Sleep Flashcards
1
Q
Sleep
A
- Complex behavioral and physiologic process
- Reversible state of perceptual disengagement
- Usually-closed eyes, postural recumbence
- Divided into 2 distinct states
- NREM (Rhythmic sleep)
- REM
- Brain is the essential organ which regulates the sleep/wake cycle
2
Q
What defines sleep onset?
A
-
No single measure can tell us.
- EEG (electroencephalogram) and self-perception may be different…
-
Distinct electrophysiologic pattern
- gradual reduction in muscle tone
- slow rolling eye movements
- reduction in alpha and increase in theta
-
Behavioral Concomitants:
- reduced sensory processing
- tapping experiments: automatic behavior persists
- visual and auditory responsiveness diminshed
- olfactory response: not a good sentinel system
- memory: transition to sleep causes impairment
3
Q
Physiology of Sleep
A
- Adults require 7-8 hours
- Adolescents need about 9 hours
- Elderly need stable amounts
- As people age, their sleep patterns change
- With aging, the sleep efficiency diminishes due to increase of stages 1 and 2 sleep and decrease in REM sleep
- Genetics can influence natural short and long sleepers (only need 4 hours or need 8-9 hours)
4
Q
Sleep stages
A
We measure this through an EEG (electro-encephalogram)
- Electrodes are attached to scalp and measure electrical activity of brain when patients are sleeping to see when they enter stages of sleep
- NREM: non-rapid eye movement (50-60% of total sleep time)
- REM: rapid-eye movement
5
Q
NREM: non-rapid eye movement (50-60% of total sleep time)
A
- As we go from stage I to stage IV, it is harder to arouse the patients.
- increasing arousal threshold and slowing of the cortical EEG
- As stages increase, the muscles get more and more relaxed.
6
Q
EEG Lines
A
- Top 4 lines are brain
- 5th line is muscle movement
- Bottom 2 lines are eye movement
7
Q
Stage I: onset of sleep / short stage
A
- Easy to arouse
- EEG: low voltage theta/alpha waves, mild eye movements, higher emg movements
- •very short stage
- ~7-8 minutes
- Easy to arouse
- Lower voltage, higher EMG movements, and mild eye movements
8
Q
Stage II: light sleep (majority of NREM is in health people is in this stage)
A
- EEG: sleep spindles and K complexes
- •Where a person spends the majority of sleep; ~45%
- Muscles begin to relax, slighter deep level
- Sleep spindles and K complexes
9
Q
Stage III: deeper
A
- EEG: delta waves
- •“slow wave” sleep stages
- Even more relaxed
- Even more difficult to arouse
- High voltage slower waves
10
Q
Stage IV: deep sleep/dream sleep
A
- Dreaming starts in stage four and continues in REM sleep
- EEG changes: High-amplitude, slow waves
11
Q
REM: rapid-eye movement
A
- Also known as paradoxical sleep
- Inc brain metabolism during this phase than when we are awake
- EEG changes: Low-amplitude, mixed-frequency EEG
- EOG: bursts of rapid eye movement
-
Our body enters a stage of atonia so EMG is absent in nearly all skeletal muscles
- Inhibition of spinal motor neurons by brainstem mechanisms
- REM sleep is characterized by a low-amplitude, mixed-frequency EEG similar to that of NREM stage N1 sleep. The EOG shows bursts of rapid eye movements similar to those seen during eyes-open wakefulness. EMG activity is absent in nearly all skeletal muscles, reflecting the brainstem-mediated muscle atonia that is characteristic of REM sleep.
