Sleep Disorders and Neurologic Diseases potx

SLEEP DISORDERS
Advisory Board
Antonio Culebras, M.D.
Professor of Neurology
Upstate Medical University
Consultant, The Sleep Center
Community General Hospital
Syracuse, New York, U.S.A.
Anna Ivanenko, M.D., Ph.D.
Loyola University Medical Center
Department of Psychiatry and Behavioral Neuroscience
Maywood, Illinois, U.S.A.
Clete A. Kushida, M.D., Ph.D., RPSGT
Director, Stanford Center for Human Sleep Research
Associate Professor, Stanford University Medical Center
Stanford University Center of Excellence for Sleep Disorders
Stanford, California, U.S.A.
Nathaniel F. Watson, M.D.
University of Washington Sleep Disorders Center
Harborview Medical Center
Seattle, Washington, U.S.A.
1. Clinician’s Guide to Pediatric Sleep Disorders, edited by
Mark A. Richardson and Norman R. Friedman
2. Sleep Disorders and Neurologic Diseases, Second Edition,
edited by Antonio Culebras

Edited by
Antonio Culebras
Community General Hospital and Upstate Medical University

Syracuse, New York, U.S.A.
Sleep
Disorders
and
Neurologic
Diseases
SECOND EDITION
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To my wife, Susan, and my daughters, Katerina and Andrea, who felt the
absences and enjoyed the successes with the same intensity that I did.

B
Foreword
Sleep is the least understood third of our lives. From its prenatal inception to its
ultimate demise, basic questions persist at all stages. We know that sleep represents
an important phase in brain function, but we know much less about possible
circadian variability in the activity of pathophysiological processes affecting the
brain. For example, we have some idea about how sleep apnea may impact brain
function, but we have no clue, yet, whether so-called silent brain infarcts occur
predominantly in sleep and, if so, why and how.
Fortunately, interest, research, and overall activity in somnology is surging.
As this comprehensive book illustrates, a number of specialties are converging to
deal with the increasingly recognized problems associated with sleep disorders.
Neurosomnology emerges as a distinct subspecialty of neurology, with its
attendant professional organizations, certifications, and, eventually, formal
training programs.
A number of distinguished investigators and practitioners of sleep medicine
contributed to this volume. Although the basics of normal sleep development, func-
tion, and dysfunction receive their due, the emphasis remains decidedly clinical.
Not only neurologists, but pediatricians, internists, pulmonologists, endocrinolo-
gists, psychiatrists, and all those dealing with sleep disorders will find parts intrin-
sically interesting and applicable in practice. This book deserves a wide readership.

The readers and their patients will benefit.
Vladimir Hachinski, MD, FRCPC, DSc
Distinguished University Professor
Department of Clinical Neurological Sciences
Schulich School of Medicine and Dentistry
University of Western Ontario
London, Ontario, Canada
v

B
Preface
Sleep is a function of the brain. However, the ultimate physiological function
of sleep remains enigmatic and unknown despite recent extensive research of this
ubiquitous and important brain activity. Sleep intervenes in functions of somatic
growth, regeneration, and memory. Sleep is important in medicine because it
modulates quality of life, while its disorders provoke family pathology, disturb
work routines, alter social activities, and, in general, affect the health of the
individual (1).
Sleep medicine is a unique specialty with input from diverse areas of the
medical sciences. Neurology, pulmonary, cardiology, pediatrics, psychiatry, otorhi-
nolaryngology, and even dental medicine have important contributions to make.
This diversity is the backbone of sleep medicine. But sleep medicine is branching
out and it is clear that sleep, being a function of the brain, suffers dysfunctions
that are distinctly neurological. Conditions such as epilepsy with expression only
in sleep, neuromuscular disorders masquerading as sleep apnea, parasomnias
mimicking seizure disorders, intrinsic hypersomnias with definite brain pathophys-
iology, sleep alterations in Parkinson’s disease, the risk of stroke in sleep, the
organic insomnias, the emerging autonomic dysfunctions of sleep, and so many
other unique neurological disturbances can only be evaluated, studied, diagnosed,
and managed with comfort by neurologists with special expertise in sleep dis-

