Sleep - Silvia Flashcards
Sleep Cycle:
Awake, NREM (N1, N2, N3 back to N2, then to ____) then back to N1.
During REM, loss of __ __, increased brain O2 usage, and increased ACH during dreaming.
Sleep Cycle:
- NREM (Non-REM)
- Stage W (Wake), N1, N2, N3 (back to N2, then back to REM, then back to N1)
During REM, loss of muscle tone, increased brain O2 usage, and increased ACH during dreaming.
Sleep Cycle in Adults:
- Stage W (Wakefulness)
- N1 (drowsiness) - EEG – brainwaves slow (___ waves), decreased eye blinking, slow eye movements
- N2 – characteristic EEG changes (___ waves)
- N3- “slow wave sleep” - Decrease eye movements, decrease in EMG (___ waves)
STAGE R (REM)
1) lower amplitude (___ waves)
2) Random Eye movements
3) low EMG activity
Sleep Cycle in Adults:
- Stage W (Wakefulness)
- N1 (drowsiness) - EEG – brainwaves slow (theta waves), decreased eye blinking, slow eye movements
- N2 – characteristic EEG changes (sleep spindles and K complexes)
- N3- “slow wave sleep” - Decrease eye movements, decrease in EMG (delta waves)
STAGE R (REM)
1) lower amplitude (beta waves)
2) Random Eye movements
3) low EMG activity
Sleep Cycling:
- ___ to ___ Cycles of NREM/REM
- __ - ___ minutes per cycle
Sleep Cycling
•3-5 Cycles of NREM/REM
•90-100 minutes per cycle
Stage REM – duration is ___ in each sleep cycle and ___ in second part of night
N3- mostly in the ____ part of night
Wake duration – ___ with age
Men– N3 ____ with age
Women– ___ does not decrease with age
Adults – Stage REM ____ with age
Stage REM – duration is longer in each sleep cycle and longer in second part of night
N3- mostly in the first part of night
Wake duration – increased with age
Men– N3 decreases with age
Women– N3 does not decrease with age
Adults – Stage REM decreases with age
Young adults:
- ____ - 5-10% of total sleep time
- ____ - 50-60%
- ____ - 15-20%
- ___ 20%
Babies:
Lighter, fragmented
Increase sleep latency
Pediatrics: % spent in REM
Infants ____% of the time are in REM
Toddlers ___%
Children ___%
•Young adults
•N1 - 5-10% of total sleep time
•N2 - 50-60%
•N3 - 15-20%
•REM - 20%
Babies:
Lighter, fragmented
Increase sleep latency
Pediatrics: % spent in REM
Infants 50% of the time are in REM
Toddlers 30%
Children 25%
The sleep stages are __. __, __, __, __, __, __ (one cycle)
Each cycle last between __ - -__ minutes. There are __ - ___ cycles per night, and you spend more time in REM at the end of the night. In normal adults, you spend the most time in ___, and as you age, you spend less time in REM and more in wake. Infants spend __% in REM. Toddlers, ___%, children __%, and adults __%.
Elderly spend less time in __ and ___. They spend more time in N1 and N2 (fewer dreams)
N1 - drowsiness or ___ state, and is accompanied by the feeling of falling and muscle jerks.
N2 - sleep___ and __ complexes
N3 - slow ___ waves (this is the stage where you sleep walk or sleep talk)
REM - mind is active but muscles are ___ (reduced muscle tone) and rapid eye movement.
For sleep deprivation, we have something called __ ____ This means that if you don’t sleep for one night, it will take __ nights of increased __ to recover.
The sleep stages are W, N1, N2, N3, N2, REM, N1 (one cycle)
Each cycle last between 90 - 100 minutes. There are 3 - 5 cycles per night, and you spend more time in REM at the end of the night. In normal adults, you spend the most time in N2, and as you age, you spend less time in REM and more in wake. Infants spend 50% in REM. Toddlers, 30%, children 25%, and adults 20%.
Elderly spend less time in REM and N3. They spend more time in N1 and N2 (fewer dreams)
N1 - drowsiness or hypnogogic state, and is accompanied by the feeling of falling and muscle jerks.
N2 - sleep spindles and K complexes
N3 - slow delta waves (this is the stage where you sleep walk or sleep talk)
REM - mind is active but muscles are paralyzed (reduced muscle tone) and rapid eye movement.
For sleep deprivation, we have something called REM rebound. This means that if you don’t sleep for one night, it will take three nights of increased REM to recover.
