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INTRODUCTION

In this chapter, we will review sleep disorders that can involve difficulties related to sleeping, including difficulty falling or staying asleep or, falling asleep at inappropriate times, excessive sleep, or abnormal behaviors associated with sleep.

INSOMNIA

  • Difficulty with sleep initiation, maintenance, and duration, or subjective quality

  • Can be primary (psychophysiological or behavioral) or secondary (med effect)

SLEEP-RELATED BREATHING DISORDERS

  • Obstructive sleep apnea vs central sleep apnea

    • Criteria for OSA: daytime sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping/choking AND at least five obstructive respiratory events

      • - Obstructive respiratory events: apnea, hypopnea, respiratory effort-related awakenings

    • Central apnea causes: Cheyne stokes (crescendo-decrescendo pattern of tidal volumes followed by a period of apnea) and primary sleep apnea of infancy (prematurity)

  • Treatment:

    • Weight loss

    • Continuous positive airway pressure (CPAP)

    • Tonsillectomy in children

    • Mandibular surgery

image   WARDS TIP

3 Cs of central sleep apnea—Congestive heart failure, CNS toxicity or trauma, Cheyne-Stokes breathing

HYPERSOMNIAS

Daytime sleepiness not due to disturbed nocturnal sleep.

Narcolepsy (with or without Cataplexy)

  • Symptoms: Excessive daytime somnolence ≥3 months, sleep attacks, cataplexy (pathognomonic, abrupt onset of REM atonia triggered by strong emotional stimuli or physical exercise) varying severity, weakness most frequent at the knee, sleep paralysis.

  • May experience hypnagogic (just before sleep) or hypnopompic (just before awakening) hallucination.

  • Onset at any age—usually second decade of life.

  • Diagnosis: Overnight polysomnogram and multiple sleep latency test.

  • Etiology:

    • Hypocretin (orexin) deficiency leads to narcolepsy with cataplexy.

    • Treatment:

      • - Modafinil first line.

      • - Daily naps and avoidance of sleep deprivation.

      • - Stimulants (eg, methylphenidate, amphetamines).

      • - TCAs (eg, clomipramine) for cataplexy.

Sleep-Associated Movement Disorders

  • Restless leg syndrome (RLS):

    • Autosomal-dominant inheritance pattern.

    • Most commonly idiopathic but sometimes secondary to some chronic conditions (eg, iron deficiency, ESRD), drugs (eg, lithium, antidepressants), and pregnancy.

    • Treatment:

      • - Iron supplementation.

      • - Discontinue offending drugs.

      • - Consider dopamine agonists and anticonvulsants (eg, gabapentin).

Periodic Limb Movement Disorder (PLMD—Formerly Called Sleep Myoclonus or Nocturnal Myoclonus)

  • Described as repetitive limb movements that occur during sleep and cause sleep disruption.

  • Usually involves the lower extremities, consisting of extension of the big toe and flexion of the ankle, the knee, and the hip.

  • Limb movements can occur in the upper extremities as well.

  • Observed in about 80% of patients with RLS.

  • PLMS can occur in over 30% of people aged 65 and older and can be asymptomatic.

  • Common in patients with narcolepsy and REM behavior disorder, and may be seen in patients with obstructive sleep apnea.

  • The limb movements occur most frequently in light non-REM sleep.

  • Dopamine agonists are considered first line of treatment.

PARASOMNIAS

Undesirable phenomena that occur while falling asleep, during sleep, and while ...

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