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SLEEP DISORDERS

SLEEP DISORDERS. Esra Tasali, MD. March 4 th , 2003. 62 % of adult Americans report having sleep problems Only 4 % of these adults with sleep problems are seeing a doctor or other health care provider for advice or treatment.

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SLEEP DISORDERS

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  1. SLEEP DISORDERS Esra Tasali, MD March 4th, 2003

  2. 62 % of adult Americans report having sleep problems Only 4 % of these adults with sleep problems are seeing a doctor or other health care provider for advice or treatment The National Sleep Foundation’s 1999 Omnibus Sleep in America Poll

  3. International Classification of Sleep Disorders • Dyssomnias Excessive sleepiness or difficulty in initiating or maintaining sleep - Intrinsic sleep disorders: OSA, narcolepsy, insomnia, RLS/PLMD - Extrinsic sleep disorders - Circadian rhythm sleep disorders: DSPS, ASPS • Parasomnias Undesirable physical phenomena predominantly during sleep - Arousal disorders: sleep walking, sleep terrors - Sleep-wake transition disorders: sleep talking - Parasomnias usually associated with REM sleep: nightmares, RBD - Other parasomnias: sleep bruxism • Sleep Disorders Associated with Mental, Neurologic, and Other Medical Disorders • Proposed Sleep Disorders

  4. Prevalence of Sleep Disorders

  5. Sleep Disordered Breathing /Sleep Apnea

  6. Sleep Disordered Breathing (SDB) Definition: Increasingly common chronic condition characterized by recurrent episodes of partial or complete upper airway obstruction during sleep

  7. Associated with increased cardiovascular morbidity: - systemic hypertension, left ventricular hypertrophy - myocardial ischemia, cardiac arrhythmias - pulmonary hypertension - stroke SDB : a public health concern • Many have features of metabolic syndrome: central obesity, hypertension, insulin resistance, dyslipidemia (syndrome Z )

  8. Obstructive sleep apnea hypopnea syndrome Central sleep apnea-hypopnea syndrome Cheyne-Stokes breathing syndrome Sleep hypoventilation syndrome Upper airway resistance syndrome Simple snoring SDB: syndrome definitions AASM Task Force, Sleep 1999

  9. Obesity (particularly central), increased visceral fat Male gender, African American race Craniofacial abnormalities ( mandibular/maxillary hypoplasia ) Increased pharyngeal soft or lymphoid tissue including tonsillary hypertrophy Increased neck circumference ( > 40cm ) Nasal obstruction Familial history Endocrine abnormalities: hypothyroidism, acromegaly * Aggravated by alcohol, sedatives, sleep deprivation, supine position, respiratory allergies, nasal congestion SDB : risk factors

  10. SDB: symptoms

  11. Patient Normal

  12. ECG Airflow Thor. Effort Abd. Effort SAO2 Obstructive Apnea Airway obstructs Airway opens Exhale Effort gradually increases Inhale Paradoxing Paradoxing ends Desaturations

  13. Mixed Apnea ECG Airway opens No airflow Exhale Airflow Respiratory effort Inhale no effort Thor. Effort Paradoxing Abd. Effort Paradoxing ends

  14. Apnea-hypopnea index (AHI):number of apneas and hyponeas per hour of sleep Respiratory events : should last at least 10 sec in duration excessive daytime sleepiness AHI> 5+ OR - choking or gasping during sleep - recurrent awakenings - unrefreshing sleep - daytime fatigue - impaired concentration SDB: Diagnostic criteria (AASM Task Force, Sleep 1999)

  15. Hypoxic stress / Sympathetic overactivity Somers et al, J Clin Invest 1995

  16. Sleep fragmentation by frequent arousals Accumulating state of “sleep debt” Insulin resistance Further weight gain and diabetes State of “sleep debt” Sleep Disordered Breathing

  17. Precaution Recommendations about driving SDB: Treatment of choice: CPAP General measures - Weight reduction - Sleep hygiene - Positional therapy - Avoiding alcohol, smoking

  18. SDB: Alternative treatments

  19. Narcolepsy

  20. Excessive daytime sleepiness Cataplexy Hypnagogic hallucinations Sleep paralysis ( Disrupted nocturnal sleep) The narcolepsy “tetrad”

  21. Continuous subjective feeling of sleepiness or irresistible sleep attacks Excessive daytime sleepiness (EDS) • Duration of sleep attacks is usually < 20 min, a refractory period of 1 to several hours before the next episode occurs • Usually they wake up feeling refreshed • Not only during passive activities but also in situations when the subject is fully involved in a task

  22. Sleep deprivation Another sleep disorder (OSA, RLS) Poor sleep quality due to medical illness (CHF) Medications, drugs,toxins Depression Delayed sleep phase syndrome Idiopathic hypersomnia Differential diagnosis of EDS

