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Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018
| Contributor Information
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Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
A 48-year-old man with a body mass index (BMI) of 31 presents complaining of tiredness. He takes naps on the weekends, and his Epworth Sleepiness Scale score is 10. He has occasional gasping at night and has nocturia (two voidings nightly). The finding shown on the slide was noted about once every 2 minutes.
What is the diagnosis?
Central sleep apnea (CSA)
Upper airway resistance syndrome (UARS)
Obstructive sleep apnea (OSA)
Ataxic breathing
Image courtesy of Medscape.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: C. Obstructive sleep apnea (OSA).
As a result of a combination of causes, including relaxation of the tongue and in turn its posterior movement, the oropharynx's diameter reduces, and the airway may close. The brain responds with brief arousals.[1] Magnetic resonance imaging (MRI) shows a patent airway (left) and a nearly obstructed airway (right).
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The slide illustrates the obstruction of the oropharynx by the base of the tongue. Available treatment options include the following[2]:
Positive airway pressure (PAP) therapy to improve airway patency
Surgical procedures
Splinting the mandible forward by mandibular advancing dental appliances
Hypoglossal nerve stimulation to increase the tongue muscle tone
Image courtesy of Inspire Medical Systems, Inc, with permission.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The hypoglossal nerve is a motor nerve that innervates the tongue. Stimulation of the nerve causes increased muscle tone and forward movement of the tongue.
Image courtesy of Inspire Medical Systems, Inc, with permission.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Inspire Medical Systems, Inc. has produced an implantable device that senses the onset of respiratory effort when the thoracic respiratory muscles contract and subsequently stimulates the hypoglossal nerve to pull the tongue forward.
FDA approved indications are:
22 years of age or older
Moderate to severe OSA (AHI range from 15-65 with <25% central apneas)
Unable to use CPAP or CPAP failure
No concentric collapse at the palate level.
Inspire therapy has not been tested in people with a BMI greater than 32.
Image courtesy of Inspire Medical Systems, Inc, with permission.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The graph shown illustrates a study with a small sample of patients (20 patients) whose moderate to severe obstructive sleep apnea was treated with hypoglossal nerve stimulation therapy.[3]
The study reported that:
Mean apnea-hypopnea index (AHI) reduced from 33.3 ± 13.0 to 5.1 ± 4.3
Mean Epworth Sleepiness Score (ESS) reduced from 10.3 ± 5.2 to 6.0 ± 4.4
Seventy percent (14/20) of patients achieved a treatment AHI <5
A 2014 hypoglossal nerve stimulation study published in the New England Journal of Medicine that included 126 patients whose obstructive sleep apnea was treated with a surgically implanted upper-airway stimulation device, reported the following[4]:
AHI at 12 months reduced by 68% (AHI of 29 reduced to 9)
Oxygen desaturation index (ODI) decreased 70% (ODI of 25 reduced to 7)
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Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
A 61-year-old woman presents with insomnia and chronic pain. Her BMI is 31. She occasionally wakes up with neck pain and takes a hydrocodone tablet. At bedtime, she takes long-acting morphine to prevent pain. She feels tired and sleepy during the day but cannot sleep at night.
What is the diagnosis?
Obstructive Sleep Apnea (OSA)
Mixed sleep apnea
Obesity-related hypoventilation
Central Sleep Apnea (CSA)
Image courtesy of Medscape.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: D. Central Sleep Apnea (CSA).
Narcotics are among the causes of CSA. Pauses in breathing cause oxygen desaturation and hypercapnia. Clinical manifestations include waking up at night, disturbed sleep, daytime sleepiness, and tiredness.[5] Treatment options include reducing the narcotic dosages and utilizing bilevel ventilation with a backup rate.
Image courtesy of Medscape.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
A 76-year-old man presents with a chief complaint of insomnia. His BMI is 32, and he has hypertension and lower-extremity edema. He is currently taking furosemide and carvedilol. Polysomnography (PSG) is done, and the findings shown in the slide are noted for a total of 3 hours during the night.
What is the diagnosis?
OSA
Mixed sleep apnea
Ataxic respiration
Cheyne-Stokes respiration (CSR)
Image courtesy of Medscape.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: D. Cheyne-Stokes respiration (CSR).
According to the American Academy of Sleep Medicine,[6] the following criteria must be met for a diagnosis of CSR:
There are episodes of three or more consecutive central apneas and/or central hypopneas separated by a crescendo-decrescendo change in breathing amplitude with a cycle length of at least 40 seconds
There are five or more central apneas and/or central hypopneas per hour of sleep associated with the crescendo-decrescendo breathing pattern recorded over at least 2 hours of monitoring
CSR may be caused by a combination of factors, including a high loop gain (LG), reduced carbon dioxide tension (PCO2), and reduced cardiac output that creates a delay between a change in PCO2 and detection of this change. Conditions that can give rise to CSR include heart failure, diffuse brain damage, and brainstem pathologies.[7]
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The actigram shown in the slide is from a 24-year-old blind woman who presents with complaints of insomnia, fatigue, sleepiness.
