Sleep

Organization

2. Physiology of the normal sleep

3. Sleep Disorders
 Definition

REST- a state of calmness, relaxation without

emotional stress, and freedom from anxiety

SLEEP- an altered state of consciousness in

which the individual’s perception of and
reaction to the environment are decreased.
Physiology of Sleep
 Theories on Sleep

1. ELECTROPHYSIOLOGIC
2.HORMONAL
3. NEURAL
 Neural approach

Views sleep as an active process involving the

RETICULAR activating system (RAS) and the
interaction of Neurotransmitters.

The RAS is a network of neurons in the

medulla, pons and midbrain with projections to
the spinal cord, hypothalamus, cerebellum and
cerebrum.
 The reticular activating system (or ARAS, for
Ascending Reticular Activating System)

 The reticular activating system (or ARAS, for Ascending

Reticular Activating System) is the name given to the part of the
brain (the reticular formation and its connections) believed to be
the center of arousal and motivation in mammals (including
humans).

Functions
 The activity of this system is crucial for maintaining the state of
consciousness.

 It is involved with the circadian rhythm; damage can lead to

permanent coma.
 It is thought to be the area affected by many psychotropic drugs.
 General anesthetics work through their effect on the reticular
formation.
 The reticular activating system (or ARAS, for
Ascending Reticular Activating System)

Functions cont
The functioning of this system is a prerequisite
for consciousness to occur

The reticular activating system controls our

sexual patterns.
Neural approach

SEROTONIN is said to be the MAJOR

neurotransmitter associated with sleep,
produced in the median raphe nuclei of the
brainstem.

Serotonin decreases the activity of the RAS

inducing sleep.

REM sleep appears to be due to the influence

of norepinephrine.
 Hormonal approach

Views sleep as a pattern affected by hormones.

MELATONIN from the pineal gland in the brain

is secreted in enormous quantities during
sleep.

Its activity is influenced by the relationship of

darkness and light.
Hormonal approach

ACTH is also high during the early period of

sleep and CORTISOL rises toward the end of
the nighttime sleep period.

GROWTH HORMONE and PROLACTIN also

increase during deep sleep.
FUNCTIONS OF SLEEP

1.Restores normal levels of activity and

normal balance among parts of the nervous
system

2. Necessary for protein synthesis

 Phases of Sleep

A. REM (Rapid Eye Movement) sleep

B. NREM (Non-Rapid Eye Movement) sleep
 Normal sleep stages

NREM sleep is divided in to four stages

according to changes in biophysiological
changes
NREM sleep is followed by REM sleep
Sleep pattern is usually NREM sleep stages 1
to 4 followed by REM sleep
NREM characteristics
NREM SLEEP

Also referred to as the SLOW wave sleep,

because the brain waves of the client are
slower than the brain waves of an awake or
alert person.
It is a deep, restful sleep
There is a decreased physiologic functions
All metabolic processes are reduced.
NREM Stages

STAGE 1- the stage of very light sleep, sleeper

can readily be awakened, lasts for a few
minutes. The eyes tend to roll slowly from side
to side, and muscle tension remains absent.
STAGE 2- the stage of light sleep, body
processes continues to slow down, and lasts
about 10-15 minutes. Constitutes 40-45% of
TOTAL sleep!
NREM Stages

STAGE 3-refers to a medium-depth sleep where

vital signs and metabolic processes slow further
because of the PARASYMPATHETIC nervous system
influence. The sleeper is difficult to arouse.
STAGE 4-this is the deepest sleep or delta sleep. It
is the stage where the heart rate and respiratory
rate drop 20-30% below those exhibited during
waking hours.
This stage is thought to restore the body
physically. Some dreaming may occur here. This
stage may be absent in the elderly.
EEG Stages of Wakefulness and Sleep
20
 NREM sleep

NREM (Non Rapid Eye Movements) consists

of relatively long stretches of dreamless sleep
in contrast to REM sleep. REM sleep is
typically characterized by dreams
Eye movements in NREM sleep are slow and
rolling in contrast to REM sleep, in which the
eye movements are rapid and conjugate
 NREM Sleep-changes in EEG and
consciousness (cerebral function)
Divided into four stages
Stages are divided according to the depth of
unconsciousness
Greater depth of unconsciousness as sleep
progresses from stage 1 to 4
EEG becomes progressively slower and shows
higher-voltage pattern ( also called slow
wave, delta wave )
 NREM-Thinking and Body Activities

Thinking in NREM is brief, rudimentary and

readily forgotten
Muscle tone is present
DTR can be elicited
EMG activities can be detected in chin and limb
muscles
 NREM sleep-autonomic changes

