Sleep Disorders RLS: creeping, crawling sensation, pins and needles during waking and

Normal Sleep sleep onset

Non-REM stages 1-4 PLMS: involuntary, rhythmic twitches (ankle dorsiflexion) that may lead to
REM brief arousal
Loss of muscle tone and REMs Treatment
80-120 minutes after onset of sleep, lasts 10 min Reduce muscle activity or sleep disruption
Neurotransmitters and neuromodulators may regulate sleep-wake Dopminergic agents, GABAergic agents, opioids
cycle
Circadian rhythms Hypersomnolence Disorder
25 hours from wake to wake time Excessive sleepiness
Cycle modified by external cues Difficulty staying awake, naps, remains in bed
Sleep pattern changes over time Tired, falls asleep sooner, harder to get up
Neonatal period REM >50% >1 mo
4 mos of age REM <40% May be caused by cumulative insufficient sleep
Young adult NREM 75%, REM 25% Not just a long sleeper (they sleep for a long time, but in nl pattern)
TX:
DSM-5 Sleep Disorders Regulating and extending sleep habits/patterns
Insomnia Disorder* Amphetamines or stimulants or SSRIs
Hypersomnolence Disorder* decrease REM, increase restorative sleep
Narcolepsy*
Breathing-Related Sleep Disorders: Narcolepsy
Obstructive Sleep Apnea Elements of sleep intrude into wakefulness & elements of wakefulness
Central Sleep Apnea intrude into sleep
Idiopathic central sleep apnea Characterized by sleep attacks
Cheyne-Stokes breathing Episodes of irresistible sleep leading to 10-20 min of sleep
Central sleep apnea comorbid with opioid use occurring at inappropriate times
Sleep-related hypoventilation REM cycle impaired
Frequent awakenings, vivid nightmares, intense, realistic
Insomnia hallucinations prior to sleep onset
Dissatisfaction with sleep quantity or quality associated with >1: Epidemiology
Difficulty initiating sleep, 0.02-0.16% of adults
difficulty maintaining sleep with frequent awakening or Etiology
problems returning to sleep, Some familial incidence
early morning awakening with inability to return to sleep. Possibly type of epilepsy or psychogenic disturbance
Epidemiology Diagnostics
1 year prevalence rate of 30-45% Polysomnography demonstrating REM sleep within 10 minutes of
The most common sleep complaint sleep onset
Etiology *Narcolepsy can be dangerous due to sleep attacks during driving, or
Stress, caffeine, physical discomfort, napping, psychiatric disorders operating machinery
DDx: Tx:
nocturia, RLS, meds, circadian rhythm disorder Sleep hygiene, Forced naps
Medications:
DSM-5 Criteria Excessive daytime sleepiness: provigil, nuvigil, stimulants
A. Predominant c/o dissatisfaction with sleep quantity or quality Cataplexy: TCAs, Venlafaxine, fluoxetime (suppress REM
associated with 1 or more: activity)
1. Difficulty initiating sleep Parasomnia
2. Difficulty maintaining sleep (frequent awakenings or Usually occurs in stage 3 & 4 of NREM sleep
problems returning to sleep) therefore patients do not remember
3. Early morning awakening with inability to return to NREM associated: Sleep walking, sleep terrors
sleep REM associated: REM behavior disorder, recurrent isolated sleep
B. Sleep disturbances causes sig. distress or impairment in social, paralysis, nightmare disorder
work, educational, academic functioning. Others: sleep enuresis, sleep-related groaning, sleep-related
C. Sleep difficulty occurs at least 3 nights/week hallucinations, sleep-related eating disorder, parasomnia due to
D. Sleep difficulty present for at least 3 mos drugs or medical conditions.
E. Sleep difficulty occurs despite adequate opportunity for sleep TX
F. Insomnia not better explained by other sleep-wake disorder Protection
G. Insomnia not attributable to use of a substance SSRIs, TCAs, benzos for NREM
H. Coexisting mental/physical disorders do not account for it
Tx Circadian Rhythm Disorders
Benzos Disruption in sleep pattern leading to excessive sleepiness or
Non-benzo: Ambien, Sonata, Lunesta insomnia due to mismatch in sleep-wake cycle from environment
Non-pharmacologic Delayed sleep phase type, advanced sleep phase type, irregular
CBT sleep-wake type, jet lag type, shift work type, non-24-hour sleep-
Sleep hygiene counseling wake type
Table 16.2-5 Kaplan & Sadock (next slide) Treatment:
Relaxation techniques, Biofeedback Chronotherapy, sleep hygiene, melatonin, light therapy
Stimulus control therapy, Sleep restriction therapy