Therapeutics Sleep Disorders

Front 1

usefulnes of sleep

Back 1

Sleep is essential but its exact biological role is
unknown
o Sleep has restorative, conservative, adaptive and
consolidative effects
o There is reinforcement and consolidation of
memory during REM sleep
o Dreaming may activate neural networks in the
brain, restructure and re-interpret data stored in
memory or remove unnecessary or useless
information

Front 2

name the two systems in the body that
determine normal human sleep

Back 2

o One that causes active generation of sleep
processes (located in the brainstem, basal
forebrain, pons… these are stimulated by various
somatic and emotional inputs). Growth Hormone
and Prolactin are involved but how is a little
unclear.
o One that causes the timing of sleep within the 24
hour day (involves melatonin and cortisol)
5

Front 3

sleep Architecture
type
time
dreams?

Back 3

During sleep the brain is extremely active
and produces a characteristic pattern of
stages that cycle during the night.
o REM and Non-REM sleep are the two types
o REM and Non-REM alternate in cycles of
90-100minutes duration (4-6 cycles a
night)

Hint 3

Non-REM Sleep
o Stage 1
o 0.5 to 7 minutes, transition phase
o Stage 2
o Stage 3 and 4
o “delta” or “slow wave” sleep
o REM Sleep
o Rapid eye movements
o Low muscle tone, but autonomic system active (HR,
perspiration, penile erection)
o 80-90% of dreams in this phase.

Front 4

Important sleep parameters

Back 4

sleep latency
time spent sleeping
sleep stage durations

Front 5

Characteristics of REM

Back 5

o Low muscle tone, but autonomic system active (HR,
perspiration, penile erection)
o 80-90% of dreams in this phase.
Occurs after 60-90 minutes sleep, rapid eye movement measure through eog, abscent chin movement through emg.

Hint 5

ECG lower frequency beta and theta. No sleep spindles or k complexes.
Tonic REM sleep is characterized by a
desynchronized EEG and muscle atonia,
and phasic REM sleep is characterized by
rapid eye movements as well as phasic
swings in blood pressure and heart rate,
irregular respiration, and phasic tongue
movements.

no or shallow breathing may occur.

Front 6

what are the changing patterns as we age

Back 6

o Newborn
o 16hours/day (~50% in REM)
o 3 months
o Cycles of sleep begin to appear
o 1-3 years old
o ~10 hours/day
o 3-7 years old
o Biphasic requirement (naps!)… ~ 25% in REM
o Adults
o Monophasic 7.5 to 8 hours (~25% in REM)
o Elderly
o Biphasic pattern returns, REM and SWS reduces so more time
spent awake

Front 7

o Intrinsic Sleep Disorders

Back 7

o Primary Insomnia
o Obstructive Sleep Apnoea,
o Central Sleep Apnoea
o Periodic Limb Movement Disorder,
o Restless Legs Syndrome
o Narcolepsy

Front 8

Extrinsic Sleep Disorders

Back 8

o Environmental,
o Inadequate sleep hygiene
o Stimulant, alcohol or hypnotic related

Front 9

Circadian Rhythm Sleep Disorders

Back 9

Related to the timing of sleep in the 24 hour day
(shift work, jet lag, delayed sleep phase)

Front 10

oArousal Disorders

Back 10

Sleepwalking,
o Sleep terrors

Front 11

Sleep-wake transition disorders

Back 11

o Sleep starts,
o Sleepwalking,
o Nocturnal leg cramps

Front 12

Parasomnias associated with REM sleep

Back 12

o Nightmares,
o Sleep paralysis,
o REM sleep behaviour disorder

Front 13

Other Parasomnias

Back 13

Sleep bruxism,
o Sleep eneuresis
dysfunctions associated with sleep, sleep
stages or partial arousal.

Front 14

Sleep Disorders-Associated with mental disorders

Back 14

o Psychoses
o Mood disorders
o Anxiety disorders
o Panic disorders
o Alcoholism

Front 15

sleep disorders - Associated with neurological Disorders

Back 15

o Dementia
o Parkinsonism

Front 16

sleep disorders Associated with other medical conditions

Back 16

o COPD/ Sleep asthma
o Sleep related GORD
o PUD
o Fibromyalgia

Front 17

Somnambulism (sleepwalking)- parasomnia
characteristics
treatment?

Back 17

is a complex motor activity that occurs during sleep
stages 3 and 4, when the sleeper performs some
repetitive activity in bed or walks freely from the bed.
The disorder is more common in children, and in males
more frequently than females. Usually no treatment is
required but if sleepwalking is frequent, and presents a
danger to the sleeper, the sleeping environment should
be made safe. Adults with recurring episodes may need
to seek psychological assistance. Diazepam may be
useful, but withdrawal usually leads to rebound
somnambulism. In addition, if patients sleepwalk while
sedated, they may fall.

