MANAGEMENT OF INSOMNIA IN THIS MANAGEMENT OF INSOMNIA IN THIS MILLENNIUMMILLENNIUM

Dr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIANDr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIANEmeritus Professor Emeritus Professor

The TamilNadu Dr M.G.R Medical UniversityThe TamilNadu Dr M.G.R Medical UniversityFormer Head- Institute of NeurologyFormer Head- Institute of Neurology

Madras Medical College, ChennaiMadras Medical College, Chennai

In Greek mythology, Hypnos was the personification of sleep; the Roman equivalent was known as Somnus. His twin was Thanatos ("death"); their mother was the goddess Nyx ("night"). His palace was a dark cave where the sun never shines. At the entrance were a number of poppies and other hypnogogic plants.

Sleep architecture revisitedSleep architecture revisited

What is it & How is it relevant What is it & How is it relevant in Psychiatry and Neurology?in Psychiatry and Neurology?

Science is below the mind; Spirituality is beyond the mind

What is sleep?What is sleep?

Sleep is a physiological state of reduced Sleep is a physiological state of reduced sensory awareness and an absence of sensory awareness and an absence of voluntary movements.voluntary movements.

Sleep is necessary for life.Sleep is necessary for life.

Sleep is also an essential component of good Sleep is also an essential component of good health (body development and restitution as health (body development and restitution as well as mental health and well-being). It is well as mental health and well-being). It is also important for optimal cognitive also important for optimal cognitive functioning. functioning.

A woman’s desire for revenge outlasts all her other emotions

50

40

30

20

10

04 5 6 7 8 9 10

Length of Sleep in Hours

Percentage ofAll People

20

Total Sleep RequirementTotal Sleep Requirement

In order to be at your peak performance you need atleast 8 hours of sleep.

Function of SleepFunction of Sleep

1.1. Restoration and recovery Restoration and recovery

– Sleep serves to reverse and/or restore Sleep serves to reverse and/or restore biochemical and / or physiological processes biochemical and / or physiological processes degraded during prior wakefulnessdegraded during prior wakefulness

2.2. Energy conservationEnergy conservation

– 10% reduction of metabolic rate below basal 10% reduction of metabolic rate below basal levellevel

3.3. Memory consolidationMemory consolidation

4.4. ThermoregulationThermoregulation

5.5. HomeostasisHomeostasis

The world shall perish not for lack of wonders but lack of wonder

Illustration of Normal vs. Insomnia

Sleep Pattern

Insomnia Sleep Pattern

Normal Sleep Pattern

Awakenings

On

set

On

set

Normal sleep Normal sleep architecturearchitecture

NATURE, TIME AND PATIENCE are the 3 great physicians

10

Normal Sleep ArchitectureNormal Sleep ArchitectureStages of sleepStages of sleep____________________________________________________1. NREM Sleep1. NREM Sleep

A. Stage 1A. Stage 1

B. Stage 2B. Stage 2

C. Stage 3C. Stage 3

D. Stage 4D. Stage 4

2. REM Sleep2. REM Sleep

Truth comes out of error sooner than that of confusion

11

REM Sleep~20% of night

NREM Sleep~80% of night

Wake2/3 of life

Sleep Stages Sleep Stages ______________________________________________________

Thought is the labour of the intellectReverie is its pleasure

Normal Sleep HistogramNormal Sleep HistogramSequences of States and Sequences of States and Stages of Sleep on a Typical Stages of Sleep on a Typical NightNight

Identification and Staging of Adult Human Sleep, L. Shigley, Sleep Academic Award

Normal Sleep StagesNormal Sleep Stages

REM

Learning and memory consolidation

‘Dreaming sleep’

3-8% 45-55% 15-20% 20%

Stage 1

Body starts to relax ‘Falling asleep’

Stage 2

Brain slows ‘Stable, light sleep’

Stage 3&4

Body and tissue restored ‘Deep, restorative sleep’

