Lecture 4 Flashcards
What are the different ways to investigate human sleep and advantage and disadvantages
actigraphy sleep diaries MSLT MWT PVT sleep questionnaires
sleep recordings and sleep patterns and behaviours help us investigate sleep
SLEEP RECORDINGS
brain acitivty
Muslce Activity
MSLT
Sleep Architecture
SLEEP PATTERNS AND BEHAVIOURS
Sleep diareis
acitigraphy
questionnairres (ESS, SSS, PSQI, ISS, Berlin, MCG)
What is fragmentation index what is it measure by what is patholgical?
total number of awakenings or shifts to n1/total sleep time in hours)
<85% suggests poor sleep efficiency
brain actiivty
PSG (6) T Se so wasp a fi
PET
Muscle activity
PSG -
allows investigation of TST, Sleep efficiency, sleep latency, wake after sleep offset, number of awakenings, fragmentation index (total number of awakenings or shifts to N1 / total sleep time in hours)
<85% suggests poor sleep efficiency
Sleep diaries
more global iew of patterns and behaviours
enhanced information but without the accuracy of PSG or actigraphy
actigraphy
more complex than sleep diaries
validated against PSG useful for estimating total sleep time, sleep % and WASO
can’t say that sleep period of no mvoemnt as there’s some movement but generally movement correlates well with sleep
cheap and tolerated well by peaditirc clincial popualtion
Insight to CR dioder used on normal sleep enviornment for long periods
may be inaccurate in elderly
Sleep questionaiires
Epworth = day time sleepiness (when doing a certain acitivty how sleepy are you)
Berlin = breathing realted how often do you snore etc
MWT and how does it diagnose sleep disorders
Test session terminated when unequivocal sleep occurs or after XX mins
tests are repeated after X hours
there are X-X trials in total
Ability to remain awake for XX mins is the strongest evidence for normal alertness
sleep onset less than X mins (longer than MSLT) considered abnormal
measures maifest sleepiness based on the idea that aiblity to stay awake may be more important to know than ability to fall asleep
subjects instructed to stay awake
Test is performed in a dimly lite room on a bed with no addition acitivites
patients have PSG at the same time so thier sleep can be assessed
40 mins 2 hours 4-5 trials in total 40 8
between trials only restriction is can’t go out into daylight
can be used to evlaute riskif someone’s jon involves public transport/saftey - some occupations require a MWT to be conducted
How might you investigate day time sleepiness?
physiological- biological drive to sleep (MSLT)
introspective - self-assessment of internal state (ESS, SSS)
SSS used as part of test of ongoing sleepiness
Manifest - behavioural signs of sleepiness, inability to volitionally stay awake, performance deficit on psychomotor or cognitive tasks (MWT, PVT)
Name two manuals used to classify disorders - what are the main cateogires
ICSD-2 8 catorgies insomnia parasomnias sleep realted breating diorders Sleep related movement disorders Hypersomnias of central origin circadian rhythm sleep disorders isolated symptoms apparently normal variants & unresolved issues other issues
ICSD-3 six categories Insomnia Sleep-related breathing disorders Central disorders of hypersomnolence Circadian rhythm sleep-wake disorders parasomnias sleep-related movement disorders
DSM-5 sleep-wake disorders. 11 diagnostic groups
ICSD- 3 categories
Insomnia Sleep-related breathing disorders Central disorders of hypersomnolence Circadian rhythm sleep-wake disorders Parasomnias Sleep-related movement disorders
What is the multiple sleep latency test, and how does it help in the diagnosis of sleep disorders?
Why? Rationale How - series of nap oopurtunites X hours after awakening PSG measure sleep onset latency X to resist falling asleep PSG use XX
Between tests what do they do?
How many tests - X-X
when? X hours apart
Terminated
XX mins after sleep onset - make sure they aren’t going into REM
if REM is before XX mins indicator of ———–
OR terminated when
– no sleep
clear sleep onset _x__ epochs of N1 and 1 of N2,N3 or REM
DIagnosing
—————- or i———– h—————–
treatments for b———— d————
sleep onset latency
determination of DTS –
People who are sleepier tend to fall asleep faster – due to (process S)
2 hours
PSG used to measure sleep onset latency (EEG, EMG and EOG)
not
Between tests subjects have to get out of bed
night before
• 4-6 tests performed, repeated every 2 hours
Terminated
15 mins after sleep onset – want to make sure they aren’t going into REM.
narcolepsy.
o 20 mins if no sleep
o Clear sleep onset – 3x30s epochs of n1 and one epoch of n2, n3 or REM)
Diagnosing: narcolepsy and idiopathic hypersomnia. Treatments for breathing disorders The time to sleep onset is averaged/ individual tests to give mean MSLT score < 8 mins are abnormal, <5 mins indicate severe EDS. Health adults = 10-20mins
Confound –
atypical sleep the previous night, hence PSG night before
Use of medications like stimulants or anti-depressants
Must consider other potential explanations, e.g. a fatigue condition.
