Insomnia Flashcards
Bell Regulations: New York State Health Code include which 6 stipulations?
1) 12-hr work limits for residents and attendings in ED
2) work periods not > 24 hrs consecutively in areas other than ED
3) Scheduled work week for resident physicians not exceeding an avg of 80 hrs/wk over a 4-wk period
4) At least one 24-hr period of nonworking time per week
5) 24 hr supervision of acute care inpatient units by experienced attendings
6) improved working conditions and ancillary support for resident physicians
How common is insomnia?
occurs in at least 1/3 of all adults at some time in their lives.
Which waves are seen on EEG when an awake person relaxes with closed eyes and becomes drowsy?
-alpha waves over occipital and parietal lobes
W/ active mental concentration, what does the EEG show?
-w/ active mental concentration, beta waves over the frontal lobes predominate
What are the 2 major physiological states in normal sleep?
rapid eye movement (REM) –> fast-wave EEG activity
nonrapid eye movement (NREM) sleep –> 4 stages ofincreasing depth and slowing of EEG
What makes up approx 75% of total sleep time?
Non-REM sleep -slow eye movements, high amplitude, low-frequency brain waves, increased muscle tone
Explain the 4 stages of Non-REM sleep (makes up up to 75% of total
Stage 1: 5% of total sleep; low voltage theta wave activity; stage 1 quickly changes to stage 2
Stage 2: spindle-shaped waves (sleep spindles) & slow, high amplitude groups of waves called K-complexes; 45% of sleep time; tooth grinding (bruxism)
Stages 3&4: slow wave or delta sleep; delta sleep takes up about 25% of sleep time and occurs mainly during the first 1/2 of the sleep cycle; delta is the deepest part of NREM sleep and can be associated with unusual behaviors (sleepwalking, night terrors, bed wetting)
In which stage of sleep does teeth grinding aka bruxism occur?
Stage 2: K complexes
In which stage of sleep does unusual behaviors (sleep walking, bed wetting, night terrors) occur?
In the deepest part of NREM sleep, stages 3 & 4 characterized by delta waves.
REM sleep is characterized by rapid eye movements, decreased muscle tone, low amplitude, high freq brain waves that form a tracing that resembles what? REM sleep occurs in the latter half of sleep cycle and is associated with?
sawtooth waves
associated with high levels of brain activity and dreaming
NREM or REM: people in which sleep stage are less likely to be woken by external stimuli but are more likely to wake spontaneously?
REM sleep
People normally experience about how many minutes of REM periods, and how often?
The avg time to first REM period after falling asleep (REM latency) is 90 min. Then, ppl normally experience periods of 10-40 min of REM, each occurring about every 90 minutes thru out the night.
REM sleep is characterized by suppression of sympathetic activity as shown by?
miosis (pupil constriction), penile and clitoral erection
but body is essentially paralyzed during REM sleep
What is REM sleep behavior disorder (RBD)?
rare condition that includes episodes of REM w/o muscle atonia. The resulting physical activity associated with dreaming or nightmares –> pts harming themselves or sleep partners during REM sleep.
REM sleep behavior disorder has been associated in some patients with development years later of which 2 conditions?
Parkinson’s disease
Lewy body dementia
What is REM rebound?
increase in REM sleep due to people being deprived of sleep. This shows that REM sleep and dreaming are impt in learning and memory consolidation (only a theory)
Explain sleep architecture
sleep goes thru 4 stages of NREM then reverses back to stage 1, followed by REM. Abt 5-6 cycle of NREM sleep with an REM period occur per night
Explain how aging affects sleep architecture
neonates -sleep 16 hrs per day; 50% in REM
young adulthood -REM is 25%
seniors -combination of changes –> nonrestful sleep and daytime tiredness (prolonged sleep latency, further reduction in REM sleep, decreased total sleep time, decreased delta sleep, increased nighttime awakenings)
How does depression affect sleep architecture?
depressed pts:
- normal sleep latency of less than 20 min or prolonged sleep latency
- short REM latency
- increased REM early in sleep cycle
- decreased REM later in sleep cycle
- Long first REM
- increased total REM
- decreased delta
- increased nighttime awakenings
(shift in REM from last to first part of sleep cycle, long first REM period, reduced slow wave sleep, shortened REM latency, greater percentage of REM)
What is fatal familial insomnia?
rare disorder due to mutations in the prion protein gene leading to degeneration of thalamus, which is associated with arousal and consciousness. This results in complete inability to sleep, followed by dementia. It is fatal within 1-2 years.
