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Fundamentals of Sleep Medicine E-Book

Fundamentals of Sleep Medicine E-Book

Richard B. Berry

(2011)

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Book Details

Abstract

Written by Richard Berry, MD, author of the popular Sleep Medicine Pearls, Fundamentals of Sleep Medicine is a concise, clinically focused alternative to larger sleep medicine references. A recipient of the 2010 AASM Excellence in Education award, Dr. Berry is exceptionally well qualified to distill today's most essential sleep medicine know-how in a way that is fast and easy to access and apply in your practice.

  • Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability. Compatible with Kindle®, nook®, and other popular devices.

  • Get clear guidance on applying the AASM scoring criteria.

  • Reinforce your knowledge with more than 350 review questions.

  • Get the answers you need quickly thanks to Dr. Berry's direct and clear writing style.

  • Access the complete contents online at Expert Consult, including videos demonstrating parasomnias, leg kicks, and more.


Table of Contents

Section Title Page Action Price
Front cover cover
Inside front cover ifc1
Fundamentals of Sleep Medicine i
Copyright page iv
Dedication v
Preface vii
Acknowledgments viii
Table of Contents ix
Online Video Content x
1 Sleep Stages and Basic Sleep Monitoring 1
Chapter Points 1
Eeg Electrode Placement 1
EEG Derivations 2
EEG Patterns 3
Eog Monitoring for Sleep 7
Eye Movement Patterns 8
Chin (Submental) EMG Monitoring 9
Clinical review questions: 10
Answers 10
References 11
2 The Technology of Sleep Monitoring: 13
Chapter Points 13
Referential and Bipolar Recording 14
Sampling Rate 16
Monitor Resolution 16
Time Window for Display 17
Filters (Low-Frequency, High-Frequency, and Notch Filters) 17
Low-Frequency Filter 17
High-Frequency Filters 19
60-Hz or Notch Filters 19
Amplifier Filter Settings for Digital Sleep Recording 20
Clinical Example of the Effects of Filter Settings 20
Digitial PSG System Overview 20
Montages for Digital Recording 21
Channel Settings/Montages 22
Impedance Checking and Referential Display View 23
Video-Audio PSG 24
Grounds 24
Clinical Review Questions 25
Answers 26
References 26
3 Sleep Staging in Adults 27
Chapter Points 27
Scoring by Epochs 27
Stage W (Wake) 27
Stage N1 31
Stage N2 31
Start and Continuation of Stage N2 31
End of Stage N2: Effects of Arousals 34
End of Stage N2: Effect of MBM 34
Stage N3 35
Stage R 36
Definite REM Sleep (REM Rule A) 36
Continuation of REM Sleep (REM Rule B) 37
End of REM Sleep 37
End of REM Sleep: Transition to Stage W or N3 37
End of REM Sleep: Increase in Chin EMG Activity 37
End of REM Sleep: Arousal Followed by LAMF EEG and SEMs 37
End of REM Sleep: MBM Followed by LAMF EEG and SEMs 38
End of REM Sleep: Appearance of Nonarousal KCs or SSs in the EEG 39
Transitions between Definite Stage N2 and Stage R 40
Epochs with a Mixture of SSs/KCs and REMs 42
Transitions Between Stage N1 and Stage R (FAQ V7 AASM Scoring Rules) 43
Effects of Arousals and MBMs: Stage N2 Versus Stage R Rules 43
Major Body Movements 44
Arousal Rules 45
References 46
4 Biocalibration, Artifacts, and Common Variants of Sleep 49
Chapter Points 49
Calibrations and Biocalibrations 49
Calibrations 49
Biocalibrations 50
Artifacts 51
Electrode Popping 52
60-Cycle Artifact 54
Slow-Frequency (Sweat) Artifact 54
ECG Artifact 55
Pulse Artifact 56
Muscle Artifact 56
Snoring/Respiratory Chin EMG Artifact 56
Eye Movement Artifact 56
Ground Artifact 56
Common Variants Seen During Sleep Monitoring 56
Alpha Non–Rapid Eye Movement Sleep Anomaly 56
Drug Spindles 59
Eye Movements Associated with Selective Serotonin Reuptake Inhibitor Medications 59
Transient Muscle Activity during Rapid Eye Movement Sleep 59
Clinical Review Questions 62
Answers 63
References 64
5 Sleep Staging in Infants and Children 65
Chapter Points 65
Bipolar Electroencephogram Recording 65
Sleep in the Premature Infant and Infants Younger Than 48 Weeks CA 65
Sleep Stages in the Newborn 65
EEG Patterns 65
Premature Infants 66
Term Infants 66
Sleep Architecture 67
Scoring Sleep in Infants Older Than 48 Weeks CA and Children 70
AASM Pediatric Rules for Scoring Sleep 70
Ages for which AASM Pediatric Sleep Scoring Rules Apply 70
Terminology of Sleep Stages 70
Scoring Sleep Stage 70
Dominant Posterior Rhythm 70
Additional Waveforms of Wakefulness 70
