Sleep Disorders Flashcards
Physiology of sleep
Retinohypothalamic tract census light or darkness (even with eyes closed) → suprachiasmatic nucleus→ superior cervical ganglia→ pineal gland→ sends melatonin to the brain
(melatonin is not sedating what transmits information for sleep)
Chemicals involved in sleep and wake regulation
Adenosine: builds when we are awake and trigger sleepiness
Orexin signaling loss causes
Fragmented sleep and wakefulness
(decrease in people with narcolepsy)
What is wake propensity?
The balance between wake and sleep drive
What happens when you don’t sleep for a day?
There is a second wind & you tend to feel better as the Circadian wave drives increases
How does the suprachiasmatic nucleus work during the day?
Activate wake pathway and turns off sleep pathway
(vice versa at night via melatonin)
What are the stages of sleep in order of occurance?
- Stage 1
- Stage 2
- Stage 3 and 4
- REM
(least in REM)
How does sleep help to clear the mind?
Extracellular space increases→ allows faster clearance of metabolic waste
(good sleep May reduce the risk of neurocognitive disorders)
Sleep spindles are seen in which stage of sleep? What happens during this stage?
- Stage 2
- Transferring short-term memory to long-term memory
What stage of sleep do delta waves appear?
Stage 3
(brain waves start to fire in synchrony)
Which stage has mostly delta waves?
Stage 4
When are factual memories laid down?
- non-REM
- first half of night
When are procedural memories laid down?
Stage 2, 3, & 4
(the last half of sleep)
Which stage asleep is responsible for creativity?
REM
(capacity to measure time is absent- if woken up during this time and try to go back to sleep, when you wake you won’t know how long you were out)
What is the problem with napping?
If you get into deep stages of sleep it will disrupt your circadian rhythm and make it difficult to fall asleep at night
The older you get, what stage of sleep decreases?
Deep sleep
(also have more awakenings. Children get the best & the most sleep)
When babies kick, what stage of sleep are they in?
REM (we don’t develop paralysis during REM until we’re born)
Adjustment/transient insomnia
Related to a stressor (illness, work or relationship stress)
Chronic insomnia characteristics
- Long-term
- Waxes and wanes
- Primary or comorbid
Situational stressors related to transient / short-term insomnia
- Environmental Factors
- Emotional upset
- Major life events
- Systemic factors
- Rx
- Circadian Rhythm disruptions
Disorders associated with chronic insomnia
- Medical disorders and conditions
- Psychiatric disorders
- Primary Sleep disorders
(don’t memorize list, familiarize)
What percentage of people say that they have difficulty sleeping?
58%
Percentage of patients with sleep difficulty who actively seek treatment
(we accept not sleeping as a way of life)
Impact of insomnia
- Psychiatric disorders
- Neurocognitive functioning
- Absenteeism (physical and cognitive)
- Accidents
- Difficulties at work (get 25% less work done)
Insomnia increases the likelihood of accidents by ____
3-4 times
Insomnia increases the utilization of Health Care Services by how much?
Insomnia maybe one of the causes of _____
Psychiatric disorder
Define dyssomnia
Disturbance in the amount, quality or timing of sleep
Define insomnia disorder
Difficulty initiating or maintaining sleep or non restorative sleep (three nights per week for 3 months)
Causes significant distress
(does not occur with other sleep or mental or medical disorders)
The three p’s of insomnia
- Predisposing factors
- Precipitating factors
- Perpetuating factors
Approach to management of insomnia
Good sleep practices (aka sleep hygiene) (7)
- Regular waking up times
- limit time in bed not sleeping
- Limit napping (shift workers need it)
- No exercise before bed
- Avoid blue light
- Reduce or eliminate nicotine caffeine and alcohol
- Don’t look at a clock after you’re in bed (it takes a lot of mental capacity to evaluate the time and stresses them out if its late)
Cognitive behavioral therapy methods for sleep (5)
- Stimulus control therapy (sleep & sex only in bed)
- Sleep restriction therapy
- Relaxation training
- Cognitive therapy
- Sleep hygiene
Sleep restriction therapy
If a patient only sleeps 4 hours a night but wants seven → restrict naps → if they can do this & sleep the full 4 hours for 4 nights → add one more hour of sleep→ repeat
(repeat until they reach their goal; this re-conditions their perpetuating behaviors due to sleep)
If a patient can’t sleep what should they do?
