Sleep Medicine Flashcards
Insomnia diagnosis
clinical diagnosis based on detailed sleep history included time needed to fall asleep, number and duration of awakings, estimated time in bed, total sleep time, description of sleep environment, habits and associated symptoms (snoring, kicking during the night, anxiety, depression)
To diagnosis insomnia and tx 1st step is
2 wk sleep diary that provdies detailed information about pts quantity and quality of sleep, bedtime routien, daytime symptoms, causative substances, relationship to environmental factors and psychosocial stressers
Benefits of sleep diary
confirms insomnia identifies sleep patterns and contributing factors allows Dr to make sleep hygiene recs and targeted behavioral guidance (stimulus control and lseep restriction) and other recs (CBT for insomnia or psychiatric eval)
Remember the people who have OSA also have
fatty liver disease
New onset insomnia, anxiety, fear, interpersonal conflicts, and escalating substance use
screen for PTSD as a reason for sleep disturbance
How to deal with excessive daytime somnolence?
Determine if it’s due to insufficient sleep time, sleep apnea, narcolepsy, recurrent hypersomnia (Kleine Levin Syn)
How to treat insufficient sleep time?
increase sleep time, improve sleep hygiene treat underlying insomnia
Symptoms of insufficient sleep time?
inadequate amt of sleep, poor sleep hygiene, may be caused by insomnia
Symptoms of sleep apnea
loud snoring, witnessed apneic spells, disrupted sleep
Tx of sleep apnea
CPAP, weight loss, avoid supine sleep
Symptoms of Narcolepsy?
severe daytime somnolence, sleep paralysis, hypnagogic hallucinations, disrupted nocturnal sleep, cataplexy, onset in teens and 20’s
Tx for narcolepsy
stimulants (modafinil) venlafaxine, fluoxetine, atomoxetine, sodium oxybate for cataplexy
Symptoms of recurrent hypersomnia (Kleine Levin syn)?
Recurrent episodes of hypersomnia hyperphagia hypersexuality onset as teen
Treatment for recurrent hypersomnia (Kleine Levin Syn)
no effective tx
Cataplexy definition
sudden loss of muscle tone associated with laughing or intense emotions
When does narcolepsy present?
20 yrs
Initial screening test for narcolepsy??
overnight polysomnogram then having a multiple sleep latency test (MSLT)
Need to have both. Cannot diagnose with multiple sleep latency test alone.
narcolepsy has a high incidence of coexisting sleep disorders like OSA and REM sleep disorder and restless leg syndrome
Need to get the PSG first to ensure that the patient had adequate sleep the night before the multiple sleep latency test (otherwise it invalidates findings if lack of sleep).
What is a multiple sleep latency test
pts are given several opportunities to nap and time to sleep onset (sleep latency) is measured
What is seen on a multiple sleep latency test with patients who have narcolepsy?
shorter sleep latency (time to sleep) than normal controls and evidence of rapid eye movement (REM) shortly after falling asleep.
1st line tx for daytime somnolence from narcolepsy?
modafinil (1st line) - good relief of daytime sleepiness and well tolerated and has a low potential for abuse. Mechanism is not understood. preferred over methylphenidate or amphetamines due to side effect and safety profile. (hypertension, tachycardia, decreased appetite and addiction) and avoid for ppl who are risk for sudden cardiac death
Does increasing sleep time for narcoleptic patients help?
no. Naroleptic pts sleep the same time as unaffected pts.
What protein is low in CSF fluid of narcoleptic patients?
CSF hypocretin 1 levels are low
What is a REM behavior disorder?
parasomnia disorder where there are dream enactment behaviors that occur during a loss of normal REM sleep atonia; behaviors are triggered by the dream
REM behavior presentation
violent trashing, punching, kicking to avoid threats related to dream content. Usually come seek advice because of partner concern for injury.
Who gets REM behavior disorder?
middle age older men
What happens with REM behavior disorder
may be a prodromal syndrome of neurodegeneration w/ vast majority develop Parkinson’s dx or dementia iwth Lewy body about 50% every decade
Treatment of REM behavior sleep disturbance
melatonin remove sharp and breakable objects, place cushion next to bed. Low dose clonazepam is effective in refractory cases.