Pediatric Stage W Rules 72
Waveforms for Scoring Pediatric Stage N1 72
Pediatric Stage N1 Rules 72
Pediatric Stage N2 72
Pediatric Stage N3 74
Pediatric Stage R 74
Pediatric Arousal Rules 74
Clinical Review Questions 76
Answers 76
References 77
6 Sleep Architecture Parameters, Normal Sleep, and Sleep Loss 79
Chapter Points 79
Normal Sleep in Adults 79
Changes in Sleep Architecture with Aging (Adults) 81
Sleep Latency and REM Latency 82
TST and Sleep Efficiency 82
WASO and Stage N1 (as a Percentage of TST) 82
Stage N2 (as a Percentage of TST) 82
Stage N3 (as a Percentage of TST) 82
Stage R (as a Percentage of TST) 83
Sleep Architecture (as a Percentage of SPT) 83
Alternations in REM Latency 83
Gender Differences 84
First-Night Effect 84
Comparison of Sleep Staging Between the Aasm Scoring Manual and Rechtschaffen and Kales 85
Normal Sleep in Infants and Children 85
Sleep Architecture in Infants 85
Children 85
Arousals 85
Sleep Fragmentation 86
Total Sleep Deprivation 87
Selective Sleep Deprivation 87
Recovery from Sleep Loss 88
Chronic Partial Sleep Deprivation (Restriction) 88
Clinical Review Questions 89
Answers 89
References 89
7 Neurobiology of Sleep 91
Chapter Points 91
Major Brain Areas Important for Sleep and Wake 91
Hypothalamic Areas 91
Lateral Hypothalamus 91
Ventrolateral Preoptic Nucleus 92
Tuberomammillary Nucleus 94
Brainstem Regions 94
Dopamine Regions 94
Reticular Formation 95
Dorsal RAS 95
Lateral Dorsal Tegmentum/Pedunculopontine Tegmentum. 95
Ventral RAS 96
Dorsal Raphe Nucleus 96
Locus Coeruleus 96
Basal Forebrain 96
Control of Nrem Sleep 96
Features of Rem Sleep 96
Control of REM Sleep 97
Effects of Medications 98
Adenosine: A Possible Mediator of Sleepiness after Prolonged Wakefulness 99
Clinical Review Questions 99
Answers 100
References 100
8 Monitoring Respiration—Technology and Techniques 101
Chapter Points 101
Techniques to Measure Airflow or Tidal Volume 101
Measuring Respiratory Effort 107
Measuring SaO2 109
Pulse Oximetry 110
SpO2 and Sleep Monitoring 111
Measurement of PaCO2 During Sleep 112
PETCO2 113
TcPCO2 Monitoring 113
Accuracy of PETCO2 and TcPCO2 113
Snoring Sensors 115
Clinical Review Questions 116
Answers 116
References 116
9 Monitoring Respiration—Event Definitions and Examples 119
Chapter Points 119
Respiratory Events in Adults 119
History of Respiratory Event Definitions 119
Recommended Respiratory Sensors in Adults 121
Definition of Apnea (AASM Scoring Manual) 121
Apnea Scoring Rules in Adults (AASM Scoring Manual) 122
Apnea Types 122
Hypopnea Scoring Rules in Adults 122
Hypopnea (Recommended) 122
Hypopnea (Alternative) 122
Event Duration Rules 122
Clarification of Event Duration Criteria for Apneas and Hypopneas 123
RERA Rule in Adults (AASM Scoring Manual) 124
RERA Detection 124
Hypopnea or RERA? 127
Relationship of Arousal and Respiratory Event 127
Scoring Apneas and Hypopneas during Wake 127
Classification of Hypopneas 127
Chest-Abdominal Paradox 128
False Classification of Apneas as Central 130
Hypoventilation in Adults 130
Hypoventilation Rule (AASM Scoring Manual) 131
Cheyne-Stokes Breathing Rule 132
Respiratory Parameters Reported in PSG (Adults) 132
Respiratory Event Scoring Rules in Children 134
Ages for Which Pediatric Scoring Rules Should Be Used 134
Recommended Sensors in Children by AASM Scoring Manual 135
Apnea Rules for Children 135
Obstructive Apnea 135
Mixed Apnea 135
Central Apnea 136
Hypopnea Rule (Children) 136
RERA Rules for Children 136
Hypoventilation Rule for Children 137
Obstructive Hypoventilation 138
Periodic Breathing Rule for Children 138
Respiratory Parameters Reported in PSG (Children) 138
Clinical Review Questions 139
Answers 139
References 139
10 Sleep and Respiratory Physiology 141
Chapter Points 141
Arterial Blood Gases 141
Oxygen Transport and Saturation 142
Determinants of PaCO2 145
Normal Changes in Ventilation During Sleep 145
Tests of Ventilatory Control 146
Acid-Base Physiology 148
Pulmonary Function Testing 149
Obesity 152
Muscle Strength 152
Muscle Forces 152
Maximum Inspiratory Pressure and Maximum Expiratory Pressure 153
Clinical Review Questions 153
Answers 154
References 154
Appendix 10-1 Severity Criteria for Pulmonary Function Testing 157
11 Cardiac Monitoring during Polysomnography 159
Chapter Points 159
ECG RECORDING DURING POLYSOMNOGRAPHY 160
SINUS RHYTHM AND NORMATIVE DATA FOR HEART RATE 162
CONDUCTION SYSTEM 164
BRADYCARDIA AND AV BLOCK DURING SLEEP 164
