faculty what is a sleep disorder?€¦ · sleep services manager baptist medical center south sleep...

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What Is A Sleep Disorder?

Produced by the Alabama Department of Public HealthVideo Communications and Distance Learning Division

Satellite Conference and Live WebcastTuesday, February 23, 20102:00 - 4:00 p.m. Central Time

Faculty

Tiras J. Jackson, RPSGTSleep Services Manager

Baptist Medical Center SouthSleep Disorders CenterPrattville Baptist Center

Generally Speaking• Any thing that interferes with a

normal sleep pattern

• Some are pulmonary related such assleep apnea

• Some are neurological such asnarcolepsy

• Some are psychological

Generally Speaking• Something as simple as a dog

barking or a light shining through awidow can be disruptive to a normalsleep pattern

What Is a Normal Sleep Pattern?

• It truly varies from person to personand varies immensely with age

– People generally need less sleepas they grow older

• On average 6 to 8 hours of sleep fora healthy adult should be adequate

What Is a Normal Sleep Pattern?– There are exceptions, meaning

people who can get by on less andpeople who need much more

– In today's society we try to cramso much into a single day that wetry to sacrifice sleep

• Not possible - your body takesneeded sleep in one form oranother

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• Having adequate sleep is still notenough to say you have a normalsleep pattern

– A pattern in itself repeats


– If we have an inconsistent sleepwake cycle then its like changingtime zones everyday

• Imagine if you were a travelingsalesman and you were on theeast coast one day and the westcoast another

Is Sleep Really Important ?• YES!!!!

– Sleep renews us

– Sleep restores us

– Quite literally a recharging of thebatteries

Is Sleep Really Important ?Lets say that you’re a light that shinesbright when fully charged. When you’renot fully charged you may shine brightat certain times, you may be dim, oryou may flicker.

When you are not rested you cannotperform what ever task you have atyour very best.

Is Sleep Really Important ?– Sleep deprivation does not occur

after you have missed severalhours of sleep or had several daysof inconsistent sleep• If you are someone that requires

8 hours of sleep and you get 6then you owe yourself 2 hours ofsleep

• That’s called sleep debt and itmust be paid back

What Could Possibly Happen?I Mean its Just Sleep Right?• Several factors

– If you are someone of poor healthor recovering from something thena lack of sleep will weaken everypart of your system• A weakened system makes you

more susceptible because yourbody can’t fend for itself in themanner that it should

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What Could Possibly Happen?I Mean its Just Sleep Right?• Medications are not cures

– The body has to respond to themedication

• An exhausted body is not goingto respond to anything in thetime that a rested body would

What Could Possibly Happen?I Mean its Just Sleep Right?

– Certain sleep disorders that we willdiscuss play a vital role inmedication resistance

• Patients that have sleep disordersgenerally are tired and want to sleepa great deal of the time

What Could Possibly Happen?I Mean its Just Sleep Right?

– We already spend a third of ourlives sleeping• If that increases a little it can

become half and times you areawake you are exhausted

• Imagine the longest time you’vespent awake and the way youfelt… now imagine that was theway you felt all day every day

Sleep Disorders AreVery Common

• Sleep disorders are more commonthan many of the more publicizeddiseases and disorders

• A vast majority of Americans sufferfrom some sort of sleep disorder

– Many of us are not gettingadequate sleep or have very poorsleep habits


• Many things that we see as harmlesscan be detrimental to long term goodsleep

– Sleeping in

• Your body won’t let you sleep inif you are adequately rested

• This is a clear sign you may besleep deprived


• Dependency

– Most people understand that bytaking a sedative every night ordrinking alcohol that we have adependency issue

– If you can’t sleep without a TV onthen you also have an issue

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– A fan for white noise, whilecompletely harmless, may give youthe inability to sleep in a place thatis perfectly tranquil but lacks a fan

• That makes you dependent onsomething outside your body’snatural ability to fall asleep

The Monster in the Room

Sleep Apnea• One of the most recognizable, easily

diagnosed, and harmful sleepdisorders

– Not the most prevalent

– Snoring can be a symptom but it isso much more than that

Normal Airway

Obstructed Airway Obstructive Sleep Apnea

Airway Patency Compensation

Hyperventilation O2 & CO2

Arousal Sleep

Airway Collapse

O2 & CO2

Increased Effort to Breathe

Wakefulness

Sleep

Decreased Compensation

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Obstructive Sleep Apnea

Airway Patency Compensation

Hyperventilation O2 & CO2

Arousal Sleep

Airway Collapse O2 & CO2

Increased Effort to Breathe

Wakefulness

Sleep

Decreased Compensation

Sympathetic Activation

Associations• Obstructive sleep apnea has been

associated with many other healthrisks including

– Hypertension: “Non-dipping”

