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The circadian rhythm is a self-sustained biological rhythm that entrains organisms' functions to the daily light-dark cycle. It is controlled by the suprachiasmatic nucleus in the brain and influenced by both genetic and environmental factors like light exposure. Disruptions to the circadian rhythm can cause misalignment between biological processes and disturbed sleep-wake cycles, leading to impaired functioning and health issues over the long term.
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How the Circadian Rhythm Affects Sleep, Wakefulness, And Overall Health
The circadian rhythm is a self-sustained biological rhythm that entrains organisms' functions to the daily light-dark cycle. It is controlled by the suprachiasmatic nucleus in the brain and influenced by both genetic and environmental factors like light exposure. Disruptions to the circadian rhythm can cause misalignment between biological processes and disturbed sleep-wake cycles, leading to impaired functioning and health issues over the long term.
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The circadian rhythm is a self-sustained biological rhythm that entrains organisms' functions to the daily light-dark cycle. It is controlled by the suprachiasmatic nucleus in the brain and influenced by both genetic and environmental factors like light exposure. Disruptions to the circadian rhythm can cause misalignment between biological processes and disturbed sleep-wake cycles, leading to impaired functioning and health issues over the long term.
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disorders PROF. DRA. ROSEMARIE FRITSCH MATERIAL DOCENTE ANDREW D. KRYSTAL, MD, MS How the Circadian Rhythm Affects Sleep, Wakefulness, and Overall Health 1 Properties of the Circadian Rhythm The field of circadian rhythm research was launched in the early 18th century (AV 1). 1 The circadian rhythm entrains an organisms functions to the environmental cycle of light and dark. This rhythm is seen in nearly all species and plays an important role in synchronizing organ systems to optimal phase relationships with each other. Variations in many biological processes occur over roughly a 24-hour period (AV 2). This type of endogenous rhythmicity is also seen in many other biological measures. For example, levels of plasma melatonin increase in the evening and early part of the night, while levels of plasma cortisol increase over the course of the night, peak at waking, and diminish throughout the day. 2 Our innate circadian rhythm can be modified by a number of factors, especially light. For example, when you travel to a new time zone, your body is on a different schedule from the new environment, because it continues to function for some time on the circadian rhythm you developed in your previous location. The longer you stay in the new environment, the more your body aligns with its new environmental clock. This process is driven by cues, especially exposure to light, which tells us when it is day or night. 2 Light has different effects on the circadian rhythm depending on when we are exposed to it. 1 Thus, if we are exposed to light late during the night, this shifts our rhythm so that we tend to go to bed and wake up earlier. If we are exposed to light in the early part of the night, this shifts our rhythm so that we tend to stay up and sleep later. Exposure to light during the period when we are usually awake has no effect at all. Other factors that can affect our internal clock include when we eat, our activity level, and caffeine intake. 3,4
Thus we often have gastrointestinal upsets in a new time zone because we are eating when our body does not expect to eat (ie, our digestive hormones are out of synch with our meal time). 5 Our innate circadian rhythm also affects how our autonomic nervous system and our brain function. 6 3 2 Anatomy of the Circadian Rhythm The important role of the suprachiasmatic nucleus (SCN) in regulating periodic behavior 7 has been confirmed by a number of findings in animal studies (AV 3). 1. When the SCN is lesioned, circadian rhythmicity goes away because the SCN is no longer able to stimulate the production of melatonin and other substances that modulate the sleep-wake pattern. 8 2. If cells are removed from the SCN and grown in vitro, they continue to show self-sustaining circadian rhythmicity. 9 3. If the SCN is transplanted from one animal to another, the recipient manifests the circadian rhythm of the donor, showing that the SCN can entrain biological activity and drive a circadian process on its own. 10 4 3 Genetics of the Circadian Rhythm Although researchers had been able to breed for changes such as different eye or hair color for a long time, it was not until the 1960s that Benzer first demonstrated that behavior could be modified genetically by breeding circadian behavioral patterns into fruit flies. 11 This demonstrated that the chemical clock in the SCN is under genetic control. A relatively small number of genes and proteins regulate this biological clock. The critical components of this genetic system are the Period, Clock, and Cryptochrome (Cry) genes, and these can be manipulated to alter the circadian cycle. 12 The role of genetic factors in our circadian rhythm is supported by the observation that preferred sleep/wake schedules (eg, being a night owl or a morning lark) tend to run in families. The tendency to go to bed and get up very early (sleep phase advance), is linked to a mutation in the human Period-2 (hPer2) gene that is an autosomal dominant trait. 13 The tendency to stay up late and sleep late (sleep phase delay) is associated with several genes, including the human Period-3 (hPer3) gene. 14 In humans, the circadian rhythm is controlled by several core genes that operate via a series of feedback loops (Figure 1). A transcriptiontranslation negative-feedback loop powers the system, with a delay between the transcription of these genes and the negative feedback being a key factor that allows the system to oscillate. 5 4 Effects on Sleep/Wake Function The SCN regulates our sleeping and waking through its effect on 3 brain regions 7 : ! Ventrolateral preoptic area: releases "- aminobutyric acid (GABA) and promotes sleep ! Lateral hypothalamic area: releases the transmitter hypocretin/orexin that promotes wakefulness ! Paraventricular hypothalamus: involved in the release of melatonin The interaction shown in the sleep/wake model 15
