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6P > Sleep > Flashcards

Sleep Flashcards

1
Q

Polysomnography

A

full/level1 sleep study

Provides information on sleep architecture

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2
Q

components of polysomnogram

A 
EEG
EMG (submentalis, ant. tibilalis)
EOG (electro-occulogram)
ECG
Airflow (nasal pressure, thermistor)
Respiratory effort
digital oximetry
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3
Q

Ambulatory sleep studies

A 
DIgital/level 3
useful only for sleep apnea
no information on sleep stages, sleep/wake cycle
measures:
- airflow
- respiratory effort
- digital oximetry
- +/- body position
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4
Q

Sleep staging

A

amplitudes and waveforms scored in 30 second epochs
EEG
Eye movements (rolling at sleep onset, rapid in REM sleep)
Muscle tone (EMG) - lessens with drowsiness and sleep depth, absent in REM

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5
Q

Normal sleep

A

Sleep latency

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6
Q

Non-REM sleep

A

Stages I, II, III
I: still input from environment
II: medium sleep
III: deep sleep

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7
Q

REM sleep

A

phasic: eye movements, twitches, variable autonomic activity
Tonic: EMG suppression, high arousal threshold, elevated brain temperature, poikilothermia, penile tumescence
Sleep apnea often worst during REM since muscles are relaxed

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8
Q

EEG patterns

A

Stage 1: theta
2: sleep spindles and mixed EEG
Stage 3: more delta waves
REM: low-voltage, high-frequency waves

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9
Q

Hypnogram

A

~ 90 min cycles between REM and non-REM

Elderly: shorter cycles, shallow sleep

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10
Q

Stage I of sleep

A

light sleep
transitional stage passed through from wake to sleep and sleep to wake
usually ~5% of TST
when increased –> indicates sleep disruption

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11
Q

Stage II of sleep

A

most of the night spent in this stage

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12
Q

Stage III of sleep

A

deepest - hard to awaken
Sleep drunkenness: sleep inertia when awakened; parasomnias occur from this stage
Most restorative
often reduced by benzodiazepines
maintained by zopiclone, zaleplon, zolpidem

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13
Q

Stage REM

A

dream sleep; ver narrative
tonic/phasic stages
tonic: voluntary muscle atonia
phasic: movements

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14
Q

Latency to stage REM shortened causes

A

REM rebound: first night of CPAP, drug/medication withdrawal
Depression (psychotic > milder forms)
Narcolepsy

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15
Q

Sleep and aging

A

more stage I, less stage III
more awakening
brain shrinks a bit - less deep sleep??

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16
Q

Complaints of normal elderly about sleep

A 
insomnia
relative advance of sleep phase
shallow sleep
less restorative
dream content often unpleasant
daytime sleepiness
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17
Q

Melatonin pathway

A

Inhibited by light
stimulated by darkness
Retinohypothalamic tract –> SCN –> made in pineal gland to go to superior cervical ganglion

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18
Q

Sleep disturbances commonly seen in the elderly

A

Respiratory sleep disorders
Restless legs/periodic limb movements
REM sleep behaviour disorder

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19
Q

Respiratory sleep disorders

A

Primary snoring
upper airway resistance syndrome
OSA - hypopnea syndrome
–> apnea: cessation of airflow >=10 seconds
–> hypopnea: decrease in airflow >=10 seconds
- respiratory effort persists
Central sleep apnea - no respiratory effort
Mixed sleep apnea

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20
Q

OSA night time symptoms

A 
snoring
witnessed apneas
choking
dyspnea
restlessnes
snocturia
diaphoresis
reflux
drooling
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21
Q

OSA daytime symptoms

A 
sleepiness, fatigue
morning headaches
poor concentration
decreased libido/impotence
decreased attention
depression
decreased dexterity
personality changes
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22
Q

