Sleep-Wake Disorders - Block 3 Flashcards
1
Q
Describe the classifications of sleep disorders according to ICSD-3?
A
2
Q
What are the types of sleep disorders according to the DSM5?
A
- Insomnia dx
- Hypersomnolence dx
- Narcolepsy
- Breathing related sleep dx
- Circadium rhythm sleep dx
- Non-REM sleep arousal dx
- Nightmare dx
- ReM sleep behaviour
- RLS
- Substance- or medication-induced sleep dx
3
Q
What are the stages of the sleep cycle?
A
4
Q
Describe the sleep patterns of an infant?
A
Up to 20 hrs, REM and NREM occurs at 3-6 months
* Cycles between active and quiet sleep
5
Q
As you age how does sleep change from infancy?
A
Amount of nightly delta sleep declinses and amount of REM sleep increases
6
Q
How is sleep affected in elderly?
A
Fragmented sleep with no delta sleep
7
Q
What are the neurotransmitters for NREM?
A
GABA and adenosine
8
Q
What are the neurotransmitters for REM?
A
Cholinergic (start)
Noradrenergic (stop)
9
Q
What are the neurotransmitters for arousal and wakefulness?
A
D, NE, Ach, H, Neuropeptides, orexin (hypocretin), serotonin
10
Q
A
11
Q
What neurotransfitter is used of diagnostics for NT1?
A
orexin
12
Q
What is insomnia?
A
The inability to initiate or maintain sleep -> daytime sleepiness
13
Q
What constitutes chronic insomnia?
A
≥ 3/week and for ≥3 months
14
Q
What are the characteristics of primary insomnia?
A
Hyperarousal state
15
Q
What are the RF of insomnia?
A
Fixed: female, advanced age, family hx
Depression/anxiety
Unemployed
Separated/widowed
Low socioeconomic status
16
Q
What are the causes of insomnia?
A
- Situational
- Medical
- Psychiatric
- Pharm-induced
17
Q
What are situational causes of insomnia?
A
- Work or financial stress
- Jet lag/shift work
18
Q
What are medical causes of insomnia?
A
- CV
- Respiratory
- Chronic pain
- Endocrine dx
- GI
- Neurologic
- Pregnancy
19
Q
What are the psychiatric causes of insomnia?
A
- Mood dx
- Anxiety
- Substance use disorders
20
Q
What are drugs that induce insomnia?
A
- Antiseizure
- Central adrenergic blockers
- Diuretics
- SSRI
- Steroids
- Stimulants
21
Q
What is an examples of insomnia diagnostic tools?
A
Pittsburgh sleep quality index
22
Q
What are the diagnostic criteria for insomnia
A
- Sleep disturbances/complaint
- Associated consequences
- Frequnecy
- Duration
- Adequate opportunity
- Relationship to another condition
23
Q
What are the goals for treating insomnia?
A
- Correct the underlying complaint
- Consolidate sleep
- Improve daytime functioning and sleepiness
- Avoid ADR
24
Q
What are the nonpharms for insomnia?
A
- CBT-I
- Stimulus control procedures
- Sleep hygiene recs
25
What are the components of CBT-I?
Cognitive + stimulus control + sleep restriction +/- relaxation therapies
26
What are ways to achieve stimulus control?
1. Establish regular time to wake/sleep
2. Sleep only to feel rested
3. Go to bed only when sleepy
4. Avoid trying to force sleep
5. Avoid blue spectrum light
6. Avoid daytime naps
7. Schedule worry time during day
27
What are recs for good sleep hygiene?
1. Exercise routinely but not close to HS
2. Create comfortable leeping environment
3. Reduce alcohol, caffeine, nicotine
4. Avoid drinking large quantities of liquid
5. Do something relaxing before HS
28
Pharm tx for insomnia?
1. Antihistamines
2. Sedating antidepressants
3. Melatonin receptor agonists
4. Dual orexin receptor antagonists
5. Benzos
6. Non-benzo GABAa agonists
29
Types of antihistamines for insomnia?
Diphenhydramine (Benadryl)
Doxylamine (Unisom)
30
Indications for using antihistamines for insomnia?
Mild insomnia for onset only due to tolerance and non-linear pk (increasing dose does nothing)
31
ADRs of antihist?
Anticholinergics: constipation, dry mouth and eyes
32
Types of sedating AD? INdication?
**TCAs:** amitriptyline (Elavil), Doxepin (Silenor), Nortriptyline (Pamelor)
**Mirtazipine**
**Trazodone**
33
How do you administer Doxepin?
30 mins prior to bed and separate from food by 3 hrs
34
ADRs of TCAs?
1. Daytime sedation
2. Anticholinergic effects
3. Adrenergic block
4. Cardiac conduction prolongation
35
Mirtazapine
| ADR
Remeron
**ADR:** Weight gain, DLD, orthostatic hypotension, anticholinergic effects, daytime sedation
36
Trazodone
| Indication, Admin, ADR
**Indication:** good in patients w/ a hx of substance abuse or SSRI and buproprion-induced insomnia
**Admin:** Shortly after a meal or snack increases absorption
**ADR:** Carryover sedation, a-adrenergic blockade, orthostasis, priapism, cardiac arrhythmias
37
BBW of sedating antidepressants?
