Clinical Sleep Disorders

Meena Khan MDAssistant Professor, Department of Neurology and Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

Meena.Khan@osumc.edu

Learning Objectives

Understand the diagnostic procedures used in sleep medicine and their appropriate use

Understand the following sleep disorders Insomnia Obstructive sleep apnea Narcolepsy Parasomnias Restless leg syndrome

Diagnostic Procedures

Overnight Polysomnograpy (PSG) Study done at night while patient is sleeping Purpose is to diagnose obstructive sleep apnea and periodic limb

movements of sleep

Multiple mean sleep latency test (MSLT) Daytime study Purpose is to objectively evaluate a person’s tendency to fall

asleep during the day

Diagnostic Procedures

Overnight Polysomnograpy (PSG)

There are 2 types of polysomnography that can be conducted Full PSG done in the sleep lab Portable study that can be done at home

Diagnostic Procedures

Full Polysomnography (PSG) Done in the sleep lab

Sleep staging Respiratory flow and effort Pulse oximetry Leg movements

Diagnostic Procedures

Portable PSG Can be done at home

Respiratory flow and effort Pulse oximetry

Diagnostic Procedures

Multiple sleep latency test 5 nap opportunity to fall asleep and see if one achieves REM

sleep Each nap

Lights turned off and pt asked to try to fall asleep The patient is given 20 min to see if they can fall asleep and if they

do- 15 more min to see if they achieve REM sleep REM within 15 minutes of falling asleep- sleep onset REM period

(SOREM) Record the sleep latency (time to fall asleep) and the presence of

REM sleep.

PSG Quiz

Common sleep disorders

Disorders of hypersomnia Obstructive Sleep apnea Narcolepsy

Disorders leading to inability to sleep Insomnia Restless leg syndrome

Abnormal behavior associated with sleep Parasomnias

Disorders of Hypersomnia

Obstructive sleep apnea (OSA)

Narcolepsy

Obstructive Sleep Apnea (OSA)

Intermittent collapse of the upper airway during sleep

Mechanism of collapse is reduced upper airway size and altered control of upper airway muscles

Obstructive Sleep Apnea (OSA)

What happens as result of closure of the upper airway??

Arousals from sleep - unrefreshing sleep and daytime sleepiness

Drops in oxyhemoglobin saturation- cardiovascular morbidity and mortality Hypertension Myocardial infarction Stroke Death

Symptoms

Nighttime symptoms Snoring- loud and habitual Gasping/choking during sleep Witnessed apneas Awakenings during sleep Restless sleep

Daytime symptoms Unrefreshing sleep Fatigue/Sleepiness Impaired concentration/memory

Risk Factors for OSA

Obesity (BMI>=30) Male gender (2-3:1) Menopausal women (M:F- 1:1) Age>=65 yrs Neck size

Male neck size >=17in. Female >=16 in.

Family history -inc by 2-4 fold Race

Africa Am and Asians

Factors that contribute to increased OSA severity

Weight gain (10% inc in body weight associated with 32% increase in AHI)

Alcohol- prolong apnea and worsen associated hypoxemia

Sedatives (benzodiazepines, anesthetics, narcotics)

Current smoking (assoc w/higher prevalence of snoring and OSA)

Proc Am Thorac Soc 2008; Vol 5; 136-143

Obstructive Sleep Apnea

Two types of airway closures that occur in obstructive sleep apnea

Apnea Complete closure of the airway resulting in absence of airflow

Hypopnea Partial closure of the airway leading to decrease in airflow

associated with a drop in oxyhemoglobin saturation

Apnea

Absence of air flow for >=10 seconds

HypopneaDecrease in airflow of >=10 seconds with oxygen desaturation of >= 4%

Obstructive Sleep Apnea

Presence and severity of obstructive sleep apnea is measured by the number of apneas and hypopneas per hour of sleep.

This measurement is called the apnea-hypopnea Index (AHI)

Normal AHI <5 Mild OSA-AHI of >=5 to <15 Moderate is AHI of 15>= to <30 Severe is AHI>=30

Treatment of OSA

Behavioral modification Weight loss Positional therapy

Interventional treatment Continuous positive airway pressure (CPAP)- Gold standard of

therapy Oral appliance Surgery

Apnea Quiz

OSA Quiz

Narcolepsy

Clinical Features A syndrome of excessive daytime somnolence and

abnormalities of REM sleep.

