What You Don't Really Need To Know, But… Flashcards
What are the nighttime symptoms of insomnia?
Long sleep latency Sleep maintenance difficulty Difficulty returning to sleep Short sleep duration Poor sleep quality Early morning awakening
What are the daytime symptoms of insomnia?
Fatigue and somatic symptoms Cognitive difficulty Affective symptoms (depression, anxiety) Distressed, impaired Seeking help Self treatment (alcohol, OTC meds) Limitation of daytime activity (attempt not to to do things that will "push the sleep away")
What is the difference between sleep deprivation and insomnia?
Sleep deprivation: adequate ability to sleep, inadequate opportunity
Insomnia: inadequate ability to sleep, adequate opportunity
What is the prevalence of insomnia?
30% of population has insomnia
10% meet diagnostic criteria (truly disabling)
50% of patients under clinical care have sleep disruption (caused by the other problem)
What percentage of patients with chronic insomnia have a mental disorder?
Half. This is bilateral (i.e. half of psychiatric disorder patients have a sleep disorder and half of sleep disorder patients have a psychiatric disorder).
What is delayed sleep phase syndrome (DSPS)?
Most common in adolescents/young adults. They cannot fall asleep until 2 or 3 a.m. and then can’t wake up at normal social hours (11 or noon). Their sleep is solid and healthy if they are allowed to sleep.
What percentage of people with insomnia have primary insomnia?
About 1 in 4 (22%).
What percentage of people with insomnia have DSPS?
7%
What percentage of people with insomnia have OSA?
6%
What percentage of people with insomnia have a medical disorder (not a sleep disorder)?
4%
What is the incidence of depression in patients with insomnia?
16% compared to 4% in patients without insomnia (4 times higher rate of depression)
What is the incidence of anxiety in patients with insomnia?
About double that of patients without insomnia (14% to 7%)
What is the incidence of alcohol abuse in patients with insomnia?
About double that of people without insomnia (because some people with insomnia use alcohol to help them sleep)
What is the incidence of drug abuse in patients with insomnia?
About 5 times higher than in people without insomnia (1% to 5%) because some people with insomnia use drugs to help them sleep
What is the most-prescribed drug for insomnia?
Trazadone. Second is Ambien.
What are the implications of insomnia in sleep dentistry?
OAT may worsen or be perceived as worsening insomnia
Side effects of OAT may present as insomnia, even if it is not the case
Sleep deprivation may be implicated as a side effect of OAT
FACT: an underlying and unrecognized or poorly managed medical or psychiatric disorder may cause insomnia and the blame placed on the OAT
Sleep dentistry is part of a triangle of possible etiologies in patients with sleep disorders. What are the three points of the triangle?
OSA (sleep dentistry/OAT), psychiatric/medical disorders, and insomnia. If any of the points is not well-treated, blame may be placed/implicated on the other points.
What is advanced sleep phase syndrome?
Common in the elderly (≥65)
Difficulty sleeping beyond 3-4 a.m.
Sleep onset time routinely no later than 8 p.m.
What is shift work sleep disorder?
Chronic desynchronization of internal circadian and external time cues. Symptoms: insomnia/hypersomnia, fatigue, poor performance, medical/psychiatric illness, drug/alcohol abuse, social impact.
What are the three circadian rhythm disorders?
Delayed sleep phase syndrome
Advanced sleep phase syndrome
Shift work circadian disorder
What are the implications of circadian rhythm disorders for sleep dentists?
Circadian disorders may present as sleep onset, maintenance, and offset insomnia or daytime hypersomnia
Adequate recognition and management of these disorders will facilitate success of OAT
Open communication b/w dentist, PCP, sleep specialist and patient is mandatory for proper management
Panic disorder and sleep?
Common
Usually occurs during NREM sleep, transition into N3 sleep
Insomnia commonly occurs w/panic disorder
Reduced sleep efficiency and REM latency
No conclusive pattern of PSG findings
Post-traumatic stress disorder and sleep?
Nightmares of traumatic event
Subjective sleep disturbance (70%-90%) – sleep study shows good sleep, but they feel that didn’t sleep well at all
No consistent abnormalities of sleep architecture
What is the prevalence of restless leg syndrome?
10% of adults
What are the correlations between age and prevalence of restless leg syndrome (RLS)?
Increases with age
Peaks above 50 y.o.
Age of onset is variable, but common onset is ≥40 y.o.
What are gender differences in occurrence of RLS?
There are none. The incidence is equal between men and women.
What is the relationship between circadian rhythm and RLS?
RLS is circadian linked. Discomfort/tingling/urge to move intensify in the late afternoon and worsen during sleep. Temporary relief is experienced with movement. Onset or worsening of symptoms occurs when at rest or inactive.
What is the best treatment for RLS?
Sleep specialist prescribes a dopamine agonist. It works like magic for a short time. Then rebound can occur (worsening).
What are the clinical features of periodic limb movement syndrome (PLMS)?
Diagnosed via PSG (EMG)
Four movements in a row of .5-5 seconds that are 5-90 seconds apart
Must have 5 or more per hour with arousals or 15 per hour withou arousals to be clinically significant
May have arm and leg movements
Implications of PLMD, RLS for sleep dentists?
Sleep onset insomnia may implicate failure of OAT
PLMS can cause fragmented/non-restorative sleep
Treatment of these conditions may improve daytime sleepiness and allow the OAT to be successful if OSA is a concurrent problem
What are the clinical features of narcolepsy?
Excessive daytime sleepiness
Disturbed nocturnal sleep
Some with cataplexy (excitement, like laughter, causes temporary paralysis)
Some have sleep paralysis – they wake up and can’t move
Hallucinations – they are dreaming but they are awake
What is narcolepsy?
It is a pathological manifestation of REM: paralysis, dreaming during wakefulness (the boundaries between NREM, REM, and wakefulness become blurred). Whenever an episode occurs, the EEG shows REM sleep, even when awake!
They also enter sleep going directly into REM instead of Stage 1 or else during the first 15 minutes of sleep. Called SOREM (sleep onset REM).
What percentage of the population experiences sleep paralysis?
15%
What percentage of the population has narcolepsy?
.04%
What happens when narcolepsy and OSA coexist in a patient?
When the OSA is treated, narcolepsy becomes evident. So, if they are compliant with OSA and objective measures show success but they are still sleepy, refer out for evaluation
Diagnosis and management of narcolepsy requires complete treatment of OSA
Narcolepsy treatment may cause changes in sleep architecture and quality and should not be considered as failure of OAT
What are the treatments for narcolepsy?
Sleepiness: modafanil or amphetamines
Cataplexy: SSRIs
Generally speaking, what are the implications of non-OSA sleep disorders in OAT?
Many sleep disorders may complicate the success of OAT
Treatment of a primary disorder may uncover a secondary disorder
Dentist’s knowledge of disorders other that OSA is important as more than one disorder may be present
Appropriate referral and management is mandatory for overall success of therapy
