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Sleep Across The Life Cycle

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Sleep Across The Life Cycle Presented by Dr. Syeda S. Munir Grand Round Presentation. Sleep Medicine Fellowship Program at LSUHSC Shreveport, LA. – PowerPoint PPT presentation

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Title: Sleep Across The Life Cycle


1
Sleep Across the Life Cycle
  • Syeda Shakeela Munir M.D.
  • Sleep Medicine

2
Objectives
  • Discuss the changes that occur in sleep from
    infancy through adulthood.
  • Discuss the normative data of sleep parameters
  • Discuss sleep changes across the life cycle in
    women
  • Discuss sleep in older Adults

3
Sleep Definition
  • sleep is a reversible behavioral state of
    perceptual disengagement from environment
    unresponsive to the environment.
  • Series of physiological behavioral process.
  • Normally associated with postural recumbence,
    behavioral quiescence ,closed eyes occasionally
    unusual behavioral activities.
  • Greek God Hypnos Sleep.

4
Sleep Across the life cycle
5
Sleep Patterns 0-12 Months
  • Sleep -major portion of lives of newborns,
    infants children.
  • A newborn typically sleeps ( 70 of every 24 Hr)
    / adults spend 25-30 of their lives sleeping.
  • Distributed equally across the day night.
  • Gain ability to sustain longer periods of sleep
    waking.
  • Total sleep duration about 14 hours.
  • Developmental mile stones of sleeping through
    the night ( i.e. at least 8 hours at night) is
    achieved by 6-9 months.
  • By age 3 ,the average child will have spend more
    time asleep than awake.

6
Sleep Patterns 0-12Months
  • Infants have a sleep cycle periodicity of 50-60
    minutes.
  • Sleep periods of 2-4 hours initially in infancy
    with REM. usually being the initial stage of
    sleep onset.
  • Infants usually spend 50 of night into REM.
  • At age 3 months REM becomes organized NREM
    finally dominates the sleep cycle.
  • NREM stages emerges in the first year.
  • Sleep spindles arising at 4 weeks.
  • High voltage slow waves at age 3 months.
  • K complexes at 6 months.

7
Sleep Patterns 0-12 months
  • EEG features not discernible in new born
    infants.
  • Combination of EEG Behavioral Criteria used to
    assign sleep stages .
  • Quiet sleep( i.e. NREM sleep)
  • Active Sleep( i.e. REM sleep)
  • Indeterminate Sleep
  • Active sleep dominates initially with
    respective percentage for preterm full term
    infants of 60 50.
  • By age six months, active sleep declines to 25 .
  • After 6 months, NREM divided into 4 stages Stage
    1,2,3,4.
  • EEG voltage significantly increases in first yr,
    with attenuation in 9-16 yrs.

8
Sleep Patterns 0-12 months
9
Sleep Patterns 0 12 months
  • REM sleep, NREM sleep based on EEG, EOG, EMG.
  • Newborn Transitional sleep with disorganized
    quiet and active sleep.
  • 1-6 Months REM is active sleep, NREM is quiet
    sleep.
  • NREM sleep low frequency, high voltage EEG
    activity, low muscle tone, absence of eye
    movement.
  • REMS Desynchronized cortical EEG activity,
    absence of muscle tone, irregular heart and resp
    rate, episodic bursts of phasic eye movements.
  • Trace alternant seen in very young high voltage
    activity with near electrical silence.

10
Sleep Patterns in 0-12 months
  • When infants fall asleep, experience sleep onset
    REM after 3 months, drift towards NREM sleep
    onset.
  • SWS greatest is early childhood, decreasing
    abruptly in puberty and further declines
    throughout life.
  • This change reflects EEG amplitude that may be
    related to age-specific programmed alterations
    in synaptic connectivity among neurons and
    changes in neuron
  • , neurotransmitter, or neuro -receptor
    properties.

