Sleep Disorders and Pharm Flashcards

1
Q

What neurotransmitters are thought to play a role in the sleep-wake cycle

A

Serotonin: arousal promoting

NE: arousal promoting

GABA: sleep promotig
Histamine:arousal promoting

Orexin: regulates arousal, wakefulness, and appetite

Ach
Dopamine

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2
Q

SLeep is divided into two categories, what are they? Describe each.

A
  1. REM (increase in eye movement, heart rate, breathing, HR, BP, & temp)
  2. Non-REM (4 stages)
    * REM + Non-REM = 90minute cycles

Description:
Non-REM: stages 1 &2 cyclic waxing and waning of TV and RR, have periodic breathing (periods of apnea), stage 3&4 breathing becomes more regular.

REM: resp become irregular and may include short periods of apnea.

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3
Q

What are the types of Sleep Disorders?

A
  • Insomnia
  • Hypersomnolence
  • narcolepsy
  • breathing-related sleep disorders
  • circadian rhythm sleep wake disorders
  • Non-REM sleep arousal disorders
  • REM sleep Behavior disorder
  • Movement Disorder
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4
Q

Insomnia:

  • what is this?
  • most common in who?
  • risk factors
A

What: difficulty initiating, maintaining sleep, or waking up early in the AM without the ability to return to sleep.

  • most common in women
  • Risk factors: Stress, caffeine, physical discomfort, daytime napping, early bedtimes, alcohol abuse, heavy smoking, depression, & manic disorders
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5
Q

Etiologies of Insomnia

A

Medical Conditions: cardiac, neurological, pulmonary, GI (acid reflux), substances (stimulants, caffeine, alcohol, corticosteroids, bronchodilators

Psychiatric Conditions: depression, Anxiety, PTSD, Panic disorder, psychotrophic meds

Environmental problems:
-bereavement, shift work, jet lag, changes in altitude

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6
Q

Sx of insomnia

A
  • difficulty falling asleep and staying asleep
  • daytime sleepiness
  • irritability
  • fatigue/malaise
  • increased errors or accidents
  • poor social or educational dysfunction
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7
Q

Dx and Tx of Insomnia

A

Dx:

  • sleep hx; # of awakenings, duration of awakening, duration of the problem
  • sleep log: bedtime, duration until sleep onset, final awakening time

Tx:
-Before therapy most patients are asked to maintain sleep log for 2-4wks, perform good sleep hygiene, avoid caffeine, nicotine, alcohol 6-8hrs before bedtime

-Meds: *short term use is preferred to restore normal sleep pattern, hypnotic drugs are used for 2wks or less

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8
Q

Insomnia Medications:

  • for each what is the half life, preg category, and MOA
  • trouble getting to sleep
  • trouble maintaining sleep
  • other
  • orexin receptor antagonists
A

Trouble getting to sleep:
-Ambien 1st line: half life 1.5-2.4hrs, Preg B, MOA: GABA

-Zaleplon(Sonata): alternative

Trouble Maintaining SLeep:
-Lunesta: Half life 5-7hrs, Preg C, MOA: GABA

Other:

  • Benzodiazepines (Triazolam, lorazepam, estazolam); MOA: GABA
  • be careful in those with breathing difficulties (COPD)

-Melatonin Agonists (Ramelteon); half life: 1.5-5hrs

Orexin receptor antagonists: Belsomra, MOA: inhibits orexin, Preg C

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9
Q

Hypersomnolence Disorder

  • what is this?
  • commonly affects who?
  • sx
A

What: recurrent epidsodes of excessive daytime sleepiness or prolonged nighttime sleep that is not caused by medications, medical conditions, not getting enough sleep, or insomnia.

  • Most commonly affects adolescents and young adults
  • Sx: anxiety, increased irritation, decreased energy
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10
Q

Hypersomnolence Disorder:

-diagnostic criteria

A

-excessive sleepiness for at least 1 mo (acute) or at least 3 mo (persistent) as evidence by either prolonged sleep episodes or daytime sleep episodes that occur at least 2 times per week.