produces a consolidated period of wakefulness, driven by the circadian rhythm, and a consolidated period of sleep that occurs when the homeostatic drive to sleep has built up and the wake-promoting systems have shut down (AV 4). 16 The circadian rhythm system enables us to stay awake for extended periods, despite a growing homeostatic drive for sleep. It does this by modulating the release of neurotransmitters, in particular hypocretin/orexin, that maintain wakefulness. Otherwise, we would have great difficulty functioning, since we would fall asleep as soon as a great enough drive to sleep had built. This is what happens in narcolepsy, which involves abnormalities in the hypocretin/orexin system. 17 6 7 Process S represents the homeostatic built-up of sleep pressure Process C represents the circadian rhythm When the distance between process S and process C is largest, sleep propensity will be highest. Borblys model of sleep-wake regulation (Borbly & Achermann, 1999). Here you can see how sleep pressure keeps building up due to sleep deprivation, but since the circadian rhythm keeps fluctuating by its regular 24 hour cycle, our sleep propensity will also fluctuate with this rhythm. In addition this picture also shows that such sleep deprivation will lead to a higher slow wave activity (SWA, representing deeper stages of sleep) during the recovery sleep. This type of activity is used as a marker for the homeostatic process. When we for example go to bed earlier when homeostatic sleep pressure hasnt built up that much, this will translate into less slow wave activity. Even within a sleep cycle itself you can see this phenomenon, with less slow-wave activity during the second part of the sleep. 8 5 Problems in Sleep/Wake Function Problems can occur when the drive for wakefulness and the drive for sleep are not correctly synchronized. Thus, if you try to sleep when your body doesnt normally sleep, you will sleep less and you will not sleep as well because your circadian processes are fighting the sleep drive. Individuals with circadian rhythm sleep disorders often experience at least partial sleep loss on a long-term basis. This is because they are trying to sleep at an unfavorable time for extended periods. Even modest prolonged sleep deprivation can produce 4 types of serious physiological abnormalities 18-23 : ! Metabolic dysfunction (increased appetite, metabolism, or oxygen consumption; sympathetic nervous system activation; decreased cerebral glucose utilization in certain subcortical structures) ! Neuroendocrine abnormalities (low thyroid-stimulating hormone; decreased levels of growth hormone, prolactin, or leptin) ! Decreased resistance to infectious disease ! Oxidative stress 9 Humans who experience prolonged sleep deprivation also demonstrate higher rates of obesity and type 2 diabetes and neurobehavioral impairment, including a shortening of voluntary and involuntary sleep latency resulting in daytime sleepiness, microsleeps (intrusion of sleep into wakefulness), and errors of omission and commission on cognitive testing. 24,25 10 6 Role of the Circadian Rhythm in Health and Disease By synchronizing the bodys biological clocks, the SCN has extensive influence on peripheral tissues through the autonomic nervous system. 26 For example, glucose is released in a gradual, oscillating, sinusoidal-like pattern over a 24-hour period. If animals are fed at times other than their natural feeding times, the original cycle continues. However, if you cut out the SCN, glucose release becomes entrained to feeding times and is no longer linked to other physiologic processes related to eating and digestion. 27 Phase dyssynchrony occurs when the rhythms of organs are out of synch with the SCN. Research in animals and humans has shown that such disruptions can have negative effects on health. For example, one study found that disrupting the normal circadian rhythmicity of hamsters with cardiomyopathy reduced their median life span by 11%. 28 In the next chapter, Dr Roth will discuss the types of negative effects that can occur in humans who experience such phase dyssynchrony, as occurs when someone has Shift Work Disorder. 11 The circadian rhythm, a self-sustained rhythm of biological processes observed in nearly all species, is determined by both genetic and behavioral factors. It plays an important role in coordinating and modulating sleep/wake function and in many other biological processes. Disturbances of the circadian rhythm cause misalignment among biological and behavioral processes that can lead to disturbances in sleep/wake function and other types of impaired functioning and may affect our capacity to fight off disease. xii Summary Comprobar respuesta Pregunta 1 de 4 The circadian rhythm is A. The determinant of cicada lifecycles B. A self-sustained rhythm of biological processes observed in nearly all species C. Another name for jet lag THOMAS ROTH, PHD Shift Work Disorder: Overview and Diagnosis 1 Circadian Rhythm Sleep Disorders According to the second edition of the American Academy of Sleep Medicines International Classification of Sleep Disorders (ICSD-2), 1 the major feature of circadian rhythm sleep disorders is a misalignment between the patients sleep pattern and the sleep pattern that is desired or regarded as the societal norm (AV 1). 14 In addition to shift work disorder (SWD), the ICSD-2 lists 8 other types of circadian rhythm sleep disorders, including time zone change (jet lag) syndrome and delayed and advanced sleep phase syndromes. Many people have experienced jet lag syndrome, caused by a lack of synchrony between your internal clock and a new time zone in which you are trying to function. Circadian rhythm disturbances can also involve delayed or advanced sleep phases (AV 2). 15 Because delayed and advanced sleep phase syndromes often cause the person to be out of synchrony with the prevailing sleep/wake patterns of society, they can lead to significant morbidity. Recent studies 2-5 have found that, when high school classes were started an hour or two later, the number of car accidents decreased and academic functioning improved. Problems can also arise when there is chronic dyssynchrony between the persons internal clock and external light and dark (ie, when a person is required to stay awake and work when it is dark and sleep when it is light), which can, in some cases, lead to SWD. 16 2 Shift Work It is important to distinguish between shift work and SWD. Shift work is a job description. The vast majority of people who work shifts adjust and do well. However, a subgroup of people have great difficulty adjusting their internal clocks and develop SWD due to a mismatch between the sleep/wake schedule required by their jobs and their own circadian sleep/wake cycles. Prevalence. It is estimated that 15%26% of the US labor force works night, evening, or rotating shifts (AV 3). 6,7 Effects of shift work on the sleep/wake cycle. Shift work affects the sleep/wake cycle in a number of ways. No matter how many hours you have slept during the day, trying to work during the downside of the circadian rhythm (eg, between 12 AM and 6 AM) is very difficult unless you can shift your internal clock. Studies have found that, over a 24-hour cycle, both subjective alertness and cognitive functioning decline 17 between 2 AM and 4 AM.8 Also, because you are not sleeping at night, the homeostatic pressure to sleep is not relieved, producing an ever-increasing pressure to sleep. 9 However, only a subset of individuals who work night or rotating shifts develop SWD, because circadian rhythms are modulated not only by light and dark, but also by other factors such as clock genes, melatonin, and environmental cues (eg, noise). 