orders. Non-neurological physicians with a title of “sleep specialist” may not
have sufficient training to tackle the above conditions, despite a sleep diploma or
certificate, and will value having immediate access to this important segment of
sleep medicine in the form of a book.
The subspecialty of neurosomnology will eventually emerge with strength
comparable to that of other subspecialties in neurology. The consequence is that
sleep centers may be compelled to add specialized neurosomnology, for which
they will need a neurosomnologist on staff. Eventually, clinical neurosomnology
will become a subspecialty of sleep medicine and neurology to incorporate all
that is new, unique, and only available in the neurology of sleep.
This book serves as a reference for those who practice sleep medicine and
encounter neurological pathology. The non-neurologist will value the special
information contained herein, and the neurologist will find updated clinical
science in their area of expertise. The chapters have a clinical orientation; pro-
cedural aspects and laboratory tests are not addressed, except where important
to enhance the understanding of clinical manifestations. Some topics are
covered in more than one chapter, not by accident but by design. This should
not be viewed as duplication but rather a way of presenting diverse views of
the same topic.
The authors are prestigious clinical neuroscientists with an international
name in the field of sleep medicine. They were invited to update work presented
in the first edition (2) or to collaborate with new information developed since
vii
this book was initially published only a few years ago. All collaborators have dili-
gently compiled their chapters despite multiple other obligations and should be
commended for their excellent work.
Antonio Culebras, MD
REFERENCES
1. Culebras A, ed. Clinical Handbook of Sleep Disorders. Boston: Butterworth-Heinemann
publishers, 1996.

2. Culebras A, ed. Sleep Disorders and Neurological Disease. First edition. New York: Marcel
Dekker, Inc publishers, 2000.
viii Preface
B
Contents
Foreword Vladimir Hachinski v
Preface . . . . vii
Contributors . . . . xiii
PART I: INTRODUCTION
1. Concept of Sleep Medicine and of Neurosomnology 1
Antonio Culebras
PART II: INFANCY AND DEVELOPMENT
2. Disorders of Development and Maturation of Sleep 7
Stephen H. Sheldon
3. Sleep Disorders Associated with Mental Retardation 27
Michael J. Rack
PART III: INSOMNIA AND CIRCADIAN DYSRHYTHMIAS
4. Insomnia in Neurology 39
Federica Provini, Carolina Lombardi, and Elio Lugaresi
5. Delayed Sleep Phase Disorder and Other Circadian
Rhythm Sleep Disorders 53
Baruch El-Ad
PART IV: NARCOLEPSY AND OTHER HYPERSOMNIAS
6. Narcolepsy 83
Claudio L. Bassetti
7. Secondary Narcolepsy 117
Thomas E. Scammell
8. Hypocretin—Hypothalamic System 135
Christian R. Baumann and Claudio L. Bassetti
9. Idiopathic Hypersomnia and Recurrent Hypersomnia 143

Douglas B. Kirsch and Ronald D. Chervin
ix
PART V: MOTOR DISORDERS OF SLEEP
10. Motor Disorders of Sleep: Periodic, Aperiodic, and
Rhythmic Motor Disorders 157
Roberto Vetrugno and Pasquale Montagna
11. Restless Legs Syndrome 171
Renata Egatz, Belen Cabrero, and Diego Garcia-Borreguero
12. Periodic Leg Movements of Sleep 193
Diego Garcia-Borreguero, Oscar Larrosa, and Renata Egatz
13. Sleep in Parkinson’s Disease 205
Robert L. Rodnitzky
PART VI: EPILEPSY AND PARASOMNIAS
14. Epilepsy and Sleep 229
Bradley V. Vaughn and O’Neill F. D’Cruz
15. Somnambulism, Somniloquy, and Sleep Terrors 255
Rosalia Silvestri
16. Rapid Eye Movement Sleep Behavior Disorder 263
Mark W. Mahowald and Carlos H. Schenck
PART VII: SLEEP APNEAS
17. Obstructive and Nonobstructive Sleep Apnea: The Neurological
Perspective 277
Gulcin Benbir and Christian Guilleminault
18. Sleep Apnea and Stroke 301
Antonio Culebras
PART VIII: NEURODEGENERATIVE DISORDERS
19. Sleep Disturbances in Dementia and Other Neurodegenerative
Disorders 315
Alon Y. Avidan
20. Autonomic Dysfunctions in Sleep Disorders 337