Neurobiology of Sleep
•Awake Promoting Neurotransmitters come from the
___ and ___ HYPOTHALAMUS. Narcolepsy can result from loss of neuropeptides ___ and ___ (aka hypocretin-1 and hypocretin-2) produced in the ___ hypothalamus. These peptides normally promote ____
Neurobiology of Sleep:
•Awake Promoting Neurotransmitters come from the LATERAL AND POSTERIOR HYPOTHALAMUS. Narcolepsy can result from loss of neuropeptides orexin-A and orexin-B (aka hypocretin-1 and hypocretin-2) produced in the lateral hypothalamus. These peptides normally promote wakefulness.
If you are trying to promote arousal, you have to send signals to and from the ___ nuclei as well as the ___ nuclei, but you also have to have projections to the cerebral cortex. When you are awake, you want your cortex to be awake!
If you are trying to promote arousal, you have to send signals to and from the brainstem nuclei as well as the hypothalamic nuclei, but you also have to have projections to the cerebral cortex. When you are awake, you want your cortex to be awake!
We start with Orexin A and B. They send excitatory projections to
- __ __ nucleus (Hcrt 1, 2)
- ___ ____(Hcrt 1)
- ____ nucleus (Hcrt 2)
All of these send ___ projections to Hcrt neurons
Note: Hcrt neurons excitatory effect on cholinergic neurons in basal forebrain contribute to ___
We start with Orexin A and B. They send excitatory projections to
- Dorsal raphe nucleus (Hcrt 1, 2)
- Locus coeruleus (Hcrt 1)
- Tuberomammillary nucleus (Hcrt 2)
All of these send inhibitory projections to Hcrt neurons
Note: Hcrt neurons excitatory effect on cholinergic neurons in basal forebrain contribute to arousal
•Hcrt Neurons are activated during sensory ____. They have maximal firing in ____ behavior. Possible issue in ___ (a medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious.)
- Hcrt Neurons are activated during sensory stimulation. They have maximal firing in exploratory behavior
- Possible issue in cataplexy (a medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious)
During REM, you have loss of muscle tone, increased O2 brain use, increase __ (from the lateral dorsal tegmentum and the pedunculopontine tegmentum) while dreaming, nightmares and penile/clitoal tumescence ocur. May serve memory processing function.
During REM sleep you are hypotonic. How does this work?
Orexin A and B project to the locus coreulus, raphe nucleus and the tuberomammilaries.
•The ubcoeruleus, sublateral dorsal tegmentum projects excitatory signals to the brainstem (medulla) but also produces inhibitory ___ neurons to motor neurons in the __ __.
Orexin A and B stimulate the tuberomamillary nucleus and this causes the nucleus to produce:
- ___
- H1— associated with ____
- H1 blockers (_____) associated with drowsiness
- H3—associated with ___ because it decrease histamine release
- Many projections (cortex, amygdala, SN, DRN, LC)
During REM, you have loss of muscle tone, increased O2 brain use, increase ACh while dreaming, nightmares and penile/clitoal tumescence ocur. May serve memory processing function.
During REM sleep you are hypotonic. How does this work?
•Subcoeruleus, sublateral dorsal tegmentum projects excitatory singals to brainstem (medulla) but also produces inhibitory GABA neurons to motor neurons in spinal cord.
Tuberommillary Nucleus
•HISTAMINE
- H1—associated with wakefulness.
- H1 blockers (Benadryl) associated with drowsiness
- H3—associated with sleep –> because it decreases histamine release.
- Many projections (cortex, amygdala, SN, DRN, LC)
Obstructive Sleep Apnea and Hypopnea
OSA
- Diagnosed on Polysomnogram
- Apnea – absent ___ at nose/mouth for __ seconds. Caused by an obstruction (usually in the __ area).
To be diagnosed:
- >__/hr abnormal if symptoms present
- >or __/hr with or without symptoms
- ___ terminates apnea
Sleep apnea is a sleep disorder characterized by repetitive cycles of ___ leading to gasping and possibly awakening from sleep.
Obstructive sleep apnea is defined as a transient obstruction of the upper airway leading to hypoxemia and arousal from sleep.
Risk factors for obstructive sleep apnea include:
Obesity (weight of neck may cause airway compression) (70%)
Anatomical abnormalities (e.g. enlarged tonsils or uvula)
The first line treatment for obstructive sleep apnea includes both ___ loss and continuous positive airway pressure (CPAP).
