2. •2
Sleep disorders are common
Sleep disorders are serious
Sleep disorders are treatable
Sleep disorders are under diagnosed
Introduction
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3. •3
Sleep complaints are usually not due to
psychiatric conditions.
Most sleep disorders are readily
diagnosable and treatable
The studies include
Polysomnography (PSG)
Multiple sleep latency test (MSLT)
Actigraphy (It is a relatively non-invasive
method of monitoring human rest/activity
cycles)
Introduction …
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4. Polysomnography
All-night recording of:
Eye movement
Electroencephalogram( EEG)
Electrocardiogram(ECG)
Electromyogram (EMG) [technique for evaluating
and recording the activation signal of muscles]
Ear Oximetry (non-invasive method allowing the
monitoring of the oxygenation of a patient's
hemoglobin), air flow at nose and mouth
Thoracic and abdominal wall motion
Physiological assessment: Esophageal pH
•4
Common Diagnostic Tests
5. Multiple Sleep Latency
Test(MSLT)
Is a measure of daytime sleepiness:
five brief naps at 2hrs interval
the time necessary to fall asleep is measured for
each of the naps
EEG, EMG, eye movement are monitored.
•5
Common Diagnostic Tests
10. SleepCycle
•10
•Stage 1: Very light sleep
•Stage 2: Light sleep
•Stage 3: Deeper sleep
•Stage 4: Very deep sleep, most restorative
•Stage 5: REM sleep, when we dream
NREM
12. Insomnia - Definition
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Insomnia and excessive daytime sleepiness are primary complaints
regardless of the stage of the disease
Insomnia includes difficulty falling asleep, difficulty staying asleep, and
early morning awakening
Insomnia is not defined by the number of hours of sleep, but rather, by
an individual‘s ability to sleep long enough to feel healthy and alert
during the day.
The normal requirement for sleep ranges between 4 and 10 hours.
Insomnia is a symptom, not a disorder by itself•12
13. Insomnia - Assessment
___________________________
Determine the pattern of sleep problem
(frequency, associated events, how long it takes to go
to sleep, and how long the patient can stay asleep)
Include a full history of alcohol and caffeine intake and
other factors that might affect sleep
Review current medications that patient is taking to
eliminate these as possible causes
Take a history to rule out physical cause and/or
psychosocial cause
•13
14. Headache
Bad or vivid dreams
Problems of breathing
Chest pain/heartburn
Need to pass urine or
move bowels
Abdominal pains
Fever/night sweats
Leg cramps
Fear/anxiety
Depression
Possible Causes of Insomnia
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•14
15. Insomnia – Associated Problems
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•15
At least one (or more) of the following
Malaise (feeling of general discomfort or uneasiness)
Attention, concentration impairment
Social/ vocational dysfunction/ poor work
Mood disturbance or irritability
Daytime sleepiness
Proneness for errors or accidents at work or while
driving
Tension, headaches or gastrointestinal symptoms in
response to sleep loss
Concerns or worries about sleep
16. Medications that causes Insomnia
___________________________
•16
Type of medication Example
CNS stimulants D-amphetamine, Methyphenindrate
Blood pressure drugs - blockers, - blockers
Respiratory medicines Albuterol, Theophylline
Decongestants Phenylephine, Pseudoephedrine
Hormones Thyroxin, Corticosteroids
Other substances Alcohol, Nicotine, Caffeine
17. Types of Insomnia
________________________
Transient insomnia
< 4 weeks triggered by excitement or stress, occurs
when away from home
Short-term
4 wks to 6 months , ongoing stress at home or work,
medical problems, psychiatric illness
Chronic
Poor sleep every night or most nights for > 6
months, psychological factors (prevalence 9%)•17
18. Management of Insomnia
___________________________
Treat underlying causes whenever possible
Advise patient to avoid exercise, heavy
meals, alcohol, or conflict situations just
before bed
Plain aspirin or paracetamol in low doses
may be helpful; or give short-acting
hypnotics or a sedative
Treat underlying depression
•18
19. Non-Pharmacologic Management
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•19
Go to bed when sleepy
Get up the same time every morning
Get up when sleep onset does not occur in
20 min, and go to another room
No daytime napping
Reduce or stop Caffeine, Alcohol, Nicotine
Exercise < 4hrs before bed
Meditation, Yoga
Hypnosis to ↓ anxiety & tension at bedtime
Progressive muscle relaxation
22. BzRAs – side effects and safety
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Amnesia
Residual sedation – longer acting BzRAs
Abuse and dependence
Prolonged use can lead to withdrawal symptoms:
headache, irritability, dizziness, abnormal sleep
Rebound insomnia - triazolam
Increased fall risk, cognitive effects in the elderly
•22
23. Benzodiazepine use
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Benzodiazepines are the drugs of choice for the
treatment of insomnia.
