Misc. Topics Flashcards
What is a hypnic headache?
Uncommon and occur exclusively during sleep
Most commonly occur during REM, can also occur in SWS
Onset typically age 50, rare in younger age
Headache is typically bilateral, not assoc w/ autonomic features
Isolated nausea, photophobia and photophobia can be present
Often respond to lithium, Indocin, and/or caffeine
Sleep dysfunction in schizophrenia
Sleep dysfunction is extremely common Occurs in about 30-80% of patients Increased SL Decreased TST Decreased SE
What is the typical chronotype in ASD patients, children and adults?
Typically present with : low SE prolonged SL insomnia irregular sleep-wake patterns EDS delayed sleep phase evening chronotype
Insulin sensitivity and sleep
SWS and HPA axis activity
Testosterone secretion during sleep
Insulin response is circadian modulated
Insulin sensitivity in adipose tissue is higher during daytime hrs compared to nighttime.
Sleep deprivation has been shown to induce insulin resistance via variety of pathways
SWS inhibits HPA axis activity
Cortisol is elevated in later portions of sleep period and during REM
Circadian disruption can increase inflammatory cytokines, increase risk for sepsis and cancer
Peak levels of testosterone occur in middle of sleep cycle, around time of REM sleep onset.
Fragmented sleep reduces amount of REM, blocks nocturnal increase in testosterone
What is overlap syndrome?
OSA and COPD
5 times more likely to have pulmonary HTN than those with OSA alone
Results in worsened nocturnal desaturations
Severe pulmonary HTN most likely to be seen in patients with daytime hypoxemia in addition to just nocturnal desat.
Impact of Crohn’s disease on RLS
Crohn’s can affect the entire GI tract, namely stomach fundus, where gastric acid is secreted, and the duodenum , where the majority of iron is absorbed
Low ferritin and low iron can contribute to RLS
What is the overall frequency of OSA in acromegaly patients?
Overall frequency is 40-50%
OSA is more common than central sleep apnea, due to structural changes
Predictive factors for development of sleep apnea include severity of GH excess, duration of disease, obesity, older age and being a male
What are the sleep characteristics with amphetamine abuse?
Causes severe fragmentation of sleep-wake cycle
Both insomnia and rebound hypersomnia (if they are unable to find the drug) occur
Prader Willi syndrome and sleep apnea
Central sleep apnea is most prominent in infants with PWS and often improves with GH therapy.
GH therapy is associated with worsening of OSA in patients with PWS, most likely due to GH stimulation of lymphoid tissue.
There are reports of deaths in patients with PWS on GH; is recommended that all patients with PWS have PSG prior to starting GH.
AAP recommends repeat PSG also at 6-10 weeks after initiation of GH therapy
What is SSRI eyes?
I.e. patient on lexapro having PSG
PSG finding of Rapid eye movements during NonREM sleep
Makes scoring of sleep stages more difficult
No known clinical significance
No need to d/c medication
What is the risk of developing depression in patients with new-onset insomnia
Two fold
Based on 2 meta-analysis
Individuals with insomnia were 2.3 times more likely to develop depression
Experimental studies showed that sleep loss may result in cognitive and affective alterations that lead to depression risk.
Sleep difficulties impair emotional regulation and stability
What is chronic paroxysmal hemicrania (CPH) ?
CPH resembles cluster h/a but shorter duration occur more frequently more common in females Patients may awaken from sleep w/ h/a (not so common w/ cluster h/a) Strongly associated with stage REM sleep Are very responsive to indocin
What are the characteristics of Familial Advanced Sleep Phase syndrome (FASPS)
FASPS is inherited abnormal sleep pattern
“Morning lark”
Goes to sleep very early, wakes up very early; ~3-4 hrs ahead of local time
Most affected people carry a single base-pair substitution in the hPer2 gene.
This variant in human sleep behavior is due to a missense mutation in a clock component, hPER2, that alters the circadian period
What are the characteristics of Fatal Familial Insomnia
It is a prion neurodegenerative disorder
Severe loss of thalamic nuclei resulting in reduced metabolism seen on PET scan
Is autosomal dominant, occurs equally in men and women
Is 100% fatal
Typical symptoms are:
severe insomnia, no sleep at night, no naps
weight loss
difficulty swallowing
frequent fevers
unsteady gait
tremors
progressive dementia is common presentation
Will die from coma, young age
Is caused by gene mutation of PRNP gene
What is motivational interviewing?