What is the maintenance of wakefulness test, and how does it help in the diagnosis of sleep disorders?
What does it measure? Why? How? What do they measure? When is it terminated? N1 for - epochs or after -- mins
How many times is it repeated?
after _ hrs - trials in total
During breaks patients patients can __ but they can’t go _______ because________
Diagnosis
ability to remain awake for __ = strongest evidence of normal altertness
sleep onset < _ mins = abnormal (longer than MSLT)
effectiveness of ______
evaluate the ____ of someon’s job involves public transport/safety - some occupations require a MWT to be conducted
measures manifest sleepiness.
stay awake may be more important to know than the ability to fall asleep.
Subjects instructed to stay awake dimly lit room, on a bed, with no additional activities such as reading or TV.
o Simultaneous PSG.
o terminated when clear unequivocal sleep occurs (at least N1, for 3 epochs) or after 40 minutes.
o Repeated after 2 hours, 4-5 trials in total.
o During breaks between trials, patients can watch TV, eat, read etc. but can’t go outside into the daylight.
Ability to remain awake for the whole 40 mins = normal alertness,
sleep onset < than 8 mins abnormal (longer than MSLT)
o Can be used to assess the effectiveness of CPAP
o Can also be used to evaluate risk if someone’s job involves public transport/safety – some occupations require an MWT to be conducted.
How might you investigate day time sleepiness? (physiological, Introspective, Manifest
Describe some sleep questionnaires
physiological
introspective
manifest
P = biological drive to sleep, measured by MSLT <5 mins = severe pathological HA= 10-15mins
I = sleep questionnaires, self-assessment of the internal state
ESS - chance of falling asleep in certain situations
SSS - over time level of alterness (may miss certain aspects of sleep)
M = behavioural signs of sleepiness, inability to volitionally stay awake performance defifict on cognitive tasks or psychomotor tasks Measures = MWT, PVT
Name two manuals used to classify disorders – what are the main categories in each manual
ICSD-2 - ICSD-3 (8 categories to 6 categories) I SRBS CDHy CRD P SRMD other
DSM5 11 I, Hy Nar OSA hyp CSA SRHv CRSWD NREM sleep arousal Nightmare REM SBD RLS
• International classification of Sleep Disorders (ICSD-3) was simplified from ICSD-2 which had 8 categories, and has been condensed down to 6 major categories
o Insomnia,
category is much shorter than ICSD-2 as all diagnoses characterised by a chronic insomnia disorder have been collapsed into a single diagnosis (chronic insomnia disorder)
o Sleep-related breathing disorders include OSA, CSA, sleep-related hypoventilation and sleep-related hypoxaemia.
o Central disorders of hypersomnolence include narcolepsy 1 and narcolepsy 2, Kleine-Levin syndrome (‘sleeping beauty syndrome’) etc.
o Circadian rhythm disorders include delayed and advanced sleep-wake phase disorder, shift work disorder, jet lag disorder etc.
o Parasomnias include sleep terrors, sleep walking, recurrent sleep paralysis, exploding head syndrome.
o Sleep-related movement disorders include PLM, RLS.
• ‘other sleep disorder’ and appendices for disorders and substance abuse which can have a secondary impact on sleep.
• DSM-5 sleep-wake disorders. 11 diagnostic groups:
Insomnia, hypersomnolence, narcolepsy, OSA hypopnea, CSA, sleep-related hypoventilation, circadian rhythm sleep-wake disorders, NREM sleep arousal disorders, nightmare disorder, REM sleep behaviour disorder, restless legs syndrome
• DSM-5 eliminated two previous diagnoses – sleep disorder related to another mental disorder, and sleep disorder related to another medical condition.
What is insomnia, what is it characterised by, what is the prevalence and how is it treated
What?
complaint of SL, SM, EA,NRS despite ao, and DTS
without DTS no diagnosis
Types: ASD PI PSyI BIC
ICSD simplies into X and X
Prevalence
Ohayon & Reynolds (2009)
X sectional study of –,— people –.-% reported at least one insomnia symptom -.-% met DSM-IV and approx -& ICSD
prevalence is depending on a– and g——
1/2 met diagnostic crtieria also met criteria for a m—- and a——- disorders are most common
MH association Jonhsonet al (2006)
I precede D
A precede I
Treatment = b————– safely adminseterd for _ weeks best when combined with —–
M——— sleep inducing aent
What complaint of sleep onset, sleep maintenance, early awakening, non-restorative sleep despite adequate opportunity to sleep and patients suffer day time impairment.
