OVERVIEW OF SLEEP DISORDERS

Gina S. de los Reyes, MD, FPCP, FPCCP, FPSSM

Objective:

to give a general overview of the evaluation and management of common sleep disorders

Overview of Sleep Disorders

Sleep related breathing disorders

ex . Obstructive sleep apnea

Sleep Related Movement disorders

ex. Restless legs syndrome & Periodic limb movement disorder

Insomnia

Hypersomnias of central origin

ex. Narcolepsy

Circadian Rhythm sleep disorders

Parasomnias

International Classification of Sleep Disorder (ICSD-2)

3 Cardinal Clinical presentations of sleep disorders

Insomnia

Excessive daytime sleepiness

Abnormal movements or behaviors in sleep

Obstructive Sleep Apnea

Characterized by repetitive episodes of upper airway obstruction that occur during sleep

usually associated with a reduction in blood oxygen saturation

Pathophysiology of OSA

Reduced cross-sectional area of the upper airway lumen due to either: excessive bulk of soft tissue (tongue, soft

palate, lateral pharyngeal walls) OR

craniofacial anatomy or both

Upper airway patency is dependent on pharyngeal dilating muscles; activity of which decreases during sleep onset

AWAKE

SLEEP

Inadequate Anatomy

Compensatory Pressure Reflexes

Activity of Pharyngeal Dilators

Upper Airway Patency Maintained

UA Muscle tone Lung Volume Central Resp.Drive

Endothelin Vagus

Cardiovascular Sequelae

Sympathetic Activation

AROUSAL Respiratory Effort

Airway Collapse

O2 CO2

Clinical Presentation

Loud snoring

Witnessed obstructive events during sleep in a habitual snorer

Observed apnea

Interrupted snoring pattern

Nocturnal gasping or choking

Severe sleepiness

Obstructive sleep apnea

Complications of OSA

Loss of alertness

Cardiovascular complications Systemic hypertension

Pulmonary artery HPN

Myocardial infarction

Cerebrovascular disease

Cardiac arrhythmias

Metabolic syndrome

Treatment options: CPAP

Gold standard for treatment of moderate-severe OSA

may be given trial basis-for milder cases; when contribution to symptoms not clear

65-90%compliance rate

Treatment options

Overview of Sleep Disorders

Obstructi ve sleep apnea

Restless legs syndrome & Periodic limb movement disorder

Psychophysiologic insomnia

Narcolepsy

Circadian disorders

Parasomnias

Restless Legs Syndrome

a sensorimotor disorder in which patients experience an irresistible desire to move the legs (akathisia)

uncomfortable or frankly painful sensation within the legs

brought on by rest, relieved with moving or walking

occur primarily at night or in the evening

Pathophysiology of RLS

Genetic basis

Dopamine imbalance dopamine (affects movement) naturally falls at

night

symptoms worse late in the day & at night

Iron deficiency Iron is important to the production of dopamine

low iron levels are often linked to RLS symptoms

Restless Legs Syndrome & Periodic Limb Movement Disorder

RLS is a symptom - awake

PLMD is an EMG finding – asleep

RLS & PLMD frequently overlap

Neither is necessary nor sufficient to make the diagnosis of the other

Periodic Limb Movement Disorder

Predisposing Conditions-RLS/PLMD Anemia (iron deficiency)

Folate /B12 deficiency

Chronic renal failure

Pregnancy

Peripheral nerve disease

Hypothyroidism

Medications (SSRIs, TCAs, caffeine)

Treatment RLS/PLMD

Regular sleep-wake schedule

Avoid caffeine, alcohol, smoking

Treat secondary causes – iron deficiency, folate deficiency, renal failure

L-Dopa, dopamine agonists, gabapentin, benzodiazepines, opioids

Overview of Sleep Disorders

Obstructi ve sleep apnea

Restless legs syndrome & Periodic limb movement disorder

Psychophysiologic insomnia

Narcolepsy

Circadian disorders

Parasomnias

Insomnia & decreased functioning

during wakefulness

Learned sleep preventing associations – “trying too hard to sleep”

