1. Disor der s of Sleep
- Adult s
In Greek mythology,
Dr A V Srinivasan M.D, D.M., PhD (Neuro) Hypnos was the
Professor in Neurology personification of sleep; the
Roman equivalent was
Institute of Neurology
known as Somnus. His twin
Madras Medical College, Chennai was Thanatos ("death");
9-7-08 at Kalpakam, Chennai their mother was the
goddess Nyx ("night"). His
palace was a dark cave
where the sun never shines.
At the entrance were a
number of poppies and

2. Sleep Disor der s
• International Classification of Sleep Disorders
(ICSD-2)
(1) insomnias
(2) sleep-related breathing disorders
(3) hypersomnias not due to a breathing disorder
(4) circadian rhythm sleep disorders
(5) parasomnias
(6) sleep-related movement disorders
(7) other sleep disorders, and
(8) isolated symptoms, apparently normal variants,
and unresolved issues.
Madras Institute of
Neurology

3. I nsomnia
• Difficulty in initiating sleep and staying
asleep
• Waking up earlier
• Poor quality sleep, non restorative.
• Subjective
• Day time impairment (RDC-AASN)
Madras Institute of
Neurology

4. Et iology
• Primary
• Secondary
Medications
Psychiatric
Medical
Sleep Disorders
Madras Institute of
Neurology

5. Dr ugs
• SSRI’s & SNRI’s
• Alpha and beta blockers
• Diuretics
• Decongestants
• Stimulants
• Steroids, thyroid harmones
Madras Institute of
Neurology

6. Psychiat r ic and Sleep
disor der s
• Mood & anxiety disorders
• Circadian rhythm disorders
• Parasomnias
• Apneas
• Movement disorders
Madras Institute of
Neurology

7. Hyper somnias
• Excessive day time sleepiness
• Interfering with day time activities,
productivity, enjoyment
• Reflects insufficient sleep, disrupted
sleep, primar sleep disorder
Madras Institute of
Neurology

8. Diagnosis
• Detailed medical and sleep history
• Snoring or apnoea
• Restlessness, jerking
• Hypnogogic or hypnopompic
hallucinations
• Sleep paralysis, cataplexy
• Automatic behavior
Madras Institute of
Neurology

9. Nar colepsy
• Excessive day time sleepiness (EDS)
Sedentary and active pursuit's
Short and refreshing
Followed by recurrent somnolence
Ranging from mild to disabling
Madras Institute of
Neurology

10. Cat aplexy
• Unique
• Paroxysmal episodes of weakness
• Triggered by emotions
• Secs to Min
• Can be localized
• Consciousness and respiration not
affected.
Madras Institute of
Neurology

11. • Develops years after EDS
• Frequency varies
• Adolescence, young adulthood
• Narcolepsy with and without
cataplexy
• Loss of hypocretin – 1 secreting
cells
Madras Institute of
Neurology

12. Cat aplexy in an Adult Male
(Video)

13. • Narcolepsy – non obligate
manifestations
Sleep paralysis – muscle atonia at
interface between sleep and
wakefulness; for few minutes.
Hypnogogic hallucinations
brief, Sec to Mins, dream-like vivid and
distressing
Automatic behavior
Purposeful/inappropriate with impaired
recollection of the activities.
Madras Institute of
Neurology

14. Ot her Hyper somnias
• Recurrent hypersomnias
Recurrent hypersomnias
Kleine – Levin syndrome
Menstrual associated
• Idiopathic hypersomnias
With long sleep time
Without long sleep time
Madras Institute of
Neurology

15. Par asomnias
• Include abnormal movements,
behaviors, emotions and
automatic activities.
• Intrusion of sleep and wakeful
state into one another with CNS
activation.
• Not a unitary phenomenon.
Madras Institute of
Neurology

16. Par asomniasis
• Disorders of arousal –
NREM sleep – confusional arousal
sleep walking
sleep terrors
REM sleep – RBD
Isolated sleep paralysis
Nightmares
Others – enuresis
eating disorders
etc
Madras Institute of
Neurology

17. RBD – REM Sleep Behavior
Disor der s
• Prevalence of 0.5%; 90% Men
• Above 50 years
• 25% with PD, OPCA, DCBD
• Complex motor activity during REM
• Augmentation of EMG tone during REM
sleep
• Toxic/metabolic disorders
Madras Institute of
Neurology

18. RBD
• During second half
• Abnormal brain stem control of medullary
inhibitory regions
• Cat models- locus ceruleous adjacent lesions
• SPECT – decrease striatal dopa innervations
decrease dopa transportation
• Withdrawal of alcohol, sedatives
• Hypnotics
• TCA, SSRI, MAOI, cholinergics
Madras Institute of
Neurology

19. Sleep-Relat ed Movement
Disor der s- Rest less Legs
Syndr ome
• 5-15% - healthy people
• 15-20% - uremia
• 30% - R.A
• High prevalence in West
• Low in South & S.E Asia
Madras Institute of
Neurology

20. Diagnost ic cr it er ia – NI H –
I RLSSG (2003)
1. Disagreeable leg sensations before
sleep onset
2. Irresistible urge to move the limbs
3. Partial or complete relief on leg
movement
4. Return of symptoms on cessation of
movement
Madras Institute of
Neurology