Which NTs promote sleep?
Serotonin (increase serotonin –> increase total sleep time and delta sleep) and acetycholine (induces REM sleep)
what are some symptoms of extended sleep deprivation?
- initial confusion
- agitation
- aggression
- loss of touch with reality including delusional thinking
Conditions associated with decreased acetylcholine, such as normal aging and Alzheimer’s, what happens to REM sleep, total sleep time and delta sleep?
they all decrease
What are NE and DA effects on sleep?
NE and dopamine promote arousal and wafefulness. Increased levels of NE may increase sleep latency and decrease both total sleep time and the percentage of time spent in REM sleep. Increased dopamine is associated with decreased total sleep time.
What is glutamate’s effects on REM sleep?
Glutamate enhances REM sleep and is particularly associated with producing REM sleep’s characteristic muscle atonia
Two major categories of sleep disorders are? Define them and which one is more common?
1) Dyssomnias (most common): problems in the timing, quality, or amt of sleep (e.g. insomnia, sleep apnea, narcolepsy, restless leg syndrome, circadian rhythm sleep disorder…)
2) Parasomnias: abnormalities in physiology or in behavior associated with sleep (e.g. bruxism, nightmare disorder, sleep terror disorder, sleepwalking, REM sleep behavior disorder (RBD))
What are characteristics of insomnia?
- difficulty falling asleep or staying asleep
- present for AT LEAST 1 month and leads to daytime sleepiness or problems fulfilling social or occupational obligations
how to manage insomnia?
- avoid caffeine
- develop a sleep ritual
- maintain a fixed sleep and wake schedule
- relaxation techniques
- non-benzodiazepine sleep agents (Zolpidem (Ambien))
What are characteristics of breathing-related sleep disorder (i.e. sleep apnea)?
A Dyssomnia
- cessation of breathing for periods during sleep
- leads to anoxia and nighttime awakenings
- results in chronic daytime sleepiness
How to manage breathing related sleep disorder like sleep apnea?
A Dyssomnia
- weight loss (if overweight)
- continuous positive airway pressure
- surgery to enlarge the airway
- respiratory stimulates
What are characteristics of nacrolepsy?
A Dyssomnia
-episodes of sudden daytime sleepiness that occur daily for at least 3 months despite a normal amount of sleep at night
How to manage narcolepsy?
A Dyssomnia
- stimulant agents
- scheduled, timed daytime naps relieve sleepiness
What are characteristics of primary hypersomnias (e.g. Kleine-Levin syndrome & menstrual-associated syndrome)?
A Dyssomnia
- recurrent bouts of excessive sleepiness occurring almost daily for at least 1 month
- sleepiness is not relieved by daytime naps
- often accompanied by hyperphagia (overeating)
What are characteristics of circadian rhythm sleep disorder?
Explain the delayed sleep phase type, the jet lag type and the shift work type.
A Dyssomnia
-sleepiness at inappropriate times during the day because of inability to sleep at appropriate times
- delayed sleep phase type: falling asleep and waking later than desired
- jet lag type: lasts 2-7 days after a change in time zone
- shift work type: changes in scheduled work hours that cause mixed insomnia and sleepiness, leading to errors in performance at work and home.
How to manage circadian rhythm sleep disorders? Be specific to the type.
A Dyssomnia
Delayed sleep phase type: gradually push back the hour of going to sleep
Jet lag type: change sleep and meal times prior to travel to conform to those of the destination
Shift work time: bright light therapy during daytime and consistent observation of new bedtime hours.
What are characteristics of Restless Legs Syndrome?
