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SPINE > Sleep and Sleep Disorders > Flashcards

Sleep and Sleep Disorders Flashcards

1
Q

What are the different features of sleep?

A
  1. Species-specific sleep posture (lying/standing)
  2. Behavioural quiescence (inactivity)
  3. Rapid reversibility to wakefulness
  4. Increased arousal threshold
  5. Compensation following sleep loss.
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2
Q

What are the different functions of sleep?

A
  1. Energy conservation
  2. Thermoregulation
  3. Somatic and neural growth regulation
  4. Immune regulation
  5. Memory consolidation
  6. Regulation of affect (effects mood)
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3
Q

What is encephalitis lethargia? (sleep sickness)

A

Rare and severe brain disease causes inflammation -> presents with a range of neurological and psychiatric symptoms.
Thought to be due to damage to the brainstem.
Acute - excessive sleepiness, poor ocular motility, fever and movement disorders.
Chronic - parkinsonian-like signs.

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4
Q

What anatomical area is responsible for sleep/wakefulness?

A

The ascending arousal system
Wake = upper brainstem and posterior hypothalamus - upper reticular formation projects to thalamus, hypothalamus and brainstem.
Sleep = preoptic area and adjacent hypothalamus

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5
Q

What region of the brain controls the circadian rhythm?

A

The suprachiasmatic nucleus within the anterior hypothalamus
Activates by sunlight to cause wakefulness
In dark is not activated - allows sleepiness

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6
Q

What is the role of the pineal gland in sleep regulation?

A

Secretes melatonin
‘The hormones of darkness’
Rises at night and suppressed by light
Help regulate the time of sleep

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7
Q

What are the different stages of sleep?

A

Wake
NREM - divided into N1 (quick, some rolling eye movement, easily aroused), N2 (50% night) and N3 (20% night - memory consolidation)
REM (rapid eye movement) - occurs about 1.5hrs into sleep.

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8
Q

What do the different stages of sleep look like on an EEG?

A

As go into different stages of sleep the complexes widen and the amplitude increases

N1 - theta waves
N2 - sleep spindles and K complex
N3 - delta waves
REM - Brandon fast sawtooth waves.

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9
Q

What is the gold standard tool used to diagnose sleep disorders?

A

Polysomnography (PSG - sleep lab)
Records brain waves and vital signs, including HR, also looks at eye movement and leg movement.

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10
Q

What is the significance of REM sleep related to sleep paralysis?

A

Completely paralysed body except from diaphragm and eyes
But with a fully awake brain

In sleep paralysis (pathological) abrupt wake before muscle tone resorted with dream-like hallucinations (REM paralysis is maintained for to long with a lag)

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11
Q

What causes the muscle paralysis seen in REM sleep?

A

Muscle atonia
Descending inhibitory signal from the pons (PPRF) to the spinal motor neurons, leads to reduction in skeletal muscle tone
Except for the diaphragm and ocular muscles.

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12
Q

What brain centres are responsible for keeping you awake?

A

LC (brainstem)
TMN (hypothalamus)
Raphe (brainstem)
The SCH increases the activity of orexin-releasing neurons which stimulates these wakefull centres
Which in turn inhibit the sleep centres.

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13
Q

What regions of the brain are responsible for sleep?

A

VLPO (hypothalamus) promotes sleepiness
Is inhibited by SCN in the daylight
As night SCN inhibition is reduced and VLPO is stimulated by adenosine
VLPO causes inhibition of wake centres directly and indirectly by inhibiting Orexin-releasing neurons.

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14
Q

What molecules prevent rapid switching/boomeraning between sleep and wake states?

A

Orexin

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15
Q

What medications promote wakefulness?

A

Dopamine
Noradrenaline

Also histamine, orexin (same as hypocretin), Ach, glutamate

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16
Q

What medication promotes NREM sleep?

A

GABA
Galanin

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17
Q

What medication promotes REM sleep?

A

Acetylcholine
GABA
Glycine
Dopamine

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18
Q

What does a hypnogram show of sleep?

