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Neuro: Sleep Disorders


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3 states of normal sleep
1. wakefullness
2. nonrapid eye movement sleep (NREM)
3. rapid eye movement sleep (REM)
REM sleep
-stage 5 of sleep characterized by rapid saccadic movements of the eyes
-activity of brain neurons is similar to waking hours
-"paradoxical sleep"
-most vivid dreams occur here
-lightest form of sleep
-~4-5 periods of REM sleep/night
-shorter REM periods in beginning of the night; longer at the end
-total REM time of ~90-120 minutes/night for adult
NREM sleep
-stage 1-4 of sleep
-little/no eye movement
-dreamin is rare
-muslces are not paralyzed
-parasympathetic dominance
Stage 1 NREM
-occurs in beginning of sleep with slow eye movemente
-people often believe they are fully awake
-during transition into stage 1 sleep, it is common to experience a hypnic jerk
Stage 2 NREM
-unconscious, though awakened easily
-no eye movements occur
-characteristic sleep spindles and K-complexes
Stage 3 NREM
-delta waves begin to occur
-reached mostly in first 1/3 of night
Stage 4 NREM
-slow wave sleep
-deepest stage of sleep
-dreaming is more common in this stage than other NREM stages, but still not as common as REM sleep
-reached mostly in first 1/3 of night
circadian rhythm
-roughly-24-hour cycle in the physiological processes
-endogenously generated so they cannot be changed but can be altered by cues such as temp and sunlight
circadian drive for wakefullness
-biomodal (peaks ar ~8 am and 8 pm, dips at ~2 am 2 pm)
-in superchiasmatic nucleus of brain
homeostatic drive for sleep
-build up over the day until they reach the peak urge at night and you fall asleep
Categories of sleep disorders
-disorders of the wake/sleep cycle (circadian rhythm disorders)
-obstructive sleep apnea
-idiopathic CNS hypersomnia
-recurrent hypersomnia
Obstructuve Sleep Apnea prevalance
-4% of men, 2% women
Obstructuve Sleep Apnea: Sx
-Horrible snoring sounds/gasping then stops everything – suddenly starts up again (often with a huge recovery breath/snort)
-Period of all this work of breathing going on in the addominal cavity and brain realizes that – so brain tell you to “arouse and take a deep breath” – so pt wakes up quickly to take a deep breath (too brief for pt to realize).
-person is sleepy bc they are waking up hundreds of times a night
-excessive daytime sleepiness (EDS)
Obstructuve Sleep Apnea: Consequences
-systemic and pulmonary hypertension
Obstructuve Sleep Apnea: Dx
Obstructuve Sleep Apnea Tx
-put brick under legs of the bed so head is up, feet are down (helps keep airway open and helps GERD)
-avoid sleeping on back
-positive airway pressure (CPAP)
-dental appliances
Continuous Positive Airway Pressure
-Acts like an air-splint – keeps upper airway open the whole night
-Best compliance (even better than PO meds); because they are finally getting restful sleep; very well tolerated; very efficacious
-Nasal (covers nose only) and full face masks (covers nose and mouth) – they are generally equally effective.
-surgical resection of tonsils, soft palate, (try to clean our back of mouth/throat)
-for mild OSA
-very painful
Dental appliances
-for mild OSA
-specialy tailored for each person
-pushed mandible forward so tongue gets pushed forward with it - improves airway)
Relationship between obesity and obstructive sleep apnea
2/3 of people with sleep apnea are obese, but MOSt people who are obese do not have sleep apnea
Narcolepsy: prevalance
Narcolepsy: Sx
-EDS: 100%
-Fragmented sleep: 100% (fragil sleep)
-Cataplexy: 65-70%
-Hypogogic Hallucinations (HH): up to 50%
-Sleep paralysis (SP): up to 60%
-fewer than 50% of pts have entire sx complex
-14-42% have cataplexy, HH, SP
-atonia from REM extends into wakeful hours
-muscular weakness ranging from barely perceptible slackening of facial muscles to dropping of the jaw or head, weakness at the knees, or a total collapse.
