Presentation on theme: "MANAGEMENT OF INSOMNIA IN THIS MILLENNIUM"— Presentation transcript:
1 MANAGEMENT OF INSOMNIA IN THIS MILLENNIUM Dr A V Srinivasan M.D, D.M., PhD (Neuro),FAAN,FIANEmeritus ProfessorThe TamilNadu Dr M.G.R Medical UniversityFormer Head- Institute of NeurologyMadras Medical College, ChennaiIn 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.Dr V N1
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 woman’s desire for revenge outlasts all her other emotions
4 Total Sleep Requirement 5040302010456789Length of Sleep in HoursPercentage ofAll People2How much sleep do people need? The real question is ….how much sleep do person need to:Get through the day?Go from the bed to the couch?Perform physical tasks that require concentration and focus such as microscopic surgery or wielding metal beams on a 60- story sky-scraper?The truth is…..the amount of sleep needed will be vary with every individual and perhaps with specific activities.However, when provided the opportunity/environment to sleep, most Americans sleep between 7-8 hours each nightShort sleepers are the exception. They only require 3-4 hours of sleep each night; however, it is rare that someone is fully functional and feels rested after short sleep periods.Conversely, there are long sleepers! These folks often require 9-10 hours of sleep to be fully functional and rested. Unfortunately, they are out of sync with a 8-4/ 9-5 society and have difficulty adjusting to demanding daytime work schedules.Animals such as cats and dogs tend to sleep at least half of the day. Larger animals such as horses, elephants and giraffes usually sleep no more than 4 hours a day.In order to be at your peak performance you need atleast 8 hours of sleep.
5 Function of Sleep Restoration and recovery Sleep serves to reverse and/or restore biochemical and / or physiological processes degraded during prior wakefulnessEnergy conservation10% reduction of metabolic rate below basal levelMemory consolidationThermoregulationHomeostasisThe world shall perish not for lack of wonders but lack of wonder
6 Memory Consolidation at Sleep Onset Impairment of Memory Consolidation during SleepWord Presentation Minutes Before Sleep OnsetAssessment of Sleepiness / Sleep Deprivation, M. Mahowald, University of Minnesota, Sleep Academic Award
7 Hormones Tightly Coupled with Sleep Sleep and HormonesHormones Tightly Coupled with SleepDeterminants of Sleepiness / Circadian Rhythms, M. Mahowald, University of Minnesota, Sleep Academic Award
8 Illustration of Normal vs. Insomnia Sleep Pattern Normal Sleep PatternOnsetInsomnia Sleep PatternTalking PointsWhat does a normal night of sleep look like diagrammatically, and how does that compare to the insomnia experience?A normal sleep pattern is illustrated by the top diagram. The good sleeper would typically report a latency to sleep onset of approximately 6 to 14 minutes and might awaken briefly (<5 mins) 1 to 2 times during the night but is able to return to sleep quickly after the brief arousals. Sleep pattern is consolidated without significant interruptions.Patients with insomnia may have difficulty falling asleep (“sleep onset”), difficulty staying asleep (“sleep maintenance”), or have early morning awakenings, and some patients have difficulty with all three. After initially falling asleep, interruptions in the sleep process (defective sleep maintenance) are said to cause “sleep fragmentation” because they impair normal “sleep consolidation.” Sleep maintenance insomnia may consist of one or multiple awakenings of variable duration.OnsetAwakenings
9 Normal sleep architecture NATURE, TIME AND PATIENCEare the 3 great physicians
10 Normal Sleep Architecture Stages of sleep __________________________ 1. NREM SleepA. Stage 1B. Stage 2C. Stage 3D. Stage 42. REM SleepTruth comes out of error sooner than that of confusion10
11 Sleep Stages ___________________________ Thought is the labour of the intellectReverie is its pleasureSleep Stages ___________________________Wake2/3 of lifeNREM Sleep~80% of nightREM Sleep~20% of night11
