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MANAGEMENT OF INSOMNIA IN THIS MILLENNIUM Dr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIAN Emeritus Professor The TamilNadu Dr M.G.R Medical University.

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Presentation on theme: "MANAGEMENT OF INSOMNIA IN THIS MILLENNIUM Dr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIAN Emeritus Professor The TamilNadu Dr M.G.R Medical University."— Presentation transcript:

1 MANAGEMENT OF INSOMNIA IN THIS MILLENNIUM Dr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIAN Emeritus Professor The TamilNadu Dr M.G.R Medical University Former Head- Institute of Neurology Madras Medical College, Chennai In Greek mythology, Hypnos was the personification of sleep; the Roman equivalent was known as Somnus. His twin was Thanatos ("death"); their mother was the goddess Nyx ("night"). His palace was a dark cave where the sun never shines. At the entrance were a number of poppies and other hypnogogic plants.

2 Sleep architecture revisited What is it & How is it relevant in Psychiatry and Neurology? Science is below the mind; Spirituality is beyond the mind

3 What is sleep? Sleep is a physiological state of reduced sensory awareness and an absence of voluntary movements. Sleep is necessary for life. Sleep is also an essential component of good health (body development and restitution as well as mental health and well-being). It is also important for optimal cognitive functioning. A womans desire for revenge outlasts all her other emotions

4 Length of Sleep in Hours Percentage of All People 20 Total Sleep Requirement In order to be at your peak performance you need at least 8 hours of sleep.

5 Function of Sleep 1. Restoration and recovery –Sleep serves to reverse and/or restore biochemical and / or physiological processes degraded during prior wakefulness 2. Energy conservation –10% reduction of metabolic rate below basal level 3. Memory consolidation 4. Thermoregulation 5. Homeostasis The world shall perish not for lack of wonders but lack of wonder

6 Memory Consolidation at Sleep Onset Word Presentation Minutes Before Sleep Onset Impairment of Memory Consolidation during Sleep Assessment of Sleepiness / Sleep Deprivation, M. Mahowald, University of Minnesota, Sleep Academic Award

7 Sleep and Hormones Hormones Tightly Coupled with Sleep Determinants of Sleepiness / Circadian Rhythms, M. Mahowald, University of Minnesota, Sleep Academic Award

8 Illustration of Normal vs. Insomnia Sleep Pattern Insomnia Sleep Pattern Normal Sleep Pattern Awakenings Onset

9 Normal sleep architecture Normal sleep architecture NATURE, TIME AND PATIENCE are the 3 great physicians

10 10 Normal Sleep Architecture Stages of sleep __________________________ 1. NREM Sleep A. Stage 1 A. Stage 1 B. Stage 2 B. Stage 2 C. Stage 3 C. Stage 3 D. Stage 4 D. Stage 4 2. REM Sleep Truth comes out of error sooner than that of confusion

11 11 REM Sleep ~20% of night NREM Sleep ~80% of night Wake 2/3 of life Sleep Stages ___________________________ Thought is the labour of the intellect Reverie is its pleasure

12 Normal Sleep Histogram Sequences of States and Stages of Sleep on a Typical Night Identification and Staging of Adult Human Sleep, L. Shigley, Sleep Academic Award

13 Normal Sleep Stages REM Learning and memory consolidation Dreaming sleep 3-8%45-55%15-20% 20% Stage 1 Body starts to relax Falling asleep Stage 2 Brain slows Stable, light sleep Stage 3&4 Body and tissue restored Deep, restorative sleep NREM 75-80%REM 20-25% 1 cycle = minutes Adapted from Damien R.Stevens MD.Sleep medicine secrets.2004

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15 Wakefulness, NREM, and REM WakeNREMREM ArousabilityHighLowestLow EEG amplitude LowHighLow EEG frequency FastSlow Mixed fast Muscle tone VariableLowAbsent Eye movements VoluntaryInfrequentRapid Heart Rate, Blood Pressure, Respiratory Rate Variable Slow/ low, regular Variable O2, CO2 response FullLowerLowest Thermoregulation Behavioral/ Physiological Physiological Reduced physiological Mental activity Full None/ limited Story-like dreams

16 Importance of sleep architecture Sleep architecture provides a useful means for quantitatively analyzing sleep. Sleep architecture provides a useful means for quantitatively analyzing sleep. It includes both macroarchitectural features (those derived from sleep staging) and microarchitectural features (those derived from waveform analysis). Architectural features can characterize: It includes both macroarchitectural features (those derived from sleep staging) and microarchitectural features (those derived from waveform analysis). Architectural features can characterize: –sleep integrity and continuity –global sleep-stage structure –presumed underlying physiologic mechanisms

