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Inv sleep 2012
1.
2. Investigations
of sleep disorders
BY
Dr.Jaidaa Mekky
Lecturer of Neuropsychiatry
Sleep Medicine Consultant
Member of the American Academy of Neurology
Member of the American Academy of Sleep
Medicine
Faculty of Medicine
Alexandria University
3. Background
• One-half to one-third of life asleep
• Sleep medicine relatively new field
• Sleep is a co-morbidity in a long list of
diseases
• It was mentioned in the holy Quran 9
times, describing the sleep fnctions and
stages
وقال إن أبقراط قال: إذا كان النوم فى المراض المزمنة يس ّب وجعً، فذلك
ا ب
. من علمات الموت
4. Milestones
• 1837 – Dickens – describes
overweight/hypersomnolent boy in the
Posthumous Papers of the Pickwick Club (term
“pickwickian” used by Osler)
• 1875 – Caton – EEG in dogs
• 1928 – Berger – Human EEG alpha waves
• 1937 – Loomis – EEG Sleep stages
described
5. Milestones
• 1953 – Aserinsky & Kleitman – REM sleep
• 1970s – Polysomnography
• 1972 – Guilleminault – coins term OSA
• 1990 – International Classification of Sleep
Disorders
6. Sleep Physiology
• What is Sleep?
– “a reversible behavioral state of perceptual
disengagement from and unresponsiveness to
the environment”
• 75% in Non-REM sleep
• 25% REM sleep – muscle atonia,
autonomic activation
10. A major input to the relay and reticular nuclei of the thalamus (yellow pathway) originates from cholinergic (ACh) cell
groups in the upper pons, the pedunculopontine (PPT) and laterodorsal tegmental nuclei (LDT). These inputs facilitate
thalamocortical transmission. A second pathway (red) activates the cerebral cortex to facilitate the processing of inputs
from the thalamus. This arises from neurons in the monoaminergic cell groups, including the tuberomammillary nucleus
(TMN) containing histamine (His), the A10 cell group containing dopamine (DA), the dorsal and median raphe nuclei
containing serotonin (5-HT), and the locus coeruleus (LC) containing noradrenaline (NA). This pathway also receives
contributions from peptidergic neurons in the lateral hypothalamus (LHA) containing orexin (ORX) or melanin-
concentrating hormone (MCH), and from basal forebrain (BF) neurons that contain γ-aminobutyric acid (GABA) or
ACh. Note that all of these ascending pathways traverse the region at the junction of the brainstem and forebrain where
von Economo noted that lesions caused profound sleepiness.
50. S taging
M ove m e nt T im e
Awak e
RE M
S tage 1
S tage 2
S tage 3
S tage 4
11 Õ 12 ã 01 ã 02 ã 03 ã 04 ã 05 ã 06 ã
Pos ition
Le ft
R ight
S upine
P rone
U pright
PL MS
With Arou s al
W/O Arou s al
Respiratory E vents
Mixe d Apne a
O bs tructive Apne a
C e ntral Apne a
Hypopne a
51.
52. The main data presented in PSG are:
• 1) Total sleep time, wake time, total recording time;
• 2) Sleep efficiency (total sleep time/total recording time);
• 3) Latency for sleep onset, latency for REM sleep and other sleep
stages.
• 4) Duration (in minutes) and proportion of total-sleep-time sleep
stages (5) Frequency of apneas and hypopneas per hour of sleep
• 6) Saturation values and events of oxyhemoglobin desaturation
• 7) Total number and index of periodic lower limb movements per hour
of sleep.
• 8) Total number and index of micro-arousals per hour of sleep and
their relationship with breathing events or lower limb movements;
• 9)Esophageal ph anormalities
• 10)Penile tumecence
58. Actigraphy
• Cost efficient
• Records motor movements
• Aallows estimates for several days,
avoiding the sampling error of NPSG
• It gives an idea about TST,SL, Nocturnal
arousals
• It is superior to sleep log
59. Uses:
• Used in assessment of Insomnia
• Useful in children and old age
• Circadian rhythm disorders
• Epidemiologic sleep studies
Limitations:
• It is not standardized yet for diagnosing
PLMS,SDB or RBD.
NREM sleep is divided into 4 stages. Stages 1 and 2 are characterized by low arousal thresholds and are considered light sleep. Stages 3 and 4 are characterized by high arousal thresholds and are considered deep or “slow wave” sleep. All 4 of these stages can be differentiated by electroencephalography (EEG). Stage 1 is marked by low voltage, mixed frequency EEG. Stage 2 is marked by the presence of K complexes and sleep spindles on EEG recordings. Both stages 3 and 4 are marked by delta waves, which have a voltage of 75 microvolts or more and a frequency range of 0.5 to 4 hertz, but differ in composition. Stage 3 is defined as sleep consisting of 20-50% delta waves and stage 4 as sleep consisting of more than 50% delta waves. REM sleep is characterized by minimal movement, low muscle tone, activation of cortical activity, and rapid eye movements accompanied by vivid dreams. [Text: Comella, p. 18-B; Pace-Schott, p. 600. Figure: Pace-Schott, p. 600] Comella CL, Walters AS, Hening WA. Sleep and wakefulness. In: Goetz CG, Pappert EJ, eds. Textbook of Clinical Neurology . Philadelphia: WB Saunders Company; 1999:18-27. Pace-Schott EF, Hobson JA. The neurobiology of sleep: genetics, cellular physiology and subcortical networks. Nat Rev Neurosci . 2002;3:591-605. Scammell TE. The regulation of sleep and circadian rhythms. Sleep Med Alert. 2004;8:1-6.