Something productive or something they enjoy
(this is cognitive therapy)
Insomnia: pharmacologic agents (6)
- Sedating antidepressants
- Antipsychotic
- Benzodiazepines
- Non-benzodiazepine
- Melatonin
- Orexin Receptor Antagonist
(low-dose antidepressants and antipsychotics)
When do you refer a patient?
- Refer to psychiatrist or sleep doctor if: Hx of trmt failure, another primary sleep disorder suspected, atypical psychological or behavioral symptoms
(Those cases manager by a primary care physician)
Define hyper-somnolence disorder
Excessive sleepiness despite sleeping more than 7 hours with one of the following:
- Recurrent periods or lapses into sleep within the same day
- Prolonged main sleep episode of at least 9 hours that is non restorative
- Difficulty being fully awake after abrupt awakening
(3 xs/week for at least 3 mo.)
Hyper-somnolence disorder diagnosis causes _____ and is a diagnosis of ______.
- impairment or distress
- Diagnosis of exclusion (cannot be explained by another condition or substance)
(5-10% of population)
Primary hypersomnia
Prolong nocturnal sleep and continue daytime sleepiness
Symptoms of primary hypersomnia
Grogginess on awakening lasting several hours
(they may take naps up to 1 hour long)
Polysomnogram findings for primary hypersomnia
- Diminished Delta sleep
- Increase number of wakening
- Reduced REM latency
(MSLT to r/o narcolepsy)
Primary hypersomnia treatment
- Sleep hygiene
- Schedule naps
- Medication
Primary hypersomnia medications
- Stimulants
- Modafinil/Armodafinil
- Protryptyline
4.
Narcolepsy epidemiology
- 1 and 2000 persons
- Men > Women
- Hereditary
Define narcolepsy
Strong need to sleep, lapsing into sleep or napping within the same day that occurs three times a week for three months
Narcolepsy diagnostic criteria (4)
- Cataplexy
- Hypocretin (aka orexin) deficiency (CSF study)
- Nocturnal polysomnogram showing REM latency less than 15 minutes
- MSLT of less than 8 minutes or two or more sleep onset REM periods
Describe sleep attack
(how long, what is included)
- Occurs in any situation
- Last seconds to 30 minutes
- Cataplexy and up to 90% (collapse may occur without loss of consciousness)
Define sleep paralysis
- Temporary loss of muscle tone with resulting in inability to move
- Happens when falling asleep or awakening
- Last several seconds to several minutes
Hypnagogic or hypnopompic hallucinations
- Occurs as falling asleep or upon awakening
- Vivid visual or auditory hallucinations
- Occur years after onset of sleep attacks
(narcoleptics can have them several times per week)
Narcolepsy treatment
- Bruce naps throughout the day
- Medication
Medication for narcolepsy
- Tri cyclic antidepressants for cataplexy or sleep paralysis
- Sodium oxybate (for cataplexy)
- Modafinil
- Stimulants
Define sleep apnea
Episodes of breathing cessation for 10 seconds or more with a frequency of 15 events per hour
(most commonly middle-aged men semicolons Central or obstructive or mixed)
What is the difference between apnea and hypopnea
- Apnea: cessation of airflow for at least 10 seconds
- Hypopnea: reduced air flow resulting in oxygen desaturation of at least 4%
(apnea hypopnea index: average frequency of the above events per hour)
Obstructive sleep apnea symptoms (8)
- Snoring or snorting
- Excessive daytime sleepiness/fatigue
- Difficulty concentrating
- Excessive nocturia
- Difficulty maintaining sleep
- Unrefreshed sleep
- Morning headaches
- Irribility
Obstructive sleep apnea recommendations (4)
- Lifestyle: weight loss, exercise, lateral sleep solution
- CPAP
- Oral Appliance
- Uvulopalatopharyngoplasty
Circadian rhythm sleep wake disorder
Frequent in night shift workers and frequent travelers
Recommendations for patients with circadian rhythm sleep wake disorder
- Shift workers: maintain sleep schedule, ensure dark quiet sleep environment
- Travelers: one day to adjust each Eastward time zone crossed, hypnotic agents may help
Parasomnias (3)
- Nightmare disorder
- Non-rem sleep arousal disorder
- REM sleep behavior disorder
Nightmares occur during _____ and are NOT _____.
