This document summarizes various breathing-related sleep disorders including obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. It also discusses parasomnias, which are disorders of arousal during sleep stages. Common parasomnias include sleepwalking, sleep terrors, REM sleep behavior disorder, recurrent isolated sleep paralysis, and nightmares. Movement disorders like restless leg syndrome are also covered. Treatment options focus on lifestyle changes, medications, CPAP, and other therapies depending on the specific condition.

1. Breathing-Related Sleep Disorders
 Includes conditions ranging from upper airway
resistance syndrome to severe obstructive
sleep apnea causing apnea (absence of
airflow) and hypopnea (reduction in airflow)
 Can also be caused by central (brainstem)
changes in ventilatory control, metabolic
factors

2. a) Obstructive Sleep Apnea Hypopnea (OSA)
b) Central Sleep Apnea
- idiopathic central sleep apnea
- cheyne-stokes breathing
- central sleep apnea comorbid with opioid use
c) Sleep-Related Hypoventilation

3. Obstructive Sleep Apnea Hypopnea
(OSA) –
repetitive collapse of the upper airway in sleep
increased respiratory effort or airway occlusion
decrease in arterial oxygen saturation and transient arousal,
after which
Respiration resumes normally

4.  Multiple such episodes occur in a night’s sleep
 Predisposing factors –
- male
- middle age
- obese
- micrognathia /retrognathia
- nasopharyngeal abnormalities
- hypothyroidism
- acromegaly

5.  Clinical features-
- excessive sleepiness
- snoring
- obesity
- restless sleep
- nocturnal awakenings with choking or gasping
for breath
- morning dry mouth , headache
- heavy nocturnal sweating

6.  Other –
- hypertension
- erectile failure
- depression
- heart failure
- nocturia
- polycythemia
- memory impairment

7.  Episodes can occur in any state of sleep but
are more typical in:
– REM sleep,
– NREM stage 1
– NREM stage 2

8. Polysomnogram findings
 Episodes of OSA in adults are characterized by:
- multiple periods of at least 10 seconds
- arterial oxygen saturation drops
- bradycardia
- may be accompanied by arrhythmias
(premature ventricular contractions).
- At the end, arousal reflex takes place, (motor
artifact on the EEG channels).

9. Treatment
 Avoidance of smoking, alcohol and depressant
medication
 Use of stimulants (caffeine)
 Regular exercise
 Correct sleeping posture
 Weight loss

10.  In some patients, sleep-disordered breathing
occurs only in the supine position.
 Tennis balls sewn onto or placed into pockets
on the back of the nightshirt or foam wedges
prevent patients from sleeping on their backs
 Modafinil- FDA approved.
- used only as an adjunct for treating the
residual sleepiness

11.  In severe cases:
Surgical intervention
- uvulopalatopharyngoplasty
- maxillomandibular surgeries
 Continuous Positive airway pressure
 Oral appliances

12. Central sleep Apnea
 CSA is defined as the absence of breathing
due to lack of respiratory effort
 repeated episodes of apneas and hypopneas
occur in a periodic or intermittent pattern
during sleep caused by variability in
respiratory effort

13. Types (DSM 5)
- idiopathic central sleep apnea
- cheyne-stokes breathing
-central sleep apnea comorbid with opioid use

14. Idiopathic CSA
 Patients typically have low normal arterial
carbon dioxide tension while awake and have
a high ventilatory response to C02 causing
– - awakening with shortness of breath,
– - daytime sleepiness,
– - insomnia,
– - Respiratory cessations

15. Cheyne-Stokes Breathing
 prolonged hyperpneas alternating with
apnea/ hypopnea episodes
 most common in older men with congestive
heart failure or stroke.

16. CSA Comorbid with Opioid Use
 Chronic use of long-acting opioid medications
can lead to impairment of neuromuscular
respiratory control leading to CSA.

17. Parasomnias
 Referred to as disorders of partial arousal.
 Diverse collection of sleep disorders
characterized by physiological or behavioral
phenomena that occurs during or are
potentiated by sleep.

18.  Wakefulness , NREM sleep and REM sleep are 3 basic
states that differ in their neurological organization
• - Wakefulness - both the body and brain are active
- In NREM sleep , both the body and brain are less
active
- In REM sleep , pairs an atonic body with an active
brain
 In some parasomnias there are state boundary
violations.
 For example - sleepwalking and sleep terrors involve
momentary or partial wakeful behaviors suddenly
occurring in NREM sleep.

19.  Frequency - variable.
 Clinical significance often has more to do
with the medical consequences or the
evoked level of distress than with how often
the abnormal events occur.
 For example - biannual REM sleep behavior
disorder, in which the patient is seriously
injured while enacting a dream, is more
clinically urgent than weekly bruxism

20. NREM Sleep Arousal Disorders
Sleepwalking {somnambulism} :-
 Condition in which an individual arises from bed
and ambulates without full awakening
 Usually occurs during slow wave sleep
 Exacerbated by sleep deprivation or interruption
of slow wave sleep

21.  Common in children
 Rare in adults
- familial pattern
- may occur as a primary parasomnia or
secondary to another sleep disorder (e.g., sleep
apnea).
 Peak prevalence between 4-8 years .
 After adolescence, it usually disappears
spontaneously.
 Individuals can engage in a variety of complex
behaviors while unconscious.

22.  Sleepwalks characteristically begin toward the end of the first or
second slow wave sleep episodes.
 Ranges from sitting up and attempted to walk to conducting an
involved sequence of semi purposeful actions
- successfully interacts with environment
- can trip over objects
- can sustain injury
- can commit violence
 Patient is :
- Blank ,
- staring face ,
- relatively unresponsive to the efforts of others to communicate ,
- difficult to awaken .

