AN OVERVIEW OF SLEEP DISORDERS

1. AN OVERVIEW OF SLEEP DISORDERS April 2010 George Makari, MD Mary Bridge Children’s Hospital

2. Three States of normal Being • Wake • REM Sleep • Non-REM Sleep

3. Sleep • Active • Essential • Complex • Highly Regulated • Involves different neuronal groups • Purpose is not well understood • Composed of two fundamentally different states : REM sleep & NREM sleep

4. The Significances of Sleep • Sleep profoundly affects cognitive and behavioral performance. • Sleep has very important effects on growth, healing, immune function, cardiopulmonary function and metabolic activities. • The quantity and quality of sleep or the lack thereof have a significant impact on every human for a substantial fraction of each day.

5. WHY DO WE SLEEP ? • ARISTOTOLE : get rid of a build up of a unneeded substance. • 19th CENTURY : blood congestion relief • EARLY 20th CENTURY : lack of external stimuli • NOW ?

6. Prolonged Wakefulness Biology • Impaired neurobehavioral function • Reduced growth hormone • Increased energy expenditure • Reduced wound healing • Impaired motor function • Transcription effects: • mitochondrial function, • synaptic plasticity • glucose metabolism

7. Developmental Circadian Ultradian Prior sleep deprivation / fragmentation Neurologic Cardiopulmonary Gastrointestinal Endocrine Dermatologic Upper respiratory Allergy Drugs Psychiatric / psychological Infectious Pain Factors that Impact on Sleep

9. Circadian Rhythm • The term "circadian" comes from the Latincirca, "around", and diem or dies, "day", meaning literally "approximately one day". • Sleep / wake cycling (amount, time) • Distribution of REM / NREM sleep • Body temperature

10. Circadian Rhythm Cardiopulmonary variables - blood pressure, heart rate, myocardial infarction, pulmonary function Drug metabolism Gastric acid secretion

11. Ultradian Rhythm Defined by the cyclic alteration of wake, REM sleep and NREM sleep during the sleep period

12. REM vs. NREM Similarities • Posture • Unresponsiveness • Reversibility • Lack of conscious awareness Differences • Brain blood flow • Glucose utilization • Neurotransmitters • Thalamic functioning

13. NREMS Biology: • parasympathetic tone and sympathetic tone •  body temperature and metabolism •  muscle tone •  responsiveness to auditory, tactile, respiratory, etc. stimuli •   growth hormone and prolactin,  thyroid stimulating hormone • Tissue repair and energy restoration

14. REM Biology: • parasympathetic tone and  sympathetic tone except in phasic rems, large bursts • Atonia in most muscles •  body temperature and body metabolism; increased brain metabolism •  responsiveness to auditory, tactile, respiratory, etc. stimuli •  prolactin, decreased thyroid stimulating hormone

15. The depth of Slow-wave (deep NREM sleep) is age-dependent and best in toddlers

16. Sleep by age

17. Sleep in Newborns • Organized REM and NREM sleep states is seen in the third trimester • 3 sleep statesin term newborns: active, quiet, indeterminate. • They enter sleep thru REM: active sleep • Total sleep time newborns 16-20 hours / day; diurnal = nocturnal sleep amounts • Sleep episodes 3-4 hours / 1-2 hrs awake; breast-fed more frequent wakings

18. Sleep in Infants • Critical sleep reorganization period at 8-12 wks; establishment of diurnal cycle • Development NREM sleep by 6 months; decreased REMamounts • At 6 months: total sleep time13-14 hrs; sleep episodes 6-8 hrs • “Sleeping through the night”: 70-80% at 9 months

19. Sleep in Toddlers • Total sleep time12 - 14 hours • Most give up 2nd nap at about one year • Developmental issues: separation anxiety® nighttime fears, mastery of independent skills® power struggles • Sleep problems common (20-40%) • Importance bedtime routines, transitional objects

20. Sleep in Pre-Schoolers • Sleep cycles: REM/Non-REM 90 minutes • Total sleep time: 11-12 hours per 24 hours • By age 4-5, many children give up regular daytime naps • “Signaled” night wakingsoccur frequently (up to 60%); role of parental reinforcement • Sleep problems may become chronic

