Sleep disorder

Sleeplessness in ALS has numerous causes. Respiratory insufficiency, difficulty repositioning in bed, anxiety and depression can all contribute to poor sleep. Treatment of depression with sedating antidepressants such as mirtazapine, tricyclic antidepressants, or trazadone can help promote sleep. Zolpidem, a non benzodiazepine sleep aid, is effective and carries a low risk of respiratory depression. Other medications that can be helpful include anithistamines, chloral hydrate and selective use of benzodiazepines (Gordon and Mitsumoto, 2006). Non-invasive positive pressure ventilation can help relieve orthopnea in those with respiratory muscle weakness, and special equipment, such as a hospital bed, can reduce nighttime discomfort. 

The sleep dysfunction in PD may also be multifactorial, but can also be due to an underlying sleep disorder. Parkinson 

To address this shortcoming, the new discipline of sleep disorders medicine has arisen in recent years. These specialists are dedicated to caring for all patients who 

Principles of Psychopharmacology for Mental Health Professionals By Jeffrey E. Kelsey, D. Jeffrey Newport, and Charles B. Nemeroff Copyright 2006 John Wiley Sons, Inc. 

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, classifies sleep disorders as shown in Table 72-1. One month of symptoms is required before a sleep disorder is diagnosed. 

Humans typically have four to six cycles of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep each night, each cycle lasting 70 to 120 minutes. Usually there is progression through the four stages of NREM sleep before the first REM period. 

Stage 1 of NREM is the stage between wakefulness and sleep. Stage 3 and 4 sleep is called delta sleep (i.e., slow-wave sleep). 

In REM sleep, there is a low-amplitude, mixed-frequency electroencephalogram, increased electric and metabolic activity, increased cerebral blood flow, muscle atonia, poikUothermia, vivid dreaming, and fluctuations in respiratory and cardiac rate. 

In the elderly, sleep is lighter and more fragmented with more arousals and 

The brain and its infinite complexity will surely puzzle us for centuries to come. But, as with any other organ in the body, things can go wrong with the brain (and the behavior it controls). Whether it is Alzheimer s or Parkinson s disease, anxiety, depression, or schizophrenia, there is no shortage of possible diseases and disorders of the brain. And sleep, which the brain closely controls and monitors, is also susceptible to going out of whack. In recent decades, with the advancement of sleep research and improved knowledge about sleep, scientists and medical doctors have come to realize that sleep disorders are much more common than anyone previously imagined. In this chapter, we discuss some of the more common sleep disorders, such as insomnia and sleep apnea, as well as more rare disorders like narcolepsy and REM behavior disorder. 

Insomnia is, by far, the most common sleep disorder it is estimated that approximately half of adults experience some form of insomnia at least once in their lives. Insomnia is less common in children and teenagers than in adults, but it is particularly prevalent in elderly people, as their sleep becomes fragmented with age. Insomnia is slightly more common in females than males. 

What causes insomnia Many things, it turns out, which is perhaps why it is so common. The number one cause of insomnia is stress, whether over an exam, school activity, personal relationship, or family and work issues. Insomnia can also be caused by anxiety or depression, illnesses such as arthritis or 

Insomnia can have a serious impact on a person s quality of life. Acute insomnia can lead to daytime sleepiness and reduced ability to concentrate, remember things, use logical reasoning, and even impair your ability to drive a car. Chronic insomnia can have major health consequences, such as an increased susceptibility to depression and some forms of heart disease and a reduced ability to fight off colds or infections. There is also a tremendous cost to society caused by insomnia—billions of dollars are spent each year on treatment, healthcare services, and hospital costs. An equal cost can be attributed to lost productivity at work and property and personal damage from accidents caused by sleepy insomniacs. 

So how is insomnia treated Most commonly, people self-medicate their insomnia with over-the-counter medications such as Tylenol PM , Sominex , Unisom , or other drugs such as antihistamines (discussed in Chapter 3). Other people try natural remedies such as melatonin (see Chapter 4). When such medications don t work, people often ask their doctor for a prescription sleep aid, which is usually a type of medication called a benzodiazepine such as Halcion or a related type of drug such as Ambien or Sonata (see Chapter 6 for more on these types of drugs). 

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Melatonin [73-31-4] C 2H N202 (31) has marked effects on circadian rhythm (11). Novel ligands for melatonin receptors such as (32) (12), C2yH2gN202, have affinities in the range of 10 Af, and have potential use as therapeutic agents in the treatment of the sleep disorders associated with jet lag. Such agents may also be usehil in the treatment of seasonal affective disorder (SAD), the depression associated with the winter months. Histamine (see Histamine and histamine antagonists), adenosine (see Nucleic acids), and neuropeptides such as corticotropin-like intermediate lobe peptide (CLIP) and vasoactive intestinal polypeptide (VIP) have also been reported to have sedative—hypnotic activities (7). 

Serotonin is a key transmitter in CNS function. Altered serotonergic function has been implicated in many CNS disorders including depression, feeding behavior, sleep disorders, schizophrenia, and Alzheimer s disease. 

Pharmacological Profiles of Anxiolytics and Sedative—Hypnotics. Historically, chemotherapy of anxiety and sleep disorders rehed on a wide variety of natural products such as opiates, alcohol, cannabis, and kawa pyrones. Use of various bromides and chloral derivatives ia these medical iadications enjoyed considerable popularity early ia the twentieth century. Upon the discovery of barbiturates, numerous synthetic compounds rapidly became available for the treatment of anxiety and insomnia. As of this writing barbiturates are ia use primarily as iajectable general anesthetics (qv) and as antiepileptics. These agents have been largely replaced as treatment for anxiety and sleep disorders. 

