Sleep disorders
Mária Tünde Magyar MD, PhD
Normal human sleep
Sleep cycle – occurs about every 90 minutes,
approximately 4-6 cycles occur per major sleep episode
Microarousal
1. NREM (70-80%)
• I-IV stage
• slow wave sleep
• heart rate, BP, breathing
• body temperature, muscle tone
2. REM (20-25%)
• rapid eye movement, paradox, fast wave sleep
• heart rate, BP, breathing , metabolic rate
• dreaming, erection
• muscleatonia, BUT: myoclonus!
More than 80 sleep disorders are known
(International Classification of Sleep Disorders, 2nd Edition
American Academy of Sleep Medicine, 2005)
I. Insomnias (33%)
II. Sleep related breathing disorders (1,4-40%)
III. Hypersomnias (0,3-16,3%)
IV. Cirkadian rhythm sleep disorders
V. Parasomnia
VI. Sleep related movement disorders
VII. Isolated symptoms, normal variants
VIII. Other sleep disorders
http://www.aasmnet.org
http://www.cochrane.org
http://www.efns.org http://www.alvastarsasag.hu
Insomnia
• Difficulty in initiating sleep or in staying asleep or
waking up earlier
• Nonrefreshing, nonrestorative sleep
• Occurs 3 nights/week
• Lasts more than 1 month
AND one daytime symptom
• Fatigue, concentration or memory impairment
• Mood disturbances, motivation, initiative reduction
• Daytime sleepiness
• Tension headache
Insomnias
• Prevalence: 33%
• Last less than 1 month: 4% (transient
insomnia)
• Last more than 1 year: 85% (persistent
insomnia)
• Male:female = 1:1.4
• Increase with age: above 65 years: 50%
Insomnias
1. Primary (idiopathic)
2. Secondary
1. Inadequate sleep hygiene (10%)
2. Paradoxical insomnia (10%)
3. Insomnia due to mental disorder (30-40%)
4. Psychophysiological insomnia (15%)
5. Insomnia due to drug or substance
6. Insomnia due to medical conditions
7. Sunday night insomnia
Treatment of insomnias
Pharmacologic Treatment:
Approach
• Select appropriate medication
• Evaluate carefully for apnea, respiratory
impairment, organic mental disorders, substance
abuse history
• Use lowest effective dose
• Use at bedtime (or later, if indicated)
• Duration of therapy
– Use as needed for 2 to 4 weeks
– Reduce dose as tolerated
– Intermittent use suggested
• Combine with behavioral strategies
Pharmacotherapy
• GABAA receptor agonists
– Benzodiazepines
– Z-hypnotics
• Melatonin, melatonin receptor agonist
(ramelteon)
• Antidepressants
• Antihistamines
• Others
Pharmacologic treatment
Benzodiazepines
1. midazolam, triazolam ~ rebound
insomnia
2. cinolazepam, quazepam
3. brotizolam, temazepam
4. nitrazepam ~ drowsiness
Pharmacologic treatment
Selective GABAA agonists: nonbenzodiazepines
– no rebound insomnia
– zolpidem, zopiclon, zaleplon (Z-hypnotics)
Sleep related breathing disorders
(International Classification of Sleep Disorders, 2nd Edition
American Academy of Sleep Medicine, 2005)
1.
2.
3. Sleep related hypoventilation/hypoxemia
Sleep diagnostics
Sleep 2007:8:402-28
Apnea-hypopnea index (AHI)
- Numbers of apneas and hypopneas/ 1 sleeping
hour
Severity of sleep related breathing
disorders:
- Normal: AHI30/h
Sleep, 1999:22:667-89.
OSAHS: symptoms
Daily Nightly
• Excessive daytime • snoring
sleepiness • apneas
• Unrefreshing sleep • choking, gasping
• Memory disturbances • arousals
• Morning headache • sweating
• Depression • dry mouth
• Decreased libido • palpitation
• Stomach ache • nycturia
OSAHS: diagnostic criteria
(1. or 2.) and 3.
AASM, Sleep, 1999:22:667-89.
Risk factors of OSAHS
• Obesitas
• Age
• Male gender
• Positive family history of OSAHS
• Alcohol consumption before bedtime
• Race
• Smoking
• Sedatives
• Craniofacial anomalies
• Hypothyroidism, acromegaly
Narcolepsy (0,02-0,18%)
• Genetics (HLA DQB1 0602, HLA-DR2)
• Hypocretin-1 (orexin) levels in cerebral spinal
fluid are low
• Begins: 15-25 years
• Excessive Daytime Sleepiness
• Cataplexy
• Sleep Paralysis
• Hypnagogic Hallucinations
• Treatment: modafinil, methylphenidate, tricyclic
antidepressant
Cirkadian rhythm sleep disorders
• Primary
– Delayed sleep phase type
– Advanced sleep phase type
– Irregular sleep phase type
• Secondary
– Jet lag type
– Shift work type
• Treatment
– Sleep hygiena
– Cronotherapy
– Light therapy
– Melatonin, ramelteon, zolpidem
Restless legs syndrome
• Primary
• Secondary
– Uremia
– Anemia (Fe, B12)
– Pregnancy
– Neuropathy (diabetic, immunological)
– Sy. Parkinson
– Medications (antidepressants, SSRI,
antipsychotics)
Primary restless legs syndrome - treatment
• Ropinirole, 1.5-4.6 mg/day
• Pramipexol, oxycodon
• Levodopa/benserazid, (159/40 mg)
• Gabapentin (800-1800 mg/nap)
EFNS, European Journal of Neurology 2006;13:1049–1065
AASM, Sleep 2004;27:557-583.