Sleep Medicine Fellowship
The Fellowship in Sleep Medicine at LSU Health Shreveport is a one-year program that is designed to provide a high-quality experience in all aspects of sleep medicine. The program has a heavy emphasis on patient centered teaching in the clinic, sleep lab and hospital, plus structured reading and conferences.
Fellows gain experience with multiple complex sleep diagnoses, and oversee the diagnosis and management of outpatients and inpatients of all ages. Adults and children are seen in our multidisciplinary sleep center. Our two training sites are the Sleep Disorders Center at Ochsner LSU Health Shreveport and the Sleep Lab at the Overton Brooks VA Medical Center.
Although housed in neurology, the sleep center faculty who attend our teaching sleep clinics are multidisciplinary and include neurology, psychiatry, internal medicine, family medicine and pulmonary care.
Unhealthy sleep is linked to many medical problems including heart disease, depression, and lower life expectancy. More than 20% of the American public suffers from chronic sleep disorders. The mission of the Sleep Disorders Center is to improve sleep health. This goal will be accomplished by:
- Using a multidisciplinary and patient-centered approach to diagnose and treat the full spectrum of sleep disorders
- Providing sleep-disorders training and education of the highest quality to sleep fellows and medical staff
- Conducting innovative basic-science and clinical research that is directly relevant to the advancement of patient care and the discipline of sleep medicine
- Offering public education in sleep medicine and research
- Circadian Rhythm Disorders
- Restless Legs Syndrome
- Pediatric Disorders
- Snoring & Sleep Apnea
- Sleep Disorders
- Nighttime Sleep Behaviors
Insomnia is a common sleep disorder that affects about 10% of the adult population. The nighttime symptoms include persistent difficulty falling and/or staying asleep. Daytime symptoms include fatigue, and difficulties with concentration and/or memory. Insomnia may be diagnosed when symptoms persist for at least a month.
Insomnia sometimes occurs alone, with no other co-existing disease. But more often insomnia occurs in conjunction with other medical or psychiatric conditions, and may worsen them or hinder their treatment. For example, people with depression and insomnia do not respond as well to depression treatment as depressed people without insomnia.
Risks for Insomnia
The known risk factors include:
- Absence of a regular wake time
- Excessive worry
- Failure to unwind from the day’s stresses
- Other sleep disorders, including restless legs syndrome and sleep apnea
- Genetic predisposition
- Gender: Women are twice as likely as men to experience insomnia
- Age: Older adults are more likely to experience insomnia
An insomnia disorder is diagnosed when the disturbed sleep lasts more than a month and negatively impacts general well being, either because the difficulty in sleeping is particularly distressing or because it leads to an impairment in performance or mood. Part of the diagnosis involves a determination of whether the symptoms are better explained by other medical or psychiatric conditions.
Circadian Rhythm Disorders
The internal activity of the human body follows a cyclic pattern called a circadian rhythm. Chemical and electrical signals are generated during the cycle that tend to produce sleep at night and wakefulness during the day. The rhythm works best when a reasonable amount of exposure to sunlight is obtained and regular routines for going to bed in the evening and awakening in the morning are maintained. Disorders involving the rhythm occur when it becomes misaligned with a person’s chosen time for sleeping and waking. Various types of disorders are recognized, the most common of which are delayed sleep-phase, advanced sleep-phase, and a disruption of the rhythm that results from shift work.
Delayed sleep-phase occurs when the timing of the internal signal for sleep is delayed several hours relative to a person’s desired bedtime. People with this disorder have difficulty falling asleep because their internal clocks do not send the signal for sleep until late into the night. They also have difficulty waking up at what is generally considered a normal time because their natural awakening is delayed. Someone with delayed sleep-phase may sleep well but wakes up late, making it difficult to begin a typical daily routine of activity in a timely fashion. People are not considered to have delayed sleep-phase disorder unless they also experience impairment in social, occupational, or other areas of life as a consequence of the sleep problem.
Advanced sleep-phase disorder is produced when the sleep signal occurs several hours or more earlier than the desired bedtime. People with this disorder go to bed and awaken unusually early because their sleep and awakening signals are mis-timed relative to their desired schedules. The disorder makes it difficult to engage in social activities because of the need to go to sleep much earlier than what is generally considered normal. Advanced sleep-phase is particularly prevalent among older adults.
Shift-work sleep disorder is a problem that stems from the mismatch between a person’s circadian rhythm and the time interval for sleep that fits a particular work schedule. Symptoms produced by the mismatch may include difficulty in initiating and maintaining sleep, excessive sleepiness when awake, difficulty concentrating, headaches, and/or a general feeling of malaise. Rotating shifts are particularly a problem because they may lead to trouble staying alert while working, and to unrefreshing sleep.
