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Clinical Sleep Disorders
Meena Khan MDAssistant Professor, Department of Neurology and Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine
Learning Objectives
Understand the diagnostic procedures used in sleep medicine and their appropriate use
Understand the following sleep disorders Insomnia Obstructive sleep apnea Narcolepsy Parasomnias Restless leg syndrome
Diagnostic Procedures
Overnight Polysomnograpy (PSG) Study done at night while patient is sleeping Purpose is to diagnose obstructive sleep apnea and periodic limb
movements of sleep
Multiple mean sleep latency test (MSLT) Daytime study Purpose is to objectively evaluate a person’s tendency to fall
asleep during the day
Diagnostic Procedures
Overnight Polysomnograpy (PSG)
There are 2 types of polysomnography that can be conducted Full PSG done in the sleep lab Portable study that can be done at home
Diagnostic Procedures
Full Polysomnography (PSG) Done in the sleep lab
Sleep staging Respiratory flow and effort Pulse oximetry Leg movements
Diagnostic Procedures
Portable PSG Can be done at home
Respiratory flow and effort Pulse oximetry
Diagnostic Procedures
Multiple sleep latency test 5 nap opportunity to fall asleep and see if one achieves REM
sleep Each nap
Lights turned off and pt asked to try to fall asleep The patient is given 20 min to see if they can fall asleep and if they
do- 15 more min to see if they achieve REM sleep REM within 15 minutes of falling asleep- sleep onset REM period
(SOREM) Record the sleep latency (time to fall asleep) and the presence of
REM sleep.
PSG Quiz
Common sleep disorders
Disorders of hypersomnia Obstructive Sleep apnea Narcolepsy
Disorders leading to inability to sleep Insomnia Restless leg syndrome
Abnormal behavior associated with sleep Parasomnias
Disorders of Hypersomnia
Obstructive sleep apnea (OSA)
Narcolepsy
Obstructive Sleep Apnea (OSA)
Intermittent collapse of the upper airway during sleep
Mechanism of collapse is reduced upper airway size and altered control of upper airway muscles
Obstructive Sleep Apnea (OSA)
What happens as result of closure of the upper airway??
Arousals from sleep - unrefreshing sleep and daytime sleepiness
Drops in oxyhemoglobin saturation- cardiovascular morbidity and mortality Hypertension Myocardial infarction Stroke Death
Symptoms
Nighttime symptoms Snoring- loud and habitual Gasping/choking during sleep Witnessed apneas Awakenings during sleep Restless sleep
Daytime symptoms Unrefreshing sleep Fatigue/Sleepiness Impaired concentration/memory
Risk Factors for OSA
Obesity (BMI>=30) Male gender (2-3:1) Menopausal women (M:F- 1:1) Age>=65 yrs Neck size
Male neck size >=17in. Female >=16 in.
Family history -inc by 2-4 fold Race
Africa Am and Asians
Factors that contribute to increased OSA severity
Weight gain (10% inc in body weight associated with 32% increase in AHI)
Alcohol- prolong apnea and worsen associated hypoxemia
Sedatives (benzodiazepines, anesthetics, narcotics)
Current smoking (assoc w/higher prevalence of snoring and OSA)
Proc Am Thorac Soc 2008; Vol 5; 136-143
Obstructive Sleep Apnea
Two types of airway closures that occur in obstructive sleep apnea
Apnea Complete closure of the airway resulting in absence of airflow
Hypopnea Partial closure of the airway leading to decrease in airflow
associated with a drop in oxyhemoglobin saturation
Apnea
Absence of air flow for >=10 seconds
HypopneaDecrease in airflow of >=10 seconds with oxygen desaturation of >= 4%
Obstructive Sleep Apnea
Presence and severity of obstructive sleep apnea is measured by the number of apneas and hypopneas per hour of sleep.
This measurement is called the apnea-hypopnea Index (AHI)
Normal AHI <5 Mild OSA-AHI of >=5 to <15 Moderate is AHI of 15>= to <30 Severe is AHI>=30
Treatment of OSA
Behavioral modification Weight loss Positional therapy
Interventional treatment Continuous positive airway pressure (CPAP)- Gold standard of
therapy Oral appliance Surgery
Apnea Quiz
OSA Quiz
Narcolepsy
Clinical Features A syndrome of excessive daytime somnolence and
abnormalities of REM sleep.
