Sleep Disorders

SUMMARY
 Insomnia
 CBT- best tx
 benzodiazepines
 non-benzodiazapines
 melatonin R agonists
 melatonin
 antihistamines
 psychotropics: antidepressants, antipsychotics, mood stabilizers
 restless leg syndrome
 iron
 dopaminergic medications
 sleep disordered breathing
 obstructive: CPAP, correct nasal obstruction, weight reduction, oral appliances, surgical
tx (ENT-not so effective) and bariatric tx
 Narcolepsy
 to keep pt awake: amphetamines
 to help pt sleep: oxybate: direct GABA agonist “date-rape drug”
 tx cataplexy: SSRI which reduce REM sleep.
 delayed sleep phase syndrome
 chronotherapy- light therapy in AM to suppress melatonin, can then take melatonin in
early evening to mimic nl cycle

Recall=
 DRUGS
 “sleep latency”= time from which ur awake till asleep

 benzodiazepine= suppresses SWS, ^GABA , poor quality of sleep

 antidepressants/ SSRI= suppress REM, increase sleep
 opiates= reduce REM
 lithium, anti-psychotics= increase SWS
 alcohol= reduce sleep latency, increase SWS, suppress REM-cause fragmented sleep
 b-blockers + thyroid medications= insomnia, increase sleep latency
 caffeine+nicotine= increase sleep latency, reduce SWS

 temperature
 delta change in temperature in hypothalamus = triggers sleep
 hot shower or warm cup of tea= sleep
 exercise late at night= increase core temperature= you will not sleep
 Insomnia
 most common complaints
 ICSD:
 -difficulty initiating sleep, maintaining sleep, early awakening, non-
restorative sleep despite adequate opportunity
 accompanied by:
 fatigue
 memory impairment
 mood disturbance
 reduction in motivation
 accidents at work
 HA, worrying about it
 primary insomnia:
 -idiopathic: starts in childhood, genetic predisposition
 -psychophysiological insomnia: under + or – circumstances (worrying or
excited). if transient or ignored, could last for a long time
 -paradoxical insomnia: think ur not sleeping but u are, seen in pts with
mental illness
 secondary insomnia:
 psychosocial stress- homeless refugee
 psychiatric disorder- ex: mania, psychotic, paranoias
 medical disorders- heart failure, gerd
 alcohol
 medications
 Psychophysiological Insomnia
 most common type
 excessive focus on sleep, anxiety
 heightened somatic tension in bed
 if persists, can last for many years

take a very detailed history !

 more common in women, and elderly

 Management:
 think positive
 don’t go to bed unless ur sleepy
 don’t look at the clock
 establish fixed wake times
 follow 20 mins toss and turn
 avoid caffeine, alcohol, nicotine within 6h of sleep
 exercise but not within 3h of sleep
 biofeedback: behavioral component of CBT – increase parasympathetic
tone- your blood vessels dilate, more blood flow to fingertips,
thermometer will become warmer
 relaxation training!

 Pharmacologic treatment
 1-main treatment (generic) : benzodiazepine = “pams” high risk of
addiction and dependence, next day fatigue, and memory loss.
 benzo bind GABA receptor has 4 types. binds to all 4= many effects
 2-non-benzodiazepines = NBZRAs = less abuse/addiction potential. less
adverse effects than BNZ
 only binds to the subunit of the GABA receptor which promotes sleep =
less side effects
 3-melatonin receptor agonists= ramelteon
 4-melatonin= decreases core body temperature
 contra-indication: children and pregnancy
 5- antihistamines
 morning hangover
 problems the next day
 6- psychotropics: antidepressants, antipsychotics, mood stabilizres
 7- best treatment for insomnia is: behavioral changes, CBT if needed

 Restless Leg Syndrome

 urge to move legs, uncomfortable and unpleasant sensations in the legs
 at night
 relieved by movement or massage (some somatic sensation)
 possible dopaminergic problem
 mimicer of insomnia bc it doesn’t let u fall sleep
 if once u fall asleep they continue, can wake u up
 symptoms happen while awake, before falling asleep
 positive family hisroty, autosomal dominant
 associated with: iron-deficiency anemia, end stage renal dz, pregnancy
 dopamine deficiency
 not enough dopamine going to motor system at night, iron is a
coenzyme for tyrosine kinase which is important for the production of
dopamine
 sometimes you can fix it by just giving iron!
 on EMG: muscle jerks
 polysomnogram (sleep study)= not necessary
 refrain from alcohol, caffeine, tobacco
 moderate exercise
 massage the legs
 tx: dopaminergic medications , iron supplements especially if Fe
deficient

