Investigation Of Patients With Sleep Disorders Or Disorders Of The Sleep-Wake Cycle

The most commonly reported schlafbezognen symptoms are insomnia and excessive daytime sleepiness (ETS). Insomnia refers to difficulty falling asleep, staying asleep or early awakening or the sensation of non-recuperative sleep. Excessive daytime sleepiness is the tendency to fall asleep during normal waking hours. ETS is not a disease but a symptom of various sleep-related disorders. Insomnia can be a disease, even if they exist in the context of other disorders, or a symptom of other diseases. Parasomnias are abnormal sleep-related events (eg. As night terrors, Schlafwandeln- parasomnias). Pathophysiology There are 2 sleep states, each of which is characterized by typical physiological changes: Nonrapid eye movement (NREM): the NREM sleep makes up about 75-80% of total sleep time from in adults. It consists of three sleep stages (N1-N3) with increasing depth of sleep. Slow rolling eye movements that characterize the quiet alert state and occur early in stage N1, disappear into deeper sleep stages. The muscle activity also decreases. The stage N3 is referred to as deep sleep because the Weckschwelle is high. People can experience this stage as a good quality sleep. Rapid eye movement (REM) REM sleep are each followed by a NREM sleep cycle. It is characterized by a rapid low-voltage EEG activity and atony of the postural muscles. Respiratory rate and depth fluctuate greatly. Most dreams are taking place during REM sleep. The 3 stages are per night run through cyclically 5- to 6 times, generally in each case followed by a short REM sleep interval (typical sleep patterns in young adults.). Short wake periods (W stage) occur at regular intervals. The individual need for sleep varies in a wide range between 6-10 h / 24 h. Infants sleep much of the day. With age, the absolute sleep time and the depth of sleep tend to take off and the sleep is interrupted frequently. In older people, the sleep stage N3 may disappear. These changes may be responsible for an increasing ETS and fatigue with aging, but their clinical significance is unclear. Typical sleep patterns in young adults. Rapid-eye-movement (REM) sleep occurs at night cyclically every 90-120 min. Short wake periods (W stage) occur at regular intervals. The sleep time is divided as follows: Stage N1: 2-5% stage N2: 45-55% stage N3: 13-23% REM: 20-25% Etiology Some diseases can cause (sometimes both) either insomnia or ETS, and some can one or the other cause (see table: causes of insomnia and excessive daytime sleepiness). Causes of insomnia and excessive daytime sleepiness disorder insomnia Excessive daytime sleepiness Inadequate sleep hygiene ? ? ? adaptation-related insomnia psychophysiological insomnia ? Physical or psy chische sleep ? ? ? Sleep Deficiency Syndrome drug addicts and induced insomnia ? ? ? Obstructive sleep apnea Central sleep apnea syndrome ? disorder s circadian rhythm ? ? narcolepsy ? Periodic-Limb-Movement Disorder (pathological periodic limb movements in sleep) ? ? restless legs syndrome ? ? = is frequently (but insomnia and / or excessive daytime drowsiness may occur in any of these disorders) , Insomnia (insomnia and excessive daytime sleepiness (ETS)) is often caused by an insomnia disorder (z. B. adjustment related sleep disturbances, psychophysiological insomnia) Inadequate sleep hygiene Psychiatric disorders, especially mood disorders, anxiety disorders and substance use disorder Various medical disorders such as cardiopulmonary disease, musculoskeletal disorders and chronic pain excessive daytime sleepiness (insomnia and excessive daytime sleepiness (ETS)) is often caused by lack of sleep syndrome Obstructive sleep apnea Different medical, neurological and psychiatric disorders disorders of the circadian rhythm such as jet lag and sleep disorders shift work Inadequate sleep hygiene refers to behaviors the for the Sleep is not conducive are (sleep hygiene). These include: consumption of caffeine or other stimulants or sympathomimetic drugs (typically just before bedtime, but in sensitive patients even in the afternoon). Emotion or excitement (z. B. an exciting TV show) compensate an irregular sleep-wake pattern patients who lack of sleep by long rest or nap by late evening, fragment continue their night sleep. Adjustment-related insomnia caused by acute emotional stress factors which disturb sleep (z. B. loss of a job, hospitalization). Psychophysiological insomnia is a (cause independent) insomnia that persists after the elimination of triggering factors, usually because patients feel an anticipatory anxiety with regard to the prospect of another sleepless night and the following day with fatigue. Typically, patients spend hours in bed and focus on and ponder about their insomnia; they have greater difficulty falling asleep in her own bedroom and go. Physical disorders that cause pain or discomfort (eg. As arthritis, cancer, herniated