A

The time spent in each stage of sleep (awake, REM, N1, N2, N3) shows when moves between these stages (like a timeline)

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19
Q

Describe the normal contribution of each stages of sleep in a normal sleep cycle

A

Early in night - majority in N3 (deep sleep) with some transition to REM
Late night - more time spent in REM or N1/N2, increased amount of awakenings.
Awakenings are normal, often occur a lot more than we are aware of.

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20
Q

What is meant by the circadian rhythm?

A

The timekeeper of sleep based on the presence of light
Based on 24hrs
Generated on SCN - receives eye input from retina to identify light intensity (retinohypothalamic tract)
Can be affected by blue light on phones (mimics sunlight)

21
Q

What are the two different regulatory systems of sleep?

A

Circadian rhythm - biological clock, responds to light cues (SCN)
Homeostatic drive - the need to sleep (example includes adenosine)

22
Q

How do our patterns of sleep change as we age?

A

At each stage of life there is a wide variation in the number of hours of sleep required by the individual.
Tends to decrease as we age
Newborn - 14-17hrs
Teenager - 8-10hrs
Older adult - 7-8hrs

23
Q

What is social jet lag in sleep?

A

Social jet lag - variation in bodies normal sleep pattern and forced sleep pattern from work/training routine etc.
Variation in sleep time between work and free days.
Mainly from chronic sleep deprivation and social jet lag.
Is sleeping more than 2hrs longer in bed during the weekend compared to the week.

24
Q

How does slow-wave sleep change as you age?
What are the consequences of this?

A

Decreases, particularly rapidly in 20s/30s into elderly.
This can decrease memory consolidation

25
Q

What are the general changes in sleep patterns as you age?

A

Homeostatic regulation of sleep declines with age - more reliant on circadian rhythm.
Decreased slow-wave sleep
Increased wakening
Decrease in total sleep time
Shift in circadian rhythm - tend to go to sleep earlier and wake up earlier.
Decrease in melatonin.

26
Q

What are some consequences of severe sleep deprivation?

A

Memory disturbance
Concentration difficulties
Paranoia
Delusions
Can cause psychosis in vulnerable individuals

27
Q

What is the role of sleep in memory?

A

Needed for normal attention
Learning and memory
For initial information encoding - need to be alert to input data
Can test this for Psychomotor vigilance test.
Relearn during sleep - hippocampus encodes information as repeated reactivation, strengthening and reorganising neocortex.
Slow eave sleep - declarative memory

28
Q

What is the impact of caffeine on sleep?

A

Adenosine antagonist - stimulant
Safe daily dose - 200-400mg
Half life 3.5 to 7hrs - dose dependent on how long to get out of the system
Single shot expresso is about 60-75mg.
Can cause insomnia, wrestlers legs and tremor
Greater effect in non-caffine consumers.

29
Q

What advice should be given to patients trying to cut back of caffeine?

A

Count the cups
Reduce by a cup a day to avoid withdrawal headache
Also useful to consider smoking habits - smoking reduces caffeine half life by 30-50%, often people stop smoking and start drinking more caffeine.

30
Q

How does alcohol affect sleep?

A

Increases sleepiness
Causes snoring due to changes to muscle physiology, can lead to sleep aponea
Fall to sleep faster
However alcohol is metabolised faster, this cause a drop in doses in the middle of the night causing awakenings, nocturia and disrupted REM sleep.

31
Q

What are the different types of sleep disorders?

A

Hypersomnias - too much
Hyposomnia - insomnia
Restless leg, parasomnia, seziure- seizures, nightmares
Circadian rhythm disorders - jet lag, shift work

32
Q

How common are primary sleep disorders?

A

Insomnia - up to 15%
Obstructive sleep apnoea 10% men and 5% women
Parasomnia 2% adults and 30% of children
Restless leg syndrome 10%
Circadian rhythm disorder - up to 4% teenage males, much higher in mental health diagnosis
Narcolepsy - up to 0.1%

33
Q

What can be used to determine if a patient is ‘too sleepy’?

A

The Epworth Sleepiness Scale
Give rankings for likelihood to fall asleep whilst completing an activity such as talking, watching TV, driving.

