Sleep disorders. Solutions beyond Benzodiazepines. By Tanjim Ovee
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This document discusses solutions for sleep disorders beyond benzodiazepines. It begins by introducing Dr. Ahmed Tanjimul Islam and his presentation on sleep disorders. It then shows several case studies of patients with various sleep complaints that are diagnosed with conditions such as obstructive sleep apnea, restless leg syndrome, jet lag, narcolepsy, somnambulism, and REM behavior disorder. For each case, it discusses the diagnostic criteria and potential treatment options. It concludes by outlining the clinical approach to diagnosing sleep disorders, including taking a patient history, performing a physical exam, reviewing a sleep diary or conducting polysomnography and sleep latency tests, and choosing appropriate treatment.
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Sleep disorders. Solutions beyond Benzodiazepines. By Tanjim Ovee
- 1. SLEEP DISORDERS Solutions Beyond Benzodiazepines Presented By: Dr. Ahmed Tanjimul Islam MD (NeuroMedicine) Rajshahi Medical College Hospital, Bangladesh
- 2. Presented By: Dr. AHMED TANJIMUL ISLAM MSc (Leeds, England), MD (Neuro-Medicine) Rajshahi Medical College Hospital Bangladesh
- 4. AHMED 31 yrs Unmarried Lawyer No Medical/Psychiatric C/C: Fatigue Headache Uncontrollable HTN Decreased Libido
- 6. DAVIS 42 yrs Married Software Engineer, Uses computer 14 hrs/ day C/C: • Fatigue whole day • Change of mood, Anger • Drinks 6-8 cups of coffee
- 8. Dr SMITH 51 yrs University Visiting Professor married C/C: • Insomnia for 5 days • Unrefreshing Sleep • Performance Decline
- 10. MARIA 19 yrs Postgraduate Student Unmarried No Medical/Psychiatric C/C: Excessive Daytime Sleep Sudden Drop attack Performance decline
- 11. MARIA MODAFINIL
- 12. ALEX 33 yrs Businessman Married C/C: •Unusual behavior complained by Relatives •Fatigue •Un-refreshing Sleep
- 13. ALEX TCA
- 14. SARAH 27 yrs University PhD student Married C/C: •Husband complains of unusual Behavior •Injury marks
- 15. SARAH CLONAZEPAM
- 17. Focus Points • Classify Sleep Disorders • Diagnostic Criteria of Sleep Disorders • Approach to Diagnosis
- 19. Sleep Disorder Insomnia Sleep Breathing Disorder HyperSomnolence Parasomnias Sleep Movement Disorder Circadian Rhythm disorder 6 International Classification
- 20. Insomnia Sleep Breathing Disorder HyperSomnolence Sleep Movement Disorder Circadian Rhythm disorder Parasomnia Dyssmonia 2 DSM 4
- 24. Wake REM •Sleep Walking •Sleep Terror •Bruxism •Sleep Eating disorder
- 27. Neurological Disorders with Insomnia Diseases: • Neuro-Degenerative •Parkinson’s, PSP, MSA •Alzheimer •Huntington •Torsion Dystonia • Headaches •Migraine, Cluster, Hypnic • Stroke • Brain Tumor • Traumatic brain Injury • Fatal Familial Insomnia
