1

4
3
6
7
8
9
10
11
Sleep ls a complex reverslble sLaLe characLerlzed by behavloral qulescence and
dlmlnlshed responslveness Lo exLernal sumull.
12
13
14
Sleep ls generaLed and malnLalned by cenLral nervous sysLem (CnS) neLworks LhaL
are locallzed ln speclñc areas of Lhe braln uslng speclñc neuroLransmluers.

13
1hls sllde llsLs Lhe ma[or sleep and wake neuroLransmluers.
16
SysLems generaung wakefulness and Lhelr respecuve neuroLransmluers are: (a)
ascendlng reucular formauon [gluLamaLe], (b) basal forebraln [aceLylchollne], (c)
perlfornlcal area of Lhe hypoLhalamus [hypocreun], (d) locus ceruleus
[noreplnephrlne], (e) Luberomammlllary nucleus [hlsLamlne], (f) subsLanua nlgra
[dopamlne], and (g) raphe nuclel [seroLonln].
17
uopamlne agonlsLs (ampheLamlnes) lncrease wakefulness, whereas dopamlne
anLagonlsLs (haloperldol) promoLe sleep. llrsL-generauon hlsLamlne recepLor
blockers (dlphenhydramlne, low dose doxepln) cause sedauon. CaLecholamlne
agonlsLs (lsoproLerenol) lncrease arousal and wakefulness.
18
SumulanLs acL by lncreaslng dopamlne and noreplnephrlne (ampheLamlnes, cocalne,
meLhylphenldaLe), or hypocreun and dopamlne (modañnll, armodañnll).

19
SysLems generaung non-rapld eye movemenL (n8LM) sleep are: (a) hypoLhalamus
[gamma amlnobuLyrlc acld, CA8A], and (b) basal forebraln [CA8A and adenoslne].
1he pons and basal forebraln [aceLylchollne] generaLe and malnLaln rapld eye
movemenL (8LM) sleep.
20
CA8A-A recepLor agonlsLs (benzodlazeplnes) cause sleeplness. Adenoslne recepLor
blockers (cañelne) lncrease wakefulness and decrease elecLroencephalographlc (LLC)
slow wave acuvlLy. Chollnerglc agonlsLs (physosugmlne) lncrease 8LM sleep, whereas
chollnerglc anLagonlsLs (Lrlcycllc anudepressanLs) decrease 8LM sleep.
21
Alcohol faclllLaLes CA8A and lnhlblLs gluLamaLe, and ls sedaung aL hlgh doses.
22
CluLamaLe ls Lhe maln CnS exclLaLory neuroLransmluer. CA8A ls Lhe maln CnS
lnhlblLory neuroLransmluer. Clyclne ls Lhe maln lnhlblLory neuroLransmluer ln Lhe
splnal cord and ls responslble for sleep-relaLed muscle aLonla-hypoLonla.
23
AceLylchollne ls Lhe maln 8LM sleep neuroLransmluer. Adenoslne ls responslble for
homeosLauc sleep drlve. llnally, hypocreun dysfuncuon ls presenL ln pauenLs wlLh
narcolepsy (and caLaplexy).

24
Changes ln amlnerglc and chollnerglc Lone occur durlng sleep. AcuvlLy of amlnerglc
neurons [noreplnephrlne, seroLonln, hlsLamlne] ls lncreased durlng waklng and
decreases durlng boLh n8LM and 8LM sleep. ln conLrasL, acuvlLy of chollnerglc
neurons (aceLylchollne) lncreases durlng boLh waklng and 8LM sleep and decreases
durlng n8LM sleep.

23
1wo baslc lnLrlnslc componenLs lnLeracL Lo regulaLe Lhe umlng and consolldauon of
sleep and wake, namely sleep homeosLasls, whlch ls dependenL on Lhe sleep-wake
cycle, and clrcadlan rhyLhm (alerung), whlch ls lndependenL of lL.
26
Sleep homeosLasls ls Lhe sleep pressure LhaL lncreases relauve Lo Lhe durauon of
prlor wakefulness (l.e., Lhe longer a person ls awake, Lhe sleepler one becomes). 1hls
sleep pressure decllnes followlng a sumclenL durauon of sleep.

27
1hese Lwo processes, clrcadlan (alerung) and homeosLasls (sleep-promoung)
lnßuence sleep laLency, durauon and quallLy, and alerLness. Speclñcally, consLanL
alerLness ls malnLalned LhroughouL Lhe waklng perlod by a rlslng clrcadlan alerLness
opposlng Lhe lncrease ln sleep-promoung homeosLauc pressure, and consLanL sleep
LhroughouL Lhe sleep perlod ls posslble because of a falllng clrcadlan alerung
Lendency opposlng Lhe decreaslng homeosLauc sleep drlve.

