Sleep Disorders


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information on sleep disorders for neurologists, primary care physicians and psychiatrists

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Sleep Disorders

  2. 2. Organization of the chapter <ul><li>Chapter is divided mainly in three sections: </li></ul><ul><li>Physiology of the normal sleep </li></ul><ul><li>Disordered sleep </li></ul><ul><li>Sleep study </li></ul>
  3. 3. Physiology of Sleep
  4. 4. Phases of Sleep <ul><li>A REM (Rapid Eye Movement) sleep </li></ul><ul><li>B NREM (Non-Rapid Eye Movement) sleep </li></ul>
  5. 5. Normal sleep stages <ul><li>NREM sleep is divided in to four stages according to changes in biophysiological changes </li></ul><ul><li>NREM sleep is followed by REM sleep </li></ul><ul><li>Sleep pattern is usually NREM sleep stages 1 to 4 followed by REM sleep </li></ul>
  6. 6. REM Sleep characteristics
  7. 7. REM sleep characteristics <ul><li>Dreaming </li></ul><ul><li>Flaccid limb paralysis </li></ul><ul><li>Eye movements- rapid, conjugate and predominantly horizontal </li></ul><ul><li>Increased autonomic activities </li></ul>
  8. 8. REM sleep-changes in autonomic activities <ul><li>Increased pulse </li></ul><ul><li>Increased blood pressure </li></ul><ul><li>Increased intracranial pressure </li></ul><ul><li>Increased cerebral flow </li></ul><ul><li>Increased muscle metabolism </li></ul><ul><li>In men, erections </li></ul><ul><li>These increase in autonomic activities are considered responsible for increased incidence of myocardial infarctions and ischemic CVA </li></ul>
  9. 9. Biochemical changes in REM sleep <ul><li>Is associated with increased cholinergic activities </li></ul><ul><li>Is associated with decreased dopamine, norepinephrine and epinephrine activities </li></ul><ul><li>REM sleep is enhanced by cholinergic agonists such as nicotine and suppressed by anti-cholinergic medications </li></ul>
  10. 10. NREM characteristics
  11. 11. NREM sleep <ul><li>NREM (Non Rapid Eye Movements) consists of relatively long stretches of dreamless sleep in contrast to REM sleep. REM sleep is typically characterized by dreams </li></ul><ul><li>Eye movements in NREM sleep are slow and rolling in contrast to REM sleep, in which the eye movements are rapid and conjugate </li></ul>
  12. 12. NREM Sleep-changes in EEG and consciousness (cerebral function) <ul><li>Divided into four stages </li></ul><ul><li>Stages are divided according to the depth of unconsciousness </li></ul><ul><li>Greater depth of unconsciousness as sleep progresses from stage 1 to 4 </li></ul><ul><li>EEG becomes progressively slower and shows higher-voltage pattern ( also called slow wave, delta wave ) </li></ul>
  13. 13. NREM-Thinking and Body Activities <ul><li>Thinking in NREM is brief, rudimentary and readily forgotten </li></ul><ul><li>Muscle tone is present </li></ul><ul><li>DTR can be elicited </li></ul><ul><li>EMG activities can be detected in chin and limb muscles </li></ul>
  14. 14. NREM sleep-autonomic changes <ul><li>Characterized by generalized decrease in autonomic activities </li></ul><ul><li>Decrease in autonomic activities causes hypotension and bradycardia </li></ul><ul><li>Decreased generalized metabolic activity </li></ul>
  15. 15. NREM sleep-Hormonal changes <ul><li>Growth Hormone is secreted almost entirely in NREM sleep (due to hypothalamic-pituitary activity) </li></ul><ul><li>GH is secreted in 30 to 60 minutes after the beginning of sleep </li></ul><ul><li>Prolactin is secreted in NREM sleep (at the beginning of sleep) </li></ul><ul><li>Cortisol is secreted in NREM sleep (late at night) </li></ul>
