The document discusses various topics related to sleep including: 1. Sleep accounts for about 1/3 of our lifetime and 1/3 of the population has a sleep disorder. 2. Sleep is regulated by our circadian rhythm located in the hypothalamus and lasts approximately 24 hours. 3. A normal sleep cycle occurs every 90 minutes and includes NREM sleep, which accounts for 70-80% of sleep, and REM sleep, which accounts for 20-25% of sleep. 4. More than 80 known sleep disorders are classified as dyssomnias involving difficulties initiating or maintaining sleep or daytime sleepiness, or parasomnias involving abnormal events during sleep.

1. Sleep, sleep disorders Professor Yasser Metwally

2. Each of us will spend about 27 years of our lifetime sleeping….. … ..And 1/3 part of the population has sleep disorder About the sleep…

3. „ Why we sleep remains one of nature’s greatest mysteries” (MG Frank, The function of sleep, 2006) Somatic theories of sleep function Neural metabolic theories: detoxification and regeneration Cognitive theories of sleep function: learning and brain development

4. Regulation of sleep Cirkadian timing: lasts about 24 hours Hypothalamus Suprachiasmatic nucleus Pituitary gland: melatonin Ultradian timing : lasts less than 24 hours Prepontin nuclei Raphe nuclei L. coeruleus

5. Normal human sleep Sleep cycle – occurs about every 90 minutes, approximately 4-6 cycles occur per major sleep episode Microarousal NREM (70-80%) slow wave sleep heart rate, BP, breathing ↓ body temperature, muscle tone ↓ REM (20-25%) rapid eye movement, paradox, fast wave sleep heart rate, BP, breathing ↑ , metabolic rate ↑ dreaming, erection muscleatonia, BUT: myoclonus!

6. NREM stage (3-8%) ~ drowsiness, sleepiness EEG: α -activity, muscle tone, eye movement ↓, myoclonus! stage (45-55%) ~ EEG: K-complexes, sleep spindles, no eye movement stage (5-10%) EEG: delta waves stage (15-20%) slow wave sleep

7. Tonic stage (desyncronized EEG ~ low voltage, frequency ↑ , muscle atonia) Phasic stage (rapid eye movements ~ fast, saccadic eye movements ~, irregular breathing, heart rate ↑ , myoclonus, apnea, hyperpnea, dreaming!!!) REM

8. Sleep disorders

9. Polysomnography multiparametric monitoring during 1 sleep period (1 night) EEG Electrooculogram EMG ECG Respiratory effort SpO 2 Body position Snoring

10. More than 80 sleep disorders are known (International Classification of Sleep Disorders, 2 nd Edition American Academy of Sleep Medicine, 2005) Insomnias (33%) Sleep related breathing disorders (1,4-40%) Hypersomnias (0,3-16,3%) Cirkadian rhythm sleep disorders Parasomnia Sleep related movement disorders Isolated symptoms, normal variants Other sleep disorders

11. Traditional classification of sleep disorders Dyssomnias : abnormalities in the quantity, quality or timing of sleep. They are associated with difficulty initiating or maintaining the sleep or daytime sleepiness. Parasomnias : abnormal behavioral or physiological events occurring during sleep but don’t involve the sleep mechanisms per se.

12. I. Insomnias Difficulty in initiating sleep or in staying asleep or waking up earlier Nonrefreshing, nonrestorative sleep Fatigue, concentration or memory impairment Mood disturbances, motivation, initiative reduction Daytime sleepiness Tension headache

13. I. Insomnias Prevalence: 33% Accompanied with daytime consequences: 10% Last less than 1 month: 4% (transient insomnia) Last more than 1 year: 85% (persistent insomnia) Male:female = 1:1.4 Increase with age: above 65 years: 50%

14. I. Insomnias Primary (idiopathic) Secunder Inadequate sleep hygiene (10%) Paradoxical insomnia (10%) Insomnia due to mental disorder (30-40%) Psychophysiological insomnia (15%) Insomnia due to drug or substance Insomnia due to medical conditions Sunday night insomnia

15. Treatment Treating the medical or psychiatric conditions (sec. insomnias) Nonpharmacologic: behavioral treatments: normalizing the circadian rhythm sleep hygiene cognitive behavior therapy sleep restriction therapy Pharmacologic treatment

16. Pharmacologic treatment Benzodiazepines midazolam, triazolam ~ rebound insomnia cinolazepam, quazepam brotizolam, temazepam nitrazepam ~ drowsiness

17. Pharmacologic treatment Selective GABA A agonists: nonbenzodiazepines no rebound insomnia zolpidem, zopiclon Melatonin receptor agonist ramelteon

18. II. Sleep related breathing disorders (International Classification of Sleep Disorders, 2 nd Edition American Academy of Sleep Medicine, 2005) 3. Sleep related hypoventilation/hypoxemia 1. 2.

19. Apnea-hypopnea index (AHI) Numbers of apneas and hypopneas/ 1 sleeping hour Severity of sleep related breathing disorders: Normal: AHI<5/h Mild: AHI: 5-15/h Moderate: AHI:16-30/h Sever: AHI>30/h Sleep, 1999:22:667-89.

20. OSAHS: symptoms Daily Excessive daytime sleepiness Unrefreshing sleep Memory disturbances Morning headache Depression Decreased libido Stomach ache Nightly snoring apneas choking, gasping arousals sweating dry mouth palpitation nycturia

21. OSAHS: diagnostic criteria (1. or 2.) and 3. AASM, Sleep, 1999:22:667-89.

22. Risk factors of OSAHS Obesitas Age Male gender Pozitive family history of OSAHS Alcohol consumption before bedtime Race Smoking Sedatives Craniofacial anomalies Hypothyroidism, acromegaly

23. Treatment of bening snoring Weight loss, alcohol withdrawal Position training Nasal, pharyngeal surgery (UPPP) Oral appliances Treatment of OSAHS : nasal CPAP

24. IV. Cirkadian rhythm sleep disorders Primary Delayed sleep phase type Advanced sleep phase type Irregular sleep phase type Secondary Jet lag type Shift work type Treatment Sleep hygiena Cronotherapy Light therapy Melatonin, zolpidem

25. V. Parasomnias In NREM Myoclonus Enuresis nocturna Pavor nocturnus, night terrors Sleep walking - somnambulism Bruxism In REM Nightmares REM sleep behavior disorder

26. VI. Sleep related movement disorders Restless legs syndroma Therapy: dopamin agonists Periodic limb movement disorder Sleep related leg cramps Sleep related rhythmic movement disorder