Sleep Disorders

Sushil Sompur MD MHA PGY-4, Child Psychiatry, University of Utah

Consequences of Poor Sleep

Decreased quality of life More depression and anxiety Greater risk of accidents and falls Slower reaction times Cognitive dysfunction including memory Predictor of long-term placement May be associated with greater mortality

Common Sleep disorders

Insomnia most common 6000 persons over age 65: 42% with problems falling and staying asleep Insomnia etiology Primary Secondary Other disorders commonly found in elderly Breathing-related sleep disorder Periodic limb movement and Restless leg syndrome REM sleep behavior disorder

Change in Insomnia Concept

Original view: insomnia is either primary or is secondary to a GMC or substance If secondary then treat the GMC or substance and the insomnia will resolve But insomnia rarely resolves with treatment of GMC or substance New View: insomnia is co-morbid to other conditions Treat the GMC, substance disorder or psychiatric disorder, AND treat the insomnia

Sleep Disorders
Primary Sleep Disorders Dyssomnias (disturbance in amount, quality, or timing of sleep) Parasomnias (abnormal behavior or events) Secondary Sleep Disorders Sleep disorders related to mental disorder Sleep disorders due to a GMC Substance-induced sleep disorders

The Dyssomnias
Primary Insomnia Primary hypersomnia Narcolepsy Breathing-Related Sleep Disorder Dyssomnia NOS Restless leg syndrome Periodic limb movement disorder Circadian rhythm sleep disorder Misalignment between sleep wake cycle and desired pattern

The Parasomnias
Nightmare disorder * Sleepwalking disorder Sleep terror disorder Parasomnia NOS REM sleep behavior disorder * Sleep paralysis * * REM related Parasominas

Secondary Sleep Disorders

Sleep disorders related to another mental disorder Insomnia related to another mental disorder Hypersomnia related to another mental disorder Sleep disorders due to a GMC Insomnia type, hypersomnia type, parasomnia type, mixed type Substance Induced sleep disorders Insomnia type, hypersomnia type, parasomnia type, mixed type

Individual Disorder
Primary and secondary insomnia Hypersomnia Shift work sleep disorder Breathing related sleep disorder Narcolepsy Nightmare disorder Sleep terror disorder Sleep Walking disorder REM sleep behavior disorder

Primary Insomnia: Diagnosis

Difficulty initiating or maintaining sleep or non-restorative sleep, for 1 month Causes distress or impairment Does not occur exclusively during narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia Not due to a GMC or a substance

Secondary Insomnias: Due to Psychiatric Disorders

Depression: insomnia occurs in 80% Sleep onset (increased sleep latency) Middle of the night (intermittent nocturnal awakenings) Early morning awakenings Panic disorder: insomnia occurs in 61% GAD: insomnia occurs in 44%

Secondary insomnias: Due to GMC

Cancer and Chronic pain Arthritis Congestive Heart Failure COPD GERD Pregnancy Dementia Prostate Disease

Secondary insomnias: Due to substances

Ethanol Initially sedating but then disruptive of sleep Medications SSRIs Stimulants Thyroid supplements Xanthine derivatives (i.e., Caffeine) Diuretics

Insomnia: Diagnosis and Treatment

Diagnostic step 1: assess insomnia syndrome Obtain sleep history Diagnostic step 2: establish etiology Psychiatric disorder? General Medical Condition? Substances: ethanol, drugs, medications? Part of more pervasive sleep disorder? Treatment Non-pharmacologic Pharmacologic

Sleep history: Nighttime symptoms

Assess nature of sleep disturbance Acute vs. Chronic Insomnia: sleep latency, frequent nocturnal awakenings, early morning awakenings Assess for associated symptoms/disorders Restless legs/ Periodic Limb movement Narcolepsy Parasomnias Sleep apnea symptoms: snoring, apneic episodes, partner sleeps in another room

Sleep History: Daytime symptoms

Headache on waking Concentration problems Naps: frequency, length, duration, time of day Daytime drowsiness and fatigue Work schedule: shift work?

Sleep History: Sleep hygiene

Daytime activity level Exercise What and when? Substances Alcohol, caffeinated drinks, cold meds, etc,. Evening routine Types of activities in bed Sleep environment Noise, light, temperature, sleep partner

Sleep History: Medical history

Medical illnesses and disabilities Cardiac disease, pulmonary disease, pain syndromes, GE reflux, prostatic disease, urinary frequency/urgency Medications: prescription and non-prescription Previous sleep assessments and treatments and response to treatment

Sleep Assessment
Epworth sleepiness scale Questionnaire of likelihood of dozing during day in various situations Multiple sleep latency test Daytime test of 4-5 naps spaced throughout day, provides physiological assessment of daytime sleepiness (esp. for narcolepsy) Polysomnography Night time monitoring of EEG waves, nocturnal breathing, movements, heart function

Polysomnography: Indications

Determines stages of sleep: wakefulness, and N1, N2, N3, REM sleep stages Sleep Apnea Restless leg syndrome and periodic limb movement disorder Nocturnal seizures Nocturnal medical and psychiatric events (e.g., sleep walking, REM sleep behaviors)

Additional Assessments
Physical exam Signs of medical/neurological illness Psychiatric assessment Depression, anxiety, substance use, other Subjective sleep log Record time to bed, sleep latency, # of awakenings, time of awakening, sleep quality and restfulness Actigraphy Objective assessment of daytime activity

Melatonin
Secreted by the pineal gland; decreases with age Regulates circadian rhythm Darkness stimulates release, light suppresses it Melatonin as sleep aid Marginally decreases sleep onset latency (SOL) in primary insomnia (better effectiveness in children) and not at all in secondary insomnia Significantly decreases SOL in delayed sleep phase syndrome

