sleep disorders Flashcards
breathing related sleep disorders
Obstructive sleep apnea hypopnea
Central sleep apnea
Sleep related hypoventilation
parasomnias
Non-rapid eye movement sleep arousal disorders
Nightmare disorder
Rapid eye movement sleep behavior disorder
Subjective estimates of sleep duration and pattern tend to (overestimate, underestimate) degree of disturbance
overestimate
t/f Transient insomnia very common (few nights) so the duration of the insomnia is very important to elucidate
t
3 types of insomnia that need to be differentiated
For a formal diagnosis
- ) Difficulty initiating or
- ) maintaining sleep or
- ) early awakening and can’t fall back asleep
how often must insomnia occur to be dx
who is it most common in
At least 3 nights a week for 3 months
More common in elderly, women, chronic medical problems, lower income, less education
tx for insomnia disorder
Start with sleep hygiene measures
Sleep medications/hypnotics
combo works best
why are benzo’s not first line for insomnia
tolerance
name some non benzo’s that are commonly used
eszopiclone
ramelteon
zaleplon
zolpidem
Targeted insomnia meds, have less day time sleepiness, less tolerance and less potential for abuse
zolpidem, eszopiclone, belsomra (suvorexant)
Excessive daytime sleepiness/somnolence
Usually involves prolonged nocturnal sleep and continual daytime drowsiness
Often 1-2 long naps (1 hour) during the day
At least 3 nights a week for 3 months
Hypersomnolence Disorder
A diagnosis of exclusion
Patients have diminished delta sleep (stage 3) and short latency to REM sleep (MSLT)
Hypersomnolence Disorder
Hypersomnolence Disorder tx
No effective cure
Treatment is symptomatic Sleep hygiene Sleep therapy Stimulants Dextroamphetamine- short half-life
Methylphenidate- short half-life (3.6 hrs)
Take in multiple, divided doses throughout the day
Modafinil- usually used for narcolepsy, single dose in AM
how can you estimate how long a drug will remain active
rules of 5
drug eliminated by 5x the half life
at 3 times the half life drug no longer having therapeutic effect
Recurrent episodes of an irrepressible need to sleep
Sleep attacks (seconds to 30 minutes or longer) occur with one or more of the following: Cataplexy (long-standing versus new onset criteria)
CSF hypocretin (Orexin) deficiency
Nocturnal polysomnography with REM latency <15 min or a MSLT sleep latency less than 8 minutes
Narcolepsy Disorder
does Narcolepsy Disorder have a known etiology
who is affected
Affects 1 in 2000, men and women equally represented, runs in families
One of the only diagnoses with known etiology
narcolepsy tx
Stimulants
Dextroamphetamine- short half-life
Methylphenidate- short half-life
Take in multiple, divided doses throughout the day
Modafinil- single dose 200-400 mg in AM
Sodium oxybate is prescribed for cataplexy, can reduce frequency of episodes
Considerable social, occupational and mental support
Safeguards in place for travel/driving
May require naps during day at work to reduce symptoms
what are the two definitions of cataplexy
1) long standing disease, brief sec to min episodes of b/l muscle tone loss. brought on by emotions
2) within 6 mo of onset, spontaneous grimaces or jaw opening episodes with tongue thrusting or global hypotonia w/o emotional triggers
Most common breathing-related disorder
obstructive sleep apnea hypoapnea disorder
what is Apnea
pause in breathing/breathing stops
what is Hypoapnea
decrease in airflow during breathing
t/f Patient usually unaware of these events on waking
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who is obstructive sleep apnea hypoapnea disorder most common in
Most common in overweight, middle-aged and older adults
Obstructive Sleep Apnea Hypoapnea Disorder tx
Obtain a sleep study
Weight loss
Sleep position training
CPAP (continuous positive airway pressure) device
Surgery to remove excess oropharyngeal tissue
Tracheostomy at extreme end of the spectrum
what do you aviod using with Obstructive Sleep Apnea Hypoapnea Disorder
Avoid sedative/hypnotic meds
There is no upper airway obstruction
The pathophysiology in CNS control
Brain fails to up-regulate breathing during periods of relative hypoxia
Snoring is not uncommon
Cheyne-Stokes and Opioid variants - Associated with heart failure, stroke, renal failure and chronic opioid use, respectively
Central Sleep Apnea Disorder
Central Sleep Apnea Disorder tx
Obtain a sleep study
Treat underlying medical conditions
CPAP
Supplemental oxygen
Adaptive servo ventilation (ASV)- provides positive expiratory airway pressure
(EPAP) and inspiratory pressure support (IPAP), which is servocontrolled based on the detection of central sleep apnea
what do you avoid with Central Sleep Apnea Disorder
Avoid sedative/hypnotic meds
Decreased response to high levels of CO2
Frequent episodes of shallow breathing, >10 secs
Sleep-related Hypoventilation Disorder
t/f OSA and CSA may occur along with SHD
true
with sleep related hypoventilation Persistent hypoventilation may result in what????!!!
pulmonary hypertension, polycythemia, right heart failure
what is Sleep-related Hypoventilation Disorder associated with
Frequently associated with lung disease, neuromuscular disorders, chest wall disorders
Patients often have headaches upon waking, insomnia, daytime sleepiness, etc.
