Sleep Disorders Flashcards
What are the 2 physiologic states of sleep
REM and NREM
What are components NREM sleep?
Stages 1-4
Starts sleep cycle
Each stage lasts 5-15 minutes
Deepest sleep
What are components of REM sleep?
High levels of brain activity
Dreaming occurs
What happens to physiologic functions in NREM?
Markedly reduced
Pulse slows 5-10 beats and is very regular
Respirations slow slightly, regular
Blood pressure lower
Seldom penile erections
Peaceful state relative to waking
What happens in stage 1 of sleep?
decreased activity from wakefulness
easily awakened
if woken up, feel like haven’t slept
may have hypnic myoclonic
what is hypnic myoclonic
feeling of falling
what happens in stage 2 sleep?
light sleep with spontaneous periods of muscle tone followed by muscle relaxation
body prepares to enter deep sleep
What happens in stage 3/4 of sleep?
deep “delta wave” sleep
repair and regeneration
builds bone and muscle
strengthens immune system
deep levels of mental functioning
associated with enuresis, somnambulance, and night terrors
what happens if awakened during stages 3-4 sleep?
often disoriented
brief arousals associated with amnesia
What happens physiologically in REM sleep?
Physiologic activity increased
Pulse, respiration, and BP high
Partial or full penile erection every REM period
Near-total paralysis of skeletal muscles
What is the most distinctive feature of REM sleep?
Dreaming
Can you dream in NREM sleep?
Yes, but usually don’t remember
How long are REM phases?
Usually about 90-100 minutes
Shorter earlier in sleep and longer after a few hours into sleep cycle
How long is the first REM period? Later? More REM periods occur when?
<10 min, 15-40 minutes each; last third of the night
Stage 4 is ____ related to REM sleep
inversely (have less stage 4 and more REM later in the night)
What does research say about serotonin and sleep?
Less serotonin–> less sleep; research has found prevention of serotonin synthesis decreases sleep
What does research/clinical say about norepinephrine?
More norepinephrine –> less sleep
Increased firing of NE neurons = less sleep
What are research/clinical findings about melatonin
Research: released in response to low light conditions
Clinical: less melatonin–> less sleep
What are research/clinical findings about dopamine?
Suppresses secretion of m….
REM sleep ____ over time
decreases
What age does REM sleep stabilize?
10 years old (20-25% sleep time is REM)
By the time you are 65+, ____ of sleep time is REM sleep and _____ is decreased
<20% (can be related to memory/cognition problems)
Stage 4 NREM
What is sleep pattern in healthy young adults?
Regular cycling between stage 1 and stage 4 sleep
Prolonged stage 4 periods earlier in sleep period
REM gradually lengthens as night goes on
What is sleep pattern generally in elderly adult
Decreased or absent deep sleep stages
More easily awakened from sleep
Less regular cycles
What does the sleep pattern in elderly adults cause?
Increased daytime fatigue and napping
Decreased quality of nocturnal sleep
How does sleep change in depressed patients?
Insomnia very common
Hypersomnia common, more in atypical depression
Increased wakefulness with more frequent wakeful periods, longer wakeful periods
Reduced sleep efficiency
Increased sleep onset latency
Reduced REM latency
Patients with depression somnogram looks similar to which population
elderly
What historical factors are important for diagnosing sleep disorders?
Problems falling asleep or staying asleep?
Excessive daytime sleepiness? (sleep apnea)
Abnormal movements or behavior during sleep?
Abnormal timing of sleep-wake cycle?
Unusal life-stressors?
Sleep environment?
What is difference between primary and secondary insomnia?
Secondary is due to other condition
What is the diagnostic criteria for insomnia?
One of more for at least a month: difficulty initiating or maintaining sleep, nonrestorative or poor quality sleep, early morning awakening
Despite adequate opportunity and circumstances for sleep
Deficits in daytime function due to impaired sleep
What are examples of deficits in daytime function that can be present due to sleep?
Impaired memory, concentration, attention
Excessive worry about sleep
Daytime somnolence, fatigue, or malaise
Depressed mood, irritability, or poor motivation
Accidents or errors while working or driving
Poor work or school performance
Tension headaches or gastrointestinal upset
What classifies as transient insomnia? Acute? Chronic?
<7 days, <30 days, 30+ days
What are causes of comorbid insomnia?
Depression or anxiety
Breathing related sleep disorder
Substance abuse or medications
What are impacts of acute alcohol intake on sleep?
Decreased sleep latency (fall asleep faster), REM sleep pattern cahnges, vivid drea,s, frequent awakening
What are impacts of chronic alcohol abuse on sleep?
