Topic 14: Sleep Wake Disorders

• reduce sleep-related motor vehicle accidents

• increase screening for sleep apnea

• high school students: get sufficient sleep and start school later

• sleep safety for infants on their backs

• all ages: get sufficient sleep

what are the healthy people 2030 initiatives for sleep

• excessive sleepiness

• sleep deprivation

• stress responsivity

• somatic pain

• reduced quality of life

• emotional distress and mood disorders

• cognitive, memory, and performance deficits

• metabolic syndrome

• type 2 DM

• colorectal cancer

• increased mortality

• difficulty staying awake

• safety risk: similar psychomotor effects of alcohol consumption

• financial costs

what are the consequences of sleep loss

• shift work

• underlying sleep disorder

• meds

• alcohol and substance use

• medical and psychiatric disorders

what are common causes of sleep restriction

excessive sleepiness

subjective self-report of difficulty staying awake that impacts social and work function nd increases risk for accident or injury

sleep deprivation

a discrepancy between hours of sleep obtained and hours of sleep required that impairs functioning, quality of life, health, and safety and can lead to DM, increased appetite, and obesity

psychiatric s/s like hearing voices or having disorganized thoughts

what can neurocognitive symptoms of chronic sleep deprivation mimic

behavioral problems and impaired cognition

what can occur in children who experience sleep deprivation

emotion and social health issues, impaired school performance, increased risk-taking behaviors

what can occur in adolescents who experience sleep deprivation

• 9+ hours nightly in adults has multiple health consequences

• 90-minute naps increased risk for stroke 25%

• even more dangerous when combined (85% increased risk for stroke)

what is considered too much sleep

• depression

• metabolic syndrome

• childhood obesity

• HA

• greater risk of dying from medical conditions

what is irregular sleep associated with

sleep

a dynamic neurological process with low/absent motor activity and reduced response to stimuli that is characterized by two stages: nonrapid eye movement (NREM) and rapid eye movement (REM)

NREM

stage of the sleep cycle that sleep normally begins with and includes progressive or deeper sleep; has 3 stages

NREM Stage 1

transition period between wakefulness and sleep that lasts around 5-10 minutes

sleep latency

the time it takes to fall asleep

• body temp declines and muscles relax

• slow rolling eye movements

• people lose awareness of their environment, but are easily aroused

what occurs in NREM stage 1

• HR and RR decline

• brain begins to produce sleep spindles

• arousal requires more stimuli

• lasts for 20 minutes

what occurs in NREM stage 2 which occupies 45-50% of total sleep

• relatively short

• further reduction in HR, RR, BP

• muscle relax even more

• deepest sleep occurs, very hard to arouse

• restorative sleep due to reduce sympathetic activity

what occurs in NREM stage 3 aka slow/delta sleep

REM

stage 4 of the sleep cycle, that is when the brain becomes more active, the body becomes more relaxed and immobilized, dreams occurs, and the eyes move rapidly

• reduction and absence of skeletal muscle tone (muscle atonia)

  • protective mechanism to prevent acting out nightmares/dreams

• bursts of rapid eye movements

• myoclonic twitches of the fcial and limb muscles

• reports dreamins

• ANS variability

what occurs in REM (stage 4)

• normally begins with NREM and the demonstrates and alternating cycle of NREM and REM

• 4-5 cycles of NREM and REM occur over 90-120 minute intervals

• The length of REM increases with each interval

what does the typical sleep cycle look like

middle of the night awakenings and reduced sleep efficacy

what does slow wave sleep decline (NREM stage 3) result in with age

• often accompanied by depression, anxiety, and cognitive changes

• persistent disturbances and impaired sleep are RF for depression, bipolar disorder, obesity, and immune system function

what are the effects of sleep disorders on BH

polysomnography

MC sleep test that is used to diagnose and evaluate patients with sleep-related breathing disorders and nocturnal seizure disorder

usually involves one/two nights of sleep in a lab with electrodes on the head, chest, and legs to monitor brain wave activity, eye movement, muscle tone, heart rhythms, and breathing

multiple sleep latency test (MSLT)

• a daytime nap test used to objectively measure sleepiness in a sleep conducive setting; usually done in patient suspected of narcolepsy and idiopathic hypersomnia

• full day test with 5 scheduled naps separated by 2 hour breaks

• measures to see how quickly you fall asleep in a quiet environment during the day once the lights go off

• then are awakened after sleeping for 15 minutes

• if you do not fall back asleep within 20 minutes, the trial will end

• Each nap occurs in a dark/quiet sleep environment that is intended for your comfort and to isolate any external factors that may affect your ability to fall asleep

