Sleep Sleep DisordersDisorders

Importance of Sleep Importance of Sleep DisordersDisorders

Patients with sleep disorders Patients with sleep disorders suffer many different suffer many different problems, ranging from problems, ranging from Losing Losing JobsJobs (due to too many missed (due to too many missed days of work) to days of work) to Serious Serious AccidentsAccidents caused by tiredness caused by tiredness during driving.during driving.

Stages of SleepStages of SleepSlow wave sleep is actually 4 different Slow wave sleep is actually 4 different stages with different EEG patterns. stages with different EEG patterns.

StageEEG Rate

(Frequency)EEG Size

(Amplitude)

Awake 8-25 Hz Low

1 6-8 Hz Low

24-7 Hz

Occasional "sleep spindles"Occasional "K" complexes

Medium

3 1-3 Hz High

4 Less than 2 Hz High

REM More than 10 Hz Low

Classifications of Sleep Classifications of Sleep DisordersDisorders

ICD-10 classificationICD-10 classification

DSM IV classificationDSM IV classification

Simply, we can classify sleep Simply, we can classify sleep disorders asdisorders as

1- Insomnia.1- Insomnia.

2- Hypersomnia2- Hypersomnia

3- Circadian rhythm Disorders.3- Circadian rhythm Disorders.

4- Parasomnia.4- Parasomnia.

1-Insomnia1-InsomniaDifficulty falling asleep or staying asleep.Difficulty falling asleep or staying asleep.

Insomnia is actually NOT considered Insomnia is actually NOT considered a a disorderdisorder. It is considered . It is considered a symptoma symptom..

Acute: Acute: occasional trouble falling or occasional trouble falling or staying asleep & usually due to transient staying asleep & usually due to transient stress (Self limited).stress (Self limited).

Chronic: Chronic: continues for weeks or months, continues for weeks or months, it's important to consider possible causes.it's important to consider possible causes.

Chronic Insomnia: Chronic Insomnia: 1 in 10 people .1 in 10 people .

Chronic InsomniaChronic InsomniaUnderling Psychiatric CausesUnderling Psychiatric CausesAnxiety, Stress & Depression Anxiety, Stress & Depression account for as account for as much as 50% of the chronic insomnia cases.much as 50% of the chronic insomnia cases.

Primary Insomnia: Primary Insomnia: 20% of chronic insomnia. 20% of chronic insomnia.

- This disorder is usually caused by - This disorder is usually caused by

a combination of stress, poor sleeping a combination of stress, poor sleeping

habits & a form of conditioned anxiety.habits & a form of conditioned anxiety.

Medical Problems: Medical Problems: such as chronic pain such as chronic pain syndrome & trauma.syndrome & trauma.

Treatment of Treatment of InsomniaInsomnia

Relaxation.Relaxation.

Often, therapy for insomnia is Often, therapy for insomnia is directed at the underlying directed at the underlying cause of sleep disruption.cause of sleep disruption.

Improving “Sleep Hygiene”.Improving “Sleep Hygiene”.

Sleep HygieneSleep HygieneRoutine! GoRoutine! Going to bed at the same time ing to bed at the same time every night, waking up at the same time every night, waking up at the same time every morning.every morning.Eliminating nicotine, caffeine, alcohol Eliminating nicotine, caffeine, alcohol and other stimulants, including asthma and other stimulants, including asthma inhalers, before bed.inhalers, before bed.No napping!No napping!Clean sheets.Clean sheets.Taking a hot shower before bed (as Taking a hot shower before bed (as your body cools, you fall asleep).your body cools, you fall asleep).

More exercise.More exercise.

Limiting working/ studying in bed.Limiting working/ studying in bed.

No eating or drinking right before bed No eating or drinking right before bed (can cause arousal by stimulating (can cause arousal by stimulating digestive system & bladder).digestive system & bladder).

Setting aside a “worrying time” so Setting aside a “worrying time” so that worrying is not saved for right that worrying is not saved for right before bed.before bed.

Good sleeping environment Good sleeping environment (temperature & lighting should be (temperature & lighting should be controlled).controlled).

Drug Treatment of Insomnia: Drug Treatment of Insomnia:

Over The CounterOver The CounterThe vast majority of over-the-The vast majority of over-the-counter sleep aids contain counter sleep aids contain antihistaminesantihistamines, which are , which are associated with drowsiness. associated with drowsiness.

Unfortunately, they also tend to Unfortunately, they also tend to cause decreased memory & cause decreased memory & concentration, dry mouth, morning concentration, dry mouth, morning sickness, blurred vision, extended sickness, blurred vision, extended sedation & constipation.sedation & constipation.

