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Primary Care Exam 3 > Sleep > Flashcards

Sleep Flashcards

1
Q

What is sleep (non-disordered sleep)?

A

Reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment

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2
Q

What is insomnia?

A

Disorder (symptom) of sleep initiation and/or sleep maintenance associated with daytime impairment(s)

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3
Q

What is obstructive sleep apnea?

A
  • Sleep related breathing disorder
  • Abnormalities of respiration during sleep
  • Repetitive apnea or hypoponeas recurring w/ sleep
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4
Q

What are the two types of functions of normal sleep?

A
  • Restorative function

- Homeostatic function

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5
Q

What systems are affected by sleep/sleep deprivation?

A
  • Every system is dependent on sleep
  • Endocrine: metabolism/fat distribution/cellular energy, obesity and insulin resistance
  • Cardiovascular: sympathetic/ANS, blood pressure regulation
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6
Q

What are the two processes that regulate normal sleep?

A 
Homeostatic process (S)
Circadian process (C)
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7
Q

How does the homeostatic process affect sleep?

A
  • Depends on the amount of sleep and wakefulness

- Balance between the need for sleep (sleep pressure) with increasing duration of wakefulness

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8
Q

How does the circadian process affect sleep?

A
  • Depends on endogenous circadian peace maker generating near 24 hour cycles of behavior
  • Regulated by the SCN (suprachiasmatic nucleus) in the hypothalamus to “consolidate” sleep and wakefulness
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9
Q

How does normal sleep change with aging?

A
  • Decrease in N3 (women preserve with aging)
  • Decrease in REM
  • Sleep efficiency decreases 80 to 85%
  • Ability to sleep in consolidated, longer sleeping bouts decreases (homeostatic dysfunction rather than circadian)
  • Need for sleep does not decrease
  • Daytime sleepiness increases
  • Napping may increase
  • And apparent shift is prevalent with earlier fall asleep an earlier awakening (Melatonin related, SCN aging)
  • Difficulty tolerating phase shifts
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10
Q

When should we assess sleep?

A

Every clinical interface

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11
Q

What are some clinically valuable sleep symptom and pattern assessment instruments?

A
  • Epworth sleepiness scale
  • Stanford sleepiness scale
  • Functional outcomes of sleep questionnaire
  • Sleep diary (Consensus diary - recommended)
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12
Q

What are some OSA screening tools?

A
  • STOP-BANG (Snore, Tired, Observed apnea, High blood pressure, BMI, Age, Neck circumference, Gender)
  • Berlin questionnaire
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13
Q

How do we determine OSA response to treatment tools?

A
  • Epworth sleepiness scale (ESS)

- Functional outcomes of sleep questionnaire (FOSQ)

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14
Q

What are some insomnia screening and response to treatment tools?

A
  • Insomnia severity instrument (ISI)
  • Pittsburgh sleep quality index (PSQI)
  • Consensus sleep diary
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15
Q

What are some general diagnostic criteria for diagnosing chronic insomnia?

A

One or more reported:

  • Difficulty initiating sleep
  • Difficulty maintaining sleep
  • Waling up earlier than desired
  • Resistance to going to bed on appropriate schedule
  • Difficulty sleeping w/o intervention
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16
Q

What are some diagnostic criteria for diagnosing chronic insomnia related to nighttime difficulty?

A

One or more reported:

  • Fatigue/malaise
  • Attention, concentration, or memory impairment
  • Impaired social, family, occupational, or academic performance
  • Mood disturbance/irritability
  • Daytime sleepiness
  • Behavioral problems
  • Reduced motivation/energy/initiative
  • Proneness for errors/accidents
  • Concerns about or dissatisfaction with sleep
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17
Q

What are some other factors to consider when diagnosing chronic insomnia?

A
  • Sleep/wake complaints can’t be explained purely by inadequate opportunity or circumstances for sleep
  • Sleep disturbance and associated daytime sx occur at least 3x/wk
  • Sleep disturbance and associated sx present for at least 3mo
  • Sleep/wake difficulty is not better explained by another sleep disorder
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18
Q

How is criteria for diagnosing chronic insomnia different from diagnosing acute insomnia?

