Sleep Disorders
When Klonopin doesn't work
, some antidepressants or melatonin may reduce the violent behavior.
Obstructive apnea occurs when
-the muscles in the back of the throat are not able to keep the throat open, despite efforts to breathe. -This causes blockages in the airway and breathing interruptions, or apneas.
35% of subjects with sleep paralysis report having a history of panic attacks
16% met the criteria for panic disorder. In severe cases, where episodes occurred at least 1x/week for 6 months, medication can be used.
the treatment of choice for OSA is
CPAP (first line treatment)
How is RBD Treated?
Clonazepam (Klonopin), a benzodiazapine eliminates the disorder about 90% of the time. -An advantage to the medication is that people usually do not develop a tolerance to the drug, even over a period of years.
Medications used to treat RLS:
Dopaminergics, benzodiazepines (CNS depressants), opioids, and anticonvulsants.
The following are possible signs and symptoms of a sleep disorder: `
Feeling irritable or sleepy during the day Having difficulty staying awake when sitting still, such as when watching TV or reading Falling asleep while driving Having difficulty paying attention or concentrating at work, school, or home Performing below your potential in work, school, or sports Often getting told by others that you look tired Having difficulty with your memory Reacting slowly Having emotional outbursts Feeling like taking a nap almost every day Requiring caffeinated beverages to keep yourself going
Episodes can be minimized by:
Getting enough sleep Reduce stress Exercise regularly (but not too close to bedtime) Keep a regular sleep schedule
Dopaminergics are used to treat
Parkinson's disease, and are considered the initial choice.
"Hag Phenomena"
They often feel as if someone is sitting on their chest and they experience the feeling of impending death and suffocation. These episodes cause people much anxiety and terror, but there is no real physical harm.
OSA occurs in all age groups, and in both sexes. Those at highest risk
are middle-aged, overweight males.
Because REM sleep is associated with muscle paralysis and dreaming, those afflicted with narcolepsy suffer from
associated paralysis, hallucinations, and other dream-like and dramatically debilitating symptoms
it is diagnosed by
clinically by evaluating the patient's history and symptoms
Anticonvulsants are useful for
decreasing sensory disturbances.
Moving the legs, or other affected parts of the body, relieves
discomfort
Symptoms often disappear by ____, allowing for some refreshing sleep at that time.
early morning
Left untreated, the condition causes
exhaustion and daytime fatigue
Older patients experience symptoms more frequently and
for longer periods of time.
What Causes RLS?
idiopathic
what is the Most common sleep complaint among Americans?
insomnia
For people with narcolepsy, sleep begins almost immediately with REM sleep, and fragments of REM occur
involuntarily throughout the waking hours.
Obstructive Sleep Apnea
is a disorder in which breathing is briefly and repeatedly interrupted during sleep.
sleep apnea can be
life threatening
In general, these approaches are most helpful for
mild disease or heavy snoring
RLS is generally a lifelong condition, for which there is
no cure
Chronic snoring is a strong indicator
of sleep apnea and should be evaluated by a health professional.
RBD is associated with
parkinsons disease
side lying during sleeping
patients with mild sleep apnea or heavy snoring have more breathing problems when they are sleeping on their backs.
Caffeine, alcohol, and tobacco may aggravate or trigger symptoms in patients
predisposed to develop RLS. Elimination of such substances can relieve symptoms.
It's a good idea to make the bedroom a safe environment,
removing all sharp and breakable objects.
Periodic limb movements in sleep are
repetitive movements, mostly in the lower limbs, that occur about every 20-40 sec. These movements cluster into episodes lasting anywhere from a few minutes to several hours
Electromyography and nerve conduction studies are done to
rule out damage or disease. If none, supports RLS diagnosis.
PLMS is not considered medically
serious. Can be a contributing factor to daytime fatigue and may cause awakenings during the night.
The cause of both disorders is
unknown.
During the day:
Consume less or no caffeine, particularly late in the day. Avoid alcohol and nicotine, especially close to bedtime. Exercise, but not within three hours before bedtime. Avoid naps, particularly in the late afternoon or evening. Keep a sleep diary to identify your sleep habits and patterns that you can share with your doctors.
The diagnosis is difficult in children, because the physician relies heavily on the patient's
explanation of symptoms Often, the syndrome is often misdiagnosed as "growing pains" or "ADD".
We now know that there is a high prevalence of people that have sleep apnea that also have
heart disease such as hypertension, heart attacks, CHF, arrhythmias, and stroke.
