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Elliott K. Lee MD, FRCP(C) Christopher R. Skinner MD, FRCP(C) SLEEP MEDICINE: An Overview.

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Presentation on theme: "Elliott K. Lee MD, FRCP(C) Christopher R. Skinner MD, FRCP(C) SLEEP MEDICINE: An Overview."— Presentation transcript:

1 Elliott K. Lee MD, FRCP(C) Christopher R. Skinner MD, FRCP(C) SLEEP MEDICINE: An Overview

2 Objectives Describe the stages of normal sleep and describe how normal sleep is regulated by the brain Discuss the usual classification of sleep disorders Briefly describe the technique of polysomnography and list the electrical and physiological variables monitored List and describe the cardinal manifestations of narcolepsy Define and give examples of parasomnias

3 Sleep Definition A reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment, is restorative and important for the proper functioning of an organism.

4 Why Study Sleep? We spend 1/3 of our lives sleeping We spend 1/3 of our lives sleeping 1 in 7 Canadians are not getting enough sleep (Statistics Canada, 2002) 1 in 7 Canadians are not getting enough sleep (Statistics Canada, 2002) Severe health consequences - DEATH! Severe health consequences - DEATH! Sleep deprivation costs Sleep deprivation costs $150 BILLION/yr in lost $150 BILLION/yr in lost productivity productivity (Nat’l Commission on Sleep Disorders, 2003) (Nat’l Commission on Sleep Disorders, 2003)

5 THE IMPACT OF SLEEP DEPRIVATION

6 Challenger Disaster Challenger Disaster 3 Mile Island 3 Mile Island Chernobyl Chernobyl

7 Purpose of Sleep Regeneration of Physiological Systems NREM – physical REM - cognitive Activation of Genes in different stages

8 Purpose of Sleep Restorative Function Restorative Function Energy Conservation Energy Conservation Immune Function Regulation Immune Function Regulation Ontogenetic Hypothesis Ontogenetic Hypothesis Memory Consolidation Memory Consolidation Protective Mechanism Protective Mechanism

9 Gene Activation in Sleep 15,000 transcripts expressed in the cerebral cortex, about 5% change their expression levels depending on behavioural state but independently of time of day Half of the modulated genes increase in wakefulness and half in sleep.

10 Waking-related transcripts Energy metabolism Excitatory neurotransmission, transcriptional activation Synaptic potentiation Memory acquisition Response to cellular stress..

11 Sleep-related transcripts Brain protein synthesis Synaptic consolidation/depression Membrane trafficking and maintenance, including cholesterol metabolism, myelin formation, and synaptic vesicle turnover

12 Major Classification Dyssomnias Sleep disorders associated with mental, neurologic, or other medical disorders Parasomnias Proposed sleep disorders

13 ICSD - International Classification of Sleep Disorders CATEGORIES: INSOMNIAS INSOMNIAS SLEEP RELATED BREATHING DISORDERS SLEEP RELATED BREATHING DISORDERS HYPERSOMNIAS OF CENTRAL ORIGIN HYPERSOMNIAS OF CENTRAL ORIGIN CIRCADIAN RHYTHM DISORDERS CIRCADIAN RHYTHM DISORDERS PARASOMNIAS PARASOMNIAS SLEEP RELATED MOVEMENT DISORDERS SLEEP RELATED MOVEMENT DISORDERS ISOLATED SYMPTOMS ISOLATED SYMPTOMS

14 Dyssomnias Intrinsic Sleep Disorders Extrinsic Sleep Disorders Circadian Rhythm Sleep Disorders

15 Intrinsic sleep disorders Psychophysiologic insomnia Sleep state misperception Idiopathic insomnia Narcolepsy Recurrent hypersomnia Idiopathic hypersomnia Posttraumatic hypersomnia Obstructive sleep apnea syndrome Central sleep apnea syndrome Central alveolar hypoventilation syndrome Periodic limb movement disorder Restless legs syndrome Intrinsic sleep disorder not otherwise specified

16 Extrinsic sleep disorders Inadequate sleep hygiene Environmental sleep disorder Altitude insomnia Adjustment sleep disorder Insufficient sleep syndrome Limit-setting sleep disorder Sleep-onset association disorder Food allergy insomnia Nocturnal eating (drinking syndrome) Hypnotic-dependent sleep disorder Stimulant-dependent sleep disorder Alcohol-dependent sleep disorder Toxin-induced sleep disorder Extrinsic sleep disorder NOS

