SLEEP DISORDERSTHE NORMAL SLEEP & ASSOCIATED DISORDERS

WHY DO WE NEED TO SLEEP?

Sleep is the ‘Reset’ system of the body. It allows time to end the ‘wear & tear’ processes, regulate the hormones for growth, appetite & moods. It also repairs muscles & allows spiritual rejuvenation through dreaming.

DEVELOPMENTAL CHANGES IN SLEEP PATTERNS WITH AGE

Subjective reports by adults: Time in bed increases Frequent awakenings Total time decreases Dissatisfied sleep Tired, sleepy & more daytime naps

Objective age-related changes in sleep cycle Reduced REM, Stage 3 &4 Reduced nocturnal sleep time Frequent awakenings Need for daytime sleep.

SLEEP STATES

There are two physiological states of sleep known as REM (Rapid Eye Movement) & NREM (Non-rapid eye movement).

Stages of sleep are known as the Sleep Architecture.

Instruments of measures- electroencephalogram (EEG) for brain activity, Eye movement (electrooculogram) & muscle tone (EMG).

NREM

It is divided into 4 stages on basis of EEG patterns.

NREM (75%) alters with REM (25%) sleep throughout the sleep period & is characterized by

Slowing of EEG rhythms

Higher muscle tone

Absence of eye movements

NREM is like an idling mind in a movable body

THE SLEEP CYCLE

Awake- Low voltage, fast Beta waves Drowsy, alpha waves, 8-12 cps Stage 1, theta waves, 3-7cps, slight slowing Stage 2, Further Slowing, sleep spindles & K complexesStage 3, Delta waves, 12-14 cpsStage 4, ½ to 2 cps delta waves >75

REM Sleep- low voltage, random, fast with saw tooth waves.

REM ( RAPID EYE MOVEMENT)

Characteristics of REM (also called paradoxical sleep)

Occurrence: 10-40 mins every 90 mins. Autonomic Instability

a. Increased HR, BP, RR,

b. Increased minute to minute variability in HR, RR, BP.

c. Appears similar to awake state on EEG

Tonic Inhibition of skeletal muscle tone leading to paralysisRapid Eye MovementDreamingRelative poikilothermia (cold-bloodedness)Penile or clitoral tumescence Reduced sensitivity to sounds REM sleep is an awake mind in a paralyzed body.

SLEEP DEPRIVATION

Greatest effect observed on Cerebral cortex. The physical body gets rest from immobility but is unaffected by sleep.

A sleep deprived, is a sleep lost

Prior loss leads to more stage 4 sleep pattern & REM declines.

In sleep-deprived individuals there is significant effect on mind & body’s

Immunity-Lymphocyte levels decline

Glucose metabolism- Cortisol levels increase

Blood pressure rises

Increased Amygdala activation

Irritable mood.

EFFECTS OF SLEEP DEPRIVATION

Neurotransmitters in Sleep

Adenosine- The longer the person is awake the higher their adenosine levels

Caffeine- is an adenosine receptor antagonist (blocker)

Gamma-aminobutyric-acid (GABA) promotes sleep

Dopamine promotes wakefulness

Histamine promotes wakefulness

Hypocretin (Orexin) promotes wakefulness (deficient in narcolepsy)

Acetylcholine promotes REM sleep

Norepinephrine (Locus Ceruleus) turns REM sleep off

Serotonin (Raphe nucleus) turns REM sleep off.

CLASSIFICATION OF SLEEP DISORDERS

Sleep disorders are classified as primary or secondary on basis of medical condition or substance use

Primary sleep disorder:

Parasomnia: Abnormal events during sleep (behavior or physiology)

Dyssomnia: Disturbances in duration, quality, or timing of sleep.

Secondary sleep disorder:

Sleep disorders related to other mental disorder

Other sleep disorder (medical condition, substance related, etc)

Primary sleep disorders

Dyssomnias Parasomnias

Primary Insomnia Nightmare disorder

Primary hypersomnia Sleep terror disorder

Narcolepsy Sleep-walking disorder

Dyssomnias NOS

Periodic Leg movements

Restless Leg syndrome (RLS)

Post-traumatic hypersomnia

Kleine Levin syndrome

Parasomnia NOS (not otherwise stated)

Enuresis

Bruxism

Somniloquy

Rhythmic movement disorder

Breathing related sleep disorder

Dyssomnias

Dyssomnias are sleep disorders related to the quality, duration or timing of sleep, which results in a patient complaining about getting too little (insomnia) or too much sleep (hypersomnia)

Primary Insomnia: Trouble initiating or maintaining sleep, or not having restorative sleep. It is characterized by hyper arousal.

