Sleep Disorders Flashcards
EEG findings characteristic of Stage 2 sleep
Sleep spindles
K complexes
Treatment for circadian rhythm disorders
Melatonin or bright light therapy
Restless legs syndrome
- Sleep disorder characterized by an urge to move legs, usually during periods of rest or inactivity
- Patients describe uncomfortable “crawling” that worsens with stillness and improves with movement
- Accompanied by periodic involuntary leg movements that last 2-3 seconds
- Etiologies:
- Genetic (autosomal dominant)
- Iron deficiency anemia
- Diagnosis:
- Polysomnography can confirm the diagnosis, but often a clinical diagnosis is sufficient. Iron studies should be ordered to screen for iron deficiency anemia.
- Treatment:
- If IDA is present, give iron
- Otherwise, dopamine agonists ropinirole or pramipexole are the preferred treatments, given 2-3 hours prior to symptom onset
Augmentation in treatment of restless leg syndrome
Symptoms develop progressively earlier in the day rather than stop when starting a pro-dopaminergic medication
If this occurs, or if there is another contraindication to pro-dopaminregic medications (induced gambling disorder, psychosis) second-line options include gabapentinoids, levodopa, opioids, benzodiazepines.
Of the pro-dopaminergics, trans-dermal rotigotine is less likely to produce augmentation.
IDA and restless leg syndrome
IDA is a risk factor for the development of IDA. But, when IDA is corrected, the restless leg syndrome may persist
Four components of narcolepsy/cataplexy
- Excessive daytime sleepiness with:
- Narcolepsy
- Cataplexy
- Sleep paralysis
- Hypnagogoic hallucinations
Narcolepsy
The irresistable urge to sleep, often taking the form of “sleep attacks”
Cataplexy
Characterized by sudden oss of muscle tone, often in the setting of laughter or other strong emotions
Hypnagogic hallucinations
Those that occur immediately upon falling asleep
Onset of narcolepsy/cataplexy syndrome
Usually onsets in late teens-20’s
Pathophysiology of narcolepsy
Related to loss of hypocretin-secreting neurons in the hypothalamus
CSF hypocretin level < 110 pg / mL is diagnostic in the appropriate clinical setting
Multiple sleep latency test
Special type of polysomnography used to diagnose narcolepsy/cataplexy
Involves several short naps and monitoring of the latency to sleep onset and latency to REM onset
Latency < 8 minutes or with more than two epsiodes of REM at sleep onset is diagnostic for narcolepsy/cataplexy
Treatment for narcolepsy
-
Modafinil is first-line
- Mechanism unclear, stimulant
- Amphetamines are second-line
- Methylphenidate, dextroamphetamine
Treatment for cataplexy
- Sodium oxybate (a GABA agonist) is first-line
- Second line options:
- Tricyclics (clomipramine)
- SSRIs (fluoxetine, venlafaxine)
SSRIs that are most likely to be “activating”
Fluoxetine (most by far)
Sertraline (less so)
Confusion arousals
A form of parasomnia and arousal disorder
When patients awaken from sleep with disorientation, slow speech, and incoordination
Sleep terrors
A form of parasomnia and arousal disorder
Involve rapid reawakening from sleep with featful behavior, often beginning with a scream
Associated with autonomic hyperactivity such as facial flushing, diaphoresis, tachycardia.
Often seen in children and self-resolves with age.
Preventing episodes of REM sleep behavior disorder in Lewy body diseases
Clonazepam at bedtime prevents these episodes
Nocturnal cramps
- Painful tightness, most often in leg muscles
- Should be differentiated from restless legs syndrome
- Treatments include:
- Gentle exercise before bedtime,
- potassium and magnesium supplementation,
- antihistamines,
- anticonvulsants,
- quinine.
Sleep starts / hypnic jerks
Commonly experienced myoclonic jerks that occur with sleep onset
Treatment for insomnia
- Behavioral:
- Sleep hygiene
- Facilitation of relaxation before bedtime
- Pharmacologic:
- Melatonin
- 1st generation antihistamines
- Benzodiazepines
- Nonbenzodiazepines (zolpidem, zaleplon, eszopiclone)
- Ramelteon (selective melatonin receptor agonist)
- Note: Many of these have addictive properties, and they should NOT be used every night – just PRN for severe difficulty sleeping
Restless leg syndrome is worsened by ____ and improved by ____
Restless leg syndrome is worsened by antidopamienrgics (often 1st generation antihistamines) and improved by prodopaminergics (pramipexole, ropinirole)
