1. LEEP DISORDERS

2. Sleep Architecture and Sleep
Stages
• divided into two independent states: NREM
and REM sleep
• NREM - further divided into three stages ie
N1, N2, N3
• After sleep onset, progresses through NREM
stages N1–N3 sleep within 45–60 min
• NREM and REM sleep alternate, with each
cycle lasting for approximately 90 to 100
minutes

3. • Four to six such cycles are noted during a
normal sleep period
• N3 predominates in the first third of the night
and comprises 15–25% of total nocturnal
sleep
• REM sleep dominates the last third
• Overall, REM sleep constitutes 20–25% of
total sleep, and NREM stages N1 and N2 are
50–60%

5. Sleep Requirements and Quantity
of Sleep
• Sleep requirement is defined as the optimal
amount of sleep required to remain alert and
fully awake and to function adequately
throughout the day
• for an average adult is approximately 7.5 to 8
hours

6. Classification of Sleep Disorders
• International Classification of Sleep Disorders
• latest edition of the International
Classification of Sleep Disorders (ICSD-2)
(AASM, 2005)
• eight broad categories of disordered
sleep, along with several subcategories

7. • I. Insomnia
• II. Sleep-related breathing disorders
• III. Hypersomnias of central origin not due to a
circadian rhythm sleep disorder, sleep-related
breathing disorder, or other cause
• IV. Circadian rhythm sleep disorders

8. • V. Parasomnias
• VI. Sleep-related movement disorders
• VII. Isolated symptoms, apparently normal
variants, and unresolved issues
• VIII. Other sleep disorders

9. Approach to the Patient: Sleep
Disorders
• an acute or chronic inability to initiate or
maintain sleep adequately at night (insomnia)
• chronic fatigue, sleepiness, or tiredness during
the day (EDS)
• Inability to sleep at the right time
• Abnormal movements and behavioural
manifestation associated with sleep itself

10. SUBJECTIVE MEASURES OF
SLEEPINESS

11. Narcolepsy
• characterized by recurrent "sleep attacks" that
the patient cannot fight
• Irresistible desire to fall asleep in inappropriate
circumstances and at inappropriate places

12. • e.g., while
talking, driving, eating, playing, walking, runni
ng, working, sitting, listening to
lectures, watching television or movies
• The sleep attacks are about 20-30 minutes
long.
• The patient feels refreshed by the sleep, but
typically feels sleepy again several hours later

13. Narcolepsy
• Symptoms of narcolepsy typically begin in the
second decade
• Once established, the disease is chronic
without remissions
• Men and women are equally affected
• affects about 1 in 4000 people in the United
States

14. ICSD-2 (AASM,
2005)
• narcolepsy withcataplexy
• narcolepsy without cataplexy
• secondary narcolepsy

15. Narcolepsy Tetrad
EDS plus 3 specific symptoms:
1. Cataplexy sudden weakness or loss of
muscle tone without loss of
consciousness, often elicited by
emotion
2. Hallucinations at sleep onset
(hypnagogic hallucinations) or upon
awakening(hypnopompic
hallucinations)- visual
3. Sleep paralysis occurs during the
transition from being asleep to waking
up.

18. GENETICS
• Most are sporadic, some are AD
• 10 to 40 times greater prevalence in families
• hypothalamic neuropeptide hypocretin
(orexin) is involved in the pathogenesis
• narcoleptics with cataplexy are positive for
HLA DQB1*0602, suggesting that an
autoimmune process

19. CURRENT THEORY
• Results from a depletion ( degeneration or
autoimmune) of hypocretin neurons in lateral
and perifornical regions of hypothalamus

20. Symptomatic or secondary
narcolepsy-cataplexy
• diencephalic and midbrain
tumors, MS, strokes, cysts,
• vascular malformations, encephalitis, cerebral
trauma, and
• paraneoplastic syndrome with anti-Ma2
antibodies

21. Treatment of Narcolepsy-Cataplexy
Syndrome
Nonpharmacological measures include
• scheduled short daytime naps,
• sleep hygiene measures
• attendance at narcolepsy support groups

23. Breathing-related Sleep Disorders
syndromes in which the patient's sleep is
interrupted by problems with his or her
breathing

24. types of breathing-related sleep disorders:
Obstructive sleep apnea syndrome. most
common form, marked by episodes of
blockage in the upper airway during sleep. It is
found primarily in obese people.
Central sleep apnea syndrome. primarily
found in elderly patients with heart or
neurological conditions that affect their ability
to breathe properly.Problem lies in the
ventilator control mechanisms in CNS.

