Sleep!!! Flashcards
How many non-REM stages of sleep are there?
1, 2, 3, 4
Aside from the non-REM stages, what is the other stage of sleep?
the REM stage
What is involved in REM sleep?
dreaming & nightmares (not night terrors)
inhibition of muscular activity
When does slow wave sleep happen? What is involved here?
stages 3 & 4 restorative sleep disinhibition of muscular activity parasomnias **this is where night terrors happen
When does REM happen? What is the pattern of this?
it happens throughout the night!!
they get longer as you progress in a night’s sleep
–>as in: right before you wake up…the REM sleep will last the longest.
When does slow wave sleep typically occur?
during the earlier portion of the night
What are the changes that happen to sleep as a person ages?
Increase in light/transitional sleep Reduction in slow-wave sleep Decline in overall sleep time Increased awakenings and arousals Decreased REM sleep Reduced sleep efficiency
Why is an ages person’s sleep efficiency lower?
their sleep latency is longer…it takes longer for them to fall asleep
What are some possible chief complaints of patients who need help sleeping?
Tiredness, fatigue, sleepiness Trouble sleeping Poor sleep quality Inadequate sleep quantity Abnormal behavior during sleep-leg keeps me awake Loud snoring
Which stages of sleep decrease with age?
REM & stage 4 sleep both decrease with age.
T/F Sleep disorders are over-diagnosed.
False. Underdiagnosed! about 1/2 adults are dissatisfied with their sleep.
What are some good questions to ask patients about their sleep?
Is your sleep at night satisfactory?
Do you tend to fall asleep or struggle to stay alert during the day?
Are you bothered by fatigue, tiredness, lack of energy most of the time?
Do you have unusual behaviors which arise from the sleep period?
Which is linked to more car accidents? Insomnia or Sleep apnea
Insomnia
What is insomnia? It is the most common sleep disorder.
Difficulty initiating, maintaining, or non - restorative sleep
How common is insomnia?
30-50% of American adults experience insomnia during a 1 year period
Prevalence of chronic/severe insomnia is estimated to range 10%-30%
About 10% of all general population have been prescribed a medication for insomnia
What are the different types of insomnia?
Sleep onset insomnia Sleep maintenance insomnia Sleep offset or late insomnia Nonrestorative sleep Transient Insomnia Short-term Insomnia Chronic Insomnia
What is sleep onset insomnia?
Difficulty falling asleep
Longer time to sleep onset
What is sleep maintenance insomnia?
Difficulty staying asleep
Frequent nocturnal awakenings
What is sleep offset or late insomnia?
Waking too early in the morning
What is nonrestorative sleep?
Fatigue despite adequate sleep duration
What is transient insomnia?
**episodic
Acute illness
Jet lag
Shift change
What is short-term insomnia?
**lasts a few days to 3 weeks
Major life event
Substance abuse
What is chronic insomnia?
**lasts longer than 3 weeks
Chronic illness
Psychiatric illness
What are some non-pharmacological treatments for sleep difficulties?
sleep hygiene stimulus control sleep restriction relaxation training cognitive therapy cognitive behavior therapy-insomnia
What is the purpose of sleep hygiene?
Promote habits that help sleep; provide rationale for subsequent instructions.
What are the basics of sleep hygiene?
- reduce arousal
- regulate sleep homeostatic & cricadian system
- minimize alcohol use etc.
How can you reduce arousal as a part of sleep hygiene?
eliminate stimulants--caffeine, tobacco exercise make it a conducive sleep environment--quiet, dark, comfortable, safe room. relaxing routine at bed to decompress avoid clock watching
What are some things involved in regulating sleep homeostatic & circadian system as a part of sleep hygiene?
regular sleep-wake schedule
avoid napping
avoid excessive amounts of time awake in bed–if you can’t sleep–>go somewhere else.
What is the purpose of relaxation training?
