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MS/HA/Stoke/Sleep > Sleep > Flashcards

Sleep Flashcards

1
Q

Sleep cycle

A

-Everyone undergoes 4-6 cycles of NREM (GABA, adenosine) and REM sleep
-each cycles lasts about 70-120 min
-NREM (stage 1 -theta): transition period (5-10 min)
-NREM (stage 2)-spindles/k-complex: body temp, HR slows, brain produces sleep spindles (20 min)
-NREM (stage 3-delta): muscles relax, BP/breathing rate drop, deepest sleep occurs
-REM - beta : brain active, body relaxes/immobilizes , dreams occur, eyes move rapidly (acetylcholine)

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2
Q

REM sleep

A

-Paradoxical sleep
-brain active
-muscles paralyzed
-controlled by cholinergic cells

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3
Q

NREM sleep

A

-Quiescent sleep
-3 stages
-dreaming = rare
-muscles not paralyzed

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4
Q

S/S

A

-excessive daytime sleepiness (EDS)
-impaired daytime functioning
-irregular breathing
-inc movement during sleep
-irregular sleep and wake cycle
-difficulty falling asleep

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5
Q

Insomnia primary disorders

A

RLS, PLMD, breathing disorder, circadian rhythm disorders

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6
Q

Insomnia secondary disorders

A

medical disorders, psych disorders, substance induced

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7
Q

Insomnia categories

A

-several days: transient insomnia
-less than 3 month: short term
-more than 3 months: chronic

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8
Q

transient treatment

A

BZDRA for 2-3 weeks

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9
Q

short term treatment

A

-correcting underlying complaint, good sleep hygiene, sleep diary
-BZDRA for 2-3 weeks followed by:
-reduction of BZDRAs & continue for 2-3 weeks
-reduction of BZDRAs to every other night and continue for 2-3 weeks
-provision of a small prn suppy of BZDRAs

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10
Q

Long term treatment

A

-CBT (preferred 1st line)
-CBT +/- meds > meds alone

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11
Q

BZDRAs

A

-FDA approved for insomnia
-caution for anaphylaxis, facial angioedema and complex sleep behavior
-take before bed

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12
Q

benzo hypnotcs

A

-reduce sleep latency
-inc stage 2 sleep and dec delta sleep
-anxiolytic effect
-do not use in pt w sleep apnea or SUB
-avoid alc and CNS depressants
-SE are dose dependent
BBW: using benzos w opioids, benzo use in pt with SUB, and long term use can lead to dependance
-Drugs: estazolam, flurazepam, quazepam, temazepam, triazolam

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13
Q

non benzo hypnotics

A

-more selective
-inc total sleep time
-less disruptive of sleep stages
-generally have less withdrawal, tolerance, and rebound insomnia
-BBW: associated w parasomnic episodes w amnesia (sleep walking, etc.)
Drugs: zolpidem, zaleplon, eszopiclone

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14
Q

Estazolam

A

-C4
-for sleep onset or maintenance
-CI: preg or w/ ketoconazole/itraconazole
-SE: hypokinesia

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15
Q

Eczopiclone

A

-C4
-Delayed onset if taken w food
-sleep maintenance or early morning awakenings (excellent)
-approved for sleep onset or sleep maintenance
-monitor use w 3A4 inhibitors (keto/itra)

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16
Q

Zopiclone

A

-C4
-not approved in US

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17
Q

Zaleplon

A

-C4
-avoid taking after high-fat meal
-short term treatment of insomnia (up to 30 days) - does not reduce nighttime awakenings
-DDI: 3A4 (cimetidine, rifampin)

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18
Q

Zolpidem

A

-C4
-IR tab or spray = sleep onset (off label = sleep main)
-ER tab = sleep onset or main
-SL tab = take if more than 4 hr remain before waking up & pt has trouble going back to sleep

19
Q

Trazodone

A

-May improve sleep continuity; off label
-BBW: suicidality
-SE: carryover sedation & alpha adrenergic block (orthostasis can occur = careful in elderly)
-Taper when d/c

20
Q

1st gen antihistamines

A

Diphenhydramine, doxylamine
-OTC for insomnia
-avoid in elderly
-tolerance develops quickly
-AC SE

21
Q

Suvorexant

A

-C4 DORA
-onset/main (turns off wake signal)
-CI: narcolepsy

22
Q

Lemborexant

A

-C4 DORA
-onset/main
-next day drowsiness/inc fall risk
-SE: abnormal dream, complex sleep behavior
-CI: narcolepsy

