ObjectivesDiscuss the changes that occur in sleep from

infancy through adulthood. Discuss the normative data of sleep

parametersDiscuss sleep changes across the life cycle in

womenDiscuss sleep in older Adults

Sleep Definitionsleep is a reversible behavioral state of

perceptual disengagement from environment & unresponsive to the environment.

Series of physiological & behavioral process.Normally associated with postural

recumbence, behavioral quiescence ,closed eyes & occasionally unusual behavioral activities.

Greek God Hypnos = Sleep.

Sleep Across the life cycle

Sleep Patterns 0-12 MonthsSleep -major portion of lives of newborns, infants &

children.A newborn typically sleeps ( 70 % of every 24 Hr) /

adults spend 25-30% of their lives sleeping.Distributed equally across the day & night.Gain ability to sustain longer periods of sleep &waking.Total sleep duration about 14 hours.Developmental mile stones of “ sleeping through the

night” ( i.e. at least 8 hours at night) is achieved by 6-9 months.

By age 3 ,the average child will have spend more time asleep than awake.

Sleep Patterns 0-12MonthsInfants have a sleep cycle periodicity of 50-60

minutes.Sleep periods of 2-4 hours initially in infancy with

REM. usually being the initial stage of sleep onset.Infants usually spend 50% of night into REM.At age 3 months REM becomes organized & NREM

finally dominates the sleep cycle. NREM stages emerges in the first year. Sleep spindles arising at 4 weeks.High voltage slow waves at age 3 months.K complexes at 6 months.

Sleep Patterns 0-12 months• EEG features not discernible in new born infants.• Combination of EEG & Behavioral Criteria used to assign

sleep stages .• Quiet sleep( i.e. NREM sleep)• Active Sleep( i.e. REM sleep)• Indeterminate Sleep

• Active sleep dominates initially with respective percentage for preterm & full term infants of 60% & 50%.• By age six months, active sleep declines to 25 %. • After 6 months, NREM divided into 4 stages: Stage

1,2,3,4.• EEG voltage significantly increases in first yr, with

attenuation in 9-16 yrs.

•

Sleep Patterns 0-12 months

Sleep Patterns 0 – 12 months• REM sleep, NREM sleep based on EEG, EOG, EMG.

• Newborn: Transitional sleep with disorganized quiet and active sleep.

• 1-6 Months: REM is active sleep, NREM is quiet sleep.

• NREM sleep: low frequency, high voltage EEG activity, low muscle tone, absence of eye movement.

• REMS: Desynchronized cortical EEG activity, absence of muscle tone, irregular heart and resp rate, episodic bursts of phasic eye movements.

• Trace alternant seen in very young: high voltage activity with near electrical silence.

Sleep Patterns in 0-12 months• When infants fall asleep, experience sleep onset

REM; after 3 months, drift towards NREM sleep onset.

• SWS greatest is early childhood, decreasing abruptly in puberty and further declines throughout life.

• This change reflects EEG amplitude that may be related to age-specific “programmed” alterations in synaptic connectivity among neurons and changes in neuron

• , neurotransmitter, or neuro -receptor properties.

Sleep Patterns of 0-2 months

Active Sleep State

Analogous to REM, low voltage irregular pattern, HR,RR variable

Sleep Pattern o-12 months

Quiet Sleep State

Analogous to NREM, Discontinuous EEG pattern, intermittent bursts of electrical activity alternates w/quiescent periods, regular HR, RR, few body movements

Sleep Patterns 0-12 Months

Quiet sleep and tracé alternant (TA)NREM sleep pattern at term, 2-6 sec burst of high amplitude slow waves separated by 4-6 secs of low voltage mixed activity, disappears by 4 weeks post term

EEG TRACING FROM AGE 2 WEEKS TO 15 years.

Sleep Patterns in 2-6 yearsChanges in sleep structure during this period

are more gradual.Sleep becomes consolidated into a long

nocturnal period of approx 10 hour.During 2-3 years day time sleep is replaced

by short day time naps.All children stop napping between ages 3-5

years.Sleep is generally consolidated into a single

nocturnal period.

Sleep Pattern in 2-6 year old

Sleep Pattern in 2-6 year old

Sleep Patterns in 2-6 yearsChanges in uniformity &duration of REM periods

i.e., The first REM of Night becomes shorter , while succeeding periods longer & associated with more intense phase activity.

REM usually occurs one hour after a sleep.By 4-5 year of age REM % decreases to an Adult

level of 20-25 %.Children of this age usually have 7 cycles during

each nocturnal sleep period.Sleep onset between 15-30 minutes.SWS usually occur during the first third of night.

