Sleep Flashcards
1
Q
This is the constant sleep that you get during the sleep perisod becuase of falling circadian alertness opposing any decrease in homeostatic sleep drive
A
Sleep homeostasis
2
Q
This is the biologic alerting rhythm that consists of one oscillarion every 24.2 hours
A
Circadian system
3
Q
What are Zeitgebers?
A
They are cues that syncrhonize the circadian rhythm to the external 24-hour period.
Can be photic (light) or nonphotic (eating times)
4
Q
This is the cognitive impairment present immediately on awakening from sleep
A
Sleep inertia
5
Q
When is sleep inertia most pronounced?
A
15-30mins after wakening
This is why you go crazy on call when paged and have no idea how to think.
6
Q
This is the master circadian rhythm generator in mammals.
A
Suprachiasmatic nuceleus
7
Q
Where in the brain is the suprachiasmatic nucleus?
A
Hypothalamus
8
Q
When is the suprachiasmatic nucleus active?
A
Active during the day, consolidates at night.
Peaks in late morning and early evening. Dips in the early morning and early afternoon (coffee times)
9
Q
What is the connection of the suprachiasmatic nucelus to light? (mainly blue-blue green light)
A
Retinohypothalamic tract
10
Q
Function of the following sleep neurotransmitter:
GABA
A
CNS inhibition
benzos, alcohol
11
Q
Function of the following sleep neurotransmitter:
Glutamate
A
CNS excitation
12
Q
Function of the following sleep neurotransmitter:
Serotonin
A
CNS excitatory
Activity increases during wake and decreases during sleep
13
Q
Function of the following sleep neurotransmitter:
NE
A
CNS excitation
Increases during wake and decreases during sleep
14
Q
Function of the following sleep neurotransmitter:
Dopamine
A
Agonists promote wakefulness
This is why Haldol makes you sleep and amphetamines make you awake for 3 days
15
Q
Function of the following sleep neurotransmitter:
Histmaine
A
1st generation antagonists promote sleep (Benadryl)
16
Q
Function of the following sleep neurotransmitter:
Ach
A
REM sleep neuroteansmitter
17
Q
Function of the following sleep neurotransmitter:
Hypocretin
A
Deficiency in this results in narcolepsy with cataplexy
18
Q
Function of the following sleep neurotransmitter:
Adenosine
A
Decrease in acitivity promotes wakefulness
Caffeine blocks adenosine receptors!!!
19
Q
This hormone is synthesized in the pineal gland and influences the circadian sleep-wake cycles
A
Melatonin
20
Q
When is melatonin secreted the most? Day or Night?
A
Night
It’s inhibited by light.
21
Q
If you have problems falling asleep too early in the evening (phase DELAY circadian sleep-wake rhythm), when should you take melatonin?
A
Early morning
22
Q
If you have problems falling asleep too late in the evening (phase ADVANCE circadian sleep-wake rhythm), when should you take melatonin?
A
Early EVENING
23
Q
Which increases in the autonomic nervous system during sleep, sympathetic or parasympathetic?
A
Parasympathetic
REST and digest
24
Q
What happens to the cardiovascular system during non-REM and REM sleep?
A
NREM: ↓HR, ↓CO, ↓BP
REM: ↑HR, ↑CO, ↑BP
25
What happens to the renal system during sleep?
Decrease in urine output:
↑water reabsorption, renin, ADH
↓GFR
This is why you can not pee at night for 8 hours but during the day barely last more that 3 hrs before having to pee.
26
Which of the following hormones are increased during sleep?
GH, PRL, PTH, Testosterone, Cortisol, Insulin, TSH
GH, PRL, PTH, Testosterone
There is ↓ Cortisol, Insulin, TSH
27
When is your body the hottest and coldest during the day?
Annual variation is due to bikini season, but on a day to day basis, peak temperature is early evening and nadir is 2 hours prior to usual wake (4-5am)
28
Which neurotransmitter is responsible for REM
Ach
29
```
19-year-old woman
sleeps from 3 am until 11
am daily. She starts
college in 1 month and has
7 am classes. What
circadian rhythm sleep
disorder does she have?
When would you give her
melatonin?
```
```
She has a delayed sleep
phase disorder; should
receive melatonin early in
the night to help her fall
asleep earlier.
```
30
```
76-year-old man sleeps
from 7 pm until 4 am once
a day. He wants to join his
local Bingo group that
meets at 8 pm, and he
would like to stay up longer
at night. What circadian
rhythm sleep disorder does
he have, and when would
you give him melatonin to
treat it?
