Parasomnias

Question 1

Define sleep disorder

Answer 1

Any medical disorder that has a negative effect on sleeping patterns.
e.g., too much/too little sleep as well as trouble falling/ staying asleep.
As well as abnormal behaviours that occur or are carried out during sleep.
There are over 80 different classified sleep disorders

Question 2

Describe how we investigate sleep disorders

Answer 2

1. Taking a patient history, includes day & nighttime symptoms e.g., fatigue, daytime sleepiness, sleep hygiene, quality of sleep and medications they are taking
2. sleep diary kept and filled by the patient to track behaviours and sleep patterns
3. complete sleep questionnaires e.g., epworth

Question 3

Describe the Epworth sleepiness scale

Answer 3

A self-report questionaire that uses 8 questions to assess daytime sleepiness
e.g., chance of dozing off whilst watching TV
This questionaire lacks objectivity, it is based on patients perception, patients may lie for condition to seem worse than it is.
It has no legal standing e.g., DVLA

Question 4

Describe the OSA screening questionnaires

Answer 4

1. Berlin questionnaire: Obstructive sleep apnoea questionnaire consists of 11 questions to classify whether patient is high or low risk for OSA.
2. Stop-bang questionnaire: OSA screening tool consisiting of 4 questions & 4 clinical attributes.
   STOP refers to: Snore, Tired, Observed events and blood pressure
   BANG refers to: BMI, Age older than 50, Neck size & Gender

Less than 3 is low risk
Greater than 5 is high risk

Question 5

Describe the questionaire for bed partner

Answer 5

A questionnaire given to the partner who shares the bed to report on the patients behaviour. Tends to be less subjective.
It asks if the partner stuggles to sleep next to them & how frequently nighttime events occur.

Question 6

Define actigraphy, it’s advantages and disadvantages

Answer 6

A non-invasive method, uses a wrist strap to measure sleep quality. It has a 3 axis accelerometer to measure backwards/ fowards, left/right & up/down. measurements made in 3 different planes

ADV: mon-invasive, It can be worn at any time, from days to weeks to assess sleep patterns and quality. It is more objective and therefore more reliable than sleep diaries and questionnaires. Data is recorded and analyzed to provide insights to a persons sleep pattern

DISADV: Cannot measure stages of sleep or their duration of stages, It may lack accuracy in detecting in those who move a lot in their sleep

Question 7

Define overnight oximetry, it’s advantages and disadvantages

Answer 7

It measures oxygen saturation of the blood & HR (95-98%) during sleep, probe is placed on finger/toe/earlobe. It is non-invasive & is key in identifying sleep apnoea or COPD
Oximeter collects and stores data regarding sleep patterns and analyzes them. Creates a graph showing HR and O2 SAT during the night and highlights irregularities

ADV: Non-invasive, simple to use, small & lightweight, less expensive then other tests. Can be used at home

DISADV: only measures O2 sats & HR, provides no data on sleep stages/patterns. It may give false positives/negatives. This may overall influence diagnosis

Question 8

Oximetry on apnoea & pulse rates

Answer 8

From long apnoea or hypopnoea, arterial blood passing through lungs picks up less O2, leading to less O2 saturation
When airflow returns to normal oxygen saturation will return to normal levels

Pulse rate: Spikes are seen in patients with PLMS & SRBD,

Question 9

Describe the use of polygraphy

Answer 9

Used to monitor and analyze various physiological parameters during sleep
measures:
Brain activity (EEG): To monitor different stages of sleep, such as REM and non-REM sleep.
Eye movement (EOG): To track eye movements, which help in identifying REM sleep.
Muscle activity (EMG): To detect muscle tone and movements, which are important for diagnosing conditions like sleep apnea or restless leg syndrome.
This type of polygraphy is typically conducted in a sleep clinic and is useful in diagnosing sleep disorders like sleep apnoea, narcolepsy, insomnia, and periodic limb movement disorder, among others.

Question 10

Describe the use of a camera, leg EMG and microphone in polygraphy

Answer 10

Camera: Helps to remove periods of wakefulness by recording sleep, aids in diagnosis of PLMD and night terrors

Leg EMG: Helps identify PLMD or RLS

Microphone: Helps to identify snoring and determine OSA or CSA (central sleep apnoea)

Question 11

Describe polysomnography

Answer 11

Uses EOG, EMG & EEG

EEG- measures the brain activity during sleep, identifies different stages, reduces false results, can diagnose non-respiratory sleep disorders

EMG- measures the muscle tone/ activity during sleep, needed ti identify REM sleep when muscles are paralysed, needed to identify PLMD

EOG- measures eye movement during sleep, needed to identify REM sleep, can determine NREM stages based on eye movements

Question 12

Describe the types of sleep disorders

Answer 12

Insomnias

Circadian rhythm sleep disorders

Parasomnias

Sleep related movement disorders

Excessive sleepiness & narcolepsy

Sleep-related breathing disorders

Question 13

Define parasomnia

Answer 13

refers to abnormal/inappropriate/movement/emotion and or perception of dreams which takes place at any time during sleep

Question 14

Describe Hypnogogic & Hypnopompic

Answer 14

Hypnogogic: occurs during the transition from wake to sleep
Hypnopompic: occurs during the transition from sleep to wake

Question 15

Define NREM parasomnias and give examples

Answer 15

NREM parasomnias refer to a group of sleep disorders that occur during Non-Rapid Eye Movement (NREM) sleep. These disorders typically happen during the deeper stages of NREM sleep, which include stages 1, 2, and 3 of the sleep cycle
examples: bruxism (teeth grinding), exploding head syndrome, confusional arousals, sex-somnia, night terrors, sleepwalking, bet wetting (enuresis), sleep related eating disorder

Question 16

What is the diagnostic criteria involved in identifying an NREM parasomnia?