NREM 75-80% REM 20-25%

1 cycle = 80-100 minutes

Adapted from Damien R.Stevens MD.Sleep medicine secrets.2004

Wakefulness, NREM, and REMWakeWake NREM NREM REMREM

ArousabilityArousability HighHigh LowestLowest LowLow

EEG amplitudeEEG amplitude Low Low HighHigh LowLow

EEG frequencyEEG frequency Fast Fast SlowSlow Mixed fastMixed fast

Muscle toneMuscle tone VariableVariable Low Low AbsentAbsent

Eye movementsEye movements Voluntary Voluntary InfrequentInfrequent RapidRapid

Heart Rate, Blood Heart Rate, Blood Pressure, Pressure, Respiratory RateRespiratory Rate

VariableVariable Slow/ low, Slow/ low, regularregular

VariableVariable

O2, CO2 O2, CO2 responseresponse

Full Full LowerLower LowestLowest

ThermoregulationThermoregulation Behavioral/ Behavioral/ PhysiologicPhysiologicalal

PhysiologicPhysiologicalal

Reduced Reduced physiologicphysiologicalal

Mental activityMental activity FullFull None/ None/ limitedlimited

Story-like Story-like dreamsdreams

Importance of sleep Importance of sleep architecturearchitecture• Sleep architecture provides a useful means Sleep architecture provides a useful means

for quantitatively analyzing sleep. for quantitatively analyzing sleep.

• It includes both macroarchitectural features It includes both macroarchitectural features (those derived from sleep staging) and (those derived from sleep staging) and microarchitectural features (those derived microarchitectural features (those derived from waveform analysis). Architectural from waveform analysis). Architectural features can characterize:features can characterize:– sleep integrity and continuitysleep integrity and continuity– global sleep-stage structureglobal sleep-stage structure– presumed underlying physiologic mechanismspresumed underlying physiologic mechanisms

Neurochemical control of Neurochemical control of sleep-wake statessleep-wake states

NeurotransmittNeurotransmitterer

LocationLocation ActionAction

AcetylcholineAcetylcholine LDT, PPT (pons)LDT, PPT (pons) REM, wakeREM, wake

HistamineHistamine TMN (posterior TMN (posterior hypothalamus)hypothalamus)

WakeWake

GABA, galaninGABA, galanin VLPOVLPO NREM sleepNREM sleep

SerotoninSerotonin Raphe nucleiRaphe nuclei Wake, NREMWake, NREM

NorepinephrineNorepinephrine Locus Locus coeruleuscoeruleus

WakeWake

HypocretinHypocretin Later hypothalLater hypothal WakeWake

Neurochemical control of Neurochemical control of sleep-wake statessleep-wake states• DopamineDopamine

• AdenosineAdenosine

• Nitrous oxideNitrous oxide

• Cytokines (IL-1, IL-6, TNF-Cytokines (IL-1, IL-6, TNF-αα))

• ProstaglandinsProstaglandins

• Hormones: melatonin, growth Hormones: melatonin, growth hormone, VIP NPYhormone, VIP NPY

• Delta sleep-inducing peptideDelta sleep-inducing peptide

Basal ForebrainThalamusPost. Hypothalamus

CholinergicSerotonergicMonoaminergicHistaminergic

Reticular Formation

Aminergic Cholinergic

Wake

Sleep

REM

Fig. 2.1 aldrich

Factors that affect sleepFactors that affect sleep

• AgeAge– Increased wakefulness during sleep periodIncreased wakefulness during sleep period– Decreased Stage 3/4 NREMDecreased Stage 3/4 NREM– Earlier timingEarlier timing– Greater daytime sleepinessGreater daytime sleepiness

• Sex (women have longer sleep, more Stage Sex (women have longer sleep, more Stage 3/4 NREM)3/4 NREM)

• Timing: Sleep is best at night!Timing: Sleep is best at night!

• Illnesses, medicationsIllnesses, medications

Social Isolation is in itself a pathogenicFactor for disease production

Sleep in healthy young and Sleep in healthy young and older adultsolder adults

20 year old woman 71 year old woman

Motivation is the Spark that lights the Fire of Knowledge and fuels the engine of Accomplishment

Sleep stages across the life Sleep stages across the life spanspanOhayon et al., SLEEP 2004; 27: Ohayon et al., SLEEP 2004; 27: 1255-731255-73

Min

ute

s

Age (years)

Is there any difference Is there any difference between sleep and sedation?between sleep and sedation?

