Sleep Disorders David Earl MD, PharmD - PowerPoint Presentation

1. SleepDisordersDavid Earl MD, PharmDUniversity of New Mexico

2. Objectives:Learn about normal sleepDescribe common sleep related disorders: insomnia, sleep apnea, sleep terrors, nightmare disorder, RLS, PLMD, REM behavior disorder, and narcolepsyIdentify various treatment strategies for common sleep disorders

3. Why Do We Sleep?Sleep is crucial for: Restoration and recovery for the body and brainSleep strengthens our immune defenses and insufficient sleep impairs themBrain growth and developmentCentral nervous system repairMaintaining normal body and hormonal functionsLearning and Consolidation of memory and daily experiencesEnergy conservationBrain anabolismBrain neurons depend on glycogen for energyStrategies for prey and predatorAnimals match their sleep wake times to their needs for foraging and safetyBefore electricity and shiftwork, we forged in hunted it when it was light and rested when night fell

4. Sleep is Important in Brain PlasticityNeurons communicate with each other by synaptic connections and networksNew neuronal firing patterns are made during sleep Connections are made efficient and effectivePrune connections you don't needReverse learning, or deleting unimportant memories so only the highly important memories are savedRejuvenate connections you do needTo learn a memory task or skill, we must first be trained, then encode and consolidate memories to retain themSufficient sleep the night before initial training is crucial for encoding new memories and learning Memories are reviewed, refined, and consolidated REM sleep enhances learningWe learn best when we are in sync with our internal circadian clockVisual learning is enhanced by sleep and impaired by sleep loss

5. Synaptic Pruning at Work During Adolescence, and Occurs in SleepSynapses are formed, strengthened and pruned at explosive rates during adolescenceRestricted sleep then may lead to improper refinement of neural circuits.If chronic, may result in aberrant or mis-wiring (e.g. schizophrenia).

6. Sleep Through the AgesAge is the strongest and most consistent factor affecting the pattern of sleep stages across the night Sleep needs decline with ageThe biological clocks of teenagers change with puberty tend to run laterBy mid puberty, adolescents are sleepier mid morning and more alert mid afternoonA teen or adult who sleeps more than two hours more at night on the weekend compared with the weekday probably needs more sleep on weekdays (insufficient sleep syndrome)

7. The (Nitty Gritty) Neurobiology of SleepThere are sleep promoting neurons and wake promoting neurons that inhibit each otherthis forms a "flip flop switch" circuitresults in rapid and complete transition in behavioral state same principle applies to the circuitry controlling transitions between REM sleep and non-REM sleepallows for consolidated waking during the day and alternation between non-REM and REM sleep at nightbreak down of the circuitry results in and explains a variety of sleep disorders including: insomnianarcolepsyREM sleep behavioral disorder

8. Multiple physiologic variables demonstrate endogenous circadian rhythms: Each of Our Cells Have Little Clocks In each cell there are circadian oscillationsGenerated by negative feedback of proteins upon transcription of the genes that encode themAt least 10 CLOCK genes (e.g. Bmal1, Clock, Per, Cry)Main Timekeeper?

9. THE SUPRACHIASMATIC NUCLEUS!(SCN)

10. Our Clock Needs to Be Reset DailyCircadian Rhythm: a near 24-hour oscillation in behavior present in almost all eukaryotic organisms from single celled algae to humansour internal clocks run slightly longer than 24 hours24.2-24.9 hoursSCN uses zeitgebers (time-givers or time cues) to help synchronize (entrain) or reset the clock daily;Key zeitgebers:LightFeeding SchedulesMelatoninActivity

11. Lighten Up to Stay AwakeMelatonin secretion

12. EyesNo light signal sent to the SCNSuprachiasmatic Nucleus (SCN)Master clock signals other circadian oscillatorsPineal GlandSecretes melatonin Promotes SleepProcess for Sleep Cycle

13. Homeostatic Sleep DriveAKA “Sleep Pressure”Sleep pressure increases the longer we are awakeAdenosine rises as sleep debt builds up (byproduct of ATP)Inhibits body processes of wakefulness“rinsed out” during sleep

