Fraser Willsey, Sleep Specialist at The Royal shares facts on sleep, what they do at the Sleep Lab, and how to treat sleep disorders.

1. SLEEP MEDICINE:
An Overview
Fraser Willsey, BA, RPSGT
Sleep Lab Technologist
Sleep Disorders Service, The Royal

2. Why Study Sleep?
• We spend 1/3 of our lives sleeping
• 1 in 7 Canadians are not getting enough sleep (Statistics
Canada, 2002)
• Severe health consequences - DEATH!
• Sleep deprivation costs
$150 BILLION/yr in lost
productivity
(Nat’l Commission on Sleep Disorders, 2003)

3. THE IMPACT OF SLEEP DEPRIVATION

4. • Challenger Disaster
• 3 Mile Island
• Chernobyl

5. Purpose of Sleep
• Restorative Function
• Energy Conservation
• Immune Function Regulation
• Memory Consolidation
• Mood Regulation and depression
• Protective Mechanism

7. WHAT WE DO AT THE SLEEP
LAB….

9. What Happens at the Sleep Lab…
• ROMHC: 6 bed clinical lab, 4 bed research lab
STEPS:
1) → Referral
2) → Consultation with a Sleep Specialist
3) → Overnight Sleep Study
4) → Data is Analyzed by RPSGTs
5) → Results Appt with a Sleep Specialist

10. How Do We Measure Sleep in the
Laboratory?
• EEG – brainwaves (Central & Occipital Leads)
• EOG – eye movements
• EMG – muscle tone
• EKG/ECG – heart
• Breathing:
1)Airflow
& 2) Effort: Thoracic & Abdominal
• Blood oxygen saturation (SaO2)
• Snore mic.
• Digital AV recording

14. STAGES OF SLEEP
• NREM & REM
• NREM = N1, N2, N3
• Sleep Cycle
• REM increases as the night progresses
• Changes across the lifespan

15. NREM SLEEP
• N1: lightest stage of sleep
(hypnic jerks/sleep starts), dozing
• N2: Sleep spindles & K complexes
• N3 (formerly stages 3 & 4): deepest most
physically restorative stage of sleep. More
difficult to awaken from this stage. Decreases
with age.
• Breathing regular, heart rate decreases

16. AWAKE

17. STAGE N1

18. STAGE N2

19. STAGE N3

20. STAGE N3

21. REM Sleep
• Rapid Eye Movements
• Muscle atonia (paralysis)
• Dream recall
• 90 minute latency
• “Paradoxical Sleep” – EEG mimics wakefulness
• Breathing irregular, heart rate fluctuates

22. REM

23. TRANSITION INTO REM

24. SLEEP APNEA

25. SLEEP APNEA
• Two Types: Obstructive & Central
• Pauses in breathing > 10 seconds in length
• Respiratory Disturbance Index: >5 hr =clinically significant
• Symptoms:
▪ Excessive daytime sleepiness (EDS)
▪ morning headaches
▪ SNORING*****
▪ pauses in breathing
▪ waking with a dry mouth
▪ nocturia
▪ Gastroesophageal reflux disease
ZZZZzzzzzzZZZZzzzzzz

26. OBSTRUCTIVE SLEEP APNEA (OSA)
• Causes
▪ Narrow Upper Airway
▪ Elevated BMI
▪ Family Hx
• Exacerbated by:
▪ Rx
▪ Alcohol Consumption
▪ Supine sleep
▪ REM sleep
▪ **Supine + REM sleep

27. Normal vs. Collapsed Airway

28. “Kissing” Tonsils

29. OBSTRUCTIVE APNEA

30. OBSTRUCTIVE APNEA, 2MIN

31. OBSTRUCTIVE APNEA 5MIN

32. TREATMENTS FOR OSA
• **CPAP – Continuous Positive Airway Pressure
• **Weight Loss - ↓ BMI = ↓ RDI
• Avoid Alcohol Consumption
• Avoid Sedative Medications
• “Snoreball” Technique / Positional Therapy
• Oral Appliance
• Upper Airway Surgery
– Tonsilectomy
– Laser Surgery
– Tracheostomy
– Uvulopalatopharyngoplasty (UPPP)

34. CPAP

35. CPAP

36. Consequences of Untreated OSA
• Memory Problems
• Depression
• Cardiovascular disease
–High blood pressure
–Stroke
–Cardiac arrhythmias

39. FASTEN YOUR SEATBELTS…
THERE’S ANOTHER CONSEQUENCE OF
UNTREATED OSA & SLEEPINESS
ANY GUESSES WHAT IT IS?

43. PARASOMNIAS

44. PARASOMNIAS
• NREM
Sleepwalking (Somnambulism)
Sleep Terrors (aka Night Terrors)
Others examples: Sleep Related Eating Disorders,
Confusional Arousals, Somniloquy
■ REM
REM Behaviour Disorder (RBD)
Measured in the sleep lab with full EEG to rule out seizure
activity