discs), v. a. if they become worse with movement, cause temporary waking and poor sleep quality. Night cramps can also disrupt sleep. Most of the major mental disorders associated with ETS and insomnia. Approximately 80% of patients with major depression report on ETS and insomnia; conversely, 40% of patients with chronic insomnia have a significant mental disorder, most commonly a mood disorder. When sleep deprivation syndrome is too little sleep at night, even though there is ample opportunity to do so, typically because of different social or occupational obligations. Medicines Associated insomnia resulting from the chronic use or discontinuation of various drugs (see table: Drugs that interfere with sleep). Drugs that interfere with sleep cause as drug / alcohol use, drug anticonvulsants (eg., Phenytoin) antimetabolite chemotherapy Certain antidepressants of the SSRI class, SNRIs, MAOIs and TCAs CNS stimulants (eg., Amphetamines, caffeine) Oral contraceptives propranolol steroids (anabolic steroids, corticosteroids) thyroid hormone preparations drug / drug withdrawal alcohol Certain classes of antidepressants SSRI, SNRI, and TCA MAOH CNS depressant drugs (eg. B. barbiturates, opioids, sedatives) Illegal drugs (eg. B. Kok ain, heroin, marijuana, phencyclidine) MAOIs = monoamine oxidase inhibitors; SNRI = serotonin-norepinephrine reuptake inhibitor, TZA = tricyclic antidepressant. Disorders of the circadian rhythm (circadian rhythm sleep disorders) may lead to a lack of balance between endogenous circadian rhythms and the light-dark cycle in the environment. The cause may be externally (for. Example, jet lag, sleep disorders in shift work) or internal (e. B. delayed sleep phase syndrome or vorverlagertes). Central sleep apnea (central sleep apnea) consists of repeated episodes of apnea or shallow breathing during sleep, it takes at least 10 s and is caused by a decreased breath performance. The disorder typically manifests as insomnia or disturbed and non-restorative sleep. Obstructive sleep apnea (obstructive sleep apnea) includes episodes with partial and / or totalem closure of the upper airway during sleep, resulting in ? 10 s long apnea. Most patients snore, and sometimes the patient awake gasping. These episodes can disrupt sleep and lead to a feeling of non-recuperative sleep and ETS. Narcolepsy (narcoleptic) is characterized by chronic ETS, often with cataplexy, sleep paralysis and hypnagogic hallucinations, or hypnopompen. A cataplexy is a short-lasting muscle weakness or paralysis without loss of consciousness, which is caused by sudden emotional reactions (eg. As happiness, anger, fear, joy, surprise). The weakness may be limited to the extremities (z. B. make patients fall fishing when a fish bites), or they can during a hearty laughter [ “weak with laughter”] fall apart or sudden anger. A sleep paralysis is the current inability to move while falling asleep or immediately upon waking. Hypnagogic and hypnopompic phenomena are lively auditory or visual illusions or hallucinations, the falling asleep (hypnagogic) or, less frequently occurring, immediately after waking up (hypnopompic). The Periodic Limb Movement Disorder (Periodic Limb Movement Disorder (PLMD) and restless legs syndrome (RLS)) is characterized by repetitive (usually every 20-40 s) twitching or kicking of the legs during sleep. Patients usually complain of interrupted sleep at night or ETS. The leg movements and the short subsequent waking them is typically not aware of and they have no sensory loss in the extremities. The Restless Legs Syndrome (Periodic-Limb-Movement Disorder (PLMD) and restless legs syndrome (RLS)) is characterized by an irresistible urge to move the legs and, less frequently, the arms, and in the usually accompanied by paresthesias in the limbs at rest (eg. as creeping or crawling sensations). To relieve symptoms, patients move the affected limb by stretching, kicking or walking. As a result, they suffer from falling asleep, repeated nocturnal awakening, or both. Clarification of history, the history of existing disease should the duration and age at symptom onset and all events include those with the onset coincide (z. B. a change in life or at work, new drugs, a newly occurring medical disorder). Symptoms during sleep and wake times are observed. The quality and quantity of sleep are by determining identified bedtime latency of sleep (time from bedtime to falling asleep) the number and time of awakenings hours of the final morning awakening and getting up frequency and duration of naps provides more accuracy than a survey a sleep diary, which the patient is to lead for several weeks. (Eg eating. B. or alcohol consumption, physical or mental activity) events related to bedtime should be clarified. Both the revenue and discontinuation of drugs, alcohol, caffeine and nicotine as well as the level and the time spent in physical activity of the patient should also be considered. If ETS is the problem, the severity should be quantified by the fall asleep in various situations (eg. As comfortable rest vs. driving). The Epworth Sleepiness Scale (see Table: Epworth Sleepiness Scale) can be used; a cumulative score ? 