Characterized by generalized decrease in

autonomic activities
Decrease in autonomic activities causes
hypotension and bradycardia
Decreased generalized metabolic activity
 NREM sleep-Hormonal changes

Growth Hormone is secreted almost entirely

in NREM sleep (due to hypothalamic-pituitary
activity)
GH is secreted in 30 to 60 minutes after the
beginning of sleep
Prolactin is secreted in NREM sleep (at the
beginning of sleep)
Cortisol is secreted in NREM sleep (late at
night)
 NREM sleep

Important characteristics of NREM sleep like

slow wave, decreased generalized metabolic
activities and deep unconsciousness help
revitalize the body
Occurs predominantly in the early night
Remaining sleep becomes lighter and dream
filled predominantly characterized by REM
sleep in the late phase
 THE REM SLEEP
This sleep type usually recurs about every 90
minutes and lasts 5 to 30 minutes.

Other name: PARADOXICAL Sleep

The EEG pattern resembles that of the

“awake” state. This is not as restful as NREM
sleep

Most dreams take place during this period

and the dreams are usually remembered or
Normal Sleep Cycles
28
REM Sleep characteristics
 REM Sleep characteristics

Dreaming
Flaccid limb paralysis
Eye movements- rapid, conjugate and
predominantly horizontal
Increased autonomic activities
REM sleep-changes in autonomic activities

Increased pulse
Increased blood pressure
Increased intracranial pressure
Increased cerebral flow
Increased muscle metabolism
In men, erections
These increase in autonomic activities are
considered responsible for increased
incidence of myocardial infarctions and
ischemic CVA
 EEG/EMG characteristics of sleep
EEG-more active in REM similar to
wakefulness. EEG shows low voltage fast
with ocular movement artifact
EMG is silent in REM sleep corresponding to
flaccid muscles
Paradoxical muscle tone, all other body
activities are as active as the wakefulness
state in REM sleep
 Sleep patterns-Latencies Definitions

 Sleep latency- the interval to fall asleep after

retiring. Normal range is 10-20 minutes

 REM latency- once asleep, normal individual enter

NREM sleep and pass in succession through four
stages. The interval from falling asleep to the first
REM sleep is called REM latency.

 Normal range is 90-120 minutes

Sleep Disorders
abnormalitiesoflatencies
 SHORTENED SLEEP LATENCY

Alcohol and drug induced sleep

Narcolepsy
Sleep apnea
Sleep deprivation
 Prolonged Sleep Latency

Delayed sleep phase syndrome

Inadequate sleep hygiene
Psychiatric disorders-Acute schizophrenia,
Major depression, and Mania
Restless leg syndrome
 Causes of shortened REM sleep
Alcohol, sedative and hypnotics
Depression
Narcolepsy
Sleep apnea
Sleep deprivation
Effects of
aging
 Effects of age on sleep

NREM sleep reduces in the elderly.

The slow wave phase disappears in people older
than 75 years of age
 Sleep disorders in Elderly

Leg movement disorders

REM behavior disorder
Sleep apnea syndrome
Medication induced sleep disorders
Medical disorders especially cardiovascular
disturbances and pain
Dementia
Neurological disorders
Depression
 Sleep Disorders
A. Dyssomnias-

Dyssomnias are a broad

classification of sleeping disorders
that make it difficult to get to
sleep, or to stay sleeping.
 Sleep Disorders
 B. Parasomnias:

 Parasomnia is a broad term used to describe various

uncommon disruptive sleep-related disorders.
 They are intense, infrequent physical acts that occur
during sleep.

 Include sleepwalking, sleep talking, sleep terrors,

nightmares, and teeth grinding
Dyssomnias
 Dyssomnias-characteristics

Patients may complain of:

difficulty getting to sleep or staying asleep
intermittent wakefulness during the night,
early morning awakening
or combinations of any of these.
Transient episodes are usually of little
significance.
Stress, caffeine, physical discomfort, daytime
napping, and early bedtimes are common
factors
Dyssomnias-causes

 There are over 30 recognized kinds of Dyssomnias. Major groups of

Dyssomnias include:
 Intrinsic sleep disorders - 12 disorders recognized, including
 narcolepsy,
 periodic limb movement disorder,
 restless legs syndrome,
 sleep apnea.
 Extrinsic sleep disorders - 13 disorders recognized, including
 alcohol-dependent sleep disorder,
 food allergy insomnia,
 inadequate sleep routine.
 Circadian rhythm sleep disorders - 6 disorders recognized, including
 advanced sleep phase syndrome,
 delayed sleep phase syndrome,
 jetlag,
 shift work sleep disorder
 Dyssomnias-conditions-Narcolepsy

 Narcolepsy is a neurological condition most

characterized by Excessive Daytime Sleepiness
(EDS).
 A narcoleptic will most likely experience disturbed
nocturnal sleep, confused with insomnia, and
disorder of REM or rapid eye movement sleep.