Mind is the great level of all things; human thought is the process by which human ends are ultimately answered - Daniel Webster

Traits to define sleep and Traits to define sleep and sedationsedation

NREM/REM sleepNREM/REM sleep

• Hypotonia/atoniaHypotonia/atonia

• Slow/fast eye Slow/fast eye movementsmovements

• Regular/irregular Regular/irregular breathing, heart breathing, heart rate, BPrate, BP

SEDATIONSEDATION

• AnalgesiaAnalgesia

• AmnesiaAmnesia

• Obtundation of Obtundation of wakingwaking

• AnxiolysisAnxiolysis

Social Isolation is in itself a pathogenicFactor for disease production

Sleep v/s sedationSleep v/s sedation

• Sleep is reversible with sensory stimulation; Sleep is reversible with sensory stimulation; sedation depresses sensory processingsedation depresses sensory processing in the in the face of noxious physical &/or aversive face of noxious physical &/or aversive psychological stimulationpsychological stimulation

• Sleep disrupts mammalian temperature regulation Sleep disrupts mammalian temperature regulation during REM phase; Sedation can alter the during REM phase; Sedation can alter the relationship between body temp and energy relationship between body temp and energy expenditureexpenditure

• Nausea and vomiting are not associated with Nausea and vomiting are not associated with sleep; but can be positively correlated with sleep; but can be positively correlated with sedation level.sedation level.

Knowledge without action is useless;Action without knowledge is foolish

Sleep architecture in Sleep architecture in neurological and psychiatric neurological and psychiatric

conditionsconditions

A bad teacher complains;A good teacher explains;The best teacher inspires;

Effect of Sleep Stage in Effect of Sleep Stage in Epileptic patients on Epileptic patients on Interictal and Ictal Interictal and Ictal DischargesDischarges

Pure love ever gives. Never seeks

Seizure effect on sleep architectureSeizure effect on sleep architecture• Seizures acutely alter the sleep-wake Seizures acutely alter the sleep-wake

state. state. • The most prominent clinical features of The most prominent clinical features of

this seizure effect are postictal this seizure effect are postictal somnolence and insomnia. somnolence and insomnia.

• Patients with nocturnal seizures are Patients with nocturnal seizures are subjectively and objectively sleepy on the subjectively and objectively sleepy on the day following a seizure.day following a seizure.

• Seizures or the postictal state produce Seizures or the postictal state produce pathophysiological changes in the CNS pathophysiological changes in the CNS that result in sleep fragmentation and that result in sleep fragmentation and suppression of REM sleep. Individuals with suppression of REM sleep. Individuals with partial or generalized seizures have less partial or generalized seizures have less REM sleep on nights with seizures.REM sleep on nights with seizures.

“Anger Begins In Folly And Ends In Repentance”

Sleep in Patients With Sleep in Patients With DepressionDepression

• Primary sleep complaintsPrimary sleep complaints1,31,3

– Difficulty falling asleepDifficulty falling asleep– Frequent nocturnal awakeningsFrequent nocturnal awakenings– Waking too early in the morningWaking too early in the morning– Daytime fatigueDaytime fatigue

• Effects on sleep architecture in depressionEffects on sleep architecture in depression1-31-3

– Prolonged sleep latency Prolonged sleep latency – Increased wake time after sleep onset (WASO)Increased wake time after sleep onset (WASO)– Decreased slow wave sleep (stages 3 and 4)Decreased slow wave sleep (stages 3 and 4)– Reduced REM sleep latency; prolonged first Reduced REM sleep latency; prolonged first

REM periodREM period

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR®). 2000:645-650.2. Perlis M, et al. Biol Psychiatry 1997;42:904-913.3. Benca RM. In: Principles and Practice of Sleep Medicine. 4th ed. 2005:1311-1326.

Sleep pattern in Alzheimer’s DiseaseSleep pattern in Alzheimer’s Disease• Sleep pattern in early stageSleep pattern in early stage: :

– Disruption in sleep-wake patterns, rhythmicity, Disruption in sleep-wake patterns, rhythmicity, – Increased amounts and frequency of nighttime Increased amounts and frequency of nighttime

wakefulness, wakefulness, – Reduction of slow-wave sleep - worsen with disease Reduction of slow-wave sleep - worsen with disease

progression. progression.

