Week 9- Insomnia Flashcards
1
Q
how long is a sleep cycle
A
90-120 mins
2
Q
what is stage N3? when is it predominant?
A
slow wave sleep; predominant in the first 1/2 of sleep
3
Q
when is REM sleep most predominant
A
in the 2nd half of sleep
4
Q
4 stages of sleep
A
REM, N1, N2, N3
5
Q
what are the 7 categories of sleep disorders
A
- Insomnia (Primary)
- Circadian rhythm sleep-wake disorders
- Central disorders of hypersomnolence – idiopathic hypersomnia, narcolepsy, Klein—Levin syndrome
- Parasomnias
- Sleep-related movement disorders
- Sleep-related breathing disorders
- “Other sleep disorders” - not captured above
6
Q
who has the most sleep problems
A
elderly and women (2x more likely than men)
7
Q
how many adults have insomnia symptoms vs insomnia disorders
A
- 35–50% of adults have insomnia symptoms
- 12–20% of adults have insomnia disorders
- As high as 50% of older adults
8
Q
what are the 3 types of insomnia (primary)
A
- chronic insomnia disorder
- short term insomnia disorder
- other insomnia disorder
9
Q
how long does chronic insomnia disorder last and how many sleep disturbances must you have per week
A
Sleep disturbances at least 3x/week, present for at least 3 months
10
Q
how long does short-term insomnia disorder last and how many sleep disturbances must you have per week
A
- Sleep disturbances at least 1 month, but < 3 months
- “Acute” or “Adjustment” Insomnia
11
Q
what falls under the other insomnia disorder category
A
Difficulty in initiating or maintaining sleep that does not meet the criteria of chronic insomnia or short-term insomnia disorder
12
Q
ICSD-3 diagnostic criteria for chronic insomnia
A
A. Difficulty initiating sleep/maintaining sleep, early waking, resistance to going to bed on
appropriate schedule, difficulty sleeping without intervention
B. As related to the nighttime sleep difficulty:
* fatigue/malaise, attention/concentration/memory impairment, impaired social/ family/ occupational/academic performance, mood disturbance/irritability, daytime sleepiness, behavioural problems (e.g. hyperactivity, impulsivity, aggression), reduced motivation/energy/initiative, prone to errors/accidents, concerns about or dissatisfaction with sleep
C. Complaints not explained only by inadequate opportunity for sleep (i.e. enough time is allotted for sleep) or inadequate circumstances (i.e. the environment is safe, dark, quiet and comfortable)
D. Sleep disturbance and associated daytime symptoms occur at least three times per week
E. Sleep disturbance and associated daytime symptoms have been present for at least 3 months
F. Sleep/wake difficulty is not explained by another sleep disorder
13
Q
ICSD-3 diagnostic criteria for short term insomnia
A
- Note: Four of the five criteria for short-term insomnia overlap with criteria A, B, C and F of chronic insomnia
- Criterion (D) is specific - ‘the sleep disturbance and associated daytime
symptoms have been present for < 3 months’
14
Q
what is the difference between short term and chronic insomnia. short term (AKA acute or adjustment) is…
A
- Shorter duration
- Presence of an identifiable cause (such as stressful life event)
triggering or precipitating insomnia is common - Also includes insomnia occurring episodically, possibly in connection with
particular daytime stressors
15
Q
short term insomnia aka
A
acute or adjustment insomnia
16
Q
what is the cause of short term insomnia
A
Presence of an identifiable cause (such as stressful life event)
triggering or precipitating insomnia is common
UNLIKE CHRONIC INSOMNIA
17
Q
risk factors for insomnia
A
- Depression, anxiety or other psychiatric conditions
- Female sex
- Older age - women of peri-menopausal and post-menopausal transitions
- Lower socioeconomic status
- Concurrent medical and mental disorders
- Marital status (divorced/separated more often than married)
- Race (blacks more often than whites)
- Obesity
Comorbid conditions: can be both the cause and effect of chronic sleep loss
18
Q
risk factors for shorter term insomnia
A
- Acute events, including changes in sleep environment, jet lag, changes in a work shift, environmental issues (excessive noise or extremes of temperature), stressful life events, acute medical or surgical illnesses, use of stimulant medications (i.e. corticosteroids, decongestants, bronchodilators, amphetamines, or cocaine), or withdrawal from central nervous system depressant substances (i.e. alcohol or benzodiazepines)
19
Q
risk factors for chronic insomnia
A
- Genetics – Apolipoprotein (Apo) E4, clock genes, etc.
- Molecular factors - orexin, catecholamine, histamine and sleep promoting chemicals like GABA, serotonin, adenosine, melatonin, and prostaglandin D2
20
Q
how can insomnia effect daily life
A
- Negative impacts on daytime social and/or occupational functioning are present in 20-60% of insomnia patients
- adverse effects on health, quality of life, academic performance, decrease productivity at work, cause irritability and increase daytime sleepiness
21
Q
insomnia and other diseases
A
- A contributing risk factor for cardiovascular diseases, chronic pain syndrome, depression, anxiety, diabetes, obesity, and asthma
- Insomnia precedes the development of mood disorders in 50% of cases and anxiety disorders in 20% of cases
- The risk of developing depression over 1 to 3 years is approximately 5-fold in patients with insomnia
22
Q
insomnia and industrial risks and road risks and falls in elders
A
Patients with insomnia have an increased risk of industrial accidents (3- to 4-fold risk), road accidents (2- to 3-fold risk) and falls and hip fracture in the elderly population
23
Q
what happens to REM with aging
A
- REM latency tends to decrease, and the length of the first REM period tends to increase
24
Q
sleep wake states - what happens to them with aging? men vs women?