28
A Lhlrd process, sleep lnerua, ls responslble for Lhe LranslenL perlod of relauve
confuslon and dlsorlenLauon durlng Lhe Lransluon beLween sleep and waklng. llnally,
Lhe umlng of sleep and waklng ls also deLermlned by behavloral lnßuences.
29
8lologlcal rhyLhms are ublqulLous and geneucally deLermlned. A clrcadlan rhyLhm ls a
blologlcal rhyLhm LhaL conslsLs of one osclllauon approxlmaLely every 24 hours.

Lndogenous human clrcadlan rhyLhms free-run aL sllghLly over 24 hours ( 24.2 hours
[referred Lo as ºLau"]).
30
LnLralnmenL ls Lhe process whereln envlronmenLal cues called zelLgebers, whlch can
be phouc (llghL) or nonphouc, synchronlze Lhe clrcadlan rhyLhm Lo Lhe exLernal 24-hr
perlod. LnLralnmenL can produce elLher phase advances (shlûs Lhe clrcadlan perlod
Lo an earller ume) or phase delays (shlûs of Lhe clrcadlan perlod Lo a laLer ume)
based on Lhe naLure and umlng of zelLgebers.
31
1he suprachlasmauc nucleus (SCn) ln Lhe anLerlor hypoLhalamus ls Lhe masLer
clrcadlan rhyLhm generaLor ln mammals. 1he acuvlLy of Lhe SCn ls greaLer durlng Lhe
dayume Lhan aL nlghL. 1he maln añerenL SCn connecuon sLarLs wlLh phoLosensluve
[mosL sensluve Lo blue-blue green wavelengLh llghL] reuna gangllon cells conLalnlng
Lhe phoLoplgmenL, melanopsln, LhaL pro[ecLs Lo Lhe SCn vla Lhe reunohypoLhalamlc
LracL.

32
1he SCn promoLes wakefulness durlng Lhe day and consolldaLes sleep durlng Lhe
nlghL. Ablauon of Lhe SCn causes random dlsLrlbuuon of sleep LhroughouL Lhe day
and nlghL, and, ln some specles, a reducuon ln durauon of Lhe waklng perlod.

33
1here are Lwo clrcadlan peaks ln alerLness (laLe mornlng and early evenlng) and Lwo
clrcadlan Lroughs ln alerLness (early mornlng and early-mld aûernoon).
34
33
36
MelaLonln, whlch ls synLheslzed and released by Lhe plneal gland, lnßuences Lhe
clrcadlan sleep-wake rhyLhms. MelaLonln secreuon ls greaLesL aL nlghL and ls
lnhlblLed by llghL exposure.
37
MelaLonln causes a phase delay when glven ln Lhe mornlng, and advances Lhe
clrcadlan phase when glven ln Lhe evenlng. MelaLonln ls less eñecuve Lhan llghL
exposure ln phase shlûlng clrcadlan rhyLhms. MelaLonln also possesses mlld hypnouc
properues.

38
LlghL ls an lmporLanL zelLgeber. LlghL exposure aûer mlnlmum core body
LemperaLure (C1mln, usually Lwo hours before hablLual wake ume) can phase
advance sleep-wake clrcadlan rhyLhms, whlle llghL exposure before C1mln wlll cause
a phase delay of sleep-wake clrcadlan rhyLhms.

39
40
41
Sleep has slgnlñcanL eñecLs on a number of physlologlc processes.
42
1here ls a relauve reducuon ln sympaLheuc acuvlLy and an lncrease ln
parasympaLheuc acuvlLy durlng n8LM sleep compared Lo wakefulness, Lhese
changes are even more pronounced durlng Lonlc 8LM sleep compared Lo n8LM
sleep. SympaLheuc acuvlLy LranslenLly lncreases durlng phaslc 8LM sleep.