• Sleep pattern in late stage:Sleep pattern in late stage: – Reduction of REM sleep, Reduction of REM sleep, – Increased REM latency, Increased REM latency, – Alteration of the circadian rhythm resulting in Alteration of the circadian rhythm resulting in

daytime sleepiness. daytime sleepiness. – Daytime napping and somnolence increase with Daytime napping and somnolence increase with

disease progression.disease progression.

Effect of drugs on sleep Effect of drugs on sleep architecturearchitecture

““The Wise Man Before He Speaks ,The Wise Man Before He Speaks , Will Consider Well What He Speaks Will Consider Well What He Speaks

Effect of antidepressants on Effect of antidepressants on sleep architecturesleep architecture

• Tricyclic antidepressantsTricyclic antidepressants– Mostly produce sedationMostly produce sedation– Variation in the reported effects on sleep from Variation in the reported effects on sleep from

TCAs.TCAs.– Amitriptyline, trimipramine, nortriptyline, Amitriptyline, trimipramine, nortriptyline,

dothiepin and doxepin have dothiepin and doxepin have all all been been associated with sedation, associated with sedation,

– Imipramine and desipramine are less likely to Imipramine and desipramine are less likely to be linked with sedation, but have been be linked with sedation, but have been associated with insomnia; associated with insomnia;

– The evidence is less clear with clomipramine.The evidence is less clear with clomipramine.

Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20: 533-559.

Effect of antidepressants on Effect of antidepressants on sleep architecturesleep architecture

• SSRIsSSRIs– SSRIs SSRIs immediately suppress REM sleep, and immediately suppress REM sleep, and

continue to do so throughout treatment.continue to do so throughout treatment.– REM parameters return to normal once the REM parameters return to normal once the

SSRI SSRI is discontinued.is discontinued.– SSRIs SSRIs block serotonin reuptake, but some block serotonin reuptake, but some

also block noradrenaline reuptake. Both also block noradrenaline reuptake. Both actions have been associated with REM actions have been associated with REM suppression and sleep disruption.suppression and sleep disruption.

Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20: 533-559.

Effect of antidepressants on sleep Effect of antidepressants on sleep architecturearchitecture• FluoxetineFluoxetine

– Sleep was significantly less efficient, and Sleep was significantly less efficient, and nocturnal awakenings were significantly nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg) - Rush greater, with fluoxetine (20-40 mg) - Rush et al. et al. (1998) (1998)

– Fluoxetine significantly suppressed REM Fluoxetine significantly suppressed REM sleepsleep

– Fluoxetine (20 mg) was associated with Fluoxetine (20 mg) was associated with less efficient, shorter and more disrupted less efficient, shorter and more disrupted sleep - Wolf sleep - Wolf et al. et al. (2001) (2001)

– Improvements in sleep latency and total Improvements in sleep latency and total sleep time were not marked for fluoxetinesleep time were not marked for fluoxetine

Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20: 533-559.

Discipline Weighs ounces: Regret weighs Tons

Effect of hypnotics drugs on Effect of hypnotics drugs on sleep architecturesleep architecture

• BenzodiazepinesBenzodiazepines– Being anticonvulsants, they tend to suppress Being anticonvulsants, they tend to suppress

synchronized EEG activity (such as slow waves) and synchronized EEG activity (such as slow waves) and confer some risk of seizure if abruptly withdrawn.confer some risk of seizure if abruptly withdrawn.

• BarbituratesBarbiturates– Decrease REM and slow-wave sleep. Decrease REM and slow-wave sleep.

• Non-BZD hypnotics. Non-BZD hypnotics. – Do not alter sleep architecture when taken at Do not alter sleep architecture when taken at

therapeutically recommended doses. therapeutically recommended doses.

Some people feel the rain;Others just get wet

16.39%

6.64%

7.27%7.27%

15.81%

7.65% 46.23%

Stage 1

Stage 0

REM

Stage 4

Stage 3Stage 2

StilnoctStilnoct®®

Preservation of Sleep Preservation of Sleep StagesStages

19.02%

44.48%

10.50%

8.51%

11.22%

6.26%6.26%

Stage 1

Stage 0REM

Stage 4

Stage 3Stage 2

Data on file. Sanofi-aventis.