11
Sleep Patterns of 0-2 months
Active Sleep State
Analogous to REM, low voltage irregular pattern,
HR,RR variable
12
Sleep Pattern o-12 months
Quiet Sleep State
Analogous to NREM, Discontinuous EEG pattern,
intermittent bursts of electrical activity
alternates w/quiescent periods, regular HR, RR,
few body movements
13
Sleep Patterns 0-12 Months
Quiet sleep and tracé alternant (TA)
NREM sleep pattern at term, 2-6 sec burst of high
amplitude slow waves separated by 4-6 secs of low
voltage mixed activity, disappears by 4 weeks
post term
14
EEG TRACING FROM AGE 2 WEEKS TO 15 years.
15
Sleep Patterns in 2-6 years
  • Changes in sleep structure during this period are
    more gradual.
  • Sleep becomes consolidated into a long nocturnal
    period of approx 10 hour.
  • During 2-3 years day time sleep is replaced by
    short day time naps.
  • All children stop napping between ages 3-5 years.
  • Sleep is generally consolidated into a single
    nocturnal period.

16
Sleep Pattern in 2-6 year old
17
Sleep Pattern in 2-6 year old
18
Sleep Patterns in 2-6 years
  • Changes in uniformity duration of REM periods
    i.e., The first REM of Night becomes shorter ,
    while succeeding periods longer associated with
    more intense phase activity.
  • REM usually occurs one hour after a sleep.
  • By 4-5 year of age REM decreases to an Adult
    level of 20-25 .
  • Children of this age usually have 7 cycles during
    each nocturnal sleep period.
  • Sleep onset between 15-30 minutes.
  • SWS usually occur during the first third of night.

19
Sleep pattern 2-6 years
  • Decrease in sleep duration across early childhood
    results from fewer daytime naps.
  • Night waking common in toddlers/preschoolers
    (20 wake once a night, 50 once a week).
  • Can be considered normal.
  • Thought to be consequence of nocturnal arousals
    driven by Ultradian rhythm of sleep cycles (50-90
    mins.).
  • Self soother vs non self soother.

20
Sleep Pattern in 2-6 years
  • Child development influence sleep behaviors.
  • gt Increased mobility leads to reactive
    co-sleeping.
  • gt Cognitive development produce fears and
    interests.
  • gt Separation anxiety.
  • gt Drive for autonomy.
  • Parents perception important factor.
  • Bedtime routine important.
  • Lifestyle co-sleeping with siblings/parents.

21
Sleep Patterns 6- 12 years
  • Growth development continues to be constant.
  • Sleep continues to develop into a more mature
    pattern.
  • Total sleep time 9-11 hours.
  • Sleep pattern becomes more stable, night to
    night consistency.
  • Low level of day time sleepiness naps rare.
  • School life styles influences-later bedtimes
    earlier. rise times, irregular sleep /wake
    schedules.

22
Sleep Pattern in Adolescent
  • Sleep duration decreases but need does not
    decline (average. 9.30 hrs).
  • Delay of sleep phase stay up late, wake later in
    am.
  • Circadian Relative phase delay
  • Environmental factor
  • Advanced wake times
  • Decreased sleep /wake regularity.
  • discrepancy between weekdays/ weekend sleep
    cycle.
  • Increased sleep tendency at mid puberty.
  • Due to autonomy, peer pressure, academic
    demands, employment, extracurricular activities.

23
Sleep Regulation in Childhood
  • Theoretical models describe 2 intrinsic
    regulatory processes determine timing of sleep
    and waking.
  • Homeostatic process-represents the drive for
    sleep that increases during wakefulness and
    decreases during sleep.
  • Circadian process- with distinct neuroanatomical
    locus.

24
Sleep Regulation in Childhood
25
Sleep Regulation in Childhood
  • Homeostatic process.
  • Dynamics of sleep homeostatic mechanisms appear
    to slow down during development.
  • Thus decreasing sensitivity to sleep loss and
    increase tolerance to sleep pressure.

26
Sleep Regulation in Childhood
  • Homeostatic process
  • Theta activity may be marker for HSP in
    children.
  • Age at which it become SW-activity unknown.
  • Adolescent sleep deprivation similar to that
    of young adults EEG changes.
  • Rise rate of HSP during the day slower in
    mature. adolescents compared to pre (early)
    pubertal children.
  • Nocturnal dissipation of sleep pressure does
    not differ.

