Neuro 51: Sleep disorders

Question 1

What are the 3 restorative fctns sleep is thought to play a role in?

Answer 1

1. immune function
2. protein/hormone synthesis
3. clear adenosine

Question 2

Stages of sleep

Answer 2

• NREM: stage 1, stage 2, stage 3/4

- REM

Question 3

Stage 1 sleep

Answer 3

• light sleep
• very slow eye mvmnts
• muscle activity slows
• can have hypnic myoclonia

Question 4

Hypnic myoclonia

Answer 4

• felling of falling you can have in stage 1 when you first go to sleep
• wont get this later in sleep or if you go back to sleep after this

Question 5

Stage 2 sleep

Answer 5

• eye mvmnts stop

- brain waves slow

Question 6

Stage 3/4 sleep

Answer 6

• “deep sleep”
• extremely slow brain waves appear
• very difficult to wake someone in this stage
• no eye mvmnts of muscle activity
• teens and kids spend most of their time in this, as you get older you will spend less time in slow wave sleep

Question 7

REM sleep

Answer 7

• need to have all 3 to be in this stage!
  1. rapid eye mvmnts
  2. atonic muscles –> all muscles are paralyzed except for the eye muscles
  3. active EEG
• breathing is more rapid, irregular, and shallow
• HR & BP increases

Question 8

Complete sleep cycle

Answer 8

• usually takes 90-110 min
• early in the night REM will be short and deep sleep will be longer
• as the night progresses the REM increases in length and the deep sleep decreases
• by morning, all sleep is in 1, 2, and REM

Question 9

Interactions of circadian rhythms and sleep

Answer 9

• desire to sleep depends on your circadian rhythm ans sleep homeostatic drive and how these interact
• circ rhythm fluctuates throughout the day
• the sun trains you to wake up at a certain point every day –> you can en-train yourself to change your bed dime +/- a few hours every day, but when its more than that amnt you have trouble = “jet lagged”

Question 10

Delayed sleep phase syndrome (DSPS)

Answer 10

• go to bed and cant fall asleep, then alarm clock goes off and they wake up before their sleep cycle is complete
• they have a problem with phase advancing

Question 11

Non-24 hr sleep-wake syndrome

Answer 11

-can happen with some types of blindness b/c they do not have light cues to keep them on a 24hr cycle and in phase

Question 12

Advanced sleep phase syndrome (ASPS)

Answer 12

• tired when they go to sleep, but then wake up early and cant go back to sleep
• cant get back into phase
• happens often in the elderly

Question 13

Irregular sleep-wake pattern

Answer 13

• sleep patterns were never organized

- this can happen in pts that had problems at birth or traumatic births

Question 14

Insomnia: epidemiology, criteria, cause

Answer 14

• very common! –> even more than apnea
• 2 major criteria:
  1. need to have the opportunity to sleep
  2. need to have clinical effects of the decreased amnt of sleep
• can have various causes (including meds!): increases w/ decreased SES or with medical comorbidities

Question 15

2 common medications used for insomnia

Answer 15

1. benzodiazapines:
   - non-selective GABA receptor agonists –> promotes sleep
2. NON-benzodiazepine receptor agonists
   - work at the GABA receptor sites
   * *the choice of medication depends on what the problem is, sleep onset or sleep maintenance?

Question 16

Stimulus control tx

Answer 16

• non-pharm insomnia tx
• using bed/room only for sleep
• go to bed when sleepy only
• get out of bed and go into another room if you cant fall asleep w/in 15-20 min –> return when sleepy
• have regular sleep/wake sched
• avoid daytime napping

Question 17

Sleep restriction tx

Answer 17

• non-pharm insomnia tx
• reduce the amnt of time spent in bed to the amnt of time actually spent sleeping
• increase the amnt of time in bed by 15 min until desired time is reached
• initially results in sleep loss, but will eventually lead to more effective sleep efficiency
• usually works very well!

