Sleep DNB

Disorders of Sleep : A Classification based Approach : 

Disorders of Sleep : A Classification based Approach Dr Yogesh Sharma

William Shakespeare : 

William Shakespeare SLEEP IS THE CHIEF NOURISHER OF LIFES FEAST.

Features of a Sleep History : 

Features of a Sleep History Sleep Complaints : Onset /Frequency / Severity / Progression. Sleep Timing/ Continuity/ Duration / Restorative nature. EDS : Excessive Daytime Somnolence. Complaints S/O : OSA/RLS. Narcolepsy. Medical Conditions : Pain/ Thyroid/CVS/ GERD/CRF/ Psych/ PD/ TBI/Spinal Trauma. Habits:Alcohol, Caffeine/ Poor Sleep Hygiene. Family History : OSA/ RLS/Narcolepsy

Physical Examination : 

Physical Examination Measure : BP/ Height, Weight/ Neck Circumference/ Pulse Oximetry. Upper Airways: Craniofacial/ Oropharynx/ Nasal CVS: Heart,Lungs/ JVP, LL Edema. Complete CNS evaluation

Classification of Sleep Disorders : 

Classification of Sleep Disorders I: International Classification of Sleep Disorders : ICD –10 II:ICD-10-CM (Clinical Modification) III. Diagnostic and Statistical manual of mental disorders of APA : DSM IV IV.ICSD : International Classification of Sleep Disorders(US, Europe,Japan,Latin America) ICSD-2 (2005) 85 Disorders under 8 heads.

Sleep Disorders : 

Sleep Disorders 1) Insomnias. 2) Sleep Related Breathing Disorders. 3)Hypersomnia. 4)Circadian Rhythm Disorders. 5)Parasomnias. 6)Sleep related Movement Disorders. 7)Other Sleep Disorders. 8)Isolated Symptoms,may be normal variants and unresolved issues.

Insomnia : Definition : 

Insomnia : Definition Difficulty of sleep initiation, maintenance and of early final awakening. In spite of adequate time and opportunity for sleep and results in some day time functional impairment. Transient >1 week : Short term >1to4weeks Chronic > more than 4 weeks.

Types of Insomnia : 

Types of Insomnia Primary – No other cause found. Secondary- Insomnia is a result of a medical neurological, psychiatric disease , other sleep disorder or substance abuse.

Primary Insomnia : 1. Psycho physiologic Insomnia : 

Primary Insomnia : 1. Psycho physiologic Insomnia Present for at least 1 month associated with heightened arousal with learned sleep preventing associations. Chief complaint is of lack of sleep.

2. Paradoxical Insomnia : 

2. Paradoxical Insomnia Sleep state Misperception. Complaints of lack of sleep when in fact good sleep. No daytime impairment.

3.Adjustment Sleep disorder. : 

3.Adjustment Sleep disorder. Associated with a specific stressor –Psychological,Physiological,Environmental, Physical and lasts for weeks and months and resolves.

4.Poor Sleep Hygiene. : 

4.Poor Sleep Hygiene. Habits leading to poor quality and quantity of sleep. Irregular sleep onset and wake up times, stimulating and alerting activities before bed time, pre sleep consumption of alcohol caffeine and tobacco. These habits provoke a different response in different people.

5. Idiopathic Insomnia. : 

5. Idiopathic Insomnia. Longstanding from childhood of insidious onset, no associated factors and no periods of remission.

6.Behavioral Insomnia of Childhood : 

6.Behavioral Insomnia of Childhood Refusal of sleep by children which subsides when the adult enforces sleep onset time.

Secondary Insomnia : 

Secondary Insomnia Due to and associated with and occurs during a medical, psychiatric neurological condition or substance abuse.

Insomnia : What is it? : 

Insomnia : What is it? State of psychological hyper arousal. 3 P Model. P> Predisposing factors : ? Genetic. P> Precipitating factors : Life Stressors. P> Perpetuating factors : Maladaptive Coping Response.

Management Issues : 

Management Issues Detailed History. Diagnosis : Sleep Log for at least 14 days. PSG done only if failure of initial therapy. Management can be 1) Non Pharmacological 2) Pharmacological.