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15. How Much Sleep is Enough?Genetically determined4-11 hours per 24 hoursAverage is 7.5-9 hours

16. Owls and LarksNight owls (delayed sleep phase) Stay up lateMorning larks (advanced sleep phase)Rise early

17. Average Percentage of Time in Each Stage of SleepNREM 15%NREM 245%NREM 325%REM 25%Darker = harder to wake

18. Effects of Prior Sleep History on Sleep DistributionRecovery sleep after sleep loss is characterized by a rebound increase in N3 sleep the first night and REM sleep the second nightThe longer we are awake the greater our need for N3 sleepThe longer you have been awake, the easier it is to fall asleep (shorter sleep latency)Recovery sleep after(specifically) N3 or REM sleep deprivation is characterized by rebound of that sleep stageUnusually early appearance of REM after sleep onset can be seen in those who have had REM disrupted by:sleep apnea chronic irregular or insufficient sleepfrequently fragmented nocturnal sleepafter acute withdrawal of REM sleep suppressing drugs

19. Other Factors that Modify Sleep Stage Distribution:Prior sleep historyDrug effects Circadian processes and homeostatic processes impact: sleep amount sleep needs are genetically determinedone cannot learn to sleep less TimingSleep phase advanceSleep phase delay It is hard to delay or advance our circadian clock by more than two hours per dayArchitectureCore body temperature affects sleep architecture

20. Effects of Drugs on Sleep Stage DistributionBenzodiazepines suppress N3 sleepabrupt with draw causes a rebound of N3 sleep Anti-depressants suppress REM sleep and increase muscle activity during sleepSSRIs can cause inappropriate eye movements during non-REM sleepAbrupt withdrawal of antidepressants and amphetamines can cause REM sleep rebound with or without sleep onset REM periodsAlcohol taken just before bed in those not too used to it can cause an increase in N3 and suppression of REM sleep in the first half of the night followed by a rebound of REM sleep in the second halfBenzodiazepine use and barbiturate use can increase brain waves typically associated with active wakefulnessChronic marijuana use suppresses N3 sleepSome drugs (i.e. gabapentin, pregabalin, pramipexole) can increase N3 sleep

21. MDDBPADGADPanicOCDPTSDSchizophrenia↑ Sleep Onset Latency Varies with depression and mania↑ Sleep Onset Latency ↑ Sleep Onset Latency ↑ Awakenings↑ Awakenings↑ Sleep Onset Latency ↑ Stage N1More wake in last 2 hours of sleep↑ Stage N1↓ Sleep Efficiency↑ Movement Time↓ Sleep Efficiency↑ Awakenings↓ Sleep Efficiency↓ Stage N3↓ Stage N3Panic attacks from N2 or early N3 sleep↓ Stage N3 Sleep↓ Stage N3↓ Delta Wave Counts↓ REM LatencyNormal REM latencyNormal REM Latency↓ REM Latency+/- REM ChangesREM Latency was slightly decreased or normalLonger 1st REMREM shorter↑ Arousals (first half of sleep period)↑ in Wake after Sleep Onset (WASO)REM more denseREM more dense↓ REM DensityNormal REM Density↓ Total Sleep Time (TST)↓ Total Sleep Time (TST)↓ Total Sleep Time↓ Total Sleep Time (TST)↓ Total Sleep Time (TST)*OBJECTIVE SLEEP CHANGES BY DIAGNOSIS*

22. MDD Subjective Sleep ComplaintsSleep disturbance can occur before the onset of other symptomsInsomnia occurred as the first symptom 41% of initial cases of MDD and the first symptom in 56% of relapsesIn contrast with anxiety disorders insomnia after the onset of anxiety symptoms

23. Antidepressant Medications and SleepOlder TCA’s sedatingSSRI’s activating ->may worsen sleepcan exacerbate RLS and PLMSmay cause rapid eye movements in NREM sleepImprove muscle tone in upper airway and may diminish snoring or improve mild sleep apneaSuppress REM sleepamount and percentage of REM particularly in first third of the nightDelay onset of REMDecreases REM densitymost pronounced early in treatment, diminishes with long term use

24. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

25. InsomniaDifficulty falling asleep, staying asleep or waking too earlyadequate sleep opportunityassociated daytime dysfunction≥ 3 nights per weekAffects ~ one-third of the adult population occasionallyAffects 9%-12% on a chronic basis

26. Spielman’s 3 Factor Model of Insomnia

27. Co-morbid Disorders Related to InsomniaPsychiatric Disorders Associated With InsomniaGeneralized anxiety disorder (GAD) Acute stress disorder Posttraumatic stress disorder (PTSD) Dysthymia Major depressionBipolar disorder Schizoaffective disorder Medical disorders that may be associated with insomniaPain syndromes (e.g., arthritis) Asthma Chronic obstructive pulmonary disease (COPD) Fibromyalgia MigraineCluster headaches Gastroesophageal reflux disease (GERD) Peptic ulcers

28. Mental Health and InsomniaUp to 45% of Patients with insomnia have a mental health disorderMajor depression- up to 80% have insomniaEarly morning awakening is a hallmark of depressionInsomnia often precedes depressionTreating both increases likelihood of treatment responseAnxiety disorders- up to 90%Difficult initiating sleep“mind racing”Bipolar disorder Insomnia is a red flag for manic episodeDo not feel tired with less sleep during maniaSubstance use disorderInsomnia typically predates alcohol dependenceInsomnia is an important risk factor for relapse

29. FDA Approved Medications for InsomniaDrug ClassGeneric Name Half LifeBenzodiazepine Receptor agonistsTriazolamShortestTemazepamShortEstazolamLongQuazepamLongerFlorazepamLongestNon Benzodiazepine Receptor agonistsZaleplon1 hrZolpidem3 hrEszopiclone6 hrSelective melatonin receptor agonistRamelteonShortAntidepressantDoxepinMediumOrexin receptor antagonistSuvorexantMediumLemborexantMedium

30. Non Pharmacological Insomnia TreatmentCognitive Behavioral Therapy for Insomnia (CBT-I): 4-8 week guided courseLearn healthy sleep habits and develop new sleep behaviors to improve sleep quality and consolidationFirst Line treatment as effective as medications for the short-term treatment of chronic insomniaUnlike medication, benefits persist beyond discontinuationOverview of sleep habitsSleep diaryPatient education and teaching Cognitive reframing techniques

31. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

32. Obstructive ApneaCentral Apnea Mixed Apnea Airflow ChestAbdomenAirflow ChestAbdomenAirflow ChestAbdomenCentralObstructiveContinued or increased effort entire period of absent airflowAbsent effort entire period of absent airflowWe classify sleep apnea in a PSG based upon INSPIRATORY effort during absent airflow

33. Obstructive Sleep ApneaSymptoms:Snoring Pauses in breathing during sleepWaking up gasping for air Excessive sweating during sleepRestless sleepFrequent nocturnal awakeningsNocturia Morning headacheExcessive daytime sleepiness

34. Obstructive Sleep ApneaRisk factors:Male sexOlder age (40-70 years)Postmenopausal statusBMI >35HypertensionConsequences:StrokeHeart failureAtrial fibrillationHeart attackInsulin resistanceObesitySudden deathMood ProblemsMemory Problems

35. Treatment for OSA

36. Before and After PAP

37. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

38. NarcolepsyDue to loss of orexin neuronsSleep Attacks Irresistible need to sleepSleep ParalysisREM atonia when going to sleep or wakingHypnagogic HallucinationsDream intrusion into wakePoor Sleep at nightDue to sleep fragmentationPoor sleep/wake stabilityCataplexy (TYPE I)Sudden loss of voluntary muscle toneReflexes are absentIn response to strong emotional stimuli

39. Narcolepsy TreatmentGoal is to stabilize sleep-wake flip flopHypersomnolence: Timed SHORT naps during the dayStimulant medicationsCataplexyAntidepressants (MORE COMMON)Decrease REM intrustionSodium Oxybate (ONLY FDA APPROVED RX)Poor sleep at night:Sodium OxybateTiming of naps and stimulant use

40. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

41. Circadian Rhythm DisordersDesire for sleep and wakefulness at “inappropriate” times Can be caused by: geneticsaltered or disrupted sensitivity to internal timekeepersBlindnessshiftworkjetlag malfunctioning internal clockmental illnessenvironmental forcesfactors that prevent sleep (too hot, noisy, or bright) neurologic diseases selective early atrophy of SCN in Alzheimer's disease

42. Delayed Sleep Phase SyndromeMay look like sleep onset insomniaInability to arise in the morningNormal sleep if initiated at a delayed bedtimeBedtimes & wake times are later on vacationse.g., 4 a.m. – 12 p.m. sleep periodPeak onset in adolescence Differentials include:Sleep-onset insomniaBipolar disorderInadequate sleep hygiene

43. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

44. NREM ParasomniasUnwanted nocturnal behaviorsOften in the first third of the nightMore Common in childrenTypically from NREM 3 sleepIncreased with: Sleep deprivationSicknessStressSide effects to medications

45. NREM ParasomniasNight TerrorsEpisodes of abrupt terrorIntense fearAutonomic arousalInconsolableEyes openBrief to 30+ minutesNot easily remembered in a.m.Confusional ArousalsMental confusion or confused behaviorAbsence of terror or ambulation

46. NREM ParasomniasSleep walkingSomnambulismSleep talkingSomniloquyBedwettingEnuresisTeeth GrindingBruxismSleep related eating disordersEating while asleep

47. ParasomniasDuring REM Sleep NightmaresRecall intact upon awakingSecond half of the night Sleep ParalysisAwake but unable to move Sleep related hallucinationsHypnogogicWhen falling asleepHypnopompicWhen waking up

48. REM Behavioral DisorderDream enactmentUsually BriefRecall intact upon awakingThemes of being pursued/fear Associated with: Neurodegenerative diseasesPredates onset of Alpha-synucleinopathiesParkinson’s DiseaseMultiple system atrophyDementia with Lewy BodiesLesions affecting brain stemMultiple SclerosisNarcolepsyStrokeMedicationsAntidepressants

49. Normal Neurophysiology of REM Sleep

50. REM Sleep Without Atonia (RSWA)

51. Acting out Dreams Freud said we are lucky we are paralyzed during sleep so we cannot act out our dreams.

52. RBD TreatmentEnsure Safe EnvironmentMelatoninClonazepamAntidepressant changeOther medications linked to RBD:SelegelineDonepezilBarbiturate withdrawalBisoprolol