A
The amount of time in childhood is high, peaks in early adolescence, and gradually declines with age until it nearly disappears around the sixth decade of life
* Men lose SWS at an earlier age
25
what % of total sleep time do young adults spend in sleep wake states
15-20%
26
what happens to sleep in Middle Aged and elderly adults
sleep is shallower, more fragmented, shorter in
duration with an increase in wakeful periods [Wakefulness after sleep onset (WASO)], and daytime sleepiness increases
* Decrease "deeper" (delta wave) stages 3 and 4
27
after 65 years old how many women and men report taking > 30 min to fall asleep
1/3 women
1/5 men
28
why does it take elders longer to fall asleep
* normal changes in circadian rhythm--> daytime fatigue--> daytime naps--> poor
nocturnal sleep
* WASO and number of arousals increase with age --> may be due to
* increased incidence of sleep-related breathing disorders, PLMs, and other physical conditions in elderly
* easier arousal by internal and external stimuli
* Related to a phase-advanced temperature rhythm, elders tend to retire and arise earlier
than younger adults
* Psychosocial alterations can disrupt zeitgebers and light exposure.
* Napping also increases with age, but the TST per 24 hours does not change with age
29
primary insomnia in older people
chronic insomnia without specific underlying medical, psychiatric, or other sleep disorders
30
what % of elderly have insomnia
40%
Up to 40 percent of older adults have insomnia, with difficulty falling asleep, early awakening, or feeling tired on awakening
31
prevalence of insomnia in older people
* increases with age
* 31-38% in persons 18 to 64 years of age, up to 45% in persons 65 to 79 years of age
* U.S. prospective cohort study – 23-34% of persons > 65 years had insomnia, and 7-15% had chronic insomnia
32
risk factors for insomnia in older people
-substance use
-medications
-primary sleep dirsoders (ie. breathing, circadian rhythm)
-health related sleep disruptions (i.e. depression, heart burn, anxiety, nocturia, pain)
-host factors (cognitive impairments, stress, sleep habits, nap, sleep related beliefs)
- environment (light and nose exposure, bedroom temperature, partners habits, limited social interactions)
33
what is the sleep and wakefulness rhythm governed by
endogenous cycle;;
* internal biological "clocks”
* environmental stimuli--> known as zeitgebers (social activities and meals, light-dark cycle)
* processes that promote or inhibit arousal
34
how to measure circadian rhythm
evaluating melatonin levels, cortisol levels, and core body temperature
35
where do the biological clocks of the circadian rhythm exist
suprachiasmatic nuclei (SCN) of the
hypothalamus
* ganglion cells in the retina illuminate and send information to SCN
* SCN process this information and stimulate the pineal gland to release melatonin
* melatonin increases in the evening in response to dim light and peaks around 3 hours
before waking
* this feedback mechanism onto the SCN supports the circadian rhythm
36
what releases melatonin
pineal gland
37
when does melatonin peak
3 hours before waking
38
how long is the circadian oscillators intrinsic cycle
just over 24 hours
39
how is the circadian oscillator entrained to a 24 hour environment
by zeitgebers which force the system to undergo phase shifts - of which the light-dark cycle is the most effective
* In the absence of zeitgebers humans tend to self-select a sleep–wake cycle of about 25 hours from wake time to wake time
40
what causes circadian rhythm system disorders
from intrinsic dysfunction or environmental factors
41
intrinsic circadian rhythm sleep disorders
-advanced sleep phase disorder
-delayed sleep phase disorder
-irregular sleep wake rhythm disorder
-non 24 hour sleep wake disorder
42
extrinsic circadian rhythm sleep disorders
-shift work sleep disorder
-jet lag
43
delayed sleep wake phase disorder (an intrinsic circadian rhythm sleep disorder)
* Delayed sleep and wake times relative to what is desired or expected à inadequate sleep and resultant daytime functional impairment
44
how much sleep is lost in a delayed sleep wake phase disorder
lose at least 2 hours of sleep/night relative to the optimal amount of sleep
45
symptoms of delayed sleep wake phase disorder
confusion/frustration upon waking, remains even with sufficient quantity and quality of sleep
46
who is delayed sleep wake phase disorder most common in
peaks in adolescents, often accompanied by depression
47
diagnosis of delayed sleep-wake phase disorder
history of persistent delayed sleep-wake cycles that interfere with desired daytime functioning
* Sleep logs - screen for other causes i.e., caffeine use, excessive evening light exposure
48
treatment for delayed sleep-wake phase disorder
behavioral modification, including good sleep hygiene and gradually moving sleep and wake times earlier, avoid caffeine, alcohol, nicotine, and daytime naps, melatonin supplementation and circadian rhythm-light training
49
Advanced Sleep-Wake Phase Disorder
* Excessive evening sleepiness and early morning awakening
* Sleep deprivation from staying awake longer due to societal obligations --> but will wake at the same early time leading to sleep deprivation and daytime sleepiness
50
Advanced Sleep-Wake Phase Disorder
go to bed late, wake up early
51
hypothesis of Advanced Sleep-Wake Phase Disorder
results from an intrinsic circadian cycle that is less than 24 hours
52
who is Advanced Sleep-Wake Phase Disorder most common in
older adults and males
53
diagnosis of Advanced Sleep-Wake Phase Disorder
history and sleep logs
54
treatment of Advanced Sleep-Wake Phase Disorder
evening bright light therapy, pharmacotherapy is not indicated
55
what is irregular Sleep-Wake Rhythm Disorder
Failure of the circadian rhythm system to consolidate sleep--> multiple short periods of sleep and wakefulness
56
diagnosis of Irregular Sleep-Wake Rhythm Disorder
no clear circadian rhythm pattern can be identified and at least 3 periods of wakefulness lasting at least one hour occur during an average 24- hour period
57
prevalence of Irregular Sleep-Wake Rhythm Disorder
generally found in older and dementia patients and is attributed to dysfunction of the SCN
* Due to lack of exposure to external time cues (zeitgebers) --> less likely to have consistent commitments and schedules.