  16. 16. NREM sleep-Biochemical changes <ul><li>Increased serotonin activity </li></ul>
  17. 17. Function of NREM sleep <ul><li>Important characteristics of NREM sleep like slow wave, decreased generalized metabolic activities and deep unconsciousness help revitalize the body </li></ul><ul><li>Thus, NREM or slow wave sleep occurs predominantly in the early night </li></ul><ul><li>Remaining sleep becomes lighter and dream filled predominantly characterized by REM sleep in the late phase </li></ul>
  18. 18. EEG/EMG characteristics of sleep <ul><li>EEG-more active than NREM similar to wakefulness. EEG shows low voltage fast with ocular movement artifact </li></ul><ul><li>EMG is silent in REM sleep corresponding to flaccid muscles </li></ul><ul><li>Paradoxical to muscle tone, all other body activities are as active as the wakefulness state in REM sleep </li></ul>
  19. 19. Sleep patterns-two latencies of sleep-definitions <ul><li>Sleep latency- the interval to fall asleep after retiring. Normal range is 10-20 minutes </li></ul><ul><li>REM latency- once asleep, normal individual enter NREM sleep and pass in succession through four stages. The interval from falling asleep to the first REM sleep is called REM latency. Normal range is 90-120 minutes </li></ul><ul><li>Changes in these two latencies are helpful in diagnosing many sleep disorders. </li></ul><ul><li>Also, the conditions affecting these two latencies are different for these two distinct latencies </li></ul>
  20. 20. Disordered Sleep
  21. 21. abnormalities of latencies
  22. 22. SHORTENED SLEEP LATENCY <ul><li>Alcohol and drug induced sleep </li></ul><ul><li>Narcolepsy </li></ul><ul><li>Sleep apnea </li></ul><ul><li>Sleep deprivation </li></ul>
  23. 23. Prolonged Sleep Latency <ul><li>Delayed sleep phase syndrome </li></ul><ul><li>Inadequate sleep hygiene </li></ul><ul><li>Psychiatric disorders-Acute schizophrenia, Major depression, and Mania </li></ul><ul><li>Restless leg syndrome </li></ul>
  24. 24. Causes of shortened or sleep onset REM sleep <ul><li>Alcohol, sedative and hypnotics </li></ul><ul><li>Depression </li></ul><ul><li>Narcolepsy </li></ul><ul><li>Sleep apnea </li></ul><ul><li>Sleep deprivation </li></ul>
  25. 25. effects of aging
  26. 26. Effects of age on sleep <ul><li>NREM sleep reduces in the elderly. </li></ul><ul><li>The slow wave phase disappears in people older than 75 years of age </li></ul>
  27. 27. Sleep disorders in aged <ul><li>Leg movement disorders </li></ul><ul><li>REM behavior disorder </li></ul><ul><li>Sleep apnea syndrome </li></ul><ul><li>Medication induced sleep disorders </li></ul><ul><li>Medical disorders especially cardiovascular disturbances and pain </li></ul><ul><li>Dementia </li></ul><ul><li>Neurological disorders </li></ul><ul><li>Depression </li></ul>
  28. 28. DSM classification of sleep disorders
  29. 29. Sleep Disorders <ul><li>DSM-IV recognizes three major categories of sleep disorders </li></ul><ul><li>A. Dyssomnias- Dyssomnias are a broad classification of sleeping disorder that make it difficult to get to sleep, or to stay sleeping. </li></ul><ul><li>B. Parasomnias:Parasomnia is a broad term used to describe various uncommon disruptive sleep-related disorders. They are intense, infrequent physical acts that occur during sleep. Some common Parasomnias include sleepwalking, sleep talking, sleep terrors, nightmares, and teeth grinding </li></ul><ul><li>C. Neurological/psychiatric disorders </li></ul>
  30. 30. Dyssomnias
  31. 31. Dyssomnias-characteristics <ul><li>Patients may complain of difficulty getting to sleep or staying asleep, intermittent wakefulness during the night, early morning awakening, or combinations of any of these. Transient episodes are usually of little significance. Stress, caffeine, physical discomfort, daytime napping, and early bedtimes are common factors </li></ul>
