SLEEP Flashcards
The neural control of circadian rhythms is
thought to reside in the_________________more specifically; in the suprachiasmatic
nuclei
ventral-anterior region of the hypothalamus,
five stages of sleep, representative
of two alternating physiologic mechanisms, have been
defined. In each stage, the electrical activity of the brain
occurs in organized and recurring cycles, referred to as
the____________
architecture of sleep .
EEG Patterns of sleep
Stage 1:
Stage 2 sleep, 0.5- to 2-s bursts
of biparietal 12- to 14-Hz waves (sleep spindles) and
intermittent high-amplitude, central-parietal sharp
slow-wave complexes appear (vertex waves
slow, rolling eye movements and is called
The American Academy of Sleep Medicine (AASM) recommends
the following staging:
stage W (wakefulness), stage Nl (non-REM sleep, or NREM 1, formerly stage 1), stage N2 (NREM 2, formerly stage 2), stage N3 (\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and stage R\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NREM 3,combining former stages 3 and 4-or slow-wave sleep)
(rapid eye movement [REM] sleep).
EEG becomes desynchronized, i.e., it has a low-voltage,
high-frequency discharge pattern.
REM
This NREM-REM cycle is repeated at
about the same interval ____________during the night,
depending on the total duration of sleep
four to six times
In the latter portion of a night’s sleep,
the cycles consist essentially of two alternating stages: _____________
REM
sleep and stage N2 (spindle-K-complex) sleep.
Newborn full-term infants spend approximately
__________of their sleep in the REM stage
50 percent
The amount
of sleep in N3 decreases with age, and persons older than
70 years of age have virtually no_________
very deep slow-wave
sleep
Because the time spent in NREM is so much
greater than that in REM, approximately ____________of
dreaming occurs outside of REM periods but REM sleep
nonetheless maintains a special relationship to dreaming
20 percent
Gross body movements occur every 15 min or so in all stages of sleep
but are maximal in the_____________________, at which time the sleeping person changes
position, usually from side to side
transition between REM and
NREM sleep,
In the nonphasic periods of REM sleep, ____________ neurons are inhibited, the H responses
diminish and and the tendon and postural
and flexor reflexes diminish or are _______
alpha and gamma spinal
abolished
REM sleep has been found to have
_____ and ________ components
phasic and tonic components.
In addition to the rapid
eye movements, phasic phenomena include activation of
the ____________with attendant alternate
dilatation and constriction of the pupils and fluctuation
of the blood pressure, heart rate, and respiration
sympathetic nervous system
In the nonphasic periods of REM sleep,_____________are inhibited, the H responses
diminish
alpha
and gamma spinal neurons
During sleep, the decline in
temperature occurs mainly during the ___________,
and the same is true of the heartbeat and respiration,
both of which become slow and more regular in this
period.
NREM period
During the____________, there is a surge of growth hormone secretion,
mainly during slow-wave sleep.
first 2 h
of sleep
The secretion
of _________and particularly of _____________ peaks at the onset of sleep .
cortisol
thyroid-stimulating
hormone
Prolactin secretion increases during the night
in both men and women, the highest plasma concentrations being found __________
soon after the onset of sleep
___________ a
peptide that assumes great importance in the pathophysiology
of narcolepsy,
Hypocretin,
the ventrolateral preoptic nucleus of the hypothalamus
(VLPO) sends fibers to all the other major cell groups
of the hypothalamus and brainstem that are engaged
in _____________
arousal
a decrease in monoamines causes an increase in __________ and vice versa
REM activity
dopaminergic systems in the _________ areas elicit or modulate dreaming
basal forebrain
Most of the integrated rhythms
of sleep that are recorded at the surface of the brain,
including the background activity of slow-wave sleep
and the faster and more synchronized sleep spindles
and vertex waves, have their origins in the ______
thalamus.
In dreaming, activation of the _______and________, with attenuation of activity in the primary visual cortex and frontal association areas
extrastriate visual cortices
limbic- paralimbic regions
In sleep deprivation, The EEG shows a ______________and closing of the eyes no longer
generates___________
decrement of alpha waves,
alpha activity
When falling asleep after a long period of deprivation,
the subject rapidly enters __________ sleep, which
continues for several hours at the expense of N2 and
REM sleep.
N3 (NREM)
__________seems to be the most important sleep stage in restoring the altered functions that result from prolonged sleep deprivation.
