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SLEEP DISORDERS

SLEEP DISORDERS. Dr. Mohan Chandran Professor & HoD Dept of Psychiatry Yenepoya Medical College Mangalore. SLEEP ?.

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SLEEP DISORDERS

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  1. SLEEP DISORDERS Dr. Mohan Chandran Professor & HoD Dept of Psychiatry Yenepoya Medical College Mangalore

  2. SLEEP ? • A natural periodic state of rest for the mind and body, in which the eyes usually close and consciousness is completely or partially lost, so that there is a decrease in bodily movement and responsiveness to external stimuli.

  3. Components of Sleep History • Bed time habits • Timing of sleep onset and waking • Day time sleepiness • Snoring • Abnormal leg kicking • Nocturia

  4. Components of Sleep History • Mood complaints • Cataplexy • Co-morbid medical or psychiatry diagnosis • Substance abuse • Stress • Family history

  5. SPECIFIC PHYSICAL EXAMINATION • Obstructive sleep apnoea-neck circumference & posterior airway size • Restless leg syndrome-peripheral neuropathy-sensory examination • Sleep behavior disorder-parkinsonism

  6. OBJECTIVE TEST • Polysomnography- EEG, EOG, EMG, EKG, pulseoxymetry • Chest & abdominal excursion monitors • Auditory recordings • Video recordings of movements in sleep

  7. POLYSOMNOGRAM

  8. EPWORTH SLEEPINESS SCALE

  9. INSOMNIA

  10. INSOMNIA • Sleep onset insomnia- difficulty falling asleep • Sleep maintenance insomnia- difficulty remaining asleep, frequent nocturnal awakenings • Early morning awakenings-non restorative sleep. • A disorder when occurring despite patients having adequate opportunity & circumstances to sleep and must be associated with impairment of day time functioning or mood symptoms.

  11. DAY TIME IMPAIRMENT • Inattention • Impaired memory • Impaired concentration • Poor performance in vocational & social settings • Increased errors at work • Increased errors while driving • Tension headache

  12. DAY TIME IMPAIRMENT continued.. • Gastro-intestinal symptoms • fatigue • Mood symptoms- decreased energy, motivation - irritability - restlessness - anxiety • Prevalence : 15% > in women > in elderly

  13. Classification: 1. Primary 2.Co-morbid with medical or prophylactic activity • Primary : Idiopathic insomnia, psycho-physiological insomnia, paradoxical • Idiopathic : pervasive sleep disturbance throughout their lives, beginning in early childhood- at risk of developing major depression, Overuseof sedatives & alcohol prevalence 0.7% to 1.0%

  14. PSYCHOPHYSIOLOGIC: Develops as a result of maladaptive thought patterns & hyperarousal, inducing somatic tension • Inability to relax at bed time, racing thought, hyper vigilance or anxiety. • Paradoxical : complaint of severe insomnia & day time sleepiness, but without any objective evidence of sleep disturbance ,rare condition • poorly understood patho-physiology

  15. COMORBID DISORDERS ASSOCIATED WITH INSOMNIA • PSYCHIATRIC : Depression -Anxiety -Somatoform disorder -Substance abuse • MEDICAL : Chronic pain - Restless leg syndrome - COPD - Asthma

  16. COMORBID DISORDERS ASSOCIATED WITH INSOMNIA continued… MEDICAL -Menopause -Nocturia -Neurological disorders • Acute insomnia (adjustment insomnia)- short lived sleep disturbance precipitates by anxiety because of a stressor. • Treatment : CBT -Pharmacological.

  17. FDA approved drugs

  18. HYPERSOMNIA • Hypersomnia disorder characterized by excessive Sleepiness, extended sleep time in a 24-hour cycle, and the inability to achieve the feeling of refreshment that usually comes from sleep.

  19. HYPERSOMNIA • Hypersomnia can be caused by- Genetic predisposition Depression Restless leg syndrome Narcolepsy Sleep apnoea Periodic limb movement disorder Medications especially psychotropics Substance abuse

  20. Pickwickian syndrome is a complex of symptoms that primarily affect patients with extreme obesity

  21. HYPERSOMNIA • Kleine-Levin Syndrome or KLS is characterized by recurring periods of excessive amounts of sleeping ,eating and hypersexuality.

