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B&B Week 5 Flashcards > Lecture 13: Sleep Medicine Part II, Neurologic Sleep Disorders > Flashcards

Lecture 13: Sleep Medicine Part II, Neurologic Sleep Disorders Flashcards

1
Q

What are the 3 cardinal symptoms of patients presenting to a sleep clinic?

A
  1. Excessive sleepiness
  2. Insomnia
  3. Nocturnal movement or behaviors
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2
Q

What is Excessive Sleepiness?

A

“I can’t stay awake”

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3
Q

What are the DDx for excessive sleepiness?

A
  1. NARCOLEPSY
  2. Sleep apnea
  3. Insufficient sleep
  4. Medication effect
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4
Q

What is insomnia?

A

“I can’t sleep or stay asleep”

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5
Q

What are the DDx for insomnia?

A
  1. Mood disturbance
  2. Circadian Rhythm Disturbance
    Delayed-sleep phase = night owls
  3. RESTLESS Legs/Periodic Limb Movement of Sleep
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6
Q

What are examples of Nocturnal movements or behaviors?

A

“I do [or feel] unusual things at night”

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7
Q

What are DDx for unsual movements or behaviors

A
  1. PARASOMNIA emerging from REM or non-REM
  2. Nocturnal Seizure
  3. Movement Disorder
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8
Q

What are the clinical tools to measure sleep disorder?

A

Polysomnography = sleep monitoring
Sleep logs
Actigraphy = looks like a wrist watch and measures motion
Lab assessment, physical exam, detailed history

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9
Q

What are the cardinal symptoms of Narcolepsy? Known as “The Tetrad”

A
  1. Hypersomnolence
    • excessive daytime sleepiness and involuntary dozing-
  2. Cataplexy
    • brief moments of weakness triggered by EMOTION like laughter, anger or surprise
  3. Hypnogogic/hypnopompic hallucinations
    • vivid dreams
  4. Sleep paralysis
    • loss of muscle tone when you wake up/are about to fall asleep
  5. Sleep quality is also often impaired
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10
Q

If someone goes into REM sleep in two naps during the day, she or he has

A

Narcolepsy

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11
Q

What is a delineating factor of narcolepsy?

A

Boundaries between wakefulness and REM sleep are not well-maintained
Sleep architecture is disrupted across the 24 hour period
-mean sleep latency = 2.3 minutes
-REM sleep in 3 of 4 naps (shouldn’t be going into REM during naps)
-Sleep paralysis in nap 2

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12
Q

What is cataplexy?

A
  1. Sudden loss of muscle tone
  2. Triggered by emotion, especially laughter
  3. Consciousness spared
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13
Q

What is the epidemiology of narcolepsy?

A

USA = .05% prevalence

Presents in 2nd to 4th decade with bimodal distribution

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14
Q

What is the pathophysiology of narcolepsy?

A

Hypocretinergic neurons from postero lateral hypothalamus project widely to areas of brain involved in sleep-wake control
-hypocretin is diminished or ABSENT in narcolepsy with cataplexy

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15
Q

What is Hypocretin (orexin)?

A

A neuropeptide produced in the posterolateral hypothalamus

  • hypocretinergic neurons project widely to areas of brain involved in sleep-wake control
  • decerased/absent in narcoleptic patients
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16
Q

What is the Flip-flop switch model?

A

AWAKE: orexin stimulates Locus coeruleus, TMN (tuberomammillary nucleus) and raphe nuclei; inhibits VLPO
Sleep: VLPO inhibits orexin and LC, TMN, raphe nuclei; VLPO induces sleep

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17
Q

What is VLPO? Location?

A

VentroLateral Preoptic Nucleus

Located in the hypothalamus

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18
Q

What are the three states of wakefulness? Significance?

A
  1. REM sleep
  2. non REM sleep
  3. Awake
    Significance: symptoms of several sleep disorders including narcolepsy can be modeled as an overlap between sleep-wake states
    Example: narcolepsy = Wake/REM combinations
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19
Q

Is hypocretin used as a diagnostic tool for narcolepsy?

A

No (Cat)

20
Q

What is the treatment for narcolepsy?

A
  1. Hypersomnolence
    -stimulants
    -modafinil/armodafinil (Provigil)
    -naps
  2. Cataplexy
    -Tricyclic antidepressants
    -SSRIs
    -gammy hydroxybutyrate (Xyrem…date rape)
    Stimulant + sedatives??
21
Q

What is one characteristic of Narcolepsy?

