Download 10:45 AM Sleep Disorders - Vanderbilt University Medical Center

Sleep Disorders
Beth A. Malow, M.D., M.S.
Associate Professor of Neurology
Director, Vanderbilt Sleep Disorders Program
NIH Research on Sleep and Sleep Disorders
Program Announcement (2-9-05)
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Estimated 70 million people in the US suffer from sleep
problems (50% have chronic sleep disorder)
30 million American adults have insomnia
18 million Americans have sleep apnea
250,000 Americans have narcolepsy
10-20% of adults have restless legs syndrome
Each year, 100,000 accidents and 1500 traffic fatalities are
related to drowsy driving
Each year, sleep disorders, sleep deprivation, and excessive
daytime sleepiness add approximately $16 billion annually to
the cost of health care in the US and result in $50 billion
annually in lost productivity
Presentation Objectives
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To discuss the differential diagnosis of common
sleep concerns and the essentials of the sleep
history
To describe polysomnography (sleep studies) and
what is measured
To highlight obstructive sleep apnea and insomnia
as examples of treatable sleep disorders
Sleep disorders– Common concerns
 “I
can’t fall asleep or stay asleep”
 “I’m
too sleepy during the day”
 “I’m
told I do unusual things in my sleep”
Sleep disorders– Common concerns
 “I
can’t fall asleep or stay asleep”
– Psychophysiological Insomnia (often stress-related)
– Inadequate Sleep Hygiene (poor sleep habits)
– Medications (corticosteroids)
– Medical Disorder (arthritis, back pain)
– Neurologic Disorder (epilepsy, Parkinson’s disease)
– Psychiatric Disorder (anxiety, depression)
– Obstructive Sleep Apnea
– Restless Legs Syndrome
Sleep disorders- Common concerns
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“I’m too sleepy during the day”
– Not enough sleep (sleep deprivation)
– Sleep is disrupted (sleep apnea, periodic limb movements
of sleep, frequent awakenings from medical or
neurological disorder)
– CNS pathology (narcolepsy, with REM intrusions into
wakefulness– cataplexy, sleep paralysis, hypnic
hallucinations)
– Medications (antiepileptic drugs)
– Depression
Sleep disorders- Common concerns
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“I’m told I do unusual things in my sleep”
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Parasomnias: disorders in which undesirable physical or
mental phenomena occur during sleep
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NREM arousal disorders (sleepwalking, night terrors)
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REM sleep behavior disorder (dream-enacting behavior)
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Rhythmic movement disorder (head banging)
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Sleep Starts (hypnic jerks)
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Nocturnal seizures may mimic parasomnias
Case example
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A house officer complained of difficulty staying
awake on afternoon rounds. Her call schedule
varied depending on the rotation, but was usually
once every three nights, with her getting at most 2
hours sleep on a call night. When not on call, she
had difficulty falling asleep and tossed and turned
worrying that she would not be able to sleep well
that night. Her bedtime when not on call varied
between 10 PM and 2 AM depending on her work
assignments and whether her twin 2-year-old sons
awakened from sleep. She would frequently
awaken about 2 hours after falling asleep.
Case example
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During the day, she drank coffee and caffeinated
soda in the afternoons and early evenings to stay
awake. She often missed her exit on the
expressway while driving home from work. Her
husband said that she snored heavily when she
slept on her back and described her sleep as
restless. She has had difficulty losing weight since
the birth of her twins and is about 30 pounds
overweight. She occasionally took Benadryl to
sleep.
Sleep disorders- Common concerns
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“I’m too sleepy during the day”
– Not enough sleep: med student with erratic schedule and
twins, stress and caffeine-related insomnia
– Sleep is disrupted: ? Obstructive sleep apnea
– CNS pathology: narcolepsy?
– Medications: Benadryl?
– Depression: maybe?
Sleep disorders-- Referral for Study
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Polysomnography: Overnight sleep study to evaluate and
quantify overall sleep architecture, breathing, leg
movements, abnormal behaviors
– Sleep apnea
– Periodic limb movements
– Parasomnias (includes video-EEG)
– Narcolepsy (along with daytime multiple sleep latency test)
– Not usually indicated for insomnia
Risk Factors, Symptoms, Outcomes, and
Comorbid Conditions of Obstructive Sleep
Apnea (OSA) in Adults
Young, JAMA, 2004
How is OSA treated?
Continuous positive airway pressure (CPAP)
 Weight loss
 Positional therapy (to get person off back)
 Oral appliances: for mild to moderate OSA
 Surgery: Uvulopalatopharyngoplasty (UPPP),
maxillofacial surgery, nasal somnoplasty,
adenotonsillectomy (in children and young adults)
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Continuous positive
airway pressure
(CPAP) works by
using pressurized air
to splint open the
upper airway,
preventing collapse
during sleep
A titration study in the
sleep lab is followed by
prescribing CPAP for
home use
Treatment of OSA with CPAP
Psychophysiological Insomnia
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People with this disorder have a few nights of insomnia,
perhaps due to some major stressor (death in family, new
job, divorce) and then learn behaviors to prevent sleep.
These behaviors include:
– Marked overconcern with the inability to sleep with focused
absorption on sleep problem: vicious cycle develops!
– Associating bedroom with not sleeping (conditioned arousal)
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Psychophysiological insomnia may also lead to:
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Inadequate sleep hygiene
Inappropriate use of stimulants or alcohol to promote sleep
Psychophys. Insomnia- Treatment
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Stimulus control (learning not to associate
bedroom with not sleeping):
Go to bed only when sleepy
 Use bed and bedroom only for sleep (no reading,
TV watching, eating, etc.)
 Get out of bed and go into another room when you
are unable to sleep for 15-20 minutes
Psychophys. Insomnia- Treatment
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Sleep restriction: curtailing the amount of time
spent in bed to the actual amount of sleep
 Many
people are so worried about how long it takes
them to fall asleep that they go to bed extra early (9
PM bedtime but don’t fall asleep until 1 AM!)
 Using sleep restriction, these people would go to bed
at 11 PM or midnight and fall asleep immediately,
thereby breaking the cycle of lying awake in bed
worrying about going to sleep.
Psychophys. Insomnia- Treatment
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Sleep hygiene education:
 Exercising,
but avoiding exercise too close to bedtime
 Regular bedtime and waketime
 Avoiding daytime naps
 Avoiding alcohol, caffeine, cigarettes
 Appropriate room temperature and noise level
 Light snack, rather than heavy meal at bedtime
 Avoid taking problems to bed
Taking a Sleep History
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Chief complaint
– Sleepiness, insomnia, abnormal sleep behavior
– How long symptoms going on? What brought patient or
parent to seek medical attention?
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Nighttime sleep (from bedpartner or parent)
– Snoring, kicking, abnormal behaviors
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Sleep/wake schedule
– Bedtime and wake time on weekdays and days off
– Time to fall asleep, wakings, any naps during day
Taking a Sleep History
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Other daytime symptoms
– Cataplexy, hallucinations, sleep paralysis
– Creeping/crawling feelings in legs while falling asleep
– Work performance, School performance
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Daytime Sleepiness (or hyperactivity)
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Medical, Neurological, and Psychiatric History
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Medications
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Remember to ask about alcohol, caffeine, cigarettes,
herbals, illicit drugs, and over-the-counter products
Vanderbilt Sleep Disorders Center
Vanderbilt Sleep Disorders Center