Placebo Stilnoct

N=36

Opinion is ultimately determined by the feelings and not by the intellect

Sleep DisordersSleep Disorders

• International Classification of Sleep Disorders (ICSD-International Classification of Sleep Disorders (ICSD-2)2)

(1) insomnias(1) insomnias(2) sleep-related breathing disorders (2) sleep-related breathing disorders (3) hypersomnias not due to a breathing disorder (3) hypersomnias not due to a breathing disorder (4) circadian rhythm sleep disorders(4) circadian rhythm sleep disorders(5) parasomnias(5) parasomnias(6) sleep-related movement disorders(6) sleep-related movement disorders(7) other sleep disorders, and(7) other sleep disorders, and(8) isolated symptoms, apparently normal variants, (8) isolated symptoms, apparently normal variants,

and unresolved issues.and unresolved issues.It is the province of the knowledge to speak and it is the privilege of the wisdom to listen - Hodly’s

InsomniaInsomnia

•Difficulty in initiating sleep and Difficulty in initiating sleep and staying asleep staying asleep

•Waking up earlierWaking up earlier

•Poor quality sleep, non restorative.Poor quality sleep, non restorative.

•SubjectiveSubjective

•Day time impairment (RDC-AASN)Day time impairment (RDC-AASN)

The meek shall inherit the earth- but not its mineral rights

EtiologyEtiology

• PrimaryPrimary

• SecondarySecondary

MedicationsMedications

PsychiatricPsychiatric

MedicalMedical

Sleep DisordersSleep Disorders

A Man Of Words And Not Of Deeds Is Like A Garden Full Of Weeds

DrugsDrugs

• SSRI’s & SNRI’sSSRI’s & SNRI’s

• Alpha and beta blockersAlpha and beta blockers

• DiureticsDiuretics

• DecongestantsDecongestants

• StimulantsStimulants

• Steroids, thyroid harmonesSteroids, thyroid harmones

What is mind no matter What is matter never mind

Psychiatric and Sleep Psychiatric and Sleep disordersdisorders

•Mood & anxiety disordersMood & anxiety disorders

•Circadian rhythm disordersCircadian rhythm disorders

•ParasomniasParasomnias

•ApneasApneas

•Movement disordersMovement disorders

''When Beauty Fires The Blood; Love Exalts The Mind"

HypersomniasHypersomnias

•Excessive day time sleepinessExcessive day time sleepiness

• Interfering with day time Interfering with day time activities, productivity, activities, productivity, enjoymentenjoyment

•Reflects insufficient sleep, Reflects insufficient sleep, disrupted sleep, primar sleep disrupted sleep, primar sleep disorderdisorderExperience : “Yesterday’s Answer To Today’s Experience : “Yesterday’s Answer To Today’s

Problems”Problems”

DiagnosisDiagnosis

• Detailed medical and sleep historyDetailed medical and sleep history

• Snoring or apnoeaSnoring or apnoea

• Restlessness, jerkingRestlessness, jerking

• Hypnogogic or hypnopompic Hypnogogic or hypnopompic hallucinationshallucinations

• Sleep paralysis, cataplexySleep paralysis, cataplexy

• Automatic behaviorAutomatic behaviorTeachers are reservoirs from which, through the process of education, the students draw the water of life

NarcolepsyNarcolepsy

•Excessive day time sleepiness Excessive day time sleepiness (EDS)(EDS)

Sedentary and active pursuit'sSedentary and active pursuit's

Short and refreshingShort and refreshing

Followed by recurrent somnolenceFollowed by recurrent somnolence

Ranging from mild to disablingRanging from mild to disablingName and form are destroyed in

the sands of time

CataplexyCataplexy

•UniqueUnique•Paroxysmal episodes of weaknessParoxysmal episodes of weakness•Triggered by emotionsTriggered by emotions•Secs to MinSecs to Min•Can be localizedCan be localized•Consciousness and respiration Consciousness and respiration

not affected.not affected.Time and tide wait for no man; And sins and sorrows are also swallowed in time

•Develops years after EDSDevelops years after EDS

•Frequency variesFrequency varies

•Adolescence, young adulthoodAdolescence, young adulthood

•Narcolepsy with and without Narcolepsy with and without cataplexycataplexy

•Loss of hypocretin – 1 secreting Loss of hypocretin – 1 secreting cellscells

Every man is a volume if you know how to read him

•Narcolepsy – non obligate Narcolepsy – non obligate manifestationsmanifestations

Sleep paralysis Sleep paralysis – muscle atonia at – muscle atonia at interface between sleep and interface between sleep and wakefulness; for few minutes.wakefulness; for few minutes.

