Sleep-wake disorders Flashcards
Sleep disorders are divided into either
Dyssomnias: insufficient (insomnia), excessive (hypersomnia), or altered timing of sleep
Parasomnias: unusual sleep-related behaviors
Components of a sleep history
Activities prior to bedtime Bed partner Consequence on waking function/QOL Drug regimen, meds Exacerbating/relieving factors Frequency/duration Genetic factors/FH Habits (EtOH, caffeine, nicotine, etc)
What are the main types of symptoms of insomnia disorder?
Difficulty going to sleep (sleep-onset insomnia)
Frequent nocturnal awakenings (sleep-maintenance insomnia)
Early morning awakenings (sleep-offset insomnia)
Nonrestorative sleep
Diagnostic criteria for insomnia disorder
- Difficulty initiating or maintaining sleep
- At least 3x/wk for 3 months
- Causes distress or dysfunction
- Occurs despite adequate opportunity to sleep
- Does not occur exclusively during another sleep-wake disorder
- Not from medications, meds, etc
Etiology of insomnia disorders
Subclinical mood or anxiety disorder
Preoccupation with perceived inability to sleep
Poor sleep hygiene
Management of insomnia disorder
Sleep hygiene
CBT
Drugs: Benzos, zolpidem, eszopiclone, zaleplon, trazodone, amitriptyline, doxepin
Diagnostic criteria for hypersomnia disorder
- Excessive sleepiness despite at least 7 hours of sleep with at least one of: multiple times sleeping in the same day; prolonged non-restorative sleep >9hrs; difficulty being fully awake
- At least 3x/wk for at least 3 mos
- Distress or dysfunction
- Etc…
Etiology of hypersomnia disorder
Viral infections (HIV, mono, Guillan-Barre)
Head trauma
Genetic
Treatment of hypersomnia disorder
Modafinil or stimulants
Scheduled napping
What are the characteristics of central sleep apnea?
Five or more central apneas per hour of sleep. Can be idiopathic with Cheyne-Stokes respirations (periodic crescendo-decrescendo variation in tidal volume due to heart failure, stroke, or renal failure) or due to opioid use
Treatment for central sleep apnea
Treat underlying condition
CPAP/BiPAP
Supplemental O2
Medications (acetazolamide, theophylline, sedative-hypnotics)
Diagnostic criteria for narcolepsy
Recurrent episodes of needing to sleep, lapsing into sleep, or napping during the day, occuring at least 3x/wk for at least 3 months with at least one of:
–Cataplexy
–Hypocretin deficiency in CSF
–Reduced REM sleep latency on polysomnography
Hallucinations and/or sleep paralysis at the beginning or end of sleep episodes are common but not necessary for diagnosis
Management of narcolepsy
Sleep hygeine
Scheduled daytime naps
Avoidance of shift work
Amphetamines or non-amphetamine stimulants for excessive daytime sleepiness
For cataplexy: sodium oxybate, TCAs, or SSRIs/SNRIs
What is delayed sleep phase disorder?
Chronic or recurrent delay in sleep onset and awakening times with preserved quality and duration of sleep
Risk factors for delayed sleep phase disorder
Puberty, caffeine or nicotine use, irregular sleep schedules
Treatments for delayed sleep phase disorder
Timed bright light phototherapy in early morning
Administration of melatonin in the evening
Chronotherapy (delay bedtime by a few hours each night)
What is advanced sleep phase disorder?
Normal duration and quality of sleep with sleep onset and awakening earlier than desired
Risk factors for advanced sleep phase disorder
Old age
Treatment for advanced sleep phase disorder
Timed bright light phototherapy prior to bedtime
What is shift-work disorder?
Sleep deprivation and misalignment of circadian rhythm 2/2 nontraditional work hours
Risk factors for sleepwalking
Sleep deprivation Irregular sleep schedules Stress Fatigue OSA Nocturnal seizures Fever Meds, including sedatives/hyponotics, lithium, anticholinergics Family history
Management of sleepwalking
Education, reassurance, ensure safe environment, sleep hygiene, low-dose benzos if refractory
What are the features of sleep terrors?
Recurrent episodes of sudden terror arousals that occur during slow-wave sleep
Signs of autonomic arousal (elevated BP, RR, diaphoresis)
Difficulty arousing during an episode
Dreams aren’t remembered and there is amnesia for the episode
What are the features of nightmare disorder?
Recurrent frightening dreams that occur during the second half of sleep episode
Terminate in awakening with vivid recall
Causes clinically significant distress or dysfunction
Management of nightmare disorder
Reassurance
Desensitization/imagery rehearsal therapy
Medications rarely indicated, but can use prazosin and antidepressants
Risk factors for REM sleep behavior disorder
Older age, generally >50
Psychiatric meds including TCAs, SSRIs, SNRIs, B-blockers
Narcolepsy
Neurodegenerative disorders: Parkinson’s, multiple system atrophy, Lewy body dementia
Treatment for restless leg syndrome
Drugs: pramipexole, ropinirole, or benzos
Iron replacement if ferritin is low
Remove offending agents if possible