 The main characteristic of narcolepsy is
overwhelming excessive daytime sleepiness (EDS),
even after adequate nighttime sleep.
 Dyssomnias-conditions-Narcolepsy

 A person with narcolepsy is likely to become drowsy

or to fall asleep, often at inappropriate times and
places
 Four other classic symptoms of narcolepsy, which
may not occur in all patients, are cataplexy,
sleep paralysis, hypnogogic hallucinations, and
automatic behavior.
 Narcolepsy treatment

 Treatment is individualized depending on the severity

of the symptoms, and it may take weeks or months
for an optimal regimen to be worked out.
 Complete control of sleepiness and cataplexy is
rarely possible
 Treatment is primarily by medications, but lifestyle
changes are also important.
 The main treatment of excessive daytime sleepiness
in narcolepsy is with a group of drugs called central
nervous system stimulants.
 For cataplexy and other REM-sleep symptoms,
antidepressant medications and other drugs that
suppress REM sleep are prescribed.
 Periodic Limb Movements

Periodic Limb Movement Disorder

(PLMD), also called nocturnal myoclonus,
is a sleep disorder where the patient moves
involuntarily during sleep
It is related to restless leg syndrome (RLS) in
that 80% of people with RLS also have PLMD.
However, most people with PLMD do not
experience RLS
These medications are also successful for the
treatment of RLS restless leg syndrome.
Dyssomnias-Restless Leg Syndrome

Criteria

(1) an urge to move the limbs

with or without sensations
(2) worsening at rest
(3) improvement with activity
(4) worsening in the evening or
 Restless Leg Syndrome- Medicinal
approach
Dopamine agonists such as ropinirole,
pramipexole, carbidopa/levodopa or pergolide
Opioids such as propoxyphene, oxycodone,
or methadone, etc.
Benzodiazepines, which often assist in
staying asleep and reducing awakenings from
the movements
Anticonvulsants, which often help people who
experience the RLS sensations as painful,
such as gabapentin
Parasomnias
Parasomnias

 A sleep disorder is a physical and psychological

condition or disturbance of sleep and wakefulness
caused by abnormalities that occur during sleep or
by abnormalities of specific sleep mechanisms

 Although the sleep disorder exists during sleep,

recognizable symptoms manifest themselves during
the day
Parasomnias

 Accurate diagnosis requires a polysomnogram,

widely known as a "sleep test.“
 Some common Parasomnias include sleepwalking,
sleep talking, sleep terrors, nightmares, and teeth
grinding
 Parasomnias-classifications

A. Arousal-Sleep terrors, Sleepwalking or

Somnambulism
B. Sleep-Wake Transition-Rhythmic movement
disorders
C. Parasomnias with REM sleep-Nightmares,
Sleep paralysis, and REM sleep Behavior
disorders

D. Other Parasomnias- Bruxism and Enuresis

 Sleep Disturbances in Alcoholism

Is associated with both insomnia and

excessive daytime sleepiness (EDS)
They have a short sleep latency, less REM
sleep and increased slow wave sleep in the
first half of night
In the second half, they have increased REM
and periods of wakefulness, as though
emerged into delirium
Alcohol withdrawl leads to insomnia and REM
rebound
 Sleep
Lack of Sleep
Dyssomnias
VS Disturbed
sleep
Parasomnia Excessive
s Sleep
 Lack of Sleep

Sleep
Insomnia
Deprivation
 Insomnia
Insomnia is the inability to fall asleep.

It is common problem that most

people

experience at least occasionally.

 Why?
Consequently, insomnia often disrupts
daily life. It can result from
 Result

When it occurs, people feel tired much

of the time and often worry a lot about

not getting enough sleep.

 Sleep Deprivation

Actually sleep deprivation is not a Disorder.

It just indicates that a person has not been

getting enough sleep.
 Result

It’ll affect person’s judgment,

reaction-time, hand-eye coordination,

memory, general well-being and immune

system.
 How can I know that I am a
Sleep Deprived patient?
üFeeling drowsy during the day?
üFalling asleep for very short period of
time(5 min or so) ?
üRegularly falling asleep immediately after
lying down?
It means you need
more SLEEP!!!

Go to bed NOW !!!

 Disturbed Sleep
Sleep Apnea

REM sleep behavior Disorder

Restless Leg Syndrome(RLS) and

Periodic limb movement Disorder
 Sleep Apnea

Sleep Apnea is interrupted breathing during

sleep.

It usually occurs because of a mechanical

problem in the windpipe.