• sensors measure if you are asleep and the sleep stage

maintenance of wakefulness test (MWT)

evaluates a patient’s ability to remain awake in a situation conducive to sleep and used to maintain alertness in individuals with careers like pilots, for which sleepiness would pose a risk to public safety

actigraphy

Involves using a wrist watch-like tracker that records body movement over a period of time and helps evaluate sleep patterns and sleep duration for patients suspected of circadian rhythm disorders and insomnia

insomnia disorder

persistent experiences of perception of insufficient amount of sleep or perception of a sufficient amount of sleep without feeling restored that occurs 3 nights/week for at least 3 months; a “normal” adult needs 7-9 hours of sleep, but each indivisual’s need may vary

• predisposing factors

  • prior history of poor quality sleep

  • history of depression and anxiety

  • state for hyperarousal

  • known as light sleepers and night owls

• precipitating factors

  • personal and vocational difficulties

  • medical and psychiatric disorders

  • grief

  • changes in role identity like retirement

• perpetuating factors

  • excessive caffeine or alcohol use

  • spending excessive amounts of time in bed or napping

  • worrying about the consequences of insomnia

what are the causes of insomnia disorder

• difficulty initiating or maintaining sleep

• early morning awakening with inability to return to sleep

• occurs at least 3 nights/week for at least 3 months

• absenteeism

• changes in affect, lack of energy, quality of life, concentration, and sleep

what are the s/s of insomnia disorder

• improve sleep hygiene

• shut off electronics

• timing of exercise and meals not immediately prior to sleep

• relaxation techniques

• CBT

• CBT-I (insomnia specific)

what are nonpharmalogical ways to help someone with insomnia

• antihistamines

• TCAs

• sedative hypnotics (short term)

  • zolpidem tartrate (Ambien)

  • eszopiclone (Lunesta)

  • Zaleplon (Sonata)

• melatonin

• ramelteon (Rozerem)

• benzos:

  • estazolam

  • flurazepam

  • quazepam

  • temazepam

  • traizolam

• orexin receptor agonists (have addictive properties)

  • lemborexant (Dayvigo)

  • Survorexant (Belsomra)

what are the pharmacological treatments for insomnia

hypersomnolence disorder

chronic daytime sleepiness characterized by recurrent periods of sleep or unintended sleep, frequent napping, and/or nonrestorative sleep that impairs function for 3 months or more

• recurrent periods of sleep or unintended lapses into sleep

• frequent napping

• non-refreshing, non-restorative sleep, no matter how long

• difficulty with full alertness during the wake period

• significantly impaired social and vocational function

• cognitive impairment

what are the s/s of hypersomnolence disorder

• maintain a regular sleep-wake schedule with an ample sleep opportunity

• may need to follow an extended sleep opportunity greater than 10 hours

• long acting amphetamine based stimulants

  • methylphenidate

• nonamphetamine based stimulants

  • modafinil (Provigil)

what are the treatments for hypersomnolence disorder

narcolepsy

The uncontrollable urge to sleep that usually begins in young adults and persists throughout a lifetime; however, s/s are generally misunderstood/mistaken, leading to an average of 7-12 hours for an accurate diagnosis, so often not treated until adulthood; cause it thought to be autoimmune with a genetic component

• excessive daytime sleepiness (EDS)

• cataplexy

• disrupted nighttime sleep with multiple middle-of-the-night awakenings and automatic behaviors characterized by memory lapses

• feel refreshed upon awakening, but within 2-3 hours feel sleepy again

• sleep paralysis

• hyponagogic/hypnopompic hallucinations

what are the s/s of narcolepsy

cataplexy

brief episodes of B/L muscle tone while maintaining consciousness that is thought to occur due to the occurrence of REM sleep paralysis during wakefulness; present in all with type 1 narcolepsy and some with type 2

strong emotions like anger, fear, frustration, joy, laughing

what are common triggers for cataplexy

sleep paralysis

A sign of narcolepsy is the inability to move or speak during the transition from sleep to wakefulness

hypnagogic/hynopompic hallucinations

false audiotry, visual, and tactile sensations that occur at the transition from wakefulness to sleep, which is a sign of narcolepsy

• scheduled daytime naps

• avoid heavy meals

• sleep hygiene

• regular exercise

what are nonpharmacologic treatments for narcolepsy

• sodium oxybate

• simulates

  • amphetamines

  • amphetamine like: modafinil, armodafinil, methylphenidate

• SNRIs, SSRIs, TCAs

• Solriamfetol

• pitolisant

what are the pharmacologic treatments for narcolepsy

sodium oxybate

CNS depressant, the 1st line treatment for type 1 narcolepsy with cataplexy, as it is the only drug that reduces excessive daytime sleepiness and cataplexy; it is the sodium salt of GHB, so it is highly regulated and controlled, and is also very expensive and requires 2 doses a night due to being eliminated from the body very quickly

