LEEP DISORDERS

What is sleep?

• Complex physiological state that occurs periodically and is characterised by relative quiescence, immobility and greatly decreased responsiveness to external stimuli

Sleep Stages

• based on EEG, EOG, EMG divided into two independent states: NREM and REM sleep

• NREM - further divided into three stages ieN1, N2, N3 – based on EEG

Sleep Requirements

• Sleep requirement is defined as the optimal amount of sleep required to remain alert and fully awake and to function adequately throughout the day

• for an average adult is approximately 7.5 to 8 hours

Classification of Sleep Disorders

• I. Insomnia

• II. Sleep-related breathing disorders

• III. Hypersomnias of central origin

• IV. Circadian rhythm sleep disorders

• V. Parasomnias

• VI. Sleep-related movement disorders

Approach to the Patient

Common sleep complaints

• Insomnia - inability to initiate or maintain sleep adequately at night

• EDS - chronic fatigue, sleepiness, or tiredness during the day

• Inability to sleep at the right time

• Abnormal movements and behavioural manifestation associated with sleep

SUBJECTIVE MEASURES OF SLEEPINESS

Narcolepsy

• characterized by recurrent "sleep attacks"• Irresistible desire to fall asleep in inappropriate

circumstances and at inappropriate places• last for a few minutes to as long as 20 to 30

minutes

Narcolepsy TetradSleep Attacks plus 3 specific symptoms:

1. Cataplexy sudden weakness or paralysis without loss of consciousness, often precipitated by emotional changes

2. Hallucinations at sleep onset (hypnagogic hallucinations) or upon awakening(hypnopompic hallucinations)- most common is visual

3. Sleep paralysis occurs near sleep onset or during arousal. Consciousness is maintained.

Narcolepsy

• Symptoms of narcolepsy typically begin in the second decade

• Once established, the disease is chronic without remissions

• Men and women are equally affected• affects about 1 in 4000 people in the United

States

GENETICS & PATHOGENESIS

• Most are sporadic, some are AD

• positivity for HLA DQB1*0602 – most specific marker

• Dysfunction of hypothalamic hypocretin(orexin) peptidergic system is involved in the pathogenesis

• decreased hypocretin 1 in CSF < 110pg/ml

Treatment of Narcolepsy-CataplexySyndrome

Nonpharmacological measures include

• scheduled short daytime naps,

• sleep hygiene measures

Breathing-related Sleep Disorders

syndromes in which the patient's sleep is interrupted by problems with his or her

breathing

OBSTRUCTIVE SLEEP APNEA

• MC medical condition @ EDS

• defined as the coexistence of unexplained EDS with at least five obstructed breathing events (apnea or hypopnea) per hour of sleep

• repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep

• arterial oxygen desaturation and arousal from sleep

Apnea-Hypopnea Index (AHI)

• number of apneas and hypopneas per hour of sleep

• AHI score of 5 or below is considered normal

• 5 to 15 - mild OSAS

• 16 to 29 - moderate OSAS

• 30 or more - severe OSAS

Pathogenesis

• Collapse of the pharyngeal airway is the fundamental factor

• During sleep, muscle tone decreases-increasing upper airway resistance and narrowing the upper airway space

Epidemiology

• prevalence is 4% in men and 2% in women between the ages of 30 and 60

• also occurs in childhood—usually associated with tonsil or adenoid enlargement

Symptoms & Signs

Consequences

• increased morbidity and mortality

• short-term consequences (impairment of quality of life and increasing traffic- and work-related accidents)

• long-term consequences from associated and comorbid conditions such as systemic hypertension, pulmonary hypertension, heart failure, cardiac arrhythmias

General Measures

• Avoid alcohol and sedative-hypnotics, especially in the evening

• Reduce body weight if overweight

• Avoid sleep deprivation

• Participate in regular exercise program

• Avoid supine sleeping position

Mechanical Devices

• Continuous positive airway pressure (CPAP) titration - treatment of choice

• Oral appliances, including mandibular advancement device

• Tongue-retaining device

Surgical Techniques

• Uvulopalatopharyngoplasty (UPP)

• Laser-assisted UPP (LAUP)

• Radiofrequency UPP (somnoplasty)

