Class 4

Question 1

stage 3 and 4 is

Answer 1

the restorative sleep, at the beginning of the night

Question 2

NREM Sleep

Answer 2

 NREM stages 1 and 2 are the light sleep
stages, whereas stage 3 is deep sleep (there
used to be 4 stages, stages 3 & 4 were combined in 2007)
 Dreaming is rare during NREM and muscles
are not paralyzed.

Question 3

REM Sleep

Answer 3

 REM sleep follows NREM sleep and occurs 4-5
times during a normal 8-hour sleep period.
 The first REM period of the night may be less than
10 minutes in duration, while the last may exceed 60
minutes.
Body is paralysed

Question 4

The NREM-REM cycles timing

Answer 4

vary in length from 70-100 minutes initially to 90-120 minutes later in the night.

Question 5

Sleep and memory

Answer 5

more activity in hippocampus when you’re sleeping

Question 6

Insomnia prevalance

Answer 6

 6 – 10% of adults meet criteria for an
insomnia disorder.
 Twice as prevalent in women as in men.
 Complaints increase with age.

Question 7

Insomnia – Comorbidity

Answer 7

 Insomniacs are 5 times as likely to present
with anxiety or depression.
 Twice as likely to present with CHF

Question 8

Insomnia Definition

Answer 8

 Patient is dissatisfied with sleep quality or quantity
 Difficulty initiating or maintaining sleep or nonrestorative sleep.
 Sleep complaint is accompanied by distress or
impairment in daytime function
 At least 3 nights per week, at least 3 months.
 Occurs despite adequate opportunity for sleep.

Question 9

Sleep latency

Answer 9

how long it takes to fall asleep, should not take more than 30 mins

Question 10

Total sleep time

Answer 10

at least 6,5 h

Question 11

Primary Insomnia Differential Diagnosis

Answer 11

 Substance Use
 Stimulants, alcohol, some medications

 GMC
 Pain disorder, LBD, etc.

 Secondary to Psychiatric Disorder

 Sleep Apnea:
 daytime drowsiness
 snoring, witnessed apneas
 morning headaches
 Common with obesity

 Restless legs
 Subjective sensation that occurs at rest, worse at night

 Circadian Rhythm Disorders
 Can sleep normally at other times
 Common with shift work

Question 12

Narcolepsy

Answer 12

A. Irresistible attacks of refreshing sleep that occur daily over at least 3 months.
B. The presence of one or both of the following:
1. cataplexy (i.e., brief episodes of sudden bilateral loss of
muscle tone, most often in association with intense emotion).
2. recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes.
C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition.

Question 13

NREM sleep arousal disorder

Answer 13

sleep terror and sleep walking

Question 14

nightmare disorder ddx:

Answer 14

PTSD, MDD, effexor/pristiq make dreams vivid

Question 15

rapid eye movement behavior disorder

Answer 15

body is not paralysed during REM sleep, so body acts out your dreams,

Question 16

Sleep Hygiene

Answer 16

 Avoid stimulants for several hours before bed time
 Avoid alcohol around bed time
 Exercise regularly
 Do not watch the clock
 Keep the bedroom environment dark, quiet and
comfortable

Question 17

Sleep Restriction Therapy

Answer 17

 Limits the time spent in bed as close as possible to actual sleep time, producing mild sleep deprivation.
 The sleep window is gradually increased throughout a few days or weeks until optimum sleep duration is achieved.

Question 18

Benzodiazepines Long Acting

Answer 18

 Diazepam = Valium (1/2 life: 20 - 50 hrs)
 Flurazepam (1/2 life: 20 – 100 hrs)
 Chlordiazepoxide (1/2 life: 8 – 33 hrs)
Less rebound insomnia
Less likely to cause withdrawal
More likely to accumulate to toxic levels

Question 19

Benzodiazepines Intermediate Acting

Answer 19

 ? Clonazepam (1/2 life: 30 – 40 hrs)
 Lorazepam = Ativan (1/2 life: 10 – 20 hrs)
 Oxazepam (1/2 life: 3 – 21 hours)
Temazepam

Question 20

BenzodiazepinesShort Acting

Answer 20

not good for treating insomnia
 ? Alprazolam = Xanax (1/2 life: 9 hours)
 Triazolam = Halcion (1/2 life 1.5 – 5.5 hours)
Xanax has a fast onset of action.
Shorter half-life means:
 Withdrawal more likely
 More rebound insomnia

