Handbook

• Jet Lag Disorder

  Def: temporary misalignment between body clock and destination solar/sleep-wake cycleTypically after trans-meridian travel across ≥3 time zones Direction of travelUsually worse with eastward travel, needs phase advancePhase advance harder to achieve than phase delay (westward)80% of people have intrinsic circadian period >24 hrs, constantly delaying...

• Shift Work Disorder (SWD)

  Def: insomnia and excessive sleepiness from work hours that overlap usual sleep timeMore common with night, early or rotating shifts than late or split shiftsPrevalence up to 38% in rotating shift workers Health and safety concernsSafety risk: occupational accidents, professional driversHigher rates of mental and...

• Irregular Sleep-Wake Rhythm Disorder

  Def: no clearly defined sleep-wake cycle, disorganized sleep and wake spread across 24 hrsMultiple (usually >3) short, arrhythmic sleep episodes of varying length (usually <4 hrs)ICSD-3: sx ≥3 months, diary or actigraphy ≥7 days (ideally 14) showing ≥3 sleep bouts/24 hrs Associated conditionsUsually coexists with...

• Non-24-Hour Sleep-Wake Rhythm Disorder

  Def: sleep-wake cycle desynchronized from the solar cyclePeriod length typically >24 hrsSleep onset delays progressively, usually 20-60+ min per dayICSD-3: sx ≥3 months, diary or actigraphy ≥14 days showing daily delay EpidemiologySeen in blind (esp no light perception) and sighted pts≥50% of totally blind individuals...

• Advanced Sleep-Wake Phase Disorder

  Def: chronic (>3 months) major advance (>2-3 hrs) in sleep-wake timing vs desired or required scheduleMain sx: early morning (terminal) insomnia EpidemiologyPrevalence <1%, possibly underreported since less disruptive than DSWPDMore common in older adultsRare autosomal dominant familial forms with PER2 and CSNK1D mutationsAssoc with neurodevelopmental...

• Delayed Sleep-Wake Phase Disorder

  Def: chronic (>3 months) major delay (>2-3 hrs) in sleep-wake timing vs desired or required schedulePrevalence 1-10%More common in teens and young adults, can start in childhoodFamily hx common (up to 40%) Consequences of social schedule:1. Sleep onset insomnia2. Difficulty waking at acceptable time, may...

• Kleine-Levin Syndrome

  Def: recurrent episodes of hypersomnia with cognitive and/or behavioral changesVery rare, prevalence 1-5 per millionMale predominanceResolves in median 13-14 yrs, may persist for decades EpisodesHallmark: discrete attacks of hypersomnolence with abrupt onset over a few hrsLast days to weeksPt appears sleepy, confused, apathetic or dream-likeSleep...

• Idiopathic Hypersomnia

  Rare chronic CNS d/o with clinical overlap with narcolepsy~10x less common than narcolepsyPoorly defined, may be a heterogeneous group of d/oOnset at any age, most often adolescence or early adulthood Clinical featuresMarked EDS is the core featureLong sleep duration, typically ≥10 hrs for main sleep...

• Narcolepsy Type 2

  Def: chronic neurological dz sharing PSG and many clinical features with NT1Cataplexy absent, CSF hypocretin-1 not proven lowClinical presentation similar to NT1 but without cataplexyAge of onset and sex distribution mirror NT1 PathophysiologyUnclear~45% HLA-DQB1*06:02 positive Dx criteria (ICSD-3, all required) Differential dx TreatmentSimilar to NT1,...

• Narcolepsy Type 1

  Def: chronic neurological dz caused by extensive loss of hypothalamic orexin (hypocretin) A and B neurons Cardinal features Other featuresDisturbed nighttime sleep with increased N1Brief naps of minutes are usually refreshingComorbid sleep d/o: RBD, OSA, PLMSDepression and anxiety, cause unclear: QoL impact or neurochemical changes...

• Restless Legs Syndrome (RLS)

  RLS is a neurological d/o that is often undiagnosed and untreated despite being commonAlso called Willis-Ekbom diseaseCauses both sleep initiation and sleep maintenance problems Dx criteria (all required) Supportive criteria: Family hx of RLS in 1st-degree relatives, Response to dopaminergic drugs, Presence of PLMS PLMS...

• Nocturnal Hypoventilation

  Def: insufficient minute ventilation during sleep, reduced breathing with reduced gas exchangeBMI ≥30, awake PaCO2 ≥45 mmHg, other causes excludedCauses prolonged nocturnal O2 desaturation and elevated CO2Increased risk of pulmonary HTN and consequent HF AASM scoring (either):a. PaCO2 or surrogate >55 mmHg for ≥10 minb....

• Central Sleep Apnea (CSA)

  Def: Recurrent cessation or reduction of airflow during sleep due to absent or reduced respiratory effortCaused by loss of central drive from the brainstem, not airway obstruction Associated conditions Cheyne-Stokes Respiration (CSR): CSA is of particular clinical relevance in HF. Crescendo-decrescendo pattern, vigorous effort gradually...

• Upper Airway Resistance Syndrome (UARS)

  Def: Increased upper airway resistance during sleep causing repeated respiratory effort-related arousals (RERAs)At sleep onset, dilator muscle tone falls and upper airway narrowsSignificant rise in airflow resistance increases inspiratory effort until pt arouses from sleepNo apneas, hypopneas or desaturations as seen in OSA, pts keep...

• Obstructive Sleep Apnea

  Def: Recurrent episodes of complete (apnea) or partial (hypopnea) upper airway collapse during sleep, despite ongoing respiratory effort, Leads to intermittent hypoxia, sleep fragmentation and arousalsMost common type of SDB of medical concernOSA + excessive daytime sleepiness = OSA syndromeAffects up to 10% of middle-aged...

• Introduction

  Respiratory function is significantly altered by sleepPts with normal awake breathing can develop significant respiratory compromise in sleepAfter sleep onset, central motor neuron output fallsReduced upper airway dilator muscle function narrows the upper airwayReduced inspiratory muscle activity causes shallower breathing vs awake state Complicating factors:...

• Non-Pharmacological Tx of Insomnia

  Psych and behavioral tx are 1st line and gold standard AASM RecommendationsStandard tx: stimulus control, relaxation training, CBT-ISome support: sleep restriction, multicomponent tx without cognitive tx, paradoxical intention, biofeedbackNot recommended as stand-alone: sleep hygiene, imagery training, cognitive tx Stimulus Control: Effective monotherapy based on classical...

• Consequences of Insomnia

  Short Term ConsequencesFatigue and tirednessUnpleasant body sx, e.g. heavy eyesHypersensitivity to noise and lightMood disturbance: irritability, increased emotional reactivityNegative personal interactions with children, partnersReduced self-esteem, optimism and confidencePoor quality of lifePts often feel alone and misunderstoodCognitive disturbance: reduced attention, concentration and performance Long Term Consequences:...

• Chronic Insomnia

  Def: difficulty falling or maintaining sleep for atleast 3 times a week for atleast 3 months. Provided other sleep disorders are ruled out.Prevelance; atleast 6-10% of adults, mostly women Subtypes of Chronic Insomnia1. Psychophysiological – racing thoughts, heightened arousals, anxiety 2. Paradoxical Insomnia – perception...

• Diagnostic Tests in Sleep Medicine

  Variety of tests exist to help diagnose sleep disorders, familarize yourself with them 1. Pulse OximetryOvernight pulse oximetry can help screen for potential Sleep breathing disordersOrganizations like Mayo Clinic use them for screening prior to sending for a consultI used them in the hospital prior...