Overview. Sleep Related Movement Disorders - Restless Leg Syndrome - Periodic Limb movements in Sleep

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2 The Structure of Sleep The Parasomnias - in REM - in Non-REM - Narcolepsy Overview Sleep Related Movement Disorders - Restless Leg Syndrome - Periodic Limb movements in Sleep Circadian Rhythm disorders - Delayed Sleep Phase of Adolescents

3 REM - Rapid Eye Movement NREM - Non-Rapid Eye Movement Stages 1 and 2 light sleep Stages 3 and 4 deep sleep Minute sleep cycles. 4 5 cycles per night to feel refreshed 25% REM, 50% Stage 2 and 25% stages 3 and 4

4 Parasomnias: (Common) In Non-REM Sleep Walking Night terrors Sleep Related Eating Disorder Sexsomnia REM related sleep disorders Nightmare REM-Sleep Behaviour Disorder Others Bruxism Sleep talking (somniloquy) Enuresis Rhythmic Movement disorders

5 Parasomnias: In Non-REM - Sleep Walking. Occurs from sudden arousal from slow wave sleep. In 1 st third of the night. Onset between 2 and 12yrs (Peak 5yrs - 6yrs). 15% - 40% sleepwalk at least once. 3% regular sleepwalkers. 4% occasionally continue to sleepwalk into adulthood. 10% will also suffer from Night Terrors

6 Parasomnias: In Non-REM - Night terrors (Parvor Nocturnus). Occurs from sudden arousal from slow wave sleep. In 1 st third of the night. Autonomic and behavioural manifestations of fear. ~ 40% of children experience Night Terrors. Onset usually between 2 and 12 years (Peak ay 2yrs 3yrs) - Sleep Related Eating Disorder and Sexsomnia. both Non-REM behaviours

7 Parasomnias: In Non-REM Treatments:. Reassurance and education. Safety measures. Sleep Hygiene. Address bedtime refusal / night-waking behaviour. Avoid waking. Guide back to bed. Avoid interfering. Avoid next-day discussion

8 Parasomnias: Most common precipitating factors: - Genetic factors - Fatigue/sleepiness - Stress - Febrile illness (occasionally, Alcohol)

9 Parasomnias: In REM - REM Sleep Behaviour Disorder. (REM without muscle atonia).tends to be in the latter 1/3 rd of the night. Overall prevalence of 0.5% (15 100yrs). More common in older men. 40% - 50% (and probably more) will later develop some Neurodevelopmental disorder, especially Parkinson s Disease.. Triggered or exacerbated by TCA s, SSRI s & MAOI s Treatment: 90% - 95% will respond to Clonazepam 0.5mg 2.0mg

10 Parasomnias: In REM - REM Sleep Behaviour Disorder. (REM without muscle atonia)

11 Parasomnias: In REM - Nightmares: - Frightening dreams, occurring in REM sleep, that usually awaken a child or adolescent - 75% of children experience a nightmare at some time. Up to 50% of them have nightmares that result in parental interaction - Risk factors. Stress/traumatic events Anxiety and anxiety disorders Sleep deprivation Medication, especially withdrawal of REM suppressants - Associated with Daytime fears Bedtime resistance

12 . Relaxation strategies for the older child. Progressive muscle relaxation Visualisation Relaxation tapes/music Parasomnias: In REM - Nightmares: - Treatments. Parental reassurance. Rehearsal therapy. Avoid exposure to frightening or over-stimulating images. Reduce stressors. Ensure adequate sleep. Security objects. Dim, low-level nightlight

13 Parasomnias: In Either REM or Non-REM - Bruxism: 8% of adults, 14% - 20% of children <11yrs Stress related, Sleep-related disorders, Chemical related RLS/PLMS, RBD, OSA, Night Terrors Alcohol, Caffeine, MDMA (ecstasy) SSRI s, Methylphenidate, Antiarrythmics, - Sleep talking: In light non-rem or REM, but no memory in the morning More frequent in times of stress, fever, sleep disturbance

14 Parasomnias: In Either REM or Non-REM - Enuresis: A disorder of arousal. Unknown aetiology. May accompany nocturnal seizures, OSA, or other sleep disorders - Rhythmic Movement Disorders (Jactatio capitis nocturna) head banging / body rocking. - Usually a soothing behaviour - May continue into adulthood

15 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Essential features - Unpleasant sensation in the legs requiring the urge to move - Urge to move is worse at times of inactivity - Unpleasant sensation is partially or completely relieved by movement - Unpleasant sensation is worse in the evening or at night.

