LMBR8: SLEEP 2. P 269-277 Flashcards
What is Behaviorally Induced Insufficient Sleep Syndrome (BIISS)
What is it associated with (5)
BR270
Young, with long work hours >40hrs, stress, depression
Voluntary restriction of sleep time
Longer sleep duration on weekends
Disparity between sleep needed and obtained
Associations: SAWED
S - Stress
A - Age - 30-39 (“< 40”)
W - Work hrs > 40/wk (“ > 40”)
E - EtOH
D - Depression
Mn: Doherty w saw in hand
What is insomnia
To meet criteria what frequency/duration ?
Behavioural associations
When talking to you about their problem it is clear that they …
BR270
- Difficulty initiating and/or maintaining
- Adequate sleep opportunity
- Ongoing for at least three months and occurring at least three times a week (3/52-12)
- Associated with Fatigue, Decreased motivation. Mood disturbances/irritability. Errors or accidents at work/driving:
F - Fatigue
A - Accidents
M - Motivation
E - Emotions (mood/irritability)
Persistent worry about sleep
Mn - ‘Insomnia is assoc w FAME’.
Define obstructive sleep apnea
How is it quantified/diagnosed ?
How long does an apnea episode last ?
List 5 characteristics / assocations
BR270 & 276
Recurrent apnea or hypopnea during sleep, lasting 10 seconds to one minute, usually quantified as Apnea-Hypopnea Index (AHI) based on polysomnography (sleep study)
AHI Classes a. Mild: 5 to 15, Moderate: 15 to 30, Severe: 30 (5 - 15 - 30 )
Associated with Overweight, Metabolic syndrome, HTN. Increased neck circumference. Loud snoring
=> 2 physical, 1 behavioral, 2 medical
What is the STOP Brief OSA assessment ?
BR270 & 276
STOP: Brief OSA assessment
a) S – Snoring (loud)
b) T – Tired often, fatigued, sleepiness during daytime that inhibits functioning
c) O – Observed patient apnea episodes
d) P – Pressure, elevated blood pressure or taking hypertension medications)
Scoring1. <2 positives = low risk for OSA2. 2 = high risk for OSA: refer for sleep study
Mn: Sam (bus driver)
Define Restless Leg Syndrome (RLS)
How common is it ?
How often does it manifest in sleep ? How ?
What is often associated with RLS ?
BR270
Feeling an urge to move the legs, which can occur with an uncomfortable sensation in the legs that happens when one rests (sitting or lying down)
Worse in the evenings
Movement helps relieve the uncomfortable sensation
Not due to another primary medical cause.
Associated periodic movements of sleep, Fatigued, Periodic involuntary and jerky movements of limbs while awake or at rest
Prevalence: 1 in 7 (5-15% of US population)
Periodic movements of sleep occur in 6/7 (85%)
Periodic limb movements are often associated with RLS
Mn: ReLeaSe a PLuM
What is short sleep misperception?
BR271
Mismatch between sleep duration (polysomnography) and interpretation (patient perceives less sleep than actual sleep duration).
What is narcolepsy ?
What should you do about it ?
BR271
Narcolepsy
= sudden, uncontrollable onset of sleep
=> refer for a sleep study & to see a sleep medicine specialist
What are Periodic Limb Movements ?
Setting with increased prevalence ?
Associations with other disorders ?
What may the patient report ?
BR271
Periodic Limb Movements
- limb movements occurring at ~ 30 second intervals during Sleep
- inc freq with age especially after 50 yrs
- often assoc w restless legs syndrome (RLS)
- may report restless sleep, middle of night awakening, increased daytime sleepiness
Mn: PLuMS
Effect of healthy night sleep on
Cortisol?
Glucose?
Insulin sensitivity?
Daytime leptin?
Food seeking behaviors?
BP and sympathetic tone?
Core body temp?