Sinus Pause/Asystole 165
AV Block 166
Aberrant Conduction 167
Premature Beats 167
TACHYCARDIAS DURING SLEEP 168
Narrow-Complex Tachycardia 168
Afib and Atrial Flutter 170
Wide-Complex Tachycardia 172
ADVERSE EVENTS DURING PSG 172
PACEMAKERS AND WIDE-COMPLEX QRS 172
References 173
12 Monitoring of Limb Movements and Other Movements during Sleep 175
Chapter Points 175
Limb Monitoring Techniques 175
Criteria for LMs and PLMs 176
LMs Associated with Respiratory Events Are Not Scored 177
Association of Arousals with PLM 178
Periodic Limb Movements in Sleep 178
Periodic Limb Movements in Wake 178
Suggested Immobilization Test 179
Clinical Significance of PLMS 179
Other LMs during Sleep 180
Alternating Leg Muscle Activation 180
Hypnagogic Foot Tremor 181
Excessive Fragmentary Myoclonus 181
Bruxism 182
PSG Characteristics of Bruxism 183
Rhythmic Movements and the Sleep-Related Rhythmic Movement Disorder 184
PSG Findings in RM 184
RBD: Scoring PSG Features 185
Clinical Review Questions 187
Answers 187
References 187
13 Polysomnography, Portable Monitoring, and Actigraphy 189
Chapter Points 189
Polysomnography 189
PSG for Patients with SRBDs (see Table 13–1) 190
PSG Titration and PSG on CPAP (see Table 13–2) 191
PSG Indications: Nonrespiratory Disorders 192
PSG Indicated (see Tables 13–3 and 13–4) 192
PSG NOT Indicated (see Tables 13–3 and 13–4) 192
Approach to the Sleepy Patient on PAP Treatment 192
Approach to Reading the PSG 192
Portable Monitoring (home sleep testing, out of center sleep testing) 192
Developments in the Use of PM 193
Accuracy of PMs 194
Clinical Use of PM 197
Indications for Attended PM 197
Indications for Unattended PM 198
Patient Selection for PM 199
Recommended PM Methodology 199
Types of PM Devices 199
Peripheral Arterial Tonometry 200
Practical Considerations in PM 201
Integration of PM into the Overall Patient Care Algorithm 202
Overall Approach to Using PSG and PM 203
Actigraphy 205
Indications 206
Actigraphy in OSA 207
Patients with Hypersomnia 207
Actigraphy in Insomnia 207
Clinical Review Questions 208
Answers 210
References 211
Appendix 13-1 AASM Practice Parameters for Polysomnography (Selected Statements) 213
Polysomnography in Other Medical Disorders 213
Alternate Tools 214
4.3 Narcolepsy 214
4.4 Parasomnias and Seizure Disorders 214
4.5 Restless Legs Syndrome and Periodic Limb Movement Disorder 214
4.6 Depression with Insomnia 214
4.7 Circadian Rhythm Sleep Disorders 214
Appendix 13-2 Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients 215
3. Methodology for Portable Monitoring 215
Appendix 13-3 First Coast Services Durable Medical Area Contractor (DMAC Region I) 217
Local Carrier Determinations for Polysomnography and Sleep Testing (L29949)—Excerpts 217
Accreditation 217
Physician Training/Certification 217
Home Sleep Testing 217
14 Subjective and Objective Measures of Daytime Sleepiness 219
Chapter Points (see also Box 14–6) 219
Subjective Measures 219
Objective Measures 221
Multiple Sleep Latency Test 221
MSLT Protocol 221
Other MSLT Considerations 223
MSL Values in Normal Populations and Patients 223
Factors Affecting the MSLT MSL 224
Number of SOREMPs 224
Utility of the MSLT for Diagnosis of Narcolepsy 225
Normative MSLT Findings in Children and Adolescents 225
Clinical Examples of MSLTs 225
Clinical Example 225
Nap 1 226
Nap 2 226
Nap 3 226
Nap 4 226
Nap 5 226
Clinical Example 227
Maintenance of Wakefulness Test 227
Specific Indications for the Use of the MWT 229
MWT Protocol 229
MWT Normative Data 229
Relationship between the MSLT and the MWT 229
MSLT and MWT Changes with Treatment 230
The MSLT and MWT Assessment of Safety or “Fit for Duty” 231
Limitations of MSLT and MWT 232
Clinical Review Questions 232
Answers 233
References 234
Appendix 14-1 Federal Aviation Administration Policy Concerning Fitness to Fly in Sleep Apnea Patients 235
15 Obstructive Sleep Apnea Syndromes: 237
Chapter Points 237
History And Definitions 237
Diagnostic Criteria 238
Epidemiology Of Osa 238
Prevalence and Progression 238
Risk Factors 239
Obesity 239
Male Sex 239
Age 239
Postmenopausal Status 239
Ethnicity 240
Smoking 240
Alcohol Intake 240
Hypothyroidism 240
Acromegaly 241
Diagnosis Of Osa 241
OSA Symptoms and Key Historical Points 241
Physical Examination 242
Laboratory Testing in OSA 244
Prediction of the Presence of OSA 244
Diagnostic Testing for Suspected Sleep Apnea 244
Portable Monitoring 247