43
Whereas boLh meLabollc and behavloral conLrols of resplrauon are presenL durlng
wakefulness, only meLabollc conLrol perslsLs durlng sleep. Compared Lo wakefulness,
sleep ls assoclaLed wlLh falls ln ÞaC
2
and SaC
2
by 2-12 mmPg and by 2°, respecuvely,
and by an lncrease ln ÞaCC
2
by 2-8 mmPg.
44
Pypoxlc and hypercapnlc venulaLory responses, upper alrway dllaLor muscle Lone,
and acuvlLy of Lhe accessory muscles of resplrauon are reduced durlng n8LM sleep
compared Lo wakefulness, and decreases furLher durlng 8LM sleep. (noLe: AcuvlLy of
Lhe dlaphragm remalns lnLacL durlng 8LM sleep).
43
© 2010 Amerlcan Academy of Sleep
Medlclne 46
© 2010 Amerlcan Academy of Sleep
Medlclne 46
© 2010 Amerlcan Academy of Sleep
Medlclne 47
© 2010 Amerlcan Academy of Sleep
Medlclne 47
8esplraLory pauerns also change durlng sleep. Þerlodlc breaLhlng wlLh eplsodes of
hypopneas and hyperpneas may develop durlng sLage 1 of n8LM sleep (n1).
8esplrauon ls sLable and regular durlng sLage 3 of n8LM sleep (n3), buL becomes
relauvely lrregular agaln wlLh varlable resplraLory raLes and udal volumes durlng 8LM
sleep. CenLral apneas or perlodlc breaLhlng may be seen durlng phaslc 8LM sleep.
48
PearL raLe (P8), cardlac ouLpuL (CC) and blood pressure (8Þ) decrease durlng n8LM
sleep compared Lo wakefulness and falls furLher durlng Lonlc 8LM sleep. PearL raLe,
CC and 8Þ lncrease durlng phaslc 8LM sleep compared Lo n8LM and Lonlc 8LM as
well as durlng arousals and awakenlngs. nlghmme sysLollc 8Þ ls commonly abouL
10° less Lhan dayume sysLollc 8Þ levels, a phenomenon called ºdlpplng".

49
Sleep ls accompanled by a decrease ln urlne ouLpuL as a resulL of an lncrease ln waLer
reabsorpuon, decreased glomerular ñlLrauon, and lncrease ln renln (n8LM sleep) and
anudlureuc hormone. CbsLrucuve sleep apnea (CSA) ls assoclaLed wlLh an lncreased
rlsk of nocLurla, Lhe lauer lmproves wlLh opumal posluve alrway pressure (ÞAÞ)
Lherapy.

30
CerLaln hormones lncrease durlng sleep (growLh hormone [CP], prolacun,
paraLhyrold hormone and LesLosLerone).
31
CLher hormones decrease durlng sleep (corusol, lnsulln and Lhyrold sumulaung
hormone [1SP]).
32
Pormone secreuon can be llnked Lo clrcadlan rhyLhms, Lo sleep, or boLh. Corusol
secreuon ls llnked prlmarlly Lo clrcadlan rhyLhms. 1hyrold sumulaung hormone (1SP)
secreuon ls llnked Lo boLh sleep and clrcadlan rhyLhms. CrowLh hormone (CP)
secreuon ls llnked prlmarlly Lo sleep (durlng n3 sleep).
33
Acromegaly ls assoclaLed wlLh a hlgher prevalence of CSA and cenLral sleep apnea
(CSA), Lherapy of acromegaly wlLh surgery or ocLreoude can lmprove sleep
dlsordered breaLhlng (Su8).
34
Þersons wlLh CSA can have low levels of CP and LesLosLerone, and boLh lncrease wlLh
ÞAÞ Lherapy. Þolycysuc ovarlan syndrome ls assoclaLed wlLh boLh lncreased
LesLosLerone levels and greaLer rlsk of CSA.
33
CbsLrucuve sleep apnea lncreases rlsk of lnsulln reslsLance and Lype ll dlabeLes
melllLus (uM), lndependenL of body mass lndex (8Ml). lnsulln sensluvlLy lmproves
wlLh ÞAÞ Lherapy. llnally, lncreases ln boLh lepun (lepun reslsLance?) and ghrelln
levels occur ln CSA, levels of boLh decrease wlLh opumal ÞAÞ Lherapy.
36
Sleep ls assoclaLed wlLh skeleLal muscle relaxauon (hypoLonla or aLonla) and
lnhlbluon of deep Lendon reßexes.

37
Þro-lnßammaLory cyLoklnes (lnLerleukln-1 [lL-1] and Lumor necrosls facLor-alpha
[1nl-]) enhance sleep, and anu-lnßammaLory cyLoklnes (lL-4 and lL-10) suppress
sleep.

Changes ln sleep are seen durlng vlral and bacLerlal lnfecuons (lncrease ln
n8LM and decrease ln 8LM sleep).
38
Changes ln Lhe lmmune sysLem are also presenL ln CSA (lncreased C-reacuve proLeln
[C8Þ], lL-6 and 1nl-), Lhese changes lmprove wlLh ÞAÞ Lherapy.

