Sleep Disorders

Question 1

Stages of Sleep

Answer 1

Falling asleep
Light sleep
Deep sleep

Question 2

How long is the NREM-REM cycle?

Answer 2

70-120 minutes and we do it 4-6x a night

Question 3

What neurotransmitters promote sleep?

Answer 3

GABA
Melatonin
Adenosine

Question 4

Dyssomnias

Answer 4

1˚ sleep disorders
1˚ insomnia
Breathing related sleep disorder
Unspecified

Question 5

Parasomnias

Answer 5

Strange behavior while asleep

Question 6

1˚ Insomnia Dx Criteria

Answer 6

Difficulty with the following for ≥1 month:
Sleep onset
Sleep maintenance
Waking too early
Poor sleep quality

Question 7

Risk Factors for Insomnia

Answer 7

Women

Age - quality decreases

Question 8

What is the difference between acute and chronic 1˚ insomnia

Answer 8

4 weeks is the turning point

Before then, give PRN sleep aids and improve sleep hygiene

Question 9

When is pharm therapy reserved for insomnia?

Answer 9

After adequate trials of non-pharm measures

Question 10

Major Sedative/Hypnotic Counseling Pts

Answer 10

Empty stomach
No pregnancy
Careful in depression, lung, liver or heart dys
Try for 2-4 weeks and re-eval
Taper/CBT when d/cing

Question 11

BZDs MOA

Answer 11

GABA Agonists

Question 12

Is there tolerance with BZDs?

Answer 12

Potential
Most are effective for up to 2-4 weeks
Intermittent dosing reduces likelihood of tolerance

Question 13

BZDs in Elderly

Answer 13

Not recommended

If used - give 1/2 to 1/3 normal adult dose of SHORT ACTING BZDs

Question 14

Shortest and Longest Onset BZD

Answer 14

Shortest: triazolam and estazolam
Longest: flurazepam

Question 15

Shortest and Longest Acting BZD

Answer 15

Shortest: triazolam
Longest: Flurazepam (active metabolite)

Question 16

BZD Withdrawal

Answer 16

Rebound sx w/in hours to days
Can cause delirium
Especially high dose

Question 17

BZDRAs

Answer 17

BZD Receptor Agonists

Bind BZD receptor on GABA

Question 18

Advantages of BZDRAs

Answer 18

Stage 3 preserved
Sedative effects only
Less dependence/tolerance

Question 19

Ambien Counseling Points

Answer 19

Diarrhea may resolve in 2 weeks

Use up to 35 days

Question 20

Dosing Considerations with BZDRAs

Answer 20

Women, >65, and liver probs = lower dose

Question 21

Intermezzo

Answer 21

IR SL zolpidem

PRN when wake up and still have at least 4 hours of sleep left

Question 22

Zaleplon

Answer 22

Sonata
Max 30 days
Only for onset
High doses (while effective for increasing total sleep time) are not recommended

Question 23

Temazepam Brand

Answer 23

Restoril

Question 24

Triazolam Brand

Answer 24

Halcion

Question 25

Flurazepam Brand

Answer 25

Dalmane

Question 26

Eszopiclone

Answer 26

S-enantiomer | Lunesta

Question 27

BZDRA Counseling Pts

Answer 27

Empty stomach right before bed

Question 28

Shortest onset BZDRA

Answer 28

Sonata

Question 29

Shortest and Longest Acting BZDRA

Answer 29

Shortest: Sonata Longest: Lunesta

Question 30

Melatonin Receptor Agonist

Answer 30

Ramelteon (Rozerem)

Question 31

Melatonin

Answer 31

Secreted by pineal gland - less with age Sleep/wake cycle Agonism = sleep

Question 32

Weird Lunesta Dosing

Answer 32

Onset: 1mg Maintenance: 2mg

Question 33

Rozerem

Answer 33

CI with fluvoxamine (1A2) | Empty stomach right before bed

Question 34

TCA Approved for Sleep

Answer 34

Doxepin (Silenor) Suicide potential Anti-Ach AEs - H1 antagonist w/in 30 min of bed empty stomach

Question 35

Off-Label Use for Insomnia

Answer 35

``` Trazodone Mirtazapine SSRIs TCAs SGAs ```

Question 36

Sleep bruxism

Answer 36

Teeth grinding

Question 37

OTC options

Answer 37

``` Benadryl Valerian Melatonin Kava 5-HT ```

Question 38

Central Sleep Apnea

Answer 38

No airflow due to no ventilation | Male, DM, CHF, old age, stroke

Question 39

Obstructive Sleep Apnea

Answer 39

No airflow, despite ventilation

Question 40

Consequences of OSA

Answer 40

Heart complications and increased mortality

Question 41

Screening tool for OSA

Answer 41

``` ISNORED Insomnia Snoring Nighttime awakenings Obesity Restorative sleep? Excessive sleepiness in day Drugs affecting sleep ```

Question 42

Drugs for OSA

Answer 42

Change drugs promoting weight gain/CNS depression Nothing approved Modafinil for daytime sleepiness if using CPAP

Question 43

Restless Leg Syndrome

Answer 43

Risk - women, PD 1˚ and 2˚ - due to low Fe, pregnancy, kidney failure Avoid stimulants or DA blockers

Question 44

RLS Treatment

Answer 44

DA Agonists Ropinirole Pramipexole Gabapentin ER - prodrug