58
treatment of Irregular Sleep-Wake Rhythm Disorder
Behavioral modification and melatonin supplementation
59
jet lag disorder; what is it? how many time zones?
* With air travel across time zones in a short amount of time --> intrinsic circadian rhythm becomes descynchronized with external light cues
* Occurs when traveling through at least two time zones
60
symptoms of jet lag disorder
inability to sleep when desired, daytime sleepiness, and decreased alertness and cognitive performance
* usually most prevalent on the day after arrival at a destination
61
how quickly can the intrinsic circadian rhythm adjust to destination cues (jet lag disorder)
rate of 1 to 1.5 time zones per day
62
which direction is more difficult for travel to adjust to
eastwards worse than westward
63
treatment for jet lag disorder
timed light exposure, melatonin supplementation
64
shift work disorder is experienced by
* Approximately one-third of night shift or swing shift workers
65
what is shift work disorder
* Insomnia occurs despite sleep debt when the circadian rhythm promotes alertness and prevents sleep
66
what type of shift work is best
* Workers who consistently work the night shift do better than those with rotating schedules
* Workers on rotating schedules do better when shifts are grouped, and the swings progress later in the day instead of earlier
67
treatment for shift work disorder
practice sleep hygiene, keep sleep schedules consistent even when not working, prefer dark, cool, quiet environment, short naps, caffeine, melatonin/sleep aids, bright lights
* Aim for at least 3 to 4 hours of "anchor" sleep at the same time every day
68
non- 24 sleep wake rhythm disorder causes
* Results from a circadian rhythm system not entrained or running without apparent regulation
* May result from blindness, where light-dark cues cannot be received but can also occur in those with normal vision
69
diagnosis of Non-24 Sleep-Wake Rhythm Disorder
* Non-24 Sleep-Wake Rhythm Disorder
70
treatment for Non-24 Sleep-Wake Rhythm Disorder
entrainment of the circadian rhythm system, Rx Tasimelteon (melatonin-receptor agonist)
71
what is an example of central disorder of hyper somnolence
Disorders of Excessive Daytime Sleepiness (EDS)
72
what are Disorders of Excessive Daytime Sleepiness (EDS) related to
related to the central nervous system
73
what are Disorders of Excessive Daytime Sleepiness (EDS)
Sleepiness is not caused by other disorders related to problems with night sleep (i.e., sleep apnea or circadian rhythm disorder)
related to CNS
74
what is the ICSD-3 classification of central disorders of hyper somnolence
* Narcolepsy Type 1 (with cataplexy)
* Narcolepsy Type 2
* Idiopathic hypersomnia
* Klein-Levin syndrome
* Hypersomnia due to medical conditions
* Hypersomnia due to medications or substances
* Hypersomnia associated with psychiatric conditions
* Insufficient sleep syndrome
75
what is narcolepsy syndrome (central disorders of hyper somnolence)
chronic neurological disorder;;
1. excessive daytime sleepiness with sudden, brief (15 min) sleep attacks
2. cataplexy
3. sleep paralysis
4. hypnagogic or hypnopompic hallucinations, visual or auditory
*abrupt transition into REM sleep
76
what is cataplexy
sudden loss of muscle tone or generalized muscle weakness
77
sleep paralysis
generalized flaccidity of muscles with full consciousness
78
symptoms of narcolepsy syndrome? do they feel refreshed after nap?
* Additional symptoms include fragmented sleep and insomnia, and automatic behaviors
* Generally feel refreshed after taking a nap (unlike idiopathic hypersomnia)
79
what age and gender for narcolepsy?
* Begins in early adult life, levels off by 30 yoa
* Affects both sexes equally
80
narcolepsy type 1
characterized by low levels hypocretin (orexin) or episodes of cataplexy
81
narcolepsy type 2
normal levels of hypocretin (orexin) and no episodes of cataplexy
82
narcolepsy type 1 vs type 2
* Narcolepsy Type 1 – characterized by low levels hypocretin (orexin) or episodes of cataplexy
* Narcolepsy Type 2 – normal levels of hypocretin (orexin) and no episodes of cataplexy
83
idiopathic hypersonic (central disorder of hypersomnolence)
ICSD-3 6 criteria:
