Somnology

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Pediatric polysomnography patient, Children's Hospital (Saint Louis), 2006 Pediatric polysomnogram.jpg
Pediatric polysomnography patient, Children's Hospital (Saint Louis), 2006

Somnology is the scientific study of sleep. It includes clinical study and treatment of sleep disorders and irregularities. Sleep medicine is a subset of somnology.

Contents

History

After the invention of the EEG, the stages of sleep were determined in 1936 by Harvey and Loomis, the first descriptions of delta and theta waves were made by Walter and Dovey, and REM sleep was discovered in 1953. Sleep apnea was identified in 1965. [1] In 1970, the first clinical sleep laboratory was developed at Stanford. [2] The first actigraphy device was made in 1978 by Krupke, and continuous positive airway pressure therapy and uvulopalatopharyngoplasty were created in 1981.

The Examination Committee of the Association of Sleep Disorders Centers, which is now the American Academy of Sleep Medicine, was established in 1978 and administered the sleep administration[ clarification needed ] test until 1990. In 1989, the American Board of Sleep Medicine was created to administer the tests and eventually assumed all the duties of the Examination committee in 1991. In the United States, the American Board of Sleep Medicine grants certification for sleep medicine to both physicians and non-physicians. However, the board does not allow one to practice sleep medicine without a medical license. [3]

The International Classification of Sleep Disorders

Created in 1990 by the American Academy of Sleep Medicine (with assistance from European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society), the International Classification of Sleep Disorders is the primary reference for scientists and diagnosticians. Sleep disorders are separated into four distinct categories: parasomnias; dyssomnias; sleep disorders associated with mental, neurological, or other medical conditions; and sleep disorders that do not have enough data available to be counted as definitive sleep disorders. The ICSD has created a comprehensive description for each sleep disorder with the following information. [4]

Diagnostic tools

Somnologists employ various diagnostic tools to determine the nature of a sleep disorder or irregularity. Some of these tools can be subjective such as the sleep diaries or the sleep questionnaire. Other diagnostic tools are used while the patient is asleep such as the polysomnograph and actigraphy.

Sleep diaries

A sleep diary is a daily log made by the patient that contains information about the quality and quantity of sleep. The information includes sleep onset time, sleep latency, number of awakenings in a night, time in bed, daytime napping, sleep quality assessment, use of hypnotic agents, use of alcohol and cigarettes, and unusual events which may influence a person's sleep. Such a log is usually made for one or two weeks before visiting a somnologist. The sleep diary may be used in conjunction with actigraphy.

Sleep questionnaires

Sleep questionnaires help determine the presence of a sleep disorder by asking a patient to fill out a questionnaire about a certain aspect of their sleep such as daytime sleepiness. These questionnaires include the Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and the Sleep Timing Questionnaire.

The Epworth Sleepiness Scale measures general sleep propensity and asks the patient to rate their chances of dozing off in eight different situations. The Stanford Sleepiness Scale asks the patient to note their perception of sleepiness by using a seven-point test. The Sleep Timing Questionnaire is a 10-minute self-administration test that can be used in place of a 2-week sleep diary. The questionnaire can be a valid determinate of sleep parameters such as bed time, wake time, sleep latency, and wake after sleep onset. [5]

Actigraphy

Actigraphy can assess sleep/wake patterns without confining one to the laboratory. The monitors are small, wrist-worn movement monitors that can record activity for up to several weeks. Sleep and wakefulness are determined by using an algorithm that analyzes the movement of the patient and the input of bed and wake times from a sleep diary.

Physical examination

A physical examination can determine the presence of other medical conditions that can cause a sleep disorder.

Polysomnography

Polysomnography involves the continuous monitoring of multiple physiological variables during sleep. These variables include electroencephalography, electrooculography, electromyography, and electrocardiography as well as airflow, oxygenation, and ventilation measurements. Electroencephalography measures the voltage activity of neuronal somas and dendrites within the cortex, electro-oculography measures the potential between cornea and retina, electromyography is used to identify REM sleep by measuring the electrical potential of skeletal muscle, and electrocardiography measures cardiac rate and rhythm. It is important to point out that EEG, in particular, always refers to a collective of neurons firing as EEG equipment is not sensitive enough to measure a single neuron.

