Sleep Disorders (insomnia) - waldron

Question 1

what are patients with sleep apnea more likely to have

Answer 1

23x more likely to have a heart attack
3x more likely to develop diabetes

Question 2

what are complications of not sleeping

Answer 2

higher risk or exacerbation of health problems
higher risk of falling (especially in elderly)
trouble focusing/concentrating - task completion concerns
anxiety/mood changes
grumpiness/irritability
slower reaction times/coordination concerns

Question 3

What is FFI

Answer 3

Fatal Familial Insomnia “the walking nightmare”

rare genetic condition where the disruption to sleep is so severe that it becomes terminal usually within 1-2 years
usual onset 32-62 years?
prion based disease

Question 4

who is more likely to be affected by insomnia

Answer 4

elderly
W>Men

Question 5

how many stages of sleep are there?

Answer 5

5 stages

Question 6

what is stage 1 of sleep

Answer 6

transition period between wakefulness and sleep
lasts only 5-10 minutes, characterized by mixed frequency theta waves; slow, rolling eye movements

Question 7

what is stage 2 of sleep

Answer 7

lasts ~ 20 minutes, involves mixed=frequency waves with rapid bursts of rhythmic wave activity aka sleep spindles
body temperature starts to decrease and HR begins to slow

Question 8

what is stage 3 of sleep

Answer 8

characterized by 2–50% slow brain waves (delta waves)
transitional period between light and deep sleep

Question 9

what is stage 4 sleep

Answer 9

greater than 50% delta waves, aka Delta sleep
lasts ~30 minutes

Question 10

what is stage 5 sleep

Answer 10

AKA Rapid eye movement (REM) sleep, when most dreaming occurs
increase in RR and Brain activity
occurs ~q90 minutes

Question 11

when is the first cycle of REM sleep

Answer 11

~90 minutes after falling asleep and only lasts a few minutes

Question 12

What is primary insomnia

Answer 12

not linked to any other health conditions
stress (job loss, divorce, pandemics)
environment (lights, noise, temperature)
Sleep schedule changes (jet lag, shift work)

Question 13

what is secondary insomnia

Answer 13

directly caused by another health condition
mental health issues (depression, anxiety)
Medications (sudafed, albuterol)
Pain and discomfort
caffeine, tobacco
hyperthyroidism or other endocrine concerns

Question 14

What are the acute presentations of Insomnia

Answer 14

brief episodes of few nights
usually caused by a life event
usually resolves without treatment

Question 15

what are the chronic presentation of insomnia

Answer 15

trouble falling or staying asleep
3+ nights per week for 3+ months

Question 16

what are the typical presenting symptoms of insomnia

Answer 16

sleepiness during the day, fatigue, grumpiness, irritability, concentration/memory concerns/changes

Question 17

how is insomnia diagnosed

Answer 17

routine H&P will focus on environment, life changes/events, chronic illness
Red Flags
Testing

Question 18

what are the red flags of insomnia

Answer 18

disturbed sleep >1mo without apparent cause
sleep partner notes patient stops breathing
associated with life-changing event
previously rx’d sleep med no longer working/helpful

Question 19

what are tests used for diagnosing insomnia

Answer 19

sleep diary
epworth sleepiness scale
ploysomnogram
actigraphy
mental health evaluation

Question 20

how do we prevent insomnia

Answer 20

routine*
done use screens before bed
avoid nicotine, caffeine, alcohol late in the day
regular exercise
dont eat heavy meal late in the day
make bedroom comfortable

Question 21

what initiation treatment medications are used for insomnia

Answer 21

Eszopicione (lunesta)
Ramelteon (Rozerem)
Zolpidem (ambien)
OTC anti-histamines

Question 22

what maintenance treatment medications are used for insomnia

Answer 22

Doxepin (silenor)

Question 23

what are alternative - herbal treatment options for insomnia

Answer 23

valerian root - sleep onset and maintenance
Chamomile
passionflower, hops, lemon balm

Question 24

what are alternative treatment options for insomnia

Answer 24

melatonin
acupuncture
relaxation and meditation
exercise

Question 25

What is Narcolepsy

Answer 25

chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep
difficult to stay awake for long periods of time, regardless of circumstances

Question 26

What are risk factors for narcolepsy

Answer 26

10-30 years old
family history (20-30x higher)

Question 27

what are narcolepsy symptoms

Answer 27

excessive daytime sleepiness
sudden loss of muscle tone - cataplexy
sleep paralysis
changes in REM sleep
hallucinations
automatisms

