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Sleep disorders Flashcards

1
Q

Pathophys of sleep disorders?

A
  • sleep-wake cycle governed by complex group of biologic processes that serve as internal clocks
  • suprachiasmatic nucleus
  • pineal gland
  • other NTs involved:
    serotonin (arousal)
    NE (arousal)
    acetylcholine
    dopamine
    GABA (sleep promoting)
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2
Q

2 diff sleep stages?

A
  • REM sleep

- non-REM (NREM) sleep: 4 progressive categories

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3
Q

How does breathing change during sleep?

A
  • stages 1&2 of NREM show cylcic waning and waxing of tidal volume and RR, which can include brief periods of apnea called periodic breathing
  • in stages 3&4 of NREM breathing becomes more regular
  • ventilation is 1-2 L/min less than awake:
    CO2 2-8 mm Hg greater, O2 5-10 mmHg les, pH decreases 0.03-0.05
  • resp control mechanisms are intact during NREM sleep
  • REM sleep respirations become irregular (not periodic) and may include short periods of apnea
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4
Q

Epidemiology of sleep disorders?

A
  • 1/3 of Americans have sleep disorders at some pt
  • 20-40% adults report difficulty, but only 17% report that it is serious problem
  • 20% report chronic insomnia
  • elderly
  • more common in women: menstrual cycle and menopause
  • OSA - more common in men
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5
Q

RFs of sleep disorders?

A
  • sleep deprivation exists when sleep is insufficient to support adequate alertness, performance and health
  • stress, depression, anxiety, jet lag
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6
Q

Types of sleep disorders?

A
  • insomnia
  • hypersomnolence
  • narcolepsy
  • breathing related sleep disorders
  • circadian rhythm sleep-wake disorders
  • non-rapid eye movement sleep arousal disorders
  • REM sleep behavior disorder
  • movement disorder
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7
Q

What is insomnia?
More common in women or men?
What can insomnia cause?

A
  • difficulty initiating, maintaining sleep, or waking up early in the AM w/o ability to return to sleep
  • prevalence of the complaint of insomsnia higher in women: 40% to 30%
  • insomnia causes: impaired ability to concentrate, and poor memory
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8
Q

Common factors assoc with insomnia?

A
  • stress, caffeine, physical discomfort, daytime napping, early bedtimes
  • depression and manic disorders
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9
Q

3 major causes of insomnia?

A
  • medical conditions
  • psych conditions
  • enviro problems
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10
Q

Medical conditions that can cause insomnia?

A
  • cardiac: CHF
  • neuro
  • pulmonary: COPD, asthma
  • GI: acid reflux
  • substances: stimulants, corticosteroids
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11
Q

Pysch conditions that can cause insomnia?

A
  • depression
  • anxiety
  • PTSD
  • panic disorder
  • psychotropic meds
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12
Q

Enviro conditions that can cause insomnia?

A
  • bereavement
  • shift work
  • jet lag
  • changes in altitude
  • temperature
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13
Q

Effects of sleep deprivation on the body?

A
  • impaired brain activity
  • cognitive dysfxn
  • moodiness
  • depression
  • accident prone
  • cold and flu
  • DM II
  • heart disease
  • HTN
  • wt gain
  • weakened immune response
  • micro sleep
  • hallucinations
  • memory problems
  • yawning
  • accidental death
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14
Q

Sxs of insomnia?

A
  • difficulty falling asleep and staying asleep
  • daytime sleepiness
  • irritability
  • fatigue/malaise
  • increased errors or accidents
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15
Q

Dx insomnia?

A

sleep hx:

  • number of awakening
  • duration of awakening
  • duration of the problem

sleep log:

  • bedtime
  • duration until sleep onset
  • final awakening time
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16
Q

Tx of insomnia?

A

-b/f instituting therapy, most pts are asked to maintain a sleep log for 2-4 weeks

sleep hygiene:

  • optimal sleep enviro
  • optimal temp, light and ambient noise
  • use bedroom only for sleep
  • wind down b/f sleep
  • avoid caffeine, nicotine, beer, wine and liquor in 6-8 hrs b/f bedtime
  • go to bed only when sleepy
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17
Q

What else should you think of b/f tx pt with insomnia?

