Sleep and sleep disorders

MUDr. Katalin ŠtěrbováCentrum pro poruchy spánku u dětíDětská neurologická klinikaFakultní nemocnice v Motole

Sleep physiology

Examining sleep disturbances

Sleep disorders

Sleep physiology Sleep occurs periodically and is characterized by

decreased reactivity to external stimuli decreased motions typical body position typical electrical activity of the brain

Sleep is immediately reversible

Sleep is an active process resulting from the cooperation of several regulatory centres

Wakefulness, NREM and REM sleep are three physiologic functional states

NREM sleep Body resting, almost no movements Regular heartbeat and respiration, depression of blood

pressure Almost no dreams Restorative function 3 stages:

NREM I – drowsiness – eyelids closing, head-drop, voices grow away, thoughts dispersing, hypnagogic jerking

NREM II – sleep spindles, K komplexes; easy to wake up NREM III – delta sleep, very regular heartbeat and respiration,

hard to wake up Muscles relaxed, no movements except sleepwalking

REM Irregular heartbeat and respiration, further depression of

blood pressure Decreased thermoregulatory activity, no sweating, no

shuddering REM sleep is very active compared to NREM: higher

oxygen consumption, higher temperature of the brain, higher cerebral perfusion, EEG resembles wakefulness and drowsiness

Muscles relaxed except extraocular and respiratory ones Muscle relaxation in neonates is not fully developed;

newborns and small infants often jerk, vocalize, kick out, grimase

Awakening somebody from REM might be difficult – outer and inner stimuli can be incorporated into dreams

Dreams – their role is not very clear

NREM x REM

The body is resting The mind is resting

The mind is active, but „disconnected“ from the body

Hypnogram

NREM I 1%

NREM II 45-50%

NREM III 20%

REM 25%

Development of sleep

REM (active sleep) appears in the 6.-7. month of pregnancy

NREM (quiet sleep) appears a month later

In full-term neonates: 50% of sleep is „active“ sleep

In preterm babies: 80% of sleep is „active“ sleep

Sleep requirements in children

Sleep regulation I. Circadian clock in

the ncl. suprachiasmaticus thalami control timing of sleep

Melatonin is released from the epiphysis in darkness and thus regulates the circadian clock in the hypothalamus

Sleep regulation II.

The „circadian clock“ regulates also other circadian rhythms as body temperature, level of cortisol, hunger

The inner „clock“ has to bee synchronized with the 24hours cycle – according to light/darkness, food intake, social activities, external temperature and noise

Drowsiness and wakefulness varies during the day – drowsiness after lunch is normal, a period of increased alertness before bedtime is physiological

Owls and larks

Why do we sleep? Both body and mind gets restoration during sleep

Different theories: mental and physical restoration, energy conservation, memory fixation, cool-down of emotions

Extracerebral processes: increased productin of growth hormone and thyreotropin, decreased salivation, decreased motility of bowels

Immunity – long-term sleep deprivation has negative effect on immunity

If somebody does not sleep one night, he is sleepy the other day and the only way to overcome sleepiness is to sleep

Optimal length of sleep for an adult is 7-8.5 hours

After an acute sleep deprivation: NREM III and ½ of REM is compensated

Acute sleep deprivation

Decreased efficiency Decreased ability to learn Instability of mood Increased vulnerability of the – e.g.

Increased risk of epileptic seizures Worsened thermoregulation Tremor, ptosis

Chronic sleep deprivation Trend of the last century in Western countries

Behaviourally induced insufficient sleep Increased day-time sleepiness Decreased efficiency Concentration affected Immune regulation deterioration Increased cardiac events Shorter life-expectancy Increased BMI

Sleep disorders

Sleep problems in the population

We spend about 1/3 of our life sleeping

Almost everybody experiences some sleep problem in his life

no systematic epidemiological studies

Diagnostic procedures

history EEG, sleep EEG, polysomnography, MSLT

(Multiple Sleep Latency Test), MWT (Maintenance of Wakefulness Test),

actigraphy ENT, paediatrics/internal medicine,

gastroenterology, immunology Psychology/psychiatry Brain imaging HLA typization (95% of White patients with

narcolepsy/kataplexy have the DQB1*0602 haplotype)

Epworths sleepiness scale

THE EPWORTH SLEEPINESS SCALE

                                                                                              

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

SITUATIONCHANCE OF DOZING

Sitting and reading ____________

Watching TV ____________

Sitting inactive in a public place (e.g a theater or a meeting) ____________

As a passenger in a car for an hour without a break ____________

Lying down to rest in the afternoon when circumstances permit ____________

Sitting and talking to someone ____________

Sitting quietly after a lunch without alcohol ____________

In a car, while stopped for a few minutes in traffic ____________

Pediatric Daytime Sleepiness Scale (PDSS) Scoring: 4 = Very often, Always 3 = Often, Frequently 2 = Sometimes 1 = Seldom 0 = Never