Non Pharmacological/ Cognitive Behavioral Therapy : 

Non Pharmacological/ Cognitive Behavioral Therapy 1) Stimulus Control: Ask to sleep only when sleepy.No reading, TV,eating in bed. Bed for sleep and intimacy only.If unable to sleep go to another room and read or TV. 2) Paradoxical Intention:Try not to sleep but be calm.- Reduce performance anxiety. 3)Sleep restriction: Fixed time wake up by alarm.If slept well then delay alarm by 15 min.

CBT : 

CBT 4)Relaxation Therapy : Yoga, Biofeedback. 5)Sleep Hygiene education: Environmental noise, temperature,alcohol, caffeine,nicotine 6) Cognitive therapy: Education and discussion. Long term trials have shown that this is as effective as pharmacotherapy.

Pharmacotherapy : 

Pharmacotherapy Alcohol Opioids Mickey Finn= Chloral Hydrate+ Alcohol R/o and treat BEP Barbiturates and BZP. Now : Non BZP drugs that block BZP receptors, eg Clonazepam .

Pharmacological : 

Pharmacological Non BZP and BZP receptor agonist : Eszoplicone/Zolpidem Pineal : Melatonin/ Melatonin Receptor Agonist : Rameltan Sedating Anti depressants : Trazadone/ TCA:Nortriptyline, Amitriptyline Antihistamines

Insomnia in CNS Disease : 

Insomnia in CNS Disease Dementia, Epilepsy, CVA, PD PLEASE RULE OUT ASSOCIATED DEPRESSION.

Sleep related breathing Disorders : 

Sleep related breathing Disorders Central sleep apnea disorders: Respiratory effort is diminished or absent in an intermittent or cyclical manner due to cardiac or CNS dysfunction. Other CSA disorders pathological or environmental eg Cheyne Stokes breathing or high altitude periodic breathing.

Primary CSA : 

Primary CSA Disorder of unknown cause characterized by recurrent episodes of cessation of breathing during sleep without associated ventilatory effort. Patient C/O EDS, Insomnia. No hypercapnia PCO2 Above 45 mm Hg(N below 40mmHg) PSG- 5 or more apneic episodes per hour.

CSA due to cheyne stokes : 

CSA due to cheyne stokes Recurrent central apnea +/- hypopnea alternating with prolonged hyperpnoea. Here the tidal volume waxes and wanes. Seen only in NREM and not in REM. Seen in heart failure CVA , CRF.

CSA- high altitude periodic breathing : 

CSA- high altitude periodic breathing In acute mountain sickness: Apnea and hypopnea without any respiratory effort for 12 to 34 sec./5 or more episodes per hour. Generally seen at elevations of 7600 m but at least 4000m.

CSA misc : 

CSA misc Medications : At least 2 months of opioid abuse Infancy : as a feature of developmental delay Often CSA is seen with OSA= Mixed apnea Apneas seen with bradycardia and hypoxemia.

Obstructive sleep apnea: OSA : 

Obstructive sleep apnea: OSA Obstruction in the airway resulting in an increased breathing effort and inadequate ventilation. In adults repetitive episode of cessation of breathing – apneas or partial air way block- hypopnea that last for at least 10 sec and with snoring with reduced oxygen saturation and sleep disruption and C/O EDS and insomnia.5 or more episodes an hour. In children 2 or more episodes/hr

Sleep related breathing disorder : 

Sleep related breathing disorder Can occur in a primary pulmonary disorder. Lung disease like COPD, Cystic fibrosis, Interstitial lung disease. Lower airway obstruction Neuro muscular disease. Chest wall disorder.

Hypersomnia not due to sleep related breathing disorder. : 

Hypersomnia not due to sleep related breathing disorder. Hypersomnia : EDS: Excessive day time sleepiness cause of this is not disturbed nocturnal sleep or a misaligned circadian rhythm.