A
  • Disturbance and associated sx present for LESS THAN 3mo
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19
Q

When would we diagnose someone with Other Insomnia Disorder?

A
  • Complain of difficulty initiating and maintaining sleep but DO NOT meet full criteria for either chronic or short-term insomnia
  • May be applied when gathering more sleep information
  • Use this diagnosis sparingly
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20
Q

What are some relevant factors in the patient history related to insomnia?

A
  • Circumstances surrounding onset
  • Type of insomnia relative to diagnostic criteria (sleep/wake sx)
  • Severity, frequency, course
  • Daytime consequences
  • Past tx
  • Factors that ameliorate/exacerbate
  • Medical factors
  • Pharmacological considerations
  • Psychiatric factors
  • Work, family, and social factors
  • Comorbid sleep disorders
  • Behavioral factors including routines, sleep practices, cognitive factors (i.e. worry)
  • Environmental factors
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21
Q

How do we diagnose insomnia?

A
  • Clinical assessment
  • Sleep diary records
    +/- Polysomnography (PSG) to r/o other sleep disorders w/ high clinical suspicion or no tx response
    +/- Actigraphy to obtain objectively measured sleep/ wake patterns
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22
Q

What are some psychological and behavioral tx for insomnia?

A
  • Sleep Restriction Therapy
  • Stimulus Control Therapy
  • Relaxation Therapy
  • Cognitive Therapy
  • Sleep Hygiene Education
  • Cognitive Behavioral Therapy
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23
Q

What is Sleep Restriction Therapy?

A
  • Restrict time in bed as close as possible to actual sleep time, strengthening the homeostatic sleep drive
  • Sleep “window” is then gradually increased over days/weeks
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24
Q

In what populations is Sleep Restriction Therapy contraindicated?

A
  • Seizures
  • Parasomnias like sleepwalking
  • Bipolar
  • Occupational drivers
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25
Q

What is Stimulus Control Therapy?

A

Standard set of instructions designed for reinforce the association btwn bed and bedroom with sleep and to establish consistent sleep/wake schedule:

  • Go to bed only when sleepy
  • Get out of bed when unable to sleep (may be contraindicated in older adults d/t falls)
  • Use bed/bedroom for sleep only
  • Arise at same time every morning
  • No napping
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26
Q

What is Relaxation Therapy?

A
  • Progressive muscle relaxation, meditation

- Requires some professional guidance at outset and daily practice for weeks-months

27
Q

What is Cognitive Therapy?

A
  • Approach using questioning and behavioral experiments to reduce excessive worrying about sleep and reframe faulty beliefs about insomnia and daytime consequences
  • Trained interventionist required
28
Q

What is Sleep Hygiene Education?

A

General guidelines about practices and environmental factors that promote or interfere with sleep

29
Q

What is Cognitive Behavioral Therapy?

A

Multimodal intervention combining some of cognitive and behavioral procedures, selection based on expert evaluation of insomnia

30
Q

What is 1st line pharmacological tx for insomnia?

A

Short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon

31
Q

What are some examples of benzodiazepine receptor agonists (BZD or newer BzRAs)?

A
  • Zolpidem
  • Eszopiclone
  • Zaleplon
  • Temazepam
32
Q

What is the next step if the initial agent is unsuccessful?

A

Alternate short-intermediate acting BzRAs or ramelteon

33
Q

What are good pharmacological agents when treating comorbid depression/anxiety?

A

Sedating antidepressants

34
Q

What are some examples of sedating antidepressants used for insomnia tx?

A
  • Trazodone
  • Amitriptyline
  • Doxepin
  • Mirtazapine
35
Q

What are some alternative insomnia tx?

