Lecture 7 Flashcards
How are sleep disorders assessed?
- primary care physician, send to sleep clinic
and/or - sleep lab, polysomnography w/ multiple physiological measurements
- patient histories, diagnostic info
- signs (observable) & symptoms (reported)
- sleep amount, quality, timing & daytime
- technicians, researchers, clinicians, psychologists & physician specialists
- meet regularly, review & discuss patients: share knowledge & for treatment
- case studies/“grand rounds”: multiple doctors visiting patient
- International Classification of Sleep Disorders
What are the symptoms of sleep disorders? (UEDUSMM)
how persistent/frequent:
- unrefreshed sleep
- excessive daytime fatigue/sleepiness
- difficulty staying/falling asleep
- unusual/violent behaviour during sleep
- snoring, breathing irregularities
- motor restlessness in the evening/previous to sleep
- mood changes/issues
What is insomnia?
cannot obtain enough time asleep, quality sleep despite adequate opportunity to do so
What is sleep onset insomnia?
difficulty initiating sleep
What is sleep maintenance insomnia?
difficulty maintaining sleep thruout the night
What is early awakening insomnia?
rapid sleep onset, good sleep continuity, but awakening much earlier than desired, inadequate total amount
What is sleep dissatisfaction?
not feeling refreshed after a night of seemingly sufficient sleep
What is idiopathic insomnia?
no found cause (15% of cases, childhood onset, life-long condition w/o treatment)
What is psychophysiological insomnia?
chronically hyper-aroused; greater arousal at night + day restless, overactive, nervous, apprehensive; intense and persistent physiological arousal
What is paradoxical insomnia?
“sleep state misperception”
- no daytime impairment
- normal sleep length & profile, but report no sleep
- highly attentive, “thinking all night”
What are the causes of insomnia? (GCCD)
- genetic component (7 genes contribute)
- cause for initial sleep disruption should be found, but not as relevant as perpetuating circumstance
- Co-morbid insomnia
- decongestants, caffeine
What are the causes of insomnia? (ATTPU)
- alcohol:
- increase sleep time, less N3 & REM
- alcoholism: permanent irreversible reduction of N3 & REM
- time zone, schedule changes
- temperature regulation
- pregnancy, menopause
- unique sleeping environments
What are the causes of insomnia? (MMGTW)
- mild to severe psychological issues
- marital, job stress
- grief
- trauma
- war, PTSD
What is co-morbid insomnia?
insomnia caused by other disorders, medication, illicit drug use, pain/discomfort, environmental factors
What are the sleep specific cognitive issues for the causes of insomnia?
- exaggerated concerns about “not enough sleep”
- self-blame/guilt of lack of sleep
- dread sleep time, pressure to sleep leading to hyper-vigilance about sleep
- if try to self-treat, cannot sleep b/c monitoring sleep treatment to evaluate its effectiveness
- mental listing/persistent problem solving
What is the impact of insomnia? (PIFBUP)
- physical & psychological issues of sleep deprivation
- impact on work performance, communication, relationships
- family/sleep partner: sleep separate, need quiet, sleep envy/resentment
- bargaining with partner/children
- unpredictable in planning, choices of activities, lifestyle
- purchasing/relying on “aids”
What are the physical and psychological issues of sleep deprivation? (CIJDIC)
- concentration
- irritability
- jitters
- diminished well being
- inappropriate sleeping locations/episodes
- clumsiness to severe accidents
What are facts about insomnia? (36V1)
- 30-50% of Western pop. report occasional/temporary insomnia
- 6-10% report serious problem, persistent
- v. rare in children 8-10 but 25-35% of retirees/post middle-aged
- 1.5x more prevalent in women than men
What are facts about insomnia? (MSSB)
- more prevalent in those w/ depression, anxiety, substance abuse, disordered breathing & recurrent health issues
- sleep onset insomnia: more common in younger adults
- sleep maintenance insomnia: more common in older adults
- BUT types can change w/ physical + psychological circumstances & aging
What are treatments for insomnia? (S)
sleeping pills:
- over-the-counter (OTC), non-prescription: ineffective/questionable effectiveness
- antihistamine, acetaminophen
- magnets, herbal treatments
What are treatments for insomnia? (P)
prescription: effective temporarily
- hypnotics, benzodiazepines: work on GABA receptors to promote sleep, relax muscles & reduce anxiety
- “psychological dependency”
- amnesia, risk of falls, serious accidents
- people tend to overdose on non-prescription, thinking they are “safer” or combine w/ other substances which can be disastrous or lethal
What is CBT for insomnia (CBT-i)? (CEFES)
- change thoughts, emotions, beh., “relearn to sleep”
- effective, long-lasting
- few sessions to several weeks, practitioner, resources provided
- examine: what contributing to issues, tracking/log
- several components sequentially, individually introduced, monitor motivation/compliance & progress; enough in place, good sleep will result
What are the components introduced in CBT-i?
