Sleep

Question 1

sleep

Answer 1

rapidly reversible state of reduced responsiveness, motor activity, and metabolism

Question 2

polysomnogram

Answer 2

primary tool for assessing sleep for clinical and research purposes using 30 second epochs of EEG, EMG, and EOG

Question 3

sleep architecture

Answer 3

*sleep stages occur in cycles lasting 90-120 minutes each
*4 to 5 cycles occur during a typical night of sleep
*typically, increased percentage of NREM in the first half of the night and increased percentage of REM in the second half

Question 4

wakefulness on polysomnogram

Answer 4

*EEG 8-13 Hz (alpha)
*variable muscle movements
*eye movements present

Question 5

stage N1 sleep

Answer 5

*transitional or light sleep (drowziness)
*at least 50% of epoch has low amplitude mixed theta (4-7 Hz)
*slow rolling eye movements
*little muscle
*VERTEX WAVES late in N1

Question 6

stage N2 sleep

Answer 6

*largest proportion of sleep time in normal adults (40-55% of night); when teeth grinding occurs
*theta frequency dominates
*SLEEP SPINDLES 11-16 Hz, central, brief
*K complexes (negative sharp followed by a positive, last > 0.5 sec

Question 7

what stage of sleep is characterized by sleep spindles

Answer 7

stage N2 sleep

Question 8

stage N3 sleep

Answer 8

*deep or slow wave sleep
*about 10-20% of sleep
*sleepwalking, night terrors, and enuresis occur during this stage
*at least 20% of epoch is 0.5-2 Hz high amplitude delta
*occurs more in first half of night

Question 9

REM (stage R) sleep - polysomnograph

Answer 9

*EEG is low voltage, mixed with sawtooth 2-6 Hz brief bursts
*EOG with conjugate irregular, sharply peaked eye movements initial phase < 500 msec
*ATONIA on EMG (inhibition of alpha motor neurons)

Question 10

which stage of sleep is characterized by atonia

Answer 10

REM sleep

Question 11

REM sleep characteristics

Answer 11

*characterized by atonia and rapid eye movements
*less than 25% of sleep time, onset after 90 minutes, duration increases later in night
*typically associated with vivid dreams
*increased brain O2, erections, variable and increased pulse and BP, may serve memory processing functions

Question 12

phasic and tonic REM

Answer 12

-phasic REM: bursts of rapid eye movements, respiratory variability, and brief EMG (twitches)
-tonic REM: fewer eye movements, more limited motor activity

Question 13

arousals (during sleep)

Answer 13

*abrupt shift of EEG frequency that lasts at least 3 seconds with 10 seconds of stable sleep preceding the change
*waking up transiently then returning back to the stage of sleep they were in
*if during REM, requires a concurrent increase in EMG for at least 1 second

Question 14

medications that suppress REM

Answer 14

*sedative-hypnotic
*barbiturates
*antiepileptic drugs
*beta blockers
*MAOI
*SSRIs
*stimulants
*tricyclic antidepressants
*EtOH

Question 15

medications that enhance REM when you withdraw from them

Answer 15

*EtOH
*BDZ
*TCA
*MAOI

Question 16

short term insomnia

Answer 16

*sx < 3 months
*often temporally related to a stressor

Question 17

chronic insomnia

Answer 17

*sx at least 3x per week over 3 or more months

Question 18

recommendations for treating chronic insomnia

Answer 18

sleep hygiene, stimulus control, include relaxation, sleep restriction therapy, cognitive therapy, and cognitive behavioral therapy for insomnia (CBT-I)

Question 19

central sleep apnea

Answer 19

*repetitive cessation or decrease of BOTH airflow and ventilatory effort during sleep
*typically present with symptoms of disrupted sleep, such as excessive daytime sleepiness, poor subjective sleep quality, insomnia, inattention, and poor concentration
*tx with nocturnal O2 (CPAP), adaptive seroventilation

Question 20

obstructive sleep apnea (OSA)

Answer 20

*obstructive apneas, hypopneas, or respiratory effort related arousals
*5+ obstructive respiratory events per hour (with accompanying medical risks) or 15 such events without any other factors
*daytime symptoms attributable to disturbed sleep, such as sleepiness, fatigue, headaches, or poor concentration
*signs of disturbed sleep, such as snoring, restlessness, or resuscitative snorts

Question 21

obstructive sleep apnea - management

Answer 21

*weight reduction
*positive airway pressure (CPAP)
*orthodontic devices
*ENT surgery
*hypoglossal nerve stimulation (Inspire)

Question 22

narcolepsy type 1

Answer 22

*narcolepsy with cataplexy
*decreased orexin (hypocretin) in lateral hypothalamus
*transient facial weakness or falls triggered by joking or laughter, or the inability to move for 1-2 minutes immediately after awakening or just before falling asleep
*begins in teens to early 20s

Question 23

narcolepsy type II

Answer 23

*narcolepsy (falling asleep abruptly) without cataplexy
+/- decreased orexin

Question 24

narcolepsy evaluation

Answer 24

1) multiple sleep latency tests (MSLT) - 4-5 repeated naps which are terminated at up to 20 minutes to document sleep latencies
*mean sleep latency < 8 minutes
*typically shows REM sleep within 15 minutes of onset of sleep (abnormal)

Question 25

excessive daytime somnolence

Answer 25

*the inability to maintain wakefulness and alertness during the major waking episodes of the day with sleep occurring unintentionally or at inappropriate times almost daily for at least 3 months

Question 26

treatments for excessive daytime somnolence

Answer 26

modafinil, armodofinil, and sodium oxybate

Question 27

Epworth Sleepiness Scale (ESS)

Answer 27

*one page questionnaire that estimates likelihood of dozing off in 8 typical sedentary situations

scores:
1-6 : normal sleep
7-8: average sleepiness
9-24: abnormal (pathologic) sleepiness

Question 28

parasomnias

Answer 28

*undesirable physical events (movements, behaviors) or experiences (emotions, perceptions, dreams) that occur during entry into sleep, within sleep, or during arousals from sleep

Question 29

NREM parasomnias

Answer 29

characterized by recurrent episodes of incomplete awakening, with absent or inappropriate responsiveness, limited cognition, and partial or complete amnesia of the event

*confusional arousals
*sleepwalking
*sleep terrors
*sleep-related eating disorders

Question 30

REM-related parasomnias

Answer 30

*sleep paralysis (inability to move for 1-2 minutes after awakening)
*nightmare disorder
*REM behavior disorder

Question 31

REM behavior disorder

Answer 31

*a type of REM-related parasomnia
*presence of REM sleep without atonia on polysomnography
*repeated episodes of sleep-related vocalization and/or complex motor behaviors

Question 32

treating REM behavior disorder

Answer 32

*avoid medications that exacerbate RBD (SSRIs and tricyclic antidepressants)
*ensure safe sleeping environment (remove weapons, provide bed alarm, sleep alone)
*melatonin in high doses at bedtimes

Question 33

restless leg syndrome (Willis-Ekbom)

Answer 33

*an urge to move the legs when sitting still/about to go to sleep
*usually accompanied or caused by uncomfortable or unpleasant sensations in the legs, worsening during periods of rest or inactivity, partially relieved by movement
*reduced CNS iron is a consistent finding

Question 34

periodic limb movement syndrome

Answer 34

*periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep
*can occur simultaneously in both legs, alternate, or occur unilaterally
*seen in > 80% of patients with restless leg syndrome