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Behavioral dynamics > Sleep disorders > Flashcards

Sleep disorders Flashcards

1
Q

Two physiologic states of sleep:

A
  1. Non-rapid eye movement (NREM) sleep
  2. Rapid eye movement (REM) sleep
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2
Q

which state of sleep is
Composed of stages 1-4
Usually how the sleep cycle begins

A

Non-rapid eye movement (NREM) sleep

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3
Q

how long is each stage in Non-rapid eye movement (NREM) sleep

A

5-15 mins

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4
Q

which state of sleep has
High levels of brain activity
Dream activity happens here

A

REM sleep

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5
Q

how are the physiologic functions during NREM sleep. Describe each (HR, rsp, etc)

A

reduced compared with wakefulness
1. HR - slowed 5-10 beats/minute, very regular
2. Rsp slowed slightly, regular
3. Bp tends to be lower than wakefulness
4. Seldom any penile erections

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6
Q

which NREM stage:
Decreased activity from wakefulness
Easily awakened during this stage
May feel like they “haven’t slept” if awakened
May have feeling of falling → hypnic myoclonia

A

stage 1

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7
Q

which NREM stage:
light sleep with spontaneous periods of muscle tone followed by muscle relaxation
Body is preparing to enter deep sleep

A

stage 2

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8
Q

which NREM stage:
“Delta wave” sleep
Time of mending
“Deeper” levels of mental functioning
If awakened during, are often disoriented
Brief arousals associated with amnesia
Typical period for enuresis, somnambulance, and night terrors

A

stage 3-4

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9
Q

describe the physiologic activity during REM sleep

A

Physiologic activity increased compared to NREM sleep
Much higher than NREM sleep, may be higher than awake
Almost every REM period in men accompanied by a partial or full penile erection

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10
Q

which state of sleep is near-total paralysis of skeletal muscles

A

REM Sleep

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11
Q

what is the most distinctive feature of REM Sleep

A

dreaming
May dream in NREM sleep, but usually don’t remember
Dreams are typically abstract, surreal

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12
Q

REM phases occur about every ____ (time)

A

90-100 minutes
Shorter periods earlier in sleep
Longer periods after a few hours into sleep cycle

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13
Q

More REM periods occur in ___ of the night

A

last third

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14
Q

how does serotonin affect sleep

A

less serotonin = less sleep
prevention of serotonin synthesis or destruction of dorsal raphe nucleus = decreased sleep

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15
Q

how does NOR affect sleep

A

more NOR = less sleep
increased firing of noradrenergic neurons (through drugs or other manipulations) = less REM sleep, increased wakefulness

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16
Q

how does melatonin affect sleep

A

less melatonin = less sleep
released naturally by our bodies’ pineal gland in response to low light conditions

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17
Q

how does dopamine affect sleep

A

more dopamine = less sleep
suppresses secretion of melatonin by the pineal gland; occurs naturally at the end of the “dark phase” (night)

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18
Q

what are the changes in REM sleep over time

A

Slowly decreases over time
- 80% of sleep time - 10-week premature infant
- 50% of sleep time - full-term infant
- 30-35% of sleep time - 2 year old child
- 20-25% of sleep time - 10 years old (stabilizes)
- <20% of sleep time - 65 years and up

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19
Q

what type of pt would exhibit this sleep pattern:
Regular cycling between stage 1 and stage 4 sleep
Prolonged stage 4 periods earlier in sleep period
REM sleep phases - gradually lengthen as the night goes on

A

Healthy young adult

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20
Q

what type of pt would exhibit this sleep pattern:
Decreased or absent deep sleep stages (3-4)
More easily awakened from sleep
Less regular cycles
Overall increased daytime fatigue and napping
Overall decreased quality of nocturnal sleep

A

Elderly adult

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21
Q

what sleep pattern in depressed pt is
Very common - 83% of depressed pts

A

insomnia

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22
Q

what sleep pattern in depressed pt is
Common, but less common than insomnia
Seen more with atypical depression

A

Hypersomnia

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23
Q

what sleep pattern in depressed pt is
More frequent wakeful periods
Longer wakeful periods

A

Increased wakefulness

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24
Q

what 6 sleep patterns could you see in depressed pts

A
  1. insomnia
  2. hyperinsomnia
  3. increased wakefulness
  4. Reduced sleep efficiency
  5. Increased sleep onset latency
  6. Reduced REM latency
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25
Q

how do you diagnose sleep disorders?

