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Objectives. Discuss the changes that occur in sleep from infancy through adulthood. Discuss the normative data of sleep parameters Discuss sleep changes across the life cycle in women Discuss sleep in older Adults. Sleep Definition.
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Objectives • Discuss the changes that occur in sleep from infancy through adulthood. • Discuss the normative data of sleep parameters • Discuss sleep changes across the life cycle in women • Discuss sleep in older Adults
Sleep Definition • sleep is a reversible behavioral state of perceptual disengagement from environment & unresponsive to the environment. • Series of physiological & behavioral process. • Normally associated with postural recumbence, behavioral quiescence ,closed eyes & occasionally unusual behavioral activities. • Greek God Hypnos = Sleep.
Sleep Patterns 0-12 Months • Sleep -major portion of lives of newborns, infants & children. • A newborn typically sleeps ( 70 % of every 24 Hr) / adults spend 25-30% of their lives sleeping. • Distributed equally across the day & night. • Gain ability to sustain longer periods of sleep &waking. • Total sleep duration about 14 hours. • Developmental mile stones of “ sleeping through the night” ( i.e. at least 8 hours at night) is achieved by 6-9 months. • By age 3 ,the average child will have spend more time asleep than awake.
Sleep Patterns 0-12Months • Infants have a sleep cycle periodicity of 50-60 minutes. • Sleep periods of 2-4 hours initially in infancy with REM. usually being the initial stage of sleep onset. • Infants usually spend 50% of night into REM. • At age 3 months REM becomes organized & NREM finally dominates the sleep cycle. • NREM stages emerges in the first year. • Sleep spindles arising at 4 weeks. • High voltage slow waves at age 3 months. • K complexes at 6 months.
Sleep Patterns 0-12 months • EEG features not discernible in new born infants. • Combination of EEG & Behavioral Criteria used to assign sleep stages . • Quiet sleep( i.e. NREM sleep) • Active Sleep( i.e. REM sleep) • Indeterminate Sleep • Active sleep dominates initially with respective percentage for preterm & full term infants of 60% & 50%. • By age six months, active sleep declines to 25 %. • After 6 months, NREM divided into 4 stages: Stage 1,2,3,4. • EEG voltage significantly increases in first yr, with attenuation in 9-16 yrs.
Sleep Patterns 0 – 12 months • REM sleep, NREM sleep based on EEG, EOG, EMG. • Newborn: Transitional sleep with disorganized quiet and active sleep. • 1-6 Months: REM is active sleep, NREM is quiet sleep. • NREM sleep: low frequency, high voltage EEG activity, low muscle tone, absence of eye movement. • REMS: Desynchronized cortical EEG activity, absence of muscle tone, irregular heart and resp rate, episodic bursts of phasic eye movements. • Trace alternant seen in very young: high voltage activity with near electrical silence.
Sleep Patterns in 0-12 months • When infants fall asleep, experience sleep onset REM; after 3 months, drift towards NREM sleep onset. • SWS greatest is early childhood, decreasing abruptly in puberty and further declines throughout life. • This change reflects EEG amplitude that may be related to age-specific “programmed” alterations in synaptic connectivity among neurons and changes in neuron • , neurotransmitter, or neuro -receptor properties.
Sleep Patterns of 0-2 months Active Sleep State Analogous to REM, low voltage irregular pattern, HR,RR variable
Sleep Pattern o-12 months Quiet Sleep State Analogous to NREM, Discontinuous EEG pattern, intermittent bursts of electrical activity alternates w/quiescent periods, regular HR, RR, few body movements
Sleep Patterns 0-12 Months Quiet sleep and tracé alternant (TA) NREM sleep pattern at term, 2-6 sec burst of high amplitude slow waves separated by 4-6 secs of low voltage mixed activity, disappears by 4 weeks post term
Sleep Patterns in 2-6 years • Changes in sleep structure during this period are more gradual. • Sleep becomes consolidated into a long nocturnal period of approx 10 hour. • During 2-3 years day time sleep is replaced by short day time naps. • All children stop napping between ages 3-5 years. • Sleep is generally consolidated into a single nocturnal period.
