Sleep disorders
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Transcript of Sleep disorders
Sleep, sleep disorders
Professor Yasser Metwally
Each of us will spend about 27 years of our lifetime sleeping…..
…..And 1/3 part of the population has sleep disorder
About the sleep…
„Why we sleep remains one of nature’s greatest mysteries”(MG Frank, The function of sleep, 2006)
Somatic theories of sleep functionNeural metabolic theories: detoxification and
regenerationCognitive theories of sleep function: learning
and brain development
Regulation of sleep
Cirkadian timing: lasts about 24 hours• Hypothalamus
• Suprachiasmatic nucleus
• Pituitary gland: melatonin
Ultradian timing: lasts less than 24 hours • Prepontin nuclei• Raphe nuclei• L. coeruleus
Normal human sleepSleep cycle – occurs about every 90 minutes, approximately 4-6 cycles occur per major sleep episodeMicroarousal
1. NREM (70-80%) • slow wave sleep• heart rate, BP, breathing ↓• body temperature, muscle tone ↓
2. REM (20-25%) • rapid eye movement, paradox, fast wave sleep• heart rate, BP, breathing ↑, metabolic rate ↑ • dreaming, erection• muscleatonia, BUT: myoclonus!
NREM
I. stage (3-8%) ~ drowsiness, sleepiness EEG: α-activity, muscle tone, eye movement ↓, myoclonus!
II. stage (45-55%) ~ EEG: K-complexes, sleep spindles, no eye movement
III. stage (5-10%) EEG: delta waves
IV. stage (15-20%) slow wave sleep
1. Tonic stage (desyncronized EEG ~ low voltage, frequency ↑, muscle atonia)
2. Phasic stage (rapid eye movements ~ fast, saccadic eye movements ~, irregular breathing, heart rate ↑, myoclonus, apnea, hyperpnea, dreaming!!!)
REM
Sleep disorders
Polysomnography
• multiparametric monitoring during 1 sleep period (1 night)
• EEG• Electrooculogram• EMG• ECG• Respiratory effort
• SpO2
• Body position• Snoring
More than 80 sleep disorders are known (International Classification of Sleep Disorders, 2nd Edition
American Academy of Sleep Medicine, 2005)
I. Insomnias (33%)
II. Sleep related breathing disorders (1,4-40%)
III. Hypersomnias (0,3-16,3%)
IV. Cirkadian rhythm sleep disorders
V. Parasomnia
VI. Sleep related movement disorders
VII. Isolated symptoms, normal variants
VIII. Other sleep disorders
Traditional classification of sleep disorders
• Dyssomnias: abnormalities in the quantity, quality or timing of sleep. They are associated with difficulty initiating or maintaining the sleep or daytime sleepiness.
• Parasomnias: abnormal behavioral or physiological events occurring during sleep but don’t involve the sleep mechanisms per se.
I. Insomnias
• Difficulty in initiating sleep or in staying asleep or waking up earlier
• Nonrefreshing, nonrestorative sleep
• Fatigue, concentration or memory impairment
• Mood disturbances, motivation, initiative reduction
• Daytime sleepiness
• Tension headache
I. Insomnias
• Prevalence: 33%• Accompanied with daytime consequences:
10%• Last less than 1 month: 4% (transient
insomnia)• Last more than 1 year: 85% (persistent
insomnia)• Male:female = 1:1.4• Increase with age: above 65 years: 50%
I. Insomnias
1. Primary (idiopathic)2. Secunder
1. Inadequate sleep hygiene (10%)2. Paradoxical insomnia (10%)3. Insomnia due to mental disorder (30-40%)4. Psychophysiological insomnia (15%)5. Insomnia due to drug or substance6. Insomnia due to medical conditions 7. Sunday night insomnia
Treatment
• Treating the medical or psychiatric conditions (sec. insomnias)
• Nonpharmacologic: – behavioral treatments: normalizing the
circadian rhythm – sleep hygiene– cognitive behavior therapy– sleep restriction therapy
• Pharmacologic treatment
Pharmacologic treatment
Benzodiazepines1. midazolam, triazolam ~ rebound
insomnia2. cinolazepam, quazepam
3. brotizolam, temazepam
4. nitrazepam ~ drowsiness
Pharmacologic treatment
Selective GABAA agonists: nonbenzodiazepines
– no rebound insomnia– zolpidem, zopiclon
Melatonin receptor agonist– ramelteon
II. Sleep related breathing disorders (International Classification of Sleep Disorders, 2nd Edition
American Academy of Sleep Medicine, 2005)
3. Sleep related hypoventilation/hypoxemia
1.
2.
Apnea-hypopnea index (AHI)
- Numbers of apneas and hypopneas/ 1 sleeping hour
Severity of sleep related breathing disorders:
- Normal: AHI<5/h- Mild: AHI: 5-15/h- Moderate: AHI:16-30/h- Sever: AHI>30/h
Sleep, 1999:22:667-89.
OSAHS: symptoms
Daily• Excessive daytime
sleepiness• Unrefreshing sleep• Memory disturbances• Morning headache• Depression• Decreased libido• Stomach ache
Nightly• snoring• apneas• choking, gasping• arousals• sweating• dry mouth• palpitation• nycturia
OSAHS: diagnostic criteria
(1. or 2.) and 3.
AASM, Sleep, 1999:22:667-89.
Risk factors of OSAHS
• Obesitas• Age• Male gender• Pozitive family history of OSAHS• Alcohol consumption before bedtime• Race• Smoking• Sedatives• Craniofacial anomalies• Hypothyroidism, acromegaly
Treatment of bening snoring
• Weight loss, alcohol withdrawal
• Position training
• Nasal, pharyngeal surgery (UPPP)
• Oral appliances
Treatment of OSAHS: nasal CPAP
IV. Cirkadian rhythm sleep disorders• Primary
– Delayed sleep phase type – Advanced sleep phase type – Irregular sleep phase type
• Secondary– Jet lag type– Shift work type
• Treatment – Sleep hygiena – Cronotherapy– Light therapy– Melatonin, zolpidem
V. Parasomnias
1. In NREM1. Myoclonus
2. Enuresis nocturna
3. Pavor nocturnus, night terrors
4. Sleep walking - somnambulism
5. Bruxism
2. In REM1. Nightmares
2. REM sleep behavior disorder
VI. Sleep related movement disorders
• Restless legs syndroma– Therapy: dopamin agonists
• Periodic limb movement disorder
• Sleep related leg cramps
• Sleep related rhythmic movement disorder