Increased somatized tension (agitation)

sleep latency, number & duration of awakenings, sleep efficiency

Psychophysiologic Insomnia

Psychophysiologic insomnia

Predisposing factors

Perpetuating factors

Precipitating factors

Insomnia – Cognitive Behavioral Therapy

Technique Patient symptoms

Stimulus control Delayed sleep onset

Sleep restriction Excessive time spent in bed; fragmented or poor sleep quality

Relaxation High physiologic, cognitive, or emotional arousal

Cognitive Racing or obsessive thoughts around bedtime

Sleep hygiene education

Any of the above or general poor sleep hygiene

Insomnia - Rx

Elimination Half lives (hrs)

Overview of Sleep Disorders

Obstructi ve sleep apnea

Restless legs syndrome & Periodic limb movement disorder

Psychophysiologic insomnia

Narcolepsy

Circadian disorders

Parasomnias

Pathologic Sleepiness-Narcolepsy

Sudden intrusion of REM sleep during wakefulness

Excessive daytime sleepiness

REM Dysregulation

Cataplexy – sleep attacks

Sleep paralysis

Hypnagogic hallucinations

Absent hypocretin/orexin in CSF

Narcolepsy

Narcolepsy Treatment

Sleepiness

Alerting agents – ex. Provigil

Stimulants – ex. Dexedrine

Naps – 20 mins

Hydroxybutyrate

Cataplexy

REM suppressing drugs – Ex. Effexor

SWS promoting drugs – Ex. Hydroxybutyrate

Overview of Sleep Disorders

Obstructi ve sleep apnea

Restless legs syndrome & Periodic limb movement disorder

Psychophysiologic insomnia

Narcolepsy

Circadian Rhythm sleep disorders

Parasomnias

Circadian Rhythm Disorders

Advanced sleep phase

Delayed Sleep phase

Irregular sleep wake type

Free-running type

Shift work sleep disorder

Time Zone Change (Jet lag) Syndrome

Circadian Rhythm Disorders

Advanced Sleep Phase Delayed Sleep Phase

“Early bird”

earlier sleep onset & earlier awakening than desired

Common with aging (>50 yo)

Sometimes confused with depression, OSA, narcolepsy

“Night owl “

later sleep onset & later awakening than desired

Common in teenagers

complaint of insomnia

May develop chemical dependency, viewed as lazy

CRSD-Treatment

melatonin

Light exposure

CRSD-Treatment

Advanced Sleep Phase Delayed Sleep Phase

Fix bed time

Exposure to bright light in late-afternoon or evening

Melatonin in am

Exercise in afternoon

Fixed wake-up time

Avoid light exposure in the evening

Exposure to am light

Melatonin in early evening

No more than 1 hr shift in wake-up time on weekend

Shift work disorder

diagnosed by the presence of excessive sleepiness (ES) and/or insomnia for ≥1 month during which the individual is performing shift work

Michael J. Thorpy, MD, Supp Jour of Family Practice n Vol 59, No 1 / January 2010

Sleep/wake patterns of day & night-shift workers

Michael J. Thorpy, MD, Supp Jour of Family Practice n Vol 59, No 1 / January 2010

Shift work disorder treatment

Avoid > 4 consecutive 12-hour night shifts

planned napping before, or on the job

bright light during work

stimulant medication- ex. Caffeine, modafinil, methamphetamine

sunglasses for the morning commute

melatonin prior to daytime sleep

hypnotic medication-

ex. zolpidem

Jet Lag

temporary mismatch between the timing of the sleep & wake cycle generated by the endogenous circadian clock & that of the sleep-wake pattern required by the change in time zone