The short-acting clomethia2ole [533-45-9] (1), sometimes used as therapy for sleep disorders ia older patients, shares with barbiturates a risk of overdose and dependence. Antihistamines, such as hydroxy2iae [68-88-2] (2), are also sometimes used as mild sedatives (see HiSTAMlNES AND HISTAMINE antagonists). Antidepressants and antipsychotics which have sedative effects are used to treat insomnia when the sleep disorder is a symptom of some underlyiag psychiatric disorder. 

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Esterification of the corresponding quinoline-4-carboxylic acid gave the ester 511 which upon reaction with pyrrolidine in THE gave the amide 512. Its phosphorylation and reaction with 513 in presence of KOBu afforded 514 which is useful in the treatment of anxiety, sleep disorders, panic states, convulsions, muscle disorders (95WOP9514020) and chronic neurodegen-erative diseases (97WOP9700074) (Scheme 87). 

Hepati tis/hepato cellular damage Sleep disorders ... 

Measurement of muscle activity, usually measured by electrodes placed on the skin. The EMG is used in sleep research to aid in the discrimination of sleep stages, and also as part of diagnosis of sleep disorders such as periodic limb movements and restless legs syndrome. 

Estrogens and progestins are diminished in menopausal or ovarectomized women. In hormone replacement therapy (HRT), these hormones are substituted to alleviate hot flushes, mood changes, sleep disorders, and osteoporosis. 

The adverse reactions most often associated with the administration of the COMT inhibitors include disorientation, confusion, light-headedness, dizziness, dyskinesias, hyperkinesias, nausea, vomiting, hallucinations, and fever. Other adverse reactions are orthostatic hypotension, sleep disorders, excessive dreaming, somnolence, and muscle cramps. A serious and possibly fatal adverse reaction that can occur with the administration of tolcapone is liver failure... 

Valerian Valeriana officinalis Restlessness, sleep disorders Rare if used as directed. May interact with the barbiturates (eg, phenobarbital), the benzodiazepines (eg, diazepam) and the opiates, (eg, morphine). 

Greenblatt DJ, Harmatz JS, Zinny MA, et al Effect of gradual withdrawal on the rebound sleep disorder after discontinuation of triazolam. N Engl J Med 317 722-728, 1987... 

The treatment of non-motor symptoms, such as psychological conditions, sleep disorders, and autonomic dysfunction, should include both pharmacologic and nonpharmacologic approaches. Patients should be given suggestions for maintaining ADLs, a positive self-image, family communication, and a safe environment. 

Evaluate the clinical outcomes of treatment by using the UPDRS. In addition, periodically ask patients to record the amount of on and off time they have with and without dyskinesias in a diary. There are a variety of scales that can be used to assess QOL, depression, anxiety, and sleep disorders. Patients with PD cannot be cured but treatment can delay the progression of symptoms and improve QOL. Delaying the patient s admission into a nursing home is a good outcome. 

Articulate the incidence and prevalence of sleep disorders, list the sequelae of undiagnosed or untreated sleep disorders, and appreciate the importance of successful treatment of sleep disorders. 

Describe the mechanisms of the sleep disorders covered in this chapter, including insomnia, narcolepsy, restless-legs syndrome, obstructive sleep apnea, and parasomnias. 

Assess patient sleep complaints, conduct sleep histories, and evaluate sleep studies to recognize day- and nighttime symptoms and characteristics of common sleep disorders. 

Recommend and optimize appropriate sleep hygiene and nonpharmacologic therapies for the management and prevention of sleep disorders. 

Recommend and optimize appropriate pharmacotherapy for sleep disorders. 

Describe the components of a monitoring plan to assess safety and efficacy of pharmacotherapy for common sleep disorders. 

Educate patients about preventive behavior, appropriate lifestyle modifications, and drug therapy required for effective treatment and control of sleep disorders. 

Patients with sleep complaints should have a careful sleep history performed to assess for possible sleep disorders and to guide diagnostic and therapeutic decisions. 

Treatment goals vary between different sleep disorders but generally include restoration of normal sleep patterns, elimination of daytime sequelae, improvement in quality of life, and prevention of complications and adverse effects from therapy. 

Treatment of excessive daytime sleepiness in narcolepsy and other sleep disorders may require the use of sustained- and immediate-release stimulants to effectively promote wakefulness throughout the day and at key times that require alertness. 

It is important to review patient medication profiles for drugs that may aggravate sleep disorders. Patients should be monitored for adverse drug reactions, potential drug-drug interactions, and adherence to their therapeutic regimens. 

Sleep disorders are common. Approximately 50% of adults will report a sleep complaint over the course of their lives.2 In general, sleep disturbances increase with age, and each disorder may have gender differences. The full extent and impact of disordered sleep on our society are not known because many patients sleep disorders remain undiagnosed. Normal sleep, by definition, is a reversible behavioral state of perceptual disengagement from... 

What sleep disorders could you diagnose subjectively What is your initial recommendation ... 

Restless-legs syndrome occurs in 5% to 15% of the population, making it a common sleep disorder.11,12 The prevalence of RLS increases with age and in various medical conditions such as end-stage renal disease (ESRD), pregnancy, and iron deficiency.13 RLS appears to be more common in women than in men and has a genetic link. The majority of RLS patients (63% to 92%) report a positive family history.14... 

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