-Usually speech is slurred, vision is impaired (double vision, inability to focus), but hearing and awareness remain normal
-attacks are triggered by strong emotions such as exhilaration, anger, fear, surprise, orgasm, and laughter
Hyponogogic Hallucination
-vivid, often frightening, dream-like experiences that occur while awake
e.g. see someone in the room that is not really there, hear someone calling you name when no one is there, etc.
Sleep Paralysis
-temporary paralysis of the body shortly after waking up (known as hypnopompic paralysis)
-resmebles REM atonia
Narcolepsy: Consequences
-psyhosocial and socioeconomic
Narcolepsy: Dx
-multiple sleep latency test (take naps and measure amt of time is takes to fall asleep, records pts brain waves or EEG, heart rate or EKG, muscle activity and eye movements)
-average sleep latency is <5 min
Narcolepsy: Tx
-stimulant for EDS
-tricyclic antidepressents for HH, SP, cataplexy
Examples of Stimulants for EDS
Narcolepsy: Cause
role of hypocretin (lack of hypocretin)
Insomnia: prevalance
-most common of all sleep related complaints
-up to 30% of adult population
Is insomnia diagnositic entity?
No, it is a symptom

NOT a diagnostic entity
Insomnia: Sx
-perception of unrestored sleep
Insomnia: Consequences
Insomnia: Dx
-thorough hx and PE
-sleep logs
-actigraphy (watch type thing pt wears at night, measure how active they are during night)
Insomnia: TX
-identiy underlying medical or psychiatric conditions and treat if necessary
-combination of behavioral and pharmacologial therapy is often effective
-Stimulus control therapy (most important and effective!)
-sleep restriction
-sedative hypnotics
Stimulus control therapy
-get all stimuli out of bedroom; use bed for sleep and sex only
-no pets, no TV, very dark, etc
-If can’t sleep for more than 15 minutes, leave the bedroom and go to low light area, do something deadly dull like needlepoint etc. (no chores, no work); this trains mind that bedroom is a good place to be and good for sleep
-No naps during the day!
-Point is to built up homeostatic drive for sleep so they can sleep at night
-Get up at same time every day, even on weekends
Restless Leg Syndrome: Prevalance
5-10% of general population
Restless Leg Syndrome: sx
-indescribable discomfort in legs relieved momentarily by movement of legs
-"creepy crawly" or "pins and needles"
-happens when falling asleep or sitting for long periods of time
Restless Leg Syndrome: Dx
-check iron levels
Restless Leg Syndrome: Tx
-iron supplement (if low iron)
-levodopa and dopaminergic agonists - 50-85% of pts improve in sx
-benzodiazepines (Klonopin)
Periodic Limb Movemement Disorder: Prevalence
-70% of pts with RLS have PLMD but only minority of pts with PLMD have RLS
Periodic Limb Movemement Disorder: Sx
-twitch of legs while sleeping
-very periodic, like a clock
Periodic Limb Movemement Disorder: Dx
Periodic Limb Movemement Disorder: Tx
-levodopa and dopaminergic agonists
-?klonopine? (if improvement more related to decreasing arousals)
Difference between RLS and PLMD
RLS: when awake; creepy/crawly

PLMD: when asleep; twitching
Primary Circadian Rhythm Disorders (Disorders of the Wake Sleep Cycle)
-delayed sleep phase syndrome
-advanced sleep phase syndrome
Secondary Circadian Rhythm Disorders (Disorders of the Wake Sleep Cycle)
-jet lag
-shift work
Delayed Sleep phase syndrome: sx
-can't fall asleep until late (until 2-6 am)
Delayed Sleep phase syndrome: dx
-presents as either sleep onset insomnia or EDS esp in AM
Delayed Sleep phase syndrome: tx
-career counsleing
-chronotherapy (sleep around clock to try to train brain)
-bright light in AM
Advanced Sleep phase syndrome: sx