OSA risk factors

A 
Obesity
neck circumference over 40 cm
macroglossia
dental overjet and retrognathia
high/narrow hard palate
elongated/low lying uvula
enlarged tonsils, adenoids
crossbite/dental malocclusion
prominent tonsillar pillars
enlarged nasal turbinates
deviated nasal septum
narrow mandible
narrow maxilla
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23
Q

Central sleep apnea

A 
similar daytime symptoms to OSA
typically have history of:
- cardiac disease
- stroke
- opioid use
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24
Q

Restless legs syndrome features

A

urge to move limbs often associated with paresthesias/dysesthesias
symptoms worse of present only during rest
partially/temporarily relieved by activity
nocturnal worsening of symptoms
Diagnosis usually made clincially, but may be confirmed through the Standarized Immobilization Test

25
Q

Associated features of restless legs syndrome

A

response to dopaminergic therapy in almost all cases
periodic limb movements occur during sleep/wakefulness in 80-90% of patients
usually progressive with age
no clear medical/physical pathology (primary form)

26
Q

Demographics of restless legs syndrome

A

5-10% of adults of Northern European studies
lower in Indian/Asian studies
treatment typically sought after age 40
1.5-2x more common in women

27
Q

Predisposing factors of restless legs syndrome

A

Fe deficiency
peripheral neuropathy
sedating antihistamines, dopamine antagonists, and most antidepressants (not buproprion)
family affected in >50%
increased risk (3-6x) in 1st degree relatives

28
Q

Causes of secondary RLS

A

pregnancy –> dilutional anemia
end-stage renal disease
Fe deficiency (involved in dopamine synthesis?0
)

29
Q

Treatment of RLS

A 
underlying factors (anemia, renal disease, neuropathy)
Medication options:
- gabapentin, pregabalin
- dopamine agonists
- clonazepam
- opioids in very severe cases
30
Q

Periodic limb movement disorder essential features

A

EMG from the polysomnogram demonstrates repetitive, highly stereotyped limb movements that meet recording criteria = inter-movement interval of 5-90 seconds
PLM index exceeds 5/hour (children) and 15 (adults)
clinical sleep disturbance or a complaint of daytime fatigue

31
Q

Periodic limb movement disorder treatment

A

only if clinically indicated (clear sleep disruption)

same option as RLS

32
Q

REM sleep behaviour disorder essential features

A

presence of REM sleep without atonia
at least one of the folllowing:
- sleep related injurious, potentially hazardous, or disruptive behaviours by history
- abnormal REM sleep behaviours documented during PSG

Absence of EEG epleptiform activity during EEG

33
Q

Associated features of RSBD

A

dream enactment typically occurs >90 min after sleep initaition
episode ends when individual awakens quickly, becomes alert, and reports dream
injury common secondary to violent dream enactment
sleepwalking uncommon
may have prodrome of sleep talking, yelling, twitching
patients often present after injury to self or bed partner

34
Q

RSBD onset/course

A

gradual/rapid onset, progressive
delayed emergence of neurodegenerative disorder is very common (2/3 later develop Parkinson’s)
can be simply a symptom of narcolepsy

35
Q

RSBD pathology

A

alpha-synucleinopathy

protein aggregates in vulnerable populations of neurons and glial cells

36
Q

Predisposing/precipitating factors of RSBD

A

underlying neurological disorder, especialyl alpha-synucleinopathies (Parkinson’s LBD, multiple system atrophy)
narcolepsy
stroke
medications/withdrawal

37
Q

Management of RSBD

A

safety first - remove obstacles, etc

Medication - best evidence clonazepam, effective in preventing violent dream enactment in most cases

38
Q

Sleep and AD

A

disruption common in AD (19-44%)
Related to patient institutionalization
Negative impact on patient and caregivers’ QOL

39
Q

Better management of sleep in AD

A

priority for improving comprehensive management of patients with AD
No long-term data
no data on behavioural interventions

