Introduction to Sleep and Sleep Disorders : Introduction to Sleep and Sleep Disorders Steven M. Scharf MD, PhD
Slide2 : Sleep Disorders - Socioeconomic Consequences 40 million Americans suffer from chronic disorders of sleep and wakefulness.
95% of these remain unidentified and undiagnosed.
The annual direct cost of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs (accidents, litigation, property destruction, hospitalization, and death).
What else about sleep? : What else about sleep? Sleep disorders are common
Sleep disorders are serious
Sleep disorders are treatable
Sleep disorders are underdiagnosed
Sleep - Definition : Sleep - Definition A very complex orchestration of physiological and behavioral processes.
Unlike coma: physiologic, recurrent, and reversible.
Slide5 : Sleep is NOT the absence of wakefulness Active
Complex
Highly Regulated
Involves different areas in the brain
Purpose is not understood
Essential to life
We all do it
Slide6 : Sleep Positions
Slide7 : State Generators
Slide8 : Sleep States of Being (adults)
Slide9 : Wake / Sleep Pattern Development
Slide10 : The Cyclic alteration of wakefulness, NREM and REM defines two rhythms
CIRCADIAN RHYTHM - daily (24 hour) biorhythms
hormonal (almost all)
temperature
BP
drug metabolism
sleep state
SLEEP STATE ASSOCIATED RHYTHMS
Slide12 : Sleep Academic Award 12 Circadian Rhythms Suprachiasmatic Nuclei (SCN) Output Rhythms
Physiology
Behavior
Slide14 : Disruption of Circadian Rhythms Aging
Many physiological and behavioral circadian rhythms are altered with advanced age:
The most notable are changes in sleep, such as earlier onset of sleepiness, early morning awakening and increased daytime napping ( 33% of older people).
Decrease in the amplitude of various circadian rhythms, including hormonal rhythms, are associated with advanced age.
Slide15 : Jet Lag Temporary desynchronization between internal circadian rhythms and external time cues
Symptoms: Malaise; Insomnia / hypersomnia; Fatigue; Poor performance
Slide16 : Shift Work Chronic desynchronization of internal circadian and external time cues
Symptoms:
Insomnia / hypersomnia; Fatigue; Poor performance; Medical / psychiatric illness; Drug abuse; Social impact
Sleep structure : Sleep structure
State Determination : State Determination Behavioral
Electrographic
Neuronal state Within each state, there is ongoing variability and fluctuation of brain/neural activity.
Polygraphic Monitoring : Polygraphic Monitoring
Slide21 : 75mn 1 sec. Stage 3 EYES Brain waves Muscle tone EKG
Slide22 : Stage REM EYES Brain waves Muscle tone EKG
Sleep Medicine Introduction : Sleep Medicine Introduction 88 recognized sleep disorders
Breathing disorders
Sleep Apnea
Neurological
Restless legs syndrome
Psychiatric
Depression
Medical
Drug associated
Alcohol, hypnotics, stimulants
Circadian Rhythms
Phase shift syndromes
Abnormal Behaviors
Sleep walking
Night terrors
Slide24 : A 27 year-old nurse is referred for evaluation of excessive daytime sleepiness. She carries a diagnosis of “narcolepsy.” In spite of having to struggle every day, she finished nursing school and works as a research nurse in a prestigious institution. She has tried stimulant with no help. She was diagnosed with depression and is taking an antidepressant with no change in symptoms. She notes that in the early evening she experiences a “funny feeling” in her calves, best described as a drawing or pulling. She thinks this improves with movement, and does try walking around. Her mother and an aunt all have the same symptoms.
A sleep study was performed: Here it is:
CASE
Slide25 : Arousals following limb movements
Limb movements Periodic Limb Movement disorder EEG1 EOG EMG Chin Airflow Resp Effort EMG Leg EEG2 EEG3 EEG4 Arousals following limb movements
Limb Movements
Slide26 : Diagnosis: Restless Legs Syndrome/Periodic Limb movement disorder
Treatment: pramapaxole (anti-parkinson’s drug)
Outcome: Terrific. She feels refreshed in the morning and functions well all day (you didn’t think I would write about any treatment failures, did you?)
Slide27 : Restless legs syndrome and periodic limb movements of sleep RLS
Characterized by an almost irresistible urge to move, usually associated with disagreeable leg sensations , worse during inactivity, and often interfering with sleep (akisthesia).
Symptoms worse at rest, partially relieved by activity
Symptoms worse in the evening or at night
Periodic limb movements: found on polysomnography
Stereotypic movements of legs (or arms) during sleep
90% pts with RLS
May be independent
May disturb sleep
Both of these may be “Primary” or secondary to a variety of medical conditions or drug therapies.
Slide28 : Posted by sleepless Sam on April 19, 2002 at 09:07:23:
In Reply to: Sorry to keep bothering everyone..... posted by Melanie on April 19, 2002 at 07:31:23:
Hi Melanie,
…. I suffer from chronic insomnia, this has been going on for 2 years now. I am also desperate. I stayed awake the whole of last night and have had zero sleep. My muscles also ache with pain, I have no energy or enthusiasm to do anything. I just feel like no-one can help me, I've done the whole doctors thing, herbal thing, sleeping pills thing, alternative medicine eg. acupunture, hypnotherapy, etc. I JUST WANT MY LIFE BACK. ...I've seen so many doctors, all they've tried to do is put me on sleeping pills or anti-depressants, they are such a joke! Why can't somebody find a cure for insomnia that doesn't involve sleeping pills?? The funny thing is that insomnia makes you depressed, we all know if we could just get some decent deep sleep, we would all be back to our normal selves! … before I got insomnia I had a real love for life and had boundless energy, I am only 27 but feel like a 60 year old. …Its terrible, just remember that there are the rest of us out here also and we're all going through it together.
