Sleep Disorders

NERM:

Stage	EEG Findings	Distribution
Stage 1	Disappearance of alpha wave and appearance of theta wave	5%
Stage 2	K complexes and sleep spindles	45%
Stage 3	Appearance of delta wave	12%
Stage 4	Continuation of delta wave	13%

REM:

Stage	EEG Findings	Distribution
REM	Bursts of sawtooth waves	25%

Stage	Facts
Stage 2	Longest of all sleep stages
Stage 3 and 4	Also called slow wave or delta sleep Hardest to arouse Tends to vanish in the elderly
REM	Easiest to arouse Lengthens in time as night progress Increased during the second half of the night

Chemical Effects on Sleep:

Tryptophan: Increases total sleep time.
Dopamine agonists: Produce arousal.
Dopamine antagonists: Decrease arousal, thus produce sleep.
Benzodiazepines: Suppress stage 4 and when used chronically increase sleep latency.
Alcohol intoxication: Suppresses REM.
Barbiturate intoxication: Suppresses REM.
Alcohol withdrawal: REM rebound.
Barbiturate withdrawal: REM rebound.
Major depression: Shorted REM latency, increased REM time, suppression of delta, multiple awakenings, and early morning awakening.

	Narcolepsy
Fx	hypocretin deficiency in lateral hypothalamus pt cant avoid falling asleep ⤵️ REM latency
S/S	• Sleep attacks: Most common symptom • Cataplexy: Pathognomonic , sudden loss of muscle tone. • Hypnagogic and hypnopompic Hallucinations that occur as the pt is going to sleep and is waking up from sleep, respectively. • Sleep paralysis: Most often occurs during awakening, when the patient is awake but unable to move. • Report falling asleep quickly at night
Dx	Clx Polysomnography
Tx	scheduled daily naps 💊: modafinil – psychostimulant (methylphenidate) If cataplexy: TCA

	Sleep Apnea
Fx	Central vs. Obstructive: both when u wake up, no more apnea What’s Central SA? no respiratory effort deriving from decreased CNS drive
S/S	Pt is not sleeping well, thus not refreshed from sleeping. chronic fatigue: similar to narcolepsy morning headache: specific to Central SA loud snoring: specific to OSA PEx: hypertension
Dx	Sleep studies (Polysomnography) ddx b/w Central vs. Obstructive CBC: polycythemia (2˚ to chronic hypoxia –> ⤴️ EPO)
Tx	Pediatrics: Weight reduction & adenotonsillectomy are the first line of management in appropriately selected children. Adults: Non-medical: weight loss / ⤵️ Alcohol intake / ❌ Smoking OSA: CPAP / Surgery: obstruction correction If central sleep apnea: BiPAP
📝	Complications: pulmonary HTN Arrhythmia –> cause of death

	Insomnia
S/S	Pt can’t sleep
Dx	Clx
Tx	Good sleep hygiene zolpidem, eszopiclone, or zaleplon

	Sleep Stage	Features	Tx
Nightmares (dream anxiety disorder)	REM	Memory of the event upon awakening Increases during times of stress Reported by 50% of the population	Usually none indicated, but may use REM suppressants such as TCAs
Night terror (sleep terror disorder)	Stages 3 and 4	Awakened by scream or intense anxiety No memory of the event the following day Seen more frequently in children More common in boys Runs in families	Treatment rarely required If medications is needed, consider benzodiazepines
Sleep-talking	All stages of sleep	Common in children Usually involves a few words May accompany night terrors and sleep-walking	No treatment is necessary
Sleep-walking	Stages 3 and 4	Sequence of behavers without full consciousness May preform perseverative behaviors Usually terminates in awaking followed by confusion May return to sleep without any memory of the event Begins at a young age More common in boys May find neurologic condition Sleep deprivation may exacerbate	Need to assure patient safety Use drugs to suppress stages 3 and 4 such as benzodiazepines Use drugs to suppress stages 3 and 4 such as such a

Sleep Terrors:

Characterized by recurrent episodes of intense fear and autonomic arousal during sleep
Occur during stages 3 and 4 (delta sleep)
Occur in children and usually benign
Occur typically during the first third of the night
Patients show a lack of responsiveness to others during an episode
Patients typically are unable to remember the sleep terror episode in the morning

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