Sleep
Normal sleep physiology
See PPT talk on sleep.
Epworth sleepiness scale (validated in obstructive sleep
apnea)
Situation
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Scale
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Sitting and reading
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0 = no chance of dozing
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Watching TV
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1 = slight chance
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Sitting inactive in public place (theatre, meeting)
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2 = moderate chance
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Passenger in car for 1 hour
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3 – high chance
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Lying down to rest in afternoon if possible
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Sitting and talking to someone
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0-9 = normal
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Sitting quietly after lunch without alcohol
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10-24 = excessive daytime sleepiness
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In car, stopped for few minutes in traffic
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International Classification of Sleep Disorders
Dyssomnias (including
insomnias and excessive daytime sleepiness)
- Intrinsic
sleep disorders
- Psychophysiologic
insomnia – disorder of somatized tension and learned
sleep-preventing associations that result in a complaint of insomnia and
associated decreased functioning during wakefulness
- Sleep
state misperception – disorder in which a complaint of
insomnia or excessive sleepiness occurs without objective evidence of
sleep disturbance
- Idiopathic
insomnia – lifelong inability to obtain adequate sleep
that is primarily due to an abnormality of the neurological control of
the sleep-wake system
- Narcolepsy
– disorder characterized by excessive sleepiness that typically is associated
with cataplexy and other REM sleep phenomena such as sleep paralysis and
hypnagogic hallucinations
- Mechanism
- Inability to maintain a state of sleep/wake/REM
- Hypocretin/orexin A and B from posterolateral hypothalamus
- 90% narcoleptics have low CSF orexin
- Preprohypocretin (common precursor)
- Hcrt cells predominantly in posterior hypothalamus,
wake-promoting
- Project to arousal systems in brainstem
- HLA DQB1*0602 association, proposed autoimmune etiology
- Symptoms:
- Excessive daytime sleepiness
- Cataplexy – sudden bilateral muscle weakness
initiated by emotions
- Sleep paralysis (on awakening)
- Hypnagogic hallucinations
- Fragmented sleep, frequent awakenings
- Investigations:
- Polysomnogram to rule out and treat obstructive sleep apnea
first
- Multiple sleep latency test – 4-5
opportunities to nap 20 minutes q2h
- normal latency >10min, narcolepsy <5min
- Sleep-onset REM periods (SOREMPs) within 15 minutes
- 2 SOREMPs in a MSLT is diagnostic
- Management:
- Daytime sleepiness
- Methylphenidate (Ritalin) 10-30mg bid
- DA reuptake inhibitor
- Side effects – insomnia, stomachaches, diarrhea, anorexia,
weight loss, dry mouth, palpitations, arrhythmias, HTN
- Dextroamphetamine
- Modafenil 100-200mg bid
- Side effects – headache, nervousness, nausea, dry mouth,
Stevens-Johnson syndrome, behavioral changes
- Cataplexy
- Clomipramine 25-100mg qhs
- Tricyclic antidepressant
- Side effects – anticholinergic (dry mouth)
- Fluoxetine, venlafaxine (SNRI)
- Gamma-hydroxybutyrate (sodium oxybate) 1.5-4.5mg qhs + 2-3h
later
- GABA metabolite
- Reduces sleepiness and cataplexy, improves sleep architecture
- Side effects – morning sedation, nausea, urinary incontinence
- Date rape drug – tight control
- Recurrent
hypersomnia – disorder characterized by recurrent
episodes of hypersomnia that occur weeks to months apart, e.g., Kleine-Levin
syndrome (3M:1F, onset age 16, hypersomnia, hyperphagia, sexual
disinhibition, apathy/irritability, rarely delusions/hallucinations)
- Idiopathic
hypersomnia – disorder of presumed CNS cause
associated with normal or prolonged major sleep episode and excessive
