Sleep disorders

Question 1

sleep disorder symptoms

Answer 1

difficulty initiating sleep, difficulty maintaining sleep, early awakenings, nonrestorative sleep with ample opportunity for sleep

Question 2

Sleep disorder

Answer 2

insomnia sx w/ sig waking sx or impairment (daytime drowsiness, drowsy driving)

Question 3

Excessive sleepiness

Answer 3

chronic excessive sleepiness affects 5% of general population, impact of drowsy driving (100,000 MVA/year)

Question 4

Risk factors of sleep disorders

Answer 4

female, oler, divorced, stressors at work, perception of health, medica and psychiatric disorders, medications, drug abuse

Question 5

Stages of sleep

Answer 5

REM (20-25%), Non REM (75-80%), 1 cycle typically last 1.5-2 hours, stage 1 relaxed wakefulness, initiates sleep, stage 2- lighter sleep, provides rest for brain and muscles, Stage 3- provides rest, feeling of rejuvenation, stage 4-immune system enhanced, growth hormone released

Question 6

Norepi, histamine, ACh

Answer 6

Promote wakefulness

Question 7

Serotonin

Answer 7

neurons in the brainstem inhibit motor activity and lessen sensory input, promoting emergence of slow wave sleep

Question 8

Opiates and GABA

Answer 8

promote sleep, GABA is more active during NREM

Question 9

Hypocretin

Answer 9

found in hypothalamus, loss of hypocretin neurons linked to narcolepsy

Question 10

Non-pharm approaches

Answer 10

use bedroom only for sex and sleep, relaxation therapy, stimulus control, use alcohol/nicotine w/ caution, sleep restriction, exercise, avoid eating close to bed time

Question 11

Pharm treatment

Answer 11

BZD, triazolam (Halcion), Temazepam (Restoril), estazolam (Prosam), recommended for short term use only; nonBZD- Zolpidem (ambien), Zaleplon (Sonata), Eszopicolone (Lunesta), Ramelteon (Rozerem), Desyrel, benedryl

Question 12

Triazolam (Halcion)

Answer 12

shortest acting BZD

Question 13

Temazepam (Restoril)

Answer 13

intermediate acting, slow onset, 15-30 mg PO once daily

Question 14

Estazolam (Prosom)

Answer 14

intermediate acting, fast onset

Question 15

Zolpidem (Ambien) dose

Answer 15

5-10 mg PO once daily at bedtime

Question 16

Eszopiclone (Lunesta) dose

Answer 16

1-3 mg PO once daily at bedtime

Question 17

MOA of non BZD

Answer 17

binds to a1 subtype of the BZD receptor

Question 18

Non BZDs pearls

Answer 18

very quick onset (30 mins), short-acting little to no hangover effect, eszopiclone is the only one approved for long term use causes metallic taste, sedation, all are C-IV controlled

Question 19

Ramelteon (Rozerem) MOA

Answer 19

melatonin agonist, not controlled substance, goal to restor circadian rhythm, use for jet lag

Question 20

Trazodone (Desyrel)

Answer 20

not FDA approved for sleep but only used for sleep, DOC for insomnia in elderly, no addiction potential, no ACh ADRs

Question 21

Diphenhydramine (Benadryl)

Answer 21

OTC, lots of ACh ADRs, tolerance develops

Question 22

Supplements for sleep

Answer 22

Valerian, chamomile, melatonin

Question 23

Sequence of agents employed

Answer 23

Temazepam, zolpidem/zaleplon, trazodone, if early morning awakening, use temazepam, if daytime anxiety use long acting BZD

Question 24

Sleep attacks

Answer 24

REM sleep at anytime during the waking state, last 10-30 mins

Question 25

Cataplexia

Answer 25

loss of muscle tone in face/limbs, often induced by emotions or laughter

Question 26

Hypnogogic hallucinations

Answer 26

perceptual disturbances that occur during sleep attack

Question 27

Sleep paralysis

Answer 27

inability to breath deeply, move limbs or speak, often occurring upon falling asleep

Question 28

Narcolepsy treatment

Answer 28

Dextroamphetamine (Adderall), Methylphenidate, modafanil (Provigil), Armdafinil (Nuvigil)

Question 29

MOA of Modafanil (Provigil)

Answer 29

inc wakefulness via a adrenergic and GABA modulating mechanisms, no effect on cataplexy, efficacy similar to stimulants