Chapter 028. Sleep Disorders (Part 1) docx

Sleep Disorders Sleep Disorders: Introduction Disturbed sleep is among the most frequent health complaints physicians encounter.. More than one-half of adults in the United States expe

Chapter 028 Sleep Disorders

(Part 1)

Harrison's Internal Medicine > Chapter 28 Sleep Disorders

Sleep Disorders: Introduction

Disturbed sleep is among the most frequent health complaints physicians encounter More than one-half of adults in the United States experience at least intermittent sleep disturbances

For most, it is an occasional night of poor sleep or daytime sleepiness However, the Institute of Medicine estimates that 50–70 million Americans suffer from a chronic disorder of sleep and wakefulness, which can lead to serious impairment of daytime functioning In addition, such problems may contribute to

or exacerbate medical or psychiatric conditions

Thirty years ago, many such complaints were treated with hypnotic medications without further diagnostic evaluation Since then, a distinct class of sleep and arousal disorders has been identified

Physiology of Sleep and Wakefulness

Most adults sleep 7–8 h per night, although the timing, duration, and internal structure of sleep vary among healthy individuals and as a function of age

At the extremes, infants and the elderly have frequent interruptions of sleep

In the United States, adults of intermediate age tend to have one consolidated sleep episode per day, although in some cultures sleep may be divided into a mid-afternoon nap and a shortened night sleep

Two principal systems govern the sleep-wake cycle: one actively generates sleep and sleep-related processes and another times sleep within the 24-h day Either intrinsic abnormalities in these systems or extrinsic disturbances (environmental, drug- or illness-related) can lead to sleep or circadian rhythm disorders

States and Stages of Sleep

States and stages of human sleep are defined on the basis of characteristic patterns in the electroencephalogram (EEG), the electrooculogram (EOG—a measure of eye-movement activity), and the surface electromyogram (EMG) measured on the chin and neck The continuous recording of this array of electrophysiologic parameters to define sleep and wakefulness is termed

polysomnography

Polysomnographic profiles define two states of sleep: (1) rapid-eye-movement (REM) sleep, and (2) non-rapid-eye-rapid-eye-movement (NREM) sleep NREM sleep is further subdivided into four stages, characterized by increasing arousal threshold and slowing of the cortical EEG

REM sleep is characterized by a low-amplitude, mixed-frequency EEG similar to that of NREM stage 1 sleep The EOG shows bursts of REM similar to those seen during eyes-open wakefulness Chin EMG activity is absent, reflecting the brainstem-mediated muscle atonia that is characteristic of that state

Organization of Human Sleep

Normal nocturnal sleep in adults displays a consistent organization from night to night (Fig 28-1) After sleep onset, sleep usually progresses through NREM stages 1–4 within 45–60 min Slow-wave sleep (NREM stages 3 and 4) predominates in the first third of the night and comprises 15–25% of total nocturnal sleep time in young adults

The percentage of slow-wave sleep is influenced by several factors, most notably age (see below) Prior sleep deprivation increases the rapidity of sleep onset and both the intensity and amount of slow-wave sleep

Figure 28-1