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Sleep Disorders

Sleep Disorders. Presented By professor Magd Galal. pP. Why Sleep. Good emotional health Good physical health Better concentration Better judgments More able to carry on ADL’s Decreased irritability. Why Sleep (cont). May be restorative time May be time of healing.

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Sleep Disorders

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  1. Sleep Disorders Presented By professor Magd Galal. pP

  2. Why Sleep • Good emotional health • Good physical health • Better concentration • Better judgments • More able to carry on ADL’s • Decreased irritability

  3. Why Sleep (cont) • May be restorative time • May be time of healing

  4. Why Take a Sleep History? • Sleep disorders arecommon • Sleep disorders areserious • Sleep disorders aretreatable • Sleep disorders areunderdiagnosed

  5. Why take a Sleep History? • Sleep Disorders are common • Estimated 70 million Americans have clinically significant sleep problems • Prevalence of insomnia about one-third of adult population • Obstructive Sleep Apnea prevalence in patients with essential hypertension is over 25%

  6. Why take a Sleep History? • Sleep Disorders are serious • Chronic insomnias report decreased quality of life, memory and attention problems, decreased physical health • Increased incidence of motor vehicle crashes in patients with OSAS • Total direct costs of insomnia in U.S. $13.9 billion (1995)

  7. Why take a Sleep History? • Sleep Disorders aretreatable • Multiple successful treatment modalities exist, including pharmacotherapy, surgical intervention, behavioral therapy, continuous positive airway pressure

  8. Why take a Sleep History? • Sleep Disorders are underdiagnosed • Less than 14% of medical interns questioned patients about sleep (Haponik,1996) • Survey of 222 V.A. patients; no sleep symptoms recorded despite 47% prevalence (Meissner,1998) • Survey of 10 million ICD dx:100,000 cases OSAS expected; 73 diagnosed (1992)

  9. The Basic Principles of Sleep • Sleep: an active process • Rhythm: exists as a 24hr biological circadian rhythm entrained to temperature, light and neuro-hormones (Melatonin, GH, ?CRH)

  10. Increase in levels of cortisol release Growth hormonepeaks Temperature at it’s nadir Melatonine secretion starts Temperature starts to drop Cortisol levels begin to decline Cortisol level peakes & melatonin secretion stops

  11. The Basic Principles of Sleep cont.90 minute cycle Components: Rapid Eye Movement (REM) sleep and non-REM sleep

  12. The Basic Principles of Sleep cont. • Stages 1 through 3 • increasingly deep sleep • pulse slows, BP drops, breathing slows • higher amplitude, lower frequency waves • Non-REM sleep: stages 1 to 4 ( stages 3 & 4 = slow wave sleep=Most Restorative) • Stage 4 • “Deepest” stage of sleep • pulse and breathing slowest • high amplitude, low frequency “DELTA” waves

  13. The Basic Principles of Sleep cont. • REM sleep: active EEG, skeletal muscle paralysis, autonomic activation, respiratory instability, dreams (Related To Memory)

  14. EEG

  15. Circadian Rhythms • Cycle can be disrupted by • stress • anxiety or depression • jet lag • alcohol and drugs • loss of sleep

  16. Age-Related Sleep Changes

  17. Human Sleep is Cyclical

  18. REM (Paradoxical) Sleep • Rapid Eye Movements: eyes move rapidly behind closed eyelids • Paradoxical: because brain is “awake” but body is asleep • Body is Paralyzed: prevents us from hurting ourselves during dreams • Dreams: most vivid and realistic dreams occur during REM sleep

  19. REM Deprivation • William Dement: Do we need REM? • Subjects were awakened each time they entered REM • Results: subjects became irritable, anxious, “NO long term effects” • REM Rebound: when allowed normal sleep, subjects spend extra time in REM • Alcoholic “DTs”: may be a severe form of REM rebound

  20. Sleep Apnea • Affects between 2 and 4% of middle-aged population • 11% of shiftworkers have OSA

  21. Definitions: Types of sleep apnea • Obstructive- absence of airflow in the presence of continuous respiratory effort (pharyngeal obstruction) • Central- absence of airflow during which no respiratory effort is present • Mixed

  22. Cessation of airflow

  23. The sleep apnea cycle: Apnea Airway restored Reduced airway tone at REM onset Pharyngeal collapse CO2 & O2  Arousal REM rebound REM deprivation by arousal REM sleep debt