17 SLEEP DISORDERS ASSOCIATED WITH MENTAL, NEUROLOGIC, OR OTHER MEDICAL DISORDERS Psychoses Mood Disorders Anxiety Disorders Panic Disorders Alcoholism Associated with Neurologic Disorders Cerebral Degenerative Disorders Dementia Parkinsonism Fatal Familial Insomnia Sleep-Related Epilepsy Electrical Status Epilepticus of Sleep Sleep-Related Headaches Associated with Other Medical Disorders Sleeping Sickness Nocturnal Cardiac Ischemia Chronic Obstructive Pulmonary Disease Sleep-Related Asthma Sleep-Related Gastroesophageal Reflux Peptic Ulcer Disease Fibromyalgia

18 Circadian rhythm sleep disorders Time zone change (jet lag) syndrome Shift work sleep disorder Irregular sleep-wake pattern Delayed sleep phase syndrome Advanced sleep phase syndrome Non—24-hour sleep—wake disorder Circadian rhythm sleep disorder NOS

19 Circadian System

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22 Fellowship training, workload, fatigue and physical stress: a prospective observational study CMAJ 2004;170(6):965-70 Although within current PAIRO–OCOTH and ACGME regulations, the workload of senior fellows in the Hospital for Sick Children’s PCCU is physically demanding, allows limited rest and is associated with sleep deprivation and objective markers of physiologic stress. Although within current PAIRO–OCOTH and ACGME regulations, the workload of senior fellows in the Hospital for Sick Children’s PCCU is physically demanding, allows limited rest and is associated with sleep deprivation and objective markers of physiologic stress. Judged by the number and destinations of its trainees, this is a highly successful program; however, trainees are unlikely to be performing optimally. This style of health care delivery is almost certainly associated with the production of error and adverse patient outcomes. Judged by the number and destinations of its trainees, this is a highly successful program; however, trainees are unlikely to be performing optimally. This style of health care delivery is almost certainly associated with the production of error and adverse patient outcomes. Current guidelines and work practices do not mitigate significant fatigue and physical stress. Guideline revision and evaluation of other means to reduce the physical demands on trainees are required if the health care system wishes to address these challenging issues. Current guidelines and work practices do not mitigate significant fatigue and physical stress. Guideline revision and evaluation of other means to reduce the physical demands on trainees are required if the health care system wishes to address these challenging issues.

23 Med Educ. 1994;28:566-572 Lingenfelser et al The effect of training experience (first- and second-year residents vs third- and fourth-year) The effect of training experience (first- and second-year residents vs third- and fourth-year) Examined the performance on a number of psychomotor tasks of 40 residents in the “off-duty” state (6 hours of reported sleep the previous night) and after 24 hours on call Examined the performance on a number of psychomotor tasks of 40 residents in the “off-duty” state (6 hours of reported sleep the previous night) and after 24 hours on call Performances on a simulated electrocardiogram, short- term recall of a list of things to do, and reaction times all deteriorated after being on call Performances on a simulated electrocardiogram, short- term recall of a list of things to do, and reaction times all deteriorated after being on call These post call performance deficits were similar for junior and senior residents These post call performance deficits were similar for junior and senior residents suggesting a lack of adaptation over time to the sleep- deprived state suggesting a lack of adaptation over time to the sleep- deprived state

24 Ann Emerg Med. 1994;24:928-934 Smith-Coggins R ER physicians found that both completion time in a simulated intubation task and clinical accuracy in a triage task were worse for night-shift physicians than for dayshift ER physicians found that both completion time in a simulated intubation task and clinical accuracy in a triage task were worse for night-shift physicians than for dayshift physicians and that performance deteriorated across night shifts but not across day shifts. physicians and that performance deteriorated across night shifts but not across day shifts. Performance deterioration across the night shift likely results from both insufficient sleep and circadian rhythm differences. circadian rhythm differences. Performance deterioration across the night shift likely results from both insufficient sleep and circadian rhythm differences. circadian rhythm differences.

