8. Sleep Disorders Flashcards by Geun Young Park

Daily rhythms in physiology and behavior that control the sleep-wake cycle; controlled by the Suprachiasmatic Nucleus of the Hypothalamus which receives info from the retina and secretes Melatonin

Circadian rhythms

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Circadian rhythm is controlled by which Hypothalamic nucleus? and received direct input from _______

Suprachiasmatic Nucleus (SCN)
retina

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The Suprachiasmatic Nucleus of the Hypothalamus controls Circadian sleep with ___________ secreted by the __________ gland to control Circadian Rhythm

Melatonin; Pineal

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Circadian rhythm is done through the nocturnal release of what chemicals?

Melatonin (pineal)
Prolactin
ACTH
Norepinephrine (SCN)

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Damage to the Suprachiasmatic Nucleus will result in what?

Insomnia

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(NREM/REM) sleep is the vast majority

NREM (Non-Rapid Eye Movement) (~80%)

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What is the pattern of normal sleep from the beginning?

NREM (Stage 1–>2–>3–>4) then REM

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Average length of first NREM-REM sleep cycle is _________________ minutes

70-100 minutes

*cycles last a little longer after that

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(NREM/REM) sleep increases as the night goes on

REM

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Patients with narcolepsy enter sleep in (NREM/REM)

REM

*normal is to start with NREM

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen in a WAKEFUL states, eyes open and alert mental concentration

Beta (high frequency, low amplitude)

*remember BATS Drink Blood

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen when you are awake with EYES CLOSED

Alpha

*remember BATS Drink Blood

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen in NREM stage 1, which is LIGHT sleep

Theta

*remember BATS Drink Blood

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen in NREM stage 2, which is moderate sleep

Sleep Spindles (and K complexes)

*remember BATS Drink Blood

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen in NREM stage 3, which is DEEP sleep; can see sleepwalking, night terrors and bedwetting

Delta

*remember BATS Drink Blood

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Which stage of sleep do you typically see Sleepwalking, Night Terrors or Bedwetting

NREM 3 (deepest sleep, Delta waves)

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(Beta/Alpha/Theta/Sleep Spindles/Delta) waves are seen in REM sleep, loss of muscle tone and extra-ocular movements due to paramedian pontine reticular activity

Predominantly Beta

*remember BATS Drink Blood

**also saw in Wakeful State

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Which STAGE of sleep do you see loss of muscle tone

REM

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Test of sleep cycles and stages through the use of continuous recordings of brain waves, muscle tone, eye movements, etc.

Polysomnogram (Sleep Study)

Examples of Sleep Disorders

Insomnia
Sleep Apnea (Obstructive)
Narcolepsy
Restless Leg Syndrome
Parasomnias (Night Terrors, Sleep Walking, etc.)

Sleep Disorder; difficulty getting to sleep or staying asleep or having non-refreshing sleep for at least 1 MONTH; can be due to stress, chronic pain, anxiety, mood disorders or caffeine

Insomnia

Treatments for Insomnia

Behavioral (reduce anxiety, relax)
Sleep Hygiene (routines, strict bedtime, hot bath, etc.)
Pharmacology (as a last resort!)

Sleep Disorder; produced by upper airway obstruction; demonstrate daytime somnolence, snoring, apnea and cognitive impairment; risk factors are age, obesity and alcohol; treat with CPAP and weight loss

Obstructive Sleep Apnea

Treatments for Obstructive Sleep Apnea

CPAP

Weight Loss

Sleep Disorder; caused by REM sleep occurring during wakefulness; characterized by Excessive Sleepiness, Cataplexy, Sleep Paralysis and Hypnagogic Hallucinations; sleep study shows REM at ONSET

Narcolepsy

What are the 4 main features of Narcolepsy

Excess Sleepiness (a must!) Cataplexy (sudden muscle weakness in the leg) Sleep Paralysis (가위) Hypnagogic Hallucinations

Sleep Disorder; uncomfortable crawling sensations and urge to move legs; associated with IRON DEFICIENCY ANEMIA; treat with Dopamine Agonists

Restless Legs Syndrome (RLS)

Tests/Treatments for Restless Legs Syndrome

Check Ferritin (due to Iron Deficiency Anemia) Replace Iron DOPAMINE Agonists

Sleep Disorder; loss of normal skeletal muscle atonia during REM sleep; end up "acting out dreams" like a dog chasing a squirrel

REM Sleep Behavior Disorder

Sleep Disorder; sudden unexplained bouts of terror/fear during Stage 3 or 4 sleep; common in CHILDREN; last about 10 minutes

Night Terrors

Sleep Disorder; wandering around in your sleep; common, especially in children; no memory of it; very difficult to arouse

Sleep Walking

Sleep Disorder; grinding of teeth during sleep; common; occurs in both children and adults

Bruxism

Examples of Hypnotic Drugs

``` Benzodiazepines (-pam/lam) Non-Benzodiazepines ("Z" drugs: Zolpidem, Zaleplon, EsZopiclone) Melatonin Agonists (Ramelteon) Orexin Antagonists (Suvorexant) Antidepressants (TCAs, Mirtazepine) ``` Older Hypnotics: Diphenhydramine, Trazodone

Examples of Non-Benzodiazepine Hypnotics

Zolpidem Zaleplon EsZopiclone (Zopiclone)

Examples of Short-Acting Benzodiazepines

Alprazolam Triazolam Oxazepam Midazolam (ATOM)

Uses of Benzodiazepines

``` Anxiety Spasticity Status Epilepticus Detox (Alcohol Withdrawal) Night Terrors Sleep Walking Anesthesia ```

Antidote for Benzodiazepines

Flumazenil (Romazicon)

Benzodiazepine receptor agonists that bind to GABA receptor sub-type (BZ1) that specifically modulate sleep; metabolized by liver RAPIDLY, so short acting

Non-Benzodiazepine Hypnotics (Zolpidem and Zaleplon)

What are some drug interactions of Non-Benzodiazepine Hypnotics

P450 inducer/inhibitor - Inducer: increase metabolism - Inhibitor: decrease metabolism Antiviral Protease inhibitor (Hep C and HIV treatment)

Drug that activates melatonin receptors in Suprachiasmatic nuclei of Hypothalamus; decreases the latency of sleep onset; side effects are dizziness, fatigue, allergic reactions, endocrine changes (dec. testosterone, inc. prolactin)

Ramelteon * only FDA approved drug for insomnia b/c it hasn't been associated with abuse and withdrawal.

Side effects of Ramelteon

``` Dizzy Fatigue Nausea Headache Allergic reaction Endocrine (dec. testosterone, inc. prolactin) ```

Ramelteon is metabolized by...

CYP450

Orexin receptor antagonist approved for insomnia; CONTRAINDICATED for Narcolepsy, Liver disease and CYP3A4 inhibitors (Macrolides and Azoles)

Suvorexant

Contraindications for Suvorexant (Orexin receptor antagonist)

Narcolepsy Liver Disease CYP3A4 inhibitors (Macrolides, Azoles, etc.)

Non-benzodiazepines should NOT be co-administered with what drugs?

Protease Inhibitors

Side effects of Non-Benzodiazepines

Ataxia Sedation/confusion Rebound insomnia Withdrawal/addiction

Side effects of Ramelteon

endocrine changes (reduced testosterone, increased prolactin)