17 Neurochemical control of sleep- wake states NeurotransmitterLocationAction Acetylcholine LDT, PPT (pons) REM, wake Histamine TMN (posterior hypothalamus) Wake GABA, galanin VLPO NREM sleep Serotonin Raphe nuclei Wake, NREM Norepinephrine Locus coeruleus Wake Hypocretin Later hypothal Wake

18 Neurochemical control of sleep- wake states Dopamine Dopamine Adenosine Adenosine Nitrous oxide Nitrous oxide Cytokines (IL-1, IL-6, TNF-α) Cytokines (IL-1, IL-6, TNF-α) Prostaglandins Prostaglandins Hormones: melatonin, growth hormone, VIP NPY Hormones: melatonin, growth hormone, VIP NPY Delta sleep-inducing peptide Delta sleep-inducing peptide

19 Basal Forebrain Thalamus Post. Hypothalamus Cholinergic Serotonergic Monoaminergic Histaminergic Reticular Formation AminergicCholinergic Wake Sleep REM Fig. 2.1 aldrich

20 Factors that affect sleep Age Age –Increased wakefulness during sleep period –Decreased Stage 3/4 NREM –Earlier timing –Greater daytime sleepiness Sex (women have longer sleep, more Stage 3/4 NREM) Sex (women have longer sleep, more Stage 3/4 NREM) Timing: Sleep is best at night! Timing: Sleep is best at night! Illnesses, medications Illnesses, medications Social Isolation is in itself a pathogenic Factor for disease production

21 Sleep in healthy young and older adults 20 year old woman 71 year old woman Motivation is the Spark that lights the Fire of Knowledge and fuels the engine of Accomplishment

22 Sleep stages across the life span Ohayon et al., SLEEP 2004; 27: Minutes Age (years)

23 Is there any difference between sleep and sedation? Is there any difference between sleep and sedation? Mind is the great level of all things; human thought is the process by which human ends are ultimately answered - Daniel Webster

24 Traits to define sleep and sedation NREM/REM sleep Hypotonia/atonia Hypotonia/atonia Slow/fast eye movements Slow/fast eye movements Regular/irregular breathing, heart rate, BP Regular/irregular breathing, heart rate, BPSEDATION Analgesia Analgesia Amnesia Amnesia Obtundation of waking Obtundation of waking Anxiolysis Anxiolysis Social Isolation is in itself a pathogenic Factor for disease production

25 Sleep v/s sedation Sleep is reversible with sensory stimulation; sedation depresses sensory processing in the face of noxious physical &/or aversive psychological stimulation Sleep is reversible with sensory stimulation; sedation depresses sensory processing in the face of noxious physical &/or aversive psychological stimulation Sleep disrupts mammalian temperature regulation during REM phase; Sedation can alter the relationship between body temp and energy expenditure Sleep disrupts mammalian temperature regulation during REM phase; Sedation can alter the relationship between body temp and energy expenditure Nausea and vomiting are not associated with sleep; but can be positively correlated with sedation level. Nausea and vomiting are not associated with sleep; but can be positively correlated with sedation level. Knowledge without action is useless; Action without knowledge is foolish

26 Sleep architecture in neurological and psychiatric conditions Sleep architecture in neurological and psychiatric conditions A bad teacher complains; A good teacher explains; The best teacher inspires;

27 Effect of Sleep Stage in Epileptic patients on Interictal and Ictal Discharges Pure love ever gives. Never seeks

28 Seizure effect on sleep architecture Seizures acutely alter the sleep-wake state. Seizures acutely alter the sleep-wake state. The most prominent clinical features of this seizure effect are postictal somnolence and insomnia. The most prominent clinical features of this seizure effect are postictal somnolence and insomnia. Patients with nocturnal seizures are subjectively and objectively sleepy on the day following a seizure. Patients with nocturnal seizures are subjectively and objectively sleepy on the day following a seizure. Seizures or the postictal state produce pathophysiological changes in the CNS that result in sleep fragmentation and suppression of REM sleep. Individuals with partial or generalized seizures have less REM sleep on nights with seizures. Seizures or the postictal state produce pathophysiological changes in the CNS that result in sleep fragmentation and suppression of REM sleep. Individuals with partial or generalized seizures have less REM sleep on nights with seizures. Anger Begins In Folly And Ends In Repentance

