sleep and sleep disorders
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Sleep and sleep disorders
MUDr. Katalin ŠtěrbováCentrum pro poruchy spánku u dětíDětská neurologická klinikaFakultní nemocnice v Motole
Sleep physiology
Examining sleep disturbances
Sleep disorders
Sleep physiology Sleep occurs periodically and is characterized by
decreased reactivity to external stimuli decreased motions typical body position typical electrical activity of the brain
Sleep is immediately reversible
Sleep is an active process resulting from the cooperation of several regulatory centres
Wakefulness, NREM and REM sleep are three physiologic functional states
NREM sleep Body resting, almost no movements Regular heartbeat and respiration, depression of blood
pressure Almost no dreams Restorative function 3 stages:
NREM I – drowsiness – eyelids closing, head-drop, voices grow away, thoughts dispersing, hypnagogic jerking
NREM II – sleep spindles, K komplexes; easy to wake up NREM III – delta sleep, very regular heartbeat and respiration,
hard to wake up Muscles relaxed, no movements except sleepwalking
REM Irregular heartbeat and respiration, further depression of
blood pressure Decreased thermoregulatory activity, no sweating, no
shuddering REM sleep is very active compared to NREM: higher
oxygen consumption, higher temperature of the brain, higher cerebral perfusion, EEG resembles wakefulness and drowsiness
Muscles relaxed except extraocular and respiratory ones Muscle relaxation in neonates is not fully developed;
newborns and small infants often jerk, vocalize, kick out, grimase
Awakening somebody from REM might be difficult – outer and inner stimuli can be incorporated into dreams
Dreams – their role is not very clear
NREM x REM
The body is resting The mind is resting
The mind is active, but „disconnected“ from the body
Hypnogram
NREM I 1%
NREM II 45-50%
NREM III 20%
REM 25%
Development of sleep
REM (active sleep) appears in the 6.-7. month of pregnancy
NREM (quiet sleep) appears a month later
In full-term neonates: 50% of sleep is „active“ sleep
In preterm babies: 80% of sleep is „active“ sleep
Sleep requirements in children
Sleep regulation I. Circadian clock in
the ncl. suprachiasmaticus thalami control timing of sleep
Melatonin is released from the epiphysis in darkness and thus regulates the circadian clock in the hypothalamus
Sleep regulation II.
The „circadian clock“ regulates also other circadian rhythms as body temperature, level of cortisol, hunger
The inner „clock“ has to bee synchronized with the 24hours cycle – according to light/darkness, food intake, social activities, external temperature and noise
Drowsiness and wakefulness varies during the day – drowsiness after lunch is normal, a period of increased alertness before bedtime is physiological
Owls and larks
Why do we sleep? Both body and mind gets restoration during sleep
Different theories: mental and physical restoration, energy conservation, memory fixation, cool-down of emotions
Extracerebral processes: increased productin of growth hormone and thyreotropin, decreased salivation, decreased motility of bowels
Immunity – long-term sleep deprivation has negative effect on immunity
If somebody does not sleep one night, he is sleepy the other day and the only way to overcome sleepiness is to sleep
Optimal length of sleep for an adult is 7-8.5 hours
After an acute sleep deprivation: NREM III and ½ of REM is compensated
Acute sleep deprivation
Decreased efficiency Decreased ability to learn Instability of mood Increased vulnerability of the – e.g.
