Sleep Disorders Flashcards
1
Q
Average Sleep requirements:
0-2 months?
2-12 months?
12-18 months?
18 months- 3 years?
3-5 years?
5-12 years?
Teenagers?
Adult?
Mature/Elderly?
A
See picture
2
Q
Sleep-wake cycle governed by what? 1. What parts of the brain are involved? 2 2. Other neurotransmitters are thought to play a role? 5
A
complex group of biologic processes that serve as internal clocks 1. -Suprachiasmatic nucleus -Pineal gland 2. -Serotonin -Norepinephrine -Acetylcholine -Dopamine -GABA
3
Q
Which neurotransmitters are sleep promoting and which are arousal promoting? 4
A
See picture
4
Q
Sleep is divided into 2 categories which is associated with distinct patterns of central nervous system (CNS) activity
A
- REM sleep 2. Non-REM (NREM) sleep
5
Q
What are the 4 progressive categories of sleep?
A
- light 2. intermediate 3. Slow wave 4. REM
6
Q
Describe the breathing during stages 1 and 2 of sleep?
A
Stages 1 and 2 of NREM sleep show cyclic waning and waxing of tidal volume and respiratory rate, which can include brief periods of apnea, called periodic breathing
7
Q
Describe breathing in stages 3 and 4?
A
In stages 3 & 4 of NREM sleep breathing becomes more regular
8
Q
- Ventilation is ____L/min less than awake
- PCO2 levels ____mm Hg greater
- PO2 levels ____ mm Hg less
- pH is _______units less
A
- 1-2
- 2-8
- 5-10
- 0.03-0.05
9
Q
Sleep deprivation exists when sleep is insufficient to support what? 3
A
-adequate alertness, -performance -health.
10
Q
TYPES OF SLEEP DISORDERS 8
A
- Insomnia disorder 2. Hypersomnolence disorder 3. Narcolepsy 4. Breathing-related sleep disorders 5. Circadian rhythm sleep-wake disorders 6. Non-rapid eye movement sleep arousal disorders 7. Rapid eye movement sleep behavior disorder 8. Movement disorder
11
Q
What is insomnia?
A
Difficulty initiating, maintaining sleep, or waking up early in the AM without ability to return to sleep Frequency of the complaint of insomnia increases with age.
12
Q
Insomnia Common risk factors? 7
A
- Stress, 2. caffeine, 3. physical discomfort, 4. daytime napping, 5. early bedtimes 6. Depression 7. manic disorders
13
Q
Insomnia causes what? 2
A
- Impaired ability to concentrate 2. Poor memory
14
Q
Major causes of insomnia may be divided what categories? 3
A
- Medical conditions 2. Psychiatric conditions 3. Environmental problems
15
Q
Insomnia Etiology: Medical Conditions 5
A
- Cardiac 2. Neurological 3. Pulmonary 4. GI 5. Substances
16
Q
Insomnia Etiology: Psychiatric 5
A
- Depression 2. Anxiety disorders 3. PTSD 4. Panic disorder 5. Psychotropic meds
17
Q
Insomnia Etiology: Environmental? 4
A
- Bereavement 2. Shift Work 3. Jet lag 4. Changes in altitude
18
Q
Symptoms of insomnia? 5
A
- Difficulty falling asleep and staying asleep 2. Daytime sleepiness 3. Irritability 4. Fatigue/malaise 5. Increased errors or accidents
19
Q
How do we diagnosis insomnia? 2
A
Sleep history Sleep log
20
Q
WHat are we asking about in the sleep history for workup of insomnia?3 What are we recording in the sleep log? 3
A
- Number of awakening 2. Duration of awakening 3. Duration of the problem 1. Bedtime 2. Duration until sleep onset 3. Final awakening time
21
Q
- Before instituting therapy, most patients are asked to maintain a sleep log for how long? 2. What is sleep hygiene? 3 3. Advice for before you sleep for the night? 2 4. What should we avoid? 5
A
- 2-4 weeks 2. -Optimal sleep environment -Optimal temperature, light and ambient noise -Use the bedroom only for sleep 3. -“winding down” before sleep -Go to bed only when sleepy
- Avoid -caffeine, -nicotine, -beer, -wine -liquor in the 6 to 8 hours before bedtime.