10 speaks for pathological daytime sleepiness. Epworth Sleepiness Scale situation sitting and reading TV Quiet sitting in a public place speak continuous driving as a passenger for 1 h couches to rest in the afternoon and sitting with someone Sitting quietly n oh lunch (without alcohol) Sitting in a car that stops for a few minutes in traffic for each situation will doze likely to be absent (0), mild (1), medium (2) or high (3) self-rated , A score ? 10 speaks for abnormal daytime sleepiness. Clinical Calculator: Epworth Sleepiness Scale (ESS) In reviewing the organ systems should be checked for symptoms of specific sleep disorders, including snoring, interrupted breathing patterns and other nighttime breathing disorders (sleep apnea syndrome) depression, anxiety, mania and hypomania (mental insomnia) Restlessness in the legs, an irresistible desire to move them, and jerky leg movements (restless legs syndrome) cataplexy, sleep paralysis and hypnagogic phenomena (narcolepsy) bed partner or other family members can best identify some of these symptoms. The history should specifically identify symptoms that can interfere with sleep, incl. COPD, asthma, heart failure, hyperthyroidism, gastroesophageal reflux, neurological disorders (particularly movement and degenerative disorders) and all painful diseases (eg., Rheumatoid arthritis). Risk factors for obstructive sleep apnea include obesity, heart disease, hypertension, stroke, smoking, snoring and nasal trauma. The drug history should also ask for all associated with sleep medications include (see Table: Drugs that interfere with sleep) .Körperliche examination The physical examination is especially for detection of findings that are associated with sleep apnea, important. Obesity with fat distributed around the neck or abdomen Great Neck circumference (? 43.2 cm for men, ? 40.6 cm in women) mandibular hypoplasia and retrognathia Nasal obstruction Enlarged tonsils, tongue, uvula or soft palate (MallampatiScore 3 or 4 Mallampati credit score.) Decreased pharyngeal patency Increased obstruction of the uvula and soft palate with the tongue Redundant throat the chest should be examined for expiratory wheezing and kyphoscoliosis. Signs of right ventricular failure should be noted. A thorough neurological examination should werden.Warnzeichen performed The following findings are of particular importance: asleep while Auotfahren or other potentially dangerous situations Repeated sleep attacks (falling asleep without warning) pauses in breathing or wheezing waking reported recently held gehabter from the bed partner Unstable cardiac or pulmonary status stroke status cataplecticus (continuous cataplexy attacks) history of violent behavior or injury to the patient or other frequent in sleep sleepwalking or other behavior out of bed interpretation of the findings Inadequate sleep hygiene and situational stressors are usually apparent in history. Excessive daytime sleepiness, which disappears when the sleep time is extended (eg. As on weekends or on vacation) suggests a lack of sleep syndrome. Excessive daytime sleepiness, which is accompanied by cataplexy, hypnagogic / hypnopompen hallucinations or sleep paralysis, indicates a narcolepsy. Difficulty falling asleep (Einschlafinsomnie) should be distinguished from maintaining sleep and early awakening (Durchschlafinsomnie). A Einschlafinsomnie speaks for a delayed sleep phase syndrome, chronic psychophysiological insomnia, restless leg syndrome or childhood phobias. A Durchschlafinsomnie speaks for major depression, central or obstructive sleep apnea, Periodic Limb Movement Disorder-or aging. Early asleep and waking up early talks for a vorverlagertes sleep phase syndrome. In patients with significant snoring, frequent Aufwachereignissen and other risk factors that physicians should suspect obstructive sleep apnea. The STOP-BANG score can help predict the risk of obstructive sleep apnea (see table: STOP-BANG risk score for obstructive sleep apnea). STOP-BANG risk score for obstructive sleep apnea Assessed characteristic findings Snoring (Snoring) Loud snoring (louder than talking or loud enough to be heard through a closed door) Tired (Fatigue) During the day, often fatigue or sleepiness Observed (observation) Will observed to have Atemaussetzter during sleep BP (Blutd jerk) High blood pressure or current hypertension treatment BMI (body mass index)> 35 kg / m2 Age (Age)> 50 Neck circumference (neck circumference)> 40 cm Gender (gender) Male ? 