Disorders of Sleep

From: Subject: Disorders of Sleep Date: Wed, 3 Jun 2009 21:15:20 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0150_01C9E490.66C6D4E0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0150_01C9E490.66C6D4E0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1113.htm Disorders of Sleep

Disorders = of Sleep=20

Sudhansu Chokroverty, M.D., F.R.C.P., = F.A.C.P.
New=20 Jersey Neuroscience Institute at John F. Kennedy Medical Center=96Seton = Hall=20 University, New York Medical College, University of Medicine and = Dentistry New=20 Jersey/Robert Wood Johnson Medical School

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

Insomnia

Difficulty initiating or maintaining sleep, or = early=20 awakening with inability to go back to sleep=20
Associated with a wide variety of medical, = psychiatric,=20 and neurologic causes; may be drug- or alcohol-induced =

Obstructive Sleep Apnea Syndrome = (OSAS)

Cessation of airflow during sleep despite = continued=20 respiratory effort=20
Decrease in breathing ≥ 10 sec, with = ≥ 5 episodes per=20 hour of sleep=20
Common in middle-aged and elderly men; = incidence=20 increases in women after menopause=20
Can lead to hypertension, cardiac arrhythmias, = heart=20 failure=20
Sleep hypopnea (decrease of breathing to < = 50% of=20 volume of preceding or following respiratory cycle, associated with = arousal or=20 4% oxygen desaturation) has same clinical significance=20
Symptoms=20
- Nocturnal=20
  
  Loud snoring=20
  Choking=20
  Cessation of breathing=20
  Sitting up and fighting for breath=20
  Abnormal motor activities, thrashing in = bed=20
  Gastroesophageal reflux=20
  Nocturia=20
  Hyperhidrosis
- Daytime=20
  
  Excessive daytime somnolence=20
  Morning headaches=20
  Forgetfulness=20

Circadian rhythm sleep disorders=20

Desynchronization between patient's internal circadian rhythm and = external=20 time=20
- Jet lag=20
- Shift work=20
- Delayed or advanced sleep-phase syndrome=20

Narcolepsy=20

Sleep attacks (irresistible desire to sleep in = inappropriate places and under inappropriate circumstances)=20
- Attacks last generally a few minutes to 30 = min=20
- Onset of attacks usually between ages 15 and = 25 yr=20
Cataplexy (transient loss of muscle tone) in = most=20 patients occurs after months or years=20
- Often triggered by emotional outburst =
Lifelong disorder; generally less severe with = old age=20

Restless legs syndrome=20

Urge to move legs, usually accompanied by = uncomfortable=20 or unpleasant sensations; arms sometimes affected=20
Symptoms begin or worsen during rest or=20 inactivity=20
Partial or total relief of symptoms with = movement, at=20 least early in illness=20
Worse in evening or early part of night =
Lifelong; may begin at any age but most severe = in=20 middle-aged or elderly persons, with chronic progressive course =

Parasomnias=20

Partial arousal disorders=20
- Confusional arousals=20
  - Most common in children < 5 yr of age=20
Sleepwalking=20
- Common in children 5=9612 yr of age=20
- May be precipitated by sleep deprivation, = fatigue,=20 concurrent illness, sedatives
Sleep terrors=20
- Peak onset 5=967 yr of age=20
- Precipitating factors similar to = sleepwalking=20
Rapid eye movement (REM) sleep behavior = disorder=20
- Commonly seen in elderly=20
- Intermittent loss of REM-related atonia or = hypotonia,=20 with abnormal motor activities (often violent)=20
- Most cases secondary to neurodegenerative=20 disease
Nocturnal frontal lobe epilepsy (nocturnal = paroxysmal=20 dystonia)=20
- Onset any time from infancy to fifth decade = of=20 life=20
- Characterized by ballismic, choreoathetoid, = or=20 dystonic movements=20
- Usually short duration (15 sec to < 2 = min)

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Differential=20 Diagnosis

Insomnia

Psychiatric disorders=20
- Anxiety=20
- Panic attacks=20
- Depression=20
- Stress=20
- Other psychophysiologic factors=20
- Medical disorders=20
  - Bronchial asthma=20
  - Coronary artery disease=20
  - Peptic ulcer disease=20
  - Rheumatic disorders
- Neurologic disorders=20
  - Stroke=20
  - Neurodegenerative disease=20
  - Brain tumors=20
  - Headache syndromes=20
  - Neuromuscular disorders (e.g., painful = peripheral=20 neuropathies)
- Traumatic brain injury=20
- Pain anywhere in the body=20
- Sleep=96wake schedule disruptions=20
- Other disorders of circadian sleep = rhythms=20
- Drug or alcohol abuse
REM Sleep Behavior Disorder=20
- Parkinson disease=20
- Multiple system atrophy=20
- Diffuse Lewy body disease=20
- Olivopontocerebellar atrophy=20
- Progressive supranuclear palsy=20
- Corticobasal ganglionic degeneration=20

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Best=20 Tests

History

Sleeping habits=20
Drug and alcohol consumption=20
Previous or current psychiatric, medical, or = neurologic=20 illness=20
Family history

Physical Examination

Obesity in 70% of patients with OSAS=20
Local upper airway anatomic disorders in many = cases of=20 OSAS

Diagnostic Studies

MRI or other neuroimaging as indicated, to = exclude=20 structural lesions=20
Laboratory tests to exclude suspected medical=20 disorders