Researchers believe narcolepsy may be caused by a deficiency in
hypocretin production in the brain (hypothalmus). Can treat symptoms with drugs (anti-depressants).
Because there is a close connection between behavior and insomnia, behavioral therapy is often part of any treatment for insomnia.
i.e. sleep restriction: following a program that limits time in bed in order to get to sleep and stay asleep throughout the night.
Obstructive apneas can result in two problems:
1. fragmented sleep 2. lowered levels of oxygen in the blood
According to National Center for Sleep Disorders at NIH, 30-40% of adults say they have symptoms of insomnia within a given year.
10-15% say they have chronic insomnia.
Pauses in breathing last ____ or more, and can occur up to 400 times per night
10-30 sec
More than ____ Americans have sleep apnea.
18 million
About __% experience violent behaviors during sleep.
2
It is harder to estimate in children because of a wide variance in monitoring techniques, but it is believed to be approximately
2-3%, with a prevalence as high as 10-20% in habitually snoring children.
long-term sleep disorders affect at least_____ Americans each year.
40 million
A family history is seen in approx. ____ of the cases. People with familial RLS tend to be younger when symptoms start and have slower progression of the condition.
50%
35% or more of people aged ___ or older experience PLMS.
65 -Younger people are less commonly affected. -Men and women are affected equally
_____ of people with RLS also experience periodic limb movement disorder (leg twitching or jerking movements during sleep, that occur every 10-60 seconds, sometimes throughout the night).
80%
___% of RBD patients are male, and the disorder usually strikes after the age of 50, although some patients as young as 9 years old display symptoms.
90
avoid alcohol
: alcohol causes frequent nighttime awakenings and causes upper airway breathing muscles to relax.
Other situations of inactivity triggering symptoms include
: long car trips, sitting in movie theatre, long-distance flights, immobilization in a cast, or relaxation exercises.
symptoms of sleep paralysis include:
A complaint of inability to move the trunk or limbs at sleep onset or upon awakening. Presence of brief episodes of partial or complete skeletal muscle paralysis Episodes can be associated with hypnogogic hallucinations or dream-like mentation
Four basic criteria for diagnosing RLS (according to the RLS study group):
A desire to move the limbs, often associated with paresthesias or dysesthesias. Symptoms that are worse or present only during rest and are partially or temporarily relieved with activity. Motor restlessness Nocturnal worsening of symptoms
How is RBD Diagnosed?
A formal sleep study must be conducted at a formal sleep center. A single night of extensive monitoring of sleep, brain, and muscle activity will almost always reveal the lack of muscle paralysis during REM sleep, and it will eliminate other causes of parasomnias.
weight loss
CPAP treats sleep apnea, weight loss can cure sleep apnea in an overweight person.
Some medications can lead to insomnia:
Cold and allergy medication High blood pressure medication Heart disease medication Thyroid disease medication Birth control medication Asthma medication Pain medication Depression medication
For mild to moderate symptoms, prevention and lifestyle changes can reduce or eliminate symptoms.
Decrease caffeine, alcohol, and tobacco Correct deficiencies in iron, folate, and magnesium Maintaining a regular sleep pattern With regular exercise Changing sleep patterns (i.e. if they have better sleep in the early am- sleep more then if possible)
Since people with sleep apnea tend to be sleep deprived, they tend to suffer from a wide range of other symptoms including:
Difficulty concentrating Depression Irritability Sexual dysfunction Learning and memory difficulties Falling asleep while at work, on the phone, or driving
Symptoms of insomnia include
Difficulty falling asleep Waking up frequently during the night Difficulty returning to sleep Waking up too early in the morning Unrefreshing sleep Daytime sleepiness Difficulty concentrating Irritability
A sleep disorder is any difficulty with sleep including:
Difficulty falling or staying asleep Difficulty staying awake during the daytime (excessive sleepiness) Sleeping too much Difficulty sleeping during normal sleep hours at nighttime Abnormal behaviors during sleep which disrupt sleep Unrefreshing sleep *Snoring by itself is not a sleep disorder, however, snoring could be a symptom of a very serious sleep disorder.*
Left untreated, symptoms of sleep apnea can include:
Disturbed sleep Excessive sleepiness during the day High blood pressure Heart attack CHF Cardiac arrhythmias Stroke Depression
The main features of narcolepsy include:
Excessive daytime sleepiness Cataplexy (a brief or sudden loss of muscle control, usually triggered by emotional stimuli: laughter, surprise, or anger)
The severity increases with
age
doctors prescribe stimulants to improve
alertness and diminish excessive daytime sleepiness
certain drugs may aggravate symptoms like
anti-nausea, anti-seizure, antipsychotic, and cold and allergy medications
What is Insomnia?