39
Core body LemperaLure (C1) peaks ln Lhe laLe aûernoon and early evenlng (6-8 pm)
and falls aL Lhe onseL of sleep, wlLh a nadlr (C1mln) aL 2 hours prlor Lo usual wake
ume (4-3 am).
60
Changes ln Lhermoregulauon LhaL occur durlng sleep lnclude (a) fall ln core body
LemperaLure, (b) decllne ln Lhermal seL polnL, (c) reduced response Lo Lhermal
challenges, and (d) loss of heaL producuon from shlverlng durlng 8LM sleep.
61
Sleep occurs durlng Lhe falllng phase of Lhe LemperaLure rhyLhm (aûer maxlmum
core body LemperaLure, C1max) and waklng occurs durlng Lhe rlslng phase of Lhe
LemperaLure rhyLhm (aûer C1mln).
62
lnluaung sleep durlng Lhe falllng phase of Lhe LemperaLure rhyLhm ls assoclaLed wlLh
a shorLened sleep onseL laLency (SCL), greaLer LoLal sleep ume (1S1) and lncreased
n3. Cn oLher hand, lnluaung sleep durlng Lhe rlslng phase of Lhe LemperaLure rhyLhm
leads Lo a longer SCL, less 1S1 and decreased n3.

63
ln summary, Lhe physlologlc parameLers LhaL ºgo down" durlng sleep are: (a)
sympaLheuc acuvlLy, (b) ÞaC
2
and SaC
2
, (c) udal volume and mlnuLe venulauon, (d)
hypoxlc and hypercapnlc venulaLory responses, (e) upper alrway dllaLor muscle Lone,
(f) acuvlLy of Lhe accessory muscles of resplrauon, (g) P8, CC and 8Þ [durlng n8LM
and Lonlc 8LM sleep], (h) frequency of premaLure venLrlcular complexes, (l)
swallowlng raLe and sallvary producuon, ([) esophageal and lnLesunal moullLy, (k)
glomerular ñlLrauon, (l) corusol [levels decrease durlng n3 sleep], (m) lnsulln
secreuon, (n) muscle Lone, (o) core body LemperaLure and LhermoregulaLory
responses Lo Lhermal challenges, and (p) meLabollc raLe [durlng n8LM sleep].
64
63
66
1he physlologlc parameLers LhaL ºgo up " durlng sleep are parasympaLheuc acuvlLy,
ÞaCC
2
, renal waLer reabsorpuon, and cerLaln hormones (CP [durlng n3 sleep],
prolacun [durlng n3 sleep], paraLhyrold hormone, renln [durlng n8LM sleep],
anudlureuc hormone and LesLosLerone).

67
68
69
70
vulnerablllLy Lo sleep deprlvauon (Su) varles wlLhln lndlvlduals across ume and
among dlñerenL lndlvlduals. Consequences of LoLal Su appear Lo dlñer Lhose of
chronlc parual sleep resLrlcuon. Þersons oûen underesumaLe Lhe negauve lmpacL of
Su on Lhelr cognluon and performance.
71
numerous physlologlc varlables lncrease durlng Su, such as sleeplness, sympaLheuc
acuvlLy, medlcal errors and moLor vehlcle accldenLs, cerLaln hormones (corusol and
ghrelln) and lnsulln reslsLance.
72
CLher physlologlc processes decrease durlng Su, lncludlng vlgllance, cognluon,
auenuon, selzure Lhreshold, reslsLance Lo lnfecuon, growLh hormone and lepun
acuvlLy.
73
74
76
Þolysomnography (ÞSC) lnvolves Lhe conunuous and slmulLaneous recordlng of
several physlologlc varlables durlng sleep.
77
1hese varlables lnclude LLC, elecLrooculography (LCC), chln elecLromyography
(LMC), elecLrocardlography (LCC), alrßow, resplraLory eñorL, oxygenauon, snorlng
and leg (anLerlor ublalls) LMC.
78
Þolysomnography ls lndlcaLed for Lhe dlagnosls of Su8, posluve alrway pressure (ÞAÞ)
uLrauon for Su8, follow-up aûer upper alrway surgery or denLal devlces for CSA, and
evaluauon of narcolepsy, perlodlc llmb movemenL dlsorder (ÞLMu), aLyplcal or
ln[urlous parasomnlas, and sleep-relaLed selzures.