Pietro Cortelli and Carolina Lombardi
PART IX: MISCELLANEOUS NEUROLOGIC DISORDERS
21. Headache Disorders and Sleep 349
Antonio Culebras
x
Contents
22. Sleep in Traumatic Brain Injury and Other Acquired Central
Nervous System Conditions 361
Mark W. Mahowald
23. Sleep Disorders Associated with Multiple Sclerosis 381
Antonio Culebras
24. Sleep Disorders and Neuromuscular Disorders 387
Antonio Culebras
PART X: PHARMACOLOGY
25. Stimulant-Dependent and Hypnotic-Dependent Sleep
Disorders 405
Harold R. Smith
Index . . . . 421
Contents xi

B
Contributors
Alon Y. Avidan Sleep Disorders Center, Department of Neurology, UCLA,
Los Angeles, California, U.S.A.
Claudio L. Bassetti Department of Neurology, University Hospital, Zurich,
Switzerland
Christian R. Baumann Department of Neurology, University Hospital, Zurich,
Switzerland
Gulcin Benbir Stanford University Sleep Medicine Program, Stanford,
California, U.S.A.

Belen Cabrero Sleep Research Institu te, Madrid, Spain
Ronald D. Chervin Department of Neurology, Sleep Disorders Center, University
of Michigan Health System, Ann Arbor, Michigan, U.S.A.
Pietro Cortelli Center for Sleep Disorders, Department of Neurological Sciences,
University of Bologna, Bologna, Italy
Antonio Culebras The Sleep Center, Community General Hospital, and
Department of Neurology, Upstate Medical University, Syracuse, New York, U.S.A.
O’Neill F. D’Cruz Division of Child Neurology, Department of Neurology,
University of North Carolina School of Medicine, Chapel Hill, North Carolina,
U.S.A.
Renata Egatz Sleep Research Institute, Madrid, Spain
Baruch El-Ad Sleep Medicine Center, Technion–Israel Institute of Technology,
Tel Aviv, Israel
Diego Garcia-Borreguero Sleep Research Institute, Madrid, Spain
Christian Guilleminault Stanford University Sleep Medicine Program, Stanford,
California, U.S.A.
Douglas B. Kirsch Division of Sleep Medicine, Harvard Medical School, and
Department of Neurology, University of Michigan, University of Michig an
Hospital, Ann Arbor, Michigan, U.S.A.
Oscar Larrosa Sleep Research Institute, Madrid, Spain
Carolina Lombardi Department of Clinical Medicine, University of Milano-
Bicocca, and Physiology and Hypertension Center, S. Luca Hospital, IRCCS, Istituto
Auxologico Italiano, Milan, Italy
xiii
Elio Lugaresi Department of Neurological Sciences, University of Bologna,
Bologna, Italy
Mark W. Mahowald Minnesota Regional Sleep Disorders Center and Depart-
ments of Psychiatry (CHS), and Neurology (MWM), Hennepin County Medical
Center, and University of Minnesota Medical School, Minneapolis, Minnesota,
U.S.A.

