SLEEP MEDICINE:An OverviewFraser Willsey, BA, RPSGTSleep Lab TechnologistSleep Disorders Service, The Royal

Why Study Sleep?

• We spend 1/3 of our lives sleeping• 1 in 7 Canadians are not getting enough sleep (Statistics

Canada, 2002)

• Severe health consequences - DEATH! • Sleep deprivation costs $150 BILLION/yr in lost productivity (Nat’l Commission on Sleep Disorders, 2003)

THE IMPACT OF SLEEP DEPRIVATION

• Challenger Disaster• 3 Mile Island• Chernobyl

Purpose of Sleep

• Restorative Function• Energy Conservation• Immune Function Regulation• Memory Consolidation• Mood Regulation and depression• Protective Mechanism

WHAT WE DO AT THE SLEEP LAB….

What Happens at the Sleep Lab…• ROMHC: 6 bed clinical lab, 4 bed research lab

STEPS: 1) → Referral 2) → Consultation with a Sleep Specialist 3) → Overnight Sleep Study 4) → Data is Analyzed by RPSGTs 5) → Results Appt with a Sleep Specialist

How Do We Measure Sleep in the Laboratory?• EEG – brainwaves (Central & Occipital Leads)• EOG – eye movements • EMG – muscle tone• EKG/ECG – heart • Breathing: 1)Airflow

& 2) Effort: Thoracic & Abdominal• Blood oxygen saturation (SaO2)• Snore mic.• Digital AV recording

STAGES OF SLEEP

• NREM & REM • NREM = N1, N2, N3

• Sleep Cycle • REM increases as the night progresses• Changes across the lifespan

NREM SLEEP

• N1: lightest stage of sleep (hypnic jerks/sleep starts), dozing

• N2: Sleep spindles & K complexes • N3 (formerly stages 3 & 4): deepest most

physically restorative stage of sleep. More difficult to awaken from this stage. Decreases with age.

• Breathing regular, heart rate decreases

AWAKE

STAGE N1

STAGE N2

STAGE N3

STAGE N3

REM Sleep

• Rapid Eye Movements• Muscle atonia (paralysis)• Dream recall• 90 minute latency • “Paradoxical Sleep” – EEG mimics wakefulness• Breathing irregular, heart rate fluctuates

REM

TRANSITION INTO REM

SLEEP APNEA

SLEEP APNEA• Two Types: Obstructive & Central• Pauses in breathing > 10 seconds in length• Respiratory Disturbance Index: >5 hr =clinically significant• Symptoms:

▪ Excessive daytime sleepiness (EDS)▪ morning headaches▪ SNORING***** ▪ pauses in breathing▪ waking with a dry mouth▪ nocturia▪ Gastroesophageal reflux disease

ZZZZzzzzzzZZZZzzzzzz

OBSTRUCTIVE SLEEP APNEA (OSA)• Causes

▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx

• Exacerbated by: ▪ Rx ▪ Alcohol Consumption

▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep

Normal vs. Collapsed Airway

“Kissing” Tonsils

OBSTRUCTIVE APNEA

OBSTRUCTIVE APNEA, 2MIN

OBSTRUCTIVE APNEA 5MIN

TREATMENTS FOR OSA• **CPAP – Continuous Positive Airway Pressure• **Weight Loss - ↓ BMI = ↓ RDI• Avoid Alcohol Consumption• Avoid Sedative Medications• “Snoreball” Technique / Positional Therapy• Oral Appliance• Upper Airway Surgery– Tonsilectomy– Laser Surgery– Tracheostomy– Uvulopalatopharyngoplasty (UPPP)

CPAP

CPAP

Consequences of Untreated OSA

• Memory Problems• Depression• Cardiovascular disease–High blood pressure– Stroke–Cardiac arrhythmias

FASTEN YOUR SEATBELTS…

THERE’S ANOTHER CONSEQUENCE OF UNTREATED OSA & SLEEPINESS

ANY GUESSES WHAT IT IS?