12 Normal Sleep Histogram Sequences of States and Stages of Sleep on a Typical NightIdentification and Staging of Adult Human Sleep, L. Shigley, Sleep Academic Award
13 Normal Sleep Stages 3-8% 45-55% 15-20% 20% REM Learning and memory consolidation ‘Dreaming sleep’3-8%45-55%15-20%20%Stage 1Body starts to relax ‘Falling asleep’Stage 2Brain slows ‘Stable, light sleep’Stage 3&4Body and tissue restored ‘Deep, restorative sleep’NREM 75-80%REM 20-25%Stilnox CR: Preservation of Sleep StagesWithin NREM sleep, there are four stages of varying ‘depths’ of sleep.Stage 1 sleep is very shallow sleep; drowsiness with closed eyes. People aroused from stage 1 sleep may feel as if they have not slept at all.Stage 2 sleep is light sleep, during which the heart rate slows and the body temperature decreases in preparation for deep sleep. Stage 2 sleep is characterised by spontaneous periods of muscle tone increase mixed with periods of muscle relaxation.Stage 3 and stage 4 are deep sleep, also known as slow-wave sleep, because the EEG records a low frequency of cycles per second (the ‘delta’ rhythm’). During these stages heart rate, blood pressure and respiratory rates are lowered. Stage 3 and 4 account for approximately 20% of total sleep time and are the dominant NREM stages of sleep at the beginning of the night.1 cycle = minutesAdapted from Damien R.Stevens MD.Sleep medicine secrets.2004Damien R.Stevens MD.Sleep medicine secrets.2004
15 Wakefulness, NREM, and REM ArousabilityHighLowestLowEEG amplitudeEEG frequencyFastSlowMixed fastMuscle toneVariableAbsentEye movementsVoluntaryInfrequentRapidHeart Rate, Blood Pressure, Respiratory RateSlow/ low, regularO2, CO2 responseFullLowerThermoregulationBehavioral/ PhysiologicalPhysiologicalReduced physiologicalMental activityNone/ limitedStory-like dreams
16 Importance of sleep architecture 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:sleep integrity and continuityglobal sleep-stage structurepresumed underlying physiologic mechanismsSleep integrity and continuity measures focus on how well sleep is preserved and how well it progresses. They best reflect a patient's difficulty initiating and maintaining sleep. Global sleep-stage structure measures provide a look into the composition of sleep, including sleep-stage percentages as well as REM (rapid eye movement)-sleep latency
17 Neurochemical control of sleep-wake states NeurotransmitterLocationActionAcetylcholineLDT, PPT (pons)REM, wakeHistamineTMN (posterior hypothalamus)WakeGABA, galaninVLPONREM sleepSerotoninRaphe nucleiWake, NREMNorepinephrineLocus coeruleusHypocretinLater hypothal
18 Neurochemical control of sleep-wake states DopamineAdenosineNitrous oxideCytokines (IL-1, IL-6, TNF-α)ProstaglandinsHormones: melatonin, growth hormone, VIP NPYDelta sleep-inducing peptide
20 Factors that affect sleep Social Isolation is in itself a pathogenic Factor for disease productionAgeIncreased wakefulness during sleep periodDecreased Stage 3/4 NREMEarlier timingGreater daytime sleepinessSex (women have longer sleep, more Stage 3/4 NREM)Timing: Sleep is best at night!Illnesses, medications
21 Sleep in healthy young and older adults 20 year old woman71 year old womanMotivation is the Spark that lightsthe Fire of Knowledge andfuels the engine of Accomplishment
22 Sleep stages across the life span Ohayon et al Sleep stages across the life span Ohayon et al., SLEEP 2004; 27:MinutesAge (years)
23 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 sleepHypotonia/atoniaSlow/fast eye movementsRegular/irregular breathing, heart rate, BPSEDATIONAnalgesiaAmnesiaObtundation of wakingAnxiolysisSocial Isolation is in itself a pathogenic Factor for disease production
25 Knowledge without action is useless; Action without knowledge is foolishSleep v/s sedationSleep is reversible with sensory stimulation; sedation depresses sensory processing in the face of noxious physical &/or aversive psychological stimulationSleep disrupts mammalian temperature regulation during REM phase; Sedation can alter the relationship between body temp and energy expenditureNausea and vomiting are not associated with sleep; but can be positively correlated with sedation level.