• Palatal implants

• Nasal surgery

• Maxillomandibular advancement

• Anterior hyoid advancement

• Tonsillectomy and adenoidectomy

PARASOMNIAS

• abnormal movements or behaviours that occur in sleep or during arousals from sleep

ICSD-2 (AASM, 2005)

Disorders of arousal (from NREM sleep),

• Confusional arousals

• Sleepwalking

• Sleep terror

Parasomnias associated with REM sleep

• RBD

• Recurrent isolated sleep paralysis

• Nightmare disorder

Other Parasomnias

Sleepwalking

• Onset: common between ages 5 and 12 yr

• Abrupt onset of motor activity arising out of slow-wave sleep during first one-third of the night

• Duration: less than 10 min

• Injuries and violent activity occasionally reported

• Treatment: benzodiazepines, imipramine

Sleep Terror• pavor nocturnus

• Onset: peak is between ages 5 and 7 yr

• Abrupt arousal from slow-wave sleep during first one-third of the night, with a loud piercing scream

• Treatment: psychotherapy, benzodiazepines, tricyclic antidepressants

Rapid Eye Movement SleepBehavior Disorder (RBD)

• Onset: middle-aged or elderly men

• Presents with violent dream-enacting behavior during sleep, causing injury to self or bed partner

• 40% idiopathic, 60% associated neurodegenerative diseases - PD, MSA, CBD, DLBD, PSP

• Treatment: clonazepam, melatonin

Nightmare Disorder

• Dream anxiety attacks

• fearful, vivid, often frightening dreams, mostly visual but sometimes auditory

• most commonly occur during the middle to late part of sleep at night

• mostly a normal phenomenon, up to 50% of children have nightmares

• side effects of certain medications such as antiparkinsonian drugs (pergolide, levodopa), anticholinergics, and antihypertensive drugs, particularly beta-blockers

• generally do not require any treatment except reassurance

Sleep-Related Movement Disorders

Restless Legs Syndrome (RLS)

• also known as Ekbom’s syndrome

• Unpleasant sensations in the legs when the patient is tired in the evenings and at the onset of sleep

• ameliorated by moving the legs• mostly diagnosed in the middle or later years• strong familial tendency • can present with daytime somnolence due to

disturbed night-time sleep

Secondary - Medical Disorders

• Anemia: iron and folate deficiency

• Diabetes mellitus

• Amyloidosis

• Uremia

• Chronic obstructive pulmonary disease

• Peripheral vascular (arterial or venous) disorder

• Rheumatoid arthritis

• Hypothyroidism

Pathophysiology

• iron-dopamine dysfunction

• abnormalities in the body’s use and storage of iron

• dopamine dysfunction - changes in dopamine receptors or dopamine uptake

Drug Treatment of RestlessLegs Syndrome

Dopaminergic agents:

• Pramipexole

• Ropinirole

Benzodiazepines:

• Clonazepam

• Temazepam

Antiepileptic agents:

• Gabapentin

• Pregabalin

Insomnia

• most common sleep disorder

• Inability to initiate or maintain sleep, early awakening, inadequate sleep time, or poor sleep quality associated with a lack of feeling restored and refreshed in the morning, leading to poor daytime functioning - AASM (2005)

Medical Disorders Comorbidwith Insomnia

• Ischemic heart disease

• Congestive cardiac failure

• Chronic obstructive pulmonary disease

• Bronchial asthma

• Peptic ulcer disease

• Gastroesophageal reflux disease

• Rheumatic disorders

Treatment of Insomnia

• most commonly used hypnotics are the benzodiazepine receptor agonists – zolpidem,zaleplon, and eszopiclone

• Melatonin receptor agonists(ramelteon) -sleep-onset insomnia

Laboratory Assessment ofSleep Disorders

• The two most important laboratory tests for diagnosis of sleep disturbance are PSG and the MSLT

• overnight PSG study is the single most important laboratory test for the diagnosis and treatment of patients with sleep disorders

• EEG, EMG, EOG, ECG, SaO2, Nasal and oral airflow, Respiratory effort (chest and abdomen)

Multiple Sleep Latency Test

• important test to effectively document EDS

• Narcolepsy is the single most important indication

• presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggest a diagnosis of narcolepsy

• circadian rhythm sleep disturbance - REM sleep abnormalities