Airflow measurements

Airflow measurement can be used to indirectly determine the presence of an apnea; measurements are taken by pneumotachography, nasal pressure, thermal sensors, and expired carbon dioxide. Pneumotachography measures the difference in pressure between inhalation and exhalation, nasal pressure can help determine the presence of airflow similar to pneumotachography, thermal sensors detect the difference in temperature between inhaled and exhaled air, and expired carbon dioxide monitoring detect the difference in carbon dioxide between inhaled and exhaled air.

Oxygenation and ventilation measurements

The monitoring of oxygenation and ventilation is important in the assessment of sleep-related breathing disorders. However, because oxygen values can change often during the course of sleep, repeated measurements must be taken to ensure accuracy. The direct measurements of arterial oxygen tension only offer a static glimpse, and repeated measurements from invasive procedures such as sampling arterial blood for oxygen will disturb the patient's sleep; therefore, noninvasive methods are preferred such as pulse oximetry, transcutaneous oxygen monitoring, transcutaneous carbon dioxide, and pulse transit time.

Pulse oximetry measures the oxygenation in peripheral capillaries (such as the fingers); however, an article written by Bohning states that pulse oximetry may be imprecise for use in diagnosing obstructive sleep-apnea, due to the differences in signal processing in the devices. [6]

Transcutaneous oxygen and carbon dioxide monitoring measure the oxygen and carbon dioxide tension on the skin surface respectively, and the pulse transit time measures the transmission time of an arterial pulse transit wave. For the lattermost, pulse transit time increases when one is aroused from sleep, making it useful in determining sleep apnea.

Snoring

Snoring can be detected by a microphone and may be a symptom of obstructive sleep-apnea. [7] [8]

Multiple Sleep Latency Test

The Multiple Sleep Latency Test (MSLT) measures a person's physiological tendency to fall asleep during a quiet period in terms of sleep latency, the amount of time it takes for someone. An MSLT is normally performed after a nocturnal polysomnography to ensure both an adequate duration of sleep and to exclude other sleep disorders. [9]

Maintenance of Wakefulness Test

The Maintenance of Wakefulness Test (MWT) measures a person's ability to stay awake for a certain period of time, essentially measuring the time one can stay awake during the day. The test isolates a person from factors that can influence sleep such as temperature, light, and noise. Furthermore, the patient is also highly suggested to not take any hypnotics, drink alcohol, or smoke before or during the test. After allowing the patient to lie down on the bed, the time between lying down and falling asleep is measured and used to determine one's daytime sleepiness.

Treatments

Though somnology does not necessarily mean sleep medicine, somnologists can use behavioral, mechanical, or pharmacological means to correct a sleep disorder.

Behavioral treatments

Behavioral treatments tend to be the most prescribed and the most cost-efficient of all treatments; these treatments include exercise, cognitive behavioral therapy, relaxation therapy, meditation, and improving sleep hygiene. [10] Improving sleep hygiene includes making the patient sleep regularly, discourage the patient from taking daytime naps, or suggesting they sleep in a different position.

Mechanical treatments

Mechanical treatments are primarily used to reduce or eliminate snoring and can be either invasive or non-invasive. Surgical procedures for treating snoring include palatal stiffening techniques, uvulopalatopharyngoplasty and uvulectomy while non-invasive procedures include continuous positive airway pressure, mandibular advancement splints, and tongue-retaining devices. [11]

Pharmacological treatments

Pharmacological treatments are used to chemically treat sleep disturbances such as insomnia or excessive daytime sleepiness. The kinds of drugs used to treat sleep disorders include: anticonvulsants, anti-narcoleptics, anti-Parkinsonian drugs, benzodiazepines, non-benzodiazepine hypnotics, and opiates as well as the hormone melatonin and melatonin receptor agonists. Anticonvulsants, opioids, and anti-Parkinsonian drugs are often used to treat restless legs syndrome. Furthermore, melatonin, benzodiazepines hypnotics, and non-benzodiazepine hypnotics may be used to treat insomnia. Finally, anti-narcoleptics help treat narcolepsy and excessive daytime sleepiness.

