Sleep disorders can be classified into six main categories. Narcolepsy is characterized by excessive daytime sleepiness and irregular sleep-wake cycles. It is caused by a lack of hypocretin in the brain and symptoms include sleep attacks, cataplexy, hallucinations, and sleep paralysis. Obstructive sleep apnea is the most common breathing-related sleep disorder and involves repetitive collapse of the upper airway during sleep causing fragmented sleep and oxygen deprivation. Parasomnias are abnormal behaviors that occur during sleep like sleepwalking, nightmares, and REM sleep behavior disorder. Restless legs syndrome involves unpleasant sensations in the legs when trying to fall asleep that are relieved by movement. Polysomnography and the

1. LEEP DISORDERS

2. What is sleep?
• Complex physiological state that occurs
periodically and is characterised by relative
quiescence, immobility and greatly decreased
responsiveness to external stimuli

3. Sleep Stages
• based on EEG, EOG, EMG divided into two
independent states: NREM and REM sleep
• NREM - further divided into three stages ie
N1, N2, N3 – based on EEG

4. Sleep Requirements
• Sleep requirement is defined as the optimal
amount of sleep required to remain alert and
fully awake and to function adequately
throughout the day
• for an average adult is approximately 7.5 to 8
hours

5. Classification of Sleep Disorders
• I. Insomnia
• II. Sleep-related breathing disorders
• III. Hypersomnias of central origin
• IV. Circadian rhythm sleep disorders
• V. Parasomnias
• VI. Sleep-related movement disorders

6. Approach to the Patient
Common sleep complaints
• Insomnia - inability to initiate or maintain
sleep adequately at night
• EDS - chronic fatigue, sleepiness, or tiredness
during the day
• Inability to sleep at the right time
• Abnormal movements and behavioural
manifestation associated with sleep

7. SUBJECTIVE MEASURES OF
SLEEPINESS

8. Narcolepsy
• characterized by recurrent "sleep attacks"
• Irresistible desire to fall asleep in inappropriate
circumstances and at inappropriate places
• last for a few minutes to as long as 20 to 30
minutes

9. Narcolepsy Tetrad
Sleep Attacks plus 3 specific symptoms:
1. Cataplexy sudden weakness or
paralysis without loss of
consciousness, often precipitated by
emotional changes
2. Hallucinations at sleep onset
(hypnagogic hallucinations) or upon
awakening(hypnopompic
hallucinations)- most common is visual
3. Sleep paralysis occurs near sleep onset
or during arousal. Consciousness is
maintained.

10. Narcolepsy
• Symptoms of narcolepsy typically begin in the
second decade
• Once established, the disease is chronic
without remissions
• Men and women are equally affected
• affects about 1 in 4000 people in the United
States

12. GENETICS & PATHOGENESIS
• Most are sporadic, some are AD
• positivity for HLA DQB1*0602 – most specific
marker
• Dysfunction of hypothalamic hypocretin
(orexin) peptidergic system is involved in the
pathogenesis
• decreased hypocretin 1 in CSF < 110pg/ml

13. Treatment of Narcolepsy-Cataplexy
Syndrome
Nonpharmacological measures include
• scheduled short daytime naps,
• sleep hygiene measures

15. Breathing-related Sleep Disorders
syndromes in which the patient's sleep is
interrupted by problems with his or her
breathing

16. OBSTRUCTIVE SLEEP APNEA
• MC medical condition @ EDS
• defined as the coexistence of unexplained EDS
with at least five obstructed breathing events
(apnea or hypopnea) per hour of sleep
• repetitive episodes of complete (apnea) or
partial (hypopnea) upper airway obstruction
during sleep
• arterial oxygen desaturation and arousal from
sleep

17. Apnea-Hypopnea Index (AHI)
• number of apneas and hypopneas per hour of
sleep
• AHI score of 5 or below is considered normal
• 5 to 15 - mild OSAS
• 16 to 29 - moderate OSAS
• 30 or more - severe OSAS

18. Pathogenesis
• Collapse of the pharyngeal airway is the
fundamental factor
• During sleep, muscle tone decreases-
increasing upper airway resistance and
narrowing the upper airway space

19. Epidemiology
• prevalence is 4% in men and 2% in women
between the ages of 30 and 60
• also occurs in childhood—usually associated
with tonsil or adenoid enlargement

21. Symptoms & Signs

23. Consequences
• increased morbidity and mortality
• short-term consequences (impairment of
quality of life and increasing traffic- and work-
related accidents)
• long-term consequences from associated and
comorbid conditions such as systemic
hypertension, pulmonary hypertension, heart
failure, cardiac arrhythmias

24. General Measures
• Avoid alcohol and sedative-hypnotics,
especially in the evening
• Reduce body weight if overweight
• Avoid sleep deprivation
• Participate in regular exercise program
• Avoid supine sleeping position

