This document discusses various sleep disorders and approaches to evaluating and treating patients with sleep problems. It covers topics like insomnia, obstructive sleep apnea, narcolepsy, restless leg syndrome, circadian rhythm disorders, and parasomnias. The key points are obtaining a thorough patient history, performing tests like polysomnography and multiple sleep latency tests to diagnose the underlying cause, and treating the specific disorder through lifestyle changes, medications, CPAP, or other therapies.

1. Dr.Sandra Mosses
JR1M3
APPROACH TO THE
PATIENT:

2. “Unmet public health problem”
 sleep deficiency and disorders cause :
Glucose
intolerance
Diabetes
Obesity
Metabolic
syndrome
Impaired
immune
responses
Accelerated
atherosclerosis
Cardiac
disease
Stroke

3. Sleep
NREM
N1
N2
N3
REM
•20-25% of sleep
•2nd hour of sleep
•EEG: low-
amplitude, mixed
frequency
•EOG-bursts of
rapid eye
movements
•EMG- absent
activity in all
skeletal muscles--
brainstem-
mediated muscle
atonia
Slow wave sleep
15-25%
Predom in 1st 1/3 of
night
Intense in child
absent in elderly
• increasing
arousal
threshold and
slowing of the
cortical EEG
• progress in
45–60 min

4. Wake-sleep Architecture
Reduction of N3 slow-wave sleep
Frequent spontaneous awakenings
Early sleep onset
Early morning awakening
Old age

5. Preoptic area
Lateral
hypothalamus
pons

6. sleepiness or tiredness during
the day
Insomnia--difficulty initiating or
maintaining sleep at night
Parasomnias-- unusual behaviors
during sleep itself

7. Obtain careful history
 Duration, severity and consistency of symptoms
 When the patient typically goes to bed, fall asleep and
wake up, awaken during sleep, feel rested in the
morning and nap during the day
 Daily sleep log for 1–2 weeks to define the timing and
amounts of sleep, work time, drug/alcohol use
 Ask for snoring, witnessed apneas, restless sensations
in the legs, movements during sleep, depression,
anxiety
 Seizures– GTCS with urinary incontinence or tongue
biting or stereotyped movements in partial complex
epilepsy in NREM-sl
 O/E-- small airway, large tonsils or a neurologic or

8. Evaluation of daytime
sleepiness
INSUFFICIE
NT SLEEP
OBSTRUCT
IVE SLEEP
APNOEA
NARCOLEP
SY
RESTLESS
LEG
SYNDROM
E/PLMD
DRUG OR
MEDICAL
CONDITION

9. Sleepiness
•propensity to fall
asleep
•most evident when the
patient is sedentary
•affect judgment in a
manner analogous to
Fatigue
• feeling of low physical or mental energy but without a tendency to actually sleep
• interfere with more active pursuits
• Won’t affect judgment
• common in inflammatory disorders such as cancer, multiple sclerosis, fibromyalgia,chronic fatigue syndrome,endocrine
deficiencies such as hypothyroidism or Addison’s disease

10. Insufficie
nt sleep
Poor
attention
span
Distracta
bility
Anxiety
Poor
Organisa
tional
Irritabilit
y
Depressio
n
Poor
motivatio
n

11. difficulty
sustaining
wakefulness
poor
regulation of
REM sleep
disturbed
nocturnal
sleep
excessive
daytime
sleepiness
feel well
rested on
awakenin
g
feel tired
throughou
t day

12. Symptoms related to intrusion of
REM sleep characteristics
• sudden muscle weakness
without LOC , triggered by
strong emotions
cataplexy
• Brief,frequentSleep attacks
• dreamlike hallucinations at
sleep onset
hypnagogic
hallucinations
• dreamlike hallucinations
upon awakening
hypnopompic
hallucinations
• muscle paralysis upon
awakening
sleep paralysis

13.  typically begins between age 10 and 20
 If established,disease persists for life
 loss of the hypothalamic neurons that produce the
orexin –hypocretins
 Autoimmune process -- HLA DQB1*06:02 (90%)
 Tumors,stroke
 Consistent emotional triggers such as heartfelt
mirth when laughing at a great joke, happy surprise
at unexpectedly seeing a friend, or intense anger

