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Sleep Flashcards

(58 cards)

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1
Q

Polysomnography

A

full/level1 sleep study

Provides information on sleep architecture

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2
Q

components of polysomnogram

A 
EEG
EMG (submentalis, ant. tibilalis)
EOG (electro-occulogram)
ECG
Airflow (nasal pressure, thermistor)
Respiratory effort
digital oximetry
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3
Q

Ambulatory sleep studies

A 
DIgital/level 3
useful only for sleep apnea
no information on sleep stages, sleep/wake cycle
measures:
- airflow
- respiratory effort
- digital oximetry
- +/- body position
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4
Q

Sleep staging

A

amplitudes and waveforms scored in 30 second epochs
EEG
Eye movements (rolling at sleep onset, rapid in REM sleep)
Muscle tone (EMG) - lessens with drowsiness and sleep depth, absent in REM

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5
Q

Normal sleep

A

Sleep latency

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6
Q

Non-REM sleep

A

Stages I, II, III
I: still input from environment
II: medium sleep
III: deep sleep

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7
Q

REM sleep

A

phasic: eye movements, twitches, variable autonomic activity
Tonic: EMG suppression, high arousal threshold, elevated brain temperature, poikilothermia, penile tumescence
Sleep apnea often worst during REM since muscles are relaxed

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8
Q

EEG patterns

A

Stage 1: theta
2: sleep spindles and mixed EEG
Stage 3: more delta waves
REM: low-voltage, high-frequency waves

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9
Q

Hypnogram

A

~ 90 min cycles between REM and non-REM

Elderly: shorter cycles, shallow sleep

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10
Q

Stage I of sleep

A

light sleep
transitional stage passed through from wake to sleep and sleep to wake
usually ~5% of TST
when increased –> indicates sleep disruption

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11
Q

Stage II of sleep

A

most of the night spent in this stage

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12
Q

Stage III of sleep

A

deepest - hard to awaken
Sleep drunkenness: sleep inertia when awakened; parasomnias occur from this stage
Most restorative
often reduced by benzodiazepines
maintained by zopiclone, zaleplon, zolpidem

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13
Q

Stage REM

A

dream sleep; ver narrative
tonic/phasic stages
tonic: voluntary muscle atonia
phasic: movements

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14
Q

Latency to stage REM shortened causes

A

REM rebound: first night of CPAP, drug/medication withdrawal
Depression (psychotic > milder forms)
Narcolepsy

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15
Q

Sleep and aging

A

more stage I, less stage III
more awakening
brain shrinks a bit - less deep sleep??

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16
Q

Complaints of normal elderly about sleep

A 
insomnia
relative advance of sleep phase
shallow sleep
less restorative
dream content often unpleasant
daytime sleepiness
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17
Q

Melatonin pathway

A

Inhibited by light
stimulated by darkness
Retinohypothalamic tract –> SCN –> made in pineal gland to go to superior cervical ganglion

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18
Q

Sleep disturbances commonly seen in the elderly

A

Respiratory sleep disorders
Restless legs/periodic limb movements
REM sleep behaviour disorder

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19
Q

Respiratory sleep disorders

A

Primary snoring
upper airway resistance syndrome
OSA - hypopnea syndrome
–> apnea: cessation of airflow >=10 seconds
–> hypopnea: decrease in airflow >=10 seconds
- respiratory effort persists
Central sleep apnea - no respiratory effort
Mixed sleep apnea

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20
Q

OSA night time symptoms

A 
snoring
witnessed apneas
choking
dyspnea
restlessnes
snocturia
diaphoresis
reflux
drooling
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21
Q

OSA daytime symptoms

A 
sleepiness, fatigue
morning headaches
poor concentration
decreased libido/impotence
decreased attention
depression
decreased dexterity
personality changes
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22
Q

OSA risk factors

A 
Obesity
neck circumference over 40 cm
macroglossia
dental overjet and retrognathia
high/narrow hard palate
elongated/low lying uvula
enlarged tonsils, adenoids
crossbite/dental malocclusion
prominent tonsillar pillars
enlarged nasal turbinates
deviated nasal septum
narrow mandible
narrow maxilla
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23
Q

Central sleep apnea

A 
similar daytime symptoms to OSA
typically have history of:
- cardiac disease
- stroke
- opioid use
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24
Q

Restless legs syndrome features

Study These Flashcards
A

urge to move limbs often associated with paresthesias/dysesthesias
symptoms worse of present only during rest
partially/temporarily relieved by activity
nocturnal worsening of symptoms
Diagnosis usually made clincially, but may be confirmed through the Standarized Immobilization Test