- REM sleep
- a sleep disorder
(one to two times per year in adults, usually remembered clearly)
Define Nightmare disorder is a repeated extended and extremely dysphoric and well-remembered dreams that involve _______.
efforts to avoid threat to survival security or physical integrity
Nightmare disorder characteristics (2)
- Individual rapidly alert and oriented after Awakening
- Causes significant distress or impairment
Non-rem sleep arousal disorder (2)
Recurrent episodes or incomplete waking from sleep the company was one of the following:
- Sleepwalking
- Sleep terrors
(they do not recall dreams; amnesia for episodes)
Sleep Terror definition (3)
- Recurrent episodes of abrupt terror & arousal from sleep
- Usually begin w/panicked scream
- Autonomic arousal and relative unresponsiveness to comfort
Sleep Terrors occur during _____ stage
3 or 4 NREM sleep
(accompanied by fear or dread but not vivid dream activity)
Sleep Terrors typically resolved by _____. There is a _____ component.
- adolescence
- familial
Sleepwalking typically occurs during the _____ (2) of the sleep episode
- first third
- stage 3 & 4 NREM
(15% of children)
Sleepwalking interventions (2)
- Safeguards (alarms and locks)
- Benzodiazepines
REM Eye Movement Sleep Behavior
Repeated episodes of arousal during sleep associated with vocalization and or Complex Motor behaviors
(acting out their dreams)
REM Eye Movement Sleep Behavior occurs during ______ (2).
- REM
- Later portions of sleep
(Individuals completely awake and alert on awakening)
REM Eye Movement Sleep Behavior typically presents with either of the following (2)
- REM sleep without hypotonia on polysomnogram (not paralyzed)
- History of REM sleep behavior disorder and an established synucleinopathy (parkinson’s, multiple system atrophy)
Define restless leg syndrome (3)
- Urge to move the legs
- Unpleasant sensation in legs
(Occurring three times a week for three months)
Hypnotics characteristics (4)
- Temporary relief for insomnia, no cure
- Used in combo w/sleep hygiene
- Habit-forming
- Increased mortality & cancer
2 main types of hypnotics
- Benzodiazepine
- Nonbenzodiazepine
What is the difference between benzodiazepine and nonbenzodiazepine
Benzodiazepine medications connect to the whole benzodiazepine receptor whereas nonbenzodiazepines only bind to a subunit of the receptor
Benzodiazepines impact all ______ subunits
GABAA receptors
What differentiates the benzodiazepines?
How long they last
(if they get to sleep okay but wake up in the middle of the night they need a longer lasting medication or if they wake up with four or more hours left in the night they can take a short-acting medication in the middle of the night)
Benzodiazepine and non benzodiazepine side effects (6)
- Ataxia
- Daytime sedation
- Cognitive effects
- Anterograde amnesia
- Respiratory depression (large doses)
- Rebound insomnia (for one night after stopping med)
Characteristics of non benzodiazepines (3)
- Less addictive
- Little tolerance
- Tends not to cause daytime sleepiness
Ramelteon (Rozerem) half life
1-2.6 hours
Ramelteon safety is not recommended for _____ (2). It has which other characteristics (3)?
- not recommended for OSA or COPD
- next-day residual effect
- abuse liability
- tolerance
Suvorexant & Lemborexant uses
increased sleep efficiency & total sleep time
(No tolerance or rebound insomnia)
Modafanil and Armodafanil indications (3)
- OSA w/daytime sleepyness
- shift-workers
- narcolepsy
(off-label: depression medication and do sleepiness or cognitive problems, MS, Fibromyalgia, PD, ADHD)
Modafanil and Armodafanil improves ______ and has _____ results
- working memory (digit span, manipulation & pattern recognition)
- Equivocal (exec. function, memory)
Modafanil and Armodafanil side effects (4)
- Anxiety
- Irritability
- Sleep disturbances
- Potential for Stevens-Johnson syndrome, toxic epidermal necrolysis
Solriamfetol indications (2)
- Wakeful promoting agent
- Excessive daytime sleepiness with narcolepsy or OSA
Solriamfetol side effects (2)
- Increase blood pressure and heart rate
- Anxiety, insomnia and irritability
______% of long-haul COVID patients develop insomnia.
40
(immune response of post-traumatic reaction, overweight or GAD contribute)
Solriamfetol MOA
Blocks dopamine and norepinephrine transporter
Suvorexant & Lemborexant MOA
Dual orexin receptor antagonist (DORA)
(Ox1R and Ox2R)
Ramelteon (Rozerem) MOA
- MT1/MT2 selective receptor agonsit
- takes several days to work (bc it aims at circadian rhythm
(17 times as potent as melatonin)
Modafanil and Armodafanil MOA
Inhibits the release of GABA (wakefullness-promoting agent; increases cognitive ability)
