STUDY - Technical - New Dacian's Medicine
Sleep
and circadian rhythm disorders (5)
Translation Draft
It's the turn of sleep apnea syndromes.
It's the turn of sleep apnea syndromes.
Respiratory dysfunction
during sleep is a common and serious cause of excessive daytime
sleepiness as well as nocturnal sleep disorders. Estimated, up
to 0.4% of the population stops breathing for 10 to 150 seconds,
from 30 times to a few hundred times each night during sleep.
These stops of breathing may be due to an occlusion of the airways (obstructive sleep apnea), the absence of respiratory exertion (central sleep apnea) or the combination of these factors (mixed sleep apnea). Not recognizing or treating these situations properly can lead to severe cardiovascular complications and an increase in mortality.
This problem is particularly in the case of overweight men and the elderly and is often associated with hypertension. Occult breathing disorders in sleep can lead to significant daytime wakefulness disorders and impaired functions in otherwise healthy elderly people.
Dyssomnia associated with limb movement has several forms of manifestation. The most common would be restless leg syndrome. Patients who experience dyssomnias associated with Restless Legs Syndrome (NSP) experience an irresistible sensation of moving their legs when they wake up or inactivity, especially when they are lying in bed in the run-up to sleep.
This situation interferes with the ability to fall asleep. They report a feeling of crawling or deep hanging in the heels or thighs, sometimes present in the upper limbs and which can only be released by movement or walking. In contrast, paresthesia secondary to peripheral neuropathy persists during activity.
The severity of this chronic idiopathic disorder may increase or decrease over time and may be exacerbated by caffeine and pregnancy. Anemia by iron deficiency or folic acid and renal failure may, in fact, cause NSPs which, in this case, is considered secondary SPN. Almost all patients with restless legs also experience periodic disturbance of limb movement during sleep, although vice versa is not a rule.
The disorder with periodic limb movement, known as nocturnal myoclonia, is the main objective polysomnographic result in 17% of patients with insomnia and in 11% of those who experience excessive daytime sleepiness. This situation can be documented in one-six of patients with insomnia.
Stereotypical, rhythmic extensions from 0.5 to 5 seconds of the toe and the dorsoflexia of the foot occur every 20 to 40 seconds during stages 1 and 2 of NREM sleep in episodes lasting from 10 minutes to several hours. Most of these episodes take place in the first half of the night.
Disorders occur in a wide variety of sleep disorders (including narcolepsy, sleep apnea, various forms of insomnia) and are associated with frequent awakenings and an increased number of transitions in the stages of sleep. However, it has not been shown that these sleep disorders always lead to insomnia.
In fact, periodic limb movements may be secondary to a chronic sleep-wake disorder rather than being the cause of it. The incidence increases with age, 44% of healthy subjects over 65 years of age without sleep disorders and almost all patients with agitated leg syndrome have regular limb movements. Physiology is not well understood.
Polysomnography with bilateral RMG records of the anterior tibial muscle, radial head extensor, triceps and/ or biceps is used to establish the diagnosis. Treatment options are limited, with some patients able to respond to a combination of carbidopa and levodopa, clonazepam or just levodopa.
Let's move on to parasomnias now. The term parasomnia considers sleep behavior disorders associated with short or partial awakenings, but not with significant sleep interruptions or changes in wakefulness during the day. The disorder with which the patient presents is usually related to the behavior itself. most manifest themselves mainly in children, but can also occur in adults, when their presence has a more pathological significance.
The most well-known form of parasomnia is sleep walking (sleepwalking). Patients affected by sleepwalking perform automatic motor activities that range from minor to complex. Subjects can leave the bed, walk, urinate in the wrong places, or leave the house while they remain unconscious or uncommunicative.
Awakening is difficult and even dangerous or fatal activities can take place. Sleepwalking occurs in stages 3 and 4 of NREM sleep. It's common in children and teenagers. Episodes are often isolated, but can be recurrent in 1 to 6% of patients. The cause is unknown.