10,11 18 3 Shift Work Disorder: An Overview Prevalence. Drake et al12 found that 28% of those who work night or rotating shifts, compared with 18% of day workers, experienced insomnia and/or excessive sleepiness, and they estimated the true prevalence of SWD to be approximately 10% of those who work night or rotating shifts. A study of 103 shift workers on a North Sea oil rig (working 2 weeks on 7 nights/7 days, 12-hour shifts, 4 weeks off) by Waage et al13 found a relatively high prevalence of SWD. They reported that 24 (23.3%) of the shift workers were suffering from SWD and that, during their 4-week period off work, the workers with SWD reported significantly poorer sleep quality, more subjective health complaints, and greater problems in coping than individuals who did not have SWD. Shift workers without SWD reported results similar to those of day workers on the rig with regard to sleep, sleepiness, subjective health complaints, and coping. Diagnosis. The ICSD-2 diagnostic criteria for circadian rhythm sleep disorder, shift work type, are shown in (AV 4). The differential diagnosis of SWD includes excessive sleepiness due to obstructive sleep apnea, narcolepsy, restless legs syndrome, and chronic insufficient sleep due to daytime conflicts (eg, child care, environmental factors, moonlighting at a second job). Comorbid conditions (eg, increased prevalence of sleep apnea in shift workers) can complicate the diagnosis of SWD. Clinicians should also rule out comorbid disorders that can cause insomnia and excessive sleepiness (eg, primary insomnia, insomnia associated with psychiatric disorders such as major depression), as well as consider whether the person may be taking medications or abusing drugs or alcohol to help with sleep, which may be causing impairment at work. 19 20 4 Consequences of Shift Work Disorder Just as animal studies have found that disruptions in circadian rhythm can affect health outcomes, studies in humans have produced similar findings. Gastrointestinal problems (eg, ulcers, functional bowel disorders) are significantly increased in individuals who work night or rotating shifts. However, the increased prevalence of ulcers is associated not just with shift work, but also with SWD. In a study comparing 360 workers on rotating shifts, 174 on night shifts, and 2,036 on day shifts, Drake et al12 found that, among those who reported excessive sleepiness and/or insomnia, the prevalence of ulcers was higher among rotating shift workers (12.5%) and night shift workers (15.4%) than day workers (6%). This effect was not seen to any marked degree in those who worked rotating or night shifts but did not have excessive sleepiness and/or insomnia. Zhen Lu et al14 found that the prevalence of functional bowel disorders was higher in a sample of nurses who worked rotating shifts (38%) than in those who worked day shifts (20%) and that functional bowel disorder symptoms were positively correlated with level of sleep disturbance. Cancer. Shift work (whether or not the person has SWD) has been found to be a risk factor for cancer. Increased odds ratios for breast cancer have been found in large samples of women who worked night shifts, particularly with increasing duration of nighttime employment.15-19 A study20 of 14,052 working men in Japan also found a significantly increased risk of prostate cancer in those who worked rotating shifts. The World Health Organization International Agency for Research on Cancer has concluded, Shift work that involves circadian dysruption is probably carcinogenic to humans.21 Depression. The prevalence of depression is significantly higher in those who work rotating and night shifts than in day workers. In addition, while insomnia or daytime sleepiness is a risk factor for depression for all individuals, it is a much greater risk factor for rotating or night shift workers.12 21 Cardiovascular effects. While insomnia is a risk factor for hypertension in all individuals, it is a significantly higher risk factor for shift workers with insomnia.12 In contrast, although shift work is associated with a significantly increased risk of heart disease compared with nonshift work, this increased risk is not associated with SWD.12 Excessive sleepiness and accidents. Insomnia is associated with excessive sleepiness, which can impair functioning, in rotating shift workers compared with day workers.12 Studies have found a 12% frequency of drowsy driving and an increased risk of driving accidents related to sleepiness in rotating shift workers with SWD compared with those without the disorder. Relative risk of injuries and accidents increases with each successive night shift worked.22 The effects of shift work on patient and employee safety are an important consideration in the health care field, where many workers have extended shifts.23 Productivity. Similarly, it is the combination of night or rotating shift work and daytime sleepiness or insomnia that decreases productivity, not each factor alone.12 Rotating shift workers with insomnia and/or excessive sleepiness (SWD) missed significantly more days of work (an average of 3 days per month over 3 months, a 10% decrease in productivity) than day workers with these symptoms, who missed approximately half a day of work per month over the 3-month period. This effect was not seen in shift workers who did not have insomnia or excessive sleepiness: they also missed a half day or less of work over 3 months.12 Rotating shift workers who experience both insomnia and excessive sleepiness are at the greatest risk for lost productivity. (See Keller23 for a review of potential productivity problems in health care workers on extended shifts.) 22 Shift work is very prevalent in our society. However, only a subset of shift workers meet criteria for SWD and need treatment. Potential targets for treatment are (1) the persons work schedule, (2) difficulty sleeping during the day, and, most important, given the accident data discussed above, (3) difficulty functioning because of excessive sleepiness (eg, commuting home safely). xxiii Summary Comprobar respuesta Pregunta 1 de 4 The Shift work disorder (SWD) is a disruption of sleep patterns affecting A. All people who work night or rotating shifts B. Primarily workers in natural resources, con struction, and maintenance occupations, such as farmers, fishermen, and construction workers C. Approximately 10% of all shift workers D. Shift workers with hypertension or cardiovascular disease RICHARD D. SIMON, JR, MD Shift Work Disorder: Clinical Assessment and Treatment Strategies 1 Identifying Circadian Rhythm Disturbances The most important clue that a patient may have a circadian rhythm sleep disorder is an irregular sleep/wake schedule. It is not possible for people to change their circadian rhythm by more than 24 hours in any given day.1,2 Thus, if a persons sleep/wake schedule varies by more than 24 hours between days on and off work, this suggests that he or she may have circadian rhythm problems. One of the best ways to identify such problems is to ask, Do you have difficulty falling asleep at bedtime (insomnia) and difficulty waking up when you need or want to (hypersomnia)? If the patient says yes, this can indicate a delayed sleep phase syndrome (ie, the person may be a night owl). Individuals with this sleep pattern often overuse the snooze button, hitting it repeatedly. This pattern is frequently seen in teenagers. People may also fall asleep very early, say at 8:00 PM (hypersomnia), and wake up long before they want to (eg, 3:00 AM). This sleep pattern reflects an advanced sleep phase syndrome, a pattern frequently seen in the elderly (AV 1). 