sleep medicine: an overview
DESCRIPTION
Fraser Willsey, Sleep Specialist at The Royal shares facts on sleep, what they do at the Sleep Lab, and how to treat sleep disorders.TRANSCRIPT
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SLEEP MEDICINE:An OverviewFraser Willsey, BA, RPSGTSleep Lab TechnologistSleep Disorders Service, The Royal
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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)
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THE IMPACT OF SLEEP DEPRIVATION
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• Challenger Disaster• 3 Mile Island• Chernobyl
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Purpose of Sleep
• Restorative Function• Energy Conservation• Immune Function Regulation• Memory Consolidation• Mood Regulation and depression• Protective Mechanism
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WHAT WE DO AT THE SLEEP LAB….
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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
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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
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STAGES OF SLEEP
• NREM & REM • NREM = N1, N2, N3
• Sleep Cycle • REM increases as the night progresses• Changes across the lifespan
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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
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AWAKE
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STAGE N1
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STAGE N2
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STAGE N3
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STAGE N3
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REM Sleep
• Rapid Eye Movements• Muscle atonia (paralysis)• Dream recall• 90 minute latency • “Paradoxical Sleep” – EEG mimics wakefulness• Breathing irregular, heart rate fluctuates
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REM
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TRANSITION INTO REM
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SLEEP APNEA
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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
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OBSTRUCTIVE SLEEP APNEA (OSA)• Causes
▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx
• Exacerbated by: ▪ Rx ▪ Alcohol Consumption
▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep
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Normal vs. Collapsed Airway
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“Kissing” Tonsils
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OBSTRUCTIVE APNEA
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OBSTRUCTIVE APNEA, 2MIN
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OBSTRUCTIVE APNEA 5MIN
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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)
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CPAP
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CPAP
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Consequences of Untreated OSA
• Memory Problems• Depression• Cardiovascular disease–High blood pressure– Stroke–Cardiac arrhythmias
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FASTEN YOUR SEATBELTS…
THERE’S ANOTHER CONSEQUENCE OF UNTREATED OSA & SLEEPINESS
ANY GUESSES WHAT IT IS?
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PARASOMNIAS
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PARASOMNIAS• NREM
Sleepwalking (Somnambulism)Sleep Terrors (aka Night Terrors)Others examples: Sleep Related Eating Disorders,
Confusional Arousals, Somniloquy
■ REMREM Behaviour Disorder (RBD)
Measured in the sleep lab with full EEG to rule out seizure activity
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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
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JAROD ALLGOOD Feb. 2, 1973 – Feb. 9, 1993
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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
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RBD
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REM BEHAVIOUR DISORDER
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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
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SLEEPWALKING vs. RBD
SleepwalkingSleepwalking
▪ ▪ Stage N3 Stage N3 (NREM)(NREM)
▪ ▪ No dream recallNo dream recall
▪ ▪ ChildrenChildren
▪ ▪ Not easily Not easily awakenedawakened
REM Behaviour REM Behaviour DisorderDisorder
▪ ▪ REM sleepREM sleep
▪ ▪ Dream recallDream recall
▪ ▪ Adults (elderly)Adults (elderly)
▪ ▪ Easily awakenedEasily awakened
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PLMs 2 MIN
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PLMS Treatment
• Rx• Iron supplementation• CPAP if PLMs secondary to apnea
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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
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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!
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SLEEP & MEDICAL ILLNESS
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Normal Fibromyalgia
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SLEEP & MENTAL ILLNESS
• Depression– Early morning awakenings– Short REM latency– Increased time in REM sleep– May mimic narcolepsy on the MSLT
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SLEEP & MENTAL ILLNESS
• Anxiety– Increased sleep onset– Prolonged awakenings– Panic attacks (with/without sleep apnea)
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SLEEP & MENTAL ILLNESS
• Psychiatric Populations and Sleep– Schizophrenia (apnea, sleep spindles)– PTSD (nightmares)– Geriatrics – Mood disorders
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INSOMNIA
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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)
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Insomnia Treatments
• Cognitive Behavioural Therapy• Sleep Restriction Therapy• Relaxation Techniques• Sleep Hygiene• Prescription medications
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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
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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
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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