A
  • eval pts for other primary sleep disorders (sleep apnea)
  • impact of Rx meds
  • underlying medical, psych and substance abuse disorders
  • consultation for medical causes:
    psychiatrist
    neurologist
    pulmonologist
    sleep medicine specialist
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18
Q

Med consideration for tx of insomnia? What is typically used?

A
  • many agents are helpful
  • short term therapy is preferred to restore normal sleep pattern
  • hypnotic drugs are approved for 2 weeks or less of continuous use
  • in chronic insomnia, longer courses may be indicated which require long term monitoring
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19
Q

What are the meds used in insomnia when the pt has trouble getting to sleep?

A
  • zolpidem (ambien): 1st line

- zalepon (sonata): alt

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20
Q

Zolpidem (Ambien) use?
MOA?
Preg?
SEs?

A
  • 1st line for insomnia - trouble getting to sleep
  • MOA: interacts with GABA- benzodiazepine receptor complexes
  • dose: 5-15 mg PO hs
  • preg: B
  • SEs: abdominal pain, rebound tenderness, HA
    half life: 1.5-2.4 hrs
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21
Q

Zaleplon (sonata) use?
MOA?
Preg?
SEs?

A
  • alt use in trouble getting to sleep (insomnia)
  • MOA: interacts with GABA-benzodiazepine receptor complexes
  • dose 5-10 mg PO qhs
  • preg C
  • SEs: HA, dizziness, nausea
  • half life: 1 hr
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22
Q

First line med for trouble maintaining sleep (insomnia)?
MOA
Preg
SEs?

A
  • Eszopiclone (lunesta)
  • MOA: interacts with GABA-benzodiazepine receptor complexes
  • dose: 1-3 mg PO qhs
  • SEs: unpleasant taste, amnesia, hallucinations
  • Half life: 5-7 hrs
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23
Q

Benzodiazepines use? MOA
SEs

What pts should use caution while on this drug?

A
  • insomnia
  • traizolam, lorazepam, estazolam
  • MOA: bind to several GABA type A receptor subtypes
  • SEs: daytime sedation, lightheadedness, dependence
  • depresses breathing - be careful in COPD, other breathing disorders
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24
Q

Melatonin agonists use?
MOA?
SEs
CI

A
  • insomnia
  • ramelteon
  • MOA: binds to melatonin receptors expressed in suprachiasmatic nucleus
  • SE: somnolence
  • CI: with fluvoxamine (Luvox)
  • half life: 1.5-5 hrs
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25
Q

Use of orexin receptor antagonists?

A
  • used for sleep onset or maintenance in insomnia
  • Suvorexant (belsomra)
  • MOA: blocks binding of wake promoting neuropeptides orexin A and orexin B to receptors OZ1R and OX2R
  • Preg C
  • SE:
    drowsiness
    HA
    abnorm dreams
    LE weakness
    cough
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26
Q

What is hypersomnolence disorder? Sxs?

A
  • charact. by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep
  • typically affects adolescents and young adults
  • have difficulty waking from a long sleep and may feel disoriented
  • other sxs:
    anxiety
    increased irritation
    decreased energy
    restlessness
    trouble fxning
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27
Q

Dx criteria for hypersomnolence?

A
  • predominant feature is excessive sleepiness for at least 1 month (acute) or at least 3 months (persistent) as evidence by either prolonged sleep episodes or daytime sleep episodes that occur at least 3x/week:
  • excessive sleepiness causes distress or impairment
  • not caused by insomnia or any other sleep disorder
  • sleepiness isn’t due to getting enough sleep
  • drugs, meds, and medical conditions can’t cause sleepiness
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28
Q

Non-pharm txs of hyper somnolence?

A
  • take naps whenever possible
  • maintain regular sleep schedule
  • avoid alcohol and meds that cause drowsiness
29
Q

Rx tx for hypersomnolence? First line?
MOA?
Preg?
SEs?