Insomnia is the latin word for "no sleep", and is the inability to fall asleep or remain asleep. Insomnia may also be used to describe the condition of waking up not feeling restored or refreshed, after a full night's sleep
What is Narcolepsy?
Narcolepsy is a neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally.
What Are the Most Common Sleep Disorders?
Obstructive sleep apnea Restless leg syndrome Periodic limb movement disorder REM behavior disorder Narcolepsy Insomnia
Researchers estimate that RLS affects as many as 12 million Americans
Others estimate that RLS is under diagnosed, and misdiagnosed. Some don't seek medical attention, afraid they won't be taken seriously. Some physicians misdiagnose as nervousness, insomnia, stress, arthritis, muscle cramps, or aging.
What is REM Behavior Disorder?
People who suffer from REM behavior disorder (RBD) act out their dreams. -They physically move limbs or even get up and engage in activities associated with waking. Some talk, shout, scream, hit, punch, or fly out of bed while sleeping.
Throughout the night, we alternate between stages of
REM and non-REM sleep.
RBD occurs during
REM sleep.
, polysomnography is done to identify the presence of
RLS
Individuals with PLMS may also experience
RLS
People with low iron levels or anemia may be prone to developing
RLS
there is no single diagnostic test for
RLS
Treating the underlying condition often provides relief from
RLS symptoms
Treating PLMS is only seen as necessary when PLMS is associated with
RLS, insomnia or daytime fatigue.
Treatments for Insomnia
Relaxation techniques such as yoga, meditation, and guided imagery may be helpful in preparing the body to sleep. Exercise done early in the day can help reduce stress and promote a deeper sleep (exercise must not be done too close to bedtime!)
What is the Normal Sleep Cycle?
Sleep happens in cycles. When we first fall asleep, we initially enter a light stage of sleep and then progress into increasingly deeper stages.
What is Sleep Paralysis?
Sleep paralysis consists of a period of inability to perform voluntary movements either at the onset of sleep (hypnogogic) or upon awakening (hypnopompic) forms.
A sleep study monitors a variety of functions during sleep including:
Sleep state Eye movement Muscle activity Heart rate Respiratory effort Airflow SpO2 levels
increased risk factors for OSA include
Small upper jaw Large tongue, tonsils or uvula Being overweight Having a recessed chin Small jaw or large overbite Large neck size (17 in. or greater for males; 16 in or greater for females) Smoking and/or alcohol use Being age 40 or older Ethnicity (African-Americans, Pacific-Islanders, and Hispanics) OSA seems to run in some families, suggesting a possible genetic basis
Insomnia can be a disorder in its own right, but it more often can be a symptom of some other disease or condition:
Stress Pain Digestive problems Depression or anxiety Sleep disorder (RLS and sleep apnea)
The disease narcolepsy is also often associated with:
Sudden sleep attacks Insomnia Dream-like hallucinations Sleep paralysis (see following slides)
Polysomnography shows at least one of the following:
Suppression of skeletal muscle tone A sleep onset REM period A dissociated REM sleep
Hypnotics should only be taken when:
The cause of the insomnia has been evaluated. The sleep problems are causing difficulties with the person's daily activities. Appropriate sleep promoting behaviors have been addressed.
Common Signs and Symptoms of RLS
Uncomfortable sensations in the legs when sitting or lying down, accompanied by an irresistible urge to move about.
Promoting Good Sleep Habits at night:
Use the bed and bedroom for sleep and sexual relations only. Establish a regular bedtime routine and a regular sleep-wake schedule. Do not eat or drink too much close to bedtime. Create a sleep-promoting environment that is dark, cool and comfortable. Avoid disturbing noises-consider a bedside fan or white-noise machine to block out disturbing sounds.
Treatment with medication called hypnotics can be useful after
a combination of behavioral approaches has been tried.
The episode lasts seconds to a few minutes and can be terminated by
a sound or a touch on the body.
Sodium oxybate
a strong sleep-inducing agent may be given at night to improve disturbed nocturnal sleep and reduce daytime sleepiness and cataplexy.
