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Management of Neuropsychiatric Disorders > Sleep > Flashcards

Sleep Flashcards

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1
Q

Learning objectives

  • understand what the different sleep investigations involve
  • understand how and why we use these investigations
  • be aware of where one can access these investigations
A
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2
Q

what are the parts of a sleep history?

A
  • homeostatic
  • circadian
  • physical
  • psychological
  • environment
  • medication
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3
Q

what are different methods of sleep investigations

A
  • sleep diary
  • epworth sleepiness scale
  • actigraphy
  • pulse oximetry
  • respiratory study
  • watchpat
  • polysomnogram (PSG)
  • multiple sleep latency test (MSLT)
  • maintenance of wakefullness test (MWT)
  • oxford sleep resistance test (OSLER)
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4
Q

sleep diary

A
  • used to determine a typical night and see how much variability there is
  • allows comparison between weekdats and weekends
  • allows you to discern patterns
  • at least a week of entries is useful to support diagnosis
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5
Q

epworth sleepiness scale

A
  • measures how likely you are to fall asleep during everyday activities
  • 0 to 10 is normal
  • score of 11 or more is considered excessively sleepy
  • relies on honest reporting from the patient
  • does not differentiate between different times of day
  • uneven scoring
  • fair reliability and validity
  • sleep apnea
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6
Q

actigraphy

A
  • measures activity and levels using an accelerometer worn on the wrist
  • collects continuous data on movements for several weeks which is then translated into sleep-wake data
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7
Q

uses of actigraphy

A
  • used to confirm circadian rhythm disorders
  • useful to determine sleep patterns in insomnia where diary entries are unreliable
  • measures sleep fragmentation in home environment
  • ensures sleep is not restricted prior to multiple sleep latency test
  • may have a role in monitoring periodic limb movements if strapped to feet
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8
Q

advantages of actigraphy

A
  • unobtrusive
  • provides a longitudinal picture of sleep in a home environment
  • can measure sleep times, fragmentation, sleep onset latency, wakefullness after sleep onset etc
  • can give an indication of sleep hygiene
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9
Q

limitations of actigraphy

A
  • usually only available in specialist sleep clinics
  • not validated in all sleep disorders and populations
  • can’t measure sleep
  • fitness trackers are not a substitute
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10
Q

pulse oximetry

A

measures oxygen saturation and pulse rate

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11
Q

obstructive sleep apnea diagnosis

A
  • epworth sleepiness scale
  • pulse oximetry
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12
Q

how is pulse oximetry used to diagnose obstructive sleep apnea

A

obstructive sleep apnea is diagnosed by visual inspection of the oxygen saturation and pulse tracing and computer calculated oxygen desaturation index

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13
Q

how is the severity of obstructive sleep apnea categorised

A
  • mild
  • moderate
  • severe
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14
Q

what scale is used to classify OSA severity

OSA: obstructive sleep apnea

A

Apnea-Hypopnea Index (AHI)

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15
Q

mild obstructive sleep apnea

A

ODI ≥ 5 < 15

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16
Q

moderate obstructive sleep apnea

A

ODI ≥ 15 < 30

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17
Q

severe obstructive sleep apnea

A

ODI ≥ 30

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18
Q

what is oximetry used for

A

it is a screening tool for sleep related breathing disorders

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19
Q

advantages of oximetry

A
  • cheap and easy
  • home or ward
  • skilled clinicians can tell if OSA is depending on sleep position or REM from looking at the trace
  • can predict periodic limb movements from pulse tracing
  • analysis takes a few minutes
  • equipment is widely available
  • high specificity

specificity measures how correctly individuals without the condition are ruled out

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20
Q

true or false

pulse oximetry tracing can be used to tell the difference between OSA due to position or REM

A

True

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21
Q

limitations of pulse oximetry

A
  • poor sensitivity
  • disagreement on what degree of desaturation should be used (e.g. 2, 3, or 4%)
  • does not detect apnoeas if there is an arousal before oxygen saturation drops
  • caution needs to be exercised where pulse oximetry is negative but positive history

sensitivity measures how well the test correctly identifies people who have the condition

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22
Q

what are the components of a respiratory story

A
  • pulse oximetry
  • nasal airflow
  • chest respiratory movements
  • abdomen respiratory movements
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23
Q

advantages of respiratory studies

A
  • can be done in a home or ward environment
  • available in sleep clinics, respiratory units and ENT units
  • can diagnose and callibrate CPAP in one night
  • can detect apnoeas that don’t lead to desaturations
  • can detect mixed apnoeas
  • ensures all body positions are monitored
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24
Q

split night

A

The first part of the night is diagnostic. If the testing is positive for OSA then then the second half of the night can be used to calibrate CPAP titration

