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Behavioral Dynamics > Sleep Disorders - Exam 3 > Flashcards

Sleep Disorders - Exam 3 Flashcards

1
Q

What are the 2 physiologic state of sleep?`

A

Non-rapid eye movement (NREM) sleep

Rapid eye movement (REM) sleep

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2
Q

Non-rapid eye movement (NREM) sleep is ____ stages. When does it start? How long is each stage?

A

composed of 1-4 stages

Usually how the sleep cycle begins

Each stage - 5-15 minutes

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3
Q

What state of sleep does dream activity happen in? Brain activity is (high/low)

A

REM sleep

brain activity is high

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4
Q

Non-REM sleep are composed of physiologic functions are markedly ____ compared with wakefulness. What happens to the pulse, respirations and BP?

A

reduced

all decrease

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5
Q

Are there any erections in NREM sleep? Typical sleep cycle will go through _____ before REM sleep occurs

A

seldom any penile erections

stages 1-4

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6
Q

What are the differences between the stages of sleep?

A

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

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7
Q

What stage of sleep? May feel like they “haven’t slept” if awakened

A

Stage 1

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8
Q

What stage of sleep? May have feeling of falling → hypnic myoclonia

A

Stage 1

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9
Q

What stage of sleep? Light sleep with spontaneous periods of muscle tone followed by muscle relaxation. Body is preparing to enter deep sleep

A

Stage 2

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10
Q

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?

A

Stage 3 and 4

often disoriented, Brief arousals associated with amnesia

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11
Q

In ____ sleep physiologic activity increased compared to ____ sleep

A

REM sleep physiological activity is increased compared to NREM

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12
Q

Almost every ____ period in men accompanied by a partial or full penile erection. With ______ of skeletal muscles

A

REM

near-total paralysis of skeletal muscles

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13
Q

What is the most distinctive feature of REM sleep?

A

dreaming (that you remember)

May dream in NREM sleep, but usually don’t remember

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14
Q

____ occur about every 90-100 minutes. They have _____ periods earlier in sleep

A

REM phases

shorter periods earlier in sleep

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15
Q

Which REM period is usually the shortest? How long are the later REM periods? When do more REM periods occur?

A

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

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16
Q

NREM sleep happens in what phase?

A

Stage 4 (a little in stage 3)

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17
Q

prevention of serotonin synthesis or destruction of dorsal raphe nucleus = ______.

(more/less) serotonin = less sleep

A

decreased sleep

less serotonin = less sleep

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18
Q

increased firing of noradrenergic neurons (through drugs or other manipulations) = ____ REM sleep, increased wakefulness

(more/less) norepinephrine = less sleep

A

less

more norepinephrine = less sleep

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19
Q

______ released naturally by our bodies’ pineal gland in response to low light conditions

(more/less) melatonin = less sleep

A

Melatonin

less melatonin = less sleep

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20
Q

_______ suppresses secretion of melatonin by the pineal gland; occurs naturally at the end of the “dark phase” (night)

(more/less) dopamine = less sleep

A

Dopamine

more dopamine = less sleep

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21
Q

_____ slowly decreases over time

_____ of REM sleep time - 10 years old (stabilizes)

A

REM Sleep

20-25% of sleep time is REM at 10 years old

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22
Q

As you age, Stage 4 NREM also ______; often nearly absent by ___

A

decreased

70

aka no more stage 3-4 when the body regenerates

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23
Q

Describe the sleep patterns of a healthy young adult

A

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

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24
Q

Describe the sleep pattern of an elderly adult

A

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

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25
Q

When does stage 3 and 4 REM occur more frequently in normal young adults?

A

more stage 3-4 REM sleep happens at the beginning on the sleep cycle

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26
Q

What does increased sleep onset latency mean? When is it commonly seen?

A

takes more time to fall asleep

commonly seen in depressed patients

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27
Q

What is the criteria for an insomnia dx?

A

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

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28
Q

What is the difference between transient, acute and chronic insomnia?

A

transient: less than 7 days

acute: less than 30 days

chronic: 30+ days

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29
Q

How does alcohol influence sleep? include acute, chronic and withdrawal

A

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

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30
Q

What is the treatment for insomnia?

A

treat the underlying cause!!

CBT!!
Pharmacologic treatment
Relaxation techniques
Meditation
Cognitive Behavioral Therapy
Regular Exercise
**Sleep Hygiene

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31
Q

What are the OTC first gen antihistamine?

A

Diphenhydramine (Benadryl, Sominex)
Doxylamine (Unisom)

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32
Q

What are the 3 Benzodiazepine Receptor Agonists?

A

Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)

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33
Q

What are the 2 melatonin agonists?

A

Ramelteon (Rozerem)
Melatonin (OTC supplement)

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34
Q

What are the benzos that are indicated for insomnia? How long should they be prescribed for?

