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Pharmaco > Class 7-sleep > Flashcards

Class 7-sleep Flashcards

1
Q

NREM sleep

?????% of TST

A

75

Heart rate and respiratory rate are generally slow and regular

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2
Q

STAGE N1

A

Transition between wakefulness and sleep

  • Drowsiness
  • 15 – 30 minutes
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3
Q

STAGE N2

A
  • No conscious awareness of environment

- Majority of sleep; half of TST

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4
Q

STAGE N3

A
  • Most restorative sleep

- Protein synthesis, wound healing, and restoration of immune function

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5
Q

REM sleep

A
  • Lowest muscle tone of the night
  • Burst of bilaterally conjugate eye movement occur
  • Associated with dreaming
    Heart rate, respiratory rate and blood pressure are irregular with rapid fluctuations
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6
Q

INSOMNIA dx

A

• Primary complaint of unsatisfying sleep quantity or quality, with presence of one or more of the
following:
1. Difficulty with sleep initiation
2. Difficulty with sleep maintenance
3. Early-morning awakening
• Sleep complaint associated with social, occupational, academic, educational, behavioral, or functional
distress or impairment
• Sleep complaint occurs at least 3 nights per week and has been present for at least 3 months

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7
Q

Sleep onset latency

A

Time that it takes to transition from
wakefulness to sleep
< 30 minutes

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8
Q

Latency to persistent sleep

A

Time from lights out until the first 10 minutes of consistent sleep

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9
Q

Total sleep time (TST)

A

7-8h

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10
Q

Sleep efficiency

A

Ratio of TST divided by the time spent in bed

> 80 – 85 %

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11
Q

Precipitating factors

A
  • Situational stress (work, finances, life events, conflicts)
  • Environmental (noise, light, altitude, etc.)
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12
Q

Perpetuating factors

A
  • Maladaptive coping strategies

- Poor sleep hygiene

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13
Q

RISK FACTORS – SUBSTANCES

A
  • Alcohol
  • Amphetamines
  • Caffeine
  • Cocaine
  • Nicotine
  • Stimulants
  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Beta blockers
  • Corticosteroids
  • Diuretics
  • Psychostimulants / modafinil
  • Theophylline
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14
Q

RISK FACTORS – MEDICAL CONDITIONS

A
  • Angina / arrythmias
  • Asthma / COPD
  • Chronic pain
  • Diabetes
  • Hyperthyroidism
  • Menopause
  • Sleep apnea
  • Anxiety disorders
  • Mood disorders
  • Personality disorders
  • Delirium / Dementia
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15
Q

ALCOHOL

A
  • Wakefulness when effect wears off

- Urination at night

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16
Q

CAFEINE

A
  • Effect can last 10 hours
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17
Q

NEUROTRANSMITTERS SLEEP PROMOTING

A
  • Melatonin

- GABA

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18
Q

NEUROTRANSMITTERS WAKE PROMOTING

A
  • Norepinephrine (NE)
  • Acetylcholine
  • Histamine
  • Serotonin (5-HT)
  • Dopamine (DA)
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19
Q

CIRCADIAN PROCESS

A

o Light supresses melatonin release
o Darkness results in production and secretion of melatonin from the pineal gland
o Circadian-mediated decrease in the body temperature activates GABA neurons to trigger sleep-generating neuronal systems
o A rise in the body temperature in the morning inhibits GABA neurons to trigger awakening and alertness
SUPRACHIASMATIC NUCLEUS
LOCATED IN THE HYPOTHALAMUS AND CONTROLS CIRCADIAN RHYTHMS

20
Q

NON-PHARMACOLOGIC MANAGEMENT

A
  • Cognitive behavioral therapy for insomnia
  • Principles of good sleep hygiene
  • Biofeedback (e.g. EMG)
  • Exercise – complete at least 4 hours before bedtime
  • Light therapy – used in delayed sleep phase disorder
  • Mindfulness
  • Hypnotherapy
21
Q

COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA (CBT-I)

A

o Standard of care
o Via telephone, internet-based modules, or through self-help books
o Efficacy
- Short term : comparable to pharmacologic treatment
- Long term : superior to pharmacologic treatment
- Combination with pharmacologic treatment superior to either treatment alone in the short-term with discontinuation of pharmacotherapy more favorable long-term