N3
The term _________ signifies a chronic inability t o sleep
despite adequate opportunity to do so; it is used popularly to indicate any impairment in the duration, depth, or restorative properties of sleep
insomnia
This term i s reserved for the condition in which nocturnal
sleep is disturbed for prolonged periods and none of the
symptoms of anxiety, depression, pain, or other psychiatric
or medical diseases can be invoked to explain the
sleep disturbance
Primary insomnia
main conditions causing secondary insomnia
pain in the joints or in the spine, abdominal
discomfort from peptic ulcer and carcinoma, pulmonary
and cardiovascular insufficiency, and the nocturia
engendered by prostatism.
___________ is otherwise called asthenia crurum paresthetica and also, anxietas tibiarum
RLS
Sx of RLS
.
unpleasant
aching and drawing sensations in the calves and thighs,
often associated with creeping or crawling feelings; other
descriptions have included “worms,” “internal itch,”
and “coldness,” and the legs may feel tired, heavy, and
weak.
The symptoms are provoked by rest, and rapidly,
but temporarily, relieved by moving the legs
Etiology of RLS
1.
2.
3.
- Idiopathic
- IDA
- Low Feritin
In RLS, _____________worsens restless legs syndrome, and there is a tendency for it to be worse in warm weather.
Fatigue
Like the restless legs syndrome, it may
result in sleep deprivation and daytime somnolence or,
more often, in disturbance of a bed partner. diagnosis depends on finding
them during polysomnographic recordings, whereas
restless leg syndrome is identified on clinical grounds
periodic leg movements
of sleep.
Associated conditions with Periodic leg movements of sleep
it also occurs independently with narcolepsy,
sleep apnea, following the use of tricyclic and serotonin
reuptake inhibiting antidepressants, L-dopa, and
withdrawal from anticonvulsants and sedative-hypnotic
drugs.
Initial Tx for RLS
Effects of these drugs;________
As a first choice, many practitioners favor treatment
with dopamine agonists such as prarnipexole (0.25
to 0.75 mg) or ropinirole (0.5 to 1 .5 mg), either one taken
1.5 to 2 h before bedtime. Long acting rotigotine may also be used
enhancement of the restless leg syndrome
Chronic and even short-term use of alcohol, barbiturates,
and certain nonbarbiturate sedative-hypnotic
drugs markedly reduces _____ as well as stages
________
REM sleep
3 and 4 of NREM sleep (N3
“Rebound insomnia,” a worsening of sleep compared
with pretreatment levels, has also been reported upon
discontinuation of short-half-life benzodiazepine hypnotics,
notably _______
triazolam
In the tx of insomnia, In the past, benzodiazepines were popular but these have been replaced by newer nonbenzodiazepine receptor
agonists with shorter half-lives and fewer side effects
such as ______.
Patients who
do not respond to these medications may be given an
intermediate-duration benzodiazepine such as _______
(e.g., zolpidem, zaleplon, and eszopiclone).
temazepam.
In the tx of insomnia, __________is inadvisable during pregnancy and
should be used cautiously in patients with alcoholism
or advanced renal, hepatic, or pulmonary disease, and should be avoided in patients with ______
Hypnotic use
sleep apnea syndrome.
________ has reportedly been as effective
as the sedative-hypnotics and may cause fewer shortterm
side effects, but both of these statements are difficult
to confirm.
Melatonin (3 to 12 mg)
_______appears to be
a sleep-enhancing drug even in those who are not anxious
or depressed.
Amitriptyline (25 to 50 mg at bedtime)
Nonprescription
drugs containing diphenhydramine (Benadryl), valerian,
or doxylamine, which are minimally or not at all effective
in inducing sleep, may impair________ and lead
to drowsiness the following morning.
the quality of sleep
Many neurologic conditions seriously derange the total
amount and patterns of sleep (see Culebras). Lesions in
the upper pons, _________, are particularly
prone to do so.
near the locus ceruleus
Lesser degrees of tegmental damage-as
might occur with Chiari malformations, unilateral medullary
infarction, syringobulbia, or poliomyelitis-may
cause _____ and __________
sleep apnea,
daytime drowsiness
___________ now an extinct illness, was
usually associated with a hypersomnolent state but
caused persistent insomnia in some instances
von Economo encephalitis,
lesions associated with insomnia
the anterior
hypothalamus and basal frontal lobes,
__________ is the virtual incapacity
to sleep and to generate BEG sleep patterns.
