These are very discrete states such that we can define them by EEG, by different physiologic parameters like heart rate changes and breathing, but also by different behaviors. And typically, we go from wake to sleep, mostly non-REM and into REM, and REM tends to cycle about every 90 to 120 minutes across the night. In normal adult sleep, most of your sleep is going to be non-REM or NREM sleep. It takes up about 75% of your total sleep time. Most of your sleep time is actually stage 2 sleep, and we'll kind of go through what it looks like over the course of the night. And the other quarter of the night is REM or rapid eye movement sleep, what some people would consider dream sleep. Again, takes up about 25% of the night. It cycles every 90 to 120 minutes. It tends to become more common as the night goes on. And actually, we tend to get most of our dream sleep later in the night or early in the morning, somewhere between 3 and 7 o'clock, assuming you have a normal body clock. So this is a hypnogram. So if you looked at a typical sleep study report from the sleep lab, so this is basically sleep across the night. So you have wakefulness here. The black is REM sleep. And what we tend to see here is, again, stage 2 sleep is the majority of the night. So if you see that line across here, where's the line? So anyway, when you see that line across there, most of the sleep is stage 2 sleep. Stage 3 sleep, or what we consider deep sleep, occurs early in the night. And we tend to see dream sleep or deep stage 3 sleep go away as we get older. So stage 3 sleep is also linked to growth hormone release. So as we get older, we tend to get less deep sleep, less growth hormone release, less muscle mass. And then finally, we have REM sleep. So again, it cycles every 90 to 120 minutes, tend to get more of it as the night goes on. I will tell you, while this is kind of an optimal hypnogram across the night, in real life, if you send somebody to the sleep lab, they're probably not going to look like this because you're putting somebody in an abnormal setting. They're just not going to sleep this well. And in fact, if you send somebody to the sleep lab and they sleep this well, they probably have a problem. So as we get older, we tend to get less stage 3 sleep, which I talked about, especially in men. And by age 60 or so, most people won't have deep sleep as defined by the EEG or release of growth hormone. We get more light sleep, or we get increased awakenings. Our body clock tends to shift earlier. The jokes are, right, as you get older, you tend to wake up for breakfast at about 4 in the morning. You go to bed for dinner at about 3 in the afternoon. And you go to bed at about 7 o'clock at night. I don't know that it's that much of a change. But again, the body clock does tend to shift earlier. People tend to go to sleep earlier, wake up earlier. And a lot of complaints of some older people is, I wake up early in the morning and I can't go to sleep. And they get put on sleeping pills for the wrong reasons. It's just a typical circadian phenomenon. Again, REM sleep tends to remain relatively constant across the lifespan. And sleep-related complaints, meaning disrupted sleep, are more likely related to comorbid diseases, meaning other medical problems, COPD, heart failure, so on and so forth, as opposed to just the aging process and or medications that people are put on. So this is kind of what happens to sleep across the night as we go across the lifespan. So an infant, they tend to sleep a lot, which we know. And actually, infants have about half of their sleep being REM sleep. And then as we, again, get a little bit older, our sleep times tends to decrease with, again, REM sleep being about 25% of the sleep time and non-REM sleep being about 75% of the sleep time. And that happens pretty early on. So usually between ages 3 and 5, we tend to see this. So what causes us to be sleepy? So if one of your patients comes in and says, I'm tired, everybody thinks it's sleep apnea, because that's what we tend to see the most of. But in reality, you need to think about what the physiologic drivers are of daytime sleepiness. So the two major drivers, so the one across the top is something called the homeostatic sleep drive. But all that means is the longer you're awake, the more sleepy you get, right? So you're awake for longer periods of time, the more sleepy you're going to get. We never get used to sleep deprivation. And the other thing that drives our sleep is our body clock. So where are we at in our body clock cycle? So we know that as the night goes on, our circadian drive for sleep goes up. And then as we sleep across the night, the circadian drive for sleep goes down. It tends to go up a little bit in the afternoon. But think about this. If I kept you awake all night and then said, I want you to go to sleep at 8 or 9 o'clock in the morning, you'd be tired. But it would be very difficult for you to fall asleep and stay asleep, because there's conflict between your homeostatic drive, which is telling you I've been awake for too long, and your circadian drive, which is telling me it's the morning I should be awake, and vice versa. That's why you can sleep all day and then work the night shift. You're still not going to be