What is the diagnosis?
Circadian rhythm sleep disorder, delayed sleep phase type, also known as delayed sleep phase syndrome (DSPS) or disorder (DSPD)
Circadian rhythm sleep disorder, advanced sleep phase type, also known as advanced sleep phase syndrome (ASPS) or disorder (ASPD)
Circadian rhythm sleep disorder, free-running type, also known as non-24-hour sleep-wake disorder (N24HSWD)
Circadian rhythm sleep disorder, shift work type, also known as shift work sleep disorder
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: C. Circadian rhythm sleep disorder, free-running type, also known as non-24-hour sleep-wake disorder (N24HSWD).
Around 50% of blind people are affected. The etiology is near-absence of light perception. Light, through the retinohypothalamic pathway, helps regulate circadian rhythmicity; the absence of light causes the circadian clock to run freely, with no daily adjustments. The symptoms are insomnia, sleepiness and irregular sleep pattern.[5] In the 10-day actigram shown in the slide, the silent areas represent sleep and the active areas wakefulness; the red line shows the sleep time shift over many days.
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The circadian clock is the master clock in humans and is located in the suprachiasmatic nuclei of the hypothalamus.[8] It includes several "clock genes," their proteins, and two feedback loops. Factors that influence clock rhythmicity include light through the retinohypothalamic pathway, melatonin, exercise, and social interactions. These cues are called zeitgebers (German for "timegivers").
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The actigram shown in the slide is from a 72-year-old woman who cannot sleep well at night, wakes up after 3 hours, and walks around the house; during the daytime, she takes frequent naps.
What is the diagnosis?
Circadian rhythm sleep disorder, free-running type (N24HSWD)
Circadian rhythm sleep disorder, advanced sleep phase type (ASPS/ASPD)
Circadian rhythm sleep disorder, irregular sleep-wake type, also known as irregular sleep-wake disorder (ISWD)
Narcolepsy
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: C. Circadian rhythm sleep disorder, irregular sleep-wake type, also known as irregular sleep-wake disorder (ISWD).
The actigram shows irregular sleep-wake cycles. ISWD is seen in neurodegenerative disorders, such as dementia, and in children with developmental disorders. It presents as insomnia and hypersomnia with frequent napping.[9] The individual is not able to sleep more than 4 hours at a time. (Note that periods of sleep are short and nonconsecutive on this actigram.)
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The actigram shown in the slide is from a 21-year-old college student who reports feeling sleepy during classes and unable to concentrate. When he comes back home during the holidays, he cannot sleep at night, but sleeps from 6 AM until noon.
What is the diagnosis?
Narcolepsy
Circadian sleep rhythm disorder, delayed sleep phase type (DSPS/DSPD)
Sleep apnea
Periodic leg movements during sleep (PLMS)
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: B. Circadian sleep rhythm disorder, delayed sleep phase type (DSPS/DSPD).
This is typically a misalignment of circadian rhythm of younger people.[10] In the previous slide's actigram, the patient's sleep starts at 6:00 AM and ends at noon. The black areas represent times when the patient is awake. Additionally, a total sleep time of 6 hours is too short for him and causes sleepiness due to insufficient sleep time.
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
The PSG shown in the slide is from a 75-year-old man who injured his head when he acted out a dream. The red arrow points to the chin electromyogram (EMG).
What is the diagnosis?
Rapid eye movement (REM) behavior disorder (RBD)
PLMS
Sleepwalking
Restless legs syndrome (RLS)
Image courtesy of the National Institutes of Health.
Sleep Disorders: Rest That Does Not Refresh
Mehran Farid-Moayer, MD | April 3, 2018 | Contributor Information
Answer: A. Rapid eye movement (REM) behavior disorder (RBD).
REM sleep is associated with atonia that prevents dream enactment. In RBD, this atonia is lost, and the failure to inhibit spinal motor neurons causes dreams to be acted out.[11] This may in turn lead to injuries to self or a bed partner. RBD is a disorder of older individuals and may be seen in alpha-synuclein proteopathy (synucleinopathy) and other forms of neurodegeneration, pontine lesions, and narcolepsy; it may also be an adverse effect of antidepressant medications.
In this slide, the first 30-second epoch (above) shows normal REM sleep with loss of muscle tone in the chin EMG. The second epoch (below) shows augmented tone in the chin EMG during REM sleep. This is a pathologic finding.
Major Depressive Disorder: Disabling and Dangerous
Depression is a common psychiatric condition, a leading cause of disability, and a risk factor for suicide. Learn more about distinguishing major depression from related disorders and providing appropriate treatment.Slideshows, March 2018
Sleep disorders are among the most common clinical problems encountered in medicine and psychiatry. Inadequate or nonrestorative sleep can markedly impair a patient's quality of life.Diseases/Conditions, January 2015
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Contributor Information
Mehran Farid-Moayer, MD
Peninsula Sleep Center
Burlingame, CA
Disclosure: Mehran Farid-Moayer, MD, has disclosed no relevant financial relationships.
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References
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