21. Middle Childhood (6-12 years old) • Total sleep time: 9-11 hours (10 - 11 hours in 6-7 year olds; 9 - 9 1/2 hours in early adol.) • Sleep pattern becomes more stable, night-to-night consistency • Low levelof daytime sleepiness; naps rare • School, lifestyle influences ® later bedtimes, earlier rise times, irregular sleep/wake schedules ? = insufficient sleep

22. Sleep Changes in Adolescence • Delayed sleep onset • Circadian: relativephase delayat puberty • Environmental factors • Advanced wake times(sleep offset) • Earlier school start times

23. Sleep Changes in Adolescence (cont) • Decreased sleep / wake regularity: • Discrepancy weekday / weekend sleep cycle • ¯ Daytime alertness • ­ Daytime sleep tendency at mid-puberty • ¯Parental protection of sleep time

24. Insufficient Sleep in Adolescents • Average sleep high school students need:9 - 9 1/4 hours / night • Average sleep high school students get:7 1/4 hours / night

26. Fragmented Sleep (Sleep Disruption) Insufficient Sleep (Sleep Deprivation) Excessive Daytime Sleepiness PrimaryDisordersof EDS Sleep Dysfunction in Children: Conceptual Framework

27. Daytime Sleepiness Neurobehavioral Deficits MoodDisturbance Performance Deficits: Academic Failure Impaired Social Functioning Behavioral Dyscontrol Daytime Sleepiness in Children:Conceptual Framework

28. Daytime Sleepiness in Children: Impact • Mood and affect changes • Behavioral problems: internalizing and externalizing (aggressiveness, hyperactivity, poor impulse control) behaviors • Neurocognitve deficits: attention, memory, executive functions • Performance deficits: academic, social, work and driving-related • Family disruption

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

30. Objective: Elucidate what happens at sleep onset Initial Question: “Does your child have any difficulty going to bed or falling asleep?” Follow-up Questions: Could you describe what happens at bedtime? What keeps your child from falling asleep? Does your child seem anxious at bedtime? BEARS: Bedtime

31. Objective: Determine the extent of excessive daytime sleepiness Initial Question: “Is your child difficult to wake in the morning, act sleepy, or seem overtired a lot?” Follow-up Questions: How does your child act when she is overtired? Does your child fall asleep during the day? when and where? Does anyone else in the family have a problem with excessive sleepiness? BEARS: Excessive daytime sleepiness

32. Objective: Characterize the extent and content of awakenings Initial Question: “Does your child have trouble with waking up at night?” Follow-up Questions: What do you think awakens him? How does your child behave when she awakens at night? Does your child move to someone else’s bed during the night? BEARS: Awakenings (Nighttime)

33. Objective: Delineate sleep habits Initial Question: “What time does your child go to bed and get up on schooldays? weekends?” Follow-up questions: Do you think your child is getting enough sleep? How much sleep do you think your child needs? BEARS: Regularity and duration of sleep

34. Objective: Screen for Obstructive Sleep Apnea Initial Question: “Does your child have loud or nightly snoring?” Follow-up Questions: Does your child ever stop breathing, choke or gasp at night? Is your child a restless sleeper? Sweat a lot at night? Do other people in your family snore loudly? BEARS: Snoring

35. Clinical Evaluation of Sleep Disorders in Children • History of Sleep Problem: • Presenting complaint • Related sleep complaints • Related am / daytime behavior • Bedtime routine, sleeping environment • Sleep habits, sleep patterns and duration • Frequency and character of night wakings • Family’s response to sleep problems, previous rx • Previous sleep patterns • Family history of sleep problems

36. Clinical Evaluation of Sleep Disorders in Children • Past and current medical history • Socialhistory / stressors • Developmental / schoolhistory • Sleep diagnostic tools: • Sleep Diaries: 2 week baseline • Home videotaping: paroxysmal arousals • Polysomnography: OSAS, PLMD, EDS, Parasomnias • MSLT : in case EDS • Actigraphy

37. POLYSOMNOGRAPHY RECORDING AND ANALYSING : • SLEEP (EEG, EOG, EMG) • CARIAC: EKG. • RESIRATORY EFFORT AND AIR FLOW • LIMB MOVEMENTS • POSITION • AUDIO AND VIDEO • O2 SATURATION and ET CO2

40. Awake

41. Stage N1

42. Stage N2

43. Stage N3

44. Stage N3

45. REM SLEEP

46. Arousal

47. Snoring

48. Apnea : Obstructive

49. Apnea :Central

50. Hypopnea