Hypnogogic hallucinationsHypnogogic hallucinations brief, Sec to Mins, dream-like vivid brief, Sec to Mins, dream-like vivid

and distressingand distressingAutomatic behaviorAutomatic behaviorPurposeful/inappropriate with impaired Purposeful/inappropriate with impaired

recollection of the activities.recollection of the activities.

Being ignorant is

not so much a shame as

being unwilling to

learn

Other HypersomniasOther Hypersomnias

• Recurrent hypersomniasRecurrent hypersomnias

Recurrent hypersomniasRecurrent hypersomnias

Kleine – Levin syndromeKleine – Levin syndrome

Menstrual associatedMenstrual associated

• Idiopathic hypersomniasIdiopathic hypersomnias

With long sleep timeWith long sleep time

Without long sleep timeWithout long sleep time

Beauty lies in the eyes of the beholder

ParasomniasParasomnias

•Include abnormal movements, Include abnormal movements, behaviors, emotions and behaviors, emotions and automatic activities.automatic activities.

•Intrusion of sleep and wakeful Intrusion of sleep and wakeful state into one another with CNS state into one another with CNS activation.activation.

•Not a unitary phenomenon.Not a unitary phenomenon.

The secret of walking on water is knowing where the stones are

ParasomniasisParasomniasis

• Disorders of arousal –Disorders of arousal –NREM sleep – confusional arousalNREM sleep – confusional arousal sleep walkingsleep walking sleep terrorssleep terrorsREM sleep – RBD REM sleep – RBD Isolated sleep paralysisIsolated sleep paralysis NightmaresNightmaresOthers – enuresisOthers – enuresis eating disorderseating disorders etcetc Future Medicine – Scientific

determinism or humanism

RBD – REM Sleep Behavior RBD – REM Sleep Behavior DisordersDisorders

• Prevalence of 0.5%; 90% MenPrevalence of 0.5%; 90% Men

• Above 50 yearsAbove 50 years

• 25% with PD, OPCA, DCBD25% with PD, OPCA, DCBD

• Complex motor activity during REMComplex motor activity during REM

• Augmentation of EMG tone during Augmentation of EMG tone during REM sleep REM sleep

• Toxic/metabolic disordersToxic/metabolic disorders

RBDRBD

• During second halfDuring second half• Abnormal brain stem control of medullary Abnormal brain stem control of medullary

inhibitory regionsinhibitory regions• Cat models- locus ceruleous adjacent lesionsCat models- locus ceruleous adjacent lesions• SPECT – decrease striatal dopa innervationsSPECT – decrease striatal dopa innervations decrease dopa transportationdecrease dopa transportation• Withdrawal of alcohol, sedativesWithdrawal of alcohol, sedatives• HypnoticsHypnotics• TCA, SSRI, MAOI, cholinergicsTCA, SSRI, MAOI, cholinergics

The sign wasn’t placed thereBy the Big Printer in the sky

Sleep-Related Movement Sleep-Related Movement DisordersDisorders- - Restless Legs Restless Legs Syndrome Syndrome •5-15% - healthy people5-15% - healthy people

•15-20% - uremia15-20% - uremia

•30% - R.A30% - R.A

•High prevalence in WestHigh prevalence in West

•Low in South & S.E AsiaLow in South & S.E AsiaA open foe may prove a curse ; but a pretended friend is worse

Diagnostic criteria – NIH –Diagnostic criteria – NIH –IRLSSG (2003)IRLSSG (2003)

1. Disagreeable leg sensations 1. Disagreeable leg sensations before sleep onsetbefore sleep onset

2. Irresistible urge to move the 2. Irresistible urge to move the limbslimbs

3. Partial or complete relief on leg 3. Partial or complete relief on leg movementmovement

4. Return of symptoms on cessation 4. Return of symptoms on cessation of movementof movement

When they tell you to grow up, they When they tell you to grow up, they mean stop growingmean stop growing