Tetrad of symptoms Excessive daytime sleepiness- first symptom Cataplexy Hypnogogic/hypnopompic hallucinations Sleep paralysis
Disturbed nocturnal sleep
Abnormalities of REM sleep
Narcolepsy
The prevalence is 0.05%
The prevalence is increased at 1-2% for family members of those with narcolepsy
Onset of symptoms is typically the second decade usually between ages 10 – 25 years.
Narcolepsy
Etiology Dysfunction of hypothalamic hypocretin systems. Hypocretin 1 is in the lateral hypothalamus and
has role in sleep-wake regulation. This is deficient in narcoleptics with cataplexy and
thought to be the etiology of the syndrome. There is also an association with gene-
DQB1*0602.
Narcolepsy
Standard for diagnosis is an in lab full PSG/MSLT
PSG- 360 minutes of total sleep time without presence of OSA
MSLT- Mean sleep latency (MSL) of <=8 min and >=2 naps with SOREM.
Narcolepsy
Supplementary testing Gene test for DQB1-0602:
This gene is positive in 95% of those with narcolepsy with cataplexy but also is present in 18-35% of the general population
Cerebrospinal fluid (CSF) hypocretin levels: 94% of narcolepsy with cataplexy will have CSF hypocretin level
<110 pg/ml. All those with a low hypocretin level will be positive for the DQB1-
0602 gene.
Narcolepsy- Treatment
Behavioral management Adequate nocturnal sleep Scheduled naps Good sleep hygiene Support groups
National Sleep Foundation Narcolepsy Network
Narcolepsy- Treatment
Pharmacologic management Excessive daytime sleepiness
Stimulants Modafinil /Armodafinil Amphetamine salts
Sodium oxybate (xyrem) Cataplexy
Sodium oxybate REM suppressing medication
Venlafaxine
Narcolepsy Quiz
Disorders that lead to inability to sleep
Insomnia
Restless leg syndrome
Definition of insomnia
Repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in daytime impairment.
Impairments Fatigue, depressed mood, irritable, cognitive impairment Physical symptoms- HA, GI upset
Marked distress and/or significant impairment in social or occupational functioning.
Insomnia
Common sleep disturbance Survey in 2005
75% have had a sleep problem 50% had one symptom of insomnia over the previous year 1/3 reported nightly symptoms
National sleep foundation 2005 sleep in America poll
Underreported and under treated 5% of pts with insomnia seek medical treatment 26% mention it to physicians during visits for other complaints
Insomnia
Chronic insomnia Correlated with increased morbidity:
Higher disability levels Increase calling off work Frequent use of medical resources- doctor
visit/testing/medication Chronic health problems Increased use of drugs Decreased quality of life
34
Risk Factors for insomnia
Female- risk 1.3 times higher than men Older age (age >65- 1.5X more likely to
experience insomnia) Divorced/ separated/widowed Low economic/education Poor health Mood D/O Chronic medical problems Substance abuse- recovery period
Features of chronic insomnia
Life and thoughts revolve around sleep and the effect of lack of sleep
Sleep anticipatory anxiety about not being able to sleep
Clock watch Calculate time left for sleep Strong and at times unrealistic thoughts about
sleep requirements and daytime consequences due to lack of sleep
Insomnia Dysfunctional thoughts • Anxiety about sleep• Neg thoughts about sleep/and daytime symptoms ANDMaladaptive Behavior• Too much time in bed• Irregular sleep schedule• Naps or resting during the day• Watch TV/ read etc• Caffeine and alcohol use
Trigger event
Predisposition1. Hyperarousal 2. Tend to
ruminate3. Blunted sleep
homeostasis
Insomnia
Treatment
Pharmacologic• Recommended for short
term use although no medical contraindication for long term use
Cognitive Behavioral Therapy
• Cognitive therapy• Aimed at maladaptive thoughts
about sleep• Behavioral therapy
• Aimed at maladaptive behaviors• Sleep hygiene• Relaxation Therapy• Stimulus Control • Sleep restriction
Sleep Hygiene
Educate about lifestyle and bedroom environment factors that can promote good sleep The bedroom should be dark, quiet, and comfortable Avoid watching TV, reading, using the computer or doing other
activities other than sleep in the bedroom. No caffeine at least four hours before bed Avoid tobacco at night Avoid alcohol at least 4 hours before bed Exercise late afternoon, early evening
