Sleep-Wake Disorders

Primary complaint of unsatisfying sleep quantity or quality and > or equal to 1 of the following:
1. Difficulty initiating sleep
2. Difficulty maintaining sleep
3. Early morning awakening
Associated with social, occupational, academic, educational, behavioral, or functional distress or impairment
Occurs > or equal to 3 nights per week for > or equal to 3 months
Sleep difficulties happen even with ample opportunity to sleep

1-3 months

>3 months

> or equal to 2 episodes within one year

Difficulty falling asleep
Difficulty maintaining sleep
Waking multiple times during the night
Waking too early

Non-restorative sleep
Excessive daytime sleepiness (EDS) or fatigue
Malaise
Difficulty concentrating
Memory impairment

Polysomnography (PSG) can be used to measure but not commonly used, sleep diarys can also be helpful.

Time that it takes to transition from wakefulness to sleep, persons without sleep complaints generally take about 15 minutes to fall asleep, increased in insomnia

Reduce to < 30 minutes

Time from lights out until the first 10 minutes of consistent sleep, increased in insomnia

~40 minutes (SOL + 10 minutes)

Total sleep period (time in bed) minus the time spent awake, measures sleep duration reduced in insomnia

> 6 hours

Time spent awake after initial sleep onset until final awakening, measure of sleep maintenance, increased in insomnia

Reduce to < 30 minutes

The ratio of TST divided by the time spent in bed (reported as a percentage), 85% is considered normal, reduced in insomnia

Achieve > 80-85%

0-7

8-14

15-21

22-28

Predisposing factors
Precipitating factors
Perpetuating factors

Genetics, personality characteristics

Situational stress (work, finances, major life events, interpersonal conflicts), environmental (light, noise, temperature extremes, high altitude)

Maladaptive coping strategies, poor sleep hygiene

Use of alcohol results in lower quality of sleep despite sedating effect
Increased number of awakenings, decreased total sleep time, decreased quality of sleep, decreased rem in first portion of night, which may lead to rebound REM causing nightmares, sweating, and vivid dreams, and increased snoring and apneas.

Anxiety disorders
Delirium
Dementia
Eating disorders
Mood disorders
Personality disorders

Angina, arrhythmias, heart failure
Arthritis
Asthma, bronchitis, COPD
Chronic liver or renal failure
Chronic pain
Cystic fibrosis
Diabetes
Epilepsy
GERD
Head injury
Hyperthyroidism
Malignancy
Menopause
MS
Parkinson’s disease
Pregnancy

Amphetamine/stimulants
Anticholinergics
Anticonvulsants
Appetite suppressants
Beta-agonists
Beta-blockers
Bupropion
Caffeine
Corticosteroids
Decongestants
Hypnotics (chronic use)
Levodopa, methyldopa
Medroxyprogesterone
Methylphenidate
Modafinil/armodafinil
Nicotine
SSRIs, SNRIs
Theophylline

CBT

pharmacological treatment used for short time if non-pharmacological treatment fails
preferred:
Short to intermediate acting BZD
Non-BZD receptor agonist (NBRA)
then:
Suvorexant
Ramelteon
Sedating antidepressants (doxepin, mirtazapine, trazodone)

short acting:
Triazolam
intermediate acting:
Temazepam

Short acting:
Oxazepam
intermediate acting:
Temazepam
Lorazepam

falling asleep, staying asleep (CR), middle of the night awakening (SL)

falling asleep, less hangover than zolpidem

Falling asleep, staying asleep

Zolpidem, must be dosed lower for women since they metabolize slower

Nausea
Dizziness
Somnolence, feeling “drugged” or hungover*
Headache

Chest pain, tachycardia
Hepatic encephalopathy (zolpidem)
Complex sleep behaviors (Parasomnias, sleep walking, eating, driving, or other activities. Has lead to serious injuries and deaths.)
Angioedema

Recurring episodes of irresistible need to sleep, fall asleep, or nap during the same day (> 3 times per week in the previous 3 months)

> 1 of the following:
1. Cataplexy episode a few times per month
2. Hypocretin deficiency
3. REM sleep latency <15 minutes and > 2 sleep-onset REM periods (SOREMPs)

Infrequent cataplexy attacks (<1 per week)

Cataplexy once daily or every few days, nocturnal sleep disturbances

Cataplexy considered drug resistant with multiple attacks per day, almost constant sleepiness, nocturnal sleep disturbances

Narcolepsy with either cataplexy or hypocretin deficiency syndrome

Narcolepsy without cataplexy

Sodium oxybate

TCAs (clomipramine), SSRIS (less effective but less side effects), venlafaxine, reboxetine

Selegiline, Phenelzine, Amphetamine

Modafinil or sodium oxybate

Methylphenidate, amphetamine, methamphetamine, dextroamphetamine

Selegiline

Evidence of > 5 obstructive sleep apneas or hypopneas per hour of sleep, confirmed by PSG + either of the following:
1. Disturbance in nocturnal breathing (snoring, snorting, gasping)
2. Fatigue, daytime sleepiness, unrefreshed sleep despite opportunit

Evidence of > 15 obstructive sleep apneas or hypopneas per hour of sleep irrespective of symptoms confirmed by PSG

0-2 on STOP-Bang Questionnaire

3-4 on STOP-Bang Questionnaire

5-8 on STOP-Bang Questionnaire

Lifestyle modifications
Continuous Positive Airway Pressure (CPAP)
Bilevel Positive Airway Pressure (BiPAP)
Oral mandibular devices
Surgery (~50% success rate)
Pharmacotherapy

Urge to move legs in response to an uncomfortable or unpleasant sensation characterized by the following:
1. Begins or worsens during periods of rest or inactivity
2. Partially or completely relieved by movement
3. Worse in the evening or at night, or occurs exclusively in the evening or at night

Symptoms occur > 3 times per week and have persisted for > 3 months and are accompanied by significant distress or impairment