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Obstructive Sleep Apnea and Other Causes of Excessive Daytime Sleepiness. Patient Scenario #1.
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A 45 year old man sought treatment of his snoring, which had been present for many years. His wife slept in another room because the snoring “shook the walls”. The patient reports excessive sleepiness (Epworth sleepiness scale score 18/24. Normal is 10 or less), morning headaches and problems concentrating at work. He admits to drinking more than five cups of coffee daily. There was no history of recent weight gain or alcohol use.
Sleep Apnea is the most common cause of excessive daytime sleepiness and snoring, but there are many other disorders that must be carefully considered.
Upper airway resistance syndromes
Periodic leg (limb)movements in sleep
Restless leg Syndrome
Circadian Sleep Disorders
Withdrawal from Stimulants
Medication side effects
Self-rating scale of Sleepiness
PolysomnographyEvaluating Causes of Excessive Daytime Sleepiness (EDS)
3= High chance of dozing; 2=moderate; 1=slight; 0=never
Multiple physiologic parameters are measured and compared with the established norms.
-Effort (chest and abdominal movements)
*Sleep conditions in the laboratory should be as close to the patients baseline sleep as possible.
Standard : 2 eye channels
The Apnea + Hypopnea Index (AHI) a.k.a Respiratory Disturbance Index (RDI) = The Number of Apneas + hypopneas Per Hours of Sleep
-non-supine sleep (pillow, etc.)
-raise the head of the bed
A 40 year old man was referred because his wife complained that he kicked in his sleep and constantly disturbed her. The patient remembered awakening several times each night, but never noticed any discomfort at those times. He admitted that at bedtime he did have an irresistible urge to move his legs and he described a feeling of “pins and needles.” However this delayed his sleep only rarely. His Epworth Sleepiness Scale was 15/24 (sleepy).
PSG shows: Periodic leg movements in sleep (PLMS) – 20% of these events were associated with arousals.
PLMS are repetitive, stereotypic dorsiflexion movements of the toes, ankles, knees and thighs that recur at regular intervals. They occur most commonly in stages 1 and 2 but can occur less commonly in other stages. Patients are rarely aware of the leg movements themselves and complaints are usually from bed partners.
This is a syndrome of leg movements + symptoms (ie. insomnia or excessive daytime sleepiness.
This is a polysomnographic diagnosis; but, it is often incorrectly used interchangeably with Restless Leg Syndrome.
International Classification of Sleep Disorders Criteria for PLMS Severity
Characterized by abnormal and uncomfortable sensations in the limbs that compel the person to move to relieve the sensation and these movements are exacerbated by rest. The symptoms occur primarily in the evening or at night.
Motor restlessness: patient is compelled to move
Symptoms precipitated by rest and relieved by activity: symptoms are worse or exclusively present at rest (i.e., sitting or lying with at least partial and temporary relief by activity
Symptoms worse in the evening or at night
Sleep disturbance and consequences: difficulty initiating or maintaining sleep; less commonly, excessive daytime sleepiness
Involuntary movements during wake or sleep (PLMS)
Normal neurologic exam in primary RLS; in secondary forms, possible evidence of neuropathy
Clinical course: onset any age, usually chronic and progressive, remissions may occur, can be exacerbated by or exclusively during pregnancy
Family history: sometimes present; suggestive of autosomal dominant patternInternational RLS Study Group Criteria for Diagnosis of RLS
PSG : Quasi-periodic movements of the legs during wakefulness with a prolonged sleep latency. After sleep, PLMs are noted in 70 –90% of Patients
Causes of RLS/PLMD
-Treats PLMs and improves sleep quality
A 30 year old woman was evaluated for excessive daytime sleepiness of 5 year duration. There was no history of snoring or observed apnea. The patient recalled having difficulty holding her head up when she laughed or was embarrassed. The patient’s husband reported that sometimes she kicked the covers at night. Rarely, the patient felt she could not move for a while as she was falling asleep at night.
1998 Hypocretin/orexin (2 peptides) secreted by the hypothalamus and other brain areas.
2 major pathways:
-hypothalamus Brain stem
-locus ceruleus- NE secreting neurons important in maintaining wakefulness
7 of 9 patients with narcolepsy had low orexin levels in their CSF.
Other studies have shown an absence of orexin-secreting neurons in the hypothalamus
Antigen DQB1* 0602 is the most sensitive marker for narcolepsy across all ethnic groups
Can be followed years later by the other SX’s
A mean sleep latency of <5 minutes and 2 or more naps with REM sleep.MSLT
Scoring and Interpretation
Stimulants are working to increase the availability of NE/DA
Largest doses should be given 1 – 2 hours before the periods of maximum sleepiness
Tx of Cataplexy/Hallucinations
GHB (Xyrem)Treatment of Narcolepsy
Patient Scenario #4
A 30 year old Female is referred for complaints of inability to sleep for more than 10 years. The patient reports it usually takes her 2 to 3 hours to fall asleep after going to bed. She also finds herself awakening 3 to 4 times during the night. She reports that it takes at least 30 minutes to fall back asleep after each awakening. Alcohol and over the counter medications sometimes helped. During the day, fatigue, but not definite sleepiness was noted. Her husband denied that she snores, kicks, or jerks during sleep.
Sleep maintenance insomnia
Early morning awakening
Acute (adjustment sleep disorder)
Sleep state misperception
Sleep disorders (sleep apnea, PLMD, RLS)
Psychiatric disorder(depression, panic attacks)
Inadequate sleep hygiene
Environmental sleep disorder
Drugs (nicotine, ethanol, caffeine)
Fibromyalgia and chronic pain syndromes
COPD and other respiratory disorders
Medications (beta blockers, theophylline)
Delayed sleep phase syndrome
Advance sleep phase syndrome
Shift work or jet lag syndromeCommon Causes of Insomnia
Primary Insomnia Secondary Insomnia
Time in bed, lights out, sleep onset, wake time
Timing and duration of naps
Changes on weekends
Effects of a new sleep environment (vacation)
Symptoms of depression. History of leg jerks, restless leg syndrome, snoring, apneaInsomnia History
stimulus control therapy
Sleep restriction therapy
Cognitive behavioral treatment
BZ receptor agonists (ie ambien, sonata)
-Same as previous patient. She averages 4 hours/night of sleep with EDS
-On weekends able to sleep in and get 7 to 8 hours of sleep and awake feeling refreshed.
Chronotherapy (progressive phase delay)
Bright light therapy
Diagnosis Usual Sleep Stage
Normal Sleep Phenomena
Sleep starts (hypnic jerks) Sleep onset
Nightmares (REM anxiety attacks) REM>>NREM
Sleep walking (somnabulism) NREM
Sleep terrors NREM
Confusional arousal NREM
Sleep talking (somniloquy) NREM and REM
REM behavior disorder REM
Parasomnia overlap disorder NREM and REM
Bruxism NREM (stage 2)
Enuresis NREM and REM (random)
Panic attacks NREM (transition stage 2 to stage 3)
Posttraumatic stress syndrome REM and NREM
Nocturnal seizures NREM>Wake>REM
Possible seizure Disorders
Nocturnal paroxysmal dystonia
Episodic nocturnal wandering