```
```
He has advanced sleep
phase disorder, and he
should receive melatonin in
the early morning, after
being cautioned that
melatonin can cause
drowsiness
```
31
This test can be used to diagnosed sleep disordered breathing (SDB), efficacy of trreatment for SDB, use of PAP titration, and diagnosis of non-respiratory sleep disorders (limb movement disorders, narcoleps, parasomnias, nocturnal seizures, REM disorders)?
Polysomnography (PSG)
32
Which waveform on PSG occurs when you're alert and awake (>13 Hz)?
Beta waves
33
Which waveform on PSG occurs when you're drowsy with eyes closes (8-13 Hz)?
Alpha waves
34
Which waveform on PSG occurs when you're in N1, N2, and REM (4-7 Hz)?
Theta waves
35
Which waveform on PSG occurs when you're in N3 sleep (<4 Hz)?
Delta waves
36
This EEG waveform are sharp negative waves in the theta range frequency, and usually occurs during the latter part of sleep stage 1
Vertex waves
37
This EEG waveform are sharp negative waves followed by slower postiive component, usually seen in stage 2?
K-complex
Like a EEG PVC
38
This EEG waveform is a cluster of short rhythmic waves in the 12-14 Hz range, seen in stage 2
Sleep spindles
39
What EEG waveforms are only seen in REM?
Sawtooth waves
40
What hormone increases during sleep, ghrelin or leptin?
Ghrelin increases (grow), leptin decreases (lean)
41
What stage of sleep is this based on the characteristics of PSG?
Chin EMG tone high, low voltage mixed frequency pattern, fast eye movements and eye blinks
Wake
42
What stage of sleep is this based on the characteristics of PSG?
Low amplitude, mixed frequency, K-complexes and/or sleep spindles
N2
43
What stage of sleep is this based on the characteristics of PSG?
Alpha activity diminished or disappeared, low amplitude mixed frequency waves, slow rolling eye movements, possible vertex waves, chin EMG levels lower than wake
N1
44
What stage of sleep is this based on the characteristics of PSG?
low amplitude, mixed frquency waves, low chin EMG, rapid eye movements
REM
Lol it's in the question stem
45
What stage of sleep is this based on the characteristics of PSG?
>20% of epoch occupied by low-frequency, high amplitude delta waves
N3
46
Apnea on the PSG is defined by what criteria on the thermal sensor?
decrease in theraml sensor amplitude by >90% of baseline for >10 sec
47
How is hypopnea defined by PSG?
decrease in nasal pressure by >30% for >10 sec with a >4% drop in oxygen saturation
48
How often do you have to move your legs to be defined has having periodic leg movement disorder (PLM)?
>4 consecutive leg movements for 0.5-10sec each
5-90 sec between movements
49
Define normal, mild, moderate, and severe SDB using AHI
Normal 0-5
Mild 5-15
Moderate 15-30
Severe >30
50
This is the number of apneas + number of hypopneas + respiratory effort-related arrousals per hour of sleep
Respiratory disturbance index
```
Classified by the same #'s as AHI:
Normal 0-5
Mild 5-15
Moderate 15-30
Severe >30
```
51
This is an 8-item questionairre that evaluates the chances of dozing off to sleep on the scale of 0 to 3 uncer certain circumstances
Epworth sleepiness scale
52
What score on the Epworth sleepiness scale determines excessive daytime sleepiness?
>10
53
This si teh test that measures tendency to fall asleep in quiet settings, where patients are told to try to fall asleep
Multiple sleep latency test (MSLT)
Requires PSG the night prior, discontinue any offending meds, and 4-5 20 min nap opportunities at 2 hour intervals with focus on sleep latency and presence or absence of REM sleep onset periods
54
What is the MSLT used to diagnose?
Narcolepsy
Also used to evaluate unexplained hypersomnia
55
On the MSLT, what causes short sleep onset latency (SOL) <8 mins?
```
Narcolepsy
Idiopathic hypersomnia (IH)
Sleep deprivation
OSA
PLMD
Acute stimulant agent withdrawal
```
56
On the MSLT, what things cuases >2 sleep onset REM sleep periods (SOREMPs)?
```
Narcolepsy
Sleep deprivation
OSA
Alcohol withdrawal
REM sleep suppressant withdrawal (antidepressants)
```
57
This SDB has the risk factors for age, male, obesity, ethnicity (black, Asian, Hispanic), and medical comorbidities (heart failure, history of CVA, renal failure)
OSA
58
What are two defining
characteristics of
narcolepsy on PSG with
MSLT?
Decreased SOL and ≥ two
| SOREMPs on MSLT
59
Whats the god standard for diangosing OSA?
In-lab PSG
60
What do patients NOT have in order to do portable sleep studies?
Co-morbidities such as CAD, CVA, COPD, hypoventilation syndromes
61
Untreated OSA puts you at an increased risk of what bad things?