functioning at your optimal, because while you've had enough sleep, your circadian drive is telling you it's time to be asleep at night. So these are the two main drivers. But if somebody comes into your office and says, I'm tired, if you know these five main things that cause you to be tired, this is about really all you need to know. So the main cause of daytime sleepiness is not getting enough sleep or poor quality sleep. So across the top, reduced sleep time or disrupted sleep. And that could be for lots of reasons. Could be sleep apnea, could be restless leg syndrome, could be I'm getting up all night because my doctor's putting me on a water pill and I got to pee four times a night. It could be your children are waking you up. So those are the two most common things. Body clock related phenomenon. So think about we talked about as people get older, they go to sleep earlier, they wake up earlier. So what do they try to do to compensate? They try to go to bed later because they think that's going to increase their ability to sleep more, but their body clock is still going to wake them up at four or five o'clock in the morning. So now they're going to be sleep deprived and they're not going to be getting enough sleep. Medications is a big problem for most people that I tend to see. And then finally, there are certain things that happen in the brain. So narcolepsy is a primary cause of being tired during the day, but there are other medical problems. People have had a stroke, people have Parkinson's disease, other things that can affect the brain integrity also can lead to daytime sleep. And it's actually a lot of times it's a combination of multiple factors that cause people to be tired. It's not just one thing. So remember, sleep deprivation, number one cause of daytime sleepiness, even with your patient with sleep apnea, when they come in and they're tired, ask them about how much sleep they're getting, how many times a night they're waking up, what medications they're on because there may be multiple factors that cause them to be tired. And we'll talk about this in the next talk, but 50% of people who have sleep apnea don't have daytime sleepiness as we commonly define it. So therefore there may be other reasons for people to be tired. So how much sleep do we need? So really that depends on the individual. So the sleep requirement is the amount of sleep necessary to avoid daytime sleepiness and physiologic dysfunction. It likely varies among individuals, probably somewhere between six and eight hours is optimal. There are some people who do just fine on five or six hours. Our president says he only needs four hours, he probably needs more. But there are some people who genetically just don't need as much sleep as the next person. So somewhere between six and eight hours a night. So again, do we ever get used to sleep deprivation? The answer is no. It's not like going to the gym where you can train yourself to need less sleep. The bottom line is you need sleep to restore your body, to restore your brain. And if you're not getting enough sleep over time, you're going to be chronically tired. So one of the questions I was asked to address, will chronic sleep deprivation increase my risk of other problems? So the answer is certain things, yes. So we do know that if you don't get enough sleep, you're going to be tired during the day. You're not going to think as well. You're not going to be able to consolidate your memories. You're not going to be able to concentrate as well. You're going to be increased risk for motor vehicle accidents and accidents at work. There's probably some alterations in endocrine function and increased risk for obesity because of changes in some of the hormones that affect your hypothalamus. And there's possibly an increased risk of things like infection and maybe even increased risk of cardiovascular disease and death. I would say these are theoretical. Most of the immune response data is based on healthy young people who they do sleep deprivation studies on, and then they look at their antibodies or on animals. So it's not really quite clear. But what I would tell you is while we all focus on not getting enough sleep as the primary problem, what we do know when we look at optimal amount of sleep, and that's why I said six to eight hours, when you look at a bunch of the prospective observational studies that are out there, it seems like six to eight hours seems to be the safest. But not getting enough sleep increases your risk for bad things like obesity and hypertension and other cardiovascular problems. But getting too much sleep on a chronic basis does the same thing, or at least it's associated with it. We don't know that there's cause and effect. And why that is, it's not clear. It may be that getting too much sleep is a marker of badness, right? You have depression, you have other chronic medical problems, you're on too much medicine, you're spending too much time in bed. It's not primarily the sleep that's causing the problem. It's just a marker of something else that's going on. So can I make up for lost sleep? The answer is yes. I've heard people say, well, you can't make up for sleep deprivation. Well, if that was true, you know, every time you have a kid and