25. Mechanical Devices
• Continuous positive airway pressure (CPAP)
titration - treatment of choice
• Oral appliances, including mandibular
advancement device
• Tongue-retaining device

27. Surgical Techniques
• Uvulopalatopharyngoplasty (UPP)
• Laser-assisted UPP (LAUP)
• Radiofrequency UPP (somnoplasty)
• Palatal implants
• Nasal surgery
• Maxillomandibular advancement
• Anterior hyoid advancement
• Tonsillectomy and adenoidectomy

28. PARASOMNIAS
• abnormal movements or behaviours that
occur in sleep or during arousals from sleep

29. ICSD-2 (AASM, 2005)
Disorders of arousal (from NREM sleep),
• Confusional arousals
• Sleepwalking
• Sleep terror
Parasomnias associated with REM sleep
• RBD
• Recurrent isolated sleep paralysis
• Nightmare disorder
Other Parasomnias

30. Sleepwalking
• Onset: common between ages 5
and 12 yr
• Abrupt onset of motor activity
arising out of slow-wave sleep
during first one-third of the night
• Duration: less than 10 min
• Injuries and violent activity
occasionally reported
• Treatment: benzodiazepines,
imipramine

31. Sleep Terror
• pavor nocturnus
• Onset: peak is between ages
5 and 7 yr
• Abrupt arousal from slow-
wave sleep during first one-
third of the night, with a loud
piercing scream
• Treatment: psychotherapy,
benzodiazepines, tricyclic
antidepressants

32. Rapid Eye Movement Sleep
Behavior Disorder (RBD)
• Onset: middle-aged or elderly men
• Presents with violent dream-enacting
behavior during sleep, causing injury to self or
bed partner
• 40% idiopathic, 60% associated
neurodegenerative diseases - PD, MSA, CBD,
DLBD, PSP
• Treatment: clonazepam, melatonin

33. Nightmare
Disorder• Dream anxiety attacks
• fearful, vivid, often
frightening dreams,
mostly visual but
sometimes auditory
• most commonly occur
during the middle to
late part of sleep at
night

34. • mostly a normal phenomenon, up to 50% of
children have nightmares
• side effects of certain medications such as
antiparkinsonian drugs (pergolide, levodopa),
anticholinergics, and antihypertensive drugs,
particularly beta-blockers
• generally do not require any treatment except
reassurance

35. Sleep-Related
Movement Disorders

36. Restless Legs Syndrome (RLS)
• also known as Ekbom’s syndrome
• Unpleasant sensations in the legs when the
patient is tired in the evenings and at the
onset of sleep
• ameliorated by moving the legs
• mostly diagnosed in the middle or later years
• strong familial tendency
• can present with daytime somnolence due to
disturbed night-time sleep

37. Secondary - Medical Disorders
• Anemia: iron and folate deficiency
• Diabetes mellitus
• Amyloidosis
• Uremia
• Chronic obstructive pulmonary disease
• Peripheral vascular (arterial or venous)
disorder
• Rheumatoid arthritis
• Hypothyroidism

38. Pathophysiology
• iron-dopamine dysfunction
• abnormalities in the body’s use and storage of
iron
• dopamine dysfunction - changes in dopamine
receptors or dopamine uptake

39. Drug Treatment of Restless
Legs Syndrome
Dopaminergic agents:
• Pramipexole
• Ropinirole
Benzodiazepines:
• Clonazepam
• Temazepam
Antiepileptic agents:
• Gabapentin
• Pregabalin

40. Insomnia
• most common sleep disorder
• Inability to initiate or maintain sleep, early
awakening, inadequate sleep time, or poor
sleep quality associated with a lack of feeling
restored and refreshed in the morning,
leading to poor daytime functioning - AASM
(2005)

41. Medical Disorders Comorbid
with Insomnia
• Ischemic heart disease
• Congestive cardiac failure
• Chronic obstructive pulmonary disease
• Bronchial asthma
• Peptic ulcer disease
• Gastroesophageal reflux disease
• Rheumatic disorders

42. Treatment of Insomnia
• most commonly used hypnotics are the
benzodiazepine receptor agonists – zolpidem,
zaleplon, and eszopiclone
• Melatonin receptor agonists(ramelteon) -
sleep-onset insomnia

44. Laboratory Assessment of
Sleep Disorders
• The two most important laboratory tests for
diagnosis of sleep disturbance are PSG and the
MSLT
• overnight PSG study is the single most
important laboratory test for the diagnosis
and treatment of patients with sleep disorders
• EEG, EMG, EOG, ECG, SaO2, Nasal and oral
airflow, Respiratory effort (chest and
abdomen)

47. Multiple Sleep Latency Test
• important test to effectively document EDS
• Narcolepsy is the single most important
indication
• presence of two sleep-onset REMs on four or
five nap studies and sleep-onset latency of
less than 8 minutes strongly suggest a
diagnosis of narcolepsy
• circadian rhythm sleep disturbance - REM
sleep abnormalities