Sleep Patterns in 2-6 years • Changes in uniformity &duration of REM periods i.e., The first REM of Night becomes shorter , while succeeding periods longer & associated with more intense phase activity. • REM usually occurs one hour after a sleep. • By 4-5 year of age REM % decreases to an Adult level of 20-25 %. • Children of this age usually have 7 cycles during each nocturnal sleep period. • Sleep onset between 15-30 minutes. • SWS usually occur during the first third of night.
Sleep pattern 2-6 years • Decrease in sleep duration across early childhood results from fewer daytime naps. • Night waking common in toddlers/preschoolers (20% wake once a night, 50% once a week). • Can be considered normal. • Thought to be consequence of nocturnal arousals driven by Ultradian rhythm of sleep cycles (50-90 mins.). • Self soother vs non self soother.
Sleep Pattern in 2-6 years • Child development influence sleep behaviors. • > Increased mobility leads to reactive co-sleeping. • > Cognitive development produce fears and interests. • > Separation anxiety. • > Drive for autonomy. • Parent’s perception important factor. • Bedtime routine important. • “Lifestyle co-sleeping: with siblings/parents.
Sleep Patterns 6- 12 years • Growth & development continues to be constant. • Sleep continues to develop into a more mature pattern. • Total sleep time 9-11 hours. • Sleep pattern becomes more stable, night to night consistency. • Low level of day time sleepiness; naps rare. • School life styles influences-later bedtimes & earlier. rise times, irregular sleep /wake schedules.
Sleep Pattern in Adolescent • Sleep duration decreases but need does not decline (average. 9.30 hrs). • Delay of sleep phase: stay up late, wake later in am. • Circadian; Relative phase delay • Environmental factor • Advanced wake times • Decreased sleep /wake regularity. • discrepancy between weekdays/ weekend sleep cycle. • Increased sleep tendency at mid puberty. • Due to: autonomy, peer pressure, academic demands, employment, extracurricular activities.
Sleep Regulation in Childhood • Theoretical models describe 2 intrinsic regulatory processes determine timing of sleep and waking. • Homeostatic process-represents the drive for sleep that increases during wakefulness and decreases during sleep. • Circadian process- with distinct neuroanatomical locus.
Sleep Regulation in Childhood • Homeostatic process. • *Dynamics of sleep homeostatic mechanisms appear to slow down during development. • *Thus decreasing sensitivity to sleep loss and increase tolerance to sleep pressure.
Sleep Regulation in Childhood • Homeostatic process • *Theta activity may be marker for HSP in children. • *Age at which it become SW-activity unknown. • *Adolescent sleep deprivation similar to that of young adults EEG changes. • *Rise rate of HSP during the day slower in mature. adolescents compared to pre (early) pubertal children. • *Nocturnal dissipation of sleep pressure does not differ.
Sleep Regulation in Childhood • Circadian Process • Sleep-wake independent clock-like process. • *Distinct neuro -anatomical locus in bilateral supra -chiasmatic nuclei of anterior hypothalamus. • *Appears to be functional in utero; not working well at birth. • *1st month- 24h core body temp rhythm emerges. • *2nd month-more sleep at night. • *3rd month-melatonin and cortisol start to cycle in 24h rhythm.
Sleep Regulation in Childhood • Circadian process- Changes appear during puberty. • *Three mechanisms • -Delay in intrinsic circadian phase. • - Mature children show later timing of melatonin secretion onset and offset phases. • -Delay may be related to lengthening of intrinsic period of circadian clock. • -Heightened sensitivity to pm light or decrease sensitivity to am light.
Sleep patterns of adults • Young adult usually sleep 7.5-8.5 hours/Night. • First NERM-REM cycle is 70-100 minutes. • Subsequent NERM-REM cycle is 90-120 minutes. • Sleep length partially determined by genetics, volitional determinants & circadian rhythm.