you don't get enough sleep for however many years, two years, 18 years, whatever it happens to be, that would mean that you would never get back to baseline. And the answer is you clearly can make up for lost sleep. And it typically takes less time than it took to accumulate that sleep debt. So specifically, you know, if I'm on call and I'm in the ICU for a month, whatever it happens to be, it's not going to take me a month to get back to baseline. I can go home and I can sleep it off over the course of, you know, four, five, six days, and I can get back to baseline faster than that sleep debt took to accumulate. So that's the basics of what makes us sleepy, why we sleep at the times that we do. And really, if you know what's in those slides when your patients come to you and say, I'm tired and you should be able to just go through that list of five or so things, not enough sleep, disrupted sleep, right, circadian rhythm problems, medications, and central types of things, and that's really about 90% of what you need to know to address people who come to you with sleepiness. So the next topic I wanted to address from the standpoint of just basic sleep is insomnia. Insomnia is actually the most common sleep disorder. So 30% of the population at any one time has at least some short-term insomnia. And 10% of the population has chronic insomnia, and we'll define that for you in a second. So short-term insomnia is defined as nighttime complaints of difficulty initiating or maintaining sleep associated with daytime symptoms for less than three months. And that's a key point for both of these definitions, is you need to have some complaints of either non-refreshing sleep or not functioning well during the day. So some daytime complaints, because I'll have some people who come in, their husband or wife sends them in because they're only sleeping for six hours a day, they feel fine, right? So the problem is not insomnia. The problem is they just need less sleep, right? So because they don't have any daytime complaints. And chronic insomnia disorder is nighttime complaints with difficulty initiating or maintaining sleep, again, with associated daytime symptoms, at least three times per week for at least three months. And this is from the International Classification for Sleep Disorders. And that hasn't changed since 2014. So this is how we define it. In terms of risk factors, as people get older, they're more at risk. Again, how much of that is age-related? How much of that is body clock related? How much of that is other medical problems? Not really clear. Women in general have a higher risk or prevalence of insomnia. And those with a family history of insomnia are at increased risk. So there are probably some genetic links to this as well. People with psychiatric disorders, specifically depression, but any of the mood disorders, bipolar disease, schizophrenia, so on and so forth, have a much higher prevalence of having insomnia. And actually, interestingly, insomnia can be the first symptoms. And it's not uncommon that it actually predates the onset of their depression or other psychiatric disease by several years. So that may be a marker of something that may be happening down the road. And we tend to see insomnia a lot in people who have other medical problems. So again, people with chronic obstructive pulmonary disease or COPD are waking up at night because they can't breathe well. They have to get up and take a breathing treatment. People with heart failure, either breathing problems or the diuretics we give them that make them get up and have to go to the bathroom at night. People with chronic pain, other neurologic diseases, various medications. And you can have comorbid sleep disorders. So people with obstructive sleep apnea, one of their complaints may be sleep maintenance insomnia. They go to sleep at night. The sleep apnea wakes them up. Once they're up, they can't get back to sleep. So they may not be complaining of snoring or daytime sleeping as their main complaint may be disrupted sleep and sleep maintenance insomnia. So in terms of screening, I mean, there's not a great way to screen. It's really all about the history, right? You make the diagnosis based on what the patient is telling you and the questions that you ask. You don't need a polysomnogram to make a diagnosis of insomnia. You do need some type of a sleep test if you think there's something else going on. You think there are limb movements. You think they have sleep disordered breathing. You think they have other types of sleep disorders that may be leading to the insomnia. A polysomnogram or a home sleep apnea test would be indicated. But for the majority of people, you don't have to do a sleep study to make the diagnosis. And the role of sleep trackers like your Fitbit or other things on your phone, it's not really clear how useful they are either for helping to determine insomnia symptoms or when people come in and say, I'm not sleeping well. I would tell you that in general, the sleep trackers are good for looking at activity and not activity. So giving you a general idea of when you might be sleeping or not. The algorithms that tell the patients deep sleep, light sleep, REM sleep, they haven't really been validated. And people