Lets try to not let us defeat us or our spirits!!
Good luck with everything,
INSOMNIA: From an Internet posting
Slide29 : Insomnia Affecting up to 30% of the adult population at one time
Chronic insomnia
8% of men; 12% women
Usually a symptom and not a disorder in and of itself
Often the symptom of many underlying medical, psychiatric (particularly depression) and psychological conditions.
Insomnia may be the presenting symptom of primary
sleep disorders
15 – 20% of insomniacs are “primary” meaning have no organic or psychologic cause
Slide30 : Insomnia Treatment Treat underlying medical or psychiatric condition if there is one
Pharmacologic: sleeping pills
For transient insomnia
Less useful for chronic insomnia – but used in selected cases
Cognitive – Behavioral therapy:
Most useful for chronic insomnia
Sleep Habits and behavioral modification
Slide31 : Inadequate Sleep Hygiene Extremely common – we go 24/7 Fix a bedtime and fix an awakening time
Avoid napping during the day
Avoid alcohol before bed
Avoid caffeine containing beverages 4 – 6 hours before bedtime
Avoid heavy, spicy, or sugary foods before bed
Regular exercise is good, not before bedtime
Comfortable bedding
Bedroom cool, dark, quiet
Bedroom reserved for sleep and sex – NOT a work room
Slide32 : Sleep Hygiene - 2 Bedtime rituals
Relaxation techniques
What to do if you wake up in the middle of the night
Television: Bad; Reading, music: good
Med problems upsetting sleep: arthritis, acid reflux with heartburn, menstruation, headache, and hot flashes.
Psyche problems upsetting sleep: Poor sleep maintenance may be only presentation of major depression
Medication effects:
Hypnotic dependent sleep disorders
Stimulant dependent sleep disorders
Meds leading to insomnia
Slide33 : Burwell et al: Extreme Obesity associated with alveolar hypoventilation: A pickwickian syndrome. Am J Med 1956;21: 811- 818
An obese patient came to the emergency room of the Peter Bent Brigham Hospital
CC: Fell asleep at Poker with a full house and a large pot
PE: Obese, hypersomnolance, hypoventilation, cor pulmonale
This reminded Burwell of Joe, the fat boy
From the Dickens novel, “The posthumous papers of the Pickwick Club.” To be fair: The term was initially coined by Osler (1918)
Slide34 : Fat Here And here
Slide35 : Sleep Apnea Syndrome Is characterized by repetitive episodes of decreased airflow that occur during sleep. Decreased airflow may be associated with a reduction in blood oxygen saturation, and enhanced autonomic activity.
Apneic events may terminate in arousals with resultant sleep fragmentation.
Slide36 : Classic Obstructive Apneas Airflow Airflow Ceases Chest wall motion continues Arousal
Slide37 : Repetitive Obstructive Apneas
Quantification in terms of “events” : Quantification in terms of “events” Apneas = airflow stops
Hypopneas = airflow decreases
Respiratory Disturbance index (RDI) = the number of events for each hour of sleep
More than 20 is often considered “severe”
Slide39 : Prevalence of Sleep Apnea Syndrome In young to middle aged men: 3 - 9 %
In young to middle aged women: 1 - 3%
Sleep Apnea-Hypopnea Syndrome : Sleep Apnea-Hypopnea Syndrome Excessive daytime sleepiness
Snoring
Obesity is a risk
Only 50% are obese, means 50% NOT obese
Poor cognition/memory
Social/sexual/psychologic problems
Cardiovascular Disease : Cardiovascular Disease The association with hypertension is striking
Increased risk for Heart Attack
Increased risk for Stroke
Increased incidence of Sudden Death
Many cardiac rhythm disturbances
Slide42 : SNA RESP BP Sympathetic Nerve Recordeings During Sleep In OSA
Slide43 : Loss of vigilence
Car Accidents in SAHS ACCIDENTS single/5yr multiple/5yr
POPULATION
SNORERS RDI>15
ODDS 3.4 7.3 Young T. SLEEP 1997;20(8):608-13 n=913
Slide44 : Physical Examination Normal SAHS Patient 44
Treatment : Treatment Medical Treatment
Lose weight if obese
Eliminate alcohol, sedatives
Improved sleep hygiene
Smoking Cessation
Continuous Positive Airway Pressure (CPAP)
Upper airway surgery
Dental orthotic or mandibular positioning devices
Note: Treatment recommendations are individualized for each patient: No “one size fits all”
Continuous Positive Airway Pressure (CPAP) : Continuous Positive Airway Pressure (CPAP) 95% effective – usually first line treatment for severe disease
Slide47 : Surgical approaches Uvulopalatopharyngoplasty
Slide48 : Dental orthotic or mandibular repositioning devices:
surprisingly effective in many cases
Slide49 : Often used devices which don’t treat sleep apnea
This one treats the partner ->
Slide50 : University of Maryland
Sleep Disorders Center Sleep Laboratory Sleep specialists Referrals (MD’s, Patients) ENT Psyche Neuro Peds Other
OP facility
PFT lab
Blood lab
X-ray
Secretarial
BILLER Dental Michelle Lynn 410-706-4771