Pasquale Montagna Department of Neurological Sciences, University of Bologna,
Bologna, Italy
Federica Provini Department of Neurological Science s, University of Bologna,
Bologna, Italy
Michael J. Rack Department of Psychiatry and Human Behavior, University of
Mississippi Medical Center, Jackson, Mississippi, U.S.A.
Robert L. Rodnitzky Department of Neurology, University of Iowa College of
Medicine, Iowa City, Iowa, U.S.A.
Thomas E. Scammell Department of Neurology, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, Massachusetts, U.S.A.
Carlos H. Schenck Minnesota Regional Sleep Disorders Center and Departments
of Psychiatry (CHS), and Neurology (MWM), Hennepin County Medical Center,
and University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A.
Stephen H. Sheldon Sleep Medicine Center, Children’s Memorial Hospital,
Chicago, Illinois, U.S.A.
Rosalia Silvestri Sleep Medicine Center, Department of Neurosciences,
Psychiatrical, and Anesthesiological Sciences, Messina Medical School,
Messina, Italy
Harold R. Smith Department of Neurology, University of California, Irvine
School of Medicine, Irvine, California, U.S.A.
Bradley V. Vaughn Division of Sleep and Epilepsy, Department of Neurology,
University of North Carolina School of Medicine, Chapel Hill, North Carolina,
U.S.A.
Roberto Vetrugno Department of Neurological Sciences, University of Bologna,
Bologna, Italy
xiv Contributors
Part I: Introduction
B
1
Concept of Sleep Medicine and

of Neurosomnology
Antonio Culebras
The Sleep Center, Community General Hospital, and Department of Neurology,
Upstate Medical University, Syracuse, New York, U.S.A.
Sleep medicine has experienced an exponential growth in the last 30 years. In the
new international classification of sleep disorders (1), more than 80 clinical sleep
disorders are codified. Neurosomnology or the neurology of sleep has grown in
parallel with the expansion of sleep medicine and the demand for the neurology
of sleep is growing fast. General neurologists agonize over the differential diagnosis
between a seizure disorder and any of the parasomnias and fret mistaking an
epileptic absence for cataplexy. Stroke physicians are seriously concerned about
sleep apnea as a risk factor for stroke. Movement disorders’ specialists are increas-
ingly battling the multiple sleep-related problems associated with Parkinson’s
disease and allied dysfunctions. Neuromuscular experts dread nocturnal respirat-
ory muscle insufficiency, whereas epileptologists think of sleep as an unknown
zone of pathological activity. Increasingly, neurologists are considering sleep a
trigger, a risk, and a modulator of neurological disorders. In consequence,
they are using more and more the sleep laboratory as a standard testing unit for
their patients.
Sleep medicine has so far served well the medical community. However,
clinical queries are becoming increasingly complex and an in-depth expertise in
the neurology of sleep is becoming a requisite. Unfortunately, not all sleep centers,
including those accredited by the American Academy of Slee p Medicine (AASM),
incorporate sleep-neurologists or neurosomnologists, who can genuinely under-
stand the technical questions posed and deliver specialized answers to the referring
neurologist and the sophisticated internist. Did the electroencephalogram (EEG)
channel show epileptiform activity? Should the patient with Park inson’s disease
and insomnia receive more dopamine agonist medication or be treated with a hyp-
notic? Is the dose of bedtime anticonvulsant medication correct? How should the
parasomnia be managed, with anticonvulsants, benzodiazepines, or tricyclics?