27
Sleep Regulation in Childhood
  • Circadian Process
  • Sleep-wake independent clock-like process.
  • Distinct neuro -anatomical locus in bilateral
    supra -chiasmatic nuclei of anterior
    hypothalamus.
  • Appears to be functional in utero not
    working well at birth.
  • 1st month- 24h core body temp rhythm emerges.
  • 2nd month-more sleep at night.
  • 3rd month-melatonin and cortisol start to
    cycle in 24h rhythm.

28
Sleep Regulation in Childhood
  • Circadian process- Changes appear during puberty.
  • Three mechanisms
  • -Delay in intrinsic circadian phase.
  • - Mature children show later timing of
    melatonin secretion onset and offset phases.
  • -Delay may be related to lengthening of
    intrinsic period of circadian clock.
  • -Heightened sensitivity to pm light or
    decrease sensitivity to am light.

29
Sleep patterns of adults
  • Young adult usually sleep 7.5-8.5 hours/Night.
  • First NERM-REM cycle is 70-100 minutes.
  • Subsequent NERM-REM cycle is 90-120 minutes.
  • Sleep length partially determined by genetics,
    volitional determinants circadian rhythm.

30
Sleep Architecture of the normal young adult
  • Sleep is made up of the two physiological states
    NREM REM.
  • Sleep begins with NERM.
  • SWS predominates in the first third of night.
  • REM sleep predominates in the last third of
    night.
  • Break down of sleep stages
  • NERM ( 75- 80 )
  • WASO stage I 5
  • Stage N1- StageII-2-5
  • Stage N2-Stage III-45-55
  • Stage N3-Stage IV-13-23
  • REM-(20-25)

31
Sleep Patterns in Young Adults
32
Sleep Patterns In Adult
33
Sleep Stages PSG
34
Normal Sleep Patterns
  • Published in Sleep 2004.
  • Meta analysis of Quantitative Sleep parameters
    from Child hood to old age in Healthy
    individuals.
  • Meta analysis of 65 studies,,3577 subjects,
    ages5-102.
  • Published articles bet 1960-2003.
  • non clinical Participants.
  • Used all night PSG or Actigraphy to measure TST,
    Sleep Latency, Sleep Efficiency, Stage I, II,
    SWS, REM sleep, REM Latency, WASO.

35
Normal Sleep Patterns
36
Normal Sleep Patterns
37
Normal Sleep Patterns
38
Normal Sleep Patterns
39
Normal Sleep Patterns
40
Normal Sleep Patterns
  • Results
  • In children Adolescent, TST decreased with age
    (on school days).
  • of slow wave sleep was negatively correlated
    with age.
  • of stage 2 NREM REM sleep significantly
    change with age.
  • In Adults TST, Sleep Efficiency, of SWS, of
    REM Sleep REM Latency all significantly
    decreased with age While Sleep Latency, of
    Stage 1 sleep, of Stage 2 sleep and WASO
    significantly increased with age.
  • Only Sleep Efficiency continued to significantly
    decrease after 60 years of age.

41
Are there gender differences in Sleep?
  • Increase in subjective sleep complaints but
    relatively few differences in sleep architecture.
  • Despite the fact that sleep complaints are about
    twice as prevalent in women of all ages compared
    to men, 75 of the sleep research has been
    conducted with males.
  • HORMONAL EFFECT ON SLEEP
  • Estrogen Primary effect on REM.
  • Decrease SOL,WASO, Increase TST.
  • Progesterone primary effect on NERM-
    Benzodiazepine like effect.
  • Decrease SOL, WASO.

42
Sleep Patterns in Women
  • Sleep in women with normal Menstrual cycle.
  • subjective longer sleep latency, lower sleep
    efficiency sleep disruption was associated with
    luteal phase. Severity of premenstrual symptoms
    was co-related with day time sleepiness.
  • Objective PSGfinding-Stage 2 was higher in luteal
    phase also increase frequency of sleep
    spindles.
  • Dysmenorrhea associated with decrease sleep
    efficiency.

43
Sleep Patterns in pregnant Women
  • Pregnancy, child birth early motherhood
    physiologically psychologically affect a
    womans sleep.
  • Contributing factors hormonal alterations
    during early pregnancy , enlargement of fetus in
    late pregnancy postpartum infants feeding
    sleeping cycles.
  • Reports of altered sleep during pregnancy range
    from 13-80 in the first trimester ,66- 97
    in third trimester.