Jet Lag symptoms

Disturbed sleep

Impaired daytime alertness & performance

Gastrointesinal problems

Loss of appetite

Inappropriate timing of bowel movement

Excessive desire to urinate during the night

~1 day for each hour of time zone change for adaptation to be complete

Jet Lag treatment

Adequate sleep must be ensured at the destination time zone

Naps prior to, or during the flight

Avoid naps during the day at the destination

should wait for the night time of the destination before retiring

daytime rather than overnight flights

Melatonin 0.3 to 0.5 mg in evening if eastward

Overview of Sleep Disorders

Obstructi ve sleep apnea

Restless legs syndrome & Periodic limb movement disorder

Psychophysiologic insomnia

Narcolepsy

Circadian disorders

Parasomnias

Parasomnias

Non - REM related

Night terror

Sleep walking

REM related

REM sleep behavior disorder

Sleep paralysis

Other parasomnias

Sudden unexplained nocturnal death syndrome(SUNDS)

Parasomnia - Night Terror

Slow wave sleep (1st half of the night)

Initial scream

Difficult to arouse

Amnesia for episode

Peak in children age 4 to 12

Resolve around adolescence

Exacerbated by disruptions of sleep (OSA)

Sleep Terrors

Parasomnia – Sleep Walking

Passive walking during sleep

Slow wave sleep (1st half of the night)

Difficult to arouse

Peak in children age 4 to 8

Resolve in adolescence

Increased in families

Exacerbated by disruptions of sleep (OSA)

Sleep walking

REM Sleep Behaviour disorder

Complaint of violent or injurious behavior during sleep

Limb or body movement is associated with dream mentation

Look for underlying secondary causes (drugs, alcohol, neurological)

Clonazepam 0.5-1 mg initially

Advice on bedroom safety precautions

REM Sleep Behaviour disorder

Sleep paralysis

consists of a period of inability to perform voluntary movements either at

sleep onset (called hypnogogic form) or

upon awakening (called hypnopompic form)

brain awakes from a REM state, but the body paralysis persists (REM atonia)

Sleep paralysis

Sleep paralysis

Occurs at least once in a lifetime in 40%-50% of normal subjects

Isolated, familial, or symptom of narcolepsy

Predisposing factors

Irregular sleep habits

Sleep deprivation

Mental stress, overtiredness, sleeping in supine position

Excessive alcohol consumption

Sudden Unexplained Nocturnal Death syndrome (SUNDS) sudden death during sleep in healthy young

adults, particularly of Southeast Asian descent

“non-laita “ (sleep death) in Loatian

“bangungut “ (to arise & moan) in Tagalog

“pokkuri” (sudden death) in Japanese

Sudden Unexplained Nocturnal Death syndrome Male sex

Choking, gurgling, gasping, or labored breathing

occurs during habitual sleep period

history of prior sleep terrors

Cardiac studies of survivors - spontaneous ventricular fibrillation after initial resuscitation

Sudden Unexplained Nocturnal Death syndrome

Brugada syndrome -

is the major cause of SUNDS

causing sudden death by causing Vfibrillation

associated with mutation(s) in the SCN5A gene that encodes for the Na channel in the cell membranes of the myocytes

Sudden Unexplained Nocturnal Death syndrome

Genetic testing, ECG pattern

Treatment : Implantable cardioverter-defribrillator (ICD)

Cardinal Clinical presentations of sleep disorders

Insomnia :

Psychophysiologic insomnia, RLS/PLMD, CRSD

Excessive daytime sleepiness:

OSA, Narcolepsy, CRSD

Abnormal movements or behaviors in sleep

Parasomnias, PLMD

Sleep Disorders: Conceptual Framework

Insufficient Sleep (Sleep deprivation)

Fragmented Sleep (Sleep disruption)

Excessive daytime somnolence

Primary disorders of EDS

THANK YOU FOR YOUR ATTENTION!!!

Sleep Disorders presenting with Insomnia

Insomnia

Sleep Related Movement Disorders: Restless Legs Syndrome (RLS)