Answer 16

Reoccurring episodes of incomplete awakening from sleep

Absent responsiveness to efforts from others to intervene or redirect the person during an episode

Limited or no association cognition of dream imagery

Disturbance cannot be explained more clearly by another sleep disorder, mental disorder, medical condition or medication/substance use

Question 17

Describe confusional arousal

Answer 17

Patients are awake during CA, they remain confused after waking for 1-40 minutes, they are able to carry out normal behaviours, but can not carry out the task effectively.
Occurs most commonly in toddlers and early age school children
Also known as sleep inertia or sleep drunkeness
Slow speech is a common symptom and vocalisation can be aggressive

Question 18

Describe sleepwalking (somnambulism)

Answer 18

It involves use of large motor control as patients may wander around the house. It can be dangerous if they wander out of the house and into the road. They can be violent & can lead to a fear of falling asleep creating insomnia.
Most sleepwalking occurs during NREM stage 3
1/5 children will experience sleepwalking, most grow out of it

Question 19

Describe night terrors

Answer 19

Known as pavor nocturnus, Experienced mainly by kids in stage 3 NREM.
It begins with vocalization e.g., crying and screaming, followed by sitting up in a jolt with eyes wide.
Patients feel intense fear, but recall little of the dream
ANS becomes activated stimulating tachycardia, dysnopea & sweating

Question 20

What is the difference between nightmares and night terrors?

Answer 20

Night terrors occur during NREM stage 3 whereas nightmares occur during REM sleep where it may be difficult to control muscles leading to enactment

Question 21

Describe bruxism

Answer 21

Refers to teeth grinding in the sleep, affects 8% of the population and is only problematic if damage to teeth occurs
Symptoms include: jaw/teeth pain, headaches,
It can wake bed partner
It can be caused by stress and anxiety manifesting in sleep

Treatment can involve using a mouthguard to protect the teeth as well as psychological treatment to treat underlying stress and anxiety

Question 22

Describe the treatment for parasomnias

Answer 22

1. Improve Sleep hygiene e.g., Keep room dark & cold
2. Avoid sleep deprivation
3. Assess the safety of sleep environment
4. Educate and reassure the patient about their disorder
5. Bed-wetting can be treated by limiting fluids before bed, meds and alarms
6. Drugs should be a LAST RESORT, benzodiazepines can help induce & maintain sleep

Question 23

Define REM parasomnias and give examples

Answer 23

REM parasomnias are sleep disorders that occur during Rapid Eye Movement (REM) sleep, the stage of sleep most associated with vivid dreams. REM parasomnias happen when the brain is active and dreaming, but the body remains in a state of paralysis that typically prevents acting out dreams. When this paralysis is disrupted, the person may engage in abnormal behaviors.
e.g., RBD & nightmares

Question 24

Describe RSBD (REM sleep behaviour disorder)

Answer 24

A disorder where the muscles fail to be paralyzed during REM sleep leading to dream enactment. Common behaviours are: kicking, running, punching
Occurs during later stages of REM

Enacted behaviours are associated with violent dreams, 60% of patients end up injuring themselves or their partners
Sleep deprivation increases RSBD risk, progression of RSBD occurs overtime

Question 25

Describe the treatment for RSBD

Answer 25

1. Good sleep hygiene to prevent sleep deprivation & excessive REM rebound 2. Safe sleeping environment 3. Benzodiazpines intiate deep sleep 4. Melatonin promotes deep sleep 5. Clonazepam reduces dream intensity & enactment 6. antidepressants e.g., SSRI's & TCA's

Question 26

Describe the link between RSBD and neurodegeneration

Answer 26

50% of those with RSBD have developed Parkinson's, dementia or multiple system atrophy within 5 years. It is associated with non-motor symptoms, hallucinations, increased levodopa dose & earlier cognitive impairment.

Question 27

Describe nightmares

Answer 27

Most common REM parasomnia, occurring in late REM stages. Scary dreams lead to awakening, patients can often recall the nightmare, this creates feelings of: anger, fear, sadness & anxiety ANS activity increases e.g., tachycardia. Treatment can be CBT to help reduce fears and irrational beliefs that may be contributing to nightmares

Question 28

Describe sleep related movement disorder of RLS (restless leg syndrome)

Answer 28

Defined as an uncomfortable leg feeling, urge to move leg, relief only given with movement. RSL has a circadian pattern & its affects 5-10% of the population. It can lead to insomnia There is a greater risk of RSL in: in pregnant, iron deficient, dialysis patients. As well as individuals on antidepressants and antipsychotics.