Please answer the following questions as honestly as you can by circling one answer. 1. How often so you fall asleep or get drowsy during class periods? Always Frequently Sometimes Seldom Never 2. How often do you get sleepy or drowsy while doing your homework? Always Frequently Sometimes Seldom Never 3.* Are you usually alert most of the day? Always Frequently Sometimes Seldom Never 4. How often are you ever tired and grumpy during the day? Always Frequently Sometimes Seldom Never 5. How often do you have trouble getting out of bed in the morning? Always Frequently Sometimes Seldom Never 6. How often do you fall back to sleep after being awakened in the morning? Always Frequently Sometimes Seldom Never 7. How often do you need someone to awaken you in the morning? Always Frequently Sometimes Seldom Never 8. How often do you think that you need more sleep? Very Often Often Sometimes Seldom Never * Reverse score this item

Abnormal Values: 6th and 7th Grade > 26, 8th Grade >30

Wakefulness - PSG

PSG

International Classification of Sleep Disorders1. Dyssomnias A. Intrinsic Sleep Disorders B. Extrinsic Sleep Disorders C. Circadian-Rhythm Sleep Disorders

2. Parasomnias A. Arousal disorders B. Sleep-Wake Transition Disorders C. Parasomnias Usually Asssociated with REM Sleep D. Other Parasomnias3. Sleep Disorders Associated with Other Disorders A. Associated with Mental Disorders B. Associated with Neurologic Disorders C. Associated with Other Medical Problems4. Proposed Sleep Disorders

source: American Academy of Sleep Medicine, 2001

Insomnia I. Difficulty with falling asleep (sleep latency >30 min) Frequent arousals (sleep efficiency < 85%) Early wake up (30 minutes earlier than planned)

Sleep has poor quality, non-refreshing, pat. has one on these complaints: Fatigue, concentration and memory deficit, mood

disturbances, irritability, social discomfort, decrease of energy, motivation, propensity to errors, headache, insomnia anticipation

Insomnia II. Acute insomnia (stress-related i.)

Disturbed sleep is due to an acute stressor

Primary (psychophysiologic, learned, conditioned) insomnia a disorder of somatized tension and learned sleep-preventing

associations Individulas with P.I. typically react to stress with somatized

tension and agitation. The meaning of stressfull events is denied and repressed but manifests itself as increased physiologic arousal (increased musce tension, increased vasoconstriction, ..)

Learned sleep-preventing associations exacerbate the state of high somatized tension and directly interfere

with sleep consist mainly of marked overconcern with the inability to sleep; a

vicious cycle then develops: patients in whom this internal factor (trying too hard to sleep) is a driving force for insomnia often find that they fall asleep easily when not trying to do so (e.g. Watching TV, driving, reading)

Insomnie III. Paradoxical insomnia (sleep

misperception)

Idiopathic insomnia (childhood onset i., lifelong i.)often with somnambulism, ADHD

Mental illness related insomnia

Insomnia IV.

Associated with neurological or other medical disorder

Associated with hypnotic-, alcohol- or stimulant dependence

Associated with inadequate sleep hygiene

Insomnia - therapy

Eliminating causes

Non – benzodiazepin hypnotics for short-term (zolpidem)

PsychotherapyCognitive-behavioral therapy

Sleep Hygiene Rules Avoid drinking coffee, black or green tea, coke or energy drinks late

afternoon (4-6hours before going to bed), reduce their consumption also during the day.

Avoid eating heavy meals in the evening. Do not deal with problems that make you upset after dinner. Find

some nice and calm activity to get rid of stress and get prepared for sleep.

A short walk after dinner can improve your sleep. Avoid major physical activity 3-4 hours before bed-time

Do not drink alcohol to facilitate falling asleep – alcohol worsens the quality of your sleep

Do not smoke before bedtime and during night-time awakenigs Use your bedroom and bed only for sleep and sex – remove TV set

from your bedroom, do not eat and do not rest in your bed Go to bed and wake up at the same time every day (– + 15 minutes) Do not spend extra time in your bed lazing, thinking. Decrease noise and light in your bedroom to minimum; room

temperature should be 18–20 °C.

