Neurology: Sleep

Question 0

As people age, which stage of sleep increase and which stages decrease?

Answer 0

Stage II increases

Stage III and IV decrease

Question 1

Describe the 5 stages of sleep as defined by EEG, EMG, and eye monitors.

Answer 1

Stage 1: light sleep
2: K complexes and sleep spindles
3&4: slow wave sleep; restorative sleep
REM: dream sleep

Question 2

Which region of the brain is the primary regulator of the circadian rhythm?

Answer 2

Suprachiasmatic Nucleus of the Hypothalamus

Question 3

List the 3 major structures in the brain important for sleep.

Answer 3

1. Basal Forebrain
2. Anterior Hypothalamus (suprachiasmatic nucleus)
3. Dorsolateral Medullary reticular formation

Question 4

What is the most common sleep disorder?

Answer 4

Insomnia (60 million people)

• sleep apnea: 10 mil.
• sleep schedule disturbance: 20 mil.
• narcolepsy: 250,000

Question 5

What is insomnia and what are risk factors associated with causing insomnia?

Answer 5

Inability to fall asleep or to maintain sleep.

-increasing age, medical, psychiatric, substance abuse can increase chances of getting insomnia.

Question 6

What is transient insomnia?

Answer 6

Insomnia that only lasts a few days.
-results from acute stress or environmental changes
(jet lag, acute illness, caffeine, alcohol, other drugs)

Question 7

What is short term insomnia?

Answer 7

Insomnia that lasts 3 weeks.

• more severe causes than transient insomnia: bereavement (death in the family), emotional trauma, pain
• marriage, divorce, moving

Question 8

What is chronic insomnia?

Answer 8

Insomnia lasting greater than 3 weeks.

• associated with physical and emotional stress
• use of meds, alcohol, illicit drugs

Question 9

How is insomnia diagnosed?

Answer 9

H&P thru primary care physician

Question 10

What are some things to ask about in the H&P when trying to diagnose insomnia?

Answer 10

Alcohol use, SNORING, dreams, nightmares, reflex movements

Question 11

What are the goals in treating insomnia?

Answer 11

Resolve underlying problem, improve quality of life, prevent progression of transient to chronic insomnia.

Question 12

What are some ways to improve sleep hygiene and prevent insomnia?

Answer 12

• avoid going to be hungry
• avoid alcohol or caffeine
• avoid exercising too late
• use bedroom for sleep and masterb…..i mean sex
• make bedroom comfortable
• maintain a regular schedule

Question 13

What is non-pharmacological factor to address before prescribing sleep medication?

Answer 13

heavy snoring

Question 14

What is a risk in using sedating antidepressants like amitriptyline?

Answer 14

Contraindicated in patients with BPH or cardiovascular disease.

-be careful when using in the elderly, can increase risk of falling

Question 15

What is a problem with using hydroxyzine or diphenhydramine in patients with insomnia?

Answer 15

They are antihistamines that may worsen insomnia and can half anti-cholinergic effects

Question 16

What are some medical conditions that can lead to restless leg syndrome?

Answer 16

• pregnancy
• uremia
• RA
• iron deficiency
• peripheral neuropathy

Question 17

What are medications that can treat restless leg syndrome?

Answer 17

1. Ropinirole or Pramipexole (PD meds)
2. Benzodiazepines
3. Opiates
4. Amitriptyline (TCAs)

Question 18

What is the mechanism of sleep apnea.

Answer 18

The airway becomes relaxed in sleep and closes off causing the patient to wake up.
-obesity and altered nasopharyngeal structure are risks

Question 19

What are some treatments for sleep apnea?

Answer 19

Lose weight
CPAP: continuous positive airway pressure, it’s a mask that maintains a specific pressure in the airway to prevent it from closing
Tennis balls
Surgery

Question 20

What is the genetic and biochemical defect of Narcolepsy?

Answer 20

Deficiency of production of hypocretin 2 because of a defective gene on chromosome 6.

Linked to HLA-DR2 and HLA-DQ1

Question 21

What is the classic tetrad features assocaited with narcolepsy?

Answer 21

1. Excessive Daytime sleepiness (only if they dream: REM sleep)
2. Cataplexy: loss of muscle tone mainly in head and neck
3. Sleep paralysis
4. Hypnagogic hallucinations: occur as the pt. falls asleep

Question 22

What other risk does cataplexy carry other than narcolepsy?

Answer 22

Increased risk of stroke

Question 23

What are the meds used to treat narcolepsy?

Answer 23

Caffeine
Methylphenidate
TCAs (inhibit REM sleep)
modafinil
sodium oxybate (mostly if caused by cataplexy)

Question 24

What is REM suppression and rebound?

Answer 24

Condition caused by alcohol, drugs (MAOIs, TCAs) that leads to sleep deprivation. When REM is suppressed for a long time and then finally allowed to occur the patients have really bizarre dreams.

Question 25

What stages of sleep does somnambulism occur?

Answer 25

Sleep Walking

Stage III and IV

Question 26

What stages of sleep does Pavor Nocturnus occur?

Answer 26

Night Terrors

Stage III and IV

Question 27

What is the drug class used to treat somnambulism and pavor nocturnus and why?

Answer 27

Benzodiazepines

-inhibits stage III and IV of sleep

Question 28

What other conditions must be ruled out when a patient presents with nocturnal enuresis?

Answer 28

• diabetes mellitus
• UTI
• diabetes insipidus
• seizure
• myelopathy

Question 29

What two meds can be given to patients to prevent bedwetting?

Answer 29

Imipramine (TCA)

Desmopressin (synthetic ADH)