  32. 32. Dyssomnias-causes <ul><li>There are over 30 recognized kinds of Dyssomnias. Major groups of Dyssomnias include: </li></ul><ul><li>Intrinsic sleep disorders - 12 disorders recognized, including </li></ul><ul><ul><li>hypersomnia , </li></ul></ul><ul><ul><li>narcolepsy , </li></ul></ul><ul><ul><li>periodic limb movement disorder , </li></ul></ul><ul><ul><li>restless legs syndrome , </li></ul></ul><ul><ul><li>sleep apnea . </li></ul></ul><ul><li>Extrinsic sleep disorders - 13 disorders recognized, including </li></ul><ul><ul><li>alcohol-dependent sleep disorder, </li></ul></ul><ul><ul><li>food allergy insomnia , </li></ul></ul><ul><ul><li>inadequate sleep routine. </li></ul></ul><ul><li>Circadian rhythm sleep disorders - 6 disorders recognized, including </li></ul><ul><ul><li>advanced sleep phase syndrome , </li></ul></ul><ul><ul><li>delayed sleep phase syndrome , </li></ul></ul><ul><ul><li>jetlag , </li></ul></ul><ul><ul><li>shift work sleep disorder </li></ul></ul>
  33. 33. Dyssomnias-treatment <ul><li>In general, there are two broad classes of treatment, and the two may be combined: psychological (cognitive-behavioral) and pharmacologic. In situations of acute distress, such as a grief reaction, pharmacologic measures may be most appropriate. With primary insomnia, however, initial efforts should be psychologically based </li></ul>
  34. 34. Dyssomnias-conditions-Narcolepsy <ul><li>Narcolepsy is a neurological condition most characterized by Excessive Daytime Sleepiness (EDS). A narcoleptic will most likely experience disturbed nocturnal sleep, confused with insomnia, and disorder of REM or rapid eye movement sleep. </li></ul><ul><li>The main characteristic of narcolepsy is overwhelming excessive daytime sleepiness (EDS), even after adequate nighttime sleep. A person with narcolepsy is likely to become drowsy or to fall asleep, often at inappropriate times and places </li></ul><ul><li>Four other classic symptoms of narcolepsy, which may not occur in all patients, are cataplexy , sleep paralysis , hypnogogic hallucinations , and automatic behavior . </li></ul>
  35. 35. Narcolepsy treatment <ul><li>Treatment is individualized depending on the severity of the symptoms, and it may take weeks or months for an optimal regimen to be worked out. Complete control of sleepiness and cataplexy is rarely possible </li></ul><ul><li>Treatment is primarily by medications, but lifestyle changes are also important. </li></ul><ul><li>The main treatment of excessive daytime sleepiness in narcolepsy is with a group of drugs called central nervous system stimulants . For cataplexy and other REM-sleep symptoms, antidepressant medications and other drugs that suppress REM sleep are prescribed. </li></ul>
  36. 36. Periodic Limb Movements <ul><li>Periodic Limb Movement Disorder (PLMD), also called nocturnal myoclonus , is a sleep disorder where the patient moves involuntarily during sleep </li></ul><ul><li>It is related to restless leg syndrome (RLS) in that 80% of people with RLS also have PLMD. However, most people with PLMD do not experience RLS </li></ul><ul><li>Nocturnal myoclonus is treated by medications aimed at reducing or eliminating the leg jerks or the arousals. Non- ergot derived dopaminergic drugs ( pramipexole and ropinirole ) are preferred. Other dopaminergic agents such as co-careldopa , co-beneldopa , pergolide , or lisuride may also be us </li></ul><ul><li>These medications are also successful for the treatment of RLS restless leg syndrome . </li></ul>
