1.By Nagaraju B 1 Sleep Disorder

2. 2 Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed Introduction ___________________________ 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 ___________________________ 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 6. 6 7. Wake System ___________________________ 7 8. Sleep System ___________________________ 8 9. Sleep Wake Cycle ___________________________ 9 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 11. Types of Sleep Disorders ___________________________ 11 1. Insomnia. 2. Hypersomnia. 3. Parasomnia. 4. Sleep Related Breathing Disorders (Sleep Apnea). 5. Circadian Rhythm Sleep Disorder. 12. Insomnia - Definition ___________________________ 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 individuals 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 itself12 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 ___________________________ 14 15. Insomnia Associated Problems ___________________________ 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 __________________________ 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 20. Pharmacologic Management __________________________ 20 Benzodiazepines Lorazepam (1-6mg) Clonezepam (0.5-5mg) Temazepam (10-20mg) Flurazepam (15-30mg) Alprazolam (0.25-1mg) Triazolam(0.125-0.25mg) Non Benzodiazepines Zolpidem (10-20mg HS) 21. Other classes of Medications __________________________ 21 Melatonin Receptor Agonists Melatonin (2-10mg) Antidepressants Trazadone (500-200mg) Mirtazapine (15-45mg) Doxepin (50-150mg) Amitryptyline (50-200mg) Antipsychotics Olanzapine (2.5-10mg) 22. BzRAs side effects and safety __________________________ 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 ____________________________ 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 24. Barbiturates ____________________________ Drug Dose (mg) Duration of action Half-life Phenobarbitone 30-210 Long 24 140 hrs. Amobarbital 50-200 Short- intermediate 8 42 hrs. Pentobarbital 150-200 Short- intermediate 15 48 hrs. Secobarbital 8-250 Short- intermediate 19 34 hrs. 24 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 27. Drugs Used to Treat Narcolepsy 27 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 apneas 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 inspiration34 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 individuals biologic clock and external demands on the sleep cycle. Circadian rhythm sleep disorders usually present with either insomnia or hypersomnia, depending on the individuals 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. Dont worry about not getting enough sleep . Change sleeping place, if unable to sleep. 42 43. Thank you Have a nice Sleep 43