22
Q

COGNITIVE THERAPY

A

• Dispels misconceptions and erroneous
assumptions about sleep and insomnia (e.g. fear of not obtaining adequate sleep)
• Paradoxical intention – patient confront fear of not sleeping to reduce anxiety about sleep

23
Q

BEHAVIORAL THERAPY

A

• Stimulus control therapy – usage of bed,
alarms, ∅ naps
• Sleep restriction therapy – limit time in bed
to the amount consistent with optimal sleep
efficiency
• Relaxation training

24
Q

PRINCIPLES OF GOOD SLEEP HYGIENE

A

o Regular time to go to bed / to wake up
o Pre-bedtime routine (30 minutes of wind-down time to relax)
o Regular moderate exercise during the day
o Avoid large quantities of food/drink in the evening
o Comfortable bedroom (cold, dark, quiet)
o Use bedroom for sleep associated activities
o If not asleep in 20 minutes, move to another room and engage in a relaxing activity
o Sleep only as much as needed to feel alerted during the day / avoid napping > 20 min
o Limit caffeine, alcohol
o Disconnect electronics

25
Q

BENZODIAZEPINES

A

GABAA RECEPTOR AGONIST
- In the absence of GABA, there is no effect
- Simultaneous use of the receptor by benzodiazepines AND GABA = potentialisation
GABAA RECEPTOR
Includes
several sub-units
Benzodiazepines
are mainly linked to sub-units
α, β and γ
Example of effect by sub-unit
α1 : sedation
α2 : anxiolytic
α 5 : anterograde amnesia
Effects on sleep: decrease sleep onset latency, increase total sleep time
Little more time sleep per night (15-30 min) compared to a placebo… and that difference is lost over time.

26
Q

SIDE EFFECTS benzos

A 
Drowsiness, sedation
Weakness
Ataxia
Dizziness
Light-headed feeling
Dry mouth
Headache
Confusion, disorientation
Tachycardia, palpitations
Anterograde amnesia
« Hangover » effect: Administer a shorter-acting BZD
Paradoxical effect: Especially children, elderly, behavioral disorder, borderline personality disorder. Stop immediately!
Rebound insomnia: Associated with abrupt discontinuation
27
Q

DURATION OF TREATMENT bentos

A

Generally short-term use : 2 weeks

Some benzodiazepines up to 12 weeks

28
Q

NBRAS

A

zopicolne, eszopiclone, zolpidem
GABAA RECEPTOR AGONIST
- More specific affinity for α1 sub-unit (sedation)
- Eszopiclone : exact mechanism unknown
Effect on sleep: decrease sleep onset latency, increase TST

29
Q

SIDE EFFECTS NBRAS

A 
oDaytime drowsiness
o Headache
o Cognitive disorders
o Dizziness
o Falls
o Alteration of taste
o Complex sleep-related behaviors
o Less risk of dependence
30
Q

PRECAUTIONS NBRAS

A
  • Sleep apnea
  • Hepatic failure
  • Respiratory failure
  • Somnambulism
  • Myasthenia gravis
31
Q

INTERACTIONS NBRAS

A 
Mainly via CYP 
Increased drowsiness
• Alcohol
• Antihistamines
• Opiates
• Some antidepressants
• Some antipsychotics
32
Q

DURATION OF TREATMENT NBRAS

A

Generally short-term use : 7 – 10 days

33
Q

DOXEPIN

A

MECHANISM OF ACTION At low doses : H1 receptor antagonism
PHARMACOKINETICS: Improvements in sleep as early as first night
Duration of action : 7 hours
SIDE EFFECTS: Anticholinergic effects

34
Q

OTHER ANTIDEPRESSANTS

A

TRAZODONE (LOW DOSE : 25 – 100 mg HS)

MIRTAZAPINE (LOW DOSE : 7,5 – 15 mg HS)

35
Q

ANTIPSYCHOTICS

A

QUETIAPINE (LOW DOSE : 6,25 mg – 100 mg HS)

Although sedating, not recommended for insomnia unless a comorbid psychiatric disorder exists

36
Q

MELATONIN

A

CONSIDER IN THE FOLLOWING SITUATIONS
Circadian rhythm disorders (e.g. jet lag)
Delayed sleep phase disorder
Patients with low endogenous melatonin levels
DOSING 0,5 – 10 mg HS in many different formulations
SIDE EFFECTS Considered safe

