Sleep Physiology and Disorders

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Sleep Physiology and Disorders

Adult Sleep Medicine
Author Credentials 

Maria Suurna, MD
Assistant Professor
Department of Otolaryngology – Head and Neck Surgery
Weill Cornell Medicine
New York, NY

Module Summary

Sleep disorders are common in adults. Sleep disturbances can be associated with medical and psychosocial problems. Often physicians are unaware of existence of sleep disordered in their patients. Ability to recognize the symptoms of common sleep disordered and referral for appropriate evaluation is essential for comprehensive management of adults with sleep complaints in otolaryngology practice. 

Module Learning Objectives 
  1. Describe sleep architecture, sleep stages and physiological changes in sleep.  
  2. Discuss sleep disorders, assessment and diagnosis of patients with suspected sleep disorders. 
  3. List treatment modalities for sleep disorders. 

Anatomy

Learning Objectives 
  1. Describe neuroanatomy and neuropharmacology of sleep and wakefulness.
    • Neuroanatomical substrates of wakefulness.
    • Neuroanatomical substrates of REM sleep.
    • Neuroanatomical substrates of Non-REM sleep.
  2. Describe Circadian Rhythm and Chronobiology of Sleep.
References 
  1. Espana RA, Scammell TE. Sleep neurobiology for clinician. Sleep. 2004;27:81-820.
  2. McCarley RW. Neurobiology of REM and NREM sleep. Sleep Med. 2007;8:302-330.
  3. Franken P, Dijik DJ. Circadian clock genes and sleep homeostasis. Eur J Neurosci. 2009;29:1820-1829.

Pathogenesis

Learning Objectives 
  1. List biological functions of sleep.
  2. Describe physiological changes in sleep:
    • Respiratory changes
    • Cardiovascular changes
    • Gastrointestinal changes
    • Endocrine function changes
    • Thermoregulation changes
  3. Describe the effects of sleep deprivation and sleepiness:
    • Performance and productivity
    • Cognitive function
    • Quality of life
    • Morbidity and Mortality
  4. Describe changes in sleep architecture:
    • Age-related sleep changes
    • Gender-related sleep architecture
    • Altitude related sleep changes
References 
  1. Kryger MH. Principles and Practice of Sleep Medicine. 5th ed. St Louis: Saunders Elsevier; 2011:27-41. 
  2. Chokreverty S. Sleep disorders Medicine: Basic Science, Technical Considerations and Clinical Aspects. 3rd ed. Philadelphia: Saunders Elsevier; 2009:80-104.
  3. Schüssler P1, Uhr M, Ising M, et al. Nocturnal ghrelin, ACTH, GH and cortisol secretion after sleep deprivation in humans. Psychoneuroendocrinology. 2006 Sep;31(8):915-23.
  4. Hirotsu C, Tufik S, Andersen ML. Interactions between sleep, stress, and metabolism: From physiological to pathological conditions. Sleep Sci. 2015 Nov;8(3):143-52.
  5. Redline S1, Kircher HL, Quan SF, et al. The effects of age, sex, ethnicity, and sleep-disordered breathing on sleep architecture.  Arch Intern Med. 2004 Feb 23;164(4):406-18.
  6. Johnson PL, Edwards N, Burgess KR, Sullivan CE. Sleep architecture changes during a trek from 1400 to 5000 m in the Nepal Himalaya. J Sleep Res. 2010 Mar;19(1 Pt 2):148-56.

Basic Science

Learning Objectives 
  1. Define sleep and sleep onset.
    • Behavioral and physiological criteria of wakefulness and sleep
  1. Describe sleep architecture and sleep stages.
    • Impact of alcohol and medications such as benzodiazepines and tricyclic antidepressants on sleep architecture and sleep stages
  2. Describe sleep requirements and quantity of sleep.
References 
  1. Ogilvie RD, Wilkinson RT, Allison S. The detection of sleep onset: behavioral, physiological, and subjective convergence. Sleep. 1989 Oct;12(5):458-74.
  2. Harris CD. Neurophysiology of sleep and wakefulness. Respir Care Clin N Am. 2005 Dec;11(4):567-86.
  3. Roehrs T, Roth T. Drug-related Sleep Stage Changes: Functional Significance and Clinical Relevance. Sleep Med Clin. 2010 Dec 1;5(4):559-570.
  4. Watson NF, et al. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. J Clin Sleep Med. 2015;11(8):931–952. 
     

