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Sleep and sleep disorders

Sleep and sleep disorders. Andy Montgomery. Talk Outline. Normal Sleep Diagnosing sleep disorders Insomnia Hypersomnia Parasomnias Circadian sleep rhythm disorders Psychiatric disorders and sleep Pharmacology and sleep. Normal sleep. 1/3 of adult lives asleep Role poorly understood

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Sleep and sleep disorders

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  1. Sleep and sleep disorders Andy Montgomery

  2. Talk Outline • Normal Sleep • Diagnosing sleep disorders • Insomnia • Hypersomnia • Parasomnias • Circadian sleep rhythm disorders • Psychiatric disorders and sleep • Pharmacology and sleep

  3. Normal sleep • 1/3 of adult lives asleep • Role poorly understood • Sleep deprivation consequences • Cognitive impairment • Hormonal rhythm disturbance • Rebound after deprivation

  4. Normal sleep • Quantity • 7-8 hours • <6 increased reports dissatisfaction • Control by 2 processes • Circadian process • Homeostatic process

  5. The Circadian process • 24 hour cycle • Many cells and organs • Principle time-keeper: • Supra-chiasmatic nucleus • Influenced by light and temperature • Some sleep disorders associated with genetic variant • Determines owl/lark

  6. The homeostatic process • Aka recovery drive to sleep • Increases in proportion to time awake • 2 processes interact • Generates • Post-lunch dip • mid-evening activity • Other influences • Arousal, relaxation, anxiety

  7. Physiology of sleep control • Orexin (hypocretin) • Peptide hormone • Promotes wakefulness • Wakefulness • Ascending arousal system dominant • Sleep • Inhibition of arousal systems

  8. Sleep structure • Polysomnography • Simultaneous record • EEG • Muscle activity • Eye movements • 4-5 cycles • Quiet sleep alternating with REM • Increased duration through night

  9. Hypnogram

  10. Sleep structure:quiet sleep • 4 stages • 1: dozing “just resting eyes” • 2: deeper, occasional jerks, reduced HR &RR • 3&4: slow HR & RR • EEG • Progressive slow synchronous activity • Reduced cortical arousal • Increased thalamo-cortical synchrony

  11. Sleep structure:REM • Rapid onset • EEG “awake” • Jerky eye movements • Muscle paralysis • Autonomic arousal • Usually several short wakenings

  12. Age variants • 24 hour rhythm • Develops at 3/12 • High levels REM in childhood • Aging • Time awake increases • Slow wave reduces • GH release reduces

  13. Dreaming • Only remembered if REM followed by wakefulness • Occurs in • REM • Bizarre, storyline • Slow wave

  14. Sleep and cognition • Sleep enhances memory consolidation • Transfer from short-term to long-term memory • Dependent on hippocampal activity • Sleep deprivation associated with reduced hippocampal neurogenesis

  15. Sleep disorders • Diagnosis • Take sleep history • Questionnaires and diaries can be helpful • Sleep centres: polysomnography, actigraphy, video recording • Classified in ICD 10 and DSM IV • 3 categories • Insomnia • Hypersomnia • Parasomnia

  16. Questions to ask • Time: • Bed, getting up, ?regular pattern • Falling asleep • Waking episodes • Quality (Pittsburgh Sleep Quality Index) • How many bad nights/week?

  17. Questions to ask • Naps during day • Mood • Motor activity during sleep • Behaviour during sleep • Day-time somnolence (Epworth sleepiness scale) • Snoring • Use of drugs

  18. Investigations • Actigraphy • Monitors movement via wrist band • Can be used over days- weeks • Sleep- less movement • Overnight video recording

  19. Actigraphy

  20. Polysomnography • Terms • Time in bed • Sleep onset (to stage 1 or 2) • Sleep onset latency • Sleep period: onset to wake • Total sleep time • Number of wakenings • Sleep efficiency (total sleep/time in bed) • Wake after sleep onset • REM onset latency • Time in each sleep stage

  21. Insomnia • Major public health problem • 10-15% adults persistent insomnia • Low quality of life • Increased absenteeism • Physical illness • Mental illness

  22. Insomnia • Symptoms • Too little • Too long to go to sleep • Poor quality • Unrefreshing • Impaired daytime function • Daytime sleepiness uncommon(circadian rhythm disorder)

  23. Insomnia • Two main types: • Sleep onset insomnia • Sleep maintenance insomnia

  24. Insomnia - precipitating factors Psychiatric disorder • Depression • anxiety Pharmacological • -blocker • AD • Caffeine • Alcohol • Stimulants • Withdrawal Psychological stress • Bereavement • Increased arousal • Worry about alarm • Noise • children Short term insomnia Physical • Pain • Pregnancy • Illness (cardio/resp) • Urinary Sleep wake cycle • jet lag • Shift work • Irregular routine