Sleep Laboratory Testing

All-night polysomnography (PSG)=20
- EEG=20
- EMG=20
- Electro-oculography=20
- Electrocardiography=20
- Airflow at nose and mouth=20
- Respiratory effort=20
- Oxygen saturation
Multiple sleep latency test=20
Actigraphy

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Best=20 Therapy

Insomnia

Transient=20
- Short-term treatment for a few nights to a = few=20 weeks=20
- Sedative-hypnotics=20
  - Zaleplon, 5=9610 mg h.s.=20
    - Cost/mo: $96
  - Zolpidem, 5=9610 mg h.s.=20
    - Cost/mo: $100
  - Zolpidem extended release, 6.25=9612.5 mg = h.s.=20
    - Cost/mo: $105=96$210
  - Eszopiclone, 1=963 mg h.s.=20
    - Cost/mo: $107
  - Ramelteon, 8 mg h.s.=20
    - Cost/mo: $102 =
- Short- or intermediate-acting = benzodiazepines
  - Temazepam, 7.5=9630 mg h.s.=20
    - Cost/mo: $12
  - Triazolam, 0.125=960.250 mg h.s.=20
    - Cost/mo: $18
  - Flurazepam, 15=9630 mg h.s.=20
    - Cost/mo: $9
  - Estazolam, 1=962 mg h.s.=20
    - Cost/mo: $28 =
Chronic=20
- Treatment of underlying disorders=20
- Sleep hygiene
  - Fixed times for retiring and = awakening=20
  - Avoidance of caffeine, tobacco, = alcohol=20
  - Regular exercise (preferably 4=966 hr = before bedtime)=20
- Stimulus-control therapy=20
- Sleep restriction=20
- Relaxation training=20
- Pharmacotherapy (intermittently combined = with=20 above)=20
  - Eszopiclone, 1=963 mg h.s.=20
  - Ramelteon, 8 mg h.s.=20
  - Other sedative-hypnotics or = benzodiazepines=20

OSAS

Avoidance of sedatives, hypnotics, = alcohol=20
Reduction of obesity=20
Continuous positive airway pressure (CPAP) = ventilation=20 in moderate to severe cases=20
- Optimal pressure determined during overnight = PSG
Laser-assisted or radiofrequency=20 uvulopalatopharyngoplasty in some mild to moderate cases=20
Dental appliance in selected mild to moderate=20 cases

Circadian Rhythm Sleep = Disorders

Bright-light therapy=20
Chronotherapy=20
Pharmacotherapy (e.g., melatonin, ramelteon,=20 zolpidem)

Narcolepsy

Stimulants for treatment of sleep = attacks=20
- Modafinil, 100=96200 mg/day=20
  - Cost/mo: $255
- Methylphenidate, 10=9660 mg/day=20
- Dextroamphetamine, 5=9660 mg/day=20
- Methamphetamine, 5=9650 mg/day =
Treatment of cataplexy
- Tricyclic antidepressants=20
  - Protriptyline, 2.5=9620 mg/day=20
    - Cost/mo: $104
  - Imipramine, 25=96200 mg/day=20
    - Cost/mo: $47
  - Clomipramine, 25=96100 mg/day=20
    - Cost/mo: $34
- Selective serotonin reuptake inhibitors = (e.g.,=20 fluoxetine, 20=9660 mg/day in divided doses; paroxetine, 20=9640 = mg/day in=20 divided doses)=20
- Endogenous hypnotics=20
  - Sodium oxybate (γ-hydroxybutyric = acid), 3=969 g in two=20 divided doses nightly

Restless Legs Syndrome

Dopaminergic drugs
- Carbidopa-levodopa, 25/100=96100/400 mg in = divided doses=20 before bedtime=20
  - Cost/mo: $81
- Dopamine agonists (best initial = agent)=20
  - Pergolide, 0.05=960.5 mg in divided doses = before=20 bedtime=20
    - Cost/mo: $94
  - Pramipexole, 0.125=961.5 mg before = bedtime=20
    - Cost/mo: $61=96$71
  - Ropinirole, 0.25=963.0 mg before = bedtime=20
    - Cost/mo: $68
- Benzodiazepines (e.g., clonazepam, 0.5=962 = mg=20 h.s.)=20
- Opioids=20
  - Codeine, 30=96120 mg/day=20
  - Propoxyphene, 65=96130 mg/day=20
  - Oxycodone, 10=9620 mg/day=20
  - Hydrocodone, 5=9610 mg/day=20
  - Tramadol, 50=96100 mg/day =
- Anticonvulsants (e.g., gabapentin, = 300=961,200 mg before=20 bedtime, in divided doses)

Nocturnal Frontal Lobe Epilepsy

Carbamazepine, 200=961,000 mg in divided = doses=20
- Cost/mo: $27

REM Sleep Behavior Disorder

Low-dose benzodiazepines (e.g., clonazepam, = 0.5=962 mg=20 h.s.)

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Best=20 References

Dagan Y: Sleep Med Rev 6:45, 2002 [PMID=20 12531141]

Earley CJ: N Engl J Med 348:2103, 2003 [PMID=20 12761367]

Flemons WW: N Engl J Med 347:498, 2003 [PMID=20 12181405]

Morin CM, et al: Curr Treat Options Neurol 3:9, = 2001 [PMID=20 11123855]

The = author has been=20 a member of the speakers' bureau for Sanofi-Aventis and has served as a=20 consultant for Boehringer Ingelheim Corp.

November=20 2006