A
  • Combined BzRA or ramelteon and sedating antidepressant
  • Anti-epilepsy
    medications (gabapentin, tiagabine)
  • Atypical antipsychotics
    (quetiapine and olanzapine)
  • These medications may only be suitable for patients
    with comorbid insomnia who may benefit
    from the primary action of these drugs as well as
    from the sedating effect*
36
Q

What medications are NOT recommended for pharmacological tx of insomnia?

A
  • OTC antihistamine or antihistamine/analgesic type drugs (OTC “sleep aids”)
  • Herbal/nutritional substances (valerian, melatonin)
  • Barbituates and barbituate-types drugs
  • Chloral hydrate
37
Q

Define obstructive sleep apnea (OSA)

A
  • Repetitive hypopneas (partial airway collapse) and apneas (complete airway collapse) during sleep
  • Results in intermittent hypoxia and sleep fragmentation
38
Q

How do we classify OSA by severity?

A
  • Mild: Apnea Hypopnea Index (AHI) 5-15 events/hr
  • Moderate: AHI 15-30 events/hr
  • Severe: AHI >30 events/hr
39
Q

How do we diagnose OSA?

A

Requires (A & B) or C

A: Presence of one or more:

  • Complaints of sleepiness, nonrestorative sleep, fatigue or insomnia sx
  • Wakes with breath holding, gasping, or choking
  • Observed habitual snoring, breath interruptions, or both during sleep
  • Diagnosed w/ HTN, mood disorder, congitive disfunction, CAD, CVA, HF, AF, of T2DM

B: Polysomnography (PSG) or Out of Center Sleep Test (OCST): >5/hr predominantly obstructive events

C: PSG or OCST: >15/hr predominantly obstructive events

40
Q

What is the pathophysiology of OSA?

A
  • Airway narrowing (velopharyngeal space, retropalatal space, retroglossal space)
  • Phasic inspiratory muscle “dullness” during sleep
  • Other factors: anatomically small airway, excess soft tissue

All result in airway partial of complete collapse

41
Q

What do cortical arousals on EEG indicate?

A
  • Protective mechanism

- Fragmentation of sleep

42
Q

Risk factors for OSA

A
  • Obesity
  • Age 65+
  • Male (2:1 or 3:1 M:F ratio in community based examples)
  • FH of SDB (2-4 fold increase)
  • ETOH exacerbates OSA
  • Ethnicity (AA, Mexican Americans, Pacific Islanders, East Asians)
  • Disorders of craniofacial abnormalities (i.e. Marfan Syndrome, Down syndrome)
43
Q

Where can you get the most reliable information about a person’s sleeping patterns?

A

The bed partner!

44
Q

What does the clinical presentation look like for a person with OSA?

A
  • Bed partner witnesses snoring, nocturnal snorting, gasping, and apneas
  • Excessive daytime sleepiness (EDS)
  • Fatigue
  • Drowsiness as opposed to EDS
45
Q

What are some other nighttime s/sx of OSA?

A
  • Choking or dyspnea that resolves quickly (as opposed to PND) in sleep
  • Unexplained awakenings and unrefreshing sleep (older adults)
  • Restlessness during sleep
  • Nocturia
  • GER
  • Dry mouth
46
Q

What are some other daytime s/sx of OSA?

A
  • MVA (single)
  • Concentration, attention, memory, and/or judgement difficulties (F)
  • Personality changes (i.e. aggression, irritability, anxiety, depression
  • Reduced libido or impotence
  • Morning or nocturnal headaches (dull, generalized; resolve 1-2 hrs after sleep)
47
Q

What physical exam components should you include when assessing someone with OSA?

A

• Height/Weight…BMI
• Neck Circumference (>40cm, 61% sensitivity, 93% specificity for OSA, regardless of sex)
• Retrognathia, dental overjet (forward extrusion upper incisors beyond lower incisors)
• Evidence of bruxism, dental clenching/grinding, TMJ on oral/dental exam
• Oropharyngeal exam may reveal macroglossia, narrow posterior pharynx,
edematous/erythematous uvula, low-lying soft palate

48
Q

What does the Mallampati scale assess and how is it scored?