A

Temazepam (Restoril), Flurazepam (Dalmane)

alprazolam (Xanax), lorazepam (Ativan),
clonazepam (Klonopin), oxazepam (Serax)

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35
Q

_______ newest class of drugs; orexin naturally promotes wakefulness

A

Dual Orexin Receptor Antagonists

Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)***

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36
Q

Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)

are all included in what drug class?
what are common SE?

A

Dual Orexin Receptor Antagonists

do NOT cause SE like ambien does

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37
Q

_____ is a low-dose TCA used for insomnia

____ is a serotonin modulator used for insomnia

_____ is a TeCA used for insomnia

A

Doxepin (Silenor)

Trazodone (Desyrel, Oleptro)

Mirtazapine (Remeron)

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38
Q

**What are some of the guidelines for sleep hygiene?

A

Establish a Regular Sleep Schedule

Cut Down on Excess Time in Bed

Make Bedroom Comfortable

relax before bedtime

regular exercise

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38
Q

What are the MC pt population that have narcolepsy?

A

equal in men and women usually begins in their 20s

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39
Q

What are the classic tetrad of narcolepsy? What percent of pts have all 4 symptoms?

A

Recurrent irresistible attacks of daytime
sleepiness
Cataplexy
Hallucinations
Sleep paralysis

Estimated that only 10-15% of narcoleptic patients have all 4 symptoms

40
Q

What is the criteria for narcolepsy?

A

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

41
Q

What is cataplexy? What percent of pts does it

A

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)

42
Q

What are the 2 different types of hallucinations? When do they happen?

A

Hypnagogic (on falling asleep)
Hypnopompic (on awakening)

43
Q

**Hypnagogic hallucinations happen _____

**Hypnopompic hallucinations happen ______

A

on falling asleep

on awakening

44
Q

______ transient generalized inability to move or speak during the transition between sleep and wakefulness

A

Sleep paralysis

45
Q

How do you dx narcolepsy?

A

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

46
Q

What is the tx for narcolepsy?

A

forced naps
stimulants: Modafinil (Provigil), Methylphenidate (Ritalin), dextroamphetamine (Dexedrine)
SSRI/SNRIs: help with symptomatic tx of cataplexy, sleep paralysis, hallucinations, suppress REM sleep

47
Q

Somnambulism occurs in ___ percentage of people. What gender?

A

15-17%

males

48
Q

When during the night is somnambulism most common? Is it easy to wake the pt? Do they remember it?

A

Usually in first ⅓ of night (stage 3-4 NREM sleep)

DIFFICULT to wake the pt

no memory of the episode

49
Q

What is the tx for somnambulism?

A

Avoid fatigue
Minimize interventions (slapping, shouting)
Lead patient back to bed
Protect from accidents
Locks on doors and windows

50
Q

What is sleep-related bruxism? What sleep cycle stage? What are some signs? What are they vulnerable to? What is the tx?

A

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

51
Q

What are circadian rhythm disorders?

A

Misalignment between the environment and an individual’s sleep-wake cycle

can be chronic or recurrent

52
Q

What are the 6 kinds of circadian rhythm disorders?

A

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

53
Q

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?

A

delayed sleep phase type

more likely in younger pts

bright light in the early morning

54
Q

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?

A

Non-24-Hour Sleep-Wake Rhythm Type

Often seen in totally blind patients

55
Q

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

A

Jet Lag Type

eastward travel is worse than westward

56
Q

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

A

shift work type

57
Q

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?

A

Advanced Sleep phase type

MC in elderly pts

bright light in the evening

58
Q

What type of circadian rhythm disorder? Characterized by lack of a clearly defined circadian rhythm of sleep and wake. MC is what population type?

A

Irregular Sleep-Wake Rhythm Type

Developmental disorders in children
Neurodegenerative diseases

59
Q

What is the tx for circadian rhythm disorders?

A

sleep hygiene

depending on the type: bring in light
melatonin: helps to resynchronise
stimulants: caffeine, modafinil

60
Q

What is apnea? What is hypopnea?

A

Apnea - breath cessation for at least 10 seconds

Hypopnea - decreased airflow with drop in oxygen saturation of at least 4%

61
Q

What are the subtypes of apnea?

A

central
obstructive
mixed

62
Q

What type of sleep apnea? ______ absent ventilatory effort during the apneic episode

A

central

63
Q

What type of sleep apnea? _______ persistent ventilatory effort persists throughout apneic episode, but no airflow occurs because of transient obstruction of the upper airway

A

Obstructive

64
Q

What type of sleep apnea? _____ absent ventilatory effort precedes upper airway obstruction during the apneic episode

A

mixed

65
Q

What are some risk factors for obstructive sleep apnea?

A

Anatomically narrowed upper airways
Ingestion of alcohol or sedatives before sleeping
nasal obstruction
hypothyroidism
cigarette smoking

66
Q

**What is the classic obstructive sleep apnea pt? What is a common CBC finding? Why?

A

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

67
Q

What is cor pulmonale? What condition is it associated with?

A

right sided heart failure

obstructive sleep apnea

68
Q

How do you dx obstructive sleep apnea?