• Without day time impairment – individuals perceived need for treatment will not receive diagnosis of insomnia.
Adjustment sleep disorder
Associated with specific stressor
Paradoxical insomnia
Subjective report of severe sleeplessness not congruent with the absence or minor degree of daytime impairment
Feel terrible but PSG = fine
Psychophysiological insomnia
Working in bed
Learned sleep preventing associations
Behavioural insomnia in childhood
Inadequate limit setting
ICSD-3 simples into immediate and long-term insomnias
Ohayon and Reynolds (2009)
25,000
34.5% reported at least one insomnia symptom (6.6% met DSM-IV criteria and approx. 2% ICSD
age and gender
mood and anxiety disorders are most common
However, this was a sleep diary study asking coarse questions – despite large cohort
MH association supported by Johnson et al (2006)
Insomnia precedes depression (3.8)
Anxiety precedes insomnia (3.5)
Treatment: medication benzodiazepines can be safely and effectively administered for longer than three weeks most efficacious when combined with –
for short-term and chronic insomnia need behavioural intervention in form of sleep hygiene education, stimulus-control therapy and CBT
• Melatonin may also be used as sleep-inducing agents
What is Fatal-familial Insomnia how does it differs from insomnia
What is it
what is it caused by - how does this differ from insomnia
progressive working memory attentionm ordering and frontal lobe functions
provides evidence for the necessiting of ____ sleep
CURE?
barbiturates —– the course of FFI
it is a transmissale prior diease
it is not a sleep disorder
mutated protien found in 40 familes world wide
It is fatal and leads to deat within 8-72 months a mean of 18 months
diagnosed around 50 yrs and therefore important for family planning 50% chance of inheritance
effects like insomnia
but the cause is due to a mutated protien PrP^C causing THALAMIC HYPOMETABOLISM and ATROPHY there are a lack of spindles and SWS but N1 is conserved
Insomnia may be caused by depression anixety or phyiscal healthconditions
deep - N1 clearly not sufficient for restoring the body
o FFI lack of a cure
o insomnia, treatments = CBT, good sleep hygiene, and sleeping medication.
Sleeping medication such as barbiturates hasten the course of FFI
What is narcolepsy
Prevalence 1/—-
HY
CAUSE abnormalities in the --- --% carrying gene However only increase from of _-_% still a --/-- fold inc vs GP
relation between O and N
O is a N—P——– confined to a small no of cells in the ——–
patients with N have often lost those o producing neruons
accroding to the / model uncontrollable passing between w and s state
CHARACTERISED DTS C Hyp Hall SP AutBeh
DIAGNOSIS (3 tests) P asses QoNS M assess REM o and S E asses sub DTS
What is normally mistaken for
L
S
Poor SH
TREATMENT
Complete not poss
LA - S, N, SH
Zucconi and Ferri (2014)
Narcolepsy in ICSD-2 Narc w and Narc wo
/ T1 and T2
allowed patients w/o to be classfied with those who have c
Hypersomnia
rare neurological disorder affecting 1/2000 people
Cause:
ocentral nervous system
90%
1-2%. Still a 10-40-fold increase vs. general population.
Relation between hypocretin and narcolepsy –
neuropeptide confined to a small number of cells in the hypothalamus.
Patients with narcolepsy have often lost these orexin-producing neurons.
flip-flop
wake and sleep state
Characterised:
o Fall asleep inappropriately times in the day – particularly in non-stimulating activities despite adequate op to sleep night before
Other symptoms include:
o cataplexy (sudden & brief spells of muscle weakness) often triggered by emotional events
o Hypnagogic hallucinations – at sleep onset or offset
o Sleep paralysis
o Automatic behaviour
o Disrupted night-time sleep
Diagnosis
o Overnight PSG to assess quality of nocturnal sleep
o MSLT to assess REM onset and sleepiness
o ESS to assess DTS
Usually diagnosed in adolescence/young adulthood, mistaken for:
laziness, depression, poor sleep habits.
Can make it harder to get a diagnosis.
Treatment:
complete control of symptoms is not possible – medication helps EDS but not the condition itself
o Lifestyle alterations to manage stress, taking naps daily (10-15 mins) more basic sleep hygiene issues
Zucconi and Ferri (2014) – narcolepsy in ICSD-2 was defined as ‘narcolepsy with’ and ‘narcolepsy without’ cataplexy. Now, it’s been subdivided into type 1 and type 2. These changes allow patients without cataplexy, but with deficient hypocretin, to be classified together with those who have cataplexy.