44
Sleep Pattern In Pregnant Women
  • First Trimester disrupted sleep but TST
    increases in first trimester back to prepreg
    level in 3rd trimester.
  • Sleep is not much affected in 2nd trimester.
  • Increase number of awakening, disrupted sleep
    Decrease TST in third trimester post partum.
  • Increase stage 2,WASO,Slight decrease in REM
    SWS
  • Decrease Sleep Efficiency.
  • Snoring increases, Increase incidence of OSA/RLS.

45
Sleep Patterns in Women
  • SLEEP MENOPAUSE
  • Prevalence of insomnia increases form 33-36 to
    44- 61 in pre post menopausal women.
  • Postmenopausal women have more subjective
    complaints of disturbed sleep but had better
    sleep documented on full night polysomnography
    longer total sleep time, increased amount of SWs,
    less time awake in bed.

46
Sleep Pattern in Women
  • SLEEP MENOPAUSE
  • Increase in SOL 20 reports sleepinglt 6 hours.
  • Difficulty in Sleep Maintenance.
  • Role of nocturnal Hot flashes more frequent
    arousal awakening, decrease SE, Increased SWS.
  • OSA increased prevalence severity Post
    menopausal
  • HRT may improve SE OSA symptoms.
  • Insomnia may become conditioned despite HRT role
    of various replacement protocols.

47
Sleep in Older Adults
  • Many elderly people C/O Disturbed sleep.
  • Need for sleep does not Change.
  • The ability to sleep does decrease with age.
  • Causes are multi-factorial.
  • Change in timing consolidation of sleep.
  • Medical psychiatric illnesses.
  • Medications.
  • Presence of specific sleep Disorder.
  • Physiologic Changes that occur in older adults.

48
Sleep in Older Adults
  • Change in Sleep with Age
  • Subjective Reports
  • Spending too much time in bed.
  • Spending less time asleep.
  • Increase number of Awakenings.
  • Increase in time to fall asleep.
  • Increase in tiredness during the day.
  • Less satisfaction with sleep.
  • Longer more frequent naps.

49
Sleep In Older Adults
50
Sleep In Elderly Population
  • OBJECTIVE FINDINGS
  • Decrease NREM Sleep.
  • Decrease REM Sleep.
  • Increase in awakening.
  • Increase Frequency of sleep D/o.
  • Decrease in Sleep Efficiency.
  • Increase in day time sleepiness.
  • Increase number of naps.

51
Sleep pattern in older Adults
  • Changes in sleep Architecture with age
  • Total sleep 7 hours.
  • Decrease of SWS ( 2 per decade of age).
  • Decrease REM sleep REM latency.
  • Decrease sleep spindle density K complex.
  • Sleep Efficiency continue to decrease till age
    90.
  • Increase stage shifts.
  • Fewer stage shifts.
  • Fewer cycles.

52
Sleep In Older Adults
53
Sleep in Older Adults
  • Causes of disturbed sleep in elderly
  • Insomnia
  • pain-arthritis, Cancer
  • neurological disorder- RLS, Parkinsons,
    dementia
  • organ system failure- lungs, CHF, GI, BPH
  • Depression, GAD.
  • Pts with disease more likely to be less satisfied
    w/sleep than healthy pts.
  • Medication use

54
Sleep in Older Adults
  • Common primary sleep disorders in adults
  • -OSA
  • -25 have apnea index of 5 or gt
  • -62 have AHI of 10 or gt
  • -Increased prevalence due to decreased resp
  • muscle strength, decreased expiratory flow
  • rates, diminished compliance of chest wall
  • -Changes in anatomy of airway
  • -RLS PLMs prevalence increase significantly
    with age

55
Sleep In Older Adults
  • Total amount of sleep does not change.
  • Timing of sleep changes.
  • Advancement of circadian rhythm and age related
    changes in output of circadian pacemaker
    contribute to sleep complaints.
  • ZEITGEBERS Inconsistency of external cues eg-low
    exposure to light, irregular mealtimes, decreased
    exercise.
  • Melatonin levels decrease with age contributing
    to poor sleep.

