"Unlocking the mystery of Sleep Disorders : What you need to know"

POLYSOMNOGRAPHY - A 'Multiparameter' SLEEP STUDY for diagnosing various sleep disorders.

SLEEP DISORDER is a common clinical problem. Sleep is essential for good health. Without restful sleep, one can develop tiredness, poor concentration, mood changes and it may eventually lead to serious issues like heart disease , high blood pressure (hypertension) and stroke. In addition , conditions like asthma, COPD, ILD and heart disease may become worse at night due to disturbed pattern in sleep. Sleep disorders are common in both adults and children.

WHAT IS NORMAL SLEEP PATTERN?

It consists of :

1) Non Rapid Eye Movement (NREM) sleep.

2) Rapid Eye Movement ( REM ) sleep.

The onset of sleep is through NREM sleep which has 4 stages. (1 to 4).

REM sleep consists of eye movements, dreaming and loss of muscle tone in rest of the body. REM and NREM sleep occur alternatively throughout the night.

Briefly there are '6 TYPES' of Sleep Disorders.

1. INSOMNIA: It is caused by stress, anxiety, depression, poor sleep habits or medical conditions. About 10 to 30% of people have it at some point of life.

SYMPTOMS : Trouble falling asleep, staying asleep, waking up too early, not feeling refreshed after waking up, resulting in fatigue, poor attention, daytime sleepiness and increased susceptibility to make accidents.

2. SLEEP DISORDERED BREATHING (SDB): It consists of a spectrum of disorders like Obstructive Sleep Apnea or OSA, Central Sleep Apnea or CSA, Obesity Hypoventilation Syndrome. Approximately 50% of older adults have sleep problems.

OSA/Obstructive Sleep Apnea : The oropharynx is the meeting place of oral cavity and throat which gets narrowed or blocked during sleep due to relaxed throat muscles leading to 'LOUD SNORING'. The risk factors for OSA are obesity, narrow hard palate due to fat deposits, nasal obstruction, retrognathia ( lower jaw is positioned backwards than normal), micrognathia ( abnormally small lower jaw) , macroglossia ( abnormally enlarged tongue) etc. It is more common in post menopausal women.

SYMPTOMS : 'SNORING' with repeated episodes of cessation or stoppage of breathing called as 'APNEA', during sleep, which is followed by sudden awakening with CHOKING/ GASPING and it can be observed by the partner. The consequences are Excessive Daytime Sleepiness ( EDS) which means the person sleeps too much during daytime leading to tiredness, morning headache and poor memory. In these people there is increased risk of heart attack, hypertension, irregular heart beat and stroke.

CSA /Central Sleep Apnea: In this the brain fails to send signals to breathe regularly. As a result breathing will repeatedly stop and start during sleep. It is seen in people with heart failure, stroke and opioid use. The interrupted sleep will cause trouble focussig, mood changes, fatigue and EDS.

3. DISORDERS OF HYPERSOMNOLENCE : In this disease there is excessive sleepiness with strong urge to sleep, sleep attacks during day time and difficulty to concentrate which the patient typically describes as BRAIN FOG.

There are 3 main subtypes:

Narcolepsy Type 1, Narcolepsy Type 2, Idiopathic Hypersomnia.

Narcolepsy is a disorder of brain's 'SLEEP-WAKE' control due to low levels of hypocretin in the brain. It may be associated with sudden sleep attacks during day, extreme muscle weakness in response to intense emotions like laughter (CATAPLEXY)) and vivid dreams. This can effect work, school and social activities and may cause accidents while driving.

4. CIRCADIAN RHYTHM 'SLEEP-WAKE' DISORDERS ( CRSD) : It occurs when the environment is not well aligned with internal circadian timing. Eg. night shift works, jet lag.

5. PARASOMNIAS: There are two types .

1. NREM RELATED parasomnias: associated with confusional arousals, sleep walking, sleep terrors, sleep eating disorders.

2. REM RELATED parasomnias: called as REM Sleep Behavioural Disorder or NIGHTMARE disorder. In response to vivid dreams, patient makes movements like kicking, punching, jumping etc.