25 2 Taking a Sleep History The first step in assessing for shift work disorder (SWD) is to take a thorough sleep history. The most important item to ask about is the persons schedule of work and sleep. Ask the person how his or her sleep/wake schedule differs on work days, days off, and vacation days. (The persons sleep schedule when on vacation can give particularly helpful clues to the persons intrinsic sleep/wake schedule.) (AV 2) Assess the quality of sleep and wakefulness by asking questions such as these: ! Do you sleep all night? Do you feel refreshed in the morning? Or do you have fragmented sleep? ! Do you find it easy to stay alert throughout the day? Or do you find yourself getting fatigued and sleepy? ! Do you snore? Has anyone you live with witnessed any episodes when your breathing appeared to stop and then start again while you were asleep (sleep apnea)? Restless legs syndrome, characterized by an uncomfortable, creeping, crawling, restless feeling in the legs, can make it very difficult to fall asleep. If the person reports snoring or witnessed episodes of apnea, abnormal nocturnal behaviors (eg, injuring self or others by acting out dreams), or symptoms suggesting narcolepsy, a sleep study is required. It is also important to ask about use of drugs or medications to help with sleep or alertness (eg, caffeine in the daytime, pills or alcohol to promote sleep) and the quality and safety of the sleeping and waking environments. A medical and psychiatric history is necessary to identify conditions that might be contributing to the sleep problems (eg, respiratory problems, pain, depression, anxiety). 26 27 3 Assessment Tools The simplest and most important assessment tool for day-to-day clinical use by primary care physicians and general psychiatrists is a sleep diary (AV 3). Several easy-to-use scales are also commonly used in sleep assessments. The Stanford Sleepiness Scale 3 and the Epworth Sleepiness Scale 4 measure level of excessive sleepiness. The Epworth Sleepiness Scale asks the person to rate the likelihood of dozing in 8 different situations on a 4-point scale (0 = would never doze to 3 = high chance of dozing), with a score of 10 or greater suggesting the need for further evaluation. The Insomnia Severity Index 5 assesses severity of current sleep problems and their effect on daytime functioning. Scales such as these are particularly useful for tracking the effectiveness of an intervention over time. In some situations, depression or anxiety scales or a general outcome scale such as the Short-Form 36-Item Health Survey, Version 2, 6 may be useful. Actigraphy, which uses a device worn on the wrist to record motion (ie, suggesting the person is awake) is not generally necessary in assessing for SWD, since an accurate history and a sleep diary will usually supply all necessary information. Referral for overnight sleep studies or polysomnography is also not indicated to diagnose SWD, but is indicated if one suspects the patient may have obstructive sleep apnea, parasomnias leading to injurious nocturnal behaviors during sleep, or narcolepsy. If narcolepsy is suspected in a shift worker, it is usually necessary to have the worker discontinue shift work for 24 weeks, because shift work itself and the associated circadian misalignment can confuse testing for narcolepsy. Narcolepsy is suggested by a history of excessive sleepiness that often started when the person was a teenager and predates his or her shift work. 28 29 4 Differential Diagnosis and Comorbid Conditions Conditions that frequently occur in conjunction with SWD include obstructive sleep apnea and restless legs syndrome. Signs suggesting sleep apnea include large neck size, crowded oropharynx, and reports of witnessed apneas. Poor sleep habits of shift workers can also cause them to develop learned insomnia behaviors, referred to as psychophysiologic insomnia. Other comorbid conditions include depressive and/or anxiety disorders and chronic fatigue, which can be difficult to distinguish in a person with chronic circadian dyssynchrony. 30 5 Treatment Goals The primary goal of treatment for SWD is to reduce the degree of circadian misalignment by fostering better sleep when it is desired and improved alertness and functioning when appropriate. Other goals are to identify and appropriately treat any intrinsic sleep disorders (eg, apnea) and any medical or psychiatric disorders that are present. Nonpharmacologic strategies should be tried before considering use of medications to promote sleep and/or alertness. Zeitgebers: Strategies for Shifting the Biological Clock The term zeitgeber (German for time giver) describes an external cue that helps synchronize a plant or animals internal clock to the earths 24-hour light/dark cycle. 7 The most powerful zeitgebers in humans are light, supplemental melatonin, dark, and exercise. Very bright light has powerful effects, 1,2 with individuals being most sensitive to the effects of light approximately 2 hours before or 12 hours after their spontaneous wake time. If a pulse of very bright light is given 24 hours before a persons spontaneous wake time (eg, 3:00 AM for someone with a usual wake time of 6:00 AM), the person is likely to wake up 24 hours later (ie, to move toward a delayed sleep phase, becoming more of a night owl). On the other hand, if you expose the person to very bright light at the spontaneous wake time or in the hour or so after, the person is likely to wake up 24 hours earlier (ie, to move toward an advanced sleep phase, becoming more of a morning lark). 31 Melatonin acts in the opposite way. 1,2 When administered in the evening, it tends to make the person fall asleep and wake up earlier (ie, to advance the sleep phase). When administered in the morning, it tends to make the person stay up later and wake up later (ie, to delay the sleep phase). Dark also has powerful effects on sleep phase. 1,2 Thus, naps in a darkened environment act in much the same way as melatonin. Greatly limiting exposure to light in the evening will help you go to sleep earlier. Conversely, absence of light in the morning will help you sleep later. Because primarily the shorter wavelengths (eg, blue light) lead to phase shifts, one strategy for exposing the biological clock to dark is to wear dark or blue-blocking sunglasses. Similar phase response curves have been found for exercise. 1,2 Exercising in the early evening tends to phase-advance you and make you more of a morning person. Exercising after midnight generally does the opposite. However, exercise is not often used to adjust sleep phase in humans (AV 4). 32 6 Practical Strategies for Sleep Problems Associated With Shift Work To minimize problems associated with shift work, workers should have as predictable a work schedule as possible. It is also helpful if employers provide sufficient breaks at work, allow shift workers to take a short nap at work, avoid schedules that involve working multiple days in a row, and provide sufficient time off between work days. These strategies are important because the vast majority of shift workers do not fully entrain (ie, their biological clocks never fully synchronize with their required work and sleep schedules). It is also useful to try to limit commuting time and overtime. Another key strategy is to minimize circadian misalignment between work days and days off, which involves educating and enlisting the support of significant others in the shift workers family and immediate social circle. For most shift workers, this means producing a phase delay in their biological clocks (ie, to make them more night owls). This is done by changing the persons environment so that he or she gets as much light as possible during the scheduled day and as little light as possible during the scheduled night and by minimizing the difference in sleep/wake patterns between work days and days off. Practically, this means having bright light at work, wearing dark glasses during the drive home when one is likely to be exposed to light, and keeping the bedroom, bathroom, and other rooms that will be used at home as dark as possible during the desired sleep period. Shift workers who achieve complete or even partial entrainment (ie, their biological clocks become realigned with a new sleep/wake schedule) show marked improvements in psychomotor vigilance, memory, reaction time, night work performance, and mood and reductions in fatigue, excessive sleepiness, and mental exhaustion compared with those who do not 8,9 (AV 5). 