Hypopneas
– reduced ___, not complete ___.
- ___% reduction in flow from baseline
- 4% or greater oxygen desaturation
- After testing oxygen levels during sleep, you refer to the AHI- __-___ Index
- RDI-Respiratory Disturbance Index
- RERA-respiratory effort related arousals
- IN order to diagnose, you must have evidence that the rest of the body is trying to breath, but can’t because of ___ restriction.
Obstructive Sleep Apnea
- Diagnosed on Polysomnogram
- Apnea – absent airflow at nose/mouth for 10 seconds. Caused by an obstruction (usually the supraglottal area).
To be diagnosed:
- >5/hr abnormal if symptoms present
- >or have 15/hr with or without symptoms
- Arousal terminates apnea
Sleep apnea is a sleep disorder characterized by repetitive cycles of hypoxia leading to gasping and possibly awakening from sleep.
Obstructive sleep apnea is defined as a transient obstruction of the upper airway leading to hypoxemia and arousal from sleep.
Risk factors for obstructive sleep apnea include:
Obesity (weight of neck may cause airway compression) (70%)
Anatomical abnormalities (e.g. enlarged tonsils or uvula)
The first line treatment for obstructive sleep apnea includes both weight loss and continuous positive airway pressure (CPAP).
Hypopneas
– reduced airflow not complete cessation
- 30% reduction in flow from baseline
- 4% or greater oxygen desaturation
- After testing, you refer to the AHI- Apnea-Hypopnea Index
- RDI-Respiratory Disturbance Index
- RERA-respiratory effort related arousals
- Evidence that the rest of the body is trying to breath, but they can’t because of supraglottic restriction.
___ symptoms
- EDS (excessive daytime sleepiness)
- Frequent nocturnal arousals
- AM Headaches
- Loud ____
- Choking, gasping in sleep
- Witnessed breathing pauses
- Restless ___ movements in sleep
- Depression, fatigue
Physical Examination
- BMI
- Mallampati score
- High ___
- Retrognathia
- Increase neck circumference (17”M, 16”F)
- Evidence of heart failure
OSA symptoms:
- EDS (excessive daytime sleepiness)
- Frequent nocturnal arousals
- AM Headaches
- Loud snoring
- Choking, gasping in sleep
- Witnessed breathing pauses
- Restless ___ movements in sleep
- Depression, fatigue
Physical Examination
- BMI
- Mallampati score
- High palate
- Retrognathia
- Increase neck circumference (17”M, 16”F)
- Evidence of heart failure
Pediatric OSA:
- Different risk factors and symptoms
- Hyperactivity, developmental delay, behavior
- Usually affects __-___ yr olds
- Obesity
- Age of tonsillar/adenoid hypertrophy max
- Don’t report ___ (excessive day time sleepiness)
- PSG-OHI>1hr, or OAHI>2/hr
- Treatment ____ or ___ not always helpful
Pediatric OSA
- Different risk factors and symptoms
- Hyperactivity, developmental delay, behavior
- Usually affects 4-6 yr olds
- Obesity
- Age of tonsillar/adenoid hypertrophy max
- Don’t report EDS
- PSG-OHI>1hr, or OAHI>2/hr
- Treatment T&A, not always helpful
Central Sleep Apnea
- ___ to ___ %of patients with sleep apnea
- Adults – __ seconds, absence of ___
- Divided into __ vs. ___
- Mostly due to pre-existing medical problems like: neuromuscular, medication induced, cardiac
Caused by:
- __ __ Syndrome
- “___ curse”
- Respiratory arrest/insufficiency with sleep
- __ or acquired
•10-15%of patients with sleep apnea
- Adults – 10 seconds, absence of effort
- Divided into hypocapnic vs. hypercapnic
- Mostly due to pre-existing medical problems
- Neuromuscular, medication induced, cardiac
Caused by:
•Congenital Hypoventilation Syndrome
•“Ondine’s curse”
•Respiratory arrest/insufficiency with sleep
•Congenital or acquired
•Restless Leg Syndrome
- Clinical diagnosis (not polysomnogram)
- Typically worse in __
- Worse when __
- “Urge” to __
- Better with ____
- Can be primary or secondary
- Can involve ___.
