Sleep DO Flashcards
Normal sleep: in a fit young person the ideal is
7.5–8 hours; latency_______minutes; wakefulness
within sleep usually_______ of time
<30
<5%
People with _______ usually present with the TATT
syndrome—‘tired all the time’. These patients are
often unaware of waking or becoming aroused
during the night
OSA
The majority of cases of excessive somnolence are
caused by ____ and _____
OSA and narcolepsy
untreated moderate to severe OSA has an_______ 5-year mortality and a ____ 8-year mortality, mainly from cardiovascular and motor vehicle accident related deaths
11–13%
37%
______is defined as the inability to initiate or
maintain sleep.
Insomnia
Pharma Tx of insomnia
It is advisable to avoid hypnotic agents as firstline
treatment. If any form of continuous agent is
necessary it is best to limit it to _____
2 weeks
Tricyclic antidepressants with sedative effects
(e.g. ________) are often used as hypnotics
but should generally be avoided in the absence
of depressive disorders
amitriptyline
The term ‘________ is used to describe cyclical brief
interruptions of ventilation, each cycle lasting 15–90
seconds and resulting in hypoxaemia, hypercapnia
and respiratory acidosis, terminating in an arousal
from sleep (often not recognised by the patient).
sleep apnoea’
Sleep apnoea is broadly classified into ___ and ____
obstructive
and central types
________ refers to the
presence of apnoeas and hypopnoeas during sleep
together with daytime dysfunction, predominantly
excessive daytime sleepiness. The effects include
snoring
Obstructive sleep apnoea (OSA)
Predisposing factors to OSA
• diminished airway size (e.g. macroglossia obesity,
tonsillar-adenoidal hypertrophy)
• upper airway muscle hypotonia (e.g. alcohol hypnotics, neurological disorders
• nasal obstruction
Effects of sleep apnea syndromes
• excessive daytime sleepiness and tiredness
• nocturnal problems (e.g. loud snoring, thrashing,
‘seizures’, choking, pain reactions)
• morning headache
• subtle neuropsychiatric disturbance—learning
difficulties, loss of concentration, personality
change, depression
• sexual dysfunction
• occupational and driving problems
\_\_\_\_\_\_ is currently the most effective treatment for OSA (consider it for CSA).
CPAP
MOA of CPAP
Provides an air splint to the upper airway and
prevents pharyngeal collapse
In children, OSA is usually due to t____ and _____ and is relieved by surgery
onsillar and/
or adenoid hypertrophy
There are no reliable drug treatment options for
OSA.
Consider:
1
2
• amitriptyline 25–100 mg (o) nocte, in severe
cases during REM sleep and intolerance of CPAP
• trial of corticosteroid sprays in children with
mild OSA
______ is a specific, permanent neurological
disorder that is characterised by brief spells of
irresistible sleep during daytime hours in inappropriate
circumstances, even during activity and usually
at times when the average person simply feels sleepy
Narcolepsy
Tetrad of Sx of Narcolepsy
• __________: sudden brief sleep
attacks (15–20 minutes).
• _________: a sudden decrease or loss of muscle
tone in the lower limbs that may cause the
person to slump to the floor, unable to move.
These attacks are usually triggered by sudden
surprise or emotional upset.
• _________: a frightening feeling of inability to
move while drowsy (between sleep and waking).
• _________
Daytime hypersomnolence
Cataplexy
Sleep paralysis
Hypnagogic (terrifying) hallucinations on falling asleep or waking up (hypnopompic hallucination).
In Narcolepsy,
____________
are of proven effectiveness in increasing alertness
Central nervous system psychostimulants
Examples of Central nervous system psychostimulants for narcolepsy
- dexamphetamine 5–10 mg (o), half an hour
before breakfast and lunchtime; up to 40 mg
daily may be required in slowly increasing doses - methylphenidate (Ritalin) 10–20 mg (o) half an
hour before breakfast and lunchtime; up to 60
mg daily may be required
Important to consider for Central nervous system psychostimulants for narcolepsy
Drug holidays from these drugs may be necessary
Tricyclic antidepressants are used to treat
______, ________, ______ (e.g. clomipramine 20–100 mg (o)
daily)
cataplexy, sleep paralysis and hypnagogic
hallucinations
This type of excessive daytime sleepiness (EDS) can
present similarly to narcolepsy without cataplexy.
The condition, which accounts for 5–10% of patients
Idiopathic hypersomnia
Difference between Idiopathic hypersomnia and narcolespy
They usually have non-refreshing deep nocturnal sleep but, unlike narcolepsy, naps are not refreshing.
Tx of idiopathic narcolepsy
Treatment is usually based on psychostimulant
therapy to improve EDS.
_________ is a sonorous sound with breathing during
sleep, caused by vibrations in the upper airways
from the nose to the back of the throat. It is caused
by partially obstructed breathing during sleep
Snoring
When does snoring need medical intervention?
Generally harmless, but if very severe, unusual or
associated with periods of no breathing (>10 s)
assessment is advisable
Periodic limb movements (PLMs) and restless legs
syndrome are important causes of insomnia and
excessive ________
daytime sleepiness
Periodic limb movements, which
are also referred to as nocturnal myoclonus or ‘leg
jerks’, tend to occur usually in the ________of the leg but can occur in the upper limbs
anterior tibialis
muscles
Dx of PLM
The diagnosis is often made during sleep studies
Mx of PLM
levodopa plus carbidopa (e.g. Sinemet 100/25,
2 tablets before bedtime)
or
clonazepam 1 mg (o) nocte increasing to 3 mg (o)
nocte
or
sodium valproate 100 mg (o) nocte
_______ also known as Ekbom syndrome, is a rather
common movement disorder of the nervous system
where the legs feel as though they want to exercise or
move when the body is trying to rest
RLS,
What are the sensations felt in RLS
Sensations that may be experienced include ‘twitching’, ‘prickling’ and ‘creeping’.