The cerebral changes consist mainly of profound neuronal loss in the anterior or _______
These cases apparently represent a usually familial
form of prion disease similar to diseases that cause
subacute spongiform encephalopathy and GerstrnannStraussler- Scheinker disease
fatal familial insomnia
anteroventral, and mediodorsal thalamic nuclei.
the alcoholic form of the_________associated
with less severe lesions in the same thalamic nuclei,
is also characterized by a sleep disturbance, taking the
form of an increased frequency of intermittent periods of
wakefulness
Korsakoff amnesic state,
Major head injury is an important cause of sleep
disturbance. The abnormalities, which may persist for
months or years, consist mainly of a decrease in _____________ and less than the expected amounts of REM sleep and dreaming
stages 1
and 2 sleep,
thus, tumors affecting the
__________are associated with excessive
daytime drowsiness, whereas medullary lesions cause
respiratory disturbances that may affect sleep
hypothalamus, and pituitary
A symptomatic form of narcolepsy is associated
with tumors located adjacent to the ____, and
________
third ventricle
midbrain
sleep problems in PD
stages of the disease complain of fragmented and unrestful
sleep, particularly in the early morning hours; some
advanced cases have pathologic insomnia, and this is
influenced also by medications used to treat the disease
and by deep brain stimulation
In striatonigral degeneration (multiple system atrophy),
Lewy-body disease, and other parkinsonian syndromes,
there is often a characteristic ________
in which the patient moves and speaks violently and
aggressively during dreaming
REM sleep disorder,
As sleep comes on, certain motor centers may be excited
to a burst of insubordinate activity. The result is a sudden
“start’’ or myoclonic bodily jerk of large amplitude,
which rouses the incipient sleeper. What is this??
S o m n o l esce nt ( S l e e p, Hyp n i c, Myoc l o n i c ) Sta rts
A small proportion of otherwise healthy infants
exhibit rhythmic jerking of the hands, arms, and legs or
abdomen, both at the onset and in the later stages of sleep. What is this condition?
(benign neonatal myoclonus).
characterized b y paroxysmal bursts o f generalized choreoathetotic,
ballistic, and dystonic movements occurring
during NREM sleep
N o ct u r n a l F ro nta l L o b e E p i l e psy
In pts with NFLE, Tx is
CBZ
2 types of attacks of NFLE
- in one, the attacks last 60 s or less;
they may be diurnal as well as nocturnal; some patients
in addition have epileptic seizures of the more usual
type; - the attacks are longer lasting (2 to 40 min). Ictal
and interictal EEGs during wakefulness and sleep are
normal, and these attacks do not respond to anticonvulsants
of any type
Curious paralytic phenomena, referred to ___________, may occur in the transition from the sleeping
to the waking state.
as pre- and postdormital
paralyses
sleep paralysis usually occurs in what conditions?
Such attacks are also observed in patients with narcolepsy
(discussed later in this chapter) and with the hypersomnia
of the pickwickian syndrome and other forms of
sleep apnea
In sleep paralysis, If frequent, as in narcolepsy, they can be prevented by the use of tricyclic antidepressants, particularly _________ which has serotonergic activity.
clomipramine,
The night terror (pavor nocturnus) is mainly a problem
of childhood. It usually occurs soon after falling asleep,
during stage______
3 or 4 sleep
Children with night terrors are often
________ as well, and both kinds of attack may occur
simultaneously.
sleepwalkers
Children with night terrors
and somnambulism do not show an increased incidence
of psychologic abnormalities and tend to outgrow these
disorders. T or F?
T
It has been
found that ________ which reduces the duration of the
deep stages of sleep, will prevent night terrors. ___________have also been used successfully,
especially when night terrors are associated
with sleepwalking.
diazepam,
Selective
serotonin reuptake inhibitors
When do Frightening dreams or nightmares occur?