Question 28

what are complications of narcolepsy

Answer 28

public misunderstanding of the condition
interference with intimate relationships
physical harm
increased risk of a car accidents, cuts and burns
obesity

Question 29

how is narcolepsy diagnosed

Answer 29

sleep history/record-diary, actigraphy
polysomnogram
multiple sleep latency test

Question 30

what is the treatment of Narcolepsy

Answer 30

stimulants - methylphenidate
non-stimulants - modafinil, armodafinil
SSRI, SNRI - suppress REM sleep
TCA - imipramine, suppresses cataplexy

Question 31

what is shift work sleep disorder

Answer 31

sleep disorder that commonly affect those who work non-traditional hours
causes difficulties adjusting to different sleep/wake schedules

Question 32

what are the symptoms of shift work sleep disorders

Answer 32

excessive sleepiness when need to be awake, alter and productive
insomnia
sleep that feels unrefreshing or insufficient
difficulty concentrating
lack of energy
irritability or depression
difficulty with personal relationships

Question 33

what are complications of shift work sleep disorders

Answer 33

increased risk for
accidents and work - related errors
irritability or mood problems
poor coping skills and impaired social functioning
health related complaints (GI, CV, and metabolic issues)
drug and alcohol dependence

Question 34

how are shift work sleep disorders managed

Answer 34

minimize exposure to light
maintain bedtime rituals and regular sleep schedule
at home, family/friends help create quiet, dark, peaceful setting during sleep time
ask household members to wear headphones with music/TV
people in household to avoid noisy activities
“do not disturb” sign so delivery people/friends dont knock or ring doorbell

Question 35

how is shift work sleep disorders treated

Answer 35

maintain sleep diary
decrease number of night shifts worked in a row
after string of nigh shifts, take > 48 hours off if possible
avoid extended work hours
ensure time to sleep and participate in family and social activities
avoid long commutes
avoid frequently rotating shifts
get enough sleep on days off - sleep hygiene
plan a nap
caffeine and prescription wake-promoting drugs
sleep aids
light exposure

Question 36

what is Willis-Ekbom disease

Answer 36

Restless leg syndrome

Question 37

What is RLS

Answer 37

strong urge to move legs (maybe arms, face, torso or genital region but rare) usually accompanied or caused by uncomfortable and unpleasant sensation in the legs

Question 38

when does RLS improve and get worse?

Answer 38

improves: with movement
gets worse: when resting or inactive and in the evening or night than during the day

Question 39

what needs to be excluded in RLS diagnosis

Answer 39

iron deficiency (with or without anemia)
peripheral neuropathy
renal failure
spinal cord conditions

Question 40

what are non-pharmacologic treatments for RLS

Answer 40

baths/massages
warm or cool packs
sleep hygiene
exercise
avoid caffeine
foot wrap
stretch beginning and end of day
dont resist urge to move

Question 41

what are pharmacologic treatments for RLS

Answer 41

ropinirole (requip), Rotigotine (Neupro) and pramipexole (mirapex) - FDA approved for treatment of moderate to severe RLS - increase DA in brain
Gabapentin, lyrica
opioids (tramadol to oxycodone)
muscle relaxers
sleep medications

Question 42

What is sleep walking

Answer 42

non-rem parasomnias
getting up from bed and walking around while still sleeping
may involve other complex actions
eyes usually open with confused glossy look
okay to wake but do not restrain

Question 43

what is confusional arousal

Answer 43

non-rem parasomnia
mind is still foggy as you wake or just after waking
speak slowly, confused thinking, poor memory, blunt answers
tend to have no memory of the episode

Question 44

what are night-terrors

Answer 44

non-rem parasomnias
sit up in bed and scream, usually intense look of fear on face, eyes wide open
no memory of event/episode
usually happens in first half of sleep/night

Question 45

what is sleep behavior disorder

Answer 45

REM parasomnia
act out vivid dreams as sleep-may kick, punch, flail
episodes usually get worse with time and can injury self, partner

Question 46

what is nightmare disorder

Answer 46

REM parasomnia
frequent and recurrent nightmares
may prevent sleep due to anxiety/fear

Question 47

what is sleep paralysis

Answer 47

REM parasomnia
when falling asleep or waking up, cannot move arms, legs or head
cannot speak
may hallucinate during episodes
may last seconds to minutes

Question 48

What is exploding head syndrome

Answer 48

hear loud imaginary nose just before falling asleep or awakening
alleviated with increased sleep per night

Question 49

what is sleep related eating disorder

Answer 49

binge eat and drink after waking during night, usually high caloric and strange combinations
may only be partially awake
may have no memory of episode
concern for injury (burns from cooking) or toxic ingestion