A

Is associated with decreased brain hypocretin level

22
Q

What is parasomnia?

A

An undesirable behavioral, motor or sensory phenomenon which occurs intermittently during sleep
-some parasomnias may be considered normal like nightmares
-can emerge from REM or REM sleep
-people don’t remember it
Symptom that is an intersection of Wake, REM and non-REM
Example: sleep walking and doing shit like getting arrested for urinating in a dorm hallway while in sleep

23
Q

When someone displays behavioral/motor/sensory phenomenon during sleep, to what extent can another person reach that sleeper?

A

No, the person who is acting out dreams does not respond to external stimuli (unless stimuli is enough to awaken him or her)

24
Q

What are types of normal parasomnia?

A
  1. Sleep-talking

2. Nightmares

25
Q

Patients who sleepwalk

A

Typically have minimal recall of their episodes the following day

26
Q

What percentage of adults sleepwalk? Sleep terrors?

A

1-2%
15-30% of children (once)
Jennifer Anniston lol
Sleep terrors – 1-6%, peaks at 5-7

27
Q

What are disorders of arousal or abnormal parasomnia?

A
  1. Confusional arousals
  2. Sleepwalking
  3. Sleep terrors
    • sympathetic response and is unaware of external stimuli
28
Q

What are the key characteristics of disorders of arousal?

A

Origin in non-REM (slow wave) sleep
Lack of recall
Positive family history common

29
Q

How do you treat sleep walking?

A
  1. Reassurance, secure environment
  2. Warning device
  3. Avoid shit like ETOH, stresss or insufficient sleep
  4. Benzodiazepines
30
Q

Patients who sleep walk

A

typically have minimal recall of their episodes the following day

31
Q

What is REM sleep behavior disorder?

A

A dissociated state characterized by
-violent dream-enacting behavior by history or polysomnogram
-increasing tonic or phasic EMG in REM sleep
-absence of epileptiform activity
Presents with resting tremor!

32
Q

What is the etiology of REM sleep behavior disorder?

A 
Idiopathic
Narcolepsy
Overlap with non-REM parasomnia
Neurodegenerative disease
Medications
Disrupted REM sleep
33
Q

What is epidemiology of chronic RBD?

A

87% MALE
Mean age = 52 years
Prodrome in 25% at 22 years

34
Q

What are comorbidities of RBD?

A
  • parkinson’s
  • Lewy Body Dementia
  • multi-system atrophy
35
Q

How do you treat RBD?

A
  1. Clonazepam (90% effective)
  2. Melatonin
  3. secure environment
36
Q

What is sleep apnea?

A

A sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep

37
Q

RBD typically presents

A

in patients in their fifties and sixties

38
Q

What are Restless legs?

A

n AWAKE sensory phenomenon with a volitional (voluntary) motor response

39
Q

What are Periodic limb movements?

A

An INVOLUNTARY SLEEP-related motor phenomenon

40
Q

How do you diagnose RLS?

A 
URGE
Urge to move the legs usually with dysesthesias
	-Dysesthesias: abnormal sensation
Onset with Rest or inactivity
Getting up = relief with movement
Evening = time of day when it is worse
41
Q

What is epidemiology of RLS?

A

6-15% of adults
Prevalence increases with age
Early onset RLS more likely idiopathic/familial
Late onset = secondary and more rapidly progressive

42
Q

What causes secondary RLS? Exacerbating factors?

A
  1. Iron deficient anemia
  2. Pregnancy
  3. Chronic renal failure
    Caffeine, poor sleep, stress can exacerbate RLS
43
Q

What is the pathophysiology of RLS?

A

Thought to be
Impaired central dopaminergic transmission
May be caused by less iron in brain
Funcitonal expression of the impairment appears to be reduced supra-spinal inhibition

44
Q

What is the link between restless leg syndrome and periodic limb movement?

A

Both may represent state-dependent reduction of supra-spinal inhibition
Affecting sensory afferents = RLS
Affecting motor efferents = PLM
RLS does not necessarily have to correlate with PLMS because a lot of PLMS patients don’t have RLS…although 80% of RLS patients have periodic limb movement

45
Q

What is the treatment for RLS?

A 
Dopamine agonists
Opiates
Gabapentin
Iron
Benzodiazepines
46
Q

RLS is best characterized as?

A

an urge to move legs which is temporarily relieved with movement

47
Q

When you see a patient with RLS, what blood tests should order?

A

Look at their iron levels!

Low iron levels could precipitate RLS

B&B Week 5 Flashcards (13 decks)

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