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Peds neuro boards, V2 > Sleep > Flashcards

Sleep Flashcards

1
Q

ICSD criteria for chronic insomnia

Criteria A (3)

Criteria B (8)

Criteria C

Criteria D

Criteria E

A
  1. Criteria A (primary problem is that they’re not sleeping)
    1. diffiicutly initiating sleep
    2. difficulty maintaining sleep
    3. waking up earlier than desired
  2. Criteria B (daytime symptoms)
    1. fatigue / malaise
    2. attention, concentration, or memory impairment
    3. impaired social / family / occupational / academic performance
    4. mood disturbance / irritability
    5. daytime sleepiess
    6. reduced motivation / energy / initiative
    7. proneness for errors / accidents
    8. conc erns about or dissatisfaction with sleep
  3. Criteria C: Symptoms cannot be explained purely by inadequate opportunity to sleep
  4. Criteria D: Symptoms occur at leats 3 times per week
  5. Criteria E: Symptoms have been present for 3 months
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2
Q

Benzodiazepine receptor agonists

A

Zolpidem

Eszopiclone : long half-life

Zaleplon: shortest half-life

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3
Q

Non BRZA sleep aids

(4)

A

Ramelton (melatonin receptor agonisit

Doxepin

Benzodiazepines

Suvorexant (dual receptor agonist)

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4
Q

Dosing considerations for sleep aids

Zolpidem

Eszopiclone

Zaleplon

A

Zolpidem: decreased dose for women and all > 65

Eszopiclone: lower dose only for those > 65

Zaleplon: none

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5
Q

ICSD for OSA (adult)

A
  1. 1+ of the following:
    1. Excessive daytime sleepiness, fatigue, or insomnia
    2. wakes up breaht holding, gasping, or choking
    3. observer reports snoring, breathing interruptions
    4. diagnosed with hypertension, mood disorder, cognitive dysfunction, CAD, stroke, CHF, afib, or DM II
  2. polysomnogrmam demonstrates 5 or more obstrucive respiratory events per hour
  • OR -
    1. PSG shows 15 or more predominately obstructive respiratoyr events per hour of sleep during PSG or per hour of monitoring
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6
Q

Risk factors for OSA (7)

A
  1. Obesity
  2. thick neck
    1. Men: >42 cm
    2. Women: > 38 cm
  3. Mallampati 3-4
  4. retrognathia / micrognathia
  5. steroid exposure
  6. PCOS
  7. HIV and antiretrovirals
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7
Q

Mallampati classification

A
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8
Q

Apnea / hypopnea index (AHI) ranges

A

Normal: <5

6-14: Mild

14-30: moderate

>30: severe

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9
Q

ICSD criteria for Central Sleep apnea

Category 1 (general):
Category 2 (3)
A
  1. Presence of at least one of the following:
    1. Sleepiness
    2. Difficulty initiating or maintaining sleep, frequent awakenings, non-restorative sleep (insomnia stuff)
    3. Awakening short of breath
    4. snoring
    5. witnessed apneas
  2. all of the following
    1. five + central apneas and/or central hyponeas per hour of sleep on PSG
    2. number of central sleep apneas and/or central hypopneas is >50% of total number of apneas / hypopneas (majority are not obstructive)
    3. absence of cheyne stokes breathing
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10
Q

Central vs obstructive sleep apnea on PSG

A
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11
Q

Risk factors for central sleep apnea (8)

A
  1. Congestive heart failure
  2. chiari malformation
  3. Stroke
  4. opioids
  5. A fib
  6. chronic renal failure
  7. Hypothyroidism
  8. high altitude
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12
Q

Contraindication for Servoventilation and BiPAP for Central sleep apnea

A

Ejection fraction < 45%

(associated with increased mortality)

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13
Q

What does this PSG show?

