Sleep Disorders Flashcards
Why do we need sleep?
- Improve concentration and memory
- Maintain appropriate function of body systems
- Brain/neuron restoration
- Maintain optimal emotional and social functioning
- Conservation of energy
What is stage 1 of sleep?
- NREM
- Transition between wake to sleep
- Described as awake, drowsy, or asleep
Stage 2 of sleep
- NREM
- Light sleep
- Heartbeat, breathing, and brain activity begins to slow
- Most sleep time is spent in this stage
Stage 3/4 of Sleep
- NREM
- Delta sleep or deep sleep
- Needed to feel refreshed
- Metabolic and brain activity slows dramatically
REM sleep
- Stage 5 of sleep
- Eye movements
- Dreaming occurs
- Generally occurs ~90 minutes after falling asleep
Which neurotransmitter promote wakefulness?
- Norepinephrine
- Orexin (Hypocretin)
- Dopamine
- Histamine
- Substance P
Which neurotransmitter promote sleepiness?
- GABA
- Adenosine
- Melatonin
Sleep-onset insomnia
- Difficulty falling asleep at the beginning of the night or whenever a person attempts to initiate sleep
- Sleep latency: 20-30 minutes–> length of time to fall asleep
Sleep maintenance insomnia
- Inability to stay asleep through the night
- Struggling to get back to sleep for 20-30 minutes
Polysomnography (PSG)
- Primary method used to assess and record variables that characterizes sleep and aid in diagnosis of sleep disorders
- Measured/observed in sleep laboratories
- Indicated when:
- Reasonable clinical suspicion of breathing or movement disorder
- Initial diagnosis is uncertain
-Treatment failure- Dangerous awakenings/violent or injurious behavior
Actinography
Method to characterize circadian rhythm patterns or sleep disturbances in individuals with insomnia
Benzodiazepines
- Traditional benzodiazepines have sedative, anxiolytic, muscle relaxant properties
- Reducing sleep latency and increasing total sleep time by INCREASING stage 2 sleep while DECREASING delta sleep
Which benzodiazepines is long lasting?
Quazepam (Doral) and flurazepam (Dalmane)
Which benzodiazepams are preferred for older adults with changes in hepatic metabolism?
- Lorazepam
- Oxazepam
- Temazepam
Are metabolized by Phase II
Rebound insomnia
- More likely to occur with shorter acting agents
- May be more severe symptoms than patients had before starting BZDs
Benzodiazepine-Receptor Agonist
- Z drugs
- Possesses ONLY sedative properties with less withdrawal, tolerance, and rebound insomnia
Zolpidem IR
- Sleep onset or maintenance insomnia–short-term use
- Duration of effect: 6-8 hours
- 10mg for male
- 5 mg for females, older patients, and those with hepatic renal impairments
- CYP3A4 drug interactions
What are the adverse effects of Zolpidem IR?
- Drowsiness
- Amnesia
- Dizziness
- Headache
- Gastrointestinal complains
Zolpidem ER
- Sleep onset or maintenance insomnia
- Duration of effect: 6-8 hours
- 12.5 mg for men
- 6.25 mg for women, elderly, and those with hepatic renal impairment
- CYP3A4 drug interactions
What are the adverse effects of Zolpidem ER?
- Drowsiness
- Amnesia
- Dizziness
- Headache
- GI upset
- Weight gain
Eszopiclone (Lunesta)
- Sleep maintenance and sleep onset
- Long term use up to 6 months
- Duration: 6 hours
- Dose: 2-3 mg
- Take immediately before bed and avoid taking with a high-fat meal
- CYP3A4 drug interactions
What are the adverse effects of Eszopiclone?
- Somnolence
- Unpleasant taste
- Headache
- Dry mouth
Zaleplon (Sonata)
- Sleep onset insomnia
- Shown effective for up to 35 nights
- Can be used for middle of the night awakenings
- Duration: 6 hours
- 10 mg for adults
- 5 mg for older adults and liver disease
- CYP3A4: Rifampin (plasma level decreases) and Cimetidine (plasma level increases)
Melatonin-Receptor Agonists (Ramelteon, Rozerem)
- Sleep onset insomnia
- Onset: 30 min
- Dosing: 8 mg once daily
- Taken within 30 min before going to bed
- Avoid taking with or soon after a high-fat meal
- Contraindicated in combination with fluvoxamine
- CYP1A2, CYP2C, and CYP3A4 interactions
What are the adverse effects of melatonin-receptor agonists?
- Somnolence
- Dizziness
- Fatigue
- Nausea
- Exacerbation of insomnia
Suvorexant (Belsomra)
- Orexin Receptor Antagonist
- Contraindication: Narcolepsy
- Dose: 10-20 mg
- Administer 30 minutes before bedtime and only if 7 hours or more until planned awakening
- Strong/moderate CYP3A4 inhibitors-AVOID
What is the MOA of Suvorexant?