12
Q
Objective measure :Gold standard is polysomnography
A
- Look at apnea-hypopnea index with synchronous periods of oxygen desaturation
- Overnight measurement of sleep stages, quality and physiology, EKG, respiration and oxygen, and muscle movements
- EEG: electrical activity of brain
- EOG: eye movement activity
- EMG: movement on chin, neck and leg
- EKG
- Chest wall movement and RR: airflow out of nose and mouth
- CO2, Pulse Ox
- Audio/video- to see what they do during sleep (snoring, gasping, moving)
13
Q
Objective Tests for Measuring Sleep: Multiple Sleep Latency Test (MSLT)
A
Five 20 minute nap opportunities measuring minutes to sleep-onset and REM-onset
14
Q
Objective Tests for Measuring Sleep: Maintenance of Wakefulness Test (MWT)
A
Four 40-minute trials measuring the ability to remain awake
15
Q
Subjective test: Epworth Sleepiness Scale
A
- Epworth Sleepiness Scale
- Chance of dozing while:
- Watching TV
- Sitting inactive in a public place (e.g. a theater or a meeting)
- Sitting and reading
- As a passenger in a car for an hour without a break
- Lying down to rest in the afternoon when circumstances permit
- Sitting and talking to someone
- Sitting quietly after a lunch without alcohol
- In a car, while stopped for a few minutes in traffic
- Chance of dozing
- 0 = would never doze
- 1 = slight chance of dozing
- 2 = moderate chance of dozing
- 3 = high chance of dozing
- 0-9 is normal, 10 and above is abnormal
- Abnormal scores mean you’ll be ordering a sleep study and/or a referral to a sleep MD…
- Chance of dozing while:
16
Q
What is normal sleep
A
“when we sleep and fall into sleep time, our brain tells our body that our hypoxic drive can decrease and ventilatory response is diminished and we are still ok”
- Input from the behavioral control system decreases → the hypoxic drive to breathe is reduced → the ventilatory response to partial pressure of carbon dioxide in arterial blood is diminished
17
Q
With age in healthy pts, both episodes tend to increase which is normal
A
- Apnea
- hypopnea
18
Q
Sleep Disturbances/Disorders
A
- 50-70 million Americans suffer from chronic disorder of sleep and wakefulness
19
Q
Men > women: why?
A
- Anatomically their pharynx is longer which can collapse easier
- Greater propensity for obesity in the neck area
***Mostly older people, but kids can get it
20
Q
Apnea
A
- complete cessation of airflow for 10 seconds or longer
- Can cause tachycardia
21
Q
Hypopnea
A
- significant decrease in airflow
- But abnormal functioning can occur more with physiological variations leading to fragmented sleep
22
Q
Obstructive sleep apnea diagnostic requirements
A
- excessively goes through apnea/hypopnea
-
Frequency of abnormal respiratory events with at least 5 episodes in one hour in sleep
- Termed Apnea-hypopnea index
- *high co-relation w/ depression
- With this inc, you get hypoxic and elevated co2 that sends signal to brain to wake up pt
- MC structures that collapse: tongue, soft palate, lateral pharyngeal walls
-
Frequency of abnormal respiratory events with at least 5 episodes in one hour in sleep
23
Q
Obstructive sleep apnea patho
A
- Pathophysiology:
- Upper airway relaxation, complete occlusion of airway, cessation, arousals, reesstablish muscle tone and air
24
Q
Obstructive sleep apnea eitology
A
- Small/narrow upper airway
- Class I through Class IV depending on opening of throat/airway
- Collapsibility of upper airway- sedative, etoh, nicotine, weight, anesthetics
- Enlarged tonsils, elongated soft palate
- Hypothyroid
- Familial – genetics; doesn’t have to obese or overwt
- Downs syndrome pts
- Sleeping on your back
- Central sleep apnea from stroke, ALS, myopathies, myasthenia gravis
25
Q
Obstructive sleep apnea, How it presents?
A
- terrible nightmares w/ apnea episodes
- Snoring, snorting, gasping, morning HA (from not getting enough O2), wt gain, dry mouth, daytime somnolence, autonomic response can cause diaphoresis of neck/chest, mood changes
26
Q
Obstructive sleep apnea on PE
A
-
Hypertension, central obesity, oropharynx is small and crowded, low-lying soft palate, large tonsils, polyps or septal deviation, cardiac dysfunction (left/right sided), neuro/cerebral dz
- Deviation can cause high level resistance that inc collapsibility
- ** concerned about cardiac and pulmonary problems
- Neuro- affects whole body systemically
27
Q
Obstructive sleep apnea, Risk factots
A
-
MAJOR: obesity (Class IV findings)
- Decreased lung volumes
- Abnormal anatomy
- Inc neck diameter > 17 in in men and > 16 in women
28
Q
