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Sleep Medicine
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Book description

Sleep disorders exact a high toll on society in terms of diminished quality of life, reduced productivity and cost to medical services. This book guides the reader through the basic science of sleep and how to evaluate individuals suffering from sleep irregularities. Complex features of sleep disorders are then discussed, including parasomnias, sleep apnea, night terrors and restless legs syndrome. The book also looks at how these sleep abnormalities can affect individuals with other psychiatric disorders such as epilepsy, depression and anxiety disorders. Covering disorders from insomnia to narcolepsy, and specialty areas from pediatric to geriatric, this wide ranging and accessible guide allows non-sleep specialists to approach and understand important information that is clinically relevant in everyday practice. Illustrated with summary tables, figures and treatment algorithms, this book will be a useful guide for neurologists, psychiatrists, psychologists, pulmonologists and internists as well as health care professionals in training.

Reviews

'This is a very user-friendly manual that does not require readers to have a background in sleep medicine. Neophtyes will get a nice overview of sleep basics and busy clinicians will find a plethora of clinical nuggets.'

Jeffrey Rado - Rush University Medical Center

'… concise, clearly written and well referenced …'

Source: Pediatric Endocrinology Reviews

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Contents

  • 1 - Normal sleep
    pp 9-24
  • View abstract

    Summary

    Sleep is a complex behavior. It may be altered by many different factors including age, genetics, volitional control, timing, previous time awake, and environment. The state of wakefulness regularly alternates with the states of sleep. Polysomnography recordings are scored for movement time. Active wakefulness is characterized by a continuous electroencephalographic (EEG) theta activity associated with eye movements and muscular artifacts. Infants, children, and adolescents show different stages of maturation of sleep, in terms of polysomnographic patterns, architecture, and duration of sleep. The duration of nocturnal sleep depends on several factors. Voluntary control of the sleep time is among the most significant in human beings. Young adults report sleeping approximately 7.5 hours a night on weekday nights and 8.5 hours on weekend nights. The timing of sleep has obvious repercussions both on the duration and on the architecture of sleep.
  • 2 - Evaluation and testing of the sleepy patient
    pp 25-46
  • View abstract

    Summary

    Sleep disturbances can affect people throughout their life span, and the frequency of sleep disturbances increases as we age. People with sleep disturbances may complain of difficulty falling asleep or maintaining sleep, abnormal behaviors during the night, daytime sleepiness or fatigue. Asking about typical bedtime rituals, sleep times and habits is a good place to start in the assessment of any sleep disorder. Many people who present with the classic symptom of insomnia may have more than one problem with sleep. Sleep disorders such as obstructive sleep apnea (OSA), parasomnias, narcolepsy, and nocturnal seizures sometimes require formal evaluation in the sleep laboratory. The most commonly used techniques used in recording and evaluating sleep disorders include the polysomnogram (PSG), the multiple sleep latency test (MSLT), and under special circumstances, the maintenance of wakefulness test (MWT).
  • SECTION 2 - SLEEP DISORDERS
  • View abstract

    Summary

    Parasomnias involve automatic behavior, i.e., seemingly goal-directed, complex purposeful behaviors enacted without the conscious awareness and volition of the individual, who cannot exercise conscious deliberate control over his or her behaviors and sleep-related experiences. It could be subdivided by taking into account the motoric versus autonomic/ sensory activation. This chapter deals with the most common disorders, covering the appropriate diagnostic and therapeutic strategies. Disorders of arousal include sleepwalking or somnambulism, sleep terrors, and confusional arousals. The pathophysiology of REM sleep behavior disorder (RBD) lies in a dysfunction of the brainstem structures modulating REM sleep. Enuresis consists of recurrent involuntary urination during sleep. It includes primary forms, where bladder control has never been achieved, and secondary variants occurring after a period of bladder control. Catathrenia, also known as nocturnal groaning or expiratory vocalization during sleep, consists of the emission of an unusual expiratory noise occurring in bursts without associated motor phenomena.
  • 4 - Circadian rhythm disorders
    pp 56-77
  • View abstract

    Summary

    This chapter discusses circadian rhythms and the known factors which influence them as well as provide an update on the evaluation and treatments of the six circadian rhythm sleep disorders. The six circadian rhythm sleep disorders include delayed sleep phase type, advanced sleep phase type, non-24-hour sleep/wake syndrome, irregular sleep/wake rhythm, shift work sleep disorder, and jet lag disorder. Zeitgebers such as light are entraining agents of the circadian system and the manipulation of zeitgebers can be used as a therapeutic tool for the circadian rhythm sleep disorders. Measurements of circadian phase can be obtained through various surrogate markers of circadian rhythms, including the core body temperature minimum and the dim light melatonin onset (DLMO). Circadian rhythm sleep disorders are commonly under recognized in clinical practice and should be a part of the differential diagnosis of people who present with symptoms of insomnia and daytime sleepiness.
  • 5 - Excessive somnolence disorders
    pp 78-96
  • View abstract

