Lecture - Sleep Disorders

Question 1

Disorders of initiating and maintaining sleep

Answer 1

• Insomnia

Question 2

Disorders of excessive sleepiness

Answer 2

• sleep apnea: OSA, CSA, obesity hypoventilation

- Narcolepsy

Question 3

Parasomnias/sleep-related movement disorders

Answer 3

• disorders of arousal, REM behavior disorder

- restless legs syndrome

Question 4

Insomnia

Answer 4

• 3x week +
• duration 3 months
• two subtypes: with normal sleep duration, with abnormal sleep duration
• 30-40% of adults have experiences some level of insomnia, 10-15% of adults report chronic or severe insomnia
• female more likely
• more with advancing age
• more likely with shift work

Question 5

Morbidity of insomnia

Answer 5

• increased risk for psychiatric disroders
• decreased QOL
• increased health care utilization and costs
• increased absenteeism/occupational performance
• Falls
• MVA
• Increased pain sensitivity
• CV disease

Question 6

Treatment for insomnia

Answer 6

• CBT
• pharmacological: benzodiacepine, melatonine
• benzodiazepine receptor agonists have significant side effects and safety concerns
• most other alternative have not been evaluated yet

Question 7

Treatment of OSA

Answer 7

• conservative measures
• CPAP
• oral appliances
• orofacial orthopedics
• Surgical
• experimental

Question 8

Mandibular advancement splints for sleep apnoea

ADVANTAGES
DISADVANTAGE

Answer 8

ADVANTAGE

• simple
• unobtrusive
• quiet
• no need for power source

DISADVANTAGE

• poorly predictive of outcome
• titration technique
• health outcomes
• influence of appliance design
• long term efficacy and complication

Question 9

Upper airway surgery for OSA

Answer 9

• underlying specific abnormality
• tracheostomy the only effective sole procedure
• minimally invasive multi-level surgery promising
• Palatal surgery rarely curative

Question 10

Obesity hypoventilation syndrome (Hypercapnic OSA)

Answer 10

• extreme obesity and alveolar hypoventilation during wakefulness (hypercapnic resp failure)
• associated with significant morbidity and mortality
• often missed
• somnolence, pulmonary hypertension, hypercapnic resp failure, absence of intrinsic lung disease, sleep disorded breathing in 90%

Question 11

Management of OHS

Answer 11

• weight loss
• avoid precipitating factors
• positive airway pressure: CPAP, bi-level ventilation

Question 12

Central sleep apnoea

Answer 12

• uncommon
• risk factors: very elderly, previous stroke, Cheyne stoke, opioids
• when present, often overlaps with OSA: can also cause sleep disruption and daytime sleepiness
• adaptive servo-controlled ventilation for symptomatic

Question 13

NArcolepsy

Answer 13

1) Excessive daytime sleepiness
2) Cataplexy
3) Sleep paralysis
4) Sleep hallucinations

• disturbed nocturnal sleep
• obesity
• prevalence 0.05 with cataplexy
• usually sporadic
• adolescent onset
• children: longer sleep periods, less REM intrusion symptoms

Question 14

Cataplexy

Answer 14

• specific and best diagnostic marker of narcolepsy
• sudden drop of muscle tone trigered by emotion especially laughter or anger
• seconds to min
• similar mechanism to REM sleep atonia

Question 15

Classification of narcolepsy

Answer 15

• Type 1: hypocretin low or absent
• Type 2: hypocretin normal
• Idiopathic hypersommia: MSLT mean sleep latency:

Question 16

Therapy for narcolepsy

Answer 16

• avoid sleep deprivation
• proper sleep hygiene
• maintain regular sleep-wake schedules
• avoid prolonged inactivity during daytime
• regular scheduled daytime naps
• appropriately timed physical activity and caffeinated beverages
• optimal weight
• avoidance of stress
• regular follow up
• driving and occupational issues

Question 17

Treatment of cataplexy, sleep paralysis and sleep hallucinations

Answer 17

• medication capable of suppressing REM sleep: TCA, SSRi, Serotonin-noradrenaline reuptake inhibitors

Question 18

Sodium oxybate (Xyrem): treatment of cataplexy, sleep paralysis and sleep hallucination

Answer 18

• used extensively overseas
• abuse potential
• recently TGA approved

Question 19

Idiopathic hypersomnolence

• clinical features
• demographics
• treatment

Answer 19

• EDS even after sufficient or increased amount of nighttime sleep and without cause
• clinical features: generally severe and constant EDS, longer naps, protracted daytime drowsiness, difficulty awakening from sleep, sleepp drunkeness
• Demographics: viral illness, adolescent, spontaneous remission, MSLT
• Treatment: stimulants

Question 20

REcurent hypersomnia

Answer 20

• medical conditions or other recurrent psychiatric disorders
• menstrual related (rare)
• Klein-Levin syndrome

Question 21

Klein-levin syndrome (very rare)

Answer 21

• hypersomnia, hyperphagia and behavioral changes (hypersexuality)
• prodormaal period 90% (infection, alcohol)
• younf with usual remission

Question 22

Parasomnias

Answer 22

• disorders of arousal, partial arousal and sleep stage transition
• undesirable physical phenomena occuring predominantly in sleep
• manifestation of CNS activation
• autonomic NS changes and skeletal muscle activity are prominent features

Question 23

REM behavioral disorder

Answer 23

• male:female 9:1
• older age
• acute: substance and medication induced
• chronic: neurodegenerative, rare, idiopathic
• need PSG to support diagnosis
• treatmentL clinazepam, melatonin

Question 24

Restless leg syndrome

Answer 24

• Urge to move limbs, rest or inactivity precipitates or worsens syndrome, getting up improves symptoms
• evening or nighttime appearance or worsening of syndrome
• primary or idiopathic (family history)
• secondary: Fe deficiency, ESRF, pregnancy, drug induced, diabetes, peripheral neuropathy

Question 25

MEdication for RLS

Answer 25

• dopamine agonists
• alpha2 Delta ligands
• side effects: nausea, headaches, impulsive behaviors, augmentation, sleep attacks, dizziness, sleepiness, weight gain