Flurazepam can be used for up to one month with
little tolerance.
Temazepam can be used for up to three months with
little tolerance.
Intermittent use recommended (every three days).
Use for no longer than 3 – 6 months.
Benzodiazepines with short half lives may be best for
patients with difficulty falling asleep, but can produce
rebound insomnia
•23
25. Hypersomnia: Narcolepsy
Extreme daytime sleepiness
Frequent brief naps
Rare, familial, presents in 20s and 30s
Requires sleep study and daytime
Main Symptoms
Cataplexy (sudden, usually brief loss of muscle tone
induced by emotions.)
Sleep paralysis: A symptom of narcolepsy; paralysis
occurring just before a person falls asleep.
Hypnagogic hallucinations - REM sleep while
conscious
•25
26. Narcolepsy :Diagnosis
History
Multiple Sleep Latency Test(MSLT)
excessive daytime sleepiness
mean sleep latency than 5 minutes
Sleep onset REM
•26
28. Parasomnias
•28
Parasomnias are a category of sleep disorders that
involve abnormal and unnatural movements,
behaviors, emotions, perceptions, and dreams that
occur while falling asleep, sleeping, between sleep
stages, or arousal from sleep. Most parasomnias are
dissociated sleep states which are partial arousals
during the transitions between wakefulness and
NREM sleep, or wakefulness and REM sleep.
Types:
Restless Leg Syndrome
Night Terror
Sleepwalking (Somnambulism)
Sleep Enuresis
REM Sleep behaviour
29. Parasomnias: Restless Leg Syndrome
Intense dysesthesias (unpleasant abnormal
sensation), repetitive jerking
- Worse at bedtime
- Often awakens patient
- Often familial, progresses with age
Etiology unknown
May be caused by uremia, Iron deficiency anemia or
alcohol abuse.
Treatment
- Carbidopa-Levodopa 25mg/100mg qhs (70%
respond)
- Clonazepam 0.5-2 mg qhs
•29
30. Parasomnias: Night Terror
Sleep Terrors
Emerge from Stage 3-4 sleep
Autonomic arousal is interpreted as fear
Arousal is abrupt
Occurs primarily in children
Sudden arousal from slow wave sleep :
cry
automatic and behavioral manifestation of intense
fear(marked tachycardia, mydriasis sweating).The
child is agitated and confused.
lasts for few minutes, sleep resumes. Amnesia +
Treatment: reassurance, diazepam, imipramine
•30
31. Parasomnias: Sleepwalking (Somnambulism)
Emerge out of Stage 3 and 4 sleep
May overlap with night terror
Involves complex behavior
sitting up in bed, walking, dressing, eating and
even driving a car.
lasts few minutes
mostly in children
Treatment: reassurance, safety restraints and if
frequent consider diazepam
•31
32. Parasomnias: Sleep Enuresis
Involuntary micturation during sleep following
attainment of control while awake
usually idiopathic
may be caused by urogenital disease, or other
medical problem
it may represent delayed micturation
Treatment: bladder training, Imipramine
•32
33. Parasomnias: REM Sleep behavior
REM Behavior Disorder
A rare neurological disorder in which a person
does not become paralyzed during REM sleep,
and thus acts out dreams.
Experiments with cats. Lesions to cellular nucleus
in the medial medulla near LC. Form inhibitory
synapses with motor neurons.
Lack of REM atonia allows patient to enact his
dreams.
