Sleep Disorders Lecture Notes PDF

Sleep Disorders Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives: Sleep Disorders 1. Evaluate the normal sleep cycle and how it varies throughout the lifespan. 2. Differentiate between REM and non-REM sleep, noting their significance. 3. Compare...

Sleep Disorders Rachel Elbing PA-C, MPH Augsburg PA Program Spring 2025  Objectives: Sleep Disorders 1. Evaluate the normal sleep cycle and how it varies throughout the lifespan. 2. Differentiate between REM and non-REM sleep, noting their significance. 3. Compare and contrast the following conditions: Insomnia Hypersomnia Narcolepsy Parasomnias 4. Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, complications, treatment and patient education for sleep disorders. 5. Determine the impact that psychiatric illness, general medical conditions, alcohol and substance abuse have on sleep disturbances. 6. Assess the function of a sleep laboratory, and recognize when a patient should be referred.  Anatomy and Physiology of Sleep Hypothalamus: nerve cells that act as control center affecting sleep and arousal Suprachiasmatic nucleus (SCN) receives info on light exposure from eye to control behavioral rhythm Brainstem (pons, medulla, and midbrain) communicates with hypothalamus to control transitions Sleep cells in hypothalamus and brain stem produce GABA → reduces activity or arousal centers in hypothalamus and brainstem  Normal Sleep Cycle - Two States NREM (Non-REM) sleep Rapid Eye movement (REM) sleep 75-80% of sleep 20-25% of sleep Body temp, HR, respirations, “Paradoxical sleep… “dream sleep” blood pressure, and muscle tone Conjugate eye movement bursts, decrease suppressed temp regulation, Divided into 3 sub-stages (N1, alterations of RR, HR and BP N2, N3) Important for memory, emotional Deep sleep: GH released, stability, cognitive processing decreased catecholamines and corticosteroids Normal Sleep Cycle Sleep Through Life Older ○ Decreased total sleep time ○ Unchanged REM sleep but decreased stage 3 and 4 NREM ○ Decreased ability to tolerate sleep deprivation Younger ○ Increased total sleep time ○ Decreased sleep cycle length & differences in percentage of time in each stage  Sleep Disorders - History Taking Sleep History PMH Social history Duration of problem ○ Stressors Number and duration of ○ EtOH/caffeine use awakenings at night Medication review Sleep times ○ Bed, wake-up, naps Family history Symptoms of disturbed sleep ○ Fatigue, daytime sleepiness Sleep log (usually Psychiatric history recommended ~ 2 weeks) Depression Mania Psychosis  Epworth Sleepiness Scale Asks likelihood of falling asleep in 8 sedentary situations 0-3 scale (never - high chance)  Sleep-Wake Disorders DSM-5 Sleep disorders are categorized into 10 disorders or disorder groups: (1) Insomnia disorder (2) Hypersomnolence disorder (3) Narcolepsy (4) Breathing-related sleep disorders (5) Circadian rhythm sleep–wake disorders (6) Non-rapid eye movement (NREM) sleep arousal disorders (7) Nightmare disorder Parasomnias (8) Rapid eye movement (REM) sleep behavior disorder (9) Restless legs syndrome (10) Substance-/medication-induced sleep disorder  Sleep-Wake Disorders Reviewed today But also consider Insomnia Sleep apnea (breathing related sleep disorders) Hypersomnia RLS (Restless leg syndrome) Narcolepsy Circadian rhythm disorder Parasomnias Comorbidities: depression, anxiety, bipolar disorder, alcohol or chemical dependency, etc…  Insomnia: Overview Difficulty getting to sleep or staying asleep, early morning awakening, intermittent wakefulness during the night Very common! Patients often don’t report this…need to ask about sleep in ROS Reduced QOL and ability to perform daily tasks Can lead to self-medication Insomnia Diagnostic Criteria - DSM V  Insomnia: Management Psychological (Cognitive Behavioral): best for primary insomnia Pharmacologic: May be most appropriate in acute distress, grief reaction  Insomnia: Psychological Management Sleep Hygiene ○ Go to be when sleepy ○ Us bed and bedroom only for sleeping and sex ○ Get out of bed if unable to fall asleep after 20 min → go to another room and pursue restful activity ○ Get up at same time each morning ○ D/C caffeine and nicotine (esp. In evening) ○ Daily exercise regimen ○ Avoid alcohol ○ Limit fluids in evening ○ Relaxation techniques ○ Bedtime routine  Insomnia: Pharmacologic Management Benzodiazepines: Lorazepam (Ativan) Nonbenzodiazepines hypnotic sedatives: Zolpidem (Ambien), Zaleplon (Sonata), Eszopiclone (Lunesta) Melatonin receptor agonists: Ramelteon (Rozerem), Melatonin Antihistamines: Diphenhydramine (benadryl), Hydroxyzine (Vistaril) Antidepressants: Trazodone When prescribing…think about specific sleep disturbance  Hypersomnia Disorders of excessive daytime sleepiness Many different causes: ○ Hypersomnolence disorder ○ Inadequate nighttime sleep ○ Medications ○ Psychiatric