Variants Of Snoring And Osa 248
Primary (Simple) Snoring 248
Upper Airway Resistance Syndrome 249
Obesity Hypoventilation Syndrome 249
Diagnosis of OHS 249
Treatment of OHS 250
Overlap Syndrome 250
Pediatric Osa 251
Epidemiology of Pediatric OSA 252
Diagnosis 252
Clinical Review Questions 254
Answers 254
References 254
Appendix 15-1 Berlin Questionnaire 259
Category 1 259
If you snore: 259
Category 2 259
If yes: 259
Category 3: Somnolence 259
Scoring: 259
Appendix 15-2 STOP-BANG Scoring Model 261
16 Pathophysiology of Obstructive Sleep Apnea 263
Chapter Points 263
Pathogenesis of Upper Airway Obstruction 263
Lung Volume Effects 269
Ventilatory Control and OSA 270
Stage R Effects 270
Gender and OSA 272
Mechanisms of Apnea Termination and Arousal 273
Upper Airway Sensation 275
Arterial Oxygen Desaturation 275
Clinical Review Questions 276
Answers 277
References 277
17 Consequences of Obstructive Sleep Apnea and the Benefits of Treatment 281
Chapter Points 281
Pathophysiology 282
Mortality 282
Excessive Daytime Sleepiness and Neurocognitive Dysfunction 284
Automobile Accidents and Sleep Apnea 286
Arterial Hypertension 286
Pulmonary Hypertension 288
Arrhythmias 289
Coronary Artery Disease 290
Atherosclerosis and Thrombosis 291
Congestive Heart Failure 292
Cerebrovascular Accidents and OSA 292
Erectile Dysfunction 293
Diabetes 293
Nocturia 293
Consequences of Childhood OSA 293
Neurobehavioral 294
Metabolic and Inflammatory Consequences 294
Cardiovascular Consequences 294
Clinical Review Questions 294
Answers 294
References 295
18 Obstructive Sleep Apnea Treatment Overview and Medical Treatments 299
Chapter Points 299
Introduction 299
Should Mild OSA Patients Be Treated? 300
Whom to Treat 300
Treatment Selection 300
Snoring 300
Mild OSA 301
Moderate OSA 301
Severe OSA 302
Patient Education Before Treatment 302
Follow-Up and Outcomes Assessment 302
Medical Treatments for OSA 303
Weight Loss 303
Posture and Positional Treatment 305
Medical Therapies to Improve Nasal Patency 306
Supplemental Oxygen 306
Persistent Daytime Sleepiness on CPAP 307
Modafinil, Armodafinil, and Stimulants 307
Overview of Treatment of Pediatric OSA 308
Medications for Pediatric OSA 309
Clinical Review Questions 309
Answers 309
References 310
19 Positive Airway Pressure Treatment 313
Chapter Points 313
Mechanism of Action 313
Effectiveness 314
Modes of PAP 314
Volume-Targeted BPAP 319
Comfort Measures 320
Ramp 320
Flexible Pressure 320
Humidification 321
Interfaces 322
Indications for PAP Treatment 322
Adherence—Definitions and Measurement 323
PAP Adherence in Large Studies 323
Factors Influencing Adherence and Importance of Early Adherence 323
How Much Adherence Is Enough? 324
Interventions to Improve Adherence 324
Hypnotics, Alcohol, and CPAP 324
CPAP/BPAP Titration for OSA 325
General Titration Considerations 326
Pediatric Considerations 326
Monitoring during Positive-Pressure Titration 326
Additional Monitoring for NPPV Titration 330
Titration Protocol 330
PAP and Supplemental Oxygen 332
Complex Sleep Apnea 333
ASV Titration Protocol 334
Adequacy of PAP Titration 334
Alternative Methods of Starting PAP Treatment 334
Patient Selection for Alternative Titrations 335
Technique of Autotitration 335
Follow-up of Patients on PAP Treatment 335
NPPV Titration and Treatment 336
Goals of NPPV Titration and Treatment 337
NPPV Titration Protocol 337
Reimbursement for NPPV Devices 338
Clinical review Questions 338
Answers 339
References 339
Appendix 19-1 Practice Parameters for APAP and CPAP/BPAP (Selected Recommendations) 343
CPAP/BPAP Recommendations* 343
APAP Recommendations 343
Appendix 19-2 The details of local carrier determinations can vary by region and are frequently updated. 345
Initial Coverage 345
Sleep Tests 345
Continued Coverage beyond the First 3 Months of Therapy 345
Appendix 19-3 Medicare Criteria for Reimbursement for Respiratory-Assist Devices 347
Requirements for Initial Coverage for 3 Months 347
Coverage beyond 3 Months 347
20 Oral Appliance and Surgical Treatment for Obstructive Sleep Apnea 349
Chapter Points 349
ORAL APPLIANCE TREATMENT FOR OSA 350
Oral Appliances 350
Evaluation of the Patient 350
Exclusions and Contraindications 351
Mechanism of Action of OAs 351
Effectiveness 352
Factors Predicting Effectiveness 352
Devices 352
Titration/Adjustment of OAs 353
Adherence to OA Treatment 353
Effectiveness Compared with Other Treatments 354
OA Treatment Guidelines 355