33 34 SWD needs to be considered in all patients who have a sleep/wake schedule that differs by more than 24 hours on work days compared with days off and who exhibit symptoms of sleepiness at work and difficulty sleeping during the desired sleep time. Asking about snoring and restless legs symptoms can lead to comorbid diagnoses that, if treated, can improve the shift workers sleep. xxxv Summary Comprobar respuesta Pregunta 1 de 4 The most important clue that a patient may have a circadian rhythm sleep disorder is: A. Complaint of restless legs syndrome B. An irregular sleep/wake schedule C. Depression D. Sleep apne 4 Cases 1 The young man with difficulty falling asleep A 24-year-old male patient reports difficulty falling asleep, followed by daytime sleepiness, a pattern that has persisted for about 5 years since his days as a student. His excessive sleepiness has become more severe during the past year due to the 8 AM starting time for his work shift. He recently needed to take 2 personal days off from work due to inability to report on time. Once asleep, he does not have difficulty staying asleep. His bedtime ranges from 11:30 PM to 1:00 AM, with time required to fall asleep averaging 2 hours. His wake time is scheduled for 6:45 AM on workdays. Weekday mornings are particularly difficult. The patient feels "out of it" until about noon. He has fallen asleep while driving to work and has had several near-miss traffic accidents the past month. The patient is being treated with sertraline 50 mg for depression, which was first diagnosed 2 years ago, and with zolpidem 10 mg as needed for insomnia. He suffers from exercise-induced asthma. His blood pressure is stable at 130/80 mm Hg, and he has a body mass index (BMI) of 26. His mother and brother both suffer from similar types of insomnia symptoms. Physical and neurological exams were normal. He had a score of 12 on an ESS questionnaire. 37 Comprobar respuesta Which of the following additional assessments would you next employ for this patient? A. Polysomnogram B. Actigraphy C. Sleep diary D. Multiple sleep latency test Like the ESS, a sleep diary is a first-line diagnostic tool for suspected sleep disorders because of its ease of administration and low cost. A sleep diary will plot the patient's sleep pattern and is suitable as the next test in this case. Actigraphy may be used but is not commonly available in primary care practices. Polysomnograms and multiple sleep latency tests are more elaborate diagnostic methods reserved for validation of initial screening tests, or to evaluate for other sleep disorders, such as OSA and narcolepsy. Circadian rhythm sleep disorders are disorders of sleep and wake timing. Thus, an essential aspect of diagnosing and treating circadian rhythm sleep disorders is to determine whether symptoms are due to chronic or short-term misalignment of the patient's circadian rhythms with external 24-hour cues, or due to other etiologies. A sleep diary is an easily administered diagnostic tool that can be easily used in a primary care setting to determine if the patient's internal circadian sleep and wake rhythm is misaligned with work or social schedules. The pathophysiology of circadian rhythm sleep disorders is multifactorial, only partially understood. What is of importance to clinicians is that they consider the full range of physiological, behavioral, and environmental factors involved in a clinical sleep disorder when developing treatment strategies. In the case of Circadian rhythm sleep disorders, their etiology can be intrinsic due to endogenous factors, or extrinsic due to factors in the environment. ASSESSMENT The patient completed a 7-day sleep diary during his normal work week (see the Figure). The diary confirms a bedtime of 10:30-11:45 PM on workdays and a prolonged time to fall asleep of over 2 hours. On weekends, bedtimes are later (midnight to 1 AM), but it still takes 1-2 hours to fall asleep. Note that on 38 Saturday, he sleeps in until 11 AM, and on Thursday, he took a nap in the afternoon between 3 to 4 PM. Average sleep duration is less than 6 hours on weekdays. The patient went on vacation for a 10-day period shortly after his initial visit, providing an opportunity for actigraphy monitoring during his preferred sleep schedule. Actigraphy showed an average bedtime of 3-4 AM and an average wake time of 10 AM to noon while on vacation. After returning from vacation, the patient said he had been able to catch up on his sleep and feels much better. However, after returning to work, he reports that his bedtime insomnia has returned, often preventing him from falling asleep before 2 AM. 39
Comprobar respuesta Pregunta 1 de 2 Based on the previous description, what is the most suitable diagnosis for the patient in case 1? A. Psychophysiologic (conditioned) insomnia B. Insomnia due to depression C. Advanced sleep-phase disorder D. Delayed sleep-phase disorder The patient's symptoms are consistent with delayed sleep-phase disorder, namely a stable pattern of delay in the nighttime sleep period until the early morning hours followed by inability to wake up until the late morning. In contrast, patients with insomnia disorder, including psychophysiologic insomnia or insomnia associated with depression, do not typically show a stable pattern of delayed sleep and when allowed to sleep at a later time have normal sleep duration. Advanced sleep-phase disorder is characterized by early sleep onset and premature awakening, the opposite of delayed sleep-phase disorder. Treatment should be aimed at advancing the timing of sleep and wake cycle. Morning bright light exposure (close to natural awakening) signals the circadian clock to advance its timing. Similarly, low-dose melatonin given in the late afternoon or early evening signals the clock to advance. (Melatonin is not approved by the FDA for the treatment of circadian rhythm sleep disorder.) One should avoid bright light exposure in the evening because it will delay or shift circadian rhythms. An advance in the timing of circadian rhythms (advance shift) will result in earlier sleep onset and awakening, which is needed to synchronize with the desired sleep/wake and work schedule. In addition, bright light in the morning can have an alerting effect, which can facilitate waking. Pharmacologic therapies such as hypnotic agents or antidepressants to treat symptoms of insomnia without resetting the circadian clock will only partially address symptoms, rather than the underlying cause of the symptoms. 40 DIAGNOSIS The patient's history confirms that his ability to perform on the job is impaired by his excessive sleepiness and lack of energy and alertness in the work place. He thinks that his occasional feelings of depression and anxiety are associated with poor sleep. Although he is concerned about poor performance associated with his sleep pattern, he does not feel anxious overall. "I'm just never sleepy at 10:30 at night," he says. He is diagnosed with delayed sleep-phase disorder. According to the International Classification of Diseases, 10th Revision (ICD-10), diagnostic billing codes for Circadian rhythm sleep disorders start with G47.2, with delayed sleep-phase disorder G47.21. 