Narcolepsy : 

Narcolepsy No cure so treatment life long EDS with periods of irrestible sleep , cataplexy, sleep paralysis, hypnogogic hallucinations that can occur at sleep onset. Gen begins as EDS between 20 to 30 yrs of age. M=F. after EDS cataplexy- Collapse during emotion laughter anger surprise. Sleep is fragmented.

Narcolepsy : 

Narcolepsy Generally under diagnosed DD: Epilepsy Psychiatric disease Depression.

Dx: Narcolepsy with Cataplexy : 

Dx: Narcolepsy with Cataplexy Almost daily EDS for at least 3 months with cataplexy PSG : Normal nocturnal PSG for at least 6 hrs. Next day MSLT – Sleep latency of less than 8 min for a sleep duration of 20 min with sleep onset REM (SOREM). Low CSF Hypocretin. No other cause for hypersomnia

Dx: Narcolepsy without cataplexy : 

Dx: Narcolepsy without cataplexy At least3 months of EDS no cataplexy but some odd dizzy feelings can occur. PSG Normal nocturnal sleep with next day MSLT sleep latency less than 8 min with SOREM. No other cause for EDS.

Dx by CSF hypocretin and PSG : 

Dx by CSF hypocretin and PSG Hypocretin containing neurones are located around the fornix and lat hypothalamus and from there communicates with the rest of the brain. An auto immune process is suspected but not proven. Hypocretin maintains muscle tone so if it drops suddenly then sudden fall. HLA DQB1*0602 seen in 85% of N+C

Narcolepsy : Therapy : 

Narcolepsy : Therapy For EDS : Methylphenidate,Selegelene, Dextroamphetamine, Modafinil. For Cataplexy : TCA, SSRI. For BOTH: Sodium oxybate : XYREM.

Circadian rhythm sleep disorders : 

Circadian rhythm sleep disorders Persistent and recurrent misalignment between the patients sleep pattern and the pattern that is desired or regarded as the norm. Not NORMAL rhythm of sleep. Sleep episode and architecture normal.

Delayed sleep phase type : 

Delayed sleep phase type Common in adolescents Sleep very late and wake up late.

Advanced sleep phase type : 

Advanced sleep phase type More in Geriatric age group. Sleep very early and wake up very very early.

Irregular sleep-wake type : 

Irregular sleep-wake type Sleep ,wake up at any time. Generally in institutionalized older adults. Shift work sleep disorder: Insomnia or EDS due to fluctuating time of duties. Due to medical conditions: Renal or hepatic failure, recovery from CVA or meningitis or medications. Jet lag –Change in time zone esp eastward.

Parasomnias : 

Parasomnias Undesirable physical events or sensory experiences during sleep. ie Abnormal sleep related movements, behaviors, emotions, perceptions, dreaming and autonomic nervous system function. Can occur with other sleep disorders like OSA, Narcolepsy. More than 1 parasomnia can co exist.

Parasomnia with NREM arousal : 

Parasomnia with NREM arousal More 1st half of sleep with poor recall. Confusional arousal : Confused at awakening esp children. Sleep walking : Walking after sudden awakening from SWS. Sleep terrors:Awakening from SWS with cry, scream, ANS activation and fear. Amnesia of episode and difficult to arouse. Often these 3 episodes co exist.

Aggravating features: Therapeutic Implications : 

Aggravating features: Therapeutic Implications Sleep disruption: Noise Temperature, mattress, new environment,stress. Sleep deprivation, Evening exercise Fever ,infection,alcohol, caffeine, tobacco. OSA, RLS, PLMS. Headaches, GERD.

Therapy : 

Therapy Avoid/ minimize aggravating factors. Low dose BZP. Anti depressants : TCA/ SSRI Behavioral therapy /Stress management If time of onset fixed wake up 15 min early and allow pt to go back to sleep – for 3 months and then stop and observe.

Parasomnias: REM sleep state : 

Parasomnias: REM sleep state More in 2nd half of night often with good recall. REM sleep behavioral disorder- RBD Abnormal behavior that can cause injury and sleep disruption. Violent action packed dream enactment. More in males above 50 yrs ? A marker of neuro degenerative diseases- PD

Sigmund Freud : 

Sigmund Freud “Lucky are we that we are paralyzed in sleep as we cannot enact out our dreams.” REM-Skeletal muscle atonia (except eye and diaphragm). RBD- Loss of atonia and hence patient inappropriately active.Seen as a very early sign of Synnucleopathies-PD, MSA, DLBD. Lesion – Locus Coeruleus.

