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(C) BD > Lecture 19: Sleeping Disorders > Flashcards

Lecture 19: Sleeping Disorders Flashcards

1
Q

What are the two physiologic states of sleep?

A
  • NREM sleep: stages 1-4.
  • REM sleep: High levels of brain activity
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2
Q

In what phase do dreams happen?

A

REM sleep

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3
Q

When does NREM sleep occur?

A

The beginning of our sleep, with each stage lasting 5-15 minutes.

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4
Q

How does our sleep generally cycle?

A
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5
Q

How does NREM sleep present physiologically?

A

Marked decreases in most physiologic functions, such as pulse, respirations, BP, and rarely any penile erections.

People are generally peaceful compared to their waking state.

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6
Q

How does stage 1 of NREM sleep present?

A
  • Minor decrease in activity
  • EASILY AWAKENED
  • Hypnic myoclonia - feeling of falling
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7
Q

How does stage 2 of NREM sleep present?

A
  • Light sleep
  • Periods of muscle tone and then relaxation
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8
Q

How does stage 3-4 of NREM sleep present?

A

Often called delta wave sleep.

  • Time of mending for repairing and regeneration.
  • Strengthening of the immune system.
  • Deeper levels of mental functioning.
  • Typical period for enuresis, somnambulance, and night terrors.
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9
Q

If someone is awoken from stage 3/4 NREM sleep, how are they likely to present?

A
  • Disoriented.
  • Amnesia of the waking event.

Constantly waking during this stage may cause immunodeficient conditions.

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10
Q

What frequency is a delta wave?

A

1-4 Hz.
Extremely slow.

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11
Q

What are the 2 big differences between REM and NREM sleep?

A
  1. REM sleep involves INCREASED physiologic activity, such as BP, HR, and RR.
    Spontaneous penile erection is common.
    Near-total paralysis of skeletal muscles
  2. Most distinctive feature: dreaming (but usually don’t remember)
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12
Q

How does REM typically occur phase-wise?

A

Phases occur every 90-100 minutes.

First REM is usually < 10 mins
Later REMs are 15-40 mins

The last third of the night has the most REM periods.

Stage 4 is inversely related to REM sleep.

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13
Q

Describe how Stage 4 sleep is related to REM sleep.

A

Inversely proportional.
You begin with more stage 4 sleep and less REM sleep.
As the night goes on, you have more REM sleep than stage 4 sleep.

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14
Q

What is the general effect of low serotonin levels on sleep?

A

Less serotonin => less sleep

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15
Q

What is the general effect of more NE on sleep?

A

More NE => less sleep

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16
Q

What is the general effect of more melatonin on sleep?

A

More melatonin => more sleep

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17
Q

What is the general effect of increased dopamine on sleep?

A

More dopamine => less sleep

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18
Q

How does our REM sleep change as we get older?

A

We need it less and less, beginning at 50% as an infant and down to 20% as a senior.

Seniors require very little REM sleep.

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19
Q

When does REM sleep stabilize in terms of age?

A

At 10 years old, it generally stays at 25% until 65.

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20
Q

How does a typical young adult’s sleep pattern present?

A
  • Regular cycling between stages 1-4.
  • Prolonged stage 4 earlier in sleep.
  • REM lengthens as night goes on.
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21
Q

How does a typical elderly adult’s sleep pattern present?

A
  • Decreased/absent stage 3-4
  • Easily awakened from sleep
  • Less regular cycles
  • Overall increased daytime fatigue and napping
  • Overall DECREASED sleep quality
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22
Q

What is the most common abnormal sleep pattern in depressed patients?

A

Insomnia

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23
Q

What are the 3 abnormal sleep patterns seen in depressed patients?

A
  • Insomnia
  • Hypersomnia
  • Increased wakefulness
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24
Q

Why is sleeping in depressed patients impaired?

A
  • Reduced sleep efficiency
  • Increased sleep onset latency
  • Reduced REM latency
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25
Q

What is the diagnostic criteria for insomnia?