Drug Treatment of Insomnia: Drug Treatment of Insomnia:

PrescriptionPrescriptionBenzodiazepinesBenzodiazepines have been the most popularly have been the most popularly prescribed hypnotic (sleeping pill).prescribed hypnotic (sleeping pill).Normally, many neurons in the brain are Normally, many neurons in the brain are inhibited by the neurotransmitter GABA.inhibited by the neurotransmitter GABA.Benzodiazepines bind to GABA receptors, thus Benzodiazepines bind to GABA receptors, thus potentiating this inhibition.potentiating this inhibition.There is a risk for developing drug dependency There is a risk for developing drug dependency with long-term use in some patients.with long-term use in some patients.Benzodiazepines can cause fatigue, dizziness, Benzodiazepines can cause fatigue, dizziness, confusion & blurred vision.confusion & blurred vision.

2-Hypersomnia2-HypersomniaExcessive daytime sleepiness.Excessive daytime sleepiness.

UnlikeUnlike those with chronic insomnia, those with chronic insomnia, only a small percentage of people only a small percentage of people with hypersomnia have an with hypersomnia have an underlying psychiatric problem. underlying psychiatric problem.

Nearly Nearly 85% 85% have one of three have one of three conditions: conditions: Sleep Apnea, Narcolepsy Sleep Apnea, Narcolepsy or Myoclonusor Myoclonus..

A. Sleep ApneaA. Sleep Apnea The Greek word “The Greek word “ApneaApnea” means ” means ““Without breathWithout breath”.”.

People with sleep apnea may People with sleep apnea may repeatedly repeatedly stop breathing stop breathing for for OVER OVER A MINUTE AT A TIME A MINUTE AT A TIME - as many as - - as many as - hundreds of times per night.hundreds of times per night.

The hallmark is very The hallmark is very loud snoring loud snoring - - the kind that sometimes wakes the the kind that sometimes wakes the neighbors.neighbors.

Obstructive Sleep Apnea Obstructive Sleep Apnea Obstructive sleep apnea (OSA): is Obstructive sleep apnea (OSA): is the most common typethe most common type of Sleep of Sleep Apnea.Apnea.

OSA is a breathing disorder, usually OSA is a breathing disorder, usually caused by partial blockage in the caused by partial blockage in the back of the throat back of the throat (Soft Palate)(Soft Palate). .

This region has This region has no rigid structure no rigid structure such as cartilage or bone to keep the such as cartilage or bone to keep the airway open.airway open.

Obstructive Sleep ApneaObstructive Sleep ApneaAs a person with OSA falls asleep, the As a person with OSA falls asleep, the musclesmuscles that hold the airway open during that hold the airway open during the day the day relaxrelax. The airway collapses & . The airway collapses & becomes obstructed. becomes obstructed.

When the airway closes, When the airway closes, breathing stops breathing stops & & the sleeper awakens to open the airway. the sleeper awakens to open the airway.

Because the person is continuously Because the person is continuously awakening to open his airway, he does not awakening to open his airway, he does not reachreach deep stage of REM sleep deep stage of REM sleep, which the , which the body needs to rest & replenish its strength.body needs to rest & replenish its strength.

Risk Factors of (OSA)Risk Factors of (OSA)Excessive Weight Gain: Excessive Weight Gain: The primary risk The primary risk factor for OSA. factor for OSA. Accumulation of Fat on The Sides of The Accumulation of Fat on The Sides of The Upper Airway: Upper Airway: causes it to become causes it to become narrow & predisposed to closure when narrow & predisposed to closure when the muscles relax. the muscles relax. Age:Age: is another prominent risk factor. As is another prominent risk factor. As muscle mass decreases in the airway muscle mass decreases in the airway with age & it may be replaced with fat.with age & it may be replaced with fat.MaleMale Hormones:Hormones: Men have a greater risk Men have a greater risk for OSA due to structural changes in the for OSA due to structural changes in the upper airway.upper airway.

Treatment of (OSA)Treatment of (OSA)Positional Therapy:Positional Therapy:

Attach a sock filled with tennis balls length-Attach a sock filled with tennis balls length-wise down the back of the patient’s pajama wise down the back of the patient’s pajama top or nightshirt. This makes it top or nightshirt. This makes it uncomfortable for the sleeper to lie on his uncomfortable for the sleeper to lie on his back.back.

Surgical Therapies.Surgical Therapies.

Oral Appliances: Oral Appliances: that physically keep the that physically keep the airway open during sleep.airway open during sleep.

Continuous Positive Airway Pressure: Continuous Positive Airway Pressure: The The most commonly prescribed therapy for OSA.most commonly prescribed therapy for OSA.

B. NarcolepsyB. NarcolepsyNarcolepsy is marked by a number of Narcolepsy is marked by a number of different symptoms, including persistent different symptoms, including persistent daytime sleepiness, cataplexy, daytime sleepiness, cataplexy, hallucinations hallucinations & & paralysisparalysis while falling while falling asleep or waking.asleep or waking.

Not all narcoleptics experience all of Not all narcoleptics experience all of these symptoms.these symptoms.

The first signs of narcolepsy usually The first signs of narcolepsy usually appear between the appear between the ages of ten & twentyages of ten & twenty..

Narcolepsy: CausesNarcolepsy: Causes

The cause of narcolepsy is The cause of narcolepsy is not not knownknown, but there seem to be both , but there seem to be both hereditary & environmental factors hereditary & environmental factors involved.involved.