Follow-up 356
Centers for Medicaid and Medicare Services Coverage of OA Treatment 356
Side Effects and Complications 356
Combinations of OA with Other Treatments 357
Effects of OA Treatment on Consequences of OSA 357
Surgical Treatments for OSA 357
Evaluation for Possible Surgical Treatment 357
Indications for Surgical Treatment 357
Surgical Options 357
Tracheostomy 357
Nasal Obstruction 358
Palatal Implants 358
Laser-Assisted Uvuloplasty 358
Radiofrequency Ablation 359
Uvulopalatopharyngoplasty 359
Uvulopalatal Flap 360
Genioglossus Advancement/Hyoid Advancement 360
Maxillomandibular Advancement 361
MMA Procedure 362
Outcomes of MMA 362
Tongue Procedures 362
Tongue Base Suspension Suture 362
Overall Surgical Approach 362
Success Rates of Upper Airway Surgery 363
Surgery for Pediatric OSA 363
Tonsillectomy and Adenoidectomy 363
Rapid Maxillary Expansion 364
Clinical Review Questions 365
Answers 366
References 366
Appendix 20-1 Summary of AASM Practice Parameters for the Use of Oral Appliances for Treatment of Snoring and Obstructive Sleep Apnea 369
Appendix 20-2 Excerpts from Local Coverage Determination for Oral Appliances for Obstructive Sleep Apnea (L28606) 371
Appendix 20-3 Summary of Practice Parameters for Surgical Treatment of Obstructive Sleep Apnea in Adults 373
21 Central Sleep Apnea and Hypoventilation Syndromes 375
Chapter Points 375
Classification of Csa Syndromes 377
Pathophysiology of Csa 379
Effects of Normal Physiologic Changes 379
Ventilatory Control in Hypocapnic CSA 380
Apneic Threshold 381
Loop Gain 382
Upper Airway and Posture Effects 382
Hypocapnic Csa Syndromes 382
Patterns of Ventilation in ICSA and CSB 382
Idiopathic CSA (Primary CSA) 383
Pathophysiology of Idiopathic CSA 384
Polysomnography 384
Treatment of ICSA 384
Csb with Csa 385
Polysomnography in CSB-CSA 385
Pathophysiology of CSB-CSA 386
Treatment of CSB-CSA 386
Complex Sleep Apnea 390
Pathophysiology 390
Incidence and Natural History 390
Polysomnography 390
Treatment of CompSA 390
High-Altitude Periodic Breathing 391
Pathophysiology 392
Treatment 392
Hypercapnic Csa and hypoventilation syndromes not due to lung disease 392
Mechanisms of Hypercapnic CSA and/or Hypoventilation 393
Evaluation of Patients with Suspected Hypoventilation 393
Congenital Central Hypoventilation Syndrome 394
Other Neural Disorders Causing Central Hypoventilation 396
Chiari’s Malformation 396
CSA Due to Medication (Opiate/Narcotic-Induced CSA) 396
Treatment 397
Primary Sleep Apnea of Infancy 397
Restrictive Thoracic Cage Disorders 398
Treatment of Restrictive Thoracic Cage Disorders 400
Neuromuscular Weakness 400
Treatment of Nocturnal Hypoventilation Due to NMD 401
Clinical Review Questions 401
Answers 402
References 403
Appendix 21–1 Sleep-Related Hypoventilation Syndromes—Diagnostic Criteria 407
22 Sleep and Obstructive Lung Disease 409
Chapter Points 409
Obstructive Ventilatory Dysfunction 409
Chronic Obstructive Pulmonary Disease 411
Sleep in COPD 412
Etiology of Abnormal Nocturnal Gas Exchange 412
Normal Individuals 412
Sleep-Related Changes in Respiration in COPD 413
Non–Rapid Eye Movement 414
Rapid Eye Movement 414
Mismatch 415
Time of Night and Circadian Variation in Lung Function 416
COPD Types and Respiration during Sleep 416
Sleep Quality in COPD 417
Treatment of Sleep-Related Hypoxemia in COPD 417
Bronchodilators 418
Hypnotics in COPD Patients 419
Nocturnal Noninvasive Positive-Pressure Ventilation 420
Overlap Syndrome 420
Treatment of OLS 420
Asthma 421
Epidemiology 421
Etiology of Nocturnal Asthma 422
Airway Inflammation 422
Melatonin 422
Factors Worsening Nocturnal Asthma 423
Allergens in the Bedroom 423
Gastroesophageal Reflux 423
OSA/Obesity 424
Diagnosis of Nocturnal Asthma 424
Chronotherapy 424
Treatment of Nocturnal Asthma 424
Clinical Review Questions 425
Answers 426
References 426
23 The Restless Leg Syndrome, Periodic Limb Movements in Sleep, and the Periodic Limb Movement Disorder 429
Chapter Points 429
Restless Legs Syndrome 430
The Essential RLS Diagnostic Criteria 431
Supportive Clinical Features 431
Differential Diagnosis of RLS/PLMS 432
Causes of RLS 433
Familial Patterns and Genetics 434
Pathophysiology of RLS 434
Clinical Features of RLS 434
Prevalence of RLS 434
Onset and Clinical Course of RLS 435
Sleep Disturbance Associated with RLS 435
Medical Evaluation in RLS 435
PSG Findings in RLS Patients 436
RLS in Children 437
Periodic Limb Movements in Sleep 437