Question 21

Benzos s/e

Answer 21

dependency, falls, memory

Question 22

Benzos and Memory

Answer 22

Benzodiazepines possess anterograde amnesic properties, disrupting both short-term and long-term memory function. forget what happened after you
took the benzo
The amount of amnesia is systematically related to dose effects and half-life differences
among the benzodiazepines.
Memory deficits are found for episodic, semantic, and iconic memory function.
The deficits in long-term memory are probably the result of a disruption of consolidation of information in memory and not retrieval from memory. The disruption is produced by rapid sleep onset.
Thus the long-term amnesia is really a retrograde effect of sleep and not the anterograde effect of the drug.

Question 23

Drug variables for increased intensity of Benzodiazepines withdrawal

Answer 23

higher dose, longer duration of trx, shorter half life, more rapid taper

Question 24

Clinical variables for increased intensity of Benzodiazepines withdrawal

Answer 24

higher pre taper anxiety or depression, more personality pathology, panic disorder, history of recreational drug/ roh abuse

Question 25

Zopiclone

Answer 25

 Binds selectively to a subtype of GABA receptor.  S/E: metallic taste, sedation, amnesia, dizziness  Seems to have less risk of dependence than benzodiazepines Not covered by RAMQ

Question 26

Medication options:

Answer 26

 Benzos: consider risk of falls, memory impairment.  Non-Benzos: less risk of dependence  Trazodone: rare risk of priapism, orthostatic hypotension  Tricyclics: Anticholinergic side effects, weight gain  Atypical antipsychotics: metabolic side-effects

Question 27

Questions to ask to evaluate sleep

Answer 27

Define the problem: when did it start, what are the sx; get the partner to define the sleep Ask about sleep apnea, restless legs, comorbid medical conditions, substance use, medications… Ask about psychiatric symptoms r/o mood disorder r/o psychotic disorder r/o anxiety disorder r/o substance use disorder Does he have good sleep hygiene? Ask about napping, exercise, stimulant intake, time spent in bed, etc.

Question 28

Name all sleep disorders

Answer 28

Insomnia, Narcolepsy, hypersomnia, obstructive sleep apnea, central sleep apnea, circadian rhythm sleep-wake disorder, NREM sleep arousal, nightmare disorder, rapid eye movement behavior disorder, restless leg syndrome

Question 29

polysomnography

Answer 29

sleep parameters; sleep onset latency, latency to persistent sleep, TST, sleep efficiency. EEG: what phase of sleep your in. + vital signs + movements. Indication: Indication: to identify any of the sleep problems: apnea main ones to be picked up + primary insomnia

Question 30

multiple sleep latency test

Answer 30

tests for excessive daytime sleepiness by measuring how quickly you fall asleep in a quiet environment during the day. Also known as a daytime nap study, the MSLT is the standard tool used to diagnose narcolepsy and idiopathic hypersomnia. The MSLT is a full-day test that consists of five scheduled naps separated by two-hour breaks. During each nap trial, you will lie quietly in bed and try to go to sleep. Once the lights go off, the test will measure how long it takes for you to fall asleep. You will be awakened after sleeping 15 minutes. If you do not fall asleep within20 minutes, the nap trial will end. Each nap will be taken in a dark and quiet sleep environment that is intended for your comfort and to isolate any external factors that may affect your ability to fall asleep. A series of sensors will measure whether you are asleep. The sensors also determine your sleep stage.

Question 31

maintenance of wakefulness test

Answer 31

The Maintenance of Wakefulness Test (MWT) is used to measure how alert you are during the day. It shows whether or not you are able to stay awake for a defined period of time. This is an indicator of how well you are able to function and remain alert in quiet times of inactivity. The test is based on the idea that your ability to stay awake may be more important to know in some cases than how fast you fall asleep. This is the case when the MWT is used to see how well a sleep disorders patient is able to stay awake after starting treatment. It is also used to help judge whether a patient is too tired to drive or perform other daily tasks. The test isolates you from outside factors that can influence your ability to fall asleep. These factors include such things as the following: ``` Temperature (too hot or too cold) Light Noise Activity The MWT is used to see if someone with a sleep disorder is responding well to treatment. Results of multiple tests may be compared over a period of time. This can show if treatment is helping a patient overcome sleepiness. ```