23
Q

Daridorexant

A

DORA
-onset/main
-no food (dec absorption)
-CI: narcolepsy
-30 min before bed

24
Q

Ramelton

A

-melatonin receptor agonist (MT1>MT2)
-onset & long term use
-not as effective in pts already treated with benzo
CI: fluvoxamine

25
Q

Melatonin

A

-not FDA approved
-sleep onset latency (jet lag, shift workers)
-avoid in autoimmune diseases
-not rec in AD

26
Q

Doxepin

A

-TCA
-Maintenance
-BBW: suicidality
-do not take within 3 hrs of meal

27
Q

Special pop

A

-Elderly (CBT, Ramelteon, Eszopiclone, Zolpidem, low dose doxepin)
-Preg (Diphenhydramine, Doxylamine, low dose doxepin)

28
Q

Other off labels for insomnia

A

Amitriptyline, Mirtazapine, Gabapentin

29
Q

Sleep apnea

A

-cessation of breathing during sleep
-diagnosed w polysomnography
-CSA
-OSA
-Mixed

30
Q

sleep apnea CSA

A

impairment of respiratory drive

31
Q

sleep apnea OSA

A

upper airway collapse and obstruction
-nasal positive airway pressure during sleep (CPAP)
-wt management
-avoid all CNS depressants and drugs that cause wt gain
-med for excessive daytime sleepiness

32
Q

Narcolepsy

A

-impairment of onset/offset of REM and NREM
-Narcolepsy tetrad: excessive daytime sleepiness, cataplexy, hallucination, sleep paralysis

33
Q

Narcolepsy treatment

A

-non pharm: good sleep hygiene, scheduled naps
-avoidance of drugs that worsen daytime sleepiness (benzos, opiates, APS)
-Modafinil or Armodafinil are standard for EDS
-TCAs, SNRIs and SSRIs = cataplexy
-Amphetamine, Methylphenadate, Xyrem (treat EDS)

34
Q

Modafinil and Armodafinil

A

-C4
-EDS meds
-avoid in preg
-may dec contraception effect
-caution in CVD
-not rec in left ventricular hypertrophy

35
Q

Solriamfetol

A

-C4
-EDS med
-CI: MAOIs
-Avoid in unstable CVD, arrhythmias

36
Q

Pitolisant

A

-CI: severe hepatic disease
-EDS med
-may prolong QTc (avoid in arrhythmias)

37
Q

Sodium oxybate (Xyrem)

A

-GHB active moiety
-C3
-BBW: CNS depression, abuse, restricted access
-dosed when pt is in bed
-REMs program

38
Q

Cataplexy meds (REM suppressing)

A

-Fluoxetine, Venlafaxine, Atomoxetine, Clomipramine, Imipramine, Nortriptyline

-Pitolisant, Xyrem

39
Q

Circadian Rhythm disorder

A

-insomnia or hypersomnia
-jet lag or work shift disorder

40
Q

Treat jet lag

A

-nap < 30 min
-timed light exposure
-melatonin
-ramelteon
-BZDRA (short acting)

41
Q

Shift disorder

A

-sleep scheduling
-sleep hygiene
-naps before or during shift
-bright light at night & darkness during the day
-melatonin
ramelteon
-BZDA (short acting)
modafinil & armodafinil to improve wakefulness

42
Q

Parasomnias

A

-sleep walking, driving, talking, etc
-could be from taking z-drug w/ alc or AD
-treatment: protect, BZDA, SSRIs or TCAs, reduce stress, anxiety, sleep deprivation to reduce nightmares

43
Q

RLS

A

-keep limbs in motion, often bilateral
-CKD, iron deficiency, Vitamin B or folate deficiency, pregnancy -cause
-treatment: nutrition, smoking cessation, exercise, sleep, withdrawal meds that may cause RLS:
meclizine, hydroxyzine, diphenhydramine, doxylamine
TCA, SSRI, SNRI (bupropion is fine)
APS
anti-nausea (metoclopramide)
treatment:
-intermittent sx: carba-levo, BZDRA (clonazepam), low dose opioid
-chronic: pregabalin, gabapentin
-dopamine agonist: pramipexole, ropinirole, rotigotine
-benzos: be careful in carryover sedation

MS/HA/Stoke/Sleep (4 decks)

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