# LMCC/Sleep Disorders

insomnia
parasomnias
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)