25. Sleep-Disordered Breathing
Terminology
Apnea - three types: obstructive, central, and
mixed
• central apnea - Cessation of airflow with no
respiratory effort, both diaphragmatic and
intercostal muscle activities as well as gas
exchange through the nose or mouth are
absent
• obstructive apnea - airflow stops while the
effort continues

26. • mixed apnea - there is an initial cessation of
airflow with no respiratory effort (central
apnea) followed by a period of upper airway
obstructive sleep apnea
• Apneas are defined in adults as breathing
pauses lasting >10 s
• hypopneas as events >10 s in which there is
continued breathing but ventilation is reduced
by at least 50% from the previous baseline
during sleep

28. OBSTRUCTIVE SLEEP APNEA
• defined as the coexistence of unexplained EDS
with at least five obstructed breathing events
(apnea or hypopnea) per hour of sleep
• Factors contributing to the pathogenesis
include local anatomical, neurological, and
vascular factors, as well as familial
predisposition

29. Pathogenesis
• Collapse of the pharyngeal airway is the
fundamental factor
• During sleep, muscle tone decreases - causes
these muscles to relax - increasing upper
airway resistance and narrowing the upper
airway space

30. Epidemiology
• prevalence is 4% in men and 2% in women
between the ages of 30 and 60
• also occurs in childhood—usually associated
with tonsil or adenoid enlargement

31. Factors predisposing to OSAS
• obesity—in Western populations around 50%
of OSAHS patients have a body mass index
(BMI) >30 kg/m2
• Hypothyroidism and acromegaly - narrowing
the upper airway with tissue infiltration
• male sex, middle age (40–65 years)

33. Symptoms and Signs

34. • sleep attacks lasting 0.5 to 2 hours and
occurring mostly when the patient is relaxing.
• The prolonged duration and the nonrefreshing
nature of these sleep attacks in OSAS
differentiate these from narcoleptic sleep
attacks

35. Consequences
• increased morbidity and mortality
• short-term consequences (impairment of
quality of life and increasing traffic- and work-
related accidents)
• long-term consequences from associated and
comorbid conditions such as
hypertension, heart failure, MI, cardiac
arrhythmias, stroke, transient ischemic
attacks, cognitive dysfunction, depression, and
insomnia

36. Mallampati classification

37. General Measures
• Avoid alcohol and sedative-
hypnotics, especially in the evening
• Reduce body weight if overweight
• Avoid sleep deprivation
• Participate in regular exercise program
• Avoid supine sleeping position

38. Mechanical Devices
• Continuous positive airway pressure (CPAP)
titration - treatment of choice
• Bilevel positive airway pressure (BiPAP)
titration
• Auto-CPAP
• Oral appliances, including mandibular
advancement device
• Tongue-retaining device

39. Surgical Techniques
• Uvulopalatopharyngoplasty (UPP)
• Laser-assisted UPP (LAUP)
• Radiofrequency UPP (somnoplasty)
• Palatal implants
• Nasal surgery
• Maxillomandibular advancement
• Anterior hyoid advancement
• Tonsillectomy and adenoidectomy

40. Insomnia
• most common sleep disorder
• Inability to initiate or maintain sleep, early
awakening, inadequate sleep time, or poor
sleep quality associated with a lack of feeling
restored and refreshed in the
morning, leading to poor daytime functioning
- AASM (2005)

41. Primary Insomnia
• onset occurs in early
childhood
• lifelong difficulty with
initiating or maintaining
sleep
• exclusion of concomitant
comorbid
medical, neurological, psych
iatric, or psychological

42. Medical Disorders Comorbid
with Insomnia
• Ischemic heart disease
• Congestive cardiac failure
• Chronic obstructive pulmonary disease
• Bronchial asthma
• Peptic ulcer disease
• Gastroesophageal reflux disease
• Rheumatic disorders

43. Treatment of Insomnia
• most commonly used hypnotics are the
benzodiazepine receptor agonists –
zolpidem, zaleplon, and eszopiclone
• Melatonin receptor agonists(ramelteon) -
sleep-onset insomnia

45. PARASOMNIAS
• abnormal movements or behaviours that
occur in sleep or during arousals from sleep
• may be intermittent or episodic, and sleep
architecture may not be disturbed

46. ICSD-2 (AASM, 2005)
• Disorders of arousal (from NREM sleep), which
include confusional
arousals, sleepwalking, and sleep terror
• Parasomnias associated with REM
sleep, which include RBD, recurrent isolated
sleep paralysis, and nightmare disorder
• other parasomnias including sleep-related
dissociative disorders, sleep enuresis, sleep-
related groaning (catathrenia)

47. Sleepwalking
• Somnambulism
• Onset: common between ages 5
and 12 yr
• High incidence of positive family
history
• Abrupt onset of motor activity
arising out of slow-wave
sleep(NREM stage N3
sleep), during first one-third of
the night

48. • Duration: less than 10 min
• Injuries and violent activity occasionally
reported
• Precipitating factors: sleep
deprivation, fatigue, concurrent
illness, sedatives
• Treatment:
precaution, benzodiazepines, imipramine

49. Sleep Terror
• pavor nocturnus
• Onset: peak is between ages
5 and 7 yr
• High incidence of familial
occurrences
• Abrupt arousal from slow-
wave sleep during first one-
third of the night, with a loud
piercing scream
• Intense autonomic and
motor components