Sleep pattern 2-6 years• Decrease in sleep duration across early childhood

results from fewer daytime naps.

• Night waking common in toddlers/preschoolers (20% wake once a night, 50% once a week).

• Can be considered normal.

• Thought to be consequence of nocturnal arousals driven by Ultradian rhythm of sleep cycles (50-90 mins.).

• Self soother vs non self soother.

Sleep Pattern in 2-6 years• Child development influence sleep behaviors.

• > Increased mobility leads to reactive co-sleeping.

• > Cognitive development produce fears and interests.

• > Separation anxiety.

• > Drive for autonomy.

• Parent’s perception important factor.

• Bedtime routine important.

• “Lifestyle co-sleeping: with siblings/parents.

Sleep Patterns 6- 12 yearsGrowth & development continues to be constant.Sleep continues to develop into a more mature

pattern.Total sleep time 9-11 hours. Sleep pattern becomes more stable, night to

night consistency.Low level of day time sleepiness; naps rare.School life styles influences-later bedtimes &

earlier. rise times, irregular sleep /wake schedules.

Sleep Pattern in Adolescent• Sleep duration decreases but need does not

decline (average. 9.30 hrs).• Delay of sleep phase: stay up late, wake later in

am.

•Circadian; Relative phase delay•Environmental factor

• Advanced wake times• Decreased sleep /wake regularity.• discrepancy between weekdays/ weekend sleep

cycle.• Increased sleep tendency at mid puberty.• Due to: autonomy, peer pressure, academic

demands, employment, extracurricular activities.

Sleep Regulation in Childhood• Theoretical models describe 2 intrinsic regulatory

processes determine timing of sleep and waking.

• Homeostatic process-represents the drive for sleep that increases during wakefulness and decreases during sleep.

• Circadian process- with distinct neuroanatomical locus.

Sleep Regulation in Childhood

Sleep Regulation in Childhood• Homeostatic process.

• *Dynamics of sleep homeostatic mechanisms appear to slow down during development.

• *Thus decreasing sensitivity to sleep loss and increase tolerance to sleep pressure.

Sleep Regulation in Childhood• Homeostatic process

• *Theta activity may be marker for HSP in children.

• *Age at which it become SW-activity unknown.

• *Adolescent sleep deprivation similar to that of young adults EEG changes.

• *Rise rate of HSP during the day slower in mature. adolescents compared to pre (early) pubertal children.

• *Nocturnal dissipation of sleep pressure does not differ.

Sleep Regulation in Childhood • Circadian Process

• Sleep-wake independent clock-like process.

• *Distinct neuro -anatomical locus in bilateral supra -chiasmatic nuclei of anterior hypothalamus.

• *Appears to be functional in utero; not working well at birth.

• *1st month- 24h core body temp rhythm emerges.

• *2nd month-more sleep at night.

• *3rd month-melatonin and cortisol start to cycle in 24h rhythm.

Sleep Regulation in Childhood• Circadian process- Changes appear during

puberty.

• *Three mechanisms

• -Delay in intrinsic circadian phase.

• - Mature children show later timing of melatonin secretion onset and offset phases.

• -Delay may be related to lengthening of intrinsic period of circadian clock.

• -Heightened sensitivity to pm light or decrease sensitivity to am light.

Sleep patterns of adultsYoung adult usually sleep 7.5-8.5

hours/Night.First NERM-REM cycle is 70-100 minutes.Subsequent NERM-REM cycle is 90-120

minutes.Sleep length partially determined by

genetics, volitional determinants & circadian rhythm.

Sleep Architecture of the normal young adultSleep is made up of the two physiological states

NREM & REM.Sleep begins with NERM.SWS predominates in the first third of night.REM sleep predominates in the last third of night. Break down of sleep stages :NERM ( 75- 80 %) WASO – stage I – 5 %Stage N1- StageII-2-5 %Stage N2-Stage III-45-55%Stage N3-Stage IV-13-23%REM-(20-25%)

Sleep Patterns in Young Adults

Sleep Patterns In Adult

Sleep Stages: PSG

Normal Sleep Patterns

Normal Sleep Patterns

Normal Sleep Patterns

Normal Sleep Patterns

Normal Sleep Patterns

Normal Sleep Patterns

Normal Sleep PatternsResults:In children & Adolescent, TST decreased with age (on

school days).% of slow wave sleep was negatively correlated with

age.% of stage 2 NREM & REM sleep significantly change

with age.In Adults TST, Sleep Efficiency, % of SWS, % of REM

Sleep & REM Latency all significantly decreased with age While Sleep Latency, % of Stage 1 sleep, % of Stage 2 sleep and WASO significantly increased with age.