    Summary

    Excessive somnolence can be a consequence of lifestyle, environmental and circadian influences, medical disorders, drugs or substances. Disorders of excessive somnolence include insufficient sleep, narcolepsy, idiopathic hypersomnia, recurrent hypersomnia and hypersomnia associated with neurological disorders, psychiatric disorders and internal disorders. This chapter focuses on hypersomnias of central origin and arising from insufficient sleep. It describes epidemiology, pathophysiology, diagnosis, and therapeutic options for each of the excessive somnolence disorder. Hypersomnia may be caused by an underlying medical or neurological disease. Secondary hypersomnias described in the chapter include Parkinson's disease, genetic disorders, endocrine disorders and psychiatric disorders. Multiple chemical substances, especially organic solvents with chronic exposure, may cause hypersomnia. Pancreatic, adrenal or renal insufficiency, and hepatic encephalopathy are other causes. Hypersomnia may occur as a side effect of many drugs, due either to the soporific effects of the drug or to the effect of the drug on reducing night-time sleep.
  • 6 - Insomnias
    pp 97-112
  • View abstract

    Summary

    Insomnia is amongst the most frequent complaints seen in medical practice, due to its high prevalence rate as a chronic medical condition and its high incidence as an acute condition. This chapter provides an overview of the development of insomnia, information required to make a diagnosis of insomnia, the various recognized insomnia diagnoses, and the pharmacologic, cognitive, and behavioral treatments available. The most important component involved in the diagnosis of insomnia is a thorough and in-depth sleep history. Insomnia due to a mental disorder is the most common diagnosis among people presenting to a sleep center with a complaint of insomnia. Mood disorders such as depression, dysthymia, bipolar disorder, as well as anxiety disorders can be associated with a complaint of insomnia. Aside from progressive muscle relaxation, data are lacking to demonstrate efficacy in insomnia treatment. The most intriguing treatment for insomnia is paradoxical intention.
  • 7 - Restless legs syndrome and periodic limb movement disorder
    pp 113-128
  • View abstract

    Summary

    The most characteristic features of the restless legs syndrome (RLS) are uncomfortable sensations in one or more usually lower limbs, associated with an urge to move the affected limbs. Those sensations vary widely in severity from merely annoying to significantly unpleasant. Periodic limb movements disorder (PLMD) can only be diagnosed when a polysomnographic recording has been performed. In the past few decades neuroimaging, neurophysiological, and pharmacological studies have contributed to the development of a variety of hypotheses on the pathogenesis of the disorder. The usually immediate and striking efficacy of treatment with dopaminergic agents, and the observation that dopamine receptor antagonism can clinically worsen RLS symptoms, indicates a central role of the dopaminergic system in RLS pathophysiology. Peripheral polyneuropathy, which, similar to RLS, often causes paresthesias and pain in the limbs and tends to worsen at night, is probably the most common differential diagnosis.
  • 8 - Sleep apnea (central and obstructive)
    pp 129-156
  • View abstract

    Summary

    This chapter focuses on the pathophysiology, clinical features, and management of obstructive and central sleep apnea (CSA). CSA accounts for less than 15% of individuals with sleep apnea evaluated at sleep disorder centers. Though central apneas can occur in people with obstructive sleep apnea (OSA), diagnosis of CSA is usually made when more than 50% of the apneic events are central in nature. Nonhypercapnic central sleep apnea is the most common form of CSA. CSA due to Cheyne-Stokes breathing is seen in people with congestive heart failure (CHF), neurological disorders such as stroke, and probably renal failure. OSA commonly affects middle-aged men and women. There are many risk factors for OSA, with obesity and craniofacial features being by far the most common. The treatment for OSA is influenced by the severity of OSA, relative efficacy of various treatment options, associated comorbid conditions, and personal preference.
  • SECTION 3 - SLEEP IN SPECIALTY AREAS
  • View abstract

    Summary

    This chapter describes a selection of neurological diseases, those which are most strongly associated with sleep disorders. Certain neurological disorders include Parkinson's disease (PD), stroke, neuromuscular diseases, headache, multiple sclerosis, and epilepsy. Sleep breathing disorders are common in PD. About half of all individuals with PD show obstructive sleep-disordered breathing. Snoring, which almost invariably accompanies obstructive sleep apnea (OSA), is reported to be a risk factor for stroke. The quality of life in those with amyotrophic lateral sclerosis correlates with both daytime respiratory muscle function and polysomnographic indices of nocturnal sleep-related respiratory disturbances. Improved sleep architecture and daytime arterial blood gases, and increased ventilatory response to carbon dioxide, result from nocturnal ventilation in neuromuscular disease. In a study of 14 children with neuromuscular disease, symptoms of daytime sleepiness and headache improved after initiation of non-invasive ventilation. Epileptic seizures during REM sleep are an extremely rare phenomenon.
  • 10 - Sleep and psychiatric disorders
    pp 170-185
  • View abstract

