#leep and #leep $isorders %y $r #adgun %handari

EEG is the recording of brain electrical activity. Some of the activity recorded by scalp electrodes is generated by action potentials of cortical neurons but most is generated by excitatory postsynaptic potentials (EPSP) and inhibitory postsynaptic potentials (IPSPs). Electrode position Electrodes are placed according to the 1 !" Electrode Placement System. #his system uses "1 electrodes placed at positions that are measured at 1 $ and " $ of head circumference. Interpretation Specific EEG %aveforms are rarely normal or abnormal& %ith the exception of certain epileptiform discharges. #he EEG is interpreted in the context of the patient's age and a%a(e!sleep state. )or example& slo% activity is normal in sleep stages * and + and abnormal in an a%a(e adult. Electroencephalographic Rhythms Alpha rhythms #he alpha rhythm is usually seen in normal& relaxed individuals %ho are a%a(e %ith their eyes closed. It is approximately 10Hz in adults %ith the maximum voltage originating from the occipital electrodes. In children& the dominant occipital rhythm is slo%er in fre,uency and may not attain the minimal -.. /0 until 1" years of age. #he posterior dominant rhythm is suppressed by eye opening& and promptly returns %hen the eyes are closed. Beta rhythms EEG activity %ith frequencies faster than 13 Hz occurs in all individuals but is usually of low amplitude. 1eta activity is normally distributed maximally over the frontal and central regions. 2 lo%!amplitude high!fre,uency beta is especially prominent during normal sleep in infants and children and is enhanced by several sedatives, especially barbiturates and benzodiazepines Theta rhythms EEG activity %ith a frequency between !Hz and "Hz is in normal dro%siness and sleep and during %a(efulness in young children. #heta is also present in normal %a(ing adults& but the content is small and the amplitude is lo%. Delta rhythms 3elta activity has a frequency less than ! Hz 3elta activity is not normally recorded in the a%a(e adult but is a prominent feature of sleep and becomes increasingly abundant during the progress from stage" to stage + sleep. )ocal polymorphic delta activity may be recorded over locali0ed regions of cerebral damage.

&he 'ormal #leep (ycle

4asts about 5 minutes and is repeated + to 6 times per night. #he normal sleep cycle consists of the follo%ing7 #tage 1 sleep7 is the initial stage upon falling to sleep8 consumes approximately 2-5 % of a normal night sleep. #tage ) #leep7 follo%s stage 1 sleep8 it composes approximately 45-55 % of a normal night sleep. EE*+ Stage " sleep is characteri0ed by sleep spindles& vertex %aves& increased theta& and the appearance of delta. /o%ever& less than " $ of the record contains delta.

#tages 3 and ! combined are called ,slow wave sleep, Stage * and + combined compose 13-23 % of a normal nights sleep. #tage 3 sleep7 called one of the 9slo% %ave9 sleep stages because brain activity slo%s do%n dramatically as the person progresses to stage + sleep EE*+ Stage * sleep is characteri0ed by increasing delta content and reduction in faster fre,uencies. 3elta comprises " !. $ of the record. #tage ! #leep7 9slo% %ave sleep9 similar to stage *& brain activity slo%s dramatically. EE*+ Stage + sleep is characteri0ed by a further increase in delta content& so that delta comprises more than . $ of the record. :ertex %aves and sleep spindles are less prominent and are often absent.

RE- .Rapid Eye -ovement #leep/7 a very active stage of sleep. ;omposes 20-25 % of a normal nights sleep. EE*+ <E= sleep is characteri0ed by& a lo% voltage bac(ground& composed of predominantly fast fre,uencies. It can be difficult to distinguish <E= sleep from light dro%siness. <hythmic 6!- /0 activity& %hich is called sa%tooth %aves may appear in the frontal regions and vertex. #he features of <E= sleep that distinguish it from dro%siness are the follo%ing7 1. <apid and chaotic eye movements (dro%siness is associated %ith slo% roving eye movements) ". /ypotonia as measured by submental E=G *. 2n irregular respiratory rate In addition it is associated %ith increased variability in the regulation of temperature& blood pressure and heart rate. #he cognitive process of dreaming is closely associated %ith <E= sleep. >hen an individual is a%a(ened from <E= sleep& there is a rapid return to an alert state& often %ith recall of dreams. <E= sleep occurs in cycles approximately every 5 minutes throughout the night& %ith the longest& most intense <E= period occurring ?ust after the body temperature nadir (around .7 2= in an individual on a 117 P= to @7 2= sleep schedule).

