Sleep Neurology

Charbi Gupta, MBBS, GMC Patiala  & Khanij Arya, 3rd MBBS, GMC Patiala

What is sleep neurology?

Sleep neurology is the study of the effects of sleep on our brain & nervous system. Sleep quality and quantity both are important for the healthy functioning of our body and nervous system.

What happens when we sleep? When we sleep, our body cycles in and out of two main stages i.e., REM & Non-REM sleep. Non-REM sleep is where we start the night and spend most of our rest time. It begins in the mild “N1” stage and progresses to the deep “N3” stage. The REM (rapid eye movement) stage of sleep, which is named for the way our eyes dart back and forth under our lids, comes after the N3 stage. In this period, we dream the most. We normally cycle through all the stages of sleep 3-5 times a night. The N3 stage tends to get shorter with each subsequent cycle, whereas the REM stage continues to get longer.


Alterations that occur as we sleep:

1. Body temperature: It begins to fall immediately before we go to sleep and reaches its lowest point two hours or so before we wake up. (A colder room aids in better sleep.) (2)

2. Breathing: As we enter deep sleep, our breathing rate slows and becomes more regular, but as soon as we reach the REM stage, it speeds up.

3. Heart Rate: The HR and BP drop during non-REM sleep, providing the cardiovascular system enough time to relax and heal. However, during the REM period, the HR fluctuates slightly.

4. Brain activity: During the Non-REM stage, the neurons fire in a steady & more rhythmic pattern; during REM sleep, the firing becomes more active & random, like when we’re awake.

5. Repair: During sleep, certain chemicals that are known to strengthen the immune system start circulating in the blood.

6. Taking out the junk: REM stage of sleep helps our brain in clearing out the unrequired information.

7. Hormone symphony: During sleep, there is an increased production of certain hormones (e.g.: Growth Hormone) while the levels of others (e.g.: cortisol) go down.(3)

Many scientists claim that REM Sleep is of utmost importance but, the author of ‘The Nocturnal Brain’ and ‘The Secret World of Sleep’, Guy Leschziner claims that a healthy body depends on the balance between non-REM and REM sleep. (4.)

How much sleep do You need?

The recommended sleep allowances as per the American Academy of Sleep Medicine are:

1.       New-born (0-3 months): 14-17 hours/day (5.)

2.       Infant (4-12 months): 12-16 hours/day (5.)

3.       Toddler (1-2yrs.): 11-14 hours/day (5.)

4.       Pre-school (3-5yrs.): 10-13 hours/day (5.)

5.       School age (6-12yrs.): 9-12 hours/day (5.)

6.       Teen (13-18yrs.): 8-10 hours/day (5.)

7.     Adult (18-60yrs.): ≥7 hours/day

            (61-64 yrs.): 7-9 hours/day

            (≥65 years.): 7-8 hours/day (6)

What are sleep disorders?

Sleep disorders can be defined as the inability and impairment of the sleep schedule causing daytime sleepiness and rendering people unable to perform daily activities attentively. (9)


In 2005, the American Academy of Sleep Medicine (AASM) published a revised form of the International Classification of Sleep Disorders (ICSD-2). The key ICSD-2 groupings include: (8)



  1. Difficulty falling asleep.
  2. Having trouble going back to sleep.
  3. Waking up too early in the morning.
  4. Facing daytime problems such as fatigue and sleepiness
  5. Problems with mood, concentration, accidents at work or while driving, etc. due to poor sleep.
  6. Obstructive sleep apnoea (OSA) includes snoring, daytime sleepiness, fatigue, restlessness during sleep, gasping for air while sleeping, and trouble concentrating.
  7. CSA patients report gasping for air, and recurrent episodes of awakenings during the night.
  8. Restless legs syndrome (RLS) causes an intense and irresistible urge to move the legs. This sensation occurs due to resting such as lying down in bed or sitting for prolonged periods such as while driving or at a theater. Associated with problems e.g., daytime sleepiness, irritability, and concentration.
  9. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime. (9)


  2. The presenting complaint(s):
  3. Onset, Duration, Course, Frequency, Severity, and Effects of the sleep disorder.
  4. The pattern of symptoms, timing, fluctuations, exacerbating/relieving factors, environmental factors, and relevant current stressors.
  5. The usual daily routine:
    1. Waking time
    1. Daily activities
    1. Bedtime (preparations for bed, time of going to bed, time of falling asleep, etc)
  6. Description of sleep:
    1. Behaviour whilst asleep.
    1. Dreams/nightmares.
    1. Episodes of wakening (and how they are dealt with).
    1. Quality and satisfaction with sleep.
  7. Daytime somnolence:
    1. General level of alertness during the day.
    1. Effects on work/social activities.
    1. Any periods of confusion.
    1. Any episodes of collapse.
  8. Family history:
    1. Past and current history of medical or psychiatric problems.
    1. Drug and alcohol history
    1. recreational drugs.
  9. Previous treatments
    1. Which type?
    1. Frequency of occurrence and any clear pattern.
    1. If any recent mood changes.
    1. Any recent change in the use of drugs or alcohol


  1. Education about sleep- Educate the patient about the stages of sleep, sleep cycles, changes in sleep patterns with age, and the nature of the sleep problem or disorder the patient presents with.
  2. Sleep hygiene- Establishing good sleep habits. Control of environmental factors (noise, light, temperature), ‘wind down’ time before going to bed; avoid any caffeine-containing drinks; no smoking for at least 1 hr before bed; regular exercise; late ‘tryptophan’ snack (warm milk or other milky drink); avoiding naps during the day; establish a regular time to get up (no more than 1hr variation at weekends and during holidays).
  3. Relaxation training (e.g., yoga and meditation)
  4. Sleep restriction- if sleep is fragmented, a sleep restriction strategy helps to reduce total time spent in bed and improves the quality of sleep due to ‘consolidation’.
  5. Medication- should be the last option. (8) Medicines prescribed are listed below.




 Charbi Gupta, MBBS, GMC Patiala                     

Khanij Arya, 3rd MBBS, GMC Patiala


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