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Royal College 2023 > Sleep > Flashcards

Sleep Flashcards

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1
Q

What are the stages of sleep?

A

N1 - awake, light sleepp
N2 - deeper sleep, bruxism
N3 - slow wave, physical recovery, sleepwalking, night terrors, bed wetting
REM - dreaming, loss of motor tone, every 90 minutes

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2
Q

What changes occur to sleep with aging?

A
  1. Shift time - go to sleep earlier, wake up earlier
  2. Decreased efficiency
  3. More night time awakenings
  4. Inc sleep latency
  5. Decrease total sleep time
  6. Inc stage 1/2, dec stage 3 and REM
  7. More daytime napping
  8. Less melatonin screted
  9. Inc sleep fragility
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3
Q

What are consequences of poor sleep?

A
  1. Inc mortality
  2. Cognitive decline
  3. Depression and anxiety
  4. Falls
  5. Imbalance
  6. CVD, DM
  7. Institutionalization
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4
Q

What are risk factors for poor sleep?

A
  1. Age
  2. Female
  3. Psych illness
  4. Medical disorders
  5. Medications
  6. Poor sleep hygiene
  7. Change to daily rhythm
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5
Q

What are the 9 Ps to rule out causes of insomnia?

A
  1. Pain
  2. PND
  3. Polypharmacy
  4. Pee
  5. Psych illness
  6. Partner
  7. Physical environment
  8. Psychosocial factors
  9. Primary sleep disorders
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6
Q

What are some medications that can disrupt sleep?

A

Activating:
Steroids
Pseudoephedrine/decongestants
Beta agonists/bronchodilators
Methylphenidate
Antidepressants (SSRI/SNRI)
Thyroid medications
Daytime drowsiness:
Antihistamine
Anticholinergic
Antiemetic
Opioids
Substances:
Alcohol
Tobacco
Caffeine

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7
Q

What are non-pharmacologic treatments for insomnia?

A
  1. Sleep hygiene - schedule, avoid naps, morning light, busy during day, avoid stimulation near bedtime, optimize sleep environment, avoid clock watching
  2. Single modality behaviour techniques: stimulus control, relaxation therapy, sleep restriction/compression
  3. CBT-insomnia
  4. Exercise
  5. Light therapy
  6. Music
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8
Q

What are pharmacologic treatments for insomnia?

A

Official indication: melatonin, zopiclone, temazepam, low dose doxepin, orexin receptor antagonists
Off label: trazodone, mirtazapine, antipsychotics

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9
Q

What are Choosing Wisely recommendations with regards to insomnia?

A

Do not use benzodiazepines or sedative hypnotics as first choice

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10
Q

What are questions to ask regarding sleep hygiene?

A
  1. Time to bed and waking up
  2. Use of caffeine, alcohol, smoking
  3. Screen time before bed
  4. Routine/consistency of schedule
  5. Daytime sleep
  6. Night time awakenings
  7. Bedroom environment
  8. Daily physical activity/exercise
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11
Q

Ddx for REM SBD

A

Periodic limb movement disorder
Sleep walking
OSA
Nocturnal seizures

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12
Q

What effects do melatonin have on sleep?

A

Decrease sleep latency
Preserved sleep architecture
Improve sleep quality

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13
Q

What are the diagnostic criteria for RLS?

A
  1. Urge to move legs, discomfort
  2. Starts/worse during rest/inactivity
  3. Dec with movement
  4. Worse or only at night
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14
Q

What are secondary causes of RLS?

A
  1. Iron deficiency
  2. CKD with hyperuricemia
  3. Peripheral neuropathy
  4. Parkinson’s
  5. Multiple sclerosis
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15
Q

What are 4 classes of pharm tx for RLS?

A
  1. Iron
  2. Pregabalin/gabapentin
  3. DA: pramipexole, ropinirole, rotigotine (risk ICD)
  4. Clonazepam (if intermittent)
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16
Q

How is RLS different from nocturnal myoclonus/periodic limb movement disorder?

A

PLMD
Needs sleep study
Unaware of movements
Don’t have associated RLS

17
Q

List 6 causes of hypersomnolence

A
  1. Medication side effect
  2. OSA
  3. Depression
  4. Dementia
  5. Delirium
  6. REM SBD
  7. Parkinson’s disease
18
Q

What are five components of cognitive behavioural therapy for insomnia?

A
  1. Cognitive restructuring - work with therapist for anxiety and catastrophic thinking
    Behavioural
  2. Sleep hygiene education
  3. Sleep restriction/compression therapy
  4. Stimulus control therapy
  5. Relaxation training
19
Q

What are signs/symptoms of alpha synucleinopathies that predict progression to neurodegenerative disease?

A
  1. Autonomic dysfunction
  2. Olfactory dysfunction
  3. Insomnia/hypersomnolence
  4. Depression
  5. Loss of colour vision
20
Q

What are 4 treatments for REM SBD?

A
  1. Melatonin
  2. Clonazepam
  3. Pramipexole
  4. Transdermal rivastigmine
21
Q

What are 8 non-pharm management strategies for sleep hygiene?

A
  1. Bedroom only for sleeping
  2. No screen time close to bed
  3. No intake of caffeine after lunch 4. No smoking close to bed
  4. Consistent schedule/timing
  5. Avoid alcohol close to bed
  6. Dark, cool environment
  7. Exercise during day
  8. Exposure to sun during day
22
Q

What are 4 classes of medications for insomnia and their side effects?

A
  1. Melatonin - vivid dreams
  2. TCAs - anticholinergic, falls, somnolence
  3. Benzodiazepines - CI, sedating, falls
  4. Z drugs - dizzy, falls, memory
23
Q

What neurodegenerative conditions associated with REM SBD?

A

Main
1. Parkinson’s
2. LBD
3. MSA
4. Non amnestic MCI
Other
1. AD
2. PSP
3. FTD
4. ALS
5. HD

24
Q

What medication can worsen/cause REM SBD?

A

SSRIs

25
Q

What are the benefits of benzos and Z drugs?

A

Short term improvement in:
Dec sleep latency
Sleep time
Sleep efficiency

26
Q

What are risks of benzos and Z drugs?

A
  1. Sedation
  2. Falls
  3. Fractures
  4. Cognitive impairment
  5. Risk of tolerance, dependence, withdrawal

Royal College 2023 (79 decks)

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