Medications/Treatment
- ____ replacement
- ____ Agonists
- Anti-___
- ____pentin
- Severe
- ____ (methadone, oxycodone)
•Restless Leg Syndrome
- Clinical diagnosis (not polysomnogram)
- Typically worse in evening
- Worse when still
- “Urge” to move
- Better with movement
- Can be primary or secondary
- Can involve arms
Medications
•Iron replacement
•Dopamine Agonists
•Anti-epileptics
•Gabapentin
•Severe
•Narcotics (methadone, oxycodone)
Narcolepsy
•EDS, diagnosed by polysomnogram
____ intrusion into wakefulness
•Decreased REM ___
60-70% of __ occurs in narcolepsy.
Low/undetectable ___ in CSF for people with narcolepsy and cateplexy,
Cataplexy –temporary loss of __ __ with __ (__)
Narcolepsy
•EDS, diagnosed by polysomnogram
REM intrusion into wakefulness
•Decreased REM latency
60-70% of cateplexy occurs in narcolepsy
Low/undetectable hypocretin-1 in CSF for people with narcolepsy and cateplexy,
Cataplexy –temporary loss of muscle tone with emotion (laughter)
Narcolepsy is characterized by daytime somnolence and “sleep attacks” where patients suddenly fall asleep. True ___ sleep occurs during these attacks.
Narcolepsy can result from loss of neuropeptides ___ and __ produced in the __ __. These peptides normally promote __
Cataplexy is a medical condition in which a patient loses all __ __ after a strong __ stimulus. Cataplexy is associated with __
Narcolepsy is associated with ___ (just before sleeping) and hypnopompic (occur during awakening) hallucinations.
Mnemonic: HypnaGOgic is just before you GO to sleep. HypnoPOmpic is POst sleep.
Patients with narcolepsy are treated with stimulants such as ___ or amphetamines during the day to decrease sleepiness.
At night, patients with narcolepsy can take sodium oxybate (GHB) to promote sleep and improve daytime somnolence.
Diagnosis:
- Multiple Sleep Latency Test
- Overnight PSG
- 5 Naps
- Mean Sleep latency <___ minutes
- 2 sleep onset ___ sleep (REM latency<15min
Causes:
___\_
- Tumors, sarcoid, AVM in hypothalamus
- MS in hypothalamus
______
• Head trauma, Parkinson’s disease
Narcolepsy is characterized by daytime somnolence and “sleep attacks” where patients suddenly fall asleep. True REM sleep occurs during these attacks.
Narcolepsy can result from loss of neuropeptides orexin-A and orexin-B (aka hypocretin-1 and hypocretin-2) produced in the lateral hypothalamus. These peptides normally promote wakefulness.
Cataplexy is a medical condition in which a patient loses all muscle tone after a strong emotional stimulus. Cataplexy is associated with narcolepsy.
Narcolepsy is associated with hypnagogic (just before sleeping) and hypnopompic (occur during awakening) hallucinations.
Mnemonic: HypnaGOgic is just before you GO to sleep. HypnoPOmpic is POst sleep.
Patients with narcolepsy are treated with stimulants such as modafinil or amphetamines during the day to decrease sleepiness.
At night, patients with narcolepsy can take sodium oxybate (GHB) to promote sleep and improve daytime somnolence.
Diagnosis:
- Multiple Sleep Latency Test
- Overnight PSG
- 5 Naps
- Mean Sleep latency <8 minutes
- 2 sleep onset REM sleep (REM latency<15min
Causes
•N+C
- Tumors, sarcoid, AVM in hypothalamus
- MS in hypothalamus
N-C
• Head trauma, Parkinson’s disease
Insomnia:
- Prevalence
- __ - ___% Adults – few times/year
- 10-15% Adults with daytime complaints
- Risk factors
- Older age
- ___Gender
- Co-morbid (psychiatric disorder, addictions)
- Depression most common (1/3 insomnia cases)
- Chronic Pain disorder (up to 80%, added to depression)
- Single/divorced/separated>married
Treatment:
____ receptor Agonists
- __-___ - Ambien
- Benzos, _____
- Benzos, not FDA – __ and ___
- Melatonin Receptor
- OTC melatonin, Ramelteon
- “Off-label” sedating medications
- Trazodone, TCAs, anti-psychotics
Insomnia:
Prevalence:
•33-50% Adults – few times/year
- 10-15% Adults with daytime complaints
- Risk factors
- Older age
•Female Gender
- Co-morbid (psychiatric disorder, addictions)
- Depression most common (1/3 insomnia cases)
- Chronic Pain disorder (up to 80%, added to depression)
- Single/divorced/separated>married
Treatment:
- Benzodiazepine receptor Agonists
- Non-benzos, Ambien
- Benzos, Temazepam
- Benzos, not FDA – lorazepam, clonazepam
- Melatonin Receptor
- OTC melatonin, Ramelteon
- “Off-label” sedating medications
- Trazodone, TCAs, anti-psychotics
Shift-work disorder
- 5-10% meet criteria
- Daytime sleep 5-6 hrs
- Naps 2hrs late afternoon
- Take ___
- Bright light during shift, sunglasses after
- Consider alerting medications
Shift-work disorder
- 5-10% meet criteria
- Daytime sleep 5-6 hrs
- Naps 2hrs late afternoon
•Melatonin
- Bright light during shift, sunglasses after
- Consider alerting medications
___ are abnormal behaviors or experiences that occur during sleep, often disturbing the patient and affecting sleep quality. They include:
REM sleep behavior disorder
Sleepwalking
Sleep terrors
Nightmare disorder
___, particularly REM sleep behavior disorder, are caused by an incomplete inhibition of skeletal muscle during REM sleep.
