SleepSleep
Anil Rama, MDAnil Rama, MDMedical Director, Division of Sleep MedicineMedical Director, Division of Sleep Medicine
The Permanente Medical GroupThe Permanente Medical Group
Assistant Adjunct Clinical FacultyAssistant Adjunct Clinical FacultyStanford School of MedicineStanford School of Medicine
Circadian Rhythm of Sleep
Wake
SleepBo
dy
tem
pe
ratu
re
7 AM
7 AM
Courtesy of R. Bogan, MD.
Time
Sleep Stages and Function
Vander et al. Consciousness and behavior. In: Human Physiology. 1990.
States Function
Active state of brain
functions in learning
and memory
Body’s rest and
metabolic restoration
Phasic eye movements
Loss of muscle tone
EEG neutral
Stage 3Stage 4
(REM)
Stage 1Stage 2
(NREM)
Sleep and Age
Hobson. Sleep and Dreaming. In: Fundamental Neuroscience. 1999.Roffwarg et al. Science. 1996;152:604.
24
0
8
16
-1 0 1 10 20 100
Conception Birth
Age (y)Death
Ho
urs
in
da
y
NREM sleep
Awake
REM sleep
Sleepy cabbie.wmv
How likely are you to doze off or fall asleep in the following s ituations, in contrast to feeling just tired? This refers to your way of life in recent times. Eve n if you have not done some of these things recently, try to work out how they would have affec ted you. Use the following scale to choose the most appropriate number for each situation.
Situation Chance of Dozing
Sitting and readingWatching TVSitting, inactive in a public place (eg, a theater or a meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic
Epworth Sleepiness Scale (ESS)
Johns. Sleep. 1991;14:540.
0 = would never doze
2 = moderate chance of dozing
1 = slight chance of dozing
3 = high chance of dozing
Sleepiness: Clinical Presentation
• Pervasive drowsiness
• Sleep attacks
• Fatigue
• Microsleep episodes
• Visual disturbances
• Apathy
• Mood changes
• Automatic activity
• Impaired alertness
• Lethargy
• Impaired memory and concentration
• Poor performance in work/school
• Accident prone
Overeem et al. J Clin Neurophysiol. 2001;18:78. Bassetti and Aldrich. Neurol Clin. 1996;14:545.J. Black, MD. Personal communications. October 2002.
The Two-process Model of Sleep The Two-process Model of Sleep RegulationRegulation
Process S (Homeostatic Process)Process S (Homeostatic Process)– Increases during waking and decreases Increases during waking and decreases
during sleepduring sleep Process C (Circadian Process)Process C (Circadian Process)
– Clock-like process that is independent of Clock-like process that is independent of sleep and wakingsleep and waking
Insomnia: Differential Insomnia: Differential DiagnosisDiagnosis
EnvironmentalEnvironmental BehavioralBehavioral Psychiatric DisordersPsychiatric Disorders Neurological DisordersNeurological Disorders Sleep-Wake Pattern Timing DisordersSleep-Wake Pattern Timing Disorders Movement DisordersMovement Disorders Respiratory DisordersRespiratory Disorders Miscellaneous Medical ConditionsMiscellaneous Medical Conditions Sleep State MisperceptionSleep State Misperception IdiopathicIdiopathic
BehavioralBehavioral InsomniaInsomnia
Adjustment Sleep DisorderAdjustment Sleep Disorder Psychophysiological InsomniaPsychophysiological Insomnia Inadequate Sleep HygieneInadequate Sleep Hygiene Limit-setting Sleep DisorderLimit-setting Sleep Disorder Sleep-onset Association Sleep-onset Association
DisorderDisorder
Psychiatric Disorders Causing Psychiatric Disorders Causing InsomniaInsomnia
Mood DisordersMood Disorders Anxiety DisordersAnxiety Disorders Panic DisorderPanic Disorder Alcohol and Drug Alcohol and Drug
DependencyDependency PsychosesPsychoses
Neurological Disorders Causing Neurological Disorders Causing InsomniaInsomnia
Parkinson DiseaseParkinson Disease Nocturnal EpilepsyNocturnal Epilepsy Degenerative Brain Degenerative Brain
DisordersDisorders Fatal Familial Fatal Familial
InsomniaInsomnia
Sleep-Wake Pattern Timing Sleep-Wake Pattern Timing Disorders Causing InsomniaDisorders Causing Insomnia
Time Zone ChangeTime Zone Change Shift WorkShift Work Delayed Sleep Phase SyndromeDelayed Sleep Phase Syndrome Advanced Sleep Phase SyndromeAdvanced Sleep Phase Syndrome Non-24 Hour Sleep-Wake SyndromeNon-24 Hour Sleep-Wake Syndrome Irregular Sleep-Wake PatternIrregular Sleep-Wake Pattern Short SleeperShort Sleeper
Movement Disorders Causing Movement Disorders Causing InsomniaInsomnia
Restless Legs SyndromeRestless Legs Syndrome Periodic Limb Movement DisorderPeriodic Limb Movement Disorder Sleep StartsSleep Starts Nocturnal SeizuresNocturnal Seizures
Respiratory Disorders Causing Respiratory Disorders Causing InsomniaInsomnia
Obstructive Sleep ApneaObstructive Sleep Apnea Central Sleep ApneaCentral Sleep Apnea Obesity-Hypoventilation SyndromeObesity-Hypoventilation Syndrome Nocturnal AsthmaNocturnal Asthma Chronic Lung DiseasesChronic Lung Diseases High AltitudeHigh Altitude
Miscellaneous Medical Conditions Miscellaneous Medical Conditions Causing InsomniaCausing Insomnia
Gastroesphageal RefluxGastroesphageal Reflux HyperthyroidismHyperthyroidism FibromyalgiaFibromyalgia PregnancyPregnancy MenopauseMenopause
Craniofacial Abnormality Craniofacial Abnormality
OSA IdentificationOSA Identification
Maxillary/Maxillary/MandibularMandibular AdvancementAdvancement
OSA Intervention OSA Intervention -- SurgicalSurgical
MandibularMandibular RepositionersRepositioners
OSA Intervention OSA Intervention -- MechanicalMechanical
Courtesy of Sleep Disorders Dental SocietyCourtesy of Sleep Disorders Dental Society