LMCC/Sleep Disorders

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  • 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[edit]

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


History[edit]

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[edit]

  • 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[edit]

  • 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[edit]

primary insomnia[edit]

  • 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[edit]

  • 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)[edit]

  • 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[edit]

  • 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[edit]

  • 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[edit]

Toronto Notes 2005

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