A

Thorough history is essential!
1. Is there a problem with falling asleep or staying asleep?
2. Is there excessive daytime sleepiness?
3. Are there abnormal movements or behavior during sleep?
4. Is there abnormal timing of the sleep-wake cycle?
5. Are there unusual life stressors precipitating the sleep problem?
6. What is the sleep environment like?

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26
Q

criteria for insomnia diagnosis

A

1+ of the following symptoms for 1 month:
1. Difficulty initiating or maintaining sleep
2. Nonrestorative or poor quality sleep
3. Early morning awakening
4. Symptoms occur despite adequate opportunity and circumstances for sleep
5. Impaired sleep produces deficits in daytime function

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27
Q

what is the duration of Transient Insomnia

A

< 7 d

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28
Q

what is the duration of acute insomnia

A

< 30 d

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29
Q

what is the duration of chronic insomnia

A

+30 d

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30
Q

which type of insomnia is often associated with anxiety

A

transient insomnia

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31
Q

what type of insomnia has no specific cause and is about <20% of chronic cases?

A

primary insomnia

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32
Q

what type of insomnia is secondary to other diseases like depression/anxiety, breathing-related, substance abuse/meds

A

comorbid insomnia

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33
Q

how does acute alc intake affect sleep

A

decreased sleep latency, REM sleep pattern changes, vivid dreams, frequent awakening

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34
Q

how does chronic alc abuse affect sleep

A

increased stage 1
decreased REM

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35
Q

how does alc withdrawal affect sleep

A

delayed sleep onset, intermittent awakening

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36
Q

how does Smoking (>1 ppd) affect sleeping

A

difficulty falling asleep

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37
Q

how does Excess stimulant intake affect sleeping

A

decreased total sleep time, delayed sleep onset
caffeine, cocaine, OTC cold medication

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38
Q

how does Sedative withdrawal affect sleeping

A

delayed sleep onset, intermittent awakening

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39
Q

tx for Comorbid Insomnia

A

Treat underlying cause
Some antidepressants (TCAs) and anxiolytics (benzodiazepines) have SE of sedation/somnolence

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40
Q

nonpharm tx for insomnia

A

Relaxation techniques
Meditation
Cognitive Behavioral Therapy
Regular Exercise
Sleep Hygiene

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41
Q

what is the first-line tx for insomnia

A

Cognitive Behavioral Therapy for Insomnia (CBT-I)

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42
Q

what is the 6 pharm tx for insomnia

A
  1. OTC 1st gen antihistamines - limited efficacy!
  2. Benzodiazepine Receptor Agonists
  3. melatonin agonist
  4. Benzodiazepines
  5. Dual Orexin Receptor Antagonists
  6. Antidepressants
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43
Q

Diphenhydramine

A

OTC 1st gen antihistamines
Benadryl, Sominex

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44
Q

Doxylamine

A

OTC 1st gen antihistamines

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45
Q

Zaleplon

A

Benzodiazepine Receptor Agonists

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46
Q

Zolpidem

A

Benzodiazepine Receptor Agonists

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47
Q

Eszopiclone

A

Benzodiazepine Receptor Agonists

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48
Q

Ramelteon

A

Melatonin agonists

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49
Q

Temazepam (Restoril)

A

Benzodiazepines

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50
Q

Temazepam (Restoril),

A

Benzodiazepines

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51
Q

alprazolam (Xanax)

A

Benzodiazepines

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52
Q

lorazepam (Ativan)

A

Benzodiazepines

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53
Q

clonazepam (Klonopin)

A

Benzodiazepines

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54
Q

oxazepam (Serax)

A

Benzodiazepines

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55
Q

Suvorexant (Belsomra)

A

Dual Orexin Receptor Antagonists

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56
Q

Lemborexant (Dayvigo)

A

Dual Orexin Receptor Antagonists

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57
Q

Daridorexant (Quviviq)

A

Dual Orexin Receptor Antagonists

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58
Q

Doxepin (Silenor)

