Clinical Sleep Disorders

Question 1

Sleep Stage 1

characteristics:

time spent in stage:

Answer 1

Sleep Stage 1

characteristics: light sleep- easily awakened. theta waves present

time spent in stage: 5% of total sleep time

Question 2

Sleep Stage 2

characteristics:

Time spent in Stage:

Answer 2

Sleep Stage 2

People in sleep stage 2 are generally easy to arouse, but may require some shaking. The majority of our total sleep time is spent in this stage (45-55%). On a polysomomogram you will see Sleep Spindles andd K complexes

Question 3

Sleep Stage 3/4

Answer 3

Deep sleep begins. A person in stage 3/4 is very hard to awaken and is unresponsive to external stimuli. Brain waves are slow delta waves. Time in stage 3/4 is aproximately 16-21% of total sleep time

Question 4

REM Sleep

Answer 4

REM Sleep is also known as actie or paradoxical sleep. It is the stage of sleep where dreaming occurs due to an increase in cholernergic activity (Ach). REM sleep is concentrated in the second half of a night’s sleep

This stage of sleep makes up about 20-25% of total sleep time.

Skeletal muscle is inhibited

Question 5

Possible consequences of sleep distrubances:

Answer 5

Consequenes of sleep disturbances include:

impaired mental functioning

emotional changes (irritability, anxiety, depression)

memory difficulties

impairment on complex motor tasks

decreased work efficiency/productivity

immune supression

reduced quality of life

weight gain

Question 6

Insomnia:

definition

Answer 6

Insomnia is repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment

Question 7

Insomnia:

Symptoms:

Characteristics:

Pathophysiology:

Treatment

Answer 7

Insomnia:

Symptoms: difficulty falling asleep, frequent awakenings with difficulty falling back to sleep, unrefreshing sleep, waking up too early, daytime sleepiness, difficulty concentrating, irritability

Characteristics:

Pathophysiology:

Treatment

Question 8

Insomnia:

Characteristics:

Answer 8

Insomnia is the most common sleep disorder affecting 10-15% of the population.

Insomnia affects more women than men and its incidence increases with age

Pt. may say “I have a hard time unwinding at the end of my day” or may also have an inability to take naps

Question 9

Insomnia:

Pathophysiology

Answer 9

The most common etiology for insomnia is psychophysiological.

It is a state of hyperarousal at bedtime leading to a conditioned difficulty falling asleep.

40% of patients with insomnia have comorbid psychiatric conditions such as anxiety or depression

Question 10

Insomnia:

Treatment

Answer 10

Treatment for insomnia is to first identify the cause of the insomnia (period of adjustment- new job, starting med school, etc. usually lasts less than 3 months)

discuss sleep hygine: regular bed/wake time, caffine use, exercise timing, tobacco use, etc

Cognitive Behavioral Therapy

pharmacology (hypnotics, antidepressants, melatonin receptor agonists)

**successful treatment= improved sleep latency by 30 minutes (from the time you go to bed to the time you fall asleep. If this time goes from 2 hours to 90 minutes the treatment is considered a success)

Question 11

Obstructive Sleep Apnea

Definition:

Answer 11

Obstructive Sleep Apnea (OSA) is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns.

Airflow stops but patient will have continued respiratory effort

Question 12

Obstructive Sleep Apnea:

Symptoms

Answer 12

Symptoms of OSA include:

general symptoms of sleep disturbances (impaired mental function, memory difficulties, etc)

+

Erectile dysfunction

nocturnal gastroesophageal reflux disease (heartburn)

Question 13

Obstructive Sleep Apnea

increases the risk for:

Answer 13

OSA is associated with an increase risk for:

Cardiovascular disease

arrhythmias (atrial fibrilation)

hypertension

Stroke (secondary to clots formed during atrial fibralation)

death (caused by stroke)

increased glucose levels

Question 14

Obstructive Sleep Apnea

Pathophysiology:

Treatment:

Answer 14

OSA occurs when the tongue and jaw fall back and block the upper airway. It can be a partial collapse (hypopnea) or a complete collapse (apneas)

Treatment:

CPAP or BiPAP

Oral appliances (keep jaw and tongue from blocking airway)

weight reduction (usually very helpful)

Surgery

Question 15

Narcolepsy:

Clinical Features:

Answer 15

Clinical Features of narcolepsy include

Excessive sleepiness (100% of patients. Sleepiness is not relieved by adequate sleep)

Disturbed Nocturnal Sleep: fragmented sleep, unexplained arousals

Sleep Paralysis: inability to move when first falling or waking up from sleep

Hypnogogic Hallucinations: very vivid dreams during the transition from wake to sleep

Cataplexy: inappropriate intrusion of REM atonia during wakefullness brought about by emotion (rag doll)

Question 16

Narcolepsy:

Pathophysiology

Diagnosis

Answer 16

Narcolepsy

Narcolepsy is caused by a lack of hypocretin neurons of the lateral hypothalamus and low CSF hypocretin levels

Narcolepsy is diagnosed with evidence of:

shortened REM latency (the time it takes from falling asleep to entering REM <60 minutes) and fragmented sleep and

short mean sleep latency (<8 minutes) and REM present in at lease 2+ naps during a multiple sleep latency test.

Question 17

Narcolepsy

pathophysiology:

Diagnosis:

Answer 17

Narcolepsy

Pathophysiology: lack of hypocretin neurons of the lateral hypothalamus or Low CSF hypocretin levels (possibly autoimmune disorder)

Diagnosis: All night polysomnogram with evidence of shortene REM Latency (time from going to sleep to entering REM sleep. <60 minutes)

Question 18

Narcolepsy:

Treatment for:

excessive sleepiness:

cataplexy:

Answer 18

Treatment for narcolepsy includes frequent naps (every 4 hours), regular sleep-wake schedule, good sleep hygine, avoiding changes in time zones, career counseling (avoid night shift work), and discussion of driving restrictions- if applicable.

Excessive Sleepiness: CNS Stimulants (methylphenidate, amphetamine)

Cataplexy: tricyclic Antidepressants, SSRIs, Sodium Oxybate

Question 19

Restless Leg Syndrome:

Periodic Limb Movements:

Treatment:

Answer 19

Restless Leg Syndrome: clinical diagnosis made primarily on subjective reports by the patient

Periodic Limb Movements: An objective polysomnographic finding. Repetitive, stereotyped dorsiflexion of the big toe with fanning of the other toes, flexion of the ankle, knee, and thigh. Movements are at pretty regullar intervals, seperatd by 5-90 seconds

Treatment: treathment for both RLS and PLM are dopamine agonists

Question 20

Restless Leg Syndrome

Core Symptoms:

Supportive features

Answer 20

Restless Leg Syndrome

“URGE”- Urge to move limbs accompained by uncomfortable, unpleasant feeling in the limbs, Rest or inactivity precipitates symptoms, Getting up and moving improves them, Evening or nighttime is associated with worsening symptoms

Supportive features: family history (1st degree relatives), response to dopaminergic therapy

Question 21

Restless Leg Syndrome:

Precipitating Factors:

Answer 21

Precipitating factors for RLS:

iron deficiency (low serum ferritin)

pregnancy

renal failure

peripheral neuropathy

Medication (antidepressants, antihistamines, antiemetics)