1. Sleep Presentation
by Mendy Peterson PA-C
April 23rd 2009

2. Objectives:
What is Normal Sleep?
-circadian rhythm and EEG's
-brain and hormones
-sex and age patterns
Common Sleep Disorders:
-parasomnias and insomnia's
-sleep apnea & obesity
-sleep lab studies
Consequences of Abnormal Sleep:
-Health
-Cost and Employers
-Car Accidents
-2007 Sleep in America Poll
How to Change!
-Day & Bedtime routines
-Medications & Alternative Meds
-Naps

3. What is Normal Sleep?

7. Cortisol is a hormone released by the adrenal
gland that sits on top of the kidney.

8. That was
quot;Cortisolquot;
NOT
quot;Caffeine!quot;

15. Theta Waves
Sleep Spindles/K Complex
Delta Waves
More Delta Waves
Dreams!

16. Which is better- REM vs Non-REM?

18. Hormones and Sleep
TSH - Thyroid
Cortisol - Adrenal Glands
Prolactin - Pituitary/Breast
milk
Growth Hormone
Melatonin
Serotonin - Mood stabilizer
Epinephrine - quot;I am speed!quot;
Estrogen - ahhhh menopause!
And..... Many Many more!

19. Men vs. Women
Hard Sleep Light Sleep
How Hard?
6 hours 8 hours +
How Long?
Better Worse
With Mate?
More Less
Sleep Apnea?
More Less
Sleep Disorders?
Car Accidents
More Less

27. Sleep
Questionnair
e

28. 0 = Would never doze 1 = Slight chance of dozing 2 =
Moderate chance of dozing 3 = High chance of dozing
Sitting and Reading _____
Watching TV _____
Sitting inactive in a public place (i.e. theatre) _____
As a car passenger for an hour without a break _____
Lying down to rest in the afternoon _____
Sitting and talking to someone _____
Sitting quietly after lunch without alcohol _____
In a car, while stopping for a few minutes in traffic _____
A score of greater than 10 is a definite cause for
concern as it indicates significant excessive daytime
sleepiness. Consider completing full questionnaire
and submit to your doctor!

29. Sleep
Disorders

33. SHORTENED SLEEP LATENCY
Alcohol and drug induced sleep
Narcolepsy
Sleep apnea
Sleep deprivation

34. Prolonged Sleep Latency
Delayed sleep phase syndrome
Inadequate sleep hygiene
Psychiatric disorders-Acute schizophrenia,
Major depression, and Mania
Restless leg syndrome

35. Causes of shortened or sleep onset
REM sleep
Alcohol, sedative and hypnotics
Depression
Narcolepsy
Sleep apnea
Sleep deprivation

36. Sleep disorders in aged
Leg movement disorders
REM behavior disorder
Sleep apnea syndrome
Medication induced sleep disorders
Medical disorders especially cardiovascular
disturbances and pain
Dementia
Neurological disorders
Depression

37. Dyssomnias-characteristics
Patients may complain of difficulty getting to
sleep or staying asleep, intermittent
wakefulness during the night, early morning
awakening, or combinations of any of these.
Transient episodes are usually of little
significance. Stress, caffeine, physical
discomfort, daytime napping, and early
bedtimes are common factors

38. Dyssomnias-causes
There are over 30 recognized kinds of Dyssomnias. Major groups of Dyssomnias
include:
Intrinsic sleep disorders - 12 disorders recognized, including
hypersomnia,
narcolepsy,
periodic limb movement disorder,
restless legs syndrome,
sleep apnea.
Extrinsic sleep disorders - 13 disorders recognized, including
alcohol-dependent sleep disorder,
food allergy insomnia,
inadequate sleep routine.
Circadian rhythm sleep disorders - 6 disorders recognized, including
advanced sleep phase syndrome,
delayed sleep phase syndrome,
jetlag,
shift work sleep disorder

