Sleep Flashcards
What is the homeostatic process of normal sleep regulation
Dependent on the amount of sleep and wakefulness
• Balance between the need for sleep (sleep pressure) with increasing duration
of wakefulness
What is the circadian process of normal sleep regulation?
Dependent on endogenous circadian pacemaker generating near 24-hour
cycles of behavior
• Regulated by the SCN (suprachiasmatic nucleus) in the hypothalamus to
“consolidate” sleep and wakefulness
What are normal changes in sleep in aging?
↓ in N3 [women preserve w/aging] • ↓ in REM • Sleep efficiency ↓ 80-85% • Ability to sleep in consolidated longer sleep bout(s) decreases (homeostatic dysfunction rather than circadian) • Need for sleep does not decrease • Daytime sleepiness ↑ • Napping may increase • An apparent shift is prevalent w/earlier fall asleep and earlier awakening (melatonin related; SCN aging) • Difficulty tolerating phase shifts
What should be included in sleep assessment?
Any sleep problems? • Sleep schedule • Bedtime • Awakening time • Consistency • Naps • Sleep latency • Awakenings & reasons • Sleep partner’s complaints • Awake schedule • Daily activities • Naps • Refreshed on awakening? • Sleep at inappropriate times? • Abnormal behaviors during sleep/naps • Driving habits • Number hrs/day driven • History of fall asleep accidents/near misses • History of single vehicle accidents • Occupational driving • Sleepiness during activities? • Short-term memory difficulties? • Mood changes? • Relationship and sexual activity changes? • Cognitive changes? • Caffeine, ETOH, tobacco, illicit drugs • Exercise, light exposure, meal times • Evening & late night activities? • Past medical history • Pre-existing sleep disturbances • CV disease • Neurologic disorders, particularly of vascular origin • Family medical history • Medications
What are clinically-valuable sleep symptom & assessment instruments?
- Epworth Sleepiness Scale
- Stanford Sleepiness Scale
- Functional Outcomes of Sleep Questionnaire (copyrighted)
- Sleep Diary (Consensus Diary – recommended)
OSA tools
OSA Screening Tools
• STOP-BANG (Snore, Tired, Observed apnea, high blood Pressure; Bmi, Age,
Neck circumference, Gender)
• Berlin Questionnaire
• OSA Response to Treatment Tools
• Epworth Sleepiness Scale (ESS)
• Functional Outcomes of Sleep Questionnaire (FOSQ
What does STOP BANG stand for?
• STOP-BANG (Snore, Tired, Observed apnea, high blood Pressure; Bmi, Age,
Neck circumference, Gender)
What is the diagnosis for chronic insomnia?
One or more reported: Difficulty initiating sleep, difficulty maintaining sleep, waking
up earlier than desired, resistance to going to bed on appropriate schedule, difficulty
sleeping without intervention
• One or more related to nighttime difficulty: 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
• Sleep/wake complaints cannot be explained purely by inadequate opportunity or
circumstances for sleep
• Sleep disturbance and associated daytime symptoms occur at least 3X/week
• Sleep disturbance and associated daytime symptoms present for at least 3mo
• Sleep/wake difficulty is not better explained by another sleep disorder
diagnosis for acute insomnia?
Report of one or more: difficulty initiating sleep, difficulty maintaining sleep,
waking up earlier than desired, resistance to going to bed on appropriate
schedule, difficulty sleeping without intervention
• Report of one or more related to nighttime sleep difficulty: fatigue/malaise;
attention, concentration or memory impairment; impaired social, family,
vocational or academic performance; mood disturbance/irritability; daytime
sleepiness; behavioral problems; reduced motivation/energy/initiative;
proneness for errors/accidents; concerns about or dissatisfaction with sleep
• Reported sleep/wake complaints not explained purely by inadequate
opportunity or circumstances for sleep
• Disturbance and associated symptoms present for LESS THAN 3 mo
• Sleep/wake difficulty not better explained by another sleep disorder
What does Other Insomnia Disorder entail?
• 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
What is included in an insomnia assessment guide?
Circumstances surrounding onset • Type of insomnia relative to diagnostic criteria (sleep/wake symptoms) • Severity, Frequency and Course • Daytime consequences • Past Treatments • Factors that ameliorate • Factors that exacerbate • Medical factors • Pharmacologic considerations (activating drugs, sedating drugs, side effects, history of hypnotic use) • Psychiatric factors • Work factors • Family and social factors • Comorbid sleep disorders • Behavioral factors including routines, sleep practices, cognitive factors (i.e., worry) • Environmental factors
How do you make an insomnia diagnosis?
Clinical Assessment
• Sleep Diary records
• ± PSG to r/o other sleep disorder with high clinical suspicion or no treatment
response
• ± Actigraphy to obtain objectively measured sleep/wake patterns
What is sleep restriction therapy? Contraindications?
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 (contraindicated: seizure, parasomnias like
sleepwalking, bipolar; occupational drivers)
What is stimulus control therapy? Contraindications?
Standard set of instructions designed to reinforce the
association between 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
What is relaxation therapy?
• Relaxation Therapy: Progressive muscle relaxation, meditation; require some
professional guidance at outset and daily practice for weeks-months
What is cognitive therapy?
Approach using questioning and behavioral
experiments to reduce excessive worrying about sleep and reframe
faulty beliefs about insomnia and daytime consequences. Trained
interventionist required.
What is sleep hygiene education?
General guidelines about practices and
environmental factors that promote or interfere with sleep.
What is cognitive behavioral therapy?
