| What are the six classifications of sleep disorders? | Central hypersomnolence, Circadian rhythm wake disorders, sleep related breathing disorders, parasomnias, sleep related movement disorders, insomnia. |
| What is excessive daytime sleepiness disorder? | Difficulty staying awake in daytime, it is different from fatigue, just sleepiness, and lack of self-recognition is common as the pt may sleep whilst driving or operating. |
| What are the causes of excessive daytime sleepiness disorder? | May be extrinsic (circumstatial) like not getting adequate sleep causing CVD, obesity, glucose intolerance..., or endogenous causes (disease-related) |
| How to assess excess sleep disorder? | Thorough history (sleep hygiene, sleep environment, time and duration...)
1-2 week diary of sleep-wake schedule (self-realization), or by a wrist actigraph-a device.
Epworth questionnaire.
May be narcolepsy or idiopathic hypersomnia --> sleep laboratory testing |
| What are the conditions that disrupt circadian rhythm? | Jet lag and Shift work sleep disorder |
| What is jet lag? | internal sleep clock is out of sync from the local time after going to another time zone, occurs for 1 or 2 days after travel (may include neuropsychiatric issues and insomnia).
Going eastwards is harder than westwards.
For short travels it is better to stay on same time, for longer ones adaptation is better
There are measures taken pre and post flight, and hypnosis during flight has a risk of parasomnia (sleep walking) |
| What is shift work sleep disorder? | Many experience excessive sleepiness, mood perturbation, neurocognitive dysfunction lasting for 3 months.
Pt are asked to see if they can edit their sleep schedule, if not feasible they look for ways to adapt like decreasing or increasing light exposure, melatonin...
Hypnosis is not very useful as it may have effects (carryover effects into nighttime work period) |
| What is obstructive sleep apnea? | OSA, sleep interruption due to repetitive upper airway narrowing or collapse.
Breathing events seen during sleep testing (apneas or hypopneas) may be divided by total sleep seen with apnea-hypopnea Index (AHI)
AHI [5-14] / hour -->mild OSA
AHI [15-30] / hour -->moderate OSA
AHI >30 / hour --> severe OSA
But sleepiness degree is not always correlated with AHI |
| How is the pathophysio of obstructive sleep apnea? | Pharyngeal muscles relax causing redundancy of soft tissues lining the airway.
Snoring, supination may cause tongue displacement narrowing the airway.
Most disordered breathing occurs during REM (rapid eye movement) cycle of sleep (all muscles are atonic except diaphragm and extraocular muscles).
Could cause arousal or microarousal (repetitive arousal is associated with developing excessive daytime sleepiness and neurocognitive symtoms of OSA (oxyhemoglobin desaturated) |
| What are the risk factors of obstructive sleep apnea? What are the symptoms? | Most important one is obesity.
Symptoms include choking or gasping (most sensitive pretest indicator), overnight awakening, nocturia, morning headaches, unrefreshing sleep and excessive daytime sleepiness in addition to neuropsychiatric symptoms (mood alteration, difficulty concentrating, problems completing tasks) |
| How is the testing for OSA? | Polysomnography (may be home tested for less costly)
Strongest suggestion of OSA is excessive daytime sleepiness that resolves with treatment of OSA. |
| How do we treat OSA? | Positive airway pressure therapy (splinting open upper airway, reduces AHI to zero)
No effective pharmacology to treat it
Weight loss improves it severely, reducing alcohol intake before bedtime, avoiding sedator medication, and supine posture
CPAP therapy (positive airway pressure)
oral appliance (exerting traction of mandible)
Upper airway surgery (maxillomandibular advancement improves AHI, patients not tolerating CPAP, maybe soft palatal procedure, tonsillectomy...) |
| What are central sleep apnea syndromes? | Pauses of airflow caused by loss of output of central respiratory generators in brainstem --> lack of respiratory effort.
Cheyen-stokes breathing is associated with heart failure, it is a crescendo decrescendo pattern of ventilation.
Risk factor fro CSA is atrial fib, in addition opioids destabilizing ventilation, strokes, brainstem lesions, kidney injury. |
| What are sleep related breathing disorders? | Associated with advanced COPD, obesity, restrictive lung diseases, neuromuscular disorders.
Impaired gas exchange that is compromised with sleep (in REM)
Hallmark of obesity hypoventilation is daytime hypercapnia, PCo2>45mmHg |
| What is parasomnia? | Sleep walking, terrors and talking (partial arousals from sleep)
Undesirable physical events occur during initiation of sleep, more common for children but may occur at any age.
Occurs for individuals 5-25 years with family history, discovered by other individuals or injury (NREM movement)
REM movement is action consistent with dream awakes the sleeper and recalls the event
NREM are outgrown no treatment, while REM are associated with degenerative brain disease |
| What is nightmare disorder? | Recurrent nightmares, causing anxiety and prolonged awakening, associated with psychopathology inversed by mental well-being (antidepressants, antihypertensives, dopamine receptors agonists.
Common for acute stress disorder or PTSD in NREM or REM |
| What are the manifestations of restless leg syndrome? | Urge to move legs in sleep, sensations beginning with resting (after lying or sitting for a period), relief with movement, worsening of symptoms in evening (NIGHT), nighttime leg twitching (periodic limb movement of sleep) |
| What are the causes of restless leg syndrome? | Peripheral neuropathy (DM and alcoholism)
iron deficiency, kidney failure, spinal cord condition, parkinson's |
| What is narcolepsy? | Severe and persistent drowsiness causing functional impairment, very rare, disrupts sleep-wake, excesive daytime sleepiness.
Cataplexy is sudden loss of muscle control (NT1) happens in response to a suddent emotion like laughter or excitement |
| What is insomnia? | Most common sleep disorder, trouble falling asleep, staying asleep or getting good quality of sleep.
Can lead to excessive daytime sleepiness, short-term may be caused by stress and can last days or weeks.
Long-term (chronic) lasts 3 months and occurs 3 times nightly, fully explained by another health problem |
| What are the symptoms of insomnia? | Trouble falling asleep, trouble staying asleep, unwanted early morning wakening, resistance of bedtime sleep, daytime symptoms of sleep loss (fatigue, impaired attention and memory, negative mentally, irritabiltity... |
| How do we diagnose insomnia? | Hx, sleep diary (week or more) Pittsburgh sleep quality index, sleep study (may be ordered) |
| What is the treatment of insomnia? | Acc to type of insomnia (if associated with a condition or event)
support sleep hygeine, CBT (relieves anxiety), sleep medication, homeopathic treatment (melatonin or dietary supplements yoga, hypnosis, aromatherapy with no scientific evidence) |
| What are healthy sleep habits? | Set sleep schedule, dedicated sleep space, mindful of substance use, control light exposure, keep sleep-related anxiety in check, adjust eating habits. |
