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Management of Disorders > Sleep Investigations > Flashcards

Sleep Investigations Flashcards

1
Q

What are the 6 main factors to consider when taking a sleep history?

A

▪️Medication
▪️Homeostatic
▪️Circadian
▪️Physical
▪️Psychological
▪️Environmental (incl. diet)

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2
Q

Ideally, how long should a sleep diary be kept for?

A

1-2 weeks

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3
Q

What are the benefits of a sleep diary?

A

▪️Determine what a typical night is
▪️Compare weekends and weekdays
▪️Discern patterns and variability

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4
Q

What is the most commonly used self-report scale of sleepiness?

A

The Epworth Sleepiness Scale

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5
Q

What is a normal score on the Epworth Sleepiness Scale?

A

0-10

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6
Q

What does a score of 11 or above indicate on the ESS?

A

Excessive sleepiness

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7
Q

What are the main problems with the ESS?

A

▪️Relies on honest reporting
▪️Doesn’t differentiate between times of day
▪️Scoring is uneven

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8
Q

What does actigraphy measure?

A

Motor activity via an accelerometer on the wrist. This can then be translated into sleep-wake data.

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9
Q

What can actigraphy be used for?

A

▪️Circadian rhythm disorders
▪️Insomnia
▪️Ensuring sleep isn’t restricted prior to Multiple Sleep Latency Test
▪️Measuring effect of medication
▪️Monitoring periodic limb movements

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10
Q

What can actigraphy measure?

A

▪️Motor activity
▪️Sleep times and fragmentation
▪️Sleep onset latency
▪️Wakefulness after sleep onset
▪️Activity levels before bed
▪️Sleep hygiene

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11
Q

What are the advantages of actigraphy?

A

▪️Unobtrusive
▪️Longitudinal (often several weeks)
▪️Can be used at home

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12
Q

What are the limitations of actigraphy?

A

▪️Usually only in specialist clinics
▪️Not validated with all sleep. disorders and populations
▪️Cannot measure sleep stages
▪️Expensive
▪️Commercial equivalents are unreliable

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13
Q

What does pulse oximetry measure?

A

Oxygen saturations and pulse rate

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14
Q

What investigations are useful in the diagnosis of obstructive sleep apnoea?

A

Pulse oximetry and respiratory study

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15
Q

How do you diagnose obstructive sleep apnoea using pulse oximetry?

A

▪️Visual inspection of oxygen saturation and pulse rate tracing
▪️Computer calculated oxygen desaturation index (ODI)

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16
Q

What does an ODI between 5 and 15 indicate?

A

Mild obstructive sleep apnoea

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17
Q

What does an ODI between 15 and 30 indicate?

A

Moderate obstructive sleep apnoea

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18
Q

What does an ODI of 30 or greater indicate?

A

Severe obstructive sleep apnoea

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19
Q

What is the oxygen desaturation index?

A

A measure of how many times blood oxygen levels drops by 4% of more per hour of sleep

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20
Q

How is pulse oximetry use clinically?

A

To screen for sleep related breathing disorders (e.g. OSA).

To determine if OSA is position dependent or REM related.

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21
Q

At what point during sleep is sleep apnoea most severe?

A

During REM because it is aggravated by the atonia

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22
Q

What are the advantages of pulse oximetry?

A

▪️Cheap and easy
▪️Can be used anywhere
▪️Analysis is quick
▪️Equipment is widely available across clinics, units and wards
▪️High specificity
▪️Can sometimes detect periodic limb movements

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23
Q

What are the limitations of pulse oximetry?

A

▪️Disagreement over what degree of desaturation should be used (4%?)
▪️Poor sensitivity
▪️Won’t detect apnoea if arousal occurs before oxygen sats drop
▪️Interpretation should be cautious

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24
Q

What are the four main components of a respiratory study?

A

▪️Pulse oximetry
▪️Nasal airflor
▪️Chest respiratory movements
▪️Abdomen respiratory movements

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25
Q

What are the advantage of a respiratory study?

A

▪️Can be done at home
▪️Widely available in sleep, respiratory and ENT units
▪️Ensures all body positions are monitored

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26
Q

What are the main clinical uses of respiratory study?

A

▪️Detect apnoea which don’t lead to desaturations
▪️Detect mixed apnoaes where there are central and obstructive elements

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27
Q

How would you conduct an inpatient split night respiratory study?

A

First half is diagnostic, looking for OSA

If OSA is found, in the second half you can do a CPAP titration to determine the right pressure needed for treatment

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28
Q

What is CPAP?

A

Continuous Positive Airway Pressure - a treatment for OSA whereby a mask delivers air at a constant, appropriate pressure to help them breathe

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29
Q

What are the limitations of respiratory study?

