Sleep and sleep disorders

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Sleep and sleep disorders

• MUDr. Katalin Šterbová
• Centrum pro poruchy spánku u detí
• Detská neurologická klinika
• Fakultní nemocnice v Motole

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• Sleep physiology
• Examining sleep disturbances
• Sleep disorders

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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

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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

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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

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NREM x REM

• The body is resting
• The mind is resting

• The mind is active, but disconnected from the
  body

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Hypnogram
NREM I 1
NREM II 45-50
NREM III 20
REM 25
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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

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Sleep requirements in children
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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

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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

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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

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• 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

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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

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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

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• Sleep disorders

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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

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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 DQB10602
  haplotype)

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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

SITUATION CHANCE 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 ____________
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• 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

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Wakefulness - PSG
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PSG
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International Classification of Sleep Disorders

• 1. 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 Parasomnias
• 3. Sleep Disorders Associated with Other
  Disorders
• A. Associated with Mental Disorders
• B. Associated with Neurologic Disorders
• C. Associated with Other Medical Problems
• 4. Proposed Sleep Disorders
• source American Academy of Sleep Medicine, 2001

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Insomnia I.

• Difficulty with falling asleep (sleep latency gt30
  min)
• Frequent arousals (sleep efficiency lt 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

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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)

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Insomnie III.

• Paradoxical insomnia (sleep misperception)
• Idiopathic insomnia (childhood onset i., lifelong
  i.)
• often with somnambulism, ADHD
• Mental illness related insomnia

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Insomnia IV.

• Associated with neurological or other medical
  disorder
• Associated with hypnotic-, alcohol- or stimulant
  dependence
• Associated with inadequate sleep hygiene

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Insomnia - therapy

• Eliminating causes
• Non benzodiazepin hypnotics for short-term
  (zolpidem)
• Psychotherapy
• Cognitive-behavioral therapy

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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 1820 C.

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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

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Sleep apnea

• Central sleep apnea syndrome
• Obstructive sleep apnea syndrome
• Central alveolar hypoventilation syndrome

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Obstructive sleep apnea syndrome
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Normal breathing, obstructive hypopnea,
obstructive apnea
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OSAS

• Video OSAS

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OSAS in PSG recording
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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

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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)

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CPAP
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Increased day-time sleepiness

• decreased ability to maintain wakefulness
  during the day
• Hypersomnia of central origin
• Narkolepsy
• Recurrent hypersomnia
• Idiopathic hypersomnia
• Hypersomnia due to other factors (organic brain
  disease drugs, alcohol)

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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 DQB10602)
• Deficit of hypocretin (orexin) peptid secreted
  in the hypothalamus

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• 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)

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Therapy of hypersomnia

• Changing day-time schedules
• Medication
• Methylfenhydate
• Modafinil
• Sodiumoxybate
• Tricyclic antidepressants (imipramin),
  thymoleptics (cytalopram, sertralin)

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Circadian-Rhythm Disorders I

• Abnormal timing and length of sleep
• Desynchronization of ones biological rhytmicity
  and the external circadian rhythm
• e.g. non-24 hour sleep-wake disorder of blind

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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

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Circadian-Rhythm Disorders III

• Therapy
• Regular physical activities and regular food
  intake to strengthen synchronization
• Morning illumination with bright light (2.5-10
  tousand Lux)
• Melatonin
• Chronotherapy (extension of the day to 27 hours)

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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

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Other parasomnias

• Bedwetting
• Somniloqia (sleep talking)
• Sleep-related eating
• Compulsive
• Not provoked by hunger
• The patient eats inedible or toxic substances
• Hypnagogic hallucinations

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Abnormal movements related to sleep

• RLS
• Bruxismus
• Rhythmic movement disorder

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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)

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Rhythmic movement disorder

• video

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• Neurological disease related sleep disorders

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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

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Neuromuscular disease

• Sleep-related breathing disorder
• Decreased dilatation of the pharynx in sleep
• Inability to change position during sleep
• Decreased ventilation
• Depression, anxiety

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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