Multimodal intervention combining
some of cognitive and behavioral procedures; selection based on
expert evaluation of insomnia
Discuss principles of pharm treatment of insomnia
Pharmacological Treatment
• SEE p. 488-9 Evaluation and Management of Chronic Insomnia in Adults
• Contraindicated in pregnancy, OSA, substance abuse disorder, liver disease
• In older adults, consider benefits and risks of using pharmacological
treatment for insomnia
• Side effects
• Drug-drug interactions
• Other comorbidities that heighten risks with pharm tx of insomnia
• ALWAYS monitor treatment response with
• Ongoing sleep diary
• Repeated insomnia and sleep quality measures
• Review person-specific goals for treatment on a regular basis with insomnia
treatment
What is OSA? Define based on severity as well.
Definition & Type by Severity Repetitive hypopneas (partial airway collapse) and apneas (complete airway collapse) during sleep; results in intermittent hypoxia and sleep fragmentation . Mild: Apnea Hypopnea Index (AHI) ≥5 -15 events/hr Moderate: AHI >15 -30 events/hr Severe: AHI >30 events/hr
Discuss the OSA diagnostic criteria.
Obstructive Sleep Apnea, Adult (ICD-10-CM G47.33): Requires (A & B)
or C
A. Presence of one or more:
• Complains of sleepiness, nonrestorative sleep, fatigue or insomnia symptoms
• Wakes with breath holding, gasping or choking
• Observed habitual snoring, breath interruptions, or both during sleep
• Diagnosed with HTN, mood disorder, cognitive dysfunction, CAD, stroke, HF,
AF or 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
What is the pathophysiology of OSA?
• Airway narrowing (velopharyngeal space, retropalatal space,
retroglossal space)
• Phasic inspiratory muscle “dullness” during sleep
• Other contributing factors
• anatomically narrow airway
• excess soft tissue
• All of which result in airway partial or complete collapse
• Cortical arousals by EEG
• Protective mechanism
• Fragmentation of sleep
What are risk factors for OSA?
• Obesity
• >65years
• Male (2-3:1 M:F ratio in community based samples)
• Family history of SDB (2-4 fold increase)
• ETOH exacerbates OSA
• Ethnicity (AA, Mexican Americans, Pacific Islanders, East Asians)
• Disorders of craniofacial abnormalities (e.g., Marfan Syndrome, Down
Syndrome)
What is the clinical presentation of OSA?
Bed partner most reliable source of information!
• Witnessed snoring, nocturnal snorting, gasping and apneas
• Excessive daytime sleepiness (EDS)
• Fatigue
• Drowsiness as opposed to EDS
• Other Night-time Signs/Symptoms: choking or dyspnea that resolves quickly (as
opposed to PND) in sleep (18-31% c/o), unexplained awakenings and
unrefreshing sleep (older adults), restlessness during sleep, nocturia (28% c/o),
GER, dry mouth (74% c/o)
• Other Daytime Signs/Symptoms: MVA (single), concentration, attention, memory
and/or judgement difficulties (F), personality changes (e.g., aggression, irritability,
anxiety, depression), reduced libido or impotence, morning or nocturnal
headaches (dull, generalized; resolve 1-2hrs after sleep)
Discuss screening tools and symptoms evaluation tools for OSA
Screening Tools
• Berlin Questionnaire
• Scored as low or high risk based on sum of points within 3 categories; High risk with 2 positive
categories; Low risk with only 1 or no categories scored as positive
• STOP-BANG
• Scored as sum score of 8 YES(1)/NO(0) items; High risk =5-8; Intermediate risk =3-4; Low risk =0-2
• Symptom Evaluation Tools
• Epworth Sleepiness Scale (ESS)
• http://epworthsleepinessscale.com/about-the-ess/
• Sum score of 8 items; >10 suggests excessive daytime sleepiness
• Fatigue Severity Scale
• 7-point Likert Scale; 9 items
• Sum score from 9 item responses
• Score >36 indicates fatigue
What is the Home sleep study test monitor for and what does it monitor?
"for pts with high likelihood of OSA and no significant comorbidities. monitors: -oximetry -airflow, resp effort -snoring -position -heart rate **NOT SLEEP
OSA treatment options
Medical Therapies
• Positive Pressure Therapy
• Oral Appliance
• Surgery (UA)
Medical therapy strategies for OSA
Weight Loss
• 10% reduction in weight = 50% reduction in AHI
• Position Therapy
• Avoid sleeping supine
• Eliminate ETOH and/or sedative use
• Medication Options
• Oxygen, methylxanthines, progestational agents, SSRIs, mixed serotonin receptor
agonists = NOT EFFICACIOUS OPTIONS
• Wake promoting agents/stimulants are considerations when EDS is present and
consequential
• Amphetamines and methylphenidate (efficacious; s/e, including dependence)
• Modafinil (Provigil) or Armodafinil (Nuvigil) safer wake promoting agents (indirect dopamine
receptor agonists)
• THESE DO NOT TREAT OSA; ONLY OSA-ASSOCIATED EDS
• FDA approved indication: persistent sleepiness ON PAP TREATMENT (and adherent)
Discuss PAP therapy
Continuous (CPAP), bi-level (inspiratory/expiratory; BPAP), or autoadjusting
(APAP)
• Delivers positive pressure to pneumatically splint upper airway open
• 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 congestion, excessive
salivation during daytime
• Nasal saline sprays, nasal corticosteroid sprays may be needed
• If using nasal only mask interface, must have patent nasal airway
Discuss surgical and laser intervention procedures
Most effective in mild-moderate OSA
• F/u polysomnogram 12-15 weeks post-procedure
• May reduce success with CPAP if needed
• BALANCE: Risk-Benefits?
Discuss oral appliances
Dentist referral
• Recurrent dental f/u to “advance” device
• F/u polysomnogram when final advancement determined by dentist
• Adherence
