Sleep Disorders Flashcards
Describe REM sleep
- Low amplitude, mixed frequency EEG
- Bursts of REM similar to wakefulness
- EMG activity absent = characteristic of REM sleep
What are the 3 stages of NREM sleep?
N1, N2, N3
Describe NREM sleep
Increased arousal threshold & slowing of cortical EEG as you move through the 3 stages
Describe stage N1
Btwn wakefulness & deeper sleep
If someone is awoken, when does vivid recall of dream imagery occur?
If awoken from REM sleep
What degrades cognitive performance?
Sleep deprivation
Sleep deficiency can cause what?
Glucose intolerance –> DM, obesity, metabolic syndrome, impaired immunity, accelerated atherosclerosis, stroke
How many hours of sleep does the average adult need?
- 5-8 hrs
* Teens need 9+ hrs
What is the impact of insufficient sleep?
- Inattentive, irritable, unmotivated, depressed
- Difficulty w/ school, work, driving
What should be included in PE when evaluating a pt for a sleep disorder?
- Airway
- Tonsils
- Neurologic
- MSK
- CV
- Pulm
- Abd
How do you dx a sleep d/o?
Polysomnography
- EEG
- EOG: measures eye movement
- EMG: measured on chin, neck, legs
What does polysomnography measure?
- Sleep stages
- Respiratory effort & airflow
- O2 sat
- Limb movements
- Heart rhythm
What are other dx tests for sleep d/o?
- Home sleep test
- Multiple sleep latency test (MSLT)
- Maintenance of wakefulness test
What scale is used for dx of sleep d/o?
Epworth sleepiness scale (ESS)
- Over 10 = excessive sleepiness
How are sleep disorders classified?
- Insomnia
- Sleep-related breathing
- Central d/o of hypersomnolence
- Circadian rhythm sleep-wake
- Parasomnias
- Sleep-related movement disorders
*There are 60 diagnoses
What are the RFs of insomnia?
- W > M
- Older
- Unemployed
- Lower SES
- Divorced, widowed, separated
- Medical, psychiatric, substance abuse
What is the dx criteria for insomnia?
- Sx at least 3 x per wk
- Sleep initiation or maintenance problem
- Adequate opportunity to sleep
- Daytime consequences
What is considered short-term insomnia?
- < 3mos
- can be a stressor, but to dx there should be an independent focus on the insomnia
- resolves when stressor does
How do you dx insomnia?
Clinically!
- But look for conditions, meds, substance abuse
How do you tx insomnia?
- Sleep hygiene & stimulus control counseling
- Behavioral therapy
- Pharmacologic therapy
What med tx can you use for insomnia?
- Benzodiazepines
- Nonbenzodiazepine sedatives
- Melatonin agonists
- Doxepin
- Suvorexant
What are 4 sleep-related breathing disorders?
- Central sleep apnea
- Obstructive sleep apnea
- Sleep-related hypoventilation
- Sleep-related hypoxemia
What is the impact of insomnia?
- Decreased QOL & performance
- Increased CV risk, DM
- Associated w/ depression, anxiety
What causes OSA?
Repetitive collapse of upper airway during sleep
Describe OSA
15+ obstructive respiratory events per hr
What is the dx criteria for OSA?
Can dx w/ 5+ events if:
- s/s of excessive sleepiness, fatigue, &/or insomnia
- waking up w/ breath holding, gasping, choking
- snoring, breathing interruptions, or both noted by bed partner or observer
- HTN, mood d/o, cognitive dysfunction, CAD, stroke, HF, AF, DM
What are the RFs of OSA?
- Obesity
- Male
- Advanced age
- Craniofacial morphology or upper airways abnormalities
What is the clinical presentation of OSA?
Excessive daytime sleepiness, snoring, choking, or gasping during sleep
In OSA, what is seen on PE?
- Obesity
- Crowded/narrow OP airway
- Elevated BP
- Signs of pulm HTN or cor pulmonale
How do you dx OSA?
