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CDM 4 Exam 2 > Sleep Disorders > Flashcards

Sleep Disorders Flashcards

1
Q

Sleep architecture

A

The basic structural organization of sleep, taking into account REM and NREM sleep as well as the different stages of sleep

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2
Q

NREM sleep

A

Non-rapid eye movement sleep. Divided into stages 1 through 4 each associated with a characteristic brain activity, where 1 is the lightest stage of sleep and 4 is the deepest stage of sleep

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3
Q

REM sleep

A

Rapid eye movement sleep. Most often associated with dreams

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4
Q

Stage 1

A

Transition between wake & sleep
Where sleep begins, over 15-30 min
Reduced muscle tone, eye movements and brain activity
Little stimulus required to wake

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5
Q

Stage 2

A

Makes up ~1/2 of total sleep time
Eye movement & muscle activity stop
Larger stimulus required to wake

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6
Q

Stage 3

A

similar to 4 but with less delta wave sleep
3-8% of sleep
deep sleep begins

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7
Q

Stage 4

A

similar to 3 but with more delta wave sleep
10-15% of sleep
Arousal threshold highest here

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8
Q

most restorative sleep

A

stage 3 and stage 4

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9
Q

REM sleep

A

when dreams occur
generalized muscle atonia
bursts of rapid eye movements
fluctuations in respiratory and cardiac rate

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10
Q

Sleep Cycle

A

6-9 hours/night
onset: 15-30 minutes
Most experience in order stages 1->2->3->4-> REM

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11
Q

Each cycle lasts

A

90-110 minutes

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12
Q

Age-related sleep changes

A

children need more sleep than adults
older adults get less deep sleep –> less stage 3 and 4

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13
Q

insomnia definition

A

The subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime sleepiness

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14
Q

Sleep promoting substances

A

GABA (inhib)
Adenosine (inhib)
Melatonin

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15
Q

Wake promoting substances

A

NE
ACh
Histamine
5-HT
DA
orexin

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16
Q

insomnia risk factors

A

Women

Advancing age

Comorbid conditions

Medications (stimulants, alcohol/opiates withdrawal, corticosteroids)

Stressors

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17
Q

Primary insomnia

A

No clear cause; abnormality of sleep-wake cycle or circadian rhythm

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18
Q

secondary insomnia

A

predisposing factors
precipitating factors
perpetuating factors

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19
Q

Predisposing factors

A

Factors that increase risk for insomnia disorder

History of childhood or interpersonal trauma
Chronic mental health conditions, depression, or anxiety
History of shift work or erratic sleep-wake patterns
Chronic pain conditions

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20
Q

precipitating events

A

Events that lead to sleep disruption

Severe accident leading to physical injury
Divorce or death of a spouse or close family member
Change in occupation such as loss of a job or transition to a new job

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21
Q

Perpetuating factors

A

Behavioral and cognitive factors that sustain poor sleep over time

Watching television in bed while trying to fall asleep
Staying in bed for extended periods of time in an effort to obtain more sleep or taking long naps during the day
Anxiety and worry about sleep loss

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22
Q

Secondary insomnia: comorbid conditions

A

Angina, arrhythmia, CHF
itchy skin conditions
DM, hyperthyroidism, menopause
GERD
Delirium, brain injury
Pregnancy, chronic pain
anxiety, bipolar,PTSD, OCD, SUD
Asthma, sleep apnea, COPD
Restless leg
BPH, overactive bladder

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23
Q

Secondary insomnia: medications/substances

A

Anticonvulsants
Stimulants
Antidepressants
Diuretics
Central adrenergic blockers
Corticosteroids
Opioids
Substance withdrawal

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24
Q

Short term insomnia

A

days-weeks (less than 3 months)
identifiable stressor

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25
Q

Chronic insomnia

A

Insomnia occurring ≥ 3 nights/week; present for ≥ 3 months

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26
Q

Initial insomnia

A

Difficulty falling asleep
Increased time (> 30 min) to sleep onset (sleep latency)

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27
Q

Middle insomnia

A

Difficulty maintaining sleep
Frequent awakenings during the night

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28
Q

Terminal insomnia

A

Early morning awakening
Total sleep time < 6h
Common in depression

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29
Q

Excessive daytime sleepiness & non-restorative sleep

A

Results in fatigue throughout the day

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30
Q

Insomnia DSM 5

A

primary
unsatisfying sleep quality/quantity
occurring ≥ 3 nights/week; present for ≥ 3 months

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31
Q

Episodic insomnia

A

lasts 1-3 months

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32
Q

Persistent insomnia

A

lasts ≥ 3 months

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33
Q

Recurrent insomnia

A

≥ 2 episodes/year

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34
Q

Insomnia complications

A

Distractibility
Poor attention span
Poor motivation
Irritability
Low frustration tolerance
Depression
Anxiety
Workplace and/or fatal injuries
Work Absenteeism
Reduced perception of QAL