Restless Legs Syndrome
Restless legs is a common syndrome in which a person has an urge to move the legs and, typically, experiences abnormal sensations including burning, tingling, or aching. The arms or other body areas may also be affected. The symptoms can range from mild to severe, and may occur occasionally or almost every evening. The disorder is about twice as common in women, and its prevalence increases with age.
The symptoms of restless legs syndrome (RLS) start or worsen during rest, especially in the evening and/or when lying down. The longer someone rests, the greater the chances the symptoms will occur and will be more severe. The symptoms improve as a result of movement. At least partial relief typically starts soon after beginning activities such as walking, and persists as long as the activity continues.
Most people with RLS also demonstrate periodic limb movements during sleep, which are abrupt leg movements that occur 20 to 30 seconds apart at various times during the night. The movements, which can also occur in other parts of the body, cause partial awakenings that disrupt sleep, resulting in poor sleep quality.
Low brain iron metabolism and abnormal levels of dopamine in the brain are probably important factors in causing RLS. The disorder commonly runs in families, especially when it is severe and starts early in life. Environmental factors and other medical problems are also associated with the disorder. RLS frequently begins or becomes worse during pregnancy, and is more frequent in people with damaged nerve endings, such as in those with diabetes. RLS may be associated with other conditions such as depression and heart disease.
The disorder may be difficult to diagnose in children because the symptoms overlap those of other pediatric disorders.
Sleep disorders can occur in infants, young children, and adolescents, resulting in developmental, behavioral, and social difficulties, and in other health problems. Children may suffer from problems falling or staying asleep, obstructive sleep apnea, restless legs syndrome, abnormal behaviors during sleep such as sleepwalking or other parasomnias, or from daytime sleepiness. Additionally, many medical or psychiatric conditions can contribute to sleep disorders. The symptoms shown by children may be quite different compared to those of adults with sleep disorders, because developmental aspects of childhood play an important role in pediatric sleep.
An arousal occurs when a child transitions from deep sleep to light sleep or partial wakefulness. During the arousal the child may appear to be alert, as evidenced by crying or walking, while simultaneously appearing to be disoriented and confused, as evidenced by unresponsiveness to parental directions or environmental challenges. A child who is awakened during an arousal typically does not recall the events that occurred during the episode.
Many kinds of behaviors may be exhibited ranging from mumbling or sitting up in bed during sleep to more elaborate behaviors including loud, distressful crying, ignoring parental directions and reassurances, and a dreamlike expression. The child may act aggressively and regard the parent as a threat. Sleepwalking and running into furniture can occur, which may appear either goal-oriented or without purpose.
Commonly only one episode occurs during the night, often within the first two hours of falling asleep, but multiple episodes are possible. There may be periods when multiple episodes occur each night followed by periods without a single episode. Overall, the timing frequency, intensity, and behavior exhibited are all quite variable.
In older teenagers, alcohol intake and sleep deprivation are possible triggers for arousals. Sometimes the aberrant behaviors are triggered by sleep-disordered-breathing, abnormal sleep-wake schedules, and/or stressful conditions.
Medical and Psychiatric Conditions
Sleep disturbances can occur as a consequence of many different conditions including:
- Attention deficit hyperactivity disorder
- Gastroesophageal reflux disease
- Developmental disorders
- Mental retardation
- Prader-Willi syndrome
- Tourette disorder
- Nocturnal asthma
- Depressive disorders
- Neuromuscular disorders
- Nocturnal seizures
- Kleine-Levin syndrome
- Chronic fatigue syndrome
Diagnosing Pediatric Sleep Disorders
If you suspect your child has a sleep disorder, you should schedule an appointment for an evaluation.
Hypersomnias are disorders that involve excessive sleep and difficulty in staying awake during the day. The core symptom is excessive daytime sleepiness that is not due to other identifiable causes. Persistent sleepiness lasting more than three months without abnormalities specifically related to REM sleep is called idiopathic hypersomnia. A pattern of periodic isolated episodes of sleepiness is called recurrent hypersomnia.
Persons with idiopathic hypersomnia sleep far more than normal, have difficulty waking up, and feel tired, sleepy, or groggy during the day, and experience these symptoms more or less continuously for three months or more with a resulting significant impact on daily life. A diagnosis of idiopathic hypersomnia requires exclusion of other causes of daytime sleepiness such as insufficient sleep, disturbed nocturnal sleep, insomnia, circadian rhythm disorder, sleep-related breathing disorders, or medical issues.