26 Sleep architecture in neurological and psychiatric conditions A bad teacher complains;A good teacher explains;The best teacher inspires;
27 Pure love ever gives. Never seeks Effect of Sleep Stage in Epileptic patients on Interictal and Ictal DischargesPure love ever gives. Never seeks
28 Seizure effect on sleep architecture Seizures acutely alter the sleep-wake state.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.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 complaints1,3Difficulty falling asleepFrequent nocturnal awakeningsWaking too early in the morningDaytime fatigueEffects on sleep architecture in depression1-3Prolonged sleep latencyIncreased wake time after sleep onset (WASO)Decreased slow wave sleep (stages 3 and 4)Reduced REM sleep latency; prolonged first REM periodSleep in Patients With DepressionSleep difficulties are a frequent symptom in patients with depression, reported to occur in 40% to 65% of outpatients1,2 and in up to 90% of inpatients1 with major depressive episode. Specific sleep complaints can include difficulty falling asleep, sleep continuity difficulties such as frequent nocturnal awakenings, and early morning awakenings.1-3Objective polysomnographic assessments of sleep in depressed patients have revealed several distinct abnormalities, including prolonged sleep latency, increased wake time after sleep onset (WASO), and decreased duration of time spent in slow wave sleep (stages 3 and 4). Additionally, reduced latency to the onset of rapid eye movement (REM), increased duration of the first REM period, and greater density of eye movements during REM have been observed.1-3Many of the neurological systems responsible for the regulation of mood (eg, hypothalamic-pituitary-adrenal axis) are also involved in the regulation of sleep and wakefulness, which offers the possibility that abnormal function of certain regions of the brain may lead to both sleep and mood disturbances.31. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR®). 2000:2. Perlis M, et al. Biol Psychiatry 1997;42:3. Benca RM. In: Principles and Practice of Sleep Medicine. 4th ed. 2005:References1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR®). Washington, DC: American Psychiatric Association; 2000:2. Perlis ML, Giles DE, Buysse DJ, Thase ME, Tu X, Kupfer DJ. Which depressive symptoms are related to which sleep electroencephalographic variables? Biol Psychiatry. 1997;42:3. Benca RM. Mood disorders. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia, PA: Elsevier Science Ltd.; 2005:
30 Sleep pattern in Alzheimer’s Disease 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: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 antidepressantsMostly produce sedationVariation 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.Rush et al. (1998) found that sleep was significantly less efficient, and nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg)Fhoxetine significantly suppressed REM sleep,Wolf et al. (2001) demonstrated that fluoxetine (20 mg) was associated with less efficient, shorter andmore disrupted sleepfluoxetine suppressed REM sleep,Satterlee and Faries (1995) showed that HAMD sleep scores tended to show better improvement for fluoxetine (20mg) than placebo, but this was not significant.Winokur et al. (2003) found no differences between fluoxetine (20-40 mg) and mirtazapine (15-45 mg) in respect of HAMD sleep scores; both showing significant improvements.However, improvements in sleep latency and total sleep time were not as marked for fluoxetine as they were for mirtazapine, which resulted in more efficient sleep and less nocturnal disturbances than fluoxetine.Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20:
33 Effect of antidepressants on sleep architecture SSRIsSSRIs 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.Rush et al. (1998) found that sleep was significantly less efficient, and nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg)Fhoxetine significantly suppressed REM sleep,Wolf et al. (2001) demonstrated that fluoxetine (20 mg) was associated with less efficient, shorter andmore disrupted sleepfluoxetine suppressed REM sleep,Satterlee and Faries (1995) showed that HAMD sleep scores tended to show better improvement for fluoxetine (20mg) than placebo, but this was not significant.Winokur et al. (2003) found no differences between fluoxetine (20-40 mg) and mirtazapine (15-45 mg) in respect of HAMD sleep scores; both showing significant improvements.However, improvements in sleep latency and total sleep time were not as marked for fluoxetine as they were for mirtazapine, which resulted in more efficient sleep and less nocturnal disturbances than fluoxetine.Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20:
34 Effect of antidepressants on sleep architecture Discipline Weighs ounces: Regret weighs TonsFluoxetineSleep was significantly less efficient, and nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg) - Rush et al. (1998)Fluoxetine significantly suppressed REM sleepFluoxetine (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 fluoxetineRush et al. (1998) found that sleep was significantly less efficient, and nocturnal awakenings were significantly greater, with fluoxetine (20-40 mg)Fhoxetine significantly suppressed REM sleep,Wolf et al. (2001) demonstrated that fluoxetine (20 mg) was associated with less efficient, shorter andmore disrupted sleepfluoxetine suppressed REM sleep,Satterlee and Faries (1995) showed that HAMD sleep scores tended to show better improvement for fluoxetine (20mg) than placebo, but this was not significant.Winokur et al. (2003) found no differences between fluoxetine (20-40 mg) and mirtazapine (15-45 mg) in respect of HAMD sleep scores; both showing significant improvements.However, improvements in sleep latency and total sleep time were not as marked for fluoxetine as they were for mirtazapine, which resulted in more efficient sleep and less nocturnal disturbances than fluoxetine.Mayers AG et al. Hum Psychopharmacol Clin Exp 2005; 20:
35 Effect of hypnotics drugs on sleep architecture BenzodiazepinesBeing anticonvulsants, they tend to suppress synchronized EEG activity (such as slow waves) and confer some risk of seizure if abruptly withdrawn.BarbituratesDecrease REM and slow-wave sleep.Non-BZD hypnotics.Do not alter sleep architecture when taken at therapeutically recommended doses.Some people feel the rain;Others just get wet
36 Stilnoct® Preservation of Sleep Stages PlaceboStilnoct19.02%44.48%10.50%8.51%11.22%6.26%Stage 1Stage 0REMStage 4Stage 3Stage 216.39%6.64%7.27%15.81%7.65%46.23%Stage 1Stage 0REMStage 4Stage 3Stage 2Stilnoct™: Preservation of Sleep StagesFollowing administration of Stilnoct (12.5 mg), very few modifications in sleep architecture were observed in healthy adults (18-40 years old, N=36) as monitored by PSG for 8 hours postdose. In this slide, the proportion of time spent in each stage of sleep is represented graphically.Opinion is ultimately determined by the feelingsand not by the intellectN=36Data on file. Sanofi-aventis.ReferenceData on file. Sanofi-aventis.