will come in and say, oh, I've only gotten like, you know, 80 percent of my sleep was light sleep last night. What should I do? I said, don't worry about it. Put your machine away. And actually, for insomnia, sometimes these sleep trackers will make things worse because people now are focusing on what's on their phone or what's on whatever app they're looking at, not how they feel. So what I would tell you is the role for sleep trackers for this or for anything right now is really up in the air. So in terms of treatment, and again, this is kind of what do I need to know as a non-sleep specialist? But again, you want to identify underlying causes. So again, medical problems or psychiatric disease or medications that may be causing the problem. You're going to have somebody keep a sleep log. So you're going to actually have them log how they're doing over time. And I'll show you an example of that. You're going to teach them about good sleep habits, which we'll talk about. You're going to give them some behavioral therapies, which are some things that are really easy for you to do. There are some apps or some online programs that you can recommend as well. There's stimulus control therapy, which we'll talk about. And the last thing that you would recommend or I would recommend are hypnotics or prescription medications or over-the-counter medications to help people sleep. That's really the last thing we want to do. And even when we're prescribing medications, we're still doing all of this other stuff. You really should never be giving people medications without trying to teach them better sleep habits. So this is what a sleep log looks like. Again, these are things now you can track on your phone. And somebody might come in with their Fitbit and kind of show you some disrupted sleep. But again, so this is the red is kind of when they're sleeping. The white is when they're awake. Time is across the top there. And what you notice is they have very disrupted sleep, right? They're waking up frequently. They're napping during the day, which is bad, right? Because we talk about the things that make people sleep well. Your homeostatic sleep drive is the longer you're awake, the more likely it is to sleep. If you're napping during the day, you're going to reduce that sleep drive during the day. You're going to be less likely to sleep at night. Because total sleep time across 24 hours for this person is probably pretty normal, right? But it's scattered across the night and they're sleeping during the day. And so in general, they're not going to feel great because they've got fragmented sleep. And they're not getting enough sleep at night, but they're making up for it during the day. So this is something that you can identify and actually fix pretty easily by making some recommendations. So here are your choices for treatment. And we kind of talked about a cognitive behavioral therapy or pharmacology, which is hypnotic. So giving drugs work for people most of the time. The problem is you're not teaching them how to do things right. So think about it as whatever sport you like to play. If you're a golfer, if you're whatever it is, the more you do it, the better you're going to be, especially when you get nervous or things aren't going well, you're teaching people the basics. The goal over here in the cognitive behavioral side is to get their basics back together and to really align the homeostatic and circadian sleep drive. So let your physiology work for you. Pharmacology, like I say, short term is fine, but you're not teaching them how to get better. And then they're going to end up being stuck on drugs that may have some adverse outcomes. So this is the sleep hygiene that you're going to recommend. So again, you're going to maximize that sleep drive. So remember what I showed you on that sleep log. This person had fragmented sleep across the night, but they were napping during the day. Well, that doesn't really work. So you want to avoid long daytime naps. So if you're tired, and I don't want to say people shouldn't nap in general. This is specifically for people with insomnia. If you're somebody who has no sleep problems and you didn't sleep well last night and you're tired during the day, taking a nap is great because it won't disrupt your sleep. You're just going to be making up for what you lost. But for people who don't sleep well, you want to avoid long daytime naps to build up that homeostatic sleep drive. You want to try to get them out of bed if they're not tired during the night because you want to break that association with their bed and not sleeping because they get frustrated. And what you also want to do is you want to try to synchronize that body clock. So your body clock is a little bit longer than 24 hours. And it's typically synchronized or re-synchronized every day by the light-dark cycle. So this is why when you go across time zones, depending on how many time zones you go across, it takes several days for your body clock to catch up. But what's happening with the sun and or the lights inside will help shift your clock. So you want to keep a regular sleep schedule. You want to make sure you're going to bed at the same time and waking up at the same time every day to keep your body