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Khaula Rehman MD Khaula Rehman MD Director of Sleep Lab Schuyler Hospital Montour Falls Sleep is not simply an absence of wakefulness, or just a passive phenomenon resulting from withdrawal of all sensory stimuli. Many areas of the brain remain active during sleep. In REM sleep our brain is more active than when we are awake. Energy conservation Restoration of the body and brain that allows them to function adequately during the wakeful period. consolidation of memory and for adequate stimulation of various circuits within the brain that ensure its proper functioning. The average requirement for a normal adult man or a woman is approximately eight hours. NREM is 75% Stage I Stage II Stage III REM sleep is 25% of our sleep. 1. Circadian Rhythm Our sleep wake habits follow a circadian rhythm and it is controlled by external light and darkness as determined by sunrise and sunset 2. Internal Clock located in the brain in the hypothalamus. This internal clock has widespread connections, not only with the retina for receiving light from the outside world but also with the other parts of the nervous system. As a result , it controls the body’s sleep wake cycle, secretions of hormones and the body’s temperature rhythm. Fatigue Sleepiness Deterioration of performance, attention, and motivation. Decreased mental concentration and intellectual capacity. Increase chances of accidents at work and while driving. Decreased glucose tolerance Decreased insulin sensitivity Increased evening concentrations of cortisol There is an epidemic of obesity in US At least 65% of population is overweight or obese Billions of dollars are spend every year to treat the complications BMI > 25 is considered to be overweight BMI > 30 is considered to be obese BMI > 40 is considered morbidly obese Less sleep increases levels of ghrelin, and decrease levels of leptin or decrease the sensitivity of leptin. These two hormones control feelings of hunger and fullness. Imbalance of these hormones can increase your chances of obesity. Insomnia Sleep apnea RLS Narcolepsy Parasomnias Circadian rhythm disorders Insomnia is difficulty initiating or maintaining sleep. Insomnia is the most common sleep disorder in the United States. It is experienced at some time by approx. 30-50% of the US adult population and is persistent problem in approx. 10%. The prevalence increases with age and is more common in women than men. Primary Insomnia Idiopathic insomnia Psycho-physiologic insomnia Paradoxical insomnia (sleep-state misperception) Secondary Insomnia Adjustment insomnia Inadequate sleep hygiene insomnia Insomnia due to a psychiatric disorder Insomnia due to a medical condition Insomnia due to a drug or substance abuse PREDISPOSING FACTORS PRECIPITATING FACTORS PERPETUATING FACTORS SLEEP HYGIENE Do not go to bed until you are sleepy. Do not increase the time in bed. Keep a regular sleep - wake schedule. Do not drink caffeinated beverages (tea, coffee, soft drinks etc.) or smoke at least 7 hrs before going to bed. Do not go to bed hungry, a small snack e,g a warm glass of milk can help promote sleep. Do not over eat. Adjust the environment in the room (lights, temperature, noise, etc.) white noise is good Do not go to bed with your worries. Try to resolve them before going to bed or make a worry list. Relaxation Therapy Relaxation therapy involves measures such as praying and meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed. Reading can help. Do not go to bed with your worries; try to resolve them before going to bed or make a worry list. STIMULUS CONTROL THERAPY Go to bed when you feel sleepy. Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep . If you do not fall asleep 30 minutes after going to bed, get up and go to another room and resume your relaxation techniques. Set your alarm clock to get up at a certain time each morning, even on weekends. Do not oversleep. Do not look at the clock at night Avoid taking long naps in the daytime. Any nap should be between 1 – 3pm and not more than an hour. Sleep Restriction Restricting time in bed only to sleep. Rigid bedtime and rise time are set, and the patient is forced to get up at the rising time even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation from the previous night. Prescription Sleep Aids Benzodiazepine sedatives: Temazipam (Restoril), Flurazepam(Dalmane), Triazolam(Halcion), Estazolam(ProSom, Eurodin) , Lorazipam(Ativan), Clonazepam (Klonopin). Nonbenzodiazepine sedatives: Eszopiclone(Lunesta), Zaleplon(Sonata), and Zolpidem(Ambien). Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. It promotes the onset of sleep and helps normalize circadian rhythm disorders. Antidepressants Amitriptyline [Elavil, Endep] and Trazodone [Desyrel] have been used for the treatment of insomnia in patients with co-existing depression because of some sedative properties. Generally, they may not be helpful for insomnia in people without depression. There are 3 types of sleep apneas: 1. Obstructive sleep apnea 2. Central sleep apnea 3. Mixed sleep apnea Incidence of OSA is 24% in men and 9% in women . Incidence increases with age and there is strong association between OSA, male gender and obesity. Incidence of OSA increases in women after menopause. Obesity (70-80% of cases) Alcohol use Hypogonathism Marfan’s syndrome Smoking ENT problems Wakefulness Airway Patency Compensation Sleep Hyperventilation O2 & CO2 Decreased Compensation Arousal Sleep O2 & CO2 Airway Collapse Increased Effort to Breathe Wakefulness Airway Patency Compensation Sleep Hyperventilation O2 & CO2 Decreased Compensation Arousal Sleep O2 & CO2 Airway Collapse Increased Effort Sympathetic Activation to Breathe Snoring Recurrent nocturnal awakenings Un-refreshing sleep Daytime fatigue Impaired concentration/memory loss Mood/behavioral changes Morning headaches Loss of sexual interest High BP Heart attacks CHF Atrial Fibrillation and other arrhythmias Strokes Diabetes Hormonal problems in women Obesity Death Weight Reduction Sleep on side Stop Smoking No alcohol CPAP or BIPAP Surgery Gold Standard Therapy CPAP acts as a pneumatic splint and keep the airway open when person is sleeping Survival was studied in 385 patients OSA patients Survival over 8 years was 96% for AI < 20 Survival over 8 years was 63% for AI > 20 Survival over 8 years was 50% for those older than 50 for AI > 20 None of the patients Rx with CPAP or traech died. Chest 94:9-14, 1988 Minimal criteria A compelling urge to move the limbs, usually associated with unpleasant sensation in the legs. Symptoms are worse or exclusively present at rest or inactivity (i.e., lying, sitting) Symptoms are partially or totally relieved by activity such as walking or stretching Symptoms are worse in the evening and at night or only occur at night Associated features Sleep disturbance and daytime fatigue Normal neurologic examination (in patients with primary RLS) Involuntary, repetitive, periodic, jerking limb movements, either in sleep or while awake and at rest Familial-50%. RLS susceptibility gene has been recognized Brain iron deficiency Problems with central dopamine transmission Uremia, anemia and folic acid deficiency and various neuropathies. Certain medications like tricyclic or other antidepressants, lithium carbonate, dopamine, D2 receptor blocking agents. Caffeine and alcohol. Good sleep hygiene Avoid caffeine and alcohol in the evening Massage of the legs. Taking hot bath or applying hot or cold on legs Moderate exercise If not able to sleep some patients have to change their sleep times to later at night and also have to change their working schedules Dopaminergic agents are treatment of choice L dopa- not used anymore because of side effects and augmentation Dopaminergic agonists- bromocriptine, pergolide, cabergoline, pramipaxole and ropinirole. Last two have least side effects and are mainstay treatment these days Opioids, only used when no other treatment is working If ferritin levels are less than 50ug/L. Take iron 325mg twice a day with vitamin C 100-200mg on empty stomach. Sometimes intravenous iron therapy has to be given. Narcolepsy is characterized by irresistible sleep attacks and is usually associated with cataplexy, sleep paralysis, hypnagogic or hynapompic hallucinations and sometimes with automatic behavior. It is very rare and prevalence is only 0.03% History, sleep study, MSLT Blood tests: HLA typing, HLA-DR2 and DQw15 Primary CRD Advanced sleep phase syndrome: Delayed sleep phase syndrome Non-24hr sleep-wake disorder Secondary CRD Jet Lag Shift- work sleep disorder Irregular sleep wake disorder Commonly seen in elderly. They go to bed early in the evening and wake up early than the desired time between 2am -4am. Bright light exposure in the evening has been successful in delaying the onset of sleep. Usually common in high school and college kids. Sleep onset is delayed in relation to the desired bed time. Typically sleep onset is between 2am-6am and wake time is between 10am -2pm. This delay causes symptoms of sleep onset insomnia or difficulty awakening at the desired time in the morning. Person cannot function adequately during daytime hours in school, college or at work or in society in general. Chronotherapy Bright Light Melatonin Sleeping pills Results from Eastward and Westward Jet
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