 Sleep disordered breathing

 anatomical features= large neck, large mass of tissue inside,
compression of airway= retrognathia
 Central sleep apnea
 loss of effort by lungs
 problem in control of respiratory system
 seen in stroke, HF, ESRD
 intermittent, cyclic fashion, Cheyne-strokes breathing
 obstructive sleep apnea
 lungs are trying to breath, but there is an obstruction
 overweight, neck aatomy
 children: immature airways

 severity: measured by respiratory distress index (RDI)= # of apnea or

hypopneas per hour of sleep
 <5/h= normal
 apnea= breathing cessation for at least 10s = 90% reduction in airflow
and 3% oxygen saturation drop
 hypopnea= less than 10s
 more in male
 estrogen seems to be protective, women after menopause catch up with
men
 snoring, alcohol= is risk factor
 HTN, craniofacial features
 sleep apnea= pressure on CV system !
 during the night severe adrenergic stress bc of thinking ur choking
 independent risk factor for severe depression!
 nocturnal signs
 snoring, nocturia, gerd, witnessed apneas
 excessive daytime sleepiness/fatigue
 sore throat in AM
 morning HA
 depression
 daytime signs and symptoms

 MRI: we can see narrowed oropharynx

  we do a polysomnogram: sensors next to nose=
 obstructive: detect no airflow for about 10s, we know its obstructive bc
abdomen and thorax are moving normally
 central: Cheyne strokes- decreased airflow with DECREASED movement
of thorax. stroke, HF, renal dz
 mixed apnea: starts with central, effort comes back, but still no
breathing= then you die. double hit= extreme CV stress
 Treatments:
 -positional therapy
 -tesoterone= big neck
 -correct nasal obstruction
 -weight reduction
 best treatment for obstructive sleep apnea: CPAP- simple pump that just
blows air, you don’t need oxygen just basic airflow
 blows open the airway
 oral appliances= advance mandible-keep airway open, for mild cases,
produces prognathia= pushing the jaw open to breath more easily
 surgical treatment = bariatric surgery for morbidly obese
 ENT surgery- not very effective
 ex-mandibular advancement- surgery to push jaw forward
 Narcolepsy
 1-excessive daytime sleepiness
 2- cataplexy= loss of muscle tone without loss of consciousness
 REM atonia is happening when you are awake! (recall-paralysis during
rem) but no loss of consciousness
 3- sleep paralysis
 4- hypnagogic -hallucinating while falling asleep, hypnopompic-
hallucinating while waking up
 hallucinations= dreams while you are awake (see your dream while ur
awake)
 5- fragmented nocturnal sleep

these symptoms can happen in someone who is sleep deprived

 frequently mis-dx as epilepsy, seizures, bc of paralysis and
hallucinations
etiology
 loss of hypothalamic neurons that produce neuro-peptide
hypocretin/prexin
 viral triggers or head trauma
 investigations
 -low hypocretin levels in the CSF
 -MSLT sleep test
 treatment
 conservative: scheduled naps, regular sleep-wake cycle, avoid time zone
change
 tx for excessive daytime sleepiness EDS:
 amphetamines (stimulants)
 (mimicking wakefulness)
 tx to help sleep:
 oxybate = direct GABA agonist= puts u in deep sleep (date-rape drug)
 (sleeping medicine at night, you sleep so deeply that you wont need to
sleep more)
 tx for cataplexy: serotonin reuptake inhibitors = helpful because they
reduce REM sleep!

 Parasomnias
 benign
 common in childhood
 sleep walking, sleep talking
 harmless
 improve in puberty
 happen in slow wave sleep
 make sure not seizures
 hypnic jerks= normal sleep phenomenon, leg jerk while falling asleep,
falling sensation. as ur brain is shutting down the switches, incomplete
disconnection btw motor cortex and lower extremities, reactivation
then stops.
 somniloquy: talking
 somnambulism: sleep walking, eyes are open
 sleep eating/nocturnal eating: unexplained weight gain
 sleep terrors: child screaming at night. not a nightmare, it is a
confusional arousal of children. = don’t remember what they were
seeing
 catathrenia: sleep groaning, moans, unusual
 exploding head syndrome: wake with startle and feeling of loud clap or
sound sensation: overactivation of vestibular system
 RBD (REM behavioral disorder): extreme agitation in sleep causing harm
to self and sleep partner. older men, predictor of parkinsons

 Nightmares
 happen in any age, in REM, awaknes afraid, good recollection of dream
 not parasomnias or sleep terrors (in those- they cant remember
anything)
 Circadian Rhythm Sleep Disorders
 delayed sleep phase syndrome= disorders of sleep timing/ delayed sleep
phase syndrome: persistent or recurrent pattern of sleep disturbance
more common in young boys
period gene error
link btw DSPS and bipolar syndrome
 learned behavior, genetic component
 Jet Lag: induced – every 1 time zone you fly, you need one day to
recover.
 up to 3 time zones (3h difference)- then u feel it
 if you travel west= you want to sleep early – advanced phase
 if you travel east= you want to sleep later- delayed phase
 free-running= we see it in site-less people (blind people)
 risk of substance abuse
 treatment
 chronotherapy-light therapy in the morning, to suppress melatonin,
then take melatonin in the early evening to mimic nl cycle