But it also indicates a neurological disorder

involving nerve cells (neurons).
 Process

1) As people age, muscle tone relaxes,

which may cause the windpipe to
collapse.

3) This condition is called Obstructive

Sleep Apnea.

5) It results in loud snoring and blocked

air flow through the windpipe.
4) It lasts from 10 to 60 seconds.

6) People may be gasping or snorting.

8) And then the brain quickly reacts to the

sudden lack of oxygen, the muscles
tighten.

10)Windpipe opens.
 Why?

Narrow nasal passages, enlarged

tonsils, and obesity are factors that
may contribute to obstructive sleep
apnea.

It also may be related to alcohol,

tobacco, or sedatives.
 Result

vThe sleep cycle can be

interrupted as many as 100
times a night.

vEvery time the windpipe closes,

the brain is deprived of oxygen.
vThis lack of oxygen eventually can
cause problems morning
headaches and decreased mental
function.

vHigh risk for heart disease and

stroke
REM Sleep behavior disorder

It causes disruptions
in the brain
during REM sleep.
REM SLEEP

Process
Cerebral Cortex

Pons

Muscles
 Result

✢It causes a type of temporary paralysis.

✢In a person with REM sleep behavior

disorder, these signals translate into
images that make up dreams.
✢ If the signals are interfered with, the person
may physically act out dreams during sleep.
For example, if a patient with REM sleep
behavior disorder dreams about running, he
or she might actually get up and run.

✢ As a result of this condition, patients may

injure themselves or others.

BUT !!! REM sleep behavior disorder is rare.

Restless leg syndrome (RLS)
and periodic limb movement disorder
(PLMD)

It is a common sleep disorder,

especially in the elderly.

Also RLS is a genetic disorder

 Result
It causes patients to want to
move their legs.

It often results in insomnia.

PLMD causes jerking in the legs
or arms that occurs frequently
during resting or sleeping.
Jerking may occur as many as 3
times in a minute and each jerk
can wake the patient.
 Narcolepsy

Cataplexy

Sleep paralysis

Hypnagogic hallucinations
 Narcolepsy

It is a condition that causes patients

to fall asleep uncontrollably throughout

the day for periods lasting less than a

minute to more than half an hour.

These sleep attacks can occur
at anytime,

even while the person is

engaged in an activity !!!
 Process

During sleep, narcoleptics have

an abnormal sleep pattern:

They enter REM sleep

prematurely without going
through the normal sequence of
sleep stages.
❃Narcolepsy usually is a
genetic (inherited) disorder,
although it may be
associated with brain
damage or neurological
disease.
 When?

qage : 15 - 30

qWhen people get

pregnant, ill, a fever, or
stress.
 Result

often feel tired most of the

time.

cataplexy,
and sleep paralysis.
 Cataplexy

✪Cataplexy is weakness or
paralysis of the muscles.

✪When cataplexy occurs,

persons who are standing may
fall down.
✪In narcoleptic patients, it may be

triggered by tiredness and intense

emotions and may be accompanied by

short, sudden episodes of laughter or

anger.
 Sleep paralysis

✾Sleep paralysis is the

inability to move the arms,
legs, or entire body that
occurs when a person is
falling asleep or waking up.
 Result

People who experience sleep paralysis

May become:

very anxious and often regain movement only

if they hear a loud noise or another stimulus.
 Hypnagogic hallucinations or
pre-sleep dreams

Hypnagogic hallucinations or
pre-sleep dreams, are dream-
like hallucinations that occur in
the transition between being
awake and being asleep.
✧Often, they are very
vivid, frightening
dreams.
Insomnias
 Insomnia-causes

Medical and neurological conditions

Drug and alcohol abuse
Psychiatric disorders
Patients older than 65 years of age
 Treatment of Insomnia

 Limited course of hypnotic is effective for the

insomnia due to the transient disturbances such as
grief
 People with neurological conditions like Alzheimer’s
disease can develop “paradoxical reaction” to
hypnotics
 Non-prescription hypnotics like antihistamines are
more hazardous than prescription hypnotics like
benzodiazepine
 In the elderly, the benzodiazepines can cause
anterograde insomnia, insomnia in the early
morning, daytime anxiety and psychomotor
impairments
Sleep Studies
 STUDY OF NORMAL SLEEP

There are mainly two ways to define the stages

of sleep
A. Clinical observations
B. Physiologic information
Polysomnography is a common method
employed to study these changes
 Recording of Polysomnography

Simultaneous recordings of EEG, EOG, EMG,

EKG, vital signs and breathing
 What answers to expect from
Polysomnography ?
Polysomnography is a comprehensive
recording of the biophysiological changes that
occur during the sleep
Polysomnography is usually performed during
the night when patient sleeps
Recording of Polysomnography