A

Diaphragmatic paralysis (note increased use of accessory muscles)

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14
Q

Circadian Rhythm sleep-wke disorders

  1. Delayed sleep phase
  2. Advanced sleep phase
  3. Irregular sleep-wke rhythm
  4. Non-24 sleep wake disorder
A
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15
Q

ICSD criteria for circadian rhythm sleep-wake disorder

Criteria A

Criteria B

Criteria C

Criteria D

A
  1. Must be > 3 months in duration and due to alteration of the circadian timing system or to a misalignment between internal circadian rhythm and the sleep-wake schedule desired or required by an individual’s physical environment or social / work schedules
  2. Leads to excessive sleepiness, insomnia, or both
  3. sleep and wake disturbances cause significant distress / impairment of health
  4. sleep diary / actigraphy monitoring for at least 7 days (but preferably 14) shows disruption of the circadian sleep-wake cycle
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16
Q

Treatment for Delayed sleep phase dosorder

A
  1. Phototherapy
    1. blue enriched (2500-10,000 lux for 1-2 hours in th emorning shortly after core body temparture minimum (about half an hour before typical melatonin onset time)
    2. avoidance of bright light in the evening and prior to CBTmin
  2. Melatonin 0.5 mg 13-14 hours after natural wake up time
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17
Q

Timeline for how to give phototherapy and melatonin for advanced versus delayed sleep phase disoders

A
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18
Q

Medications specificaclly for Non-24 patients who are blind

A
  1. Tasimelton (Melatonin receptor type 1 and type 2 agonist)
  2. 20 mg before bedtime at the same time every night
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19
Q

Treatment for Jet lag

A
  1. Melatonin 0.5 mg at bedtime on arrival (can repeat up to 4 nights)
  2. on eastward flights - sstay awake and avoid bright light in morning and be exposed to as much light as possible in the afternoon (“heading toward the rising sun, avoid the sunrise!)
  3. westward flights, attempt to stay awake while light is out and not sleep until nighttime at the destination
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20
Q

ICSD criteria for Narcolepsy Type 1 and Type 2

A

Present in both:

  1. daily periods of irrepressible need for sleep or daytime lapses in sleep
  2. MSLT < 8 minutes and 2+ sleep onset REM periods on MSLT (or one + another within 15 minutes of sleep onset on preceding nocutrunal PSG)

What makes narcolepsy Type 1

  1. Presence of Cataplexy
  2. CSF hypocretin-1 <110 pg/mL
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21
Q

Pathology of Narcolepsy

A
  1. Reduction of hypocretin II (orexin B) producing cells in posterior and lateral thalamus by 85%-95%
  2. reduced CSF hypocretin
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22
Q

Gene associated with Narcolepsy (and chromsome). Two other important notes about this mutation

Two other chromosomes seen with narcolepsy

A

HLA-DQB1-0602 (85% of type 1) - Chromosome 6

severity increases with more alleles

NOTE: present in 20% of general population

Mutations also seen chromosmes 4 and 21

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23
Q

Non-stimulant treatments for Cataplexy

Category 1 (3)
Category 2 (2)
Category 3 (1)
Category 4 (1)
A

Antidepressants

  1. Protriptyline
  2. clomipramine
  3. nortriptyline
  4. fluoxetine
  5. sertraline
  6. Venlafaxine (SNRI)

Sodium oxybate (strong Gaba-B agonist) - AT NIGHT

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24
Q

Criteria for OSA (pediatric)

A
  1. at least one of the following:
    1. Snoring
    2. labored, obstructive, or paradoxical breathing durin gslep
    3. hyperactivity, cognitive troubles, or sleepiness during the day
  2. AND at least one obstructive or mixed apnea or hyponea during each our of sleep
  • OR -
  1. PaCO2 is >50 mmHG for >25 % of total sleep time
  2. AND any of the following
    1. child snores
    2. has paradoxical thoracoabdominal motion
    3. flattened instpiratory nasal pressure waveform
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25
Q

How does Early RLS differ from Late RLS?

(3)

A
  1. before age 45
  2. more gradual progressino
  3. greater family history of RLS
26
Q

Treatments for REM sleep behavior disorder

A
  1. Melatonin (first time)
  2. clonazepam (alternative or add-on, particularlywith neurodegenerative disease)
27
Q

Side effects of Amitriptyline

(3 vague and 10 less vague)

A

Four D’s, Four F’s

  1. Dry (constipation, urinary retention, dry mouth)
  2. Dizzy
  3. Drowsiness
  4. Disorientated
  5. Fat (weight gain)
  6. Fidgety Heart (arrythmia)
  7. Fidgety Legs (RLS exacerbation, REM sleep behavior disorder, Periodic limb disorder)
  8. Falling over (orthostatic hypotention)
28
Q

