1. Making Your Sleep Healthy and Happy: Sleep Disorders Dr. Barbara C. Fisher Clinic Director 47818 Van Dyke Ave Shelby Twp., MI 48317 Phone # 586-323-3620 Fax # 586-323-3568 Brainevaluation.com

2. Seminar Objectives 1.Defining sleep 2.Sleep parameters: Process C and S, sleep stages 3.Developmental changes in sleep: changes in sleep requirements with age 4.Sleep Disorders 5.Good sleep hygiene 6.Behavioral therapies

3. Factors that Impact Sleep Developmental Circadian Ultradian Prior sleep deprivation Neurological Cardiopulmonary Gastrointestinal Sleep Hygiene Endocrine Dermatologic Pain Upper respiratory Allergies Drugs Psychiatric Infections

4. Fundamental Processes of Sleep Circadian Homeostatic Ultradian Physiological Hyperarousal –muscle tension –Agitation –Reactivity –Cardiac –Anxiety Cardiorespiratory Upper airway Neurological Psychiatric Behavioral Drugs and Alcohol Other medical conditions Developmental

5. Sleep Dysfunction in Children: Conceptual Framework Excessive Daytime Sleepiness (EDS) Primary Disorders of EDS Insufficient Sleep (Sleep is Deprived) Fragmented Sleep (Sleep is Disrupted)

6. Daytime Sleepiness in Children: Conceptual Framework Daytime Sleepiness Behavioral Problems: Irritability, Low Frustration Tolerance Mood Disturbance: Emotional Lability Performance Deficits: Difficulties in school Short term memory Attention and Concentration

7. Poor sleep at night leads to: Mood and emotional changes Behavioral problems: aggressiveness, hyperactivity, poor impulse control Cognitive deficits: attention, memory, confusion, not thinking clearly Performance deficits: academic and social Affects whole family if child awake at night

8. Sleep in Infants Development NREM sleep by 6 months; decreased REM amounts At 6 months: total sleep time 13-14 hrs; sleep episodes 6-8 hrs “Sleeping through the night”: 70-80% at 9 months

9. Sleep in Toddlers Total sleep time 12 - 14 hours Most give up 2nd nap at about one year Developmental issues: separation anxiety, night time fears, independent sleeping, ability to self-soothe Awakenings, sleep terrors: Sleep problems common (20-40%) Importance of bedtime routines

10. Sleep in Pre-Schoolers Sleep cycles: REM/Non-REM 90 minutes Total sleep time: 11-12 hours By age 4-5, many children give up regular daytime naps Sleep problems that are present are at risk to become chronic

11. Middle Childhood (6-12 years old) Total sleep time: 9-11 hours (10 - 11 hours in 6-7 year olds; 9 - 9 1/2 hours in early adolescence) Sleep pattern more stable, night-to-night consistency Naps rare, not sleep in the daytime School and lifestyle influences, bedtimes, insufficient sleep

12. Sleep Changes in Adolescence Delayed sleep onset Circadian: relative phase delay emerges at puberty Advanced wake times (sleep offset) Earlier school start times Sleep Deprivation Decreased sleep / wake regularity

13. Sleep Changes in Adolescence Sleep deprivation during the week with makeup sleep on the weekend Sleep deprivation leads to decreased attention and focus as well as depression, emotionality lability, decreased attention and concentration.

14. Normal Adult Sleep Average amount of sleep per night: range of 6.5 to 8.3 hours Normal sleep latency: 10 minutes Normal sleep structure –5% stage 1 –50% stage 2 –15-25% stages 3 and 4 (slow wave sleep) –25% REM Napping occurs at the beginning and the end of life (in our culture)

15. Sleep Changes with Age Increased awakenings and arousals Decreased REM sleep (Probably) decreased SWS Increased stage shifts Fewer “cycles” Reduced sleep efficiency Phase advancement

16. Sleep Disorders Two factors influence how sleepy or alert anyone is during a 24 hour period of time. 1. Sleep-wake Balance: how long it has been since you last slept- the longer you stay awake the sleepier you become 2. Circadian Rhythm: your body’s biological clock, the natural timing system which tells you when to sleep and when to be awake. Responsible for the feeling of a mild need to sleep during the afternoon and a strong need to sleep in the evening-the urge is pre-set to occur at specific times. When these times are changed by staying up too late or by a sleeping disorder the result is daytime sleepiness.