Restless Leg SyndromeRestless Leg Syndrome•Bilateral, though asymmetricalBilateral, though asymmetrical

•Ankle & knees. Can involve thigh Ankle & knees. Can involve thigh or feet & armor feet & arm

•Minutes to hoursMinutes to hours

•Dopamine dysfunction, Iron Dopamine dysfunction, Iron storage deficiencystorage deficiency

•Anti emetics, antihistamines, Anti emetics, antihistamines, TCA, SSRI, neurolepticsTCA, SSRI, neuroleptics

Restless Leg Syndrome with Periodic Limb Movements

Speak obligingly even if you cannot oblige

Periodic Limb Movement Periodic Limb Movement Disorder Disorder •Common as age advancesCommon as age advances•Nocturnal myoclonus captured on Nocturnal myoclonus captured on

PolysomnographyPolysomnography•Extension of the big toe with Extension of the big toe with

flexion of ankle, knee & hipflexion of ankle, knee & hip•Sleep may or may not be affectedSleep may or may not be affected•Centrally mediated eventCentrally mediated event

“The True Art of Memory is The Art of Attention” - S.Johnson

•Can accompany OSA & Can accompany OSA & NarcolepsyNarcolepsy

•Uremia, metabolic disordersUremia, metabolic disorders

•TCA, MAOITCA, MAOI

•Withdrawal of AED, Withdrawal of AED, benzodiazepines, hypnoticsbenzodiazepines, hypnotics

•Hypnic jerks & nocturnal seizures Hypnic jerks & nocturnal seizures to be differentiatedto be differentiated

Through Action You Create your Own Education - D.B. ELLIS

PLMS –Secondary (previous PLMS –Secondary (previous Myelopathy)Myelopathy)

“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”Imp.Your Memory Skills

Sleep Related Leg CrampsSleep Related Leg Cramps

• Not uncommon with increasing ageNot uncommon with increasing age

• ““Charley horse” muscular tightness Charley horse” muscular tightness involving the calf & foot during sleepinvolving the calf & foot during sleep

• Results in arousal and can lead to Results in arousal and can lead to insomnia or EDSinsomnia or EDS

• Pregnancy, DM, fluid & electrolytes, Pregnancy, DM, fluid & electrolytes, arthritis, vigorous exercisearthritis, vigorous exercise

Sleep related BruxismSleep related Bruxism

•Children and adults, MRChildren and adults, MR

•Stereotyped grinding or clenchingStereotyped grinding or clenching

•Diurnal & nocturnalDiurnal & nocturnal

•Situational or psychological stressSituational or psychological stress

•SSRI, dopa, alcohol exacerbateSSRI, dopa, alcohol exacerbate

Thought is the labour of the intellectReverie is its pleasure

Sleep-Related Rhythmic Sleep-Related Rhythmic Movement Disorder Movement Disorder

•Head Banging – back & forth down Head Banging – back & forth down into the pillowinto the pillow

•Head Rolling – side to sideHead Rolling – side to side

•Body Rocking – forward & Body Rocking – forward & backwardbackward

•Humming or chantingHumming or chanting

•Persistence with autism, MRPersistence with autism, MRWhatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill

Nocturnal Paroxysmal Dystonia Nocturnal Paroxysmal Dystonia (NPD)(NPD)

• Repeated, stereotyped, dystonia or Repeated, stereotyped, dystonia or dyskinetic episodes in NREM sleepdyskinetic episodes in NREM sleep

• Sleep related epilepsySleep related epilepsy

• Short episodes < 1 min. every night Short episodes < 1 min. every night and many timesand many times

• Long episodes – up to 60 minLong episodes – up to 60 min

• Can have sleep disruptionCan have sleep disruptionImagination is more Important than Knowledge

Sleep-Disordered Breathing Sleep-Disordered Breathing (SDB)(SDB)• Primary snoringPrimary snoring

• Upper airway resistance syndrome (UARS) – Upper airway resistance syndrome (UARS) – lab support, day time dysfunctionlab support, day time dysfunction

• Obstructive sleep apnea-hypopnea Obstructive sleep apnea-hypopnea syndrome (OSAHS) syndrome (OSAHS)

• Central sleep apneaCentral sleep apnea

• AsthmaAsthma

• Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD).(COPD).