PSG diagnosis of Periodic limb movements of sleep

and criteria for Periodic limb movement disorder

A
  1. Separated by 5-90 seconcds (measured by movement of one limb to another)
  2. duration of 0.5-10 seconds each
  3. Occur in runs of at leat 4
  4. movement of at least 8 microvolts above resting EMG

disorder = >5 per hour (children) or 15/hour (adults)

29
Q

Best respiratory setting for patients with neuromuscular disease during sleep

A

Bilevel: Spontaneously Timed (ST) mode

30
Q

Mechanism of action: suvorexant (Belsomra)

A

Orexin / hypocretin mechanism (first in class)

31
Q

Steps of sleep restriction therapy

A
  1. Keep daily log to determine about of time actually spent asleep
  2. limit time in bed to that time for 7 days
  3. If >85% sleep efficiency: Increase time in bed by 15 minutes for 7 days
  4. If <80% sleep efficiency: Decrease time in bed by 15 minutes for 7 days
  5. If 80-85% sleep efficiency: keep time the same, recheck in 7 days
32
Q

Sleep walking is most common during:

A

Slow wave sleep

33
Q

Medical treatments for restless leg syndrome

A

FIRST LINE = iron supplementation

* = FDA approved

Hydrocodone = not typically used

34
Q

Congenital central hypoventilation syndrome:

  1. Gene and type of mutation
  2. Onset
  3. symptoms (3 main)
  4. Symptoms (9 other)
  5. treatment (2)
A
  1. trinucleotide repeats in PHOX2B gene
  2. Onset: first year of life
  3. Symptoms
    1. hypoxia
    2. hypercapnia
    3. prolonged central apneas during sleep with cyanosis (autonomic dysfunction)
  4. symptoms (other)
    1. difficulty regulating HR and blood pressure
    2. pupillary abnormalities
    3. impaired pain sensation
    4. hypothermia
    5. hyperhydrosis
    6. Hirschprung disease (due to abnormalities in enteric nervous system)
    7. Cancer (neuroblastoma, ganglioneuroma, ganglioneuroblastoma)
    8. “box-shaped” face
    9. leraning disabilities
  5. Treatment
    1. mehcanical ventilation
    2. diaphragm pacemakers
35
Q

What test should you order in patient with chronic insomnia with “med seeking” behavior

A

PSG

36
Q

Sleep recovery nights

First night:

Second night:

A
  1. First night:
    1. Less time in N1, N2, and W
    2. Increased N3
    3. Relatively decreased R
  2. Second night
    1. Times spent in N3 may decrease
    2. REM may incrase (especially in younger individuals)
37
Q

Augmentation in restless leg syndrome:

  1. What is it?
  2. How does it present?
  3. What do you do about it?
A
  1. worsening of RLS symptoms after administration of dopaminergic medication
  2. How does it present?
    1. Earlier symptom onset
    2. spreading symptoms to upper extremities
    3. worsening of preexisting symptoms
  3. How do you treat it?
    1. switching from dopaminergic drug ot medicaiton iwth different mechanism of action (such as gabapentin enacarbil)
38
Q

Sleep-related adverse effects of venlafaxine (5)

A
  1. decreased sleep efficiency
  2. incrased wake time after sleep onset
  3. increase in REM sleep latency
  4. decrease in REM sleep
  5. Causing or exacerbating periodic limb movements of sleep
39
Q

Big conditions associated with REM sleep behavior disorder (3)

A
  1. parkinson disease (33-50%)
  2. Multi-system atrophy (80-95%)
  3. Dementia with Lewy bodies (80%)
40
Q

Criteria for Hypoventilation with hypothalamic dysfunction:

A

2+ of the following:

  1. Hypothalamic endocrine abnormalities (diabetes insipidus, SIADH, Hypothyroidism, hyperprolactinemia)
  2. obesity
  3. tumor of neural origin
  4. emotional / behavioral disturbance
41
Q

Which thalamic nuclei are affected in fatal familial insomnia?

A

Mediodorsal nuclei

42
Q

workup for Restless leg syndrome

(5)

A
  1. Serum Ferritin
  2. Screen for uremia
  3. screen for diabetes
  4. consider pregnancy test (can exacerbate RLS)
  5. PSG only if refractory to treatment (to look for other issues)
43
Q

RLS versus PLMS

A

Restless leg:

  1. Symptom
  2. diagnosed in physician’s office
  3. 80% of RLS will have PLM

Periodic limb movements of sleep

  1. electromyographic finding
  2. diagnosed in sleep lab
  3. 30% of patients with PLM have RLS symptoms
44
Q

What does htis Sleep study show?