1. Daytime lapses into sleep or an irrepressible need to sleep on a daily basis, for at least 3 months.
* NOTE additional supporting features are: a) sleep drunkenness; and/or b) naps that are unrefreshing and long (greater than 1 hour)
2. Insufficient sleep syndrome is confirmed absent, preferably with a week of wrist actigraphy
3. MSLT (Multiple Sleep Latency Test) shows one of the following:
* Fewer than 2 sleep onset REM periods (SOREMPs); Or
* No SOREMPs, if the REM latency on the preceding overnight sleep study was less than or equal to 15 minutes
4. The presence of one or both of the following:
* Average sleep latency of less than or equal to 8 minutes on MSLT
* Total 24-hour sleep time is greater than or equal to 660 minutes (more typically 12-14 hours) when measured by:
* a) a 24-hour sleep study performed after correcting any chronic sleep deprivation; or
* b) wrist actigraphy recorded along with a sleep log and averaged over at least 7 days of unrestricted sleep
5. No cataplexy
6. Not explained by another condition - i.e., sleep disorder, medical or psychiatric disorder, or drug/medication use
84
does idiopathic hypersonic have cataplexy
no
Cataplexy—sudden loss of muscle tone or generalized muscle weakness
85
what is kleine-levin syndrome (central disorders of hyper somnolence)
Characterized by hypersomnic attacks 3-4 times a year lasting up to 2 days
Between episodes alertness, behaviour and thinking are normal
86
who does kleine-levin syndrome effect most
Rare disorder, occurs mostly in young men
87
symptoms of kleine-levin syndrome
include hyperphagia, hypersexuality/disinhibition, irritability, and confusion on awakening
88
cause of kleine-levin syndrome
unknown
89
4 forms of central disorders of hyper somnolence that are caused by or related to different condition
1. hypersomnia due to medical condition
2. hypersomnia due to medication or substance
3. insufficient sleep syndrome
4. hypersomnia associated with psychiatric disorder
90
hypersomnia due to a medical condition
* caused by a head injury, a neurodegenerative disease such as Parkinson’s disease, or a neuromuscular disorder such as myotonic dystrophy, or rare conditions such as Ehlers-Danlos syndrome, POTS (postural tachycardia syndrome)
91
hypersomnia due to a medication or substance
sleepiness caused by a prescription or non-prescription medication or drug
92
insufficient sleep syndrome
Not sleeping enough hours per night on a regular basis—i.e., 7-9 hours in adults, with individual variation in duration of sleep needed within that range
93
hypersomnia associated with a psychiatric disorder
* Comorbid diagnosis of depression, psychosis, bipolar disorder, etc.
94
what are parasomnias
abnormal behaviours during sleep
95
who is most effected by parasomnia
kids
96
ICSD-3 definition of parasomnias
undesirable physical events or experiences that occur
during entry into sleep, within sleep, or during arousals from sleep
* May occur during any sleep stage: NREM, REM or during transitions to and from sleep
* Characterized by the occurrence of complex motor or behavioural events or experiences at sleep onset, within sleep or during arousal from sleep
* abnormal sleep-related complex movements, behaviours, emotions, perceptions, dreams and autonomic nervous system activity - potentially harmful and can cause injuries (also to the bed partner), sleep disruption, adverse health consequences and undesirable psychosocial effects
97
3 types of parasomnias (abnormal behaviours during sleep/ physical events)
1. disorders from non REM sleep
2. disorders with REM sleep
3. other parasomnias
98
parasomnias - disorders from non REM sleep
-confusional arousal
-sleepwalking
-sleep terrors
99
parasomnias - disorders with REM sleep
-REM sleep behaviour disorder
-recurrent isolated sleep paralysis
-nightmare disorder
100
parasomnias- other parasomnias
-sleep enuresis
-sleep related groaning
-sleep related eating disorder
-exploding head syndrome
-sleep related dissociative disorders
101
sleep terrors (N-REM related parasomnia)
* an abrupt, terrifying arousal from sleep, usually in preadolescent boys although it may occur in adults as well
* Occur in stage 3 or stage 4 sleep
* distinct from sleep panic attacks
* Sx: fear, sweating, tachycardia, and confusion for several minutes, with amnesia for the
event
102
sleep walking (somnambulism) (N-REM related parasomnia)
* includes ambulation or other behaviors while asleep, with amnesia for the event
* affects mostly children aged 6–12 years
* Occur during stage 3 or stage 4 sleep in the first third of the night and in REM sleep in the
later sleep hours
* In adults:
* may be a feature of dementia in older adults
* May be due to Idiosyncratic reactions to drugs (eg, marijuana, alcohol) and medical
conditions (eg, partial complex seizures)
103
what stage do sleep terrors occur in
stage 3 or 4
104
symptoms of sleep terrors
fear, sweating, tachycardia, and confusion for several minutes, with amnesia for the
event
105
who does sleep terrors occur in mostly
preadolescent boys
106
who's mostly affected by sleep walking
kids 6-12
107
when does sleepwalking occur in sleep stage
* Occur during stage 3 or stage 4 sleep in the first third of the night and in REM sleep in the
later sleep hours
108
when do nightmares occur
REM sleep
109
what is enuresis (not able to control pee)
* involuntary micturition during sleep in a person who usually has voluntary control * more common in children, usually in the 3–4 hours after bedtime
* not limited to a specific stage of sleep
* confusion during the episode and amnesia for the event are common
110