A

antidepressant - low dosed TCA

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59
Q

Trazodone (Desyrel, Oleptro)

A

antidepressant

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60
Q

Mirtazapine (Remeron)

A

antidepressant

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61
Q

6 ways to enhance sleep hygiene

A
  1. Establish a Regular Sleep Schedule
  2. Cut Down on Excess Time in Bed
  3. Make Bedroom Comfortable
  4. Relax Before Bedtime
  5. Techniques to Make You Tired
    - Regular exercise - ideally 6+ hrs before bedtime
    - Light snack or warm drink near bedtime
  6. things to avoid
    - No exercise within 90 minutes of bedtime
    - No over stimulating activities just before bed
    - Avoid caffeine after lunchtime (caffeine half-life >4 hrs)
    - No heavy meals within 2 hrs of bed or excess fluids immediately before bed
    - No alcohol to induce sleep
    - Do not look at clock when awakening
    - No turning on light when getting up mid-sleep
62
Q

narcolepsy usually begins at what age?

A

20s

63
Q

what is the Classic tetrad of symptoms for narcolepsy

A
  1. Recurrent irresistible attacks of daytime sleepiness
  2. Cataplexy
  3. Hallucinations
  4. Sleep paralysis
64
Q

clinical presentation of narcolepsy

A
  1. Recurrent irresistible attacks of daytime
    sleepiness, Cataplexy, Hallucinations, Sleep paralysis
  2. Recurrent irresistible attacks of daytime sleep - at least 3 months
  3. Cataplexy
  4. Hallucinations
    - Hypnagogic (on falling asleep)
    - Hypnopompic (on awakening)
    - Intrusions of REM sleep elements into the transition between sleep and wakefulness
  5. Sleep paralysis
65
Q

how do you diagnose narcolepsy

A

Multiple sleep latency test (MSLT)
1. Recorded naps - show rapid onset of sleep and REM sleep (2 or more REM cycles during test)
2. Shortened REM latency period

66
Q

tx for narcolepsy

A
  1. Forced naps
  2. Stimulants
    - Modafinil (Provigil) - least risk of abuse/dependence
    - Methylphenidate (Ritalin), dextroamphetamine (Dexedrine)
  3. SSRIs, SNRIs
    - Symptomatic tx of cataplexy, sleep paralysis, hallucinations
    - Suppress REM sleep
67
Q

epidemiology of somnambulism

A
  1. 15-17% of normal children 4-15 y/o
    - Peaks ages 8-12
  2. MC in males
68
Q

risk factors of Somnambulism

A

FHx of sleepwalking
GERD
Acute stress
Sleep deprivation
Obstructive Sleep Apnea

69
Q

Episodes of semi-purposeful behavior during sleep

A

Somnambulism
Usually difficult to wake patient up
Usually no memory of episode upon awakening

70
Q

tx for Somnambulism

A
  1. Avoid fatigue
  2. Minimize interventions (slapping, shouting)
  3. Lead patient back to bed
  4. Protect from accidents
    - No bunk beds
    - Gates across stairs
  5. Locks on doors and windows
71
Q

Involuntary, non-functional, forceful clenching, grinding, or rubbing of teeth during NREM sleep

A

Sleep-Related Bruxism

72
Q

Sleep-Related Bruxism may be more likely to have what other associated symptoms

A

HA
TMJ disorders
mechanical tooth wear

73
Q

tx for Sleep-Related Bruxism

A
  1. Occlusive splints
  2. Controlling anxiety
74
Q

Misalignment between the environment and an individual’s sleep-wake cycle

A

Circadian Rhythm Disorders

75
Q

what is the Normal sleep cycle

A

sleep propensity greatest in mid-afternoon and at night

76
Q

6 types of Circadian Rhythm Disorders

A
  1. Delayed Sleep Phase Type
  2. Jet Lag Type
  3. Shift Work Type
  4. Advanced Sleep Phase Type
  5. Irregular Sleep-Wake Rhythm Type
  6. Non-24-Hour Sleep-Wake Rhythm Type
77
Q

Persistent late sleep onset and late awakening times, with inability to fall asleep and
awaken at a desired earlier time