PLMSI and PSG Findings 437
PLMS and Arousals 438
Differential Diagnosis of PLMS 438
Clinical Significance of the PLMSI and PLMS Arousal Index 438
PLMS and Other Disorders 439
Periodic Limb Movement Disorder 439
Prevalence and Manifestations of PLMD 439
PSG and Objective Findings 439
Treatment of RLS and PLMD 440
Nonpharmacologic Treatments 440
Dopaminergic Medications 440
Augmentation 442
Opioids/Opiates 443
Anticonvulsant Medications 443
Sedative Hypnotics 443
RLS Treatment Algorithm 444
Daily RLS 444
Refractory/Severe RLS 445
Clinical Review Questions 446
Answers 446
References 447
24 Hypersomnias of Central Origin 451
Chapter Points 451
Narcolepsy Syndromes 451
History 452
Epidemiology 453
Genetics 453
HLA Typing 453
Importance of Hcrt Neurons 453
Pathophysiology of Narcolepsy 454
N+C Group 454
N–C Group 454
Mechanisms of Cataplexy 454
Manifestations of Narcolepsy 455
Excessive Daytime Sleepiness (N+C and N–C) 455
Sleep-Related Hallucinations (N+C and N–C) 456
Sleep Paralysis (N+C and N–C) 457
Disturbed Nocturnal Sleep and Other Symptoms: N+C, N–C 457
Cataplexy: N+C 457
Diagnostic Testing for Narcolepsy 457
History 457
Polysomnography 458
Multiple Sleep Latency Test 458
HLA Typing 459
CSF Hcrt Levels 459
Diagnostic Criteria and Important Findings for N+C and N–C Forms of Narcolepsy 459
Narcolepsy with Cataplexy (N+C) 459
N+C Manifestations 460
Onset of N+C 460
Polysomnography 460
Multiple Sleep Latency Test 460
Other Studies in N+C 460
Narcolepsy without Cataplexy (N–C) 460
Polysomnography (N–C) 460
MSLT Findings (N–C) 460
Treatment of Narcolepsy 460
Treatment of EDS 460
Stimulant Medications 462
Modafinil and Armodafinil 463
Sodium Oxybate 464
Other Interventions for Daytime Sleepiness 465
Choosing Treatment for Daytime Sleepiness 465
Treatment of Cataplexy, HGH/HPHs, and SP 465
Future Treatments for Narcolepsy 466
Narcolepsy in Children 467
Narcolepsy Due to Medical Condition 468
Disorders Associated with NDMC, Isolated Cataplexy, or HDMC 469
Genetic Disorders Causing NDMC or Isolated Cataplexy 469
Prader-Willi Syndrome 469
Myotonic Dystrophy 469
Rare Genetic Disorders Causing NDMC or Isolated Cataplexy 469
Idiopathic Hypersomnia 470
IH with Long Sleep Time (IH+LST) 470
Manifestations 470
Autonomic Dysfunction 470
Prevalence 470
Onset 470
Polysomnography 470
Multiple Sleep Latency Test 470
CSF Hcrt 470
Diagnostic Approach 470
25 Insomnia 481
Chapter Points 481
Prevalence of Insomnia and Risk Factors 482
Insomnia Subtypes 482
Evaluation of Insomnia Complaints 483
Questionnaires, Sleep Logs, and Actigraphy 485
Questionnaires 485
Sleep Logs 486
Actigraphy 487
Polysomnography 488
Physiologic Findings in Primary Insomnia 489
Individual Insomnia Subtypes 489
Adjustment Insomnia (Acute Insomnia) 489
26 Circadian Rhythm Sleep Disorders 515
Chapter Points 515
Melatonin 516
The SCN and Sleep-Wake Cycle 517
Markers of Circadian Phase 518
Shifting the Circadian Rhythms 520
Phase Shifting by Light 520
Phase-Response Curve for Light 521
Phase Shifting by Exogenous Melatonin 522
Melatonin PRC Curve 522
Summary of Effects of Light and Melatonin 523
Genomics of CRSD 524
Circadian Rhythm Sleep Disorders 525
Morningness-Eveningness Questionnaire 526
Sleep Logs and Actigraphy 526
Delayed Sleep Phase Disorder 526
Epidemiology 526
Pathophysiology 527
Sleep Logs and Actigraphy 527
Treatment of DSPD 528
Advanced Sleep Phase Disorder 529
Epidemiology 529
Pathophysiology 529
Diagnosis 529
Morningness-Eveningness Questionnaire 529
Sleep Logs and Actigraphy 529
Core Body Temperature, Dim Light Melatonin Onset 529
Treatment 529
CRSD—Irregular Sleep-Wake Type 530
Epidemiology 530
Etiology 531
Sleep Logs and Actigraphy 531
Diagnosis of ISWR 531
Treatment of ISWR 531
CRSD—Free-Running Type (Non–24-Hour Sleep-Wake Syndrome) 532
Epidemiology 532
Pathophysiology 533
Sleep Logs and Actigraphy 533
CBTmin and DLMO 533
Treatment of CRSD-FRT 533
CRSD–Jet Lag Type 533
Epidemiology 534
Pathophysiology 534
Antidromic Entrainment 535
Symptoms Associated with Jet Lag CRSD 535
Treatment of Jet Lag 535
Eastward Flights 535
Westward Flights 536
Crossing More than Eight Time Zones 537
Circadian Rhythm Sleep Disorder— Shift-Work Type 537
Epidemiology 537
Risk Factors 537
Pathophysiology 537
Sleep Logs and Diaries 538
Circadian Markers 538
Night Shift Work 538
Rotating Shifts 539
Complications of Night Shifts 539
Treatment of Shift-Work Disorder 539
CRSD—Due to Medical Condition (Box 26–16) 540