Tetrad of symptoms Excessive daytime sleepiness- first symptom Cataplexy Hypnogogic/hypnopompic hallucinations Sleep paralysis

Disturbed nocturnal sleep

Abnormalities of REM sleep

Narcolepsy

The prevalence is 0.05%

The prevalence is increased at 1-2% for family members of those with narcolepsy

Onset of symptoms is typically the second decade usually between ages 10 – 25 years.

Narcolepsy

Etiology Dysfunction of hypothalamic hypocretin systems. Hypocretin 1 is in the lateral hypothalamus and

has role in sleep-wake regulation. This is deficient in narcoleptics with cataplexy and

thought to be the etiology of the syndrome. There is also an association with gene-

DQB1*0602.

Narcolepsy

Standard for diagnosis is an in lab full PSG/MSLT

PSG- 360 minutes of total sleep time without presence of OSA

MSLT- Mean sleep latency (MSL) of <=8 min and >=2 naps with SOREM.

Narcolepsy

Supplementary testing Gene test for DQB1-0602:

This gene is positive in 95% of those with narcolepsy with cataplexy but also is present in 18-35% of the general population

Cerebrospinal fluid (CSF) hypocretin levels: 94% of narcolepsy with cataplexy will have CSF hypocretin level

<110 pg/ml. All those with a low hypocretin level will be positive for the DQB1-

0602 gene.

Narcolepsy- Treatment

Behavioral management Adequate nocturnal sleep Scheduled naps Good sleep hygiene Support groups

National Sleep Foundation Narcolepsy Network

Narcolepsy- Treatment

Pharmacologic management Excessive daytime sleepiness

Stimulants Modafinil /Armodafinil Amphetamine salts

Sodium oxybate (xyrem) Cataplexy

Sodium oxybate REM suppressing medication

Venlafaxine

Narcolepsy Quiz

Disorders that lead to inability to sleep

Insomnia

Restless leg syndrome

Definition of insomnia

Repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in daytime impairment.

Impairments Fatigue, depressed mood, irritable, cognitive impairment Physical symptoms- HA, GI upset

Marked distress and/or significant impairment in social or occupational functioning.

Insomnia

Common sleep disturbance Survey in 2005

75% have had a sleep problem 50% had one symptom of insomnia over the previous year 1/3 reported nightly symptoms

National sleep foundation 2005 sleep in America poll

Underreported and under treated 5% of pts with insomnia seek medical treatment 26% mention it to physicians during visits for other complaints

Insomnia

Chronic insomnia Correlated with increased morbidity:

Higher disability levels Increase calling off work Frequent use of medical resources- doctor

visit/testing/medication Chronic health problems Increased use of drugs Decreased quality of life

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Risk Factors for insomnia

Female- risk 1.3 times higher than men Older age (age >65- 1.5X more likely to

experience insomnia) Divorced/ separated/widowed Low economic/education Poor health Mood D/O Chronic medical problems Substance abuse- recovery period

Features of chronic insomnia

Life and thoughts revolve around sleep and the effect of lack of sleep

Sleep anticipatory anxiety about not being able to sleep

Clock watch Calculate time left for sleep Strong and at times unrealistic thoughts about

sleep requirements and daytime consequences due to lack of sleep

Insomnia Dysfunctional thoughts • Anxiety about sleep• Neg thoughts about sleep/and daytime symptoms ANDMaladaptive Behavior• Too much time in bed• Irregular sleep schedule• Naps or resting during the day• Watch TV/ read etc• Caffeine and alcohol use

Trigger event

Predisposition1. Hyperarousal 2. Tend to

ruminate3. Blunted sleep

homeostasis

Insomnia

Treatment

Pharmacologic• Recommended for short

term use although no medical contraindication for long term use

Cognitive Behavioral Therapy

• Cognitive therapy• Aimed at maladaptive thoughts

about sleep• Behavioral therapy

• Aimed at maladaptive behaviors• Sleep hygiene• Relaxation Therapy• Stimulus Control • Sleep restriction