clock's exposure to light and dark the same. All right, you want to minimize physiologic arousal. So this is kind of the stimulus control thing. So you want to have a quiet room. Again, you don't want to be in the room if you're not sleeping. You want to get out of a room if your bed partner is snoring and waking you up, or maybe you should kick them out and you'll sleep better. You want to avoid things like alcohol. Alcohol is great for getting you to sleep, but when it wears off, it actually has a rebound and will keep you from getting back to sleep, even if you're tired at night. The timing of exercise is not clear. We used to tell people that they shouldn't be exercising too close to bedtime, but in reality, what we found is for some people, exercising within an hour of bedtime works great for them because it helps them relax. So if they're exercising at night and it's not bothering them, then I'm totally fine with that if that's what they need to wind down before they go to sleep. So in general, like if you were to take a test, I don't know, from a board exam or whatever it happens to be, but if they ask you what's the best treatment for insomnia, the answer is always cognitive behavioral therapy, right? It's recommended by the American College of Physicians. It's recommended by the American Academy of Sleep Medicine as well. And this is kind of how you, what it's all about. So the behavioral part, they're doing things and we'll talk about this like sleep restriction and sleep hygiene. The cognitive part is really just helping people think more realistically about their sleep. So people who are worried that if I don't sleep enough, I'm gonna die or I'm gonna have a heart attack or whatever, those things aren't gonna happen. The reality is if you stay up long enough, you're gonna sleep. You know what I mean? So you're not gonna die if you're not sleeping enough. And this is to change the individual's belief about sleep and wake. And you can prescribe it several ways. You could do it yourself. You can send them to a sleep medicine person. There are various online and cloud-based applications that actually work pretty well. So there's something called ShutEye or CBTI, which is an app. All of these things actually can work pretty well and they're pretty straightforward. Most of what the app type things do is they do this behavioral component, which sleep restriction is probably the easiest thing. So again, if you think about that sleep log that I showed you with somebody who was in bed and it was fragmented, but they're spending more time in bed than they're sleeping. So what we call their sleep efficiency or the amount of sleep they're getting over the time in bed that they're having is not good. And you wanna try to maximize that, right? So if this is their ideal sleep time of eight hours and this is what they're currently doing, what you wanna do is you wanna just take their time in bed and smoosh it together, right? So you wanna try to make it that the amount of time in bed that they're having is the amount of sleep that they're gonna do. So if you're in bed for eight hours, but you're only sleeping five, you would prescribe five hours of sleep. So don't go to bed until two o'clock and wake up at seven. Once you can do that and you're sleeping pretty well through the night for several nights, you can start increasing the amount of time in bed that they have. So you go to five and a half, and then you go to six and then six and a half. And it may turn out that they don't really need eight hours. Maybe they're fine with six and a half or seven hours. But again, here you're aligning that homeostatic sleep drive. So you're keeping them up until their maximum tired and that aligns with their circadian drive for sleep. And what you're doing is you're getting them to sleep well over time. Again, keeping that wake time every day about the same. So their body clock is seeing light at the same time and it can reset every day. There are things out there for people who get really frustrated or nervous in bed like progressive relaxation therapy, deep breathing, biofeedback. There's various apps out there that can help you do this. So there's a Andrew Johnson Sleep Relax and there's probably a whole bunch of other ones. I'm not here to sell any apps to anybody, but this works pretty well. And sometimes the combination of an app like this and the sleep restriction therapy is all people need to really kind of get back in line. Again, sleeping pills, predominantly indicated for short-term insomnia. I'm not gonna go through all of the sleeping pills that are out there. Most of the medicines that are out there work on something called your GABA receptors and those are your zolpidems and your benzodiazepines. There are various antidepressants that are used, mostly used because of their side effects that make you sleepy. Now, if you're not sleeping well because you're depressed, then an antidepressant is what should be prescribed, but that probably should be in conjunction with their primary care physician and or their psychiatrist. And there are not a whole lot of data for things like diphenhydramine or Benadryl. And you think about that, that's probably the number one sleep aid that's sold. So in all the