PARASOMNIAS

PARASOMNIAS• NREM

Sleepwalking (Somnambulism)Sleep Terrors (aka Night Terrors)Others examples: Sleep Related Eating Disorders,

Confusional Arousals, Somniloquy

■ REMREM Behaviour Disorder (RBD)

Measured in the sleep lab with full EEG to rule out seizure activity

SLEEPWALKING• Stage N3 (slow wave sleep)• Common in children• Do not awaken. Secure the environment• No recall of a dream or of the episode • Aggravated by sleep deprivation, stress, alcohol • Positive family history• Perform complex behaviours with heightened pain

threshold

JAROD ALLGOOD Feb. 2, 1973 – Feb. 9, 1993

REM Behaviour Disorder (RBD)

• No muscle atonia during REM sleep• Ability to act out complex dream behaviour• Bedpartner often the “victim”• Age of onset: 50 – 60yrs. Males• Usually opposite of waking personality• Case study: “baseball player” at ROMHC

RBD

REM BEHAVIOUR DISORDER

Treatments for RBD

• Full EEG montage during PSG• CT Scan, MRI – r/o lesions• Securing the environment (mattress on floor, bed

rails, restraints)• Bedpartner sleeps in another room • Rx

SLEEPWALKING vs. RBD

SleepwalkingSleepwalking

▪ ▪ Stage N3 Stage N3 (NREM)(NREM)

▪ ▪ No dream recallNo dream recall

▪ ▪ ChildrenChildren

▪ ▪ Not easily Not easily awakenedawakened

REM Behaviour REM Behaviour DisorderDisorder

▪ ▪ REM sleepREM sleep

▪ ▪ Dream recallDream recall

▪ ▪ Adults (elderly)Adults (elderly)

▪ ▪ Easily awakenedEasily awakened

PLMs 2 MIN

PLMS Treatment

• Rx• Iron supplementation• CPAP if PLMs secondary to apnea

Restless Legs Syndrome (RLS)• Disorder of WAKEFULNESS (PLMs = sleep)• Subjective report of an uncomfortable sensation in

the legs while at rest• Irresistible urge to move the legs• Symptoms subside with movement• “Creeping”, “itching”, “creepy-crawly”, “pulling”,

“tugging”, “gnawing”, “toothache in my legs”, “bugs or worms crawling under my skin”

• Symptoms worse in the evening• Almost all patients with RLS display PLMs during sleep

RLS Treatments• Pharmacological (dopamine agonists)• Non-Pharmacological:– Iron supplementation – Warm bath– Exercise– Massage, acupuncture, relaxation techniques– Keeping mind engaged when having to stay seated– Eliminate caffeine and alcohol– Bar of soap under the sheets!

SLEEP & MEDICAL ILLNESS

Normal Fibromyalgia

SLEEP & MENTAL ILLNESS

• Depression– Early morning awakenings– Short REM latency– Increased time in REM sleep– May mimic narcolepsy on the MSLT

SLEEP & MENTAL ILLNESS

• Anxiety– Increased sleep onset– Prolonged awakenings– Panic attacks (with/without sleep apnea)

SLEEP & MENTAL ILLNESS

• Psychiatric Populations and Sleep– Schizophrenia (apnea, sleep spindles)– PTSD (nightmares)– Geriatrics – Mood disorders

INSOMNIA

INSOMNIA• Difficulty initiating and maintaining sleep• Early morning awakenings• Complaint of poor, insufficient or nonrefreshing

sleep• Impact on waking behaviour• Sleep Efficiency < 85%• Longer SOL (> 30 minutes), short total sleep time

(TST)

Insomnia Treatments

• Cognitive Behavioural Therapy• Sleep Restriction Therapy• Relaxation Techniques• Sleep Hygiene• Prescription medications

GOOD SLEEP HABITS• Get up at the same time each morning. Even if

you fall asleep very late, you should still get up at the same time each morning

• To avoid “Sunday night insomnia, Monday morning blues”, don’t stay up late on weekends and then sleep in

• Go to bed only when sleepy• Develop a relaxing pre-sleep ritual such as

reading, taking a bath, brushing your teeth, etc

GOOD SLEEP HABITS

• Use the bed only for sleep and intimacy• Nicotine is a stimulant. Try not to smoke near

bedtime• Hunger may disturb sleep. Perhaps try to have a

light snack before bed. A glass of warm milk contains a natural sleep aid

• Exercise regularly. Get vigorous exercise either in the morning or the afternoon and do only mild exercise two to three hours before bed

GOOD SLEEP HABITS• Don’t stay in bed if you can’t fall asleep within 15

minutes. Tossing and turning will just make you more frustrated

• Get as much sleep as you need, but no more• If you find yourself worrying at bedtime, set aside

a “worry time” – perhaps 30 minutes in the early evening to write down both problems and solutions

Zzzzzz QUESTIONS?? Zzzzzz

fraser.willsey@theroyal.ca