sleppiness consisting of prolonged (1-2h) episodes of non-REM sleep
- Post-traumatic
hypersomnia
- Obstructive
sleep apnea syndrome – characterized by repetitive episodes
of upper airway obstruction during sleep resulting in oxygen desaturation
- Central
sleep apnea syndrome – characterized by cessation or decrease
of ventilatory effort during sleep usually with associated oxygen
desaturation
- Central
alveolar hypoventilation syndrome – syndrome
characterized by ventilatory impairment resulting in arterial oxygen
desaturation worsened by sleep in patients with normal lungs
- Periodic
limb movement disorder – characterized by
episodes of repetitive and highly stereotyped limb movements that occur
during sleep
- Restless
leg syndrome – disorder characterized by disagreeable
leg sensations, usually prior to sleep onset, that cuase an almost
irresistible urge to move the legs
- Intrinsic
sleep disorder NOS
- Extrinsic
sleep disorders
- Inadequate
sleep hygiene
- Environmental
sleep disorder
- Altitude
sleep disorder
- Insufficient
sleep syndrome
- Limit-setting
sleep sleep disorder
- Sleep-onset
association disorder
- Food
allergy insomnia
- Nocturnal
eating (drinking) syndrome
- Hypnotic-dependent
sleep disorder
- Stimulant-dependent
sleep disorder
- Alcohol-dependent
sleep disorder
- Toxin-induced
sleep disorder
- Extrinsic
sleep disorder NOS
- 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
- Circadian
rhythm sleep disorder NOS
Parasomnias
- Arousal
disorders
- Confusional
arousals – confusion during and following arousals from
sleep, most typically from deep sleep in the first part of the night
- Sleepwalking
– series of complex behaviours that are initiated during slow wave sleep
and result in walking during sleep
- Sleep
terrors – sudden arousal from slow wave sleep with a
piercing scream or cry, accompanied by automatic and behavioural
manifestations of intense fear
- Sleep-wake
transition disorders
- Rhythmic
movement disorder – stereotyped, repetitive movements
involving large muscles, usually of the head and neck, which typically
occur immediately prior to sleep onset and are sustained into light
sleep, e.g., head banging
- Sleep
start – sudden, brief contractions of the legs
(sometimes arms and head) which occur at sleep onset
- Sleep
talking
- Noctural
leg cramps
- 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 behaviour disorder – intermittent loss
of REM sleep EMG atonia with elaborate motor activity associated with
dream mentation
- More common in older men >60 years
- Precedes Parkinson disease, dementia w/ Lewy bodies, multiple
system atrophy by years
- Other
parasomnias
- Sleep
bruxism
- Sleep
enuresis
- Sleep-related
abnormal swallowing syndrome
- Nocturnal
paroxymal dystonia – repeated dystonia or dyskinetic
episodes stereotyped during NREM sleep – can respond to CBZ ?frontal
seizures
- Sudden
unexplained nocturnal death syndrome (SUND)
- Primary
snoring
- Infant
sleep apnea
- Congenital
central hypoventilation syndrome
- Sudden
infant death syndrome
- Benign
neonatal sleep myoclonus
- Other
parasomnia NOS
Sleep
disorders associated with mental psychiatric disorders
- Associated
with mental disorders
- Psychoses
- Mood
disorders
- Anxiety
disorders
- Panic
disorders
- Alcoholism
- Associated
with neurological disorders
- Cerebral
degenerative disorders
- Dementia
- Parkinsonism
- Fatal
familial insomnia
- Sleep-related
epilepsy
- Electrical
status epilepticus in sleep
- Sleep-related
headaches
- Associated
with other medical disorders
- Sleeping
sickness
- Nocturnal
cardiac ischemia
- Chronic
obstructive pulmonary disease
- Sleep-related
asthma
- Sleep-related
GERD
- Peptic
ulcer disease
- Fibrositis
syndrome
- Proposed
sleep disorders
- Short
sleeper
- Long
sleeper
- Subwakefulness
syndrome
- Fragmentary
myoclonus
- Sleep
hyperhidrosis
- Menstrual-associated
sleep disorder – insomnia or excessive sleepiness
related to menses or menopause
- Pregnancy-associated
sleep disorder
- Terrifying
hypnagogic hallucinations
- Sleep-related
neurogenic tachypnea
- Sleep-related
laryngospasm – episodes of abrupt awakening from
sleep with intense sensation of inability to breathe and stridor (more in
smokers and GERD)
- Sleep
choking syndrome