1. Suicidality
2. Seratonin syndrome
3. Withdrawal
38
What are the dual orexin receptor antagonists?
Suvorexant (Belsomra)
Lemborexant (DayVigo)
Daridorexant (Quviviq)
39
Dual orexin receptor antagonists
| Indication, Admin, ADR, CI/Warning
**Indication:** Onset and maintence of insomnia
**Admin:** 30 min before bed and ≥ 7 hr before planned awakening
**ADR:** Complex sleep behaviors and REM sleep effects
**CI:** Narcolepsy, depression, worsens mood and trigger thoughts of suicide
40
Types of melatonin receptor agonists?
Ramelteon (Rozerem)
Tasimelteon (Hetlioz)
41
Melatonin receptor agonists
| Admin, ADR, DDI
**Admin:** 30min-1hr of bed and separate from food
**ADR:** HA, DZ, somnolence, complex SB
**DDI:** Ramelteon is a substrate of CYP1A2, 2C9, and 3A4
42
What are the non benzo indicated for insomnia?
Zaleplon (Sonata)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
43
Benzos for insomnia?
1. Estazolam
2. Flurazepam (Som-Pam)
3. Quazepam (Doral)
4. Temazepam (Restoril)
5. Triazolam (Halcion)
44
Zolpidem
| Dosing, Forms, Admin, ADR
Ambien
**Dosing:** 10 mg for males, 5 mg for females, elderly, hepatic impairment
**Form:** SRm SL, reduce strength
**Admin:** empty stomach
**ADR:** Weight gain, drowsiness, amnesia, DZ, HA, GI
45
Zaleplon
| Indication, ADR, DDI
Sonata
**Indication:** Sleep onset only
**ADR:** DZ, HA, Somnolence
**DDI:** Levels increase with cimetidine and decrease with rifampin
46
Eszopiclone
| ADR
Somnolence, unpleasant taste, HA, dry mouth
47
Benzos
| Indications, CI, ADR, Caution
**Indication:** sedative, anxiolytic, muscle relaxant, antiseizure
**CI:** pregnancy, Substance use disorder, untreated sleep apnea
**ADR:** tolerance
**Caution:** elders, liver dys, med interactions
48
What are the benzos indicated for elderly? Why?
Lorazepam, Oxazepam, Temazepam: no active metabolites or hepatic metabolism
49
What are short acting benzos?
Midozolam, triazolam
50
What are the intermediate acting benzos?
1. Estazolam
2. Temazepam
3. Oxazepam
4. Lorazepam
51
What are the long-acting benzos?
1. Flurazepam
2. Quazepam
3. Clonazepam
4. Diazepam
52
What are the herbal agents for insomnia? Why are they not recommended by the guidelines?
Melatonin
L-tryptophan
Valerian
**Not regulated**
53
Melatonin
| ADR, DDI
**ADR:** comnolence, Dz, HA, N
**DDI:** CNS depressants, anticoags/platelets, anticonvulsants, CYP1A2 and CYP2C19
54
L-tryptophan
| DDI
Serotonergic meds
55
Valerian
| ADR, DDI
**ADR:** somnolence, dx, ha, GI, excitability, vivid dream
**DDI:** CNS depressants
56
What are the AASM recs for sleep onset insomnia? Maintenance? Both?
**Onset:** Ramelteon, Triazolam, Zaleplon
**Maintenance:** Doxepin, Suvorexant
**Both:** Eszopiclone, Temazepam, Zolpidem
57
What ways can you evaluate insomnia therapy?
**Monitoring:** sleep diary (TST), questionaires, ADR
**Follow up:** 3-4 weeks until stable, afterwards, every 6 months
58
What is sleep apnea?
Repetitave episodes of cessation of breathing during sleep followed by blood o2 desaturation and brief arousal from sleep to restart breathing
59
How are most affected by sleep apnea?
Males, Affrican americans, hispanics
60
Diffentiate the types of sleep apnea?
**Central:** impairment of the respiratory drive (i.e. drug-induced)
**OSA:** Uppeer airway collapse and obstruction
**Mixed:** both CSA and OSA
61
How is sleep apnea diagnosed?
Respiratory disturbance index: number of apnea and hypopnea episodes documented by PSG, or home sleep study
**MIld:** 5-15 episodes/hr
**Moderate:** 15-30 episodes/hr
**Severe:** >30 episodes/hr
62
What is a cormoditity that contributes to OSA?
HTN and obesity
63
What are the non pharms for sleep apnea?
1. Positive airway pressure (CPAP, BiPAP, AutoPAP)
2. Weight reduction
3. Surgery
4. Positional therapies and oral appliances
5. Hypoglossal nerve stimulators
64
How long should you reassess sleep apnea tx?
After 1-3 months for alertness and daytime sx and weight reduction
65
Pharms for sleep apnea?
1. Avoid all CNS depressants
2. Wake-promoting medications for EDS
66
What are the sx of narcolepsy?
