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 problems-
difficulty 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 well-
ventilated
– Eat dinner 4-5 hours before bedtime