Sleep-Wake Disorders

• Sleep-wake disorders are a category of conditions affecting the ability to fall asleep, stay asleep, or stay awake.

Objectives

• Accurately diagnose Insomnia Disorder, Hypersomnolence Disorder, and Narcolepsy based on DSM 5 criteria.
• Recognize and classify Breathing-Related Sleep Disorders (Obstructive Sleep Apnea, Central Sleep Apnea, Sleep Related Hypoventilation).
• Determine diagnoses for Circadian Rhythm Sleep-Wake Disorders, Parasomnias (Non-REM Sleep Arousal Disorders, REM Sleep Behavior Disorder), and Restless Legs Syndrome.
• Identify Substance/Medication-Induced Sleep Disorder based on DSM 5 diagnostic criteria.
• Classify sleep disorders based on specific characteristics.
• Compare and contrast nightmares and sleep terrors to differentiate the disorders.
• Predict the likely progression and prognosis of various sleep-wake disorders.
• Organize an effective strategy for evaluating and treating sleep-wake disorders within a general medical practice.

Insomnia

• It involves dissatisfaction with sleep quantity or quality characterized by difficulty initiating sleep, difficulty maintaining sleep, and early-morning awakening with inability to return to sleep.
• Marked by clinical distress or impairment that occurs at least three nights per week for at least 3 months, despite adequate opportunity for sleep.
• Insomnia cannot occur during another sleep-wake disorder or be secondary to a substance, and cannot be fully explained by medical or mental disorders.

Insomnia (Specifiers)

• Comorbidity in insomnia can occur with a mental disorder, a medical condition, and/or another sleep-wake disorder.
• Length of insomnia can be episodic (1-3 months), persist (≥ 3 months), or be recurrent (two or more episodes within a year).

Complications of Sleep Deprivation

• Sleep deprivation can cause an increased risk of depression and anxiety.
• Sleep deprivation can cause lower performance and decreased reaction time.
• Sleep deprivation can cause an increased risk of diabetes and of heart disease/high blood pressure.
• Sleep deprivation can cause a decreased immune system function.
• Sleep deprivation can cause increased weight.

Insomnia (Treatment)

• Can be treated with improved sleep hygiene and CBT-Insomnia.
• Benzodiazepines are a treatment with first choice of treatment, risk of being habit forming, and risk of daytime somnolence.
• Temazepam (Restoril), Triazolam (Halcion), and Estazolam (ProSom) are Benzodiazepines.
• Non-benzodiazepines have less abuse potential, little tolerance, and no daytime somnolence.
• Examples of Non-benzodiazepines include: Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta), Ramelteon (Rozerem), and Suvorexant (Belsomra).
• Chloral hydrate was discovered in chlorination of Ethanol, augments the effect of alcohol, and is not FDA approved.
• Antihistamines of low potency develop tolerance fast and can impair sleep in long-term use.
• Diphenhydramine (benadryl) and Doxylamine (unisom) are Antihistamines.
• Other treatments include: Trazodone and doxepin (Silenor).

Hypersomnolence Disorder

• This involves excessive sleepiness despite at least 7 hours of sleep with either recurrent lapses into sleep, unrefreshing sleep of >9 hours, and/or difficulty being awake after abrupt awakening.
• Characterized by clinical distress or impairment with symptoms occurring at least three times per week for at least 3 months.
• Not due to another sleep disorder, substance, or medical/mental conditions.

Hypersomnolence Disorder (Specifiers)

• Hypersomnolence Disorder can present with comorbidity that includes a mental disorder, a medical condition, and/or another sleep disorder.
• Length: acute is less than one month, subacute is 1-3 months, and persistent is more than 3 months.
• Severity is based difficulty maintaining daytime alertness.
• Mild is 1-2 days/week, moderate is 3-4 days/week, and severe is 5-7 days/week.

Hypersomnolence Disorder (Treatment)

• Treatment includes Sleep hygiene and Stimulants.
• Methylphenidate can be administered in doses of 5 to 60 mgs per day.
• Dextroamphetamine: 10 to 60 mg per day could treat it.
• Modafinil (Provigil) can be administered in doses of 200-400 mg per day.
• Erythema multiforme or Stevens-Johnson syndrome are possible side effects of Modafinil.
• Scheduled naps are an alternative if other treatments are ineffective.