Of particular interest are the benzodiazepine drugs which reduce insomnia by increasing the efficiency of GABA. GABA decreases the excitability of neurons by increasing the firing threshold. Benzodiazepine causes the GABA receptor to better bind to GABA, allowing the medication to induce sleep. [12]

Generally, these treatments are given after the behavioral treatment has failed. Drugs such as tranquilizers, though they may work well in treating insomnia, have a risk of abuse which is why these treatments are not the first resort. Some sleep disorders such as narcolepsy do require pharmacological treatment.

See also

Related Research Articles

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea, also spelled sleep apnoea, is a sleep disorder in which pauses in breathing or periods of shallow breathing during sleep occur more often than normal. Each pause can last for a few seconds to a few minutes and they happen many times a night. In the most common form, this follows loud snoring. A choking or snorting sound may occur as breathing resumes. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. In children, it may cause hyperactivity or problems in school.

<span class="mw-page-title-main">Obesity hypoventilation syndrome</span> Condition in which severely overweight people fail to breathe rapidly or deeply enough

Obesity hypoventilation syndrome (OHS) is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels. The syndrome is often associated with obstructive sleep apnea (OSA), which causes periods of absent or reduced breathing in sleep, resulting in many partial awakenings during the night and sleepiness during the day. The disease puts strain on the heart, which may lead to heart failure and leg swelling.

Somnolence is a state of strong desire for sleep, or sleeping for unusually long periods. It has distinct meanings and causes. It can refer to the usual state preceding falling asleep, the condition of being in a drowsy state due to circadian rhythm disorders, or a symptom of other health problems. It can be accompanied by lethargy, weakness and lack of mental agility.

Hypersomnia is a neurological disorder of excessive time spent sleeping or excessive sleepiness. It can have many possible causes and can cause distress and problems with functioning. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hypersomnolence, of which there are several subtypes, appears under sleep-wake disorders.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, orthodontics, surgery, or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Polysomnography</span> Multi-parameter study of sleep and sleep disorders

Polysomnography (PSG), a type of sleep study, is a multi-parameter study of sleep and a diagnostic tool in sleep medicine. The test result is called a polysomnogram, also abbreviated PSG. The name is derived from Greek and Latin roots: the Greek πολύς, the Latin somnus ("sleep"), and the Greek γράφειν.

<span class="mw-page-title-main">Mandibular advancement splint</span>

A mandibi splint or mandibi advancement splint is a prescription custom-made medical device worn in the mouth used to treat sleep-related breathing disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators, and sleep apnea mouth guards.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

The Multiple Sleep Latency Test (MSLT) is a sleep disorder diagnostic tool. It is used to measure the time elapsed from the start of a daytime nap period to the first signs of sleep, called sleep latency. The test is based on the idea that the sleepier people are, the faster they will fall asleep.

Actigraphy is a non-invasive method of monitoring human rest/activity cycles. A small actigraph unit, also called an actimetry sensor, is worn for a week or more to measure gross motor activity. The unit is usually in a wristwatch-like package worn on the wrist. The movements the actigraph unit undergoes are continually recorded and some units also measure light exposure. The data can be later read to a computer and analysed offline; in some brands of sensors the data are transmitted and analysed in real time.

The Epworth Sleepiness Scale (ESS) is a scale intended to measure daytime sleepiness that is measured by use of a very short questionnaire. This can be helpful in diagnosing sleep disorders. It was introduced in 1991 by Dr Murray Johns of Epworth Hospital in Melbourne, Australia.

Circadian rhythm sleep disorders (CRSD), also known as circadian rhythm sleep-wake disorders (CRSWD), are a family of sleep disorders which affect the timing of sleep. CRSDs arise from a persistent pattern of sleep/wake disturbances that can be caused either by dysfunction in one's biological clock system, or by misalignment between one's endogenous oscillator and externally imposed cues. As a result of this mismatch, those affected by circadian rhythm sleep disorders have a tendency to fall asleep at unconventional time points in the day. These occurrences often lead to recurring instances of disturbed rest, where individuals affected by the disorder are unable to go to sleep and awaken at "normal" times for work, school, and other social obligations. Delayed sleep phase disorder, advanced sleep phase disorder, non-24-hour sleep–wake disorder and irregular sleep–wake rhythm disorder represents the four main types of CRSD.