Incidence

Learning Objectives 

Discuss the prevalence of sleep disorders such as insomnia, circadian rhythm disorders, narcolepsy, etc.

References 
  1. The National Sleep Foundation http://www.sleepfoundation.org/
  2. Kryger MH. Principles and Practice of Sleep Medicine. 5th ed. St Louis: WB Saunders;2011:42-53.
  3. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006–1014.

Genetics

Learning Objectives 
  1. Discuss genetics of sleep disorders
  • Narcolepsy
References 
  1. Mignot E. Genetic and familial aspects of narcolepsy. Neurology. 1998;50:S16-S22.

Patient Evaluation

Learning Objectives 
  1. Outline the relevant history for patients with suspected sleep disorders 
  2. Describe the following sleep evaluation modalities; specify their indications and diagnostic utility 
    • Sleepiness scale
    • Sleep log
    • Actigraphy
    • Oximetry
    • Overnight Polysomnography (PSG)
      • Define the following terms and understand the normal parameters
        • Total sleep time
        • Sleep latency
        • REM sleep latency
        • Sleep efficiency
        • Sleep stages
        • Wake after sleep onset
        • Sleep cycle
        • Stage shift
        • Arousal index 
      • Describe common indications for PSG
    • Video Polysomnography
    • Multiple Sleep Latency Test (MSLT)
    • Maintenance of Wakefulness Test (MWT)
References 
  1. The AASM Manual for the Scoring of Sleep and Associated Events.
  2. Kushida CA, et al. Practice Parameters for the Indications for Polysomnography and Related Procedures: An Update for 2005. Sleep. 2005 Apr 1;28(4):499-521.
  3. Littner MR. Practice Parameters for Clinical Use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test Sleep. 2005 Jan 1;28(1):113-21.
  4. Kapur VK, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(3):479–504.
  5. Littner M, et al. Practiced parameters for the role of actigraphy in the study of sleep and circadian rhythms: and update for 2002. Sleep. 2003;26(3):337-341.
  6. Ko PR, Kientz JA, Choe EK, Kay M, Landis CA, Watson NF. Consumer sleep technologies: a review of the landscape. J Clin Sleep Med 2015; 11(12):1455–1461.

Measurement of Functional Status

Learning Objectives 
  1. Describe subjective and objective measures used to assess excessive daytime sleepiness.
  2. Discuss effects of excessive daytime sleepiness on school and work performance, cerebral function, quality of life, morbidity and mortality.
  3. Discuss association and effects of sleep disturbances on medical disorders.
References 
  1. Johns MW.  A new method for measuring daytime sleepiness; the Epworth Sleepiness Scale. Sleep. 1991;14(6):540-545.
  2. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485–491.
  3. Excessive Sleepiness. National Sleep Foundation website. Accessed April 24, 2018. 
  4. Roth T, Roehrs TA. Etiologies and sequelae of excessive daytime sleepiness. Clin Ther. 1996 Jul-Aug;18(4):562-76.
  5. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.  Washington (DC): National Academies Press (US); 2006.  