A

Delayed Sleep Phase Type

78
Q

Delayed Sleep Phase Type is MC in what type of pts

A

younger

79
Q

Sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone

A

jet lag

80
Q

which jet lag is worse

A

Eastward travel usually worse than westward

81
Q

Insomnia during major sleep period or excessive sleepiness during major awake period associated with night shift work or frequently changing shift work

A

Shift Work Type

82
Q

Persistent early sleep onset and early awakening times, with an inability to fall asleep and awaken at a desired later time

A

Advanced Sleep Phase Type

83
Q

Advanced Sleep Phase Type is MC in what type of pts

A

elderly

84
Q

Characterized by lack of a clearly defined circadian rhythm of sleep and wake

A

Irregular Sleep-Wake Rhythm Type

85
Q

Irregular Sleep-Wake Rhythm Type is MC in what type of pts

A

Developmental disorders in children
Neurodegenerative diseases

86
Q

Characterized by insomnia or excessive sleepiness that occurs because the intrinsic circadian pacemaker is not entrained to a 24-hour light/dark cycle

A

Non-24-Hour Sleep-Wake Rhythm Type

87
Q

Non-24-Hour Sleep-Wake Rhythm Type is MC seen in what type of pts

A

blind pts

88
Q

tx for Circadian Rhythm Disorders

A
  1. Promotion of sleep hygiene
  2. Attempt to synchronize sleep and wakefulness with the underlying circadian rhythm
  3. Advanced Sleep Phase Type - Bright light in evening
  4. Delayed Sleep Phase Type - Bright light in early morning
  5. Melatonin - Can help resynchronise
  6. Stimulants - caffeine, modafinil
89
Q

breath cessation for at least 10 seconds

A

Apnea

90
Q

decreased airflow with drop in oxygen saturation of at least 4%

A

Hypopnea

91
Q

Subtypes of Apnea

A
  1. Central - absent ventilatory effort during the apneic episode
  2. Obstructive - persistent ventilatory effort persists throughout apneic episode, but no airflow occurs because of transient obstruction of the upper airway
  3. Mixed - absent ventilatory effort precedes upper airway obstruction during the apneic episode
92
Q

risk factors for obstructive sleep apnea

A
  1. Anatomically narrowed upper airways
    - Micrognathia, macroglossia, obesity, tonsillar hypertrophy
  2. Ingestion of alcohol or sedatives before sleeping
  3. Nasal obstruction of any type
    - Includes nasal congestion, e.g. the common cold
  4. Hypothyroidism
  5. Cigarette smoking
93
Q

classic pt for obstructive sleep apnea

A

obese, middle-aged male with HTN

94
Q

PE of obstructive sleep apnea

A

HTN
Cor Pulmonale
Sleepy appearance
Narrowed oropharynx
Nasal obstruction
Nasal twang to speech
“Bull neck” appearance

95
Q

lab findings of obstructive sleep apnea

A

Erythrocytosis

96
Q

pt-reported and bed partner-reported symptoms of obstructive sleep apnea

A

pt-reported:
Excessive daytime somnolence
Morning sluggishness and headaches
Daytime fatigue
Cognitive impairment
Recent weight gain
Impotence

bed partner-reported:
Loud cyclical snoring
Witnessed apneas
Restlessness
Thrashing movements of the extremities
Personality changes, depression, or poor judgment
Work-related problems or intellectual deterioration

97
Q

how to diagnose obstructive sleep apnea

A
  1. Home Overnight Pulse Oximetry
    - Negative - High rule-out value
  2. Overnight Polysomnography
    - Measures EEG, electrooculography, EMG, ECG, pulse oximetry, respiratory effort and airflow
    - Reveals apneic episodes lasting up to 60 sec
    - Oxygen saturation falls, often to very low levels
    - Bradydysrhythmias - sinus bradycardia, sinus arrest, or AV block may occur
    - Tachydysrhythmias - paroxysmal SVT, a fib, or v tach may be seen once airflow is reestablished
98
Q

tx for obstructive sleep apnea

A
  1. wt Loss - 10-20% of body weight
  2. Strict avoidance of alc and hypnotic meds
  3. Mechanical appliances to hold jaw forward
  4. Nasal continuous positive airway pressure (nasal CPAP):
    - Given at night - Curative in many patients
    - Polysomnography - usually needed to determine level of CPAP (usually
    5–15 cm H2O) to stop obstruction
    - Only 75% of pts continue to use after 1 yr
  5. Supplemental O2 - can decrease hypoxia, but may lengthen apnea duration
  6. Surgical repair
99
Q

which sleep disorder med
Facilitate GABA-mediated inhibition of cell firing by binding to the BZD receptor, a subunit of the GABA receptor complex