EDS, cataplexy, hallucinations, sleep paralysis
67
Describe the characteristics of NT1?
1. Loss of hypocretin/orexin
2. Autoimmune
3. HLADQB106:02
4. Molecular mimicry
5. Brain injury
6. Tumor
7. Stroke
68
What are the characteristics of NT2?
1. Normal orexin levels
2. Uncharacterized cause
69
What are the diagnostic criteria for NT1?
1. EDS every day for ≥3 months
2. Plus 1 or more of the following:
* CSF of ≤100 or 1/3 average
* Cataplexy and mean sleap latency ≤8 minutes plus:
* ≥2 sleep onset REM on MSLT
* 1 SOREMP on MSLT and 1 SOREMP within 15 minutes of sleep onset on PSG
70
What are the diagnostic criteria for NT2?
1. EDS every day for ≥3 months
2. Plus both of the following:
* CSF of >100 or 1/3 average
* No hx of Cataplexy and mean sleap latency ≤8 minutes plus either:
* ≥2 sleep onset REM on MSLT
* 1 SOREMP on MSLT and 1 SOREMP within 15 minutes of sleep onset on PSG
71
What are the goals of tx narcolepsy?
Achieve the fullest possible reutn to normal function:
* Management of EDS and REM sleep abnormalities
72
What are the non-pharm for narcolepsy?
1. Sleep hygiene
2. Schedules ≥ 2 daytime naps (15 minutes)
73
Pharm tx of narcolepsy?
**EDS:** Modafinil and armodafinil, stimulants, solriamfetol, pitolisant
**REM sleep abnormalities:** TCAs, SNRIs, SSRIs, selegiline
**Both:** sodium oxybate
74
What are the stimulants for wakefulness?
Modafinil (Provigil)
Armodafinil (Nuvigil)
74
Modafinil and Armodafinil
| ADR, Indication, DDI
**ADR:** SJS/TEN, insomnia, HTN, tachy, HA, ax, N
**Indication:** EDS associated with narcolepsy, OSA
**DDI:** reduce effectiveness of hormonal contraceptives
75
What are the approved stimulants for narcolepsy? Off-label?
Dextroamphetamine
Methylphenidate
Methamphetamine and mixed amphetamine salts
76
Solriamfetol
| MOA, ADR, DDI
Sunosi - CIV
**Indication:** narcolepsy
**MOA:** NDRI
**ADR:** insomnia, HTN, tachy, ax, irratibility, HA, decreased appetite, n
**DDI:** Washout period with MOAIs for 14 days
77
Pitolisant
| MOA, INdication, ADR
**MOA:** H3 antagonist/inverse agonist
**INdication:** cataplexy
**ADR:** QT prolongation
78
Antidepressants indicated for narcolepsy?
**TCAs:** Nortriptyline (pamelor), Imipramine (Tofranil), Protriptyline (Vivactil)
**SSRIs:** Fluoxetine (Prozac)
**SNRI:** Venlafaxine (Effexor), Atomoxetine (strattera)
**MAOIs:** Selegiline (Zelapar)
79
What antidepressant is not helpful in REM for adults? Indicated for children?
Atomoxetine (Straterra)
80
What antidepressant is good for cataplexy?
Selegiline (Zelapar)
81
What is the difference between Xyrem and Xyway?
Xyway is the low sodium formulation for narcoleptics with HTN or HF
82
Types of CNS depressants for narc?
Sodium oxybate (Xyrem)
Low sodium formulation (Xyway)
83
Sodium oxybate
| Admin, ADR
**Admin:** only available through REMS and CIII
* Take at bedtime and again 2.5-4 hr later
**ADR:** incontinece, dz, confusion, somnolence, n
84
Tx for EDS and/or caraplexy?
Seligine, pitolisant
85
Tx for EDS and/or REM ab?
Sodium oxybate or salts
86
What is the difference between jet lag and shift work disorder?
**Jet lag:** CR disruption from traveling across time zones, last 2-3 days, Eastward travel associated with longer jet lag duration
**Shift work:** CR disruption due to working shifts during normal sleep time (20% of workforce)
87
What are the rf for jet lag?
1. Increased number of time zones
2. Eastward travel
3. Sleep loss during travel
4. Lack of time cues during travel (sunlight)
5. Advanced age
88
RF of shift work disorders?
1. Social pressure
2. Unwillingness to maintain consistent schedule on days not working
3. Advanced age
89
Non pharm for jet lag?
1. Sleep hygiene
2. Sleep scheduling (trip >2 days)
* Shift sleep schedule 1 hr each day for 3 days prior to travel
90
Non pharm for shift work disorder?
1. SLeep hygiene
2. Planned napping
3. Increase light exposure during night
4. Limit light exposure during day
91
Pharm for CR disorders?
**Improve alertness:** Modafinil (shift work only), Caffeine
**Improve sleep:**
* BZRA: Benzo (Triazolam, temazepam) and Non-benzo (eszopiclone, zolpidem, zaleplon)
* Ramelteon
* Melatonin
92
Overall tx for sleep disorders?
| Chart