Dual orexin A and orexin B receptor antagonist (DORA) which turns off wake signaling
What are the adverse effects of Suvorexant?
- Somnolence
- Rare: Sleep paralysis, cataplexy, and other narcolepsy-like symptoms
Leborexant (Davigo)
- Orexin Receptor Antagonist
- Sleep onset and maintenance
- Contraindication: Narcolepsy
- Dose: 5-10 mg
- Administer immediately before bedtime and only if 7 hours or more left until planned awakening
- Strong/moderate CYP3A4 inhibitors - AVOID
What are the adverse effects of Lemborexant?
- Somnolence
- Rare: Sleep paralysis, cataplexy, and other narcolepsy-like symptoms
Daridorexant (Quivivq)
- Orexin Receptor Antagonist
- Sleep onset and maintenance
- Contraindication: Narcolepsy
- Dose: 25-50 mg
- Administer immediately before bedtime and only if 7 hours or more left until planned awakening
- Strong CYP3A4 inhibitors: AVOID
- Strong/moderate CYP3A4 inducers: AVOID
What are some adverse effects of Daridorexant (Quivivq)?
- Somnolence
- Rare: Sleep paralysis, cataplexy, and other narcolepsy-like symptoms
What is the MOA of Doxepin (Silenor)?
Tricyclic antidepressants medication that is unique in this class in having antihistaminic activity
* Histamine H1 receptor antagonist = sedating effects
Doxepin (Silenor)
- Sleep maintenance
- Onset: 30 min
- Dose: 3-6 mg
- Doxepin <= 6 mg is NOT on the Beers Criteria
- CYP2D6 and CYP2C19 interactions
Which antidepressants are used off-label for insomnia?
- Trazodone
- Mirtazapine
- Tricyclic Antidepressants
What are the side effects of Trazodone?
- Carryover sedation
- Alpha-adrenergic blockade
- Orthostasis
What are the side effects of Mirtazapine?
- Daytime sedation
- Weight gain
- Anticholinergic effects
Which atypical antipsychotics are used off-label for insomnia?
- Quetiapine
- Risperidone
- Olanzapine
What over the counter medications are used for insomnia?
- Diphenhydramine
- Doxylamine
Sleep apnea
Repetitive episodes of cessation of breathing during sleep followed by blood oxygen desaturation and brief arousal from sleep to restart breathing
Obstructive Sleep Apnea
Collapse or obstruction of upper airway
What are the risk factors of obstructive sleep apnea?
- Male sex
- Obesity
- CHF, atrial fibrillation, refractory hypertension
- T2DM
- Stroke
- Pulmonary Hypertension
What are the some symptoms of obstructive sleep apnea?
- Loud, disruptive snoring
- Witnessed apneas during sleep
- Excessive daytime sleepiness
How do you assess for obstructive sleep apnea?
- Polysomnography (PSG)
- STOP-BANG questionnaire
CPAP
- Standard treatment for OSA
- Positive pressure column in the upper airway using room air to maintain patency by using a flexible tube that connects the PAP machine to a mask that covers the nose or mouth
Central Sleep Apnea (CSA)
- Impairment of respiratory drive
What are the risk factors of Restless Legs Syndrome?
- Family history/genetics
What are the four cardinal signs/symptoms of Restless Legs Syndrome?
- An urge to move the limbs that usually associated with paresthesia or dysesthesia
- Symptoms that start or become worse with rest
- At least partial relief of symptoms with physical activity
- Worsening of symptoms in the evening or at night
What can secondary RLS be due to?
- Iron deficiency
- Kidney failure
- Peripheral neuropathy
- Caffeine
- Alcohol
- Stress
- Fatigue
What are the some pharmacological treatments for RLS?
- Dopamine agonists
- Gabapentin enacarbil
Ropinerole/Requip
- Dopamine agonist
- 0.25 mg PO 1-3 hours before bedtime (max: 4 mg/day)
Pramipexole/Mirapex
- Dopamine agonists
- 0.125. mg PO 2-3 hours before bedtime (max: 0.5 mg/day)
Rotigotine/Neupro
- Dopamine agonist
- 1 patch (1mg/24 hours) transdermally daily (max: 3 mg/24 hours)
What are some adverse effects of dopamine agonist?
- Impulse control disorders
- Nausea
- Somnolence
- Headache
- Dizziness
- Vomiting
Gabapentin enacarbil (Horizant)
- Gabapentin pro-drug
- Dose: 600 mg once dailiy at 5 pm w/ food
Periodic Limb Movements of Sleep (PLMS)
- Repetitive limb movements during sleep
- Can caus arousal from sleep