Insomnia of children Sleep-onset association disorder

Typically the child falls asleep under certain set of conditions (using a bottle, sucking on a pacifier, nursing, rocking)

Return to sleep during night-time waking is difficult unless the conditions associated with sleep onset are re-established

Limit-setting sleep disorder The child refuses to go to bed at an appropriate time Asserts requirements verbally or leaving bed (drinking, eating,

urination, more fairy- tales) „Curtain-calls“

Medical reasons (pain, infant colic, itching)

Fear, anxiety

Sleep apnea

Central sleep apnea syndrome Obstructive sleep apnea syndrome Central alveolar hypoventilation syndrome

Obstructive sleep apnea syndrome

Normal breathing, obstructive hypopnea, obstructive apnea

OSAS

Video OSAS

OSAS in PSG recording

What is the problem with apnea?

Acute problem: each apnea/hypopnea is followed by desaturation and arousal → sleep fragmentation → bad quality of sleep → day-time symptoms (sleepiness, concentration problems)

Chronic consequences: arterial and pulmonary hypertension, obesity, increased risk of ischemic heart desease and cerebrovascular infarcts, decreased somatotropin release, insulin and leptin resistance

Therapy of OSAS

Change diet and increase physical activity to decrease BMI

ENT surgery (adenotonsilectomy, plastic surgery on the soft palate)

Stomatosurgery CPAP (continuous positive airway pressure)

CPAP

Increased day-time sleepiness = decreased ability to maintain

wakefulness during the day Hypersomnia of central origin

NarkolepsyRecurrent hypersomnia Idiopathic hypersomnia

Hypersomnia due to other factors (organic brain disease; drugs, alcohol)

Narkolepsy Symptoms:

Excessive sleepiness with repeated episodes of naps or lapses into sleep of short duration

Cataplexy (sudden loss of bilateral muscle tone propvoked by strong emotion)

Sleep paralysis Hypnagogic hallucinations

PSG and MSLT: reduced sleep latency, sleep-onset REM (SOREM)

Genetic features (HLA typing: DQB1*0602) Deficit of hypocretin (orexin) – peptid secreted

in the hypothalamus

Idiopathic hypersomnia Increased need of day-time sleep, but not

episodic

Recurrent hypersomia Kleine-Levin syndrome

Episodes of hypersomnia, hyperphagia, hypersexuality, mental status changes (aggression)

Therapy of hypersomnia Changing day-time schedules

MedicationMethylfenhydateModafinilSodiumoxybateTricyclic antidepressants (imipramin),

thymoleptics (cytalopram, sertralin)

Circadian-Rhythm Disorders I

Abnormal timing and length of sleep

Desynchronization of one’s biological rhytmicity and the external circadian rhythme.g. non-24 hour sleep-wake disorder of blind

Circadian-Rhythm Disorders II.

Delayed/advanced sleep-phase syndrome Irregular sleep-wake pattern Jet lag syndrome

Better tolerance of Western fligths Shift work sleep disorder

Circadian-Rhythm Disorders III

Therapy:Regular physical activities and regular food

intake to strengthen synchronizationMorning illumination with bright light (2.5-10

tousand Lux)MelatoninChronotherapy (extension of the day to 27

hours)

Parasomnias NREM x REM

NREM parasomnias – arousal disorders Confusional arousals Sleepwalking Sleep terrors

REM parasomnias REM sleep behavior disorders Nightmares – terrifying dreams provoke arousal with

highly emotional and anxious reaction

Other parasomnias

Bedwetting Somniloqia (sleep talking) Sleep-related eating

CompulsiveNot provoked by hungerThe patient eats inedible or toxic substances

Hypnagogic hallucinations

Abnormal movements related to sleep

RLS Bruxismus Rhythmic movement disorder

Restless Legs Syndrome

Disagreeable leg sensations that usually occur prior to sleep onset and cause an almost irresistible urge to move the legs

Causes sleep onset insomnia Etiology

Primary (idiopathic) Secondary (pregnancy, uraemia, anaemia)

Rhythmic movement disorder

video

Neurological disease related sleep disorders

Epilepsy and sleep I

Sleep EEG recordings can show epileptic discharges that were not present in wakefulness

In general epileptic discharges are more frequent in NREM then in REM sleep

Sleep deprivation or bad quality sleep can provoke epileptic seizures

Seizures appear typically during sleep or on awakening in some epilepsy syndromes

Neuromuscular disease

Sleep-related breathing disorderDecreased dilatation of the pharynx in sleep Inability to change position during sleepDecreased ventilation

Depression, anxiety

Cerebral palsy, neurodegenerative diseases Limited perception of extrinsic stimuli Limited social contacts Limited abilities of education in mental retardation Altered ascendant reticular formation maintaining

wakefulness Loss of circadian regulation Epileptic seizures Episodes of increased sleepiness, apathy, irritability Hyperactivity Hypnagogic jerking (sleep starts) interfering with

falling asleep Pain, crying