45. SLEEPWALKING
• Stage N3 (slow wave sleep)
• Common in children
• Do not awaken. Secure the environment
• No recall of a dream or of the episode
• Aggravated by sleep deprivation, stress, alcohol
• Positive family history
• Perform complex behaviours with heightened
pain threshold

46. JAROD ALLGOOD
Feb. 2, 1973 – Feb. 9, 1993

47. REM Behaviour Disorder (RBD)
• No muscle atonia during REM sleep
• Ability to act out complex dream behaviour
• Bedpartner often the “victim”
• Age of onset: 50 – 60yrs. Males
• Usually opposite of waking personality
• Case study: “baseball player” at ROMHC

48. RBD

49. REM BEHAVIOUR DISORDER

50. Treatments for RBD
• Full EEG montage during PSG
• CT Scan, MRI – r/o lesions
• Securing the environment (mattress on floor, bed
rails, restraints)
• Bedpartner sleeps in another room
• Rx

51. SLEEPWALKING vs. RBD
SleepwalkingSleepwalking
▪▪ Stage N3 (NREM)Stage N3 (NREM)
▪▪ No dream recallNo dream recall
▪▪ ChildrenChildren
▪▪ Not easily awakenedNot easily awakened
REM BehaviourREM Behaviour
DisorderDisorder
▪▪ REM sleepREM sleep
▪▪ Dream recallDream recall
▪▪ Adults (elderly)Adults (elderly)
▪▪ Easily awakenedEasily awakened

52. PLMs 2 MIN

53. PLMS Treatment
• Rx
• Iron supplementation
• CPAP if PLMs secondary to apnea

54. Restless Legs Syndrome (RLS)
• Disorder of WAKEFULNESS (PLMs = sleep)
• Subjective report of an uncomfortable sensation in
the legs while at rest
• Irresistible urge to move the legs
• Symptoms subside with movement
• “Creeping”, “itching”, “creepy-crawly”, “pulling”,
“tugging”, “gnawing”, “toothache in my legs”, “bugs
or worms crawling under my skin”
• Symptoms worse in the evening
• Almost all patients with RLS display PLMs during
sleep

55. RLS Treatments
• Pharmacological (dopamine agonists)
• Non-Pharmacological:
– Iron supplementation
– Warm bath
– Exercise
– Massage, acupuncture, relaxation techniques
– Keeping mind engaged when having to stay seated
– Eliminate caffeine and alcohol
– Bar of soap under the sheets!

56. SLEEP & MEDICAL ILLNESS

57. Normal Fibromyalgia

58. SLEEP & MENTAL ILLNESS
• Depression
– Early morning awakenings
– Short REM latency
– Increased time in REM sleep
– May mimic narcolepsy on the MSLT

59. SLEEP & MENTAL ILLNESS
• Anxiety
– Increased sleep onset
– Prolonged awakenings
– Panic attacks (with/without sleep apnea)

60. SLEEP & MENTAL ILLNESS
• Psychiatric Populations and Sleep
– Schizophrenia (apnea, sleep spindles)
– PTSD (nightmares)
– Geriatrics
– Mood disorders

61. INSOMNIA

62. INSOMNIA
• Difficulty initiating and maintaining sleep
• Early morning awakenings
• Complaint of poor, insufficient or nonrefreshing
sleep
• Impact on waking behaviour
• Sleep Efficiency < 85%
• Longer SOL (> 30 minutes), short total sleep time
(TST)

63. Insomnia Treatments
• Cognitive Behavioural Therapy
• Sleep Restriction Therapy
• Relaxation Techniques
• Sleep Hygiene
• Prescription medications

64. GOOD SLEEP HABITS
• Get up at the same time each morning. Even if
you fall asleep very late, you should still get up at
the same time each morning
• To avoid “Sunday night insomnia, Monday
morning blues”, don’t stay up late on weekends
and then sleep in
• Go to bed only when sleepy
• Develop a relaxing pre-sleep ritual such as
reading, taking a bath, brushing your teeth, etc

65. GOOD SLEEP HABITS
• Use the bed only for sleep and intimacy
• Nicotine is a stimulant. Try not to smoke near
bedtime
• Hunger may disturb sleep. Perhaps try to have a
light snack before bed. A glass of warm milk
contains a natural sleep aid
• Exercise regularly. Get vigorous exercise either in
the morning or the afternoon and do only mild
exercise two to three hours before bed

66. GOOD SLEEP HABITS
• Don’t stay in bed if you can’t fall asleep within 15
minutes. Tossing and turning will just make you
more frustrated
• Get as much sleep as you need, but no more
• If you find yourself worrying at bedtime, set aside
a “worry time” – perhaps 30 minutes in the early
evening to write down both problems and
solutions

67. Zzzzzz QUESTIONS?? Zzzzzz
fraser.willsey@theroyal.ca