illness ○ Sleep apnea ○ Narcolepsy ○ Restless leg disorder ○ Chronic medical conditions: hypothyroidism, renal failure Hypersomnolence Disorder - DSM V  Hypersomnolence Disorder - Management Review potential causes/exacerbating factors ○ Sleep hygiene ○ CPAP ○ RLS medication ○ Changes in meds that may cause hypersomnolence ○ Stimulants for central disorder (i.e. narcolepsy or idiopathic hypersomnia) Sleep Medicine Referral  Narcolepsy Clinical syndrome of chronic daytime sleepiness + additional symptoms Cataplexy Disrupted nighttime sleep Sleep paralysis Hypnagogic and hypnopompic hallucinations Narcolepsy - DSM V  Narcolepsy: Diagnosis Excessive daytime sleepiness w/ the following characteristics: ○ Sudden, brief attacks - can occur during any activity ○ Cataplexy - sudden loss of muscle tone Often associated with emotional reactions Can be mistaken as ____________? ○ Sleep paralysis - generalize flaccidity of muscles with full consciousness in transition zone between sleep and waking ○ Hypnagogic & hypnopompic hallucinations (visual or auditory) - precede sleep or during sleep attack Usually begins in teens/early 20s, male/female affected equally  Narcolepsy - Workup Low hypocretin (orexin) levels in CSF associated with cataplexy Orexin orchestrates release of other neurotransmitters to help with wakefulness Type 1 - cataplexy, CSF hypocretin deficiency Type 2 - no cataplexy, hypocretin levels nl or not documented Sleep Study: w/ multi-sleep latency testing ○ Typically enter REM sleep rapidly  Narcolepsy - Management Non-pharm ○ Sleep hygiene ○ Scheduled naps (2-3 20 min naps/day) Pharm ○ Modafinil (Provigil) - CNS Stimulant ○ Stimulants (Methylphenidate) Life with Narcolepsy  Parasomnias - Overview Abnormal behaviors, experiences or physiologic events during sleep cycle Sleepwalking ○ Ambulation or other intricate behaviors while still asleep ○ 6-12 y/o Sleep terror ○ Abrupt, terrifying arousal from sleep, usually in preadolescent boys ○ Fear, sweating, tachycardia, and confusion Nightmares ○ Vivid, dysphoric dreams occurring during REM sleep with full alertness and recall upon awakening ○ Often involve threats to survival or security ○ Associated with PTSD and exacerbated with stress  Parasomnias - NREM Sleep Arousal Disorders A) Recurrent episodes of “incomplete awakenings” usually occurring during first third of major sleep episode a) Sleep walking b) Sleep terrors B) No or little dream imagery is recalled C) Amnesia for the episode D) Distress or impairment in social, occupations, or other area of cuntions E) Not d/t effects of substance/drug F) Not d/t other medical or mental conditions **Occur during deep sleep. More common in children, can persist into adulthood  Parasomnias- REM Sleep Arousal Disorders Nightmare Disorder A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams the usually involve efforts to avoid threats to survival, security, or physical integrity generally during the 2nd ½ of the major sleep episode B. On awakening, rapidly oriented and alert C. Causes clinically significant distress or impairment in social, occupations or other important areas of functioning D. Not d/t effects of substance/drug E. Not d/t other medical or mental conditions **Occur during REM - so usually > 90 min after sleep onset and more frequent in later portions of sleep  Parasomnias - Management Sleepwalking and Sleep terrors: rarely need treatment ○ Education on triggers (sleep deprivation) ○ Counseled on safe sleep environments REM sleep behavior disorders: Melatonin or Clonazepam  When to refer to Sleep Medicine Depends on experience and comfort of pcp History suggests OSA or RLS Primary insomnia, especially if it is psychophysiologic insomnia and long duration Requirement of daily or near-daily sedative-hypnotics for 30 days or more Some sleep centers require before polysomnography or other testing  Diagnostic Studies Polysomnography “Sleep Studies” ○ Assess EEG activity, HR, respirations, O2 sats ○ Helpful for OSA, narcolepsy, sleep movement disorders, and others Multiple sleep latency testing ○ Determine how long it takes to go to sleep during naps - measuring daytime sleepiness ○ Usually after polysomnogram ○ Often used with _______________? Home testing…used primarily for sleep apnea  Comorbidities Depression, Anxiety, Substance Abuse, PTSD Pulmonary diseases HTN, Diabetes Cancer Chronic pain Heart failure Neurologic dz (Parkinsons, Alzheimer)  Impact of medications and substances… Smoking: difficulty falling asleep (usually more than 1 ppd) Cocaine and other stimulants: decreased sleep time (NREM) and increased sleep latency Alcohol: ○ Acute: decreased sleep latency with reduced REM sleep; vivid dreams and frequent awakenings ○ Chronic: increased stage 1 and decreases REM - persists for months Meds: ○ Beta blockers and calcium channel blockers ○ Glucocorticoids ○ Respiratory stimulants Questions?