- sleep restricted to bedroom
- progressive muscle relaxation, bath/shower, reading
- scheduled worry, thinking and resting time
- write lists of tasks and worry targets
- change expectations about sleep
What is sleep compression, restriction?
- no daytime napping
- change sleep onset time: 5 hours at a certain time, increase in 10-15 min intervals
- start sleep prep later, even if fatigued
- sleep drive will increase, less time awake
What is narcolepsy?
- appears in teens, early 20’s can appear in adulthood, both genders
- complain of excessive, perpetual sleepiness
- intractable sleep attack, w/o warning, even in stimulating situations
- can have narcolepsy w/o cataplexy
- hallucinations paired with sleep paralysis: reported in half of sufferers
- blackouts
What are hallucinations paired with sleep paralysis like?
- vivid, dream-like occurrence
- visual, auditory, tactile or involve movement
- hypnagogic: entry to sleep
- hypnopompic: from sleep
What are blackouts?
typical wakefulness behaviour w/ no memory of events, behaviours
What is cataplexy?
weakness in limbs, face, speech muscles; mild to complete wilting collapse
- triggered by emotions/stress response
- blurred vision, irregular respiration, slurred speech
- if minutes, consciousness remains, but over 2min, REM sleep triggered
- less than 1x/week to several per day
What are the causes for narcolepsy? (GCAAI)
- genetic predisposition
- catalyst: brain damage, infection/other medical conditions
- autoimmune disorder: body attacking own tissue in lateral hypothalamus
- abnormally low/absent hypocretin in cerebral spinal fluid
- increased activity of acetylcholine & decreased activation of locus coeruleus
What are the impacts of narcolepsy? (WSPAF)
- work: fall asleep on the job (fired)
- social: dating, outings, events
- personal: safety driving
- appear dull, emotionally flat, unmotivated, withdrawn, aggressive, lazy or bored
- feel guarded, anxious, frustrated: depression can result
What are treatments for narcolepsy?
- no cure
- behavioural + pharmacological treatments necessary
- naps: can be refreshing, although inconvenient
- good sleep hygiene
- medication:
- stimulant for daytime activities, side effects
- noradrenergic reuptake blocking, SSRI or gamma-hydroxybutyrate for cataplexy
- psychological support (learn to anticipate attacks, support groups)
- family, peer education & therapy
What are new possibilities of treatment for narcolepsy?
- stem cell transplant to regenerate hypocretin producing cells
- gene replacement therapy: use virus to insert hypocretin procurer genes in cells to encourage hypocretin production
What is restless leg syndrome (RLS)? (UUWRPMD)
- unpleasant sensation at legs, tingling to painful
- urge to move legs
- when stationary, seated or lying, or at rest esp. at night
- relieved w/ continuous movement
- physical exam, lab tests = no issues
- misdiagnosed as cramps, vericose veins, “nerve problems”
- daytime: report fatigue, sleepiness
What are facts about RLS?
- 5-15% of pop. report it; 2x often in females
- onset at any age, can be misdiagnosed as growing pains/hyperactivity disorder
- highest incident in middle-age to elderly
- family history, genetic component
- 1/3 of cases due to iron deficiency
- 15-40% of people on dialysis complain of RLS
- 20% of pregnant women (temporary)
What are the causes of RLS? (CDDIBI)
- caffeine, warm rooms & exposure to cold intensifies symptoms
- disappears w/ fever
- depletion of dopamine & blood loss worsens symptoms
- iron: deficiency, transferrin malfunction
- iron therapy may improve symptoms
What are treatments for RLS? (IAIASM)
- improved sleep hygiene
- awareness of & control for worsening circumstances + substances
- iron supplementation
- aware of blood loss
- stretching, relaxation massage
- medication:
- dopamine agonists; issues with impulse control behaviours, increased dosing causes worsening symptoms
- oxicodon hydrocodone, issues with dependency
What is periodic limb movement (PLM’s)?
- jerking of arms/legs during sleep
- short duration (0.5-10 secs) at regular intervals
- clusters (every 5 secs-90 secs) lasting several minutes to hours
- more likely during first half of night
- no awareness of movements, aware of multiple awakenings
- accompany OSA, narcolepsy, REM beh. disorder
- treatment similar to RLS
What is bruxism?
- teeth clenching, grinding, crunching, scraping
- damage to teeth, jaw, muscle injury
- due to stress, pre-existing mandibular/maxillary condition
- during N2 sleep & REM; accompanied by partial arousal but no awareness
- higher HR/other body movements accompany
What is the goal of CBT-i?
- alleviate perceived, actual nighttime sleep issues
- eliminate self-blame & analysis
- relief from consequences of poor/lack of sleep
What is treatment for bruxism?
- dental exam & correction of anatomic abnormalities
- soft/hard guard over teeth
- check for sleep apnea
What is periodic limb movement disorder (PLMD)?
periodic limb movement + insomnia/excessive daytime sleepiness