39. Dyssomnias-conditions-Narcolepsy
Narcolepsy is a neurological condition most characterized by
Excessive Daytime Sleepiness (EDS). A narcoleptic will most
likely experience disturbed nocturnal sleep, confused with
insomnia, and disorder of REM or rapid eye movement sleep.
The main characteristic of narcolepsy is overwhelming
excessive daytime sleepiness (EDS), even after adequate
nighttime sleep. A person with narcolepsy is likely to become
drowsy or to fall asleep, often at inappropriate times and
places
Four other classic symptoms of narcolepsy, which may not
occur in all patients, are cataplexy, sleep paralysis,
hypnogogic hallucinations, and automatic behavior.

40. Periodic Limb Movements
Periodic Limb Movement Disorder (PLMD), also called nocturnal
myoclonus, is a sleep disorder where the patient moves involuntarily
during sleep
It is related to restless leg syndrome (RLS) in that 80% of people with
RLS also have PLMD. However, most people with PLMD do not
experience RLS
Nocturnal myoclonus is treated by medications aimed at reducing or
eliminating the leg jerks or the arousals. Non-ergot derived dopaminergic
drugs (pramipexole and ropinirole) are preferred. Other dopaminergic
agents such as co-careldopa, co-beneldopa, pergolide, or lisuride may also
be us
These medications are also successful for the treatment of RLS restless
leg syndrome.

42. Restless Leg Syndrome-types
Primary RLS is considered idiopathic, or with no known
cause.
Secondary RLS often had a sudden onset and may be daily
from the very beginning
The most commonly associated medical condition is iron
deficiency (medicine), which accounts for just over 20% of
all cases of RLS. The conditions include: pregnancy, varicose
vein or venous reflux , folate deficiency, uremia, diabetes,
thyroid problems, peripheral neuropathy, Parkinson's disease
and certain auto-immune disorders such as Sjögren's
syndrome, Celiac Disease, and rheumatoid arthritis.
Treatment of the underlying condition often eliminates the
RLS.

43. Parasomnias-what, why and which ?
A sleep disorder is a physical and psychological
condition or disturbance of sleep and wakefulness
caused by abnormalities that occur during sleep or
by abnormalities of specific sleep mechanisms
Although the sleep disorder exists during sleep,
recognizable symptoms manifest themselves during the
day
Accurate diagnosis requires a polysomnogram, widely
known as a quot;sleep test.“

44. Parasomnias-classifications
A. Arousal-Sleep terrors, Sleepwalking
B. Sleep-Wake Transition-Rhythmic
movement disorders
C. Parasomnias with REM sleep-Nightmares,
Sleep paralysis, and REM sleep Behavior
disorders
D. Other Parasomnias- Bruxism and Enuresis

46. Parasomnias-Bruxism
Sleep related, stereotyped, forceful teeth
grinding or clenching
Is also associated with dementias, mental
retardation and Parkinson’s disease

47. Insomnia-causes
Medical and neurological conditions
Drug and alcohol abuse
Psychiatric disorders
Patients older than 65
years of age

48. Recording of Polysomnography
Simultaneous recordings of EEG, EOG,
EMG, EKG, vital signs and breathing

49. What answers to expect from
Polysomnography ?
Polysomnography is a comprehensive
recording of the biophysiological changes that
occur during the sleep
Polysomnography is usually performed during
the night when patient sleeps
Usually performed with CPAP titration if
needed.

50. Consequences of Abnormal Sleep
- Health Effects
- Cost to Employers
- Car Accidents

53. When do most sleep
deprivation car accidents
occur?
In the early to mid afternoon and
in the very early morning hours.
These are the times when
everyone is least alert.

