LMCC/Sleep Disorders
< LMCC
- characterized by one of three complaints
insomnia
- difficulty falling alseep, maintaining sleep, early morning wakening or non-refreshing sleep
parasomnias
- night terrors, nightmares, restless leg syndrome, somnambulism
excessive daytime sleepiness
Epidemiology
edit- 1/3 of people have occasional sleep problems
- 10% have chronic sleep problems
- > in women with increasing age
History
editA thorough sleep history includes:
- history from patient and partner
- sleep environment (noise, temperature, light)
- shift work or life stresses
- use of tobacco, alcohol, caffeine, pharmaceuticals and illicit drugs
- snoring, apneic episodes, limb jerks, sleep paralysis
- daytime consequences, impact on quality of life
Investigations
edit- complete sleep diary every morning for 1-2 weeks
- record bedtime, sleep latency, total sleep time, awakenings, quality of sleep
- rule out specific medical problems (CBCD, TSH)
- sleep study referral if suspect periodic leg movements of sleep or sleep apnea
- night time polysomnogram or daytime multiple sleep latency test
Treatment
edit- treat and manage any suspected medical or psychiatric caueds
- psychologic treatment
- sleep hygiene
- avoid caffeine, nicotine, alcohol, exercise regularly, comfortable sleep environment, regular sleep schedule
- relaxation therapy
- stimulus control therapy
- sleep restriction therapy
- sleep hygiene
- pharmacologic treatment
- short term benzodiazepines
Specific problems
editprimary insomnia
edit- majority of cases
- person reacts to the insomnia with fear or anxiety around bedtime or with a change in sleep hygiene
- can progress to a chronic disorder called psychophysiological insomnia
Snoring
edit- results from soft tissue vibration at the back of the nose and throat due to tubulent airflow through narrowwed air passages
- risk factors: male gender, obesity, alcohol consumption, ingestion of tranquilizers or muscle relaxants and smoking
- Physical exam: obesity, nasal polyps, septal deviation, hypertrophy of the nasal turbinates, enlarged uvula and tonsils
- Investigations if severly symptomantic
- noctural polysomnography
- airay assessment (CT or MRI)
- treatment
- sleep on side, weight loss
- nasal dilators, tongue retaining devices, mandibular advancement devices
- risk is development of obstructive sleep apnea
Obstructive sleep apnea (OSA)
edit- apnea resulting from upper airway obstruction due to collapse of the base of the tongue, soft palate with uvula, and epiglottis
- respiratory effort is present
- leads to a distinctive snorting, choking awakening type pattern as the body arouses itself to open the airway
- apneic episodes can last from 20seconds - 3 minutes
- can have 100-600 episodes/night
- diagnosis based on nocturnal polysomnography
- >15 apneic episodes with arousal recorded per night
- risk factors
- 2% women, 4% men
- between ages 30-60
- obesity causing upper airway narrowing: BMI >28kg/m present in 60-90% of cases
- children: commonly tonsils or adenoids
- aging which causes decreased muscle tone
- persistent URT infections, allergies, nasal tumours, hypothyroidism
- Family medical history
- consequences
- Daytime somnolence, nonrestorative sleep
- Poor social and work performance
- mood changes: anxiety, irritability, depression
- sexual dysfunction: poor libido, impotence
- morning headache due to hypercapnia
- Hypertension, coronary artery disease, stroke, arrhythmias
- pulmonary hypertension, RV dysfunction, cor pulmonale due to chronic hypoxemia
- memory loss, decreased concentration, confusion
- investigations
- blood gas not helful, TSH if clinically warrented
- evaluate BP, inspect nose, oropharynx for enlarged adenoids or tonsils
- nocturnal polysomnography
- Treatment
- modifying factors: avoid sleeping supine, lose weight, avoid alcohol, sedative, narcotics, inhaled steroids if nasal swelling present
- primary treatment of OSA is CPAP which maintains patent airway in 95% of OSA cases
- dental appliances to modify mandibular position
- surgery: somnoplasty, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty
- report patient to ministry of transportation if OSA is not controlled by CPAP
Central Sleep Apnea
edit- pathophysiology
- brain fails to send appropriate signals to breathing muscles to initiate respirations
- the defining feature is absent respiratory effort
- often secondary to CNS diseases ie. brainstem infarct, infection, neuromuscular disease
- investigations: PFTs, nocturnal polysomnography, MRI
- treatment: CPAP or mechanical ventilation if brainstem origin
- prognosis: poor
Sleep Tips
edit- Keeping a routine is important. Try going to sleep at the same time every night and get up at the same time every morning.
- Make sure the environment you sleep in is dark and quiet. Ask others to be respectful of your sleep and not disturb you while your asleep.
- Do not eat or drink at least two hours before bed.
- Take only 30 minute naps during the day if needed.
- Stay away from fatty foods during the day and especially before bed.
- Exercise on a regular bases but never right before bed. (MayoClinic.com, 2010)
References
editToronto Notes 2005
MayoClinic.com. (2010). 10 Tips for Better Sleep. Retrieved from http://www.mayoclinic.com/health/shift-work/AN01616