what are sleep related movement disorders
Movements that occur during sleep or at its onset AND Disturbed night sleep or daytime sleepiness/fatigue
111
what are examples of sleep related movement disorders
1. Restless legs syndrome
2. Periodic limb movement disorder
3. Sleep-related leg cramps
4. Sleep-related bruxism
5. Sleep-related rhythmic movement disorder
6. Benign sleep myoclonus of infancy
7. Propriospinal myoclonus at sleep onset
8. Sleep-related movement disorder due to a medical disorder
9. Sleep-related movement disorder due to a medication or substance
10.Sleep-related movement disorder, unspecified
11.Isolated symptoms and normal variants (a) Excessive fragmentary myoclonus (b) Hypnagogic
foot tremor and alternating leg muscle activation (c) Sleep starts (hypnic jerks)
112
what is periodic limb movements during sleep
* Occur only during sleep with subsequent daytime sleepiness, anxiety,
depression, and cognitive impairment
113
what are 4 diagnostic criteria for periodic limb movements during sleep
* A. Polysomnography demonstrates PLMS
* B. Frequency is AHI >5/h in children or >15/h in adults
* C. PLMS cause clinically significant sleep disturbance or impairment in mental, physical, social, occupational, educational, behavioural or other important areas of functioning
* D. PLMS and the symptoms are not explained more clearly by another current sleep disorder, medical or neurological disorder or mental disorder (e.g. PLMS occurring with apneas or hypopneas should not be scored)
114
what does restless leg syndrome include
movements while awake as well
115
diagnostic criteria of restless leg syndrome
* A. An urge to move the legs, usually accompanied by or thought to be caused by uncomfortable and unpleasant sensations in the legs. These symptoms must:
* 1. Begin/worsen during periods of rest or inactivity;
* 2. Be partially or totally relieved by movement; and
* 3. Occur exclusively/predominantly in the evening/night
* B. Not related to another medical or a behavioural condition (e.g. leg cramps, positional discomfort, myalgia, venous stasis, leg edema, arthritis, habitual foot- tapping)
* C. Symptoms cause concern, distress, sleep disturbance or impairment in mental, physical, social, occupational, educational, behavioural or other important areas of functioning
116
differential diagnoses for insomnia (conditions that mimic sleep loss)
-mental health disorders
-medical or neurologic disorders
-medications and substances
-lifestyle
-other sleep disorders
117
what is the most common condition that mimic sleep loss (DD)
mental health disorders
118
mental health disorders that mimic sleep loss
Depressive disorders, anxiety disorders (PTSD, GAD, panic disorder),
bipolar disorder, other disorders
119
medical or neurologic disorders that mimic sleep loss
Chronic pain, CHF, IHD, COPD/asthma, respiratory distress syndromes, PUD, GERD, perimenopause, CFS/FM/RA/MSK disorders, uremia, end stage kidney disease, nocturia due to BPH, urinary incontinence, thyroid disorders (hyperparathyroidism, hyperthyroidism, hypothyroidism, etc.), DM/DI, allergic rhinitis, stroke, dementia, neurodegenerative and movement disorders, brain tumors, posttraumatic insomnia due to brain injury, epilepsy, headache syndromes, fatal familial insomnia
120
medications and substances that mimic sleep loss
Side effects of OTC and Rx drugs, substance abuse
(marijuana)/illicit drug use, opioid use, alcohol use disorder,
caffeine, nicotine, withdrawal from CNS depressants,
121
lifestyle conditions that mimic sleep loss
Shift work (10%), poor sleep hygiene/environmental factors (i.e. noise, temperature), jet lag, stressful life events,
122
other sleep disorders that mimic sleep loss
Sleep apnea syndromes (OSA), sleep state misperception (15%),
RLS/PMLD, circadian rhythm disorders (delayed sleep phase syndromes), altitude insomnia
123
acute alcohol intake effects which phase of sleep most
decrease sleep latency and REM sleep in 1st 1/2 and increase REM in 2nd 1/2, increase N3, N4
124
alcohol (ACUTE VS CHRONIC) use disorder effecting insomnia
* Acute alcohol intake à a decreased sleep latency with reduced REM sleep during
first half of the night while REM sleep is increased in the second half of the night, with an increase in total amount of slow wave sleep (stages 3 and 4)
* Vivid dreams and frequent awakenings are common
* Chronic alcohol abuse increases stage 1 and decreases REM sleep, with symptoms
persisting for many months after the individual has stopped drinking
* Acute alcohol or other sedative withdrawal causes delayed onset of sleep and
REM rebound with intermittent awakening during the night
125
chronic alcohol abuse effects what sleep stages
increase N1, decrease REM
126
nicotine effect on insomnia
heavy smoking (more than a pack a day) causes difficulty falling asleep
* often independently associated with an increase in coffee drinking
127
caffeine effect on insomnia
(excess intake), cocaine, and other stimulants (eg, over-the-counter cold
remedies) near bedtime causes decreased total sleep time
* Mostly affects NREM sleep - with some increased sleep latency
128
what does caffeine affect in sleep most
* Mostly affects NREM sleep - with some increased sleep latency
129
prevalence of sleep apnea
2-14% and up to 21-90% for patients referred for sleep evaluation
130
what is obstructive sleep apnea-hypopnea syndrome
characterized by repetitive collapse of upper airway which may be either partial or total resulting in reduction of airflow (hypopnea) or nighttime breathing cessation (apnea), respectively
131
what does obstructive sleep apnea cause>?