41 Episodic and paroxysmal disorders G40- G47 Sleep disorders G47 Circadian rhythm sleep disorder G47.2 delayed sleep phase type G47.21 INITIAL TREATMENT The patient was instructed to purchase a bright light box, readily available on the Internet, and sit in front of the light source (1-2 feet away) for 1 hour in the morning, starting at 10:30 AM on a weekend day (off work). Light box exposure was then advanced by 1 hour each morning until he started treatment at his normal workday wake up time of 6:30 AM. He was also instructed to take melatonin 1 mg at 8 PM for the next 3 weeks. Recognizing the pattern of the patient's sleep-wake cycle is the key to both the diagnosis and treatment of circadian rhythm sleep disorders. The goal of circadian rhythm sleep disorder is to synchronize (entrain) the sleep-wake cycle with the appropriate external physical environment and work schedule. Treating symptoms of insomnia or excessive sleepiness without resetting the circadian rhythm sleep disorder patient's circadian clock will only partially address the symptoms, rather than the underlying cause of the symptoms. Thus, the principal goal of therapy for the delayed sleep-phase disorder patient (as illustrated in case 1) is to advance the timing of circadian rhythms. Conversely, the goal of therapy for an advanced sleep-phase disorder patient would be to delay the timing of circadian rhythms. 42
Comprobar respuesta What is the principal goal in managing the sleep disorder for this case? A. Advance the timing of the patient's circadian rhythms B. Increase the duration of sleep C. Provide treatment with the use of prescription drugs D. Avoid sleeping so late on weekends FOLLOW-UP The patient reported good compliance with nightly MLT treatment but could tolerate morning light therapy for only 30-40 minutes on some days. He reports a bedtime of 11 PM, falling asleep by midnight on most days. He is able to awaken with the aid of an alarm clock at 6:30 AM on workdays, but feels like he could sleep longer. He wakes up naturally at 8-10 AM on weekends. 43 2 The old man with a history of difficulty staying asleep PRESENTATION AND PATIENT HISTORY A 66-year-old man has a history of difficulty staying asleep. This has caused him to be a habitual early riser around 5 AM virtually every day for about 10 years. His difficulty in staying asleep has become progressively worse. His typical sleep pattern is to fall asleep on the couch by 7 PM, wake up 90 minutes to 2 hours later, and then go to bed around 9:30-10 PM. He usually sleeps until 3-4 AM or until he goes to the bathroom, after which he has difficulty going back to sleep. He often lays awake in bed for up to 2 hours until he rises at 5-5:30 AM. By the afternoon and early evening, he is excessively sleepy and struggles not to fall asleep. He reports that his ES has affected his social life and relationship with his wife due to his drowsiness. He says his ideal sleep schedule would be to fall asleep about 10 PM and wake at 5-6 AM. His score on an ESS questionnaire is 12. He has a history of hypertension and hyperlipidemia, for which he is treated with olmesartan and atorvastatin. The patient has a paternal family history of early risers. His wife has informed him that he snores lightly but has not witnessed any breathing irregularities during his sleep. He has no restless legs symptoms and is not depressive, but he is frustrated by his sleep problem. He has reflux symptoms when he eats late. His physical examination, cognition, and mental health status are normal. 44 Comprobar respuesta What is the most likely diagnosis for the patient in this case? A. Advanced sleep-phase disorder B. Delayed sleep-phase disorder C. Irregular sleep-wake pattern D. Insomnia due to nocturia The patient's symptoms are consistent with advanced sleep-phase disorder, a stable pattern of sleep onset several hours earlier than the usual nighttime sleep period and sleep offset several hours before the normal or desired wake time. Advanced sleep-phase disorder is more common in older adults. Nighttime urination typically occurs in men of the patient's age but is not the primary cause of an advanced sleep-wake cycle or daytime sleepiness in this case. Schematic of typical sleep phase vs 4 circadian rhythm sleep disorders. A feature of ASPD, DSPD, and non-24-hour sleep pattern is that the sleep architecture and total amount of sleep are comparable to the normal pattern, but timing of sleep does not conform to a conventional 24-hour schedule. 45 46 47 ASSESSMENT The patient returns 3 weeks later and provides a 7-day sleep diary (Figure). The diary shows that he lays awake for 1-2 hours before getting out of bed at 5-5:30 in the morning. The premature wake times are preceded by involuntary drowsiness and napping in the early evening from 5:30-8 PM. His symptoms support a diagnosis of Advanced sleep-phase disorder. 48
Comprobar respuesta Which treatment is most appropriate for this patient? A. An antidepressant B. A stimulant C. Melatonin D. Light therapy Timed light exposure for 1-2 hours in the evening (7-9 PM) is indicated as standard first-line therapy to delay onset of the sleep cycle in cases of advanced sleep-phase disorder. In addition, the patient is counseled on sleep hygiene and told to avoid naps before a targeted bedtime of 10:30 PM. Physical activity such as walking before or after dinner is recommended to maintain wakefulness during the evening. Low-dose Melatonin taken in the morning may be useful but may induce residual sleepiness. The patient does not suffer from mood disorders, so antidepressant medication is not indicated. Stimulants have a limited role in treating advanced sleep-phase disorder. Caffeine taken in moderation is acceptable for maintaining wakefulness but is not considered a primary therapy for advanced sleep-phase disorder. The wake-promoting agents modafinil and armodafinil are approved for short-term use in treating excessive sleepiness associated with sleep apnea, narcolepsy, and shift-work disorder, but not advanced sleep-phase disorder. 49 Actigraphy Consiste en un pequeo aparato que se coloca en la mueca del individuo y registra sus movimientos a lo largo de la noche. Los datos obtenidos se analizan mediante un sistema computarizado que permite acumular datos hasta un mximo de 22 das consecutivos, y estimar diversos parmetros del sueo (Hauri & Wisbey, 1992). Contrariamente a la polisomnografa, la actigrafa de mueca no es un instrumento costoso ni intrusivo y su utilizacin es sencilla. Permite registrar periodos de 24 horas y proporciona informacin del ritmo circadiano. No obstante, slo mide vigilia y sueo y no estadios especficos de sueo. Trminos del glosario relacionados ndice Captulo 4 - The young man with difficulty falling asleep Arrastrar trminos relacionados aqu Buscar trmino Chronic fatigue El Sndrome de Fatiga Crnica (SFC) es una enfermedad grave compleja y debilitante caracterizada por una fatiga intensa, fsica y mental, que no remite, de forma significativa, tras el reposo y que empeora con actividad fsica o mental. La aparicin de la enfermedad obliga a reducir sustancialmente la actividad y esta reduccin de actividad se produce en todas las Actividades de la Vida Diaria (AVD). El impacto del SFC en la vida del enfermo es demoledor, tanto por la enfermedad en s misma como por el aislamiento e incomprensin del entorno, de hecho, las medidas validadas de calidad de vida, cuando se comparan con otras