  23. Sudden bilateral loss of muscle tone, provoked by strong emotions, most typically by laughter Cataplexy • Jaw sags, head falls forward, arms drop to the side, knees unlock or buckle • Consciousness is preserved, eye movements and respiration are not compromised • Few seconds to a couple of minutes

  24. Vivid dream like experiences that occur during sleep onset Hypnagogic hallucinations • Usually content is bizarre and frightening • Visual imagery is predominant Auditory and tactile components are present • Lasts less than 10 minutes May occur with sleep paralysis

  25. Inability to move the limbs, to open the eyes, to speak or even to breath deeply Sleep Paralysis • Occurs either on falling asleep or awakening and the patient is fully aware of the condition • People are usually terrified during an attack, particularly the first time • Up to 10 min and ends spontaneously or after mild sensory stimulation ( “shake out of it”) • Can occur in 15% of otherwise normal persons, with familial clustering and association with sleep loss

  26. Automatic behavior Other associated features • Memory disturbances • Tiredness or fatigue • REM behavior disorder (RBD) • Depression • Obesity • Hypothyroidism

  27. Subjective scales: - Stanford Sleepiness Scale - Epworth Sleepiness Scale Objective testing: - Multiple Sleep Latency Test (MSLT) - Maintenance of Wakefulness Test (MWT) Evaluation of sleepiness

  28. Multiple Sleep Latency Test (MSLT) Roth T & Roehrs T, 2000

  29. PSG:Sleep latency <10 min PSG: REM latency < 20 min MSLT : mean sleep latency < 5min MSLT:  2 sleep onset REM periods PSG and MSLT findings in narcolepsy

  30. + Recurrent daytime naps or lapses into sleep occurs almost daily for at least 3 months + cataplexy Narcolepsy: diagnostic criteria (ICSD) + Excessive sleepiness or sudden muscle weakness + Associated features: sleep paralysis, hypogogic hallucinations, automatic behaviors, disrupted major sleep episode + 1 PSG or MSLT findings

  31. Narcolepsy: pathophysiology • REM dysregulation: inappropriate intrusions of REM sleep into wakefulness • HLA-DQB1*0602 (> 90% with narcolepsy-cataplexy ) is the best HLA marker • Recent studies have shown that narcolepsy with cataplexy is usually caused (>90%) by the lack of two related brain chemicals called "hypocretin-1" and "hypocretin-2"

  32. What are hypocretin (=orexin) molecules? • Were found on hypotalamus and some resemblance to gut secretin • Also found to stimulate food intake: orexin A, orexin B • Small neuronal group with dense projections to cortex and to brain stem • Excitatory stimulus to locus coeruleus

  33. The discovery of the hypocretin/orexin peptides:

  34. Undetectable levels of hypocretin in CSF ( Lancet, 2000) Absence of hypocretin neurons in the hypotalamus by histopathologic examination of brains of narcoleptic patients ( Nature Med, 2000; Neuron, 2000) Hypocretin/orexin in human narcoleptics

  35. Nonpharmacologic - Regular timing of nocturnal sleep, avoiding shifts - Avoid heavy meals and alcohol intake - Scheduled naps: 15 min at lunch time and at 5:30pm Narcolepsy :Treatment • Pharmacologic For sleepiness : Stimulants ( Modafinil, Methylphenidate ) For cataplexy : TCA, SSRI , sodium oxybate (Xyrem)

  36. Restless Leg Syndrome / Periodic Limb Movement Disorder

  37. Restless Leg Syndrome: Disagreeable leg sensations that usually occur prior to sleep onset and cause almost an irresistible urge to move the legs Periodic Limb Movement Disorder: Periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep

  38. Primary or idiopathic - no identifiable predisposing factor - tends to occur in families ( genetic?) Pathogenesis of RLS • Secondary - Iron deficiency anemia - Uremia ( % 15-40 of dialysis patients) - Pregnancy - Neuropathies - Drug induced (TCA, SSRI, lithium, neuroleptics) - Diabetes, Parkinson disease, Rheumatoid Arthritis

  39. RLS essential features (IRLSSG criteria) • Desire to move the limbs usually associated with paresthesias or dysesthesias • Motor restlessness • Symptoms worse at rest partially relieved by activity • Symptoms worse in the evening or at night

  40. Creepy, crawly, tingly Like worms or bugs crawling under the skin Painful, burning, achy, itchy Like water running over the skin Sometimes indescribable Uncomfortable Sensations

  41. RLS: additional common features • Sleep disturbance and its consequences (EDS) • Involuntary movements while awake and at rest, disappearing when patient gets up to walk • Usually chroniccourse but spontaneous remissions relapses may occur • Circadian variability: symptoms typically peak between midnight and 4 am • Periodic limb movement disorder (PLMD)

  42. Management of RLS

  43. Insomnia

  44. Medical Psychiatric Pharmacologic Primary sleep disorder Genetic (Fatal Familial Insomnia) Tobacco/ Alcohol Insomnia The perception of insufficient, disturbed or non restorative sleep

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