17. Circadian Rhythm Sleep Disorders Delayed Sleep Phase type Advanced Sleep Phase type Irregular sleep-wake type Free Running Type Jet Lag type Shift Work type Due to medical condition or substance abuse

18. Sleep Related Breathing Disorders Central Sleep Apnea (Cheyne Stokes, High altitude, Medical condition, Substance abuse, Infancy) OSA (arrthymia 58%) Sleep related Hypoventilation/Hypoxemic Syndrome Sleep related Hypoventilation/Hypoxemic due to medical condition Sleep Related Breathing Disorder/ Upper Airway Resistance Syndrome (UARS)

19. Sleep Apnea Decreased REM sleep, sleep not refreshing Chronic, loud snoring, Gasping or choking episodes Excessive daytime sleepiness (drowsy when driving)  Automobile or work related accidents due to fatigue Personality changes or cognitive difficulties:  Neuropsychological evaluation reveals memory deficits and frontal deficits

20. Causes of Sleep Apnea  Age (tonicity decreases)  Smaller-than-normal jaw  Enlarged tonsils  Lateral pharyngeal walls close in  Large tongue  Tongue moves posterior which displaces the soft palate  Tissues that partially block the entrance to the airway

21. Symptoms of Sleep Disordered Breathing-Adult Snoring  How loudly  How often  In all sleeping positions Apnea  Does breathing stop in the night  Snorting, choking, gasping, waking up to breathe? Daytime Tiredness/Sleepiness  Do you awaken feeling refreshed or relaxed and ready to go?  Do you awaken with a headache, tiredness & fatigue or confusion?  Daytime sleepiness, in the car? At the work setting? In a business meeting? Anytime you sit down? When reading? Watch TV? Sleep  How long to get to sleep?  Hours sleeping?  Awakenings during the night?

22. Symptoms of Sleep Disordered Breathing-Children Breathing during sleep  Mouth breathing  Choking, snorting, and snoring  Increased breathing effort  Apnea-breathing stops Restless sleep  Frequent awakening at night  Unusual sleep patterns  Sweating or perspiration Enuresis Behavioral problems  Hyperactivity  Poor school performance  Refusal to go to bed at night (toddlers) Growth changes  Weight gain  Failure to thrive-poor appetitive (possible consequence of sleep apnea)

23. Sleep Disordered Breathing in Children Snoring Sleep apnoea In children >1 apneic event per hour is abnormal May be present from birth

24. Relationship between ADHD and Sleep Disorders School performance improved inattentive, hyperactive and disruptive behavior improved when sleep disorder treated Relationship between sleep apnea and ADHD symptoms 25% of diagnosed ADHD no longer showed symptoms following treatment

25. Hypersomnias of Central Origin (not due to Circadian Rhythm, SRBD, or other Narcolepsy with Cataplexy Narcolepsy without Cataplexy Narcolepsy due to a medical condition Narcolepsy unspecified Recurrent Hypersomnia (Kleine-Levin Syndrome, Menstrual related hypersomnia) Ideopathic Hypersomnia with Long sleep time Ideopathic Hypersomnia without Long sleep time Behaviorally induced insufficient sleep syndrome Hypersomnia due to medical condition or substance abuse

26. Narcolepsy Excessive daytime sleepiness –Not uniform across patients –May be caused by other conditions Cataplexy – More common for facial muscles than for leg weakness-complete loss of motor tone, usually less than two minutes, range of weakness (full attack less common) loss of motor tone precipitated by strong emotions (anger or laughter) Sleep Paralysis- Cannot move just as awakening, feel like cannot breathe Hypnogogic Hallucinations- Armchair talking in evil ways, faces on the bed, green men