Sleep Architecture of the normal young adult • Sleep is made up of the two physiological states NREM & REM. • Sleep begins with NERM. • SWS predominates in the first third of night. • REM sleep predominates in the last third of night. • Break down of sleep stages : • NERM ( 75- 80 %) • WASO – stage I – 5 % • Stage N1- StageII-2-5 % • Stage N2-Stage III-45-55% • Stage N3-Stage IV-13-23% • REM-(20-25%)
Normal Sleep Patterns • Results: • In children & Adolescent, TST decreased with age (on school days). • % of slow wave sleep was negatively correlated with age. • % of stage 2 NREM & REM sleep significantly change with age. • In Adults TST, Sleep Efficiency, % of SWS, % of REM Sleep & REM Latency all significantly decreased with age While Sleep Latency, % of Stage 1 sleep, % of Stage 2 sleep and WASO significantly increased with age. • Only Sleep Efficiency continued to significantly decrease after 60 years of age.
Are there gender differences in Sleep? • Increase in subjective sleep complaints but relatively few differences in sleep architecture. • Despite the fact that sleep complaints are about twice as prevalent in women of all ages compared to men, 75% of the sleep research has been conducted with males. • HORMONAL EFFECT ON SLEEP • Estrogen :Primary effect on REM. • Decrease SOL,WASO, Increase TST. • Progesterone: primary effect on NERM- Benzodiazepine like effect. • Decrease SOL, WASO.
Sleep Patterns in Women • Sleep in women with normal Menstrual cycle. • subjective :longer sleep latency, lower sleep efficiency & sleep disruption was associated with luteal phase. Severity of premenstrual symptoms was co-related with day time sleepiness. • Objective PSGfinding-Stage 2 was higher in luteal phase & also increase frequency of sleep spindles. • Dysmenorrhea associated with decrease sleep efficiency.
Sleep Patterns in pregnant Women • Pregnancy, child birth& early motherhood physiologically & psychologically affect a woman’s sleep. • Contributing factors – hormonal alterations during early pregnancy , enlargement of fetus in late pregnancy& postpartum infant’s feeding & sleeping cycles. • Reports of altered sleep during pregnancy range from 13%-80 % in the first trimester ,66- 97 % in third trimester.
Sleep Pattern In Pregnant Women • First Trimester: disrupted sleep but TST increases in first trimester back to prepreg level in 3rd trimester. • Sleep is not much affected in 2nd trimester. • Increase number of awakening, disrupted sleep& Decrease TST in third trimester & post partum. • Increase stage 2,WASO,Slight decrease in REM & SWS • Decrease Sleep Efficiency. • Snoring increases, Increase incidence of OSA/RLS.
Sleep Patterns in Women • SLEEP & MENOPAUSE • Prevalence of insomnia increases form 33%-36% to 44%- 61% in pre & post menopausal women. • Postmenopausal women have more subjective complaints of disturbed sleep but had better sleep documented on full night polysomnography longer total sleep time, increased amount of SWs, less time awake in bed.
Sleep Pattern in Women • SLEEP & MENOPAUSE: • Increase in SOL; 20% reports sleeping< 6 hours. • Difficulty in Sleep Maintenance. • Role of nocturnal Hot flashes; more frequent arousal & awakening, decrease SE, Increased SWS. • OSA: increased prevalence & severity Post menopausal • HRT may improve SE: OSA symptoms. • Insomnia may become conditioned despite HRT; role of various replacement protocols.
Sleep in Older Adults • Many elderly people C/O Disturbed sleep. • Need for sleep does not Change. • The ability to sleep does decrease with age. • Causes are multi-factorial. • Change in timing & consolidation of sleep. • Medical & psychiatric illnesses. • Medications. • Presence of specific sleep Disorder. • Physiologic Changes that occur in older adults.
Sleep in Older Adults • Change in Sleep with Age • Subjective Reports: • Spending too much time in bed. • Spending less time asleep. • Increase number of Awakenings. • Increase in time to fall asleep. • Increase in tiredness during the day. • Less satisfaction with sleep. • Longer & more frequent naps.
Sleep In Elderly Population • OBJECTIVE FINDINGS • Decrease NREM Sleep. • Decrease REM Sleep. • Increase in awakening. • Increase Frequency of sleep D/o. • Decrease in Sleep Efficiency. • Increase in day time sleepiness. • Increase number of naps.