16 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Other, non-essential but common features - Family history - Association with Periodic Limb Movement in Sleep (80%) - Response to dopaminergic therapy - May cause sleep disturbance, especially sleep onset - May begin at any age, but usually progressively worse with age - Usually gone in the morning

17 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Secondary Restless Leg Syndrome - Anaemia. Ferritin < 50 RLS is associated with low CNS iron (not specifically serum iron) - Uremia. 15% - 40% undergoing dialysis suffer from RLS - Pregnancy. Especially in the third trimester

18 Sleep Related Movement Disorders: Periodic Limb Movements in Sleep (Von Ekbom 1945) - Daytime sleepiness - Restlessness during sleep - Nighttime arousals - Observed limb jerking at night. Typically extension of the big toe, dorsiflexion of the ankle, occasional flexions of the knee, and hip

19 Sleep Related Movement Disorders: Periodic Limb Movements in Sleep (Von Ekbom 1945) - PLM Index (PLM/hr), on PSG or Actigraphy - 20% Suffer with RLS - May have periodic leg movements at rest

20 Sleep Related Movement Disorders: Treatments. RLS / PLMS Non-pharmacologic - Good sleep practices to avoid psychophysiological insomnia - Avoidance of caffeine and alcohol in the evening - Massage. Hot/Cold compresses. - Mental distraction - Moderate exercise - Remain physically active until bedtime

21 Sleep Related Movement Disorders: Treatments. RLS / PLMS Pharmacologic - Dopaminergic Medication. L-dopa. (Sinemet. Madopar) Tolerance, augmentation, rebound, side effects ½ life of 3-4hrs Dopaminergic Agonists. (Ropinerole. Bromocriptine) Less tolerance, augmentation and rebound ½ life of ~6hrs - Opioids. Codeine Start low and go slow. Check Hx or substance abuse Use low dose in conjunction with dopaminergic Rx

22 Sleep Related Movement Disorders: Treatments. RLS / PLMS Pharmacologic - Anticonvulsants. Gabapentin Not as powerful as Dopaminergic Rx useful for those with painful RLS, especially when symptoms begin after the age of ~45yrs Daytime fatigue, and dizziness - Neuropathic pain Pregabalin (Lyrica) - Benzodiazepines. Non-Benzodiazepines Used to induce sleep, and improve sleep continuity. No direct beneficial effect on PLS/PLMS - Iron (+- Folate) supplementation. Useful if Ferritin is <50% First line therapy in children

23 Sleep Related Movement Disorders: Treatments. RLS / PLMS Drugs that aggravate RLS/PLMS - Antihistamines. Block Dopamine receptors Older antihistamines are worse. Check OTC use - Antiemetics Block Dopamine receptors Metoclopramide, Prochlorperazine - Antidepressants? Because it increases Serotonin TCA s, SSRI s,?maoi s

24 Other Nighttime disorders: - Narcolepsy. Four cardinal symptoms: Excessive Daytime Sleepiness Sleep Paralysis Hypnagogic / Hypnopompic Hallucinations Cataplexy (only Cataplexy is unique to Narcolepsy) Not all are necessary for the diagnosis of Narcolepsy. Other common symptoms: Fragmented nocturnal sleep Sleep attacks Naps are temporarily refreshing. Onset: Most commonly in late teenage, and less often in late 30 s May occur in children, especially with strong genetic links ` May investigate with overnight Polysomnography (PSG), and Multiple Sleep Latency Test (MSLT)

25 Other Nighttime disorders: - Narcolepsy. Prevalence: 1/600 in Japan 1/4000 in North America and Europe (1000 in NZ) 1/500,000 in Israel. Gender: Equal Male/Female. Family History: 8% - 12% have a 1 st degree relative with narcolepsy. Thought to be related to a deficiency of Orexin/Hypocretin. Most carry the Human Leukocyte Antigen (HLA) DQB1*0602 However, so do up to 40% of the population, and some narcolepsy patients do not have this marker

26 Other Nighttime disorders: - Narcolepsy Treatments:. Education. Sleep hygiene, and management of sleep attacks.. Increase activity. Avoid boring / repetitive tasks. Avoid dangerous activities ie driving, unsupervised swimming. Stimulant medication: Methylphenidate / Modafinil. Avoid caffeine, especially in the evening

27 Other Nighttime disorders: - Narcolepsy

28 Thank You Dr Alex Bartle The SLEEP WELL Clinics Throughout New Zealand

29 Adolescent Sleep How much sleep do they need? 8½ 9¼ hrs How much sleep do they get? Only 15% reported getting 8½hrs sleep on week nights

