Download Diagnosis of Sleep Disorders

Diagnosis of Sleep Disorders
Dr Kirstie Anderson
Regional Sleep Service
Newcastle UK
www.neurone.org/sleep-resources
Your job description?
1. Psychiatrist
2. Neurologist
3. Neuroscientist
4. Psychologist
5. Other
The anatomy of sleep – of the brain, by
the brain and for the brain
• Hours – homeostatic drive to
sleep that builds for every
hour awake
• Clocks – intrinsic circadian
rhythm, we are hard wired to
light – retinohypothalamic
tract to SCN
How bright is the light you are in now?
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2.
3.
4.
5.
10 Lux
500 Lux
1000 Lux
10,000 Lux
100,000 Lux
The physiology of sleep
The things that go wrong with sleep
Bedtime stories
how to take a sleep history
• Do you snore heavily – obstructive sleep apnoea
• Do you need to move your legs in bed at night – restless legs
• What drugs are taken and when (including
caffeine/nicotine/alcohol)
• A typical 24 hour day – shift work, sleep restriction
• Daytime napping ? (fatigue versus sleepiness)
• Parasomnia – witness description, ? childhood, ? time of night
• Epworth sleepiness score >10 sleepy, >15 very sleepy, 0-1
insomnia.
The cause of sleepiness ?
• 42 year old lawyer with 2 year history of daytime sleepiness,
epworth sleepiness score 14
• Slim (BMI 24) without history of snoring or restless legs. No
sedative medications
• Some dream recall
What would be the best test to start
with?
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5.
MRI brain scan and EEG
Cerebrospinal fluid hypocretin
In-patient polysomnography
and multiple sleep latency tests
Two weeks of wrist actigraphy
Sleep diaries
The cause of sleepiness ?
• 42 year old lawyer with 2 year history of daytime sleepiness,
epworth sleepiness score 14
• Slim (BMI24) without history of snoring or restless legs. No sedative
medications
• Some dream recall
• “take me through your 24 hours” – typically week days bed after
midnight, up between 5 and 6 for gym”
• Sleep diaries – average total sleep time 4.8 hours weekdays with
most daytime naps fridays and weekends – SLEEP RESTRICTION
Causes of hypersomnia
1. Too little sleep – count the hours - 30% adults in the western
world have some sleep restriction
2. Poor quality sleep – obstructive sleep apnoea, restless legs
syndrome
3. A sleepy brain – sedating medication, narcolepsy, idiopathic
hypersomnia
4. Circadian rhythm disorder – shift work >40yrs, delayed sleep
phase syndrome <25 years
Obstructive sleep apnoea
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10% of men and 5% of women over
40
Home respiratory sleep study for
diagnosis
High risk populations
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Alcohol
Metabolic syndrome
Psychotropic / sedative medication
20% of those with severe mental health
problems
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Clues for those who sleep alone
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Neck cirumference > 17inches
Nocturia, insomnia (25%)
dry mouth, sore throat, choking
unrefreshing night sleep
The cause of sleepiness?
• 26 yr old female
• Very sleepy since age 14 (ESS 21) and never learnt
to drive
• Fragmented night sleep, vivid dream recall,
occasionally had dream enactment
• On direct questioning – odd episodes of knees
buckling or face feeling loose with head and jaw
drop when laughing with friends
Which of the following statements is
correct
1.
2.
3.
4.
5.
MRI brain and EEG can be used to diagnose narcolepsy
Overnight respiratory sleep study should always be performed
first
In-patient polysomnography and multiple sleep latency tests are
the only test that can be used to diagnose narcolepsy
Undetectable cerebrospinal fluid hypocretin levels can be
sufficient to diagnose narcolepsy with a typical clinical history
Haplotyping and screening for the HLA DQB*0602 is needed for all
patient and is a diagnostic test
Narcolepsy
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“seized by somnolence” – first
described 1880 by Gelineau
A sleep switch disorder
Young onset for most (mean age
onset 14). 0.1% population but mean
of 10 years to diagnosis
Brief, refreshing naps for many and a
broken night
Hypnagogic hallucinations can lead to
referral to psychiatry, sleep paralysis
is common
1/3 don't have cataplexy
They are VERY sleepy
“Tell me when you last fell asleep”
Narcolepsy
A restless night
• 54 year old man with
daytime sleepiness, ESS19
• BMI 33 and did snore so
referred as possible sleep
apnoea but…..