Reduce arousal & decrease anxiety
What are some important relaxation techniques?
progressive muscle relaxation (PMR)-->tense release exercise passive muscle relaxation-body scan. Imagery Meditation (mindfulness) biofeedback diaphragmatic breathing (deep breathing)
When should you make a detailed to do list?
scheduled worry time.
an effective thing to treat generalized anxiety disorder
**if you have a random thought in the middle of the night-can jot on your to do list.
T/F You should only use the bed for sleep & sex.
True.
What are some indicators of circadian dysregulation?
erratic, variable schedule for sleep lack of consistent time cue anchors (get up time, meal times etc) sedentary "jet lag" symptoms after a treap. shiftwork can cause daytime fatigue GI distress tired muscles headaches
T/F Circadian rhythm sleep disorders are the same as insomnia.
False. separate things.
What are 2 types of circadian rhythm sleep disorder?
delayed sleep phase-young adults
advanced sleep phase-old adults
Which is easier westbound or eastbound travel?
westbound b/c it is easier to delay the circadian rhythm than to advance it.
What is delayed sleep phase circadian rhythm sleep disorders?
Pattern of delayed sleep onset and awakening times with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time
What is advanced sleep phase circadian rhythm sleep disorder?
Pattern of advance sleep onset and awakening times with an inability to remain awake or sleep until the desired or conventionally acceptable later sleep or wake time
What is narcolepsy?
Recurrent periods of irrepressible need to sleep, lapsing into sleep or napping occurring within the same day.
What are 4 symptoms of narcolepsy?
- *Excessive daytime sleepiness
- *Cataplexy-sudden loss of muscle tone often triggered by strong emotions
- *Sleep paralysis – inability to move at sleep onset or upon awakening
- *Hypnagogic hallucinations –rem sleep occurring during wakefulness
T/F You can have narcolepsy without cataplexy.
True.
How do you diagnose narcolepsy?
sleep polysomnography (PSG) and multiple sleep latency (MSLT) to diagnose.
Findings: 2 sleep onset REM periods
average sleep latency of 6 minutes or less
What are the treatments of narcolepsy?
stimulant medications, timed naps and good sleep hygiene
How does obstructive sleep apnea differ from insomnia?
OSA is caused by structures, anatomic problems with physiological consequences
What is the treatment for OSA?
CPAP or surgery
Can sleep walking & other parsamonias be improved with CPAP if a patient has OSA?
yeah
What are the 2 types of sleep apnea?
Obstructive Sleep Apnea (more common)
Central sleep apnea
What happens in OSA?
Patient has recurrent obstruction of upper airway during sleep produces apnea (cessation of airflow for 10 seconds or more)
What are the risk factors for obstructive sleep apnea?
Risk factors include age, gender (more common in middle aged men and post-menopausal women), neck circumference, and structural abnormalities
What are the symptoms of central sleep apnea?
Symptoms include insomnia, mild or absent snoring, no obstruction, but absence of ventilatory effort = cessation of airflow
What are some questions to ask to assess for sleep apnea?
“Have you or anyone else noticed that you snore loudly?”
“Have you or anyone else noticed that you stop breathing in your sleep?”
What are parasomnias?
Sleep disorders characterized by abnormal behavioral or physiological events which occur during sleep or during sleep-wake transitions
Ex: sleep walking, nightmares, night terrors
T/F Parasomnias cause insomnia or excessive sleepiness.
False. Doesn’t cause these things.
When do nightmares most often happen?
during REM, usu 2nd half of night closer to morning
**common in children
What’s the deal with night terrors?
these are confused arousals
a person may cry out
unlike nightmares–person doesn’t remember usu
occurs during slow wave sleep–>usu in first half of the night
common in children under 10 yo
What is one of the most common complaints of patients with mood disorders?
disturbed sleep
What is an important diagnostic criteria for mood & anxiety disorders?
sleep disturbance
**fatigue can be another diagnostic criteria
What are some sleep complaints that you often see with major depression?
Difficulty in falling asleep Frequent nocturnal awakenings Early morning awakening Non-restorative sleep Decreased total sleep time Disturbing dreams
What are some of the things on your ddx for sleep disturbance?