Developed by Miller and Rollnick
Client centered and directive in nature
Purpose of MI is to help people resolve their natural ambivalence about health behavior change in order for the behavior change to occur
4 principles of MI:
- Express empathy
- Develop discrepancy (eliciting/reflecting inconsistencies between patient’s current behavior and his or her stated goals/values)
- Roll with resistance
- Support self-efficacy
What are 4 key strategies used to build rapport?
- Reflective listening (warm, non-judgemental restatement, clarification, enhancement)
- Open-ended questions (encourage patient to talk about thoughts and feelings, prompt to elaborate)
- Affirmations (express appreciation)
- Summaries (brings together thoughts or feelings patient has shared)
What is the duration of an epoch on a PSG?
1 epoch = 30 seconds
Total # of epochs/2= minutes # of minutes x2 = epochs
How do you count on MSLT if there is no sleep onset in one of the nap periods?
If no sleep onset, Sleep latency is counted as 20 minutes or 40 epochs
Newborn sleep
Sleep by 6 months of age
Newborns have 2 stages of sleep: REM and NREM
Distinct NREM stages (1,2,3) develop during 1st 6 months of life, typically present by 6 mos of age
Sleep terrors, other info
More accurate term than night terrors
These events can occur during naps or other bouts of daytime sleep (i.e., not during the night)
Events tend to occur during first 1/3 of the night when SWS is at its highest
Children typically have no recall of the event
Peak prevalence during preschool years
More information on treatment of Delayed Sleep phase disorder
CBTmin occurs ~2-3 hrs prior to habitual wake time
Light administered prior to CBTmin results in phase delay (moves it later)
Light given after the CBTmin results in phase advance of the clock (moves it earlier)
DLMO occurs ~2 hrs prior to habitual sleep onset
Giving low dose melatonin 5 hrs prior to DLMO or 7 hrs prior to habitual sleep onset will give a consistent phase advance.
Light “pushes” the rhythm and melatonin “pulls” the rhythm
Strict scheduling is recommended, but difficult
Pharmacotherapy not recommended as first line therapy
What are side effects of dopaminergic agents for RLS (pramipexole) ?
Nausea Nightmares Fatigue Sleepiness Up to 9% of patients experience impulse control disorders (ICDs) such as inappropriate shopping, gambling, and sexual activities. Patients on these drugs should be routinely asked about ICDs on clinic visits
Augmentation with dopamine agonists
Patients report worsening sx and sx start to occur earlier in the day.
Augmentation has been reported for all dopaminergic medications and for tramadol, but not for Alpha 2 ligands.
Tx for augmentation is to decrease dose of dopamine agonist.
Alpha 2 ligands are now considered the 1st line medications because of side effect of augmentation with dopamine agonists.
Ferritin level in RLS patients should be maintained >75 ng/ml.
Differences between Narcolepsy and Idiopathic hypersomnia
Both Narcolepsy Type 1 and IH are disorders of EDS, but differ in typical sleep durations.
Narcolepsy Type 1 typically sleep normal amounts in 24 hr period, similar to non-sleepy controls.
They may have more daytime naps, their nocturnal sleep is fragmented, so 24 hr sleep duration
is often close to 8 hrs
Naps are typically refreshing
Patients with IH may have normal sleep durations, but often have very prolonged sleep durations, which contribute to functional limitations created by this disorder. Naps are typically not refreshing.
Melatonin synthesis pathway includes?
L-tryptophan 5-hydroxytryptophan (5HTP) Serotonin N-acetylserotonin Hydroxindol-0-methyltransferase (HIOMT, enzyme) Melatonin
Dopamine is NOT in the melatonin synthesis pathway
About what proportion of population reports habitual sleep duration of 6 hrs or less
20-35% (1/3)
The biological basis of sleep-wake regulation is best represented by functions managed by?