Motor activity may be harmful
most patients are elderly
The condition usually idiopathic
Neurological cause in 1/3rd.
Treatment: sleep study, clonazepam
•33
34. Sleep-Disordered Breathing
(Sleep Apnea)
Symptoms include loud snoring, choking,
gasping during sleep
Associated with daytime sleepiness
Risk factors include:
Older age
Male sex
CVD risk factors such as obesity
Sleep apnea’s are divided into two:
Central sleep apnea: (CSA) causes fragmented sleep
and consequent daytime somnolence.
Obstructive sleep apnea:(OSA) is characterized by
partial or complete closure of the upper airway, posterior
from the nasal septum to the epiglottis, during inspiration•34
35. Pathogenesis
Occlusion of the oropharyngeal airway results in progressive
asphyxia (condition of severely deficient supply of oxygen to the
body that arises from being unable to breathe normally) until
there is a brief arousal from sleep, whereupon airway patency
is restored and airflow resumes.
The patient then returns to sleep and the process is repeated,
up to 300 - 400 times per night & sleep becomes fragmented.
During wakefulness upper airway muscle activity is greater than
normal to compensate for airway narrowing and high airway
resistance
• Normal Snoring Sleep Apnea
•35
36. Etiology
•36
Obesity as a risk factor
Anatomical abnormalities like neck obesity,
narrow airway, and fixed upper airway lesions
(e.g., polyps, enlarged tonsils)
Alcohol
37. Diagnostic Tests of Sleep Apnea
Polysomnography is a detailed overnight
sleep study with recordings of:
ECG (arrhythmias), EEG (brain waves – level
of sleep )
Ventilatory variables: movement of chest wall
and airflow at the mouth and nose
Arterial O2 saturation (finger/ear-oximetry)
Heart rate
•37
38. Management
upper airway muscle tone: mild OSA – avoid alcohol and
sedatives
upper airway lumen size: 1.Mild to moderate OSA –weight
reduction, avoid supine position and use oral prosthesis to keep
airway patent
2.Severe OSA: Surgery (uvulopalatopharyngoplasty)
Bypass occlusion: severe OSA – tracheotomy
– Weight Loss
– Continuous Positive Airway Pressure (CPAP)
– Medication
The most important pharmacologic intervention is the avoidance
of all CNS depressants (e.g., alcohol, hypnotics) and drugs that
promote weight gain. There is no drug therapy for OSA.
Tricyclic antidepressants (TCAs) (i.e., imipramine, protriptyline),
and clonidine have effects on sleep architecture or upper airway
patency but do not clinically improve severity of OSA.
•38
39. •39
CIRCADIAN RHYTHM DISORDER
The sleep-wake cycle is under the circadian
control of oscillators and can be disrupted by
misalignment between an individual’s biologic
clock and external demands on the sleep cycle.
Circadian rhythm sleep disorders usually present
with either insomnia or hypersomnia, depending
on the individual’s performance requirements.
Two commonly occurring circadian rhythm sleep
disorders are jet lag and shift work sleep
problems.
40. Jet Lag
•Jet lag occurs when a person travels across time
zones, and the external environmental time is
mismatched with the internal circadian clock.
•Symptoms: malaise, insomnia / hypersomnia,
fatigue, poor performance, gastrointestinal
disturbance.
•Treatment: Short-acting benzodiazepine receptor
agonists or 0.5 to 5 mg melatonin taken at
appropriate target bedtimes
•40
41. Shift Work
• Night shift work causes a misalignment in the
sleep-wake cycle and circadian rhythm that is
associated with a decrease in alertness,
performance, and quality of daytime sleep.
•Treatment: Short-acting benzodiazepine receptor
agonists or 0.5 to 5 mg melatonin taken at
appropriate target bedtimes
•41
42. Principles of Sleep Hygiene
Sleep in cool, quiet, comfortable place.
Keep regular sleep-wake schedule.
When having trouble sleeping at night, avoid daytime
naps.
Exercise < 4hrs before bed.
Avoid caffeine, food close to bedtime.
Make bed a restful heaven for sleep.
Don’t worry about not getting enough sleep .
Change sleeping place, if unable to sleep.
•42