Question 18

Relaxation tx

Answer 18

• non-pharm insom tx
• relaxion-based intervention for pts with high levels of arousal both at night and daytime
• aims to deactive the arosal system

Question 19

Cognitive restruction tx

Answer 19

• non-pharm insom tx
• figure out the pts thoughts and feelings about sleep and if they have fears or misconceptions help them change their mindset

Question 20

4 Characteristic sx of narcolepsy

Answer 20

1. excessive daytime sleepiness (EDS)
2. cataplexy* –> 60% of pts
3. hypnagogic hallucinations *
4. sleep paralysis* –> can be an isolated sx, not necessarily narc
   * *believed to be caused by REM intruding into wakefulness

Question 21

Narcolepsy epidemiology

Answer 21

• onset is in second decade of life
• men = female
• specific gene found in all pts w/ cataplexy

Question 22

Narcolepsy pathophysiology

Answer 22

• etiology unknown, esp for narc w/ out cataplexy
• may be autoimmune
• could be due to loss of function of neuropeptide orexin –> esp. w/ cataplexy

Question 23

Orexin

Answer 23

• neuropeptide made by lateral thalmus
• loss of function of this protein is though to play a role in narcolepsy
• synaptically released during wakefulness
• help stabilize wakefulness and prevent inappropriate transitions into REM & non-REM sleep

Question 24

Orexin levles

Answer 24

• will be low in the CSF in pts with cataplexy!

- not necessary to get these levels for dx! but this test is pretty sensitive and specific!

Question 25

Multiple sleep latency test

Answer 25

• after a full night sleep test wake the pt up, and tell them to nap every couple of hrs
• add all the hours of sleep in these naps to get a mean
• not diagnostic, but will show the pt is very sleepy, normal pts should not really take a nap every time
• on average, normal ppl fall asleep in 10-15min, narcoleptics fall asleep in less than 8min
• naps of narcoleptics often include REM, not normal
• not always a definite test for narcoleptics

Question 26

Parasomnia definition

Answer 26

• disruptive undesirable motor or verbal phenom that occur during sleep
• results in abnormal arousals
• can occur in any stage of sleep or even during sleep transitions
• involves abnormal muscle and/or autonomic NS activity

Question 27

Arousal disorders: features

Answer 27

• occur during slow wave sleep
• usually occur about 2 hrs after falling asleep
• confusion, slow mentation, and disorientation are common
• can include sleep walking and night terrors
• last 30 sec-5 min
• best thing to do is allow a confusional arousal to resolve spontaneously

Question 28

Arousal disorders: causes

Answer 28

• genetic factors
• disturbances that trigger and increase in shifts from slow wave sleep to lighter stages of sleep - ex. sleep-disordered breathing, periodic limb mvmnts, GERD, etc.
• acute triggers = stress, sleep deprivation, alcohol –> all have synergisitc role!

Question 29

4 tx options for Arousal disorders

Answer 29

1. education
2. behavioral
3. hypnosis
4. medication

Question 30

4 REM parasomnias

Answer 30

1. nightmares
2. sleep paralysis
3. sleep related painful erections
4. REM behavior disorder

Question 31

REM behavior disorder: what is it

Answer 31

• more prevalent in elderly

- vivid dreams with violent theme + loss of REM atonia –> acting out dreams

Question 32

REM behavior disorder acute form

Answer 32

• can be b/c
  1. w/drawl from drugs/alcohol
  2. adverse rxn to antidepressants

Question 33

REM behavior disorder chronic form

Answer 33

• usually males > 60 yrs
• can be asociated w/ neurologic disorders (ex. parkinson’s, dementia, etc)
• need to address bed partner’s safety

Question 34

RLS definition + epidemiology

Answer 34

• urge to move legs caused by an uncomfortable/unpleasant sensation in the legs –> worsened by inactivity & relieved w/ mvmnt
• more prevalent in young (20-29) or elderly (60-69)
• women > men
• risk increases w/ use of some anti-depressants

Question 35

RLS pathophysiology

Answer 35

-has to do with reduced iron stores which is necessary to make dopamine

Question 36

3 features of RLS

Answer 36

1. • family hx of RLS
2. response to dopaminergic agents
3. periodic limb mvmnts

Question 37

RLS dx

Answer 37

• hx: w/ drgu & fmaily hx
• neuro exam (normal if idioathic)
• measure serum ferritin
• do a sleep study if unsure, or if narcolepsy is suspected

Question 38

2 Less common-sense effects of sleep deprivation

Answer 38

1. obesity - due to increased grhelin

2. diabetes - due to insulin resistance