Sleep-related Hypoventilation Disorder tx
Obtain a sleep study
Treat underlying disorder
For example, bronchodilators for patients with obstructive lung disease
Supplemental oxygen
But as underlying disorder progresses, may require more extreme support and ultimately mechanical ventilation/tracheostomy
what do you avoid in Sleep-related Hypoventilation Disorder
Avoid sedative/hypnotic meds
Circadian Rhythms Influenced/integrated by:
Light exposure
Sleep wake/centers of the brain
Genetics
Sleep disturbances from altered sleep-wake cycle
May be delayed (night-owls) or advanced phase ”morning people”
Or their schedule, job, other factors may interfere (shift-work), morning light exposure constantly “resets” their clock
Circadian Rhythm Sleep-Wake Disorders
t/f with Circadian Rhythm Sleep-Wake Disorders Sleep itself is of normal quality and patients can usually sleep enough if allowed to
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Circadian Rhythm Sleep-Wake Disorders tx
Delayed sleep phase - Delay sleep on successive nights for 30 min to 3 hours unit full 24 hr period of wakefulness achieved. Then sleep at “normal” time.
Shift work - stop working the night shift or there is an FDA approved stimulant drug, Nuvigil (armodafinil)
Jet lag (not DSM-5) - Zolpidem or melatonin short term; keep normal sleep schedule if possible
Sleep walking and sleep terrors, usually during first 1/3 of major sleep episode
Complex motor behavior without conscious awareness during NREM sleep, little to no memory
NREM Sleep Arousal Disorders
Sleep walking
very hard to arouse patient, blank stare, amnesia upon awakening. STAGE 3 NREM
Sleep terrors
partial arousal from delta sleep, usually with screaming in terror, motor activity, may not fully awaken and will not remember episode
Both are familial, most common in children, usually outgrown by adolescence
sleep walking, sleep terrors
NREM Sleep Arousal Disorders
Keep them safe!!!
Identify triggers, stressors
Avoid caffeine/alcohol
Benzodiazepines promote stage 3 sleep
TCAs, SSRIs and melatonin have been used but no controlled studies proving effectiveness
Sleep hygiene
Vivid, terrifying dreams, usually focused on imminent threat to one’s survival
Well-remembered, immediately alert after waking
In children, they may not be able to distinguish between reality and the dream
Nightmare Disorder
what do you need to rule out with Nightmare Disorder
Rule out substance abuse, withdrawal, other mental illness
when does Nightmare Disorder occur
Usually occurs during 2nd half of a sleep period
Usually occur during REM sleep
t/f Body movements and vocalizations are typical
f they are not typical
Nightmare Disorder tx
Treat underlying cause if clear -
- EtOH withdrawal, benzodiazepine withdrawal
Treat underlying mental illness -
depression, trauma counseling
Judicious use of hypnotics/sedatives
Arousal during sleep associated with vocalizations and/or complex motor movements
Often dream of being attacked or escaping
Can usually recall dream content
Complex motor activity has the ability to cause injury to the patient or others, and often does
REM Sleep Behavior Disorder
when does REM Sleep Behavior Disorder occur
During REM sleep
Usually later in sleep cycle (> 90 minutes)
what is REM Sleep Behavior Disorder associated with
Association with PD, Lewy Body Dementia, and multiple system atrophy
50% of those presenting to sleep clinics will develop a neurodegenerative disorder
REM Sleep Behavior Disorder tx
Keep them safe!!!
May have to have partners sleep in different rooms
Identify triggers, stressors if possible
TCAs, SSRIs and beta-blockers have been associated with this disorder, minimize/stop if possible
Clonazepam is the drug of choice, but symptoms will often return if meds are stopped
drug of choice to treat REM Sleep Behavior Disorder
clonazepam
Desire to move legs associated with unpleasant sensations, tingling, “creeping, crawling”
Symptoms at least 3x a week for 3 months
Sensations and movements delay sleep or wake patients from sleep
Movement of their legs relieves the unpleasant sensations
Restless Legs Syndrome
Restless Legs Syndrome tx
Dopamine agonists are mainstay:
Ropinirole 0.25 mg -4.0 mg/day
Pramipexole 0.125 mg -0.5 mg/day
what do you need to rule out for Restless Legs Syndrome
Rule out medical conditions such as: Leg cramps Positional ischemia/PAD Arthritis Myalgias Peripheral neuropathy
