SLEEP AND WAKE DISORDERS

• Tense wake

• Wake

• Relaxed wake

• Drowse

• Light sleep

• Deep slow sleep

• Rapid-eye-movement sleep (REM sleep)

Human functional conditions

Regulation of sleep and wake

THALAMUSCortex activation

Synchronisation of EEG

HYPOTHALAMUSShift sleep/wake

SUPRACHIASMATIC NUCLEUSBiological hours

MEDULLACortex activationShift “REM/slow" sleep

Functions of sleep

• Functions of non-REM sleep– anabolic– Optimization of visceral organs regulation

• Functions of REM-sleep– Psychological adaptation– Formation of behavioral program

• Insomnia– primary disorders of initiating or maintaining sleep,

characterized by a disturbance in the amount, quality, or timing of sleep

• Hypersomnia– disorder characterized by excessive sleepiness

• Parasomnia– a category of sleep disorders that involve abnormal and

unnatural movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep

Classification of sleep disorders

Insomnias

• Intrinsic sleep disorders– idiopathic insomnia– psychophysiological insomnia– distorted perception of sleep– restless legs syndrome– periodic limb movement disorder

• Extrinsic sleep disorders• Circadian rhythm sleep disorders

Sleep hygiene

• Waking up at the same time

• Eliminate naps, especially in the second half of the day

• Allowing enough time for sleep. Most people need 7-9 hours of sleep each day

• Avoiding heavy meals and alcohol before sleep and reducing intake of caffeine and

other stimulants several hours before bedtime

• Arranging a sleep environment that is very dark, comfortable, quiet, and cool to

facilitate falling asleep quickly and staying asleep

• Avoiding TV beds and other media-furniture

• Following an exercise routine (but not within 3 hours before bedtime), as daily physical

activity improves sleep, helps with stress management, and promotes general health

• Seeking assistance from healthcare providers for continuing difficulties with sleep,

since specific sleep disorders may require particular treatments

Principles for hypnotics purpose

• Preferable to start treatment of insomnia with herbal sleeping pills or

melatonin

• Predominant use of short half-life drugs

• Duration of use sleeping pills as possible should not exceed 3 weeks. This

period does not form addiction and dependence

• For elderly patients should be given half the daily dose of sleeping pills, and

take account of their interactions with other drugs

• You can assign the sleeping pills “on demand“ not more than 3 times a week

(or 10 days in a month)

HypnoticsGroup od drugs Drug Duration of

action (hours)Dependence

Benzodiazepines Phenazepam 12 +

Nitrazepam (Raderodorm)

8 +

Midazolam (Dormicum) 6 +

Triazolam (Halcion) 6 +

Nonbenzodiazepines, agonists of benzodiazepine receptors

Zopiclon(Imovan, Somnol, Piclodorm)

6-8

-

Zolpidem(Ivadal, Sanval)

5-6 -

Zaleplon(Andante)

2-3 -

Antidepressants with sedative effect

Amitriptylin 12 -

Miamserin (Lerivon) 12 -

Trazodon (Trittico) 8 -

Barbiturates as hypnotics unacceptable!

• Narcolepsy

• Sleep apnea

Principal forms of hypersomnia

Clinical manifestations of narcolepsy

• Excessive daytime sleepiness (EDS)• Cataplexy• Hypnagogic hallucinations• Automatic behavior (a person continues to function (talking, putting

things away, etc.) During sleep episodes)• Sleep paralysis

Simultaneously, all these manifestations are rare. 

For clinical diagnostics it is enough combination of daily falling asleep with one or two of additional clinical symptoms see above).

Treatment of narcolepsy

Cataplexy

• Tricyclic antidepressants (Melipramin)

• Selective serotonin reuptake inhibitors (Fluoxetine, Venlafaxine)

Excessive daytime sleepiness • Psychostimulants (Caffeine, Ritalin,Modafinil)Sleep disorders• Hypnotics (Zopiclon, Zolpidem)

Causes of obstructive apnea syndrome

Obstructive apnea syndrome -

condition, characterized by multiple episodes of upper respiratory tract obstruction in sleep

Complaintsintermittent snoring 95%daytime sleepiness 90%restless sleep 40%morning headaches 10%nocturia 10%episodes of shortness of breath 5%

PrevalenceM - 4% F - 0,5 %

Region of obstruction

DiagnosisAdults - 5 and more episodes in hourChildren - 1 and more episodes in hour

Danger of sleep apnea

• Encephalopathy• Dementia• Arterial hypertension• Pulmonary heart• Cardiac arrhythmias• Increased risk of stroke and heart attacks 2-7 times• Impotence• The increased risk of road accidents in 2-12 times• Sudden death in sleep

Treatment of sleep apnea

Causative :

• weight loss program

• correction of ORL-pathology

• exception of alcohol

• exception of sedatives

• treatment of endocrine, neurological, and

systemic diseases

Continuous positive airway pressure (CPAP, BiPAP and other)

respiratory support in an open state

Treatment of sleep apnea

Treatment of sleep apneaPathogenetic• Surgery

– Uvulopalatopharyngoplasty (UPPP)

– Septoplasty

• Oral appliances – for the tongue and lower jaw

• Pharmacotherapy (Theophylline, Diacard, Protriptylin, Modphynil)

Parasomnias – adverse events related in occurrence with sleep

• Arousal disorders – Confusional arousals – Sleep terrors (night terrors) – Sleepwalking (somnambulism)

• REM parasomnias• REM sleep behavior disorder

– frightening dreams • Nocturnal enuresis • Teeth grinding (bruxism) • Restless legs syndrome & periodic limb movements

• An urge to move the limbs with or without sensations.

• Improvement with activity. Many patients find relief when moving and the relief continues while they are moving.

• Worsening at rest. Patients may describe being the most affected when sitting for a long period of time, such as when traveling in a car or airplane, attending a meeting, or watching a performance.

• Worsening in the evening or night. Patients with mild or moderate RLS show a clear circadian rhythm to their symptoms, with an increase in sensory symptoms and restlessness in the evening and into the night.

The clinical signs of restless legs syndrome (RLS)

Etiology and pathogenesis of restless legs syndrome

• Primary (idiopathic)– failure of descending dopaminergic pathways

• Secondary– pregnancy (19-26%)– deficiency of iron (10-18%)– uremia (12-23%)– myelopathy, peripheral neuropathy, radiculopathy– Parkinson disease– smoking cessation– venous insufficiency of the lower limbs– amyloidosis, rheumatoid arthritis, leg injuries– congestive heart failure– medication (neuroleptics, lithium, tricyclic antidepressants)

Treatment of restless legs syndrome

• Sleep hygiene

• Correction of iron deficit

• Nonergoline dopamine agonists

• Levodopa drugs

• Benzodiazepines (Clonazepam)

• Anticonvulsants (Carbamazepine, Gabapentin)

• Opiates (Codeine, Tramadol)

• Differential diagnosis with epilepsy

• Organization of safe sleeping environment

• Mode of sleep

• If parasomnias do not violate social adaptation – medical treatment is needed

• Sedative herbs

• Benzodiazepines (clonazepam, nitrazepam)

Management of parasomnias