Disorders associated with Daytime Sleepiness

Primary hypersomnia Narcolepsy Breathing related sleep disorder Circadian rhythm sleep disorder Dyssomnia NOS Restless leg syndrome Periodic limb movements Insomnia due to environmental Sleepiness due to sleep deprivation 1 in 5 adults suffer with excessive daytime sleepiness from any etiology

Primary Hypersomnia
Excessive sleepiness for 1 month (or less if recurrent) as evidenced by prolonged sleep episodes OR daytime sleep episodes that occur almost every day Causes distress or impairment Exclusions Does not occur exclusively during the course of another mental disorder Not due to a GMC or substance Specifier: recurrent excessive sleepiness of 3 days occurring several times a year for at least 2 years

Narcolepsy
Irresistible attacks of refreshing sleep that occur daily over at least 3 months Presence of one or both Cataplexy: loss of muscle tone (often with intense emotion) Recurrent intrusions of REM sleep into sleep/ wake transition (hypnopompic or hypnagogic hallucinations or sleep paralysis) Not due to GMC or a substance Prevalence - 0.5% (genetically linked)

Circadian Rhythm Sleep Disorder

Persistent or recurrent sleep disruption leading to excessive sleepiness or insomnia due to mismatch between required sleep-wake schedule and persons circadian rhythm sleep-wake pattern Distress or impairment Not due to substance, GMC, or occurring exclusively during another sleep disorder Types Delayed sleep phase type Jet lag type Shift work type Unspecified type

Breathing related sleep disorder

Repeated cessation of breathing (apnea) and/ or significant reductions of breathing Multiple episodes of hypoxemia Multiple brief awakenings from sleep Impaired daytime function (day-time sleepiness, morning headaches, cognitive impairment) Obstructive sleep apnea most common form - assoc. with obesity, snoring, daytime sedation, exacerbated by CNS depressants Greater frequency in older vs. younger adults

Restless Legs Syndrome

Strong pre sleep urge to move ones legs Itching, tingling, pins and needles The problem is sleep onset insomnia Increases in elderly Women twice that of men

Periodic Limb Movement Disorder (PLMD)

AKA: Nocturnal Myoclonus Rapid, stereotypic, and periodic flexions of the leg and foot and is associated with repeated awakenings High comorbidity with RLS Increases dramatically in elderly: 45% incidence Equally prevalent men/ women

Parasomnias
Deep sleep (stage N3) disorders Sleep walking disorder Sleep terror disorder Confusional arousal disorder (not listed in DSM) REM sleep disorders Nightmare disorder Sleep paralysis (parasomnia NOS) REM sleep behavior disorder (parasomnia NOS)

Sleep Walking Disorder

Diagnosis Repeated episodes of risking from bed during sleep and walking about - usually in first third of sleep Difficulty in arousing pt during an episode Amnesia following an episode Within minutes no impairment in mental activity Not due to GMC or substance induced Features: a non-REM parasomnia Usually eyes open and returns to bed if undisturbed Occurs in stage N3 sleep; begins before puberty Often clumsy and injuries occur Medications, GMCs, and psych disorders increase risk

Sleep Terror Disorder

Diagnosis Recurrent episodes of abrupt wakening from sleep, with panicky scream - usually in first third of night Intense fear and autonomic arousal Relative unresponsiveness to others No related dream content Not due to GMC or substance Features: a non-REM parasomnia Related to sleepwalking but with more intense autonomic arousal, agitation, and risk of violence Occurs in 5% children, 1-2% adults Intervening may lead to injury

Nightmare disorder
Diagnosis Repeated awakenings for sleep with detailed recall of frightening dreams Rapid orientation when awakened Not due to another mental disorder, GMC, substance Features: REM-related parasomnia Prevalence: 5-8% Occurs in latter part of night With depression, anxiety, PTSD, substance use Anticipatory fear may lead to insomnia

Sleep Paralysis
Symptoms Paralysis of voluntary musculature associated with a conscious state at onset or offset of sleep Features Lifetime prevalence: 2 - 40% REM intrusion into wakefulness Management Antidepressant to reduce REM intrusion

REM Sleep Behavior Disorder (RSBD)

Symptoms Motor activity, often violent during REM - loss of normal REM muscle atonia Vivid dream recall; occurs later in night Pathophysiology Prevalence: 0.04% - 0.5% Reduced striatal presynaptic dopamine transporters Impaired cortical activity Chronic type: May be prodrome to DLB or PD Acute type: SSRIs and other meds may trigger

RSBD
Disease of elders mostly High risk of injury 32% injured themselves 64% have assaulted their spouses Idiopathic or secondary Parkinsons disease, DLB disease, brainstem neoplasm, multiple sclerosis, olivopontocerebellar atrophy, alzheimers dementia, progressive supranuclear palsy, Shy Drager syndrome Treatment 90% benefit from Clonazepam; others - Melatonin, Levodopa

Parasomnia - Diff. Diag.

Kleine-Levin syndrome Hypersomnia, hyperphagia, hypersexuality Nocturnal panic attacks Post traumatic stress disorder Nocturnal dissociative syndrome Frontal lobe seizures Delirium Breathing related sleep disorder Periodic limb movement disorder

Thank you !
Acknowledgements: Ameet Daftary, M.D., M.S. Emily M. Grossell, M.D. Jack Krasuski, M.D. Kristi Kleinschmit, M.D. Mary E. Steinmann, M.D.