Many accredited sleep centers are manned by board-certified sleep specialists
originally trained in a non-neurological discipline. They know and understand
superbly sleep apnea disorders and may have a profound knowledge of its periph-
eral cardiopulmonary complications, but only a working superficial understanding
of neurologically related sleep problems. It is no secret that in sleep centers where
non-neurologists reign, EEG channels are limited to the bare minimum. Is it fair to
ask a pulmonary physician and sleep specialist to evaluate a neurological patient
with a sleep problem? Would the referring neurologist feel confident and satisfied
with the diagnosis and recommendat ion for management dispensed by a non-
neurologist sleep medicine specialist in the case of a complicated seizure problem
or in rapid eye movement (REM) sleep behavior disorder secondary to some
obscure neurological disease?
1
Neurosomnology is an active subspecialty of neurology and of sleep medicine
that will acquire increasing notoriety among neuroscientists and clinical neurol-
ogists as basic and clinical research continue to unravel the neurological intricacies
of sleep and its disorders. To advance the subject of sleep, the doors to the brain
need to be opened and those who can open them are neuroscientists by training
or by adoption. Neurosomnologists should have supra-specialized knowledge of
the links between sleep and stroke, epilep sy, neuromuscular disorders, movement
disorders, multiple sclerosis, neurodegenerative disorders, headaches, and trau-
matic brain injury. They should also possess in-depth knowledge of intrinsic
brain sleep disorders such as narcolepsy, idiopathic hypersomnia, REM sleep beha-
vior disorder, parasomnias, circadian dysrhythmias, and fatal familial insomnia.
Worthy sleep centers need subspecialists in neurosomnology. Encouraging
a sleep center to have a neurologist on board is not sufficient. There should be a
guarantee that a neurologist with expertise in sleep disorders is in the staff. The
day will come when that expertise is documented with a certificate in neurosomnol-
ogy, verifying that the professional is an expert in neurological sleep disorders.
To achieve such lofty goal, I have suggested exploring the acquisition of a

certificate in the subspecialty of neurosomnology through the American
Academy of Neurology (AAN)-sponsored United Council for Neurologic Subspe-
cialties ( mechanism. My vision
is that certified neurologists who are American Board of Sleep Medicine (ABSM)
diplomates or American Board of Internal Medicine (ABIM)-certified in sleep
medicine would be eligible to reach this very specialized branch of neurology.
The certificate would become an addition to th e current title of specialist in
sleep medicine, not a substitute. It should have no effect in the feared split of sleep
medicine into sleep apnea disorders (80% of current sleep medicine) and every-
thing else, as only sleep specialists would be eligible. The new title would
empower the presence of neurologists in all sleep centers, improving the evaluation
and management of patients and conferring rationality to the process, as sleep is,
after all, a function of the brain.
CORPORATE ORGANIZATION OF SLEEP MEDICINE
The AASM () is the core sleep organization in the United
States. Its mission is to enhance the quality and effectiveness of health care by
fostering excellence and professionalism in the field of Sleep Medicine. It strives
to assure quality care for patients with sleep disorders, the advancement of
sleep research, and public and professional education. In 2005, AASM listed 2993
diplomates in Sleep Medicine (Fig. 1) and 550 accredited sleep centers. AASM pub-
lishes the journals Sleep and the Journal of Clinical Sleep Medicine and participates
in the organization of the Associated Professional Sleep Societies Annual meeting
(APSS, http:// www.apss.org) that celebrated its 20th anniversary at the Salt Lake
City convention in June 2006.
ACCREDITATION
AASM also offers accreditation of sleep centers and sleep-related breathing labora-
tories. This is a voluntary process that serves to document and validate excellence
in the provision of care in Sleep Medicine. It serves to guarantee that the center has
met all standards set by the AASM, such as employing skilled and qualified staff,
2 Culebras

creating a clean and comfortab le environment, developing a quality assurance plan,
and adhering to evidence-based practice parameters. Accreditation is given for a
period of five years.
FELLOWSHIP TRAINING AND CERTIFICATION IN SLEEP MEDICINE
In June 2004, the American Council for Graduate Medical Education (ACGME)
() approved the program requirements for graduate
medical education in the subspecialty of Sleep Medicine. Sleep Medicine is
defined as “a discipline of medical practice in which sleep disorders are assessed,
monitored, treated, and prevented by using a combination of techniques and medi-
cation.” Fellowship education must be undertaken following ACGME-approved
training programs in any of the following specialties: neurology (four years), internal
medicine (three years), pediatrics (three years), psychiatry (four years), and otolar-
yngology (five years). Fellowship training in Sleep Medicine should be separate
from all other specialties, but should provide exposure to neurology, cardiology,
otolaryngology, oral maxillofacial surgery, pediatrics, pulmonary medicine, psy-
chiatry, psychology, and neuropsychology. Fellowship programs can only be accre-
dited in institutions where the sponsoring specialty has an ACGME-accredited
residency program.
One or more institutions may participate in the training program, but there
must be assurance of continuity of the educational experience. There should be
only one sleep center per facility. Resources must include sufficient inpatient and
outpatient populations of all ages encompassing the major categories of sleep
disorders that include: sleep apnea, narcolepsy, parasomnias, circadian rhythm
Diplomates 1978 - 2005: 3,993
0
500
1000
1500
2000
2500

