Sleep Disorders - Exam 3 Flashcards
What are the 2 physiologic state of sleep?`
Non-rapid eye movement (NREM) sleep
Rapid eye movement (REM) sleep
Non-rapid eye movement (NREM) sleep is ____ stages. When does it start? How long is each stage?
composed of 1-4 stages
Usually how the sleep cycle begins
Each stage - 5-15 minutes
What state of sleep does dream activity happen in? Brain activity is (high/low)
REM sleep
brain activity is high
Non-REM sleep are composed of physiologic functions are markedly ____ compared with wakefulness. What happens to the pulse, respirations and BP?
reduced
all decrease
Are there any erections in NREM sleep? Typical sleep cycle will go through _____ before REM sleep occurs
seldom any penile erections
stages 1-4
What are the differences between the stages of sleep?
Stage 1 - Decreased activity from wakefulness
easily awakened. May feel like they “haven’t slept” if awakened
Stage 2: light sleep with spontaneous periods of muscle tone followed by muscle relaxation. Body is preparing to enter deep sleep
Stage 3-4: “delta wave” sleep
Stage 4 is more intense than stage 3
repair and regeneration happens here
What stage of sleep? May feel like they “haven’t slept” if awakened
Stage 1
What stage of sleep? May have feeling of falling → hypnic myoclonia
Stage 1
What stage of sleep? Light sleep with spontaneous periods of muscle tone followed by muscle relaxation. Body is preparing to enter deep sleep
Stage 2
What stage of sleep? Repair and regeneration
Builds bone and muscle. Appears to strengthen the immune system. What happens if you awake them during this stage?
Stage 3 and 4
often disoriented, Brief arousals associated with amnesia
In ____ sleep physiologic activity increased compared to ____ sleep
REM sleep physiological activity is increased compared to NREM
Almost every ____ period in men accompanied by a partial or full penile erection. With ______ of skeletal muscles
REM
near-total paralysis of skeletal muscles
What is the most distinctive feature of REM sleep?
dreaming (that you remember)
May dream in NREM sleep, but usually don’t remember
____ occur about every 90-100 minutes. They have _____ periods earlier in sleep
REM phases
shorter periods earlier in sleep
Which REM period is usually the shortest? How long are the later REM periods? When do more REM periods occur?
First REM period usually shortest ( < 10 min )
Later REM periods may last 15-40 minutes each
More REM periods occur in last third of the night
NREM sleep happens in what phase?
Stage 4 (a little in stage 3)
prevention of serotonin synthesis or destruction of dorsal raphe nucleus = ______.
(more/less) serotonin = less sleep
decreased sleep
less serotonin = less sleep
increased firing of noradrenergic neurons (through drugs or other manipulations) = ____ REM sleep, increased wakefulness
(more/less) norepinephrine = less sleep
less
more norepinephrine = less sleep
______ released naturally by our bodies’ pineal gland in response to low light conditions
(more/less) melatonin = less sleep
Melatonin
less melatonin = less sleep
_______ suppresses secretion of melatonin by the pineal gland; occurs naturally at the end of the “dark phase” (night)
(more/less) dopamine = less sleep
Dopamine
more dopamine = less sleep
_____ slowly decreases over time
_____ of REM sleep time - 10 years old (stabilizes)
REM Sleep
20-25% of sleep time is REM at 10 years old
As you age, Stage 4 NREM also ______; often nearly absent by ___
decreased
70
aka no more stage 3-4 when the body regenerates
Describe the sleep patterns of a healthy young adult
Regular cycling between stage 1 and stage 4 sleep
Prolonged stage 4 periods earlier in sleep period
REM sleep phases - gradually lengthen as the night goes on
Describe the sleep pattern of an elderly adult
Decreased or absent deep sleep stages (3-4)
More easily awakened from sleep
Less regular cycles
Overall increased daytime fatigue and napping
Overall decreased quality of nocturnal sleep
When does stage 3 and 4 REM occur more frequently in normal young adults?
more stage 3-4 REM sleep happens at the beginning on the sleep cycle
What does increased sleep onset latency mean? When is it commonly seen?
takes more time to fall asleep
commonly seen in depressed patients
What is the criteria for an insomnia dx?