A

▪️Cannot detect impact if respiratory events on sleep
▪️Cannot detect respiratory effort related arousals
▪️Home studies arent widely available and probe to technical problems
▪️Cannot usually detect non-respiratory sleep problems as it can’t give insight into sleep stages or brain activity

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30
Q

What is WatchPat?

A

A device on the wrist that measures finger blood volume (PAT), HR, oximetry, actigraphy, body position, snoring, and chest motion

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31
Q

What can WatchPat be used for?

A

Detecting OSA, sleep fragmentation, and sleep architecture

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32
Q

What are the limitations of WatchPat?

A

▪️Expensive
▪️Poor insight into sleep stages

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33
Q

What is the gold standard investigation for sleep disorder?

A

Polysomnography

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34
Q

What are the three components of a basic polysomnogram?

A

▪️EEG (brain activity)
▪️EOG (eye movements)
▪️Submental EMG (upper airway muscle activity)

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35
Q

What other components can be added to a polysomnogram?

A

▪️Respiratory channels
▪️ECG
▪️Tibialis EEG (lower limb movement)
▪️Video
▪️Audio

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36
Q

What extra components may be added to polysomnography to investigate REM behaviour disorder?

A

▪️ECG
▪️Tibialis EMG
▪️Video

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37
Q

What conditions can you investigate with polysomnography?

A

▪️OSA
▪️Periodic limb movement disorder
▪️Insomnia
▪️NREM parasomnias
▪️REM behaviour disorder
▪️Nocturnal epilepsy

38
Q

Ideally, for how many nights would you use polysomnography?

A

2-3

39
Q

What are the advantages of polysomnography?

A

▪️Gold standard
▪️Differentiates sleep stages
▪️Can detect epileptic phenomena
▪️Measures sleep time, awakenings and arousals
▪️Can determine impact of sleep disorders on sleep (e.g. things too mild for other investigations to detect but still important)

40
Q

What are the limitations of polysomnography?

A

▪️Expensive
▪️Analysis requires highly skilled professionals and a lot of time
▪️Very invasive - doesn’t represent normal sleep environment
▪️Only in specialist sleep centres

41
Q

What is the Multiple Sleep Latency Test (MSLT)?

A

A test used to measure daytime sleepiness / the ability to initiate sleep

42
Q

What are the main clinical uses of MSLT?

A

▪️Daytime sleepiness in central hypersomnolence
▪️Differentiates narcolepsy from idiopathic hypersomnolence
▪️OSA patients with ongoing sleepiness despite good control with CPAP

43
Q

When and why is actigraphy used for the Multiple Sleep Latency Test?

A

For a week at the beginning, to ensure that sleep opportunity is not restricted

44
Q

What is conducted the night before the MSLT and why?

A

An overnight polysomnogram with full array to ensure the patient gets adequate sleep the night prior to the test and to screen for other sleep disorders.

45
Q

What is the main MSLT procedure?

A

Patient stays in clinic for the day with the basic polysomnogram array and is asked to try to nap every two hours, up to 5 times.

The nap trial ends after 20 minutes if they haven’t fallen asleep or 15 minutes after sleep onset. Sleep is staged.

46
Q

What is the overall MSLT procedure?

A
  1. One week actigraphy
  2. One night polysomnography
  3. Up to 5 nap trials every two hours (stop after 20 mins if unsuccessful and 15 is successful)
47
Q

What are the two main variables measured with the MSLT?

A
  1. Sleep onset latency
  2. Sleep onset REM
48
Q

What is sleep onset latency?

A

The time from the start of a nap trial to the first 30 second epoch scored as sleep

49
Q

In normal subjects, what is the mean sleep onset latency (SOL)?

A

10-20 minutes

50
Q

What does a mean SOL of 8 minutes or less indicate?

A

Excessive sleepiness

51
Q

What does a mean SOL of 3 minutes indicate?

A

Narcolepsy

52
Q

What does two or more naps with REM indicate during the MSLT?

A

Narcolepsy

53
Q

What does fewer than two naps with REM in the presence of SOL of 8 minutes or less indicate?

A

Idiopathic hypersomnolence

54
Q

Why is it important to differentiate between narcolepsy and idiopathic hypersomnolence?

A

Narcolepsy may need treatment with intense stimulants or medication.

Idiopathic hypersomnolence may be indicative of other comorbidities such as depression or medication side effects, for which treatment might cause more damage

55
Q

What are the advantages of the MSLT?

A

▪️Can give an objective measure of sleepiness if you’re considering stimulants
▪️Can differentiate narcolepsy without associated features of REM instability from idiopathic hypersomnolence

56
Q

What are the limitations of the MSLT?

A

▪️False positives and negatives are not uncommon
▪️Anxiety may prevent sleep
▪️Medications may interfere (increasing or decreasing sleepiness)
▪️Protocol is not well standardised

57
Q

How might antidepressants effect the interpretation of MSLT?

