Sleep Disorders PDF

Sleep Disorders Dr. Montserrat Ezquerra  Objectives 01 02 03 Describe the sleep Recognize and Explore Etiological cycle Differentiate Sleep Factors, Clinical Disorders features, and...

Sleep Disorders Dr. Montserrat Ezquerra  Objectives 01 02 03 Describe the sleep Recognize and Explore Etiological cycle Differentiate Sleep Factors, Clinical Disorders features, and Treatment options 01 Sleep Cycle Sleep Physiologically recurring state of rest characterized by relative suspension of consciousness and inaction of voluntary muscles. It is regulated by the circadian rhythm.  Circadian rhythm Neural control of circadian rhythms reside in the anterior ventral region of the hypothalamus. (suprachiasmatic nuclei) Stimulates the pineal gland for melatonin production A serotonin-derived hormone which modulates sleep patterns Production decreases with age  Rhythms of Waking and Sleep Light resets the SCN via a small branch Travels directly from the of the optic nerve known as the retina to the SCN retinohypothalamic path. Neurotransmitters are released Comes from a special depending on the time of the cycle population of ganglion cells that have their own photopigment called melanopsin. 8 Neurotransmitters Promoting Wakefulness Promoting Sleep Norepinephrine. Gamma-aminobutyric acid (GABA). Dopamine: Serotonin Acetylcholine: Adenosine. Orexin (Hypocretin) Melatonin Glutamate Ultradian rhythm Awareness and cognitive performance cycles: 90 a 120 minutes during the day.  Normal Sleep Cycle A full night's rest typically consists Every cycle consists: 3 non-rapid of about 4–5 sleep cycles of eye movement (NREM) stages and approx. 90–120 minutes each. 1 rapid eye movement (REM) stage.  Reduced REM sleep: after consumption of Lightest stage of sleep (transitional phase between alcohol, barbiturates, TCAs, MAO wakefulness and sleep) inhibitors, and benzodiazepines 5–10% of total sleep time NREM Sudden myoclonic jerks (sensation of twitching or falling) STAGE 1 NREM REM Sleep Cycle STAGE 90 -120 min 2 18–23% of total sleep time Deeper sleep Maximum muscle relaxation with 45–55% of total sleep time simultaneous REM HR slows Activation of autonomic functions High dream activity NREM Increases over the course of the night STAGE Slow-wave sleep (deep sleep) Irregular, sharply peaked eye 10–20% of total sleep time (decreases movements 3 over the course of the night) Body makes repairs Created by Montse ☺ Curious Facts It is possible to easily awaken the person from REM sleep, but it is more difficult to do so during stage N3; awakening takes 5 minutes or more, and in that time the person may be disoriented and confused (for that reason, if the doctor is called during the night to care for a person, you should avoid making complex decisions in this short time). Gross body movements occur every 15 min at all stages of sleep but are greatest at the transition between REM and NREM dreams, at which time the sleeper changes position, usually from one side to the other.  Deprived of sleep → die within a few weeks (4) Drowsiness, depression, impaired motor functions, memory impairment, psychosis, hormonal impairment Effects of sleep deprivation 02 Sleep Disorders Sleep Disorders Potentially serious and very common concern. Affects up to 1/3 of the US adult population. Primary → due to an intrinsic problem with the sleep-wake cycle Secondary →due to underlying medical condition PRIMARY Dyssomnias Parasomnias Sleep-related movement disorders  Classification Dyssomnias Parasomnias Difficulty falling and/or staying asleep OR Abnormal behaviors or experiences that occur hypersomnia (excessive daytime sleepiness) while falling asleep, during sleep, or while waking up (isolated cases are quite normal in children) Insomnia disorder Sleepwalking Hypersomnolence disorder Sleep terrors(NREM) Obstructive sleep apnea Nightmare disorder(REM) Narcolepsy Restless legs síndrome Circadian rhythm sleep-wake disorder Delayed sleep phase disorder Jet lag disorder Shift work disorde Dyssomnias  Insomnia Definition % Etiology Clinical Features Treatment Chronic inability 20 to 40% Poor sleep Difficulty initiating Improve sleep to sleep despite of the hygiene sleep higiene adequate population Anxiety Frequently waking Melatonin opportunity disorders from sleep Benzodiazepines Poor Awakening early in the Antidepressants Acute: < 3 secretion of morning Non- months melatonin Feeling fatigued after benzodiazepine Chronic: ≥ waking sedatives 3months (zolpidem)  Hypersomnolence disorder Definition % Etiology Clinical Features Treatment Is a condition where 10% of Genetic Excessive sleep (with Regularly a person patients (autosomal decreased sleep scheduled naps experiences with sleep dominant) quality) First-line significant episodes disorders Head trauma Difficulty awakening therapy: of sleepiness, even Viral infections from sleep modafinil or after having 7 hours 15–25 Sleep inertia (impaired methylphenidate or more of quality years of alertness or excessive Second-line sleep age Is related to fatigue after waking) therapy: destruction or Automatic behaviors atomoxetine functional paralysis (with no memory of Example: of dopamine-rich the episode after Kleine-Levin neurons of the waking) syndrome substantia nigra, resulting in hyperactivity of raphe neurons (serotonergic)  Narcolepsy Definition % Etiology Clinical Features Treatment Long-term 1 per Genetic Periods of excessive Modafinil is first- neurological 2,000 Low levels of daytime sleepiness line disorder that persons the and brief involuntary