Sleep: From Deep to Disordered- Rothrock Flashcards
What is the ultimate regulator of normal sleep?
hypothalamus (suprachiasmatic nuclei)
Total sleep declines with (blank)
age
How long do neonates sleep?
How long do adolescent sleep?
How long do adults sleep?
10-12 hours
7-7.5 hours
6.5 hours
When you go to sleep what hormones decrease, increase, etc?
decrease-cortisol and TSH secretion
increase- growth hormone and prolactin secretion
melatonin production begins
The pineal gland makes melatonin when you sleep and ceases with exposure to (blank)
sunlight
When you read an EEG, what are the 2 things you look at?
voltage (is it high or low?)
frequency (fast or slow)
What are the frequencies of EEGs?
beta (fast wave), delta (slow wave), alpha, theta,
HOw many stages of sleep are there?
4 and then REM
What is stage 1 (NREM 1) of sleep?
(NREM1)-> drowsiness/slow, roving horizontal eye movements/reduced EEG voltage
What is stage 2 (NREM2) of sleep?
(NREM2)-> EEG shows “sleep spindles” (bursts of biparietal 12-14 Hz waves), slow “vertex waves”
What are stages 3 and 4 (NREM 3) of sleep?
EEG shows high amplitude slow waves (delta hz= <3)
What is stage 5 (REM) of sleep?
REM-> EEG nonsynchronized, shows fast wave; bursts of REMs
What stages of sleep have a synchronized EEG?
NREM 1-3
During normal sleep you have a succession of NREM-REM cycles (blank) times a night.
4-6
In the latter portion of your sleep you spend most your time in what stages?
NREM 2 (stage 2) and REM
How long do sleep cycles last?
60-90 mins/cycle
How long does it take after sleep onset to get to the FIRST rem stage?
70-100 minutes
When does most dreaming occur?
during REM sleep (some occurs during different stages)
WHen are you most easily aroused?
REM sleep (less so w/ NREM 3)
What stage decreases with aging?
NREM3
What do you see in REM sleep?
- minimal tonic muscle activity,
- conjugate REMs (can be horizontal (typically) or vertical)
- Penile erection
What happens if you are deprived of sleep for more than 60 hours?
- increasing sleepiness, fatigue, irritability
- difficulty concentrating
- impaired skilled motor function (esp if require speed, perserverence)
- inattention
- impaired judgement
- nystagmus, loss of accomodation, bilat hand remor, ptosis, expressionless face, thick speech, mispronunciations, word substit.
If you have persistant sleep deprivation what can happen?
you get visual/tactile hallucinations, psychosis, seizure activity
If you have chronic sleep deprivation what are you at risk for?
- HTN
- Stroke
- MI
- Pulmonary HTN
- Early death
What are the 6 major categories of sleep disorders?
- insomnias
- narcolepsy
- sleep apnea
- restless leg syndrome (RLS) and periodic leg movements of sleep
- REM sleep behavioral disorder
- Excessive daytie somnolence
What is the difference between primary and secondary insomnia?
primary-> sleep disturbance for prolonged perios in absence of any causal psychiatric or medical disorder
secondary-> caused by something
What do doctors call people with primary insomnia?
sleep hypochondriacs
Is secondary insomnia consistant or transitory?
transitory
What are the 2 ways to get secondary insomnia?
non-medically and medically
What are some non-medical ways to get secondary insomnia?
- EtOH or other drug abuse
- psychological
What are some medical ways to cause secondary insomnia?
- arthritic pain
- GERD, PUD
- prostatism/nocturia
What is a sleep diary?
a real-time assessment of sleep ->
completed over 7 days, patient records bedtime, awakening, out of bed, naps, use of sedatives and stimulants, and symptoms
What are the 2 ways you can quantify somnolence?
- Validated symptom assessment systems
- Polysomnography
What are the 2 types of validated symptom assessment systems?
- epworth sleepiness score
- stanford sleepiness score
What are the 2 types of polysomnographies (basically an EEG)?
- multiple sleep latency test
- maintenance of wakefulness test
What is a drug that you can use for sleep and doesnt make you feel that groggy the next day?
trazidone
(blank) can be used as a sleep promotor but can cause motor and cognitive impairment.
Clonazepam
Why do sleep drugs sort of suck?
because you cant really get off them and patients develop tolerance
How can you treat chronic primary insomnia?
- sleep hygiene
- CBT
- Medications
Wht is sleep hygiene?
- Re-set sleep cycle: no naps; dec non-sleep time in bed, exercise
- Re-set circadian rhythm: ights out, quiet time
- Avoid caffeine, alcohol, tobacco
- Bedroom: quiet, dark, rituals, no clock
What can CBT teach you to help with chronic primary insomnia?
Relaxation and stimulus control
Does rozarum work?
no
What are the breathing disorders in sleep?
- obstructive sleep apnea
- central sleep apnea
- mixed sleep apnea
- complex sleep apnea
- upper airway resistance syndrome
How do you diagnose breathing disorders in sleep?