79
Þolysomnography ls performed wlLh a polygraph, whlch ls a serles of alLernaung
currenL (AC) and dlrecL currenL (uC) ampllñers and ñlLers. AC ampllñers are used for
hlgh-frequency (fasL) physlologlc varlables (LLC, LCC, LMC) and uC ampllñers are
used for low-frequency (slow) physlologlc varlables (SaC
2
). Alrßow and resplraLory
eñorL are recorded uslng elLher AC or uC ampllñers.
80
A derlvauon ls Lhe dlñerence ln volLage beLween Lwo elecLrodes, and can be (a)
blpolar lf Lwo sLandard elecLrodes are maLched Lo each oLher or (b) referenual lf a
sLandard elecLrode ls maLched Lo a reference elecLrode.

81
LlecLrode placemenL ls based on Lhe lnLernauonal 10-20 sysLem ln whlch each
elecLrode ls provlded wlLh a leuer (reglon of Lhe scalp) and a numerlcal subscrlpL,
namely l = fronLal, C = cenLral, C = occlplLal, and M = masLold. Cdd numbers = leû-
slded elecLrodes, even numbers = rlghL-slded elecLrodes, and ºz" = mldllne
elecLrodes. Þlease refer Lo examples on Lhe nexL sllde.

82
1he recommended LLC elecLrode placemenLs are l4M1, C4M1 and C2M1. Addluonal
LLC elecLrodes can be applled for evaluaung nocLurnal selzures.

84
LlecLroencephalographlc waves are classlñed, based on frequency, lnLo delLa (< 4 Pz),
LheLa (4-7 Pz), alpha (8-13 Pz) and beLa (> 13 Pz).
83
8eLa waves domlnaLe durlng alerL wakefulness. Alpha waves are seen durlng
wakefulness wlLh eyes closed. 1heLa waves are presenL durlng n1, sLage 2 of n8LM
sleep (n2) and 8 sleep. uelLa waves are mosL promlnenL durlng n3 sleep.
86
1here are Lwo addluonal LLC waveforms LhaL are lmporLanL ln Lhe sLaglng of sleep,
namely k complexes (hlgh-ampllLude, blphaslc waves wlLh durauon of 0.3-sec) and
sleep splndles (osclllauons wlLh a frequency of 12-14 Pz lasung 0.3-1.3 sec).

87
Leû arrow polnLs Lo a sleep splndle. 8lghL arrow polnLs Lo a k complex.
8ecommended LCC elecLrode placemenLs are L1M2 and L2M2 (L1 = below Lhe leû
ouLer canLhus, L2 = above Lhe rlghL ouLer canLhus, and M2 = rlghL masLold process).
89
1hese LCC elecLrodes record Lhe dlñerence ln poLenuals (dlpole) beLween a
posluvely charged cornea and a negauvely charged reuna. ulpole changes wlLh eye
movemenLs - an eye movlng Lowards an elecLrode creaLes a posluve volLage
(downward deßecuon) whereas an eye movlng away from an elecLrode resulLs ln a
negauve volLage (upward deßecuon).

90
1here are Lwo baslc pauerns of eye movemenLs, namely slow and rapld eye
movemenLs. Slow rolllng eye movemenLs conslsL of slow undulaung
deßecuons LhaL are presenL durlng wakefulness wlLh closed eyes, n1 sleep or
brlef awakenlngs, and LhaL dlsappear durlng n2 sleep.
Arrow shows an example of a slow rolllng eye movemenL.
8apld eye movemenLs, on Lhe oLher hand, are sharper deßecuons LhaL can
occur durlng wakefulness wlLh open eyes (eye bllnks) or 8LM sleep.

Arrow shows an example of a rapld eye movemenL.

1hree chln elecLrodes are used for ÞSC: (a) mldllne, above Lhe mandlble, (b) rlghL of
mldllne below Lhe mandlble, and (c) leû of mldllne below Lhe mandlble. Chln LMC
derlvauon conslsLs of any one elecLrode below and Lhe mldllne elecLrode above Lhe
mandlble.

93
1he oronasal Lhermal sensor ls Lhe recommended Lechnlque for ldenufylng apneas,
and nasal alr pressure Lransducers are recommended for ldenufylng hypopneas. WlLh
nasal alr pressure Lransducers, lnsplraLory ßow slgnals are ßauened (plaLeau) wlLh
obsLrucuve evenLs, and reduced buL rounded wlLh cenLral evenLs.

98
8ecommended sensors for measurlng resplraLory eñorL are esophageal manomeLry
or lnducLance pleLhysmography. 1hese sensors are lmporLanL ln dlsungulshlng
obsLrucuve, cenLral and mlxed apneas.

99
Leg (anLerlor ublalls) LMC ls used Lo deLecL perlodlc llmb movemenLs durlng sleep.
Addluonal elecLrodes ln Lhe upper exLremlues may help ldenufy 8LM sleep behavlor
dlsorder (88u).