How to treat jet lag?
choose daytime flights, drink water, avoid caffeine, alcohol, large meals during normal sleep period consider melatonin if crossing >4 time zones avoid importnat meetings, long distance driving, or sedentary behavior on 1st day exercise in daytime.
Symptoms of Jet lag
sleep disturbance, daytime fatigue, reduced performance, malaise, GI (constipation)
manifestations of narcolepsy
daytime sleepiness,
falling alseep at inappropriate times,
vivid dreams when falling asleep or waking up.
Paralysis when waking up
cataplexy (fainting or facial paralysis) with strong emotion as laughing.
most common symptom is daytime sleepiness.
diagnosis of narcolepsy:
3 months of severe daytime sleepiness with cataplexy and mean sleep latency time <8 minutes and at least two lseep onset REM sleep latency test for type 1- narcolepsy with cataplexy
or
2 an overnight polysomnogram plus next day multiple sleep latency tests with MEN latency time <8 minutes and at least two sleep onset REM sleep periods can see low orexin A in CSF for type one
Cataplexy treatment?
Cataplexy seen in type 1 nacrolepsy.
rarely needs treatment.
Options include drugs that suppress REM (venlafaxine, atomoxetine, fluoxetine and sodium oxybate)
pt presents with urge to move legs and unpleasant sensations on legs before bed.
Restless leg syndrome reports having sensations which are worse with inactivity and relieved by movement
secondary causes of restless leg syndrome
Fe deficiency uremia DM2 MS and parkinson’s dx pregnancy drugs (SSRI and metoclopramide)
Treatment of RLS
iron supplementation if serum ferritin is <75 ug/L leg massage heating pads, lowering caffeine intake, and exercise dopamine agonists (pramiprexole) gabapentin and pregabalin
when should exercise be done to promote good slep?
at least 20 minutes and done >4-5 hrs prior to bedtime exercising before bedtme can be activating and further disrupts sleep
Restricting time in bed to help one’s sleep is only used in:
people who are insomniacs and try to stay in bed longer in attempt to make up for lost sleep (pt who says in bed for 9 hrs but only sleeps for 5 hrs) by limiting to 5-6 hrs then the sleep efficiacy can improve
non pharmacological treatment of insomnia
non pharmacological treatment of insomnia is broken down into
sleep hygiene - encourage good sleep habits
stimulus control - break the link between bedroom and fear and frustration
relaxation- reduce tension and stress
sleep restriction - improve sleep efficiency
cognitive therapy - change maladaptive beliefs.
what is narcolepsy?
disorder of sleep-wake control in which the line between the two is blurred.
sleep can invade into wakefulness by causing sudden onset sleep during inappropriate times or by causing cataplexy - sudden loss of control of face or entire body with strong emotion like laughter.
wakefulness invades sleep by c_ausing vivid dreams at the onset of or offset of sleep._
can be categorized into
type 1: cataplexy
type 2: no cataplexy
Shift work sleep disorder
common phenomenon where pts have difficulty sleeping during the day
need to make sure no sleep apnea and optimize sleep hygeine habits by
sleeping in dark room,
avoiding bright screens like computers or televisions before bed
avoiding caffeine 8 hrs before bed
can give a stimulant modafinil prior to shift.
melatonin and light therapy don’t help
1st line treatment for narcolepsy?
modafinil - good relief of daytime sleepiness and is generally well tolerated and low potential for absue
it does decrease effectiveness of oral contraception in women.
can also use methylphenidate and amphetamines as dextroamphetamine)
how to treat cataplexy?
seldom requires treatment but if it does, options include medications that suppress REM (venlafaxine, atomoxetine, fluoxetine and sodium oxybate) sodium salt of a gamma hydroxybuytrate)
Treat insomnia with cognitive behavioral therapy
1st line treatment to insomnia is cognitive behavioral therapy for insomnia.
combines sleep hygeine with behavioral interventiosn and cognitive behavioral therapy.
melatonin and diphenydramine are OTC remedies that don’t have enough evidence to recommend their use before a CBT-I. also sedating medications like anti-histamines are associated with anticholinergic side effects and carry over daytime sleepiness.