Pathology

Learning Objectives 
  1. Describe clinical manifestations of sleep disorders
    • Insomnia
    • Sleep related breathing disorders
      • Central sleep apnea syndromes
      • Obstructive sleep apnea syndromes (See Adult OSA module)
      • Sleep-related hypoventilation/hypoxemia 
    • Hypersomnias  
      • Narcolepsy 
      • Idiopathic hypersomnia
    • Circadian rhythm sleep disorders 
      • Delayed sleep phase disorder
      • Advanced sleep phase disorder
      • Irregular sleep/wake rhythm
      • Free-running type
      • Jet lag
      • Shift work disorder
    • Parasomnias
      • Confusional arousals 
      • Sleepwalking 
      • Sleep terrors 
      • REM sleep behavior disorder 
      • Recurrent isolated sleep paralysis 
      • Nightmare disorder
    • Sleep related movement disorders
      • Restless legs syndrome 
      • Periodic limb movement disorder 
      • Sleep-related leg cramps 
      • Sleep-related bruxism 
  2. Describe pathophysiology of sleep disorders
    • Insomnia
    • Sleep related breathing disorders
      • Central sleep apnea syndromes
      • Obstructive sleep apnea syndromes (See Adult OSA module)
      • Sleep-related hypoventilation/hypoxemia 
    • Hypersomnias  
      • Narcolepsy
      • Idiopathic hypersomnia
    • Circadian rhythm sleep disorders 
      • Delayed sleep phase disorder
      • Advanced sleep phase disorder
      • Irregular sleep/wake rhythm
      • Free-running type
      • Jet lag
      • Shift work disorder
    • Parasomnias
      • Confusional arousals
      • Sleepwalking
      • Sleep terrors
      • REM sleep behavior disorder
      • Recurrent isolated sleep paralysis
      • Nightmare disorder
    • Sleep related movement disorders
      • Restless legs syndrome
      • Periodic limb movement disorder
      • Sleep-related leg cramps
      • Sleep-related bruxism
References 
  1. Sateia MJ. International Classification of Sleep Disorders-third edition: highlights and modifications. Chest. 2014 Nov;146(5):1387-1394.
  2. Ali M, Auger RR, Slocumb NL, Morgenthaler TI. Idiopathic hypersomnia: clinical features and response to treatment. J Clin Sleep Med. 2009 Dec 15;5(6):562-8.
  3. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Jul 19;165(2):125-33.
  4. Zhu L, Zee PC. Circadian rhythm sleep disorders. Neurol Clin. 2012 Nov;30(4):1167-91.
  5. Avidan AY, Kaplish N. The parasomnias: epidemiology, clinical features, and diagnostic approach. Clin Chest Med. 2010 Jun;31(2):353-70.
  6. Silber MH. Sleep-related movement disorders. Continuum (Minneap Minn). 2013 Feb;19(1 Sleep Disorders):170-84.

Treatment

Learning Objectives 
  1. Describe sleep hygiene measures
  2. Discuss role of medical and behavioral treatments of the following disorders
    • Insomnia
    • Hypersomnolence
      • Narcolepsy
      • Idiopathic Hypersomnolence
    • Central sleep apnea
    • Restless Leg Syndrome/Periodic Leg Movement
    • Circadian Rhythm disorders
    • Parasomnias
References 
  1. Sateia M. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307–349.
  2. Aurora RN, et al. Best Practice Guide for the Treatment of REM Sleep Behavior Disorder (RBD). J Clin Sleep Med. 2010 Feb 15;6(1):85-95.
  3. Wise MS, et al. Treatment of Narcolepsy and other Hypersomnias of Central Origin. Sleep. 2007 Dec 1;30(12):1712-27. 
  4. Schutte-Rodin S, et al. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.
  5. Morgenthaler T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. Sleep. 2006 Nov 1;29(11):1415-9. 
  6. Aurora RN, et al. The treatment of restless legs syndrome and periodic limb movement disorder in adults—an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses. Sleep. 2012;35(8):1039-1062.
  7. Watson NF, et al. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. J Clin Sleep Med. 2015;11(8):931–952. 
  8. Morgenthaler TI, et al. Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders. Standards of Practice Committee of the American Academy of Sleep Medicine.  Sleep. 2007 Nov 1;30(11):1445-59.
  9. Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35(1):17–40.
  10. Costanzo MR, Ponikowski P, Javaheri S, et al.  Sustained 12 Month Benefit of Phrenic Nerve Stimulation for Central Sleep Apnea. Am J Cardiol. 2018 Jun 1;121(11):1400-1408.
  11. Schwartz JR. Pharmacologic management of daytime sleepiness. J Clin Psychiatry. 2004;65 Suppl 16:46-9.
Resources 

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  1. Annual Meeting Webcast (AMW):