The brainstem and midbrain
What is an important brain region for generating human sleep
Ventrolateral preoptic area (VLPO)
Adenosine
Neurochemical positively associated with sleep, not wakefulness
What decreases with age in adults?
SE
% SWS
% REM sleep
Melatonin secretion
WASO increases w/ age, doesn’t decrease
What is True re: relationships between self-reported characteristics of sleep and age?
Older adults
Older adults report greater satisfaction w/ sleep overall
Older adults show a weaker relationship between short TST and cardio metabolic disease risk
Older adults show greater resilience to neurobehavioral performance effects of sleep loss
Older adults report less insufficient sleep overall
Older adults are less likely to report that their social schedules interfere w/ ability to get more sleep
What can be used to assess for circadian rhythm disorders?
Actigraphy
Not MSLT, PSG, MWT
Non 24 hr sleep-wake disorder, characterized by?
Misalignment of circadian rhythms that presents as relatively steady and continual delay in sleep-wake timing
May present as periods of insomnia, EDS, or asymptomatic
Most often found in individuals who are blind
What is treatment for Non-24 hr Sleep-wake-disorder?
Melatonin receptor agonist or melatonin
You would NOT use: hypnotics, benzos or modafanil
9 month old nursed in rocking chair in her bedroom
Put into rocking chair in her bedroom and put into crib after falling asleep
Has normal awakening at night, cries for mother so she can repeat way she is used to falling asleep.
This informant associates the behavioral cues of being nursed and rocked with sleep onset.
This is an example of?
Negative sleep-onset associations- parent centered
Classical conditioning
What is the treatment for the 9 month old on previous flash card?
Ask mother to nurse infant in rocking chair and put into crib when drowsy but awake and leave the room.
Nurse infant earlier in evening outside the bedroom
2 year old has transitioned out of crib, falling asleep w/ mother laying next to him in his twin bed
Playing w/her hair, cuddling right before falling asleep
Lullaby music playing for 30 min. And shutting off
After getting his core sleep (3-4 hrs later) Max screams for his mother so he can reenact how he is used to falling asleep. This toddler associates his mother’s presence, cuddling with her, playing with her hair, listening to lullabies w/ falling asleep
The behavioral treatment to use includes?
Establishing short bedtime routine that involved parent initially, then allows Max to be independent at initial sleep onset
Use white noise machine throughout the night rather than playing music
Encourage hugging favorite stuffed animal while waiting to fall asleep
Extinction is a behavioral treatment used with pediatric patients to?
“Extinguish” infant crying at bedtime by discontinuing the reinforcement of child crying via parental attention/presence
May be graduated or the reinforcement of desired behaviors occurs over time
May include parental presence in the child’s room w/o actively attending to child while crying
Bedtime pass uses these principles for child resistance to bedtime:
Positive reinforcement
Limit setting
Arzin’s dry bed training protocol for enuresis includes:
1974
Fluid intake before bedtime
Scheduled awakenings
Positive practice
Protocol actually involves increasing fluid intake before bed
Positive practice on hr before bed
Urine alarm
Scheduled awakenings
Cleanliness training if child wet the bed, morning praise for dry bed
2 year old with PSG
Hx snoring, apnea
AHI = 7.5
What is appropriate options for f/u care?
Adenotonsillectomy
In children w/AHI >5, considered moderate OSA and intervention is warranted
Adenotonsillectomy is considered 1st line treatment in children
Parent discontinues extinction early, picking up her infant son because she finds it too difficult to tolerate his prolonged crying. From the perspective of the parent, what behavioral contingency has occurred?
Negative reinforcement
The parental behavior of picking up the child is reinforcing to the parent because it results in removal of an aversive stimulus (infant crying)
Compare sleep terrors vs nightmares
Sleep terrors: First 1/3 of night Sleep stage SWS High to extreme agitation High arousal threshold (agitated if awakened) No associated daytime sleepiness No recall or fragmentary recall of event
Nightmares: Last 1/3 of night Sleep stage REM Mild to high agitation Low arousal threshold (awake and agitated after event) Associated daytime sleepiness if prolonged awakening Frequent and vivid recall of event Prevalence: very common