3000
3500
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005

Total Number of Diplomates
FIGURE 1 Graph showing the growth of diplomate members since 1978. Provided by the American
Academy of Sleep Medicine.
Concept of Sleep Medicine and of Neurosomnology
3
disorders, insomnia, and sleep problems related to internal medicine, neurology,
and psychiatry. The facility should have a minimum of two fully equipped poly-
somnography bedrooms and support space; it should also contain meeting
rooms, office space, educational aids, library materials, and diagnostic, therapeutic,
and research facilities. Sleep laboratories should be accredited by the AASM or an
equivalent body.
The program director is accountable for the operation of the program and
should be fully comm itted to the fellowship program and its fellows. The
program director must be a diplomate of the ABSM or be certified in Sleep Medicine
by the ABIM and possess qualifications judged to be acceptable by the residency
review committee (RRC). There must also be a sufficient number of participating
faculties with documented qualifications to instruct fellows in the program.
There should be at least two core faculties, including the director, who are
specialists in any of the recognized sponsoring specialties and who are certified
in Sleep Medicine. Faculty should be available to participate in consultation and
teaching in disciplines related to Sleep Medicine including cardiology, neurology,
otolaryngology, oral maxillofacial surgery, pediatrics, pulmonary medicine,
psychiatry, and psychology.
An atmosphere of scholarship must prevail as evidenced by peer-reviewed
funding or by publication of original research in peer-reviewed journals,
production of review articles and chapters in textbooks, and presentation of case
reports, or clinical series at local, national, or international scientific meetings.
In addition, there should be participation in journal clubs, grand rounds, and
research conferences.
The program curriculum should be approved by the RRC. The program must

be didactic and clinical and fellows should have the opportunity to participate in
research. The didactic program should cover all areas of sleep medicine, as well
as techniques for diagnostic assessment, administr ation and interpretation of
tests, financing and regulation of sleep medicine, medical ethics, legal aspects,
and research methods. In addition, there should be seminars and conferences in
all areas of sleep medicine and related specialties. The clinical skills should
focus on interviewing patients, history taking, physical examination, formulating
a differential diagnosis, diagnosis, treatment plans, and continuous care.
Overall, fellows must have at the completion of their training formal instruc-
tion, clinical experience and competence in all areas of Sleep Medicine. They should
be able to work in outpatient and inpatient settings and effectively utilize health-
care resources. All patient care must be supervised by qualified faculty. Duty
hours must be limited to 80 hours per week, averaged over a four-week period,
inclusive of all in-hours call activities. One in seven days should be free from all
educational and clinical responsibilities. Final evaluation of a fellow completing
the program must include a review of the fellow’s performa nce and should
verify that the fellow has demonstrated sufficient professional ability to practice
competently and independently. Fellows thus trained may seek certification in
Sleep Medicine by the ABIM newly recognized sleep board.
OTHER NATIONAL AND INTERNATIONAL SLEEP SOCIETIES
The Sleep Research Society (SRS) () fosters
scientific investigation, professional education, and career development in sleep
research and academic Sleep Medicine at both the national and international
4 Culebras
levels. In 2005, SRS had 1090 registered members, 30% international from
32 countries. SRS is closely allied with the AASM.
The Academy of Dental Sleep Medicine (ADSM) (talsleep-
med.org) is a professional membership organization promoting the use and
research of oral appliances and oral surgery for the treatment of sleep disordered
breathing. It provides training and resources for those who work directly with