30 Factors Affecting Adolescent Sleep Biological Influences Psychological development Emotional development Physical development o hormonal changes o somatic growth o circadian rhythm changes

31 Controlled by: Internal Body Clock Circadian Rhythms Circa Diem(s) = About a Day o The Suprachiasmatic Nucleus (SCN) o Melatonin o Core body temperature o Many hormonal fluctuations External Environment Cues Zeitgebers (time keepers) o Light o Exercise o Meal times o Work schedule

32 Circadian Rhythms In Adults: o The internal circadian clock runs for an average of 24.2 hours and varies between 24 and 25 hours, if independent of external environmental cues. In Adolescents: o The circadian period tends to be longer, closer to 25 hours. In addition they may be more sensitive to low light.

33 10pm Bed Core Body Temperature 10:30 11:00 Sleep 12:00 midday 2pm 5pm o C Drop 5am Circadian Process Process C Cortisol 6:30 7:00 Wake am pm pm X 5am 12pm 10pm Sleep Wake X Increased Sleep Pressure Adapted from: Achermann P. The two-process model of sleep regulation revisited. Aviat Space Environ Med 2004 X Wake Homeostatic Process Process S

34 Circadian Rhythms Two behavioral treatment regimes: 1. Phase delay (chronotherapy) 2. Phase advancement

35 Circadian Rhythms 1. Phase delay: Best for those with very severe DSP (>4am) o Delay bed time and wake time by 3 hours every night until target sleep time is reached o Allow no more than 8 hours sleep opportunity ie 4am midday 7am pm 10am pm etc o Difficult to manage in a family environment

36 Circadian Rhythms 2. Phase advancement: Best for those with less severe DSP o Go to bed when sleepy o Advance bed time and wake time by 15 minutes every night until target sleep time is reached o Allow no more than 8 hours sleep opportunity ie 2:00am :00am 1:45am :45am 1:30am :30am etc o Easier to manage in a family environment

37 Circadian Rhythms Summary: Morning light o Timing after lowest core body temperature o Intensity the brighter the light the more rapid the effect (outside is ideal) o Duration ideally at least ½ hour outside (longer in dim light)

38 Circadian Rhythms Summary: Evening darkness o Dim the lights in the evening o Avoid electronic media for at least two hours before bed o Use blue blocking glasses in the evening o Avoid caffeine in the afternoon and evening o Avoid vigorous exercise within 4 hours of bedtime

39 Melatonin: Circadian Rhythms o Produced in the Pineal gland o Has a number of physiological functions o Responsible for peripheral vasodilation (consequent fall in core body temperature) From: The journal of clinical endocrinology & metabolism; Salti,R; 85(6): (2000)

40 Circadian Rhythms Summary Melatonin: o Less effective than light manipulation o Large doses (3mg 5mg) tend to be sedative o Small doses (0.3mg 0.5mg) given 5-6 hours before target sleep onset is effective o Most effective when endogenous melatonin is not present e.g. shiftwork / jet lag o Results in peripheral vasodilation and fall in core body temperature

41 Circadian Rhythms Important considerations: Teenager buy-in. Appeal to: o Sporting ability o Academic performance o Vanity! Parent buy-in : o Explanation of the process o Construct a schedule

42 Important considerations: Circadian Rhythms Relaxation of the process will result in a rapid return to the DSP Late nights to bed on Friday and Saturday nights will result in difficulty sleeping on Sunday night and difficulty getting up on Monday morning. Moving West will have immediate benefit but it won t last!

43 Circadian Rhythms Important considerations: Remove all electronic media from the bedroom. The earlier this regime is begun the better, especially in pre-teen years. Blue-blocking sunglasses in the evening No sunglasses in the morning Ensure morning light exposure is after the calculated lowest core body temperature

44 Brief questions: - Do you have any concern about your sleep? - Have you been told that you snore? - Do you wake refreshed in the morning?

45 Brief questionnaires: - Epworth Sleepiness scale (General feeling of Sleepiness in 8 situations) - Stop-bang (Considering the possibility of OSA) - Auckland Sleep Questionnaire (Is longer, but covers many aspects of sleep) - Morningness-Eveningness Questionnaire

46 The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing It is important that you put a number (0 to 3) in each of the eight boxes.

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48 Thank You Dr Alex Bartle The SLEEP WELL Clinics Throughout New Zealand