50. • Precipitating factors: stress, sleep
deprivation, fever
• Treatment:
psychotherapy, benzodiazepines, tricyclic
antidepressants

51. Rapid Eye Movement Sleep
Behavior Disorder (RBD)
• Onset: middle-aged or elderly men
• Presents with violent dream-enacting
behavior during sleep, causing injury to self or
bed partner
• Often misdiagnosed as a psychiatric disorder
or nocturnal seizure (partial complex seizure)

52. • Etiology: 40% idiopathic, 60% causal
association with structural central nervous
system lesion or related to alcohol or drugs
(sedative-hypnotics, tricyclic
antidepressants, anticholinergics)
• Polysomnography: rapid eye movement sleep
without muscle atonia
• Treatment: 90% response to
clonazepam, melatonin

53. Nightmare Disorder
• Dream anxiety attacks
• fearful, vivid, often
frightening
dreams, mostly visual
but sometimes
auditory, and seen
during REM sleep
• most commonly occur
during the middle to
late part of sleep at
night

54. • mostly a normal phenomenon, up to 50% of
children have nightmares beginning at age 3
to 5 years
• side effects of certain medications such as
antiparkinsonian drugs
(pergolide, levodopa), anticholinergics, and
antihypertensive drugs, particularly beta-
blockers
• generally do not require any treatment except
reassurance

55. Sleep-Related
Movement Disorders

56. Restless Legs Syndrome (RLS)
• most common movement disorder but is
uncommonly recognized and treated
• irresistible urge to move their legs while at
rest.
• experience a vague, uncomfortable feeling
while at rest that is only relieved by moving
the legs.
• mostly diagnosed in the middle or later years

57. Clinical Diagnostic Criteria
Essential Criteria
• An urge to move the legs, usually
accompanied by or caused by uncomfortable
sensations in the legs
• begins or worsens during periods of rest or
inactivity, such as lying or sitting
• partially or totally relieved by movement such
as walking or stretching
• worse in the evening or night

58. Supportive Features
• Dopaminergic responsiveness
• Presence of periodic limb movements in sleep
or wakefulness – 80%
• Positive family history

59. Associated Features
• Usually progressive clinical course
• Normal neurological examination in the
idiopathic form
• Sleep disturbance

60. Secondary - Medical Disorders
• Anemia: iron and folate deficiency
• Diabetes mellitus
• Amyloidosis
• Uremia
• Chronic obstructive pulmonary disease
• Peripheral vascular (arterial or venous)
disorder
• Rheumatoid arthritis
• Hypothyroidism

61. Pathophysiology
• iron-dopamine dysfunction
• abnormalities in the body’s use and storage of
iron
• dopamine dysfunction - changes in dopamine
receptors or dopamine uptake

62. Drug Treatment of Restless
Legs Syndrome
Dopaminergic agents:
• Pramipexole
• Ropinirole
Benzodiazepines:
• Clonazepam
• Temazepam
Antiepileptic agents:
• Gabapentin
• Pregabalin

63. Circadian Rhythm Sleep Disorders
• Mismatch between the body’s internal clock
and geophysical environment
• either as a result of malfunction of the
biological clock or a shift in the environment
causing this to be out of phase
• Most common are jet lag and shift-work sleep
disorder

64. Types of Circadian Rhythm Sleep
Disorders

65. Jet lag
sleepiness and alertness that
occur at an inappropriate
time of day relative to local
time, occurring after
repeated travel across
more than one time zone

66. Shift work
insomnia during the major sleep period or
excessive sleepiness during the major awake
period associated with night shift work or
frequently changing shift work

67. • Modafinil (200 mg, taken 30–60 min before
the start of each night shift) is approved by
the U.S. Food and Drug Administration as a
treatment for the excessive sleepiness during
night work in patients with SWD

68. Laboratory Assessment of
Sleep Disorders
• The two most important laboratory tests for
diagnosis of sleep disturbance are PSG and the
MSLT
• overnight PSG study is the single most
important laboratory test for the diagnosis
and treatment of patients with sleep disorders

71. Multiple Sleep Latency Test
• important test to effectively document EDS
• Narcolepsy is the single most important
indication
• presence of two sleep-onset REMs on four or
five nap studies and sleep-onset latency of
less than 8 minutes strongly suggest a
diagnosis of narcolepsy
• circadian rhythm sleep disturbance - REM
sleep abnormalities

72. Sleep Education
"Sleep hygiene" or sleep education for sleep disorders often
includes instructing the patient in methods to enhance sleep.
Patients are advised to:
• wait until he or she is sleepy before going to bed
• avoid using the bedroom for work, reading, or watching
television
• get up at the same time every morning no matter how much
or how little he or she slept
• avoid smoking and avoid drinking liquids with caffeine
• get some physical exercise early in the day every day
• limit fluid intake after dinner; in particular, avoid alcohol
because it frequently causes interrupted sleep
• learn to meditate or practice relaxation techniques
• avoid tossing and turning in bed; instead, he or she should get
up and listen to relaxing music or read