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25
CPAP
continuous positive airway pressure
26
CPAP titration
a sleep study used to determine optimal air pressure to set CPAP to prevent upper airway obstruction during sleep and eliminate breathing pauses
27
OSA
obstructive sleep apnea is when the throat collapses during sleep stopping breathing
28
mixed apnoeas
both central and obstructive elements
29
limitations of respiratory studies
* can't detect the impact of respiratory events on sleep * misses respiratory effort related arousals * more time and expertise required for analysis * more technical problems with home studies * cannot detect non respiratory sleep disorders
30
watchpat
* measures PAT signal, heart rate, oximetry, actigraphy, body position, snoring and chest motion * single use disposable versions * can detect OSA, sleep fragmentation and sleep architecture
31
PAT signal
peripheral arterial tonometry signal
32
sleep fragmentation
disruption of normal sleep patterns due to frequent arousals or waking up during the night
33
sleep architecture
the structure of normal sleep; patterns and progression of different sleep stages throughout the night
34
polysomnography (psg)
* eeg * eog * emg * ecg * video * audio * tibialis emg * respiratory channels (clinical)
35
what sleep disorders can be diagnosed with PSG
* obstructive sleep apnea * periodic limb movement in sleep * insomnia * non REM parasomnias * REM behaviour sleep disorder * nocturnal epilepsy (with extended montage)
36
parasomnia
a group of sleep disorders characterized by unwanted behaviors, movements, or experiences that occur during sleep or the transition between sleep and wakefulness
37
38
advantages of polysomnography
* gold standard * differntiates between sleep stages * determines which stage of sleep disorders are occuring * can detect epileptic phenomena * measures sleep time, awakenings, arousals etc. * determines the impact of sleep disorders on sleep
39
limitations of polysomnography
* expensive * highly skilled professionals for analysys * sleep may be affected by wires, awareness of video, strange environment etc. * only available in specialist sleep centres * sod's law
40
Sod's law
the event that you are looking for will not happen on the night you are trying to monitoring it
41
multiple sleep latency test (mslt)
used to gain an objective measure of daytime sleepiness; the ability to initiate sleep * measures sleepiness in central hypersomnolence * differentiates between narcolepsy and idiopathic hypersomnolence * can used in OSA patients with ongoing sleepiness despite CPAP
42
central hypersomnolence
excessive daytime sleepiness (EDS) that isn't caused by sleep apnea, poor sleep quality, or circadian rhythm issues
43
what is the multiple sleep latency test procedure
* wrist actigraphy for one week * immediately followed by overnight full array polysomnogram * basic PSG and asked to try and nap every two hours * up to five nap trials * nap trials end after 20 minutes if they haven't fallen asleep or 15 minutes after sleep onset * sleep staging
44
MSLT interpretation: sleep onset latency
time from start of the trial to the first 30 second epoch scored as sleep
45
sleep onset latency
the time it takes to transition from full wakefulness to sleep
46
MSLT interpretation: sleep onset REM
two or more naps with REM indicative of narcolepsy
47
what is the SOL in normal subjects
10 to 20 mintues
48
what does a mean SOL ≤ 8 minutes indicate
excessive daytime sleepiness
49
what is the mean SOL in narcoleptics
3 minutes
50
what is an indication of idiopathic hypersomnolence
less than two naps with REM and a SOL ≤ 8 minutes
51
advantages of MSLT
* provides an objective measures of sleepiness * differentiates between narcolepsy without associated features of REM instability and indiopathic hypersomnolence
52
limitations of MSLT
* frequently produces false positives and false negatives * antidepressants suppress REM and give a false negative for narcolepsy * antidepressant withdrawal within two weeks of testing can lead to REM rebound giving a false positive of narcolepsy * medication effects on sleepiness * protocol not standardised between different labs * clinical and research protocols differ
53
maintenance of wakefullness test
used to test ability to resist sleep; used to confirm that a patient with a sleep disorder is sufficiently alert to drive safely, work etc.
54
MWT procedure
* sometimes actigraphy and PSG the night before * four hour trials at two hour intervals * PSG, dim room, reclining and pillow without activities e.g. TV * attempt to stay awake for the whole trial * trial is between 20 to 60 minutes, mean 40 minutes
55
conditions for terminating MWT procedure
* three continous 30 second epochs of N1 (lightest sleep stage) ***or*** * one 30 second epoch of any other sleep stage
56
MWT interpretation
mean SOL ≤ 8 minutes is abnormal mean SOL > 40 minutes indicates good alertness mean SOL between 8 to 40 minutes less certainty normal mean SOL 30.4 minutes
57
advantages of MWT
* negative study reassuring * better than the MSLT to determine fitness to drive * discriminate between self reported alertness and observed sleepiness
58
limitations of MWT
* poor ecological validity * restrictions on caffeine, smoking, exercise may not reflect real life situation * protocol not standardise across labs * microsleeps which can be fatal at 70mph aren't scored they are less than half the 30 second epoch or are not in consecutive epochs
59
oxford sleep resistance test (OSLER)
* similar procedure as the MWT * 4 trials of 40 minutes each * light flashes every three seconds * participant has to press a button in response to the light * if seven consecutive flashes are missed indicate sleep *advantages* * no eeg * easy to administer * easy to interpret
60
which tests should be used to assess insomnias
actigraphy
61
which tests should be used to assess hypersomnias
actigraphy and MSLT
62
which tests should be used to assess parasomnias
PSG
63
which tests should be used to assess movement disorders
PSG
64
which tests should be used to assess sleep reated breathing disorders
* oximetry * respiratory study * PSG * watchpat
65
which tests should be used to assess circadian rhythm disorders
actigraphy
66
which tests should be used to assess safety to drive, work etc.
MST, OSLER
67
what are the three most common complaints about sleep
* too sleepy * can't sleep * parasomnias
68
what are the differentials for complaints of feeling too sleepy
* obstructive sleep apnea * periodic limb movement * circadian rhythm disorders * narcolepsy * idiopathic hypersomnia * sleep deprivation
69
what are the differentials for complaints of not being able to sleep
* insomnia * restless legs * circadian rhythm disorders
70
what are the differentials for complaints of parasomnias
* nightmares * sleep paralysis * hallucinations * sleep terrors * sleepwalking/ eating/ sex * REM behaviour sleep disorder

Management of Neuropsychiatric Disorders (25 decks)

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