22
Q
Medicines for trouble getting to sleep? (first line?) 2
A
- Zolpidem (Ambien) First-line 2. Zaleplon (Sonata) Alternative
23
Q
What is the MOA, Preg cat, and side effects of each of the following: 1. Zolpidem (Ambien) First-line (3SE) 2. Zaleplon (Sonata) Alternative (3SE)
A
- -MOA: interacts with GABA-benzodiazepine receptor complexes -Preg B Side-effects -Abdominal pain -Rebound insomnia -HA 2. -MOA: interacts with GABA-benzodiazepine receptor complexes -Preg C Side-effects -HA -Dizziness -Nausea
24
Q
What medication should we prescribe for maintaining sleep?
A
Eszopiclone (Lunesta) First-line
25
Eszopiclone (Lunesta) First-line 1. MOA? 2. Preg Cat? 3. SE? 3
1. MOA: interacts with GABA-benzodiazepine receptor complexes 2. Preg C 3. Side-effects -Unpleasant taste -Amnesia -Hallucinations
26
What are two other medications for insomnia that we ca use?
1. Benzodiazepines (Triazolam, lorazepam, estazolam) 2. Melatonin agonists (Ramelteon) 3. Suvorexant (Belsomra)
27
What is the MOA and side effects of each of the following: 1. Benzodiazepines (3SE) 2. Melatonin agonists (1SE) 3. Suvorexant (Belsomra) (5SE)
1.MOA -Bind to several GABA type A receptor subtypes SE -Daytime sedation -Lightheadedness -Dependence 2. MOA -Binds to melatonin receptors expressed in the suprachiasmatic nucleus SE -Somnolence 3. MOA -Blocks binding of wake-promoting neuropeptides orexin A and orexin B to receptors OZ1R and OX2R SE -Drowsiness -HA -Abnormal dreams -LE weakness -Cough
28
WHo is melatonin contraindicated in?
Contraindicated with fluvoxamine (Luvox)
29
1. HYPERSOMNOLENCE DISORDER is characterized by what? 2. WHo does this typically affect? 3. What do they have difficulty with? 4. Other symptoms include? 3
1. Characterized by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep 2. Typically affects adolescents and young adults 3. from a long sleep and may feel disoriented 4. -Anxiety -Increased irritation -Decreased energy
30
What is the diagnosis criteria for HYPERSOMNOLENCE DISORDER? 2
1. Predominant feature is excessive sleepiness for at least 1 month (acute) or 2. at least 3 months (persistent) as evidence by either prolonged sleep episodes or daytime sleep episodes that occur at least 3 times per week
31
HYPERSOMNOLENCE DISORDER 1. Excessive sleepiness causes 2. Not caused by\_\_\_\_\_\_\_ or any other sleep disorder 2. Sleepiness is not due to what? 3. What cannot cause the sleepiness for this diagnosis? 3
1. distress or impairment 2. insomnia 3. getting enough sleep 4. -Drugs, -medications -medical conditions
32
HYPERSOMNOLENCE DISORDER: Nonpharm treatments? 3
1. Take naps whenever possible 2. Maintain regular sleep schedule 3. Avoid alcohol and meds that cause drowsiness
33
HYPERSOMNOLENCE DISORDER: 1. First line pharm treatment? 2. MOA? 3. Preg Cat? 4. SE? 4
1. Modafinil (Provigil) 2. MOA: not well understood, but may increase dopaminergic signaling 3. Preg C 4. Side-effects common -HA -Nausea -Nervousness -Dry mouth
34
1. Second line for HYPERSOMNOLENCE DISORDER? 2. MOA? 3. Preg Cat? 4. SE? 2
1. Dextroamphetamine 2. MOA: not well understood, but stimulates CNS activity; blocks reuptake and increases release of norepinephrine and dopamine in extraneuronal space (sympathomimetic) 3. Preg C 4. Side-effects common -HTN -Anorexia
35
1. WHat is narcolepsy? 2. When does it typically begin? 3. Etiologies? 3
1. Syndrome of daytime sleepiness with cataplexy, hypnagogic hallucinations, and sleep paralysis. 2. teens and early twenties 3. -Loss of orexin (hypocretin) signaling -Genetic factors DQB1\*0602 haplotype (subtype of DR2) -Brain lesions (rare)
36
Consist of a tetrad of symptoms for narcolepsy? 3
1. Lasts for about 15 minutes each, can be longer. 2. May happen after eating, while driving, talking to someone or during other situations 3. Most often, person wakes up feeling refreshed.
