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BMB Lectures > Sleep And Its Disorders > Flashcards

Sleep And Its Disorders Flashcards

1
Q

Sleep Disturbance in Old Age

A

Parasomnias

Hypersomnia

Sleep Disordered Breathing: most deadly but not the most common

Insomnia: most common

Circadian Rhythm Sleep Disorders

Sleep related movement disorders: 2nd most common

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2
Q

Epworth Sleepiness Scale

A

A scale intended to measure daytime sleepiness

  • a short questionnaire
  • 11+ is abnormal
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3
Q

Sleep Studies

A

What info do they provide

  • sleep duration
  • sleep latency: how quickly they fell asleep
  • sleep architecture: sleep stage distribution, seizures, EEG patterns, arousals
  • Breathing patterns: apnea, hypopnea
  • muscle movements: bruxism, limb movements (grinding teeth)
  • body position
  • behaviors awake and asleep: sleep walking, groaning, dream enactment, waking up and eating or using the phone, etc.
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4
Q

Sleep Stages

A
  • Wakefulness: alpha waves are relaxed wakefulness (occur as you close your eyes, open eyes and they go away)
  • Stage 2: sleep spindles and K complexes
  • Stages 3+4: delta waves
  • REM: look a lot like wake
Distribution: (normal adult)
-NREM sleep: 80%
     Stage 1: 5%
     Stage 2: 55%
     Stage 3: 15%
-REM Sleep: 25%
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5
Q

Normal Sleep

A
  • sleep latency: 20-30 mins
  • sleep progression: N3 dominant during the first third of the sleep period; and REM during the last 3rd
  • Sleep is entered thru NREM sleep
  • duration varies by age, but generally 7.5 hours nightly
  • survival curve is U shaped; decreased survival with short (less than 5 hours) or long (over 9 hours) sleep
  • W during sleep less than 5%
  • REM recurs every 90 to 120 mins
  • AHI < 5
  • PLMI < 5
  • Arousals increase with age (by age 40, people generally don’t sleep thru the night)
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6
Q

Sleep Studies

A

-PSG (polysomnogram): Gold standard
Measures: EEG, EMG, EOG (eye movements), EKG, SpO2, resp., air flow, nasal pressure, body position and sometimes ETCO2
-Diagnostic
-split night: first part is diagnostic, 2nd part to treat
-therapeutic
-should be performed during pt’s NORMAL sleep time

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7
Q

Obstructive Apnea

A

Cessation of airflow for 10+ seconds with continued effort in thoraco-abdominal signals

-pt is trying to breathe

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8
Q

Central Apnea

A

Cessation of airflow for 10+ seconds without demonstrable effort; diaphragmatic and intercostal EMG electrodes often indicate effort not picked up by surface sensors

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9
Q

Mixed Apnea

A

Initial central component followed 2 to 3 obstructed breathes

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10
Q

RERA

A

Respiratory Effort Related Arousals

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11
Q

AHI (Apnea-hypopnea index)

A

number of both types of events per hour of sleep

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12
Q

Arousal

A

Increased EEG frequency lasting 3 seconds

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13
Q

Limb Movements

A

Defined by amplitude and duration

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14
Q

Periodic Limb Movements

A

Repetitive muscle twitches in the extremities occurring within 5 to 90 seconds of on another, with at least 4

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15
Q

REM w/o Atonia

A

Absence of the expected loss of EMG tone in REM sleep

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16
Q

RDI (respiratory disturbance index)

A

AHI plus RERAs

Gov. Has decided to only pay for tx for apnea and not RERA

17
Q

PLMI (periodic limb movement index)

A

Number of limb movements per hour of sleep

18
Q

PLMAI (periodic limb movement arousal index)

A

Number of limb movements with arousals per hour of sleep

19
Q

Sleep Studies (types)

A

HSAT (home sleep study): airflow, thoracoabdominal movements, SpO2, HR

PAT: peripheral arterial tonometry (if they’re positive then apnea is here. Recommend only for people with moderate to severe likelihood for having obstructive apnea)

—these are screening studies with a false negative rate of 17% in the moderate to high risk population

Actigraphy: light and motion; surrogates for sleep time

20
Q

Indications for a home sleep study

A
  • high probability for mod to severe OSA
  • absence of comorbid heart, lung, or neurologic disease
  • not indicated for other sleep disorders (central apnea, parasomnias, PLMS, insomnia, etc.)

pt must be able to apply the device

-no EEG, no muscle movement. All there is, is breathing. Need a 4% drop in saturation to say something is wrong

21
Q

Snoring

A

-At age 35: 15% of F and 35% M snore
-At age 55: 35% of F and 65% M snore
—-not sure if primary snoring is a disorder
A study looked at a group of men who didn’t have sleep apnea
—snoring far more likely to have carotid stenosis. Something specific to the carotid and not the femoral artery
IMPORTANT: studies showing increase risk of stroke for people who are heavy snorers. Vibration of the snoring that causes small tears and stuff

22
Q

Insufficient Sleep

A
  • chronic sleep deprivation due to inadequate time for sleep
  • over scheduling activities
  • computers, gaming, exercise close to bedtime
  • work, childcare responsibilities
23
Q

Meds

A 
Opioids
Myorelaxants
DA agents
Anti-hypertensives
Antidepressants
Antiepileptics
Alcohol/illicit drug use
24
Q

Obstructive Sleep Apnea (in detail)

A
  • most common type of SDB
  • muscles that control the tongue and soft palate relax causing the airway to narrow and close
  • patient tries to breathe but can’t due to airway obstruction
  • patient stops breathing for more than 10 seconds

-pure OSA: responds very well to simple nasal CPAP (provided one keeps the deleterious effects of positive pressure on cardiac output in the dehydrated patient in mind)