```
MI
CVA
Pulm HTN
HTN
Sudden death
Worsened DM and CHF
Increases pro-inflammatory immune mediators
MVAs
Cognitive problems
```
62
What is the mainstay of treatment for OSA?
CPAP
63
When is CPAP indicated based on AHI?
Moderate-severe OSA (>15 AHI) regardless of symptoms
Mild OSA (AHI >5) with symptoms/comorbidities
64
What is deemed "compliant" with CPAP?
>4 hours at least 70% of observed nights
65
```
What is the #1 reason for
residual daytime
sleepiness in patients who
are on CPAP therapy for
SDB?
```
CPAP noncompliance
66
What intervention is as effective as CPAP for improving daytime sleepiness but less effective than CPAP for improving oxygenation and AHI?
Oral appliances
67
What surgery improves SDB but does not result in resolution of sleep apnea?
Bariatric surgery
68
What surgery is the reduction or removal of portions of the soft palate and uvula, is UNsuccessful in resolving OSA, and is NOT recommended?
UPPP
Name is too long to type
69
What surgery moves the upper and lower jaw forward, and is noted to be successful in resolving OSA?
Maxillomandibular advancement
70
What surgery is a last resort for refractory OSA in patients intolerant of CPAP?
Tracheostomy
71
What surgery is effective in children and infants for OSA?
Adenotonsillectomy
72
Which outcome is the most
likely to improve with use
of CPAP in OSA?
Daytime sleepiness
73
This is the loss of ventilatory effort during sleep resulting in repetitive cessation of airflow
Central sleep apnea (CSA)
74
This is the normal or low PaCO2 and increased ventilatory response to hypercapnea in CSA
Nonhypercapnic CSA
75
This type of breathing in CSA is characterized by crescendo-decrescendo periodic breathing
Cheyne-stokes breathing
76
What is the pathophysiology for cheyne-stokes breathing?
↑ CO2 sensitivity
↑ ventilatory drive
↑ circulatory time secondary to decreased CO
↓ oxygen reserve
77
```
74-year-old man with
heart failure (LVEF 20%)
and atrial fibrillation is
referred for frequent
nocturnal desaturations
noted during a recent
hospitalization. What type
of SDB would you be
concerned about?
```
Cheyne stokes breathing
78
What sleep stages does cheyne stokes breathing occur in?
N1 and N2
79
What is the best treatment for cheyne-stokes respirations?
Optimize heart failure
Adaptive servo-ventilation
Supplemental oxygen
80
Would a patient with cheyne stokes respirations be hypercapnic, hypocapnic, or eucapnic on a daytime arterial blood gas?
Hypocapnic
81
This type of complex sleep apnea occurs predmoninantly during non-REM sleep, in high altitudes over 2500 meters, caused by enhanced ventilatory response to hypoxemia, and trreated with oxygne and acetazolamide
High-altitude periodic breathing
82
This type of complex sleep apnea occurs because of fluctuations in PaCO2 above and below the apneic threshold as sleep onset occurs, resolves as sleep progresses, and does not need therapy?
Sleep-onset central sleep apnea
83
This condition is characterized by elevated awake PaCO2 > 45 and BMI >30
OHS
84
Treatment of OHS?
CPAP +/- oxygen
| BiPAP for persistent hypoxemia
85
What conditions can lead to congential central hypoventilation due to lack of responsiveness to O2 and CO2, possibly due to mutation in the PHOX2B gene?
Autonomic dysfunction
Hirschsprung disease
Neural crest tumors
86
This diagnosis causes dyspnea at night due to increased vagus nerve tone, circadian variability with decreased FEV1, and increased inflammatory agents (eosinophils) during early morning hours (3-6am)
Nocturnal asthma
87
True or False: nocturnal hypoxemia can be diagnosed in COPD using portable PSG
FALSE
Don't use ambulatory sleep tests in pts with underlying co-morbidities
88
What are the indications for nocturnal oxygen therapy for COPD patients?
Either:
PaO2 <55 mmHg
SaO2 <88%
Fall of PaO2 > 10mmHg during sleep
Fall of SaO2 > % during sleep
89
This condition is characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, and sleep hallucinations
Narcolepsy
90
What neurotransmitter is specifically low in narcolepsy patients?
Orexin (AKA hypocretin)
91
What is the normal function of orexin?
Fucntions to heighten alertness and inhibits REM sleep through orexin-mediated nerve conduction in the lateral hypothalamus
92
True or False: sleep and daytime naps are refreshing in narcolepsy
TRUE
This is what distinguishes narcolepsy from idiopathic hypersomnia, where sleep is not refreshing
93
This is the sudden loss of muscle tone, usually triggerred from strong emotions
Cataplexy
Patognomonic of narcolepsy
94
When do sleep hallucinations in narcolepsy occur, when falling asleep or awakening?
