TOP 10 LIST OF SLEEP QUESTIONS. Kenneth C. Sassower, MD Sleep Disorders Unit Massachusetts General Hospital for Children

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1 TOP 10 LIST OF SLEEP QUESTIONS Kenneth C. Sassower, MD Sleep Disorders Unit Massachusetts General Hospital for Children

2 QUESTION #1: ARE SLEEP ISSUES IN CHILDREN THE SAME AS IN ADULTS?

3 Distinctive Features of Pediatric Sleep Daytime sleepiness uncommon Attentional and behavioral disturbances common Parasomnias common Psychophysiologic insomnia nonexistent Sleepiness vs fatigue

4 QUESTION #2: WHAT DOES IT MEAN TO BE SLEEPY?

5 Sleepiness Drowsiness that interferes with daytime activity Irresistible daytime naps Increased sleep requirements Combination of all of the above

6 QUESTION #3: IS BEING FATIGUED THE SAME AS BEING SLEEPY?

7 Fatigue Tiredness, exhaustion Not necessarily sleepy Lack of energy Lack of motivation Loss of exercise capacity Loss of endurance May co-exist with sleepiness in same pt

8 Fatigue: Causes Circadian rhythm sleep disorder Neuromuscular and mitochondrial disorder Anemia, infection Cardiac or chronic lung disease Rheumatologic or endocrinologic disease Psychiatric Physical de-conditioning

9 QUESTION #4: WHAT ARE THE MOST COMMON SLEEP SYMPTOMS?

10 Evaluation Define chief sleep symptom: Insomnia Excessive daytime sleepiness Disturbed behavior during sleep

11 QUESTION #5: IS THERE AN ACTUAL WAY TO MEASURE SLEEPINESS?

12 Sleepiness: Diagnostic Tools Subjective scales (Epworth, Stanford) Sleep diary Performance tests (Wilkinson Auditory Vigilance test) Neurophysiologic tests (Multiple Sleep Latency Test, Maintenance of Wakefulness Test, Overnight Sleep Study)

13 QUESTION #6: WHAT DOES A.D.D. (ATTENTION DEFICIT DISORDER) HAVE TO DO WITH SLEEP?

14 Attentional Deficit Disorder and Sleep Sleep deprivation may exacerbate ADHD symptoms May need to search for occult sleep apnea and periodic limb movements Hyperactivity of restless legs may mimic ADHD behaviors Effect of stimulants on sleep unclear

15 Attention Deficit Disorder and Sleep - II Bi-directional relationship ADD behaviors impact sleep Bedtime resistance Sleep-onset insomnia Night awakenings/motor restlessness Insufficient sleep Stimulant therapy Sleep disturbances affect ADD symptoms Sleep apnea, Periodic limb movement disorder, Restless legs syndrome

16 QUESTION #7: WHAT DOES AUTISM HAVE TO DO WITH SLEEP?

17 Autism and Sleep Mostly derived from parental surveys, few overnight sleep studies Prevalence of sleep disorders: 44-83% (vs typically developing children 11-33%) Insomnia: Co-existent sleep disorder (sleep apnea, periodic limb movement disorder), neurologic/systemic conditions (epilepsy, reflux disease), psychiatric disorders, medications, behavioral factors, enhanced sensitivity to ambient stimuli Nocturnal events: Non-REM arousals, REM behavior disorder, sleep-related epilepsies

18 QUESTION #8: WHAT ARE THE MOST COMMON CAUSES OF DAYTIME SLEEPINESS?

19 Sleepiness: Differential Diagnoses Inadequate sleep hygiene Delayed sleep phase syndrome Insufficient sleep syndrome Limit-setting sleep disorder Sleep-onset association disorder Intrinsic sleep disorders

20 QUESTION #9: WHAT ARE THE MOST COMMON EXTRINSIC SLEEP ISSUES OR SLEEP DISORDERS?

21 Extrinsic Sleep Issues or Sleep Disorders Inadequate Sleep Hygiene Delayed Sleep Phase Syndrome Limit-Setting Sleep Disorder Sleep-Onset Association Disorder Insufficient Sleep Syndrome

22 Inadequate Sleep Hygiene: Common Complaints Trouble falling asleep Difficulty staying asleep Increased early morning awakenings Not enough sleep Nonrestorative, unrefreshing sleep Unpredictable sleep Unable to sleep when work schedule permits Needs sleeping pills to fall asleep

23 Inadequate Sleep Hygiene: Common Associations Consuming alcohol or caffeine Tobacco use Varying the time of going to sleep/waking up Excessive time in bed Excessive napping or dosing Developing hypnotic drug dependency and tolerance

24 Inadequate Sleep Hygiene: Medications That Cause Insomnia Brochodilators Decongestants Stimulants (caffeine, appetite suppressants) Diuretics Activating antidepressants Corticosteroids Alcohol