#he body cycles or 9drifts9 through the four stages of sleep7 Stage 1& "& *& and +. /eart rate and respirations become slo%er. #he body then returns to stage " before moving into 9<E=9.

Developmental changes in sleep #otal sleep decreases steadily from about 16 hoursAday in the ne%born. 1y 1 year of age the typical child sleeps approximately 11 hours per night& %ith another "1A"!*hours of sleep obtained in t%o separate daytime naps. 1y age * the average child gets about 1 1A" hours of sleep per night %ith one 11A"!hour nap. >ith aging the amount of slo% %ave and <E= sleep diminishes& there are more fre,uent arousals& and decreased sleep efficiency is manifested by interruptions %ith long periods of %a(efulness.

0##E##-E'& 12 #3EE4 $5#1R$ER#

Guidelines for taking a sleep history 3efine the specific sleep problem 2ssess the onset and clinical course of the condition 3istinguish bet%een sleep disorders <eassess previous diagnosis Evaluate "+!h sleepA%a(efulness patterns Buestion the bed partner 3etermine the presence of other sleep disorders Cbtain a family history of sleep disorders Evaluate the personal and societal impact of the sleep disorder

'octurnal 4olysomnography Docturnal PSG is indicated in& patients %ho have clinical evidence of sleep apnea or %ho have excessive daytime sleepiness. #hese conditions suggest a nocturnal sleep disorder. -ultiple sleep latency testing =ultiple sleep latency testing is indicated %hen narcolepsy is suspected.

#3EE4 $5#1R$ER#
#here are many classifications of sleep disorders and specialist clinics generally recognise a large number of conditions. #he main groupings are those %here there is7 inade uate sleep& that is insomnia& %here there is e!cessive sleep such as narcolepsy& hypersomnia and sleep apnea parasomnias& including sleep %al(ing& night terrors and nightmares.

5'#1-'50
&ransient insomnia ! lasting for a fe% nights #hort6term insomnia ! t%o or four %ee(s of poor sleep (hronic insomnia ! poor sleep that happens most nights and lasts a month or longer

&ransient and short6term insomnia

*enerally occurs in people who are temporarily e7periencing one or more of the following+ stress environmental noise extreme temperatures change in the surrounding environment sleepA%a(e schedule problems such as those due to ?et lag medication side effects

(hronic insomnia
$epression and an7iety disorders are common causes 1ther underlying causes include7 arthritis& (idney disease& heart failure& asthma& sleep apnea& restless legs syndrome& Par(insonEs disease& and hyperthyroidism. %ehavioral factors, causing insomnia include+ the misuse of caffeine& alcohol& or other substances8 disrupted sleepA%a(e cycles as may occur %ith shift %or( or other nighttime activity schedules8 and chronic stress. 5nsomnia in some people is caused by poor sleep hygiene in general7 expecting to have difficulty sleeping and %orrying about it ingesting excessive amounts of caffeine drin(ing alcohol before bedtime smo(ing cigarettes before bedtime excessive napping in the afternoon or evening