A
  • Visually evaluate position of soft palate, tip of uvula,
    lateral tonsillar pillars, and tongue in seated, mouth wide open and tongue protrusion
  • Scored as class 1-4
    Class I: Can see bottom of uvula
    Class 2: Can’t see bottom of uvula but can still see large portion of posterior pharynx
    Class 3: Can barely see top of uvual
    Class 4: Cannot see uvula or posterior pharynx
49
Q

What are 2 clinically valuable SCREENING tools for assessing OSA?

A
  • Berlin Questionnaire

- STOP-BANG

50
Q

How is the Berlin Questionnaire scored?

A

Scored as low or high risk based on sum of points w/in 3 categories:

  • High risk: 2 positive categories
  • Low risk: only 1 positive category
51
Q

How is the STOP-BANG scored?

A

Scored as sum score of 8 YES(1)/NO(0) items:

  • High risk: 5-8
  • Intermediate risk: 3-4
  • Low risk: 0-2
52
Q

What are 2 clinically valuable SYMPTOM EVAL tools for assessing OSA?

A
  • Epworth Sleepiness Scale

- Fatigue Severity Scale

53
Q

How is the Epworth Sleepiness Scale Scored?

A
  • Sum score of 8 items

- >10 suggests excessive daytime sleepiness

54
Q

How is the Fatigue Severity Scale scored?

A
  • 7pt Likert Scale
  • Sum score from 9 item responses
  • Score >36 indicates fatigue
55
Q

For OSA diagnosis, when woukd you use Home Sleep Study/Test (HSS/HST) vs PSG?

A
  • HSS/HST unattended, portable monitoring
  • For pts w/ high likelihood of OSA and no significant comorbidities
  • Includes monitoring of oximetry, airflow, respiratory effort, snoring, position, heart rate
56
Q

How do we tx OSA?

A
  • Medical therapies
  • Positive Pressure Therapy
  • Oral appliance
  • Surgery (UA)
57
Q

What are some medical therapy strategies for OSA?

A
  • Weight loss: 10% reduction in weight = 50% reduction in AHI
  • Position therapy: avoid sleeping supine
  • Eliminate ETOH and/or sedative use
  • Medications
58
Q

What are some medications that are NOT efficacious options for tx OSA?

A
  • O2
  • Methylxantines
  • Progestational agents
  • SSRIs
  • Mixed serotonin receptor agonists
59
Q

What are some wake promoting agents/stimulants that can be considered when EDS is present and consequential?

A
  • Amphetamines and methylphenidate (efficacious, SE include dependence)
  • Modafinil (Provigil) or Armodafinil (Buvigil) safer wake promoting agents (indirect dopamine receptor agonists)
  • THESE DO NOT TX OSA, ONLY ASSOCIATED EDS
  • FDA approved indication: persistent sleepiness ON PAP TX (and adherent)
60
Q

What is positive airway pressure (PAP)?

A
  • Continuous (CPAP), bi-level (inspiratory/expiratory; BPAP), or auto-adjusting (APAP)
  • Delivers positive pressure to pneumatically splint upper airway open
61
Q

What are some important factors to management of the patient on PAP?

A
  • Can add O2 (not indicated in OSA without underlying CVD, HF, COPD, restrictive pulmonary disease)
  • Mask selection important to users
  • Heated humidification reduces dry mouth, nasal congestions, excessive salivation during daytime
  • Nasal saline sprays, nasal corticosteroid sprays may be needed
  • If using nasal only mask interface, must have patent nasal airway
62
Q

When is surgical/laser tx indicated in OSA?

A
  • Most effective in mild-moderate OSA
  • F/u polysomnogram 12-15 weeks post-procedure
  • May reduce success with CPAP if needed
63
Q

What are the steps necessary for getting oral appliances for patients with OSA?

A
  • Dentist referral
  • Recurrent dental f/u to “advance” device
  • F/u polysomnogram when final advancement determined by dentist
  • Adherence

Primary Care Exam 3 (4 decks)

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