27. Parasomnias Disorders of arousal from NREM sleep –Confusional arousals –Sleepwalking –Sleep Terrors Parasomnias usually associated with REM sleep –REM Sleep behavior disorder –Recurrent isolated sleep paralysis –Nightmare disorder Other parasomnias –Sleep related dissociative disorders –Sleep enuresis –Sleep related groaning –Exploding head syndrome –Sleep related hallucinations –Sleep related eating disorder (SRED) –Parasomnia, unspecificied, related to medical or substance abuse

28. Things that go bump in the Night Parasomnias: Episodic nocturnal behaviors, often involve disorientation, autonomic, skeletal muscle disturbances; related CNS immaturity

29. Somnambulism: Sleep Walking Prevalence: up to 15% of population; most between 6 and 16 years Age onset: usually 4 - 6 years Duration: one third for 5 years; 12% for 10 Quiet vs. agitated; displacement from bed, often complex behaviors; SAFETY issues

30. Pavor Nocturus: Night Terrors A few strangled words or cries precede bloodcurdling shrieks; the child sits up and stares wide-eyed. He may stumble out of bed or by movement, words, and expression reveal how he would seek to avoid some horror. Oblivious of his parents or soothing words he does not see their alarmed faces. Within minutes he is again sleeping soundly and in the morning remembers nothing untoward.

31. Sleep / Night Terrors Arousal from slow wave sleep first or second episode Incidence: 1-3%; 10% of sleepwalkers; peaks at age 5-7 years Male > female Age onset: 4-12 years Frequency: often highest at onset; often higher ( > once a week) with younger onset Usual disappearance by adolescence

32. Insomnia Adjustment Insomnia Psychophysiological Insomnia Paradoxical Insomnia Idiopathic Insomnia Inadequate Sleep Hygiene Behavioral Insomnia of Childhood Insomnia due to substance abuse Insomnia due to a medical condition

33. Factors Affecting the Development of Insomnia Personality Sleep-Wake cycle Circadian Rhythm Coping Mechanisms Conditioning Substance Abuse Performance Anxiety Poor sleep hygiene Situational Environmental Medical Psychiatric Prescription Medication

34. Sleep Related Movement Disorders RLS Restless Legs Syndrome PLMD: Periodic Limb Movement Disorder Sleep related leg cramps Sleep related bruxism Sleep Related Rhythmic Movement disorder Sleep Related Rhythmic Movement disorder due to medical condition or substance abuse

35. Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) RLS is a symptom PLMS is an EMG finding RLS and PLMS frequently overlap Neither is necessary nor sufficient to make the diagnosis of the other

36. Restless Legs Syndrome (RLS) Uncomfortable leg sensations Worse at night Worse with inactivity / relieved with activity Associated motor hyperactivity

37. Periodic Limb Movement Disorder (PLMD) Stereotypic, repetitive movements of the legs (or arms) During sleep / inactivity Every 20-40 seconds May be associated with arousals from sleep Occur in minimum clusters of 4

38. Patient Complaints with RLS Sleep disturbances Difficulty falling asleep and staying asleep Need to walk around (“nightwalkers”) Daytime sleepiness

39. Associated Conditions Neuropathies, myelopathies, and radiculopathies Pregnancy Anemia (iron deficiency) Chronic renal failure Folate / B12 deficiency Medications (tricyclics, SSRI’s, caffeine) Obesity Hypothyroidism

40. RLS and ADHD RLS were greater in patients who had ADHD versus those who did not- (p<0.001) Recommendation if patient diagnosed with ADHD need to screen for RLS Recommendation if patient diagnosed with RLS need to screen for ADHD Consider medication such as dopamine agonists

41. Reported Clinical Signs of Seizure Motionless Stare, drop attacks, nausea, funny smell, Deja Vu Obsessive rituals, compulsive order Automatisms (lip smacking, chewing, facial grimacing, rocking, noises) Blatant personality change, mood shift Emotionally reactive, overly focused, negative, dark, gloomy, pessimistic Spontaneous, undirected violence, rage Sleep is fearful, tired in morning

42. Reported Night-time Symptoms Nocturnal wandering Sleepwalking Thrashing, restless sleep Unintelligible talking, moaning Continual movement vs. RLS or PLMS All of the above leads to sleep deprivation

