Rothrock: Sleep!

Question 1

What is the probable ultimate regulator of sleep?

Answer 1

hypothalamus

Question 2

What happens to total sleep time with increasing age?

Answer 2

it declines

Question 3

Which hormones decrease with sleep? Which increase?

Answer 3

cortisol and TSH; growth hormone and prolactin

Question 4

During sleep, pineal derived (blank) production begins and ceases w/ exposure to sunlight

Answer 4

melatonin

Question 5

“a natural repeated unconsciousness” whose reason and purpose are unknown

Answer 5

sleep

Question 6

What are the 4 stages of sleep?

Answer 6

4 non-REM cycles;

1 REM cycle

Question 7

> drowsiness/slow, roving horizontal eye movements/reduced EEG voltage

Answer 7

stage 1 sleep

Question 8

EEG shows “sleep spindles” (bursts of biparietal 12-14 Hz waves), slow “vertex waves”

Answer 8

stage 2 sleep

Question 9

EEG shows high amplitude slow waves (delta Hz=EEG synchronized

Answer 9

stages 3 & 4

Question 10

EEG nonsynchronized*, shows fast wave; bursts of REMs; minimal tonic muscle activity; conjugate REMs; penile erection

Answer 10

stage 5 sleep

Question 11

How many non-rem/REM cycles do you go through in a night? During latter portion of the night, what stage of sleep are you primarily in?

Answer 11

4-6;

NREM-REM 2

Question 12

How many minutes are spent on each sleep cycle?

Answer 12

60-90 mins/cycle

Question 13

How long does the first REM cycle last after sleep onset?

Answer 13

70-100 minutes

Question 14

Most dreaming occurs during (blank)

Answer 14

REM sleep

Question 15

Are you easily aroused from REM sleep? From NREM 3 sleep?

Answer 15

yes; no

Question 16

Things that happen if we don’t sleep for >60hrs?

Answer 16

sleepiness, fatigue, irritability
difficulty concentrating
impaired skilled motor function 
inattention
impaired judgement
nystagmus, loss of accomodation, bilat hand tremor, ptosis, expressionless face, thick speech, mispronunciations, word substit.

if persists: visual/tactile hallucinations, psychosis, seizure activity

Question 17

More serious consequences of chronic lack of sleep?

Answer 17

hypertension
stroke
myocardial infarction
pulmonary hypertension 
early death

Question 18

sleep disturbance for prolonged periods in the absence of any causal psychiatric or medical disorder
“sleep hypochondriacs”

Answer 18

primary insomnia

Question 19

What are some non-medical causes of secondary insomnia? Some medical causes?

Answer 19

EtOH and drug abuse, psychological;

arthritic pain, GERD, PUD, prostatism/nocturia

Question 20

What is a sleep diary?

Answer 20

a real-time assessment of your sleep for 7 consecutive days; include bedtime, awakening, out of bed, naps, use of sedatives and stimulants, and symptoms

Question 21

Two most commonly used systems to assess how much sleeplessness you have

Answer 21

Epworth Sleepiness Score

Stanford Sleepiness Score

Question 22

If you have a secondary insomnia, how do you treat it?

Answer 22

treat the underlying disorder

Question 23

Is there any good treatment currently for primary insomnia?

Answer 23

No! We need good therapy for primary insomnias

Question 24

3 things that you might suggest for a patient with chronic primary insomnia?

Answer 24

sleep hygiene
cognitive and behavioral therapy
medications

Question 25

Re-set sleep cycle: no naps; dec non-sleep time in bed; exercise Re-set circadian rhythm: lights out, quiet time Avoid caffeine, alcohol, tobacco Bedroom: quiet, dark, rituals, no clock

Answer 25

Sleep hygiene

Question 26

What is the problem with having patients on sleep medications?

Answer 26

they may work great, but they are terribly hard to stop using over time

Question 27

What are the two types of sleep apnea?

Answer 27

central - caused by CNS | obstructive - problem with the airway

Question 28

What is essential for diagnosis of sleep apneas?

Answer 28

polysomnography

Question 29

Two forms of central sleep apnea?

Answer 29

primary: Ondine's curse secondary: lower brain stem abnormalities

Question 30

posterior pharyngeal muscles collapse and narrow airway noisy, cyclic snoring> apnea (10 to >30 secs)> breathing resumes/brief arousal occurs during REM and non-REM sleep

Answer 30

obstructive sleep apnea

Question 31

How does obstructive sleep apnea present? What patients typically get OSA?

Answer 31

excessive daytime somnolence; overweight, middle-aged men

Question 32

Screening tool for sleep apnea with fairly high sensitivity?

Answer 32

STOP-BANG

Question 33

What are 6 components of polysomnography?

Answer 33

``` EMG - looks at muscle activity Airflow EEG O2 sat Cardiac rhythm Leg movements ```

Question 34

When might you find these symptoms: ``` Nasal obstruction Long, thick soft palate Retrodisplaced mandible Narrowed oropharynx Redundant pharyngeal tissues Large lingual tonsil Large tongue Large or floppy epiglottis Retro-displaced hyoid complex ```

Answer 34

obstructive sleep apnea

Question 35

How to treat central sleep apnea?

Answer 35

treat underlying cause | low-flow oxygen

Question 36

Are meds helpful for OSA?

Answer 36

Not really

Question 37

Treatment for obstructive sleep apnea?

Answer 37

CPAP **mainstay therapy surgical options, like uvulectomy or mandibular advancement dental appliances behavioral means, like weight loss and avoidance of alcohol, sedatives, smoking non-supine sleep

Question 38

unpleasant sensation ( leg>arms) with irresistible urge to move the affected limb delays sleep onset and occurs in early stages of sleep common (prevalence>2%) symptoms provoked by rest, alleviated (briefly) by moving limb(s) may persist into daytime

Answer 38

restless leg syndrome

Question 39

Things that worsen restless leg syndrome?

Answer 39

worsens with fatigue and warm weather

Question 40

Restless leg syndrome is associated with what diseases?

Answer 40

iron deficiency anemia** check iron level hypo/hyperthyroidism pregnancy certain drugs (TCAs, anti-histamines)

Question 41

Treatment of restless leg syndrome?

Answer 41

``` iron supplementation dopamine agonists long acting L-dopa gabapentin clonazepam ```

Question 42

If a patient w RLS, what should you check?

Answer 42

iron level - look for iron deficiency anemia

Question 43

RLS might be due to decreased (blank)

Answer 43

dopamine

Question 44

What is in the narcoleptic tetrad?

Answer 44

recurrent attacks of irresistible sleep (“narcolepsy”) cataplexy (~70%) - loss of muscle tone usu provoked by emotions sleep paralysis (as you're falling asleep, you can't move your limbs) hallucinations (usu visual)

Question 45

When does narcolepsy usu begin? How long do sleep periods last?

Answer 45

ages 15-35; | <15 minutes, 2-6 times a day

Question 46

There is an abnormality in what hypothalamic neuropeptide in narcolepsy? These neurons project to sleep structures

Answer 46

hypocretin

Question 47

With narcolepsy, what happens to REM and non-REM sleep?

Answer 47

they are reversed - you begin with REM sleep **sleep latency reduced - just drop into sleep

Question 48

How do you diagnose narcolepsy?

Answer 48

overnight polysomnography followed by multiple sleep latency test

Question 49

naps at 2 hour intervals/detect REM activity within 15 minutes of sleep onset

Answer 49

multiple sleep latency test

Question 50

How to treat narcolepsy?

Answer 50

take short naps! stimulant drugs, like modafinil TCAs (antidepressants)