Sleep Hygiene

Educate about lifestyle and bedroom environment factors that can promote good sleep The bedroom should be dark, quiet, and comfortable Avoid watching TV, reading, using the computer or doing other

activities other than sleep in the bedroom. No caffeine at least four hours before bed Avoid tobacco at night Avoid alcohol at least 4 hours before bed Exercise late afternoon, early evening

Relaxation Therapy

Goal- reduce sleep related tension

Somatic, mental relaxation and biofeedback

Regularly practice therapies during the day and implement them while in bed

Stimulus Control

Aimed at idea that those with insomnia have developed an association of their bedroom with poor sleep

Goal is to re-associate bedroom with rapid sleep Eliminate the stimuli that interfere with sleep in the

bedroom -bed for sleep only- Avoid reading, TV, eating, talking on the phone

Go to bed only if sleepy Get out of bed if no sleep after 20 min Same rise time every AM Avoid naps

Sleep restriction

Insomniacs tend to increase time in bed to allow for more sleep but this results in decreased sleep efficiency (ex: in bed for 8-9 hours but only sleep 5-6 hours)

Goal Restrict person’s time in bed so there is a better match

of sleep time to time in bed Example- someone states they sleep only 6 hours. Have them pick a wake time- must get up at that time every morning Bedtime is 6 hours before that Should only be in bed for those times Ex- wake time is 6 AM, bedtime would be 12 am. Never restrict less than 5 hours

Restless Leg Syndrome (RLS)

4 cardinal criteria Abnormal sensation leading to urge to move legs

Movement of legs improves sensation

Occurs at rest

Occurs mostly at night

Restless Leg Syndrome (RLS)

Etiology: Most cases are idiopathic but can be hereditary. There are also secondary causes of RLS which include:

iron deficiency anemia pregnancy end stage renal disease medications peripheral neuropathy Diabetes Rheumatoid arthritis

Restless Leg Syndrome (RLS)

Diagnosis- made by history not sleep study

Evaluation and treatment Check serum ferritin (should be >=50) – if less than 50 than give

patient iron supplementation Standard medical therapy- dopamine agonists

Periodic Limb Movements of Sleep

Leg movements that occur during sleep

Commonly seen in patients with RLS

Diagnosis made by sleep study

Evaluation and Treatment is same as RLS

Waking Quiz

Abnormal movements during sleep

Parasomnias Definition

Undesirable and typically abnormal motor or subjective phenomena that occur during the transition of wake/sleep or during arousals from sleep

Parasomnias

NREM Parasomnias Confusional arousals Sleep walking Night terrors

REM Parasomnias REM behavior disorder

NREM Parasomnias

NREM (Disorders of Arousal) Occur during slow wave sleep (SWS) First third of sleep when SWS more prominent Occurs in 20% children- most resolve once child reaches

adulthood but 25% persist into adulthood Occurs in 4% adults

NREM Parasomnias

Confusional arousals Arousals out of NREM sleep- associated with confusion and

disorientation Simple or complex movements in bed without walking or night

terror behavior Amnestic of event Not violent but may become agitated if forcibly awakened

NREM Parasomnias

Sleep walking Ambulation with impaired consciousness- behavior is

inappropriate

Ex: Cook, eat, drink, play instruments, drive a car

Memory impairment for the event but the person may remember fragments

Difficult to arouse person during an event

NREM Parasomnias

Night terrors Sudden arousal from sleep with scream or cry Afraid, anxious, panicked, fearful, disoriented Inconsolable!!!!!! Motor activity- intense and disorganized Autonomic activity

Tachycardia, tachypnea, sweating, flush skin, mydriasis

Amnestic to event- increased agitation if try to arouse

REM sleep behavior disorder (RBD)

Person has loss of normal muscle atonia that occurs during REM sleep

Clinical symptoms Dream enactment behavior-moving in response to

content of their dreams Dream content may be more violent leading to violent

actions Typically patient is alert if awoken during the event

and can recall the dream vividly

RBD

More common in age>50

Males > females (9:1)

Often associated with the development of neurological disorders- most commonly- Parkinson’s disease

Sleep Episodes Quiz

Conclusions

A good history is key to the diagnosis of most if not all sleep disorders

Sleep studies of various types have a specific role to diagnose certain sleep disorders but are not beneficial to diagnose all sleep disorders or to be done without a specific goal in mind.

Thank you for completing this module

Questions? Contact me at:

Meena.Khan@osumc.edu

?

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