They occur during periods of normal REM sleep and are
particularly prominent during periods of increased REM
sleep (REM rebound) following the withdrawal of alcohol
or other sedative-hypnotic drugs
This condition occurs far more commonly i n children
(average age: 4 to 6 years) than in adults, and is often
associated with nocturnal enuresis and night terrors
C h i l d h o o d S o m n a m b u l i s m a n d
S l ee p Auto m at i s m
It is estimated that __________ of children
have at least one episode of sleepwalking, and that
1 in 5 sleepwalkers has a family history of this disorder
15 percent
The onset of sleepwalking or night terrors for the first
time in adult life is most unusual, and, in an occasional
case, may suggest the presence of ________ or
_______
psychiatric disease
drug intoxication
Adult somnambulism also occurs during
_________ but unlike the childhood type, is not
confined to the earlier part of the night.
N3 of NREM sleep,
In somnambulism, They can be eliminated or
greatly reduced by the administration of __________. Some patients respond better to a
combination of clonazepam and _________or to flurazepam
clonazepam (0.5 to 1 .0 mg) at bedtime
phenytoin
It is characterized by attacks of vigorous, agitated, and often dangerous motor activity accompanied by vivid dreams.
The episodes, which occur exclusively during REM sleep, usually in the second half of the night, are out of keeping with the patient’s waking personality.
R E M S l ee p B e h a vi o r D i s o r d e r
Postuma and
coworkers have reported that one-quarter of individuals
with idiopathic REM sleep disorder later developed a
_________ similar to or slightly lower
than other series
neurodegenerative disorder,
Tx of REM sleep behavior DO
The episodes can be suppressed by the administration
of clonazepam in doses of 0.5 to 1 . 0 mg at bedtime
and by melatonin, 3 to 12 mg.
In the Tx of REM sleep behavior DO:
Antidepressants are said to exacerbate the disorder with the possible exception of________
bupropion.
In nocturnal epilepsy, Seizures may occur soon after the onset of sleep or at any time during the night, but mainly in __________ or, rarely, in REM sleep .
stages 1 and 2 of NREM sleep
__________ is the name given to a special
form of hypersomnia, characterized by a failure of the
patient to attain full alertness for a protracted period
after awakening
Sleep dru nken ness
a n episodic
disorder characterized by somnolence and overeating
Kleine-Levin Synd ro m e
Among general medical conditions, ________ and
________ must always be considered when daytime
sleepiness is a prominent feature
hypothyroidism
hypercapnia
________ is characterized by
irregular breathing, and this may include several brief
periods of apnea up to 10 s in duration
REM sleep
This pathologic form of sleep apnea may
be the result of a __________ (so-called
central apnea), an ___________ or a
combination of these two mechanisms.
reduction of respiratory drive
obstruction of the upper airway,
Apnea of the obstructive
type in which the ____________ collapse
and narrow the upper airway is far more common than
the central variety
posterior pharyngeal muscles
___________ or perhaps other stimuli induce an arousal
response, either a lightening of sleep or a very brief
awakening, which is followed by an immediate resumption of breathing
Hypoxia
__________is predominantly a disorder
of overweight, middle-aged men and usually presents as
excessive daytime sleepiness, a complaint that is sometimes mistaken for narcolepsy
Obstructive sleep apnea
OSA in combination with systemic and pulmonary arterial hypertension, cor pulmonale, polycythemia, and heart failure may develop. When combined with obesity, these symptoms have been referred to as the _________
“pickwickian syndrome,”
total loss of automatic breathing, especially
during sleep
hypoventilation syndrome
Complex sleep apnea, or ______________occurs most often in patients with
cardiovascular conditions, particularly congestive heart
failure, wherein, after sleep apnea is treated with positive
airway pressure, central apnea emerges
“treatment emergent central
sleep apnea,”
In the treatment of obstructive apnea,
________________is the most useful measure.
continuous positive airway pressure (CPAP) or bilevel
positive airway pressure (BIPAP)
In the tx of OSA, pts may benefit from?
Patients benefit from losing weight, lateral positioning
during sleep, and avoidance of alcohol and other sedative
drugs
Those few patients with the most severe hypersomnia
and cardiopulmonary failure who cannot tolerate
nocturnal positive pressure ventilation require _______
tracheostomy
and nocturnal respirator care
short term tx for central apnea
medications: acetazolamide,
medroxyprogesterone, protriptyline, and
particularly clomipramine
____________oxygen may also be
useful in reducing central sleep apnea
Low-flow
used to designate the brief, episodic loss
of voluntary movement that occurs during the period of
falling asleep (hypnagogic, or predormital) or less often
when awakening (hypnopompic, or postdormital
sleep paralysis-
These four conditions-narcolepsy; cataplexy;
hypnagogic paralysis, and hallucinations-constitute a
clinical tetrad.