Not accountable for by medical condition or substance use.

Secondary insomnia

Due to medical, psychiatric or sleep disorder.

Chronic insomnias is associated with increased depression, reduced quality of life & more usage of health resources.

COMMON CAUSES OF INSOMNIA

Symptoms Medical Conditions Psychiatric or Environmental conditions

Difficulty Falling Asleep Any Pain or discomfort CNS lesions Conditions listed below

AnxietyTension anxiety, Muscular Envoirnmental changesCircardian rhythm sleep disorders

Difficulty Staying Asleep Sleep apnea syndromeNoctural myoclonus & Restless leg syndromeDietary factorsSubstance use (direct or withdrawal)Endocrine or metabolic diseasesInfections or neoplastic diseasesAging

Depression, especially 1˚ disorderPTSDSchizophrenia

Treatment for insomnias

Relaxation Techniques

Meditation (transcendal)

Sedative-hypnotics (Benzodiazepines, Antidepressants, Antipsychotic, Melatonin-receptor-agonist, anticonvulsants)

CBT (Cognitive Behavioral therapy) effective

Sleep restriction therapy

Sleep hygiene

Non-Pharmacological ways to induce sleep (Sleep hygiene)

Primary Hypersomnia

Rare & include excessive daytime sleepiness; more than average daily sleep.

Not due to medical condition or medication.

Narcolepsy: Reece williams slept over 23 hours & fell 25 times/day.

Excessive daytime somnolence ‘sleep attacks’ characteristic feature.

Distinguished from fatigue by duration which is <15 mins.

Sleep attacks precipitated by monotonous or sedentary activity.

Naps last 30-120 mins.

Tx: SSRI (Floxetine) Clomipramine, Imipramine, sodium oxybate.

Cataplexy:

Reported by 50% of the Narcoleptics

Brief (seconds to minutes) episodes of muscle weakness (Slurred speech, dropped jaw, buckled knee) or paralysis

Patient returns to completely normal after attack.

Usually triggered by strong emotions (Laughter, anger, excitement, sexual intercourse fear or embarrassment)

Sleep Paralysis

Temporary partial or complete paralysis in sleep-wake transitions

Conscious but unable to move or open eyes

“Scary experience” that lasts <1 min.

Sleep onset REM periods (SOREMPS)

Defined as appearance of REM within 15mins (Normal time 90mins)

Other associated features with narcolepsy:

Periodic leg movements

Sleep apnea

Frequent night awakenings

Memory problems

Ocular symptoms (blurring, diplopia)

Treatments :

Regular bedtime

Scheduled daytime naps

Safety considerations

Stimulants (Modanafil, Methyphenidate, amphetamine-dexatroamphetamine )

Daytime sleepiness Propanolol in high dose.

TCAs (Imipramine, Clomipramine, Desipramine)

SSRIs (Sertraline, Citalopram)

Breathing related sleep disorders

Characterized by sleep disruption that is caused by a sleep related breathing disturbance leading to excessive sleepiness, insomnia or hypersomnia. Breathing disturbances include apneas, hypoapneas & oxygen desaturation.

Apnea:

There are 3 types of apnea: Obstructive Central Mixed

Obstructive sleep apnea

Caused by cessation of air flow through mouth/nose in presence of continuing thoracic breathing movements, leading to oxygen saturation decrease & transient arousal from sleep.

Usually in middle-aged, obese men (Pickwickian syndrome)

Also common in small jaws, acromegaly & hypothyroidism

Loud snoring with intervals of apnea

Other symptoms: Daytime sleepiness, depression, fatigue. Anxiety/confusion.

Medical consequence: Arrhythmias, Inc Bp, Pulmunary HTN, sexual dysfunction.

Event lasts 10-20 seconds each.

Obstructive sleep apnea

Treatment:

Nasal continuous positive airway pressure

Surgery (Uvulopharyngoplasty).

Weight Loss

Medication: Buspirone, SSRI, TCAs.

Avoidance of sedatives & alcohol.

Apnea

Central Sleep apnea

Cessation of flow secondary to lack of respiratory effort.

Elderly

Tx: Mechanical ventilation or nasal CPAP.

Mixed Type:

Elements of Both obstructive & Central sleep apnea.

Circadian rhythm sleep disorder

Includes a wide range of conditions involving a misalignment between desired & actual sleep periods

Disturbance types include

Delayed sleep phase, Jet lag, shift-work, unspecified

Sleep quality is normal.

