Sleep Disorders Flashcards
What is a dyssomnia and what are two examples?
a dyssomnia is a sleep disorder with insufficient, excessive, or altered TIMING of sleep
includes insomnia and hypersomnia
What is a parasomnia?
a sleep disorder with unusual sleep-related BEHAVIORS
What are some symptoms associated with primary insomnia?
- difficulty initiating sleep (sleep-onset insomnia)
- frequent nocturnal awakenings (sleep-maintenance insomnia)
- early morning awakenings (sleep-offset insomnia)
- waking up feeling fatigued and unrefreshed (nonrestorative sleep)
What is the time cutoff between acute and chronic insomnia?
1 month
What is the prevalence of insomnia?
5-10%
What are some common etiologies for insomnia?
- subclinical mood and/or anxiety disorders
- preoccupation with a perceived inability to sleep
- poor sleep hygiene
- idiopathic (and usually chronic)
What is considered the first-line therapy for chronic insomnia?
CBT
What are some general classes of medications used to treat insomnia?
- benzos
- non-benzo hypnotics
- antidepressants
True or false; benzos have good evidence to support long-term efficacy
nope. totally false. they’re as effective as CBT during short periods of treatment (like 4-8 weeks), but otherwise not
What are some side effects of benzos when used for insomnia?
development of tolerance and addiction of course
also daytime sleepiness and rebound insomnia
In what group would you want to avoid benzos and why?
the elderly - they have an increased morality, particularly from falls, confusion and dizziness
What are the non-benzo sleep meds (aka the z-hypnotics)?
zolpidem (ambien)
aszopiclone (lunesta)
zaleplon (sonata)
Why are they better than the benzos? Why are they still risky?
they have less of the tolerance and addiction concerns, but they are still associated with some daytime sleepiness and orthostatic hypotension
zolpidem can still increase the risk of falls in the elderly
What are some antidepressants that are often used for insomnia?
trazodone
amitriptyline
dozepin
What are some signs/symptoms of obstructive sleep apnea?
excessive daytime sleepiness apneic episodes sleep fragmentation loud stertor (snoring) frequent awakenings due to gasping or choking nonfreshing sleep morning headaches
What are a few risk factors for obstructive sleep apnea?
obesity
increased neck circumference
airway narrowing (particularly with oropharyngeal abnormalities)
What are some treatments for obstructive sleep apnea?
CPAP or biPAP
behavioral strategies like weight loss and exercise
surgery
What is the classic narcolepsy tetrad?
- excessive daytime sleepiness or “sleep attacks”
- sleep paralysis
- hypnagogic/hypnopompic hallucinations
- cataplexy with strong emotions w/o LOC
What is the likely neurophysiology behind narcolepsy?
linked to a loss of hypothalamic neurons that contain hypocretin
What are some behavioral treatments for narcolepsy?
- sleep hygiene
- scheduled daytime naps
- avoidance of shift work
What medications are often used for the excessive daytime sleepiness in narcolepsy?
amphetamines like B-amphetamine or methamphetamine
methylphenidate, modafinil, and sodium oxybate
What are some medications that can be used for the cataplexy in narcolepsy?
sodium oxybate
TCAs like imipramine
SSRIs or SSNRIs
What is the name of the rare disorder that is characterized by excessive daytime sleepiness, prolonged nocturnal sleep episodes, and frequent irresistible urges to nap?
idiopathic hypersomnia
What is the name of the disorder characterized by recurrent hypersomnia with episodes of daytime sleepiness with hyperphagia, hypersexuality and aggression?
Kleine-Levin Syndrome
What are the two general causes of circadian rhythm sleep disorers?
- intrinsic defect in the circadian pacemaker (aka the suprachiasmic nucleus in the hypothalamus)
- impaired entrainment (absence of light or other time-signaling stimuli)
What are the four different circadian rhythm sleep disorders?
delayed sleep phase disorder
advanced sleep phase disorder
shift-work disorder
jet lag disorder
Describe delayed sleep phase disorder.
What is the main risk factor for this?
chronic or recurrent delay in sleep onset and awakening times with preserved quality and duration of sleep - so going to bed late and getting up late but with good sleep
biggest risk factor is puberty due to the temporal changes in melatonin secretion
Describe advanced sleep phase disorder. What is the main risk factor for this?
It’s just the opposite of delayed sleep phase disorder….
you have good sleep, but you go to bed really early and wake up really early
older age is the main risk factor
What are the general treatments for the sleep phase disorder?
timed bright light phototherapy depending on which one they have: so in the morning for delayed sleep phase and in the evenings for advanced sleep phase
evening melatonin for delayed, but early morning melatonin isn’t recommended for early because it can cause daytime sedation
What medication is used especially in shift work disorder?
modafinil
Describe some characteristics of sleep walking?
- simple to complex behaviors during SLOW-WAVE sleep , like sitting up in bed, eating, going outside, etc.
- eyes usually open with glassy look
- difficult to arouse sleepwalkers during episode
- confusion on awakening with amnesia for episode
- usually end with pt returning to bed or awakening confused/disoriented
- rarely associated with violent behavior upon forced awakening
What is the prevalence of sleep walking in adults? in kids?
1-4% in adults, but 10-20% of kids
What are some medical conditions that will increase the risk for sleep walking?
hyperthyroidism
OSA
Seizures
Migraines
What medication classes will increase the risk for sleep walking?
sedatives/hypnotics
lithium
anticholienrgics
What electrolyte deficiency is associated with sleep walking?
hypomagnesemia
Patients often benefit from addressing precipitating factors and many resolve spontaneously. If they are refractory cases, what are some medication options?
clonazepam or TCAs
What are some features of night terrors?
episodes of sudden arousal with screaming from slow wave sleep in what appears to be a state of complete terror
sympathetic hyperactivation with tachycardia, tachypnea, diaphoresis and increased muscle tone
patient usually return to sleep without even awakening
they’re usually amnesic about the episode
confused and disoriented upon forced awakening
What are some risk factors for sleep terrors?
fever nocturnal asthma GERD sleep deprivation other sleep disorders like OSA
What are the features of nightmare disorder?
recurrent frightening dreams that tend to terminate in awakening with vivid recall
no confusion or disorientation upon awakening
can cause significant distress and anxiety
Nightmare disorder occurs in what percent of adults? What about in PTSD patients?
5% of adults
50% of PTSD cases
What is the main therapy for nightmare disorder?
imagery rehearsal therapy - using mental imagery to modify the outcome of a recurrent nightmare, writing down the improved outcome and then mentally rehearsing it in a relaxed state
What are the features of REM sleep behavior disorder?
Muscle tonia during REM sleep with complex motor activity associated with dream enactment (sleep walking, yelling, limb jerking, walking/running, punching/other violent behaviors)
What are some risk factors for RBD?
older age, male gender psychiatric meds like TCAs, SSRIs, MAOIs Narcolepsy brain stem lesions dementias like olivopontocerebellar atrophy and diffuse lewy body disease
What is the main drug of choice for RBD?
clonazepam - efficacious in 90% of patients
other options are imipramine, carbamazepine, pramipexole or levodopa