Only Sleep Efficiency continued to significantly decrease after 60 years of age.

Are there gender differences in Sleep?Increase in subjective sleep complaints but relatively

few differences in sleep architecture.Despite the fact that sleep complaints are about

twice as prevalent in women of all ages compared to men, 75% of the sleep research has been conducted with males.

HORMONAL EFFECT ON SLEEPEstrogen :Primary effect on REM.Decrease SOL,WASO, Increase TST.Progesterone: primary effect on NERM-

Benzodiazepine like effect.Decrease SOL, WASO.

Sleep Patterns in WomenSleep in women with normal Menstrual

cycle.1. subjective :longer sleep latency, lower sleep

efficiency & sleep disruption was associated with luteal phase. Severity of premenstrual symptoms was co-related with day time sleepiness.

2.Objective PSGfinding-Stage 2 was higher in luteal phase & also increase frequency of sleep spindles.

3.Dysmenorrhea associated with decrease sleep efficiency.

Sleep Patterns in pregnant WomenPregnancy, child birth& early motherhood

physiologically & psychologically affect a woman’s sleep.

Contributing factors – hormonal alterations during early pregnancy , enlargement of fetus in late pregnancy& postpartum infant’s feeding & sleeping cycles.

Reports of altered sleep during pregnancy range from 13%-80 % in the first trimester ,66- 97 % in third trimester.

Sleep Pattern In Pregnant WomenFirst Trimester: disrupted sleep but TST

increases in first trimester back to prepreg level in 3rd trimester.

Sleep is not much affected in 2nd trimester.Increase number of awakening, disrupted sleep&

Decrease TST in third trimester & post partum.Increase stage 2,WASO,Slight decrease in REM

& SWSDecrease Sleep Efficiency.Snoring increases, Increase incidence of

OSA/RLS.

Sleep Patterns in Women SLEEP & MENOPAUSEPrevalence of insomnia increases form

33%-36% to 44%- 61% in pre & post menopausal women.

Postmenopausal women have more subjective complaints of disturbed sleep but had better sleep documented on full night polysomnography longer total sleep time, increased amount of SWs, less time awake in bed.

Sleep Pattern in WomenSLEEP & MENOPAUSE:Increase in SOL; 20% reports sleeping< 6 hours.Difficulty in Sleep Maintenance.Role of nocturnal Hot flashes; more frequent

arousal & awakening, decrease SE, Increased SWS.

OSA: increased prevalence & severity Post menopausal

HRT may improve SE: OSA symptoms.Insomnia may become conditioned despite HRT;

role of various replacement protocols.

Sleep in Older AdultsMany elderly people C/O Disturbed sleep.Need for sleep does not Change.The ability to sleep does decrease with age.Causes are multi-factorial.

Change in timing & consolidation of sleep. Medical & psychiatric illnesses. Medications. Presence of specific sleep Disorder. Physiologic Changes that occur in older adults.

Sleep in Older AdultsChange in Sleep with AgeSubjective Reports:

Spending too much time in bed. Spending less time asleep.Increase number of Awakenings.Increase in time to fall asleep.Increase in tiredness during the day. Less satisfaction with sleep.Longer & more frequent naps.

Sleep In Older Adults

Sleep In Elderly Population

OBJECTIVE FINDINGSDecrease NREM Sleep.Decrease REM Sleep.Increase in awakening.Increase Frequency of sleep D/o.Decrease in Sleep Efficiency.Increase in day time sleepiness.Increase number of naps.

Sleep pattern in older AdultsChanges in sleep Architecture with age

Total sleep = 7 hours.Decrease of SWS ( 2% per decade of age).Decrease REM sleep & REM latency.Decrease sleep spindle density & K complex.Sleep Efficiency continue to decrease till age

90.Increase stage shifts.Fewer stage shifts.Fewer cycles.

Sleep In Older Adults

Sleep in Older Adults • Causes of disturbed sleep in elderly

• Insomnia

• pain-arthritis, Cancer

• neurological disorder- RLS, Parkinson’s, dementia

• organ system failure- lungs, CHF, GI, BPH

• Depression, GAD.

• Pts with disease more likely to be less satisfied w/sleep than healthy pts.