25 Inadequate Sleep Hygiene: Conservative Treatment Guidelines Consistent times of sleep onset/offset Avoid daytime naps Eliminate late afternoon caffeine use Avoid evening alcohol use Reduce or eliminate tobacco use Avoid evening exercise Keep bedroom dark, quiet and cool Avoid excessive light from laptop computers, I-pads, I-phones Use bedroom only for sleep

26 Delayed Sleep Phase Syndrome Sleep phase occurs later than desired Difficulty in initiating sleep, waking up Most common in young adults Problem exacerbated on weekends Propensity for jobs that do not require regular hours Mood disorders common

27 Delayed Sleep Phase Syndrome: Diagnosis and Treatment Dx: Sleep diary Tx: Chronotherapy Early-evening Melatonin, Ramelteon Bright-light exposure in AM (Light box of 2500 lux)

28 Sleep Log Two-week diary Time the patient begins to try to sleep When the patient ends the night by getting out of bed Sleep (at any time in 24-hour period) Times of caffeine, alcohol, nicotine consumption

29 Limit-Setting Sleep Disorder Inadequate enforcement of bedtimes by caretaker Difficulty in initiating sleep Stalling or refusing No associated medical condition Normal polysomnography

30 Sleep-Onset Association Disorder Difficulty > 3 months Occurs when not holding, rocking, breastfeeding, etc. If holding, etc., sleep is otherwise normal If not holding, increased sleep onset latency and awakenings

31 Insufficient Sleep Syndrome Most common cause of sleepiness Sleep inertia (confusion, disorientation, and grogginess on awakening) Decreased daytime performance on vigilance tasks, irritability, concentration difficulties, depression, muscle aches Catch-up sleep common: weekends/days off Often do not come to medical attention

32 Insufficient Sleep Syndrome: Treatment Increase sleep time of one or more hours Strategic use of caffeine or other wake-promoting agents

33 QUESTION #10: WHAT ARE THE MOST COMMON INTRINSIC SLEEP DISORDERS?

34 Common Intrinsic Sleep Disorders

35 Sleep apnea Periodic limb movements of sleep Restless legs syndrome Narcolepsy Idiopathic CNS hypersomnia Non-REM parasomnia REM parasomnias Intrinsic Sleep Disorders

36 Intrinsic Sleep Disorders: Sleep Apnea Symptoms: Snoring Respiratory pauses Increased awakenings Excessive sleepiness Diagnosis: Sleep study Management: Sleep on sides Weight loss CPAP/Bi-level Oral dental device ENT surgical approaches

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39 Intrinsic Sleep Disorders: Periodic Limb Movements of Sleep Symptoms: Lower limb twitching movements during 1 st half of night Increased awakenings and excessive sleepiness Diagnosis: Sleep study Management: Dopamine agonists, Gaba-ergic meds Low-dose benzodiazepines

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43 Intrinsic Sleep Disorders: Restless Legs Syndrome Symptoms: Restless lower limb sensory complaints during drowsiness or just prior to going to sleep Diagnosis: Clinical hx, confirmed by sleep study Management: Same as for PLMS

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45 Intrinsic Sleep Disorders: Narcolepsy Symptoms: Extreme daytime sleepiness and REM sleep-wake dissociative behaviors Diagnosis: MSLT, sleep study Management: Daytime naps, Modafanil, Sodium Oxybate, Traditional stimulants

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50 Intrinsic Sleep Disorders: Idiopathic CNS Hypersomnia Symptoms: Extreme daytime sleepiness Markedly increased sleep requirements Nonrestorative sleep Sleep drunkenness Diagnosis: MSLT, sleep study Management: Similar to narcolepsy

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52 Abnormal Arousal Behaviors Confusional Arousals Sleepwalking Night terrors Nightmares REM behavior disorder Sleep-related epilepsies

53 Non-REM Arousal Disorder Sleepwalking, Night terrors, Confusional arousals Activated by stress, fever, or relative sleep deprivation Non-REM stage III ( slow-wave ) sleep Monosyllabic utterances

54 Non-REM Arousal Disorder II Led back to bed peacefully Partial or total amnesia Family history common

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56 Intrinsic Sleep Disorders: Symptoms: Nightmares Sleep paralysis Increased motor agitation (REM Behavior Disorder) Diagnosis: Sleep study Management: Increased total sleep time Tricyclics (sleep paralysis) Low-dose benzodiazepines (REM Behavior Disorder) REM Parasomnias

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60 Sleep-Related Epilepsies Complex partial seizures May be benign or refractory May have lateralizing features May mimic nightmares or arousal disorders Continuous spike waves during slow sleep

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64 Polysomnography: Indications Early-morning awakenings of unspecified cause (either frequent awakenings, or infrequent awakenings with increased wake times) Paroxysmal nocturnal disturbances of unclear etiology Part of hypersomnia evaluation

65 THANK YOU!