irregular or continually disrupted sleepA%a(e schedules &reatment or transient and short6term insomnia #ransient and short!term insomnia may not re,uire treatment since episodes last only a fe% days at a time. the use of short!acting sleeping pills may improve sleep and next!day alertness &reatment for chronic insomnia consists of7 )irst& diagnosing and treating underlying medical or psychological problems. Identifying behaviors that may %orsen insomnia and stopping (or reducing) them. Possibly using sleeping pills& although the long!term use of sleeping pills for chronic insomnia is controversial. #rying behavioral techni,ues to improve sleep& such as relaxation therapy& sleep restriction therapy& reconditioning& and bright light. 1&HER -E&H1$# 12 &RE0&-E'& Rela7ation &herapy #here are specific and effective techni,ues that can reduce or eliminate anxiety and body tension. 2s a result& the personEs mind is able to stop 9racing&9 the muscles can relax& and restful sleep can occur. It usually ta(es much practice to learn these techni,ues and to achieve effective relaxation. #leep Restriction. Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. #hey may benefit from a sleep restriction program that at first allo%s only a fe% hours of sleep during the night. Gradually the time is increased until a more normal nightEs sleep is achieved. Reconditioning 2nother treatment that may help some people %ith insomnia is to recondition them to associate the bed and bedtime %ith sleep. )or most people& this means not using their beds for any activities other than sleep and sex. 2s part of the reconditioning process& the person is usually advised to go to bed only %hen sleepy. If unable to fall asleep& the person is told to get up& stay up until sleepy& and then return to bed. #hroughout this process& the person should avoid naps and %a(e up and go to bed at the same time each day. Eventually the personEs body %ill be conditioned to associate the bed and bedtime %ith sleep. %right 3ight If you are having trouble getting to sleep early enough at night it %ill help to %a(e up at the same time every morning and try to get as much bright light in the morning as possible. #his %ill help reset the internal cloc( to an earlier time at night for sleep. If you are having trouble staying a%a(e in the evening and %a(ing up too early in the morning then try to get bright light in the evening. #his %ill help rest the internal cloc( to go to sleep later and %a(e up later.

#leep Hygiene
$o+ Go to bed at the same time each day. Get up from bed at the same time each day. Get regular exercise each day& preferably in the morning. #here is good evidence that regular exercise improves restful sleep. #his includes stretching and aerobic exercise. Get regular exposure to outdoor or bright lights& especially in the late afternoon. Feep the temperature in your bedroom comfortable. Feep the bedroom ,uiet %hen sleeping. Feep the bedroom dar( enough to facilitate sleep. Gse your bed only for sleep and sex. #a(e medications as directed. Its is often helpful to ta(e prescribed sleeping pills one hour before bedtime& so they are causing dro%siness %hen you lie do%n& or 1 hours before getting up& to avoid daytime dro%siness. Gse a relaxation exercise ?ust before going to sleep. =uscle relaxation& imagery& massage& %arm bath& etc. Feep your feet and hands %arm. >ear %arm soc(s andAor mittens or gloves to bed.

$on8t+ Exercise ?ust before going to bed. Engage in stimulating activity ?ust before bed& such as playing a competitive game& %atching an exciting program on television or movie& or having an important discussion %ith a loved one. /ave caffeine in the evening (coffee& many teas& chocolate& sodas& etc.) <ead or %atch television in bed. Gse alcohol to help you sleep. Go to bed too hungry or too full. #a(e another personEs sleeping pills. #a(e over!the!counter sleeping pills& %ithout your doctorEs (no%ledge. #olerance can develop rapidly %ith these medications. 3iphenhydramine (an ingredient commonly found in over!the!counter sleep medications) can have serious side effects for elderly patients. #a(e daytime naps. ;ommand yourself to go to sleep. #his only ma(es your mind and body more alert. 5f you lie in bed awa9e for more than )0630 minutes, get up, go to a different room .or different part of the bedroom/, participate in a quiet activity .e g non6e7citable reading or television/, then return to bed when you feel sleepy $o this as many times during the night as needed