Increased risk of epileptic seizures Worsened thermoregulation Tremor, ptosis
Chronic sleep deprivation Trend of the last century in Western countries
Behaviourally induced insufficient sleep Increased day-time sleepiness Decreased efficiency Concentration affected Immune regulation deterioration Increased cardiac events Shorter life-expectancy Increased BMI
Sleep disorders
Sleep problems in the population
We spend about 1/3 of our life sleeping
Almost everybody experiences some sleep problem in his life
no systematic epidemiological studies
Diagnostic procedures
history EEG, sleep EEG, polysomnography, MSLT
(Multiple Sleep Latency Test), MWT (Maintenance of Wakefulness Test),
actigraphy ENT, paediatrics/internal medicine,
gastroenterology, immunology Psychology/psychiatry Brain imaging HLA typization (95% of White patients with
narcolepsy/kataplexy have the DQB1*0602 haplotype)
Epworths sleepiness scale
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
SITUATIONCHANCE OF DOZING
Sitting and reading ____________
Watching TV ____________
Sitting inactive in a public place (e.g a theater or a meeting) ____________
As a passenger in a car for an hour without a break ____________
Lying down to rest in the afternoon when circumstances permit ____________
Sitting and talking to someone ____________
Sitting quietly after a lunch without alcohol ____________
In a car, while stopped for a few minutes in traffic ____________
Pediatric Daytime Sleepiness Scale (PDSS) Scoring: 4 = Very often, Always 3 = Often, Frequently 2 = Sometimes 1 = Seldom 0 = Never
Please answer the following questions as honestly as you can by circling one answer. 1. How often so you fall asleep or get drowsy during class periods? Always Frequently Sometimes Seldom Never 2. How often do you get sleepy or drowsy while doing your homework? Always Frequently Sometimes Seldom Never 3.* Are you usually alert most of the day? Always Frequently Sometimes Seldom Never 4. How often are you ever tired and grumpy during the day? Always Frequently Sometimes Seldom Never 5. How often do you have trouble getting out of bed in the morning? Always Frequently Sometimes Seldom Never 6. How often do you fall back to sleep after being awakened in the morning? Always Frequently Sometimes Seldom Never 7. How often do you need someone to awaken you in the morning? Always Frequently Sometimes Seldom Never 8. How often do you think that you need more sleep? Very Often Often Sometimes Seldom Never * Reverse score this item
Abnormal Values: 6th and 7th Grade > 26, 8th Grade >30
Wakefulness - PSG
PSG
International Classification of Sleep Disorders1. Dyssomnias A. Intrinsic Sleep Disorders B. Extrinsic Sleep Disorders C. Circadian-Rhythm Sleep Disorders
2. Parasomnias A. Arousal disorders B. Sleep-Wake Transition Disorders C. Parasomnias Usually Asssociated with REM Sleep D. Other Parasomnias3. Sleep Disorders Associated with Other Disorders A. Associated with Mental Disorders B. Associated with Neurologic Disorders C. Associated with Other Medical Problems4. Proposed Sleep Disorders
source: American Academy of Sleep Medicine, 2001
Insomnia I. Difficulty with falling asleep (sleep latency >30 min) Frequent arousals (sleep efficiency < 85%) Early wake up (30 minutes earlier than planned)
Sleep has poor quality, non-refreshing, pat. has one on these complaints: Fatigue, concentration and memory deficit, mood
disturbances, irritability, social discomfort, decrease of energy, motivation, propensity to errors, headache, insomnia anticipation
Insomnia II. Acute insomnia (stress-related i.)
Disturbed sleep is due to an acute stressor
Primary (psychophysiologic, learned, conditioned) insomnia a disorder of somatized tension and learned sleep-preventing
associations Individulas with P.I. typically react to stress with somatized
tension and agitation. The meaning of stressfull events is denied and repressed but manifests itself as increased physiologic arousal (increased musce tension, increased vasoconstriction, ..)
Learned sleep-preventing associations exacerbate the state of high somatized tension and directly interfere
with sleep consist mainly of marked overconcern with the inability to sleep; a
vicious cycle then develops: patients in whom this internal factor (trying too hard to sleep) is a driving force for insomnia often find that they fall asleep easily when not trying to do so (e.g. Watching TV, driving, reading)
Insomnie III. Paradoxical insomnia (sleep
misperception)
Idiopathic insomnia (childhood onset i., lifelong i.)often with somnambulism, ADHD
Mental illness related insomnia
Insomnia IV.
Associated with neurological or other medical disorder
Associated with hypnotic-, alcohol- or stimulant dependence
Associated with inadequate sleep hygiene
Insomnia - therapy
Eliminating causes
Non – benzodiazepin hypnotics for short-term (zolpidem)
PsychotherapyCognitive-behavioral therapy
Sleep Hygiene Rules Avoid drinking coffee, black or green tea, coke or energy drinks late
afternoon (4-6hours before going to bed), reduce their consumption also during the day.
Avoid eating heavy meals in the evening. Do not deal with problems that make you upset after dinner. Find
some nice and calm activity to get rid of stress and get prepared for sleep.
A short walk after dinner can improve your sleep. Avoid major physical activity 3-4 hours before bed-time
Do not drink alcohol to facilitate falling asleep – alcohol worsens the quality of your sleep
Do not smoke before bedtime and during night-time awakenigs Use your bedroom and bed only for sleep and sex – remove TV set
from your bedroom, do not eat and do not rest in your bed Go to bed and wake up at the same time every day (– + 15 minutes) Do not spend extra time in your bed lazing, thinking. Decrease noise and light in your bedroom to minimum; room
temperature should be 18–20 °C.