The most important observations regarding the pathophysiology of this process
have been special relationship to a disordered _________, and the more recent finding of abnormalities
in ___________
pattern of REM sleep
hypothalamic substances that induce sleep
narcolepsy has a gradual onset between the
ages of 15 and 35 years; in fully 90 percent of narcoleptics,
the condition is established by the_________
25th year of life.
What distinguishes the typical narcoleptic
sleep attacks from commonplace postprandial drowsiness and napping is the frequent occurrence of the former ____________ their irresistibility; and their occurrence in unusual situations
(two to six times every day as a rule),
narcoleptics,
like other very drowsy persons, may experience
episodes of _________
automatic behavior and amnesia.
Narcoleptics have an increased incidence of sleep
apnea and periodic leg and body movements, but not of
__________
somnambulism
____________ refers to a sudden loss of muscle tone
brought on by strong emotion-that is, circumstances in
which hearty laughter or, more rarely; excitement, surprise, anger, or intense athletic activity cause the patient’s head to fall forward, the jaw to drop, the knees to buckle, even with sinking to the ground-all with perfect preservation of___________
Cataplexy
consciousness.
Most attacks of cataplexy are partial (e.g., only a
dropping of the j aw or “weakening of the knees”).
Wilson found that the_________were abolished during the attack. ________are absent in some cases.
tendon reflexes
Pupillary reflexes
Once established, narcolepsy and cataplexy usually
continue for the ______of the patient’s life
remainder
The hypocretins were
thought in the past to regulate________ and
__________ indeed, they were also designated
“orexins,”
feeding behavior
energy metabolism;
the absence
of ___________distinguished narcoleptic individuals
from patients with other categories of sleep disorders
CSF hypocretin
In Narcolepsy, it has long been known that there is an
almost universal association with specific alleles of the
histocompatibility antigen ___________
HLA-DQ (B1 -0602)
symptomatic narcolepsy has been associated with
tumors of the third ventricle or upper brainstem, head
trauma, or a sarcoid granuloma within the hypothalamus
the night sleep pattern
of patients with narcolepsy-cataplexy may begin with a
________
REM period.
Another important
finding in narcoleptics is that ___________ (the interval
between the point when an individual tries to sleep
and the point of onset of EEG sleep patterns), measured
repeatedly in diurnal nap situations, is greatly reduced
sleep latency
___________
followed by a _________, in which the patient is afforded opportunities for napping
at 2-h intervals, permit the quantification of drowsiness
and increase the probability of detecting short-latency
REM activity
Overnight polysorrmography
standardized multiple sleep latency test
Control of narcolepsy:
(1) strategically placed 15- to 20-min naps (during lunch hour, before or after dinner, etc.);
(2) the use of stimulant drugs-_______________
to heighten alertness; and
(3) __________(sertraline,
venlafaxine, protriptyline, imipramine, or clomipramine)
for control of cataplexy.
All these drugs are potent suppressants
of __________
modafinil, dextroamphetamine
sulfate, or methylphenidate hydrochloride
antidepressants
REM sleep.
___________ (200 mg daily, up to 600 mg in
divided doses) may prove to be the safest of the stimulants
(Fry)
Modafinil
________ because of its prompt action
and relative lack of side effects, is also widely used. It is
usually given in doses of 10 to 20 mg tid on an empty
stomach.
Methylphenidate,
The tricyclic antidepressants had been used to reduce
cataplexy, but they have been overtaken by selective serotonin
reuptake inhibitors such as___________ and by norepinephrine
reuptake inhibitors such as ________
sertraline
venlafaxine
problem with
the stimulant drugs is the development of tolerance over
a ___________, which requires the switching and
periodic discontinuation of drugs
6- to 12-month period
presumed
autoimmune attack on hypothalamic neurons, has introduced
__________ in early cases of narcolepsy
immune globulin infusions
___________is a state in which there is longer and unrefreshing daytime sleep
periods, deep and undisturbed night sleep, difficulty in
awakening in the morning or after a nap (“sleep drunkenness”),
all of these occurring in the absence of REMonset
sleep and cataplexy.
Idiopath ic Hyperso m n ia ( Essenti a l
N a rcol epsy; N R E M N a rcolepsy)
