Day 2 - Neuro3 Sleep/LOC Flashcards
Sleep patterns depressed v. elderly
Depressed - decreased sleep slow wave (less stage 3 and 4), more REM, decreased REM latency (hitting REM early on); Elderly - opposite in terms of REM - less REM & increased REM latency, also have decreased slow wave (less stage 3 and 4)
Nightmares vs. Night terrors
Nightmares - REM sleep, patients appear to wake up & actually awake; Night terrors - not during REM but slow wave, deep (stage 3 or 4) sleep, appear to wake up but not really awake, elevated autonomic (tachycardic, diaphoretic)
Pickwickian syndrome
Obesity hypoventilation syndrome, characterized by hypersomnolence (not breathing/sleeping well at night), excessive daytime sleepiness, dyspnea, hypoxemia, resulting in cyanosis, polycythemia, & plethora as well as pHTN (Right heart failure may also result & cause edema)
Dx narcolepsy criteria
(1) Cataplexy (sudden loss of muscle tone, diagnostic when present) (2) Other causes of excessive daytime sleepiness r/o’d - Overnight polysomnogram r/o OSA & periodic limb movement, r/o sedating meds, multiple sleep latency test (narcolepsy 45 opportunities to nap every 2 hrs, fall asleep in less than 8 min, may also be present in chronic sleep deprivation)
Tx Narcolepsy
Avoid sedating meds (e.g., alcohol, benzos, anticonvulsants); Scheduled naps 1-2x day for 10-20 min; Stimulants - Modafenil (Provigil) is first-line, may use ADHD stimulants; Support group; In case of cataplexy, Venlafaxine, Fluoxetin, or Amoxetine
Tx insomnia
(1) Melatonin - naturally secreted by pineal gland to help w/ circadian rhythms, warn patients may have vivid dreams, safe for 3 mo. (2) Valerian - herb, may be placebo effect (3) Antihistamines - diphenhydramine (Tylenol PM), doxylamine, assoc. w/ poor sleep quality, not for long-term use, anticholinergic side effect so avoid in elderly and/or demented patients (4) Trazodone - antidepressant, increase REM sleep, small risk of priapism, small dose may be used for just insomnia w/o depression (5) TCAs - Amitriptyline, Doxepin, antidepressants, small risk of arrhythmias (may get EKG prior to use), anticholinergic s/e so avoid in elderly/demented - Nortriptyline less than Amitriptyline (6) Long-acting benzos - Temazepam, Lorazepam, Clonazepam, Diazepam, Chlordiaxepoxide, only short-term no more than 35 days, decrease slow wave/deep sleep (7) Zolpidem (Ambien), Zaleplon (Sonata) - work at benzo receptor, short-term, rebound insomnia when d/c, depressed pt need something to sleep before antidepressant starts working in 2-4 weeks - may use thse (8) Eszopiclone (Lunesta) - long-term (9) Ramelteon (Rozerem) - non-addictive, melatonin receptors, NOT w/ liver disease (metabolized by liver)
Restless leg syndrome p/w
Sensation of unpleasant paresthesias compels patient to have voluntary but spontaneous, continuous movements that temporarily relieve sensation; Discomfort works at rest, evening, & during sleep; Described as sensation of ants or spiders being in or on calf muscles;
Cause of restless leg syndrome
Usually primary idiopathic, but may result from iron def, ESRD, diabetic neuropathy, Parkinson’s, pregnancy, rheumatic diseases, varicose veins, or caffeine intake
Tx restless leg syndrome
Dopamine agonists - Levidopa/Carbidopa, Pramipexole, Ropinirole (like Parkinson’s Disease); Iron replacment, Avoid caffeine; Benzo, Gabapentin, or last line, Opioid if refractory to dopamine agonists
Causes of syncope
Decreased cerebral perfusion: (1) Reflex syncope - vasovagal (emotional stress, trauma, pain, site of blood, prolonged standing) or situational (micturition, defecation, coughing, GI stimulation) (2) Carotid sinus hypersensitivity - head turning, shaving, tight collar; Cardiogenic - exertion, palpations, chest pain, or SOB; Orthostatic - stand up bp drops, dx tilt test or bp orthostatics; Cerebrovascular - prolonged loss of consciousness, seizures, neuro defects; No cause found in at least 20%
W/U syncope
History; Tilt test or orthostatics; R/o seizure: H & P, history of seizures, prodrome/de javu/aura, postical confusion, tongue lacerations; Syncope - prodrome of lightheadness, history of prolonged standing, non-specific brief limb jerking and urinary incontinence also; CBC, lytes, glucose (hypoglycemia), volume status, pulse ox, EKG (r/o arrhythmias, cardiac cause), meds; R/o carotid sinus hypersensitivity via massage (not do if known carotid artery disease); Consider: Serial cardiac enzymes, serial EKGs, echo (especially if murmur, exertion related, or history of heart disease), cardiac stress (especially if older), b/l carotid duplex, holter monitor, CT head
DDx LOC
AEIOU TIPS: Alcohol, Epilepsy/Environment (e.g., hypo/hyperthermia), Insulin (too much or little), Opioids/Overdose, Uremia, Trauma, Infx, Psychogenic, Stroke
Empiric tx for LOC
Check glucose, may give glucose for presumed hypoglycemia; Thiamine prior to glucose; Naloxone for presumed opioid ovedose.
Thiamine given before glucose infusion to alcoholics w/ hypoglycemia
Glucose w/o thiamine can exacerbate damage to mamillary bodies and worsen wernicke encephalopathy