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Restless legs syndrome
5% of the population
Current diagnostic criteria emphasise
episodic and chronic symptoms
Most present > 40, 50% have a family
history
Common associations are with iron
deficiency, pregnancy, medication,
dialysis, diabetes, high dose
nicotine/caffeine/alcohol
The most sensitive diagnostic test - ask
the patient!
Video polysomnography diagnoses
periodic limb movements
Much night to night variability so home
foot actigraphy may be a better test
• 62 yr old male
Acting out dreams
• “shouting out at night” 10 year
history of occasional vocalisations
+/- limb movement. Getting
worse.
• 2 months ago kicked his wife and
one month ago tried to strangle
her. Otherwise well with
refreshing sleep
• Recurrent violent dreams
including escape from prison,
being chased by guards
Which of the following statements are
correct
1. The symptoms are most compatible with post
traumatic stress disorder
2. The symptoms are most likely to be a nocturnal
epilepsy
3. The diagnosis can be made on the basis of the
history alone
4. This clinical history strongly predicts a future
neurodegenerative problem
• 62 yr old male
Acting out dreams
• “shouting out at night” 10 year
history of occasional vocalisations
+/- limb movement. Getting
worse.
• 2 months ago kicked his wife and
one month ago tried to strangle
her. Otherwise well with
refreshing sleep
• Recurrent violent dreams
including escape from prison,
being chased by guards
• REM sleep behaviour disorder –
loss of the normal REM atonia
seen on polysomnography
• 80% will develop a parkinsonian
neurodegeneration at 15years
•
Diagnosis of parasomnia
NREM Parasomnia
first hour, first half of the night, complex motor
actions, little or no recall, out of bedroom. Hard to
wake, last several minutes. Most have childhood or
young adult onset
•
REM Parasomnia
rare first hour, usually second half of night, violent
brief movements, dream recall. Easy to wake. Older.
Polysomnography part of diagnostic criteria
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Nocturnal seizures
Younger groups, can have recall, brief violent but
stereotyped dystonic posturing, often sleepy,
multiple times per night.
A broken clock – Circadian Rhythm
Disorder
• Diagnosis made by history, sleep
diaries +/- actigraphy
• Key features in the history
– Quality of sleep often
remains good
– “if you could sleep when you
want to – would you sleep
well?”
– “Take me through your 24
hours”
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6 Distinct circadian rhythm disorders
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Delayed sleep phase syndrome <25yrs
Advanced sleep phase syndrome
Shift work disorder >40yrs
Jet lag syndrome
Irregular sleep wake disorder
Non 24 hour pattern
Case history
• As patient is drifting off to sleep – a sound
loud noise and flash of light that causes a
physical jolt – distressing, sits up, heart racing
• The happens three further times before
consultation
What is the patient describing and
what should you do
1. Possible brain aneurysm- refer for urgent
vascular brain imaging
2. An auditory seizure phenomenon – MRI brain
and EEG
3. Psychogenic symptoms – refer to psychiatry
4. Exploding head syndrome – direct them to
Wikipedia (or any online encyclopaedia of your
choice)
Insomnia disorder
• The commonest sleep disorder 510%, F>M
• 50% comorbid with anxiety /
depression or other medical
problems
• Diagnosis typically made on
history alone with exclusion of
secondary causes
• Difficulty initiating and
maintaining sleep with
subsequent daytime dysfunction
and >3 nights a week for > 3
months
• Red flags – what is not “just
insomnia”
• Beware daytime sleepiness – this
should be a hypervigilant
phenotype. Older patients
commonly have comorbid sleep
apnoea, thinner and atypical Hx
• The three R’s
– Restless legs syndrome (at least 10%)
– Reflux
– Rhythm – ? delayed sleep phase in
those< 25
Which of the following tests are useful
for severe insomnia
1. Monitoring sleep with a gadget
(fitbit/jawbone etc)
2. Polysomnography
3. Wrist actigraphy
4. Screening questionnaires for depression
5. Pen and paper sleep diaries for 2 weeks
Insomnia Disorder – sleep diaries
How much time does the average
medical student spend learning about
sleep disorders (UK/US)
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2.
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4.
2 minutes
2 hours
10 hours
20 hours
Diagnosis of sleep disorders - summary
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Take a sleep history in all your patients
The commonest cause of sleepiness in those > 40 is sleep apnoea
Ask everyone about restless legs
Review the prescription – sedatives / stimulants, timing and dose of
caffeine/nicotine/alcohol
• Simple sleep questionnaires and sleep diaries – underused but
effective for diagnosis of insomnia and circadian rhythm disorder
• Parasomnia – in the young look for triggers (and wear pyjamas!), in
the elderly think about an associated parkinsonian disorder