Terrifying dreams, a disorder known as "nocturnal carpet", manifest themselves mainly in young children in the first hours after the onset of sleep, in stages 3 and 4 of NREM sleep. The child screams suddenly, showing an automatic awakening with sweating, tachycardia and hyperventilation. The subject may be difficult to wake up and he rarely evokes episodes when he wakes up in the morning.
Recurrent attacks are rare, and treatment is usually represented by the presence of parents. Both terrifying dreams and sleepwalking are anomalies of awakening. By contrast, nightmares (anxiety attacks in the dream) occur in REM sleep and lead to full awakening, with the memory of the dream associated with the unpleasant episode.
Behavior disorders in REM sleep are a type of rare parasomnia that occurs in REM sleep and not in slow-wave sleep, as happens in many common parasomnias. It mainly affects middle-aged or older men, many of them having a history of previous neurological diseases (e.g. degenerative diseases, Guillain-Barre syndrome, dementia, subarachnoid hemorrhage, apoplexy).
The present symptoms are manifested by violent behavior in sleep, reported by the bed partner. Unlike typical sleepwalking, the injury of the patient or the person next door is common and, upon awakening, the patient recounts images of the dream, which they find real and often unpleasant. The main referential diagnosis is made with nocturnal epileptic seizure and this can be excluded by polysomnography.
In behavior disorders in REM sleep, seizures are absent and the EOG/ EOG pattern of REM sleep highlights a high amplitude EMG. Complex motor behavior, intentional, occurs during REM sleep episodes. Pathogenesis is unclear, but pre-existing neurological disease may involve the areas of the brain stem responsible for descending motor inhibition during REM sleep.
In support of this hypothesis, the remarkable similarities between behavioural disorders in REM sleep in animals with bilateral lesions of pontine tegment in the areas controlling motor inhibition in REM sleep. Treatment with clonazepam ensures sustained improvement in almost all reported cases.
Sleep bruxism is an involuntary, strong clenching of teeth in sleep that affects 10-20% of the population. Usually, the patient is not aware of this problem, and details related to this parasomnia are provided by roommates or bed partner, alarmed by the specific noise and by dentists who notice the traces of destruction of the malt and dentin. The typical age of onset is 17 to 20 years and spontaneous remissions usually occur around the age of 40. Gender distribution is equal.
Hypotheses related to physiopathology suggest the predisposing role of dental abnormalities, for example, dental malocclusion and central nerve mechanisms. psychological factors can also play a role in the sense that stress exacerbates the disorder. Treatment is dictated by the risk of dental injury. In many cases, the diagnosis is established during dental examination, if the lesion is small treatment is not indicated.
In more severe cases, treatment with a rubber dental prosthesis is indicated to avoid disfiguring and permanent destruction of teeth. Control of stress or, in some cases, biofeedback can be useful when bruxism is a manifestation of strong stress. No useful drug therapy has been described until now.
Nocturnal enuresis, or urination in bed, just like sleepwalking and restlessness in sleep, is another form of parasomnia that occurs during slow-wave sleep in young people. Before the age of 5 or 6, nocturnal enuresis should probably be considered as a normal feature in the child's development.
This situation improves spontaneously in puberty, in adolescents occurs in a percentage of 1 to 3% and is rare in adults. The age threshold for initiating treatment depends on parental and patient concern about this problem. The persistence of enuresis in adolescents or adults may reflect a variety of underlying conditions. In elderly patients with nocturnal enuresis, differentiation should be made between primary and secondary enuresis, the secondary one being defined by bed urination in patients who were fully continent for 6 to 12 months.
Treatment of primary enuresis is reserved for patients of the right age (older than 5 to 6 years) and consists of bladder exercises and behavioral therapy. Urological abnormalities are more common in the case of primary enuresis and should be found on urological examination. Important causes of secondary enuresis include emotional disorders, urinary tract infections, horsetail injuries, epilepsy, sleep apnea and urinary tract malformations.
In patients for whom enuresis may be a significant source of stress, symptomatic drug therapy may be appropriate and special attention will also be paid to the underlying causes. The elective treatment is usually with oxybutinin hydrochloride and imipramin. Desmopressin administered as nasal drops has been used in some cases.