Associated with dec. life expectancy: people who stop breathing 20 or more times in an hour (life expectancy cut in half)

Increased risk for:

  • cancer
  • diabetes
  • accidents
  • cognitive dysfunction
  • heart disease
  • stroke
  • HTN

Tx:
-positional therapy (some people only have it when sleeping on back)
-weight loss: thin people do have sleep apnea tho
-surgery: bariatric is most effective (80% of people still need CPAP after) and upper airway surgery works 20% of time
-Oral appliance
-CPAP: gold standard
It’s a pneumatic splint keeping the upper airway open

25
Q

Central Sleep Apnea

A
  • patient makes no effort to breathe in thorax nor abdomen during apnea
  • patient stops breathing for more than 10 seconds
  • typical in severe heart failure patients
  • may be characterized by Cheyne-Stokes respiration (CSR) separated by periods of apnea or hypopnea
  • we also see it now in patients using methadone

increased risk for:

  • cancer
  • heart disease
  • diabetes
  • accidents
  • cognitive dysfunction
  • HTN
  • stroke
26
Q

Narcolepsy

A
  • characterized by rapid transitions from wake to REM
  • genetic predisposition: HLA DQB1*0602 highly associated with cataplexy
  • however, only 30% concordance with monozygotic twins
  • may be associated with recent strep infection and H1N1

Tetrad:

  • sleepiness: naps are short and refreshing
  • sleep paralysis: inability to move or speak during transitions from sleep to wake. May occur in normals
  • hypnogogic/hynopompic hallucinations: dreamlike experiences at sleep onset/offset
  • Cataplexy: suddenly loss of muscle tone triggered by strong emotion, particularly laughter
  • age of onset: usually between 15 and 25
  • sleepiness is generally the presenting complaint (includes automatic behaviors like sleeping with eyes open: typing the same word or driving and you don’t know how you got home)
  • diagnosis is made by PSG/MSLT (polysomnogram/multisleep latency test)
  • presence of cataplexy is pathognomonic

Tx:
-symptomatic: stimulants for sleepiness
Sodium oxybate and/or antidepressants for cataplexy
-Other disorders may coexist (e.g. REM behavior disorder, OSA, PLMD)
-insomnia due to REM sleep fragmentation may be present

27
Q

Idiopathic CNS Hypersomnia

A
  • familial 50% of time
  • age of onset is between 10 and 30 (usually in the 20s)
  • naps are prolonged and unrefreshing
  • Sleep drunkenness more likely with awakenings (can’t wake up, in a fog)
  • nocturnal sleep tends to be prolonged

Eval:

  • NO OTHER CAUSE of EDS-all other sleep pathology treated
  • 2 weeks of sleep logs +/- actigraphy
  • NPSG (nocturnal polysomnogram): NL
  • MSLT (multiple Sleep latency test): MSL less than or equal to 8, < 2 SOREMS
28
Q

EDS Associated with Treated OSA

A

-despite adequate PAP tx of OSA
50% of subjects demonstrate MSL <11 min
25% complains of EDS
-etiology is uncertain but studies in mice suggest lesions of the RAS as a consequence of the apnea before it was treated

Tx:
Stimulants

29
Q

Restless Leg Syndrome (RLS)

A

-international RLS rating scale 1
Desire to move legs, often associated with abnormal leg sensations
Symptoms worsen at rest
partial of temporary relief with activity
Worsening of sx’s later in the day or night
-IRRLS 2: 10 questions with sx rated from 0 to 4
-11% in primary care clinic have RLS

Dx:

  • clinical based on Hx
  • PE noncontributory
  • PSG not indicated unless another Dx is also being considered
  • differentiate from nervous tapping, circulatory disorders and neuropathy
  • presence of PLMs increases specificity
  • associated with major depression and panic disorder
  • don’t tx unless it’s happening 3 or more times a week

Tx:

  • Fe replacement for ferritin < 50
  • DA agents
  • Benzodiazepines
  • Gabapentin
  • Narcotics
30
Q

Periodic Limb Movements (PLM)

A
  • usually occur during sleep but may occur while awake
  • 5 or more movements lasting > 0.5 sec to <10 sec, occuring at intervals of 5 to 90 seconds

-associated with dec. in survival in systolic HF and ESRD

Tx:

  • gabapentin
  • DA agents
  • GABA receptor agonists
  • Narcotics
  • Fe if appropriate
31
Q

Circadian Rhythm Disorders

A
  • delayed sleep phase
  • misalignment between endogenous and external clocks
  • habitual sleep times are delayed by 2+ hours relative to conventional times
  • subsequent sleep is normal
  • often associated with difficulty waking up at socially acceptable times

-delayed sleep phase:
Common among adolescents and young adults affecting 7-16%
Genetic factors, shift work and travel across mult. Time zones may precipitate the disorder
Tx: timed bright light exposure, chronotherapy

Advanced Sleep Phase
Jet Lag (west to east travel most difficult)
Shift work
irregular sleep wake rhythm
Free running rhythm (most pts are blind)
32
Q

Insomnia

A

Risk factors:

  • gender
  • age
  • marital status
  • employment status
  • race
  • underlying med/physical disorder
  • ENV factors
Primary:
-predisposing factors: biologic
-precipitating factors: social
-perpetuating factors: compensatory behaviors
     Worry directed at sleep itself
     Individual attitudes 
     conditional arousal 
CoMorbid:
-associated with other disorders such as
   Depression 
   Generalized Anxiety
   Substance abuse
   ADHD
   Dementia
   Medical disorders

DDx:

  • circadian rhythm disorder
  • phase delay
  • phase advance
  • shift work sleep disorder
  • non 24-hour sleep/wake syndrome
  • irregular sleep/wake pattern

BMB Lectures (14 decks)

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