Why sleep?

1. Why sleep? The origins and development of Sleep Medicine A.W.A.K.E. NOVEMBER 4, 2009

3. light

6. 2007Grand Rounds RIH • How many of you would aggressively treat HTN in a patient with a TIA or stroke? • How many of you would treat a hypercoaguable state in a patient with a TIA or stroke? • How many of you would treat an O2 sat of 80% in an acute stroke patient? • How many of you would test for OSA in a patient with stroke or TIA?

8. To tell a story…

9. Circadian rhythm disorder • Obstructive Sleep Apnea (OSA) • REM sleep behavior disorder • Narcolepsy

10. Circadian rhythm disorder • Obstructive Sleep Apnea (OSA) • REM sleep behavior disorder • Narcolepsy

16. You?

18. Hypermetabolic state • Skin lesions and erosions • Hypothermia • Death (sepsis)

19. …as torture

20. Equipment for EEG Recording (1926)

21. Discovery of the electroencephalogram • 1875 Caton • 1929 Berger

22. The original ‘sleep stages’ • 1937 Loomis

23. Discovery of REM sleep 1951 Kleitman & Aserinsky

26. Circadian rhythm disorders • Definition: Unable to sleep and wake at the times required for normal work, school, and social needs. Unless they have another sleep disorder, their sleep is of normal quality. Timing of sleep is the problem. • Extrinsic type • Jet lag • Shift work sleep disorder • Intrinsic type • Delayed sleep phase syndrome (DSPS) • Advanced sleep phase syndrome (ASPS) • Non-24-hour sleep-wake syndrome (Non-24) • Irregular sleep-wake pattern

28. Image:second scn image

29. Treatments?

30. Circadian rhythm disorders • Affect us health care shiftworkers • Affect our patients • Neuroanatomy elucidates the problem

31. A clamor of incessant knocking besieged Mr. Pickwick’s lodgings. Once opened, the doorway revealed a “wonderfully fat boy” who stood “upright. His eyes closed as if in sleep,” his expression one of “calmness and repose. Asked his business, he said nothing, but “nodded once, and seemed . . .to snore feebly,” immobile through three repetitions of the question. Then, as the door was about to close on him, he “suddenly opened his eyes, winked several times, sneezed once, and raised his hand as if to repeat the knocking.”

32. Pickwickian Syndrome

33. OSA Misconceptions • 1956, Burwell’s “obesity hypoventilation (Pickwickian) syndrome”  pulmonologists’ misconception • Not corrected until 1966 by Gastaut

34. “What happens?” • Upper airway collapses during sleep  reduction, or cessation, of airflow  less oxygen saturation  increases in inspiratory efforts  sleep fragmentation

36. 1993, Wisconsin Sleep Cohort Study • AHI > 5 • 9% women • 24% men

37. Epidemiology of OSA Cadilhac 2005

38. OSA treatment up to early 1980’s

40. Why ask about OSA? • Worsens hypertension • Causes endothelial cell dysfunction • Increases inflammatory response • Alters cerebral hemodynamics • Increases hypercoagulability • Increases insulin resistance and obesity • Increases atrial fibrillation • Increased cholesterol (dyslipidemia) • Proven stroke prevention

41. Dr. Johnson’s Summary Slide:OSA and Stroke • 1. OSA is an independent stroke risk factor and worsens other stroke risk factors • 2. OSA is common in stroke patients and increases stroke mortality and morbidity, which can be decreased with CPAP • 3. Treating OSA with CPAP in asymptomatic patients decreases cardiovascular morbidity and mortality • 4. Decision to test for OSA can’t be based on positive sleep history alone, so screening with polysomnography is necessary

43. REM sleep behavior disorder (RBD)

46. VIDEO • http://med.stanford.edu/news_releases/2009/may/narcolepsy.html

47. narkenumbness, stupor + lepsisattack, seizure Narcolepsy ‘Tetrad’ (1957) • Cataplexy • sleep paralysis • hypnagogic hallucinations • automatic behavior

49. VIDEO • http://med.stanford.edu/news_releases/2009/may/narcolepsy.html

50. You can go back to sleep now.