• Medication use

Sleep in Older Adults• Common primary sleep disorders in adults

• -OSA

• -25% have apnea index of 5 or >

• -62% have AHI of 10 or >

• -Increased prevalence due to decreased resp

• muscle strength, decreased expiratory flow

• rates, diminished compliance of chest wall

• -Changes in anatomy of airway

• -RLS & PLMs : prevalence increase significantly with age

Sleep In Older Adults• Total amount of sleep does not change.

• Timing of sleep changes.

• Advancement of circadian rhythm and age related changes in output of circadian pacemaker contribute to sleep complaints.

• ZEITGEBERS –Inconsistency of external cues eg-low exposure to light, irregular mealtimes, decreased exercise.

• Melatonin levels decrease with age contributing to poor sleep.

Sleep Pattern in Older Adults• Age related deterioration of the hypothalamic

nuclei that drives CR also affects sleep

• Older adults wake up earlier and fall asleep earlier in relation to nightly melatonin secretion

• Aging assoc with adv of sleep and CR, decreased melatonin release, and change in internal phase relationship b/w sleep-wake cycle and output of circadian pacemaker

• Increase in cortisol level

• Diminished sleep related growth hormone release

• Reduction in retinal sensitivity to light.

Sleep In Older Adults• Associations with disturbed sleep.

• EDS can cause social and occupational difficulties, reduced vigilance, cognitive deficits- decreased concentration, slowed response time, memory difficulties.

• Impaired Mood.

• This can be interpreted as dementia or exacerbate mild or moderate cognitive impairment.

Subjective & Objective Sleep Quality & Aging in Sleep Heart Health StudyObjectives: To examine the extent to which

Subjective & objective sleep Quality are related to age independent of chronic health conditions.

Participants 5470 Adults, Mean age 63 range-45-99; 52% women

Measurement : Home PSG & Sleep QuestionnaireResults: Older age was associated with shorter

sleep time, diminished sleep efficiency, & more arousal in Men & women In men age was independently associated with more stage 1 ,2 sleep & less SWS & REM sleep , In women older age was less strongly associated with sleep stage

Po0r subjective sleep Quality was not associated with men but older women

Sleep Heart Health Study• Sleep Heart Health Study in thousands of adults

aged 40-98 who had sleep disordered breathing

• -AHI > 15 increased with age

• - 10% at 45 yrs and 20% at 60 yrs

• Prevalence of PLMS and RLS increases with age from 5-6% in younger adults to 45% in older adults

• Increased incidence of RBD

• - PET scan show a decrease in binding to presynaptic dopamine transporter

SLEEP QUIZ6. REM sleep is first evident at what stage of development?a) In uterob) Immediately post-partumc) At 1month of aged) At 3 months of agee) At 1year of age

2. Total REM sleep decrease from 50% at birth to the normal adult range 20 % by what age?

a) Infancyb) Preschoolc) Schoold) Adolescencee) Adult

3. Sinusoidal waves at9-11 HZ are recorded in the EEG during which of following circumstances?

a) Wakefulness with eyes closed.b) Wakefulness with eyes open.c) Light sleep.d) Deep sleep.

4. Which of the following muscle group is flaccid or atonic during REM sleep?

a) Anti- gravitional muscles in upper & lower extremities

b) Extensor muscles in back & armc) Abdominal inter-costal musclesd) Proximal girdle muscles.

5. The most common cause of excessive day time sleepiness in adolescent is:

a) Depressionb) Substance use or abusec) OSAd) Inadequate amount of sleepe) Delayed sleep phase d/o

6. Which of the following statement characterizes changes in sleep associated with aging

a) The average total time spent a sleep in 24 hour decreased

b) Total time in REM sleep decreasesc) REM latency increasesd) Delta wave amplitude decrease & less time is

spent in stage 3 & 4

7. Which of the following sleep stage is the most important in restoring the altered functions that result from prolong sleep deprivation

a) REM Sleepb) Stage 1 NREMc) Stage 2 NREMd) Stage 3 and 4 NREM

Bibliography Principles and Practice of Sleep Medicine: Kyger,

Roth Dement Basics of Sleep Guide SRS: Charles J. Amlaner, D.

Phil, and Patrick M. Fuller Ph. D.Sleep Medicine Essentials: Teofilo L. Lee-Chiong Subjective and Objective Sleep Quality and Aging

in the Sleep Heart Health Study: Mark L. Unruh M.D., Susan Redline, M.D., Ming-Wen An, Ph. D.

Meta-Analysis of Quantative Sleep Parameters From Childhood to Old Age in Healthy Individuals: Developing Normative Sleep Values Across the Human Life Span: Mary A. Carskadon Ph. D., Michael V. Vitiello Ph. D.