• Refers to a lack of a normal dropin systolic blood pressure duringsleep

Associations• Is a known risk factor for

hypertension and cardiovasculardisease

• Increases the risk for stroke by40% and the risk for CAD by 15%

– Refractory Hypertension

• Clinical blood pressure ≥140/90mmHg while taking 3 ormore anti-HTN meds

Associations– High OSA incidence supports

potential role in drug resistanthypertension

– Congestive heart failure, atrialfibrillation, and a host of otherailments

Hallmark OSASigns and Symptoms

• Loud, disruptive snoring

• Excessive daytime sleepiness (EDS)unexplained by other factors

with or

• Nocturnal choking/gasping/snorting

or

• Nocturnal pauses in breathing

Additional Symptoms of OSA• Recurrent nocturnal awakenings

• Un-refreshing sleep

• Daytime fatigue

• Impaired concentration/memory loss

• Mood/behavioral changes

• Morning headaches

• Loss of sexual interest

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Polysomnogram• Test used to diagnose most sleep

disorders

• Performed in a sleep disorderscenter or a sleep lab

• Consists of monitoring of severalphysiological components

Polysomnogram– Brain waves, eye movements,

muscle activity, leg movements,respiratory pattern, snoring, ECG,oxygen saturations, body position,etc.

CPAP: Pneumatic Splint Delayed Sleep Phase Syndrome• A misunderstood sleep disorder

• It can occur with a move to adifferent time zone or with shiftworkers

• Also occurs in situations wherepeople are hospitalized or never seethe sun and are generally disorientedas to what time of day it is

Delayed Sleep Phase Syndrome• Your body is set to sleep in phases

– Awake or sleep

– If your body wants to sleep from 9p.m. to 6 a.m. and you sleep from11 p.m. to 8 a.m. there is a conflict,even if you get the exact sameamount of sleep, because yoursleep phase is delayed

Delayed Sleep Phase Syndrome

– This can work in the oppositefashion also where you sleepearlier then your body would like

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Treatment Options• Keep a set bedtime and sleep time

– Your bed times should be asconsistent as possible even onyour days off

– Remember your body is not set bya clock on the wall so if you go tosleep at 9 p.m. on the west coastthen on the east coast it will bemidnight

Treatment Options– A sleep aid may be needed in some

instances to help you fall asleep atthe appropriate time until yourbody can change phases

Narcolepsy• A central nervous system disorder

that is an important cause ofpersistent sleepiness

• The second most common cause ofdisabling daytime sleepiness aftersleep apnea

Narcolepsy• Typically begins in the teens and

early twenties, but can occur as earlyas age 5 or after age 40

• Symptoms may worsen over the firstfew years and then persist for life

• Half of all patients report thatsymptoms interfere with job,marriage, or social life

Narcolepsy• Can be considered a disorder of

state control

– Elements of sleep intrude intowakefulness, and wakefulnessintrudes into sleep

– This state instability results incharacteristic symptoms

Narcolepsy Symptoms• Almost all patients with narcolepsy

have chronic sleepiness

• Over 24 hours they do not sleepmore than normal controls

– Prone to fall asleep throughout theday, often at inappropriate times

• “Sleep attacks”

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Narcolepsy Symptoms• Hypnagogic hallucinations

– Vivid, often frighteninghallucinations that occur just asthe patient is falling asleep

– Likely result from a mixture of REMsleep dreaming and wakefulness

Narcolepsy Symptoms• Sleep paralysis

– A complete inability to move for aminute or two just after awakening

– Episodes of sleep paralysis may beaccompanied by hypnagogichallucinations

Narcolepsy Symptoms• Cataplexy

– Sudden episodes of bilateralmuscle weakness leading to partialor complete collapse

– Often triggered by strong emotionssuch as laughter, anger, orexcitement

Narcolepsy Symptoms– Episodes of Cataplexy last one to

two minutes, and are notassociated with impairment ofconsciousness

– Sixty percent of narcolepticindividuals develop Cataplexy

Diagnosing Narcolepsy

• Complete evaluation includes anovernight polysomnogram (PSG)

• Multiple Sleep Latency Test (MSLT)

Treatment for Narcolepsy• Mainstays of therapy

– Stimulants for the treatment of sleepiness

– REM sleep-suppressing medications for the treatment of Cataplexy

• Napping and sleep hygiene

• Psychosocial support

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Treatment for Narcolepsy• A few may get by with an occasional

nap

• Most patients require a wake-promoting drug

– These drugs improve performanceas measured by reaction time andsimulated driving tasks

Treatment for Narcolepsy• Performance usually does not

exceed 70 to 80 percent of normalcontrol levels

• Goal is obtaining "normal" alertnessthroughout conventional wakinghours

Treatment for Cataplexywith Narcolepsy

• Gamma hydroxybutyrate (GHB)