A key difference in distinguishing nightmare disorder from sleep terrors is that patients with nightmare disorder recall their dreams. This is because of the difference in sleep stage during which the nightmares/terrors occur.
REM sleep behavior disorder is characterized by dream-enacting behaviors, where patients may jerk limbs, walk, yell, and perform various actions. The first line treatment is melatonin, and second line is clonazepam.
Sleepwalking is characterized by walking during sleep, with or without the presence of other complex behaviors. Patients’ eyes are open with a “glassy” look, and they have amnesia for the episode. Sleepwalking is associated with:
Sleep deprivation
Stress
Hyperthyroidism
Sleep apnea
Magnesium deficiency
Sleep terrors are episodes of sudden arousal with screaming. Patients do not recall their dream and may be disoriented upon waking. Sleep terrors occur during sleep stages N3-4 (delta wave sleep).
Nightmare disorder is marked by recurrent frightening dreams, which are particularly vivid. This disorder has a strong association with PTSD.
Imagery rehearsal therapy (IRT) involves using mental imagery to modify the outcome of a recurrent nightmare. It is very successful in treating recurrent nightmares in PTSD.
Nightmares in nightmare disorder occur during REM sleep.
Parasomnias are abnormal behaviors or experiences that occur during sleep, often disturbing the patient and affecting sleep quality. They include:
REM sleep behavior disorder
Sleepwalking
Sleep terrors
Nightmare disorder
Parasomnias, particularly REM sleep behavior disorder, are caused by an incomplete inhibition of skeletal muscle during REM sleep.
A key difference in distinguishing nightmare disorder from sleep terrors is that patients with nightmare disorder recall their dreams. This is because of the difference in sleep stage during which the nightmares/terrors occur.
REM sleep behavior disorder is characterized by dream-enacting behaviors, where patients may jerk limbs, walk, yell, and perform various actions. The first line treatment is melatonin, and second line is clonazepam.
Sleepwalking is characterized by walking during sleep, with or without the presence of other complex behaviors. Patients’ eyes are open with a “glassy” look, and they have amnesia for the episode. Sleepwalking is associated with:
Sleep deprivation
Stress
Hyperthyroidism
Sleep apnea
Magnesium deficiency
Sleep terrors are episodes of sudden arousal with screaming. Patients do not recall their dream and may be disoriented upon waking. Sleep terrors occur during sleep stages N3-4 (delta wave sleep).
Nightmare disorder is marked by recurrent frightening dreams, which are particularly vivid. This disorder has a strong association with PTSD.
Imagery rehearsal therapy (IRT) involves using mental imagery to modify the outcome of a recurrent nightmare. It is very successful in treating recurrent nightmares in PTSD.
Nightmares in nightmare disorder occur during REM sleep.
