Sleep Flashcards
What are the stages of sleep?
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
What changes occur to sleep with aging?
- Shift time - go to sleep earlier, wake up earlier
- Decreased efficiency
- More night time awakenings
- Inc sleep latency
- Decrease total sleep time
- Inc stage 1/2, dec stage 3 and REM
- More daytime napping
- Less melatonin screted
- Inc sleep fragility
What are consequences of poor sleep?
- Inc mortality
- Cognitive decline
- Depression and anxiety
- Falls
- Imbalance
- CVD, DM
- Institutionalization
What are risk factors for poor sleep?
- Age
- Female
- Psych illness
- Medical disorders
- Medications
- Poor sleep hygiene
- Change to daily rhythm
What are the 9 Ps to rule out causes of insomnia?
- Pain
- PND
- Polypharmacy
- Pee
- Psych illness
- Partner
- Physical environment
- Psychosocial factors
- Primary sleep disorders
What are some medications that can disrupt sleep?
Activating:
Steroids
Pseudoephedrine/decongestants
Beta agonists/bronchodilators
Methylphenidate
Antidepressants (SSRI/SNRI)
Thyroid medications
Daytime drowsiness:
Antihistamine
Anticholinergic
Antiemetic
Opioids
Substances:
Alcohol
Tobacco
Caffeine
What are non-pharmacologic treatments for insomnia?
- Sleep hygiene - schedule, avoid naps, morning light, busy during day, avoid stimulation near bedtime, optimize sleep environment, avoid clock watching
- Single modality behaviour techniques: stimulus control, relaxation therapy, sleep restriction/compression
- CBT-insomnia
- Exercise
- Light therapy
- Music
What are pharmacologic treatments for insomnia?
Official indication: melatonin, zopiclone, temazepam, low dose doxepin, orexin receptor antagonists
Off label: trazodone, mirtazapine, antipsychotics
What are Choosing Wisely recommendations with regards to insomnia?
Do not use benzodiazepines or sedative hypnotics as first choice
What are questions to ask regarding sleep hygiene?
- Time to bed and waking up
- Use of caffeine, alcohol, smoking
- Screen time before bed
- Routine/consistency of schedule
- Daytime sleep
- Night time awakenings
- Bedroom environment
- Daily physical activity/exercise
Ddx for REM SBD
Periodic limb movement disorder
Sleep walking
OSA
Nocturnal seizures
What effects do melatonin have on sleep?
Decrease sleep latency
Preserved sleep architecture
Improve sleep quality
What are the diagnostic criteria for RLS?
- Urge to move legs, discomfort
- Starts/worse during rest/inactivity
- Dec with movement
- Worse or only at night
What are secondary causes of RLS?
- Iron deficiency
- CKD with hyperuricemia
- Peripheral neuropathy
- Parkinson’s
- Multiple sclerosis
What are 4 classes of pharm tx for RLS?
- Iron
- Pregabalin/gabapentin
- DA: pramipexole, ropinirole, rotigotine (risk ICD)
- Clonazepam (if intermittent)
How is RLS different from nocturnal myoclonus/periodic limb movement disorder?
PLMD
Needs sleep study
Unaware of movements
Don’t have associated RLS
List 6 causes of hypersomnolence
- Medication side effect
- OSA
- Depression
- Dementia
- Delirium
- REM SBD
- Parkinson’s disease
What are five components of cognitive behavioural therapy for insomnia?
- Cognitive restructuring - work with therapist for anxiety and catastrophic thinking
Behavioural - Sleep hygiene education
- Sleep restriction/compression therapy
- Stimulus control therapy
- Relaxation training
What are signs/symptoms of alpha synucleinopathies that predict progression to neurodegenerative disease?
- Autonomic dysfunction
- Olfactory dysfunction
- Insomnia/hypersomnolence
- Depression
- Loss of colour vision
What are 4 treatments for REM SBD?
- Melatonin
- Clonazepam
- Pramipexole
- Transdermal rivastigmine
What are 8 non-pharm management strategies for sleep hygiene?
- Bedroom only for sleeping
- No screen time close to bed
- No intake of caffeine after lunch 4. No smoking close to bed
- Consistent schedule/timing
- Avoid alcohol close to bed
- Dark, cool environment
- Exercise during day
- Exposure to sun during day
What are 4 classes of medications for insomnia and their side effects?
- Melatonin - vivid dreams
- TCAs - anticholinergic, falls, somnolence
- Benzodiazepines - CI, sedating, falls
- Z drugs - dizzy, falls, memory
What neurodegenerative conditions associated with REM SBD?
Main
1. Parkinson’s
2. LBD
3. MSA
4. Non amnestic MCI
Other
1. AD
2. PSP
3. FTD
4. ALS
5. HD
What medication can worsen/cause REM SBD?
SSRIs
What are the benefits of benzos and Z drugs?
Short term improvement in:
Dec sleep latency
Sleep time
Sleep efficiency
What are risks of benzos and Z drugs?
- Sedation
- Falls
- Fractures
- Cognitive impairment
- Risk of tolerance, dependence, withdrawal