3 findings = high risk for obstructive sleep apnea ( OSA). <3 findings = low risk for obstructive sleep apnea (OSA). BMI = body mass index; OSA = obstructive sleep apnea. Tests tests are usually done when certain symptoms or signs of obstructive sleep apnea, nocturnal seizures, narcolepsy, Periodic Limb Movement Disorder-or other diseases whose diagnosis is based on identification of characteristic polysomnographic findings speak. Test will also be performed when the clinical diagnosis is doubtful or if the response to an initial presumptive treatment measure is inadequate. If symptoms or signs clearly point to specific causes (eg. As restless legs syndrome, poor sleep habits, temporary stress, shift worker syndrome), no testing is required. A polysomnography is particularly useful when obstructive sleep apnea, narcolepsy, nocturnal seizures or Periodic Limb Movement Disorder-or parasomnias are suspected. It also helps clinicians to assess violent and potentially harmful sleep-related behaviors. It is characterized (EEG), eye movements, heart rate, breathing, O2 saturation, muscle tone and activity during sleep the brain activity. A video recording can be used to identify abnormal movement patterns during sleep. A polysomnography is usually done in a sleep laboratory; Devices for home use were indeed developed, however, they are intended to support only the diagnosis of obstructive sleep apnea and other sleep disorders not. The multiple sleep latency test examines the Einschlafgeschwindigkeit at 5 occasions to take a nap every 2 h during a typical day for the patient. Patients lie in a darkened room and are prompted to sleep. The sleep onset and sleep stage (incl. REM sleep) are recorded using polysomnography to determine the amount of drowsiness. Main purpose of this test is the diagnosis narcolepsy. In multiple wax home test, patients are asked to stay awake in a quiet room for 4 opportunities to alertness at intervals of 2 hours, while sitting on a bed or couch. This test is probably a more accurate measurement of the ability to stay awake in everyday situations. In patients with ETS and laboratory studies of the kidney, liver and thyroid function may be necessary. Treatment Specific findings are discussed. A good sleep hygiene (see table: sleep hygiene) is important, regardless of the cause. It is often the only in patients with mild problems necessary measure. Sleep hygiene measure implementation Regular sleep-wake pattern, the bedtime and especially the wakeup should every day, even on weekends, be the same. Patients should not spend too much time in bed. Proper use of the bed restriction of time in bed improves sleep continuity. Patients should, if they can not fall asleep within 20 minutes, get up and go back to bed when sleepy. The bed should not be used for activities other than sleep or sex (z. B. for not reading, eating, watching TV or paying bills). Avoiding daytime naps, except for shift workers, the elderly and patients with narcolepsy nap a day can aggravate insomnia in patients insomnia. However nap reduce the need for stimulants in patients with narcolepsy, and improve performance among shift workers. Nap should be held every day at the same time and limited to 30 min. General processes before bedtime A activity pattern brushing, washing, alarm clock mood make-can be set to sleep. Bright light should be avoided before bedtime and at night-time awakenings. Sleep-promoting environment The bedroom should be dark, quiet and reasonably cool; it should be used only for sleeping and sexual activity. Heavy curtains or a sleep mask can take away light, and ear plugs, fans or devices that produce white noise, can eliminate annoying noise. Pillow pillow between the knees or under the belly can increase the convenience. For patients with back problems are among the most useful positions the supine position with a large pillow under the knees and on one side to sleep with a pillow between your knees. Regular exercise sports promotes sleep and reduces stress, but it takes place in the late evening hours, it can stimulate the nervous system and disrupt sleep. Relaxation stress and anxiety interfere with sleep. Reading or a warm bath before bed can help you relax. Techniques such as visual imagining, progressive muscle relaxation and breathing exercises can be used. Patients should not look at the clock. Avoiding stimulants and diuretics Drinking alcoholic or caffeinated drinks, smoking, consumption of caffeine-containing foods (such. As chocolate) and anorectic intake or prescription diuretics should be particular-bedtime-avoided before. Bright light in the waking state, light exposure during the day can help to correct the circadian rhythms, but if this comes too close to bedtime, it can interfere with sleep. Hypnotics General guidelines for the use of hypnotics (see table: Guidelines for the use of hypnotics) aim to minimize misuse, abuse and dependence. Guidelines for the use of hypnotics Define a clear indication and a treatment goal. Prescribe the lowest effective dose. Limit, except for certain hypnotics and patients, the application period of a few weeks. Individualize the dose for each patient. Use lower Dos

Health Life Media Team

Leave a Reply