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11
Q

Hypersomnolence disorder:

-Tx

A

-non-pharm: takes naps whenever possible, maintain regular sleep schedule, avoid alcohol and meds that cause drowsiness

Pharm:
1st line: Provigil, Preg C
2nd line: Dextroamphetamine; stimulates CNS, Preg C, BBW: high potential for abuse

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12
Q

Narcolepsy

  • what is this?
  • most common in what age?
  • causes
A

What: daytime sleepiness

Most common in teens and early twenties

  • Causes: loss of orexin(hypocretin)
  • genetic
  • brain lesion
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13
Q

Narcolepsy:

-sx and symptoms

A
  • extreme drowsiness during the day with a strong urge to sleep, often followed by a short nap (sleep attack)
  • naps last about 15minutes each, may happen after eating, while driving, talking to someone, etc. Wake up feeling refreshed

Tetrad of Sx:
-sleep paralysis (generalized flaccidity of muscles)

  • cataplexy: sudden loss of muscle tone in muscles while awake that makes them slump to the floor unable to move; may be triggered by strong emotions. usually last less than 30seconds
  • hypnagogic hallucinatinos: visual or auditory which may precede or occur during the sleep attack
  • excessive daytime sleepiness
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14
Q

Narcolepsy:

  • dx
  • tx
A

Dx:

  • hx of daytime sleepiness
  • absence of underlying nocturnal sleep disorders
  • epworth sleep scale
  • polysonogram (EEG, eye movements, EMG, EKG)
  • multiple sleep latency test (series of naps 2hrs apart and measure the REM cycle for each nap)

Tx:

  • good sleep hygiene
  • take 1-3 planned 15-20min naps/day
  • Meds:
  • -1st line: Provigil, Preg C
  • -2nd line: Dextroamphetamine; Preg C, BBW: abuse potential
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15
Q

Sleep related Breathing Disorders:

-what are the 3 types?

A
  • obstructive sleep apnea hypopnea
  • central sleep apnea
  • obesity hypoventilation syndrome
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16
Q

Obstructive Sleep Apnea:

  • most common in who?
  • presentation
  • results in…
  • risk factors
A

Most common in middle aged or elderly men

Presentation:

  • obese
  • loud snoring
  • multiple arousals during night
  • gasping for breath

Result in:

  • daytime sleepiness
  • morning HA
  • impaired performance
  • exacerbated by alcohol use at bedtime

Risk Factors:

  • Obesity (BMI greater than 30)
  • Neck circumference is greater than 17 inches
  • narrow airway
  • large tongue
17
Q

Obstructive Sleep apnea

  • screening and dx
  • tx
A

Screening and Dx:

  • Epworth Sleepiness scale
  • Sleep studies:
  • -Polysomnography (PSG)
  • –Electrooculogram
  • –electromyelogram
  • –electroencephalogram
  • –electrocardiogram
  • –tracheal noise
  • –nasal and oral airflow
  • –thoracic and abd resp effort
  • –leg movement
  • –pulse ox, capnography, tidal CO2

Tx:

  • weight loss
  • smoking cessation
  • CPAP
  • oral appliances
  • Surgery: mandibular advancement, uvulopalatopharyngoplasty
18
Q

Central Sleep Apnea

  • what is this:
  • cause
  • tx
A

What: repetitive cessation or decrease of both airflow and ventilatory effort during sleep

Cause:

  • stroke/brain tumor
  • Afib, CHF
  • neuromuscular disorder

Tx:

  • treat underlying cause
  • CPAP = 1st line … did he mean BIPAP?
  • Meds: acetazolamide, Theophylin
19
Q

Pickwickian Syndrome:

  • aka
  • what?
  • dx
  • tx
A

Aka: obesity hypoventilation syndrome

What: combo of brains control over breathing and obesity. (blunted ventilatory drive and increase mechanical load on the chest by obesity)

-often tired d/t sleep loss/poor sleep quality/chronic low blood O2 levels.

Dx: PSG polysomnogram

Tx:

  • weight loss
  • BiPAP
  • resp stimulants: theophylline, acetazolamide
  • O2
  • Tracheostomy in severe cases
20
Q

Circadian Rhythm Disorders

  • what?
  • what are the common disorders?
A

WHat: a disruption in a persons internal body clock that regulates a 24hr cycle of biological processes.
–disruption may result from either a malfunction in “internal clock” or mismatch between “internal body clock” and the external environment.

Disorders:

  • delayed sleep phase disorder
  • advanced sleep phase disorder
  • non-24hr sleep wake disorder
  • irregular sleep-wake disorder
  • shift work disorder
21
Q

Delayed Sleep Phase disorder:

  • most common in who?
  • characteristics

Advanced Sleep Phase Disorder:

  • most common in who?
  • characteristics
A

Delayed SLeep phase disorder:

  • most common in adolescents/young adults
  • characteristics: “night owl”, sleeps in, most alert, productive, and creative late at night.

