as depression or anxiety from
dreams that continue to bother you
• Resistance to going to bed or to sleep for fear you'll have
another bad dream
• Suicidal thoughts or suicide attempts
85. TREATMENT
• Stress reduction techniques such as Yoga, meditation and exercise
may help to eliminate stress and create a more peaceful sleeping
atmosphere
• Diagnosis and medication can only be given to patients that report the
recurring nightmares to a psychiatrist or other physician.
• Medications like prazosin are sometimes used to treat nightmares in
people with PTSD.
• Therapy usually helps to deal with the frightening themes of the
nightmares and alleviate the recurrence of the dreams.
• The persistent nightmares will usually improve as the patient gets
older. Treatments are generally very successful
86. NIGHT TERRORS
• Sleep terrors are episodes of screaming, intense fear and flailing
while still asleep. Also known as night terrors, sleep terrors often
are paired with sleepwalking.
• Sleep terrors affect almost 40 percent of children and a much
smaller percentage of adults
• Children usually don't remember anything about their sleep
terrors in the morning. Adults may recall a dream fragment they
had during the sleep terrors.
87. During a sleep terror episode, a person may:
• Begin with a frightening scream or shout
• Sit up in bed and appear frightened
• Stare wide-eyed
• Sweat, breathe heavily, and have a racing pulse, flushed face and dilated pupils
• Kick and thrash
• Be hard to awaken, and be confused if awakened
• Be inconsolable
• Have no or little memory of the event the next morning
• Possibly, get out of bed and run around the house or have aggressive behavior if blocked
or restrained
88. CAUSES
• Sleep deprivation and extreme tiredness
• Stress
• Sleep schedule disruptions, travel or sleep interruptions
• Fever
89. COMPLICATION
• Excessive daytime sleepiness, which can lead to difficulties at
school or work, or problems with everyday tasks
• Disturbed sleep
• Embarrassment about the sleep terrors or problems with
relationships
• Injury to oneself or rarely to someone nearby
90. TREATMENT
• Treating any underlying condition.
• Addressing stress.
• Anticipatory awakening.
• Medication. Medication is rarely used to treat sleep terrors,
particularly for children. If necessary, however, use of
benzodiazepines or certain antidepressants may be effective.
91. • Get adequate sleep.
• Establish a regular, relaxing routine before bedtime.
• Make the environment safe.
• Put stress in its place.
• Offer comfort.
• Look for a pattern.
92. SLEEP WALKING
DISORDER/SOMNABULISM
Sleepwalking, formally known as somnambulism, is a behavior
disorder that originates during deep sleep and results in walking
or performing other complex behaviors while asleep.
It is much more common in children than adults and is more
likely to occur if a person is sleep deprived
93. SYMPTOMS
• Sleeptalking
• Little or no memory of the event
• Difficulty arousing the sleepwalker during an episode
• Inappropriate behavior such as urinating in closets (more
common in children)
• Screaming (when sleepwalking occurs in conjunction with sleep
terrors)
• Violent
94.
95. TREATMENT
• There is no specific treatment for sleepwalking. In many cases
simply improving sleep hygiene may eliminate the problem.
• Treatment for sleepwalking in adults may include hypnosis. In
fact, there are many cases in which sleepwalking patients have
successfully treated their symptoms with hypnosis alone.
• Also, pharmacological therapies such as sedative-hypnotics or
antidepressants have been helpful in reducing the incidence of
sleepwalking in some people.
96. SLEEP PARALYSIS
• Sleep paralysis is a feeling of being conscious but unable to
move.
• It occurs when a person passes between stages of wakefulness
and sleep.
• During these transitions, you may be unable to move or speak
for a few seconds up to a few minutes.
• Some people may also feel pressure or a sense of choking.
