Determinant of nocturia upon sleep

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					Determinant of nocturia
      upon sleep
• Nocturia    is    usually   caused by  underlying
  pathophysiologic disorders, which may be present
  separately or in combination.

• These include diurnal and nocturnal overproduction of
  urine (polyuria), or a reduced bladder capacity.

• Sleep disorders as a result of nocturia or any other of
  these conditions have a substantial negative impact on
  an individual’s QoL.

• Fequency        of    nocturnal     voids     was
  shown to be positively correlated with the severity
  of sleep impairment.
       Diagnostic algorithm

           Bother            No Bother
                                               No Presentation
             Patient Presents


            Further Evaluation

Polyuria    Nocturnal Polyuria           Apparent Bladder
                                         Storage Problems

                        Other Classification       Primary Sleep Disorder
 Why do people wake up at night?
• All the reasons that cause others to wake up:
   –   noise/light
   –   dreams/nightmares
   –   pain/stress/anxiety
   –   partners
   –   jet lag
   –   full bladder
• Additional reasons due to changes/pathology:
   – central nervous system, e.g., psychological factors
   – cardiovascular system, e.g., congestive cardiac failure
   – respiratory system, e.g., asthma
   – urinary tract including renal pathology, e.g., overactive
   – behavioural
How bothersome is nocturia?

• Nocturia is a bothersome condition.
• It negatively affects quality of life by
  – lack of sleep which results in decreased
    productivity at work
  – low energy levels resulting in significant levels
    of indirect and intangible costs to society
        Normal sleep pattern

• Five different well-defined stages of sleep were

• Stages 1 to 4 represent the stages with increasing
  sleep depth after falling asleep, also known as the non–
  rapid-eye-movement (nREM) sleep.

• Stages 3 and 4 are often grouped together and are
  referred to as deep sleep or slow wave sleep (SWS)
                                   Stage 1
•   Represents the shift from being awake to sleeping, i.e. light or drowsy
    sleep, only takes 3-5 minutes, and therefore represents 1-5% of total
    sleep time.

                                    Stage 2
•   Concerns a deeper stage of sleep and is often referred to as true sleep
    because we spend half of the total sleep time in this stage.

•   Although we spend almost 50% of the night in stage-2 non-rapid-
    eyemovement sleep, it does not seem to be of vital importance.

                                  Stages 3 & 4
•   Are the deepest stages of sleep with the highest arousal threshold.
    they are also referred to as deep sleep. Deep sleep represents
    approximately 25% of total sleep time.

•   Deep sleep is considered to be the most important part of the night and
    to represent the daily process of restitution

                                          Stage 5
•   The initial four stages of nREM sleep are followed by REM sleep, which is
    typically characterised by a state of high brain activity and a metabolic rate that is
    increased above resting waking levels
         Normal sleep pattern
• It is believed that rapid-eye-movement sleep contributes
   to psychological rest and long-term emotional wellbeing,
  and that it may also bolster memory.

• During normal sleep, rapid-eye-movement sleep
  represents approximately 20 25% of total sleep time.

• The other 75 80% of sleep time is referred to as non-
  rapid-eye-movement sleep which is thought to contribute
  to physical rest and to bolstering of the immune system.
• The first part of the night is predominated by deep sleep
  stages 3 and 4, whereas the amount of REM sleep
  increases during the last part.

• Provoked awakening during SWS interferes significantly
  with the normal sleep pattern and gives rise to
  decreased daytime energy and performance.

• Therefore, interruption of sleep during the first part of
  the night should be avoided as much as possible.
• Non-rapid-eye-movement (stage 4) deep sleep predominates during
    the first part of the night and rapid-eye-movement (REM) sleep
                       during the second half   f
     Impact of nocturia on sleep

• Nocturia is the most important cause of disturbed sleep
  in older men.

• Furthermore, increased sleep disturbance such as
  frequent awakenings and poor sleep is related to the
  severity of nocturia
  Impact of ageing on sleep
• Sleep is highly age-dependent           and sleep
  characteristics have been shown         to change
  profoundly in the elderly.

• With ageing, there is a gradual decline in overall
  sleep time. Although older people spend more time in
  bed, the total sleep time decreases: this is called
  decreased sleep efficiency. Often this is associated
  with daytime napping.

• In older people, there is in particular a decrease in
  nonrapid- eye-movement stages 3 and 4 (deep
  sleep), and it may even become completely absent.
Nocturia is the most frequent cause of disturbed
   sleep continuity in men aged 50-93 years

  Old age
• To evaluate the impact of nocturia on QoS more
  thoroughly, the concept of ‘‘Hours of Undisturbed
  Sleep’’ (HUS) was developed, which is defined as
  ‘‘the time between falling asleep and first awakening
  to void’’.

• Because of the importance of the restorative function
  of sleep during the first part of the night HUS should
  ideally be at least 3–4 h.

• Treatment of nocturia in should aim to increase HUS
  to positively influence the QoS.

• Reduction in nocturnal void & is associated with
  improvement in the hours of nondisturbed sleep
Association between the number of nocturnal voiding
 episodes, sleep quality, daytime vitality and general
            feeling of health in older men
Effects of sleep deprivation
• Adequate sleep is a basic requirement for good

•    Adults need about 7 to 8 hours sleep per night and
    that adequate sleep has a restorative effect.

• Older adults have shallower and more fragmented
  sleep patterns, possibly as a result of the reduction
  in growth hormone secretion with age.
Physiological changes seen with
       sleep deprivation
• Changes in temperature regulation, mood status
  (temporary euphoria in depressed subjects) and central
  nervous system function (paranoia, delusions).

• Physical and mental disorders, particularly depression
  and mood alterations.

• Excessive daytime sleepiness leading to poor motivation
  and job performance.

• A connection between chronic somatic disease and
  sleep complaints by immune system supression.
• Emerging evidence also indicates that disturbed sleep
  brings about alterations in immunologic, endocrine, and
  metabolic functions.

• Sleep deprivation affects our host    defence system
  through the diminution of cytokine     levels and the
  amount of natural killer cells seem   to Increase the
  propensity for the development of     type 2 DMand
  cardiovascular diseases

• it has been demonstrated that there is a significant
  association between nocturia and depression and even
  that elderly people diagnosed with nocturia have a
  higher mortality rate
    Consequences of sleep fragmentation
      and deprivation associated with
•   Increased daytime sleepiness/reduced daytime alertness
•   Longer reaction time
•   Reduced daytime energy
•   Reduced psychomotor performance
•   Reduced concentration/memory/cognitive function
•   Poor mood

•   Depression
•   Increased susceptibility to somatic disease
•   Increased risk of cardiovascular disease
•   Increased risk of car accidents and/or falls with fractures
•   Death
     Sleep disorders related to
          nocturia include:

•   Insomnia
•   Obstructive and central apnea syndromes,
•   Restless legs syndrome.
•   Parasomnias
•   systemic and neurogenic sleep disorders

• Nocturia should be regarded as a serious
  condition because of its negative impact on
  sleep quality.

• Sleep disruption caused by nocturia has been
  associated with a negative quality of life and
  significantly increased mortality and risk for falls,
  particularly among the elderly.

• Feeling tired during the day and reduced
  general health, is related to the number of
  nocturnal void.

• Treatment should aims at increase in the
  hours of undisturbed sleep which
  translates into improved daytime energy
  and quality of life of the patient
Thank You

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