over-the-counter medications, so Motrin, PM, Tylenol, PM, the PM is diphenhydramine. So it's just Benadryl. Not a great drug because it lasts for a long time, lasts about 12 hours. So especially in older people, they take it at night, they can get a daytime hangover from it. It can increase prostate problems. It can cause problems with glaucoma. So all the stuff across the bottom is stuff that we probably shouldn't be using because there's no real data for it. So when you look at recommendations, and I think I've already driven this point home, both the American College of Physicians and the ASM really don't find a lot of data for long-term hypnotic use. And even if you're gonna use hypnotics, for whatever reason, you should be doing cognitive behavioral therapy in addition to the use of hypnotics. And then the goal is to make things better and wean them off of the sleeping pills as fast as you can. So there's just something that came out. Well, here's a question for you. Or I get this question about sleeping pills. Will taking sleeping pills increase my risk of dying, getting cancer, increase risk of dementia? I mean, there's actually a lot of data out there that shows these types of associations. What I would tell you is they're all observational. These are not cause and effect randomized controlled trials. All the data on, you know, pick the prescription hypnotic that's out there does not show an increased risk for any of these outcomes. So all I would tell you is take it with a grain of salt, but it's something that you should know about. So the bottom line on insomnia treatment is, again, cognitive behavioral therapy is really the way to go for everybody. And you can consider hypnotics for short-term use, but always prescribe cognitive behavioral therapy in addition to and get them off the sleeping pills as fast as possible. If you know this, this is really the cornerstone of what you need to know about coaching your patients from an insomnia standpoint. And then finally, I'm just gonna spend the last few minutes talking about some other common sleep disorders that you're not gonna treat, but you should know about because when you're taking your sleep history, you should be taking a history about more than just, do you snore? How tired are you? Do you have disrupted sleep? So there's restless leg syndrome, which was, it's probably been about five years now, was renamed as Willis-Eckbom disease as the person who first named it, although most people still go by restless leg syndrome. All right, so this is a report of an urge to move the legs, although it couldn't be in your arms too, but mostly in the legs, usually accompanied by uncomfortable or unpleasant sensations in the legs. So it can be anything from numbness, just a feeling of discomfort, pain, tingling. All right, it tends to be worsened during periods of rest or inactivity. So you're sitting on a plane, you're on a bus, you're sitting in a lecture like this for several hours a day. It gets better with movement, but there's a circadian component to this. So it tends to get worse in the evening and into the early morning hours. So it becomes a sleep problem because people have more of their symptoms at night and it makes it more difficult for them to either go to sleep or stay asleep because it's waking them up. So it's not really a sleep disorder per se. It is a neurologic disorder that causes sleep problems, but it's something that commonly that we see in the office. Right, it's not better explained by other types of diagnosis. So it's different than things like peripheral neuropathy because of that circadian component. So we see peripheral neuropathy in people with diabetes and lots of other types of medical problems, but those people have problems all the time. It's not, there's no circadian basis to it. And we do see this in kids as well. They may not give all of these symptoms. They would give symptoms in their own words. And I don't treat pediatrics. I don't treat children. In fact, when my wife, when my kids were younger, said, oh, my kids have X, Y, and Z, I said, call the pediatrician. Anyway, so the diagnosis is clinical. You don't need a sleep study. You don't need any of these other tests that are out there. It's all based on a clinical diagnosis. So again, you don't need to send somebody to the sleep lab to make a diagnosis of restless leg syndrome. In terms of risk factors, so some of the things you'd want to ask about is family history. So this is certainly more common in families. It's more common in women. It's more common when women get pregnant, probably because they get iron deficient. And iron deficiency is also something that's associated with this. Smoking, obesity, peripheral neuropathy, end-stage renal disease for lots of other reasons. But probably the top, one, two, the top four or five things are the top things that are associated or increase your risk. In terms of treatment, there are several FDA-approved medications for restless leg syndrome. Most of them work on your dopamine receptors in your brain. So a lot of these drugs initially were drugs that were used to treat Parkinson's disease. Now there's rotigotine, which is a patch, and then gabapentin or Neurontin, long-acting is also a drug that's FDA-approved. There