  24. Obstructive Sleep – Disordered Breathing Comes in Two Flavours • Obstructive Sleep Apnea (OSA) - pharyngeal occlusion • High Upper Airway Resistance (HUAR) - inspiration flow limitation • Both OSA and HUAR can cause severe impairments of quality of life

  25. Obstructive Sleep Apnea

  26. High Upper Airway Resistance

  27. Diagnostic Classification

  28. Risk Factors • Risk factors: • Smoking • Obesity • Having a neck size 17 inches or greater • Regular use of alcohol or sleeping pills • Moderate sleep deprivation

  29. OSA Most Common Symptoms • Loud Snoring • Waking up non refreshed and having trouble staying awake during the day • Waking up with headaches • Waking up during the night sometimes with the sensation of choking • Waking up sweating

  30. Fragmented Sleep (Sleep Disruption) Insufficient Sleep (Sleep Deprivation) Excessive Daytime Somnolence Primary Disorders of EDS Sleep Disorders:Conceptual Framework

  31. Excessive Daytime Somnolence NeurobehavioralDeficits Performance Deficits Increased Morbidity/Mortality DecreasedQuality of Life Sleep Disorders:ClinicalImpact

  32. Pulmonary Vasoconstriction Pulmonary Hypertension Right heart failure Sleep Onset Systemic Vasoconstriction Systemic Hypertension Apnea Vagal Bradycardaia Cardiac Ischemia and Irritability Cardiac Arrhythmias sudden “unexpected” death O2 CO2 PH Stimulation of Erythropoiesis Polycythemia Arousal from sleep Celebral Impairment or damage Excessive Daytime Sleepiness Intelletual Detorioration persnality changes behavioral disorders Resumptiom of Airflow SleepFragmentation loss of deep sleep Return to sleep Excessive Motor Activity

  33. Physical exam • Alertness • BMI • Neck circumference • Blood pressure • Enlarged or crowded oral structures • Nasal passages • Assessment • History • Questionnaires • Snoring • Witnessed apneic episodes • Daytime hypersomnolence • Nocturnal choking

  34. Diagnostic Sleep Tools • Sleephistory • Sleep diaries, logs • Sleepiness rating scales: • Epworth Sleepiness Scale • Stanford Sleepiness Scale • Sleep study/ Polysomnography • Multiple Sleep Latency Test(MSLT)

  35. Sleep Screen:“BEARS” • Bedtime • Excessive daytime sleepiness • Awakenings: night waking early morning waking • Regularity and duration of sleep • Snoring

  36. Epworth Sleepiness Scale (ESS) 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

  37. A polysomnogram measures the following parameters during sleep: • EEG • EOG • Leg movement • ECG • EMG • Oxygen saturation • Airflow • Chest movement • Abdomen movement

  38. Polysomnogram interpretation • Sleep staging • RDI/AHI • Oxygen saturation • Central vs obstructive apnea • Mild, moderate, severe apnea • Periodic leg movements • Other sleep related difficulties

  39. Arousal Desat Apnea Diagnosis confirmed by polysomnogram

  40. Arousal Limb movements Diagnosis confirmed by polysomnogram

  41. Diagnosis Diagnosis (continued)

  42. Diagnosis Diagnosis (continued)

  43. Diagnosis Diagnosis (continued)

  44. Diagnosis Diagnosis (continued)

  45. Diagnosis Diagnosis (continued)

  46. Objective TestsTO ASSESS DAY TIME ALERTNESS • Multiple Sleep Latency Test (MSLT) • Measures patient’s tendency to fall asleep • Assesses patient’s ability to fall asleep when lying down in a dark room without stimuli • Maintenance of Wakefulness Test (MWT) • Measures patient’s ability to remain awake • Assesses ability to remain awake when semi-reclining in a dimly lit room • Both are 20-minute tests performed 4 times a day at 2-hour intervals beginning approximately 2 hours after nocturnal polysomnography is completed

  47. Treatment Options • Therapies • CPAP (BiLevel, AutoPap) • Oral appliance (airway dilators) • Surgery (UPPP, LAUP) • Somnoplasty • Treatment • Conservative • Weight loss • Avoidance of alcohol • Smoking cessation • Alteration of body position during sleep • Treatment of nasal obstruction

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