Sleep Disorders

SLEEP DISORDERS

SLEEP • A natural state of rest during which muscle movements and awareness of the surroundings diminish. • It restores energy and well-being, allowing us to function optimally the next day • It is easily interrupted-or prevented- by noise, light and other external stimuli. • Internal factors, such as stress and anxiety can decrease the amount and

Sleep stages • Stage I – The lightest stage of sleep; occurs as a person falls asleep. – The muscles relax and brain waves are fast and irregular. Called theta waves, these spike-like waves have a low medium amplitude and occur 3-7x per second – It accounts for approximately 5% of an adult’s total sleep time

Sleep stages • Stage 2 – A relatively light stage of sleep, theta waves continue but become interspersed with sleep spindles (sudden increases in wave frequency) and K complexes (sudden increases in wave amplitude) – It comprises approximately 50% of total sleep time.

• Stages 3 and 4 – Deepest stages of sleep. – Delta waves-large, slow waves of high amplitude and low frequency, appear on the EEG – Arousing a sleeper from stage 3 or 4 is harder than during any other stage. Because these stages are marked by decreased by body temperature and metabolism – They account for 10%-20% of total sleep time.

Sleep stages • Stage 5 – A deep sleep called rapid-eye movement (REM) sleep. – The sleeper shows darting eye movements, muscle twitching, and short, rapid brain waves resembling those seen during the waking state – Usually begins about 90 minutes after sleep onset – It accounts for 20% to 25% of total sleep time

Factors that affect sleep • Age – Amounts and patterns of sleep differ at each major stage of the life cycle. Both REM and NREM sleep periods decrease with age. – Newborns sleeps the most averaging 17-18 hours a day, with REM accounting for roughly half of total sleep time. – Toddlers sleep about 11or 12 hours a night, with a 1-to 2-hour nap after lunch – Preadolescents need about 10 hours of sleep. – A typical young adult needs about 8 hours of sleep.

Factors that affect sleep • Environment – Environmental influences on sleep include noise, bright lights or sunlight, excessive activity and an uncomfortable room temperature

• Lifestyle – Travel, shift work, and anxiety can greatly influence sleep.

• Medications and substances • Alcohol

• • • • •

Breathing-related sleep disorders Circadian rhythm sleep disorder Narcolepsy Primary hypersomnia Primary insomnia

Breathing-related sleep disorders • Marked by abnormal breathing during sleep. – Obstructive sleep apnea syndrome (OSAS) is the most common – Central sleep apnea syndrome – Central alveolar hypoventilation syndrome

Diagnostic criteria for breathing-related sleep disorder

• The patient experiences sleep disruption (causing excessive sleepiness or insomnia) that’s judged to stem from a sleep-related breathing condition. • The sleep disturbance isn’t better explained by another psychiatric disorder • It doesn’t result form direct physiologic effects of a substance or

Obstructive sleep apnea syndrome • The upper airway becomes blocked during sleep, impeding airflow • With either partial or complete airway obstruction, the patient struggles to breath • Blockage of airflow last 10 seconds to 1 minute and arouses the patient from sleep as the brain responds to decreased blood oxygen levels. • This pattern causes disturbed and fragmented sleep, with periods of loud snoring or gasping when the airway is partly open alternating with silence when the airway is blocked

Obstructive sleep apnea syndrome • Complications – Repetitive cycles of snoring, airway collapse, and arousal may lead to cardiovascular problems-high BP, arrhythmias, and even myocardial infarction or stroke. – Frequent awakenings leave the patient sleepy during the day and can cause irritability or depression-morning headaches, decreased mental functioning, and a reduced sex drive

• Causes: Most patients with OSAS are overweight with a short, thick neck and fat infiltration around the pharynx that increases the risk of airway blockage

Obstructive sleep apnea syndrome • Signs and Symptoms – Typically report chronic daytime sleepiness – Frequent headaches; general feeling of tiredness and fatigue – Frequent daytime naps – Irritability; difficulty paying attention – Learning or memory problems – Excessive urination at night

• Diagnosis – Polysomnography is the gold standard for diagnosing OSAS. It is an overnight sleep study, performed in a special laboratory or a sleep center that measures various physiologic functions related to sleep and wakefulness

Obstructive sleep apnea syndrome • Treatment – Lifestyle changes • Weight loss • Sleeping on the side rather than in a supine position may reduce apneic episodes

– Continuous positive airway pressure (CPAP) • Most common and effective treatment for OSAS

– Dental devices – Surgery

Circadian rhythm sleep disorder • The patient’s internal sleep-awake pattern is out of synch with the demands of his work schedule, travel requirements, or social activities resulting in insomnia and sleepiness • Types: – Delayed sleep phase – Jet lag – Shift work disorders

Circadian rhythm sleep disorder • Delayed sleep phase disorder – The patient sleeps according to a delayed clock time, relative to the light-dark cycle and social, economic, and family demands – Typically. He has trouble falling asleep until the early hours of morning and ends up sleeping through much of the day. – Often begins in childhood and is relatively common among adolescents – Patients may report • • • • •