  37. 37. Dyssomnias-Restless Leg Syndrome <ul><li>NIH criteria </li></ul>(1) an urge to move the limbs with or without sensations (2) worsening at rest (3) improvement with activity (4) worsening in the evening or night
  38. 38. Restless Leg Syndrome-types <ul><li>Primary RLS is considered idiopathic , or with no known cause. </li></ul><ul><li>Secondary RLS often had a sudden onset and may be daily from the very beginning </li></ul><ul><li>The most commonly associated medical condition is iron deficiency (medicine) , which accounts for just over 20% of all cases of RLS. The conditions include: pregnancy, varicose vein or venous reflux , folate deficiency , uremia , diabetes , thyroid problems, peripheral neuropathy, Parkinson's disease and certain auto-immune disorders such as Sjögren's syndrome , Celiac Disease , and rheumatoid arthritis . Treatment of the underlying condition often eliminates the RLS. </li></ul>
  39. 39. Restless leg syndrome-treatment <ul><li>Treatment of primary RLS should not be considered unless all the secondary medical conditions are ruled out </li></ul><ul><li>Drug therapy in RLS is not curative and is known to have significant side effects and needs to be considered with caution. </li></ul><ul><li>The secondary form of RLS has the potential for cure if the precipitating medical condition ( iron deficiency , Venous reflux / varicose vein , thyroid , etc.) is managed effectively </li></ul>
  40. 40. Restless Leg Syndrome- Medicinal approach <ul><li>Dopamine agonists such as ropinirole , pramipexole , carbidopa / levodopa or pergolide </li></ul><ul><li>Opioids such as propoxyphene , oxycodone , or methadone , etc. </li></ul><ul><li>Benzodiazepines , which often assist in staying asleep and reducing awakenings from the movements </li></ul><ul><li>Anticonvulsants , which often help people who experience the RLS sensations as painful, such as gabapentin </li></ul>
  41. 41. Parasomnias
  42. 42. Parasomnias-what, why and which ? <ul><li>A sleep disorder is a physical and psychological condition or disturbance of sleep and wakefulness caused by abnormalities that occur during sleep or by abnormalities of specific sleep mechanisms </li></ul><ul><li>Although the sleep disorder exists during sleep, recognizable symptoms manifest themselves during the day </li></ul><ul><li>Accurate diagnosis requires a polysomnogram, widely known as a &quot;sleep test.“ </li></ul><ul><li>Some common Parasomnias include sleepwalking, sleep talking, sleep terrors, nightmares, and teeth grinding </li></ul>
  43. 43. Parasomnias-classifications <ul><li>A. Arousal-Sleep terrors, Sleepwalking </li></ul><ul><li>B. Sleep-Wake Transition-Rhythmic movement disorders </li></ul><ul><li>C. Parasomnias with REM sleep-Nightmares, Sleep paralysis, and REM sleep Behavior disorders </li></ul><ul><li>D. Other Parasomnias- Bruxism and Enuresis </li></ul>
  44. 44. Parasomnias-Bruxism <ul><li>Sleep related, stereotyped, forceful teeth grinding or clenching </li></ul><ul><li>Is also associated with dementias, mental retardation and Parkinson’s disease </li></ul>
  45. 45. sleep disturbances in psychiatric disorders
  46. 46. Major Psychiatric Causes of sleep disorders <ul><li>Psychosis/ schizophrenia </li></ul><ul><li>Depression </li></ul><ul><li>Alcoholism </li></ul>
  47. 47. Sleep Disturbances in Schizophrenia <ul><li>Schizophrenia, schizophreniform disorder and psychosis are associated with both insomnias and excessive daytime sleepiness (EDS) </li></ul><ul><li>PSGs are inconsistent because of diversities in presentations and use of antipsychotic </li></ul><ul><li>In acute schizophrenia, the sleep time is decreased and sleep latency is increased </li></ul><ul><li>In chronic schizoprenia, patients have normal sleep pattern and can distinguish their dreams from hallucinations </li></ul>