43. Isolated Symptoms: Apparently Normal variants and unresolved issues Long sleeper Short sleeper Snoring Sleep talking Sleep starts –hypnic jerks Benign sleep myoclonus of infancy Hypnagogic food tremor and alternating leg muscle activation during sleep Propriospinal myoclonus at sleep onset Excessive fragmentary myoclonus

44. Sleep disorders associated with conditions classifiable elsewhere Fatal familial insomnia Fibromyalgia Sleep related epilepsy Sleep related headaches Sleep related gastroesophageal reflux disease Sleep related coronary artery ischemia Sleep related abnormal swallowing, choking and laryngospasm

45. PTSD Sleep Problems Universal complaints, fragmented sleep Inability to sleep, difficulty initiating & maintaining Anxiety arousals are common in PTSD REM and non-REM nightmares Repetitive nightmares are common Nightmares often represent a "re-living" of the original trauma and associated emotions

46. Menopause and Sleep Fragmented sleep due to hot flashes and night sweats Increased anxiety and panic attacks, mood swings, depression Rule out sleep apnea and sleep disordered breathing -more common in post-menopause

47. Good Sleep Habits Regular relaxing routine to unwind at night just before bedtime Avoid all products containing caffeine (soda and chocolate) Avoid smoking and smokeless tobacco Avoid use of alcohols No stimulating activities in the evening Promote calm family atmosphere prior to bedtime

48. Good Sleep Habits Do not allow fall asleep while watching television or video Establish regular exercise routine and healthy diet Avoid late afternoon and evening bright light Go to bed later on weekend awaking within two hours of usual weekday wake time Avoid napping-short nap only limited to 30 to 45 minutes American Academy of Sleep Medicine, 2002

49. Identify the Specifics Sleep History Sleep logs Sleep diary: morning and bedtime habits Actigraphy PSG Sleep schedule Bedtime routine, bedroom environment Sleep related cognitions Identify the factors: daytime sleepiness, memory

50. Behavioral Treatment Sleep hygiene Daytime, evening, morning habits Exercise-evening walk for the aged Limit napping Nocturnal activities hour Children: scheduled awakenings, Bedroom environment Cognitive behavioral therapy (CPT)

51. Problematic Sleep Habits Night time habits: Irregular sleep wake schedule Too much Time TIB Falling asleep to the radio/TVs Trying too hard to sleep Clock watching Long awakenings Morning Habits Lingering in bed awake in morning Extra sleep on weekends Bedroom disturbance (noise, sun light)

52. Treating Techniques for childhood Insomnia 1. infants and children learn to fall asleep at the beginning of the night under specific conditions (teach to fall asleep independently) 2. An overtired child does not transition as well as when tired (increased sleep drive via sleep delay, tiredness leads to dysregulation of affective states 3. Finding the optimal bedtime can be difficult, varies with age, not overly tired and sleep drive high (danger zone-not easily tired) 4. Parent education (day and nighttime sleep patterns, explanation of multiple night time awakenings.

53. Address the Sleep Problem: Don’t Wait Daytime sleepiness is a big deal! Don’t try to do everything at night- schedule your day for maximum performance Set specific times in office or home for paperwork vs. phone calls on daily basis-avoid build-up and worry

54. Don’t Worry-Be Happy Too anxious: Exercise twenty minutes on a daily basis-often running or biking are helpful Feeling overwhelmed: Watch the stress & feeling overwhelmed- too many things are going on at one time Too much to do and no time to do it: Manage time by specifically estimating each task- add up time for exact time estimates-to decrease over-planning

55. Don’t Worry-Be Happy Staying up late to complete all your goals: Issue of diminishing returns- time spent vs. being tired-examine from larger perspective- what really has to be done in the grand scheme of things- is this last task more important than health? Distractibility increased: –Stress & lack of food tend to increase distractibility- increased lack of focus

56. Don’t Worry-Be Happy Easily frustrated- short fuse: Result of too much stress, lack of food, feeling totally overwhelmed- wake up call for life changes & “nice moments of time” More tired, energy loss, channel clickers Wake up call for life changes-check sleep, eating habits- often result of energy expended continually compensating for something else (sleep disorder, ADD..)

57. Sleep is a necessary function of life Make it Healthy Increase your happiness