37 Sleep Disorders (1) insomnias (2) sleep-related breathing disorders 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 speakand it is the privilege of the wisdom to listen - Hodly’sDr V N37
38 Insomnia Difficulty in initiating sleep and staying asleep Waking up earlierPoor quality sleep, non restorative.SubjectiveDay time impairment (RDC-AASN)The meek shall inherit the earth- but not its mineral rights
39 Etiology Primary Secondary Medications Psychiatric Medical Sleep DisordersA Man Of Words And Not Of Deeds Is Like A Garden Full Of Weeds
40 Drugs SSRI’s & SNRI’s Alpha and beta blockers Diuretics Decongestants StimulantsSteroids, thyroid harmonesWhat is mind no matterWhat is matter never mind
41 Psychiatric and Sleep disorders Mood & anxiety disordersCircadian rhythm disordersParasomniasApneasMovement disorders''When Beauty Fires The Blood; Love Exalts The Mind"
42 Experience : “Yesterday’s Answer To Today’s Problems” HypersomniasExcessive day time sleepinessInterfering with day time activities, productivity, enjoymentReflects insufficient sleep, disrupted sleep, primar sleep disorderExperience : “Yesterday’s Answer To Today’s Problems”
43 Diagnosis Detailed medical and sleep history Snoring or apnoea Restlessness, jerkingHypnogogic or hypnopompic hallucinationsSleep paralysis, cataplexyAutomatic behaviorTeachers are reservoirs from which, through the process of education,the students draw the water of life
44 Name and form are destroyed in the sands of time NarcolepsyExcessive day time sleepiness (EDS)Sedentary and active pursuit'sShort and refreshingFollowed by recurrent somnolenceRanging from mild to disablingName and form are destroyed in the sands of time
45 Cataplexy Unique Paroxysmal episodes of weakness Triggered by emotions Secs to MinCan be localizedConsciousness and respiration not affected.Time and tide wait for no man;And sins and sorrows are also swallowed in time
46 Every man is a volume if you know how to read him Develops years after EDSFrequency variesAdolescence, young adulthoodNarcolepsy with and without cataplexyLoss of hypocretin – 1 secreting cellsEvery man is a volume if you know how to read him
47 Being ignorant is not so much a shame as being unwilling to learn Narcolepsy – non obligate manifestationsSleep paralysis – muscle atonia at interface between sleep and wakefulness; for few minutes.Hypnogogic hallucinationsbrief, Sec to Mins, dream-like vivid and distressingAutomatic behaviorPurposeful/inappropriate with impaired recollection of the activities.
48 Beauty lies in the eyes of the beholder Other HypersomniasRecurrent hypersomniasKleine – Levin syndromeMenstrual associatedIdiopathic hypersomniasWith long sleep timeWithout long sleep timeBeauty lies in the eyes of the beholder
49 The secret of walking on water is knowing where the stones are ParasomniasInclude abnormal movements, behaviors, emotions and automatic activities.Intrusion of sleep and wakeful state into one another with CNS activation.Not a unitary phenomenon.