Obstructive Sleep Apnea-Obstructive Sleep Apnea-Hypopnea Syndrome Hypopnea Syndrome

• Asphyxia with decreased OAsphyxia with decreased O22 & & increased COincreased CO22

• Associated with snoring and Associated with snoring and obstruction of the pharynxobstruction of the pharynx

• Day time – sleepiness, decreased Day time – sleepiness, decreased concentration, fatigueconcentration, fatigue

• Nocturnal – chocking, dyspnoea, Nocturnal – chocking, dyspnoea, diaphoresis, nocturiadiaphoresis, nocturia

A open foe may prove a curse ; but a pretended friend is worse

•Apnoea – 70% reduction in Apnoea – 70% reduction in airflowairflow

•Hypopnea – 30% reduction in Hypopnea – 30% reduction in airflow for minimum 10 secairflow for minimum 10 sec

•Apnea-hypopnea index (AHI) of Apnea-hypopnea index (AHI) of at least five apneas plus at least five apneas plus hypopneas per hour of sleep hypopneas per hour of sleep together with complaints of together with complaints of persistent daytime sleepiness.persistent daytime sleepiness. It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silentLa Broyers character

Risk FactorsRisk Factors

• Obesity ( BMI > 30 kg/mObesity ( BMI > 30 kg/m22))• Male gender Male gender • Family history of obstructive sleep apnea-hypopnea Family history of obstructive sleep apnea-hypopnea

syndrome syndrome • Consumption of alcohol before bedtime Consumption of alcohol before bedtime • Smoking Smoking • Drugs (growth hormone, β-blockers, testosterone, Drugs (growth hormone, β-blockers, testosterone,

flurazepam) flurazepam) • Use of sedatives Use of sedatives • Sleeping in a supine position Sleeping in a supine position • Anatomic upper airway obstruction Anatomic upper airway obstruction • Comorbid medical conditions Comorbid medical conditions

Central Sleep Apnea Central Sleep Apnea

•10 sec of no airflow10 sec of no airflow

•Reduced ventilatory driveReduced ventilatory drive

•Ventilatory responses to hypoxia, Ventilatory responses to hypoxia, hypercapnia are reducedhypercapnia are reduced

•Day time sleepiness, mild snoringDay time sleepiness, mild snoring

•PSG – no airflow or ventilatory PSG – no airflow or ventilatory efforteffort

You are what you think and not what you think you are

Circadian rhythm Sleep Circadian rhythm Sleep Disorders (CRSD)Disorders (CRSD)• Master Clock – SCN in anterior hypothalamusMaster Clock – SCN in anterior hypothalamus

Sleep wake cycle/temperature control and Sleep wake cycle/temperature control and melatonin levels.melatonin levels.

• Zeitgebers (time given) are light and Zeitgebers (time given) are light and melatoninmelatonin

• Input into SCN from ganglion cells-melanopsinInput into SCN from ganglion cells-melanopsin

• Melatonin > pineal > SCN, shifts circadian Melatonin > pineal > SCN, shifts circadian rhythmrhythm

Discipline Weighs ounces; Regret weighs Tons

• DD for insomnia & hypersomniaDD for insomnia & hypersomnia

Delayed sleep phaseDelayed sleep phase

Advanced sleep phaseAdvanced sleep phase

Free runningFree running

Irregular sleep-wakeIrregular sleep-wake

Shift work sleep disorderShift work sleep disorder

Jet lagJet lagA great many people think they are thinking when they are merely re arranging their prejudices

W. James

Criteria for CRSDCriteria for CRSD

• Persistent or recurrent pattern of sleep Persistent or recurrent pattern of sleep disturbance due todisturbance due to

- Alteration in circadian timing or misalignment Alteration in circadian timing or misalignment of endogenous & external factorsof endogenous & external factors

- Leading to insomnia, EDS or bothLeading to insomnia, EDS or both

- Associated with impairment of functionAssociated with impairment of function

• CRSDs are important in practice but CRSDs are important in practice but parameters for treatment have not been parameters for treatment have not been established.established.

When they tell you to grow up, they mean stop growing -Piccaso

Thank youThank you

Many Ideas grow better when transplanted into another mind than in the one where they sprang UP

O.W. Holmos