- 28. Psychiatric Disorders for Insomnia Psychiatric % Anxiety Disorder 23.9 % Major Depression 14 % Dysthymia 8 % Alcohol Abuse 7 % Drug Abuse 5.1 % Other Psychiatric Disorders 4.2 % Psychiatric disorders Undiagnosed 60 %
- 29. Medical Disorders with Insomnia System Diseases Cardiology •MI, Angina •Heart Failure Respiratory •COPD, Asthma GIT •PUD, GERD Rheumatology •Fibromyalgia •RA, OA, AS Infectious • AIDS, Scabies
- 30. Causes of Insomnia in Real world Psychiatric 50% Primary Insomnia 15% Sleep Disorders 25% Medical, Drugs, 10%
- 31. PRIMARY INSOMNIA
- 32. > 1 Month Initiating Sleep Maintaining Sleep Non Restorative Sleep Significant Distress / Functioning Problem Duration Difficulty Distress ‘Primary Insomnia’ Diagnostic Criteria‘Primary Insomnia’ Diagnostic Criteria
- 33. Treatment Approach Primary Insomnia Sleep Hygiene Identify Root Cause Drug TreatmentNon BDZ BDZ
- 34. Sleep Hygiene • Coffee • Carbonated drink • Champagne • Cigarette • Cold Compression (Hot day) • Counter drugs (TCA, SSRI, Antihistamines) • Computer • Clock
- 35. BDZ vs Non-BDZ Non - BDZ BDZ Hypnotic Effect No Yes Hangover effect No Yes Tolerance & Dependence No Yes Anti Convulsant Muscle Relaxant effect No Yes Effect takes 2 weeks (Delayed) Quick
- 38. Diagnosis
- 40. Obstructive Sleep Apnea Diagnostic Criteria 1. EDS 2. Sleep that interrupted by Breath holding 3. Loud Snoring 4. Polysomnography : > 5 apnea/hr Sleep
- 41. OSAS Clinical Findings History Examination Daytime Sleepiness •CBC: Polycythemia Headache •BMI Learning Problem •Hypertension •Neck Circumference > 17 in •Tonsils & Adenoids
- 42. OSAS Treatment Mechanical Devices • CPAP •Mandibular advancement device Surgery •Uvulo-Palato-Pharyngo-Plasty •Laser UPP •Tonsillectomy & Adenoidctomy
- 43. CPAP
- 47. DAVIS 42 yrs Married Software Engineer, Uses computer 14 hrs/ day No Psychiatric/ family history C/C: • Fatigue whole day • Change of mood, Anger • Drinks 6-8 cups of coffee
- 49. Diagnosis
- 51. Diagnostic Criteria of RLS Essential Criteria 1. Urge to move the Legs 2. Rest triggers / worsens symptoms 3. Movement makes symptom vanish Ancillary Criteria: 1. Response to Dopamine agonist or Levadopa (At the start of treatment)
- 52. Treatment Options for RLS Drugs Dose (mg) Iron 325 BD Pramipexol 0.25 - 0.5 Ropirinol 0.25 – 2 Gabapentine 300 – 600 Pregabalin 50 – 300 Levadopa 25/200 Clonidine 0.1 Treatment Options for RLS
- 53. Similar Case
- 55. Diagnosis
- 57. RLS Vs PLMD RLS PLMD •Keeps patient awake •Occurs when the patient is already asleep.
- 58. Potential Causes of RLS & PLMD With Medications SSRI, Alcohol With Medical Conditions • Iron Deficiency Anemia • Renal Failure • DM Neurological: MS, Parkinson’s
- 59. Dr SMITH 51 yrs University Visiting Professor married No Medical/Psychiatric C/C: Insomnia for 5 days Unrefreshing Sleep Performance Decline
- 60. Dr Smith’s history • Traveled from UK to Japan, 6 days back • Sudden Insomnia for 5 days • Declined performance in morning Lectures
- 61. Diagnosis ?