55. Women & Sleep:
Key Findings Overall

56. 2007 Poll Roadmap
The 2007 Sleep in America Poll
findings:
Sleep among women overall
The effect of women’s biology on
sleep
The effect of women’s lifestyle on
sleep

57. Women Are Not Getting the
Sleep They Need
60% say they only get a good night’s sleep a
few nights per week or less
60
%

58. Why Are Women Not Getting
the Sleep They Need?
67% experience sleep problems at least a few nights
each week, with 46% experiencing sleep problems
every night
67
%

59. Why Are Women Not Getting the
Sleep They Need?
Lifestyle impacts sleep
Working mothers (72%) and single working
women (68%) are more likely to experience
sleep problems like insomnia
Other factors that wake women up
Noise (39%)
Giving care to children (20%)
Pets (17%)

61. Why Are Women Not
Getting the Sleep They Need?
Women who allow kids
(9%) or pets (14%) to
share their bed have the
most disturbed sleep
47% of women say they
have no one helping them
care for children at night

63. Consequences of Poor Sleep
Poor sleep and poor mood are intertwined
Poor sleep can worsen mood
Approximately 80% of women report being
stressed out, anxious or worried
55% state they have been unhappy, sad, and
depressed in the last month
Mood can in turn worsen sleep and lead to
heightened depression and anxiety

64. How Women Cope with Poor
Sleep…
80% accept daytime sleepiness and
keep going
65% drink caffeinated beverages
Of those, 37% drink 3 or
more caffeinated beverages a day

65. Although Consistently Tired,
Women Do Not Go to Bed Earlier
In the hour prior to bed they :

66. How Women Cope with Poor
Sleep…
Anti-depressants prescribed by a doctor 12%
Sleep medication prescribed by a doctor 8%
Combination sleep aid and pain reliever 9%
OTC or store-bought sleep aids 6%
Alternative therapy or herbal supplements 2%

67. Compromise: Choices Women
Make
When women are tired or run out of time
during the day…
Healthy lifestyle activities are sacrificed
Forego sleep (52%) and exercise (48%)
Reduce time spent with family and friends (39%)
Stop healthy eating (37%)
Don’t participate in sexual activity (33%)
Work remains a priority
Only 20% of women put work on the “back burner”

68. Sleep & Women’s Biology
Women experience more sleep
problems than men
A woman’s overall health affects her
ability to sleep well
As women progress through different
life stages, changing biology affects
their ability to get a good night’s sleep

69. Sleep and Health
Poor health is linked to sleep problems
Of women who are in fair to poor health:
66% experience a symptom of a sleep
disorder at least a few nights per week
40% diagnosed with a sleep disorder
46% experience daytime sleepiness a few
days per week
26% have missed work in the past month
54% use a sleep aid a few nights per week

70. Different Life Stages
Respondents were asked about the quality
and quantity of their sleep during 5
reproductive stages
Women of Childbearing Age
Pregnancy
Post Partum
Perimenopausal
Postmenopausal

71. Women of Childbearing Age
67% experience insomnia a few nights
per week
34% report experiencing a sleep disorder
such as snoring, sleep apnea or RLS
33% say their sleep is disturbed during
the week of their menstrual cycle
16% have missed work during the past
month due to a sleep problem

72. Pregnant Women
30% say they rarely or never get a good night’s
sleep
84% have insomnia at least a few nights each week
40% report sleep disorders such as snoring, sleep
apnea or RLS
54% nap at least twice per week

73. Post Partum Women
This is the first national sleep
survey of post partum women.
Post partum women have insomnia at the
same rate as pregnant women (84%)
42% say they rarely/never get a good
night’s sleep, more than any other group
47% report no one helping with kids
20% have driven drowsy with kids
19% experience post partum
blues/depression

74. Perimenopausal Women
59% have insomnia a few nights per week
43% report symptoms of a sleep disorder
such as snoring, sleep apnea or RLS
Noise (36%) and co-sleeping with pets
(20%) are the most common nighttime
disturbances
20% experience night sweats and hot
flashes