1+ month of:
Difficulty initiating or maintaining sleep
Nonrestorative or poor quality sleep
Early morning awakening
Symptoms occur despite adequate opportunity and circumstances for sleep
impaired sleep produces deficits in daytime function
What is the difference between transient, acute and chronic insomnia?
transient: less than 7 days
acute: less than 30 days
chronic: 30+ days
How does alcohol influence sleep? include acute, chronic and withdrawal
Acute alcohol intake → decreased sleep latency, REM sleep pattern changes, vivid dreams, frequent awakening
Chronic alcohol abuse → increased stage 1 and decreased REM
Alcohol withdrawal → delayed sleep onset, intermittent awakening
What is the treatment for insomnia?
treat the underlying cause!!
CBT!!
Pharmacologic treatment
Relaxation techniques
Meditation
Cognitive Behavioral Therapy
Regular Exercise
**Sleep Hygiene
What are the OTC first gen antihistamine?
Diphenhydramine (Benadryl, Sominex)
Doxylamine (Unisom)
What are the 3 Benzodiazepine Receptor Agonists?
Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)
What are the 2 melatonin agonists?
Ramelteon (Rozerem)
Melatonin (OTC supplement)
What are the benzos that are indicated for insomnia? How long should they be prescribed for?
Temazepam (Restoril), Flurazepam (Dalmane)
alprazolam (Xanax), lorazepam (Ativan),
clonazepam (Klonopin), oxazepam (Serax)
_______ newest class of drugs; orexin naturally promotes wakefulness
Dual Orexin Receptor Antagonists
Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)***
Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)
are all included in what drug class?
what are common SE?
Dual Orexin Receptor Antagonists
do NOT cause SE like ambien does
_____ is a low-dose TCA used for insomnia
____ is a serotonin modulator used for insomnia
_____ is a TeCA used for insomnia
Doxepin (Silenor)
Trazodone (Desyrel, Oleptro)
Mirtazapine (Remeron)
**What are some of the guidelines for sleep hygiene?
Establish a Regular Sleep Schedule
Cut Down on Excess Time in Bed
Make Bedroom Comfortable
relax before bedtime
regular exercise
What are the MC pt population that have narcolepsy?
equal in men and women usually begins in their 20s
What are the classic tetrad of narcolepsy? What percent of pts have all 4 symptoms?
Recurrent irresistible attacks of daytime
sleepiness
Cataplexy
Hallucinations
Sleep paralysis
Estimated that only 10-15% of narcoleptic patients have all 4 symptoms
What is the criteria for narcolepsy?
Recurrent irresistible attacks of daytime sleep
unexpected, attacks that occur on a daily basis for at least 3 months
Usually 2-6 times a day, 10-20 minutes per episode
What is cataplexy? What percent of pts does it
25-30% of narcolepsy patients
Brief, sudden bilateral loss of muscle tone
Often associated with emotional trigger
Localized (jaw drop, head sag) to generalized (full collapse)
What are the 2 different types of hallucinations? When do they happen?
Hypnagogic (on falling asleep)
Hypnopompic (on awakening)
**Hypnagogic hallucinations happen _____
**Hypnopompic hallucinations happen ______
on falling asleep
on awakening
______ transient generalized inability to move or speak during the transition between sleep and wakefulness
Sleep paralysis
How do you dx narcolepsy?
Multiple sleep latency test (MSLT)
Recorded naps - show rapid onset of sleep and REM sleep (2 or more REM cycles during test)
Shortened REM latency period
What is the tx for narcolepsy?
forced naps
stimulants: Modafinil (Provigil), Methylphenidate (Ritalin), dextroamphetamine (Dexedrine)
SSRI/SNRIs: help with symptomatic tx of cataplexy, sleep paralysis, hallucinations, suppress REM sleep
Somnambulism occurs in ___ percentage of people. What gender?
15-17%
males
When during the night is somnambulism most common? Is it easy to wake the pt? Do they remember it?
Usually in first ⅓ of night (stage 3-4 NREM sleep)
DIFFICULT to wake the pt
no memory of the episode
What is the tx for somnambulism?
Avoid fatigue
Minimize interventions (slapping, shouting)
Lead patient back to bed
Protect from accidents
Locks on doors and windows
What is sleep-related bruxism? What sleep cycle stage? What are some signs? What are they vulnerable to? What is the tx?
Involuntary, non-functional, forceful clenching, grinding, or rubbing of teeth during NREM sleep
HA and TMJ disorders
tooth wear
occlusive splints to prevent grinding, reduce anxiety
What are circadian rhythm disorders?
Misalignment between the environment and an individual’s sleep-wake cycle
can be chronic or recurrent
What are the 6 kinds of circadian rhythm disorders?