23.  Once awake, they will usually appear confused.
 In their confused state, may think they are being
attacked and may react violently to defend
themselves.
 Recall of these events is poor
 Episodes last from a few minutes to an hour
 Nightly to weekly sleepwalking episodes
associated with physical injury to the patient
and others are considered severe.

24. Etiology
- Admixtures /Rapid oscillation between states
of sleep occurs (flip flop switches)
- Allows portion of non REM and REM state to
coexist with other
- Resulting in unusual autonomic and motor
behaviours appearing during states in which
EEG suggests that the person is actually asleep

25. Treatment
 Patient should be protected by appropriate locks
on doors
 Hazardous objects should be removed from his
room
 Patient must avoid becoming sleep deprived and
maintain a good sleep hygiene
 It is best to gently attempt to lead sleepwalkers
back to bed rather than to attempt to awaken
them by grabbing, shaking the patient.

26. • Sleep- related eating –
- episodes of ingesting food during sleep with
varying degrees of amnesia .
• Sexsomnia –
- engage in sexual activities during sleep
without conscious awareness .

27. • Sleep Terrors :-
 Arousal in first third of night during deep
NREM (stages 3 and 4) sleep
 Characterized by a sudden arousal with
intense fearfulness
 Usually begins with a piercing scream or cry
and are accompanied by a behavioral
manifestation of intense anxiety bordering on
panic

28.  Autonomic and behavioral correlates of fright
typically mark the experience
 Sits up in the bed , unresponsive to stimuli
and if awakened , is confused or disoriented
- vocalizations may occur , usually incoherent .
- amnesia for the episode usually occur .
- arises from slow wave sleep .

29.  Fever and CNS depressants withdrawal
potentiate the episode .
 Devoid of images or contain only fragments of
very brief but frighteningly vivid sometimes
static images .
 Severity ranges from less than one per month
to almost nightly .

30. Associated with REM Sleep
• REM Sleep behavior disorder :-
 Failure to have atonia (sleep paralysis) during
the REM stage sleep
- patient enacts on his dreams
 Under normal circumstances , the dreamer is
immobilized by REM – related hypopolarization
of alpha and gamma motor neurons

31.  Without this paralysis , punching , kicking ,
leaping and running from bed can occur
 Patients and bed partners frequently sustains
injuries (lacerations , fractures)
 May results from diffuse hemispheric lesions ,
bilateral thalamic abnormalities or brain stem
lesion
 Clonazepam is helpful in treatment

32. • Recurrent Isolated Sleep Paralysis
 Inability to make voluntary movements at sleep
onset or on awakening , a time when the
individual is partially conscious and aware of the
surroundings .
 Extremely distressing , when hypnagogic
hallucinations are occurring .
 Lasts from 1 to several minutes .

33.  Sleeper experienced it as been attacked by some
sort of creature
 Called as incubus , Old Hag , a vampire , ghost
oppression or an alien encounter .
 Irregular sleep , sleep deprivation , psychological
stress and shift work , increases the likelihood of
sleep paralysis .
 Occurs in 7-8 % of young adults .

34.  Life time experience in general population is
25 -50 % .
 First line therapies are Improved sleep hygiene
and assurance of sufficient sleep .
 Episodes can be terminated by
- very rapid eye movements or when touched
by another person .

35. Nightmare Disorder
 Frightening or terrifying dreams
 Also called as dream anxiety attacks
 Produces sympathetic activation and ultimately
awaken the dreamer
 Occurs in REM sleep
 On arousal person remembers the dream

36.  Common in children ages 3-6 years , rare in
adults (1% or less) .
 Frequent and distressing nightmares can
cause insomnia
 According to Freud , nightmare is an example
of the failure of the dream process that
diffuses the emotional content of the dream
by disguising it symbolically , thus preserving
sleep .

37.  Most patients afflicted with nightmares are
free from psychiatric conditions .
 Those at risk for nightmares include –
schizotypal , borderline and schizoid
personality disorders and schizophrenia .
 L-DOPA , beta adrenergic blockers and alcohol
provoke nightmares .

38.  Treatment using behavioral techniques are
helpful .
- Universal sleep hygiene
- stimulus control therapy
- lucid dream therapy
- cognitive therapy
 Nightmares related to PTSD – NEFAZODONE
(an atypical antidepressant ) is helpful.

39.  PRAZOSIN (alpha 1 receptor antagonist ) also
used in nightmares associated with PSTD .
 Benzodiazepines may be helpful

40. Other Parasomnias
• Sleep enuresis
• Sleep related Groaning
• Sleep – Related Hallucinations
• Sleep – Related Eating Disorder .

41. Parasomnia due to Medical
Conditions
 Seizure Disorder
 Sleep related breathing disorder
 Neurological conditions-
- Parkinson's Disease
- dementia
- progressive supranuclear palsy
- shy-Drager syndrome
- narcolepsy

42. Sleep-Related Movement Disorder
• Restless leg syndrome
{Ekbom syndrome}
• Uncomfortable , subjective sensation of limbs
, usually legs , (creepy crawly feeling) and
irresistible urge to move the legs when at rest.
• Worse at night
• Moving the legs helps alleviating the
discomfort .

43. • Neuropathies , uraemia , iron and folic acid
deficiency anemias can produce secondary RLS
• Also associated with – fibromyalgia , RA , diabetes
, thyroid disease and COPD .
• Ferritin levels should be checked .
• Treatment of choice – dopamine agonists as
Pramipexole and Ropinirole (FDA approved)

44. • Other agents –
- dopamine precursors (levodopa)
- benzodiazepines
• Non pharmacological –
- avoid alcohol use close to bed time
- massaging the affected parts of the legs
- taking hot baths
- engaging in moderate exercise