SleepSleep

Anil Rama, MDAnil Rama, MDMedical Director, Division of Sleep MedicineMedical Director, Division of Sleep Medicine

The Permanente Medical GroupThe Permanente Medical Group

Assistant Adjunct Clinical FacultyAssistant Adjunct Clinical FacultyStanford School of MedicineStanford School of Medicine

Circadian Rhythm of Sleep

Wake

SleepBo

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tem

pe

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7 AM

7 AM

Courtesy of R. Bogan, MD.

Time

Sleep Stages and Function

Vander et al. Consciousness and behavior. In: Human Physiology. 1990.

States Function

Active state of brain

functions in learning

and memory

Body’s rest and

metabolic restoration

Phasic eye movements

Loss of muscle tone

EEG neutral

Stage 3Stage 4

(REM)

Stage 1Stage 2

(NREM)

Sleep and Age

Hobson. Sleep and Dreaming. In: Fundamental Neuroscience. 1999.Roffwarg et al. Science. 1996;152:604.

24

0

8

16

-1 0 1 10 20 100

Conception Birth

Age (y)Death

Ho

urs

in

da

y

NREM sleep

Awake

REM sleep

Sleepy cabbie.wmv

How likely are you to doze off or fall asleep in the following s ituations, in contrast to feeling just tired? This refers to your way of life in recent times. Eve n if you have not done some of these things recently, try to work out how they would have affec ted you. Use the following scale to choose the most appropriate number for each situation.

Situation Chance of Dozing

Sitting and readingWatching TVSitting, inactive in a public place (eg, a theater or a meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic

Epworth Sleepiness Scale (ESS)

Johns. Sleep. 1991;14:540.

0 = would never doze

2 = moderate chance of dozing

1 = slight chance of dozing

3 = high chance of dozing

Sleepiness: Clinical Presentation

• Pervasive drowsiness

• Sleep attacks

• Fatigue

• Microsleep episodes

• Visual disturbances

• Apathy

• Mood changes

• Automatic activity

• Impaired alertness

• Lethargy

• Impaired memory and concentration

• Poor performance in work/school

• Accident prone

Overeem et al. J Clin Neurophysiol. 2001;18:78. Bassetti and Aldrich. Neurol Clin. 1996;14:545.J. Black, MD. Personal communications. October 2002.

The Two-process Model of Sleep The Two-process Model of Sleep RegulationRegulation

Process S (Homeostatic Process)Process S (Homeostatic Process)– Increases during waking and decreases Increases during waking and decreases

during sleepduring sleep Process C (Circadian Process)Process C (Circadian Process)

– Clock-like process that is independent of Clock-like process that is independent of sleep and wakingsleep and waking

Insomnia: Differential Insomnia: Differential DiagnosisDiagnosis

EnvironmentalEnvironmental BehavioralBehavioral Psychiatric DisordersPsychiatric Disorders Neurological DisordersNeurological Disorders Sleep-Wake Pattern Timing DisordersSleep-Wake Pattern Timing Disorders Movement DisordersMovement Disorders Respiratory DisordersRespiratory Disorders Miscellaneous Medical ConditionsMiscellaneous Medical Conditions Sleep State MisperceptionSleep State Misperception IdiopathicIdiopathic

BehavioralBehavioral InsomniaInsomnia

Adjustment Sleep DisorderAdjustment Sleep Disorder Psychophysiological InsomniaPsychophysiological Insomnia Inadequate Sleep HygieneInadequate Sleep Hygiene Limit-setting Sleep DisorderLimit-setting Sleep Disorder Sleep-onset Association Sleep-onset Association

DisorderDisorder

Psychiatric Disorders Causing Psychiatric Disorders Causing InsomniaInsomnia

Mood DisordersMood Disorders Anxiety DisordersAnxiety Disorders Panic DisorderPanic Disorder Alcohol and Drug Alcohol and Drug

DependencyDependency PsychosesPsychoses

Neurological Disorders Causing Neurological Disorders Causing InsomniaInsomnia

Parkinson DiseaseParkinson Disease Nocturnal EpilepsyNocturnal Epilepsy Degenerative Brain Degenerative Brain

DisordersDisorders Fatal Familial Fatal Familial

InsomniaInsomnia

Sleep-Wake Pattern Timing Sleep-Wake Pattern Timing Disorders Causing InsomniaDisorders Causing Insomnia

Time Zone ChangeTime Zone Change Shift WorkShift Work Delayed Sleep Phase SyndromeDelayed Sleep Phase Syndrome Advanced Sleep Phase SyndromeAdvanced Sleep Phase Syndrome Non-24 Hour Sleep-Wake SyndromeNon-24 Hour Sleep-Wake Syndrome Irregular Sleep-Wake PatternIrregular Sleep-Wake Pattern Short SleeperShort Sleeper

Movement Disorders Causing Movement Disorders Causing InsomniaInsomnia

Restless Legs SyndromeRestless Legs Syndrome Periodic Limb Movement DisorderPeriodic Limb Movement Disorder Sleep StartsSleep Starts Nocturnal SeizuresNocturnal Seizures

Respiratory Disorders Causing Respiratory Disorders Causing InsomniaInsomnia

Obstructive Sleep ApneaObstructive Sleep Apnea Central Sleep ApneaCentral Sleep Apnea Obesity-Hypoventilation SyndromeObesity-Hypoventilation Syndrome Nocturnal AsthmaNocturnal Asthma Chronic Lung DiseasesChronic Lung Diseases High AltitudeHigh Altitude

Miscellaneous Medical Conditions Miscellaneous Medical Conditions Causing InsomniaCausing Insomnia

Gastroesphageal RefluxGastroesphageal Reflux HyperthyroidismHyperthyroidism FibromyalgiaFibromyalgia PregnancyPregnancy MenopauseMenopause

Craniofacial Abnormality Craniofacial Abnormality

OSA IdentificationOSA Identification

Maxillary/Maxillary/MandibularMandibular AdvancementAdvancement

OSA Intervention OSA Intervention -- SurgicalSurgical

MandibularMandibular RepositionersRepositioners

OSA Intervention OSA Intervention -- MechanicalMechanical

Courtesy of Sleep Disorders Dental SocietyCourtesy of Sleep Disorders Dental Society