40
Q

Features of sleep in AD

A 
similar to but worse than disturbances seen in non-dementing elderly
increased freq/duration of awakenings
increased stage I
decreased stage III, REM sleep
increased daytime napping
sleep disturbances associated with:
- increased memory/functional impairment
- more rapid cognitive decline
More severe in more demented patients
41
Q

Mechanism of sleep disturbance in AD

A

Loss/damage to neuronal pathways that initiate and maintain sleep
Degenerative changes in brainstem regions/pathways that regulate sleep-wake cycles
Changes in cortical tissue that generate EEG low-wave activity during sleep
Changes in hypothalamic-suprachiasmatic nucleus and other parts of the circadian timing system
severe: day-night reversal occurs

42
Q

Sleep apnea and AD

A

significant correlation between dementia and sleep apnea severity

apnea associated with increased nocturia
worsens with sedative medications

43
Q

Sleep disturbance in AD treatments

A

Buspirone: anxiety/depressive
SSRI: depressed/non-specific mood
Agitation: benzo, anti-psychotic
Insomnia:trazodone, zopiclone, benzodiazepines,
use safest, most effective drug at lowest dose, short duration
Watch out for side effects: falls, fractures, confusion, etc

44
Q

Behavioural interventions in sleep disturbance in AD

A

no empirical studies in this population
Physical environment/institutional routines
reduce daytime napping
address care-giver concerns about “upsetting routine”

45
Q

Ideal hypnotic

A 
rapid absorption
short half-life
no drug-drug interactions
no tolerance to effect
free from side effects (memory, psychomotor)
no rebound
cheap
46
Q

Rebound insomnia

A

Transient exacerbation of insomnia commonly occurs when sedative/hypnotic medications are withdrawn

47
Q

Sleep hygiene basic rules

A

sleep only as much as needed to feel rested, get out of bed
keep regular sleep schedule
avoid forcing sleep
Exercise regularly >=20 min, preferably 4-5 hours befor bedtime
avoid caffeinated beverages after lunch
avoid alcohol near bedtime
avoid smoking
don’t go to bed hungry
adjust bedroom environment
avoid prolonged use of light-emitting screens befoe bedtime
stimulus control!!

48
Q

Rx sleep onset insomnia

A

Short-acting
Zaleplon, zolpidem, triazolam, lorazepam
Ramelteon: melatonin agonist - more effective in sleep onset rather than sleep maintenance insomnia
Adverse effects milder in melatonin agonists than benzodiazepines

49
Q

Rx sleep maintenance insomnia

A

Longer-acting preferable
Zolpidem extended release, eszopiclone, temazepam, estazolam, low dose doxepin
- may increase risk for hangover sedation

50
Q

Benzodiazepine MOA in insomnia

A

binds several subtypes of GABAa receptors
reduce time to onset of sleep
prolonged stage II
prolong total sleep time
may slightly reduce amount of REM
decrease anxiety, impair memory, have anticonvulsive properties

51
Q

Short acting genzo

A

triazolam

52
Q

Intermediate acting benzo

A

estazolam
lorazepam
temazepam

53
Q

Long acting benzo

A

flurazepam

quazepam

54
Q

Nonbenzodiazepine receptor agonists

A

more targeted action at one GABA type A receptor
greater specificity - less anxiolytic and anticonvulsant
improve subject/veobjective sleep outcomes
decrease sleep latency & number of awakenings, while improving sleep duration and sleep

55
Q

Zaleplon

A

very short halflife
effective for sleep-onset insomnia
not indicated for long-term use

56
Q

Zolpidem

A

1.5-2.4 half life
for sleep onset insomnia
not indicated for long-term use

57
Q

Eszopiclone

A

longest half life of approved nonbenzos
effective for both sleep onset/maintenance insomnia
not limited to short-term use, little evidence for abuse/dependance

58
Q

Zolpidem extended release

A

1.5-2.4 half life
improve both sleep onset/maintenance insomnia without hangover effects
not limited to short-term use, little evidence for abuse/dependence in most patients

6P (13 decks)

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