A

1+ of the following for 1 month:
* Difficulty initiating/maintaining sleep
* Nonrestorative or poor quality sleep
* Early morning awakening

Symptoms occur DESPITE adequate opportunity/circumstances for sleep
Impaired sleep producing daytime function deficits

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26
Q

What are the two types of insomnia?

A
  • Primary insomnia: idiopathic (20%)
  • Secondary/comorbid insomnia: Secondary to another condition.
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27
Q

What are the 3 duration types of insomnia?

A
  • Transient insomnia: < 7 days
  • Acute insomnia: < 30 days
  • Chronic insomnia: > 30 days
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28
Q

How does alcohol abuse affect sleep?

A
  • Increased stage 1
  • Decreased REM
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29
Q

How does alcohol withdrawal affect sleep?

A
  • Delayed sleep onset
  • Intermittent awakening
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30
Q

What substances tend to affect sleep?

A
  • Alcohol
  • Smoking (> 1 ppd)
  • Excess stimulant intake
  • Sedative withdrawal
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31
Q

How do we treat secondary insomnia pharmacologically?

A

Treat underlying cause.

Consider TCAs or anxiolytics for SE of somnolence (but careful of abuse potential)

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32
Q

How do we treat insomnia non-pharmacologically?

A
  • Relaxation techniques
  • Meditation
  • CBT
  • Regular Exercise
  • Sleep Hygiene
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33
Q

How do we improve sleep hygiene?

A
  • Cut down on excess time in bed
  • Establish a consistent schedule
  • Make bedroom comfortable/dark
  • Relax before bedtime
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34
Q

What is the first-line treatment for insomnia?

A

CBT

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35
Q

What are the pharmacologic options for insomnia?

A
  • OTC 1st gen antihistamines (Diphenhydramine/doxylamine)
  • Benzo receptor agonists (Zaleplon/Sonata, Zolpidem/Ambien, Eszopiclone/Lunesta)
  • Melatonin agonists (Ramelteon/Rozerem, Melatonin OTC)
  • Benzos (Temazepam/restoril, Flurazepam/Dalmane)
  • Dual Orexin Receptor Antagonists (Newest class of drugs)
  • Antidepressants (Doxepin/TCA, Trazodone, Mirtazapine/remeron)

Doxylamine preferred in pregnancy?

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36
Q

What is the concern with using benadryl for insomnia?

A

Loses efficacy overtime.

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37
Q

What is the concern with melatonin OTC?

A
  • Unknown/inconsistent dosing
  • Not FDA regulated

Advised to stick with one brand if it works.

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38
Q

What is the primary medication to AVOID with treating an obese insomniac?

A

Mirtazapine/Remeron

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39
Q

What is the MOA of a dual orexin receptor antagonist?

A

Antagonizes orexin, which naturally promotes wakefulness.

40
Q

What are the examples of dual orexin receptor antagonists?

A
  • Suvorexant/Belsomra
  • Lemborexant/Dayvigo
  • Daridorexant/Quviviq
41
Q

When does narcolepsy typically begin?

A

20s

42
Q

What is the classic tetrad of narcolepsy?

A
  1. Recurrent irresistible attacks of daytime sleepiness
  2. Cataplexy (muscle weakness/paralysis)
  3. Hallucinations
  4. Sleep Paralysis

Only 10-15% have all symptoms

43
Q

How do you diagnose narcolepsy clinically?

A
  • Occurs unexpectedly and at inappropriate times.
  • Occurs daily for 3+ months, occuring 2-6 times a day.
44
Q

What is cataplexy in narcolepsy often associated with?

A

Emotional triggers

45
Q

What is hypnagogic and hypnopompic?

A

Hypnagogic: hallucinations upon falling asleep.
Hypnopompic: hallucinations upon awakening.
Intrusions of REM sleep elements in transition between sleep and wakefulness.

Pompoms = excited to awake

46
Q

What suggests that narcoleptics are in REM sleep?

A
  • Cataplexy symptoms
  • Hallucinations symptoms
47
Q

How do we completely diagnose narcolepsy?