Disorders Associated with CRSD 540
Treatment 540
CRSD—Not Otherwise Specified 540
CRSD Due to Drug or Substance 540
Clinical Review Questions 540
Answers 541
References 542
27 Clinical Electroencephalography and Nocturnal Epilepsy 545
Chapter Points 545
Electroencephalographic Monitoring 545
Bipolar Monitoring and Standard Montages 546
Waveform and Seizure Terminology 548
Phase Reversal 549
Localization in Referential and PSG Montages 549
Normal Sleep Waveforms in the 10-Second Window 551
Eye Movements and Bell’s Phenomenon 551
Posterior Rhythm 551
Positive Occipital Sharp Transients of Sleep and Lambda and Mu Rhythms 552
Ictal Activity 554
Classification of Seizures and Terminology 556
Nocturnal Epilepsy 556
Focal Nocturnal Epilepsy— General Characteristics 557
Temporal Lobe Epilepsy 559
Mesial TLE 559
Neocortical TLE 559
PSG and TLE 559
Nocturnal Frontal Lobe Epilepsy 559
NFLE Syndromes 560
Familial NFLE 561
Supplemental Motor Area Epilepsy 561
Parasomnia Versus NFLE 561
Benign Epilepsy of Childhood with Centrotemporal Spikes 562
Generalized Epilepsy Syndromes with Nocturnal Seizures 562
Generalized Epilepsy Syndromes 562
Generalized Seizures During or After Sleep 562
Epilepsy with GTC Seizures on Awakening 562
Juvenile Myoclonic Epilepsy 562
Absence Epilepsy 563
Lennox-Gastaut Syndrome 563
Ictal Effects on Sleep 563
Antiepileptic Drugs—Effects on Sleep 563
Epilepsy and Obstructive Sleep Apnea 563
Clinical Review Questions 565
Answers 566
References 566
28 Parasomnias 567
Chapter Points 567
Nrem Parasomnias 568
Confusional Arousals 568
Prevalence 568
Precipitating and Predisposing Factors 569
Variants of Confusional Arousals 569
PSG Findings during Confusional Arousals 569
Diagnosis of Confusional Arousals 569
Differential Diagnosis of Confusional Arousals 569
Treatment of Confusional Arousals 569
Sleepwalking (Somnambulism) 569
Epidemiology and Familial Pattern of Sleepwalking 570
Familial, Precipitating, and Predisposing Factors 570
PSG in Sleepwalking 571
Diagnosis of Sleepwalking 571
Differential Diagnosis of Sleepwalking 571
Sleep-Related Sexual Behavior and Sleep-Related Violence 571
Sleep Disorders and the Law 572
Treatment of Sleepwalking 572
Sleep Terrors 572
Epidemiology 573
Precipitating and Predisposing Factors 573
PSG Findings Associated with Sleep Terrors 573
Diagnosis of Sleep Terrors 573
Treatment of Sleep Terrors 573
Differential Diagnosis of NREM Parasomnias 573
Parasomnias Usually Associated With Rem Sleep (Stage R) 574
REM Sleep Behavior Disorder (RBD; Including Variants) 574
Epidemiology of RBD 574
Pathophysiology of RBD 574
Classifications and Causes of RBD 574
Pseudo-RBD 575
PSG in RBD 575
Diagnosis of RBD 575
Variants of RBD 577
REM Sleep without Atonia 577
Parasomnia Overlap Disorder 577
Status Dissociatus 577
Differential Diagnosis of RBD 577
Treatment of RBD 577
Recurrent Isolated Sleep Paralysis 578
Epidemiology of Sleep Paralysis 578
Precipitating Events 578
Diagnosis of Recurrent Sleep Paralysis 578
Differential Diagnosis of Recurrent Sleep Paralysis 578
Treatment of Sleep Paralysis 578
Nightmare Disorder 578
Epidemiology of Nightmare Disorder 579
PSG Recordings in Nightmare Disorder 579
Diagnosis of Nightmare Disorder 579
Differential Diagnosis 579
Treatment of Nightmare Disorder 579
Other Parasomnias 579
Sleep-Related Dissociative Disorders 579
Types of Dissociative Disorders Associated with Sleep 580
Dissociative Identity Disorder 580
Dissociative Fugue State 580
Dissociative Disorder Not Otherwise Specified 580
Epidemiology 580
Diagnosis of SRDD 580
Treatment of SRDDs 580
Sleep Enuresis 580
Primary Enuresis 581
Secondary Enuresis 581
PSG in Evaluation of Enuresis 581
Treatments for Enuresis 581
Sleep-Related Groaning—Catathrenia 581
Epidemiology 581
Polysomnography 581
Diagnosis of Catathrenia 582
Differential Diagnosis of Catathrenia 582
Treatment of Catathrenia 583
Exploding Head Syndrome 583
Epidemiology 583
Diagnosis 583
Demographics 583
Polysomnography 583
Differential Diagnosis of Sleep-Related Headaches 583
Treatment of Exploding Head Syndrome 583
Sleep-Related Hallucinations 583
Epidemiology 584
Factors Precipitating SRH 584
Associations with SRHs 584
PSG in SRHs 584
Diagnosis of SRHs 584
Treatment 584
Sleep-Related Eating Disorders 584
Demographics 585
Pathophysiology 585
Causes of SRED and Association with Other Sleep Disorders 585
PSG in SRED 585
SRED Complications 585
Diagnosis 585
