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Sleep and sleep disorders. Andy Montgomery. Talk Outline. Normal Sleep Diagnosing sleep disorders Insomnia Hypersomnia Parasomnias Circadian sleep rhythm disorders Psychiatric disorders and sleep Pharmacology and sleep. Normal sleep. 1/3 of adult lives asleep Role poorly understood

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Sleep and sleep disorders


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    1. Sleep and sleep disorders Andy Montgomery

    2. Talk Outline • Normal Sleep • Diagnosing sleep disorders • Insomnia • Hypersomnia • Parasomnias • Circadian sleep rhythm disorders • Psychiatric disorders and sleep • Pharmacology and sleep

    3. Normal sleep • 1/3 of adult lives asleep • Role poorly understood • Sleep deprivation consequences • Cognitive impairment • Hormonal rhythm disturbance • Rebound after deprivation

    4. Normal sleep • Quantity • 7-8 hours • <6 increased reports dissatisfaction • Control by 2 processes • Circadian process • Homeostatic process

    5. The Circadian process • 24 hour cycle • Many cells and organs • Principle time-keeper: • Supra-chiasmatic nucleus • Influenced by light and temperature • Some sleep disorders associated with genetic variant • Determines owl/lark

    6. The homeostatic process • Aka recovery drive to sleep • Increases in proportion to time awake • 2 processes interact • Generates • Post-lunch dip • mid-evening activity • Other influences • Arousal, relaxation, anxiety

    7. Physiology of sleep control • Orexin (hypocretin) • Peptide hormone • Promotes wakefulness • Wakefulness • Ascending arousal system dominant • Sleep • Inhibition of arousal systems

    8. Sleep structure • Polysomnography • Simultaneous record • EEG • Muscle activity • Eye movements • 4-5 cycles • Quiet sleep alternating with REM • Increased duration through night

    9. Hypnogram

    10. Sleep structure:quiet sleep • 4 stages • 1: dozing “just resting eyes” • 2: deeper, occasional jerks, reduced HR &RR • 3&4: slow HR & RR • EEG • Progressive slow synchronous activity • Reduced cortical arousal • Increased thalamo-cortical synchrony

    11. Sleep structure:REM • Rapid onset • EEG “awake” • Jerky eye movements • Muscle paralysis • Autonomic arousal • Usually several short wakenings

    12. Age variants • 24 hour rhythm • Develops at 3/12 • High levels REM in childhood • Aging • Time awake increases • Slow wave reduces • GH release reduces

    13. Dreaming • Only remembered if REM followed by wakefulness • Occurs in • REM • Bizarre, storyline • Slow wave

    14. Sleep and cognition • Sleep enhances memory consolidation • Transfer from short-term to long-term memory • Dependent on hippocampal activity • Sleep deprivation associated with reduced hippocampal neurogenesis

    15. Sleep disorders • Diagnosis • Take sleep history • Questionnaires and diaries can be helpful • Sleep centres: polysomnography, actigraphy, video recording • Classified in ICD 10 and DSM IV • 3 categories • Insomnia • Hypersomnia • Parasomnia

    16. Questions to ask • Time: • Bed, getting up, ?regular pattern • Falling asleep • Waking episodes • Quality (Pittsburgh Sleep Quality Index) • How many bad nights/week?

    17. Questions to ask • Naps during day • Mood • Motor activity during sleep • Behaviour during sleep • Day-time somnolence (Epworth sleepiness scale) • Snoring • Use of drugs

    18. Investigations • Actigraphy • Monitors movement via wrist band • Can be used over days- weeks • Sleep- less movement • Overnight video recording

    19. Actigraphy

    20. Polysomnography • Terms • Time in bed • Sleep onset (to stage 1 or 2) • Sleep onset latency • Sleep period: onset to wake • Total sleep time • Number of wakenings • Sleep efficiency (total sleep/time in bed) • Wake after sleep onset • REM onset latency • Time in each sleep stage

    21. Insomnia • Major public health problem • 10-15% adults persistent insomnia • Low quality of life • Increased absenteeism • Physical illness • Mental illness

    22. Insomnia • Symptoms • Too little • Too long to go to sleep • Poor quality • Unrefreshing • Impaired daytime function • Daytime sleepiness uncommon(circadian rhythm disorder)

    23. Insomnia • Two main types: • Sleep onset insomnia • Sleep maintenance insomnia

    24. Insomnia - precipitating factors Psychiatric disorder • Depression • anxiety Pharmacological • -blocker • AD • Caffeine • Alcohol • Stimulants • Withdrawal Psychological stress • Bereavement • Increased arousal • Worry about alarm • Noise • children Short term insomnia Physical • Pain • Pregnancy • Illness (cardio/resp) • Urinary Sleep wake cycle • jet lag • Shift work • Irregular routine