- 62. Diagnosis Jet Lag (Circadian Rhythm Disorder)
- 63. Diagnostic Criteria of Circadian Rhythm: Persistent Sleep disturbance (Insomnia/ EDS) Delayed / Advanced Sleep Phase Irregular Sleep Wake Shift Work/ Jet Lag Dysfunction in Social & Occupational
- 65. ‘Eye Pad’ during Traveling
- 66. Motorized Window Shade with sensor
- 67. Treatment of Circadian Rhythm Disorder Alter Circadian Rhythm Night Time Alertness •Modafinil •Met-Amphetamine •Melatonin •Ramelteon •Timed Light Exposure
- 68. MARIA 19 yrs Postgraduate Student Unmarried No Medical/Psychiatric C/C: Excessive Daytime Sleep Sudden Drop attack Performance decline
- 70. Diagnosis
- 72. Narcolepsy Diagnostic Criteria Narcolepsy Type 1 Narcolepsy Type 2 •Daily EDS > 3 months • Daily EDS > 3 months • Cataplexy • No Cataplexy • Mean Sleep Latency < 8 • Mean Sleep Latency < 8 • Hypocretin < 110 pgm • Hypocretin > 110 pgm
- 73. Drugs for Narcoleptic Syndrome Excessive day time Sleep Dose Modafinil 200 – 600 Met-amphetamine 5- 50 Sodium Oxybate 4.5 – 10 Cataplexy Venlafexine 75 – 200 Clomipramine 10 – 150 Fluxetine 20 - 40 Drugs for Narcoleptic Syndrome
- 74. ALEX 33 yrs Businessman Married No Medical/ psychiatric C/C: •Fatigue •Un-refreshing Sleep •Unusual behavior complained by Relatives
- 76. Diagnosis
- 78. Diagnostic Criteria of Somnambulism: • Repeated episodes of rising from Bed during Sleep & Walk. (1st half of sleep) • Blank staring of face • Unresponsiveness in efforts to communicate • On awakening: Amnesia of Episode
- 79. Drug Dose (mg) Sleep Walking •Clonazepam 0.5 – 1 •Clomipramine 50 – 300 Sleep Terror •Clonazepam 0.5 – 1 •Peroxetine 20 – 40 Bruxism •Mandibular Device Treatment of NREM Parasomnias
- 80. SARAH 27 yrs University PhD student Married No Medical/ psychiatric C/C: •Husband complains of unusual Behavior •Injury marks
- 82. Diagnosis
- 85. Diagnostic Criteria of REM Behavior Repeated Episode of Sleep Vocalization Complex Motor Behavior Based on Bed Partner Polysomnography: REM Sleep, No Atonia
- 86. Treatment options for RBD Drugs Dose (mg) •Clonazepam 0.25 – 2 •Melatonin 3 – 12 •Zopiclone 3 – 7 •Sodium Oxybate Unknown
- 87. NREM vs REM Parasomnia NREM Parasomias REM Behavior Disorder Timing Within 90 min (1st part) After 90 min (Last part) Number of Attacks Few / week Every night (Usual) Duration >10 min <10 min Dream mention No Yes Vocalization + Motor No Yes Age of onset Childhood Adult (>50 yrs) Potential for Injury No Yes
- 88. NREM Parasomias REM Behavior Disorder Timing Within 90 min (1st part) After 90 min (Last part) Number of Attacks Few / week Every night (Usual) Duration >10 min <10 min Dream mention No Yes Vocalization + Motor No Yes Age of onset Childhood Adult (>50 yrs) Potential for Injury No Yes NREM vs REM Parasomnia • Regular • Repeated • Rough • Remembe r • Risky
- 90. Primary Secondary Medical Disorder Neurologcal Disorder Psychiatric Disorder Movement disorders Breathing Disorder Circadian Rhythm Disorder Insomnia
- 93. Parasomnia Sleep Walking REM Behavior Disorder REMNREM Bruxism Sleep Terror Sleep Enuresis Bed Partner Caregivers
- 95. Patient History Bed Partner Caregiver History Polysomno Graphy Sleep Latency Test Examination Investigations 2 3 1 CLINICAL STEPS TO DIAGNOSIS Sleep Diary
- 97. Sleep Log Diary • Sleep Log Sample
- 98. Sleep Lab Study Overnight Sleep Study Day time Sleep Study Polysomnography MSLT
- 103. Legal Issues related to Sleep Disorders
- 107. Take Home Message: • Find out the Root Cause • Involve the Bed Partner/ Caregiver • Sleep Study for Undetermined cases • Choose the Appropriate Drug • Benzodiazepine is not the only Option available
- 108. Thank You