Narcolepsy

• Narcolepsy is diagnosed by recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping within same day; occurring at least three times per week over past 3 months.
• It must include cataplexy, hypocretin deficiency (CSF Value ≤110pg/mL), or nocturnal sleep polysomnography showing REM latency ≤15 minutes/mean sleep latency ≤ 8 minutes.

Cataplexy

• Cataplexy refers to brief (seconds-minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness, typically precipitated by laughter or joking.
• Cataplexy may present as spontaneous grimaces or jaw-opening with tongue thrusting/global hypotonia, without obvious emotional triggers.

Narcolepsy Specifiers

• Narcolepsy can occur with or without cataplexy, or secondary to another medical condition.
• Autosomal dominant cerebellar ataxia, deafness, and narcolepsy is possible.
• Autosomal dominant narcolepsy, obesity, and type 2 diabetes is possible.

Narcolepsy Diagnostic Specifiers

• Mild narcolepsy is defined by cataplexy occuring <1 per week, 1-2 naps per day, minimal sleep disruption and is responsive to treatment.
• Moderate narcolepsy:Cataplexy occuring 1/day; >2 naps/day; moderately disruptive sleep; responsive to treatment.
• Severe narcolepsy: Multiple cataplexy/day; constant sleepiness; very disturbed sleep; not responsive to medications.

Narcolepsy Treatment

• Treatment includes Pharmacotherapy.
• Stimulants like methylfenidate, modafinil, and dextroamphetamine that may counter the constant sleep urges.
• Sodium oxybate (Xyrem) doses are prescribed to be taken at bedtime and again 2.5-4 hours later.
• It is classifed a schedule III drug.
• Other treatments used are tricyclic antidepressants, family education, and employer education.
• There are concerns regarding potential sleep attacks while driving.

Breathing Related Disorders

• Breathing Related Disorders Include: Central Sleep Apnea, Obstructive Sleep Apnea/Hypopnea, and Sleep Related Hypoventilation.

Obstructive Sleep Apnea/Hypopnea

• Polysomnography indicating at least five obstructive apneas/hypopneas per hour of sleep, accompanied by snoring/gasping/breathing pauses.
• Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities, cannot be attributable to another medical condition.
• Polysomnography can also be showing 15 or more obstructive apneas per hour of sleep regardless of accompanying symptoms.

Obstructive Sleep Apnea/Hypopnea Specifiers

• Severity is based on Apnea hypopnea index: mild is less than 15, moderate is 15-30, and severe is greater than 30.

Obstructive Sleep Apnea/Hypopnea Treatment

• Treatment includes: weight loss (at least 10% recommended), avoidance of sedatives, and sleep in the supine position.
• Oral appliances to keep airway open are a treatment.
• CPAP (Continuous Positive Airway Pressure) is a treatment.
• Uvulopalatopharyngoplasty (UPPP) for severe/refractory cases is also an option for treatment.

Central Sleep Apnea

• Central Sleep Apnea is diagnosed by Evidence of 5 or more central apneas per hour of sleep from polysomnography and the disorder is not attributable to another existing sleep disorder.

Central Sleep Apnea Specifiers

• Idiopathic central sleep apnea involves repeated apneas/hypopneas without airway obstruction evidence.
• Cheyne-Stokes breathing presents with periodic tidal variation, that can be related to CHF, stroke, or renal failure.
• Comorbidity with Central sleep apnea can involve opioid use.
• Severity is determined by breathing disturbances and oxygen desaturation.

Sleep Related Hypoventilation

• Diagnosed when Polysomnography shows episodes of decreased respiration associated with elevated CO2 levels.
• The disturbance is not better explained by another current sleep disorder.

Sleep Related Hypoventilation

• The types include: Idiopathic hypoventilation.
• Congenital central alveolar hypoventilation is rare and it occurs in the perinatal period.
• Comorbid sleep-related hypoventilation can stem from pulmonary disorder, neuromuscular chest wall disorder, certain medications, or obesity.
• Severity is graded according to hypoxemia and hypercarbia, as well as evidence of end-organ damage.

Breathing Disorder (Treatment)

• Treatment includes: bronchodilators (albuterol), theophylline, avoidance of CNS depressants, and weight loss
• CPAP, and endotracheal ventilation with mechanical intubation is a treatment.

Circadian Rhythm Sleep Wake Disorders

• Defined by sleep disruption due to alteration of circadian rhythm, causing excessive sleepiness, insomnia, or both; clinically significant impairment or distress results.