The The locus coeruleus locus coeruleus also plays a also plays a role in narcolepsy.role in narcolepsy.

CataplexyCataplexyCataplexy is the sudden, temporary loss Cataplexy is the sudden, temporary loss of of skeletal muscle skeletal muscle tone without loss of tone without loss of consciousnessconsciousness..

The The eye muscles eye muscles are not affected during are not affected during cataplexy. cataplexy.

Cataplexy is usually triggered by Cataplexy is usually triggered by strong strong emotionemotion (shock, anger or embarrassment, (shock, anger or embarrassment, even even athletic activities athletic activities oror sexual sexual intercourseintercourse..

Narcolepsy: TreatmentNarcolepsy: TreatmentGetting Sufficient Sleep: Getting Sufficient Sleep: (Sleep Hygiene).(Sleep Hygiene).

Changing Sleeping Patterns: Changing Sleeping Patterns: Spreading Spreading out 8 hours of sleep throughout a 24-hour out 8 hours of sleep throughout a 24-hour period.period.

Drug Therapies:Drug Therapies:1. Stimulants:1. Stimulants: For excessive daytime For excessive daytime sleepiness (Ritalin).sleepiness (Ritalin).2. Antidepressants & Antipsychotics:2. Antidepressants & Antipsychotics: For For cataplexy, hallucinations & sleep cataplexy, hallucinations & sleep paralysis.paralysis.

C. MyoclonusC. MyoclonusMyoclonus refers to abnormal Myoclonus refers to abnormal twitching of the twitching of the Calf Muscles Calf Muscles during sleep & accounts for during sleep & accounts for about 10% of hypersomnia about 10% of hypersomnia cases.cases.

3- Circadian Rhythm Disorders3- Circadian Rhythm Disorders

Abnormal timing Abnormal timing of sleep-wake of sleep-wake cycles.cycles.

Circadian rhythm disorders include Circadian rhythm disorders include the common "the common "jet lagjet lag" syndrome, as " syndrome, as well as well as sleeping too late sleeping too late or or awakening too early awakening too early because of because of irregular shift work -- a common irregular shift work -- a common cause of cause of on-the-job accidentson-the-job accidents..

4- Parasomnias4- ParasomniasAbnormal Abnormal stages stages of sleep.of sleep.

Parasomnias are disorders in Parasomnias are disorders in which the normal which the normal ""architecturearchitecture" of sleep is " of sleep is distorted or disrupted.distorted or disrupted.

Parasomnias DisordersParasomnias Disorders1- Sleepwalking (Somnambulism). 1- Sleepwalking (Somnambulism). 2- Abnormal REM Behavior Disorder: 2- Abnormal REM Behavior Disorder: Agitated or Violent Behavior.Agitated or Violent Behavior.3- Hallucinations/ Confusion upon 3- Hallucinations/ Confusion upon awakening awakening 4- Nocturnal Enuresis & Encopresis.4- Nocturnal Enuresis & Encopresis.5- Familial Sleep Paralysis.5- Familial Sleep Paralysis.6- Nocturnal Headache.6- Nocturnal Headache.7- Nocturnal Epilepsy.7- Nocturnal Epilepsy.8- Burxism.8- Burxism.9- Painful Penile Erection.9- Painful Penile Erection.10- No Nocturnal Penile Erection.10- No Nocturnal Penile Erection.

Diagnosis of Sleep DisordersDiagnosis of Sleep Disorders

A Careful Medical History: A Careful Medical History: is needed is needed to determine the presence & severity to determine the presence & severity of concomitant disease. of concomitant disease. Bed Partner or Other Observers: Bed Partner or Other Observers: To To describe snoring, breathing pauses describe snoring, breathing pauses or periodic movements during sleep. or periodic movements during sleep. Prescribed Medications:Prescribed Medications: especially especially sedatives, alcohol use & self sedatives, alcohol use & self medication can have a significant medication can have a significant effect on sleep & may impair cardio-effect on sleep & may impair cardio-pulmonary functions during sleep.pulmonary functions during sleep.

Psychiatric History & Evaluation: Psychiatric History & Evaluation: Identify anxiety, depression or major Identify anxiety, depression or major life events which are known to affect life events which are known to affect sleep habits. sleep habits.

Appropriate Physical Examination:Appropriate Physical Examination: depends upon the nature of the depends upon the nature of the complaint & history elicited from the complaint & history elicited from the patient (For example, heavy snoring patient (For example, heavy snoring may necessitate a detailed examination may necessitate a detailed examination of the nose & throat). of the nose & throat).

Appropriate Laboratory Tests: Appropriate Laboratory Tests:

May be similarly indicated.May be similarly indicated.

What Are the Indications for What Are the Indications for Treating of Sleep Disorders?Treating of Sleep Disorders?

Goals of Therapy: Goals of Therapy:

Reducing Reducing MorbidityMorbidity..

Reducing Reducing Excess MortalityExcess Mortality. .

Improving Improving Quality of Life Quality of Life

for patient & his family.for patient & his family.