29 Sleep in Patients With Depression Primary sleep complaints 1,3 Primary sleep complaints 1,3 –Difficulty falling asleep –Frequent nocturnal awakenings –Waking too early in the morning –Daytime fatigue Effects on sleep architecture in depression 1-3 Effects on sleep architecture in depression 1-3 –Prolonged sleep latency –Increased wake time after sleep onset (WASO) –Decreased slow wave sleep (stages 3 and 4) –Reduced REM sleep latency; prolonged first REM period 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR ® ). 2000: Perlis M, et al. Biol Psychiatry 1997;42: Benca RM. In: Principles and Practice of Sleep Medicine. 4th ed. 2005:

30 Sleep pattern in Alzheimers Disease Sleep pattern in early stage: Sleep pattern in early stage: –Disruption in sleep-wake patterns, rhythmicity, –Increased amounts and frequency of nighttime wakefulness, –Reduction of slow-wave sleep - worsen with disease progression. Sleep pattern in late stage: Sleep pattern in late stage: –Reduction of REM sleep, –Increased REM latency, –Alteration of the circadian rhythm resulting in daytime sleepiness. –Daytime napping and somnolence increase with disease progression.

31 Effect of drugs on sleep architecture The Wise Man Before He Speaks, Will Consider Well What He Speaks

32 Effect of antidepressants on sleep architecture Tricyclic antidepressants Tricyclic antidepressants –Mostly produce sedation –Variation in the reported effects on sleep from TCAs. –Amitriptyline, trimipramine, nortriptyline, dothiepin and doxepin have all been associated with sedation, –Imipramine and desipramine are less likely to be linked with sedation, but have been associated with insomnia; –The evidence is less clear with clomipramine. Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20:

33 Effect of antidepressants on sleep architecture SSRIs SSRIs –SSRIs immediately suppress REM sleep, and continue to do so throughout treatment. –REM parameters return to normal once the SSRI is discontinued. –SSRIs block serotonin reuptake, but some also block noradrenaline reuptake. Both actions have been associated with REM suppression and sleep disruption. Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20:

34 Effect of antidepressants on sleep architecture Fluoxetine Fluoxetine –Sleep was significantly less efficient, and nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg) - Rush et al. (1998) –Fluoxetine significantly suppressed REM sleep –Fluoxetine (20 mg) was associated with less efficient, shorter and more disrupted sleep - Wolf et al. (2001) –Improvements in sleep latency and total sleep time were not marked for fluoxetine Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20: Discipline Weighs ounces: Regret weighs Tons

35 Effect of hypnotics drugs on sleep architecture Benzodiazepines Benzodiazepines –Being anticonvulsants, they tend to suppress synchronized EEG activity (such as slow waves) and confer some risk of seizure if abruptly withdrawn. Barbiturates Barbiturates –Decrease REM and slow-wave sleep. Non-BZD hypnotics. Non-BZD hypnotics. –Do not alter sleep architecture when taken at therapeutically recommended doses. Some people feel the rain; Others just get wet

36 16.39% 6.64% 7.27% 15.81% 7.65% 46.23% Stage 1 Stage 0 REM Stage 4 Stage 3 Stage 2 Stilnoct ® Preservation of Sleep Stages 19.02% 44.48% 10.50% 8.51% 11.22% 6.26% Stage 1 Stage 0 REM Stage 4 Stage 3 Stage 2 Data on file. Sanofi-aventis. PlaceboStilnoct N=36 Opinion is ultimately determined by the feelings and not by the intellect

37 Sleep Disorders International Classification of Sleep Disorders (ICSD-2) International Classification of Sleep Disorders (ICSD-2) (1) insomnias (2) sleep-related breathing disorders (3) hypersomnias not due to a breathing disorder (4) circadian rhythm sleep disorders (5) parasomnias (6) sleep-related movement disorders (7) other sleep disorders, and (8) isolated symptoms, apparently normal variants, and unresolved issues. It is the province of the knowledge to speak and it is the privilege of the wisdom to listen - Hodlys

38 Insomnia Difficulty in initiating sleep and staying asleep Difficulty in initiating sleep and staying asleep Waking up earlier Waking up earlier Poor quality sleep, non restorative. Poor quality sleep, non restorative. Subjective Subjective Day time impairment (RDC-AASN) Day time impairment (RDC-AASN) The meek shall inherit the earth - but not its mineral rights