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35
Q

Screening/monitoring

A

Sleep diary, sleep history, questionnaires

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36
Q

insomnia diagnosis

A

Physical exam
Lab: TSH, ferritin, toxicology
Sleep studies - polysomnography (OSA), Actigraphy (CRSWD), Multiple sleep latency test: Narcolepsy

37
Q

insomnia treatment goals

A

Correct underlying sleep complaint
Improvement in sleep quality and/or time
Improvement of insomnia-related daytime impairments such as improvement of energy, attention or memory difficulties, cognitive dysfunction, fatigue, or somatic symptoms
Avoid adverse effects from therapies

38
Q

CBT

A

Education, cognitive therapy, behavioral therapy

39
Q

Brief therapies for insomnia (BTI)

A

smaller shorter version of CBT
includes education about sleep, focuses on stimulus control, and sleep restriction

40
Q

non pharm for insomnia NOT RECOMMENDED

A

acupuncture
exercise
tai chi
yoga
phototherapy

41
Q

CBT-I Education

A

Enhance patient understanding of normal sleep and the behaviors that affect sleep

42
Q

CBT-I Sleep hygiene principals

A

Reduce practices/ behaviors which may increase arousal or interfere with sleep drive

set regular bedtime/wake-up time
avoid napping
minimize non sleep activities in bedroom
avoid watching tv/ phone in bed
exercise but not late
avoid drinking lots of fluids in the evening

43
Q

CBT-I Cognitive therapy

A

Change dysfunctional beliefs about sleep
Reduce anxiety surrounding sleep
Confront the fear of not sleeping

44
Q

CBT-I Stimulus control therapy

A

Reduce stimuli that increase arousal in sleep environment before and during sleep; associate the bed with sleep

only go to bed when tired
over use bed for sleep
avoid naps
avoid screens right before bed
set alarm same time every morning

45
Q

CBT-I relaxation training

A

Reduce physiologic/cognitive/emotional/physical tension prior to bed

Deep breathing, mindfulness

46
Q

CBT-I Sleep restriction therapy

A

To increase sleep efficiency and reduce sleep latency; stabilize circadian rhythm

Start by limiting time in bed to 6 – 7 hours/night

Gradually increase or decrease time in bed by 15 min increments

47
Q

Avoid sleep restriction therapy in patients with h/o

A

epilepsy
bipolar
OSA
sleepwalking disorders

48
Q

CBT-I Somryst

A

FDA Approved, prescription-only digital CBT-I in patients 22+ years of age with chronic insomnia

App that has CBT-I modules focused on sleep restriction and consolidation

49
Q

Who can use Somryst

A

Pts ≥22 YOA with chronic insomnia
Have access to a mobile device (e.g., smart phone or tablet) to access the app
Is familiar with how to use mobile apps
Have access to internet to allow you to periodically upload data to the app
Is able to read and understand English for the app
Is under the supervision of a Health Care Provider

50
Q

Who shouldn’t use Somryst

A

Pts with any disorder worsened by sleep restriction (e.g. bipolar disorder, schizophrenia, other psychotic spectrum disorders)
Pts with untreated obstructive sleep apnea
Pts with parasomnias
Pts with epilepsy
Pts who are at high risk of falls
Pts who are pregnant
Pts with any other unstable or degenerative illness judged to be worsened by sleep restriction delivered as part of Cognitive Behavioral Therapy for Insomnia

51
Q

Pharmacologic options for insomnia

A

OTC agents (1st gen antihistamines, valerian, L-tryptophan)
Melatonin receptor agonists
BZD
Z-Drugs
Sedating antidepressants
Orexin antagonists

52
Q

1st gen antihistamines MOA

A

Non-selective histamine antagonist; “antihistamine”
Cross blood-brain barrier –> binds to H1 (brain) & H2 (stomach) –> blocks histamine release –> promotes drowsiness

53
Q

1st gen antihistamines ADE

A

Anticholinergic ADE (blurred vision, dry mouth, constipation, somnolence, dizziness, fatigue)

54
Q

1st gen antihistamines DDI

A

Other anticholinergic agents, sedating agents, alcohol

55
Q

1st gen antihistamines Precautions

A

CNS depression, BPH, glaucoma

56
Q

1st gen antihistamines monitoring

A

Improved sleep, ADE

57
Q

1st gen antihistamines pt education

A

Avoid activities requiring mental alertness
Likely to cause hangover feelings the next day

58
Q

1st gen antihistamines clinical considerations

A

FDA-approved and OTC
sensitivity in elderly and liver disease
do not use for > 10 days
Doxylamine safe in pregnancy

