LMCC/Sleep Disorders

insomnia parasomnias excessive daytime sleepiness
 * characterized by one of three complaints
 * difficulty falling alseep, maintaining sleep, early morning wakening or non-refreshing sleep
 * night terrors, nightmares, restless leg syndrome, somnambulism

Epidemiology

 * 1/3 of people have occasional sleep problems
 * 10% have chronic sleep problems
 * > in women with increasing age

History
A thorough sleep history includes:
 * history from patient and partner
 * sleep environment (noise, temperature, light)
 * shift work or life stresses
 * use of tobacco, alcohol, caffeine, pharmaceuticals and illicit drugs
 * snoring, apneic episodes, limb jerks, sleep paralysis
 * daytime consequences, impact on quality of life

Investigations

 * complete sleep diary every morning for 1-2 weeks
 * record bedtime, sleep latency, total sleep time, awakenings, quality of sleep
 * rule out specific medical problems (CBCD, TSH)
 * sleep study referral if suspect periodic leg movements of sleep or sleep apnea
 * night time polysomnogram or daytime multiple sleep latency test

Treatment

 * treat and manage any suspected medical or psychiatric caueds
 * psychologic treatment
 * sleep hygiene
 * avoid caffeine, nicotine, alcohol, exercise regularly, comfortable sleep environment, regular sleep schedule
 * relaxation therapy
 * stimulus control therapy
 * sleep restriction therapy
 * pharmacologic treatment
 * short term benzodiazepines

primary insomnia

 * majority of cases
 * person reacts to the insomnia with fear or anxiety around bedtime or with a change in sleep hygiene
 * can progress to a chronic disorder called psychophysiological insomnia

Snoring

 * results from soft tissue vibration at the back of the nose and throat due to tubulent airflow through narrowwed air passages
 * risk factors: male gender, obesity, alcohol consumption, ingestion of tranquilizers or muscle relaxants and smoking
 * Physical exam: obesity, nasal polyps, septal deviation, hypertrophy of the nasal turbinates, enlarged uvula and tonsils
 * Investigations if severly symptomantic
 * noctural polysomnography
 * airay assessment (CT or MRI)
 * treatment
 * sleep on side, weight loss
 * nasal dilators, tongue retaining devices, mandibular advancement devices
 * risk is development of obstructive sleep apnea

Obstructive sleep apnea (OSA)

 * apnea resulting from upper airway obstruction due to collapse of the base of the tongue, soft palate with uvula, and epiglottis
 * respiratory effort is present
 * leads to a distinctive snorting, choking awakening type pattern as the body arouses itself to open the airway
 * apneic episodes can last from 20seconds - 3 minutes
 * can have 100-600 episodes/night
 * diagnosis based on nocturnal polysomnography
 * >15 apneic episodes with arousal recorded per night
 * risk factors
 * 2% women, 4% men
 * between ages 30-60
 * obesity causing upper airway narrowing: BMI >28kg/m present in 60-90% of cases
 * children: commonly tonsils or adenoids
 * aging which causes decreased muscle tone
 * persistent URT infections, allergies, nasal tumours, hypothyroidism
 * Family medical history
 * consequences
 * Daytime somnolence, nonrestorative sleep
 * Poor social and work performance
 * mood changes: anxiety, irritability, depression
 * sexual dysfunction: poor libido, impotence
 * morning headache due to hypercapnia
 * Hypertension, coronary artery disease, stroke, arrhythmias
 * pulmonary hypertension, RV dysfunction, cor pulmonale due to chronic hypoxemia
 * memory loss, decreased concentration, confusion
 * investigations
 * blood gas not helful, TSH if clinically warrented
 * evaluate BP, inspect nose, oropharynx for enlarged adenoids or tonsils
 * nocturnal polysomnography
 * Treatment
 * modifying factors: avoid sleeping supine, lose weight, avoid alcohol, sedative, narcotics, inhaled steroids if nasal swelling present
 * primary treatment of OSA is CPAP which maintains patent airway in 95% of OSA cases
 * dental appliances to modify mandibular position
 * surgery: somnoplasty, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty
 * report patient to ministry of transportation if OSA is not controlled by CPAP

Central Sleep Apnea

 * pathophysiology
 * brain fails to send appropriate signals to breathing muscles to initiate respirations
 * the defining feature is absent respiratory effort
 * often secondary to CNS diseases ie. brainstem infarct, infection, neuromuscular disease
 * investigations: PFTs, nocturnal polysomnography, MRI
 * treatment: CPAP or mechanical ventilation if brainstem origin
 * prognosis: poor

Sleep Tips

 * Keeping a routine is important. Try going to sleep at the same time every night and get up at the same time every morning.
 * Make sure the environment you sleep in is dark and quiet. Ask others to be respectful of your sleep and not disturb you while your asleep.
 * Do not eat or drink at least two hours before bed.
 * Take only 30 minute naps during the day if needed.
 * Stay away from fatty foods during the day and especially before bed.
 * Exercise on a regular bases but never right before bed. (MayoClinic.com, 2010)