Circadian Rhythm Sleep Wake Disorders Specifiers

• Delayed Sleep phase, Advanced sleep phase, Irregular sleep wake type, Non-24hr sleep wake type, shift work type, and unspecified. Familial is also a type.
• Severity can be: Episodic (1-3 months), Persistent (at least three months), or Recurrent (two or more episodes per year).

Delayed Sleep Wake Phase (Treatment)

• The treatment is based around: Chronotherapy, light restriction at night, bright light exposure during morning, hypnotics, and melatonin.

Advanced Sleep Wake Phase (Treatment)

• The treatment is based around: Bright light exposure during afternoon, and Chronotherapy.

Work Shift Type (Treatment)

• The treatment is based around: Armodafinil, and job/shift change.

Parasomnias

• These are a category of sleep disorders characterized by abnormal behavioral, experiential, or physiological events occurring in association with sleep, specific sleep stages, or the sleep-wake transition.

Non-REM Sleep Arousal Disorder Criteria

• Diagnosed through incomplete awakenings from sleep, usually during the first third of major sleep episode, with either sleepwalking or sleep terrors.
• Features absence of dream recall, amnesia for episodes, and clinically significant distress.
• Not due to substance use, medical conditions, or other mental conditions.

Non-REM Sleep Arousal Disorder (Specifiers)

• Sleepwalking type: with sleep-related eating or sexual behavior.
• Sleep terror type

REM-Sleep Arousal Disorder

• It occurs in stage 3 of Non-REM sleep.
• Presents hHigh amplitude slow waves.
• 15% of children show signs of sleep walking, and 5% with sleep terrors.
• It usually disappears by adulthood.
• If new and continues into adulthood explore other sleep or mental disorders.
• Can be familial.

REM Arousal Disorder (Treatment)

• Treatment is based on good sleep hygiene and avoid stimulants.
• Protection from injury and the protection from upsetting situations.
• Benzodiazepines suppress stage 3 sleep.
• TCA, SSRIs, and Melatonin can be effective.

Nightmare Disorder (Criteria)

• Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams involving threats to survival/security/physical integrity during the second half of major sleep episode.
• Clinically significant distress or impairment
• On awakening, individuals rapidly become oriented and alert.
• Not attributable to physiological effects of a substance and is not always explained by other disorders.

Nightmare Disorder (Criteria Specifiers)

• This occur during sleep onset.
• Has Associated non-sleep disorder(s), is non-sleep disorders like substance use disorder.
• There can be Associated medical and sleep disorder(s).

Nightmare Disorder (Criteria Specifiers II)

• Specify: can be in form of acute, subacute and persistant
• Acute lasts for a month or less.
• Subacute lasts between one month and 6 months.
• Persistant lasts for 6 months or greater.
• Specify severity: The episodes can be mild, moderate or severe
• Mild occurrs one ecisode per week on average.
• Moderate occurrs as one or more ecisodes per week
• Severe occurrs nightly.

REM Behavior Disorder (Criteria I)

• Diagnosed with repeated arousal vocalization, occurring during REM.
• Awakens easily, is alert, and oriented.
• Polysomnogram will show REM sleep without atonia and has a suggestive history of Lewi body, multiple system atrophy.

REM Behavior Disorder (Criteria II)

• There is often clinically significant distress.
• It is not directly linked to substance use or medical conditions.
• Preexisting disorders do not explain episodes.

REM Disorder (Treatment)

• Treatment is based on sleeping in different rooms.
• Clonazepam can be administered with continuation, but symptoms relapse on discontinuation.
• Treatment includes: Tricyclic antidepressants, SSRIs, serotonin-norepinephrine reuptake inhibitors, and beta-blockers.

Restless Legs Syndrome (Criteria I)

• Urge to move legs due to uncomfortable sensations; begins or worsens during periods of rest, movement relieves it, worse or present only at night. Minimum of 3 times per week over 3 months.

Restless Legs Syndrome (Criteria II)

• There is a clinically significant distress.
• It is not secondary to medical or mental condition.
• Occurs also with arthritis, edema, positional discomfort, and foot tapping.
• Not due to substance.

Restless Legs Syndrome (Treatment)

• Dopamine agonists: Pramipexole (Mirapex), Ropinirole (Requip), Rotigotine (Neupro).
• Gabapentin enacarbil is a valid treatment.
• Give Iron if less than 50ng/mL.

Substance/Medication-Induced Sleep Disorder

• Defined by prominent sleep disturbances, it is directly associated with known effects of substance abuse or medication use.
• Some substances include: caffeine, stimulants, cocaine, Benzodiazepines, and alcohol.