34
Q

What is obstructive sleep apnoea?

A

Snoring with partial or complete collapse of the upper airway leading to reduce in airflow
This triggers a micro arousal to restore airway patency, resulting in fragmented sleep.
Long term cycles lead to SANS activation + ROS + systemic inflammation -> long term complications such as HTN, CVD, Metabolic disorders.

35
Q

How does obstructive sleep apnoea present?

A

Partner often complains of excessive snoring and periods of apnoea
Consequence - day time somnolence, compensated respiratory acidosis, hypertension

36
Q

What is the recommended management for sleep apnoea?

A

Weight loss
Continuous positive airwat pressure (CPAP) - if mod or severe
Intra-oral devices if CPAP not tolerated or only mild conditions with no daytime sleepiness
DVLA should be informed in excessive daytime sleepiness
Limited evidence to support pharmacological agents.

37
Q

What is the screening tool for obstructive sleep apnoea?

A

STOP BANG
6/8 = 80% chance of abnormal resp study at home
S - snore
T - tired during the day
O - observed apnea
P - pressure = high
B - BMI more than 35
A - Age over 50yrs
N - Neck circumference
G - Gender - male

38
Q

What is central apnoea?

A

Brainstem problem
Does not stimulate breathing
Often:
Heart failure
Broad overprescribing of high dose opiods

39
Q

What is narcolepsy?

A

Loss of orexin - autoimmune
Causes cataplexy - laughter causes sleep
Vivid dreams
Profound daytime sleepiness
Sleep paralysis
Sleep fragmentation

40
Q

What is NREM Parasomnia?

A

Incomplete awakening from slow wave sleep, eyes will be open.
Including:
Night terros
Hypnagogic
Sleep walking
Sleep eating
Sleep sex
Confusional Arousals
Wax and wane

41
Q

What are some risk factors for sleep apnoea?

A

Obesity - mechanical load on resp system
Age - increase due to changes in muscle/fat around neck
Male - difference in fat, hormones and anatomical variations
Menopause - post increase
FH - inherited variation in airway
Smoking
Alcohol/sedatives
Anatomy - andeotonsillar hypertrophy etc
Medical conditions - hypothyroidism, acromegaly, POCS

42
Q

What are the risk factors for NREM parasomnia?

A

Young onset
Very common in children
Up to 3% of adults - generally starting before they turn 20yrs
Can be triggered again in adults if sleep disrupted - insomnia, stress, shift work etc
Family history

43
Q

What is REM Sleep Behaviour Disorder?

A

Insidious progressive disorder of dream enactment and dream recall.
The paralysis normally seen in REM sleep is not preserved
When combined with lucid dreams that normally occur can cause patients to move out/shout out
Commonly dream fighting off attacker.
Can be a risk to themselves or partner from injury.
Occurs in up to 1% older males - less common in females

44
Q

What test is required for diagnosis with REM sleep Behaviour Disorder?

A

Video polysonography
Night sleep study with EEG and video - captures loss of REM atonia whilst in REM stage

45
Q

What conditions is REM sleep behaviour disorder often associated with?

A

Neurodegenerative disorders
Parkinsons disease
Dementia with Lewy Bodies (72% patient develop at 12yrs post diagnosis)

46
Q

What are some examples of circadian rhythm disorder?

A

Shift work disorder
Delayed sleep phase syndrome - very late night owls
Irregular sleep wake pattern
Advacned sleep phase syndrome
Non-24hrs (free running) sleep-wake pattern
Jet lag disorder.

47
Q

What is insomnia?

A

Difficulty falling asleep and difficult staying asleep with daytime impact
At least 3 months >3 days a week.

48
Q

What are some risk factors for insomnia?

A

Female
Age
3Ps model - predisposition (genetic), precipitant and then perpetuating (sleep early then agitated as not sleep)

49
Q

How do we treat insomnia?

A

CBT for insomnia - sleep log, sleep rescheduling and education around sleep.
Online - Sleepful
Advice - try to get up at the same time everyday, go to bed when sleepy, avoid bringing day life into bedroom.
Daylight and out of breath activity.

SPINE (20 decks)

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