S58 - Sleep Wake Disorders Flashcards
Narcolepsy - Excessive daytime sleepiness
Stimulant: modafinil
Narcolepsy - Sleep paralysis, catalexy or hypnagogic hallucinations
venlafexine
fluoxetine
sodium oxybate
Obstructive Sleep Apnea - after CPAP therapy still sleepy
modafinil
armodafinil
Short Term Insomnia
Sleep hygiene
Short-acting Benzodiazepine receptor agonists
Ramelteon
Chronic Insomnia
Sleep hygiene
Treat underlying condition
Benzodiazepine receptor agonists
Primary hypersomnia DSM-5 criteria
Excessive sleepiness for at least one month, prolonged sleep episodes or daytime sleepiness almost daily
Primary hypersomnia - Kleine-Levin Syndrome – usually males
Binge eating and hypersomnia
Sleep as long as 18-20 hours/day.
About 500 cases world-wide reported.
Disoriented, forgetfulness, depressed mood, irritability, and possibly aggressive behaviors.
Treatment with stimulants reported to be effective in ¾ cases.
Obstructive Sleep Apnea (OSA).
Loud snores or brief gasps that alternate with episodes of silence that lasts 20-30 seconds.
Disturbs partner; subject is often unaware.
Cessation of breathing 60-90 seconds with cyanosis.
Most subjects are overweight
Obstructive Sleep Apnea (OSA).
Complications –
arrhythmias, hypertension, cor pulmonale, and sudden death.
Obstructive Sleep Apnea (OSA).
Symptoms –
daytime HA, poor memory and irritability.
Airflow ceases, episode stops by a reflex action from the decrease in O2 => arousal which breathing resumes.
Severe: > 20/apneas/hr and excessive daytime sedation; moderate: 5-20 apneas/hr.
Obstructive Sleep Apnea (OSA).
Non-Pharm Treatment:
nonpharmacologic includes weight loss, remove obstruction (e.g. tonsillectomy).
Obstructive Sleep Apnea (OSA).
Pharm Treatment:
Modafinil (Provigil®) is indicated for OSA. Dose is 200-400 mg/day.
Narcolepsy
Irresistible sleep attacks of short duration.
DSM-5 criteria: occurs 3 times/week for at least 3 months.
Narcolepsy
Pathophysiology –
Neuropeptide orexin or “hypocretin” found only in the posterior or lateral hypothalamus.
Innervate aminergic and cholinergic areas to promote wakefulness.
Decrease orexin levels = > sleepiness in animal models.
Narcolepsy
Daytime sleep attacks: lasts up to 30 min.
Cataplexy –
precipitated by laughter (84%), excitement (74%) or surprise (64%).
Narcolepsy – Treatment.
Sleep scheduling – routine of bedtime and naps.
Record keeping – daily charting of episodes.
Medications.
Stimulants. Modafinil and armodafinil are FDA approved for EDS in narcolepsy.
Antidepressants.
Gamma - hydroxybutyrate.
Narcolepsy – Treatment options
Stimulants – sleep attacks Drug Daily Dose Dextroamphetamine (C-II) 5-60 mg Methylphenidate (C-II) 10-60 mg Modafinil (C-IV) 200-400 mg Amodafinil (C-IV) 150 mg-250 mg
Amodafnil: R-enatiomer of modafinil.
True
Narcolepsy – Treatment.
Cataplexy
Tricyclic antidepressants (TCA’s) –protriptyline (< 20 mg/day) least sedating agent.
SSRI’s - fluoxetine and others.
SNRI’s – venlafaxine
Gamma - hydroxybutyrate
Used in sexual assaults – “date-rape” drug causes anterograde amnesia leaves victims unable to recall details of the event
Circadian rhythm sleep disorders
sleep disruptions either increase. sleepiness or insomnia mismatch in the sleep-wake cycle.
Non-24 Hour Sleep-Wake Type (DSM-5).
Common among the blind, visual impairment and patients with a traumatic brain injury (TBI).
Tasimelton (Hetlioz®) MT1 and MT2 receptor agonist
Sleepwalking (somnambolism) – rising out of bed and walking about.
Blank, staring face, unresponsive to efforts to wake.
On awakening – amnesia for the episode.
True
Treatment of Sleepwalking and Sleep Terrors.
BZ’s, SSRI’s or TCA’s antidepressants.
Sleep-related eating disorder – frequent episodes of nocturnal eating without full conscious awareness.
Treatment:
Tx with opiates, dopaminergic agents (L-dopa) or topiramate.
Insomnia is the most common sleep problem.
True
Parasomnias are often self-limiting.
True
What are the two most common symptoms found in persons with narcolepsy?
Daytime sleepiness and Cataplexy
What agent used for narcolepsy is available with only by a Risk Management program?
Gamma - hydroxybutyrate GHB
What agents is used for “blind” persons with sleep difficulty?
Tasimelton