excessive daytime sleepiness
132
what is obstructive sleep apnea associated with
significant morbidity - including hypertension, heart failure, arrhythmia, and diabetes, and mortality
133
how to treat obstructive sleep apnea
treated effectively with weight loss, nocturnal continuous positive airway pressure (CPAP), and some surgical procedures
* CPAP improves hypertension control and quality of life and reduces depression and motor vehicle crashes
134
what is apnea
breathing cessation for >10 seconds
135
hypopnea
reduced respiratory airflow by 30% with a 4% decrease in oxygen saturation
136
apnea-hypopnea index (AHI)
number of apnea and hypopnea events recorded per hour of sleep
mild OSA: AHI > 5-15/h
moderate OSA: AHI > 15-30/h
severe OSA: AHI >30/h
137
mild vs moderate vs severe obstructive sleep apnea
mild OSA: AHI > 5-15/h
moderate OSA: AHI > 15-30/h
severe OSA: AHI >30/h
138
obstructive sleep apnea syndrome
apnea-hypopnea index AHI >5 times per hour during sleep
139
prevalence of obstructive sleep apnea
* Prevalence of OSA varies based on:
* the AHI threshold used for the evaluation
* 5 events/h, prevalence 14%
* 15/h, prevalence 6%
* and whether the disease definition requires symptoms in addition to an abnormal AHI
* 5/h with symptoms, prevalence 2%-4%
140
who does obstructive sleep apnea risk factors
* Male sex, older age (40-70 years, mean age 50yo), AHI > 10
* Postmenopausal women
* Family history of sleep apnea
* may be related to craniofacial structures and upper airway abnormalities (e.g. enlarged tonsils or long upper airway)
* Obesity (higher BMI 31.4 (95% CI, 30-5-32.2) & lifestyle factors leading to obesity
* Black, Hispanic/Latino, and Native American/Alaska Native persons have a higher prevalence
of OSA compared with White persons
* Hypertension
* May be risk as well as consequence
* However minimal impact on likelihood or OSA at AHI >10 or >15
* Normotensive patients have lower likelihood (LR- 0.60, 95% CI, 0.51-0.72)
* Tobacco, Alcohol, Sedative use
* History of motor vehicle crashes –moderate or severe OSA (AHI 15/h)
141
symptoms of obstructive sleep apnea
-witnesses report habitual, loud, disruptive snoring, nocturnal gasping or choking, and apnea during the patents sleep
-snoring-->
-primary: occurs without sleep apnea or significant day time sleepiness
-habitual: snorting that occurs most nights of the week
-severe: occurs all night, every night, and is audible down the hall from the sleeping individual
-apnea: breathing cessation after which a patient may awaken with a gasping or choking sensation
-daytime sleepiness: sleepiness that occurs in a situation when an individual would be expected to be alert
-fatigue: a subjective sense of weariness
-morning headache: possibly related to increased CO2 during apneic episodes
142
greatest LR+ for sleep apnea
nocturnal choking/gasping and morning headache
143
signs of obstructive sleep apnea
* Anthropometric measurements from examination of oropharyngeal and craniofacial structure
* Anthropometric Measurements
* Obesity – BMI
* Neck circumference - performed with the patient in the upright position
* Craniofacial Structure
* Cricomental space and the thyromental angle and distance
* Malocclusions - associated with retrognathia
* Overjet
* Oropharyngeal Examination - Enlargement of the tonsils, tongue, and uvula * Mallampati airway class 3-4
144
obstructive sleep apnea- mallampati classification system
class 1-4
class 1 can see the soft palate, uvula, palatine tonsils and pillars
as class increases these structure become obscured until only the hard palate is visible
145
LR+ for sleep apnea signs
mallampati class 3 or 4
pharyngeal narrowing
overall clinical impression
STOP bang questionnaire
snoring severity scale >4 and BMI > 26
146
sleep apnea clinical score and neck circumference
* As neck circumference increases, fewer of the other 3 variables are required to increase the likelihood of OSA
* On its own, neck circumference of 50 cm or higher is associated with a SACS above 15, and so even without any other features of OSA this confers modestly increased risk
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the sleep apnea clinical score 4 criteria
snoring
nocturnal gasping or choking
hypertension
neck circumference
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STOP BANG questionnaire for sleep apnea
STOP
-do you SNORE loudly
-do you often feel TIRED
-has anyone OBSERVED you stop breathing
-do you have high blood PRESSURE
BANG
-BMI >35
-AGE >50
-NECK >16inches/40cm
-GENDER; male
high risk of OSA= 5-8
intermediate risk= 3-4
low risk= 0-2
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score of what for STOP BAND
>3 for moderate OSA
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advantages of stop bang questionnaire
* High diagnostic accuracy (high discriminative power to exclude moderate to severe and severe OSA)
* Easy to use, and clear thresholds for risk stratification
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insomnia interview framework
*history is critical to successful assessment and treatment*
* Sleep complaints usually fall into four general categories:
* Insomnia: complaints of difficulty initiating sleep or staying
asleep
* Hypersomnia: difficulty staying awake during the day
* Parasomnia: abnormal movements or behavior during sleep
* Circadian rhythm disorders: timing of the sleep–wake cycle at undesired or inappropriate times over a 24-hour day
* ...or a combination of the above
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insomnia vs hypersomnia vs parasomnia vs circadian rhythm disorder
* Insomnia: complaints of difficulty initiating sleep or staying
asleep
* Hypersomnia: difficulty staying awake during the day
* Parasomnia: abnormal movements or behavior during sleep
* Circadian rhythm disorders: timing of the sleep–wake cycle at undesired or inappropriate times over a 24-hour day
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interview framework for insomnia
* Detail the nature and development of the sleep problem. * Determinethechiefsleepsymptom
* difficultyinitiatingasleep,stayingasleeporboth? * earlyawakenings?
* poororunrefreshing/non-restorativesleep?
* Determinethechronologyoftheinsomniaincluding: * onset
* predisposing,precipitatingorperpetuatingfactors
* amelioratingorexacerbatingfactors
* duration,andfrequency
* Evaluatethepatient'ssleephygiene
* Detail the nature and development of the sleep problem.