A

Benzo Receptor Agonists

100
Q

which sleep disorder med
Reduce stage 1 NREM sleep; does not reduce stage 3 NREM sleep; may decrease REM sleep

A

Benzo Receptor Agonists
benzodiazepines DO reduce stage 3 NREM

101
Q

pt-important effects of Benzo Receptor Agonists

A

Easier to fall asleep, increased total sleep time, less sleep awakening, less daytime sleepiness, improved ability to concentrate

102
Q

pros vs cons of Benzo Receptor Agonists vs benzodiazepines

A

pros:
May be slightly safer for pts with chronic respiratory dysfunction (e.g. COPD)
May be less likely to cause tolerance
No reduction of deep sleep stages

cons:
No anxiolytic effects

103
Q

all Benzodiazepine receptor agonist are what schedule drug

A

schedule IV

104
Q

SE of Zaleplon

A

Headache (30-42%), dizziness, drowsiness, GI upset

105
Q

interactions with Zaleplon

A

Avoid or use caution if taking in conjunction with any other sedative
High-fat meals impair absorption

106
Q

which sleep disorder med has a
Very short half-life (0.5 hr)
Good for sleep-onset insomnia; Bad for sleep-maintenance insomnia
Little to no “hangover” or rebound insomnia
Not indicated for long-term use

A

Zaleplon (Sonata)

107
Q

which drug has dosing available as extended-release tablet and mid-sleep dissolvable tablet

A

Zolpidem

108
Q

SE of Zolpidem (Ambien)

A

Headache (7-19%), dizziness, drowsiness

109
Q

DI of Zolpidem (Ambien)

A

Avoid using or use caution in conjunction with any other sedative
Do not take with meals or grapefruit juice

110
Q

which insomnia med has
Longer half-life (1.5-2.4 hr)

A

Zolpidem (Ambien)

111
Q

which Zolpidem dosage has
Good for sleep-onset insomnia, bad for sleep-maintenance insomnia; little to no “hangover” or rebound insomnia; not for long-term use

A

immediate release

112
Q

which zolpidem dosage is
released more slowly; indicated for sleep-onset and sleep-maintenance insomnia; can impair activity the following day

A

Extended-release

113
Q

SE of Eszopiclone (Lunesta)

A

Unpleasant (metallic) taste (8-34%), headache (15-21%), dizziness, drowsiness, impaired next-day activity

114
Q

DI of Eszopiclone (Lunesta)

A

Avoid using or use caution in conjunction with any other sedative
Do not take with meals

115
Q

DI of Eszopiclone (Lunesta)

A

Avoid using or use caution in conjunction with any other sedative
Do not take with meals

116
Q

which sleep disorder med
Longest half-life of any BZD agonist (5-7 hrs)
Indicated for sleep-onset and sleep-maintenance insomnia

A

Eszopiclone (Lunesta)

117
Q

Released at night into blood and CSF by pineal gland

A

melatonin

118
Q

melatonin rises by ___ at night

A

10-30x

119
Q

Increase in concentration blunted in elderly patients → ?

A

more nighttime awakenings

120
Q

Prolonged use of exogenous melatonin can ?

A

desensitize receptors

121
Q

what is recommended for melatonin if pt formerly had relief and now has stopped responding to therapy

A

take a break

122
Q

SE of melatonin

A

Decreased nocturnal BP, drowsiness, worsening insomnia (receptor desensitization)

123
Q

DI with melatonin

A

Avoid in patients taking warfarin (Coumadin)
CNS depressants

124
Q

avoid melatonin in who?