59
Q

Do not use 1st gen antihistamines for more than ___ due to ___

A

10 days, tolerance

60
Q

____ is a 1st gen antihistamine that is safe in pregnancy

A

Doxylamine

61
Q

L-trypotphan/5-HTP

A

Metabolized into 5-hydroxytryptophan (5-HTP), then converted into serotonin, melatonin, and vitamin B6

HA,N/V/D, sedation
found in egg whites, cheese, cod, soybean

62
Q

Valerian

A

Binds to the beta subunit on the GABA-A receptor; increased GABA

Morning drowsiness, HA, anxiety
extract, infusion tea, tincture

63
Q

OTC and herbal products

A

Tart cherry juice
Magnesium
Lavender
Chamomile tea
Alcohol
Canabinoids

64
Q

Melatonin Receptor Agonists MOA

A

light-induced activation of SCN prevents the production of melatonin by pineal gland

65
Q

Melatonin

A

MT1, MT2 & MT3 receptor agonist
Dizziness, nausea, headache, drowsiness
CNS depressants
Take 30 min before bedtime

May be most helpful for pts with jet lag, delayed sleep phase syndrome or low endogenous melatonin
May help with sleep onset

66
Q

Ramelteon

A

MT1 & MT2 receptor agonist (more selective)
GI upset, increase prolactin in women, decrease testosterone in men

DDI: Substrate CYP1A2 (major)/3A4 (minor); contraindicated for use with strong CYP1A2 inhibitors (e.g., fluvoxamine)

Take 30 min before bed
avoid taking with high fat meal

67
Q

BZD MOA

A

Non-selectively bind to GABAA interface between the α- and γ-subunits; GABA agonist

68
Q

BZD Triazolam vs Temazepam

A

Triazolam –> hepatic metabolism, CYP3A4, short half-life, good for sleep onset
Temazepam –> conjugation metabolism, long half-life, good for onset and maintenance

69
Q

BZD precautions

A

Do not use for more than 7-10 days
tolerance will develop ~4 weeks

70
Q

BZD clinical considerations

A

increase risk of fall in elderly
avoid in pregnancy, sleep apnea, SUD
7-10 days of use (no more)

71
Q

Z- drugs MOA

A

Selective binding of GABAA a-1 subunit (the hypnotic subunit)

72
Q

Z drugs

A

Zaleplon
Zolpidem
Eszopiclone (Lunesta)

73
Q

Z drugs: Zolpidem

A

higher affinity for alpha-1 subunit
women require lower starting dose

74
Q

Lunesta

A

Max 2 mg in hepatic impairment or use with CYP3A4 inhibitors

75
Q

Z drugs ADE

A

similar to BZD
withdrawal risk present
fatigue, dizziness, N/V, headache, somnolence
Eszopiclone has unpleasant taste and headache

76
Q

Z drug DDI

A

CNS depressants
CYP3A4
Cimetidine increases zalepon
Rifampin decreases zalepon

77
Q

Z drug monitoring

A

ADE, sleep improvement, tolerance

78
Q

Z drug patient education

A

devote ≥ 7-8 hours to sleep for zolpidem ER/lunesta
Take on empty stomach

79
Q

Z drug clinical considerations

A

possibly less tolerance & less rebound insomnia as compared to benzodiazepines

Should limit to < 4 weeks to  risk of tolerance & dependence (eszopiclone FDA-approved for up to 6 months)

80
Q

Sedating Anti-Depressants

A

Doxepin, Trazodone, Mirtazapine

81
Q

Orexin Receptor Antagonists MOA

A

OX1R & OX2R receptor antagonist

82
Q

Orexin Receptor Antagonists Agents

A

Suvorexant, lemborexant, daridorexant

83
Q

Orexin Receptor Antagonists cautions

A

precaution in patients with depression
CI in patients with narcolepsy
CYP3A4 medications DDI
hepatic considerations

84
Q

Tiagabine

A

MOA: Inhibits GABA reuptake into presynaptic neuron (GAT-1 inhibitor)

ADE: Abdominal pain, nausea, asthenia, ataxia, confusion, dizziness, nervousness, somnolence

Take with food; avoid driving

85
Q

Total Sleep time

A

Diphenhydramine
Doxepin
Eszopiclone
Suvorexant
Temazepam
Tiagabine
Trazodone
Zaleplon
Zolpidem

86
Q

Sleep Latency

A

Everything but tiagabine

87
Q

Waking after sleep onset

A

Diphenhydramine
Doxepin
Eszopiclone
Suvorexant
Temazepam
Tiagabine
Trazodone
Tryptophan*
Zolpidem

88
Q

Sleep onset

A

Zaleplon
Zolpidem SL/oral spray
Triazolam
Ramelteon

89
Q

Sleep maintenance

A

Suvorexant
Doxepin

CDM 4 Exam 2 (13 decks)

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