Wk 31 - Sleep disorders 2 Flashcards
What is insomnia?
Inability to fall asleep and/or by waking up during the night + difficulty going back to sleep
What is the major cause of insomnia in terms of medical conditions?
- Cardiac
- Neurologic
- Endocrine
- Pulmonary
- Gastrointestinal
- Hematologic conditions
- Substances
- Meds
What is the major cause of insomnia in terms of psychiatric conditions?
- Depression
- Post traumatic stress disorder
- Psychotropic medication
What is the major cause of insomnia in terms of environmental conditions?
- Stressful or life-threatening events
- Shift work, jet lag or changes in altitude
- Overly warm sleeping env
Give examples of behavioural changes that may be used to treat insomnia
- Following specific nighttime routine
- Improving sleep env
- Red caffeine + alcohol intake
- Red afternoon nap
How does alcohol affect REM sleep?
Alcohol inhibits REM sleep, restorative stages of sleep + tf doesn’t promote good restful sleep
Which class of drugs are used to combat insomnia?
- Antihistaminergic
- Benzodiazepines
- Z drugs
- Antidepressants
Which antihistamines are used to aid sleep?
- Diphenhydramine
- Doxylamine
Which benzodiazepines are used to aid sleep?
Higher activity at a1 GABAA subunit receptor:
- Temazepam
- Flunitrazepam
- Triazolam
- Flurazepam
- Midazolam
- Nitrazepam
What can hypnotic BZD lead to?
- Tolerance
- Physical dependence
- W/drawal upon discontinuation
Which Z-drugs are used to aid sleep?
- Zolpidem
- Zaleplon
- Zopiclone
- Eszopiclone
Which antidepressants are used to aid sleep?
- Amitriptyline
- Doxepin
- Mirtazapine
- Trazodone
What are the effects of antidepressants?
Can lead withdrawal effect which may induce rebound insomnia:
- Amitriptyline + doxepin: have antihistaminergic, anti-cholinergic + anti-adrenergic properties
- Mirtazapine: has antihistamine + anti-serotonergic activity, s/e: drowsiness + weight gain
- Trazodone: s/e: orthostatic hypotension + sedation
- Trimipramine: does not suppress REM sleep
Agomelatine
- Melatonergic antidepressant
- Doesn’t cause daytime drowsiness
- Agonist at MT1 + 2
- Antagonist at 5-HT2B + 5-HT2C receptor
What are the interactions of agomelatine?
- Birth control pills inc melatonin
- Caffeine dec melatonin
- Fluvoxamine inc melatonin
- Melatonin inc blood sugar tf dec effectiveness of diabetes med
Circadin
- Contains melatonin
- Relieves insomnia for >55
What is narcolepsy?
Chronic neurological disorder caused by brain’s inability to regulate sleep-wake cycle normally (pass from wakefulness to REM)
What can narcolepsy lead to?
Hypersomnia -> excessive sleepiness during day -> sudden bouts of sleep that occur several times per day
When is narcolepsy most evident?
- Adolescence/young adulthood
- Affects men + women
What is 3 symptoms that may not occur in people with narcolepsy?
- Cataplexy
- Sleep paralysis
- Hypnagogic hallucinations
What are some measures that can be used for someone suffering from narcolepsy?
- Weight loss
- Abstain from alcohol + nicotine
- Sleep hygiene
- Psychotherapeutic techniques
What is the primary treatment to help people with narcolepsy to stay awake during the day?
CNS stimulant - except methylphenidate + amphetamine
Give examples of psychostimulants used to help with narcolepsy
- Pemoline: ADHD + narcolepsy, not used due to hepatotoxicity
- Modafinil: non-amphetamine, used to treat sleepiness associated w/ narcolepsy, sleep work shift disorder + obstructive sleep apnea
Give other examples of medication used for narcolepsy other than psychostimulants
Fluoxetine + Venlafaxine suppress REM
What is used for treatment of cataplexy?
- Sodium oxybate (xyrem)
- Take 2 doses at bedtime + 4 hrs later
- S/e: nausea, bedwetting + worsening sleep walk
- W/ sleep meds, narcotic pain reliever + alcohol -> difficulty breathing, coma + death
What is cataplexy a result of?
Absence of orexin NT in hypothalamus
What plays a role in narcolepsy?
Hypocretins (orexins) prod by hypothalamus
What is suvorexant?
- Blocks orexin receptors
- Indicated: insomnia difficulty w/ sleep onset + maintenance
- Contraindicated for narcolepsy
- Not for liver impairment
- Causes fetal harm during pregnancy
What is restless legs syndrome?
- Irresistible urge to move legs
- Symptoms exacerbated by rest/inactivity
- Partially relieved by movement
People with RLS have increased number of what?
K-complexes
Which medications reduce RSL?
- L-dopa but doesn’t red K-complex
- Clonazepam - inhibits REM + dec freq. K complexes -> improves sleep restoration
Give examples of mild RSL treatments
- Exercise
- Leg massages
- Eliminate alcohol + caffeine
Which medications are used for RSL?
- DA agonist = 1st line
- Pramipexole + ropinirole
- Pergolide (less effective + more s/e)
- Zolpidem, zaleplon + clonazepam: muscle relaxants
What are the types of sleep apnea + what are their differences?
- Obstructive sleep apnea (obstruction of upper airway)
- Central sleep apnea (no effort made to breath)
What is obstructive sleep apnea?
- Cessation/dec in airflow in presence of breathing effort
- Untreated: heart arrhythmias, HF, high BP + stroke
- Goal: keep airway open
What is central sleep apnea?
- Effort to breathe diminished/absent for 10-30 secs
- Leads to problems w/ brainstem
What are conditions that can cause central sleep apnea?
- Stroke affecting brain stem
- Encephalitis
- PD
- Arthritis in cervical spine/base of skull
- Complications in cervical spine surgery
- Radiation of cervical spine
- Bulbar poliomyelitis
- Obesity
- Primary hypoventilation syndrome
- Narcotic containing painkillers
What is the treatment for central sleep apnea?
- Addressing med problem
- Red opioid med
- CPAP
- BPAP
- ASV
- Supplemental oxygen
- Acetazolamide