6. SLEEP RELATED MOVEMENT DISORDERS : Eg. Restless Leg Syndrome (RLS) and Periodic Limb Movement (PLM) Disorder.

Restless leg syndrome(RLS) : These disorders are linked to iron deficiency, kidney disease, pregnancy, genetic predisposition. It is associated with uncomfortable sensation in the legs which is worse during nights or resting or sitting positions. This sensation is relieved by movement of the limbs. It effects about 5 to 10 % of adults and common in women.

Periodic Limb Movement (PLM) : Here they experience leg or arm twitches/ jerks frequently in sleep but they are unaware of the movement.

These conditions are aggravated by antidepressants, antipsychotics..

DIAGNOSTIC APPROACH OF A SLEEP SPECIALIST/ PULMONOLOGIST:

After detailed history of sleep habits, life style and medical background, physical examination is done to check BMI, neck size, throat lumen size, nostrils .

"QUESTIONNAIRE TOOLS" USEFUL IN DIAGNOSING SLEEP DISORDERS:

EPWORTH SLEEPINESS SCALE,

FATIGUE SEVERITY SCALE,

SLEEP DIARY / SLEEP LOG,

MSLT (Multiple Sleep Latency Testing) or NAP TEST, help to identify the type of sleep disorders.

POLYSOMNOGRAPHY is a 'SLEEP STUDY' which is the GOLD standard for diagnosing OSA and other Sleep disorders. During the SLEEP STUDY, numerous devices are connected to the patient allowing the patient to sleep. Various parameters like Sleep stages, Breathing pattern, ECG, EEG, EMG , Airflow, Body position, Limb movements, SPO2 are assessed to determine the cause of sleep disturbances. Other tests are Thyroid function tests, drug and alcohol toxicity screening, Iron studies, ABG.

TREATMENT/ MANAGEMENT:

TREATMENT OF OSA:

CPAP ( Continious Positive Airway Pressure therapy ) or APAP (Automatic Positive Airway Pressure Therapy ) : Its a highly effective therapy in which the machine generates enough pressure through a mask , to keep the narrowed airways open, preventing collapse and thereby reducing excessive daytime sleepines.

ORAL APPLIANCES : Mandible Advancement Devices, Dental devices,

Surgical procedures like Bariatric surgery, Mandibular or Maxillary advancement surgery (MMA), UPPP, Tonsillectomy and Adenoids surgery .

Drugs like Modafinil, Solriamfetol are useful in increasing wakefulness.

Most importantly life style changes like, weight reduction, regular exercise, balanced diet and improving sleep hygiene are necessary.

TREATMENT OF INSOMNIA :

Cognitive Behavioural Therapy (CBT) is advised for Insomnia. CBT 1 is a set of behavioural and psychological techniques using individual or group therapies. Drugs like Benzodiazepines ( temazepam, triazolam), Zolpidem, Zaleplon, Melatonin receptor agonists like Ramelteon may help.

PATIENT EDUCATION:

All patients should be educated well and encouraged to practise 'GOOD SLEEP HYGIENE'. It describes good sleep habits.

WHAT IS GOOD SLEEP HYGIENE?

*Maintain regular schedule, i.e, 'Go to bed and Wake up' at same time every day.

*Use the bed for SLEEP only. Avoid watching TV, looking at phones.

*Exercise almost every day, but not right before bed time.

*Avoid caeffine or smoking, mainly during evening.

*Maintain a dark, calm and quiet environment.

*Avoid struggling to fall asleep in bed. If not possible, get up and try again.

*If on hypnotic,sedative medications, avoid driving and operating machines.

"IF YOU SNORE LOUDLY

OR

FEEL TIRED ALL DAY

OR

HAVE TROUBLE SLEEPING,

DONT IGNORE IT."

TALK TO PULMONOLOGIST/ SLEEP SPECIALIST.

"MOST SLEEP DISORDERS ARE TREATABLE."

CPAP THERAPY IN A PATIENT WITH OSA

NARROW OROPHARYNX WITH ENLARGED TONSILS AND INVISIBLE UVULA

SLEEP HYGIENE TIPS