A Dyssomnia
- uncomfortable sensation in the legs (and sometimes arms) needing frequent motion
- causes insomnia and repetitive limb jerking during sleep
- more common with aging, pregnancy, and kidney disease
- assoc with dopamine deficiency in subcortical brain areas; iron deficiency, which disrupts dopamine production in brain, and low magnesium
How to manage Restless Legs Syndrome?
A Dyssomnia
dopaminergic agents (levodopa)
iron supplements
magnesium supplements
What are characteristics of Sleep drunkenness?
A Dyssomnia
- difficulty awakening fully after adequate sleep
- rare, associated with genetic factors
- must be differentiated from substance abuse or other sleep disorder
How to manage sleep drunkenness?
A Dyssomnia
stimulant agents
What are some characteristics of nocturnal myoclonus?
- repetitive, abrupt, muscular contractions in the legs from toes to hips causing nighttime awakenings
- more common in the elderly
How to manage nocturnal myoclonus?
A Dyssomnia
benzos
quinine
L-dopa
opiods
What’s a common cause of insomnia?
caffeine use
What are characteristics of bruxism, a parasomnia?
- tooth grinding
- occurs primary in stage 2 sleep (k waves)
- can lead to tooth damage and jaw pain
How to manage bruxism, a parasomnia?
- dental appliance worn at night
- corrective orthodontia
What are characteristics of nightmare disorder, a parasomnia?
-repetitive, frightening dreams that occur during REM sleep and are recalled on nighttime awakenings
How to manage nightmare disorder?
pharmacologic agents that suppress REM sleep like tri-cyclic antidepressants and benzodiazepines
What are characteristics of sleep terror (pavor nocturnus) disorder?
- repetitive experiences of fright in which a person (usu. a child) screams in fear but cannot be awakened and has no memory of having a dream
- occur during delta (slow-wave) sleep
- onset in adolescence may presage temporal lobe epilepsy
How to manage sleep terror disorder?
pharmacologic agents that suppress delta sleep like benzodiazepines
What are characteristics of sleepwalking disorder, a parasomnia?
- repetitive walking during sleep
- no memory of the episode on awakening
- beings in childhood (usu. 4-8 years of age)
- has a genetic component
- is associated with enuresis
How to manage sleep walking disorder?
pharmacologic agents that suppress delta sleep like benzodiazepines
What are characteristics of REM sleep behavior disorder (RBD), a parasomnia?
- REM sleep and dreaming without skeletal muscle atonia
- highly active sleeping patients can harm themselves and their sleeping partners.
How to manage RBD?
- anticonvulsants (carbamazepine)
- pharmacologic agents that suppress REM sleep (benzodiazepines)
- associated with parkinson’s disease –> treat with antiparkinson agents.
Why are the newer non-benzodiazepines (e.g. zolpidem, zaleplon) better at treating insomnia than sedative agents like barbiturates and benzodiazepines?
Sedative agents cause daytime sedation, dependence and tolerance, reduced REM sleep and delta sleep, which can exacerbate pt’s sleep problems. Nonbenzodiazepine sleep agents cause fewer changes in sleep architecture and are less likely to cause dependence and tolerance.
Tylenol PM is over-counter sleep product. What’s in tyelonol PM?
antihistamine agents, such as diphenhydramine + acetaminophen
Anti-histamine can be used along with acetaminophen to treat insomnia, but why shouldn’t it be drug of choice for elderly?
b/c antihistamine can cause delirium
instead a better choice is a sedating antidepressant like trazodone
In patients, without significant psychopathology, the initial management strategy for insomnia is?
avoidance of caffeine
Insomnia management also involves developing a sleep ritual/sleep hygiene, which involves developing a set of behaviors that become associated with bedtime, such as?
- taking a warm bath
- listening to music
- developing and following a fixed sleep schedule
- daily exercise
- relaxation techniques
What are the 2 types of sleep apneas?
1) central sleep apnea –> airway is open but little or no respiratory offer occurs.