  22. OBSTRUCTIVE SLEEP APNOEA • Sleep disorder breathing- episodic upper airway obstruction with reduced blood oxygenation & brief arousal from sleep, lasts for 30sec-1min or longer. • Excessive day time sleepiness • Non refreshing sleep • Witnessed pauses in breathing during sleep. • Prevalence : 2% of women & 4% men aged 30 to 60 yrs

  23. OBSTRUCTIVE SLEEP APNOEA

  24. MANAGEMENT • Strategies to minimizes airway obstruction • Sleeping with head & trunk slightly elevated , avoiding supine position , • No alcohol or sedatives • Weight reduction • Night use of contagious positive air way pressure(CPAP)or bi-level positive airway pressure (BIPAP)

  25. MANAGEMENT continued… • On severe cases: surgical treatment • Uvulo-palato-pharyngoplasty: to reduce soft tissue bulk • Tracheostomy in very severe condition. • Modafinilis tried to prevent excessive day time sleepiness.

  26. NARCOLEPSY • Severe excessive day time sleepiness occurring almost daily (at least 3 months) • Interfere with functioning • Cataplexy • Hypnogogic hallucinations • Sleep paralysis • Rare 0.02% to 0.18%(US & Europe) men >women. • Any age but more before the age of 25.

  27. NARCOLEPSY

  28. CAUSES • Interplay of genetic & environmental factors. • Auto-immune process results in loss of hypothalamic neurons responsible for producing the neuropeptideHypocretin • MANAGEMENT • Stimulants & wakefulness promoting agents • Modafinil: low potency for abuse well tolerated Promotes wakefulness.

  29. MANAGEMENT continued… • Sodium oxybate – short acting adequate hypnotic, it helps consolidate REM sleep & increase slow wave sleep. • Reduce day time sleepiness, • Improves cataplexy • Selegiline is also tried

  30. PARASOMNIAS • Undesirable experiences or behaviors that occur during transition between sleep & waking. • Represent central nervous system activation & intrusion of wakefulness into REM or NREM sleep. • Results in non volitional motor, emotional, or autonomic activity. • NREM: confusion arousal & sleep terrors • REM: night mares, sleep related behavior disorder (RBD)

  31. SLEEP TERRORS - 3% of children aged 4-12 dramatic sudden arousal from NREM sleep , • Screaming ,fear, increased autonomic activity or amnesia • Resolves over time • In severe cases- low dose benzodiazepines at bed time

  32. Rapid eye movement BD • Rapid eye movements sleep behavior disorder, abnormal loss of muscle tone inhibition during REM sleep. • Vigorous movements while dreaming • Screaming ,punching, kicking or bed partner. • Common in men older than 50 • 40% associated with neuro-degenerative condition like parkinsonism disease or multisystem atrophy. • Movements are not stereo typed.

  33. MANAGEMENT :avoid antidepressants, alcohol, caffeine • Remove dangerous objects from sleep environment . • Medications - Clonazepam 0.25 to 1 mg bed time -TCAs -Levodopa -Carbamazepine -Melatonin in high doses

  34. RESTLESS LEG SYNDROME

  35. RESTLESS LEG SYNDROME • Over whelming urge to move the legs or sometimes the arms • Disrupt sleep initiation • Accompanied by an uncomfortable sensation • Rest or inactivity exacerbating the urge to move legs. • Physical activity temporarily relieving the urge • Evening & night times predominance of symptoms

  36. PREVALANCE : 5%-10 % • More common in older adults & women • Positive family history • Secondary to other conditions - pregnancy end stage renal disease iron or folate deficiency peripheral neuropathy radiculopathy rheumatoid arthritis fibromyalgia

  37. MANAGEMENT OF RLS • Dopamine agonist : Pramipexole Ropinirole • Dopaminergic : Levodopa • Anticonvulsants : Gabapentin • Benzodiazepines :Clonazepam • Opioid : Propoxyphene -Acetaminophen • Iron

  38. CIRCADIAN RHYTHM SLEEP DISORDER • When the body’s interval timing system get altered insomnia or hypersomnia. 1.delayed sleep phase type : sleep & wake times- later than desired, • more common in men • Affects 7% of adolescents 2. Advanced sleep phase : rare , earlier than desired sleep & awakening. 3. Jet lag : rapid changein time zones. More common in older people

  39. TREATEMENT • Difficult to treat • Triads of various modality for delayed or advanced sleep phase type disorders , • Bright light therapy –exposure to bright light • Chronotherapy JET LAG behavioral strategies : good sleep hygiene , Shifting sleep – wake times gradually before travel • Avoiding bright light exposure before bed time MEDICATION : MELATONIN0.5-5mg Zolpidem 10mg caffeine ? To improve day time sleepiness

  40. Guess I kept you awake….

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