Sleep Disorders

• REM:
• -20-25% of sleep
• -dreams
• -rapid eye movements
• -atonia/paralysis
• -later in sleep

• N1:
• -5% of sleep
• -transition from wake to sleep

• N2:
• -50% of sleep
• -EEG shows spindles and K complexes

• N3/N4:
• -20% of sleep
• -slow wave sleep
• -occurs earlier in sleep

amount of time required to fall asleep

• -decreased in anxiety
• -ok in MDD

overall balance of sleep and wakefulness during a night of sleep

-decreased in MDD

percentage of time in bed that is spent asleep

• -measures night time sleep
• -EEG, EMG, EKG, air flow, breathing effort, leg movements

• -daytime test
• -how quickly patient falls asleep during series of short naps
• -determines stage of sleep

-used to diagnose narcolepsy

-records movement while patient is asleep

• Dysomnias:
• -disorders of initiating or maintaining sleep OR of excessive sleepiness
• 1. Primary insomnia
• 2. Primary hypersomnia

• Parasomnias:
• -abnormal behavioral or psychological events in association with sleep
• 1. Nightmare disorder
• 2. Sleepwalking disorder
• 3. Sleep terror disorder
• 4. REM sleep behaviour disorder

-greater than 1 months of difficulty falling asleep, difficulty staying asleep or nonrestorative sleep

• Epidemiology:
• -35% of adult population
• -10% meet criteria
• -25 of elderly meet criteria

• Impairments:
• -decreased cognitive function, increased pain or psych sx, increased accidents

• Course:
• -light sleeper prior
• -onset may occur with stress
• -(conditioned response)
• -increased sleep latency
• -decreased sleep efficiency
• -increased N1, decreased N3
• -increased muscle tension

• Assessment:
• -history
• -sleep log

• Non-Pharmacologic:
• -sleep hygiene
• -stimulus control
• -relaxation and biofeedback
• -CBT

• Pharmacologic:
• -Antihistamines: rapid tolerance, constipation, morning hangover, delirium (esp elderly)
• -Melatonin
• -Ramelteon (melatonin agonist)
• -Sedative hypnotics (Zolpidem --> Ambien)

-excessive sleepiness for at least one month

-due to substance

• -alcohol
• -caffeine
• -nicotine
• -antidepressants
• -steroids
• -decongestants
• -beta agonists
• -statins
• -stimulants
• -DA agonists

-irresistible attacks of refreshing sleep that occur daily over at least 3 months

• Presentation:
• -cataplexy
• -recurrent intrusions of REM sleep
• -hallucinations (hypnopompic or hypnagogic)

• Epidemiology:
• -0.1%
• -men=women

• Pathophysiology:
• -reduction of hypocretin-containing neurons

• Treatment:
• -modafinil
• -armodafinil
• -methylphenidate
• -sodium oxybate

Apnea for longer than 5 seconds

• 1. Obstructive sleep apnea syndrome
• 2. central sleep apnea syndrome
• 3. central alveolar hypoventilation syndrome

• Epidemiology:
• -increased in elderly and obese
• -hx of snoring

• Course:
• -chronic and progressive
• -increased risk of death from cardiac causes

• Treatment:
• -weight loss
• -don't sleep on back
• -stop alcohol and drugs
• -positive airway pressure (CPAP, CiPAP)
• -surgery

-mismatch between sleep-wake cycle and schedule required by environment

• 1. Jet leg type
• 2. Shift work type

• Treatment:
• -light therapy
• -melatonin
• -sedative hypnotic drugs

• -uncomfortable sensation in the limbs (crawly, electrical, worms, pain)
• -relieved by movement
• -worse in evening or night

• Course:
• -usually life long (may wax or wane)
• -80% have periodic movements of sleep)

**rarely associated with iron deficiency

• Treatment:
• -DA agonists (ropinirole)
• -Carbidopa/levodopa
• -Benzos
• -Opiates
• -Gabapentin

• -repetitive movements of feet and legs (every 20-90s for hour)
• -may disturb sleep partner
• -daytime sleepiness

• Course:
• -typically lifelong (may wax and wane)

• Treatment:
• -dopaminergic or benzo drugs

• -repeated awakenings with good recall of frightening dreams
• -rapidly become oriented and alert

• Epidemiology:
• -5% of children
• -male > female
• -3-6 years

• -repeat episodes of rising from bed during sleep and walking about
• -blank stare
• -unresponsive
• -difficult to awaken
• -amnesic for episode

• Epidemiology:
• -3% of children
• -4-12
• -during first 1/3 of sleep

• Treatment:
• -make environment safe
• -Benzos (suppress slow wave sleep)

• -recurrent episodes of abrupt awakening from sleep
• -panicky scream
• -increased autonomic arousal
• -unresponsive to comforting
• -don't recall dream
• -amnesic for episode

• Epidemiology:
• -3% of children
• -males > females
• -4-12 years

• Treatment:
• -Benzos (suppress slow wave sleep)

• -"act out dreams"
• -amount and degree of movement varies
• -rapidly fully awake

• Epidemiology:
• -most often in older patients

• Pathophysiology:
• -loss of activity of system that paralyzes muscles during REM sleep

***early sx of a neurodegenerative disorder that usually includes Parkinsonsm

• Treatment:
• -Benzos (suppress REM sleep)
• -high does melatonin