'arcolepsy
Darcolepsy is a serious clinical problem that usually begins before the age of ". and persists throughout life. Incidence is 1 per thousand& %ith =7) e,ual. (linical features It is characteri0ed by e7cessive daytime sleepiness and irresistible sleep attac9s that usually occur in con?unction %ith one or more of the three auxiliary symptoms7 cataple7y, sleep paralysis and hypnagogic hallucinations. Gp to three fourths of narcolepsy patients have cataplexy& a brief and sudden loss of muscle control %ithout loss of consciousness. Episodes are precipitated by strong emotions such as fear& surprise& laughter& or anger. Sleep paralysis and hypnagogic hallucinations are short episodes that occur during the transition bet%een %a(efulness and sleep. Etiology+ )amily studies sho%ing a 1 !. $ incidence of affected first!degree relatives and a high incidence of /42 (/42!3B11H 6 ") concordance (almost 1 $ of patients %ith narcolepsy and cataplexy) imply a strong genetic predisposition. #he sleep attac(s and other auxiliary symptoms appear to be closely related to aberrations in the neurophysiologic mechanisms of <E= sleep. /ypocretin!1 and !" (also called orexin!2 and !1) are ne%ly discovered neuropeptides processed from a common precursor& preprohypocretin. /ypocretin!containing cells are located exclusively in the lateral hypothalamus& %ith %idespread pro?ections to the entire neuroaxis. #%o (no%n receptors& /crtr1 and /crtr"& have been reported. #he functional significance of the hypocretin system is rapidly emerging in both animals and humans. /ypocretin abnormalities cause narcolepsy in dogs& human and mice. #he finding of a deletion in the transcription of the hypocretin receptor " gene in narcoleptic 3oberman pinschers and the development of a (noc(out of the hypocretin gene in mice pointed to the relevance of this system in the sleep!%a(e cycle. $iagnosis+ ;linical features. )amily history is also useful as an indicator.

-ultiple #leep 3atency &est #his is performed during the daytime. #he =S4# is performed as follo%s 1. Patient has a normal night's sleep prior to the recording. ". Electrodes are placed according to the 1 !" Electrode Placement System. In addition to EE* leads& electrodes should be placed for monitoring the follo%ing physiologic parameters7 a E1* b #ubmental E-* c E(* *. 2t least four naps are begun at scheduled intervals. 2t least 1. minutes are recorded before the first nap. <ecordings are made until the follo%ing criteria are met. a. " minutes %ithout sleep b. 1. minutes of continuous sleep c. " minutes of interrupted sleep& even if less than 1. minutes of sleep occurred. -anagement7 Patients should be %arned about the potential dangers of driving or other activities re,uiring full alertness and muscle control. #herapeutic naps enhance daytime alertness and reduce the need for high doses of stimulants. #ricyclic antidepressants& including imipramine and clomipramine& can be helpful in preventing cataplexy. =odafinil is a novel medication recently approved for the treatment of narcolepsy and idiopathic hypersomnia.

4arasomnias+ #leepwal9ing, 'ight &errors and 'ightmares

#leepwal9ing (somnambulism) occurs in episodes lasting several minutes. 3uring this period& patients generally have blan( expressions& behave as if indifferent to the environment& and exhibit lo% levels of a%areness and reactivity& manifested by clumsiness and purposeless activity. #hey rarely recall the events upon a%a(ening. 'ight terror episodes have the additional and often dramatic characteristic of extreme vocali0ation and movement& excessive autonomic discharges& and panic. 'ightmares are usually associated %ith fears of attac(& falling or death and in many patients the nightly themes recur. Dightmares occur during <E= sleep. <ecently a <E=!sleep behavior disorder has been described that is associated %ith dream! enacting behavior& often resulting in violent acts or in?uries. $ifferential $iagnosis+ Dight terrors should be differentiated from temporal lobe epilepsy& although the latter rarely expresses during sleep. =ost Isleep%al(ingJ in elderly persons reflects episodes of confusion and nocturnal %andering rather than parasomnia. -anagement+ Protection from in?ury. <eassurance& minimi0ing children's exposure to potentially traumatic experiences can help reduce nightmares. 1en0odia0epines help in adults %ho have night terrors and sleep%al(ing. .