Delayed Sleep Phase Type
Jet Lag Type
Shift Work Type
Advanced Sleep Phase Type
Irregular Sleep-Wake Rhythm Type
Non-24-Hour Sleep-Wake Rhythm Type
What type of circadian rhythm disorder? Persistent late sleep onset and late awakening times, with inability to fall asleep and awaken at a desired earlier time. What age is MC? What is the tx?
delayed sleep phase type
more likely in younger pts
bright light in the early morning
What type of circadian rhythm disorder? Characterized by insomnia or excessive sleepiness that occurs because the intrinsic circadian pacemaker is not entrained to a 24-hour light/dark cycle. What pt population is MC?
Non-24-Hour Sleep-Wake Rhythm Type
Often seen in totally blind patients
What type of circadian rhythm disorder? Sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone
Jet Lag Type
eastward travel is worse than westward
What type of circadian rhythm disorder? Insomnia during major sleep period or excessive sleepiness during major awake period associated with night shift work or frequently changing shift work
shift work type
What type of circadian rhythm disorder? Persistent early sleep onset and early awakening times, with an inability to fall asleep and awaken at a desired later time. What age is MC? What is the tx?
Advanced Sleep phase type
MC in elderly pts
bright light in the evening
What type of circadian rhythm disorder? Characterized by lack of a clearly defined circadian rhythm of sleep and wake. MC is what population type?
Irregular Sleep-Wake Rhythm Type
Developmental disorders in children
Neurodegenerative diseases
What is the tx for circadian rhythm disorders?
sleep hygiene
depending on the type: bring in light
melatonin: helps to resynchronise
stimulants: caffeine, modafinil
What is apnea? What is hypopnea?
Apnea - breath cessation for at least 10 seconds
Hypopnea - decreased airflow with drop in oxygen saturation of at least 4%
What are the subtypes of apnea?
central
obstructive
mixed
What type of sleep apnea? ______ absent ventilatory effort during the apneic episode
central
What type of sleep apnea? _______ persistent ventilatory effort persists throughout apneic episode, but no airflow occurs because of transient obstruction of the upper airway
Obstructive
What type of sleep apnea? _____ absent ventilatory effort precedes upper airway obstruction during the apneic episode
mixed
What are some risk factors for obstructive sleep apnea?
Anatomically narrowed upper airways
Ingestion of alcohol or sedatives before sleeping
nasal obstruction
hypothyroidism
cigarette smoking
**What is the classic obstructive sleep apnea pt? What is a common CBC finding? Why?
obese, middle-aged male with HTN
“bull neck” appearance
erythrocytosis, because the body is not getting enough oxygen to the tissue due to decreased intake
What is cor pulmonale? What condition is it associated with?
right sided heart failure
obstructive sleep apnea
How do you dx obstructive sleep apnea?
Home Overnight Pulse Oximetry, if the test is negative (stays in the 90’s the entire night, rules OUT sleep apnea)
overnight polysomnography: Measures EEG, electrooculography, EMG, ECG, pulse oximetry, respiratory effort and airflow while the pt is sleeping
What is the tx for obstructive sleep apnea?
Weight Loss - 10-20% of body weight - can be curative
Strict avoidance of alcohol and hypnotic medications
Mechanical appliances to hold jaw forward
Nasal continuous positive airway pressure (nasal CPAP)
supplemental O2
sx: to create a larger hole in the back of the throat
hypoglassal nerve stimulation: EXPENSIVE!
______ facilitate GABA-mediated inhibition of cell firing by binding to the BZD receptor, a subunit of the GABA receptor complex. Does it help with sleep onset? Describe the effects it has on the sleep cycle
Benzo Receptor Agonists
Sleep quality – Reduced time to sleep onset
sleep cycle: Reduce stage 1 NREM sleep; do not reduce stage 3 NREM sleep (BZDs do); may decrease REM sleep. Long acting agents also reduce wakefulness and increase total sleep time
What are the patient effects of benzo receptor agonists?
Easier to fall asleep, increased total sleep time, less sleep awakening, less daytime sleepiness, improved ability to concentrate
What are advantages of benzo receptor agonists? What is a disadvantage?
-May be slightly safer for pts with chronic respiratory dysfunction (e.g. COPD)
-May be less likely to cause tolerance
0No reduction of deep sleep stages
disadvantage: will not reduce anxiety
What are the benzo receptor agonist? What schedule are they?
Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)
schedule 4
What is the dosing strengths for an elderly pts taking Zaleplon (Sonata)? What is a pt education point? What is the 1/2 life?
In elderly - recommended 5 mg, max 10 mg/d
normal adult: max is 20mg
High-fat meals impair absorption
Very short half-life (0.5 hr)
Is zaleplon better for sleep onset for sleep maintenance?
Better for sleep ONSET, bad for maintenance!!!
**Which sleep aid do you have to give a lower dose to females?
zolpidem
5 mg (females), 5-10 mg (males) PO QHS; max 10 mg/d
What is the pt education for zolpidem? Is immediate release zolpidem good for onset, maintenance or both? What about extended release zolpidem?
Do not take with meals or grapefruit juice
Immediate release - Good for sleep-onset insomnia, bad for sleep-maintenance insomnia; little to no “hangover” or rebound insomnia; not for long-term use
Extended-release - released more slowly; indicated for sleep-onset and sleep-maintenance insomnia; can impair activity the following day
Unpleasant (metallic) taste (8-34%), headache (15-21%), dizziness, drowsiness, impaired next-day activity. These are SE of ______.
What is the pt education point?
Eszopiclone (Lunesta)
Do not take with meals
_____ has the longest 1/2 life of any BZD agonist (5-7 hours). Is ______ good for onset, maintenance or both?
eszopiclone
eszopiclone: Indicated for sleep-onset and sleep-maintenance insomnia
______ max dose in the elderly is 2mg po qhs.
eszopiclone
melatonin is released at night into blood and CSF by ______. How high do the concentrations rise at night? What effect does prolonged use have?
pineal gland
Concentrations are low in the day, rise by 10-30x at night
Prolonged use of exogenous melatonin can desensitize receptors
**______ should be avoided in pts taking warfarin and caution with CNS depressants (due to interaction with anti-seizure meds). What are some SE?
melatonin
Decreased nocturnal BP, drowsiness, worsening insomnia, wild dreams
_____ is the prescription strength melatonin receptor agonist. What is the MOA?
Ramelteon (Rozerem)
Binds with higher affinity to melatonin receptors than melatonin itself
**Do not use Ramelteon (Rozerem) with ________. Avoid in patients with a hx of _____ and in _____. Pt is an important pt education point?
fluvoxamine
Avoid in patients with a history of seizures and in children
Do not administer with a meal
Is Ramelteon (Rozerem) good for onset, maintenance or both? What is the 1/2 life?
Better for sleep onset than sleep maintenance insomnia
1.5-5 hours
What is the MOA of Dual Orexin Receptor Antagonist?
Antagonize orexin receptors which facilitates sleep by decreasing the wake drive
_____ drug interactions: avoid using or use caution if patient is taking in conjunction with any other CNS depressant; CYP34A inhibitors / inducers.
Suvorexant (Belsomra)
Is Suvorexant (Belsomra) good for onset, maintenance or both? What is the 1/2 life?
Indicated for sleep-onset and sleep-maintenance insomnia
Peaks in 2 hours, intermediate half-life (up to 12 hrs)
Which Dual Orexin Receptor Antagonist do you need to decrease dose for the elderly? What is the 1/2 life?
Lemborexant (Dayvigo)
In elderly (>65) max dose 5 mg
Long half-life (17-19 hrs)
Which Dual Orexin Receptor Antagonist is the safest in the elderly? (also the newest) What is the 1/2 life?
Daridorexant (Quviviq)
Intermediate half-life (8 hrs)
Newest FDA approval
_____ needs to be avoided/use caution if patient is taking in conjunction with any other CNS depressant; CYP34A inhibitors / inducers
Daridorexant (Quviviq)
Is Daridorexant (Quviviq)
good for onset, maintenance or both?
Indicated for sleep-onset and sleep-maintenance insomnia
What is the overall caution when using Orexin Receptor Antagonists? **They are CI in _____ patients
Class has significant drug interactions with other CYP34A inhibitors / inducers (dose of ORA must be reduced)
CI in narcoleptic patients
_____ are indicated for narcolepsy and shift work disorder. What schedule? When do you need to avoid?
Modafinil (Provigil)
schedule 4
Avoid using or use caution if patient is taking in conjunction with any other stimulants
_____ are indicated for narcolepsy, carry a risk for respiratory depression and access is restricted in the US. What schedule?
Sodium Oxybates
schedule 3
_____ MOA works because it is a metabolite of GABA and works on GABA-B receptors
Sodium Oxybates