Dx of RLS
The diagnosis is made from the history—there
are no special diagnostic tests.
Cause of RLS
unclear
Secondary causes of RLS
• anaemia (common) • iron deficiency (common) • uraemia • hypothyroidism pregnancy (usually ceases within weeks of delivery)
What drugs cause RLS
antihistamines, anti-emetics, selective
antidepressants, lithium, selective major
tranquillisers and antihypertensives
What to do if Fe deficiency is the cause of RLS
Iron studies should be performed and, if low, treat
with iron and vitamin C tablets
T or F
getting out of bed and going for a
walk or run seem to help RLS.
F
getting out of bed and going for a
walk or run does not seem to help RLS.
Good exercise of RLS
a popular treatment is gentle stretching
of the legs, particularly of the hamstring
and calf muscles, for at least 5 minutes before
retiring.
Tx of mild RLS
clonazepam 0.5–1 mg (o) 1 hour before retiring
or
levodopa ( + benserazide or carbidopa) 100–200 mg (o) (especially if limb movements at sleep onset are infrequent
Tx of severe RLS
pramipexole 0.125 mg (o) daily, increasing as
tolerated to 0.75 mg
or
ropinirole 0.5 mg (o) → 4 mg daily
______ is the habit of grinding, clenching or tapping
teeth, which may occur while awake (especially in
children) or more commonly while asleep
Bruxism
What is the result of Bruxism?
It may result in headaches and TMJ dysfunction in the person during the day.
_______ are defined as dysfunctional episodes
associated with sleep, sleep stages or partial arousal.
They are more common in children.
Parasomnias
Drugs associated with nightmares/ dream anxiety
alcohol, barbiturates, drugs such as zolpidem, SSRIs, β -blockers, benzodiazepines
Mx of dream anxiety
Psychological evaluation with cognitive behaviour
therapy (CBT) is appropriate. Medication that may
help includes phenytoin, clonazepam or diazepam
A feature is complex and elaborate motor activity
associated with dreams. The behaviour may be
violent with profane verbalisation
REM sleep behaviour disorder
Tx of REM sleep behaviour disorder
Diagnosis is by sleep studies and treatment is low-dose clonazepam
This is a complex motor activity in which the person
performs some repetitive activity in bed or walks
around freely while still asleep. There is amnesia
for the event
Somnambulism (sleepwalking)
In Somnambulism,
Benzodiazepines such as_______ may
be useful but withdrawal usually leads to rebound
problems.
diazepam
Sleep disorders in children are very common in _______, _______, ______
late
infancy, toddlerhood and early preschool age groups
Toddlers begin to have dreams coinciding with
_________in the second year of life
language development
Why not use sedative meds for sleep disturbances in children?
Not recommended for children <2 years although the
judicious use of a sedative/hypnotic for a short
term may break the sleepless cycle
What sedative hypnotic drug can be given to children?
Such drugs include promethazine 0.5 mg/kg (max. 10 mg) and trimeprazine (Vallergan) 1–2 mg/kg per dose (not for
infants under 6 months)
These are not true sleep disorders or night-time
arousals. They occur in deep non-REM sleep
Parasomnias
Desrcibe the event clusters happening in each age group
- ________4–8 years
- _______8–12 years
- _______ 6–10 years
- _______3–6 years
sleep terrors
sleep walking
sleep talking
nightmares
A study of elderly patients with insomnia showed
that:
• 25% had insomnia either coexisting with or
related to other sleep disorders, such as sleep
apnoea or periodic limb movement disorder
• 10% had insomnia related to _______
• 13% had insomnia associated with an _____
medical or psychiatric conditions
inability to stop taking sedative–hypnotic agents
There are three types of stratified squamous
epithelium in the oral mucosa:
1 ________—surface layer, cornified
(orthokeratinised), attached to underlying
periosteum (e.g. hard palate and gingivae)
2 ________—(e.g. lip and buccal mucosa, alveolar
mucosa, floor of mouth, soft palate and tongue—
lateral and undersurface)
3 ______—with taste buds and papillae e.g. on
dorsum of tongue
masticatory
lining
specialised
_________ is an important cause of
many oral mucosal disorders, such as ulceration,
bleeding gums and hyperplasia
Dental trauma or neglect
Non-healing oral ulcers warrant biopsy to exclude
______
squamous cell carcinoma (SCC
________ persisting for 3 weeks
after injury, e.g. sharp tooth or denture, should
have an incisional biopsy
Erythroplasia or leucoplakia
Any oral ulcer or soft-tissue lesion that persists
______ after the apparent cause has been
removed should be biopsied.
3 weeks
Consider ________infection
with unusual faucial ulceration and petechial
haemorrhages of the soft palate.
Epstein–Barr virus (EBV)
______ are usually 3–5 mm in diameter—
minor ones have an erythematous margin
Aphthous ulcers
______, other than palatal and
mandibular tori, are often variations from normal
Intraoral bony exostoses
Histology of oral ulceration
The histology of oral ulceration is usually non-specific,
with fibrin slough covering granulation tissue, and
the aetiology is varied