Differential Diagnosis 585
Treatment 585
Parasomnia, Unspecified 585
Parasomnia Due to Drug or Substance 585
Parasomnia Due to Medical Condition 586
Other Nocturnal Behaviors In The Differential Diagnosis Of Parasomnia 586
Sleep Talking (Somniloquy) 586
Hypnic Jerks 586
Propiospinal Myoclonus 587
Differential Diagnosis of Nocturnal Behavior 587
The Differential Diagnosis Of Parasomnias 587
Clinical Review Questions 588
Answers 589
References 590
29 Psychiatry and Sleep 593
Chapter Points 593
Mood Disorders 593
Depression Questionnaires and Severity Rating Scales 594
Mood Episodes 594
Major Depressive Episode 594
Impact of MDE on Sleep 595
Manic Episode 596
Impact of Mania on Sleep 596
Mixed Episode 596
Hypomanic Episode 596
Impact of Hypomania on Sleep 597
Summary of Minimum Episode Durations 597
Mood Disorders 597
Major Depressive Disorder 597
Sleep and MDD 598
Differential Diagnosis of Sleep Disturbance in MDE 599
Treatment of Depression 599
Effects of Antidepressants on Sleep 600
Pharmacotherapy for Co-morbid Insomnia of Psychiatric Disorders 600
Dysthymic Disorder 602
Cyclothymic Disorder 603
Bipolar Disorders 603
Bipolar Depression 603
Sleep in Bipolar Disorder 603
Genetics in Mood Disorders 604
Treatment of Bipolar Disorders 604
Acute Mania 604
Mixed Episode 605
Maintenance Treatment 605
Bipolar Depression 605
Anxiety Disorders 606
30 Sleep and Nonrespiratory Physiology—Impact on Selected Medical Disorders 615
Chapter Points 615
Endocrine Physiology and Sleep 615
Growth Hormone 615
Etiology of Sleep-Related GH Burst 616
GHRH and GH—Effects on Sleep 616
Changes in GH Secretion with Age 616
Sleep and the Corticotropic Axis 617
Sleep Deprivation and Sleep Loss 617
Sleep and the Thyroid Axis 617
TSH Secretion 619
Thyroid Hormone Levels 619
Sleep and Prolactin Secretion 619
Evidence for the Role of PRL in Regulation of Sleep 620
Summary of Control of Hormone Secretion 620
Sleep and the Gonadal Axis 621
Leptin and Ghrelin 621
Obesity and Sleep Duration 622
Sleep and Glucose Tolerance 622
Sleep and Gastrointestinal Physiology and Disorders 622
Gastric and Intestinal Function 622
Gastroesophageal Reflux and Sleep 623
Normal Gastroesophageal Physiology 623
Nocturnal Gastroesophageal Reflux 623
pH Monitoring 624
Nocturnal Asthma and GER 624
GER and OSA 625
Sleep-Related Laryngospasm 625
Treatment of Nocturnal GER 625
Sleep and Rheumatology 626
Fibromyalgia Syndrome 626
Manifestations of Fibromyalgia 626
Sleep in FS 626
Treatment of FS 626
Sleep and Renal 627
Renin-Aldosterone and Sleep 627
Clinical Review Questions 628
Answers 628
References 628
31 Sleep and Neurologic Disorders 631
Chapter Points 631
Sleep and Neurodegenerative Disorders 631
Synucleopathies 631
Dementias 632
Alzheimer’s Disease 632
Etiology of Sleep Disturbances in AD 632
Sleep Disturbances in AD 632
OSA in AD 632
Treatment of AD 633
Medication-Induced Insomnia in AD 633
Progressive Supranuclear Palsy 633
Physical Examination 634
Epidemiology in PSP 634
Histology 634
Sleep in PSP 634
Polysomnography in PSP 634
Corticobasal Degeneration 634
Frontotemporal Dementia 634
Parkinsonism Syndromes (PD, PD+) 634
Differential Diagnosis of Parkinsonism 634
Parkinson’s Disease 634
Differential Diagnosis of PD 635
Treatment of PD 635
Sleep-Related Manifestations of PD 636
Sleep Disturbance Due to Motor Manifestations 636
Daytime Sleepiness in PD 636
Nocturnal Behavior: RBD, Nocturnal Hallucinations, Nocturnal Psychosis 637
Dementia in PD 637
Diffuse Lewy Body Dementia 638
Manifestations of DLBD 638
Visual Hallucinations 638
Sensitivity to DA Blockers 638
Dementia Variant 638
Multiple System Atrophy 638
Symptoms 639
Epidemiology of MSA 639
Diagnosis 639
Pathology of MSA 639
Vocal Cord Palsy and Stridor in MSA 639
Central Apnea and Cheyne-Stokes Breathing 640
Treatment of MSA 640
Other Neurodegenerative Disorders 640
Fatal Familial Insomnia 640
Topography of Degeneration 640
FFI Manifestations 640
Diagnosis 640
Positron Emission Tomography Scan 640
Summary 640
Sleep Disturbances in Stroke 640
Clinical Review Questions 641
Answers 642
References 642
Appendix 31-1 Medications Used to Treat Alzheimer’s Disease 645
Glossary 647
A 647
B 647
C 647
D 647
E 647
F 647
H 648
I 648
K 648
L 648
M 648
N 648
O 648
P 648
R 648
S 649
T 649
U 649
V 649
W 649
Index 651
A 651
B 652
C 652
D 653
E 653
F 653
G 654
H 654
I 654
J 655
K 655
L 655
M 655
N 656
O 656
P 657
Q 659
R 659
S 659
T 660
U 661
V 661
W 661
Z 661