enfermedades, evidencian que el SFC es una de las enfermedades que peor calidad de vida lleva aparejada. Adems de estas caractersticas bsicas, algunos pacientes de Sndrome de Fatiga Crnica (SFC) padecen diversos sntomas inespecficos, como debilidad muy especial en las piernas, dolores musculares y articulares, deterioro de la memoria o la concentracin, intolerancia a los olores, insomnio y una muy lenta recuperacin, de forma que la fatiga persiste ms de veinticuatro horas despus de un esfuerzo. Casi siempre la enfermedad es crnica (curaciones inferiores al 5-10%) y de un gran impacto en la vida del enfermo. De hecho, la mejor medida del impacto de la enfermedad es evaluar las actividades previas y posteriores a la instauracin de la enfermedad, tanto en la esfera fsica, como en la intelectual, aunque disponemos de escalas validadas de Clasificacin de la Severidad e Impacto de la Fatigabilidad Anormal en un paciente concreto, como por ejemplo la Escala IFR de Fatigabilidad Anormal. Trminos del glosario relacionados ndice Captulo 3 - Differential Diagnosis and Comorbid Conditions Arrastrar trminos relacionados aqu Buscar trmino Circadian rhythm Los ritmos biolgicos endgenos pueden ser de diferentes frecuencias [Adn; 1995, Goldbeter; 2008,Haus; 2009,Ohdo; 2010,Smolensky et al; 2007,Valds-Rodrguez; 2009,Volpato et al; 2005]: Ritmos de frecuencia alta (con periodos cortos menores a 30 minutos): - Ritmos con periodos de un milisegundo a 10 segundos de duracin, como el de la actividad elctrica cortical. - Ritmos con periodos de segundos de duracin, como el cardaco y respiratorio. - Ritmos con periodos de 30 segundos a 20 minutos de duracin, como las oscilaciones bioqumicas. Ritmos de frecuencia media (con periodos intermedios desde media hora hasta 6 das de duracin): - Ritmos ultradianos, ciclos de media hora a 20 horas de duracin, como los ritmos hormonales, las fases del sueo, la depresin pospandrial o post-lunch. - Ritmos circadianos o nictamerales, con periodos alrededor de 24 horas de duracin (24 4 horas), producidos por la rotacin terrestre y que determinan los ciclos del da y la noche (luz-oscuridad) fundamentales para regular la temperatura corporal, la secrecin de cortisol y melatonina, el ciclo de vigilia-sueo, etc. - Ritmos dianos, con periodos de 24 2 horas de duracin. - Ritmos infradianos, con periodos de 28 horas a 6 das de duracin, como los procesos metablicos. Ritmos de frecuencia baja (con periodos largos de ms de 6 das de duracin): - Ritmos circaseptanos, con periodos de 7 3 das de duracin, como el del bienestar subjetivo. - Ritmos circadiseptanos, con periodos de 14 3 das de duracin. - Ritmos circavigintanos, con periodos de 21 3 das de duracin. - Ritmos circatrigintanos o circamensuales, con periodos de unos 30 das de duracin (30 5 das), definidos por el ciclo lunar de traslacin lunar y que determinan la alternancia de las mareas y la luminosidad del cielo nocturno. - Ritmos circanuales o estacionales, con periodos de aproximadamente 1 ao de duracin (1 ao 2 meses), definidos por el ciclo solar de traslacin terrestre y que determinan las estaciones del ao, con sus diferencias en intensidad de luz y temperatura y regulan la reproduccin e hibernacin animal. - Ritmos de aos de duracin, como en ecologa y epidemiologa. De todos ellos los ms estudiados son los circadianos y los estacionales. Trminos del glosario relacionados ndice Captulo 1 - Properties of the Circadian Rhythm Arrastrar trminos relacionados aqu Buscar trmino Circadian rhythm sleep disorders LOS TRASTORNOS DEL SUEO POR ALTERACIN DEL RITMO CIRCADIANO Ante situaciones extremas para el individuo se pierde la periodicidad circadiana de aproximadamente 24 horas, (como en el turno laboral nocturno, enfermedades intercurrentes, etc.). Hay una interrupcin transitoria del funcionamiento del NSQ y pierde el control de los osciladores perifricos. [Haus; 2009,www.sleepassociation.org]. Es lo que ocurre en los TSRC en los que la perturbacin del patrn de sueo es consecuencia de la desincronizacin entre el ritmo de vigilia-sueo deseado (por las circunstancias del entorno del individuo) y su propio ritmo vigilia-sueo circadiano marcado por el marcapasos interno o reloj biolgico [Barion et al; 2007,Haus et al; 2006,Lu et al; 2006, Martinez et al; 2010]. Las repercusiones que tendrn en estas personas (hasta que se adapte su ritmo) sern alteraciones del sueo (insomnio de conciliacin y mantenimiento y excesiva somnolencia diurna [Lu et al; 2006]), biolgicas a nivel celular y molecular, cambios en la actividad cerebral, alteraciones funcionales y del metabolismo de lpidos y carbohidratos, cambios en la resistencia a la insulina, cambios hormonales-endocrinos (secrecin de hormona de crecimiento, melatonina, etc.), etc. [Haus et al; 2006,www.sleepassociation.org].
Los TSRC segn la segunda edicin de la Clasificacin Internacional de los Trastornos del Sueo [Westchester; 2005] de la Academia Americana de Medicina del Sueo (American Academy of Sleep Medicine o AASM) pueden ser primarios, por mal funcionamiento del reloj biolgico, (Sndromes del retraso y adelanto de fase, Patrn irregular del ciclo vigilia-sueo y Sndrome de ciclo vigilia-sueo diferente a 24 horas); secundarios, en los que son las circunstancias del medio ambiente las que provocan el desfase del reloj biolgico, (Jet lag, TSRC secundario al trabajo a turnos, TSRC secundario a enfermedades y al consumo de frmacos u otras sustancias) y otros TSRC no especificados [Martinez et al; 2010]. Trminos del glosario relacionados ndice Captulo 2 - Circadian Rhythm Sleep Disorders Arrastrar trminos relacionados aqu Buscar trmino Delayed or advanced sleep phases Sndrome de la fase del sueo retrasada. Se caracteriza, como su propio nombre indica, por un retraso habitualmente mayor de dos horas en los tiempos de conciliacin del sueo y despertar, en relacin con los horarios convencionales o socialmente aceptados. Los individuos afectados por esta entidad tienen una prctica imposibilidad para dormirse y despertarse a una hora razonable, hacindolo ms tarde de lo habitual. La estructura del sueo es normal, destacando nicamente en los estudios polisomnogrficos un importante alargamiento de la latencia del sueo o el tiempo que tardan en dormirse los pacientes. Estos tienen con frecuencia problemas socio-laborales, ya que sus horas de mayor actividad suelen ser las de la noche. En estos individuos estn tambin retrasados otros ciclos biolgicos circadianos, como son el de la temperatura y el de la secrecin de melatonina. Sndrome de la fase del sueo adelantada. Es menos frecuente que el sndrome de la fase retrasada. Los periodos de conciliacin del sueo y de despertar son muy tempranos o precoces con respecto a los horarios normales o deseados. Los sujetos que padecen este sndrome suelen quejarse de somnolencia durante la tarde y tienen tendencia a acostarse muy pronto, y se despiertan espontneamente tambin muy pronto por la maana. Cuando se acuestan muy tarde, por factores exgenos, sufren un dficit de sueo, ya que su ritmo circadiano les despierta igualmente pronto. No se conoce su prevalencia, pero se estima en torno al 1% en los adultos y ancianos, y aumenta con la edad (probablemente porque con la edad se acorta el ritmo circadiano). Afecta a ambos sexos por igual. Trminos del glosario relacionados ndice Captulo 2 - Circadian Rhythm Sleep Disorders Arrastrar trminos relacionados aqu Buscar trmino Endogenous rhythmicity La periodicidad circadiana, como la del ritmo vigilia-sueo, est mediada genticamente, tiene un control y est