Sleep disorders and treatment Flashcards
Define sleep disorder
any medical disorder which has a negative effect on sleep patterns
What do we do when investigating sleep disorders?
-medication
-day time symptoms
-sleep hygiene
-evening symptons
-does the patient have difficulty falling or staying asleep
-quality of sleep
What is epworth sleepiness scale?
-self reported questionare, 8 questions to assess daytime sleepiness
-big limitations- some questions not applicable
-no legal standing-DVLA
What is the Berlin questionaire?
-11 questions divided into 3 categories to classify the patient as high or low risk for OSA
What is the STOP-BANG questionnaire?
an OSA screening tool, 4 easy questions and 4 clinical attributes
What does STOP-BANG stand for?
Snore
Tired
Observed events
Pressure ( blood)
BMI
Aged older than 50
Neck size more than 16cm
Gender male?
<3 low risk >5 high risk for OSA
Name some sleep studies
-actigraphy
-overnight pulse oximetry
-polygraphy (limited multichannel sleep study)
-detailed polygraphy ( additional EMG video)
-polysomnography( EEG and EOG)
What is actigraphy?
-worn on wrist or ankle
-contains accelerometer to record movement
-worn for days/weeks
-more accurate than a sleep diary
What does oxygen saturation do in overnight pulse oximetry?
-after long apnoea or hyponoea, arterial blood passing theough lungs picks up less o2, leading to desaturation
-when airflow returns to normal, o2 sats normally respond by returning to the original level
What does pulse rate do during overnight pulse oximetry?
-spikes in pulse rate seen with: PLMD ( periodic limb movement disorders) or sleep related breathing disorders
flat pulse rates seen in patients with diabetic cardiac autonomic neuropathy (CAN) or those of beta blockers
What is polygraphy?
nasal flow-can identify apnoeas that don’t cause significant desaturation, identify oximetry artefacts
chest and abdomen bands- differentiate between central and obstructive events and mixed events. if flow fails then it can act as a back up and often is of diagnostic quality
What is a detailed polygraphy?
-Leg EMG for PLMD
-Microphone -identifys snoring and determine obstructed apnoes vs central
-Camera -Helps to remove periods of wakefulness (reduced false negatives)
Helps to support diagnosis of - Periodic leg movement disorder (PLMD). Special bed sheets. Sleep parasomnias: Night terrors etc
What is an electroencephalogram - EEG?
-only technique to categorically measure actual sleep
-reduces false negatives
-sleep staging can produce a hypnogram to diagnose non-resp sleep disorders
What is an electrooculography- EOG?
-identifys REM sleep
-determines other stages of sleep based on pattern of eye movement
What is an electromyography - EMG?
-Submental EMG- identify’s REM sleep
Limb EMG- identify’s PLMD
Name 6 sleep disorders
1-insomnias
2-circadian rhythm sleep disorders
3-parasomnias
4-sleep related movement disorders
5-excessive sleepiness(hypersolnolence and narcolepsy
6-sleep related breathing disorders
Define parasomnias
abnormal or innappropriate behaviour and or movement/ emotion/ perception of dreams which take place at any time during sleep.
-occurs furing transitions between sleep stages
Name some parasomnias
-hypnogogic-occurs during transition from wake to sleep
-hypnopompic-occurs during the transion from sleep to wake
What are the 2 groups parasomnias fall under?
-NREM
-REM
What is the ICSD diagnostic criteria?
-recurrrent episodes of incomplete awakening from sleep
-limited or no associated cognition of dream imagery
-Inappropriate or absent responsiveness to efforts of others to intervene or redirect the person during the episode
-The disturbance is not explained more clearly by another sleep disorder, mental disorder, medical condition, medication of substance use
Name some NREM parasomnias
-Bruixsm (teeth grinding)
-Exploding head syndrome
-Confusional arousals
-Night terrors
-Sleepwalking
-Sexsomnia
-Enuresis (bed wetting)
-Sleep related eating disorder
Describe confusional arousals
-appears awake, confused and diorientated for 1-40 mins
-carry out normal behaviours, not concious of them/ effectively perform them
-known as sleep inertia
-slow speech is common feature
-ranges from simple vocalization by occas aggressive or violent
-may occur at night or morning
-most common in toddlers and early age school children
Describe sleep walking/ somnuambulism
-large motor control, not fine motor skills
-can endanger patients
-can occas result in violent behaviour
-usually occurs in NREM3
-can lead to insomnia -somniliquy can occur at any sleep stage ( sleep talking)
Describe night terrors/pavor nocturnus
-experienced on waking in NREM3
-starts with vocalization
-often sit up and look very frightened with eyes open
-feeling of intense fear but little memory of the event
-inc ANS- tachycardia, tachypnoea, sweating, dilated pupils, muscle tone
-different to nightmares that occur during REM sleep
-may be violent movement
What is bruxism?