25 Sleep Stage % by Age

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29 Parasomnias Arousal disorders Confusional arousals Sleepwalking Sleep terrors Sleep-wake transition disorders Rhythmic movement disorder Sleep starts Sleep talking Nocturnal leg cramps

30 WHAT WE DO AT THE SLEEP LAB….

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32 What Happens at the Sleep Lab… ROMHC: 5 bed clinical lab, 4 bed research lab ROMHC: 5 bed clinical lab, 4 bed research lab TOH: 15 bed clinical lab, MSLT, MWT TOH: 15 bed clinical lab, MSLT, MWT STEPS: STEPS: 1) → Referral 1) → Referral 2) → Consultation with a Sleep Specialist 2) → Consultation with a Sleep Specialist 3) → Overnight Sleep Study 3) → Overnight Sleep Study 4) → Data is Analyzed by RPSGTs 4) → Data is Analyzed by RPSGTs 5) → Results Appt with a Sleep Specialist 5) → Results Appt with a Sleep Specialist

33 How Do We Measure Sleep in the Laboratory? EEG – brainwaves (Central & Occipital Leads) EEG – brainwaves (Central & Occipital Leads) EOG – eye movements EOG – eye movements EMG – muscle tone EMG – muscle tone EKG/ECG – heart EKG/ECG – heart Breathing: Breathing: 1)Airflow 1)Airflow & 2) Effort: Thoracic & Abdominal & 2) Effort: Thoracic & Abdominal Blood oxygen saturation (SaO 2 ) Blood oxygen saturation (SaO 2 ) Snore mic. Snore mic. Digital AV recording Digital AV recording

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37 Diagnostic Tools Overnight Polysomnogram Multiple Sleep Latency Test Maintenance of Wakefulness Test Actigraphy Sleep Diaries Sleep Surveys – Epworth Sleep Scale Stanford Sleepiness Rating

38 Overnight Sleep Study Sleep Architecture Sleep Disordered Breathing Oxygen Desaturation Periodic Limb Movements Restless Legs

39 Multiple Sleep Latency Test MSLT Repeated naps at 2 hour intervals during the day Measures Normal > 12 minutes Pathological Sleepiness < 6 minutes Sleep Latency REM Onset

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41 Maintenance of Wakefulness Test MWT Subjects lie in darkened room in daytime Try to remain awake 40 min version Some use performance tests Validation and sensitivity – not established

42 Epworth Sleepiness Scale SITUATION CHANCE OF DOZING Sitting and reading3 Watching TV3 Sitting inactive in a public place (e.g. a theater or a meeting)3 As a passenger in a car for an hour without a break3 Lying down to rest in the afternoon when circumstances permit3 Sitting and taking to someone3 Sitting quietly after a lunch without alcohol3 In a car, while stopped for a few minutes in traffic3

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44 STAGES OF SLEEP NREM & REM NREM & REM NREM = N1, N2, N3 NREM = N1, N2, N3 Sleep Cycle Sleep Cycle REM increases as the night progresses REM increases as the night progresses Changes across the lifespan Changes across the lifespan

45 Sleep Histogram RL

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47 Arousal System

48 NREM SLEEP N1: lightest stage of sleep N1: lightest stage of sleep (hypnic jerks/sleep starts), dozing N2: Sleep spindles & K complexes N2: Sleep spindles & K complexes N3 (formerly stages 3 & 4): deepest most physically restorative stage of sleep. More difficult to awaken from this stage. Decreases with age. N3 (formerly stages 3 & 4): deepest most physically restorative stage of sleep. More difficult to awaken from this stage. Decreases with age. Breathing regular, heart rate decreases Breathing regular, heart rate decreases

49 Non-REM Control

50 REM Sleep Giant Cells of Pontine Tegmentum (Brain Activation) Laterodorsal Tegmental Nucleus Pediculopontine Tegmental Nucleus Subcerulean Nuclei – (Atonia and Paralysis) Medial and Descending Vestibular Nuclei (Phasic Phenomena) Hypothalamic Component (Autonomic, sexual, neuroendocrine) REM On Neurons REM Off Neurons

51 REM Sleep Rapid Eye Movements Rapid Eye Movements Muscle atonia (paralysis) Muscle atonia (paralysis) Dream recall Dream recall 90 minute latency 90 minute latency “Paradoxical Sleep” – EEG mimics wakefulness “Paradoxical Sleep” – EEG mimics wakefulness Breathing irregular, heart rate fluctuates Breathing irregular, heart rate fluctuates

52 Orexin System

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54 AWAKE

55 STAGE N1

56 STAGE N2

57 STAGE N3

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59 REM

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64 Objectives Describe the stages of normal sleep and describe how normal sleep is regulated by the brain Discuss the usual classification of sleep disorders Briefly describe the technique of polysomnography and list the electrical and physiological variables monitored List and describe the cardinal manifestations of narcolepsy Define and give examples of parasomnias


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