Movement Disorders of Sleep and Sleep-disordered Breathing

Movement Disorders of Sleep and Sleep-disordered Breathing

Alon Y Avidan,, Lori Panossian
Published: US Neurological Disease 2007 - Issue II
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While sleep disorders are extremely common in the general population, their study represents a relatively new focus of medicine. This article is a brief review of two commonly encountered sleep disturbances in neurology practice: sleep-disordered breathing (SDB) and movement disorders of sleep.

Sleep-disordered Breathing
SDB can be grouped into two major subtypes: obstructive sleep apnea (OSA) and central sleep apnea.

Obstructive Sleep Apnea

Epidemiology
OSA is a highly prevalent disorder affecting both children and adults. It has been estimated that among the working population between 30 and 60 years of age, 2% of women and 4% of men meet the minimal diagnostic criteria for OSA.1 However, this number may be an underestimate as a subsequent investigation using polysomnography (PSG) showed that up to 93% of middle-aged women and 82% of men with moderate to severe OSA have not been clinically diagnosed by their physicians.2 OSA is approximately two to four times more prevalent in men than in women,3–5 and becomes more common with advancing age, occurring in 21–26% of men over 65 years of age.6 Independent risk factors for OSA include age, male sex, increased body mass index (BMI), hyperlipidemia, and alcohol ingestion.5,7 The influence of race and ethnicity is inconclusive. While some studies show no effect,5,8 others have suggested increased risk in African-American, American-Indian, and Asian populations, primarily based on weight and craniofacial dimensions.9–12 OSA may also be influenced by hormonal factors in women, with increased risk after menopause.4 The estimated prevalence of sleep-disordered breathing in children eight to 11 years of age is 2.2%, with increased risk among pre-term children9 and increased risk in boys compared with girls.8

Diagnostic Criteria
Patients with OSA typically experience sleep symptoms of snoring, nocturnal dyspnea, witnessed apneas, and nocturnal restlessness. These patients may also have difficulties with nocturia, diaphoresis, acid reflux, and drooling. During the day, many complain of excessive sleepiness, headaches, poor concentration, decreased energy, and depression.13,14 The diagnosis of OSA is based on a combination of clinical and laboratory data. Important components of the medical history include sleepiness severity as quantified by the Epworth Sleepiness Scale (an eight-point questionnaire designed to measure daytime sleepiness). Comorbidities such as hypertension and cardiovascular disease should also be evaluated. The physical examination includes measurement of BMI and neck circumference. The Mallampati classification can be helpful in predicting the severity of OSA by evaluating the anatomy of the oral cavity (see Figure 1).14


Figure 1: Mallampati Classification

Mallampati Classification



The class is determined by looking at the oral cavity as the patient protrudes the tongue, and tongue size is described relative to oropharyngeal size. The test is conducted with the patient in the tongue wide open and relaxed and protruding to the maximum. The subsequent classification is based on the pharyngeal structures that are visible.
Scoring is as follows:
Class 1: Full visibility of tonsils, uvula, and soft palate.
Class 2: Visibility of hard and soft palate, upper portion of tonsils, and uvula.
Class 3: Soft and hard palate and base of the uvula are visible.
Class 4: Only hard palate visible.
Modified after Mallampati SR, Gatt SP, Gugino LD, et al., A clinical sign to predict difficult tracheal intubation: a prospective study, Can Anaesth Soc J, 1985;32:429–34.
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