Question 29

Describe the diagnosis and treatment of RLS

Answer 29

RSL is reported by the patient, there is no objective test for it, but a EMG can help identify it treatment: 1. good sleep hygiene 2. avoid sleep deprivation 3. avoid behaviours that aggravate RSL e.g., alcohol 4. Iron supplements can help 5. Dopamine agonists, benzodiazepines and opioids have been seen to help, should be used as a last resort, can have side effects Amitriptyline and melatonin cannot be used, not approved for RSL treatment

Question 30

Describe the movement related sleep disorder of PLMD ( periodic limb movement disorder)

Answer 30

It is defined as repetitive, involuntary movements during NREM sleep. It can be small/large movements. Movements last between 0.5-5 seconds and can occur every 20-40 seconds It can result in insomnia Patients may be asymptomatic or show daytime sleepiness Likelihood increases with age, 80% of those with RSL also have PMLS, those with PMLS do not experience RLS.

Question 31

Describe the diagnosis and treatment of PLMD

Answer 31

Diagnosis: 1. Other sleep disorders are ruled out, patient reports daytime sleepiness and disturbed sleep 2. Bed partner witnesses movements 3. Actigraphy & polygraphy with leg EMG & camera to record movements 4. Polygraphy has EEG to show arousals in stages of NREM Treatment: - GABA agonists relax muscle contractions e.g., Baclofen - Tricyclic antidepressants can worsen symptoms - Good sleep hygiene - Treatment of underlying cause e.g., anaemia with iron supplementation - Optimising kidney function - Drug withdrawal e.g., parkinsons - Pharmalogical therapy e.g., benzodiazepines reduce muscle activity & promotes deep sleep - Dopamine antagonists regulate muscle movement e.g., levodopa - Anticonvulsant e.g., gabapentin, reduces muscle contraction

Question 32

Describe hypersomnolence (not including narcolepsy)

Answer 32

This is defined as excessive sleepiness with an increased tendency to fall asleep Sleep onset can occur due to active situations such as eating or having conversations. Patients with this condition can suffer from memory & concentration problem 50% patients with hypersomnia met criteria for a psychiatric disorder Hypersomnia is associated with mood disorders

Question 33

Describe the causes & treatment of hypersomnolence

Answer 33

Cause: Medical disorders, Neurodegenerative disorders, psychiatric disorders, medications/drugs, sleep disorders Treatment: 1. Good sleep hygiene 2. Avoid sleep deprivation 3. Treatment of underlying medical conditions 4. Behavioural strategies e.g., nap scheduling 5. Patients with hypersonia not related to insufficient sleep may benefit from stimulants e.g., caffeine 6. Medications used to treat: modafinil which increases dopamine levels, amphetamines which increases adrenaline and dopamine

Question 34

Describe narcolepsy

Answer 34

A rare neurological condition in which a person cannot regulate their sleep-wake switch likely caused by an orexin deficiency in CSF Identified by excessive daytime sleepiness with an irresistible urge to sleep. Sleep attacks occur during low stimulating environments e.g., when reading It is associated with cataplexy, sleep paralysis and hallucinations. 75% of patients with narcolepsy also have cataplexy

Question 35

Describe the causes and treatment of narcolepsy

Answer 35

Cause: 1. Genetic predisposition 2. Brain injury e.g., trauma to hypothalamus 3. Immune dysfunction, body attacks orexin producing cells treatment: 1. stimulants such as modafinil can promote wakefulness 2. Antidepressants can help manage cataplexic symptoms 3. Scheduled Naps: Short, planned naps during the day can help manage sleep attacks and improve alertness.

Question 36

Describe cataplexy

Answer 36

It refers to a loss of muscle tone as a result of strong emotions, severe cataplexy can have a person fall to the ground. Patients may feel weak, light, wobbly and have slurred speech Attacks can last from seconds-minutes Patients are aware, but cannot move as they have temporary loss of muscle control

Question 37

Describe the causes and treatments of cataplexy

Answer 37

Causes: 1.Narcolepsy 2. Deficiency of orexin in CSF 3. Genetic predisposition 4. REM dysfunction, muscle weakness during REM can leak into daytime wakefulness Treatment: 1. Stimulants: used to address excessive daytime sleepiness, medications like modafinil help reduce the frequency of cataplexy episodes by improving wakefulness 2. Stress Management: use relaxation techniques to manage strong emotions that could trigger an episode 3. Scheduled Naps: can help alleviate sleepiness and reduce the likelihood of experiencing cataplexy episodes.

Question 38

How do we diagnose excessive sleeping disorders?

Answer 38

1. Clinical & sleep history 2. Epworth sleepiness scale 3. Sleep diary 4. Overnight sleep study 5. Multiple sleep latency tests 6. Maintenance of wakefulness test 7. Lumbar punctures to look for orexin deficiency in CSF