Treatment of Other Sleep Disorders Flashcards
Monitoring during Polysomnography (Sleep Study)
EEG EOG Electromyogram Ab and thoracic strain belts Oxygen sat ECG
Define EEG
Electroencephalogram
Electrodes are placed centrally on the scalp and record electrical activity of the brain to stage sleep
Define EOG
Electro-oculogram of each eye
Eye movement recording of both the left and right eye are obtain through electrodes
Define Electromyogram
Recordings of muscle activity measure activity regulated by brainstem nuclei, with electrodes
Factors associated with Obstructive Sleep Apnea (OSA)
Obesity Snoring HTN Daytime sleepiness Family hisotyr
Consequences of untreated OSA
Fragmented sleep Decreased deep sleep Negative impact on mood/behavior Decreased cognition Increased CV mortality and morbidity
Diagnosis of OSA
Polysomnography
Severity determination
DSM-5 criteria
Severity of OSA
Mild: 5-15 episodes/hr
Moderate: 15-30 episodes/hr
Sever: >30 episodes/hr
DSM-5 Criteria for OSA
- Must meet criteria #1 or #2
i. Polysomnography results show 5 or more apnea/hypopnea episodes per hour of sleep and either of the following:
o Nocturnal breathing disturbances: snoring, gasping, or breathing pauses during sleep
o Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep - Polysomnography of 15 or more apnea/hypopnea episodes per hour of sleep regardless of accompanying symptoms.
Non-pharm treatment of OSA
PAP- continuous or bilevel (less pressure given during expiration)
Weight reduction
Pharm Treatment of OSA
Modafinil and Armodafinil
Modafinil and Armodafinil Use, Onset, Duration
- Treat excessive daytime sleepiness
Onset- short
Duration- 6-8 hours
Modafinil and Armodafinil Interactions and AE
Metabolized by 3A4
Mod: inhibits 2C19, induces 3A4 and 1A2 (induces its metabolism & decreases effectiveness of contraceptives)
AE: elevated BP and pulse, GI, anxiety or jitteriness, SJS
Approach to Treatment of Adult OSA
- Avoid CNS depressants at night
- PAP is #1
- Weight reduction is recommended
- If daytime sedation continues even with PROPER use of PAP then use Modafinil and Armodafinil
- Reevaluate in 1-3 months are PAP with sleep study
Diagnosis of Narcolepsy
Polysomnograph and DSM5
DSM-5 for Narcolepsy
- Irresistible attacks of refreshing sleep occurring almost daily for at least 3 months
- At least one of the following exists:
i. Cataplexy
ii. Hypocretin deficiency measured in the CSF
iii. Sleep polysomnography showing REM sleep latency less than or equal to 15 minutes or a multiple sleep latency test (MSLT) showing mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.
Define Cataplexy
o Loss of muscle tone usually triggered by emotions (laughing, crying, excitement)
o Episodes usually lasts
Nonpharm treatment for Narcolepsy
10-20 minute naps BID or TID
Avoid caffiene and alcohol before bed
Pharm Treatment of Excessive Daytime Sedation in Narcolepsy
Modafinil or armodafinil
Or methylphenidate or dextroamphetamine
Pharm Treatment of Cataplexy in Narcolepsy
TCA
Venlafaxine
Fluoxetine
Pharm Treatment of Excessive Daytime Sedation AND cataplexy in Narcolepsy
Sodium Oxybate (gama-hydroxybutyrate GHB)
Sodium Oxybate Drug Info, Onset, Duration, Effect
Only dispensed by 1 pharmacy- must be registered Controlled Onset: 30 minutes Short duration Hangover effect Cataplexy improves within days
Sodium Oxybate AE
GI upset, disorientation, feel drunk, sleep walking, incontinence, night sweats, weight loss
***Sodium Oxybate Counseling
Prepare 2 dose before bed
Take first dose at bedtime and second dose 2.5-4 hours later (set an alarm)
Take meds while seated and on an empty stomach
Do not drink alcohol or other sedatives
Pts with CHF, HTN, or renal disease should caution due to sodium content
Restless Leg Syndrome Symptoms
Urge to move legs with unpleasant/uncomfortable sensation
Worsen during periods of rest or inactivity or at night
Symptoms relieved partially or completely by movement
**Define Augmentation
Worsening of RLS due to continuous medication treatment
- Symptoms become more intense
- Onset become quicker during rest
- Symptoms occur earlier, spread to other body parts, return earlier after relief of meds
Medications that worse RLS
Antipsychotics SSRI, SNRI, TCA Antihistamines Lithium Phenytoin Antiemetics (promethazine, metoclopramide)
Nonpharm treatment of RLS
Good Sleep Hygiene
Moderate exericise
Brief walk, bath/shower, limb massage before bed
Cessation of smoking, alcohol and caffeine
Stop offending meds
Compression devices
Pharm treatment of RLS
Check ferritin levels (Less than 50 = RLS severity increase) Dopamine agonists (ropinirole-requip, pramipexole- mirapex, rotigotine patch- neupro) = first line Carbidopa/levodopa Gabapentine enacarbil
Ferritin in RLS
Less than 50, supplement with ferrous sulfate
Dopamine agonists in RLS
Augmentation can develop in 40-70% of pts
Carbidopa/Levodopa (sinemet_ in RLS
Highest rate of augmentation
Gabapentin enacarbil (Horizant) in RLS
600 mg at 5 PM
Lower risk of augmentation
- Not currently in guidelines but will be when they update