Other clinical entities complete the definition of parasomnia, in the sense that they occur selectively during sleep and are associated to some extent with sleep disruption. Examples include "jactatio capitis nocturnala" (swinging the head in sleep), talking in sleep and leg cramps during sleep. But about these various parasomnias, the data are few and quite controversial.
These stops of breathing may be due to an occlusion of the airways (obstructive sleep apnea), the absence of respiratory exertion (central sleep apnea) or the combination of these factors (mixed sleep apnea). Not recognizing or treating these situations properly can lead to severe cardiovascular complications and an increase in mortality.
This problem is particularly in the case of overweight men and the elderly and is often associated with hypertension. Occult breathing disorders in sleep can lead to significant daytime wakefulness disorders and impaired functions in otherwise healthy elderly people.
Dyssomnia associated with limb movement has several forms of manifestation. The most common would be restless leg syndrome. Patients who experience dyssomnias associated with Restless Legs Syndrome (NSP) experience an irresistible sensation of moving their legs when they wake up or inactivity, especially when they are lying in bed in the run-up to sleep.
This situation interferes with the ability to fall asleep. They report a feeling of crawling or deep hanging in the heels or thighs, sometimes present in the upper limbs and which can only be released by movement or walking. In contrast, paresthesia secondary to peripheral neuropathy persists during activity.
The severity of this chronic idiopathic disorder may increase or decrease over time and may be exacerbated by caffeine and pregnancy. Anemia by iron deficiency or folic acid and renal failure may, in fact, cause NSPs which, in this case, is considered secondary SPN. Almost all patients with restless legs also experience periodic disturbance of limb movement during sleep, although vice versa is not a rule.
The disorder with periodic limb movement, known as nocturnal myoclonia, is the main objective polysomnographic result in 17% of patients with insomnia and in 11% of those who experience excessive daytime sleepiness. This situation can be documented in one-six of patients with insomnia.
Stereotypical, rhythmic extensions from 0.5 to 5 seconds of the toe and the dorsoflexia of the foot occur every 20 to 40 seconds during stages 1 and 2 of NREM sleep in episodes lasting from 10 minutes to several hours. Most of these episodes take place in the first half of the night.
Disorders occur in a wide variety of sleep disorders (including narcolepsy, sleep apnea, various forms of insomnia) and are associated with frequent awakenings and an increased number of transitions in the stages of sleep. However, it has not been shown that these sleep disorders always lead to insomnia.
In fact, periodic limb movements may be secondary to a chronic sleep-wake disorder rather than being the cause of it. The incidence increases with age, 44% of healthy subjects over 65 years of age without sleep disorders and almost all patients with agitated leg syndrome have regular limb movements. Physiology is not well understood.
Polysomnography with bilateral RMG records of the anterior tibial muscle, radial head extensor, triceps and/ or biceps is used to establish the diagnosis. Treatment options are limited, with some patients able to respond to a combination of carbidopa and levodopa, clonazepam or just levodopa.
Let's move on to parasomnias now. The term parasomnia considers sleep behavior disorders associated with short or partial awakenings, but not with significant sleep interruptions or changes in wakefulness during the day. The disorder with which the patient presents is usually related to the behavior itself. most manifest themselves mainly in children, but can also occur in adults, when their presence has a more pathological significance.
The most well-known form of parasomnia is sleep walking (sleepwalking). Patients affected by sleepwalking perform automatic motor activities that range from minor to complex. Subjects can leave the bed, walk, urinate in the wrong places, or leave the house while they remain unconscious or uncommunicative.
Awakening is difficult and even dangerous or fatal activities can take place. Sleepwalking occurs in stages 3 and 4 of NREM sleep. It's common in children and teenagers. Episodes are often isolated, but can be recurrent in 1 to 6% of patients. The cause is unknown.
Terrifying dreams, a disorder known as "nocturnal carpet", manifest themselves mainly in young children in the first hours after the onset of sleep, in stages 3 and 4 of NREM sleep. The child screams suddenly, showing an automatic awakening with sweating, tachycardia and hyperventilation. The subject may be difficult to wake up and he rarely evokes episodes when he wakes up in the morning.