BR271
Cortisol- lower
Glucose- lower
Insulin sensitivity- higher
Daytime leptin- higher
Food seeking behaviors- reduced
BP and sympathetic tone- lower
Core body temp- lower/cooling
Effect of impaired sleep quality & short duration on:
1) Food intake (2)
2) Daytime [leptin]
BR271
Effect of impaired sleep quality & short duration on:
1) Food intake: increased CHO dense foods, calories esp calories from saturated fat
2) Daytime [leptin] is lower
BR271
List 4 (related) health consequences of short duration and disrupted sleep:
BR271
4 (related) health consequences of short duration and disrupted sleep:
1) Elevated BMI
2) Obesity (2x increased risk)
3) Metabolic syndrome
4) NIDDM
Mn: nurse seen 9/2019 - ‘BOMeD’
BR271
List 3 cardiovascular outcomes of healthy sleep duration and quality:
BR271
3 cardiovascular outcomes of healthy sleep duration and quality:
1) Lower sympathetic tone & BP
2) Greater nighttime peripheral perfusion & core body temp cooling
3) Increased stamina & faster CV recovery time.
BR271
List 4 intermediate cardiovascular outcomes of impaired sleep duration and quality:
BR271
4 intermediate cardiovascular outcomes of impaired sleep duration and quality:
1) Elevated sympathetic tone
2) Elevated BP esp at night
3) Reduced nighttime peripheral perfusion
4) Increased nighttime core body temperature.
BR271
List 4 cardiovascular outcomes of impaired sleep duration and quality:
BR271
4 cardiovascular outcomes of impaired sleep duration and quality:
1) D - Death - from CV disease
2) I - Infarctions - inc MIs
3) S - Spasm - inc vasospastic disorders
4) H - Htn - refractory w no reduction in early morning hours.
BR271
Mn - GC ‘If you don’t get a good nights sleep, it’s like your heart is on a dish’
Healthy sleep and effects of REM and non REM
BR272
- Higher proportion of sleep time spent in slow wave sleep (stage three, which is the deepest, most restorative stage of non-REM sleep
- Higher proportion in REM leads to enhanced learning and memory, faster cognitive processing, greater anxiety and fear extinguishment(amygdala is able to get rid of the memory of fearful events)
Mn - ‘REM is like RAM - helps memory’
Short sleep correlates with worse or good outcomes?
- CV system
- Mental health
- Cancer (list)
- Immune (cytokines)
- DNA
BR272
It correlates with heart attacks, heart disease, depression, bipolar, PTSD, seasonal affective disorder, traumatic brain injury
Melatonin and immune system suppression
Increased cancer-stimulating cytokines (IL-10)-AML, Breast, prostate, Endometrial, Colorectal cancer
Dysfunction in gene transcription and cell cycle
Aberrant DNA methylation, meaning DNA expression is not being coded correctly (usu results in repression of gene transcription)
- Mnemonic CA: ABCDE (de prostate)
Mental health conseqs of short sleep duration
BR272
Short sleep duration correlates with:
a) Depressive disorders:
Major depression, bipolar disorder, Seasonal Affective Disorder, premenstrual syndrome
b) Trama associations
- worsened PTSD if sleep deprivation 2 weeks prior
- tramatic brain injury is worse if sleep deprivation occurs before or after the injury
Lifestyle prescription for sleep environment
Role of ‘power naps’
When to quit …
BR273
- Use bed for sleep and sex only
- Establish regular sleep cycle for bedtime and wake time
- Increase bedtime peripheral cutaneous vasodilation by Bath/shower, Socks or heating pad for cold feet, Non-caffeinated tea/beverages
- Allow air temperature to gradually warm extremities using Bedding, socks, heating pad, blankets
- Minimize/eliminate bedroom noise and lights
- Power naps may be helpful if they’re less than 30 minutes
- Stop working or doing stimulating activities 90 minutes before bed.
Lifestyle prescription for sleep –light exposure
BR273
1) . Increase daytime exposure to sunlight
2) . Increase daytime physical activity. Get up and move at least once an hour. Increase physical activity in late afternoon and early evening.
3) . Decrease light at night. Turn off or dim unnecessary lights at least one hour before bedtime, especially blue light, compact fluorescent, halogen light, and backlit screens. Use 2,500 Kelvin color warm spectrum lights.