Polysomnography
How do you tx OSA?
- Behavioral
- + airway pressure (CPAP) = initial therapy
What is the avg nightly use of CPAP?
4 hours
What is the impact of OSA?
- Decreased QOL, daily function
- Increased risk MCV & poor neurocognitive performance
- Increased all-cause & cardiovascular mortality
What are central disorders of hypersomnolence?
Narcolepsy types 1 & 2
Describe narcolepsy
- Loss of hypothalamic neurons that produce orexin neuropeptides
- May have autoimmune component
- Difficulty sustaining wakefullness, poor regulation of REM, disturbed nocturnal sleep
What is the difference btwn Type 1 & 2 narcolepsy?
Type 1 = w/ cataplexy
Type 2 = w/out cataplexy
What is cataplexy?
Sudden muscle weakness w/out loss of consciousness, triggered by emotions
Besides cataplexy, what are other presentations of narcolepsy?
- Hypnagogic hallucinations: dream-like, at sleep onset or upon awakening
- Sleep paralysis: muscle paralysis upon awakening or just before falling asleep
What is the clinical presentation of narcolepsy?
- Excessive daytime sleepiness
- Fragmented sleep
- Other sleep disorders
- Psychiatric comorbidities
How do you dx narcolepsy?
- H&P
- Polysomnogram
- MSLT: sleep latency < 8 mins & REM episodes in at least 2 of the naps
How do you tx narcolepsy?
- Nonpharmacologic
- Pharmacologic: Modafinil = 1st line, methyphenidate, amphetamines
How do you tx cataplexy?
Antidepressants
What is the clinical presentation of shift work d/o?
- Fragmented sleep
- Difficulty falling/staying asleep
- Poor sleep quality
- Reduced sleep duration
How do you manage shift work d/o?
- Change work schedule
- Improve daytime sleep
- Regular sleep schedule
- Sleep hygiene
- CBT
- Therapeutics: short-acting hypnotics, melatonin, caffeine
What are parasomnias?
Undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep
What population is most commonly affected by parasomnias?
Children!
Parasomnias: What are NREM-related components?
Disorders of arousal
- Confusional
- Sleepwalking
- Sleep terrors
- Sleep-related eating d/o
Parasomnias: What are REM-related components?
Intrusion of features of REM sleep into wakefulness
- Sleep paralysis
- Exaggerated features of REM sleep
- Aberrations of REM sleep
What is the criteria for parasomnia dx?
- Recurrent episodes of incomplete awakening
- Absent or inappropriate responsiveness
- Limited or no cognition or dream report
- Partial or complete amnesia for the event
How do you dx parasomnia?
- History
- PSG (if suspect comorbid sleep d/o)
What are precipitating factors of parasomnias?
- Sleep deprivation, emotional stress
- Fever, malaise, environmental or internal stimuli
- Comorbid sleep disorders
- Meds, substances
What are sleep terrors?
Sudden arousal from sleep associated w/ sitting up in bed, intense fear, a piercing scream, & intense autonomic activation including tachycardia, tachypnea, diaphoresis, facial flushing, & mydriasis
How do people w/ sleep terrors present?
- Frightened, confused, inconsolable, difficult to arouse
- No recollection
- Lasts several mins
- Quietly return to sleep
How do sleep walkers present?
- Slow, quiet ambulation w/ eyes open
- Might prepare food, eat, clean, rearrange furniture, drive
- Terminate spontaneously
- Appear confused, agitated or aggressive when aroused
- Self-injury
What is sleep related eating d/o?
- Variant of sleepwalking
- Involuntary eating associated w/ diminished LOC during an arousal from sleep
How do you tx parasomnias?
- Avoid sleep deprivation, ETOH, certain meds
- Maintain consistent, regular sleep-wake cycles
- Safety interventions
- Bystanders should allow pt to move freely but ensure safety. Gently coax back to bed.
- Anticipatory awakening