37
Other symtpoms of Narcolepsy: 1. What is Sleep paralysis? 2. What is Cataplexy?
1. generalized flaccidity of muscles with full consciousness in the transition zone between sleep and wakening 2. This is a sudden loss of muscle tone in small muscles or generalized muscle weakness while awake that makes them slump to the floor unable to move. Strong emotions can trigger this.
38
1. How long to most cateplexy episodes last? 2. What may follow these episodes?
1. Most attacks last less than 30 seconds 2. Hypnagogic hallucinations, visual or auditory, which may precede sleep or occur during the sleep attack
39
Diagnosis of Narcolepsy? 5
1. History of daytime sleepiness 2. Absence of underlying nocturnal sleep disorders 3. Epworth Sleepiness Scale 4. Polysomnogram (PSG) 5. Multiple sleep latency test
40
What will we see on the PSG? 4
1. EEG, 3. eye movements (EOG), 3. muscle activity (EMG) 4. heart rhythm (ECG)
41
Treatment for narcolepsy? 4
1. Good sleep hygiene 2. Take one to three planned 15-20 minute naps/day 3. Avoid certain drugs 4. Medications
42
1. First line therapy for narcolepsy? 2. Second line therapy for narcolepsy?
1. Modafinil (Provigil) 2. Dextroamphetamine
43
State the MOA, Preg cat, and SE of the drug: 1. Modafinil (Provigil) (4SE)? 2. Dextroamphetamine (3SE)?
1. -MOA: not well understood, but may increase dopaminergic signaling -Preg C Side-effects common -HA -Nausea -Nervousness -Dry mouth 2. -MOA: not well understood, but stimulates CNS activity; blocks reuptake and increases release of norepinephrine and dopamine in extraneuronal space (sympathomimetic) -Preg C Side-effects common -HTN -Anorexia -Addiction
44
Black Box warning for Dextroamphetamine
High abuse potential
45
Sleep Related Breathing Disorders 3
1. Obstructive Sleep Apnea Hypopnea 2. Central Sleeping Apnea 3. Obesity Hypoventilation Syndrome
46
Obstructive Sleep Apnea (OSA) Classic presentation? 4
1. Obese patient 2. Loud snoring 3. Multiple arousals or awakenings during the night 4. Gasping for breath
47
Obstructive Sleep Apnea (OSA) Results in: 5
1. Sleep fragmentation 2. Daytime sleepiness 3. Morning headache 4. Impaired occupational performances 5. Exacerbated by alcohol use at bedtimes and sedative hypnotic drugs
48
Obstructive Sleep Apnea (OSA) Risk factors 4
1. Obesity (BMI \>30) 2. Neck circumference \> 17 inches 3. Narrow airway 4. Large tongue
49
Obstructive Sleep Apnea (OSA) Screening and diagnosis? 4
1. Patient complaints 2. Sleep partner complaints 3. Epworth Sleepiness Scale 4. Sleep studies
50
Polysomnography (PSG)-OSA What are we recording? 9
1. EOG: Electrooculogram (recording eye movements) 2. EMG: Electromyelogram 3. EEG: Electroencephalogram 4. EKG: Electrocardiogram 5. Tracheal noise 6. Nasal & oral airflow 7. Thoracic & abdominal respiratory effort 8. Leg movement 9. Pulse Oximetry, Capnography, End Tidal CO2
51
Treatment for OSA 3
1. Weight loss 2. Smoking cessation 3. CPAP mask
52
What does the CPAP do? 3
1. Air pressure mask 2. Keeps upper airway passages open 3. Delivers O2
53
What are the surgeries for OSA? 2
1. Mandibular advancement 2. Uvulpalatopharyngoplasty
54
1. Central sleep apnea is defined by what? 2. How does it present and how can it be identified? 3. Causes? 3 4. Treatment 3 (what is first line therapy?) 5. What meds are used? 2
1. Defined by repetitive cessation or decrease of both airflow and ventilatory effort during sleep 2. Presents similar to OSA and is identified on polysomnography 3. Causes for CSA: -Stroke or brain tumor -A-fib or CHF -Neuromuscular disorders 4. Treatment -Treat the underlying cause -If patient is symptomatic with no apneic side-effects then monitor Positive airway pressures (CPAP) First line therapy -BPAP may also be used 5. Meds -Acetazolamide (Diamox) -Theophylin
55
What is Pickwickian Syndrome: 1. What is a combination of? 2. Often tired due to what? 3 3. Alveolar hypoventilation results from combination of what two things? 4. Most patients suffer from what?