100
101
103
Þolysomnographlc daLa are dlvlded lnLo 30-second ume perlods (epochs). Lach epoch
ls asslgned a sleep sLage LhaL comprlses Lhe greaLesL percenLage of Lhe epoch.
104
A healLhy adulL Lyplcally spends Lhe followlng percenLages of Lhe nlghL ln dlñerenL
sleep sLages, namely n1 (3°), n2 (43°), n3 (23°) and 8LM (23°).
103
Wakefulness (wake W) ls deñned by > 30° of an epoch havlng alpha LLC waves when
eyes are closed. lf alpha waves are absenL, Lhe presence of verucal eye bllnks,
readlng eye movemenLs or volunLary rapld open eye movemenLs are useful ln
ldenufylng sLage W. Chln LMC Lone ls hlgh.

106
Arrow polnLs Lo alpha waves.
ln Lhls sleep sLage, alpha waves are replaced by low ampllLude, mlxed frequency (4-7
Pz) waves LhaL occupy > 30° of Lhe epoch. 1here are no k complexes or sleep
splndles. Slow eye movemenLs may be presenL. 1onlc chln LMC levels are lower Lhan
ln sLage W.

108
Arrow polnLs Lo low ampllLude, mlxed frequency (4-7 Pz) waves.
Low ampllLude, mlxed frequency waves, as ls n1, are presenL. ln addluon, k
complexes (noL assoclaLed wlLh arousals) or sleep splndles are seen durlng Lhe 1sL
half of Lhe epoch or durlng Lhe lasL half of Lhe prevlous epoch. lmporLanLly, crlLerla
for sLage n3 (see sllde explalnlng n3 sleep) are absenL.

110
Arrow polnLs Lo low ampllLude, mlxed frequency (4-7 Pz) waves. PlnL: search for
sleep splndles and a k complex ln Lhls epoch.

Sleep ls scored as n3 lf 20° of Lhe epoch ls occupled by slow wave (0.3-2 Pz and >
73 µv) LLC acuvlLy.

112
Arrow polnLs Lo delLa waves.
Arrow polnLs Lo delLa waves.

8apld eye movemenL sleep ls characLerlzed by low ampllLude, mlxed frequency LLC
acuvlLy, rapld eye movemenLs, and low chln LMC Lone.

113
Arrow polnLs Lo low ampllLude, mlxed frequency (4-7 Pz) waves. PlnL: search for Lhe
rapld eye movemenLs ln Lhls epoch.

1hls epoch has low ampllLude, mlxed frequency (4-7 Pz) LLC waves and rapld eye
movemenLs ln Lhe LCC.
A summary of Lhe scorlng rules for adulL sleep sLages.
118
An apnea ls deñned as a decrease ln peak Lhermal sensor ampllLude by 90° of
basellne for 10 sec. LvenLs can be obsLrucuve (lnsplraLory eñorL ls presenL
LhroughouL Lhe enure evenL), cenLral (lnsplraLory eñorL ls absenL LhroughouL Lhe
enure evenL) or mlxed (cenLral evenL followed by an obsLrucuve evenL).
119
Lxample of obsLrucuve apnea.
Lxample of cenLral apnea.
Lxample of mlxed apnea.
A hypopnea ls scored lf Lhere ls a decrease ln nasal pressure by 30° of basellne for
a durauon of 10 sec accompanled by 4° C
2
desaLurauon.
123
Lxample of hypopnea.
Sleep hypovenulauon ls presenL lf Lhere ls an lncrease ln ÞaCC
2
, LranscuLaneous CC2
(ÞLcCC2) or end-udal CC2 (ÞeLCC2) by 10 mmPg durlng sleep compared Lo suplne
wake values.

123
Leg LMC acuvlLy ls scored as perlodlc llmb movemenLs (ÞLM) lf (a) 4 consecuuve
leg movemenLs, (b) each leg movemenL ls 0.3-10 seconds ln durauon, and (c) 3-90
sec beLween leg movemenLs. Leg movemenLs on dlñerenL legs are counLed as one
movemenL lf separaLed by < 3 seconds.

126
Arrow polnLs Lo a serles of ÞLMs.
Scorlng arousals from n8LM sleep requlre changes ln LLC only (abrupL LLC
frequency shlû [alpha, LheLa or > 16 Pz, buL noL splndles] 3 seconds and preceded
by 10 seconds of sLable sleep). Scorlng 8LM arousals requlre changes ln boLh LLC
(as ln n8LM arousals) and LMC (lncrease ln chln LMC 1 second).