A

Periodic limb movements in sleep

45
Q

Treatment for Bruxism (5) and med to avoid

A
  1. Mouth guard
  2. botox of masseter
  3. PT
  4. biofeedback
  5. amitryptiline

AVOID: SSRIs (aggravate bruxism)

46
Q

Sleep Related eating disorder

  1. What is it?
  2. Diagnostic criteria (3)
  3. More common in _(3)\_
  4. Treatment (2)
  5. Innefective (2)
A
  1. Recurrent episodes of eating during sleep with no or impaired recollection of events
  2. Need 1+ of the following
    1. consumption of peculiar foods or inedible / toxic substances
    2. sleep related injuries or potential injuries while in pursuit of food
    3. adverse health consequences from recurrent sleep eating
  3. More common in
    1. Women (4:1)
    2. people with daytime eating disorders
    3. zolpidem or other sedative hypnotics
  4. treatment
    1. low dose topiramate or pramipexole
  5. Doesn’t work
    1. CBT
    2. benzodiazepines
47
Q

Sleep disorders associated with:

Parkinson disease

A
  1. REM sleep behavior disorder (46%)
  2. multifactorial insomnia and daytime sleepiness
48
Q

Sleep disorders associated with:

Multisystem atrophy

A
  1. RBD
  2. STridor
  3. OSA
  4. central alveolar hypovenitlation
49
Q

Sleep disorders associated with:

Demintia with Lewy Bodies

A

RBD (80%

50
Q

Sleep disorders associated with:

Spinocerebellar degeneration (3)

A
  1. non REM parasomnias
  2. RBD
  3. Sleep architecture abnormalties
51
Q

Sleep disorders associated with:

Huntington disease

A
  1. Insomnia
  2. Daytime sleepiness
  3. Delayed sleep phase syndrome
52
Q

Sleep disorders associated with:

ALS

A
  1. Sleep related hypovenilation (nearly all affected patients with ALS)
  2. PLMD
  3. RBD
53
Q

Sleep disorders associated with:

Alzheimers

A

All sleep disturbances; most commonly irregular sleep wake rhythm disorder leading to sundowning

54
Q

Criteria for hypoventilation scoring

A

Either:

  1. increased PCO2 > 55 mmHG for >10 minutes
    - OR -
  2. Increased PCO2 by >10 mmHG during sleep compared to awake supine value, with PCO2 > 50 mmHG for >10 minutes
55
Q

Sleep Changes with schizophrenia

(3)

A

Reduction in total sleep time

Less time in slow wave sleep

Shortened REM latency

56
Q

What is responsible for sleep in the first and second half of sleep?

A

First half: homeostatic sleep drive
Second half: ceircadian sleep drive

57
Q

Percentage of total sleep time:

Stage 1

Stage 2

Stage 3

REM

A

Stage 1: 5% (transition phase)

Stage 2: 50% of sleep

Stage 3: 10-20% of sleep

REM = 20-25% of sleep

58
Q

Neurophysiological signs of hyperarousal in primary insomnia

(5)

A
  1. Decreased Low-frequency delta power
  2. increased cortisol and ACTH levels
  3. Increased global metabolic rate in brain during waking and sleep
  4. Increased Heart rate
  5. increased whole metabolic rate
59
Q

Adverse effects of oral airway devices

A

Tooth discomfort

Hypersalivation

Mucosal dryness

changes in dental occlusion

60
Q

Sleep breathing patterns:

  • Crescendo-Decrescendo breathing
  • Deep inspiration and expiration (typically acid-base related)
  • Long deep inspiration followed by pause at full inspiration + short, insufficient exhale
  • Short, gasping breaths without chronicity or rhythmicity
A
  • Crescendo-Decrescendo breathing
    • Cheyne-Stokes
  • Deep inspiration and expiration (typically acid-base related)
    • Kussmaul
  • Long deep inspiration followed by pause at full inspiration + short, insufficient exhale
    • Apneustic
  • Short, gasping breaths without chronicity or rhythmicity
    • Ataxic

Peds neuro boards, V2 (29 decks)

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