Inability to fall asleep before 2 am to 6 am difficulty awakening in the morning Feeling of being sleep-deprived Significant social or work impairment Need for multiple means to awaken

Circadian rhythm sleep disorder • Jet lag sleep disorder – Results from rapid travel across more then one time zone. Until the body clock full adjusts to the new time zone, the patient feels sleepy or alert at an inappropriate time of day relative to local time. – Jet lag often requires a recovery period of 1 day for every time zone passed over – Patients complain of grogginess and a general malaise, which may last up to 1

Circadian rhythm sleep disorder • Shift work sleep disorder – Night shift work or frequently changing shift work causes insomnia during the major sleep period or excessive sleepiness during the major awake period – Chronic sleep disruption – Patients usually report: • Sleepiness while performing their jobs, especially if they work at nights • Insufficient daytime sleep because of family or social demands • Significant social or work impairment

Circadian rhythm sleep disorder • Treatment – Chronotherapy involves manipulating the patient’s sleep schedule by progressively delaying bedtime by one or more hours each night, until the patient can go to sleep and wake up at appropriate times. – Luminotherapy is the use of bright light to manipulate the circadian system. – Chronopharmacotherapy involves the use of drugs to induce sleep or promote wakefulness when desired,

Narcolepsy • Characterized by sudden, uncontrollable attacks of deep sleep lasting up to 20 minutes. These sleep attacks come on without warning and maybe accompanied by paralysis and hallucinations. • Sleep paralysis and hallucinations typically occur during sleep onset (hypnagogic hallucinations) or during the transition from sleep to wakefulness (hypnopompic hallucinations) • About 70% of patients with narcolepsy experiences attacks of cataplexy-sudden loss of muscle tone and strength. • The second leading cause of daytime sleepiness. OSAS is the most common.

Narcolepsy • Assessment findings – Excessive daytime sleepiness, even during active states, such as eating or talking. – Cataplexy – Brief episodes of brief paralysis – Dreamlike hallucinations at sleep onset or when awakening from sleep. – Disturbed nighttime sleep, such as tossing and turning, leg jerks, nightmares, frequent awakenings and abnormal REM sleep.

Narcolepsy • Treatment: no cure • Behavioral and pharmacologic interventions

Primary hypersomnia • A condition of excessive sleepiness characterized by either prolonged sleep periods at night or daytime sleep episodes occurring nearly everyday. • During long periods of drowsiness, the patient may exhibit automatic behavior, acting in semi-controlled fashion. • He may have trouble meeting morning obligations, frequently

Primary hypersomnia • Findings include – Excessive sleepiness on a daily basis. – Daytime napping without feeling refreshed – Long nighttime sleeping (8-12 hours)

• Treatment – Behavioral approaches – Sleep hygiene techniques. – Pharmacologic interventions

Primary insomnia • The most common sleep disorder which encompasses many types of problemsdifficulty falling asleep, sleeping too lightly, frequent awakenings during the night, inability to fall back to sleep once awakened, and waking up in the early morning and being unable to fall back to sleep. • Can be acute or chronic. With chronic insomnia, the person may become preoccupied with getting enough sleep. The more he tries to sleep, the greater his sense of frustration and distress- and the more elusive sleep becomes.

Primary insomnia • Consequences: – Daytime drowsiness that causes poor concentration, memory impairments, difficulty coping with minor problems, and reduced ability to enjoy family and social relationships.

• Causes: – A physical or emotional stressor – Significant life change – Environmental disturbance that makes sleep difficult

Primary insomnia • Signs and symptoms – – – – – – – – – – –

Difficulty falling asleep Difficulty staying asleep Waking up too early in the morning Inability to fall back to sleep once awakened Non refreshing sleep Daytime fatigue and lack of energy Haggard appearance Irritability Short attention span Poor concentration Inappropriate use of sedative-hypnotic drugs, alcohol or caffeine

Primary insomnia • Diagnosis: – Based on the patient history and physical findings – Polysomnography can rule out other sleep disorders such as OSAS. In primary insomnia, polysomnography usually shows increased stage 1 sleep and decreased slow-wave sleep

• Treatment: – – – – – –

Relaxation techniques Improved sleep hygiene Behavioral interventions Cognitive therapy Alternative and complementary measures Pharmacologic options

Primary insomnia • Sleep hygiene-simple lifestyle changes • Sleep promoting measures – Use the bed only for sleep and sex – Establish a regular bedtime and a regular time for getting up in the morning. Stick to these times even on weekends and on vacations – Exercise in the evening – Take a hot bath 90 minutes to 2 hours before bedtime. This alters core body temperature and helps you fall asleep more easily. – During 30 minutes before bedtime, do something relaxing such as reading, meditating or taking a leisurely walk – Keep the bedroom quiet, dark, relatively cool and wellventilated – Eat dinner 4-5 hours before bedtime