Sleep cycling
__ to ___ cycles of NREM/REM
___ to ___ minutes per cycle
Stage REM - duration ____ in each successive cycle
You dream more towards the ____of sleep
N3 - most in ___ part of night
Wake duration - increases w/___
Increased arousals w/age
Men -____ decreases w/age
Women - ___ does not decrease w/age
Adults - Stage ___ decreases w/age
Sleep cycling
3-5 cycles of NREM/REM
90-100 minutes per cycle
Stage R - duration longer in each successive cycle
You dream more towards the end of sleep
N3 - most in first part of night
Wake duration - increases w/age
Increased arousals w/age
Men - N3 decreases w/age
Women - N3 does not decrease w/age
Adults - Stage R decreases w/age
Young adults
N1 ___ to ___% of total sleep time
N2 __ to ___ %
N3 ___ to ___%
R ___%
Normal sleep - changes with aging
Lighter, fragmented
Increase sleep latency
Pediatrics
Infants ___% stage REM
Toddlers __%
Children __%
Young adults
N1 5 to 10% of total sleep time
N2 50 to 60 %
N3 15 to 20%
R 20%
Normal sleep - changes with aging
Lighter, fragmented
Increase sleep latency
Pediatrics
Infants 50% stage REM
Toddlers 30%
Children 25%
Clinical Symptoms of Sleep Deprivation
Longer ____ time
Lapses in ____
____ information
Poor ___ term memory
Poor mood
___ motivation
Sleepiness
Poor performance
____ when sedentary
Worse with no feedback
Worse with reduced light or sound
Worse with low motivation, interest, or novelty
Worse at circadian low points
Clinical Symptoms of Sleep Deprivation
Longer reaction time
Lapses in attention
Lost information
Poor short term memory
Poor mood
Reduced motivation
Sleepiness
Poor performance
Worse when sedentary
Worse with no feedback
Worse with reduced light or sound
Worse with low motivation, interest, or novelty
Worse at circadian low points
Sleep deprivation - chronic partial
Less than 7 hours/night (8.16)
Chronically sleep deprived does not recognize the degree of impairment
Increased:
____ lapses
Norepinephrine
Cortisol and ACTH
___ (hunger)
Insulin ___
Glucose ____
Medical errors
Motor vehicle accidents
Don’t fall asleep at the wheel. It’s not worth it.
Decrease
Vigilance
Pain tolerance
Cognition and attention
Seizure threshold
Leptin
Acute antibody response
Working memory
Cognitive processing
Sleep deprivation - chronic partial
Less than 7 hours/night (8.16)
Chronically sleep deprived does not recognize the degree of impairment
Increased:
Attention lapses
Norepinephrine
Cortisol and ACTH
Ghrelin (hunger)
Insulin resistance
Glucose increases
Medical errors
Motor vehicle accidents
Don’t fall asleep at the wheel. It’s not worth it.
Decrease
Vigilance
Pain tolerance
Cognition and attention
Seizure threshold
Leptin
Acute antibody response
Working memory
Cognitive processing
Neurobiology of sleep: The hypothalamus is your friend
Awake promoting neurotransmitters
___ and ____ HYPOTHALAMUS release
___ (Orexin A)
Binds to Hcrt 1 and 2 receptors
___ (Orexin B)
Binds only to Hct 2 receptors
Neurobiology of sleep: The hypothalamus is your friend
Awake promoting neurotransmitters
LATERAL AND POSTERIOR HYPOTHALAMUS release
Hypocretin 1 (Orexin A)
Binds to Hcrt 1 and 2 receptors
Hypocretin 2 (Orexin B)
Binds only to Hct 2 receptors
Pediatric OSA
Different risk factors and symptoms
____activity, ___ delay, behavior
Affects __ to ___ yr olds
___ are largest during this age
May fall back and hit back of throat
Obesity
Age of tonsillar/adenoid hypertrophy max
Don’t report ____
PSG-OHI > 1hr, or OAHI > 2/hr
Treatment T&A (Tonsillectomy and adenoidectomy), not always helpful
Pediatric OSA
Different risk factors and symptoms
Hyperactivity, developmental delay, behavior
Affects 4-6 yr olds
Tonsils are largest during this age
May fall back and hit back of throat
Obesity
Age of tonsillar/adenoid hypertrophy max
Don’t report EDS
PSG-OHI > 1hr, or OAHI > 2/hr
Treatment T&A, not always helpful
Tonsillectomy and adenoidectomy
Central Sleep Apnea
__ to ___% of patients with sleep apnea
Adults - 10 seconds, absence of effort
Brain ain’t telling body to breathe
Divided into hypo___ vs hyper___
Mostly due to pre-existing medical problems