Advanced SLeep:

  • most common in elderly
  • early bedtimes and early morning wakenings, “morning larks”
22
Q

Non-24hr sleep-wake disorder

  • what is this?
  • commonly seen in who?
  • sx
  • tx
A

What: condition in which a persons day length is longer than 24hrs

Commonly seen in the blind

Sx:

  • cognitive dysfunction
  • confusion
  • extreme fatigue
  • HA

Tx:

  • bright light therapy, melatonin
  • Hetlioz (Tasimelteon): DOC for blind pts.
23
Q

Irregular sleep-wake syndrome:

  • what is this?
  • sx
A

What: sleeping without a sleep schedule

sx: sleeping or napping more than usual during the day, trouble falling asleep or staying asleep, waking up often during the night

24
Q

Shift Work Disorder:

  • what?
  • tx
A

What; ppl who rotate shifts or work at night, work schedule conflicts with circadian rhythm, results in insomnia or excessive sleepiness

Tx: light therapy, combination of planned sleep schedule, timed light exposure, and timed melatonin
-good sleep hygiene

25
Q

Non-rapid eye movement sleep arousal disorders;

what are the 3 types?

A
  • sleepwalking
  • sleep terrors
  • enuresis
26
Q

Sleep walking:

  • aka
  • occurs during what stages of sleep?
  • causes
  • most common among what ages?
A

aka: somnambulism

occurs during sleep stages 3-4 of Non-REM and in REM sleep

Cause:

  • idiosyncratic drugs (marijuana, ETOH)
  • medical conditions (seizures)

Common in ages 8-12yrs old

27
Q

Night terrors

  • aka
  • occurs during what sleep stages?
  • common in who?
  • describe these to me.
  • tx
A

aka: Pavor nocturnus

occurs during stages 3&4 Non-REM

common in preadolescent boys

Description: abrupt terrifying arousal from sleep, marked vocalization, hard to wake up, unable to recall event.
*fear, sweating, tachycardia

Tx:

  • improve sleep by…
  • -setting a regular bedtime
  • -practice relaxation
  • -limit food or drink before sleep
  • -establish bedtime routine
  • -scheduled awakenings
28
Q

Enuresis

  • what is this?
  • common in who?
  • occurs during what stage of sleep?
  • tx
A

What: involuntary micturition during sleep in a person with voluntary control “ you pee the bed “ - Lauren Theis

Common in children

Occurs during stages 3&4 non REM

Tx:

  • simple behavioral interventions are 1st line approaches.
  • DDAVP (desmopressin) (clotting promoter and antidiuretic)
  • oxybutynin
  • imipramine
  • alarm system
29
Q

Rapid Eye movement Sleep Behavior Disorder

  • what is this?
  • potential causes
  • dx
  • tx
A

What: dream enactment that happens during a loss of REM sleep atonia, ranges from hand gestures to violent thrashing, punching, and kicking

Cause:
-antidepressants, narcolepsy, or alpha-synuclein neurodegeneration (eldery population)

Dx:
-polysomnography (PSG)

Tx:

  • establish safe sleep enviornment
  • melatonin = 1st line
  • clonazepam
30
Q
Movement Disorder: 
RLS
-what is this?
-cause 
-tx
A

What: urge to move legs to stop unpleasant sensations

Cause: DM, Parkinsons, Pregnancy, peripheral neuropathy, iron deficiency,
caffeine, chronic venous insufficiency

Tx:

  • stretching, massage, warm baths
  • avoid stimulants
  • Meds:
  • -iron supplememnt if iron deficient
  • -Dopamine agonist (requip)
  • alpha-2 delta Ca chennel ligand (Gabapentin)
31
Q

Bruxism

  • aka
  • common hx complaints
  • tx
A

aka: teeth grinding

Hx: jaw soreness, flattening of teeth radiating AM HAs.

Tx:

  • clonazepam
  • botox
  • nocturnal oral appliances
  • relaxation and behavioral therapy
32
Q

Periodic Limb Movement Disorder:

  • what?
  • dx
  • tx
A

What: pt moves limbs involuntarily during sleep and has sx or problems related to the movements.

Dx: PSG

Tx:

  • dopamine agonists = 1st line
  • anticonvulsants
  • benzodiazepines