    25. Short term insomnia Poor sleep habits Good sleep habits Anxiety about sleep Good sleep Long term insomnia Insomnia- perpetuation

    26. Insomnia- treatment • Establish primary diagnosis • Acknowledge distress • Treat precipitating factors/primary cause • Educate about trigger factors and reassure • Establish good sleep habits

    27. Insomnia- treatmentHypnotics • Act at GABA-A benzodiazepine receptor • Generally safe and effective in short term • SE • Muscle relaxation • Memory impairment • Ataxia • Potentiated by EtOH • Avoid long term px

    28. Insomnia- other drugs • Sedative AD • Mirtazapine • Agomelatine • Melatonin • Anti-histamines

    29. Psychological treatments • Sleep hygiene • Regular hours • Daytime exercise • Morning daylight exposure • Reduced daytime napping • Avoid stimulants • Bed-time routine

    30. Psychological treatments • Behavioural techniques • Stimulus control • Avoid clock watching • Don’t watch TV • Don’t stay in bed if awake • Sleep restriction • Relaxation training

    31. Psychological treatments • Cognitive techniques • CBT • Avoid negative thoughts associated with not sleeping • Rehearsal and planning session • Paradoxical intent

    32. Sleep restriction

    33. Hypersomnia • Feeling sleepy during day • Distinct from tired • 37% adults a few days a month • 16% a few days / week • Main causes • Fragmentation of sleep • Obstructive sleep apnoea • Intrusion of sleep phenomena into wake • narcolepsy • Disturbed circadian rhythm.

    34. Obstructive sleep apnoea: symptoms • Excessive daytime sleepiness • Loud snoring • Interruptions of breathing • Resumes with loud gasp, violent movement • Marital problems • Dry mouth, sore throat, headache • Depression • Present in 0.5% men BMI >25

    35. Obstructive sleep apnoea: treatment • Weight loss • Continuous positive pressure ventilation • Consider modafinil if remain sleepy during day

    36. Narcolepsy • 3-4/10,000 • HLA DQB1*0602 (18-35% in controls) • Symptoms • Sudden onset sleep • Sleepiness • Cataplexy • Hypnogogic/pompic hallucinations • Poor nocturnal sleep

    37. Narcolepsy • Cause • Lack of orexin neurones/release in hypothalamus • Possible cross-reaction autoimmune disorder after infection in adolescence • Diagnosis • Clinical picture • Reduced REM latency

    38. Narcolepsy • Treatment • Education • Day-time naps • Drugs • Daytime sleepiness • Modafinil/dexamphetamine • Cataplexy • 5HT enhancing drug: SSRI, clomipramine • Night-time sleep disruption • Sodium oxybate

    39. Other causes of daytime sleepiness • Idiopathic hypersomnia • Kleine-Levine syndrome • Rare, reversible disorder • Hypersomnia +/- excessive eating & hypersexuality • Onset adolescence • Typical duration 4-8 years • ? autoimmune

    40. Parasomnias • Unusual behaviours occurring during sleep • Exacerbated by anxiety • Variable drug treatments

    41. Night terrors • Recurrent episodes of abrupt waking usually first 1/3 of night • Intense fear and autonomic arousal • Unresponsive to comforting • No detailed recall • Significant distress

    42. Night terrors • Occur in 30-40% children • Generally resolve with aging • Can recur at times of stress • Comorbidity with anxiety common • Often run in families

    43. Night terrors • Cause • Genetic component • Incomplete arousals from SW sleep • Treatment • Clonazepam • Paroxetine (immediate effect)

    44. Night terrors hypnogram

    45. Parasomnias -SWS • Sleep walking • Automatic behaviour • No recall • 15-20% lifetime prevalence • Confusional arousals • Semi-purposeful movements • Sleep bruxism • Sleep talking

    46. Parasomnias -REM • Nightmares • Wake oriented (vs night terrors) • Association with depression and PTSD • Psychological treatment • Guided imagery- rehearse happy endings • Sleep paralysis • Waking with fear, foreboding, unable to move • Common-25% experience • Treatment- good sleep hygiene

    47. Parasomnias -REM behaviour disorder • Violent, short duration • Several episodes/night • Can wake • Remembers dream • Violent unpleasant content • Strong association with subsequent IPD OR LBD (45-85%) • Made worse by AD • Treat by making sleep environment safe

    48. Circadian rhythm sleep disorders • Jet lag • Worse for travel east (natural clock 24.5hr) • Melatonin may help • Delayed sleep phase syndrome • Unable to sleep before 2-3AM • Preferred wake time after 10 AM • Causes insomnia and sleepiness on work days • Advanced sleep phase disorder • rare

    49. Circadian rhythm sleep disorders • Non 24hr circadian sleep disorder • Sleep pattern advances daily • Most common in congenitally blind • Irregular sleep wake rhythm • Seen in dementia- ? Loss of melatonin neurons in SCN • Shift work sleep disorder