Recurrent attacks are rare, and treatment is usually represented by the presence of parents. Both terrifying dreams and sleepwalking are anomalies of awakening. By contrast, nightmares (anxiety attacks in the dream) occur in REM sleep and lead to full awakening, with the memory of the dream associated with the unpleasant episode.
Behavior disorders in REM sleep are a type of rare parasomnia that occurs in REM sleep and not in slow-wave sleep, as happens in many common parasomnias. It mainly affects middle-aged or older men, many of them having a history of previous neurological diseases (e.g. degenerative diseases, Guillain-Barre syndrome, dementia, subarachnoid hemorrhage, apoplexy).
The present symptoms are manifested by violent behavior in sleep, reported by the bed partner. Unlike typical sleepwalking, the injury of the patient or the person next door is common and, upon awakening, the patient recounts images of the dream, which they find real and often unpleasant. The main referential diagnosis is made with nocturnal epileptic seizure and this can be excluded by polysomnography.
In behavior disorders in REM sleep, seizures are absent and the EOG/ EOG pattern of REM sleep highlights a high amplitude EMG. Complex motor behavior, intentional, occurs during REM sleep episodes. Pathogenesis is unclear, but pre-existing neurological disease may involve the areas of the brain stem responsible for descending motor inhibition during REM sleep.
In support of this hypothesis, the remarkable similarities between behavioural disorders in REM sleep in animals with bilateral lesions of pontine tegment in the areas controlling motor inhibition in REM sleep. Treatment with clonazepam ensures sustained improvement in almost all reported cases.
Sleep bruxism is an involuntary, strong clenching of teeth in sleep that affects 10-20% of the population. Usually, the patient is not aware of this problem, and details related to this parasomnia are provided by roommates or bed partner, alarmed by the specific noise and by dentists who notice the traces of destruction of the malt and dentin. The typical age of onset is 17 to 20 years and spontaneous remissions usually occur around the age of 40. Gender distribution is equal.
Hypotheses related to physiopathology suggest the predisposing role of dental abnormalities, for example, dental malocclusion and central nerve mechanisms. psychological factors can also play a role in the sense that stress exacerbates the disorder. Treatment is dictated by the risk of dental injury. In many cases, the diagnosis is established during dental examination, if the lesion is small treatment is not indicated.
In more severe cases, treatment with a rubber dental prosthesis is indicated to avoid disfiguring and permanent destruction of teeth. Control of stress or, in some cases, biofeedback can be useful when bruxism is a manifestation of strong stress. No useful drug therapy has been described until now.
Nocturnal enuresis, or urination in bed, just like sleepwalking and restlessness in sleep, is another form of parasomnia that occurs during slow-wave sleep in young people. Before the age of 5 or 6, nocturnal enuresis should probably be considered as a normal feature in the child's development.
This situation improves spontaneously in puberty, in adolescents occurs in a percentage of 1 to 3% and is rare in adults. The age threshold for initiating treatment depends on parental and patient concern about this problem. The persistence of enuresis in adolescents or adults may reflect a variety of underlying conditions. In elderly patients with nocturnal enuresis, differentiation should be made between primary and secondary enuresis, the secondary one being defined by bed urination in patients who were fully continent for 6 to 12 months.
Treatment of primary enuresis is reserved for patients of the right age (older than 5 to 6 years) and consists of bladder exercises and behavioral therapy. Urological abnormalities are more common in the case of primary enuresis and should be found on urological examination. Important causes of secondary enuresis include emotional disorders, urinary tract infections, horsetail injuries, epilepsy, sleep apnea and urinary tract malformations.
In patients for whom enuresis may be a significant source of stress, symptomatic drug therapy may be appropriate and special attention will also be paid to the underlying causes. The elective treatment is usually with oxybutinin hydrochloride and imipramin. Desmopressin administered as nasal drops has been used in some cases.
Other clinical entities complete the definition of parasomnia, in the sense that they occur selectively during sleep and are associated to some extent with sleep disruption. Examples include "jactatio capitis nocturnala" (swinging the head in sleep), talking in sleep and leg cramps during sleep. But about these various parasomnias, the data are few and quite controversial.
Have a good day!
Dorin, Merticaru