Front 18

Night terrors- parasomnia

Back 18

occur early in the sleep cycle, in stage 3 and
stage 4 sleep. They are characterised by sharp
screams, violent, thrashing movements and
autonomic discharge with sweatiness and
tachycardia. The sleeper may or may not wake
up and there is no recall of the event.

Front 19

oDream anxiety (nightmares),

Back 19

is the only parasomnia associated with REM sleep. They
usually occur later in the sleep period and are
accompanied by body movements which usually cause
wakening. It is sometimes associated with the
withdrawal of REM suppressing drugs, such as alcohol
and some hypnotics. Adults with severe dream anxiety
and night terrors usually require psychological
evaluation and therapy. Nightmares and vivid dreams
can be associated with a range of medications, including
on discontinuation. Diazepam may provide some relief,
due to inhibition of stage 4 sleep in which night terrors
arise.

Front 20

Insomnia - defn, characteristics

Back 20

o Inability to function well with the amount and quality of
sleep experienced
o May consist of
o trouble getting to sleep,
o suffer frequent nocturnal arousals, or
o awaken too early

Front 21

insomnia misconception

Back 21

o Many patients have unrealistic expectations of the required
amount of sleep. Some patients, particularly the elderly,
frequently have daytime naps that need to be included
when calculating sleep duration.
o Many patients function well on the amount of sleep they
obtain and need only to be reassured.
o Night-time or early morning waking may also
result from inappropriate timing of sleep, rather
than from inadequate sleep duration.

Front 22

insomnia drug cause

Back 22

Front 23

Insomnia causes non drugs

Back 23

Front 24

Treatment of Insomnia

Back 24

o Treatment of the underlying problem
o Insomnia can often be improved by better management
of any underlying problem, for example, nocturnal
asthma, angina,

Sleep hygiene
o An important first step in treatment of insomnia is to
educate the patient in sleep hygiene, encouraging
adoption of habits that promote good sleep, and
elimination of those which may inhibit sleep. Advice
should be individualised

Stress Management

Drug treatment

Stimulus control

Sleep restriction

Front 25

Outline sleep hygiene for insomnia

Back 25

o regular time of arising;
o avoiding a daytime nap;
o regular daytime exercise, which increases stage 4 sleep;
o avoidance of strenuous exercise close to bedtime;
o avoiding a heavy meal before retiring;
o taking a hot bath before retiring;
o removing pets/digital clocks from the bedroom before retiring;
o avoidance of alcohol and caffeine- containing beverages close
to bedtime;
o a warm milk drink and a carbohydrate snack before retiring;
o ensuring a comfortable temperature and quiet environment for
sleep.
31

Front 26

outline stress management for insomnia

Back 26

o The patient with insomnia who has anxiety problems can
benefit from advice on structured problem-solving and
specific stress management.
o Relaxation therapy reduces muscle tension, but may also
assist mental relaxation by helping the patient to
concentrate on specific calming thoughts.
o Other useful methods include
o progressive muscle relaxation, hypnosis, electromyographic
(EMG), biofeedback and meditation.
o The choice of relaxation technique is probably based on
patient preference and the clinician's expertise, and should
be practised regularly during the day, not just when trying
to sleep.

Front 27

outline Drug treatment for insomnia

Back 27

o Hypnotics should not be first-line treatment.
o If they are prescribed, the duration of therapy
should be for the shortest time possible and a
definite duration of usage agreed with the patient
at the outset.
o Before starting treatment, the limitations and
potential problems of medications, including the
risk of dependence with long-term use, should be
explained.
o temazepam 10 mg orally, before bedtime
o zolpidem 5 to 10 mg orally, at bedtime
o zopiclone 3.75 to 7.5mg orally, before bedtime.

o Continuous treatment with hypnotics, if needed at all, should
normally be limited to less than 2 weeks.
o Intermittent therapy may be considered for those with severe
long-standing insomnia that is not relieved by
nonpharmacological management

Front 28

Issues with drug treatment for insomnia

Back 28

o There are few long-term (greater than 4 week) studies of
hypnotic use and the issue of tolerance with regard to these
treatments remains controversial.
o Broken sleep with vivid dreams and increased rapid eye
movement (REM) sleep may occur when hypnotics, particularly
benzodiazepines with longer half-lives, are ceased.
o It takes several days or weeks for a normal sleep rhythm to be
re-established. This rebound insomnia may indicate falsely to the
patient that a further prescription is needed. Patients may need a
lot of support and encouragement to help them through this
period without medication, until their sleep cycle stabilises.