39 Etiology Primary Primary Secondary Secondary Medications Medications Psychiatric Psychiatric Medical Medical Sleep Disorders Sleep Disorders A Man Of Words And Not Of Deeds Is Like A Garden Full Of Weeds

40 Drugs SSRIs & SNRIs SSRIs & SNRIs Alpha and beta blockers Alpha and beta blockers Diuretics Diuretics Decongestants Decongestants Stimulants Stimulants Steroids, thyroid harmones Steroids, thyroid harmones What is mind no matter What is matter never mind

41 Psychiatric and Sleep disorders Mood & anxiety disorders Mood & anxiety disorders Circadian rhythm disorders Circadian rhythm disorders Parasomnias Parasomnias Apneas Apneas Movement disorders Movement disorders ''When Beauty Fires The Blood; Love Exalts The Mind"

42 Hypersomnias Excessive day time sleepiness Excessive day time sleepiness Interfering with day time activities, productivity, enjoyment Interfering with day time activities, productivity, enjoyment Reflects insufficient sleep, disrupted sleep, primar sleep disorder Reflects insufficient sleep, disrupted sleep, primar sleep disorder Experience : Yesterdays Answer To Todays Problems

43 Diagnosis Detailed medical and sleep history Detailed medical and sleep history Snoring or apnoea Snoring or apnoea Restlessness, jerking Restlessness, jerking Hypnogogic or hypnopompic hallucinations Hypnogogic or hypnopompic hallucinations Sleep paralysis, cataplexy Sleep paralysis, cataplexy Automatic behavior Automatic behavior Teachers are reservoirs from which, through the process of education, the students draw the water of life

44 Narcolepsy Excessive day time sleepiness (EDS) Excessive day time sleepiness (EDS) Sedentary and active pursuit's Short and refreshing Followed by recurrent somnolence Ranging from mild to disabling Name and form are destroyed in the sands of time

45 Cataplexy Unique Unique Paroxysmal episodes of weakness Paroxysmal episodes of weakness Triggered by emotions Triggered by emotions Secs to Min Secs to Min Can be localized Can be localized Consciousness and respiration not affected. Consciousness and respiration not affected. Time and tide wait for no man; And sins and sorrows are also swallowed in time

46 Develops years after EDS Develops years after EDS Frequency varies Frequency varies Adolescence, young adulthood Adolescence, young adulthood Narcolepsy with and without cataplexy Narcolepsy with and without cataplexy Loss of hypocretin – 1 secreting cells Loss of hypocretin – 1 secreting cells Every man is a volume if you know how to read him

47 Narcolepsy – non obligate manifestations Narcolepsy – non obligate manifestations Sleep paralysis – muscle atonia at interface between sleep and wakefulness; for few minutes. Hypnogogic hallucinations brief, Sec to Mins, dream-like vivid and distressing brief, Sec to Mins, dream-like vivid and distressing Automatic behavior Purposeful/inappropriate with impaired recollection of the activities. Being ignorant is not so much a shame as being unwilling to learn

48 Other Hypersomnias Recurrent hypersomnias Recurrent hypersomnias Kleine – Levin syndrome Kleine – Levin syndrome Menstrual associated Menstrual associated Idiopathic hypersomnias Idiopathic hypersomnias With long sleep time With long sleep time Without long sleep time Without long sleep time Beauty lies in the eyes of the beholder

49 Parasomnias Include abnormal movements, behaviors, emotions and automatic activities. Include abnormal movements, behaviors, emotions and automatic activities. Intrusion of sleep and wakeful state into one another with CNS activation. Intrusion of sleep and wakeful state into one another with CNS activation. Not a unitary phenomenon. Not a unitary phenomenon. The secret of walking on water is knowing where the stones are

50 Parasomniasis Disorders of arousal – Disorders of arousal – NREM sleep – confusional arousal sleep walking sleep walking sleep terrors sleep terrors REM sleep – RBD Isolated sleep paralysis Isolated sleep paralysis Nightmares Nightmares Others – enuresis eating disorders eating disorders etc etc Future Medicine – Scientific determinism or humanism

51 RBD – REM Sleep Behavior Disorders Prevalence of 0.5%; 90% Men Prevalence of 0.5%; 90% Men Above 50 years Above 50 years 25% with PD, OPCA, DCBD 25% with PD, OPCA, DCBD Complex motor activity during REM Complex motor activity during REM Augmentation of EMG tone during REM sleep Augmentation of EMG tone during REM sleep Toxic/metabolic disorders Toxic/metabolic disorders