A
  • Modafinil (provigil)
  • MOA: not well understood, but may increase dopaminergic signaling
  • dose: 200 mg qAM, up to 300-400 mg
  • Preg C
  • common SEs:
    HA
    Nausea
    nervousness
    dry mouth
30
Q 
2nd line tx for hyper somnolence?
MOA
preg?
SEs?
BBW?
A
  • dextroamphetamine
  • MOA: not well understood, stimulates CNS activity, blocks reuptake and increases release of NE and dopamine in extraneuronal space (sympathomimetic)
  • dose: 5 mg bid
  • preg C
  • SEs:
    HTN, anorexia, and addiction
    BBW: high abuse potential!!
31
Q

What is narcolepsy?

etiology?

A
  • syndrome of daytime sleepiness with cataplexy (transient muscle weakness resulting in sudden loss of postural tone - result in falls to floor), hypnagogic hallucinations, and sleep paralysis
  • 2nd most common cause of disabling daytime sleepiness
  • typically begins in teens and early 20s
  • etiology:
    loss or orexin (hypocretin) signaling
    genetic factors
    brain lesions (rare)
32
Q

Signs and sxs of narcolepsy?

A

-periods of extreme drowsiness during the day, may feel strong urge to sleep, often followed by short nap (sleep attack)

-tetrad of sxs:
lasts for about 15 min each, can be longer
may happen after eating, driving, talking to someone
most often - person wakes feeling refreshed

  • sudden brief (15 min) sleep attacks may occur during any type of activity
  • sleep paralysis: generalized flaccidity of muscles with full consciousness in transition zone b/t sleep and wakening
  • cataplexy: sudden loss of muscle tone in small muscles or generalized muscle weakness while awake that makes them slump to floor unable to move, strong emotions can trigger this - attacks lasts shorter than 30 sec, in severe cases - person may fall and stay paralyzed for as long as several minutes
  • hypnagogic hallucinations, visual or auditory, whichmay precede sleep or occur during sleep attack
33
Q

dx of narcolepsy?

A
  • hx of daytime sleepiness
  • absence of underlying nocturnal sleep disorders
  • epworth sleepiness scale
  • polysomnogram (PSG): recording of biophysiological changes during sleep: EEG, eye movements (EOG), muscle activity (EMG), and heart rhythm (ECG)
  • mult sleep latency test
34
Q

non-pharm tx for narcolepsy?

A
  • good sleep hygiene
  • take 1 to 3 planned 15-20 min naps/day
  • avoid certain drugs
35
Q 
First line Rx tx for narcolepsy?
What else is this used for? 
MOA?
preg?
SEs?
A
  • modafinil (provigil)
  • also used 1st line for hypersomnolence
    = MOA: may increase dopaminergic signaling
  • preg C
  • Ses: HA, Nausea, nervousness, dry mouth
36
Q

2nd line therapy for narcolepsy?

A
  • dextroamphetamine
  • also used 2nd line for hyper somnolence
  • MOA: stim CNS activity, blocks reuptake and increases release of NE and dopamine in extraneuronal space (symp)
  • preg C
  • SEs: HTN, anorexia, addiction
  • BBW: high abuse potential
37
Q

How common is OSA?

Who does ic commmonly affect?

A
  • 2-5% of adults in US

- primarily middle aged or elderly men

38
Q

Classic presentation of OSA?

A
  • obese pt
  • loud snoring
  • multiple arousals or awakenings during the night
  • gasping for breath
39
Q

What does OSA result in?

A
  • sleep fragmentation
  • daytime sleepiness
  • morning HA
  • impaired occupational performances
  • exacerbated by alcohol use at bedtime and sedative hypnotic drugs
40
Q

RFs for OSA?

A
  • obesity (BMI greater than 30)
  • neck circum greater than 17 in
  • narrow airway
  • large tongue
41
Q

Screeninga nd dx for OSA?

A
  • pt complaints
  • sleep partner complaints
  • epworth sleepiness scale
  • sleep studies
42
Q

What is included in the polysomnography (PSG)?

A
  • EOG: electrooculogram (recording eye movements)
  • EMG
  • EEG
  • EKG
  • tracheal noise
  • nasal and oral airflow
  • thoracic and abdominal resp effort
  • leg movement
  • pulse Ox, capnography, end tidal CO2
43
Q

Tx of OSA?