50 Future Medicine – Scientific determinism or humanism ParasomniasisDisorders of arousal –NREM sleep – confusional arousalsleep walkingsleep terrorsREM sleep – RBDIsolated sleep paralysisNightmaresOthers – enuresiseating disordersetcFuture Medicine – Scientific determinism or humanism
51 RBD – REM Sleep Behavior Disorders Prevalence of 0.5%; 90% MenAbove 50 years25% with PD, OPCA, DCBDComplex motor activity during REMAugmentation of EMG tone during REM sleepToxic/metabolic disorders
52 RBDDuring second halfAbnormal brain stem control of medullary inhibitory regionsCat models- locus ceruleous adjacent lesionsSPECT – decrease striatal dopa innervationsdecrease dopa transportationWithdrawal of alcohol, sedativesHypnoticsTCA, SSRI, MAOI, cholinergicsThe sign wasn’t placed thereBy the Big Printer in the sky
53 Sleep-Related Movement Disorders- Restless Legs Syndrome 5-15% - healthy people15-20% - uremia30% - R.AHigh prevalence in WestLow in South & S.E AsiaA open foe may prove a curse ; buta pretended friend is worse
54 Diagnostic criteria – NIH –IRLSSG (2003) 1. Disagreeable leg sensations before sleep onset2. Irresistible urge to move the limbs3. Partial or complete relief on leg movement4. Return of symptoms on cessation of movementWhen they tell you to grow up, they mean stop growing
55 Restless Leg Syndrome Bilateral, though asymmetrical Ankle & knees. Can involve thigh or feet & armMinutes to hoursDopamine dysfunction, Iron storage deficiencyAnti 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 advancesNocturnal myoclonus captured on PolysomnographyExtension of the big toe with flexion of ankle, knee & hipSleep may or may not be affectedCentrally mediated event“The True Art of Memory is The Art of Attention” S.Johnson
58 Through Action You Create your Own Education - D.B. ELLIS Can accompany OSA & NarcolepsyUremia, metabolic disordersTCA, MAOIWithdrawal of AED, benzodiazepines, hypnoticsHypnic jerks & nocturnal seizures to be differentiatedThrough Action You Create your Own Education - D.B. ELLIS
59 PLMS –Secondary (previous Myelopathy) “ We Sometimes think we have forgotten something whenin fact we never really learned it in the first place” Imp.Your Memory Skills
60 Sleep Related Leg Cramps Not uncommon with increasing age“Charley horse” muscular tightness involving the calf & foot during sleepResults in arousal and can lead to insomnia or EDSPregnancy, DM, fluid & electrolytes, arthritis, vigorous exercise
61 Sleep related Bruxism Children and adults, MR Stereotyped grinding or clenchingDiurnal & nocturnalSituational or psychological stressSSRI, dopa, alcohol exacerbateThought is the labour of the intellectReverie is its pleasure
62 Sleep-Related Rhythmic Movement Disorder Head Banging – back & forth down into the pillowHead Rolling – side to sideBody Rocking – forward & backwardHumming or chantingPersistence with autism, MRWhatever 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 sleepSleep related epilepsyShort episodes < 1 min. every night and many timesLong episodes – up to 60 minCan have sleep disruptionImagination is more Important than Knowledge
65 Obstructive Sleep Apnea-Hypopnea Syndrome Asphyxia with decreased O2 & increased CO2Associated with snoring and obstruction of the pharynxDay time – sleepiness, decreased concentration, fatigueNocturnal – chocking, dyspnoea, diaphoresis, nocturiaA open foe may prove a curse ; but a pretended friend is worse
66 Apnoea – 70% reduction in airflow Hypopnea – 30% reduction in airflow for minimum 10 secApnea-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 wellnor sufficient judgment to keep silentLa Broyers character
67 Risk Factors Obesity ( BMI > 30 kg/m2) Male gender Family history of obstructive sleep apnea-hypopnea syndromeConsumption of alcohol before bedtimeSmokingDrugs (growth hormone, Î²-blockers, testosterone, flurazepam)Use of sedativesSleeping in a supine positionAnatomic upper airway obstructionComorbid medical conditions
68 Central Sleep Apnea 10 sec of no airflow Reduced ventilatory drive Ventilatory responses to hypoxia, hypercapnia are reducedDay time sleepiness, mild snoringPSG – no airflow or ventilatory effortYou are what you think and not what you think you are
69 Circadian rhythm Sleep Disorders (CRSD) Master Clock – SCN in anterior hypothalamusSleep wake cycle/temperature control and melatonin levels.Zeitgebers (time given) are light and melatoninInput into SCN from ganglion cells-melanopsinMelatonin > pineal > SCN, shifts circadian rhythmDiscipline Weighs ounces; Regret weighs Tons
70 DD for insomnia & hypersomnia Delayed sleep phase Advanced sleep phase Free runningIrregular sleep-wakeShift work sleep disorderJet lagA great many people think they are thinking when they are merely re arranging their prejudices W. James
71 Criteria for CRSDWhen they tell you to grow up, they mean stop growing -PiccasoPersistent or recurrent pattern of sleep disturbance due toAlteration in circadian timing or misalignment of endogenous & external factorsLeading to insomnia, EDS or bothAssociated with impairment of functionCRSDs are important in practice but parameters for treatment have not been established.
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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