Sleep Disorders RLS: creeping, crawling sensation, pins and needles during waking and
Normal Sleep sleep onset
Non-REM stages 1-4 PLMS: involuntary, rhythmic twitches (ankle dorsiflexion) that may lead to REM brief arousal Loss of muscle tone and REMs Treatment 80-120 minutes after onset of sleep, lasts 10 min Reduce muscle activity or sleep disruption Neurotransmitters and neuromodulators may regulate sleep-wake Dopminergic agents, GABAergic agents, opioids cycle Circadian rhythms Hypersomnolence Disorder 25 hours from wake to wake time Excessive sleepiness Cycle modified by external cues Difficulty staying awake, naps, remains in bed Sleep pattern changes over time Tired, falls asleep sooner, harder to get up Neonatal period REM >50% >1 mo 4 mos of age REM <40% May be caused by cumulative insufficient sleep Young adult NREM 75%, REM 25% Not just a long sleeper (they sleep for a long time, but in nl pattern) TX: DSM-5 Sleep Disorders Regulating and extending sleep habits/patterns Insomnia Disorder* Amphetamines or stimulants or SSRIs Hypersomnolence Disorder* decrease REM, increase restorative sleep Narcolepsy* Breathing-Related Sleep Disorders: Narcolepsy Obstructive Sleep Apnea Elements of sleep intrude into wakefulness & elements of wakefulness Central Sleep Apnea intrude into sleep Idiopathic central sleep apnea Characterized by sleep attacks Cheyne-Stokes breathing Episodes of irresistible sleep leading to 10-20 min of sleep Central sleep apnea comorbid with opioid use occurring at inappropriate times Sleep-related hypoventilation REM cycle impaired Frequent awakenings, vivid nightmares, intense, realistic Insomnia hallucinations prior to sleep onset Dissatisfaction with sleep quantity or quality associated with >1: Epidemiology Difficulty initiating sleep, 0.02-0.16% of adults difficulty maintaining sleep with frequent awakening or Etiology problems returning to sleep, Some familial incidence early morning awakening with inability to return to sleep. Possibly type of epilepsy or psychogenic disturbance Epidemiology Diagnostics 1 year prevalence rate of 30-45% Polysomnography demonstrating REM sleep within 10 minutes of The most common sleep complaint sleep onset Etiology *Narcolepsy can be dangerous due to sleep attacks during driving, or Stress, caffeine, physical discomfort, napping, psychiatric disorders operating machinery DDx: Tx: nocturia, RLS, meds, circadian rhythm disorder Sleep hygiene, Forced naps Medications: DSM-5 Criteria Excessive daytime sleepiness: provigil, nuvigil, stimulants A. Predominant c/o dissatisfaction with sleep quantity or quality Cataplexy: TCAs, Venlafaxine, fluoxetime (suppress REM associated with 1 or more: activity) 1. Difficulty initiating sleep Parasomnia 2. Difficulty maintaining sleep (frequent awakenings or Usually occurs in stage 3 & 4 of NREM sleep problems returning to sleep) therefore patients do not remember 3. Early morning awakening with inability to return to NREM associated: Sleep walking, sleep terrors sleep REM associated: REM behavior disorder, recurrent isolated sleep B. Sleep disturbances causes sig. distress or impairment in social, paralysis, nightmare disorder work, educational, academic functioning. Others: sleep enuresis, sleep-related groaning, sleep-related C. Sleep difficulty occurs at least 3 nights/week hallucinations, sleep-related eating disorder, parasomnia due to D. Sleep difficulty present for at least 3 mos drugs or medical conditions. E. Sleep difficulty occurs despite adequate opportunity for sleep TX F. Insomnia not better explained by other sleep-wake disorder Protection G. Insomnia not attributable to use of a substance SSRIs, TCAs, benzos for NREM H. Coexisting mental/physical disorders do not account for it Tx Circadian Rhythm Disorders Benzos Disruption in sleep pattern leading to excessive sleepiness or Non-benzo: Ambien, Sonata, Lunesta insomnia due to mismatch in sleep-wake cycle from environment Non-pharmacologic Delayed sleep phase type, advanced sleep phase type, irregular CBT sleep-wake type, jet lag type, shift work type, non-24-hour sleep- Sleep hygiene counseling wake type Table 16.2-5 Kaplan & Sadock (next slide) Treatment: Relaxation techniques, Biofeedback Chronotherapy, sleep hygiene, melatonin, light therapy Stimulus control therapy, Sleep restriction therapy