* Assesseffectsondaytimefunctioningandsocialoroccupationalfunctionto gauge the severity of insomnia
* validatedquestionnaires–PittsburghSleepQualityInventory(PSQI)Epworth Sleepiness Scale (ESS) or Insomnia Severity Index (ISI)
* Assessexcessivedaytimesleepinesslackofdaytimefatigueorsleepiness suggests the insomnia is not clinically significant
* Reviewprevioustreatmentsandassesstheirefficacy
* Explore
* Sleep-wake schedule?
* Cognitive attitude toward sleep?
* Negative expectations regarding the ability to sleep and distortions about the effects of insomnia lead to perpetuation of the insomnia.
* Attitudes toward previous treatments are also important.
* Expand the history to cover potentially contributing medical, psychiatric, and sleep disorders
* Reviewpastmedicalandpsychiatrichistory
* Anycomorbidorpsychiatricdisorderspresent?
* Anypre-existingmedicalillnesseswithnocturnalsymptoms?
* Reviewmedications,andsubstanceusehistory
* Performareviewofsymptomsthathavenotbeencoveredbyyourotherquestions
* If possible, get collateral history from a bed partner
* For information on the quality and quantity of sleep, daytime consequences, and nocturnal events (e.g., snoring, apneas, and limb movements)
* Complete a sleep diary - to determine an accurate diagnosis and assess treatment response in the future
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alarm symptoms
-heavy snoring, apnea
-suicidal
-nocturnal chest pain
-nocturnal breathing patterns
*Heavy snoring, observed sleep apneas, daytime somnolence
*Consider obstructive sleep apnea or central sleep apnea
* Suicidal or homicidal thoughts
*Consider severe psychiatric disorders (depression, bipolar disorder, psychosis)
* Nocturnal chest pain or pressure
* Unstable coronary artery disease
* Nocturnal breathing patterns
*Decompensated pulmonary disease (asthma,COPD) * Unstable coronary disease
*Undiagnosed sleep apnea syndromes
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sleep logs/ diaries
Maintain logs for 2 to 4 weeks--> quantifies sleep performance and variability
* Used to determine the total sleep time (TST), wakefulness after sleep onset (WASO), sleep efficiency (SE), and circadian rhythm disturbances
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advantages and limitations to sleep logs/diaries
* Advantage – identifies behaviours or patterns that may be targeted for intervention, reliable, cost-effective
* Limitation - reliability and validity based on adequate documentation
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what can be included in a sample sleep diary
rise time
bedtime
time asleep
# of awakenings
restful?
naps
alcohol
caffeine
stress
activities in the evening
time of meals
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SLIDE 78 chart for diagnostic algorithm
very important Claire, dont be lazy, go back and look at it :)
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Pittsburg sleep quality inventory
* Measures different domains of sleep (quality, latency, duration, efficacy, medication use, daytime symptoms, and disturbances) over one month
* Accepted reference or gold standard
* Available in many languages
* 19 questions: Global PSQI score > 5 (sensitivity 89.6%,
specificity 86.5%) helps distinguish good and poor sleepers
* Demonstrates good consistency, reliability and validity
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what is the gold standard for sleep quality
Pittsburgh Sleep Quality Inventory (PSQI)
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Pittsburgh Sleep Quality Inventory (PSQI) questions
when do you usually go to bed
how long to fall asleep
how many hours
when do you wake up
how often can you;
not fall asleep in 30 mins
feel too hot or cold
have pain
have bad dream
cant breath
have to pee
take medicine
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insomnia severity index focuses on
Measures perceived insomnia severity focusing on:
* level of disturbance to the sleep pattern
* consequences of insomnia
* degree of concern and distress related to the sleep problem
* 7 Questions; item with time interval of the past 2 weeks
* Available in three versions: patient(self- administered), significant other, and clinician
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insomnia severity index questions
how SATISFIED are you with sleep
does it INTERFERE with daily functioning
how NOTICEABLE to others
how WORRIED are you
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Epworth sleepiness scale
* Measures sleepiness/sleep tendency in eight different daily situations
* Convenient, standardized, and cost-effective
* Good internal consistency and validity
* Differentiates individuals with excessive daytime sleepiness (EDS) from alert people
* can be caused by OSA, narcolepsy, idiopathic hypersomnia, insomnia, periodic limb movement disorder
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Epworth sleepiness scale question
from 0-3 chance of dozing when... watching tv, sitting and reading, in passenger seat of car, lying down in afternoon, etc
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physical exams for insomnia
* Vitals
* Height & weight – calculate body mass index (BMI)
* Craniofacial morphology
* Oropharyngeal examination
* Neck circumference
* Cardiovascular examination
* Digital clubbing
* Neurologic examination
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complications of insomnia
pancreas: diabetes
lymph nodes: poor immune function
psychological: lower performance, slow reaction time, depression, anxiety
systemic: overweight or obese
muscular: aches, weakness
heart: risk of high blood pressure or risk of heart disease
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sleep specialist for evaluation
* sleep apnea
* PLMs during sleep
* narcolepsy
* parasomnias with potential for serious injury
* intractable insomnia
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advantages and disadvantages of polysomnogrpahy and actigraphy
* Advantages: Demonstrate high reliability in obtaining information on sleep parameters
* Disadvantages: Not readily available to most clinicians in their daily practice, expensive and time-consuming
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actigraphy accuracy?