  48. 48. Sleep Disturbances in Depression <ul><li>Associated with both insomnia and excessive daytime sleepiness (EDS) </li></ul><ul><li>There is no diagnostic REM abnormalities </li></ul><ul><li>A typically short REM latency (less than 60 minutes) is followed by abnormally long, intense REM period. </li></ul><ul><li>Subsequent REM periods occur in relatively quick succession, leaving the latter half virtually devoid of REM sleep </li></ul><ul><li>They are considered to be in phase-shift advance </li></ul><ul><li>They have an earlier excretion of cortisol and their metabolites and tempreature nadir </li></ul>
  49. 49. Sleep Disturbances in Mania <ul><li>Sleep latency can be excessive </li></ul><ul><li>REM sleep can be abolished </li></ul><ul><li>Total sleep time can be reduced markedly </li></ul>
  50. 50. Sleep Disturbances in Alcoholism <ul><li>Is associated with both insomnia and excessive daytime sleepiness (EDS) </li></ul><ul><li>The clinical and PSG data are variable </li></ul><ul><li>They have a short sleep latency, less REM sleep and increased slow wave sleep in the first half of night </li></ul><ul><li>In the second half, they have increased REM and periods of wakefulness, as though emerged into delirium </li></ul><ul><li>Alcohol withdrawl leads to insomnia and REM rebound </li></ul>
  51. 51. sleep disturbances in neurological conditions
  52. 52. Neurological Disorders-sleep disturbances <ul><li>Dementia </li></ul><ul><li>Parkinson’s disease </li></ul><ul><li>Basal ganglia syndrome- causing involuntary movements </li></ul><ul><li>Fatal familial insomnia </li></ul><ul><li>Epilepsy </li></ul><ul><li>Headaches </li></ul><ul><li>Other medical conditions </li></ul>
  53. 53. Sleep Disturbances in Dementia <ul><li>Dementia of Alzheimer’s type in moderate severity disturbs sleep-wake cycle </li></ul><ul><li>Causes nighttime thoughts </li></ul><ul><li>Causes behavioral disturbances </li></ul><ul><li>During the night, patient becomes confused, agitated and disoriented </li></ul><ul><li>PSGs shows increased stage 1 NREM sleep, fragmentation and decreased efficiency </li></ul><ul><li>Daytime exercises and restricted nap during the daytime helps. Patient may need tranquilizers or sedatives </li></ul>
  54. 54. Sleep Disturbances in Parkinson’s Disease <ul><li>Sleep disorder is an integral part of Parkinson’s disease possibly because the disease depigments locus ceruleus and substantia nigra. Part of the problem is iatrogenic </li></ul><ul><li>Affects the most patients as the disease advance </li></ul><ul><li>Causes mainly combinations of nocturnal hallucinations, nightmares and agitated confusion </li></ul><ul><li>Other manifestations are fragmented sleep, insomnia or hypersomnia; REM sleep behavior disorder and depression which interferes with the sleep </li></ul><ul><li>Dopaminergic drugs causes vivid dreams and visual hallucinations </li></ul><ul><li>Clozapine (with minimal Parkinson’s side effects ) is indicated for serious nocturnal thought and behavioral disturbances </li></ul>
  55. 55. Fatal Familial Insomnia <ul><li>Inherited tendency to develop a progressively severe insomnia that is refractory to medicine </li></ul><ul><li>Is seen at average age of 50 </li></ul><ul><li>Is accompanied by neuropsychological problems like inattentiveness, confusion and amnesia </li></ul><ul><li>Thalamus undergoes atrophy in this condition </li></ul><ul><li>Cerebral biopsy shows spongiform cerebral cortical changes </li></ul>