Idiopathic hypersomnia can have many causes including brain abnormalities, low-grade infections, or a brain imbalance associated with psychiatric conditions. The disorder may arise from an abnormal sleep schedule, or sedative or stimulant medications taken in excess or at the wrong time.
Recurrent hypersomnia is characterized by recurrent, reversible episodes of hypersomnia, often associated with other symptoms, that typically occur weeks or months apart. During the episodes the sufferers experience extreme sleepiness and have big sleep requirements, sometimes as much as 16 to 20 hours a day.
Snoring and sleep apnea are sleep-related breathing disorders that involve abnormal breathing during sleep.
When the airway becomes partially blocked, some of the inhaled air becomes redirected from the lungs to the mouth, producing a pressure that vibrates the soft tissue of the palate, resulting in snoring.
Snoring is associated with disrupted sleep, daytime fatigue and sleepiness, and low oxygen levels in the body. Snoring can also seriously disturb the bed partner’s sleep, resulting in difficulties in interpersonal relationships.
Obstructive Sleep Apnea
The soft tissues in the throat relax during sleep. Obstructive sleep apnea (OSA) occurs when the airway repeatedly collapses during the night, either completely or partially, thereby disrupting breathing. When the airway is blocked, the oxygen levels in the body drop, causing the person to awaken and begin breathing normally. The affected person often is unaware of the awakenings because they may last only a few seconds. Someone with severe sleep apnea may awaken hundreds of times during the night. The awakenings fragment and interrupt the sleep cycle, which causes the common symptoms of sleep apnea, daytime fatigue and sleepiness. OSA is a treatable disease, but if untreated it is associated with serious medical conditions.
Symptoms of OSA in adults include:
- Choking or gasping during sleep
- Observed pauses in breathing
- Daytime fatigue and/or sleepiness
- Dry and/or sore throat in the morning
- Morning headaches
- Night sweats
- Poor concentration and attention
- Memory problems
- Sleepwalking or night terrors
Symptoms of sleep apnea in children include:
- Daytime cognitive and behavioral problems including problems paying attention, easy distractibility, aggressive behavior, and hyperactivity
- Mouth breathing
- Enlarged tonsil and adenoids
- Problems sleeping and restless sleep
- Parasomnias such as sleepwalking or night terrors
- Failure to thrive
- Excessive daytime sleepiness
- Upper airway resistance syndrome is a condition in which the throat becomes blocked, resulting in periodic episodes of reduced air flow. Although the resulting disturbance of sleep is not as great as that associated with OSA, upper airway resistance syndrome can cause similar symptoms.
Other Sleep-Related Breathing Disorders
Other sleep-related breathing disorders include central sleep apnea (CSA) and sleep-related hypoventilation syndromes (SHS). CSA occurs when the brain fails to signal the body to breathe. Unlike obstructive sleep apnea, in CSA there is no breathing effort because there is no drive to breathe. SHS are the result of a decreased response to low oxygen or high carbon dioxide during wakefulness and sleep. The syndromes are characterized by frequent episodes of shallow breathing during sleep that last longer than 10 seconds.
A comprehensive history and physical examination by a sleep physician and an overnight sleep study is needed to diagnose sleep-related breathing disorders in children or adults.
Narcolepsy is a chronic neurological sleep disorder characterized by excessive daytime sleepiness, and abnormal REM sleep. A person with narcolepsy will experience a high level of fatigue and may fall asleep at odd and inappropriate times, such as during work or school. A brief nap may be refreshing, but the sleepiness can reoccur after a few hours.
Most patients with narcolepsy also experience cataplexy, which is a sudden feeling of paralysis or weakness in the head, legs or other body parts especially after excitement or laughing.
In most cases of narcolepsy without cataplexy, the cause of the symptoms is unclear and the diagnosis is based on the results of a sleep study.
Sleep is critically important for health and happiness, yet sleep is often neglected and its importance underappreciated in our busy society. About one of every four Americans has a sleep problem. If you are sleeping too much, experiencing excessive daytime sleepiness (falling asleep at inappropriate times), having difficulty falling or staying asleep, or experiencing abnormal behaviors associated with sleep, you may have a sleep disorder.
- Sleepwalking and/or Sleeptalking
- Sleep Terrors
- Confusion Arousals
- REM Behavior Disorder
- Sleep Paralysis
Sleepwalking and/or sleeptalking are conditions in which a sleeping person appears to be awake and exhibits behaviors associated with being awake, but is actually sleeping. During sleeptalking the person’s vocalizations may be anything from a few words to long conversations. Sleepwalking involves activities ranging from sitting up in bed or walking to the bathroom, to extreme behaviors such as getting in a car and driving. Persons who talk or walk in their sleep are rarely aggressive, but may become confused and combative when attempts are made to arouse them. The episodes usually occur in the first half of the night during the deepest stage of sleep, and the sleeper often has little or no memory of the events.
