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)
2
Q
2 diff sleep stages?
A
- REM sleep
- non-REM (NREM) sleep: 4 progressive categories
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
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
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
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
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
8
Q
Common factors assoc with insomnia?
A
- stress, caffeine, physical discomfort, daytime napping, early bedtimes
- depression and manic disorders
9
Q
3 major causes of insomnia?
A
- medical conditions
- psych conditions
- enviro problems
10
Q
Medical conditions that can cause insomnia?
A
- cardiac: CHF
- neuro
- pulmonary: COPD, asthma
- GI: acid reflux
- substances: stimulants, corticosteroids
11
Q
Pysch conditions that can cause insomnia?
A
- depression
- anxiety
- PTSD
- panic disorder
- psychotropic meds
12
Q
Enviro conditions that can cause insomnia?
A
- bereavement
- shift work
- jet lag
- changes in altitude
- temperature
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
14
Q
Sxs of insomnia?
A
- difficulty falling asleep and staying asleep
- daytime sleepiness
- irritability
- fatigue/malaise
- increased errors or accidents
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
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
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
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
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
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
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
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
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
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
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
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
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
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