At sleep onset (hypnogogic)
95
What test is useful for diagnosing narcolepsy?
MSLT
96
What times of non-pharmacologic treatment should be administered for narcolepsy?
Structured sleep schedule
Scheduled naps
No drama in life
97
What medications can be used to treat the hypersomnolence with narcolepsy?
Stimulants (modafinil, armodafinil)
| Amphetamines (methylphenidate, dextremphetamine)
98
What medications can be used to treat the cataplexy with narcolepsy?
SSRIs
| Sodium oxybate
99
What medications can be used to treat the sleep fragmentation with narcolepsy?
Hypnotics (zolpidem, eszopiclone)
| Sodium oxybate
100
Treatment for idiopathic hypersomnia?
Modafinil or armodafinil
101
Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia (IH)?
Continuously sleepy throughout the day
IH
102
Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?
Naps are refreshing
Narcolepsy
103
Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?
Presence of cataplexy
Narcolepsy
104
Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?
10% of cases remit spontaneously
IH
Narcolepsy is life-long
105
Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?
Treatments include other agents such as SSRIs and zolpidem in addition to modafinil
Narcolepsy
106
This condition is characterized by uncomfortable sensation in the legs at rest which are relieved with movement
RLS
107
Deficiency in which substance can cause RLS due to ineffective dopamine synthesis?
Iron
108
First line agents for treatment for RLS?
Dopamine agonists (pramipexole, ropinirole)
109
Second line agents for treatment of RLS?
Gabapentin, opioids, carbidopa/levodopa
110
This group of diagnosis is characterized by abnormal or complex body movement during sleep, and include sleep terrors, sleep walking, sleep talking, and sleep eating.
Parasomnias
111
Do parasomnias occur during REM or NREM sleep?
NREM
112
This diagnosis is characterized by presence in childhood, child will sit of screaming or mumbling, appearing panicked, amnesia to event
Night terrors
113
Treatment of night terrorss?
Supportive unless frequent and disruptive, in which benzos or TCAs may be beneficial
114
This parasomnia occurs in older male patients in REM sleep, where dreams are acted out, memories of event are present, and often associated with Parkinsons
REM sleep behavior disorder
115
Treatment for REM sleep behavior disorder?
NONPHARMACOLOGIC first (mattress on floor, sleep in separate beds, eetc) --> Clonazepam
116
Treatment for delayed sleep phase syndrome?
Bright light in the morning, melatonin at night to promote sleep
117
Treatment for advanced sleep phase syndrome?
Bright light at night, melatonin in the morning
118
Treatment for shift work sleep disorder (if unable to change jobs)?
Bright light while at work to suppress melatonin, can use modafinil or armodafinil, use dark glasses when driving home and block sun when sleeping during the day
119
Treatment for free running disorder (non-24-hour syndrome) in blind patients??
Maltonin at night, alarm clocks
120
This is the inability to initiate or maintain sleep despite adequate time and opportunity to do so
Insomnia
121
```
32-year-old woman
reports sleeping only 3
hours per night for many
years. She reports good
sleep quality, denying any
daytime impairment,
sleepiness, or distress.
Does this patient have
insomnia?
```
```
No because the patient is
not experiencing
impairment or distress as a
result of the short sleep
duration
```
122
What is the gold standard for treatmnet for insomnia?
Cognitive behavior therapy (CBT)
This is a systematic approach that addresses cognitive stress that exacerbates insomnia, and the maladaptive behaviors that perpetuate further sleep disturbances. Equally effective as meds!
123
This medication for insomnia is a selective GABA agonist, lasts 4-5 hours, used for sleep initiation insomnia, and can cause side effects such as sleep eating, depression, headaches, and fatigue?
Zolpidem
124
This medication for insomnia is a benzodiazepine, lasts 6-8 hours, used short term (7-10 days) for sleep initiation insomnia, and causes side effects such as respiratory depression, fatigue, dependency, or dizziness?
Temazepam
125
This medication for insomnia is a selective GABA agonist that lasts 6-8 hours, used for sleep initiation and maintenance insomnia, and can cause side effects such as depression, headaches, dizziness, and unpleasant metallic taste?
Eszopiclone
126
This medication for insomnia is a melatonin receptor agonist, lasts 4-5 hours, used for sleep initiation insomnia, and can cause side effects such as depression, headaches, and fatigue?
Ramelteon
127
This medication for insomnia that is a selective GABA agonists, lasts 1-2 hours, used for sleep initiation insomnia, and can cause depression, headaches, dizziness, and amnesisa?
Zaleplon
128
This medication for insomnia that is an SNRI, lasts 3-5 hours, used for sleep maintenance insomnia, and can cause side effects such as fatigue, nausea, and depression?
Doxepin
