LMCC/Sleep Disorders

• characterized by one of three complaints

insomnia

• difficulty falling alseep, maintaining sleep, early morning wakening or non-refreshing sleep

parasomnias

• night terrors, nightmares, restless leg syndrome, somnambulism

excessive daytime sleepiness

Epidemiology

• 1/3 of people have occasional sleep problems
• 10% have chronic sleep problems
• > in women with increasing age

History

A thorough sleep history includes:

• history from patient and partner
• sleep environment (noise, temperature, light)
• shift work or life stresses
• use of tobacco, alcohol, caffeine, pharmaceuticals and illicit drugs
• snoring, apneic episodes, limb jerks, sleep paralysis
• daytime consequences, impact on quality of life

Investigations

• complete sleep diary every morning for 1-2 weeks
  • record bedtime, sleep latency, total sleep time, awakenings, quality of sleep
• rule out specific medical problems (CBCD, TSH)
• sleep study referral if suspect periodic leg movements of sleep or sleep apnea
• night time polysomnogram or daytime multiple sleep latency test

Treatment

• treat and manage any suspected medical or psychiatric caueds
• psychologic treatment
  • sleep hygiene
    • avoid caffeine, nicotine, alcohol, exercise regularly, comfortable sleep environment, regular sleep schedule
  • relaxation therapy
  • stimulus control therapy
  • sleep restriction therapy
• pharmacologic treatment
  • short term benzodiazepines

Specific problems

primary insomnia

• majority of cases
• person reacts to the insomnia with fear or anxiety around bedtime or with a change in sleep hygiene
• can progress to a chronic disorder called psychophysiological insomnia

Snoring

• results from soft tissue vibration at the back of the nose and throat due to tubulent airflow through narrowwed air passages
• risk factors: male gender, obesity, alcohol consumption, ingestion of tranquilizers or muscle relaxants and smoking
• Physical exam: obesity, nasal polyps, septal deviation, hypertrophy of the nasal turbinates, enlarged uvula and tonsils
• Investigations if severly symptomantic
  • noctural polysomnography
  • airay assessment (CT or MRI)
• treatment
  • sleep on side, weight loss
  • nasal dilators, tongue retaining devices, mandibular advancement devices
• risk is development of obstructive sleep apnea

Obstructive sleep apnea (OSA)

• apnea resulting from upper airway obstruction due to collapse of the base of the tongue, soft palate with uvula, and epiglottis
• respiratory effort is present
• leads to a distinctive snorting, choking awakening type pattern as the body arouses itself to open the airway
• apneic episodes can last from 20seconds - 3 minutes
• can have 100-600 episodes/night
• diagnosis based on nocturnal polysomnography
  • >15 apneic episodes with arousal recorded per night
• risk factors
  • 2% women, 4% men
  • between ages 30-60
  • obesity causing upper airway narrowing: BMI >28kg/m present in 60-90% of cases
  • children: commonly tonsils or adenoids
  • aging which causes decreased muscle tone
  • persistent URT infections, allergies, nasal tumours, hypothyroidism
  • Family medical history
• consequences
  • Daytime somnolence, nonrestorative sleep
  • Poor social and work performance
  • mood changes: anxiety, irritability, depression
  • sexual dysfunction: poor libido, impotence
  • morning headache due to hypercapnia
  • Hypertension, coronary artery disease, stroke, arrhythmias
  • pulmonary hypertension, RV dysfunction, cor pulmonale due to chronic hypoxemia
  • memory loss, decreased concentration, confusion
• investigations
  • blood gas not helful, TSH if clinically warrented
  • evaluate BP, inspect nose, oropharynx for enlarged adenoids or tonsils
  • nocturnal polysomnography
• Treatment
  • modifying factors: avoid sleeping supine, lose weight, avoid alcohol, sedative, narcotics, inhaled steroids if nasal swelling present
  • primary treatment of OSA is CPAP which maintains patent airway in 95% of OSA cases
  • dental appliances to modify mandibular position
  • surgery: somnoplasty, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty
  • report patient to ministry of transportation if OSA is not controlled by CPAP

Central Sleep Apnea

• pathophysiology
  • brain fails to send appropriate signals to breathing muscles to initiate respirations
  • the defining feature is absent respiratory effort
  • often secondary to CNS diseases ie. brainstem infarct, infection, neuromuscular disease
• investigations: PFTs, nocturnal polysomnography, MRI
• treatment: CPAP or mechanical ventilation if brainstem origin
• prognosis: poor

Sleep Tips

• Keeping a routine is important. Try going to sleep at the same time every night and get up at the same time every morning.
• Make sure the environment you sleep in is dark and quiet. Ask others to be respectful of your sleep and not disturb you while your asleep.
• Do not eat or drink at least two hours before bed.
• Take only 30 minute naps during the day if needed.
• Stay away from fatty foods during the day and especially before bed.
• Exercise on a regular bases but never right before bed. (MayoClinic.com, 2010)

References

Toronto Notes 2005

MayoClinic.com. (2010). 10 Tips for Better Sleep. Retrieved from http://www.mayoclinic.com/health/shift-work/AN01616