INTRODUCTION TO SLEEP

•Sleep provides the rest, our body

needs.
•If you sleep well at night,you
function well in at day time.
•Thus sleep is vital for healthy brain
activity during day time such as
moods, emotions, refluxes etc.
 The Sleep Cycle
• During some portion of their sleep their
eyes darted rapidly in a highly co-ordinated
way.This is called Rapid Eye
Movement(REM).
• Using electroencephalogram (EEG) that
measures the electrical activity in the brain
and differentiated between REM and Non-
REM sleep.
•Sleep occurs in a series of cycle , each lasting
between sixty and ninety minutes.

Each cycle has two main parts:

In first part,our level of consciousness falls,

change in heart rate, breathing, and overall
slowing of brain activity.
We do not dream during this phase.
• In the second part of the cycle we do dream.Its is
characterized by rapid eye movement.
• Each of this two main period occupies about 50%
of the cycles elapsed time.
• However, the balance between the two periods
shifts during the course of the night.
• Non-REM sleep actually consists of four distinct
sub stages .
• The stages are defined according to the types and
intensity of brain wave activity as measured by
EEG tracings .
• Initial stage of sleep is known as Threshold.
 THE DIFFERENT STAGES
OF SLEEP CYCLE
• Stage 1 Non-REM Sleep
• Breathing becomes slow and even
• The heartbeat becomes regular
• Blood pressure falls
• Brain temperature decreases
• Blood flow to the brain is reduced
• Little or no body movement
• Lasts for 10min.

• Brain waves become

smaller and irregular
characterized by low
voltage fast EEG.
 Stage 2 NREM
• It initially lasts about twenty minutes.
• Stage 2 is an intermediate stage of sleep. It initially lasts about
twenty minutes. The sleeper will gradually descend deeper into
sleep, becoming more and more detached from the outside
world and progressively more difficult to awaken. Stage 2 is
characterized by:
• Larger brain waves and occasional quick bursts of activity
• The sleeper will not see anything even if the eyes are
opened
• A sleeper can easily be awakened by sounds
• Bodily functions slow down, Blood pressure, metabolism,
secretions, and cardiac activity decrease
 Stage 3 NREM

• Stage 3 is the beginning of deep sleep, occurring

about thirty to forty five minutes after you first fall
asleep. Stage 3 is characterized by:
• Brain waves are slow and quite large. These
brain waves are known as delta waves
• The sleeper is far more difficult to awaken as
compared to stage 1 or 2 sleep; it takes a louder
noise or an active attempt to wake him or her.
 Stage 4 NREM
• The brain waves are quite large, making a
slow, jagged pattern on the EEG
• The sleeper experiences virtual oblivion. If the
sleeper is a sleepwalker or a bed wetter, those
activities will begin in this phase
•The sleeper awakened from deep sleep will
probably be groggy, confused, or disoriented.
 Amount of sleep as we age
• Newborn infants need sixteen hours of sleep for
every twenty-four-hour day.
• By age six, children need only nine hours of sleep.

• By age twelve, it is down to eight hours of sleep.

•
• By adulthood, our totals sleep time requirement
drops to an average of seven and a half hours.
 Deep sleep as we age
• Young adults spend some 25 percent of
their sleep time in deep sleep.
• Adults aged fifty to sixty spend 10 percent
or less of their sleep time sleeping deeply.
• For many older adults, they worry that they
are not getting enough sleep and have
developed insomnia.
 REM Sleep Stage
Characteristics of REM State :
• Brain waves are small and irregular, with big bursts of eye activity.
• The four NREM phases are characterized by progressive relaxation.
But during REM phase, the body's activity perks up considerably

• Blood pressure may increase drastically .

• Pulse rates increase in an irregular way .
• The sleeper with cardiac problems faces the greatest risk of heart
attack at this time .
• Breathing becomes irregular and oxygen 'consumption increases .
• The first REM period is usually brief. After this, the sleeper may
wake up briefly. This is quite normal. A good sleeper may not
remember it the next day. A poor sleeper, however, may wake up at
this point and have difficulty getting back to sleep
 THE INTERNATIONAL
CLASSIFICATION OF SLEEP
DISORDERS
• Dyssomnias
B. Intrinsic sleep disorders
iii. Psychophysiological
insomnia
iv. Idiopathic insomnia
B. Extrinsic sleep disorders
vi. Altitude insomnia
vii. Insufficient sleep syndrome
C. Circadian rhythm sleep
disorders
ix. Time zone change (jet lag)
syndrome
x. Shift work sleep disorder
2. Parasonmias
• Arousal disorders
• Confusional arousals
• Sleepwalking
B. Sleep-wake transition disorders
• Rhythmic movement
disorder
• Sleep talking
C. Parasomnias usually associated
with REM sleep
• Nightmares
• Sleep paralysis
D. Other Parasomnias
• Sleep bruxism
• Sleep enuresis
3. Sleep Disorders Associated 4.Proposed sleep disorders
with Medical/Psychiatric
i. Menstruation-associated sleep
Disorders
disorder
B. Associated with mental
disorders ii. Pregnancy-associated sleep
• Mood disorders disorder
• Alcoholism
B. Associated with neurological
disorders
• Dementia
• Parkinsonism
C. Associated with other medical
disorders
• Sleeping sickness
• Sleep-related asthma
 Causes of Insomnia
Sleep-Onset Insomnia Sleep-Maintenance
• Anxiety or tension Insomnia
EnvirolID1entai change • Depression
Emotional arousal • Environmental change
• Fear of insomnia • Nocturnal myoclonus
• Phobia of sleep • Hypoglycemia
• Disruptive environment • Parasomnias such as
• Pain or discomfort apnea, restless legs
• Caffeine syndrome, etc.
• Alcohol • Pain or discomfort Drugs
• Alcohol
 Vulnerability to Insomnia
• Persistant Stress
• Depression
• Anxiety
• Post-Traumatic Stress Disorder (PTSD)
• Learned Insomnia
• Use of stimulants
• Use of alcohol
• Erratic hours
• Sedentary Behaviour
 Food

