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Disorders of sleep adults

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Disorders of sleep adults

  1. 1. Disor der s of Sleep - Adult s In Greek mythology, Dr A V Srinivasan M.D, D.M., PhD (Neuro) Hypnos was the Professor in Neurology personification of sleep; the Roman equivalent was Institute of Neurology known as Somnus. His twin Madras Medical College, Chennai was Thanatos ("death"); 9-7-08 at Kalpakam, Chennai their mother was the goddess Nyx ("night"). His palace was a dark cave where the sun never shines. At the entrance were a number of poppies and
  2. 2. Sleep Disor der s• International Classification of Sleep Disorders (ICSD-2)(1) insomnias(2) sleep-related breathing disorders(3) hypersomnias not due to a breathing disorder(4) circadian rhythm sleep disorders(5) parasomnias(6) sleep-related movement disorders(7) other sleep disorders, and(8) isolated symptoms, apparently normal variants, and unresolved issues. Madras Institute of Neurology
  3. 3. I nsomnia• Difficulty in initiating sleep and staying asleep• Waking up earlier• Poor quality sleep, non restorative.• Subjective• Day time impairment (RDC-AASN) Madras Institute of Neurology
  4. 4. Et iology• Primary• Secondary Medications Psychiatric Medical Sleep Disorders Madras Institute of Neurology
  5. 5. Dr ugs• SSRI’s & SNRI’s• Alpha and beta blockers• Diuretics• Decongestants• Stimulants• Steroids, thyroid harmones Madras Institute of Neurology
  6. 6. Psychiat r ic and Sleep disor der s• Mood & anxiety disorders• Circadian rhythm disorders• Parasomnias• Apneas• Movement disorders Madras Institute of Neurology
  7. 7. Hyper somnias• Excessive day time sleepiness• Interfering with day time activities, productivity, enjoyment• Reflects insufficient sleep, disrupted sleep, primar sleep disorder Madras Institute of Neurology
  8. 8. Diagnosis• Detailed medical and sleep history• Snoring or apnoea• Restlessness, jerking• Hypnogogic or hypnopompic hallucinations• Sleep paralysis, cataplexy• Automatic behavior Madras Institute of Neurology
  9. 9. Nar colepsy• Excessive day time sleepiness (EDS)Sedentary and active pursuitsShort and refreshingFollowed by recurrent somnolenceRanging from mild to disabling Madras Institute of Neurology
  10. 10. Cat aplexy• Unique• Paroxysmal episodes of weakness• Triggered by emotions• Secs to Min• Can be localized• Consciousness and respiration not affected. Madras Institute of Neurology
  11. 11. • Develops years after EDS• Frequency varies• Adolescence, young adulthood• Narcolepsy with and without cataplexy• Loss of hypocretin – 1 secreting cells Madras Institute of Neurology
  12. 12. Cat aplexy in an Adult Male (Video)
  13. 13. • Narcolepsy – non obligate manifestationsSleep paralysis – muscle atonia at interface between sleep and wakefulness; for few minutes.Hypnogogic hallucinations brief, Sec to Mins, dream-like vivid and distressingAutomatic behaviorPurposeful/inappropriate with impaired recollection of the activities. Madras Institute of Neurology
  14. 14. Ot her Hyper somnias• Recurrent hypersomnias Recurrent hypersomnias Kleine – Levin syndrome Menstrual associated• Idiopathic hypersomnias With long sleep time Without long sleep time Madras Institute of Neurology
  15. 15. Par asomnias• Include abnormal movements, behaviors, emotions and automatic activities.• Intrusion of sleep and wakeful state into one another with CNS activation.• Not a unitary phenomenon. Madras Institute of Neurology
  16. 16. Par asomniasis• Disorders of arousal –NREM sleep – confusional arousal sleep walking sleep terrorsREM sleep – RBD Isolated sleep paralysis NightmaresOthers – enuresis eating disorders etc Madras Institute of Neurology
  17. 17. RBD – REM Sleep Behavior Disor der s• Prevalence of 0.5%; 90% Men• Above 50 years• 25% with PD, OPCA, DCBD• Complex motor activity during REM• Augmentation of EMG tone during REM sleep• Toxic/metabolic disorders Madras Institute of Neurology
  18. 18. RBD• During second half• Abnormal brain stem control of medullary inhibitory regions• Cat models- locus ceruleous adjacent lesions• SPECT – decrease striatal dopa innervations decrease dopa transportation• Withdrawal of alcohol, sedatives• Hypnotics• TCA, SSRI, MAOI, cholinergics Madras Institute of Neurology
  19. 19. Sleep-Relat ed Movement Disor der s- Rest less Legs Syndr ome• 5-15% - healthy people• 15-20% - uremia• 30% - R.A• High prevalence in West• Low in South & S.E Asia Madras Institute of Neurology