53. The ICSD-3 Sleep Disorder Categories1. InsomniaChronic insomnia disorderShort-term insomnia disorder2. Sleep-related breathing disordersObstructive sleep apnea disordersCentral sleep apnea syndromes3. Central disorders of hypersomnolenceNarcolepsy type I and IIIdiopathic hypersomniaKleine-Levin syndromeInsufficient sleep syndrome4. Circadian rhythm sleep-wake disordersDelayed sleep-wake phase disorderAdvanced sleep-wake phase disorderIrregular sleep-wake rhythmNon-24-hour sleep-wake rhythm disorderShift work disorderJet lag disorder5. ParasomniasNREM-related parasomnias Confusional arousals Sleepwalking Sleep terrors Sleep-related eating disordersREM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder6. Sleep-related movement disordersRestelss leg syndromePeriodic limb movement disorderSleep related leg crampsSleep-related bruxismThe ICSD-3 Sleep Disorder Categories [1]*For further information on various disorders click the highlighted disorders for in depth articles.*1. InsomniaThe ICSD-3 defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment."The ICSD-3 groups insomnia into 4 major categories listed below.a. Chronic insomnia disorderb. Short-term insomnia disorderc. Other insomnia disorderd. Isolated symptoms and normal variant2. Sleep-related breathing disordersThese disorders are divided into those of central origin (characterized by a lack of breathing effort) and those caused by an obstruction of the airways.a. Obstructive sleep apnea disordersi. Obstructive sleep apnea, adultii. Obstructive sleep apnea, pediatricb. Central sleep apnea syndromei. Central sleep apnea with Cheyne-Stokes breathingii. Central sleep apnea due to a medical disorder w/o Cheyne-Stokes breathingiii. Central sleep apnea due to high altitude periodic breathingiv. Central sleep apnea due to medicaiton or substancev. Primary central sleep apneavi. Primary central sleep apnea of infancyvii. Primary central sleep apnea of prematurityviii. Treatment-emergent central sleep apneac. Sleep-related hypoventilation disordersi. Obesity hypoventilation syndromeii. Congenital central alveoloar hypoventilation syndromeiii. Late-onset central hypoventilation with hypothalamic dysfunctioniv. Idiopathic central alveolar hypoventilationv. Sleep-related hypoventilation due to medication or substancevi. Sleep-related hypoventilation due to medical disorderd. Sleep-related hypoxemia disordere. Isolated symptoms and normal variantsi. Snoringii. Catathrenia3. Central disorders of hypersomnolenceThe ICSD-3 categorizes this class of sleep disorders as those in which "the primary complaint is daytime sleepiness not caused by disturbed nocturnal sleep or misaligned circadian rhythms."a. Narcolepsy type Ib. Narcolepsy type IIc. Idiopathic hypersomniad. Kleine-Levin syndromee. Hypersomnia due to a medical disorderf. Hypersomnia due to a medication or substanceg. Hypersomnia associated with a psychiatric disorderh. Insufficient sleep syndrome4. Circadian rhythm sleep-wake disordersThese disorders are characterized by a disturbance or disruption to the normal circadian rhythm, which causes patients to experience excessive daytime sleepiness, insomnia, or both.a. Delayed sleep-wake phase disorderb. Advanced sleep-wake phase disorderc. Irregular sleep-wake rhythmd. Non-24-hour sleep-wake rhythm disordere. Shift work disorderf. Jet lag disorderg. Circadian rhythm sleep-wake disorder not otherwise specified (NOS)5. ParasomniasA parasomnia is an unwanted physical movement or action during sleep. This group of disorders is classified by disorders or arousal from NREM sleep, those associated with REM sleep, and other parasomnias.a. NREM-related parasomniasi. Disorders of arousal from NREM sleepii. Confusional arousalsiii. Sleepwalkingiv. Sleep terrorsv. Sleep-related eating disordersb. REM-related parasomniasi. REM sleep behavior disorderii. Recurrent isolated sleep paralysisiii. Nightmare disorderc. Other parasomniasi. Exploding head syndromeii. Sleep-related hallucinationsiii. Sleep enuresisiv. Parasomnia due to medical disorderv. Parasomnia due to medication or substancevi. Parasomnia, unspecifiedd. Isolated symptoms and normal variantsi. Sleep talking6. Sleep-related movement disordersThis class of disorders is characterizeed by simple, often repetitive movements during sleep or wake that can disrupt the sleep of the patient, the patient's bed partner, or both.a. Restelss leg syndromeb. Periodic limb movement disorderc.Sleep related leg crampsd. Sleep-related bruxisme. Sleep-related rhythmic movement disorderf. Benign sleep myoclonus of infancyg. Propriospinal myoclonus at sleep onseth. Sleep-related movement disorder due to medical disorderi. Sleep-related movement disorder due to medication or substancej. Sleep-related movement disorder, unspecified

54. Restless Leg SyndromeU- urge to move the legsR- rest G-getting up = better E- eveningS- something else Family history Improvement with dopaminergic therapyPeriodic limb movements of sleep in 80%Serum ferritin <50 mg/LMiddle to older ageUsually progressive course

55. Restless Leg Syndrome versus Periodic Limb Movement DisorderRestless Leg SyndromeBothersome while awakeAssociated with iron deficiencyFerritin < 50FamilialOverlap with Periodic Limb Movements Disorder80% of those with RLS have PLMDTreat with iron, then dopamine agonistsPeriodic Limb Movement DisorderBothersome During SleepMovements interrupt/worsen sleepOverlap with RLS20% of those with PLMD have RLS may not be a disorder:if not interrupting sleepnot causing daytime dysfunction

56. QUESTIONS?