56
Sleep Pattern in Older Adults
  • Age related deterioration of the hypothalamic
    nuclei that drives CR also affects sleep
  • Older adults wake up earlier and fall asleep
    earlier in relation to nightly melatonin
    secretion
  • Aging assoc with adv of sleep and CR, decreased
    melatonin release, and change in internal phase
    relationship b/w sleep-wake cycle and output of
    circadian pacemaker
  • Increase in cortisol level
  • Diminished sleep related growth hormone release
  • Reduction in retinal sensitivity to light.

57
Sleep In Older Adults
  • Associations with disturbed sleep.
  • EDS can cause social and occupational
    difficulties, reduced vigilance, cognitive
    deficits- decreased concentration, slowed
    response time, memory difficulties.
  • Impaired Mood.
  • This can be interpreted as dementia or exacerbate
    mild or moderate cognitive impairment.

58
Subjective Objective Sleep Quality Aging in
Sleep Heart Health Study
  • Objectives To examine the extent to which
    Subjective objective sleep Quality are related
    to age independent of chronic health conditions.
  • Participants 5470 Adults, Mean age 63
    range-45-99 52 women
  • Measurement Home PSG Sleep Questionnaire
  • Results Older age was associated with shorter
    sleep time, diminished sleep efficiency, more
    arousal in Men women In men age was
    independently associated with more stage 1 ,2
    sleep less SWS REM sleep , In women older age
    was less strongly associated with sleep stage
  • Po0r subjective sleep Quality was not associated
    with men but older women

59
Sleep Heart Health Study
  • Sleep Heart Health Study in thousands of adults
    aged 40-98 who had sleep disordered breathing
  • -AHI gt 15 increased with age
  • - 10 at 45 yrs and 20 at 60 yrs
  • Prevalence of PLMS and RLS increases with age
    from 5-6 in younger adults to 45 in older
    adults
  • Increased incidence of RBD
  • - PET scan show a decrease in binding to
    presynaptic dopamine transporter

60
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62
SLEEP QUIZ
  • REM sleep is first evident at what stage of
    development?
  • In utero
  • Immediately post-partum
  • At 1month of age
  • At 3 months of age
  • At 1year of age
  • Total REM sleep decrease from 50 at birth to
    the normal adult range 20 by what age?
  • Infancy
  • Preschool
  • School
  • Adolescence
  • Adult

63
  • Sinusoidal waves at9-11 HZ are recorded in the
    EEG during which of following circumstances?
  • Wakefulness with eyes closed.
  • Wakefulness with eyes open.
  • Light sleep.
  • Deep sleep.
  • Which of the following muscle group is flaccid
    or atonic during REM sleep?
  • Anti- gravitional muscles in upper lower
    extremities
  • Extensor muscles in back arm
  • Abdominal inter-costal muscles
  • Proximal girdle muscles.

64
  • The most common cause of excessive day time
    sleepiness in adolescent is
  • Depression
  • Substance use or abuse
  • OSA
  • Inadequate amount of sleep
  • Delayed sleep phase d/o
  • Which of the following statement characterizes
    changes in sleep associated with aging
  • The average total time spent a sleep in 24 hour
    decreased
  • Total time in REM sleep decreases
  • REM latency increases
  • Delta wave amplitude decrease less time is
    spent in stage 3 4

65
  • Which of the following sleep stage is the most
    important in restoring the altered functions that
    result from prolong sleep deprivation
  • REM Sleep
  • Stage 1 NREM
  • Stage 2 NREM
  • Stage 3 and 4 NREM

66
Bibliography
  • Principles and Practice of Sleep Medicine Kyger,
    Roth Dement
  • Basics of Sleep Guide SRS Charles J. Amlaner, D.
    Phil, and Patrick M. Fuller Ph. D.
  • Sleep Medicine Essentials Teofilo L. Lee-Chiong
  • Subjective and Objective Sleep Quality and Aging
    in the Sleep Heart Health Study Mark L. Unruh
    M.D., Susan Redline, M.D., Ming-Wen An, Ph. D.
  • Meta-Analysis of Quantative Sleep Parameters
    From Childhood to Old Age in Healthy
    Individuals Developing Normative Sleep Values
    Across the Human Life Span Mary A. Carskadon Ph.
    D., Michael V. Vitiello Ph. D.

67
The END!!!!!!!!?
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