Polysomnography
What are the 2 causes of sleep apnea? Which is more common?
central (nervous system) or Obstructive (physical blockage)
Obstructive apnea is more common, central apnea is super rare
What is Ondine’s curse?
central sleep apnea
Why do you typically get secondary sleep apnea?
destructive lesions in the medulla (lower brain stem abnormalities)
What can cause the lower brain stem abnormalities found in secondary sleep apnea?
stroke and syringobulbia
What happens in obstructive sleep apnea?
posterior pharyngeal muscles collapse and narrow the upper airway
What are the clinical manifestations of obstructive sleep apnea?
noisy, cycic snoring> apnea (10 to 30 seconds) > breathing resumes/ brief arousal
During what stages of sleep do you get OSA?
during REM and non-REM sleep
What is the usual presentation of OSA?
excessive daytime somnolence
What is the clinical phenotype of people with OSA?
overweight, middle-aged men (BMI over 34)
What is the STOP-BANG?
validated screening tool for OSA
When taking the STOP-BANG, answering yes to (blank) or more items indicates a high risk of OSA
3
Does the STOP-BANG have good sensitivity?
YESSSSS
for mild OSA-83.6%
for moderate -92.9%
for severe- 100%
TO evaluate sleep you often use a polysomnography, what all does a polysomnography encompass?
- EMG (muscle movements)
- Airflow
- EEG
- Oxygen sat
- Cardiac Rhythm
- Leg movements
What are the pathological findings in OSA?
- nasal obstruction
- long, thick soft palate
- retrodisplaced mandible
- narrowed oropharynx
- redundant pharyngeal tissues
- large lingual tonsils
- large tongue
- large or floppy epiglottis
- retro-displaced hyoid complex
OSA narrows the (blank)
upper airway
How do you treat central sleep apnea?
- treat underlying cause
- low-flow oxygen
- meds dont really help
How do you treat OSA?
CPAP (continous positive airway pressure) or BiPAP (bilevel positive airway pressure), Surgically, dental appliances, behavioral measures
What does a CPAP do?
blows up the pharynx
What are the surgical options for treating OSA?
- uvulectomy
- mandibular advancement
What are the behavioral measures for treating OSA?
- weight loss
- avoidance of alcohol
- avoidance of sedatives
- avoidance of smoking
- non-supine sleep
What is this: unpleasant sensation (leg>arms) with irresistible urge to move the affected limb
restless leg syndrome
Restless leg syndrome (RLS) delays sleep onset and occures in (Blank) stages of sleep
early
Is RLS common?
Prevalence >2%
Symptoms of RLS are provoked by (blank) and is alleviated (briefly) by (Blank)
rest
moving limbs
RLS worsens with (blank) and (blank)
fatigue and warm weather
What causes RLS?
it’s idiopathic but there is an association with iron deficiency anemia, dysthryoidism, pregnancy, certain drugs
RLS may persist for (blank)
years
What drugs are associated with RLS?
anti-histamines and tricyclic antidepressants
RLS may possibly be related to decreased (Blank) production and/or binding
dopamine
What is the treatment for RLS?
- iron supplementation
- dopamine agonists
- long-acting carbidopa/L-dopa
- gabapentin
- clonazepam
How do you treat periodic leg movements of sleep?
All the same as RLS treatment except you dont give iron
Why do you give carbidopa with L-dopa?
to prevent the L-dopa from becoming decarboxylated in the periphery and becoming dopamine before it had a chance to cross the BBB (carbidopa cant cross the BBB)
What is this:
a medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious.
Cataplexy
What is the narcoleptic tetrad?
- recurrent attacks of irresistible sleep
- cataplexy (70%)
- sleep paralysis (hypnagogic)
- hallucinations (hypnagogic)
- hypnagogic->of or relating to the state before falling asleep*
Is it typical to have cataplexy with narcolepsy?
absolutely, if you dont have cataplexy you should be suspicious of a faker of narcolepsy
In narcolepsy, do you have a gradual or immediate onset of symptoms?
gradual onset b/w ages 15-35 (by age 25 in 90%)
What are the sleeping periods like in narcolepsy?
sleep periods less than 15 mins, 2-6/day
Narcoleptic patients will experience excessive daytime (blank)
somnolence
Is narcolepsy familial?
yes
Narcolepsy is caused by an abnormality involving a hypothalamic neuropeptide called (blank)
hypocretin
Where do hypocretin neurons project to?
sleep structures ->locus ceruleus, ventral tegmentum (bottom roof of midbrain)
Researchers think that narcolepsy can be caused by a genetic predisoposition with a superimposed (blank) disorder that affect hypocretin neurons
autoimmune disorder
In narcolepsy you have a reversal of (blank) and (Blank) sleep
REM and non-REM sleep. I.e you go straight into REM and your sleep cycle is backward.
In narcolepsy, sleep (blank) is greatly reduced
latency
How do you diagnose narcolepsy?
overnight polysomnography followed by mutliple sleep latency tests
also measure CSF levels of hypocretin**
How does the multiple sleep latency test (MSLT) work?
naps at 2 hour intervals/detect REM activity w/in 15 minutes of sleep onset.. if they numerous episodes of early onset REM with their napping then they have narcolepsy
How do you treat narcolepsy?
- strategic napping
- stimulant drugs
- tricyclic antidepressants
- immune globulin infusion
What are the stimulants you can give to narcoleptics?
modafinil/Provigil, dextroamphetamine, methylphenidate (ritalin)
What are the tricyclic antidepressants you can give to narcoleptics?
protriptyline
imipramine
What is imipramine more commonly used for?
to suppress cataplexy
What are the 2 things that consitute medicolegal malpractice?
- liability (perform below the standards)
- causation (if you had done what you were supposed to do, the patient would have more than likely had a better outcome)
Should you practice defensive medicine as a successful means to avoid being sued?
hell no