1. Combination of brain’s control over breathing and obesity. 2. -sleep loss, -poor sleep quality -chronic low blood oxygen levels 3. -blunted ventilatory drive -increase mechanical load imposed on the chest by obesity 4. Obstructive sleep apnea
56
Pickwickian Syndrome: How should we diagnose?
Polysomnogram
57
Pickwickian Syndrome: Treatment? 5
1. Weight loss (diet and surgery) 2. BiPAP 3. Respiratory stimulants 4. O2 5. Tracheostomy (severe cases)
58
What are the respiratory stimulants we may use for Pickwickian Syndrome? 3
1. Theophylline, 2. acetazolamide 3. medroxyprogesterone acetate
59
1. Circadian Rhythm Disorders are defined as what? 2. The disruption results from what two things? 2
1. A disruption in a person’s internal body clock that regulates a 24-hour cycle of biological process Disruption results from either 1. a malfunction in “internal body clock” or 2. mismatch between “internal body clock” and the external environment regarding timing and duration of sleep
60
Circadian Rhythm Disorders: Common disorders include? 5
1. Delayed sleep phase disorder (DSPD) 2. Advanced sleep phase disorder (ASPD) 3. Non-24-Hour sleep-wake disorder (NON-24) 4. Irregular sleep-wake disorder (ISWD) 5. Shift work disorder
61
Delayed sleep phase disorder Most common in adolescents/young adults: 1. “night owl” tendencies delay what? 2. If the pt is allowed to do what they are usually ok? 3. Causes what? Most are often alert, productive, and creative late at night
1. sleep onset 2. sleep onset 3. daytime sleepiness
62
Advanced sleep phase disorder 1. Is usually seen in who? 2. Describe when they go to sleep and when they wake up? 3. At what times do they experience sleepiness?
1. Usually seen in elderly 2. Person has early evening bedtimes (6-9pm) and early morning waking (2-5am) 3. Are usually sleepy in late afternoon or early evening
63
1. Non-24-Hour sleep-wake disorder is described as what? 2. Who is it commonly seen in? 3. Symtpoms? 4 4. Treatment? (med treatment in non-blind) (med treatment in blind)
1. Condition in which a person’s day length is longer than 24 hours 2. Commonly see in the blind 3. Symptoms -Cognitive dysfunction -Confusion -Extreme fatigue -HA 4. Treatment -Bright light therapy and melatonin -Hetlioz (tasimelteon): First drug for Non-24 in blind patients
64
1. Hetlioz (tasimelteon) MOA? 2. Preg Cat? 3. SE? 2
1. binds to melatonin MT1 and MT2 receptors 2. Preg C 3. Side-effects -HA -Abnormal dreams
65
1. What is Irregular sleep-wake syndrome? 2. Who does it usually occur in? 3. Symptoms? 3
1. sleeping without any real schedule. 2. It usually occurs in a person who has a problem with brain function and who does not have a regular routine during the day. 1. Sleeping or napping more than usual during the day 2. Trouble falling asleep and staying asleep at night 3. Waking up often during the night
66
What is shift work disorder?
People who rotate shifts or work at night Work schedule conflicts with circadian rhythm Results in insomnia or excessive sleepiness
67
Treatment for shift work disorder? 3
1. Light therapy 2. Combination of planned sleep scheduling, timed light exposure, and timed melatonin 3. Good sleep hygiene
68
Non-rapid eye movement sleep arousal disorders are what three?
