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CDM 4 Exam 2 > Sleep Disorders > Flashcards

Sleep Disorders Flashcards

(89 cards)

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1
Q

Sleep architecture

A

The basic structural organization of sleep, taking into account REM and NREM sleep as well as the different stages of sleep

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2
Q

NREM sleep

A

Non-rapid eye movement sleep. Divided into stages 1 through 4 each associated with a characteristic brain activity, where 1 is the lightest stage of sleep and 4 is the deepest stage of sleep

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3
Q

REM sleep

A

Rapid eye movement sleep. Most often associated with dreams

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4
Q

Stage 1

A

Transition between wake & sleep
Where sleep begins, over 15-30 min
Reduced muscle tone, eye movements and brain activity
Little stimulus required to wake

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5
Q

Stage 2

A

Makes up ~1/2 of total sleep time
Eye movement & muscle activity stop
Larger stimulus required to wake

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6
Q

Stage 3

A

similar to 4 but with less delta wave sleep
3-8% of sleep
deep sleep begins

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7
Q

Stage 4

A

similar to 3 but with more delta wave sleep
10-15% of sleep
Arousal threshold highest here

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8
Q

most restorative sleep

A

stage 3 and stage 4

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9
Q

REM sleep

A

when dreams occur
generalized muscle atonia
bursts of rapid eye movements
fluctuations in respiratory and cardiac rate

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10
Q

Sleep Cycle

A

6-9 hours/night
onset: 15-30 minutes
Most experience in order stages 1->2->3->4-> REM

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11
Q

Each cycle lasts

A

90-110 minutes

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12
Q

Age-related sleep changes

A

children need more sleep than adults
older adults get less deep sleep –> less stage 3 and 4

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13
Q

insomnia definition

A

The subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime sleepiness

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14
Q

Sleep promoting substances

A

GABA (inhib)
Adenosine (inhib)
Melatonin

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15
Q

Wake promoting substances

A

NE
ACh
Histamine
5-HT
DA
orexin

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16
Q

insomnia risk factors

A

Women

Advancing age

Comorbid conditions

Medications (stimulants, alcohol/opiates withdrawal, corticosteroids)

Stressors

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17
Q

Primary insomnia

A

No clear cause; abnormality of sleep-wake cycle or circadian rhythm

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18
Q

secondary insomnia

A

predisposing factors
precipitating factors
perpetuating factors

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19
Q

Predisposing factors

A

Factors that increase risk for insomnia disorder

History of childhood or interpersonal trauma
Chronic mental health conditions, depression, or anxiety
History of shift work or erratic sleep-wake patterns
Chronic pain conditions

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20
Q

precipitating events

A

Events that lead to sleep disruption

Severe accident leading to physical injury
Divorce or death of a spouse or close family member
Change in occupation such as loss of a job or transition to a new job

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21
Q

Perpetuating factors

A

Behavioral and cognitive factors that sustain poor sleep over time

Watching television in bed while trying to fall asleep
Staying in bed for extended periods of time in an effort to obtain more sleep or taking long naps during the day
Anxiety and worry about sleep loss

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22
Q

Secondary insomnia: comorbid conditions

A

Angina, arrhythmia, CHF
itchy skin conditions
DM, hyperthyroidism, menopause
GERD
Delirium, brain injury
Pregnancy, chronic pain
anxiety, bipolar,PTSD, OCD, SUD
Asthma, sleep apnea, COPD
Restless leg
BPH, overactive bladder

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23
Q

Secondary insomnia: medications/substances

A

Anticonvulsants
Stimulants
Antidepressants
Diuretics
Central adrenergic blockers
Corticosteroids
Opioids
Substance withdrawal