52 RBD During second half During second half Abnormal brain stem control of medullary inhibitory regions Abnormal brain stem control of medullary inhibitory regions Cat models- locus ceruleous adjacent lesions Cat models- locus ceruleous adjacent lesions SPECT – decrease striatal dopa innervations SPECT – decrease striatal dopa innervations decrease dopa transportation decrease dopa transportation Withdrawal of alcohol, sedatives Withdrawal of alcohol, sedatives Hypnotics Hypnotics TCA, SSRI, MAOI, cholinergics TCA, SSRI, MAOI, cholinergics The sign wasnt placed there By the Big Printer in the sky

53 Sleep-Related Movement Disorders- Restless Legs Syndrome 5-15% - healthy people 5-15% - healthy people 15-20% - uremia 15-20% - uremia 30% - R.A 30% - R.A High prevalence in West High prevalence in West Low in South & S.E Asia Low in South & S.E Asia A open foe may prove a curse ; but a pretended friend is worse

54 Diagnostic criteria – NIH –IRLSSG (2003) 1. Disagreeable leg sensations before sleep onset 2. Irresistible urge to move the limbs 3. Partial or complete relief on leg movement 4. Return of symptoms on cessation of movement When they tell you to grow up, they mean stop growing

55 Restless Leg Syndrome Bilateral, though asymmetrical Bilateral, though asymmetrical Ankle & knees. Can involve thigh or feet & arm Ankle & knees. Can involve thigh or feet & arm Minutes to hours Minutes to hours Dopamine dysfunction, Iron storage deficiency Dopamine dysfunction, Iron storage deficiency Anti emetics, antihistamines, TCA, SSRI, neuroleptics Anti emetics, antihistamines, TCA, SSRI, neuroleptics

56 Restless Leg Syndrome with Periodic Limb Movements Speak obligingly even if you cannot oblige

57 Periodic Limb Movement Disorder Common as age advances Common as age advances Nocturnal myoclonus captured on Polysomnography Nocturnal myoclonus captured on Polysomnography Extension of the big toe with flexion of ankle, knee & hip Extension of the big toe with flexion of ankle, knee & hip Sleep may or may not be affected Sleep may or may not be affected Centrally mediated event Centrally mediated event The True Art of Memory is The Art of Attention - S.Johnson

58 Can accompany OSA & Narcolepsy Can accompany OSA & Narcolepsy Uremia, metabolic disorders Uremia, metabolic disorders TCA, MAOI TCA, MAOI Withdrawal of AED, benzodiazepines, hypnotics Withdrawal of AED, benzodiazepines, hypnotics Hypnic jerks & nocturnal seizures to be differentiated Hypnic jerks & nocturnal seizures to be differentiated Through Action You Create your Own Education - D.B. ELLIS

59 PLMS –Secondary (previous Myelopathy) We Sometimes think we have forgotten something when in fact we never really learned it in the first place Imp.Your Memory Skills

60 Sleep Related Leg Cramps Not uncommon with increasing age Not uncommon with increasing age Charley horse muscular tightness involving the calf & foot during sleep Charley horse muscular tightness involving the calf & foot during sleep Results in arousal and can lead to insomnia or EDS Results in arousal and can lead to insomnia or EDS Pregnancy, DM, fluid & electrolytes, arthritis, vigorous exercise Pregnancy, DM, fluid & electrolytes, arthritis, vigorous exercise

61 Sleep related Bruxism Children and adults, MR Children and adults, MR Stereotyped grinding or clenching Stereotyped grinding or clenching Diurnal & nocturnal Diurnal & nocturnal Situational or psychological stress Situational or psychological stress SSRI, dopa, alcohol exacerbate SSRI, dopa, alcohol exacerbate Thought is the labour of the intellect Reverie is its pleasure

62 Sleep-Related Rhythmic Movement Disorder Head Banging – back & forth down into the pillow Head Banging – back & forth down into the pillow Head Rolling – side to side Head Rolling – side to side Body Rocking – forward & backward Body Rocking – forward & backward Humming or chanting Humming or chanting Persistence with autism, MR Persistence with autism, MR Whatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill

63 Nocturnal Paroxysmal Dystonia (NPD) Repeated, stereotyped, dystonia or dyskinetic episodes in NREM sleep Repeated, stereotyped, dystonia or dyskinetic episodes in NREM sleep Sleep related epilepsy Sleep related epilepsy Short episodes < 1 min. every night and many times Short episodes < 1 min. every night and many times Long episodes – up to 60 min Long episodes – up to 60 min Can have sleep disruption Can have sleep disruption Imagination is more Important than Knowledge

64 Sleep-Disordered Breathing (SDB) Primary snoring Primary snoring Upper airway resistance syndrome (UARS) – lab support, day time dysfunction Upper airway resistance syndrome (UARS) – lab support, day time dysfunction Obstructive sleep apnea-hypopnea syndrome (OSAHS) Obstructive sleep apnea-hypopnea syndrome (OSAHS) Central sleep apnea Central sleep apnea Asthma Asthma Chronic obstructive pulmonary disease (COPD). Chronic obstructive pulmonary disease (COPD).