21. Rest less Leg Syndr ome
• Bilateral, though asymmetrical
• Ankle & knees. Can involve thigh or
feet & arm
• Minutes to hours
• Dopamine dysfunction, Iron storage
deficiency
• Anti emetics, antihistamines, TCA,
SSRI, neuroleptics
Madras Institute of
Neurology

22. Rest less Leg
Syndr ome wit h
Per iodic Limb
Movement s
Madras Institute of
Neurology

23. Per iodic Limb Movement
Disor der
• Common as age advances
• Nocturnal myoclonus captured on
Polysomnography
• Extension of the big toe with flexion of
ankle, knee & hip
• Sleep may or may not be affected
• Centrally mediated event
Madras Institute of
Neurology

24. • Can accompany OSA & Narcolepsy
• Uremia, metabolic disorders
• TCA, MAOI
• Withdrawal of AED, benzodiazepines,
hypnotics
• Hypnic jerks & nocturnal seizures to
be differentiated
Madras Institute of
Neurology

25. PLMS –Secondar y (pr evious
Myelopat hy)
Madras Institute of
Neurology

26. Sleep Relat ed Leg Cr amps
• Not uncommon with increasing age
• “Charley horse” muscular tightness
involving the calf & foot during sleep
• Results in arousal and can lead to
insomnia or EDS
• Pregnancy, DM, fluid & electrolytes,
arthritis, vigorous exercise
Madras Institute of
Neurology

27. Sleep r elat ed Br uxism
• Children and adults, MR
• Stereotyped grinding or clenching
• Diurnal & nocturnal
• Situational or psychological stress
• SSRI, dopa, alcohol exacerbate
Madras Institute of
Neurology

28. Sleep-Relat ed Rhyt hmic
Movement Disor der
• Head Banging – back & forth down
into the pillow
• Head Rolling – side to side
• Body Rocking – forward & backward
• Humming or chanting
• Persistence with autism, MR
Madras Institute of
Neurology

29. Noct ur nal Par oxysmal Dyst onia
(NPD)
• Repeated, stereotyped, dystonia or
dyskinetic episodes in NREM sleep
• Sleep related epilepsy
• Short episodes < 1 min. every night and
many times
• Long episodes – up to 60 min
• Can have sleep disruption
Madras Institute of
Neurology

30. Sleep-Disor der ed Br eat hing
(SDB)
• Primary snoring
• Upper airway resistance syndrome
(UARS) – lab support, day time
dysfunction
• Obstructive sleep apnea-hypopnea
syndrome (OSAHS)
• Central sleep apnea
• Asthma
• Chronic obstructive pulmonary disease
Madras Institute of
Neurology

31. Obst r uct ive Sleep Apnea-
Hypopnea Syndr ome
• Asphyxia with decreased O2 & increased
CO2
• Associated with snoring and obstruction of
the pharynx
• Day time – sleepiness, decreased
concentration, fatigue
• Nocturnal – chocking, dyspnoea,
diaphoresis, nocturia
Madras Institute of
Neurology

32. • Apnoea – 70% reduction in airflow
• Hypopnea – 30% reduction in airflow
for minimum 10 sec
• Apnea-hypopnea index (AHI) of at
least five apneas plus hypopneas per
hour of sleep together with complaints
of persistent daytime sleepiness.
Madras Institute of
Neurology

33. Risk Fact or s
• Obesity ( BMI > 30 kg/m2)
• Male gender
• Family history of obstructive sleep apnea-hypopnea
syndrome
• Consumption of alcohol before bedtime
• Smoking
• Drugs (growth hormone, β-blockers, testosterone,
flurazepam)
• Use of sedatives
• Sleeping in a supine position
• Anatomic upper airway obstruction
• Comorbid medical conditions
Madras Institute of
Neurology

34. Cent r al Sleep Apnea
• 10 sec of no airflow
• Reduced ventilatory drive
• Ventilatory responses to hypoxia,
hypercapnia are reduced
• Day time sleepiness, mild snoring
• PSG – no airflow or ventilatory effort
Madras Institute of
Neurology

35. Cir cadian r hyt hm Sleep
Disor der s (CRSD)
• Master Clock – SCN in anterior
hypothalamus
Sleep wake cycle/temperature control and
melatonin levels.
• Zeitgebers (time given) are light and
melatonin
• Input into SCN from ganglion cells-
melanopsin
• Melatonin > pineal >ofSCN, shifts circadian
Madras Institute
rhythm Neurology

36. • DD for insomnia & hypersomnia
Delayed sleep phase
Advanced sleep phase
Free running
Irregular sleep-wake
Shift work sleep disorder
Jet lag
Madras Institute of
Neurology

37. Cr it er ia f or CRSD
• Persistent or recurrent pattern of sleep
disturbance due to
- Alteration in circadian timing or
misalignment of endogenous & external
factors
- Leading to insomnia, EDS or both
- Associated with impairment of function
• CRSDs are important in practice but
parameters for treatment have not been
Madras Institute of
established. Neurology

38. Thank you
Madras Institute of
Neurology