Hypopnea is overly shallow breathing or an abnormally low respiratory rate. Hypopnea is defined by some to be less severe than apnea, while other researchers have discovered hypopnea to have a "similar if not indistinguishable impact" on the negative outcomes of sleep breathing disorders. In sleep clinics, obstructive sleep apnea syndrome or obstructive sleep apnea–hypopnea syndrome is normally diagnosed based on the frequent presence of apneas and/or hypopneas rather than differentiating between the two phenomena. Hypopnea is typically defined by a decreased amount of air movement into the lungs and can cause oxygen levels in the blood to drop. It commonly is due to partial obstruction of the upper airway.

Excessive daytime sleepiness (EDS) is characterized by persistent sleepiness and often a general lack of energy, even during the day after apparently adequate or even prolonged nighttime sleep. EDS can be considered as a broad condition encompassing several sleep disorders where increased sleep is a symptom, or as a symptom of another underlying disorder like narcolepsy, circadian rhythm sleep disorder, sleep apnea or idiopathic hypersomnia.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

<span class="mw-page-title-main">Sleep study</span> Sleep Medicine

A sleep study is a test that records the activity of the body during sleep. There are five main types of sleep studies that use different methods to test for different sleep characteristics and disorders. These include simple sleep studies, polysomnography, multiple sleep latency tests (MSLTs), maintenance of wakefulness tests (MWTs), and home sleep tests (HSTs). In medicine, sleep studies have been useful in identifying and ruling out various sleep disorders. Sleep studies have also been valuable to psychology, in which they have provided insight into brain activity and the other physiological factors of both sleep disorders and normal sleep. This has allowed further research to be done on the relationship between sleep and behavioral and psychological factors.

Idiopathic hypersomnia(IH) is a neurological disorder which is characterized primarily by excessive sleep and excessive daytime sleepiness (EDS). The condition typically becomes evident in early adulthood and most patients diagnosed with IH will have had the disorder for many years prior to their diagnosis. As of August 2021, an FDA-approved medication exists for IH called Xywav, which is oral solution of calcium, magnesium, potassium, and sodium oxybates; in addition to several off-label treatments (primarily FDA-approved narcolepsy medications).

Central sleep apnea (CSA) or central sleep apnea syndrome (CSAS) is a sleep-related disorder in which the effort to breathe is diminished or absent, typically for 10 to 30 seconds either intermittently or in cycles, and is usually associated with a reduction in blood oxygen saturation. CSA is usually due to an instability in the body's feedback mechanisms that control respiration. Central sleep apnea can also be an indicator of Arnold–Chiari malformation.

Sleep disorder is a common repercussion of traumatic brain injury (TBI). It occurs in 30%-70% of patients with TBI. TBI can be distinguished into two categories, primary and secondary damage. Primary damage includes injuries of white matter, focal contusion, cerebral edema and hematomas, mostly occurring at the moment of the trauma. Secondary damage involves the damage of neurotransmitter release, inflammatory responses, mitochondrial dysfunctions and gene activation, occurring minutes to days following the trauma. Patients with sleeping disorders following TBI specifically develop insomnia, sleep apnea, narcolepsy, periodic limb movement disorder and hypersomnia. Furthermore, circadian sleep-wake disorders can occur after TBI.

<span class="mw-page-title-main">Behavioral sleep medicine</span>

Behavioral sleep medicine (BSM) is a field within sleep medicine that encompasses scientific inquiry and clinical treatment of sleep-related disorders, with a focus on the psychological, physiological, behavioral, cognitive, social, and cultural factors that affect sleep, as well as the impact of sleep on those factors. The clinical practice of BSM is an evidence-based behavioral health discipline that uses primarily non-pharmacological treatments. BSM interventions are typically problem-focused and oriented towards specific sleep complaints, but can be integrated with other medical or mental health treatments. The primary techniques used in BSM interventions involve education and systematic changes to the behaviors, thoughts, and environmental factors that initiate and maintain sleep-related difficulties.

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