  20. 20. Diagnost ic cr it er ia – NI H – I RLSSG (2003)1. Disagreeable leg sensations before sleep onset2. Irresistible urge to move the limbs3. Partial or complete relief on leg movement4. Return of symptoms on cessation of movement Madras Institute of Neurology
  21. 21. Rest less Leg Syndr ome• Bilateral, though asymmetrical• Ankle & knees. Can involve thigh or feet & arm• Minutes to hours• Dopamine dysfunction, Iron storage deficiency• Anti emetics, antihistamines, TCA, SSRI, neuroleptics Madras Institute of Neurology
  22. 22. Rest less Leg Syndr ome wit h Per iodic Limb Movement sMadras Institute ofNeurology
  23. 23. Per iodic Limb Movement Disor der• Common as age advances• Nocturnal myoclonus captured on Polysomnography• Extension of the big toe with flexion of ankle, knee & hip• Sleep may or may not be affected• Centrally mediated event Madras Institute of Neurology
  24. 24. • Can accompany OSA & Narcolepsy• Uremia, metabolic disorders• TCA, MAOI• Withdrawal of AED, benzodiazepines, hypnotics• Hypnic jerks & nocturnal seizures to be differentiated Madras Institute of Neurology
  25. 25. PLMS –Secondar y (pr evious Myelopat hy) Madras Institute of Neurology
  26. 26. Sleep Relat ed Leg Cr amps• Not uncommon with increasing age• “Charley horse” muscular tightness involving the calf & foot during sleep• Results in arousal and can lead to insomnia or EDS• Pregnancy, DM, fluid & electrolytes, arthritis, vigorous exercise Madras Institute of Neurology
  27. 27. Sleep r elat ed Br uxism• Children and adults, MR• Stereotyped grinding or clenching• Diurnal & nocturnal• Situational or psychological stress• SSRI, dopa, alcohol exacerbate Madras Institute of Neurology
  28. 28. Sleep-Relat ed Rhyt hmic Movement Disor der• Head Banging – back & forth down into the pillow• Head Rolling – side to side• Body Rocking – forward & backward• Humming or chanting• Persistence with autism, MR Madras Institute of Neurology
  29. 29. Noct ur nal Par oxysmal Dyst onia (NPD)• Repeated, stereotyped, dystonia or dyskinetic episodes in NREM sleep• Sleep related epilepsy• Short episodes < 1 min. every night and many times• Long episodes – up to 60 min• Can have sleep disruption Madras Institute of Neurology
  30. 30. Sleep-Disor der ed Br eat hing (SDB)• Primary snoring• Upper airway resistance syndrome (UARS) – lab support, day time dysfunction• Obstructive sleep apnea-hypopnea syndrome (OSAHS)• Central sleep apnea• Asthma• Chronic obstructive pulmonary disease Madras Institute of Neurology
  31. 31. Obst r uct ive Sleep Apnea- Hypopnea Syndr ome• Asphyxia with decreased O2 & increased CO2• Associated with snoring and obstruction of the pharynx• Day time – sleepiness, decreased concentration, fatigue• Nocturnal – chocking, dyspnoea, diaphoresis, nocturia Madras Institute of Neurology
  32. 32. • Apnoea – 70% reduction in airflow• Hypopnea – 30% reduction in airflow for minimum 10 sec• Apnea-hypopnea index (AHI) of at least five apneas plus hypopneas per hour of sleep together with complaints of persistent daytime sleepiness. Madras Institute of Neurology
  33. 33. Risk Fact or s• Obesity ( BMI > 30 kg/m2)• Male gender• Family history of obstructive sleep apnea-hypopnea syndrome• Consumption of alcohol before bedtime• Smoking• Drugs (growth hormone, β-blockers, testosterone, flurazepam)• Use of sedatives• Sleeping in a supine position• Anatomic upper airway obstruction• Comorbid medical conditions Madras Institute of Neurology
  34. 34. Cent r al Sleep Apnea• 10 sec of no airflow• Reduced ventilatory drive• Ventilatory responses to hypoxia, hypercapnia are reduced• Day time sleepiness, mild snoring• PSG – no airflow or ventilatory effort Madras Institute of Neurology
  35. 35. Cir cadian r hyt hm Sleep Disor der s (CRSD)• Master Clock – SCN in anterior hypothalamus Sleep wake cycle/temperature control and melatonin levels.• Zeitgebers (time given) are light and melatonin• Input into SCN from ganglion cells- melanopsin• Melatonin > pineal >ofSCN, shifts circadian Madras Institute rhythm Neurology
  36. 36. • DD for insomnia & hypersomnia Delayed sleep phase Advanced sleep phase Free running Irregular sleep-wake Shift work sleep disorder Jet lag Madras Institute of Neurology
  37. 37. Cr it er ia f or CRSD• Persistent or recurrent pattern of sleep disturbance due to- Alteration in circadian timing or misalignment of endogenous & external factors- Leading to insomnia, EDS or both- Associated with impairment of function• CRSDs are important in practice but parameters for treatment have not been Madras Institute of established. Neurology
  38. 38. Thank youMadras Institute ofNeurology

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