Insomnia of children Sleep-onset association disorder
Typically the child falls asleep under certain set of conditions (using a bottle, sucking on a pacifier, nursing, rocking)
Return to sleep during night-time waking is difficult unless the conditions associated with sleep onset are re-established
Limit-setting sleep disorder The child refuses to go to bed at an appropriate time Asserts requirements verbally or leaving bed (drinking, eating,
urination, more fairy- tales) „Curtain-calls“
Medical reasons (pain, infant colic, itching)
Fear, anxiety
Sleep apnea
Central sleep apnea syndrome Obstructive sleep apnea syndrome Central alveolar hypoventilation syndrome
Obstructive sleep apnea syndrome
Normal breathing, obstructive hypopnea, obstructive apnea
OSAS
Video OSAS
OSAS in PSG recording
What is the problem with apnea?
Acute problem: each apnea/hypopnea is followed by desaturation and arousal → sleep fragmentation → bad quality of sleep → day-time symptoms (sleepiness, concentration problems)
Chronic consequences: arterial and pulmonary hypertension, obesity, increased risk of ischemic heart desease and cerebrovascular infarcts, decreased somatotropin release, insulin and leptin resistance
Therapy of OSAS
Change diet and increase physical activity to decrease BMI
ENT surgery (adenotonsilectomy, plastic surgery on the soft palate)
Stomatosurgery CPAP (continuous positive airway pressure)
CPAP
Increased day-time sleepiness = decreased ability to maintain
wakefulness during the day Hypersomnia of central origin
NarkolepsyRecurrent hypersomnia Idiopathic hypersomnia
Hypersomnia due to other factors (organic brain disease; drugs, alcohol)
Narkolepsy Symptoms:
Excessive sleepiness with repeated episodes of naps or lapses into sleep of short duration
Cataplexy (sudden loss of bilateral muscle tone propvoked by strong emotion)
Sleep paralysis Hypnagogic hallucinations
PSG and MSLT: reduced sleep latency, sleep-onset REM (SOREM)
Genetic features (HLA typing: DQB1*0602) Deficit of hypocretin (orexin) – peptid secreted
in the hypothalamus
Idiopathic hypersomnia Increased need of day-time sleep, but not
episodic
Recurrent hypersomia Kleine-Levin syndrome
Episodes of hypersomnia, hyperphagia, hypersexuality, mental status changes (aggression)
Therapy of hypersomnia Changing day-time schedules
MedicationMethylfenhydateModafinilSodiumoxybateTricyclic antidepressants (imipramin),
thymoleptics (cytalopram, sertralin)
Circadian-Rhythm Disorders I
Abnormal timing and length of sleep
Desynchronization of one’s biological rhytmicity and the external circadian rhythme.g. non-24 hour sleep-wake disorder of blind
Circadian-Rhythm Disorders II.
Delayed/advanced sleep-phase syndrome Irregular sleep-wake pattern Jet lag syndrome
Better tolerance of Western fligths Shift work sleep disorder
Circadian-Rhythm Disorders III
Therapy:Regular physical activities and regular food
intake to strengthen synchronizationMorning illumination with bright light (2.5-10
tousand Lux)MelatoninChronotherapy (extension of the day to 27
hours)
Parasomnias NREM x REM
NREM parasomnias – arousal disorders Confusional arousals Sleepwalking Sleep terrors
REM parasomnias REM sleep behavior disorders Nightmares – terrifying dreams provoke arousal with
highly emotional and anxious reaction
Other parasomnias
Bedwetting Somniloqia (sleep talking) Sleep-related eating
CompulsiveNot provoked by hungerThe patient eats inedible or toxic substances
Hypnagogic hallucinations
Abnormal movements related to sleep
RLS Bruxismus Rhythmic movement disorder
Restless Legs Syndrome
Disagreeable leg sensations that usually occur prior to sleep onset and cause an almost irresistible urge to move the legs
Causes sleep onset insomnia Etiology
Primary (idiopathic) Secondary (pregnancy, uraemia, anaemia)
Rhythmic movement disorder
video
Neurological disease related sleep disorders
Epilepsy and sleep I
Sleep EEG recordings can show epileptic discharges that were not present in wakefulness
In general epileptic discharges are more frequent in NREM then in REM sleep
Sleep deprivation or bad quality sleep can provoke epileptic seizures
Seizures appear typically during sleep or on awakening in some epilepsy syndromes
Neuromuscular disease
Sleep-related breathing disorderDecreased dilatation of the pharynx in sleep Inability to change position during sleepDecreased ventilation
Depression, anxiety
Cerebral palsy, neurodegenerative diseases Limited perception of extrinsic stimuli Limited social contacts Limited abilities of education in mental retardation Altered ascendant reticular formation maintaining
wakefulness Loss of circadian regulation Epileptic seizures Episodes of increased sleepiness, apathy, irritability Hyperactivity Hypnagogic jerking (sleep starts) interfering with
falling asleep Pain, crying
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