Like ALS
Neuromuscular, medication induced, cardiac
Diagram: during apnea, there is no ___ effort or chest movement
Congenital hypoventilation syndrome
“Ondine’s curse”
___ arrest/insufficiency with sleep
Congenital or acquired
Central Sleep Apnea
10-15% of patients with sleep apnea
Adults - 10 seconds, absence of effort
Brain ain’t telling body to breathe
Divided into hypocapnic vs hypercapnic
Mostly due to pre-existing medical problems
Like ALS
Neuromuscular, medication induced, cardiac
Diagram: during apnea, there is no respiratory effort or chest movement
Congenital hypoventilation syndrome
“Ondine’s curse”
Respiratory arrest/insufficiency with sleep
Congenital or acquired
Restless Leg Syndrome
____ diagnosis (not polysomnogram)
Typically worse in ___
Worse when __
“Urge” to move
Better with ___
Can be primary or secondary
Can involve __
Treatment
____ replacement
____ agonists
Anti-____
Gabapentin
Severe cases:
___ (methadone, oxycodone)
Restless Leg Syndrome
Clinical diagnosis (not polysomnogram)
Typically worse in evening
Worse when still
“Urge” to move
Better with movement
Can be primary or secondary
Can involve arms
Treatment
Iron replacement
Dopamine agonists
Anti-epileptics
Gabapentin
Severe cases:
Narcotics (methadone, oxycodone)
Narcolepsy
EDS, diagnosed by MSLT (multiple sleep latency testing)
___ intrusion into wakefulness
Decreased ___ latency
For N+C (___ to ___ %) (narcolepsy + cataplexy)
Low/undetectable ___ in CSF
____ - temporary loss of muscle tone with emotion (laughter)
Affects: ___/____, M=F
EDS
Very closely associated with ___
___ or ___ hallucinations
Sleep ___
Dream enactment
Clinical features
EDS - out of proportion to sleep hours
Can fall asleep during
Work
Eating
Talking
Driving
Social situations
Napping helps temporarily
Diagnosis??
Multiple sleep latency test
Overnight PSG (polysomnogram)
___ naps
Mean sleep latency <__ minutes
2 sleep onset REM sleep (REM latency <___ min)
See how long it takes you to fall asleep, and then how long it takes to go into REM
Narcolepsy
EDS, diagnosed by MSLT (multiple sleep latency testing)
REM intrusion into wakefulness
Decreased REM latency
For N+C (60-70%) (narcolepsy + cataplexy)
Low/undetectable Hypocretin-1 in CSF
Cataplexy - temporary loss of muscle tone with emotion (laughter)
Affects 1/2000, M=F
EDS
Very closely associated with cataplexy
Hypnogogic or hypnopompic hallucinations
Sleep paralysis
Dream enactment
Clinical features
EDS - out of proportion to sleep hours
Can fall asleep during
Work
Eating
Talking
Driving
Social situations
Napping helps temporarily
Diagnosis??
Multiple sleep latency test
Overnight PSG (polysomnogram)
5 naps
Mean sleep latency <8 minutes
2 sleep onset REM sleep (REM latency <__ min)
See how long it takes you to fall asleep, and then how long it takes to go into REM
Cataplexy
Almost always associated with ____ (60-70%)
Cataplexy w/o narcolepsy
Abnormal neurologic function
Mechanisms
Not completely understood
Thought to involve ____ (emotion)
Maintained ____
Treatment
Medications to suppress __ sleep
TCA (side effects)
__
____ (Venlafaxine)
___ - Amoxetine
Sodium ___
Cataplexy
Almost always associated with narcolepsy (60-70%)
Cataplexy w/o narcolepsy
Abnormal neurologic function
Mechanisms
Not completely understood
Thought to involve amygdala (emotion)
Maintained consciousness
Treatment
Medications to suppress REM sleep
TCA (side effects)
SSRI
NSRIS (Venlafaxine)
SNRIS - Amoxetine
Sodium Oxybate
Narcolepsy - medical illness
N+C
caused by:
___, sarcoid, ___ in hypothalamus
MS in hypothalamus
N-C
__ trauma, ___ disease
Narcolepsy - medical illness
N+C
Tumors, sarcoid, AVM in hypothalamus
MS in hypothalamus
N-C
Head trauma, Parkinson’s disease
Light sets the rhythm:
The ____ nucleus is important for circadian rhythms. Eye perceives light, signal goes to ___, output from which affects physiology and behavior.
Light sets the rhythm:
The suprachiasmatic nucleus is important for circadian rhythms. Eye perceives light, signal goes to SCN, output from which affects physiology and behavior.