37
Q

VALERIAN

A

MECHANISM OF ACTION: Appears to act on central GABA systems
DOSING: 300 – 900 mg HS
SIDE EFFECTS : GI upset, headache, restless sleep, bitter taste, heart palpitations, rare cases of hepatotoxicity
INTERACTIONS : may interact with medication via CYP

38
Q

PATIENT EDUCATION FOR ALL SEDATIVE/HYPNOTICS

A

Do not take unless you have sufficient time to devote to sleep (sleep medications generally require at least 7 – 8 hours)
Do not combine with alcohol or other CNS depressants, because this can intensify side effects
Ask a professional if it is safe to take any newly prescribed medication with this medication to avoid interactions
If insomnia does not improve in 7 – 10 days, consult the provider because insomnia may be a symptom of another underlying illness

39
Q

GENERAL PRINCIPLES OF TREATMENT

A

Start at the lowest effective dose and initiate a short-term duration of treatment (e.g. 1 – 2 weeks)
Evidence suggests that pharmacotherapy should be used no longer than a month due to the risk of dependence and tolerance
Principles of behavioural management should remain the focus, even if medication is used
Long- term use of hypnotics may be appropriate in some cases (e.g. severe refractory insomnia) : regular follow-up and reassessment are beneficial to ensure that comorbidities, tolerance and/or dependence do not emerge
Short to intermediate-acting BZD or NBRA
If symptoms persist, consider an alternative short to intermediate-acting BZD or NBRA

40
Q

DISCONTINUE THE USE OF SLEEPING PILLS CAN

A
  • ↑ alertness
  • ↑ energy
  • ↑ daily function
  • ↓ risk of falls
  • ↓ traffic accidents
41
Q

LONG-TERM USE OF SLEEPING PILLS CAN

A
  • Cause serious side effects : confusion, memory problems, falls and hip fractures
  • ↑ risk of car accidents
  • Cause addiction
  • Only help a little
42
Q

NARCOLEPSY

A
  • Recurring episodes of an irresistible need to sleep, fall asleep or nap during the same day. During the previous 3 months, must occur at least 3 times per week
  • At minimum, occurrence or experience one of the following :
  • Cataplexy (sudden loss of muscle tone triggered by emotion) episodes at least a few times per week each month
  • Hypocretin deficiency
  • REM sleep latency 15 min or less on nighttime PSG or MSLT, revealing a mean sleep latency eight minutes or less
43
Q

NARCOLEPSY SYMPTOMS

A
  • Excessive daytime sleepiness (EDS): irresistible urge to sleep attacks occur in 100 % of cases
  • Cataplexy : sudden loss of muscle tone triggered by emotion (e.g. laughing, excitement, anger)
  • Hallucinations
  • Sleep paralysis : total or partial paralysis occurring at the onset or termination of sleep in which the muscles are inhibited but the brain is aware of physiologic
    change
44
Q

NARCOLEPSY Neurotransmitters implicated

A
  • Hypocretin (also called OX) – deficiency
  • Dopamine / noradrenaline – hypofunction
  • Acetylcholine – excess
  • Histamine neurons – have a role in the «waking action» of OX
45
Q

NARCOLEPSY TREATMENT GUIDELINES

A
  • Modafinil (AlertecMD)
  • If ineffective : stimulants (refer to ADHD class)
  • Available in the USA : Sodium oxybate (GHB)
46
Q

MODAFINIL

A

MECHANISM OF ACTION UNKNOWN ; HYPOTHESIS :
- Binds the DA transporter to inhibit reuptake
- ↑ histamine in hypothalamus to stimulate the release of hypocretin
CLINICAL EFFECT
- ↑ daytime vigilance and ↓ number and duration of daytime sleep episodes with little effect on nocturnal sleep
- Similar to traditional CNS stimulants, but with improved tolerability and ↓ risk of abuse and tolerance
- Onset of action < 1 hour ; duration 6 – 8 hours

47
Q

MODAFINIL SIDE EFFECTS

A
  • ↑ blood pressure in initial hypertension
  • Headache
  • GI upset
  • Nausea / vomiting
  • Anxiety
  • Insomnie
  • Dizziness

Pharmaco (11 decks)

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