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RRCCPA Clinical Medicine I > Sleep Meds Final > Flashcards

Sleep Meds Final Flashcards

1
Q

Sleep disorders are more common in?

A

Women and older patients

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2
Q

One theory on sleep disturbance is increased ______ activation (i.e. ____, ____, ____, ___)

A

physiological

  • cardiac
  • metabolic
  • hormone
  • EEG
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3
Q

Sleep disturbance may also arise from increased activation of the _____.

A

Hypothalamus

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4
Q

Risk factors for sleep disturbance include

A 
Older age
female
previous insomnia
FH insomnia
-predisposed to waking easily
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5
Q

Psychiatric disorders associated with sleep disturbance

A

depression
anxiety
substance use disorder
PTSD

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6
Q

Pulmonary diseases linked to insomnia

A

chronic pain
CHF
Parkinson dz
HTN

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7
Q

Meds that can cause insomnia

A

CNS stimulants i.e. caffeine, cocaine, modafinil

  • appetite supressants
  • antidepressants (MAOIs, some SSRI esp. prozac/wellbutrin is a DNRI
  • Glucocorticoids
  • Beta blockers
  • alcohol
  • nicotine
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8
Q

What can beta blockers cause that can produce sleep disturbance?

A

Sleep-onset insomnia, vivid dreams and increased awakening

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9
Q

Two main types of insomnia?

A

Short term < 3 mos

Chronic >/= 3X/week and >/= 3 mos

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10
Q

Short term insomnia can also be termed…

A

Adjustment/acute insomnia

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11
Q

Clinically insomnia is classified as taking >/= ___ minutes to fall asleep or spend >/= ___ minutes awake during the night, or wake up >/= ___ minutes prior to desired time.

A

30, 30, 30

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12
Q

What is the first line therapy for insomnia?

A

CBT-I

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13
Q

What are the behavioral components of CBT-I?

A
  • stable bedtime 7 days/wk
  • only stay in bed while sleeping or sex
  • get out of bed if not sleepy
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14
Q

How do you evaluate insomia?

A
  1. Detailed sleep hx & sleep diary
  2. Screening tools i.e. Pittsburg sleep quality index
  3. Sleep problem questionnaire
  4. Ddx
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15
Q

Tx for acute?

A
  1. Discuss the stressors

2. +/- short-term intermittent use of sedative (up to 4 wks)

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16
Q

List of benzos

A 
Estazolam
flurazepam
lorazepam
temazepam
triazolam
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17
Q

List of non benzos

A

Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopicline (Lunesta)

18
Q

What is the cognitive aspect of CBT-I

A

treat:
- anxious thoughts about sleeplessness
- inappropriate expectations about hours of sleep
- misbeliefs about the effects of sleeplessness
- relaxation through mindfulness, progressive muscle relaxation and meditation

19
Q

What is the concern with chronic use of sedatives for chronic insomnia?

A
  • abnormal thinking
  • behavioral changes
  • CNS depression
  • rx abuse
  • increase sleep-related activities i.e. sleep driving or eating
20
Q

Non controlled meds for insomnia?

A

Melatonin
Trazodone (off label antidepressant)
Doxepin (Silenor [TCA])
Suvorexant (Belsomra) >orexin receptor antagonist

21
Q

What meds do you want to avoid for insomnia

A

Antipsychotics
Benadryl
Barbiturates
Alcohol

22
Q

Sequelae of insomnia

A

Adverse cardiac outcomes from SNS activation i.e. HTN/MI

  • Increased SI
  • Self medication/substance abuse
23
Q

Narcolepsy is daytime sleepiness with:

A

Cataplexy (type I with, type II without)

  • Hypnagogic hallucinations
  • sleep paralysis
  • sleep attacks
24
Q

When does narcolepsy usually begin?

A

Teens - early 20s
M=F
1 in 2000 people

25
Q

Pathophysiology behind narcolepsy?

A

Loss of orexin-A & orexin-B

26
Q

What the hell is orexin?

A

released during wakefulness and increase activity of brain regions that keep a person awake

27
Q

Clinical features of narcolepsy

A
  • fall asleep at inappropriate times without warning (sleep attack)
  • sleepiness improves with nap
  • usually feel rested in morning
  • Epworth score >15
  • sleep paralysis
  • hypnagogic hallucinations
28
Q

How to eval narcolepsy

A
  1. Sleep study (polysomnogram) showing spontaneous awakening, reduced sleep efficiency, increased light non-REM sleep
    - Enters REM sleep quickly w/in 15 min (normal takes 80-100 min)
  2. Multiple sleep latency test (falls asleep in < 8 min, normal is 10-15 min)
    - naps often include REM sleep (>/= 2 naps with REM essential feature of narcolepsy)
29
Q

Non-Rx tx of narcolepsy

A

1-2 20 min naps/day (around 1 pm best, can reduce sleepiness up to 3 hrs)

  • maintain regular sleep schedule
  • avoid alcohol/benzos/opiates
  • psychosocial support
30
Q

1st line rx for narcolepsy

A

Modafinil (Provigil)
-does not affect sleep
s/e: HA, nausea, dry mouth, anorexia, diarrhea

31
Q

2nd line meds for narcolepsy include

A

Stimulants i.e. ritalin/concerta/amphetamines

  • s/e: HTN, HA, sudden death, dependency
  • Newly approved last 2019 solriamfetol
32
Q

What is the narcolepsy medication that has to be taken QHS then 2.5-4 hrs later?

A

Sodium oxybate (liquid) show results in few days but up to >3 mos for full effect

  • s/e: weight loss, dizzy, mood swings, worsening depression
  • overdose potential with respiratory depression
33
Q

What is the most common sleep-related breathing disorder?

A

OSA

34
Q

Risk factors for OSA

A 
getting old
M>F
Obesity 
Got a weird face or airway 
nasal congestion
35
Q

What does OSA cause at a cellular level?

A

Gas exchange disturbances (hypercapnia and hypoxia)

36
Q

Some maybe not so normal sxs of OSA

A

morning headaches

37
Q

PE findings that might lead you to evaluate OSA

A

Obesity
Crowded airway (Malompati score)
Big ol’ neck
HTN

38
Q

How to dx OSA

A

First-line is in lab sleep study or secondary home sleep apnea testing (HSAT)

39
Q

Sleep study diagnostic criteria for positive OSA

A

Need an AHI (apnea hypopnea index) of 5 or more (AHI of 15 diagnostic on its own) per hour AND at least one of these (no shit criteria)

  • sleepy, fatigue, insomnia
  • wake up choking/gasping
  • chronic snoring/apnea observed by partner
  • HTN, mood disorder, cognitive dysfunction, CAD, CVA, CHF, AF, DM2
40
Q

Complications of OSA besides the obvious

A 
MVAs
Metabolic syndrome 
DM2
Perioperative complications
NAFLD
2-3 fold increase in all cause mortality

RRCCPA Clinical Medicine I (49 decks)

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