-can't stay up as late as desired, wake up far earlier than desired
-more common in older adults
Advanced Sleep phase syndrome: dx
-present as EDS particularly in evening or sleep maintainence insomnia (awaking too early)
Advanced Sleep phase syndrome: tx
-bright light in evening
Jet Lag
-varying degrees of EDS; difficulty initiating/ maintaining sleep
Jet Lag: pathophsioogy
-desynchronization between the internal clock and external clock
Jet Lag: Dx and Tx
-bright light exposure
Shift Work
-EDS, insomnis
Shift work: managment
-strict sleep schedule 7 days a week
-dark bedroom
-avoid light during sleep period
-undesirable behavioral or experiential phenomena that occur during sleep
Types of Parasomnias:
-disorders of arousal (confusional arousal, sleep walking, sleep terrors)
-REM sleep behavior disorder
-nocturnal seizures
-psychogenic dissociative disorders
Disorders of Arousal
-nonREM; usually first 2 hours of sleep (mostly Slow wave sleep, stage 3-4)
-simultaneous or rapid oscillations of wake and NonREM
-no remebered dream mentation
-unaware of episode
Confusional arousals: prevalence
extremely common before age 5
Confusional arousals: sx
-sudden arousal from sleep associated with complex behaviors without full awareness
Confusional arousals: predisposing factors
-anything that increases slow wave sleep (sleep deprivation, irregular sleep habits, alcohols, fevers, sleep apnea)
Confusional arousals: dx
-video EEG/PSG
Confusional arousals: management
-maintain regular sleep habits
-avoid sleep deprivation
-treate disorders causing sleep fragmentation
Sleep Walking: Prevalence
-peak 4-8 y/o
-10-30% of children
-3-4% of adults
Sleep Walking: sx
-series of complex behaviors initiated in nonREM sleep and result in walking, inappropriate behavior
-can last several minutes to hours
-amnestic to it afterwards
Sleep Walking: predisposing factos
-any factor that increases slow wave sleep
Sleep Walking: dx
-video EEG/PSG
Sleep Walking: Management
-maintain regular sleep habits
-avoid sleep deprivation
-treat disorders causing sleep fragmentation
Sleep Terrors: prevalance
-3% childern
-less than 1% adults
Sleep Terrors: sx
-sudden arousal from slow wave sleep with piercing cry, accompanied by autonomic and behavioral manifestations of intesne fear during which pt is unresponsive and inconsolable
-amnestic afterwards or have vague recollection
Sleep Terrors: predisposing factors
-anything that increases slow wave sleep
Sleep Terrors: Dx
-video EEG
Sleep Terrors: management
-maintain regular sleep habits
-avoid sleep deprivation
-treat disorders causing sleep fragmentation
REM Sleep Behavior Disorder: Prevalence
-older men
-1/3 od cases have underlying neurodegenerative dz (eg parkinsons)
REM Sleep Behavior Disorder: sx
-prominent motor behvior associated with vivid dreamlike behavior (acting out dreams)
-episode is follwoed by complete and immediate alertness and dream recall
REM Sleep Behavior Disorder: pathophysioogy
-presumed disruption of the neurologic systems responsible for intiating and maintaining atonia during REM sleep
-occurs during REM sleep
REM Sleep Behavior Disorder: dx
-video EEG/PSG
REM Sleep Behavior Disorder: management
0.5-2.0 mg clonazepam
Nocturnal Seizures: prevalence
-more than 20% of pts with epilepsy have seizures exclusively at night
-30-40% have seizures during sleep and wakefulness
Nocturnal Seizures: sx
-recurrent, stereotyped, inappropriate
Nocturnal Seizures: dx
Psychogenic Dissociatve State: Prevalance
-most commonly seen in women
Psychogenic Dissociatve State: sx
-may perfectly mimic complex sleepwalking or nocturnal seizures
Psychogenic Dissociatve State: dx
video EEG/PSG

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