  25. Short term insomnia Poor sleep habits Good sleep habits Anxiety about sleep Good sleep Long term insomnia Insomnia- perpetuation

  26. Insomnia- treatment • Establish primary diagnosis • Acknowledge distress • Treat precipitating factors/primary cause • Educate about trigger factors and reassure • Establish good sleep habits

  27. Insomnia- treatmentHypnotics • Act at GABA-A benzodiazepine receptor • Generally safe and effective in short term • SE • Muscle relaxation • Memory impairment • Ataxia • Potentiated by EtOH • Avoid long term px

  28. Insomnia- other drugs • Sedative AD • Mirtazapine • Agomelatine • Melatonin • Anti-histamines

  29. Psychological treatments • Sleep hygiene • Regular hours • Daytime exercise • Morning daylight exposure • Reduced daytime napping • Avoid stimulants • Bed-time routine

  30. Psychological treatments • Behavioural techniques • Stimulus control • Avoid clock watching • Don’t watch TV • Don’t stay in bed if awake • Sleep restriction • Relaxation training

  31. Psychological treatments • Cognitive techniques • CBT • Avoid negative thoughts associated with not sleeping • Rehearsal and planning session • Paradoxical intent

  32. Sleep restriction

  33. Hypersomnia • Feeling sleepy during day • Distinct from tired • 37% adults a few days a month • 16% a few days / week • Main causes • Fragmentation of sleep • Obstructive sleep apnoea • Intrusion of sleep phenomena into wake • narcolepsy • Disturbed circadian rhythm.

  34. Obstructive sleep apnoea: symptoms • Excessive daytime sleepiness • Loud snoring • Interruptions of breathing • Resumes with loud gasp, violent movement • Marital problems • Dry mouth, sore throat, headache • Depression • Present in 0.5% men BMI >25

  35. Obstructive sleep apnoea: treatment • Weight loss • Continuous positive pressure ventilation • Consider modafinil if remain sleepy during day

  36. Narcolepsy • 3-4/10,000 • HLA DQB1*0602 (18-35% in controls) • Symptoms • Sudden onset sleep • Sleepiness • Cataplexy • Hypnogogic/pompic hallucinations • Poor nocturnal sleep

  37. Narcolepsy • Cause • Lack of orexin neurones/release in hypothalamus • Possible cross-reaction autoimmune disorder after infection in adolescence • Diagnosis • Clinical picture • Reduced REM latency

  38. Narcolepsy • Treatment • Education • Day-time naps • Drugs • Daytime sleepiness • Modafinil/dexamphetamine • Cataplexy • 5HT enhancing drug: SSRI, clomipramine • Night-time sleep disruption • Sodium oxybate

  39. Other causes of daytime sleepiness • Idiopathic hypersomnia • Kleine-Levine syndrome • Rare, reversible disorder • Hypersomnia +/- excessive eating & hypersexuality • Onset adolescence • Typical duration 4-8 years • ? autoimmune

  40. Parasomnias • Unusual behaviours occurring during sleep • Exacerbated by anxiety • Variable drug treatments

  41. Night terrors • Recurrent episodes of abrupt waking usually first 1/3 of night • Intense fear and autonomic arousal • Unresponsive to comforting • No detailed recall • Significant distress

  42. Night terrors • Occur in 30-40% children • Generally resolve with aging • Can recur at times of stress • Comorbidity with anxiety common • Often run in families

  43. Night terrors • Cause • Genetic component • Incomplete arousals from SW sleep • Treatment • Clonazepam • Paroxetine (immediate effect)

  44. Night terrors hypnogram

  45. Parasomnias -SWS • Sleep walking • Automatic behaviour • No recall • 15-20% lifetime prevalence • Confusional arousals • Semi-purposeful movements • Sleep bruxism • Sleep talking

  46. Parasomnias -REM • Nightmares • Wake oriented (vs night terrors) • Association with depression and PTSD • Psychological treatment • Guided imagery- rehearse happy endings • Sleep paralysis • Waking with fear, foreboding, unable to move • Common-25% experience • Treatment- good sleep hygiene

  47. Parasomnias -REM behaviour disorder • Violent, short duration • Several episodes/night • Can wake • Remembers dream • Violent unpleasant content • Strong association with subsequent IPD OR LBD (45-85%) • Made worse by AD • Treat by making sleep environment safe

  48. Circadian rhythm sleep disorders • Jet lag • Worse for travel east (natural clock 24.5hr) • Melatonin may help • Delayed sleep phase syndrome • Unable to sleep before 2-3AM • Preferred wake time after 10 AM • Causes insomnia and sleepiness on work days • Advanced sleep phase disorder • rare

  49. Circadian rhythm sleep disorders • Non 24hr circadian sleep disorder • Sleep pattern advances daily • Most common in congenitally blind • Irregular sleep wake rhythm • Seen in dementia- ? Loss of melatonin neurons in SCN • Shift work sleep disorder

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