2) obstructive sleep apnea –> respiratory effort occurs, but an airway obstruction prevents air from reaching the lungs (more common)
What is Pickwickian syndrome?
related condition to sleep apnea in which daytime sleepiness results from airway obstruction. seen in ppl with central obesity, and a short, fat neck, a body
When compared with normal patients, narcoleptics experience longer or shorter sleep latency, normal or abnormal REM sleep, increase or decrease in total REM?
narcoleptics experience the same amount of total nighttime sleep but demonstrate:
- decreased sleep latency (< 2 min)
- abnormalities in REM sleep (short REM latency, reduced total REM, interrupted REM periods, sleep fragmentation)
so narcolepsy is characterized by intrusion of characteristics of REM sleep
What is cataplexy (a symptom in narcolepsy)?
sudden physical collapse caused by loss of all muscle tone after a strong emotional stimulus, such as anger, laughter or sexual stimulation
What is sleep paralysis (a symptom in narcolepsy)?
an alarming symptom identified by the inability to move the body for a few seconds after waking.
In which stage of sleep will you find episodic body movements, sleep walking, night terrors and enuresis?
Delta waves so stages 3 and 4
In which type of sleep do you find clitoral erection, paralysis of skeletal muscles, nightmares and increased brain oxygen?
during REM sleep
How many nights per week for how long does a person experience sleep disturbances to be diagnosed with insomnia witht he DSM5 criteria?
disturbance occurs at least 3 nights per week and is present for at least 3 months
Endogenous causes of insomnia: list the NTs that are in excess and are deficient at night.
-excitatory NTs in excess at night NE from locus ceruleus 5-HT from raphe nucleus DA from ventral tegmental area HT from tuberomammillary nucleus
-inhibitory NTs deficiency at night
Loss of GABA tone
Loss of melatonergic tone
Loss of adenosinergic tone
What are some physical exogenous causes of insomnia
- use of CNS stimulants (caffeine)
- withdrawal of sedating agents (alcohol, barbiturates, benzos)
- Medical conditions (chronic pain, pulmonary disease, endocrine disorders)
In addition to major depressive disorders, what other 2 mental disorders that can affect sleep?
1) bipolar disorder -manic and hypomanic pts have problems falling and maintaining sleep
2) generalized anxiety disorder/PTSD -trouble falling asleep/nightmares
Explain what anxiety does to cause insomnia.
anxiety can cause insomnia then the person will also start feeling anxious about the insomnia causing a bad cycle which will cause their brain to be in a more vigilant, wakeful state. This is conditioned that a stimulus and response relationship exists (I get in bed, therefore i am wide awake and worried about falling to sleep)
The first step of managing insomnia is diagnosis, informed consent and education. The second is behavioral counseling involving sleep hygiene rules and stimulus controls. List the 5 stimulus controls
- go to bed only when sleepy
- do not watch TV, read, eat or worry while in bed. use bed only for sleep and sex
- get out of bed if unable to fall asleep w/in 20 minutes and go to another room. Return to bed only when sleepy. Repeat this step as many times necessary throughout the night.
- set an alarm clock to wake up at a fixed time each morning including weekends
- do not take a nap during the day.
After 1st step (diagnosis, informed consent, and education) and second step (behavioral counseling) in treating insomnia, the 3rd step involves which 3 therapies?
- sleep restriction therapy
- cognitive therapy (talking through, imagery)
- behavioral therapy (diary/log book, progressive relaxation, self hypnosis)
The last and fourth step in treating insomnia after diagnosis, informed consent, education, behavorial counseling (sleep hygiene/stimulus control), sleep restriction therapy, cognitive therapy, behavioral therapy is?
pharmacotherapy, which is a stepwise approach, starting with non-addicting meds first like OTC agents (melatonin, antihistamines. Then, escalate as needed from non-habiting forming to mild habit forming to habit forming.
Explain the pharmacokinetics of drugs that aid in inducing sleep/treating insomnia. Comment on absorption, half life
- faster absorbed allows faster sleep onset
- shorter half life allows for the drug to leave your system by morning but risks less hours of sleep
- longer half life allows for longer sleep, but greater chanc eof being under the influence in the morning.
In treating insomnia with medications, one has to decide if patients will be medically compromised. What should apnea patients NOT get? Patients with restless legs should get?
Apnea must not get sedatives
Restless legs get D2 agonists
T/F: Always address underlying medical, psychiatric or environmental causes of insomnia and treat those first
True
