SLEEP DISORDERS

July 14, 2011

NORMAL SLEEP CYCLE
NEUROTRANSMITTERS INVOLVED IN SLEEP
Increased acetylcholine in the reticular formation increases both sleep efficiency and REM
sleep. These decrease with normal aging and Alzheimer disease.
Increased dopamine decreases total sleep time. Treatment with antipsychotics may
improve sleep in patients with psychotic symptoms.
Increased levels of norepinephrine decrease both sleep efficiency and REM sleep.
Increased serotonin increases both total sleep time and delta wave sleep. Treatment with
antidepressants, can improve sleep in depressed patients
SLEEP DISORDER CLASSIFICATION
Sleep disorders can be primary or secondary.
Primary sleep disorders are further classified as:
Dyssomnias disturbance in timing, quality or amount of sleep
Parasomnias abnormal physiology or behavior during sleep
Some causes of secondary sleep disorders include:
Medical: pain, metabolic disorders, endocrine disorders
Psychiatric: depression, mania, anxiety
Substance abuse (cocaine, amphetamines, caffeine) or withdrawal (sedatives)
DYSSOMNIAS
Primary Insomnia
Difficulty initiating or maintaining sleep, resulting in daytime drowsiness or difficulty fulfilling
tasks. Disturbance occurs three or more times per week for at least 1 month.
Tx: sleep hygiene (regular schedule, limit caffeine, avoid naps, etc) and/or short -term
pharmacotherapy (benadryl, zolpidem, trazodone)
Primary Hypersomnia
At least 1 month of excessive daytime sleepiness or excessive sleep not attributable to medical
condition, medications, insufficient sleep, or narcolepsy. Usually begins in adolescence and is
often accompanied by hyperphagia.
Tx: amphetamines, SSRIs
Narcolepsy
Repeated, sudden attacks of sleep in the daytime for at least 3 months, associated with
cataplexy, short REM latency, brief paralysis on awakening, hypnagogic/hypnopompic
hallucinations
Tx: timed daily naps, amphetamines, methylphenidate; also SSRIs or sodium oxalate for cataplexy
DYSSOMNIAS
Sleep Apnea
Sleep disruption and excessive daytime sleepiness caused by abnormal sleep ventilation.
Can either be obstructive or central.
OSA risk factors: male, obese, deviated septum, kissing tonsils
CSA correlated with heart failure
Tx: nasal continuous positive airway pressure (OSA); mechanical ventilation (CSA)
Circadian Rhythm Sleep Disorder
Disturbance of sleep due to mismatch between circadian sleepwake cycle and
environmental sleep demands. Subtypes include jet lag type, shift work type, and
delayed sleep or advanced sleep phase type.
Restless Leg Syndrome
Uncomfortable sensation in the legs necessitating frequent motion and repetitive limb
jerking during sleep. Common with aging.
PARASOMNIAS
Nightmare Disorder
Repeated awakenings with recall of extremely frightening dreams. Occurs during REM sleep.
Tx: tricyclics may help
Night Terror Disorder
Repeated episodes of apparent fearfulness during sleep, usually beginning with a scream and associated with intense
anxiety. Usually occur during non-REM sleep in the first third of the night. Patients do not remember the episodes.
High comorbidity with sleepwalking disorder
Tx: small doses of diazepam at bedtime may help
Somnambulism
Repeated episodes of getting out of bed and walking, associated with blank stare and difficulty being
awakened. Usually occurs during non-REM sleep and is not remembered.
Peak prevalence at age 12.
Bruxism
Tooth grinding during stage 2 sleep. Treated with dental device worn at night.
REM Sleep Behavior Disorder
REM sleep without the normal muscle paralysis. Treated with antiparkinson agents.
QUESTIONS
Due to her jobs requirements, a per
diem nurse works different shifts
almost every week. She is constantly
sleepy and fatigued but, even when
she has days off, she has great
difficulty falling asleep at night and
remaining asleep for more than two to
three hours at a time.
For the past two years a 28-year-old
man has found himself in many
dangerous or embarrassing situations
due to his inconvenient habit of falling
abruptly asleep in the middle of any
activity. Once he hit a pole because he
fell asleep while driving and his wife
still teases him for taking a nap while
they were having sex. The young man
reports that he starts dreaming as
soon as his eyes close and when he
wakes up, 10 to 20 minutes later, he
feels wide awake and refreshed.
ANSWERS
Circadian sleep disorders are due to a Narcolepsy is a disorder of unknown
lack of synchrony between an origin characterized by an irresistible
individuals internal circadian sleep- urge to fall asleep. Sleep attacks last
wake cycles and the desired times of from 10 to 20 minutes and may take
falling asleep and waking. The place at very inopportune times.
disorder can arise from an idiopathic
variance in the periodic firing of the
hypothalamic suprachiasmatic
nucleus.
QUESTIONS
The parents of a 5-year-old boy report that A 52-year-old overweight man reports that
the child often screams during the night. They
are particularly concerned because during he often wakes up with a headache. He
these disturbances the child sits up, opens also is tired all the time and repeatedly
his eyes, and looks right through them, and falls asleep during the day. Evaluation of
they are unable to awaken him. The child has
no memory of these experiences in the the arterial blood of this patient is most
morning. Physical examination is likely to reveal
unremarkable and the child is doing well in
kindergarten. During these disturbances the (A) respiratory acidosis
childs EEG is most likely to be primarily
characterized by (B) respiratory alkalosis
(A) sawtooth waves (C) metabolic alkalosis
(B) theta waves
(D) increased PaO2
(C) K complexes
(E) decreased PaCO2
(D) delta waves
(E) alpha waves
ANSWERS
D. delta waves. This child
demonstrates sleep terror disorder that
is characterized by repetitive
occurrences of screaming during the
night and the inability to be awakened
or to remember these experiences in
the morning. Sleep terrors typically
occur during delta sleep. If the child
were having nightmares, which occur
in REM sleep, the child would awaken
and relate the nature of his frightening
dreams.
A. respiratory acidosis. This
overweight middle-aged male patient
is likely to have sleep apnea. Like
other patients with pulmonary
disorders leading to depressed
breathing, patients with sleep apnea
typically show chronic respiratory
acidosis (increased partial pressure of
carbon dioxide [PaCO2]).
NOT JUST A HUMAN DISEASE
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