sincronizada al ciclo regular de 24 horas de luz-oscuridad ambiental por los osciladores internos, y por ltimo est modulada por influencias ambientales que permiten su adaptacin a las condiciones variables del entorno [Adn; 2004,Aschoff; 1967,Chiesa et al; 1999, Haus et al; 2006]: Trminos del glosario relacionados ndice Captulo 1 - Properties of the Circadian Rhythm Arrastrar trminos relacionados aqu Buscar trmino Escala de Somnolencia de Epworth La Escala de Somnolencia de Epworth (Johns, 1991) estima la somnolencia subjetiva diurna de individuos adultos. La escala de ocho tems, pide al individuo que punte de 0 a 3 el grado de somnolencia en diferentes situaciones cotidianas, diferenciando somnolencia de fatiga. Actualmente, un puntaje de 10 o ms se considera como el punto de corte ms apropiado para detectar somnolencia patolgica. La Escala de Somnolencia de Epworth es sencilla de administrar, es actualmente la medida subjetiva de somno- lencia diurna ms corrientemente empleada. Chung (2000) en su estudio encontr que la escala resultaba ser un instrumento til para diferenciar pacientes con y sin un grado patolgico de somnolencia objetiva diurna. Tambin Sanford, Lichstein, Durrence, Riedel, Taylor & Bush (2006) detectaron que los sujetos con insomnio obtienen puntuaciones ms elevadas en la Escala de Somnolencia de Epworth que los sujetos sin insomnio, lo que puede ayudar a discriminar sujetos con el trastorno de aquellos sin el mismo. La escala ha sido traducida al alemn y espaol y se ha encontrado que su uso no resulta afectado por factores culturales o de lenguaje (Chung, 2000; Izquierdo-Vicario, Ramos-Platn, Conesa-Peraleja & Lozano-Parra, 1997). Trminos del glosario relacionados ndice Captulo 4 - The young man with difficulty falling asleep Captulo 4 - The young man with difficulty falling asleep Captulo 4 - The old man with a history of difficulty staying asleep Arrastrar trminos relacionados aqu Buscar trmino Genetic control En las clulas del organismo (en cerebro y tejidos perifricos), el mantenimiento de la ritmicidad circadiana depende de algunos genes que hay en su ncleo, genes del reloj o genes circadianos, que componen la maquinaria molecular del reloj circadiano [Haus; 2009,Hofman et al; 2005]. Se expresan mediados por seales humorales y neuronales, como la melatonina, que parten de los osciladores internos [Haus et al; 2006,Hofman et al; 2005]. Las lneas de investigacin gentica han tratado de identificar los polimorfismos y mutaciones que sufren estos genes y se asocian al cronotipo de una persona (medido por el Cuestionario de matutinidad-vespertinidad de Horne y stberg), determinados TSRC en algunas familias, adicciones (a drogas y alcohol) y otras enfermedades (diabetes, enfermedades cardiovasculares, cncer, etc.) [Bechtold et al; 2010,Eismann et al; 2010,Rosenwasser; 2010,Sack et al; 2007b]. Trminos del glosario relacionados ndice Captulo 1 - Genetics of the Circadian Rhythm Arrastrar trminos relacionados aqu Buscar trmino Obstructive sleep apnea El sndrome de apnea e hipopnea obstructiva del sueo (SAHOS) es una enfermedad frecuente que afecta al 4% de la poblacin adulta. Su sntoma cardinal es la somnolencia diurna excesiva que, junto a la alteracin del nimo y deterioro cognitivo, producen un deterioro progresivo en la calidad de vida de los pacientes. Adems, se ha asociado a mayor riesgo de hipertensin arterial, morbimortalidad cardiovascular, accidentes laborales y de trnsito. Esta entidad est ostensiblemente subdiagnosticada, por lo que es necesario mejorar su conocimiento para aumentar la pesquisa para su adecuado tratamiento. Trminos del glosario relacionados ndice Captulo 3 - Differential Diagnosis and Comorbid Conditions Arrastrar trminos relacionados aqu Buscar trmino Restless legs syndrome Corresponde a un trastorno del movimiento caracterizado por la presencia de sensaciones desagradables localizadas en extremidades inferiores que llevan a la imperiosa necesidad de moverlas. Esta sensacin empeora con el reposo e interfiere con el sueo. La prevalencia de este sndrome es variable segn los estudios y va de 10,6% en USA, y 11,6% en Espaa con una mayor proporcin de mujeres versus hombres de 3:1. La prevalencia va aumentando con la edad, incluso los primeros sntomas pueden aparecer en la infancia. Trminos del glosario relacionados ndice Captulo 3 - Differential Diagnosis and Comorbid Conditions Arrastrar trminos relacionados aqu Buscar trmino Shift work disorder Trastorno del sueo por alteracin del ritmo circadiano (TSRC) de Tipo trabajo a turnos segn la segunda edicin de la Clasificacin Internacional de los Trastornos del Sueo (ICSD-2 [Westchester; 2005]) de la Academia Americana de Medicina del Sueo, o Trastorno del sueo por horarios cambiantes de trabajo. Este TSRC se produce cuando el horario laboral se solapa con el periodo de sueo habitual para el trabajador y no consigue adaptar su ritmo biolgico a este horario de vigilia-sueo que, debido a sus circunstancias laborales, debe seguir [Lu et al; 2006, Martinez et al; 2010,Waage et al; 2009]. Puede darse en trabajos con guardias nocturnas ocasionales, turnos rotatorios, horario fijo nocturno y aquellos que empiezan muy temprano por las maanas (antes de las 6 a.m.) [Barion et al; 2007,Sack et al; 2007]. Trminos del glosario relacionados ndice Captulo 2 - Circadian Rhythm Sleep Disorders Arrastrar trminos relacionados aqu Buscar trmino Zeitgebers The four most important time givers: ! The light (and thus the rising hour) controls the melatonin secretion. It is proven that the exposure to light has an arousing effect and an influence on the sleep rhythms. Phototherapy has shown its efficiency in a large number of pathologies (insomnia, depression, fibromyalgia...). ! Physical exercice has a significant influence on the body temperature. The warmer the organism was during the day, the stronger becomes the action of melatonin on the fall of body temperature in the evening. Endurance sports (walking, jogging, swimming, ski...) are traditionally associated with a deeper sleep.(Cf.) On the opposite, it is not advised to practice an intensive sport less than three hours before going to sleep. Be careful, that advice for insomniacs must not lead the sick people to stop all activity too early in the evening, like some bad sleepers do who "wait for the train of sleep" from 9 PM on and hope to find sleep in trying not to do anything. ! The meal hours influence the brain through hormones that have been discovered quite recently like the hypocretin/orexin (which has a common action in the food intake behaviors and the circuits of sleep). ! Social contacts, love, laughter and pleasure also play a role that is not to be neglected in the synchronization of the sleep rythms. These new "somnications" are rarely the subject of specific scientific studies but some observations suggest their importance. In 1532, Rabelais already asserted very opportunely that "The cheerful always recover" The pleasures of life are often associated with a short and efficient sleep whereas "clinophilia" (the need to lie down), in which the tired subjects seek shelter, prolonges the sleep duration but diminishes the slow wave activity, thus making the sensation of tiredness even worse. (Cf. "hypo-sleep syndrome) Besides, it is known that (like in cases of forced bed rest), the sudden decrease of activity induces sleep disturbances and functional disorders very quickly.
Trminos del glosario relacionados ndice Captulo 3 - Sin ttulo Arrastrar trminos relacionados aqu Buscar trmino