– 2002 - approved by the FDA for thetreatment of Cataplexy

– Especially useful in patients withsevere Cataplexy

– Can also improve daytimesleepiness

Treatment for Cataplexywith Narcolepsy

– GHB is a metabolite of GABA

– Mechanism of action in patientswith Cataplexy is unknown

– Gained notoriety as a "date-rape"drug

Periodic Limb Movements Disorderand Restless Leg Syndrome

• They are not the same thing

• Sometimes patients suffer from bothailments but they are completelydifferent

Periodic LimbMovements Disorder

• Repetitive movements in sleep

• Typically occur in the lower limbs

• Occur about every 20-40 seconds

• Also referred to as PLMD, periodiclimb movement disorder

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• Movements can be brief muscletwitches, jerking movements, or anupward flexing of the feet

– They cluster into episodes lastinganywhere from a few minutes toseveral hours


• PLM is found with high frequency inthose suffering from restless legssyndrome, with as many as 85% ofpeople with RLS also having PLM

• Conversely, the number of peoplewith PLM also having RLS is quitelow, owing to the fact that PLM issomewhat more common than RLS


• Like RLS, PLM can occur in the legsor arms but most often appears inthe legs

• PLM is found in 5% of adults over 30and nearly 50% of adults over theage of 65, lending credence to theclaim that it is tied to the immunesystem and more likely to appear inthose with weaker immune systems

• It occurs rarely in children

Restless Leg Syndrome (RLS)• A neurologic sensor motor disorder

that is characterized by anoverwhelming urge to move the legswhen they are at rest– The urge to move the legs is

usually, but not always,accompanied by unpleasantsensations

– This is typically felt while a personis still awake

Restless Leg Syndrome• There are two types of RLS

– Primary RLS

• The most common

• Also called idiopathic RLS

• “Primary” means cause unknown

• Usually becomes lifelongcondition

Restless Leg Syndrome• Over time symptoms tend to get

worse and occur more often,especially if they began inchildhood or early in adult life

• In milder cases, there may belong periods of time with nosymptoms, or symptoms maylast only for a limited time

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Restless Leg Syndrome– Secondary RLS

• Caused by another disease orcondition or, sometimes, fromtaking certain medicines

• Symptoms usually go awaywhen the disease or conditionimproves, or if the medicine isstopped

Diagnosis• How is Periodic Limb Movement

Disorder diagnosed?

– The polysomnogram (overnightsleep study) is the best method fordetecting the severity of themovements and also for detectingany other possible sleepingdisorders that may be contributingto it

Diagnosis• How is Restless Leg Syndrome

diagnosed?

– The way that you describe yoursymptoms is very important indiagnosing restless leg syndrome(RLS)

– Your doctor will

• Take a complete medical history

Diagnosis• Do a complete physical

examination

• Order other tests

– The diagnosis of RLS usuallyrequires the following fourconditions be present

• An urge to move the legs due toan unpleasant feeling in the legs

Diagnosis• The urge to move the legs or the

unpleasant feeling in the legsbegins or gets worse when youare at rest or not moving aroundfrequently


unpleasant feeling in the legs ispartly or completely relieved bymovement (such as walking orstretching) for as long as themovement continues

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unpleasant feeling in the legs isworse in the evening and atnight, or only occurs in theevening or at night

– There is no test currently availableto diagnose RLS

Treatment for PLMD• Similar to RLS treatment so someone

with both conditions will likely findrelief from both syndromes with onetreatment

• Treatment includes– Iron supplements when low iron

levels are considered to be at theroot of the problem

– Anti-seizure medications

Treatment for PLMD– Sleeping pills or pain killers in

extreme cases– Changes in your daily routine

• Healthier diet and balancedexercise schedule

– Good sleep hygiene practices• Will improve the speed you

reach REM sleep and your abilityto stay in it

Treatment for PLMD• The chances of PLM occurring

during REM sleep are muchlower than while in earlier sleepphases

Treatment for PLMD• Good sleep hygiene includes

improving the sleepconduciveness of theenvironment you sleep in, havinga comfortable bed and pillowthat is right for you, and avoidingstimulants of any kind beforebed time

Treatment for RLS• Medicines can help relieve some

symptoms of RLS

• Doctors prescribe medicines to treatRLS in people

– With clearly defined symptoms

– Whose symptoms cannot becontrolled by lifestyle and non-drug treatment

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Treatment for RLS• Lifestyle changes can improve and

relieve symptoms of RLS and may bethe only treatment needed for mildRLS

• Avoid things that can makesymptoms of RLS worse

– Tobacco

– Alcohol

Treatment for RLS– Caffeine

• Chocolate, coffee, tea, and somesoft drinks contain caffeine

• Although it may seem to helpovercome daytime sleepiness,caffeine usually only delays ormasks RLS symptoms and oftenmakes them worse

Treatment for RLS– Some over-the-counter and

prescription medicines can alsomake RLS symptoms worse

• Antidepressants (most of them)

• Antinausea medicines

• Antipsychotic medicines

• Antihistamines

• Adopt good sleep habits• Follow a program of moderate

exercise• Other activities that may help relieve

symptoms– Walking or stretching– Taking a hot or cold bath– Massaging the leg or arm– Using heat or ice packs

Treatment for RLS

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