Lifestyle prescription for sleep -dietary
BR273
1) Drinks
a) Eliminate nighttime caffeinated beverages.
b) Limit daytime caffeinated beverages.
c) Avoid alcohol within 3 hours of bed.
d) Assure adequate daytime fluid intake, especially late afternoon because it affects vascular tone and vasodilation.
2) Food
Eliminate after dinner and late-night snacking.
Avoid high sodium foods, especially at dinner because it affects vascular tone and vasodilation.
3) Other
Weight reduction if BMI is elevated.
What is included in intensive therapy for sleep ?
In terms of evidence-based psychological treatment criteria for adults > 60 yo (‘EBMC’)
Which of these meets EBMC ?
Which of these partially meet EBMC ?
Which of these do not meet EBMC ?
BR274
CBT – FIRST line for chronic insomnia combined with behavioral methods
Behavioral Methods
1) Sleep restriction- Meets evidence-based psychological treatment (EBT) criteria for adults >60 y/o
2) Stimulus control –partially meets evidence >60yrs
3) Relaxation training therapy- did not meet evidence in >60yrs
4) Sleep hygiene Did not meet evidence in >60yrs
Supplemental melatonin -when is it efficacious ?
What is the evidence for insomnia ?
Is there an effect on endogenous melatonin ?
Side-effects …
Best bioavailability when …
Beware of preparations which also include __
BR 274
Is efficacious for jetlag mitigation and circadian rhythm disorders
Mixed evidence for insomnia (esp in adults)
No evidence for adverse effects at typical doses (1-6mg), but possible interaction with some cytochrome P-450 drug
Supplementation does not appear to suppress endogenous melatonin
Sublingual may have better bioavailability (take 30-60 min before sleep for insomnia)
Supplements with B6 (pyridoxine) may cause an acute altering effect
Prescription strength hypnotic medications and mortality
Causes of death include …
The main class of prescription hypnotics is …
BR 274
Prescription strength hypnotic medications are associated with significant increase in death rates in adults age 18 to 55-year-olds and increased risk of all-cause mortality in all age groups that used hypnotics from overdose, car accidents, falls, depression, cancer and suicide.
The main class of prescription hypnotics is benzodiazepines
Suggestions for jetlag travelling East
BR 275
Suggestions for jetlag travelling East (to London)
Envt
1) Get exposure to bright light, preferably outdoor, close to new ideal wake-up time.
2) Get ony dim-light exposure starting 1 hr before new ideal sleep time
Diet: Eat a hearty breakfast within 30-45 minutes of new ideal wake-up time.
Melatonin 1mg sl, one hour before new ideal sleep time.
Mn: Breakfast w bright light in London
Suggestions for jetlag travelling West
BR 275
Suggestions for jetlag travelling West (Los Angeles)
Envt
1) Get late afternoon & early evening bright light, preferably outdoor.
2) Avoid dim-light exposure until 1 hr before new ideal sleep time
Diet:
1) Eat a hearty breakfast within 30-45 minutes of new ideal wake-up time.
2) Eat complex CHO-rich dinner 2-3 hrs before new ideal sleep time
Melatonin 1mg sl, one hour before new ideal sleep time.
Mn: Pasta meal in sunset (bright) in LA
Mini sleep assessment questions and red flags
BR 276
Perceived sleep quality
H - Hours
a) Typical weekday hours of sleep
b) Typical weekend hours of sleep
Attitude towards sleep
- RED flags - 3 D’s
Duration - <7h, >9h, irregular
Difference between weekend/weekday > 1hr
Despite 7 hr or more, poor sleep quality
Frequency of daytime Fatigue
Mn: PH(F)AD nights sleep
In BR book:
S - Snoring (loud)
T - Tired often, daytime sleepiness (inhibits functioning)
O - Observed pt apnea episodes
P - Pressure - Htn or on meds for htn
If < 2 + then low risk for OSA
If >= 2 then refer for sleep study
On web: STOP-BANG:
B - BMI > 35
A - Age > 50 yrs
N - Neck circumference > 40 cm
G - Gender - Male
High risk OSA >= 3 positive
Low risk: < 3 positive.