are several treatments that are out there that are not FDA-approved that can be used. Benzodiazepines, especially long-acting ones like clonazepam have been used for long periods of time. They don't really do anything to fix the leg movement part of this. They just sedate you through the leg movements. Not a great drug to use, but I do see it used quite frequently. For people who have really resistant restless leg syndrome, opioids, or some type of narcotics are used. I don't use them, but some people would. And then for people with iron deficiency, that may be the cause. The treatment has fixed the iron deficiency because that may fix their problem. Also think about medicines that may make things worse. So most of the older or newer antidepressants actually can make limb movements and or restless leg syndrome worse. So it may be the treatment is don't put them on something new, talk to their psychiatrist or primary care doc, see if you can get them on something different to fix the problem. A common misconception is that periodic limb movements and restless leg syndrome are the same thing. They're not, okay? So periodic limb movements are relatively common, right? Depending on the study, four to 40 or five to 45% of the population have them. They're common in restless leg syndrome. Most individuals' periodic limb movements do not have restless leg syndrome and PLMs are not required for the diagnosis. So again, you don't need the sleep study to make the diagnosis. And in general, it's not really clear that periodic limb movements in and of themselves are really a disorder. It may just be an interesting finding and probably don't need to be treated. I have a lot of people who come to me, they have a sleep study that shows periodic limb movements and they're on medicine X, Y, and Z because of what they saw in the sleep study, but they don't have a clinical diagnosis or symptoms to support restless leg syndrome, so they shouldn't be on medication for that. So again, the bottom line here, it's a clinical diagnosis. It's increased in families, not the same as periodic limb movements. And in terms of treatment, if you were gonna treat them, you would stick to FDA approved treatments. Getting on to the last couple of topics, you should know about this. So parasomnia, so parasomnia is again, abnormal behaviors that happen during sleep. They can occur predominantly during non-REM sleep. We'll talk about a few of those. Those that occur during REM sleep, the one that's most common is something called REM sleep behavior disorder where you act out your dreams. And again, now that you're all sleep experts, you would know that REM related parasomnias are more likely to have some kind of periodicity to them. So they're gonna occur every 90 to 120 minutes. They're more likely to happen at the end of the night because that's when REM sleep occurs versus non-REM parasomnias, which typically occur in deeper sleep are gonna occur towards the beginning of the night. So when you're taking your history, that's one of the ways you might be able to help differentiate these. So again, the non-REM parasomnias, I kind of went over some of this stuff, but typically occur in the first one to two hours of sleep, tend to be more associated with deep sleep or stage three sleep. Sleep deprivation tends to be a common precipitant because when you get sleep deprived, one of the first things that happens is you get increases the amount of deep sleep as a way of recovery. So it's not uncommon, especially in kids, they don't sleep enough. And then when they get their recovery sleep, they start sleepwalking or sleep talking or whatever. It's because they have a rebound of stage three sleep. And the treatment really is to avoid sleep deprivation. In most cases, there has been some anecdotal evidence of using benzodiazepine, which may suppress stage three sleep. But in general, we don't treat these types of things. And most of these occur in kids. And with kids, if they get enough sleep and just with time alone, typically over the course of time, they're just gonna kind of outgrow it. So these are some of the ones that are out there. So sleep terror. So if you have kids, they wake up at night, they're screaming, they're confused, they look like they're awake, but they're not. And the thing that differentiates sleep terrors from confusional arousals is this intense autonomic discharge, meaning they're sweaty, they have a high heart rate, they're breathing really fast, and you don't tend to see that in confusional arousals. Somebody will look like they're awake, but they'll be confused and then they fall back to sleep. And they tend not to remember any of this because it's happening during deep sleep. It's like anybody who's been on call at night, you gotta call at two in the morning. You know, the ICU calls me and I do X, Y, and Z. And then the next day, I don't really remember what I did. Anyway, it depends on what stage of sleep you happen to be in. You should know that as of May 2019, there's a black box warning on many of the FDA-approved hypnotics, so Zolpidem, Azopiclone, Saloplan, noting that there has been an association between these medications and abnormal behavior. So you've read about people who get up at night and eat