Sleep Disorders Flashcards
What is sleep onset latency?
Time it takes to transition from wakefulness to sleep
What is sleep maintenance?
The ability to stay asleep
What is sleep efficiency?
Amount of sleep in relation to the amount of time in bed
What is sleep architecture?
Structure and pattern of sleep (including sleep cycle, duration spent asleep during 24 hour period etc)
Where does the circadian rhythm originate from?
Superchiasmatic nucleus in the hypothalamus
What does the circadian rhythm control?
Physiologic functions, hormone secretions, body temperature, and sleep wake cycle
Why do we care about sleep in the elderly?
50% of community-dwelling older adults complain of some form of sleep difficulty
How is sleep affected in older adults?
Takes longer to fall asleep
Wake more often
Lower sleep efficacy
What are the etiologies of sleep disorders?
Primary sleep disorders
Endogenous changes in circadian clock
Medical and psychiatric illnesses
Medications
What psychiatric illnesses can lead to sleep disorders?
Depression
Dementia
Anxiety
What happens to the superchiastmatic nucleus with age?
Degenerates
What hormone secretion is decreased at night with age?
Endogenous melatonin
With age, do we become more or less sensitive to exposure to external signals?
Less sensitive
How does the sleep-wake cycle shift in the elderly?
Earlier shift
Older people may get sleepy earlier in the evening and wake earlier in the morning
Are there required treatments for changes in sleep with aging?
No, nonpharmacologic treatment is preferred if patient wants to change habits
What are nonpharmacologic treatments for adjusting sleep habits?
Sleep-wake cycle retraining
Bright light therapy
What are the types of sleep disorders?
Circadian rhythm sleep disorder
Periodic limb movement in sleep(PLMS) /restless leg syndrome (RLS)
REM behavior disorder
Insomnia
What is PLMS?
Jerking movement of extremities every 20-40 seconds during the night
What is RLS?
Dysesthesia of the legs (“creeping, crawling sensation” or “pins and needles”)
What is the hypothesis for the cause of PLMS/RLS?
Dysfunction of DA system - treat with DA agonists
How do PLMS/RLS affect sleep?
Arouses patient out of sleep, or prevents them from falling asleep
What is a primary presenting sign of PLMS/RLS?
Insomnia
What is REM behavior disorder?
Complex motor behaviors while in a sleeping state
What actions occur in REM behavior disorder?
Walking, talking, eating, etc
What part of sleep does REM behavior disorder occur?
During a lack of skeletal muscle tone during REM stage sleep
What is the usual treatment of REM behavior disorder?
Clonazepam which decreases motor movements partially or completely
Is it more common for RLS to have PLMS or PLMS to have RLS?
90% of patients with RLS have PLMS
20% of patients with PLMS have RLS
What is insomnia?
Low quantity and/or poor quality of sleep resulting in nonrestorative sleep
What may insomnia result from?
Problems with sleep onset, sleep maintenance, or early morning awakening with inability to return to sleep
What are sedating agents?
Hypnotics
Antihistamines
Antipsychotis
Antidepressants
What are activating agents?
Nicotine CNS stimulants Thyroid hormones Bronchodilators Corticosteroids
What are non-pharm approaches for sleeping?
Avoid caffeine, alcohol, and cigarettes after lunch
Limit liquids in the evening
Keep a regular bedtime-waketime schedule
Avoid naps (no longer than 20 minutes)
Spend times outdoows, particularly in later afternoon or early evening
Exercise, but avoid in the evening
What can many sedating medications cause?
Falls, fractures, and cognitive slowing
What % of community dwelling older adults complain of some form of sleep difficulty?
50%
If a patient has difficulty falling asleep, what type of agent should be used?
Shorter half-lives
If a patient has difficulty maintaining sleep, what type of agent should be used?
Intermediate half-lives
What is the MOA of benzo receptor agonists?
Enhances activity of GABA (inhibitory neurotransmitter) at various receptor sites leading to sedative and hypnotic effects resulting from decreased neuronal excitability
What are benzo receptor agonists?
Non-benzo/non-barbiturate
Ambien
Lunesta
Zaleplon
How do benzo receptor agonists compare to benzos?
Lower tolerance effects
Rebound insomnia
Residual daytime sleepiness
What is Ambien effective for?
Sleep onset (ER can help with sleep maintenance as well)
Where does ambien work?
Benzodiazepine-1 receptor
What is Lunesta effective for?
Sleep onset and maintenance
Where does Lunesta work?
GABA-receptor complex domain
What is zaleplon effective for?
Sleep onset
Where does zaleplon work?
Omega-1 receptor GABA-A
What are common SEs for benzodiazepine receptor agonists?
HA
Dizziness
Somnolence
Which benzo receptor agonist leaves a found taste in the mouth?
Lunesta
What is melatonin’s MOA?
Binds to melatonin receptor at the suprachiasmatic nucleus of the hypothalamus, which plays a key role in circadian rhythms and synchronization of sleep-wake cycle. MT1 receptor responsible for inducing sleepiness, MT2 receptor responsible for circadian rhythms
Which type of patients is melatonin most beneficial for?
Melatonin deficient
What are common SEs of melatonin agonists?
Similar to placebo HA Dizziness Nausea Drowsiness
What are the melatonin agonists?
Melatonin
Ramelteon (Rozerem)
What is ramelteon effective for?
Sleep onset
What is Ramelteon more selective for?
MT1 > MT2
Does melatonin or ramelteon have a higher affinity for MT1?
Ramelteon
What is ramelteon more effective for?
Primary insomnia (w/o melatonin deficiency)
What are the antidepressants that can be used for insomnia?
Trazodone
Mirtazapine
Doxepin
Which patients receive Trazodone?
With concomitant depression
What are SE of trazodone?
Nausea Dry mouth Dizziness HA Somnolence Blurred vision Nervousness Fatigue Priapism
Who receives mirtazapine?
With concomitant depression and/or decreased appetite/weight
What type of mirtazapine doses are sedating?
Lower
What are the SE for Mirtazapine?
Increased appetite Increased TG Constipation Dry mouth Somnolence
What does the insomnia dose of doxepin do?
Selectively antagonizes H1 receptors
What other medications may be used for depression but are on the Beers list?
Antihistamines
Antipsychotics
Benzos