Therapy : RBD : 

Therapy : RBD Safe bed room environment- remove hazards Protect bed partner- Separate bed or room. Clonazepam/ Melatonin/ Donepezil/ Dopamine agonist/ TCA.

Other REM Parasomnias : 

Other REM Parasomnias Recurrent isolated sleep paralysis: Inability to perform voluntary movement at sleep onset or awakening.May or may not be associated with auditory visual or tactile hallucinations. Nightmares: Unpleasant dreams during REM with awakenings with fear and anxiety.

Contd : 

Contd Sleep related dissociative disorders: Psychiatric misperception. Sleep enuresis:Recurrent at least 2 times a week involuntary voiding of urine during sleep after the age of 5 yrs. Primary- Child never been dry Secondary dry for at least 6 months.

Contd : 

Contd Sleep related groaning: Catathrenia; Chronic nightly groaning in expiration in REM sleep. Rx : try CPAP. Exploding head syndrome: feeling of loud imagined noise. Sleep hallucinations:At onset/awakening Eating in sleep.

Sleep related movement disorder : 

Sleep related movement disorder Simple stereotyped movements that disturb sleep. RLS: Strong irresistible urge to move legs worse at rest more in evening most at bed time relieved by walking and moving legs. PLMD-Periodic limb movement disorder- limbs move during undisturbed sleep. Cramps in sleep relieved by stretching. Sleep related Bruxism-wears out teeth and disturbs

RLS : Criteria for Dx : 

RLS : Criteria for Dx Essential: Urge to move legs with an unpleasant sensation in legs.More when sitting and lying down. Less while standing and moving. More in evening and night.

RLS : Criteria for Dx : 

RLS : Criteria for Dx Non essential: Family Hx of RLS Improvement with dopaminergic therapy Low ferretin levels, associated with PLMS Disturbed sleep/ +/- Root or nerve lesion Gen progressive and onset in middle aged.

RLS:DD : 

RLS:DD Leg Cramps Positional Discomfort Neuroleptic induced Akathesia Painful Legs and moving Toes

RLS: Other Medical Conditions : 

RLS: Other Medical Conditions Iron Deficiency : Ser Ferritin < 50ug/ml Peripheral Neuropathy/ Radiculopathy Pregnancy +/- Folate and Fe deficiency Renal failure / RA/ MS/ Fibromyalgia Hypertension/ IHD Anxiety/ Depression/ ADHD Meds: Antipsychotics, Antihistaminics, Antidepressants

RLS : Neurological Conditions : 

RLS : Neurological Conditions Tourettes Syndrome Parkinson's Disease Essential Tremor Charcot Marie Tooth Disease Spino Cerebellar Ataxia

RLS: Therapeutic Options : 

RLS: Therapeutic Options First Line : Dopaminergic: Levadopa,Dopa Agonists: Non Ergots like Ropinirole, Pramipexol. Ergots like Bromocriptene, Pergolide, Cabergoline. Second Line : Opioids, Oxycodone, Codeine. Anticonvulsants: Gabapentin, BZP: Clonazepam, Diazepam. Iron Therapy.

Other Sleep Disorder : 

Other Sleep Disorder Environmental Sleep Disorder

Isolated Symptoms apparently normal variants & unresolved issues : 

Isolated Symptoms apparently normal variants & unresolved issues Long sleeper/ Short sleeper/ Loud Snore without OSA/ Sleep starts- Hypnic Jerks/ Benign Sleep Myoclonus of Infancy Sleep Related- Headaches/ GERD/ IHD/ Epilepsy.

Nocturnal Seizure : 

Nocturnal Seizure 20% of patients of established epilepsy have seizures predominantly at night. Nocturnal Seizure- Stereotypic Behavior Frontal and Temporal lobe Epilepsy relatively more common in sleep.

