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Sleep Disorders Medicine Back to Basics April 9, 2014

Sleep Disorders Medicine Back to Basics April 9, 2014. Elliott K. Lee MD, FRCPC, Dip. ABPN, Dip. Amer. Board of Sleep Medicine Asst. Professor, Dept of Psychiatry, University of Ottawa Sleep Disorders Service, Royal Ottawa Hospital. Sleep disorders. Insomnia Excessive Daytime Sleepiness

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Sleep Disorders Medicine Back to Basics April 9, 2014

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  1. Sleep Disorders MedicineBack to BasicsApril 9, 2014 Elliott K. Lee MD, FRCPC, Dip. ABPN, Dip. Amer. Board of Sleep Medicine Asst. Professor, Dept of Psychiatry, University of Ottawa Sleep Disorders Service, Royal Ottawa Hospital

  2. Sleep disorders • Insomnia • Excessive Daytime Sleepiness • Nocturnal Spells

  3. Insomnia • Circadian • Psychiatric • “Adjustment”/Psychophysiologic • Medical/Neurologic “Adjustment”/Psychophysiologic (Psychologic factors,Physiologic factors,Negative conditioning) INSOMNIA

  4. Excessive Daytime Sleepiness • Lack of sleep • Insufficient time in bed • Inadequate quality of sleep • Sleep Apnea, PLMD • Intrinsic sleepiness • Narcolepsy; Idiopathic Hypersomnia • Medical/psychiatric disorder • Major Depression • Medications, medical – thyroid, anemia etc. • Circadian Rhythm Disturbance • Shift work, delayed sleep phase, etc.

  5. “Nocturnal Spells” • NREM parasomniaNight Terrors, Sleepwalking • REM parasomniaNightmares, REM behavior disorder etc • Seizure Disorder • Psychiatric e.g. Panic attack etc.

  6. Purpose of Sleep • Restorative Function • Energy Conservation • Immune Function Regulation • Ontogenetic Hypothesis • Memory Consolidation • Protective Mechanism

  7. Sleep Architecture

  8. STAGES OF SLEEP • NREM & REM • NREM = N1, N2 (light stages) N3 (SWS – slow wave sleep) • Sleep Cycles • REM increases as the night progresses • Changes across the lifespan

  9. SLEEP HYPNOGRAM W N1 N2 1 N3 REM 1 2 3 4 5 6 7 Hours

  10. Stg% Table of Stg. %

  11. Sleep Stage % by Age

  12. REM Sleep • Rapid Eye Movements • Muscle atonia (paralysis) • Dream recall • 90 minute latency • “Paradoxical Sleep” – EEG mimics wakefulness • Breathing irregular, heart rate fluctuates

  13. REM sleep onset Onset of REM R & K 1968

  14. REM Control Nuclei

  15. Monoamines controlled by Orexin SCNclock DA(+) ~ Orexin / Hypocretin Histamine (+) 5HT(+) NA (+)

  16. Orexin-Hypocretin projections

  17. Sleep waveform schematic

  18. EEG Frequencies “Deep” “Awake” “Stage II”

  19. Sleep disorders

  20. Sleep Disorders • Obstructive Sleep Apnea/hypopnea (OSA) • Restless Legs Syndrome (RLS)Periodic Limb Movement Disorder (PLMD) • REM behavior disorder (RBD) • Narcolepsy

  21. SLEEP APNEA • Two Types: Obstructive & Central • Pauses in breathing > 10 seconds in length • Respiratory Disturbance Index: >5 hr =clinically significant ZZZZzzzzzz

  22. OSA Clinical Symptoms

  23. OBSTRUCTIVE SLEEP APNEA (OSA) • Causes ▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx • Exacerbated by: ▪ Medications – BDZs, Opioids ▪ Alcohol Consumption ▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep

  24. Normal vs. Collapsed Airway

  25. “Kissing” Tonsils

  26. TREATMENTS FOR OSA • **CPAP – Continuous Positive Airway Pressure • **Weight Loss - ↓ BMI = ↓ RDI • Avoid Alcohol, Sedatives • “Snoreball” Technique / Positional Therapy • Oral Appliance • Provent • Upper Airway Surgery • Tonsillectomy (pediatrics) • Uvulopalatopharyngoplasty (UPPP) • Tracheostomy

  27. Provent

  28. Continuous Positive Airway Pressure (CPAP)

  29. Uvulopalatopharyngoplasty (UP3)

  30. Hypertension Motor vehicle accidents OSA Consequences Impaired glucose control Heart attack and stroke Irritability, mental illness e.g. depression Memory problems

  31. Sleep Deprivation and Children • Not the same as adults • May be “hyperactive”- fidget- poor attention- cranky • Undiagnosed OSA may be mistaken for ADHD

  32. Periodic Limb Movements (PLMs) & Restless Legs Syndrome (RLS)

  33. Periodic Limb Movements (PLMs) • Repetitive leg (limb) movements DURINGSLEEP • Typically 20-40 seconds apart • Cause awakenings and fragmentation • Patient often unaware. Bedpartner reports “kicking” • c/o frequent awakenings, light sleep • aka Nocturnal Myoclonus

  34. PLMs 2 MIN

  35. Restless Leg Syndrome • “URGE” U – rge to move legs R – est – symptoms worsened at rest G – ets better with movement E – vening – symptoms worse in evening

  36. RLS/PLMD Periodic Limb Movement Disorder (PLMD) Restless Leg Syndrome (RLS) 80% 20%

  37. RLS – PLMD: neurochemistry • Likely due to iron deficiency in basal ganglia (Fe is co-factor in enzymes that synthesize DA). • May predict onset of “syn-nucleinopathies” (REM behaviour disorder, Parkinson’s, Lewy Body dementia).

  38. Address Exacerbating Factors • Caffeine • Tobacco • Alcohol • Medications- dopamine blockers – antipsychotics, GI motility agents- antidepressants (SSRI’s)

  39. Check Iron (Ferritin)! • Intake – food? • Absorption - GI difficulties • Blood loss?- Anemia – Cough? Poop? - Menstrual Periods/Pregnancy- Blood donations • Target ferritin > 50 μg/L • May replace e.g. FeSO4 with vitamin C tid 2 hours before or after meals

  40. Intermittent (<2x/week)- Levodopa (Sinemet)eg. Sinemet CR 25/100 1 tab po qhs prntake as abortive therapy when symptoms arise Daily or almost daily (>3x/week)- Pramipexole (Mirapex)- Ropinirole (Requip)eg Pramipexole 0.25-0.5 mg po qpmtake 2 hours before symptoms are worst Dopaminergic Agents Silber MH et al. Mayo Clin Proc (2004) 79(7) : 916-22

  41. Nausea Nasal stuffiness Constipation Leg swelling Insomnia Sleepiness(caution driving) *Pathological gambling and compulsive behaviors Side Effects

  42. Second and Third Line Agents • Gabapentin (Neurontin) - anticonvulsant • Benzodiazepines (sedative hypnotics)- Clonazepam (rivotril / klonopin)- Lorazepam (ativan)- Diazepam (valium) • Opioids- Codeine- Hydrocodone- Methadone* • (Quinine obsolete)

  43. REM Behaviour disorder (RBD)

  44. REM Behaviour Disorder (RBD) • No muscle atonia during REM sleep • Ability to act out complex dream behaviour • Bedpartner often the “victim” • Age of onset: 50 – 60yrs. Males (90%) • Usually opposite of waking personality • Strongly associated with synucleinopathies- Parkinsonism/Parkinson’s- Lewy Body Dementia

  45. Treatments for RBD • Full EEG montage during PSG • CT Scan, MRI – r/o lesions • Securing the environment (mattress on floor, bed rails, restraints) • Bedpartner sleeps in another room • Rx – Clonazepam * (Melatonin) * (Pramipexole)

  46. SLEEPWALKING vs. RBD

  47. Narcolepsy

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