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