1. Sleepwalking 2. Sleep terrors 3. Enuresis
69
Sleepwalking (somnambulism) 1. Occurs during what stages? 2. What can happen when they are aroused? 3. Do they remember the event? 4. Causes? 2
1. Occurs during sleep stages 3 & 4 2. Can be agitated or aggressive when aroused 3. No recollection of event 4. Causes -Idiosyncratic drugs (marijuana, ETOH) -Medical conditions (seizures)
70
1. What are Night terrors (pavor nocturnus)? 2. During what stages of sleep? 3. Occurs in what demographic most often? 4. What is it difficult to do during a night terror episode? 5. Do they remember the event? 6. SYmptoms? 3
1. Abrupt terrifying arousal from sleep 2. Stages 3&4 3. Usually preadolescent boys 4. Hard to wake person during episode 5. Unable to recall the event 6. Symptoms -Fear -Sweating -tachycardia
71
Treatment for Night terrors? 5
Improving sleep is the first line treatment -Setting a regular bedtime -Practicing relaxation -Limit food or drink before sleeping -Establishing a bedtime routine -Scheduled awakenings
72
1. What is enuresis? 2. Who is it more common in? 3. Usually occurs when? 4. Do they remember the episode? 5. Treatment? 5 (what is first line?) What are the medications?3
1. Involuntary micturition during sleep in a person with voluntary control 2. More common in children Usually in the 3rd or 4th hour of bedtime 3. Not limited to any stage of sleep 4. Amnesia for event is common 5. Treatment -Simple behavioral interventions first-line approaches -DDAVP (desmopressin) 0.2-0.6mg daily -Oxybutynin (Ditropan) 2.5-5mg PO tid or at bedtime -Imipramine 50-100mg PO at bedtime -Alarm systems
73
1. Rapid eye movement sleep behavior disorder are chracterized by what? 2. Ranges to and from what levels of severity? 3. Among young adults who take what? 3 4. Diagnosis? 5. Three treatments? (first line)
1. Characterized by dream-enactment that happens during a loss of REM sleep atonia 2. Ranges from hand gestures to violent thrashing, punching and kicking 3. -antidepressant meds, -narcolepsy, or -alpha-synyclein neurodegeneration (Elderly population) 4. Diagnosis Polysomnography 5. Treatment -Establishing a safe sleep environment is the primary goal -Melatonin (First-line therapy) -Clonazepam
74
Melatonin (First-line therapy) 1. MOA? 2. SE? 3
MOA: Prepares the body for sleep Side-effects 1. Abnormal heartbeat, 2. dizziness, 3. fatigue
75
Causes of RLS? 9
1. Chronic kidney disease 2. Diabetes 3. Iron deficiency 4. Parkinson’s disease 5. Peripheral neuropathy 6. Pregnancy 7. Use of certain medications such as caffeine, calcium channel blockers, lithium or neuroleptics 8. Withdrawal from sedative 9. Chronic Venous insufficiency
76
RLS Treatments 4
1. Stretching, massage, warm baths 2. Avoid caffeine containing products such as chocolate, coffee, tea and soft drinks 3. Treat or control underlying disease 4. Medications:
77
What are the mediations for RLS? 1. First line? 2. First and second line after that? 2
1. Iron supplement -Try first with non-pharm options First-line after the above has been tried 2. Dopamine agonist Ropinirole (Requip) 3. Alpha-2-delta calcium channel ligands Gabapentin
78
1. What is bruxism? 2. What would we find in the history? 3 3. Treatment? 4
1. Teeth gnashing/grinding 2. Hx: -pt c/o jaw soreness, -flattening of teeth -radiating AM headaches 3. Treatment: -Clonazepam -Botox -Referral to be custom fitted for nocturnal oral appliances -Relaxation and behavioral therapy
79
1. What is Periodic Limb Movement Disorder (PLMD) 2. Diagnoses? 3. Treatment? 3 (first line)
1. Patient moves limbs involuntarily during sleep and has symptoms or problems related to the movement. 2. with aid of a Polysomnogram (PSG) 3. -Doamine agonist first-line -Anticonvulsants -benzodiazepines
80
1. What is an EEG? 2. USes? 3
1. Measures and records the electrical activity of the brain. 1. Study sleep disorders 2. Diagnose epilepsy and see what type of seizure 3. Check for problems with LOC or dementia
81
1. In outpatient sleep study what do we record? 2. In inpatient sleep study what do we record?
1. Outpatient: -Overnight Oximetry -Actigraphy (measures gross motor activity) 2. Inpatient: -Polysomnogram -Multiple Sleep Latency Test
82
What is the Epworth Sleepiness Scale?
0 = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping Situation: Chance of Dozing or Sleeping while sitting and reading ____ Watching TV ____ Sitting inactive in a public place ____ Being a passenger in a motor vehicle for an hour or more ____ Lying down in the afternoon ____ Sitting and talking to someone ____ Sitting quietly after lunch (no alcohol) ____ Stopped for a few minutes in traffic while driving ____ Total score (add the scores up) \_\_\_\_