Front 29

When is insomnia defined as persistant, what should be done

Back 29

o If the sleep problem persists for more than a
month, the diagnosis should be reviewed.
o Psychiatric illnesses such as depression, many
physical illnesses and some medications can
interfere with the sleep-wake cycle. Insomnia
associated with depression usually improves as
depression remits.
o However, selective serotonin reuptake inhibitors
(SSRIs) may induce insomnia unrelated to
depression.
o Chronic sleep morbidity can result from failing to
seek appropriate additional help at an early stage
in treatment.

Front 30

outline Stimulus control for insomnia

Back 30

o helps the patient learn to associate the bed and
bedroom with sleep
o requires the patient to go to bed only when
sleepy and to get out of bed if sleepless for more
than 15 to 20 minutes, rather than remain in bed
while awake.
o The patient returns to bed when sleepy, and
leaves it again if they again remain awake. Fears
of the consequences of sleep deprivation need to
be allayed and the patient needs to organise
suitable activities (reading, music) in another
room.
38

Front 31

outline Sleep restriction

Back 31

based on evidence from the sleep diary.
o The patient with a very disorganised sleep pattern goes to bed at an
agreed time, for example, 4 hours before required wake time of 6
am. This allows consolidation of sleep with increments of time in bed
based on improved sleep efficiency.
o Patients who have been taking benzodiazepines to aid sleep for more
than 4 to 6 months (and often for many years) are likely to have
become, unwittingly, dependent.
o However, if they continue to sleep well with the same dose of
benzodiazepine, have no adverse effects on careful questioning, are
aware that they may be dependent, and do not wish to carry out a
reduction plan, then continued treatment is appropriate. Should they
wish to cease medication, this needs to be done gradually.

Front 32

what is Sleep apnea
different types

Back 32

o Obstructive
o Central
o This most commonly presents with daytime
sleepiness but can present with insomnia. The
frequent apneas result in repeated brief arousals
from sleep which cause tiredness the following
day.
o The patient is often not aware of arousal during
the night.
o The condition is usually associated with heavy,
habitual snoring in overweight middle-aged
l lh h h ld l fb h
40
males, although it can occur in the elderly of both
sexes, in the absence of obesity and snoring.

Front 33

treatment of mild sleep apnea

Back 33

Weight reduction in obese subjects of 10% to 15% has been associated
with significant reductions in upper airway obstruction; however, there is a
poor correlation between the amount of weight loss and the clinical
response.
o Smoking cessation helps if an improvement in nasal patency follows;
however, if the patient puts on weight, this may increase the severity of the
upper airway obstruction. For further information, see Assessment and
treatment of smoking.
o Avoidance of night-time alcohol and drugs causing sedation, as they
can reduce oropharyngeal muscle tone during sleep.
o Treatment of nasal congestion, if present: This may require the use of
topical nasal corticosteroids or decongestants if allergic rhinitis is present
(see Allergic rhinitis), or referral to an appropriate surgeon if structural
abnormali

Hint 33

Tonsillectomy, if the patient has very large tonsils, may result in a marked
improvement or resolution of upper airway obstruction. Such patients should
be established on continuous positive airway pressure (CPAP) prior to
surgery, so that their upper airway obstruction may be adequately
controlled in the hours and days following surgery. For further information
on CPAP, see below.
o Changing sleeping position: If the patient has predominantly supine
obstructive sleep apnoea, measures to encourage them to sleep on their
side may help (eg attaching balls to their nightwear posteriorly in the mid
44
scapular position has been reported to help)

Front 34

treatment of more severe sleep apnea

Back 34

Continuous positive airway pressure
o Patients with moderate to severe obstructive sleep apnoea should
be considered for continuous positive airway pressure (CPAP) in
addition to addressing the general measures (see above) where
appropriate. CPAP works by pneumatically splinting the upper
airway, preventing its closure during sleep. CPAP is achieved by
machines specifically designed to blow air via a flexible hose into
a close fitting nasal mask, which is worn during sleep. Adherence
(compliance) with CPAP therapy is related to severity of
underlying obstructive sleep apnoea.
o CPAP pressure settings should initially be set during sleep
polysomnography; although increasingly, data collected from
CPAP machines that monitor flow and adjust the pressure in
response to flow limitation, apnoeas and hypopnoeas (autotitrate)
are being used to determine an appropriate CPAP pressure. Some
patients choose these machines in preference to fixed pressure
machines as they seem to be more comfortable.

Hint 34

Mandibular splinting devices
o The mandibular advancement splint, an oral device worn during sleep,
is an alternative to the use of CPAP for the management of selected
cases of mild to moderate obstructive sleep apnoea. A large range of
devices of varying utility are available. The best results are generally
obtained when the device is made to measure, is adjustable, is fitted
by an experienced person, and where the patient is followed-up to
assess their response.
o Surgical options
o Surgical treatment for obstructive sleep apnoea is usually
disappointing unless clear-cut abnormalities (eg nasal obstruction or
tonsillar enlargement) are present.
o Uvulopalatopharyngoplasty (UPPP)
o A number of procedures designed to stiffen the soft palate with scar
tissue have been advocated (eg cautery, lasering and high-frequency
ultrasound), but the results are very unpredictable,
o Craniofacial surgery has a role in the correction of specific contributory
anatomical upper airway abnormalities
47
o Tracheostomy to bypass the pharyngeal airway during sleep is the
treatment of last resort in severe cases resistant to other therapy.