  56. 56. Epilepsy-sleep disturbances <ul><li>Some seizures occurs primarily in sleep </li></ul><ul><li>About 45% of patients with primary generalized epilepsy have seizures in the sleep </li></ul><ul><li>Sleep deprivation precipitates seizures in the susceptible patients. Obtaining an EEG after enforced sleep deprivation elicits variety of spike-and sharp activities in more than one third of epileptics </li></ul><ul><li>Anticonvulsants promote normal sleep </li></ul><ul><li>Anticonvulsants raise the efficiency of sleep </li></ul><ul><li>Even at therapeutic level, the anticonvulsants can lead to excessive daytime sleep (EDS) </li></ul>
  57. 57. some important systemic causes of sleep disturbances
  58. 58. Other Medical Disorders That Disturb Sleep <ul><li>Cardiovascular diseases-angina pectoris and myocardial infarctions causes disturbances of REM sleep </li></ul><ul><li>Thrombotic CVA causes disturbances in the NREM sleep </li></ul><ul><li>Attacks of asthma, exacerbation of COPD and GERD and peptic ulcers tend to develop during the sleep </li></ul>
  59. 59. Insomnias
  60. 60. Insomnia-causes <ul><li>Medical and neurological conditions </li></ul><ul><li>Drug and alcohol abuse </li></ul><ul><li>Psychiatric disorders </li></ul><ul><li>Patients older than 65 years of age </li></ul>
  61. 61. Treatment of Insomnia <ul><li>Limited course of hypnotic is effective for the insomnia due to the transient disturbances such as grief </li></ul><ul><li>People with neurological conditions like Alzheimer’s disease can develop “paradoxical reaction” to hypnotics </li></ul><ul><li>Non-prescription hypnotics like antihistamines are more hazardous than prescription hypnotics like benzodiazepine </li></ul><ul><li>In the elderly, the benzodiazepines can cause anterograde insomnia, insomnia in the early morning, daytime anxiety and psychomotor impairments </li></ul><ul><li>Benzodiazepine use in the elderly have been linked to hip fracture from falls and withdrawal seizures </li></ul>
  62. 62. Sleep Studies
  63. 63. STUDY OF NORMAL SLEEP <ul><li>There are mainly two ways to define the stages of sleep </li></ul><ul><li>A. Clinical observations </li></ul><ul><li>B. Physiologic information </li></ul><ul><li>Polysomnography is a common method employed to study these changes </li></ul>
  64. 64. Recording of Polysomnography <ul><li>Simultaneous recordings of EEG, EOG, EMG, EKG, vital signs and breathing </li></ul>
  65. 65. What answers to expect from Polysomnography ? <ul><li>Polysomnography is a comprehensive recording of the biophysiological changes that occur during the sleep </li></ul><ul><li>Polysomnography is usually performed during the night when patient sleeps </li></ul>
  66. 66. Recording of Polysomnography
  67. 67. Polysomnography-clinical applications
  68. 68. Polysomnography-when to use <ul><li>As Polysomnography is expensive, it is useful only in certain cases </li></ul><ul><li>Treatment resistant insomnia, insomnia associated with mental aberrations, associated with sleep apnea and dangerous to health </li></ul>
  69. 69. Polysomnography-usefulness <ul><li>Provide a diagnosis </li></ul><ul><li>Confirm a clinical impression </li></ul><ul><li>Can help to justify surgery </li></ul><ul><li>Indicate a prescription medication in the following disorders A. Sleep apnea syndrome; B. Narcolpesy0cataplexy; C. REM behavior disorder; D. Periodic limb movements; E. Parasomnias </li></ul><ul><li>Useful in detecting neurological disorders that develop exclusively in the sleep like seizures </li></ul>
  70. 70. Cheaper Alternative to PSG <ul><li>Home video with luminescent clock in the background can provide many in formations about the sleep </li></ul>