A
  • wt loss
  • smoking cessation
    CPAP:
    -air pressure mask
    -keeps upper airway passages open
    -Delivers O2
    -cumbersome but getting better

other options:
oral appliances
surgery - mandibular advancement, UPPP

44
Q

What is Central sleep apnea?
How is it ID?
causes?

A
  • defined by repetitive cessation or decrease of both airflow and ventilatory effort during sleep
  • primary CSA is rare, usually mixed with OSA
  • presents similar to OSA and ID on polysomnography
  • causes:
    stroke or brain tumor
    a-fib or CHF
    neuromuscular disorders
45
Q

Tx for CSA?

A
  • tx underlying cause
  • if pt is sx with no apneic SEs then monitor
  • CPAP - 1st line therapy, BiPAP may be used if no response to CPAP
  • meds: acetazolamide (diamox), or theophylin
46
Q

What is Pickwickian syndrome?
Dx?
Tx?

A
  • obesity hypoventilation syndrome:
  • combo of brain’s control over breathing and obesity. -Often tired due to sleep loss, poor sleep quality, and chronic low blood O2 levels
  • alveoloar hypoventilation results from combo of blunted vent drive and increase mechanical load imposed on chest by obesity
  • most pts suffer from OSA

-dx: polysomnogram
-tx: wt loss (diet and surgery)
Bipap
resp stimulants: theophylline, acetazolamide, and medroxyprogesterone acetate, O2, tracheostomy (severe cases)

47
Q

What is a circadian rhythm disorder? What disorders are included?

A
  • disruption in person’s internal body clock that regulates 24 hr cycle of biological procees
  • disruption results from either malfxn in internal body clock or mismatch b/t internal body clock and external enviro regarding timing and duration of sleep
  • includes:
    delayed sleep phase disorder (DSPD)
    advanced sleep phase disorder (ASPD)
    non-24-hr-sleep wake disorder (NON-24)
    irregular sleep-wake disorder (ISWD)
    shift work disorder
48
Q

What is delayed sleep phase disorder? (DSPD)

Most common in?

A
  • most common in adolescents/young adults
  • night owl tendencies delay sleep onset
  • if allowed to sleep in (around 3 pm) person ok
  • causes daytime sleepiness
  • most are often alert, productive and creative late at night
49
Q

WHat is ASPD? Seen in what pop?

A
  • usually seen in elderly
  • person has early bedtimes (6-9) and early morning waking (2-5 am)
  • usually sleep in late afternoon or early evening
  • morning larks
50
Q

NON-24? Common in what pops?
Sxs?
Tx?

A
  • condition in which a person’s day length is longer than 24 hrs
  • commonly seen in blind
  • impairs ability to fxn at school, work, or at their social lives
  • sxs: cog dysfxn, confusion, extreme fatigue, HA

tx: bright light therapy and melatonin
- hetlioz (tasimelteon): first drug for NON-24 in blind pts
moa: binds to melatonin MT1 and 2 receptors
- preg C, SEs: HA, and abnormal dreams

51
Q

ISWD? Sxs?

A
  • irregular sleep wake syndrome is sleeping w/o any real schedule
  • usually occurs in person who has problem with brain fxn and who doesn’t have a regular routine during the day
  • sxs:
    sleeping or napping more than usual during the day.
    Trouble falling asleep or staying asleep at noc
    Waking up often during the noc
52
Q

What is shift work disorder?

A
  • people who rotate shifts or work at noc
  • work schedule conflicts with circadian rhythm
  • results in insomnia or excessive sleepiness
53
Q

Tx of CRD?

A
  • light therapy
  • combo of planned sleep scheduling, timed light exposure, and timed melatonin
  • hetlioz for non-24 pts who are blind
  • good sleep hygiene
54
Q

What are NREM sleep arousal disorders?

A
  • sleepwalking
  • sleep terrors
  • enuresis
55
Q

What part of sleep stage does sleepwalking (somnambulism) occur? What occurs during sleepwalking?
Causes?

A
  • occurs during stage 3 & 4
  • usually 8-12 yo
  • during first few hours of sleep and in REM sleep in later hours
  • includes ambulation or other intricate behaviors while sleeping
  • can be agitated or aggressie when aroused
  • no recollection of event
  • causes: idiosycratic drugs (marijuana, ETOH), medical conditions (seizures)
56
Q

What are night terrors? when do they occur, and in who are they most common in? Sxs?