Front 35

What is nacolepsy and diagnosis

Back 35

o Neurological disorder of REM sleep
o Usually becomes apparent between adolescence
and 30 years of age.
o Characterised by chronic daytime somnolence
and sudden uncontrollable sleep 'attacks'.
o Episodes are classically associated with cataplexy
(sudden loss of muscle tone, usually associated with
emotion), and muscle paralysis while going to sleep or
waking up (hypnagogic and hypnopompic
hallucinations).
o Diagnosis is made by a characteristic response to
a multiple sleep latency test
48

Front 36

treatment of narcolepsy

Back 36

Treatment of narcolepsy is mainly symptomatic.
o Central nervous system stimulants are of proven
effectiveness in increasing alertness. Tricyclic
antidepressants are helpful in treating cataplexy,
sleep paralysis and hypnagogic hallucinations.
o Where a tricyclic antidepressant is indicated, use
o clomipramine 25 to 100 mg orally, daily.

Hint 36

o For pharmacological treatment, use
o dexamphetamine 5 to 10 mg orally, half an hour before
breakfast and lunch. Up to 40 mg orally, daily may be
required, or
o methylphenidate 10 to 20 mg orally, half an hour before
breakfast and lunch. Up to 60 mg orally, daily may be
required.
o Higher doses may be required in select patients.
o Drug holidays may be necessary for stimulant
tolerance.
50

Front 37

Periodic limb movements of sleep and
restless legs syndrome characteristics

Back 37

oCommon causes of insomnia and excessive
daytime sleepiness, and often coexist in the same
patient.
o Periodic twitching of the anterior tibialis muscles
frequently causes multiple awakenings during the
night, but sometimes the patient is unaware of
the condition, which is found on PSG recording in
the sleep clinic.
o The condition is also called nocturnal myoclonus
or leg jerks, but can occur in the upper limbs.

o Note: Periodic limb movements of sleep and
restless legs syndrome often require no specific
drug therapy.
o If symptoms are disabling, review should be
sought from a sleep clinic or a neurologist or a
psychiatrist for advice on further treatment

Front 38

Restless Legs Syndrome characteristic and causes

Back 38

For restless legs syndrome, a careful
history will elicit a typical description of
unpleasant crawling sensations in the legs
relieved by moving around, often worse in
the evening at times of inactivity or at
sleep onset. Restless legs syndrome can
be secondary to drugs (eg lithium,
clomipramine, venlafaxine) and other
medical conditions, (eg iron deficiency,
uraemia).

Front 39

restless legs syndrome drug treatment

Back 39

o Levodopa/Decarboxylase Inhibitor combination
o For those who do not respond to levodopa or who
develop complications, changing to a dopamine
agonist in a dose lower than that used for
Parkinson’s disease, is often helpful.
o Pergolide 50 micrograms orally, at bedtime, increase by
50 micrograms every 2 nights up to 250 micrograms
daily. Adverse effects, in particular nausea, are common
but are controlled by domperidone in most
patients.
o Multiple dosing may be required for symptoms
persisting during daytime hours.
o Opioids, benzodiazepines, carbamazepine and
gabapentin are sometimes suggested but are not
recommended for routine use.

Front 40

Circadian rhythm sleep
disorders defined

Back 40

o These disorders are related to the timing of sleep
within the 24hour day. Transient disturbances of
the sleep-wake schedule commonly occur with
shift work and jet lag.
o Delayed and advanced sleep-phase syndromes
are characterised by normal sleep duration
accompanied by an inability to wake up and fall
asleep at socially required times, due to a
permanent shift forwards and backwards in the
underlying circadian rhythm.
57

Front 41

Circadian rhythm sleep
disorders treatment

Back 41

Drug treatment with hypnotics does not correct
circadian rhythm disturbance whether transient
or permanent. A hypnotic can induce sleep
following a major time zone change. For
shift-workers, a hypnotic can be prescribed on
occasion for 1 to 2 sleep periods immediately
after a sleep schedule shift but chronic use is to
be avoided. Where a choice of shifts is possible,
patients should be aware that slow rotation is
preferable, with morning, afternoon and night
shifts in that order.
58

Phototherapy with high intensity broad-spectrum
light is being used increasingly for delaying or
advancing the sleep-wake cycle. The bright light
is given in the morning for delayed sleep phase,
and the late afternoon for advanced sleep-phase
syndrome.
o Hypnotics will not assist readjustment of the
sleep-wake cycle.
59