Sleep Medicine in Clinical Practice S ilb e Second Edition r Sleep Medicine in • K r a h About the book About the authors n • Since the publication of the first edition of Sleep Medicine MIchAEl h. SIlbEr, M.b.ch.b., F.c.P. (S.A.), Professor of M Clinical Practice in Clinical Practice, sleep medicine has progressed into Neurology, college of Medicine, Mayo clinic. Dr. Silber is o a fully realized medical specialty. This new edition co-Director of the center for Sleep Medicine, Mayo clinic, r g provides a comprehensive overview of this emerging field, rochester, Minnesota. he is Associate Dean for Academic e while addressing numerous developments in the science and Faculty Affairs in the Mayo School of health Sciences. n of sleep. Written from the perspectives of a neurologist, He is a Past President of the American Academy of Sleep th a psychiatrist and a pulmonologist, this text offers a Medicine. a multi-disciplinary approach to the clinical management le Second Edition loIS E. KrAhN, M.D., Professor of Psychiatry, college of r of sleep disorders. Medicine, Mayo clinic. Dr. Krahn is chair, Department S Extensively updated since the previous edition, this of Psychiatry, Mayo Clinic, Scottsdale, Arizona. She is an l book offers: Associate Dean in the Mayo Medical School. She is a past e • A uniquely structured text based on sleep symptoms Administrative Director of the center for Sleep Medicine, e Mayo clinic, rochester, Minnesota. • Illustrative case histories p • Important background information on the basics of TIMoThy I. MorgENThAlEr, M.D., Associate Professor sleep medicine of Medicine, College of Medicine, Mayo Clinic. M Dr. Morgenthaler is a consultant in the center for Sleep • A review of sleep disorders, such as narcolepsy, sleep e Medicine and Division of Pulmonary and critical care apnea, insomnia, circadian rhythm disorders, restless Medicine, Mayo clinic, rochester, Minnesota. he is d leg syndrome, and parasomnias Associate chair for Quality of the Department of Medicine, i c • A review of sleep in patients with Parkinsonism, Mayo clinic, rochester, Minnesota. he is a Director of the dementia, epilepsy, respiratory diseases, and psychiatric American Academy of Sleep Medicine. in disorders e • Diagnostic tools, therapeutic options and management algorithms in • Evidence-based treatment recommendations C incorporating AASM practice parameters. l This Second Edition is an essential reference for all i n practicing sleep clinicians. i c a l P r a c t i c e S e c o n d E d it io n Michael H. Silber Lois E. Krahn Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK 52 Vanderbilt Avenue, New York, NY 10017, USA Timothy I. Morgenthaler www.informahealthcare.com [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] Sleep Medicine in Clinical Practice [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] This page intentionally left blank [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] Sleep Medicine in Clinical Practice Second Edition Michael H. Silber, MBChB, FCP (SA) Professor of Neurology, College of Medicine, Mayo Clinic Rochester, Minnesota, U.S.A. Lois E. Krahn, MD Professor of Psychiatry, College of Medicine, Mayo Clinic Scottsdale, Arizona, U.S.A. Timothy I. Morgenthaler, MD Associate Professor of Medicine, College of Medicine, Mayo Clinic Rochester, Minnesota, U.S.A. [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] First publishedin2004byTaylor&Francis,animprintoftheTaylor&FrancisGroup,11NewFetterLane,London EC4P4EE,U.K. Thiseditionpublishedin2010byInformaHealthcare,TelephoneHouse,69-77PaulStreet,LondonEC2A4LQ,UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue,7th Floor, New York,NY 10017, USA. InformaHealthcareisatradingdivisionofInformaUKLtd.RegisteredOffice:37–41MortimerStreet,LondonW1T3JH, UK.RegisteredinEnglandandWalesnumber1072954. #2010MayoFoundationforMedicalEducationandResearch. 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Ultimatelyitisthesoleresponsibilityofthemedicalprofessionaltomakehisorherownprofessionaljudgements,soas appropriatelytoadviseandtreatpatients.Savefordeathorpersonalinjurycausedbythepublisher’snegligenceandtothe fullestextentotherwisepermittedbylaw,neitherthepublishernoranypersonengagedoremployedbythepublishershall beresponsibleorliableforanyloss,injuryordamagecausedtoanypersonorpropertyarisinginanywayfromtheuseof thisbook. ACIPrecordforthisbookisavailablefromtheBritishLibrary. LibraryofCongressCataloging-in-PublicationDataavailableonapplication ISBN-13:9781616310042 Ordersmaybesentto:InformaHealthcare,SheepenPlace,Colchester,EssexCO33LP,UK Telephone:+44(0)2070175540 Email:[email protected] Website:http://informahealthcarebooks.com/ Forcorporatesalespleasecontact:[email protected] Forforeignrightspleasecontact:[email protected] Forreprintpermissionspleasecontact:[email protected] TypesetbyMPSLimited,aMacmillanCompany PrintedandboundintheUnitedKingdom [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] Dr Silber dedicates this edition to his mother, Dr Leila Arens, and his late father, Prof Wolf (Bill) Silber, physician investigators, who taught him by example how to combine clinical research with compassionate patient care. Dr Krahn dedicates this edition to her parents, Dr Henry and Mrs Frances Krahn, who have dedicated their lives to their family as well as to innumerable patients in New York, Manitoba, and Minnesota. Dr Morgenthaler dedicates this edition to his parents, Dr George and Mrs Luella Morgenthaler, who inspired their sons to look beyond the horizons. [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] This page intentionally left blank [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] Disclaimer Nothing in this publication implies that Mayo Foundation endorses any of the products mentioned in this book. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisherarenotresponsibleforerrorsoromissionsorforanyconsequencesfromapplication oftheinformationinthisbookandmakenowarranty,expressorimplied,withrespecttothe contents of the publication. The authors, editors, and publisher have exerted every effort to ensure that drug selectionanddosagesetforthinthistextareinaccordancewithcurrentrecommendationsand practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drugreactions,thereaderisurgedtocheckthepackageinsertforeachdrugforanychangein indicationsanddosageandforaddedwarningsandprecautions.Thisisparticularlyimportant when the recommended agent is a new or infrequently employed drug. Some of the indications suggested for drugs described in this book may not have been approvedbytheU.S.FoodandDrugAdministration(FDA).Itistheresponsibilityofreaders toascertainwhichindicationsare“offlabel”andtodecidewhetherthemedicationsshouldbe prescribed for these purposes. Some drugs and medical devices presented in this publication mayhaveFDAclearanceforlimiteduseinrestrictedresearchsettings.Itistheresponsibilityof health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] This page intentionally left blank [Shaji][7x10 Tight][D:/informa_Publishing/SILBER_2400043/z_production/z_3B2_3D_files/978- 1-6163-1004-2_CH0000_O.3d][11/8/010/18:45:29][1–14] Preface to the second edition Andiftonightmysoulmayfindherpeace insleep,andsinkingoodoblivion, andinthemorningwakelikeanew-openedflower thenIhavebeendippedagaininGod,andnew-created. D.H.Lawrence:Shadows Sincethepublicationofthefirsteditionofthisbook,muchhaschangedinsleepmedicine.Our knowledge of sleep science, especially neurobiology, has dramatically increased. New therapies for sleep disorders have been developed and old ones modified. Understanding of theadversephysiologiceffectsofsleepdeprivationandsleepfragmentationhasgrown.Over 12,000scientificpaperswith“sleep”intheirtitleshavebeenindexedinthePubMeddatabase in the past five years! The influential Institute of Medicine of the National Academies has completed two major reports on sleep and society: Sleep Disorders and Sleep Deprivation: An UnmetPublicHealthProblem(1)andResidentDutyHours:EnhancingSleep,Supervision,andSafety (2). The American Academy of Sleep Medicine (AASSM) has completed and published two seminalworks,thesecondeditionoftheInternationalClassificationofSleepDisorders(3)andthe AASM Manual for the Scoring of Sleep and Associated Events (4). The U.S. Accreditation Council for GraduateMedicalEducation (ACGME)beganaccreditingsleepmedicinefellowshipsand 71programshadbeenaccreditedbyOctober2009.TheAmericanBoardofMedicalSpecialties approved a multidisciplinary specialist examination in sleep medicine set jointly by representativesofsixprimaryspecialties.In2007,1882candidatessatforthefirstexamination (5).Thus,sleepmedicinehasnotonlydevelopedscientificallyinthepasthalfdecade,buthas achieved recognition as a growing medical specialty whose practitioners can greatly enhance the quality of their patients’ health. As a result of these changes, we have extensively modified the second edition of this book.Newdevelopmentsinthescienceofsleepareincorporated.Inparticular,thechapteron the physiologyof sleephasbeenessentiallyrewrittenwith specialreferenceto the roleofthe preoptic nuclei and the hypocretin system. We emphasize advances in understanding the metabolic,cardiovascular,andbehavioralconsequencesofsleepdeprivation.Wediscussnew concepts in the pathogenesis of sleep disorders, such as the current understanding of autoimmunityinnarcolepsy,theroleneurodegenerativediseasesplayinREMsleepbehavior disorder,andthegeneticbasisofrestlesslegssyndrome.Thechaptersonthediagnosisofsleep disorders incorporate the technical recommendations and scoring rules set out in the AASM manual.Wediscusscurrentdataoninterpretingthemultiplesleeplatencyandmaintenanceof wakefulness tests. The classification of sleep disorders follows the nosology described in the secondeditionoftheInternationalClassificationofSleepDisorders.Diagnosticcontroversies,such as the classification of idiopathic hypersomnia and the concept of complex sleep apnea, are explored. New diagnostic techniques and therapeutic advances are discussed, such as home sleeptestingandtheroleofadaptiveservoventilationinthemanagementofsleepapnea.We have updated drug therapy for conditions such as narcolepsy, insomnia, parasomnias, and sleep-relatedmovementdisorders,withpracticalalgorithmsforpatientmanagement.Wehave paid attention to novel adverse reactions, such as impulse control disorders as a result of dopaminergic therapy, cardiac arrhythmias with use of stimulants and atypical neuroleptic agents, and parasomnias associated with short-acting hypnotics. Wherever possible, recommendations are evidence based and incorporate AASM standards of practice parameters. The bibliography has been thoroughly updated and includes references to new studiespublishedin2009.Tablesandfigureshavebeenmodifiedorredrawn.Webelievethe