(linical (haracteristics of #leepwal9ing and 'ight &errors Episodes occur early in night ;onfusion on %a(ing and minimal recall of event /igh ris( of in?ury )amily history of sleep%al(ing or night terrors usually present Cnset usually in childhood or early adolescence =ost often outgro%n by late adolescence Psychopathology suspected if onset is in adulthood

$ifferentiation of 'ight &errors and 'ightmares (haracteristic :ocalization 0utonomic activity 0rousal -otility Recall #leep stage Dight #errors Intense =ar(ed increase 3ifficult =ar(ed =inimal Don!<E= Easy 4imited :ivid <E= Dightmares 4imited Slight increase

5'$5:5$;03 #&0&E-E'&# 1. %aves in an EEG are maximal over the occiput. ". #heta %aves can occur normally in a%a(e adults. *. 1en0odia0epines increase the occurrence of %aves in EEG. +. 3uring <E= sleep EEG is the same as the normal %a(ing state. .. #he sleep EEG of a normal * years old man sho%s periods of <E= sleep %hich increase throughout the night. 6. <E= sleep occupies more than * $ of the night in a normal adult. @. 3elta %aves are normally seen in Stage II sleep. -. =ost deep sleep occurs during the second half of the night. 5. Stage * and + of sleep are differentiated on the basis of theta %aves. 1 . #he threshold for arousal is higher during <E= sleep 11. Slo% %ave sleep comprises . $ of total sleep time. 1". )ollo%ing sleep deprivation rebound only affects <E= sleep. 1*. 3uring sleep slo% %ave sleep is more prominent in the second half of the night. 1+. <apid eye movement sleep is characterised by increased muscular activity. 1.. 2n increase in <E= sleep may follo% %ithdra%al from ben0odia0epines. 16. 2bout " $ of individuals report dreams on %a(ing from <E= sleep.

1@. Dight terrors can occasionally occur during <E= sleep. 1-. =ore than on one!third of patients suffering from depression present %ith hypersomnia. 15. 3epressed patients have been sho%n to have a prolonged <E= latency.

#here are * types of Sleep 2pnea7 Cbstructive sleep apnea is fairly common #he air%ay becomes bloc(ed by the tongue& excesses tissue or relaxed throat muscles during sleep. 1reathing usually stops for 1 to 5 seconds. #he body struggles for air !!! briefly %a(ing the sleeper. 1reathing then begins again. #he person may %a(e hundreds of times per night. >a(ing does necessarily mean the person opens their eyes and then returns to sleep. It may simply lighten the person sleeping thus inhibiting the normal sleep cycle& thus interrupting good ,uality sleep. #his can then ma(e the person sleepy throughout the daytime hours. ;entral Sleep 2pnea...is fairly rare. It usually affects adults over age 6 . #he brain 9forgets9 to tell the breathing muscles to move. #he lac( of oxygen causes the brain to %a(e the sleeping person. #hen breathing resumes. #he person may remember %a(ing& but not remember %hy. =ixed Sleep 2pnea Involves brief periods of central sleep apnea follo%ed by longer periods of obstructive sleep apnea. Signs of sleep apnea7 loud snoring follo%ed by a breathless pause .... ending %ith a gasp or snort. People %ith central sleep apnea usually do not snore. <estless movements& high blood pressure& morning headache& impotence& problems %ith memory and concentration& extreme tiredness or sleepiness caused by the fre,uent interruptions of sleep. 5n 'octurnal 4#* the follo%ing physiologic parameters are measured7 EEG Electro!oculogram Submental E=G E;G <espiration 1lood oxygenation Expired carbon dioxide 1ody and limb movement 2udiovisual monitoring and behavioral observation 4inear and elapsed time

#he #reatment of Sleep 2pnea7 Dasal ;P2P ;ontinuous Positive 2ir%ay Pressure (;P2P) is a device that can be placed at home to treat obstructive sleep apnea. #he ;P2P device %or(s during sleep by gently blo%ing air from a machine into a mas( applied over the personEs nose. #he air pressure (eeps the air%ay open& thus eliminating the apnea and fre,uent a%a(enings. >eight 4oss Even a small %eight loss may ma(e a difference in obstructive sleep apnea. It may also decrease the amount of air needed for treatment. Sleeping on the side as it can help to (eep the air%ay open. 3ental appliances they are used to help (eep the tongue from falling bac( during sleep or to move the ?a% for%ard. =edication .. used to stimulate the breathing in central apnea. Surgery .. is used to %iden the air%ay or create an opening in the %indpipe