25
Associated features of restless legs syndrome
response to dopaminergic therapy in almost all cases periodic limb movements occur during sleep/wakefulness in 80-90% of patients usually progressive with age no clear medical/physical pathology (primary form)
26
Demographics of restless legs syndrome
5-10% of adults of Northern European studies lower in Indian/Asian studies treatment typically sought after age 40 1.5-2x more common in women
27
Predisposing factors of restless legs syndrome
Fe deficiency peripheral neuropathy sedating antihistamines, dopamine antagonists, and most antidepressants (not buproprion) family affected in >50% increased risk (3-6x) in 1st degree relatives
28
Causes of secondary RLS
pregnancy --> dilutional anemia end-stage renal disease Fe deficiency (involved in dopamine synthesis?0 )
29
Treatment of RLS
``` underlying factors (anemia, renal disease, neuropathy) Medication options: - gabapentin, pregabalin - dopamine agonists - clonazepam - opioids in very severe cases ```
30
Periodic limb movement disorder essential features
EMG from the polysomnogram demonstrates repetitive, highly stereotyped limb movements that meet recording criteria = inter-movement interval of 5-90 seconds PLM index exceeds 5/hour (children) and 15 (adults) clinical sleep disturbance or a complaint of daytime fatigue
31
Periodic limb movement disorder treatment
only if clinically indicated (clear sleep disruption) | same option as RLS
32
REM sleep behaviour disorder essential features
presence of REM sleep without atonia at least one of the folllowing: - sleep related injurious, potentially hazardous, or disruptive behaviours by history - abnormal REM sleep behaviours documented during PSG Absence of EEG epleptiform activity during EEG
33
Associated features of RSBD
dream enactment typically occurs >90 min after sleep initaition episode ends when individual awakens quickly, becomes alert, and reports dream injury common secondary to violent dream enactment sleepwalking uncommon may have prodrome of sleep talking, yelling, twitching patients often present after injury to self or bed partner
34
RSBD onset/course
gradual/rapid onset, progressive delayed emergence of neurodegenerative disorder is very common (2/3 later develop Parkinson's) can be simply a symptom of narcolepsy
35
RSBD pathology
alpha-synucleinopathy | protein aggregates in vulnerable populations of neurons and glial cells
36
Predisposing/precipitating factors of RSBD
underlying neurological disorder, especialyl alpha-synucleinopathies (Parkinson's LBD, multiple system atrophy) narcolepsy stroke medications/withdrawal
37
Management of RSBD
safety first - remove obstacles, etc | Medication - best evidence clonazepam, effective in preventing violent dream enactment in most cases
38
Sleep and AD
disruption common in AD (19-44%) Related to patient institutionalization Negative impact on patient and caregivers' QOL
39
Better management of sleep in AD
priority for improving comprehensive management of patients with AD No long-term data no data on behavioural interventions
40
Features of sleep in AD
``` similar to but worse than disturbances seen in non-dementing elderly increased freq/duration of awakenings increased stage I decreased stage III, REM sleep increased daytime napping sleep disturbances associated with: - increased memory/functional impairment - more rapid cognitive decline More severe in more demented patients ```
41
Mechanism of sleep disturbance in AD
Loss/damage to neuronal pathways that initiate and maintain sleep Degenerative changes in brainstem regions/pathways that regulate sleep-wake cycles Changes in cortical tissue that generate EEG low-wave activity during sleep Changes in hypothalamic-suprachiasmatic nucleus and other parts of the circadian timing system severe: day-night reversal occurs
42
Sleep apnea and AD
significant correlation between dementia and sleep apnea severity apnea associated with increased nocturia worsens with sedative medications
43
Sleep disturbance in AD treatments
Buspirone: anxiety/depressive SSRI: depressed/non-specific mood Agitation: benzo, anti-psychotic Insomnia:trazodone, zopiclone, benzodiazepines, use safest, most effective drug at lowest dose, short duration Watch out for side effects: falls, fractures, confusion, etc
44
Behavioural interventions in sleep disturbance in AD
no empirical studies in this population Physical environment/institutional routines reduce daytime napping address care-giver concerns about "upsetting routine"
45
Ideal hypnotic
``` rapid absorption short half-life no drug-drug interactions no tolerance to effect free from side effects (memory, psychomotor) no rebound cheap ```
46
Rebound insomnia
Transient exacerbation of insomnia commonly occurs when sedative/hypnotic medications are withdrawn
47
Sleep hygiene basic rules
sleep only as much as needed to feel rested, get out of bed keep regular sleep schedule avoid forcing sleep Exercise regularly >=20 min, preferably 4-5 hours befor bedtime avoid caffeinated beverages after lunch avoid alcohol near bedtime avoid smoking don't go to bed hungry adjust bedroom environment avoid prolonged use of light-emitting screens befoe bedtime stimulus control!!
48
Rx sleep onset insomnia
Short-acting Zaleplon, zolpidem, triazolam, lorazepam Ramelteon: melatonin agonist - more effective in sleep onset rather than sleep maintenance insomnia Adverse effects milder in melatonin agonists than benzodiazepines
49
Rx sleep maintenance insomnia
Longer-acting preferable Zolpidem extended release, eszopiclone, temazepam, estazolam, low dose doxepin - may increase risk for hangover sedation
50
Benzodiazepine MOA in insomnia
binds several subtypes of GABAa receptors reduce time to onset of sleep prolonged stage II prolong total sleep time may slightly reduce amount of REM decrease anxiety, impair memory, have anticonvulsive properties
51
Short acting genzo
triazolam
52
Intermediate acting benzo
estazolam lorazepam temazepam
53
Long acting benzo
flurazepam | quazepam
54
Nonbenzodiazepine receptor agonists
more targeted action at one GABA type A receptor greater specificity - less anxiolytic and anticonvulsant improve subject/veobjective sleep outcomes decrease sleep latency & number of awakenings, while improving sleep duration and sleep
55
Zaleplon
very short halflife effective for sleep-onset insomnia not indicated for long-term use
56
Zolpidem
1.5-2.4 half life for sleep onset insomnia not indicated for long-term use
57
Eszopiclone
longest half life of approved nonbenzos effective for both sleep onset/maintenance insomnia not limited to short-term use, little evidence for abuse/dependance
58
Zolpidem extended release
1.5-2.4 half life improve both sleep onset/maintenance insomnia without hangover effects not limited to short-term use, little evidence for abuse/dependence in most patients

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