patients. In 2005, there were 540 members, mostly in North America. The ADSM
is closely allied with the AASM.
The ABSM () was established in 1978 to encourage the
study, improve the practice, elevate the standards of Sleep Medicine, and issue cer-
tificates of special knowledge in Sleep Medicine. ABSM is closely allied with the
AASM. ABSM has been a “rogue” board, not recognized by the American Board
of Medical Specialities (ABMS), but accepted by most institutions in the United
States as the “Sleep Board.” Specialists certified by the ABSM are called diplomates.
The last ABSM exam will be given in the fall of 2006. The first board exam in
the specialty of sleep recognized by the ABMS will be given in the fall of 2007
by the ABIM. Having ABMS recognition, individuals who pass the exam may
claim to be certified in Sleep Medicine.
The Association of Polysomnographic Technologists (http://www.
aptweb.org) is an international society of professionals dedicated to improve the
quality of sleep and wakefulness in all people. In 2005, there were 1540 members
mostly technologists. The Board of Registered Polysomnographic Technologists
() certifies individuals in polysomnographic techniques while
promoting national and international recognition and acceptance of the RPSGT
credential as the professional standard for polysomnographic technologists. The
board is active in the United States, Canada, China, Japan, and Australia. Exams
are given annually.
The AAN () supports a Sleep Section with 450 members
in 2006, charged with organizing the educational and scientific presentations at
AAN annual meetings.
The World Federation of Neurology () sponsors
a Sleep Research Group that intervenes in the organization and structure of sympo-
sia and educational courses at the World Congress of Neurology. The next congress
will take place in Bangkok in 2009.
International Congresses of Sleep Medicine are also organized at the regional
and world levels. The World Association of Sleep Medicine (m.

org) held the first Congress of Sleep Medicine in Berlin in 2005. It was attended
by almost 1000 registrants, indicating the vigor of the specialty at the international
level. In view of the initial success, the Second World Congress of Sleep Medicine
was held in Bangkok, Thailand, in February 2007.
The World Federation of Sleep Research Societies (epresearch-
society.org) also organizes international meetings, such as the one in Cairns,
Australia in 2007.
Regional international congresses in sleep medicine have been held at various
times in the recent past organized by European, Latin American, and Asian societies.
FUTURE
Sleep Medicine will grow exponentially in the foreseeable future. Much of that
growth will come in the heels of the expansion of neurosomnology. Sleep is a
Concept of Sleep Medicine and of Neurosomnology 5
function localized in brain structures, which follows the dynamics of maturation,
evolution, and decay of other complex functions also localized in the brain, such
as motor development, cognition, and language. There is no one cerebral center
where sleep lodges but a multiplicity of structures tightly linked in a network of
nuclei, tracts, and neurotransmitters that respond to the orchestrating mandates
of the circadian rhythm. Basic research in the neurosciences will advance the under-
standing of sleep as a ubiquitous function of the nervous system present in all
vertebrates. The demands to comprehend and manage sleep dysfunctions, to
study its pathology, and to develop treatment modalities will come from
a variety of fronts, the most obvious of which has been sleep disorders as a
medical discipline in which individual ailments such as narcolepsy, sleep apnea,
and others are studied. Developing fronts are also emerging in the academic
sector where educators are requesting increased learning efficiency, a process that
requires an alert brain. Other fronts have appeared in government departments,
where authorities are concerned about fatigue eroding safety on the road; in indus-
try and labor, where leaders are asking for guidance in shift-work programs; and
in aerospatial science, where jet-lag distortions of sleep and wakefulness create

safety hazards. Inde ed, neurosomnology is destined to develop as a subspecialty
of the neurosciences with a corporate structure of its own.
REFERENCE
1. American Academy of Sleep Medicine. ICSD-2, International Classification of
Sleep Disorders. Diagnostic and Coding Manual. 2nd ed. Westchester, Illinois, American
Academy of Sleep Medicine, 2005.
6 Culebras