A

Most of them suppress REM, possibly giving a false negative for narcolepsy

58
Q

How might antidepressant withdrawal affect the MSLT?

A

Within a couple of weeks of the test can lead to REM rebound, giving a false positive for narcolepsy

59
Q

What is the Maintenance of Wakefulness Test (MWT)?

A

A test used to measure ability to resist sleep.

60
Q

What is the main use of the MWT?

A

To confirm whether someone with a sleep disorder is sufficiently alert to be safe to drive, work, etc

61
Q

Does the MWT procedure have to be preceeded by actigraphy and a polysomnogram?

A

Not always

62
Q

What is the MWT procedure?

A

A patient with PSG array is placed in a dim room on a reclining bed. There are four trials, usually 40 minutes, at 2 hour intervals during with which they have to try to stay awake.

63
Q

When is an MWT trial terminated?

A

After three continuous 30 second epochs of N1, or after one 30 second eposh of any other sleep stage

64
Q

What would a SOL of 8 minutes or less indicate during the MWT?

A

Abnormal alertness

65
Q

What would an SOL between 8 and 40 minutes during the MWT indicate?

A

Uncertain alertness

66
Q

What SOL would indicate good alertness during the MWT?

A

Greater than 40 minutes (i.e. no sleep in any trial)

67
Q

What is the mean SOL of presumed normal subjects during the MWT?

A

30.4 minutes

68
Q

What test would you use to investigate ability to initiate sleep?

A

The Multiple Sleep Latency Test

69
Q

What test would you use to investigate ability to resist sleep?

A

The Maintenance of Wakefulness Test

70
Q

What are the advantages of the MWT?

A

▪️A negative result is very reassuring
▪️It is better than MSLT for fitness to drive
▪️Useful if there’s a discrepancy between self-report and observed alertness

71
Q

Does ability to initiate sleep relate to ability to resist sleep?

A

Not necessarily

72
Q

What are the limitations of the MWT?

A

▪️Is it really representative of trying to stay awake behind the wheel?
▪️Restrictions on caffeine, smoking or exercise is not representative of real life (BUT should be able to function without them)
▪️Protocol isn’t standardised
▪️Microsleeps may not be picked up

73
Q

What is the Oxford Sleep Resistance Test (OSLER)?

A

A similar test to the MWT, patients lie in a dim room and complete 4x 40 minute trials where light is flashed every 3 seconds and have to press a button in response it. 7 consecutive misses are taken as sleep.

74
Q

What are the advantages of the OSLER test?

A

▪️Easy to use and interpret
▪️Can be done in any setting
▪️Doesn’t require EEG

75
Q

What study should you request for insomnia?

A

Actigraphy

76
Q

What study should you request for hypersomnia?

A

Actigraphy, polysomnography, and MSLT

77
Q

What study should you request for parasomnias?

A

Polysomnography

78
Q

What study should you request for movement disorders?

A

Polysomnography

79
Q

What study should you request for sleep related breathing disorders?

A

Oximetry, respiratory study, polysomnography, WatchPat

80
Q

What study should you request for
circadian rhythm disorders?

A

Actigraphy

81
Q

What study should you request for assessing safety to drive?

A

MWT and OSLER

82
Q

What are the six categories of sleep disorder?

A
  1. Breathing disorders (e.g. OSA)
  2. Insomnia
  3. Hypersomnolence (e.g. narcolepsy, idiopathic hypersomnia)
  4. Movement disorders (e.g. periodic limb movements)
  5. Circadian rhythm disorders - body clock out of sync (e.g. delayed sleep wake phase disorder)
  6. Parasomnias - unwanted experiences and behaviours
83
Q

What are examples of NREM parasomnia?

A

Sleepwalking, night terrors

84
Q

What are examples of REM parasomnia?

A

REM sleep behaviour disorder, nightmares

85
Q

What sleep related movement disorder might present as excessive sleepiness?

A

Periodic limb movement disorder

86
Q

What sleep related movement disorder might present as inability to sleep?

A

Restless legs

87
Q

What type of circadian rhythm disorder is more prevalent in the elderly?

A

Advanced sleep wake phase disorder

88
Q

What type of circadian rhythm disorder is more prevalent in the adolescence and periods of development?

A

Delayed sleep wake phase disorder

89
Q

In what type of parasomnia are you more likely to see sexonomia and why?

A

Non-REM because it is an automatic behaviour

90
Q

What type of parasomnia is more likely to result in behavioural abnormalities later on in the night?

A

REM sleep behaviour disorder

91
Q

What is chronotherapy?

A

Sleep restriction therapy - calculate how long it usually takes them to sleep and don’t let them sleep til then then gradually allow them to sleep earlier.

Potentially useful for insomnia

Management of Disorders (28 decks)

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