Sleepwalking can occur at any age, but is most common in children and usually diminishes as children grow older. Conditions such as fatigue, stress or anxiety, lack of sleep, illness, physiological stimuli such as a full bladder, or alcohol are often associated with sleepwalking episodes.
In persons who show regular, persistent, or alarming behavior, tests are needed to help evaluate the possible role of specific triggers, such as sleep-disordered breathing or nocturnal seizure disorder.
Sleep terrors are episodes characterized by extreme fright and a temporary inability to attain full consciousness. Affected persons may abruptly exhibit fear, panic, confusion, or a desire to escape, and remain unresponsive to soothing from others. Vocalizations including gasping, moaning or screaming may occur even though the person is not fully awake. Typically a person undergoing a sleep terror returns to normal sleep after the episode ends, without ever fully waking up, and with no recollection of the episode in the morning.
Terror episodes occur during deep sleep, usually during the first part of the night. The timing of the events helps differentiate the episodes from nightmares, which occur later in the sleep period. Sleep terrors can occur at any age, but are more common in children. Emotional stress during the day, fatigue or an irregular routine may trigger episodes, and a predisposition to sleep terrors may be hereditary.
A confusional arousal is an event in which a sleeping person appears to be awake but exhibits unusual or strange behavior. The person may be disoriented, unresponsive, and exhibit slow speech or confused thinking. Confusional arousals typically occur in the first two hours after falling asleep. The episodes may last only a few minutes, or they may last much longer. The next morning there is usually little or no recall of the events that occurred during the arousal.
Confusional arousals can occur at any age, but are more common in children. Sleep disruptions caused by fever or other health problems, travel, abrupt sleep loss, migraine, and irregular sleep-wake schedules may trigger an episode. Other disorders including sleep-disordered breathing and restless legs syndrome, or nocturnal asthma can occur in association with the confusional arousals.
Dreaming occurs during rapid eye movement (REM) sleep. Normally, in REM sleep, the tone in many of the body’s muscles becomes reduced. REM behavior disorder is a condition in which the brain fails to send the signals necessary to cause reduced muscle tone, thereby allowing sleeping persons to move and act out their dreams. The movements can be minor such as leg twitches, or complex behaviors that are manifestations of action-filled or violent dreams. A person may awaken and become quickly alert at the end of an episode and be able to provide a coherent description of the dream.
The prevalence of the disorder increases with age and may be associated with certain neurological disorders. Adverse reactions to certain drugs or drug withdrawal can sometimes appear as REM behavior disorder. Evaluation of REM behavior disorder requires appropriate tests including a sleep study to evaluate for other sleep disorders and the occurrence of abnormal muscle tone during REM sleep.
Loss of muscle tone is a normal part of REM sleep but is an abnormal condition, termed sleep paralysis, when it occurs outside of REM sleep. Sleep paralysis can occur in otherwise healthy people or as a presenting symptom in narcolepsy or other sleep disorders. Sleep paralysis commonly occurs when a person is either falling asleep or awakening. If an individual has awareness as the body enters or exits REM sleep, they may experience sleep paralysis, which can last from several seconds to several minutes. Episodes of longer duration are typically disconcerting and may even provoke a panic response. The paralysis may be accompanied by vivid hallucinations, which is often attributed to being part of dreams.
Sleep paralysis can occur in otherwise normal sleepers, and is relatively common in its occurrence and universality. It has also been linked to various conditions such as increased stress, excessive alcohol consumption, sleep deprivation, and narcolepsy.
Treatment of sleep paralysis is often limited to education about sleep phases and atonia that normally occur during sleep. If episodes persist, the person will be evaluated for narcolepsy, which is commonly present in those suffering from sleep paralysis.
ightmares are vivid dreams that contain frightening images or cause negative feelings such as fear, terror, and/or extreme anxiety. When awakened during a nightmare, the sleeper can usually provide a detailed description of the dream content. A nightmare can cause the sufferer to awaken in a heightened state of distress, resulting in perspiration and an elevated heart rate. Often it takes time to recover from the negative emotions provoked by the nightmare, leading to difficulty in returning to sleep.
Nightmares are distinguished from sleep terrors based on the timing of the episodes and on whether dream content can be recalled. Nightmares are more likely to occur during the last third of the night when there is a higher concentration of REM sleep.
Nightmares can have both psychological and physical causes. Factors including illness, anxiety, or even sleeping in an uncomfortable position can lead to bad dreams. Post-traumatic stress disorder can trigger frequent nightmares, as can side effects from various medications and narcotics including amphetamines and cocaine.