A

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

69
Q

What is the tx for obstructive sleep apnea?

A

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!

70
Q

______ 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

A

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

71
Q

What are the patient effects of benzo receptor agonists?

A

Easier to fall asleep, increased total sleep time, less sleep awakening, less daytime sleepiness, improved ability to concentrate

72
Q

What are advantages of benzo receptor agonists? What is a disadvantage?

A

-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

73
Q

What are the benzo receptor agonist? What schedule are they?

A

Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)

schedule 4

74
Q

What is the dosing strengths for an elderly pts taking Zaleplon (Sonata)? What is a pt education point? What is the 1/2 life?

A

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)

75
Q

Is zaleplon better for sleep onset for sleep maintenance?

A

Better for sleep ONSET, bad for maintenance!!!

76
Q

**Which sleep aid do you have to give a lower dose to females?

A

zolpidem

5 mg (females), 5-10 mg (males) PO QHS; max 10 mg/d

77
Q

What is the pt education for zolpidem? Is immediate release zolpidem good for onset, maintenance or both? What about extended release zolpidem?

A

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

78
Q

Unpleasant (metallic) taste (8-34%), headache (15-21%), dizziness, drowsiness, impaired next-day activity. These are SE of ______.

What is the pt education point?

A

Eszopiclone (Lunesta)

Do not take with meals

79
Q

_____ has the longest 1/2 life of any BZD agonist (5-7 hours). Is ______ good for onset, maintenance or both?

A

eszopiclone

eszopiclone: Indicated for sleep-onset and sleep-maintenance insomnia

80
Q

______ max dose in the elderly is 2mg po qhs.

A

eszopiclone

81
Q

melatonin is released at night into blood and CSF by ______. How high do the concentrations rise at night? What effect does prolonged use have?

A

pineal gland

Concentrations are low in the day, rise by 10-30x at night

Prolonged use of exogenous melatonin can desensitize receptors

82
Q

**______ should be avoided in pts taking warfarin and caution with CNS depressants (due to interaction with anti-seizure meds). What are some SE?

A

melatonin

Decreased nocturnal BP, drowsiness, worsening insomnia, wild dreams

83
Q

_____ is the prescription strength melatonin receptor agonist. What is the MOA?

A

Ramelteon (Rozerem)

Binds with higher affinity to melatonin receptors than melatonin itself

84
Q

**Do not use Ramelteon (Rozerem) with ________. Avoid in patients with a hx of _____ and in _____. Pt is an important pt education point?

A

fluvoxamine

Avoid in patients with a history of seizures and in children

Do not administer with a meal

85
Q

Is Ramelteon (Rozerem) good for onset, maintenance or both? What is the 1/2 life?

A

Better for sleep onset than sleep maintenance insomnia

1.5-5 hours

86
Q

What is the MOA of Dual Orexin Receptor Antagonist?

A

Antagonize orexin receptors which facilitates sleep by decreasing the wake drive

87
Q

_____ drug interactions: avoid using or use caution if patient is taking in conjunction with any other CNS depressant; CYP34A inhibitors / inducers.

A

Suvorexant (Belsomra)

88
Q

Is Suvorexant (Belsomra) good for onset, maintenance or both? What is the 1/2 life?

A

Indicated for sleep-onset and sleep-maintenance insomnia

Peaks in 2 hours, intermediate half-life (up to 12 hrs)

89
Q

Which Dual Orexin Receptor Antagonist do you need to decrease dose for the elderly? What is the 1/2 life?

A

Lemborexant (Dayvigo)

In elderly (>65) max dose 5 mg

Long half-life (17-19 hrs)

90
Q

Which Dual Orexin Receptor Antagonist is the safest in the elderly? (also the newest) What is the 1/2 life?

A

Daridorexant (Quviviq)

Intermediate half-life (8 hrs)

Newest FDA approval

91
Q

_____ needs to be avoided/use caution if patient is taking in conjunction with any other CNS depressant; CYP34A inhibitors / inducers

A

Daridorexant (Quviviq)

92
Q

Is Daridorexant (Quviviq)
good for onset, maintenance or both?

A

Indicated for sleep-onset and sleep-maintenance insomnia

93
Q

What is the overall caution when using Orexin Receptor Antagonists? **They are CI in _____ patients

A

Class has significant drug interactions with other CYP34A inhibitors / inducers (dose of ORA must be reduced)

CI in narcoleptic patients

94
Q

_____ are indicated for narcolepsy and shift work disorder. What schedule? When do you need to avoid?

A

Modafinil (Provigil)

schedule 4

Avoid using or use caution if patient is taking in conjunction with any other stimulants

95
Q

_____ are indicated for narcolepsy, carry a risk for respiratory depression and access is restricted in the US. What schedule?

A

Sodium Oxybates

schedule 3

96
Q

_____ MOA works because it is a metabolite of GABA and works on GABA-B receptors

A

Sodium Oxybates

97
Q
A

Behavioral Dynamics (16 decks)

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