A

hx of seizures
children

125
Q

what med Binds with higher affinity to melatonin receptors than melatonin itself

A

Ramelteon (Rozerem)

126
Q

SE of Ramelteon (Rozerem)

A

Dizziness, somnolence, fatigue

127
Q

DI of Ramelteon (Rozerem)

A

fluvoxamine (Luvox; an SSRI)
caution in conjunction with other CNS depressants
Do not administer with a meal

128
Q

Ramelteon (Rozerem) should not be given in what type of pts

A

history of seizures
children

129
Q

what melatonin receptor agonist has a
Half-life of 1.5-5 hrs
Better for sleep onset than sleep maintenance insomnia
Binds with higher affinity to melatonin receptors

A

Ramelteon (Rozerem)

130
Q

what med
Antagonize orexin receptors which facilitates sleep by decreasing the wake drive

A

Dual Orexin Receptor Antagonist

131
Q

what is the Orexin system / Hypocretin system

A
  1. promotes and stabilizes wakefulness
    - Orexin system → hypothalamus → wake-promoting neurotransmitters (histamine, acetylcholine, dopamine, serotonin, and norepinephrine)
132
Q

SE of Suvorexant (Belsomra)

A

drowsiness, headache, dizziness, abnormal dreams, diarrhea

133
Q

DI of Suvorexant (Belsomra)

A
  1. avoid using or use caution in conjunction with any other CNS depressant
  2. CYP34A inhibitors / inducers
    - Leads to higher serum concentration of DORA
134
Q

which dual orexin receptor antagonist
Peaks in 2 hours, intermediate half-life (up to 12 hrs)
Indicated for sleep-onset and sleep-maintenance insomnia
Recent meal may delay onset

A

Suvorexant (Belsomra)

135
Q

SE of Lemborexant (Dayvigo)

A

drowsiness, fatigue, headache

136
Q

DI of Lemborexant (Dayvigo)

A

avoid using or use caution in conjunction with any other CNS depressant
CYP34A inhibitors / inducers

137
Q

which dual orexin receptor antagonist
Long half-life (17-19 hrs)
Indicated for sleep-onset and sleep-maintenance insomnia
Recent meal may delay onset

A

Lemborexant (Dayvigo)

138
Q

which dual orexin receptor antagonist has no dose adjustment needed for elderly

A

Daridorexant (Quviviq)

139
Q

SE of Daridorexant (Quviviq)

A

drowsiness, fatigue, headache, dizziness, nausea

140
Q

DI of Daridorexant (Quviviq)

A

avoid using or use caution in conjunction with any other CNS depressant
CYP34A inhibitors / inducers

141
Q

which Dual Orexin Receptor Antagonist
Intermediate half-life (8 hrs)
Indicated for sleep-onset and sleep-maintenance insomnia
Recent meal may delay onset

A

Daridorexant (Quviviq)

142
Q

what sleep disorder med class has
significant DI with other CYP34A inhibitors / inducers
CI in narcoleptic patients

A

Orexin Receptor Antagonists

143
Q

scheduling for ORA

A

IV

144
Q

dosing of Modafinil (Provigil)

A

Narcolepsy - first thing in AM
Shift Work Disorder - 1 hour before beginning of shift

145
Q

SE of Modafinil (Provigil)

A

Headache (34%, dose-dependent), decreased appetite, nausea, abdominal pain

146
Q

DI of Modafinil (Provigil)

A

Avoid using or use caution if patient is taking in conjunction with any other stimulants

147
Q

schedule of Modafinil (Provigil)

A

IV

148
Q

what med is in the class: CND depressant; Gamma hydroxybutyrate (GHB)

A

Sodium Oxybates

149
Q

which sleep disorder med MOA
metabolite of GABA; work on GABA-B receptors

A

Sodium Oxybates

150
Q

SE of Sodium Oxybates

A
  1. Deep sedation; wt loss, nausea, vomiting, urinary incontinence, condusion, dizziness, HA (>10%); mood swings, worsening depression, somnambulance, psychosis (<10%)
  2. OD can results in rsp depression, coma, and death
151
Q

DI of Sodium Oxybates

A

Avoid using with alcohol, other sedatives, or hypnotics

152
Q

which sleep disorder med is
schedule III
Access is restricted in the U.S.
Must register with Risk Evaluation and Mitigation Strategies program if a patient or prescriber

A

Sodium Oxybates

Behavioral dynamics (19 decks)

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