Paresthesias
abnormal sensations
Chronic disease such as kidney failure, diabetes, Parkinson's, and peripheral neuropathy are
associated with RLS
RLS sensations are described as
burning, creeping, tugging, or like insects crawling inside the legs
The combination of sleep disturbance and low oxygen saturations can result in
car accidents, hypertension, heart disease, and mood and memory problems, stroke, CHF, and arrhythmias
Antidepressants are also often used to treat
cataplexy, hypnogogic hallucinations, and sleep paralysis
insomnia Can be acute (lasting one to several nights), or
chronic, lasting months to years.
quit smoking
cigarette smoke worsens swelling in the upper airway, making apnea and snoring worse
Sufferers are often unable to
concentrate, have impaired memory, or fail to accomplish daily tasks.
Current therapies can
control the disorder, minimizing symptoms, and increasing periods of restful sleep.
_______ is very important for people with narcolepsy. The symptoms are not widely understood by the general public, and this may cause patients to feel uncomfortable, alienated, or depressed. The disease can also be frightening and the fear of falling asleep inappropriately often significantly alters their life.
counseling
RBD is usually noticed when it causes
danger to the sleeping person, their bed partner, or others they encounter.
the second line of treatment for OSA is
dental appliances, which reposition the lower jaw and tongue, and upper airway surgery to remove tissue in the airway.
Behavioral therapy may help to control symptoms, including
including taking 3 or more scheduled naps throughout the day (10-15 min.) Patients should avoid heavy meals and alcohol, which can disturb or induce sleep. Routine sleep schedule Maintain regular exercise
Left untreated, insomnia is linked to
increased illness or morbidity.
All hypnotics
induce sleep and some help to maintain sleep.
Sensations occur deep inside the leg, between the
knee and ankle; more rarely in the feet, thighs, arms, and hands.
Some pregnant women experience RLS, especially in their
last trimester
what activates symptoms of RLS?
laying down
Most RBD patients are good-natured when awake; many of them display rhythmic movements in their
legs during non-REM and slow wave sleep.
Treatment includes
medication as well as behavioral therapy.
The syndrome may begin at any age, but most are affected during
middle age or older
Sometimes sleep paralysis runs in families. It can be associated with
narcolepsy
There is no cure for narcolepsy, but symptoms can be alleviated to the point of
near-normal functioning in many patients.
RLS is a
neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings
Both light and deep sleep stages are called
non-REM (rapid eye movement) sleep.
Prevalence of insomnia is higher in
older people and women (menstruation, pregnancy, and menopause).
Insomnia is considered chronic when it lasts longer than
one month.
For severe cases, ____ may be prescribed to induce relaxation and diminish pain.
opioids
Research indicates that those with insomnia have poorer
overall health, more work absenteeism, and a higher incidence of depression.
Benzodiazepines (mild to moderate symptoms)
provide a more restful sleep, but do not fully alleviate RLS symptoms and can cause daytime sleepiness.
If someone suspects they have sleep apnea, the first thing they should do is
see the doctor (It helps to bring a sleep record, a record of fatigue levels throughout the day, and any other symptoms that may be present. Ask a bed partner if they notice you snoring heavily, choking, gasping, or stopping breathing during sleep. Take an updated list of medications, including over the counter meds and all herbal preparations.)
A sleep study can determine if sleep apnea is present and its
severity
Narcolepsy affects both
sexes equally, and develops with age. -Symptoms usually first develop in adolescence or young adulthood, and may remain unrecognized as they gradually develop
sensations usually occur on both
sides of the body
Those with narcolepsy are perpetually sleepy, but do not
sleep more than the average person. They sleep a normal amount, but cannot control the timing of sleep.
The most common way to diagnose sleep apnea is with a
sleep study
In some cases, when hypnogogic hallucinations are present, people feel as if
someone is in the room with them.
REM sleep is also normally characterized by
temporary muscle paralysis.
After approximately 90 minutes, we enter the firsts stage of REM sleep, which is
the dreaming portion of sleep
Symptoms are usually less during the day, and more pronounced in the evening or at night, especially during
the onset of sleep
dysesthesias
unpleasant abnormal sensations
Sleep involves transitions between three different stages
wakefulness, rapid eye movement (REM) sleep, which is associated with dreaming, and non rapid eye movement (N-REM) sleep.
During this state, the electrical activity of the brain, recorded by an EEG, looks similar to the electrical activity that occurs during
waking
Lifestyle changes can lessen symptoms of sleep apnea. They include:
weight loss avoid alcohol quit smoking side laying during sleeping
RLS occurs in both genders, but the incidence is slightly higher in
women