65 Obstructive Sleep Apnea-Hypopnea Syndrome Asphyxia with decreased O 2 & increased CO 2 Asphyxia with decreased O 2 & increased CO 2 Associated with snoring and obstruction of the pharynx Associated with snoring and obstruction of the pharynx Day time – sleepiness, decreased concentration, fatigue Day time – sleepiness, decreased concentration, fatigue Nocturnal – chocking, dyspnoea, diaphoresis, nocturia Nocturnal – chocking, dyspnoea, diaphoresis, nocturia A open foe may prove a curse ; but a pretended friend is worse

66 Apnoea – 70% reduction in airflow Apnoea – 70% reduction in airflow Hypopnea – 30% reduction in airflow for minimum 10 sec Hypopnea – 30% reduction in airflow for minimum 10 sec Apnea-hypopnea index (AHI) of at least five apneas plus hypopneas per hour of sleep together with complaints of persistent daytime sleepiness. Apnea-hypopnea index (AHI) of at least five apneas plus hypopneas per hour of sleep together with complaints of persistent daytime sleepiness. It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent La Broyers character

67 Risk Factors Obesity ( BMI > 30 kg/m 2 ) Obesity ( BMI > 30 kg/m 2 ) Male gender Male gender Family history of obstructive sleep apnea-hypopnea syndrome Family history of obstructive sleep apnea-hypopnea syndrome Consumption of alcohol before bedtime Consumption of alcohol before bedtime Smoking Smoking Drugs (growth hormone, β-blockers, testosterone, flurazepam) Drugs (growth hormone, β-blockers, testosterone, flurazepam) Use of sedatives Use of sedatives Sleeping in a supine position Sleeping in a supine position Anatomic upper airway obstruction Anatomic upper airway obstruction Comorbid medical conditions Comorbid medical conditions

68 Central Sleep Apnea 10 sec of no airflow 10 sec of no airflow Reduced ventilatory drive Reduced ventilatory drive Ventilatory responses to hypoxia, hypercapnia are reduced Ventilatory responses to hypoxia, hypercapnia are reduced Day time sleepiness, mild snoring Day time sleepiness, mild snoring PSG – no airflow or ventilatory effort PSG – no airflow or ventilatory effort You are what you think and not what you think you are

69 Circadian rhythm Sleep Disorders (CRSD) Master Clock – SCN in anterior hypothalamus Master Clock – SCN in anterior hypothalamus Sleep wake cycle/temperature control and melatonin levels. Sleep wake cycle/temperature control and melatonin levels. Zeitgebers (time given) are light and melatonin Zeitgebers (time given) are light and melatonin Input into SCN from ganglion cells- melanopsin Input into SCN from ganglion cells- melanopsin Melatonin > pineal > SCN, shifts circadian rhythm Melatonin > pineal > SCN, shifts circadian rhythm Discipline Weighs ounces; Regret weighs Tons

70 DD for insomnia & hypersomnia DD for insomnia & hypersomnia Delayed sleep phase Delayed sleep phase Advanced sleep phase Advanced sleep phase Free running Free running Irregular sleep-wake Irregular sleep-wake Shift work sleep disorder Shift work sleep disorder Jet lag Jet lag A great many people think they are thinking when they are merely re arranging their prejudices W. James

71 Criteria for CRSD Persistent or recurrent pattern of sleep disturbance due to Persistent or recurrent pattern of sleep disturbance due to - Alteration in circadian timing or misalignment of endogenous & external factors - Leading to insomnia, EDS or both - Associated with impairment of function CRSDs are important in practice but parameters for treatment have not been established. CRSDs are important in practice but parameters for treatment have not been established. When they tell you to grow up, they mean stop growing -Piccaso

72 Thank you Many Ideas grow better when transplanted into another mind than in the one where they sprang UP O.W. Holmos


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