A
  • (pavor nocturnus)
  • abrupt terrifying arousal from sleep
  • stages 3 & 4
  • usually in preadolescent boys
  • marked vocalization and movement
  • hard to wake person during episode
  • unable to recall the event
  • sxs: fear, sweating, tachycardia
57
Q

Tx of NREM sleep arousal disorders?

A
  • improving sleep first line tx
  • setting a regular bedtime
  • practicing relaxation
  • limit food or drink b/f sleeping
  • est a bedtime routine
  • scheduled awakenings
58
Q

Enuresis? When does it occur?

Tx?

A
  • involuntary micturition during sleep in person with voluntary control
  • more common in kids
  • usually 3-4th hr of bedtime
  • not limited to stages of sleep
  • amnesia for event is common
  • difficult to awake

-tx:
simple behavioral interventions first line approaches, DDAVP, oxybutynin, imipramine,alarm systems
(parents have to take active role)

59
Q

REM sleep behavior disorder?
Common in?
Dx?
Tx?

A
  • chracterized by dream-enactment that happens during a loss of REM sleep atonia
  • ranges from hand gestures to violent thrashing, punching, and kicking
  • among young adults who take antidepressants, narcoplepsy, or alpha-synyclein neurodegeneration (elderly)
  • dx: polysomnography
  • tx:
    est safe sleep enviro
    melatonin: 1st line, moa: prepares body for sleep, SEs: abnorm heartbeat, dizziness, and fatigue
    clonazepam
60
Q

What is RLS?

A
  • disorder in which there is an urge or need to move legs to stop unpleasant sensations
  • C/O sensation of wanting to move legs while awake, “heebie jeebies”, or “creepy crawler” sensations
  • occurs while awake as well as when sleeping
  • makes falling asleep difficult
  • sleep partner complaints
61
Q

Causes of RLS?

A
  • CKD
  • diabetes
  • Fe deficiency
  • parkinson’s disease
  • peripheral neuropathy
  • pregnancy
  • use of certain meds such as caffeine, CCBs, lithium or neuroleptics
  • withdrawal from sedative
  • chronic venous insufficiency (varicose veins)
62
Q

Tx for RLS?

A
  • stretching, massage, warm baths
  • avoid caffeine: chocolate, coffee, tea and pop
  • tx or control underlying disease
  • meds:
    Fe supp: try first with non-pharm options
    1st line after above has been tried:
    dopamine agonist - ropinirole (requip)
    alpha-2-delta calcium channel ligands: gabapentin
63
Q

For what other disease do we use ropinirole (requip)?

A
  • parkinson’s
64
Q

What is bruxism?
pts hx?
tx?

A
  • teeth gnashing/grinding
  • hx: pt c/o of jaw soreness, flattening of teeth and radiating AM headaches
-tx: 
clonazepam
botox
referral to be custom fitted for nocturnal oral appliances
relaxation and behavioral therapy
65
Q

What is periodic limb movement disorder?
Dx?
Tx?

A
  • pt moves limbs involuntarily during sleep and has sxs or problems related to the movement
  • pt is often unaware
  • unknown etiology but may be related to other medical problems sich as PD or narcolepsy
    -dx with aid of PSG
  • tx:
    1st line: dopamine agonist
    anticonvulsants
    benzodiazepines
66
Q

EEG? Uses?

A
  • measures and records the electrical activity of the brain
  • electrodes placed and connected to a computer
    -uses:
    study sleep disorders
    Dx epilepsy and type of seizure
    Check for problems with LOC or dementia
67
Q

Other dxs used in sleep disorders?

A
  • sleep hx
  • sleep diary
  • outpt: overnight oximetry, actigraphy (measures gross motor activity)
  • inpt: PSG, mult sleep latency test
68
Q

What should be included in your pt hx?

A
  • psch, medical or med changes
  • impairment of sleep onset
  • trouble staying asleep: mult awakenings, early awakenings
  • partial arousal
  • breathing abnorm
  • involuntary movements
  • normal but non refreshing sleep
  • epworth sleepiness scale

Neuro (19 decks)

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