• only used for those 7 years and older

• client teaching requires extensive training before being able to take the meds due to safety reasons

amphetamine and amphetamine like stimulants (modafinil, armodafinil, methylphenidate)

the 2nd line treatment for narcolepsy that are only effective in keeping patients awake but can be addictime

solriamfetol (Sunosi)

NDRI that is recently been FDA approved to treat narcolepsy; no not use with MAOIs, monitor BP and HR while using

pitolisant (Waxik)

novel histamine 3 antagonist that has been newly approved to treat narcolepsy; SE include insomnia, nausea, anxiety

obstructive sleep apnea (OSA)

The MC disorder of breathing and sleeping is characterized by repeated episodes of upper airway collapse and obstruction that result in sleep fragmentation; common RF are age and obesity

• loud, disruptive snoring

• apnea episodes witnessed by other people

• breathing interruptions

• excessive daytime sleepiness

• waking with choking or gasping feelings

what are the S/S of OSA

• CPAP

• BiPAP

• Semi recumbent sleeping position

• anti snoring mouthpieces

What are the treatments for OSA

continuous positive airwar pressure (CPAP)

treatment for OSA that provides constant positive airflow to keep the airways open when they would otherwise be obstructed

bilevel positive airway pressure (BiPAP)

treatment for OSA that adjusts pressure for insertion and exhalation to use positive airflow to the airway when it would otherwise obstruct

shift work/circadian rhythm sleep disorder

a sleep disorder that occurs when there is a misalignment between the timing of the individual’s normal circadian rhythm and external factors that affect the timing or duration of sleep; common in HCP and other shift works due to night work hours

• bright light therapy to enhance wakefulness and decrease melatonin production

• remaining on alternative schedule even on off days from work

• requesting a scheduling change when possible

• medications: can help, but it is not primarily indicated for the treatment of the problem

what are treatments for shift work/circadian rhythm sleep disorder

NREM sleep arousal disorders

sleep disorder that includes night terrors, nightmares, sleepwalking, or other unsafe activities

• place alarms or locks on windows and doors

• put gates on stairs

• good sleep hygiene: limit alcohol before bed, obtain adequate amount of sleep, reduce stress

• benzos if the risk for accident/injury is likely

what are the ways to manage sleepwalking

• have regular sleep habits

• benzos short term

• explore areas of stress that can be managed and may be contributing

what are the ways to manage sleep terrors

nightmare disorder

long, frightening dreams form which people awaken scared that can begin in preschool and last into adulthood; occurs during REM and usually late in the night and can be aggravated by frequent past adverse events, sleep problems, and family history

• hypnotic therapy

• lifestyle modification

• attention to sleep hygiene

• stress reduction

what are the ways to manage nightmares

REM sleep behavior disorder

sleep disorder characterized by elaborate motor activity associated with dreaming in which individuals act out their dreams; common in elderly men and those with PD

• SSRIs or SNRIs

• place a mattress on the floor

• use intermediate-acting benzo if severe

• maintain patient and sleep partner’s safety

what are the ways to manage REM sleep behavior disorder

restless leg syndrome

a sensory and movement disorder that causes uncomfortable sensations in the legs accompanied by the urge to move that onsets during inactivity and is worse in the evening and at bedtime, which may disturb sleep; relieved by physical activity (walking, stretching, flexing)

• females

• pregnancy

• use of SSRIs, SNRIs, Benadryl, dopamine blockers (antipsychotics)

• low iron

• monozygotic twins and family history

what are the RF for restless leg syndrome

relaxis

Nonpharmacological treatment for restless leg syndrome, which is a pad that works by counterstimulating the legs in the form of vibration that slowly tapers off through the night; contraindication for DVT within the last 6 months

• dopamine receptor agonists: long-term use can worsen s/s

  • ropinirole, pramipexole, rotigotine

• gabapentin

• iron supplements

• levodopa

what are the FDA approved meds to treat restless leg syndrome

• maintain a regular sleep-wake schedule

• develop a pre-sleep routine that signals the end of the day

• reserve the bedroom for sleep and a place for intimacy

• create an environment that is conducive to sleep consider light, temp, and clothing

• avoid clock watching

• limit caffeine to 1-2 a day and non in the evening

• avoid heavy meals before bed

• avoid daytime napping

• exercise daily, but not right before bed

what does good sleep hygiene include

• acute confusion

• agitation

• anxiety

• apathy

• fatigue

• poor concentration

• irritability

• lethargy

• malaise

• perceptual disorders

• slowed reaction

what are s/s of sleep deprivation