14.  polysomnogram followed by an MSLT
 Polysomnogram -- rule out other possible causes of
sleepiness such as sleep apnea
 MSLT
 essential, objective evidence of sleepiness plus REM
sleep dysregulation
 consists of five 20-min nap opportunities every 2 h
across the day
 patient is instructed to try to fall asleep
 average sleep latency across the naps of less than 8
min is considered objective evidence of excessive
daytime sleepiness
 occurrence of REM sleep in two or more of the MSLT

15.  adequate sleep each night and 15- to 20-min nap in the
afternoon
 Modafinil (200–400 mg OD)
 relatively long half life ,fewer S/E
 Methylphenidate (10mg BD) /dextroamphetamine (10
mg BD)
 sympathomimetic side effects, anxiety,potential for
abuse
 Sodium oxybate (gamma hydroxybutyrate)
•NARCOLEPSYTreatment

16. Treating cataplexy
 Antidepressants--Venlafaxine (37.5–150 mg
each morning) fluoxetine (10–40 mg each
morning)
 TCAs-protriptyline (10–40 mg/d) or
clomipramine (25–50 mg/d)
 Sodium oxybate-given at bedtime and 3–4 h
later

17. Obstructive sleep apnea/hypopnea
syndrome (OSAHS)
Risk factors
Obesity
Male sex
Mandibular retrognathia and micrognathia
Positive family history
Genetic syndromes that reduce upper airway patency (Down
syndrome, Treacher-Collins syndrome), adenotonsillar
hypertrophy,menopause (in women), acromegaly,

18. Health Consequences and
Comorbidities
 Daytime sleepiness
 Hypertension
 Coronary Artery Disease
 Heart failure
 Arrythmias
 Stroke
 IR and Diabetes mellitus
 Depression

19. Treatment:OSAHS
 reduce weight
 optimize sleep duration (7–9 hours) and regulate sleep
schedules (with similar bedtimes and wake times across
the week)
 treat nasal allergies, eliminate alcohol ingestion within 3
h of bedtime and minimize use of sedatives
 CPAP is the standard medical therapy --works as a
mechanical splint to hold the airway open, thus
maintaining airway patency during sleep
 Oral appliances --advancing the mandible, thus opening
the airway by repositioning the lower jaw and pulling the
tongue forward
 Upper airway surgery--Uvulopalatopharyngoplasty

20. Restless leg syndrome
 RLS is very common / 5–10% of adults /
more common in women and older adults
Diagnostic
criteria

21. Causes
•Idiopathic
•Genetic factors --polymorphisms
in a variety of genes (BTBD9,
MEIS1, MAP2K5/LBXCOR, and
PTPRD)
Primary
• Iron deficiency
• Peripheral neuropathies
• Uremia
• Pregnancy
• Varicose veins
• Parkinsons disease
• Caffeine,alcohol,antidepressants,
lithium,neuroleptics and
Secondary

22. Treatment
 Symptomatic
 Treat underlying disorder
 dopamine agonists :pramipexole or ropinirole
 Opioids, benzodiazepines, pregabalin, and
gabapentin may also be of therapeutic value

23. PERIODIC LIMB MOVEMENT
DISORDER
 rhythmic twitches of the legs that disrupt sleep
 triple flexion reflex with extensions of the great toe
and dorsiflexion of the foot for 0.5 to 5.0 s, which
recur every 20–40 s during NREM sleep, in
episodes lasting from minutes to hours
 polysomnogram -- includes recordings of the
anterior tibialis and sometimes other muscles
 EEG - brief arousals that disrupt sleep and can
cause insomnia and daytime sleepiness
 PLMD can be caused by the same factors that
cause RLS
 Rx:dopamine agonists

24. INSOMNIA
 difficulty initiating or maintaining sleep
• 30% of adults
• precipitated by stressful life events
• increased nocturnal light exposure, frequently
checking the clock, or attempting to sleep more
by napping, it can lead to chronic insomnia
Acute or short-
term insomnia
•>3 months
•10% of adults
• more common in women, older adults,
individuals with medical, psychiatric,
substance abuse disorders
Chronic
insomnia

25. • negative expectations
• worry about their insomnia
during the day and have
increasing anxiety as
bedtime approaches
• frequently check the clock,
which only heightens anxiety
and frustration
Psychophysiologic
Factors
• daytime napping
• irregular sleep-wake schedule
• use of wake-promoting substances
(caffeine, tobacco) too close to
bedtime
• engaging in alerting or stressful
activities close to bedtime
• using the bedroom for activities
other than sleep (e.g., TV, work)
Inadequate Sleep
Hygiene