Increased stage 1 and decreased REM
What are impacts of alcohol withdrawal on sleep?
Delayed sleep onset, intermittent awakening
What are impacts of smoking on sleep?
Difficulty falling asleep
What are impacts of excess stimulant (caffeine, cocaine, OTC) intake on sleep?
decreased total sleep time, delayed sleep onset
what are impacts of sedative withdrawal on sleep?
delayed sleep onset, intermittent awakening
How is comorbid insomnia treated?
Treat underlying cause/adjust medication to have SE of sedation if needed (benzodiazepines, TCAs)
nonpharmacologic treatment
Relaxation techniques
Meditation
Cognitive behavioral therapy
Regular exercise
Sleep hygiene
What is the first-line treatment for insomnia?
Cognitive behavioral therapy for insomnia
How is insomnia managed pharmacologically?
OTC 1st gen antihistamines
Benzodiazepine receptor agonists
melatonin agonists
benzodiazepines
Dual orexin receptor antagonists (newest class of drugs)
antidepressants
What 1st gen antihistamines can be used for insomnia?
diphenhydramine, doxylamine (limited efficacy)
What are benzodiazepine receptor agonists that can be used for insomnia?
zaleplon (sonata), zolipidem (ambien), eszopiclone (lunesta)
What are melatonin agonists that can be used for insomnia?
ramelteon, melatonin
what benzodiazepines can be used for insomnia and what duration?
temazepam, flurazepam, alprazolam, lorazepam, clonazepam, oxazepam; <2 weeks if possible
what dual orexin receptor antagonists can be used for insomnia?
suvorexant, lemborexant, daridorexant
what antidepressants can be used for insomnia?
doxepin, trazodone, mirtazapine
What are sleep hygiene recommendations?
Establish a regular sleep schedule
Cut down on excess time in bed
Make bedroom comfortable
relax before bedtime
What are techniques that can help patients feel tired?
regular exercise ideally 6+ hours before bedtime
light snack or warm drink near bedtime
regular sleep schedule recommendations
education on cutting down excess time in bed
education on making bedroom comfortable
What are things to avoid with insomnia?
no exercise within 90 minutes of bedtime
no over stimulating activities just before bed
avoid caffeine after lunchtime
no heavy meals within 2 hours of bed or excess fluids immediately before bed
no alcohol to induce sleep
do not look at clock when awakening
no turning on lights when getting up mid-sleep
What is epidemiology for narcolepsy?
Equal in men and women
Usually begins in 20s
Can be idiopathic or secondary to brain tumor, cerebrovascular insufficiency, head trauma, encephalopathy
What is the classic tetrad of narcolepsy symptoms?
recurrent irresistable attacks of daytime sleepiness
cataplexy
hallucinations
sleep paralysis
cannot be attributed to effects of a substance or medication
How can you diagnose narcolepsy clinically?
Recurrent irresistible attacks of daytime sleep, unexpectedly and at inappropriate times, daily for at least 3 months
Cataplexy: brief, sudden, bilateral loss of muscle tone, often with emotional trigger, localized or generalized
what are characteristics of hallucinations in narcolepsy?
can by hypnagogic (on falling asleep) or hypnopompic (on awakening)
intrusions of REM sleep elements into transition between sleep and wakefulness
REM sleep within 10 minutes of falling asleep
what is sleep paralysis in narcolepsy?
inability to move or speak during transition between sleep and wakefulness
how is narcolepsy diagnosed?
referral to sleep clinic for work up
multiple sleep latency test
what is the multiple sleep latency test>
recorded naps to show rapid onset of sleep and REM sleep
shortened REM latency period is diagnostic
What is treatment of narcolepsy?
Forced naps at regular times of day
Stimulants: modafinil- least risk of abuse/dependence, methylphenidate, dextroamphetamine
SSRIs, SNRIs: for symptomatic treatment of cataplexy, sleep paralysis, hallucinations, suppresses REM sleep
Somnambulism can be normal in _____ and is more common in ____
children, males
what are risk factors for somnambulism?
family history of sleepwalking, GERD, acute stress, sleep deprivation, obstructive sleep apnea
What is the presentation of somnambulism?
Semi-purposeful behavior during sleep usually in first 1/3 of night
Eyes open but gaze unfocused
Limited or more complex behavior
Usually difficult to wake patient up
No memory of episode upon awakening
What is treatment of somnambulism?
avoid fatigue
minimize interventions
lead patient back to bed
protect from accidents: no bunk beds, gates across stairs
lock on doors and windows
What is sleep related bruxism?