* Studies with large populations have shown an agreement between actigraphy and PSG in total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) parameters
* Some studies have demonstrated that actigraphy consistently underestimated sleep onset latency (SOL) in comparison with PSG
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what does actigraphy record
limb movement ; wake and sleep patterns
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what does actigraphy measure
* Uses non-invasive devices (3D accelerometer) - worn on the wrist, ankle or waist, for days to weeks
* Records the occurrence and degree of limb movement and provides a graphical summary of wakefulness and sleep patterns over time
* Assesses total sleep duration, wakefulness after sleep onset (WASO), sleep latency, sleep interruptions, daytime naps, sleep quality and efficiency, posture changes, lifestyle patterns
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limitations of actigraphy
* It cannot access the periodic limb movements (PLM) or abnormal breathing
patterns in insomnia--> indicates need for polysomnography
* The recorded activity is only a proxy for sleep and is not sleep itself
* There are a variety of devices and scoring algorithms available that limit the
comparability between different actigraphic devices
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when to use actigraphy
* Suggests using actigraphy in adults and pediatric patients with insomnia disorders, circadian rhythm sleep-wake disorder, suspected central disorders of hypersomnolence, sleep-disordered breathing, insufficient sleep syndrome
* Strongly recommends that clinicians not use actigraphy in place of electromyography for the diagnosis of periodic limb movement disorder in adult and pediatric patients
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what is the gold standard for diagnosing sleep related breathing disorders like obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation/hypoxia and parasomnias
* Also utilized to evaluate nocturnal seizures, narcolepsy, periodic limb movement disorder, and rapid eye movement sleep behavior disorder
polysomnography
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when is a polysomnogrpahy not indicated
Not indicated in the initial assessment of primary insomnia unless a co-existing sleep disorder is suspected
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what does polysomnography track
* Sleep stages are constructed by monitoring electroencephalogram, chin electromyogram, and eye movements by electrooculogram
* Cardiorespiratory function and movement disorders during sleep assessed by continuous monitoring of respiratory effort, nasal and oral airflow during inspiration and expiration, arterial oxygen saturation, electrocardiogram, and limb electromyogram
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limitations of polysomnography
* Costly and inconvenient
* The first-night effect --> underestimating OSA due to the potential for decreased REM sleep being captured
* Medication changes before a PSG--> quality and quantity of sleep
* Nocturnal seizures and sleep related rapid breathing disorders may
occur too infrequently
* Equipment issues--> PSG inaccuracies
* Requires
* An adequate sleep period
* Highly trained technicians to administer the study, and sleep providers interpreting the studyàhigh cost
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co-management of sleep disorders or things that mimic sleep disorders
* Primary care practitioner
* Psychiatrist, Psychotherapist
* Sleep disorder specialist
* Pharmacist
* Nurse practitioner
* Neurologist
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educational treatment of insomnia
* Education – set realistic goals
* Sleep relaxation exercises
* Encourage a healthy lifestyle
* Address causative medical and psychiatric conditions
-avoid naps, alcohol, caffeine, tobacco, dont eat too much or go on screens before bed, consistent sleep schedule
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behavioural treatment of insomnia
Sleep restriction, stimulus control, cognitive behavioral therapy (CBT), aerobic exercise
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brief pharmacologic therapy treatment of insomnia
* Inappropriate to use side effects of other meds (i.e., antidepressants) or self- medicating with diphenhydramine
* Combined effects - hypnotics used with other CNS depressants, never combine hypnotics with alcohol
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hypnotics treatment of insomnia
L-tryptophan, melatonin
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first line treatment for OSA (obstructive sleep apnea) is PAP during sleep
Includes CPAP (continuous positive airway pressure) and auto-titrating continuous positive airway pressure (APAP)
185
sleep deficiency vs insomnia
sleep deficiency
- insufficient amount of sleep (sleep deprivation) and/or
- lack of sleep quality potentially affecting all phases of sleep
insomnia
-sleep disorder with trouble falling or staying asleep, lack of quality of sleep despite desirable time and environment
-diagnosis required 3+ nights a week fro 3+ months
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sleep and memory consolidation
SLOW WAVE
-hippocampo-neocortical communication
SLOW WAVE AND REM
-selective refining of memory representations/rescaling of synaptic weight
REM
-strengthening of neocortical memory representations
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insomnia complications
* Sleep disturbances are associated with neurocognitive dysfunctions, attention deficits, impaired cognitive performance, stress, and poor impulse controls
* Impairments in memory, executive functions, and attention over time--> may develop psychiatric disorders such as depression, anxiety, psychosis and even suicide
* Poor sleep can severely affect daytime performance, both socially and at work
* Increases the risk of occupational and automobile accidents and injuries, alcohol use, poor quality of life and poor overall health
* Can develop dependence on medication to sleep
* Strong associations with diabetes mellitus & insulin resistance, asthma, obesity, obstructive sleep apnea, hypertension, vascular disease, stroke, myocardial infarct
* Overall lower self-reported quality of life, decreased family well-being, and increased mortality & morbidity
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short term vs chronic insomnia prognosis
* Short-term insomnia - good long-term prognosis if interventions and treatments are made appropriately and promptly
* Chronic insomnia - usually very persistent, especially in patients with significant comorbid medical and psychiatric conditions
* 46% to 72% of patients with insomnia continue to have insomnia symptoms 3 years later
* Insomnia impacts quality of life and poses a substantial economic burden on the society
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elderly persons with primary insomnia prognosis
at greater risk of dependence on hypnotic medications, depression, dementia, and falls, and may be more likely to require residential care