128
1here are Lhree general pauerns of sleep archlLecLure, namely hlgh sleep lnpuL
pauern, low sleep lnpuL pauern, and clrcadlan rhyLhm sleep dlsorder pauerns. Plgh
sleep lnpuL pauern (shorL SCL, lncrease ln sleep emclency [SL, LoLal sleep ume (1S1) -
ume ln bed], greaLer 1S1 and low wake ume aûer sleep onseL [WASC]) ls seen ln Su,
dlsorders presenung wlLh excesslve dayume sleeplness (LuS) or use of sedaung
medlcauons. Low sleep lnpuL pauern (prolonged SCL, decreased SL and 1S1 and
lncrease ln WASC), on Lhe oLher hand ls characLerlsuc of dlsorders presenung wlLh
lnsomnla or use of sumulanL medlcauons. Clrcadlan rhyLhm sleep dlsorder pauerns
wlll be descrlbed ln Lhe chapLer on ºCLher Sleep ulsorders."

129
1here are excepuons Lo Lhese general rules of sleep archlLecLure. Þersons wlLh
narcolepsy, a dlsorder assoclaLed wlLh hypersomnla, may occaslonally have
decreased SL and 1S1 and lncrease ln WASC. ldlopaLhlc hypersomnla wlLhouL long
sleep ume, by deñnluon, ls assoclaLed wlLh normal 1S1. Þolysomnographlc
parameLers may be normal ln (a) psychophyslologlc lnsomnla (reverse ñrsL-nlghL
eñecL or sleeplng beuer ln a new sleep envlronmenL), (b) paradoxlcal lnsomnla, ln
whlch pauenLs complaln of slgnlñcanL sub[ecuve sleep dlsLurbance desplLe normal
SCL and 1S1, and (c) envlronmenLal sleep dlsorder when ÞSC ls performed ln Lhe
sleep laboraLory and away from Lhe usual home bedroom envlronmenL.

130
CLher facLors añecung general sleep archlLecLure lnclude aglng (decrease ln n3),
recovery from sleep deprlvauon (Su, lncrease ln n3 and 8 sleep), and (c) ºñrsL-nlghL
eñecL" or sleeplng poorly ln a new sleep envlronmenL (decrease ln n3 and 8 sleep).

131
ln addluon Lo ÞSC, oLher LesLs, lncludlng LpworLh sleeplness scale (LSS), muluple
sleep laLency LesL (MSL1) and malnLenance of wakefulness LesL (MW1), are
commonly used ln Lhe evaluauon of persons wlLh sleep-relaLed complalnLs.

132
1hls ls an 8-lLem quesuonnalre LhaL measures propenslLy Lo fall asleep ln recenL
umes, namely (a) slmng and readlng, (b) waLchlng Lelevlslon, (c) slmng and lnacuve ln
a publlc place, (d) as a passenger ln a car for an hour wlLhouL a break, (e) lylng down
Lo resL ln Lhe aûernoon, (f) slmng and Lalklng Lo someone, (g) slmng quleLly aûer
lunch wlLhouL drlnklng alcohol, and (h) sLopped ln a car for a few mlnuLes ln Lramc.

133
Chances of dozlng durlng Lhese slLuauons are graded as 0 (never), 1 (sllghL chance), 2
(moderaLe chance) and 3 (hlgh chance). An aggregaLe score beLween 0-9 ls normal,
and 10 suggesLs LhaL sleeplness ls presenL and LhaL a sleep speclallsL advlce ls
recommended.
134
unforLunaLely, correlauon beLween severlLy of sleeplness measured by LSS, MSL1
and MW1 ls poor. LpworLh sleeplness score ls lncreased ln pauenLs wlLh CSA, and
scores lmprove wlLh eñecuve Lherapy of CSA.
133
1he MSL1 ls a measure of a person's Lendency Lo fall asleep ln quleL slLuauons.
Þolysomnography ls requlred prlor Lo Lesung. 1hls LesL conslsLs of four Lo ñve nap
opporLunlues performed aL 2-hour lnLervals. uurlng each 20-mlnuLe nap Lrlal, Lhe
pauenL ls asked Lo lle down ln a comforLable posluon ln a dark, quleL room, Lo close
hls eyes, and Lo Lry Lo fall asleep. LlecLroencephalography, LCC, chln LMC and LCC
are monlLored conunuously. Lach nap Lrlal ls LermlnaLed lf Lhere ls no sleep noLed
aûer 20 mlnuLes, or 13 mlnuLes aûer Lhe onseL of any sleep sLage.
136
1he MalnLenance of Wakefulness 1esL ls a measure of a person's ablllLy Lo remaln
awake ln quleL slLuauons. unllke MSL1, ÞSC ls noL requlred prlor Lo Lesung. 1he MW1
conslsLs of four 40-mlnuLe nap opporLunlues conducLed aL 2-hour lnLervals. uurlng
Lesung, Lhe pauenL ls lnsLrucLed Lo slL ln bed ln a seml-recllned posluon and ln a dark,
quleL room, and Lo Lry Lo sLay awake. SLandard MW1 leads conslsL of LLC, LCC and
chln LMC. Lach MW1 nap Lrlal ls LermlnaLed lf Lhere ls/are (a) Lhree consecuuve
epochs of n1 sleep, (b) one epoch of any oLher sleep sLage, or (c) no sleep aûer 40
mlnuLes.