Semiology : 

Semiology Frontal: Complex bizarre motor activity, vocalization, posturing, clonic activity, ambulation, pelvic thrusting, bicycling, bouncing. Temporal: Staring,Psychic phenomena, olfactory and auditory hallucinations, Parietal and occipital lobe epilepsy; GTC Sz less common in sleep.

Semiology : 

Semiology GTC Sz and CP Sz : No recollection of the event. Partial motor Sz may recall. Can occur in night sleep or day time nap. Most often in NREM ( REM sleep an antiepileptic state)

Tips to Dx Sz : wrt Parasomnias : 

Tips to Dx Sz : wrt Parasomnias Stereotypy Hx of Sz in the day time when awake Family Hx of Sz Hx of head injury Multiple events and a continuity from a milder episode to a severe episode is more in FL Ep. Insist on a sleep EEG.

Nocturnal Epilepsy Syndromes : 

Nocturnal Epilepsy Syndromes ADFLE Benign Focal Epilepsy with Centro temporal spikes- Rolandic epilepsy Epileptic myoclonus on awakening Sleep disorders – like OSA can worsen Sz

Why do we Sleep? (1/3rd our life) : 

Why do we Sleep? (1/3rd our life) Energy conservation and physical restoration : Rest for body and brain. Brain anabolism eg. Synthesis of glycogen. Preserve synaptic efficiency and brain plasticity: Tissue repair. Memory consolidation and learning. Brain growth/development-REM –Infancy. Immune Function.

Sleep Definition : 

Sleep Definition Reversible behavioral state of perceptual disengagement and relative insensitivity to the environment typically accompanied by a recumbent posture closed eyes and absent or very little mobility. Not a passive state but an active dynamic state as seen in PSG.

PSG: Polysomnagraphy : 

PSG: Polysomnagraphy It analyses physiological criteria like wakefulness ,NREM and REM state. Each of this state has its own distinct functional, neuronal metabolic substrate with its own distinct and separate physiology chemistry and pharmacology.

PSG : 

PSG Measures primarily : EEG 4to 6 leads, Eye movement and chin activity. Also Leg EMG, Breathing, Pulse Oximetry, Snoring Sensors, ECG,Body Positioning. Or a video on Infra red light. Extra probes: Co2( hypercapnea), Extra EEG, Esophageal pressure and pH,UL sensors for RBD, Nocturnal penile tumescence: for suspected ED.

Sleep and CVS : 

Sleep and CVS Restful normal sleep is a parasympathetic moment with respect to heart rate, BP. So there is an increased vagal tone and reduced sympathetic nerve activity(SNA). Even transient wakefulness can cause up to 300% increase in SNA. REM-SNA seen. Sleep disorders now considered a major risk for vascular events.

Sleep and Heart Rate : 

Sleep and Heart Rate HRV(Heart rate Variability) measures cardiac sympathetic vs parasympathetic dominance.Loss of circadian HRV= Risk of adverse events. Loss of HRV 1st seen in sleep. Also seen in medically refractory epilepsy in those with a higher risk for SUDEP and in those where Ep Sx tends to fail.

HRV : 

HRV In ICU patients- loss of HRV indicates poor prognosis in patients of head injury and CVA. Loss of sleep HRV also seen in patients with advanced PD, MSA, in Alcoholics and untreated OSA. Untreated Xs SNA> risk of HTN, CVA, MI and Sudden Death.

Sleep and BP : 

Sleep and BP Systolic BP less by15% in NREM and may be more by 40% in REM. Loss of nocturnal falls in BP + more risk for CVA, arrhythmia and earlier end organ damage.Excess falls in BP esp in elderly silent cerebral infarcts and poor Px from CVA. Very high rise in REM –higher risk of ICH. Severe OSA – Non dippers.

Impact of Sleep Deprivation : 

Impact of Sleep Deprivation Poor Judgment – Accidents ,injuries and even death.Worst time for mishaps- ?3AM Chernobyl, Exxon – Valdez oil spill, Challenger space shuttle disaster, Bhopal gas leak. Car Accidents, Medical mishaps of judgment.