Foods That Can Interfere With Sleep

•Coffee
•Soft Drinks
•Tea
•Chocolate candy or dessert
•Chocolate milk or hot chocolate
•Onion
Vulnerability to Insomnia (cont.)
• Food Intolerance
• Nocturnal Hypoglycemia
• Physiological Factors
• Misuse or overuse of sleeping pills
• Environmental Factors
• Noise
• Light
 Insomnia due to Medication
• Alcohol • Oral Contraceptives
• Antihypertensives • Phenytoin (Dilantin)
• Antineoplastics • Protriptyline (Vivactil)
• Beta Blockers • Corticosteroids
• Caffeine • Stimulants
• Diuretics • Theophylline
• Levodopa • Thyroxine
 Treatment
• Conventional Treatment
• Transient Insomnia
• Medication (Drug Therapy)
• Education
• Chronic Insomnia
• Cognitive restructuring
• Light phase shift
• Support, counseling, or psychotherapy
• Cognitive behavioral therapy (CBT)
 DRUG CLASSES USED TO TREAT SLEEP DISORDERS

Barbiturates
Barbiturates slow down central nervous system function, heart rate, an use them
continually may become tolerant to the effects of barbiturate potentially serious side
effects.

Drugs in the class

Amobarbital (Amytal)
Butabarbital (Butalan Elixir, Butisol, Sarisol No.2)
Pentobarbital Oral (Nembutal)
Phenobarbital (Bellatol, Solfoton)
Secobarbital (Seconal)
Pentobarbital Injection (Nembutal Injection)
MEDICATIONS COMMONLY USED FOR THE TREATMENT
OF INSOMNIA

-Nonbenzodiazepine, selective benzodiazepine receptor agonists

Zaleplon

Common Initial Dose (half-dose is generally recommended in elderly): 10

mg FDA Approved Maximum Daily Dose 20 mg
When: at bed time or during night
Residual Effects - none
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: none
Zolpidem

Common Initial Dose (half-dose is generally recommended in elderly) 10 mg FDA

Approved Maximum Daily Dose 10 mg

When: at bed time only

Residual Effects - minimal
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: minimal
Sedating antidepressants frequently used as hypnotics (off-label)

Trazodone

Common Initial Dose (half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose
400 mg divided (for depression)

Amitriptyline

Common Initial Dose/(half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose
300 mg divided (for depression)
Doxepin

Common Initial Dose (half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose
300 mg divided (for depression)

Diphenhydramine

Common Initial Dose (half-dose is generally recommended in elderly) 25 mg FDA Approved Maximum Daily Dose
100 mg

Gabapentin

Common Initial Dose (half-dose is generally recommended in elderly) 300 mg FDA Approved Maximum Daily
Dose 1800 mg divided (for seizures)
 Melatonin

Melatonin has been called the body's own natural sleeping pill. It is N-acetyl-5-
methoxy tryptamine, the principal hormone of pineal gland. It plays a key role in the
sleep cycle by helping you fall asleep. Low melatonin levels can cause sleep-onset
insomnia.
This is how our body utilizes melatonin in controlling our sleep:

The body changes serotonin into melatonin.

• The pineal gland releases melatonin only during times when the level of light is
low. Practically
Melatonin isspeaking,
stored inthis
the means
pineal that
glandmelatonin
inside theis brain.
secreted only at night, while
you are asleep. In the morning, when you open your eyes, the presence of light is a
sign to your brain to shut down the melatonin production.
 Do not take melatonin supplement if:

You are pregnant or breast-feeding

You are under the age of 35

You are suffering from cancer of the blood or

immune system

You have kidney disease

Dosage: Start with 1.5 mg daily, taken 2 hours or less

before bedtime. If this is not effective, gradually
 5-HTP
5-HTP (5-hydrbxytryptophan) is a compound produced by the
body from tryptophan. It is naturally found in many foods and
most commonly extracted from the seeds of the Griffonia plant.

5-HTP increases REM sleep significantly (typically by about

25 percent) while simultaneously increasing deep sleep stages 3
and 4 without increasing total sleep time.

Higher doses may lead to a greater number of disturbing·

dreams and nightmares due to abnormally prolonged REM
sleep. It can also lead to mild nausea.
New Drug with novel mechanism of action (MOA) to be
developed in 35 years in the area of insomnia

Takeda Global Research & Development Center announced

today that it has submitted a new drug application (NDA) to
the U.S. Food and Drug Administration (FDA) to market :-
ramelteon (TAK-375), its investigational drug for insomnia.
Ramelteon belongs to a new class of prescription drugs .

Ramelteon specifically targets the MT 1 and MT 2

receptors in the brain, which are believed to be critical in the
regulation of the body's sleep-wake cycle.
 Common Sense Remedies
• 1. Go to bed only when you are sleepy. Get up at about the same time
every morning, no matter when you go to bed.
∀ 2. If you wake up at night and can't go back to sleep, remain quiet
and relaxed. Be patient; sleep usually returns.
• 3.Laughter is a powerful way to defuse stress and anxiety.
• 4. A void alcohol and caffeine for several hours before bedtime.
• 5. Set an alarm clock and get out of bed at the same time every
morning.
• 6. Exercise regularly in the late afternoon or early evening- but not
right before bedtime.
• 7.Learn to put worries out of your mind.