Amphetamines involves a. neuropeptide sleep episodes. decreased ability More orexin. (effects Sudden loss of Cataplexy: to regulate sleep- common promoting muscle strength Sodium oxybate wake cycles in males wakefulness) (cataplexy) (drug of choice) than Lesions to the Sleep paralysis females posterior Hallucinations hypothalamus and midbrain  OBSTRUCTIVE SLEEP APNEA Definition % Etiology Clinical Features Treatment Chronic Middle- Obesity, Excessive daytime CPAP breathing-related aged Increased sleepiness. Weight loss and disorder neck Cessation of breathing or exercise. Male hypopneic episodes of characterized by circumferenc reduced airflow (more repetitive Children: Airway than 15 per hour). collapse of the 1–2% narrowing Sleep fragmentation. upper airway Snoring. during sleep Middle- Frequent awakenings aged due to gasping or adults: 2– choking. 15%; Nonrefreshing sleep or fatigue. Older Morning headaches. adults: Hypertension. >20%. 25 Circadian rhythm sleep disorders Common features: Insomnia Excessive daytime somnolence Irritability Frequent waking during abnormal hours Headaches and impaired concentration Parasomnias  Non-REM sleep (no memory of dream) Epidemiology: 7% of adults and 30% of children (disorder is rare.) Associated with sleep deprivation, irregular sleep schedules, some medications (sedatives/hypnotics, lithium, and anticholinergics) Etiology: idiopathic or genetic (inherited in 80% of cases) Clinical features ○ Recurrent episodes during the first third of the sleep cycle, including sitting up, walking, or eating (rarely, violence) ○ Blank stare and difficulty arousing patient during the episode ○ Followed by amnesia of the event Treatment: Education and reassurance, Benzodiazepines (clonazepam) Sleepwalking disorder  Non-REM sleep (no memory of dream) Epidemiology: 2% of adults and 20% of children Etiology: unknown; thought to be genetic (family history) Clinical features ○ Screaming or crying suddenly upon awakening ○ Intense fear and agitation ○ Tachypnea, diaphoresis, tachycardia during episodes ○ Difficulty arousing patients during episodes; patients will often return to sleep and not remember the episode the next day Treatment: Education and reassurance ,Benzodiazepines (clonazepam) Sleep terror disorder  REM sleep (patient remembers the dream) Epidemiology: 2% of adults (early adulthood) Clinical features ○ Recurrent frightening dreams during the second half of sleep cycle (middle of the night or early in the morning) ○ Patient remembers the dream after awakening ○ Causes functional impairment or distress Treatment: Therapy, Antidepressants (Prazosin and antidepressants) Nightmare disorder  Uncomfortable sensations in the legs and an irresistible urge to move them. (Relief with movement) 7-10 percent of the U.S. population Risk Factors: Low levels of iron, Dysfunction in the basal ganglia (control movement), Neuropathy, Medications, Stress. Treatment: ○ Dopamine agonists (pramipexole and ropinirole) and benzodiazepines are first-line treatments ○ Muscle relaxants, Opiods, Gabapentine/Pregabalin (ion channels). Restless legs syndrome (Willis-Ekbom disease)  Startles We have all when experienced…….. sleeping  We are in the This happens when transition from stage Somnolescent the sleep cycle 3 NREM to REM stage and the motor startles develops slowly or overlap center is excited greater force. The muscles are suddenly activated, We wake up and we have that immediately feeling of falling. Another experienced…….. Sleep Paralysis  Sleep State in which a person is aware but unable to move or Paralysis speak. Triggered by sleep deprivation, psychological stress, or abnormal sleep cycles. 8% and 50% of people experience sleep paralysis at some point in their life REM stage (shorter periods) Neural functions that regulate sleep are out of balance in such a way that causes different sleep states to overlap. Hallucinations can occur  How to measure brain activity? An electroencephalogram (EEG) is a measurement of the activity of the brain, recorded from the surface of the scalp. ‐ Setup: ‐ 24 or so electrodes taped to scalp at standard positions ‐ Differences between the charges recorded at each electrode are made and display on a graph versus time. ‐ Measurements of individual neurons is not possible from the scalp, but the activity of collections of neurons is possible.  Polysomnography (PSG) sleep medicine. Is a multi-parametric test used in the study of sleep and as a diagnostic tool in sleep medicine Indications; Obstructive sleep apnea, parasomnias, periodic limb movements, narcolepsy, or REM sleep behaviour disorder 3 to 4 hours of recordings is usually enough to detect the above conditions The components of a polysomnogram include the following: Electroencephalogram (EEG) Electromyography (EMG), specifically the submentalis muscle (bruxism) and anterior tibialis (restless legs) Electro-occulogram (EOG), to monitor for rapid eye movements Electrocardiogram (ECG), to monitor cardiac function Oral and nasal airflow pressure and temperature (using nasal pressure transducer and thermistor) Chest and abdomen movement (i.e. - respiratory effort, measured using chest and abdominal belts) Oxygen saturation (using finger probe digital pulse oximetry) Transcutaneous CO2 (TcCO2) RESOURCES Davidson's Principles and Practice of Medicine, Twentyfourth Edition, Penman, Ian D, BSc(Hons), MBChB, MD, FRCPE, 2023, Elsevier Available at: https://bibliodig.uag.mx:2113/#!/browse/book/3- s2.0-C20190045633 AMBOSS First Aid for the® Psychiatry Clerkship, Sixth Edition