75. Postmenopausal Women
Have the highest incidence of:
Limited time in bed - less than 6 hours (14%)
Sleep disorders such as snoring or sleep apnea
(42%)
RLS (22%)
Sleep aid use (41%)
Obesity (30%)

76. Sleep &
A Woman’s Lifestyle

77. Lifestyle and Sleep
Sleep is greatly impacted by lifestyle
2007 NSF Sleep in America poll
examined sleep among 6 segments of
women
Working, Single Women
DINKs and Empty Nesters
Stay-at-Home Moms
Part-time Working Moms
Briefcases with Backpacks
50-somethings

78. Working, Single Women
Spend the least time in bed, generally
less than 6 hours
54% wake up un-refreshed a few
days each week
70% accept this and keep going
47% consume more than 3 cups/cans of caffeinated
beverages per day
Nearly 30% use the weekends to “catch up” on sleep

79. DINKs & Empty Nesters
Working married/partnered women with no
children or grown children get better sleep
than most groups - despite being in bed less
than 7 hours per night
Low incidence of sleep problems (15%)
Yet, healthy lifestyle choices are still compromised
because women are tired or run out of time
46% report having no time for sleep
47% sacrifice exercise
38% don’t participate in sexual activity

80. Stay-at-Home Moms
74% rarely get a good night’s sleep
Despite this, 61% say they spend over 8
hours in bed each night
In the hour before bed, 71% complete
household chores and activities with kids
57% nap at least once per week
43% curtail leisure activities
39% forego sexual activity

81. Part-time Working Moms
Report getting the best sleep of all the
groups
50% say they are in bed for over 8 hours
per night
68% accept the day’s challenges and keep going
Napping is frequent; 60% take a nap at least once per week

82. Briefcases with Backpacks
Married/partnered women with school-aged kids,
who work full time
Spend less than 6 hours in bed per night
72% have insomnia
70% accept sleepiness and keep going
56% use caffeine
Highest rate of drowsy driving (35%)
Lifestyle compromises are high
60% give up sleep and exercise
52% do not socialize regularly with family and friends
44% do not have time for sex

83. 50-somethings
Are not employed, no children at home
Have highest frequency of sleep disorders
Highest sleep aid usage (41%)
32% say they get a good night’s sleep only a few
nights per month
Spend over 8 hours in bed per
night and frequently nap

84. NSF 2007 Poll Overview
American women are…
Not sleeping well which affects all aspects
of their life- work, relationships, sex?
Struggling to “do it all” and as a result
sacrifice sleep
Using many coping strategies to sustain the
pace of daily life
Impacted by biological and lifestyle factors
affecting their sleep

86. Insulin resistance
Increased blood sugar
Elevated Cortisol levels
Systemic inflammation
Disrupted Immunity
Impaired thyroid
function
Disruption of your body
clock or body rhythm
Premature Aging

87. Why aren’t we sleeping well?
Temperature fluctuations, tossing &
turning
Mental Stress
Discomfort & physical stress
Environment
Diet & lack of regular exercise

88. Time for Change!
How do we help ourselves?

89. What Women Can Do?
Make healthy sleep a priority!
Make time to get 7-9 hours of sleep
Create a relaxing and quiet environment
Exercise regularly (not less than 3 hours
before bed time) and eat healthy
Avoid caffeine and alcohol before bed
If you have a new infant, arrange for help
Set a sleep schedule
Try a warm bath before bed

90. Natural Sleep Solutions:
Sleep Masks/CPAP
Ear Plugs
Acupuncture
Massage
Meditation/Sleep Therapy
Melatonin
Prescription Medications:
Rozarem- melatonin derivative
Ambien/Lunesta- Hallucinogenics
Provigil- for Narcolepsy
Others- GABA receptors- Neurontin/Lyrica
Anti-depressants
Hormones? (Estrogen, etc.)

91. Controversial Topics??
Work Less?
Less Co-Sleeping?
quot;Cry it Outquot; Sleep Methods?

92. What about naps?

96. Questions?