Obstructive sleep apnea, Complications
A
- due to continuous apnea and hypopnea
-
HTN: as the sympathetic tone increases, this can vasoconstrict vessels and cause HTN
- Leading to right sided HF and pulmonary HTN
-
Arrhythmias: pressure becomes more negative with inspiration causing hypoxemia
- You have inc risk of CVA and CAD with OSA
-
HTN: as the sympathetic tone increases, this can vasoconstrict vessels and cause HTN
29
Q
Obstructive sleep apnea, Tx
A
- wt loss, avoid sedatives and alcohol, CPAP, surgery (removal of anatomical structures), oral device
- You can have mild, moderate and severe sleep apnea that dictates the treatment
- Cannot wear oral device w/pregnancy due to inc laxity
- Oral device may make jaw displaces some so ppl are taught exercises to fix it
- CPAP: positive airway pressure to prevent collapse bc machine senses when an episode is going to occur
- Nasal pillows, dreamer mask
30
Q
Central Sleep apnea: not the same as OSA
A
- Simple cessation of breathing rather than obstructed airway
MC w/CNS disorders (CVA, ALS, polio, brain neoplasm, muscular dystrophies)
31
Q
Narcolepsy: pretty common
A
- Excessive daytime sleepiness
- Neuro disorder from excitatory neurotransmitter deficiency
- Decreased levels of NT in CSF – not common
- Unusual REM phenomena
- Begins btwn 10-20
- **When cataplexy occurs, this is indicative of Narcolepsy
32
Q
Cataplexy
A
- What happens is you get “REM” like characteristics: they are not getting enough REM cycles overall
- Muscle paralysis upon awakening
- Dream-like hallucinations at sleep onset and awakening
- Sudden muscle weakness without loss of consciousness – triggered by strong emotions
33
Q
Cataplexy Tx
A
- treat with Rem suppressors like antidepressant or Xyrem (CNS depressant)
- Naps, behavioral advice
-
Stimulants –Provigil, Ritalin, Dexadrine, Desoxyn
- Drug holidays: period where you stop taking drug- “free-period”
34
Q
Sleep Terrors
A
pt doesn’t remember episode/dreams
- Young children during NREM N3 stage
- What do you see:
- Child sits up in sleep and screams, hyperventilation, large pupils, hyperventilation, sweating, hard to arouse
- Self-limiting and benign
35
Q
Sleep Terrors Causes
A
- OSA, sleep deprivation
- Fatigue
- Stress, migraines, head injuries, fmhx
- Order PSG to check
36
Q
Nightmares
A
- Patient will remember the dreams
- Normally due to a loss whether real or not
- Due to: stress, fatigue, psychiatric disorder (PTSD)
37
Q
Nightmares Tx
A
- image rehearsal therapy, desensitization, relaxing
- Meds: Prazosin (alpha blocker that crosses BBB)
38
Q
Sleepwalking
A
- Symptoms: walk, urinate inappropriately, eat, exit house, drive car w/o awareness
- Hard to wake up and may be violent
- MC in kids and adolescents
- Can run in families
39
Q
Sleepwalking Tx
A
- antidepressants and benzos, relax, hypnosis PRN
40
Q
Restless Legs Syndrome
A
- MC in females
- Uncomfortable sensation in limbs when sedentary; Irresistible urge to move legs with creepy crawly feelings
- Worse at night and first half of night
41
Q
Restless leg syndrome cause
A
-
MCC: iron deficiency
- Also caused by: peripheral neuropathies, uremia, pregnancy, caffeine, alcohol, rheumatic, lithium, antihistamines (MEDS, dialysis pts, DM, anemics)
42
Q
Restless leg syndrome Dx
A
- don’t use polysomnography (PSG)
- LABS: serum ferritin, renal function, glucose, thyroid, B-12, connective tissue screen (RA)
43
Q
Restless leg syndrome Tx
A
- treat the underlying disorder; iron supplementation; temporarily relieved by movement
- For symptoms: dopamine agonists 1st line
44
Q
Insomnia
A
- Inability to satisfactorily initiate or maintain sleep, or awakening prematurely at least 3 nights per week
-
Unrefreshing sleep due to impaired daytime functioning or distress
- Can dec quality of life, inc use of medical resources, MVA, poor cognitive functioning, psychiatric disorders
- Wont find impairment with empirical tests like with MSLT aka daytime nap study (how quickly you fall asleep in daytime environment- would be normal w/insomnia)
45
Q
Insomnia Dx
A
- clinical, self report, psychological tests (beck depression/mood/anxiety), lab measures are secondary
- Labs: PSG, MSLT, MWT – all would be normal
46
Q
Insomnia Tx
A
- CBT, pharmacological (sedative/melatonin), bright light tx, sleep hygiene-watching tv/using phone, chronotherapy (restrict sleeps)
- Eat/exercise several hours before, dark room, no electronics
- Meds: if needed/if severe
- Benzos (alprazolam, lorezampam, ambien)
- Antidepressants (trazadone)
- Antihistamines (Benadryl, Tylenol pm)
- Barbiturates