A

Multiple sleep latency test (MSLT): recording naps

48
Q

How do we treat narcolepsy?

A
  • Forced naps regularly during the day.
  • Stimulants (Modafinil is least risky, methylphenidate, dextroamphetamine)
  • SSRIs/SNRIs (Symptomatic treatment and suppress REM)
49
Q

What is somnambulism? Who is it MC in?

A

Episodes of sleep walking with semi-purposeful behavior.
Usually males.

Hard to wake them up
No memory of episode when it occurs
First 1/3 of night usually.

50
Q

What are the risk factors for somnambulism?

A
  • Family MHx of somnambulism
  • GERD
  • Acute stress
  • Sleep deprivation
  • Sleep Apnea
51
Q

How do we treat somnambulism?

A
  • Avoid fatigue
  • Minimize interventions (don’t slap them)
  • Lead them back to bed
  • Protect from accidents
  • Lock doors and windows
52
Q

What is sleep-related bruxism?

A

Teeth-grinding during sleep.
Characterized by involuntary, non-functional, forceful clenching, grinding , or rubbing of teeth during NREM sleep.

53
Q

What might suggest someone is having sleep-related bruxism?

A
  • Headaches
  • TMJ pain
  • Sudden jaw clenching
54
Q

How do we treat sleep-related bruxism?

A
  • Occlusive splints
  • Controlling anxiety
55
Q

What are circadian rhythm disorders?

A

Chronic or recurrent sleep disturbances related to a misalignment between the environment and the individual’s sleep-wake cycle.

56
Q

What are the subtypes of circadian rhythm disorders?

A
  • Delayed sleep phase type (younger patients)
  • Jet Lag type (eastward travel)
  • Shift work type (night shift)
  • Advanced sleep phase type (elderly)
  • Irregular sleep-wake rhythm type (Developmental issue in kids)
  • Non-24-hour sleep-wake rhythm type (blind patients)
57
Q

How do we treat circadian rhythm disorders?

A
  • Promotion of sleep hygiene
  • Synchronize sleep
  • Advanced sleep: bright light in evening
  • Delayed sleep: bright light in early morning
  • Melatonin: resynchronize
  • Stimulants
58
Q

What is sleep apnea? Hypopnea?

A

Apnea is breath cessation for at least 10 seconds!
Hypopnea: decreased airflow resulting in an spo2 drop of >= 4%

59
Q

What are the subtypes of sleep apnea?

A
  • Central: Absent ventilatory effort throughout episode
  • Obstructive: Persistent ventilatory effort but obstructed
  • Mixed: Absent ventilatory effort precedes the obstruction
60
Q

What are the risk factors for obstructive sleep apnea?

A
  • Micrognathia (small jaw)
  • Macroglossia
  • Obesity
  • Tonsillar hypertrophy
  • Alcohol/sedatives
  • Nasal obstructions
  • Hypothyroidism
  • Cigarette smoking
61
Q

What is the classic patient for obstructive sleep apnea?

A

Obese, middle-aged male with HTN.

62
Q

What PE findings might suggest obstructive sleep apnea?

A
  • HTN
  • Cor Pulmonale (RV dysfunction)
  • Sleepy apperance
  • Narrowed oropharynx
  • Nasal obstruction
  • Nasal twang
  • Bull neck appearance
63
Q

How do we rule out obstructive sleep apnea?

A

Overnight pulse oximetry showing no significant spo2 drops.

64
Q

How do we diagnose obstructive sleep apnea?

A

Overnight polysomnography (EEG, Electrooculography, EMG, EKG, pulse ox, and end tidal co2 monitoring)

65
Q

What EKG changes might appear during sleep apnea?

A
  • Bradydysrhythmias
  • Tachydysrhythmias
66
Q

How do we treat obstructive sleep apnea?

A
  • Weight loss (10-20% loss can be curative)
  • Avoid alcohol/hypnotic meds
  • Mechanical device to hold jaw forward
  • Nasal CPAP (most curative)
  • Supplemental O2 (can lengthen apnea duration)
  • Surgical repair
67
Q

What are the 4 big pharmacotherapy options for sleep disorders?