Obstructive Sleep Apnea (snoring / observed apnea / daytime sleepiness)
Insomnia
Circadian Rhythm Disorders
Insufficient Sleep or inadequate sleep hygiene
Excessive Sleepiness (narcolepsy)
Parasomnias (nocturnal behaviors)
Mood Disorders
Once again, which studies are required for the diagnosis of narcolepsy, sleep apnea?
Narcolepsy: PSG & MSLT
Sleep apnea: PSG
What % of patients present to their primary care physician complaining of sleep problems?
50%
What are some of the main determinants of sleep?
Obstructive Sleep Apnea (snoring / observed apnea / daytime sleepiness)
Insomnia
Circadian Rhythm Disorders
Insufficient Sleep or inadequate sleep hygiene
Excessive Sleepiness (narcolepsy)
Parasomnias (nocturnal behaviors)
Mood Disorders
Disruption of circadian rhythm is associate with which bad things?
tumors
shortened life
What are some factors affecting circadian rhythm?
Wake/sleep Hormonal Temperature Immune Drug metabolism Renal function Airway function
What is a normal sleep latency?
10 minutes
What percentage of time is spent in each sleep stage?
Stage 1: 5%
Stage 2: 50%
Stages 3 & 4 (Slow Wave): 20%
REM: 25%
What are some medical conditions that can cause insomnia?
asthma COPD heart failure parkinsonism diabetes allergies thyroid disorder chronic pain itching
What are some psychological disorder that can cause insomnia?
depression anxiety panic attacks mania bereavement post-traumatic general stress
What are some sleep disorders that include insomnia?
obstructive sleep apnea central apnea periodic limb movement disorder restless leg syndrome advanced phase delayed phase sleep disorder
What are some pharmacological agents that can cause insomnia?
methylphenidate theophylline albuterol pernoline dextroamphetamine pseudoephedrine nicotine alcohol SSRI
What are some environmental factors that can cause insomnia?
temperature excessive light excessive noise bed discomfort pets
What are some of the indirect economic costs of insomnia?
Decreased productivity
Higher accident rate
Increased absenteeism
Increased comorbidity
The most common treatment for sleep difficulties are sleeping pills. But what are the problems with this potentially?
drowsiness is common the next day
not good for chronic insomnia (long term side effects)
tolerance & dependency (physiological & psychological) possible
T/F Benzodiazepines are an FDA approved treatment for sleep disturbances.
False. But they are often prescribed for this.
What % of people over the age of 65 use sleeping pills?
10-20%
What are some of the factors playing into chronic insomnia?
circadian dysregulation
arousal system working too well & at the wrong time
sleep incompatible conditioning (bed paired with frustration, not sleep)
What is the purpose of stimulus control?
strengthen bed & bedroom as sleep stimulus
**involves removing TV, phones etc from the bedroom.
What is the purpose of sleep restriction?
restrict time in bed to consolidate sleep & improve depth of sleep
**involves a rigid sleep schedule
What is the purpose of cognitive therapy for sleep help?
address thoughts & beliefs that interfere with sleep
What is the purpose of using light therapy as a part of circadian rhythm shifting?
use morning & evening light exposure, restrict light at other times to try to stimulate a normal rhythm.
circadian rhythm pace maker is found in the suprachiasmatic nucleus
What is the epworth sleepiness scale?
it is a scale that asks while you are doing various activities that are low movement (reading, watching TV, sitting in traffic etc)…what is the chance that you will fall asleep for a bit?
0-no chance; 1-slight chance; 2-moderate chance; 3-high chance
**patients with obstructive sleep apnea have a high Epworth Sleepiness scale score
What are some important aspects of treatment planning?
- what are our goals for improving sleep-which part of sleep cycle? Which daytime symptoms are we trying to improve?
- what is the cause & what are the exacerbating factors
- diagnostic testing-maybe PSG, MSLT
- educate on behavioral changes
- sleep diary
- remove obstacles
- follow up!!
