Sleep-Wake Disorders Flashcards
What are the stages of non-REM sleep?
1: Transitional
2: Light Sleep
3 and 4: disoriented upon awakening and amnesia for a brief awakening
night terrors
What occurs during REM sleep??
Physiological activation
dreaming
paralysis
What are the six major sleep wake disorders?
1) Insomnia Disorder
2) Hypersomnolence Disorder
3) Breathing related sleep disorder
4) Narcolepsy
5) Circadian Rhythm Sleep Disorder
6) Parasomnias
How does one diagnose a sleep disorder?
1) Interview with patient
2) Polysomnography (PSG)
What is the diagnostic criteria for Insomnia Disorder (primary insomnia)?
Difficulty initiating or maintaining sleep for > 3 months
What is the etiology for Insomnia?
The bed is used for wakefulness activities therefore the bed is not a cue for sleep its a cue for wake
What is one of the treatments for Insomnia?
Stimulus Control Technique:
Make the bed a cue or trigger for falling asleep.
Only go to bed when your really tired after 10 minutes if not asleep then get out of bed and do another activity.
Do not go to bed until you fall asleep in 10 minutes
takes a few weeks to cure this
What are the pharmacological approaches to treatment of insomnia?
Sedatives: benzodiazepines (diazepam)
Benzodiazepine-like drugs: Zolpidem (fewer side effects)(try these drugs first)
What are the side effects of pharmacological treatments?
poor sleep quality due to decreased slow wave sleep and REM
aka changes the sleep architecture
What is the diagnostic criteria for Hypersomnolence Disorder (primary hypersomnia)?
Excessive sleepiness despite significant sleep (at least 7 hrs) for > 3 months
What are the features of an individual who has hypersomnolence?
Sleeping average of 9 hours a night
Taking naps throughout the day
Normal PSG
Still tired even though enough sleep is had
What is the treatment for Hypersomnolence?
Stimulants (methylphenidate)
What is the diagnostic criteria for Narcolepsy?
1) Irresistible sleep occurring within the same day, several times per week, for >3 months
2) At least one of the following
* Cataplexy
* Hypocretin deficiency
* characteristic PSG abnormalities
Cataplexy is the sudden loss of muscle tone while awake or while asleep?
while awake
When typically do cataplexy episodes happen?
precipitated by emotion
how is a nap attack different from cataplexy?
Nap attack occurs while sleeping
Cataplexy occurs while awake
Is cataplexy considered an aberrant manifestation of REM or non-REM sleep?
REM sleep
How would a physician diagnose hypocretin deficiency?
spinal tap needed
The final criteria measure for a diagnosis of Narcolepsy is PSG abnormalities. What is seen with REM sleep in the PSG?
Decreased REM sleep latency (aka individuals enter REM super fast) (normally takes 90 minutes for individuals to enter REM)
What are the treatments for Narcolepsy?
1) Stimulants (modafinil) –> help with the tiredness
2) Antidepressants —> helps with the cataplexy
these two need to be given together
(Xyrem aka sodium oxybate is an option but this is very tightly controlled)
What are the two breathing related sleep disorders?
1) Obstructive Sleep Apnea Hypopnea (OSAH)
2) Central Sleep Apnea
What is the diagnostic criteria for obstructive sleep apnea hypopnea (OSAH)?
Multiple episodes of breathing cessation/reduction occur per night due to an upper airway obstruction
In OSAH what causes the obstruction?
extra tissue in the throat that occludes the trachea when person lays on back
What is the typical profile of a patient who has OSAH?
middle aged fat male who snores
YUMMY–> Vanessa’s Future Husband
Why do periods of apneas/hypopneas cause sleepiness?
Rise in CO2 causes temporary arousal from sleep which makes person go from deep to light sleep
Often patients are unaware because they dont awake so they think they are getting enough sleep
What is the gold standard treatment for patients with OSAH?
Continuous Positive Airway Pressure (CPAP)
device maintains an open airway at specific air pressure
What is the diagnostic criteria for central sleep apnea (CSA)?
Multiple episodes of cessation of breathing per night caused by CSN dysregulation of breathing
What is the etiology of CSA?
Idiopathic (aka no idea)
Drugs
CHF
How does a PSG test distinguish OSAH from CSA?
OSAH –> thoracic effort occurs
CSA –> No thoracic effort occurs
Which is more severe OSAH or CSA? Why?
CSA because individuals just stop breathing and the cause is usually unknown
What is the diagnostic criteria for circadian rhythm sleep wake disorder (CRSWD)??
Excessive sleepiness or insomnia resulting from a mismatch between a persons circadian sleep wake pattern and the sleep wake schedule required by the environment
What is the treatment for CRSWD?
phototherapy at strategic times during the day
Settings of the circadian clock is governed by which nucleus?
suprachiasmatic nucleus (SCN)
Describe the pathway for waking up
Light –> SCN –> inhibits pineal gland –> decreases melatonin –> alert
Describe the pathway for a drowsy person
No light –> SCN –> activates pineal gland –> increases melatonin -> drowsy
What are the parasomnias?
1) Non-REM sleep arousal disorder
2) Nightmare disorder
3) REM sleep behavior disorder
4) Restless leg syndrome
5) Periodic Limb movements
In general terms what is Non-REM sleep arousal disorder?
Repeated episodes of incomplete awakening from sleep with either sleep walking or sleep terrors
can patients have both sleep walking and sleep terrors?
of course
What is the difference between sleep walking and sleep terrors?
walking —> walking about with a blank and staring face; difficulty awakening
Terrors –> abrupt terror arousals
what is the treatment for non-rem sleep arousal disorder?
Benzodiazepines
typically when does non-rem sleep arousal disorder occur?
within first 1/3 of sleep (during slow wave sleep (SWS))
In general what does nightmare disorder involve?
Extremely dysphoric dreams that typically involve threats to survival, security or physical integrity.
What is nightmare disorder characterized by?
1) Awakening in the 2nd half of sleep period (during REM sleep)
2) Rapid alterness upon awakening
3) Dream content is well remembered
4) good recall of awakening the next morning
What is a treatment option for nightmare disorder?
antidepressants to decrease REM
Describe REM sleep behavior disorder (RSBD)
Vocalizations and/or complex motor movements occur during REM sleep
REM sleep without atonia in RSBD is confirmed by what test?
PSG
What are typical features of RSBD?
action filled, violent dreams
immediately awake, oriented and alert with dream recall
most common in males >50 y.o
progressive and associated with neurodegenerative disease
What is the key drug used for treatment of RSBD?
Clonazepam (benzodiazepine)
What are the features of restless leg syndrome (RLS)?
urge to move legs in response to uncomfortable sensations with features:
- occurs/worsens during inactivity
- nocturnal worsening of symptoms
- temporary relief from discomfort by moving
During RLS are patients aware of their symptoms ?
YES
typically complain of insomnia
What is the treatment for RLS?
Anti parkinson’s drugs due to increased DA
Describe periodic limb movements (PLMs)
repetitive muscle contractions during sleep, usually of the lower limb.
what typically does the patient complain of in PLMs?
daytime sleepiness
is patient aware movements during PLMs?
no
Is PLMs associated with a specific sleep stage?
no
involves multiple sleep stage arousals
How do you confirm PLMs?
leg electromyogram during PSG
What are treatments for PLMs?
Same drugs as RLS
