Sleep Disorders and Pharm Flashcards
What neurotransmitters are thought to play a role in the sleep-wake cycle
Serotonin: arousal promoting
NE: arousal promoting
GABA: sleep promotig
Histamine:arousal promoting
Orexin: regulates arousal, wakefulness, and appetite
Ach
Dopamine
SLeep is divided into two categories, what are they? Describe each.
- REM (increase in eye movement, heart rate, breathing, HR, BP, & temp)
- 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.
What are the types of Sleep Disorders?
- Insomnia
- Hypersomnolence
- narcolepsy
- breathing-related sleep disorders
- circadian rhythm sleep wake disorders
- Non-REM sleep arousal disorders
- REM sleep Behavior disorder
- Movement Disorder
Insomnia:
- what is this?
- most common in who?
- risk factors
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
Etiologies of Insomnia
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
Sx of insomnia
- difficulty falling asleep and staying asleep
- daytime sleepiness
- irritability
- fatigue/malaise
- increased errors or accidents
- poor social or educational dysfunction
Dx and Tx of Insomnia
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
Insomnia Medications:
- for each what is the half life, preg category, and MOA
- trouble getting to sleep
- trouble maintaining sleep
- other
- orexin receptor antagonists
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
Hypersomnolence Disorder
- what is this?
- commonly affects who?
- sx
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
Hypersomnolence Disorder:
-diagnostic criteria
-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.
Hypersomnolence disorder:
-Tx
-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
Narcolepsy
- what is this?
- most common in what age?
- causes
What: daytime sleepiness
Most common in teens and early twenties
- Causes: loss of orexin(hypocretin)
- genetic
- brain lesion
Narcolepsy:
-sx and symptoms
- 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
Narcolepsy:
- dx
- tx
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
Sleep related Breathing Disorders:
-what are the 3 types?
- obstructive sleep apnea hypopnea
- central sleep apnea
- obesity hypoventilation syndrome
Obstructive Sleep Apnea:
- most common in who?
- presentation
- results in…
- risk factors
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
Obstructive Sleep apnea
- screening and dx
- tx
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
Central Sleep Apnea
- what is this:
- cause
- tx
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
Pickwickian Syndrome:
- aka
- what?
- dx
- tx
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
Circadian Rhythm Disorders
- what?
- what are the common disorders?
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
Delayed Sleep Phase disorder:
- most common in who?
- characteristics
Advanced Sleep Phase Disorder:
- most common in who?
- characteristics
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”
Non-24hr sleep-wake disorder
- what is this?
- commonly seen in who?
- sx
- tx
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.
Irregular sleep-wake syndrome:
- what is this?
- sx
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
Shift Work Disorder:
- what?
- tx
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
Non-rapid eye movement sleep arousal disorders;
what are the 3 types?
- sleepwalking
- sleep terrors
- enuresis
Sleep walking:
- aka
- occurs during what stages of sleep?
- causes
- most common among what ages?
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
Night terrors
- aka
- occurs during what sleep stages?
- common in who?
- describe these to me.
- tx
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
Enuresis
- what is this?
- common in who?
- occurs during what stage of sleep?
- tx
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
Rapid Eye movement Sleep Behavior Disorder
- what is this?
- potential causes
- dx
- tx
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
Movement Disorder: RLS -what is this? -cause -tx
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)
Bruxism
- aka
- common hx complaints
- tx
aka: teeth grinding
Hx: jaw soreness, flattening of teeth radiating AM HAs.
Tx:
- clonazepam
- botox
- nocturnal oral appliances
- relaxation and behavioral therapy
Periodic Limb Movement Disorder:
- what?
- dx
- tx
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
