Insomnia & Sleep Disorders

Question 1

how many cycles of REM & NREM occur throughout the night

Answer 1

4-6 cycles with each cycle being 70-120 minutes

Question 2

describe generally the stages of sleep

Answer 2

1 NREM: transition between awake/sleep
2 NREM: light sleep, HR, RR slow down
3-4 NREM: delta sleep/deep sleep
REM: eye movements, dreaming occurs

Question 3

how long after falling asleep does REM occur

Answer 3

90 minutes

Question 4

changes in sleep from infant to older adult

Answer 4

infant: 20 hours/day, differentiation btwn REM/NREM occurs at 3-6 months, circadian patterns by age 3
child: delta sleep declines & REM increases
midlife: gradual decline in sleep efficiency & time
older: lighter, fragmented sleep, intermittent wakeups

Question 5

what are the transmitters that promote WAKEFULNESS

how do we target them to treat sleep disorders

Answer 5

norepinephrine
orexin
dopamine
histamine
substance P

target with antagonists

Question 6

what are the transmitters that promote SLEEPINESS

how do we target them to treat sleep disorders

Answer 6

GABA
adenosine
melatonin

target with agonists

Question 7

diagnostic criteria of insomnia

Answer 7

occurs at least 3 nights per week

present for at least 3 months

not better explained by another sleep disorders

Question 8

definition of sleep onset insomnia

Answer 8

sleep latency 20-30 minutes

Question 9

definition of sleep maintenance insomnia

Answer 9

inability to stay asleep through the night, struggling to get back to sleep for 20-30 minutes

Question 10

who has a higher incidence of insomnia

Answer 10

women, elderly, unemployed, widowed, low socioeconomic status

Question 11

who rarely has insomnia

Answer 11

kids

Question 12

which type of insomnia is more common in younger adults

Answer 12

sleep onset insomnia

Question 13

which type of insomnia is more common in older adults

Answer 13

sleep maintenance insomnia

Question 14

which medications can cause insomnia

Answer 14

narcotics: opioids
CV meds: BBs, statins, diuretics, alpha ags/antags
antidepressants: SSRI, MAOI,SNRI
steroids
stimulants: caffeine, MPH, adderall, cocaine
decongestants: sudafed
respiratory meds: albuterol, theophylline
alcohol

Question 15

define short term insomnia

Answer 15

persisting <3 months

Question 16

define chronic insomnia

Answer 16

persisting>3 months

Question 17

nonpharmacologic options for insomnia

Answer 17

CBT, sleep hygiene

Question 18

name 5 classes of drugs that can be used for insomnia

Answer 18

benzodiazepines
z drugs
melatonin receptor agonist
orexin receptor antagonist
TCA (doxepin)

Question 19

which prescription drugs are NOT recommended for insomnia

Answer 19

trazodone
mirtazapine
TCAs
atypical antipsychotics

Question 20

which OTC drugs are NOT recommended for insomnia

Answer 20

diphenhydramine, doxylamine
melatonin, valerian, chamomile

Question 21

which benzos are used for sleep

Answer 21

quazepam
estazolam
flurazepam
temazepam
triazolam

Question 22

what are the z drugs

Answer 22

zolpidem
eszopiclone
zaleplon

Question 23

which drug is a melatonin receptor agonist

Answer 23

ramelteon

Question 24

which drugs are orexin receptor antagonists

Answer 24

suvorexant
lemborexant
daridorexant

Question 25

when are orexin receptor antagonists contraindicated

Answer 25

narcolepsy

they can cause sleep paralysis, cataplexy, narcolepsy-like symptoms

Question 26

doxepin pearls

Answer 26

a TCA unique in having H1 antihistaminic activity that can be used for sleep maintenance

Question 27

define obstructive sleep apnea

Answer 27

collapse or obstruction of upper airway, repetitive episodes of cessation of breathing during sleep following by blood oxygen desaturation & brief arousal from sleep to restart breathing

Question 28

obstructive sleep apnea risk factors

Answer 28

male, obese, CHF, AFib, HTN, T2DM, stroke, neck circumference

Question 29

questionnaire used for obstructive sleep apnea

Answer 29

STOP BANG
snoring, tired, observed, blood Pressure, BMI, age, neck circumference, gender

Question 30

symptoms of sleep apnea

Answer 30

loud disruptive snoring, witnessed apneas during sleep, excessive daytime sleepiness

Question 31

nonpharm treatments for sleep apnea

Answer 31

weight reduction, surgery, positional therapy, oropharyngeal exercise, palatal implants, CPAP or BiPAP

Question 32

what is the standard treatment for obstructive sleep apnea

Answer 32

positive airway pressure (PAP)

Question 33

pharm treatment for obstructive sleep apnea

Answer 33

none

Question 34

medications to avoid with obstructive sleep apnea

Answer 34

CNS depressants, agents that promote weight gain, medications that cause rhinopharyngeal inflammation or cough

Question 35

risk factors for restless legs syndrome

Answer 35

female, family, genetics

Question 36

common cause of secondary restless legs syndrome

Answer 36

iron deficiency

Question 37

nonpharm for restless legs syndrome

Answer 37

correct iron deficiency if applicable
avoid caffeine/alcohol
exercise
warm or cool packs
foot wrap or vibrating pad

Question 38

pharm options for restless legs syndrome

Answer 38

dopamine agonists: ropinirole, pramipexole, rotigotine
gabapentin enacarbil

off label: opioids, pregabalin, carbamazepine, clonidine

iron supplements only in those with iron deficiency

Question 39

meds for sleep onset only

Answer 39

ramelteon
triazolam
zaleplon

Question 40

meds for sleep maintenance only

Answer 40

doxepin