    Summary

    Sleep disturbances, especially insomnia, may be caused by a broad range of psychiatric disorders, in particular by mood and psychotic disorders, anxiety disorders, dementia, substance related and personality disorders. Depression is the most frequent cause of insomnia. The group of anxiety disorders consists of phobic disorders, panic disorder, generalized anxiety disorder, and combined fear and depression. Women are more than twice as likely as men to develop posttraumatic stress disorder (PTSD) after exposure to a psychological trauma. The lifetime prevalence of schizophrenia has been reported as ranging from 1% to 2%, and about 0.025% to 0.05% of the total population is treated for schizophrenia in any single year. Sedating neuroleptics may be suitable for treatment of sleep disturbances because these substances are well tolerated and may positively influence both insomnia and anxiety/confusion with only minor hangover effects.
  • 11 - Sleep and medical disorders
    pp 186-207
  • View abstract

    Summary

    This chapter describes both the impact of medical diseases and their treatments on sleep, and how disordered sleep can contribute to medical illnesses. Airway function has a normal circadian variation, with peak airflow in the afternoon and the lowest in the early morning. In people with asthma, this morning trough is associated with worsening of asthma symptoms and sleep disturbance. In individuals with heartburn at least once weekly, three-quarters complain of heartburn affecting their sleep. Polysomnography helps to clarify the nature and severity of the primary sleep disorder and aid in the management of end-stage renal disease (ESRD). Disruption of sleep is common in people with arthritic or muscular pain. Pain, sleep disturbance, and low mood are all believed to contribute to fatigue, a common complaint of those with rheumatic disorders. Circadian sleep/wakefulness is intricately linked to neuroendocrine and neuroimmune functions.
  • 12 - Sleep and pediatrics
    pp 208-223
    • By Roberta Leu, Department of Pediatrics, Case University School of Medicine, USA, Carol L. Rosen, Department of Pediatrics, Case University School of Medicine, USA
  • View abstract

    Summary

    This chapter helps clinicians to understand developmental changes in sleep patterns, screen for and identify common pediatric sleep disorders, know what tests and treatments to consider, and decide when to refer to a specialist. It describes the clinical presentation, basic evaluation, and management strategies for the most common sleep disorders in children in the following categories: insomnia, sleep-disordered breathing, hypersomnias, circadian rhythm sleep disorders, parasomnias, and sleep-related movement disorders. Obstructive sleep apnea (OSA) is a common health problem, affecting 2% of children. Onset of narcolepsy typically occurs between 15 and 25 years of age with a prevalence rate of 2 per 1000. Multiple physiologic processes of our bodies, including our sleep/wake cycle, follow circadian rhythms with a periodicity of roughly 24 hours. Sleep-related movement disorders involve restless legs syndrome (RLS) and rhythmic movement disorder (RMD).
  • 13 - Sleep and geriatrics
    pp 224-239
    • By Marcel Hungs, Sleep Disorders Centre, University of California Irvine Department of Neurology, USA
  • View abstract

    Summary

    The analysis of age-related changes in sleep requires the accumulation of data on a healthy population over 65 years of age. However, increased age raises the risk of cardiovascular, metabolic, cognitive, psychiatric, musculoskeletal, renal, hepatic, and hematological conditions. Structural decline in the elderly, including reduced brain mass and numbers of neurons, might lead to functional brain loss. Certain primary sleep disorders affecting sleep in the elderly includes insomnia, sleep-disordered breathing (SDB), periodic limb movement disorder and restless legs syndrome, circadian rhythm sleep disorders, and sleep in dementia. This chapter provides the clinical presentation, diagnosis and treatment for each disorder. As sleep and its restorative function become more widely recognized for their impact on both medical conditions and quality of life in the elderly, the healthcare community has ever-increasing responsibility for translating the growing knowledge of sleep medicine into clinical practice in geriatric medicine.
  • 14 - Forensic sleep medicine issues: violent parasomnias
    pp 240-255
  • View abstract

    Summary

    Violent behaviors during sleep may result in events which have forensic science implications. The apparent suicide (for example, leap to death from a second-storey window), assault or murder (for example, molestation, strangulation, stabbing, shooting) may be the unintentional, non-culpable but catastrophic result of disorders of arousal, sleep-related seizures, REM sleep behavior disorder (RBD), or psychogenic dissociative states. Violent sleep-related behaviors have been reviewed in the context of automatic behavior in general, with many well-documented cases resulting from a wide variety of disorders. Conditions associated with sleep-period-related violence fall into two major categories: neurologic and psychiatric. Psychogenic dissociative disorders may arise exclusively or predominantly from the sleep period. Recent interest in the forensic aspects of parasomnias provides sleep medicine professionals with an opportunity to educate and assist the legal profession in cases of sleep-related violence. One infrequently used tactic to improve scientific testimony is to use a court-appointed impartial expert.

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