A
  • Benzo receptor agonists
  • Melatonin agonists
  • Dual orexin receptor antagonists
  • Stimulants
68
Q

What is the MOA of a benzo receptor agonist?

A

Facilitate GABA-mediated inhibition of cell firing via binding to the receptor, which is a subunit of the GABA receptor complex.

69
Q

What stages of sleep do benzo receptor agonists affect?

A
  • Stage 1 NREM sleep reduction.
  • May decrease REM
  • DOES NOT REDUCE STAGE 3
70
Q

What is the main effect on sleep quality for benzo receptor agonists?

A

Reduced time to sleep onset (you fall asleep faster)

71
Q

When are benzo receptor agonists preferred over benzos?

A
  • Slightly safer for patients wth chronic respiratory dysfunction.
  • Less likely to develop tolerance
  • No reduction of deep sleep
72
Q

What kind of drug is zaleplon/sonata?

A

Schedule IV, benzo receptor agonist.

73
Q

When is zaleplon/sonata used?

A

Short half-life, not indicated for long-term use.

74
Q

What is the BBW of zaleplon/sonata?

A

Do not use for complex sleep-related disorders.

75
Q

What kind of drug is zolpidem/ambien?

A

Schedule IV, benzo receptor agonist.

76
Q

What is the BBW for zolpidem/ambien?

A

Do Not Use for complex sleep-related disorders

77
Q

What should you avoid when taking zolpidem/ambien?

A
  • Meals
  • Grapefruit juice
  • Sedatives
78
Q

When is zolpidem/ambien indicated?

A
  • IR: Sleep-onset insomnia
  • ER: sleep-onset and sleep-maintenance insomnia. May be drowsy.
79
Q

What kind of drug is eszopiclone/Lunesta?

A

Schedule IV, benzo receptor agonist

80
Q

What benzo receptor agonist has the longest half-life?

A

Eszopiclone/Lunesta

81
Q

What is the danger of taking exogenous melatonin chronically?

A

Desensitized receptors

82
Q

How should you educate regarding OTC melatonin use?

A
  • Short-term
  • Maintain consistent sleep hygiene
  • Caution in hypotensive patients
  • Do not take with coumadin
  • Avoid if hx of seizures or young.
83
Q

What is ramelteon/rozerem?

A
  • Melatonin receptor agonist.
  • Superior affinity for receptors.
84
Q

What drug must you avoid with ramelteon/rozerem use?

A

Fluvoxamine/Luvox

85
Q

What is ramelteon/rozerem generally best for?

A

Improving sleep onset

86
Q

How do dual orexin receptor antagonists work?

A

Antagonize the orexin receptors, which decreases the wake drive.

87
Q

What are the dual orexin receptor antagonists?

A
  • Suvorexant
  • Lemborexant
  • Daridorexant

All Schedule IV!
Orex ants

88
Q

Which CYP enzyme do dual orexin receptor antagonists interact with?

A

3A4 inhibitor/inducer

89
Q

What are the half-lives of the dual orexin receptor agonists?

A
  • Suvorexant: shortest, fastest peak
  • Daridorexant: medium
  • Lemborexant: longest
90
Q

Which dual orexin receptor antagonists does not require a dosage adjustment for the elderly?

A

Daridorexant

Newest one.

91
Q

What patients are orexin receptor antagonists CId in?

A

Narcoleptic patients

92
Q

What drug is used for narcoleptic patients?

A

Stimulant, specifically modafinil/provigil

Schedule IV

93
Q

What are the two indications for modafinil? Dosing time?

A

Narcoleptics: first thing in the AM.
Shift work: 1 hour prior to shift.

94
Q

What are sodium oxybates?

A
  • Metabolite of GHB (date-rape drug)
  • Strong CNS depressant.

Schedule III drug!

95
Q

What is required to prescribe sodium oxybate?

A

REMS program registration, due to the potential of date-rape.

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