-teeth grinding
-only considered a problem if it results in damage to teeth, jaw, tooth pain, headache or wakes partner
How do we diagnose NREM parasomnias
-significant delay to diagnosis
-clinical history and PSG often necessary but tricky
How do we treat NREM parasomnias
-good sleep hygiene
-limit anything causing sleep fragmentation
-avoid sleep deprivation
-safety assess sleep environment
-education and reassurance
-treatment for enuresis-limit fluid intake, alarms and medication
-drug therapy such as benzodiazepines
Name some types of REM parasomnias
-REM sleep behaviour disorder
-sleep paralysis
-nightmares
Describe REM sleep behaviour disorder (RSBD)
-muscle atonia not maintain leading to dream enactment
-enacting violent behaviours often from unpleasant and aggressive dreams
-may be accompanied by vocalisation
-tend to occur during latter part of night
-sleep deprivation leads to REM rebound and inc risk of RSBD
-progressive over time
What is the treatment of RSBD?
-Limit sleep deprivation to prevent excessive REM rebound
-safe sleep environment
-drug therapy (benzodiazepines, melatonin, clonazepam, antidepressants)
What does clonazepam do for RSBD?
reduces dream intensity and acting-out behaviours
What is the association between RSBD and neurodegeneration?
50% of patients with RSBD will have developed Parkinsons, Dementia with lewy body or multiple system atrophy by 5 years
Describe nightmares
-subjects can usually recall the nightmares
-increased ANS activity
-occurs during REM sleep
Name some sleep related movement disorders
Restless leg syndrome
-Periodic limb movement disorder- PLMD
Describe RLS
-irrestible urge to move legs and symptoms only relived by movement
-has a circadian pattern (night only)
-often familial and progressive over years
-can lead to difficulties going to sleep
-increased prevelance in pregnancy, iron def dialysis, antidepressants antipsychotics
What is the diagnosis for RLS?
-self-reported by patient
-no specific objective diagnostic test
What is the treatment for RLS?
-Good sleep hygiene
-avoid sleep deprivation
-avoid medication or behaviours that aggrevate ( alcohol,nicotine)
-iron replacement helps if patients are anaemic
-in severe cases consider drug therapy
What drugs can we use to treat RLS?
-dopamine agonists(levodopa and ropinirole
-benzodiazepines
-opiates
-gabapentin/pregabalin
NOT amitriptyline or melatonin
What is PLMD?
-repetitive, involuntary movements during NREM sleep
-(EMG of tibialis anterior is used to detect movements)
-movements last 0.5-5 s and occur in a repetitive pattern every 20-40s for mins or hours
-complete arousal
-patients may be asymptomatic or complain of excessive daytime sleepiness
-CVD risk
-incidence increases with age
How do we diagnose PLMD?
level 1- patients present with HX of disturbed sleep and daytime sleepiness and other causes are ruled out
level 2- bed partner has witnessed movements
level 3- actigraphy
level 4a-PG study with limb EMG
level 4B- PG study with limb EMG and camera
Level 5 - PSG that has additional EEG to show arousals
How do we treat PLMD?
-good sleep hygiene
-treat underlying cause
-optimise kidney function
-drug withdrawal-neurological, anti dopaminergic agent
-pharmacological treatment
What are some underlying causes of PLMD?
-iron def
-B12
-DM
-OSA
What are some pharmacological treatments of PLMD?
-sedatives ( clonazepam/benzodiazepines)
-dopamine agonists ( ropinirole, levodopa, pergolide( regulate muscle movements
-anticonvulsants (gabapentin) reduce muscle contraction
-GABA agonists ( Baclofen) relaxation of contractions
Tricyclic antidepressants (cyclozine) can make it worse
Describe hypersolmnolence including narcolepsy
-increased effort to stay awake in low stimulus or inactive situations
-increased tendency to fall asleep
-sleep onset can occur during active situations such as during a conversation or eating a meal
-patients experience problems with memory and conc and are often irritable
Describe hypersolmnolence not including narcolepsy
-often associated with psychiatric disorders
-high incidence of hypersomnia in patients with mood disorders
Name some treatments for hypersomnolence
-good sleep hygiene
-avoid sleep deprivation
-treatment of underlying conditions
-behavioural strategies such as planning naps to reduce the homeostatic pressure for sleep
-patients with hypersomnia not related to insufficient sleep benefit from stimulants such as caffeine
Name some treatments for narcolepsy
-modafinil- increases dopamine levels
-Amphetamines- increases noradrenaline and dopamine level
What are some common causes of hypersomnolence?
-medical disorders
-neurological/degenerative disorders
-psychiatric disorders
-medications/substances
-sleep disorders
-insufficient sleep, sleep related breathing disorders, sleep related movement disorders, circadian rhythm disorders
what is Narcolepsy?
-unable to regulate sleep-wake switch ( defic in orexin/hypocretin measured in CSF)
excessive daytime sleepiness- chronic and persistent
-sleep attacks occur during low stimulus situations
-associated with cataplexy, sleep paralysis and hypnogogic hallucinations
What is cataplexy?
-loss of muscle tone occurring in response to strong emotions
-patients feel weak, clumsy, slurred speech
-attacks last from secs to mins
-patient aware of what’s happening but can’t move
-loss of muscle tone due to inability to regulate the sleep/wake status so that there are overlapping elements, REM insertion into wakefulness
-75% of patients with narcolepsy have cataplexy
What is the diagnosis for cataplexy?
-clinical and sleep history
-epworth sleepiness scale
-PSG
-multiple sleep latency test < 5 mins in most narcoleptics evidence of REM
-maintenance of wakefulness test
-lumber puncture- defic in orexin in CSF
