sleep-wake disorders

sleep disorders

difficulty initiation or maintaining sleep (insonya - those who know), xs daytime sleepiness, unusual behaviors during sleep (paprasomnia), circadian rhythm disorders

common sleep disorders

insomnia (insonya), secondary insomnia

insomnia disorder

difficulty falling asleep, difficulty staying asleep, trouble waking early w/ an inability to fall back asleep, sufficient to impair functioning, can affect any part of sleep cycle

insomnia affects on sleep cycle parts

sleep onset, sleep maintenance (middle insomnia, late insomnia, non-restorative sleep)

middle insomnia

presents as frequent/prolonged awakenings throughout the night

late insomnia

presents as inability to return to sleep

non-restorative sleep

presents as poor sleep quality and does not feel refreshed even if adequate sleep duration

causes of insomnia

drugs and meds: caffeine anti-convulsants, anti-depressants, B blockers, bronchodilators, steroids, stimulants, some sedatives and opioids/alcohol

secondary insomnia

movement disorders impair ability to fall asleep; restless leg syndrome, periodic limb movements of sleep

insomnia diagnosis

true insomnia is diagnosis of exclusion, pts must meet criteria (rule of 3s) to be diagnosed w/ primary insomnia, approach: "DEEP" -> D (drugs), E (environment), E (emotions), P (physical problems)

NREM parasomnia

occur during deep sleep (1st half of night), partial awakening w/ absent/little memory of events, common in children but also affects adults

NREM parasomnia examples

sleepwalking, night terrors, confusional arousals

NREM parasomnia triggers

stress, sleep deprivation, fever, noise

NREM parasomnia Tx

safety measures, good sleep hygiene, sometimes benzos or melatonin

NREM parasomnia subtypes

sleepwalking, sleep terrors

sleepwalking (NREM)

repeated episodes of rising from bed while sleeping and performing complex motor activity, blank staring faces, don't respond to communication from others, difficult to awaken, can't remember

sleep terrors (NREM)

arise from N3 (slow wave) sleep in usually the 1st third of the night, if awakened can't remember, sudden piercing scream/cry, intense fear/panic, autosomnic urge (inc HR/BP, sweating)

sleep terrors Dx

polysomnography w/ or w/out sleep EEG

sleep terrors Tx

benzos or TCAs, CBT therapy can also be helpful

sleep terrors triggers

sleep deprivation, fever, CNS-dependent w/drawal, familial tendency

REM-related disorder subtypes

REM sleep behavior disorder, nightmare disorder

REM sleep behavior disorder (REM)

loss of normal REM atonia (pt acts out dreams), often last third of the night, behaviors: punching, kicking, leaping, diving, grabbing (movements match dream content)

REM sleep behavior disorder triggers

drug-induced or worsened (antidepressants), associated w/ neurologic disease

nightmare disorder (REM)

recurrent distressing dreams that are vivid and frightening, lead to awakening and cause daytime distress/impairment, evolves from long elaborate dreams, on awakening remembers, autonomic signs (symp activation: tachy, sweating) that resolve upon awakening, common in children 3-6 y/o and less common in adults, can drive a fear of sleeping

nightmare disorder triggers

PTSD/trauma, can persist for years, meds (L--dopa, B blockers, rebound after stopping REM suppressants, alcohol, some antidepressants), stress, sleep deprivation/irregular schedule

muscle atonia

LOST in REM sleep behavior disorder -> allows dream enactment, normal paralysis during sleep

triggers/risk factors for sleep terrors

sleep deprivation, fever, CNS-depressant w/drawal; can be potentiated by OSA (obstructive sleep apnea) and meds; familial tendency

circadian rhythm sleep-wake disorders

sleep timing problem not sleep quality, body clock is out of sync w/ desired schedule, SCN pacemaker (24 hr) sets rhythms (links to core body temp, melatonin), normally resets daily by light/social cues/activity/stimulants/caffeine, desynchrony (travel, intrinsic clock issues) --> circadian disorders

hypersomnolence disorder

abnormally prolonged sleep or xs sleepiness despite adequate/long nighttime sleep (10+ hrs and still feel tired), difficulty walking/cognitive slowing/poor daytime function

primary: idiopathic hypersomnia

secondary: depression, sleep apnea, meds

hypersomnolence disorder Dx

xs sleepiness despite sleeping at least 7 hrs AND one of the following: recurrent naps often lasting at least 1 hr, prolonged sleep period of 9+ hrs a day as non-restorative, difficulty being awake, occus at least 3x weekly for at least 3 months (rule of 3s), symptoms cause distress/impairment, symptoms NOT attributable to another psychiatric/medical condition/substance use

narcolepsy

xs daytime sleepiness, irresistible sleep attacks, can fall asleep inappropriately

narcolepsy Dx

requires at least 1 of the following: episodes of cataplexy (present as spontaneous grimaces or jaw-opening episodes, tongue thrusting, global hypotonia in children or newly-diagnosed pts), hypocretin deficiency showing REM latency <15 mins or MSLT showing sleep latency <8 mins, cataplexy (genetic testing for HLF DQB1*06:02 almost always positive)

narcolepsy Tx

meds are treatment of choice: modafinil (provigil) treats somnolence, stimulants also often used, anti-depressants (may help INC serotonergic tone), pt couseling on sleep hygiene and use of short scheduled naps to help DEC symptoms

narcolepsy subtypes

type 1 narcolepsy, type 2 narcolepsy, secondary narcolepsy

type 1 narcolepsy

narcolepsy w/ cataplexy, xs daytime sleepiness and cataplexy (sudden muscle weakness triggered by emotions), low CSF lvls of hypocretin/orexin (brain chemicals that regulate wakefulness), enter REM sleep rapidly after falling asleep

type 1 narcolepsy Sx

sleep paralysis, hypnagogic hallucinations, fragmented nighttime sleep

type 2 narcolepsy

narcolepsy W/OUT cataplexy, xs daytime sleepiness but NO cataplexy, CSF hypocretin lvls usually normal, Sx less severe than NT1

type 2 narcolepsy Dx

requires exclusion of other causes of xs sleepiness

secondary narcolepsy

rare, results from brain injury, tumors, inflammation, lesions affecting hypothalamus area responsible for sleep regulation

key features of narcolepsy

cataplexy, sleep paralysis, hypnagogic/hypnopomping hallucinations

cataplexy

sudden loss of voluntary muscle strength and control that is usually triggered by an intense emotion

sleep paralysis

the experience of waking up unable to move

hypnagogic hallucinations

visual images at sleep ONSET

hypnopompic hallucinations

visual images upon AWAKENING from sleep

insomnia first line treatment

behavioral changes encouraged, sleep hygiene should be emphasized and cognitive behavioral therapy techniques can be used

NREM parasomnia Tx

safety measures, good sleep hygiene, sometimes meds like benzos or melatonin

REM parasomnia Tx

meds (clonazepam, melatonin), safe sleep environment

sleep terrors Tx

good sleep hygiene, maintain good sleep-wake schedule, CBT can be helpful

narcolepsy Tx

meds are treatment of choice; modafinil, stimulants, anti-depressants

good sleep hygiene and short scheduled naps to reduce symptoms