L9 Sleep Disorders

Question 1

What can we say about sleep disorders?

Answer 1

Common
Serious
Treatable
Under-diagnosed
Costly

Question 2

What is the prevalence of insomnia?

Answer 2

4-19%

Question 3

What is the prevalence of OSA?

Answer 3

up to 4% of adults

Question 4

What is the prevalence of narcolepsy?

Answer 4

1 in 2000 (0.03-0.16%) - many are not diagnosed

Question 5

What are the consequences of poor sleep in relation to car accidents?

Answer 5

Car crashes are more common when sleep deprived
1 in 6 car crashes are related to fatigue and the cost is huge
53% of individuals have driven a vehicle whilst feeling drowsy

Question 6

What are morbidities of poor sleep?

Answer 6

Obesity
Metabolic syndrome
Depression and suicide (relative risk for depression is 4x higher when SD and suicide risk is 7x higher)

Question 7

What are the consequences for relationships with poor sleep?

Answer 7

Less enjoyment and a reduced QOL

Question 8

What are some examples of problems caused by sleepiness?

Answer 8

Selby train crash - 10 fatalities, driver fell asleep and car went onto train line, now in prison
Bhopal chemical disaster - over 10,000 fatalities, plant blew up after worker fell asleep on night shift and toxic gases released
Chernobyl disaster - 56 fatalities and radiation, chief of plant fell asleep and reactor blew up
Challenger space shuttle disaster - put off take off for 10 days due to weather, made decision after SD which was more risky and fuel tank exploded

Question 9

What are some treatment examples for sleep disorders?

Answer 9

Pharmacotherapy
Behavioural therapy
Continuous positive airway pressure (CPAP) for OSA
Surgical therapy

Question 10

What are the rates of people being undiagnosed?

Answer 10

As many as 95% of people with a sleep problem remain undiagnosed
Lot of people think they’re not treatable so don’t bother seeing anyone about it
Few healthcare providers question patients about sleep and it is rarely taught in medical schools
If treat the sleep side effects of other disorders may be able to manage it more successfully

Question 11

What is normal sleep?

Answer 11

Between 6-8 hours
Changes throughout life
If have a sleep partner it can impact quality of sleep
Context and locations of normal sleep can vary

Question 12

How is sleep history relevant in diagnosing sleep disorders?

Answer 12

Have to go through a lot of the history and different aspects:
What happens at different times, look at physical and psychological aspects, are any drugs being taken? family history
Should evaluate the 24 hour sleep/wakefulness patterns

Question 13

What is the Epworth Sleepiness Scale

Answer 13

Scale to measure quality of sleep
Good for seeing how a patient is responding to treatment
Not entirely accurate but best there is

Question 14

What can be seen in outpatient neurophysiology studies?

Answer 14

The patient might be asked about something but they’re in a poor position to know about it as they might not know what they’re doing
Need to look at objective measures
Can assess breathing, EEG, PSG and movement of limbs which can give lots of data

Question 15

What happens in inpatient telemetry studies?

Answer 15

Patients come into the hospital for objective measures and can also video what they do - providing comprehensive data

Question 16

What are other objective measures?

Answer 16

Multiple Sleep Latency Test (MSLT)
Maintenance of wakefulness test
Vigilance tests - psychomotor vigilance test

Question 17

What is the classification of insomnia?

Answer 17

Can be initial, middle of the night or terminal
Can involve hypnic phenomena such as falling off a cliff
Or people can sometimes experience hallucinations of pain such as a burning in the body as they’re falling asleep which can in turn cause insomnia or sleep phobia

Question 18

What is treatment for insomnia and why is it important?

Answer 18

Can be treated through CBT
Can lead to more significant and more resistant depression so important to treat
TST isn’t actually that relevant, look at whether the patient feels refreshed and is effective during the day

Question 19

What are some examples of disordered breathing hypersomnias?

Answer 19

OSA - an obstruction causing disordered breathing, narrow airways, too much tissue around the throat e.g. snoring
Central SA - dysfunction of the brain as it is an issue with control

Question 20

What is narcolepsy?

Answer 20

An abnormality of REM sleep, intrusions into other stages and disrupts the quality of sleep rendering the individual very tired the next day
Can happen with or without cataplexy (about 3/4 have cataplexy)
Involves irresistible sleep attacks
Thought to be due to loss of hypocretin found in the hypothalamus
Memory can be pretty bad and can take a while to find the right medication
Need adult supervision sometimes

Question 21

What is cataplexy?

Answer 21

A sudden drop/atonia due to intrusion of REM sleep into wakefulness but retain awareness
Can be triggered by emotions such as anger

Question 22

What treatments are available for narcolepsy?

Answer 22

Planned naps, good sleep hygiene

Stimulants - modafinil, amphetamines, methylphenidate (is an amphetamine)

Question 23

What treatments are available for cataplexy?

Answer 23

Antidepressants - the effect is immediate

Sodium oxybate - can improve narcolepsy and cataplexy

Question 24

What are SWS parasomnias?

Answer 24

Sleep walking/talking
They are disorders of arousal which are common in childhood and usually get better with adulthood
Sleep terror treatment should also manage the parents as can be distressing and child has no recollection of them
Treatments include: reassurance, benzodiazepines and trazadone

Question 25

What is REM behavioural disorder?

Answer 25

A loss of generalised atonia in REM sleep
Dream enactment, can be violent, experienced in last 3rd of the night
Might be able to remember some of the episode
Clonazepam appears to be useful
BUT medication might not be best as they can make people feel drowsy and decreases in mood, if they live on their own may not be disturbing anyone but can be embarrassing
Can sometimes be confused with epilepsy

Question 26

What is Restless Leg Syndrome?

Answer 26

Aching, pain or numbness if not moving legs
An irresistible urge to move legs, difficult to describe
More common towards evening
Common yet frequently undiagnosed
Can be due to a genetic predisposition, iron deficiency or renal failure
Antipsychotics, SSRIs and TCAs make it worse - possibly due to serotonin depletion?

Question 27

Outline sleep apnoea

Answer 27

Occurs predominantly in middle aged men and is associated with obesity and cardiovascular problems
Weight loss and use of CPAP appear to be the most effective and frequently recommended modalities of treatment

Question 28

What can sometimes be seen in insomniacs before and during sleep?

Answer 28

Autonomic hyperactivity

Increased heart rate, muscle tension, increased body temp and peripheral vasoconstriction

Question 29

How do insomniacs generally handle external stress?

Answer 29

By internalising their emotions, generating a combination of emotional arousal and physiological activation
This mental and physiological hyper arousal leads to difficulty in initiating sleep

Question 30

What is helpful to do when counselling an insomniac?

Answer 30

Explain how anxiety participates in the vicious cycle that exacerbates and maintains the condition