Sleep Disorders Anneka Rose ST5 Psychiatrist
Agenda Basic overview of sleep structure Interactive case based discussions 5 min interventions MCQs Questions
Hypnogram
Actigraphy
Common Scenario Patient books an appointment in primary care, doc I m tired all the time Differentials
Cases Taken from Iranzo et al, Sleep Medicine 2007 Sleep disturbances in Disney animated films
Case 1 Donald Duck has spent several weeks lying awake in bed staring at the ceiling. He has recently purchased a new alarm clock with a loud ticking sound. He looks at the clock and thinks if I go to sleep now I will get 5 hours sleep, if I go to sleep now I will get 3 hours sleep Disney Early to bed 1941
Insomnia Difficulty initiating or maintaining sleep Poor sleep quality without underlying cause Sleep onset latency > 30 mins Wake time after sleep onset < 30 mins Sleep efficiency of <85% Tired 24 hours a day, not sleepy
Treatment Education CBT- I Medication short term
Case 2 Gepetto is well known for his loud snoring which is notorious for stopping Jiminy Cricket from getting to sleep. Despite this it is Gepetto that complains of feeling unrefreshed the next day and often wakes with a headache. Disney- Pinocchio 1940
Obstructive Sleep Apnoea Must be excluded in anyone with excessive daytime sleepiness Risk of RTA, increased CVD risk Symptoms- morning headaches, unrefreshed, snoring, fatigue Respiratory referral Weight loss, CPAP, oral devices, tracheostomy
Become an Astronaut
Case 3 Cinderella lives with Bruno the dog and Lucifer the evil cat belonging to her stepmother. She walks in to find Bruno fast asleep in his bed, panting, barking, moving body and paws, biting the carpet. When he wakes up she asks, Dreaming again Chasing Lucifer? If you don t want to lose that bed, you better get rid of those dreams Disney- Cinderella 1950
REM Behavioural Disorder Abnormal motor activity during REM sleep Loss of REM muscle atonia Elderly males Linked with Parkinson s Disease and Lewy Body Dementia Talk/laugh/kick out/act out dreams
Anosmia REM Behavioural Disorder Constipation Safety concerns for them and partner Melatonin >55, clonazepam, dopamine agonists
Case 4 Donald Duck goes to sleep appears to get out of bed an hour later and leave the house still in his pj s. He walks across the street and enters a lions cage, then crosses the street and climbs the wall of a tall building whilst still talking to his girlfriend Daisy Duck, who has to keep protecting him without waking him up. Disney Sleep time Donald 1947
Non REM Parasomnia Confusional arousal, night terror, sleep walking, sexsomnia First third night, poor recall Usually start in childhood, genetic link Can be triggered by stress, fever, sleep deprivation
Non REM Parasomnia Avoid Z drugs Safety advice Mindfulness, anxiety management Clonazepam, pregabalin, clomipramine
Non REM Parasomnia makes the headlines
Case 5 Thumper has an irresistible urge to move his legs, he just cannot keep still. When he moves his legs he feels much better Disney Bambi - 1942
Restless Legs Sensorimotor disorder Urge to move legs, can affect other body parts Worse at night Relief from movement
Restless Legs Fhx >40s Pregnancy Diabetes Rheumatoid Arthritis Vegetarians Blood donors
Restless Legs Avoid Venesection Replace Iron Pregabalin/Gabapentin Clonazepam Ropinerole/Pramipexole Compression device
Case 6 Sleepy is always falling asleep involuntarily whether he is playing the clarinet or walking to work with his peers in the mine. These episodes of sleep are not refreshing and he remains sleepy throughout the day. Disney- Snow White and the seven dwarfs 1937
CNS Hypersomnia Rare, familial >10 hours sleep plus EDS Difficult to rouse from sleep Need to rule out brain stem pathology- MRI
CNS Hypersomnia No diagnostic test/treatment trials Polysomnography- MSLT <8 Stimulants
Case 7 Aurora is walking through the castle, feeling terrified, when she pricks her finger on a spindle of a spinning wheel. She has an irresistible urge to sleep, sees a giant figure looming in front of her, feels weak and collapses to the floor Disney Sleeping Beauty 1959
Narcolepsy Sleep paralysis Hypnogogic/hypnopompic hallucinations Excessive daytime sleepiness Cataplexy (70%)
Narcolepsy Sleep Paralysis -onset or offset, often with associated hallucination
Narcolepsy 0.05% prevalence HLA association Links to H1N1 flu vaccine and proposed link to nasal flu vaccine in children
Narcolepsy MSLT <8 Low CSF hypocretin EPS >16 Clinical Hx Polysomnography REM onset within 15 mins sleep
Post Sodium Oxybate
Case 8 Goofy is falling in the office, whilst walking down the street, in fact anywhere but in his bed at night when he is wide awake. His boss shouts at him one day sleep on your own time and he is fired. Disney How to sleep 1953
Circadian Rhythm Disorder Clock problem Teenagers- decelerated sleep phase Elderly accelerated sleep phase Link with Autistic Spectrum Disorder
Circadian Rhythm Disorder Accelerated- Treat with light- 10,000 LUX white light in the evening 18:00, enriched blue if migraineur Decelerated- Melatonin or mirtazapine 10pm, light in the morning 3-6 months of commitment
Referrals When you suspect: -non REM parasomnia - REM behavioural disorder -Excessive daytime sleepiness Epworth >16- include? Narcolepsy, hypersomnia -Circadian rhythm disorder
MCQs True or False Q1) Clinical features of narcolepsy include the following: - Catalepsy - Irresistible episodes of unrefreshing sleep during daytime - Sleep paralysis - Delayed REM onset - Hypnogogic hallucinations
MCQs Q2) Regarding obstructive sleep apnoea.. - there is obstruction of the airway? -results in brief episodes of arousal in which airway is restored -majority of snorers have this condition -cardiac arrhythmias are a known complication -associated with hyperthyroidism
MCQs Q3) Regarding insomnia -high dose mirtazapine is more sedating than low dose mirtazapine -melatonin is efficacious - zolpidem is useful for middle insomnia -alcohol suppresses REM sleep -restricting sleep can be beneficial
Questions