26. •Depression--early
morning awakening,
interfere with the
onset and
maintenance of sleep
•Mania and
hypomania
•Anxiety disorders
•Panic attacks can
occur during sleep
•schizophrenia and
other psychoses--
fragmented sleep,
less deep NREM
sleep,reversal of the
day-night sleep
Caffeine
Theophylline
Stimulants
Antidepressants
Glucocorticoid
Withdrawal of
alcohol,
narcotics,BZD
Psychiatric
Conditions Medications and
Drugs of Abuse

27. day
altered circadian
rhythms
weakened output of the
brain’s sleep-
promoting
mechanisms
Parkinson’s disease --due to
rigidity, dementia
Fatal familial insomnia
rare neurodegenerative
condition
mutations in the prion protein
gene
thalamus undergo atrophy
asso with insomnia,dementia,
myoclonus,
dysarthria, or
autonomic dysfunction
Rheumatologic
disorders
Painful neuropathy
Asthma
COPD
Cystic fibrosis
Restrictive lung
disease
Congestive heart
failure
Menopause
GERD
Neurologic
Medical
Conditions

28. •INSOMNIATREATMENT
TREATMENT OF MEDICAL AND
PSYCHIATRIC DISEASE
• Treat pain
• Improving breathing
• Adjust timing of medications
IMPROVE SLEEP HYGIENE

30. COGNITIVE BEHAVIORAL
THERAPY (CBT)
• cognitive psychology techniques --to reduce excessive
worrying about sleep
• Relaxation techniques--progressive muscle relaxation or
meditation, to reduce autonomic arousal, intrusive thoughts
and anxiety
PHARMACOTHERAPY
• Antihistamines-- diphenhydramine--produce rapid tolerance
and can produce anticholinergic side effects such as dry
mouth and constipation
• Benzodiazepine receptor agonists --lorazepam,
triazolam, clonazepam, zolpidem, zaleplon

31. Problems with drugs
 Risk of injurious falls
 Confusion in the elderly
 Morning sedation can interfere with driving and
judgment
 Benzodiazepines carry a risk of addiction and
abuse
 Worsen sleep apnea
 Complex behaviors during sleep--sleep
walking and sleep eating

32. PARASOMNIAS
 abnormal behaviours or experiences that
occur during sleep
• Brief confusional arousals
• Sleep walking
• Sleep terrors
• Sleep bruxism
• Sleep enuresis
NREM
• REM sleep behavior disorder
(RBD)
• Nightmares
REM

33. Sleepwalking (Somnambulism)
 carry out automatic motor activities that range from
simple to complex:walk, urinate inappropriately, eat, exit the
house, or drive a car with minimal awareness
 NREM:N3 sleep, usually in the first few hours of the
night,children and adolescents
 EEG usually shows the slow cortical activity of deep NREM
sleep even when the patient is moving about
 worsened by insufficient sleep, alcohol, stress
 Treatment:
antidepressants and benzodiazepines hypnosis
home safety relaxation techniques

34. Sleep Terrors
 young children
 NREM stage N3 sleep
 child sits up during sleep and screams, exhibiting
autonomic arousal with sweating, tachycardia,
large pupils,hyperventilation
 difficult to arouse and rarely recalls the episode on
awakening in the morning
 Treatment --reassuring the parents that the
condition is self-limited and benign,improve by
avoiding insufficient sleep

35. Sleep Bruxism
 involuntary, forceful grinding of teeth during
sleep t
 10–20% of the population
 age of onset is 17–20 years, and spontaneous
remission usually occurs by age 40.
 tooth guard is necessary to prevent tooth injury
 Stress management /biofeedback can be
useful when bruxism is a manifestation of
psychological stress

36. Sleep Enuresis
 Before age 5 or 6 years, nocturnal enuresis should be
considered a normal feature of development
 Important causes of nocturnal enuresis in patients who were
previously continent for 6–12 months -- urinary tract
infections or malformations, cauda equina lesions, emotional
disturbances, epilepsy, sleep apnea, and certain medications
 The condition usually improves spontaneously by puberty,
has a prevalence in late adolescence of 1–3%, and is rare in
adulthood
 Treatment
 blAdder training exercises
 Behavioral therapy
 Pharmacotherapy --desmopressin (0.2 mg qhs), oxybutynin