a bunch of food and don't remember it, get in their car, drive around. So there have been people who have fell down the stairs. So there's a black box warning. So typically now, if you prescribe these drugs, you should tell people that they are at increased risk for having abnormal behaviors at night. REM sleep behavior disorder, that's what we had just talked about. This is where people are acting out their dreams at night. They typically will remember this as opposed to the people who are having the non-REM parasomnias where they'll typically not remember it. Here, you need a polysomnogram to make the diagnosis. Okay, so risk factors tends to be more in men, typically older, depending on how you wanna define older, but older than 50. More common in Parkinson's disease and other neurodegenerative disease. People who have isolated REM sleep behavior disorder, meaning that's the only thing that they have, are at increased risk for Parkinson's down the road. So it may be, just like I said, insomnia was the first sign or symptom of depression. Many people who will have isolated REM sleep behavior disorder, they will, about 85% of these individuals will actually develop Parkinson's or something like that down the road. And you need to counsel people to let them know that that's something that potentially could happen. Treatment is clonazepam or melatonin at bedtime. Why they work, it's not clear, but they're both pretty effective. And you wanna avoid things that make it worse. So again, most of the older or even newer antidepressants tend to make these types of things worse. This is basically, this is circadian rhythms 101. So across the top, the gray is where you sleep relative to external clock time, and the yellow or the orange is when you're awake. So this is normal. So people with advanced sleep phase disorder, so think about those older individuals who are going to sleep early and waking up early. There are some, there's a genetic component, so it can happen at any age, but the typical history is go to sleep early, wake up early, and if they just follow their body clock, they're fine, but again, they try to keep themselves awake at night to go to bed later, thinking that they'll sleep longer and their body clock still wakes them up at four o'clock. So they'll come in complaining of sleep maintenance, insomnia, and daytime sleepiness. There's delayed sleep phase syndrome. So these are the night owls. So anybody who has teenagers out there, they go to sleep at two in the morning, they wake up at noon. They typically tend to shift back as they get older, but there are some people who just stay like this. These are great night shift workers. So if you can find them, you need people in the ICU to take call for you, whatever it happens to be. There are people with this irregular sleep wake disorder. These are people mostly who have dementia and problems with their, they have degenerative brain problems. And then there's the non-24. So those people who tend to drift across the day. So this is mostly in people who are blind. So remember I told you the typical body clock is longer than 24 hours. It needs to be reset every day. When you wake up and you see light, it tends to reshift. But if your eyes don't work and you don't sense light, you can't do that. So your body clock will tend to shift across the day. These people are adequately treated actually with melatonin. So you give them melatonin in the evening and that will tell their body clock, it's time to go to sleep and that will reset them. So you can either buy melatonin that costs like five bucks and that works really well, or you can, there's the drug that you see that's advertised on TV that's about $100,000 a year. That works great too, but I would probably go with the $5 one. And then finally, the last thing to talk about are what we call the central disorders of hypersomnia. So these are brain problems that cause you to be tired. So narcolepsy probably is the one that's the most common, but again, any kind of neurodegenerative disease like Parkinson's, people with multiple strokes, so on and so forth, may be at risk for these types of disorders. In general, they're not that common. Certainly the primary ones like narcolepsy, you're not gonna see much of that, but just know that there are other things that deal with the brain primarily that are not related to sleep deprivation or some of the other stuff that can cause daytime sleepiness. So in conclusion, I think the takeaways for this would be that the homeostatic and circadian systems are the two main determinants of sleep and wake. So when we go to sleep, when we wake up, how tired we are. The most common cause of daytime sleepiness is sleep deprivation or not getting enough sleep. Other common causes of daytime sleepiness, again, disrupted sleep, medication, central cause is body clock related. Insomnia is the most common sleep disorder and is best treated with cognitive behavioral therapy or CBT. And other sleep disorders exist that we had talked about that are less common, but you as sleep providers need to know about them. So that's the end of the first talk. Thank you for your attention.

sleep

stages of sleep

amount of sleep

age groups

sleep deprivation

insomnia

sleep disorders