Involuntary, non-functional, forceful clenching, grinding, or rubbing of teeth during NREM sleep
What are common presentations of bruxism?
Headaches, temperomandibular disorders, mechanical teeth wear
what is treatment of sleep related bruxism?
occlusive splints
controlling anxiety
What is a circadian rhythm disorder?
Chronic or recurrent sleep disturbance due to misalignment between the environment and an individual’s sleep wake cycle
Persistent late sleep onset and late awakening times, with inability to fall asleep and awaken at a desired earlier time
More likely in younger patients
Delayed sleep phase type
Sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel accross more than one time zone
Jet lag type
Insomnia during major sleep period or excessive sleepiness during major awake period associated with night shift work or frequently changing shift work
shift work type
persistent early sleep onset and early awakening times, with an inability to fall asleep and awaken at a desired later time, more common in elderly patients
advanced sleep phase type
characterized by lack of a clearly defined circadian rhythm of sleep and wake, developmental disorders in children and neurodegenerative diseases predispose
irregular sleep-wake rhythm type
characterized by insomnia or excessive sleepiness that occurs because the intrinsic circadian pacemaker is not entrained to a 24-hr light/dark cycle, often seen in totally blind patients
non-24-hour sleep-wake rhythm type
what is treatment of circadian rhythm disorders?
Promotion of sleep hygiene
Attempt to synchronize sleep and wakefulness with underlying circadian rhythm
Melatonin
Stimulants: caffeine, modafinil
What is treatment of advanced sleep phase type?
bright light in evening
what is treatment of delayed sleep phase type
bright light in early morning
breath cessation for at least 10 seconds
apnea
decreased airflow with drop in oxygen saturation of at least 4%
hypopnea
subtype of apnea with absent ventilatory effort during the apneic episode
central
subtype of apnea with persistent ventilatory effort persisting throughout apneic episode, but no airflow occurs because of transient obstruction of the upper airway
obstructive
subtype of apnea where absent ventilatory effort precedes upper airway obstruction during the apneic episode
mixed
What are risk factors for obstructive sleep apnea?
anatomically narrowed upper airways: micrognathia, macroglossia, obesity, tonsillar hypertrophy
ingestion of alcohol or sedatives before sleeping
nasal obstruction of any type
hypothyroidism
cigarette smoking
What is the classic patient for obstructive sleep apnea?
obese, middle-aged male with HTN
What can be present on physical exam of patient with obstructive sleep apnea?
HTN
Cor Pulmonale
Sleepy appearance
Narrowed oropharynx
Nasal obstruction
Nasal twang to speech
Bull neck appearance
what laboratory finding may be present with sleep apnea
erythrocytosis on CBC
what are key symptoms patients report with sleep apnea?
excessive daytime somnolence
morning sluggishness and headaches
daytime fatigue
cognitive impairment
recent weight gain
impotence
What are key symptoms bed partners report in sleep apnea?
loud cyclical snoring
witnessed apneas
restlessness
thrashing movements of the extremities
personality changes, depression, or poor judgement
work related problems
how is obstructive sleep apnea diagnosed?
home overnight pulse oximetry: negative has a high rule-out value
overnight polysomnography
What is overnight polysomnography?
Measuring EEG, electrooculography, EMG, ECG, pulse oximetry, respiratory effort and airflow to reveal apneic episodes
what can be present on polysomnography in patients with obstructive sleep apnea?
oxygen saturation falling
bradydysrhythmias
tachydysrhythmias
What is treatment of obstructive sleep apnea?
weight loss
avoidance of alcohol and hypnotic medications
mechanical appliances to hold jaw forward
nasal CPAP: curative in many patients
Supplemental O2
Surgical repair
What are benzo receptor agonists function in sleep?
facilitate inhibition of cell firing by binding to BZD, a subunit of GAB receptor complex
Reduced time to sleep onset
Reduce stage 1 NREM sleep but not stage 3 NREM sleep, may decrease REM sleep
What are effects of benzo receptor agonists on patients?
Easier to fall asleep, increased total sleep time, less sleep awakening, less daytime sleepiness, improved ability to concentrate
what are advantages of benzo receptor agonists vs benzodiazepines?
slightly safer for patients with chronic respiratory dysfunction
may be less likely to cause tolerance
no reduction of deep sleep stages
All benzo receptor agonists are schedule ___ and have a black box warning for ____
IV, sleep-related disorders
What are dosing considerations with benzodiazepine receptor agonists in elderly?
reduce dose in elderly(due to possibility of falling, hurting self)
high-fat meal impairs absorption
What are common side effects of benzodiazepine receptor agonists?
headache, dizziness, drowsiness, GI upset
