Disorders of sleep adults

Disorders of Sleep - Adults

Dr A V Srinivasan M.D, D.M., PhD (Neuro)Professor in NeurologyInstitute of Neurology

Madras Medical College, Chennai9-7-08 at Kalpakam, Chennai

In Greek mythology, Hypnos was the personification of sleep; the Roman equivalent was known as Somnus. His twin was Thanatos ("death"); 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 other hypnogogic plants.

Madras Institute of Neurology

Sleep Disorders• 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.


Insomnia

• Difficulty in initiating sleep and staying asleep

• Waking up earlier• Poor quality sleep, non restorative.• Subjective• Day time impairment (RDC-AASN)


Etiology

• Primary• Secondary Medications Psychiatric Medical Sleep Disorders


Drugs

• SSRI’s & SNRI’s• Alpha and beta blockers• Diuretics• Decongestants• Stimulants• Steroids, thyroid harmones


Psychiatric and Sleep disorders

• Mood & anxiety disorders• Circadian rhythm disorders• Parasomnias• Apneas• Movement disorders


Hypersomnias

• Excessive day time sleepiness• Interfering with day time

activities, productivity, enjoyment

• Reflects insufficient sleep, disrupted sleep, primar sleep disorder


Diagnosis

• Detailed medical and sleep history• Snoring or apnoea• Restlessness, jerking• Hypnogogic or hypnopompic

hallucinations• Sleep paralysis, cataplexy• Automatic behavior


Narcolepsy

• Excessive day time sleepiness (EDS)

Sedentary and active pursuit'sShort and refreshingFollowed by recurrent somnolenceRanging from mild to disabling


Cataplexy

• Unique• Paroxysmal episodes of weakness• Triggered by emotions• Secs to Min• Can be localized• Consciousness and respiration

not affected.


•Develops years after EDS•Frequency varies•Adolescence, young adulthood•Narcolepsy with and without

cataplexy•Loss of hypocretin – 1 secreting

cells

Cataplexy in an Adult Male (Video)


• Narcolepsy – non obligate manifestations

Sleep 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.


Other Hypersomnias

• Recurrent hypersomnias Recurrent hypersomnias Kleine – Levin syndrome Menstrual associated• Idiopathic hypersomnias With long sleep time Without long sleep time


Parasomnias

•Include abnormal movements, behaviors, emotions and automatic activities.

•Intrusion of sleep and wakeful state into one another with CNS activation.

•Not a unitary phenomenon.


Parasomniasis

• Disorders of arousal –NREM sleep – confusional arousal sleep walking sleep terrorsREM sleep – RBD Isolated sleep paralysis NightmaresOthers – enuresis eating disorders etc


RBD – REM Sleep Behavior Disorders

• 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


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


Sleep-Related Movement Disorders- Restless Legs

Syndrome •5-15% - healthy people•15-20% - uremia•30% - R.A•High prevalence in West•Low in South & S.E Asia


Diagnostic criteria – NIH –IRLSSG (2003)

1. Disagreeable leg sensations before sleep onset

2. Irresistible urge to move the limbs

3. Partial or complete relief on leg movement

4. Return of symptoms on cessation of movement


Restless Leg Syndrome• 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


Restless Leg Syndrome with Periodic Limb Movements


Periodic Limb Movement Disorder

• 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


• Can accompany OSA & Narcolepsy

• Uremia, metabolic disorders• TCA, MAOI• Withdrawal of AED,

benzodiazepines, hypnotics• Hypnic jerks & nocturnal seizures

to be differentiated


PLMS –Secondary (previous Myelopathy)


Sleep Related Leg Cramps

• 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


Sleep related Bruxism

•Children and adults, MR•Stereotyped grinding or

clenching•Diurnal & nocturnal•Situational or psychological

stress•SSRI, dopa, alcohol exacerbate


Sleep-Related Rhythmic Movement Disorder

• Head Banging – back & forth down into the pillow

• Head Rolling – side to side• Body Rocking – forward &

backward• Humming or chanting• Persistence with autism, MR


Nocturnal Paroxysmal Dystonia (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


Sleep-Disordered Breathing (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

(COPD).


Obstructive Sleep Apnea-Hypopnea Syndrome

• 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


• 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.


Risk Factors

• Obesity ( BMI > 30 kg/m2)• Male gender • Family history of obstructive sleep apnea-

hypopnea syndrome • Consumption of alcohol before bedtime • Smoking • Drugs (growth hormone, Î²-blockers, testosterone,

flurazepam) • Use of sedatives • Sleeping in a supine position • Anatomic upper airway obstruction • Comorbid medical conditions


Central 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

Circadian rhythm Sleep Disorders (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 > SCN, shifts circadian rhythm


• DD for insomnia & hypersomnia Delayed sleep phase Advanced sleep phase Free running Irregular sleep-wake Shift work sleep disorder Jet lag


Criteria for 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 established.



Thank you

Health & Medicine

Disorders of sleep adults