Circadian Rhythm Sleep Disorders

Sleep Disorders presenting with Excessive Daytime Sleepiness

Sleep Related Breathing Disorders:OSA

Hypersomnias of Central Origin

Narcolepsy

Klein-Levin Syndrome

Idiopathic Hypersomnia

Circadian Rhythm sleep disorders

Jet Lag, Shift Work, Delayed & Advanced Sleep Phase syndromes

International Classification of Sleep Disorders

I. Dyssomnias A. Intrinsic Sleep Disorders

B. Extrinsic Sleep Disorders

C. Circadian Rhythm Sleep Disorders

II. Parasomnias A. Arousal Disorders

B. Sleep Wake Transition Disorders

C. Parasomnias usually associated with REM sleep

D. Other Parasomnias

International Classification of Sleep Disorders

III. Sleep Disorders associated with mental, neurologic, or other medical disorders

A. Associated with Mental Disorders

B. Associated with Neurologic Disorders

C. Associated with other Medical Disorders

IV. Proposed Sleep Disorders

Sleep Disorders presenting with Abnormal Movements or Behaviors in Sleep Non REM Parasomnias

Confusional arousals

Sleepwalking

Sleep terrors

• REM Parasomnias

Nightmare disorder

REM Behaviour disorder

• Sleep related movement disorders

RLS, PLMD

I. Dyssomnias

Disorders that produce either difficulty initiating or maintaining sleep or excessive sleepiness

A. Intrinsic Sleep Disorders

Psychophysiologic Insomnia

Sleep state misperception

Idiopathic insomnia

Narcolepsy

Recurrent Hypersomnia

Idiopathic Hypersomnia

Post traumatic hypersomnia

Obstructive sleep apnea

Central sleep apnea

Central alveolar hypoventilation syndrome

Periodic Limb Movement disorder

Restless legs Syndrome

B. Extrinsic Sleep Disorders

Inadequate sleep hygiene

Environmental sleep d/o

Altitude Insomnia

Adjustment Sleep d/o

Insufficient sleep syndrome

Limit-setting sleep d/o

Sleep-onset assocn d/o

Food allergy insomnia

Nocturnal Eating (Drinking) syndrome

Hypnotic-dependent sleep d/o

Stimulant-dependent sleep d/o

Alcohol-dependent sleep

Toxin-induced sleep d/o

C. Circadian-Rhythm Sleep Disorder Time Zone Change (Jet lag) Syndrome

Shift work sleep disorder

Irregular sleep-wake pattern

Delayed sleep-phase syndrome

Advanced sleep-phase syndrome

Non-24 hour sleep wake disorder

II. Parasomnias

Disorders that intrude into the sleep process and are not primarily disorders of sleep and wake states per se

Manifestations of CNS activation, usually transmitted through skeletal muscle or ANS

A. Arousal Disorders

Confusional arousals

Sleepwalking

Sleep terrors

B. Sleep-wake transition disorders Rhythmic movement d/o

Sleep starts

Sleep talking

Nocturnal leg cramps

C. Parasomnias usually associated with REM sleep Nightmares

Sleep paralysis

Impaired sleep related penile erections

Sleep related painful erections

REM sleep-related sinus arrest

REM sleep behavior d/o

D. Other parasomnias

Sleep bruxism

Sleep enuresis

Sleep related abnormal swallowing syndrome

Nocturnal paroxysmal dystonia

Sudden unexplained nocturnal death synd

Primary snoring

Infant sleep apnea

Congenital hypoventilation synd

Sudden infant death synd

Benign neonatal sleep myoclonus

III. Sleep d/o associated with mental, neurologic, or other medical d/o Are not primarily sleep d/o but are mental,

neurologic, or other medical d/o that have either sleep d/b or excessive sleepiness as a major feature of the d/o

A. Associated with Mental Disorders Psychoses

Mood disorders

Anxiety d/o

Panic d/o

alcoholism

B. Associated with Neurologic d/o Cerebral degenerative d/o

Dementia

Parkinsonism

Fatal familial insomnia

Sleep related epilepsy

Electrical status epilepticus of sleep

Sleep related headaches

C. Associated with Other Medical Disorders

Sleeping sickness

Nocturnal cardiac ischemia

COPD

Sleep related asthma

Sleep related gastroesophageal reflux

Peptic ulcer disease

fibromalgia

Parasomnias – REM Behavior disorder Injurious behavior during sleep

Acting out of dreams

Increased EMG during REM

Increased in older men

Increased with pontine lesions

Increased association with Parkinson’s disease