137
138
Muluple sleep laLency LesL ls lndlcaLed Lo evaluaLe unexplalned hypersomnla and
suspecLed narcolepsy, and Lo dlsungulsh beLween narcolepsy and ldlopaLhlc
hypersomnla.
139
A shorL mean SCL (< 8 mln) suggesLs Lhe presence of LuS. Causes of shorL SCL lnclude
narcolepsy, ldlopaLhlc hypersomnla, Su, CSA, ÞLMu and acuLe wlLhdrawal of
sumulanL agenLs. An esumaLed 13-30° of normal lndlvlduals wlll have a shorL SCL
durlng Lesung.

140
Sleep onseL 8LM perlods (SC8LMÞs, or Lhe occurrence of 8LM sleep durlng MSL1) ls
seen ln persons wlLh narcolepsy, Su, CSA, wlLhdrawal from 8LM suppressanLs, or
alcohol wlLhdrawal. SC8LMÞs may also be presenL ln 1-3° of normal lndlvlduals.

141
1he MW1 ls less sensluve Lhan MSL1 ln measurlng sleeplness. Mean SCL correlaLes
wlLh Lhe ablllLy Lo sLay awake (< 8 mln = abnormal, > 8 and < 40 mln = lndeLermlnaLe,
and 40 mln = normal).
142
WlLh aglng, speclñc sleep parameLers may elLher remaln unchanged (sleep
requlremenLs), lncrease (nocLurnal sleep dlsLurbance, excesslve dayume sleeplness,
frequency of napplng, Lolerance Lo Su, and prevalence of lnsomnla, CSA, CSA,
resLless legs syndrome [8LS], ÞLMu, 88u and advanced sleep phase syndrome
[ASÞS]), or decrease (n3 sleep, melaLonln secreuon, ampllLude of clrcadlan sleep-
wake rhyLhms, homeosLauc sleep drlve, arousal Lhreshold, CP secreuon durlng sleep,
and Lolerance Lo shlû work and [eL lag).
143
Þlease refer Lo prevlous sllde.
144
Sleep dlsLurbance ln older adulLs can resulL from aglng physlology lLself (rarely Lhe
sole cause), menopause, medlcal dlsorders (e.g., nocLurla), neurologlcal dlsorders
(e.g., demenua and Þarklnson dlsease), psychlaLrlc dlsorders (e.g., depresslon),
adverse eñecLs of medlcauons, or prlmary sleep dlsorders.

143
CbsLrucuve sleep apnea ls more common ln men, Lhls dlñerence ln prevalence
perslsLs wlLh aglng. 8lsk of CSA lncreases wlLh menopause. Pormone replacemenL
Lherapy (P81) decreases Lhe prevalence of CSA ln posLmenopausal women, buL daLa
do noL supporL Lhe use of P81 as Lherapy for CSA ln Lhls populauon.

146
CerLaln sleep dlsorders are more common ln men (sleep relaLed breaLhlng dlsorders
[S88u] and 88u) whlle oLhers are more prevalenL ln women (lnsomnla and 8LS).

147
Sleep and waklng are conLrolled by speclñc neuroLransmluers locaLed ln speclñc
areas of Lhe braln. Changes ln physlologlc processes occurrlng durlng sleep are
responslble for dlñerences ln cllnlcal presenLauon of varlous medlcal dlsorders.
CharacLerlsuc changes ln LLC, LCC and LMC are used Lo deñne speclñc sleep sLages.

Abbrevlauons used ln Lhe presenLauon.
149
Abbrevlauons used ln Lhe presenLauon.

130
Abbrevlauons used ln Lhe presenLauon.

131
Abbrevlauons used ln Lhe presenLauon.

132
Abbrevlauons used ln Lhe presenLauon.

133
Abbrevlauons used ln Lhe presenLauon.

134