Self-limited.

Tx: Regular schedule of bright light therapy. Melatonin, natural hormone (Pineal gland) to induce sleep.

Dyssomnias (NOS)

Periodic Leg movement disorder- Stereotypical movements (20-60seconds)

Restless Leg Syndrome- Uncomfortable sensation in legs

Kleine-Levin Syndrome- Periodic disorder of episodic hyper somnolence (Young men- wake to only eat)

Triad comprises of hypersomnolence, hypersexuality & overeating. Lasts 1 dy-1 mth.

Menstruation-associated syndrome- Intermittent marked hypersomnia, altered behavior /appetite patterns

Post-traumatic hypersomnia Excessive sleepiness after head injury within past year.

Parasomnias

Sleep disorders in which undesired activities or behaviors are performed during sleep or in sleep-wake transitions.

Nightmare disorder: Nightmares occur more during REM sleep. They result in awakening from sleep at night.

No confusion/disorientation. (Meds causing: Beta blockers, TCAs, Alcohol, clozapine, L-dopa)

Sleep Terrors: Defined by sudden arousals from with autonomic & behavioral manifestation of extreme fear.

(screams or yells & does not remember next day).

Tx: Therapy or Diazepam.

Sleep walking (Somambulism) 3-4% children walk. There is confusion/agitation & retrograde amnesia.

Tx: Parental education & safety measures.

Parasomnias NOS REM behavior disorder (RBD): Usually with onset in men over 50. Unlike most people not paralyzed

during REM sleep & the patient ‘acts out their dreams’. Could be indicator of onset of Parkinsonism & can be related to brain injury, dementia, Multiple sclerosis.

Tx: Clonazepam or Carbamazepine.

Enuresis: Self-limited in children most commonly. Family history increases likelihood. New onset should be assessed for medical causes (Diabetes, apnea, nocturnal seizures, UTI, Spinal cord tumors & renal disease)

Rhythmic movement disorder: Head banging : rhythmic head jerking (less likely whole body jerking)

Bruxism: Defined as repetitive teeth grinding or clenching during sleep. Worsened by anxiety, stimulant medication & SSRI.

C/o- Dental pain, dental damage, muscular pain & headache.

Sleep talk (Somniloquy): Common in children & adults & found in all stages of sleep. No treatment.

Psychiatric disorders with Sleep symptomsSleep complains are common in psychiatric conditions.

Depression: Early morning wakenings, decrease sleep latency, trouble falling asleep/ staying asleep. Sometimes presents with hypersomnia.

Anxiety disorders (Panic disorder, PTSD, OCD, GAD): Insomnia, night panic attacks, increased arousal, Difficulty falling asleep.

Mood Disorders: (Depression, SAD, BAD Mania): Insomnia, hypersomnia, decreased sleep need.

Psychotic: (Schizophrenia) Insomnia, nightmares, Reversed sleep-wake cycle

Dementia: Insomnia, Reversed sleep-wake cycle

Alcoholism: Insomnia

ADHD: In children sleep apnea presents with behavioral problems (Consider tonsillectomy/ adenoidectomy)

Neurologic disorders with sleep symptoms

Stroke: There is increased risk of obstructive & central apnea but apnea may have existed prior to stroke.

Headaches: Cluster headaches may occur more in sleep. They can awaken a person often in first REM period.

Parkinsonism: 90% have sleep complaints, sleep fragmentation, daytime sleepiness & insomnia.

Features of Parkinsonism: Cogwheel rigidity, Resting tremors, bradykinesia.

Seizures: Sleep deprivation increases risk. Can be confused as sleep. Frontal seizures involve activities such as bicycling, vocalizations or running movement.

Dementia EEG finding –diffuse slowing while awake

Increased sleep fragmentation & less slow wave sleep.

Substance induced sleep disorders

Substances can contribute to a range of sleep symptoms ranging from insomnia, hypersomnia, parasomnia or a combination caused by use of medication or by intoxication or withdrawal from a drug of abuse.

Stimulants: Cocaine, Amphetamine, nicotine, Depressants: Alcohol, Opiates

Somnolence: Tolerance/Withdrawal from CNS stimulant or sustained use of CNS depressants.

Insomnia: Associated with tolerance to or withdrawal from sedative-hypnotic drugs, CNS stimulants & long term alcohol consumption.

Sleep problems might be side-effects of drugs (Thyroid preparations, antidepressants, antiepileptics)

Thank You