37. REM Sleep Behavior Disorder
(RBD)
 patient or the bed partner usually reports agitated or
violent behavior during sleep, and upon awakening, the
patient can often report a dream that accompanied the
movements
 movements can be dramatic, and it is not uncommon for
the patient or the bed partner to be injured
 polysomnogram --limb movements during REM sleep,
lasting for seconds to minutes
 older men, synucleinopathy such as Parkinson’s
disease, dementia with Lewy bodies or occasionally
multiple system atrophy ,antidepressants
 Synucleinopathies -- cause neuronal loss in brainstem
regions that regulate muscle atonia during REM sleep

38. CIRCADIAN RHYTHM SLEEP
DISORDERS
 disorder of sleep timing
ORGANIC
abnormality of
circadian pacemakers
ENVIRONMENTAL/BEHAVI
ORAL
disruption of environmental
synchronizers

39. Delayed Sleep-Wake
Phase Disorder
• young adults
• sleep onset and wake times
intractably later than desired
• normal sleep on
polysomnography (except for
delayed sleep onset)
• Dim-light melatonin onset
(DLMO) typically occurs later in
the evening than normal, which is
about 8:00–9:00 pm (1–2 h
before habitual bedtime)
• Treatment :
• phototherapy with blue-enriched
light during the morning
• melatonin administration in the
evening hours
Advanced Sleep-
Wake Phase
Disorder
• older people
• cannot sleep past 5:00 am
• wake up too early at least several
times per week
• sleepy during the evening hours
• normal sleep on
polysomnography (except for
early sleep onset)
• early onset of dim-light melatonin
secretion
• Treatment:
• bright-light and/or blue enriched
phototherapy during the evening
hours to reset the circadian
pacemaker to a later hour

40. Jet Lag Disorder
 excessive daytime sleepiness, sleep-onset insomnia, and
frequent arousals from sleep, particularly in the latter half of
the night
 transient, typically lasting 2–14 d depending on the number of
time zones crossed, the direction of travel, and the traveler’s
age and phase-shifting capacity
 Travelers who spend more time outdoors at their destination
reportedly adapt more quickly than those who remain in hotel
rooms, presumably due to brighter (outdoor) light exposure
 Laboratory studies suggest that low doses of melatonin can
enhance sleep efficiency, but only if taken when endogenous
melatonin concentrations are low (i.e., during the biologic
daytime).

41. SHIFTWORK DISORDER
 Night shift workers :decreased alertness &
performance, increased reaction time, increased
risk of performance lapses, resulting in greater
safety hazards among night workers
 Motor vehicle operators: accidents
 Resident physicians: impairs psychomotor
performance, increases the risk of serious medical
errors in ICUs, including a fivefold increase in the
risk of serious diagnostic mistakes

42. Treatment
 Postural changes, exercise, and strategic placement of
nap opportunities
 Properly timed exposure to blue-enriched light or bright
white light --enhance alertness and facilitate more rapid
adaptation to night-shift work
 Modafinil (200 mg) or armodafinil (150 mg) 30–60 min
before the start of each night shift -
 Work schedules should be designed to minimize: (1)
exposure to night work (2) the frequency of shift
rotations (3) the number of consecutive night shifts (4)

43. MEDICAL IMPLICATIONS OF
CIRCADIAN RHYTHMICITY
 Platelet aggregability is increased in the early morning hours-
-peak incidence of acute myocardial infarction, sudden
cardiac death and stroke
 Recurrent circadian disruption combined with chronic sleep
deficiency(nightshift work) --increased plasma glucose
concentrations after a meal due to inadequate pancreatic
insulin secretion
 Night shift workers with elevated fasting glucose have an
increased risk of progressing to diabetes
 Blood pressure of night workers with sleep apnea is higher
than that of day workers

44.  Diagnostic and therapeutic procedures may also be
affected by the time of day at which data are collected
(BP, Temp, dexamethasone suppression test, and
plasma cortisol)
 The timing of chemotherapy administration has been
reported to have an effect on the outcome of treatment
 both the toxicity and effectiveness of drugs can vary with
time of day(Anesthetic agents)
 Finally, the physician must be aware of the public health
risks associated with the ever-increasing demands made
by the 24/7 schedules in our round-the-clock society.