Relaxation Therapy
Goal- reduce sleep related tension
Somatic, mental relaxation and biofeedback
Regularly practice therapies during the day and implement them while in bed
Stimulus Control
Aimed at idea that those with insomnia have developed an association of their bedroom with poor sleep
Goal is to re-associate bedroom with rapid sleep Eliminate the stimuli that interfere with sleep in the
bedroom -bed for sleep only- Avoid reading, TV, eating, talking on the phone
Go to bed only if sleepy Get out of bed if no sleep after 20 min Same rise time every AM Avoid naps
Sleep restriction
Insomniacs tend to increase time in bed to allow for more sleep but this results in decreased sleep efficiency (ex: in bed for 8-9 hours but only sleep 5-6 hours)
Goal Restrict person’s time in bed so there is a better match
of sleep time to time in bed Example- someone states they sleep only 6 hours. Have them pick a wake time- must get up at that time every morning Bedtime is 6 hours before that Should only be in bed for those times Ex- wake time is 6 AM, bedtime would be 12 am. Never restrict less than 5 hours
Restless Leg Syndrome (RLS)
4 cardinal criteria Abnormal sensation leading to urge to move legs
Movement of legs improves sensation
Occurs at rest
Occurs mostly at night
Restless Leg Syndrome (RLS)
Etiology: Most cases are idiopathic but can be hereditary. There are also secondary causes of RLS which include:
iron deficiency anemia pregnancy end stage renal disease medications peripheral neuropathy Diabetes Rheumatoid arthritis
Restless Leg Syndrome (RLS)
Diagnosis- made by history not sleep study
Evaluation and treatment Check serum ferritin (should be >=50) – if less than 50 than give
patient iron supplementation Standard medical therapy- dopamine agonists
Periodic Limb Movements of Sleep
Leg movements that occur during sleep
Commonly seen in patients with RLS
Diagnosis made by sleep study
Evaluation and Treatment is same as RLS
Waking Quiz
Abnormal movements during sleep
Parasomnias Definition
Undesirable and typically abnormal motor or subjective phenomena that occur during the transition of wake/sleep or during arousals from sleep
Parasomnias
NREM Parasomnias Confusional arousals Sleep walking Night terrors
REM Parasomnias REM behavior disorder
NREM Parasomnias
NREM (Disorders of Arousal) Occur during slow wave sleep (SWS) First third of sleep when SWS more prominent Occurs in 20% children- most resolve once child reaches
adulthood but 25% persist into adulthood Occurs in 4% adults
NREM Parasomnias
Confusional arousals Arousals out of NREM sleep- associated with confusion and
disorientation Simple or complex movements in bed without walking or night
terror behavior Amnestic of event Not violent but may become agitated if forcibly awakened
NREM Parasomnias
Sleep walking Ambulation with impaired consciousness- behavior is
inappropriate
Ex: Cook, eat, drink, play instruments, drive a car
Memory impairment for the event but the person may remember fragments
Difficult to arouse person during an event
NREM Parasomnias
Night terrors Sudden arousal from sleep with scream or cry Afraid, anxious, panicked, fearful, disoriented Inconsolable!!!!!! Motor activity- intense and disorganized Autonomic activity
Tachycardia, tachypnea, sweating, flush skin, mydriasis
Amnestic to event- increased agitation if try to arouse
REM sleep behavior disorder (RBD)
Person has loss of normal muscle atonia that occurs during REM sleep
Clinical symptoms Dream enactment behavior-moving in response to
content of their dreams Dream content may be more violent leading to violent
actions Typically patient is alert if awoken during the event
and can recall the dream vividly
RBD
More common in age>50
Males > females (9:1)
Often associated with the development of neurological disorders- most commonly- Parkinson’s disease
Sleep Episodes Quiz
Conclusions
A good history is key to the diagnosis of most if not all sleep disorders
Sleep studies of various types have a specific role to diagnose certain sleep disorders but are not beneficial to diagnose all sleep disorders or to be done without a specific goal in mind.
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