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24
Q

Short term insomnia

A

days-weeks (less than 3 months)
identifiable stressor

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25
Chronic insomnia
Insomnia occurring ≥ 3 nights/week; present for ≥ 3 months
26
Initial insomnia
Difficulty falling asleep Increased time (> 30 min) to sleep onset (sleep latency)
27
Middle insomnia
Difficulty maintaining sleep Frequent awakenings during the night
28
Terminal insomnia
Early morning awakening Total sleep time < 6h Common in depression
29
Excessive daytime sleepiness & non-restorative sleep
Results in fatigue throughout the day
30
Insomnia DSM 5
primary unsatisfying sleep quality/quantity occurring ≥ 3 nights/week; present for ≥ 3 months
31
Episodic insomnia
lasts 1-3 months
32
Persistent insomnia
lasts ≥ 3 months
33
Recurrent insomnia
≥ 2 episodes/year
34
Insomnia complications
Distractibility Poor attention span Poor motivation Irritability Low frustration tolerance Depression Anxiety Workplace and/or fatal injuries Work Absenteeism Reduced perception of QAL
35
Screening/monitoring
Sleep diary, sleep history, questionnaires
36
insomnia diagnosis
Physical exam Lab: TSH, ferritin, toxicology Sleep studies - polysomnography (OSA), Actigraphy (CRSWD), Multiple sleep latency test: Narcolepsy
37
insomnia treatment goals
Correct underlying sleep complaint Improvement in sleep quality and/or time Improvement of insomnia-related daytime impairments such as improvement of energy, attention or memory difficulties, cognitive dysfunction, fatigue, or somatic symptoms Avoid adverse effects from therapies
38
CBT
Education, cognitive therapy, behavioral therapy
39
Brief therapies for insomnia (BTI)
smaller shorter version of CBT includes education about sleep, focuses on stimulus control, and sleep restriction
40
non pharm for insomnia NOT RECOMMENDED
acupuncture exercise tai chi yoga phototherapy
41
CBT-I Education
Enhance patient understanding of normal sleep and the behaviors that affect sleep
42
CBT-I Sleep hygiene principals
Reduce practices/ behaviors which may increase arousal or interfere with sleep drive set regular bedtime/wake-up time avoid napping minimize non sleep activities in bedroom avoid watching tv/ phone in bed exercise but not late avoid drinking lots of fluids in the evening
43
CBT-I Cognitive therapy
Change dysfunctional beliefs about sleep Reduce anxiety surrounding sleep Confront the fear of not sleeping
44
CBT-I Stimulus control therapy
Reduce stimuli that increase arousal in sleep environment before and during sleep; associate the bed with sleep only go to bed when tired over use bed for sleep avoid naps avoid screens right before bed set alarm same time every morning
45
CBT-I relaxation training
Reduce physiologic/cognitive/emotional/physical tension prior to bed Deep breathing, mindfulness
46
CBT-I Sleep restriction therapy
To increase sleep efficiency and reduce sleep latency; stabilize circadian rhythm Start by limiting time in bed to 6 – 7 hours/night Gradually increase or decrease time in bed by 15 min increments
47
Avoid sleep restriction therapy in patients with h/o
epilepsy bipolar OSA sleepwalking disorders
48
CBT-I Somryst
FDA Approved, prescription-only digital CBT-I in patients 22+ years of age with chronic insomnia App that has CBT-I modules focused on sleep restriction and consolidation
49
Who can use Somryst
Pts ≥22 YOA with chronic insomnia Have access to a mobile device (e.g., smart phone or tablet) to access the app Is familiar with how to use mobile apps Have access to internet to allow you to periodically upload data to the app Is able to read and understand English for the app Is under the supervision of a Health Care Provider
50
Who shouldn't use Somryst
Pts with any disorder worsened by sleep restriction (e.g. bipolar disorder, schizophrenia, other psychotic spectrum disorders) Pts with untreated obstructive sleep apnea Pts with parasomnias Pts with epilepsy Pts who are at high risk of falls Pts who are pregnant Pts with any other unstable or degenerative illness judged to be worsened by sleep restriction delivered as part of Cognitive Behavioral Therapy for Insomnia
51
Pharmacologic options for insomnia
OTC agents (1st gen antihistamines, valerian, L-tryptophan) Melatonin receptor agonists BZD Z-Drugs Sedating antidepressants Orexin antagonists
52
1st gen antihistamines MOA
Non-selective histamine antagonist; “antihistamine” Cross blood-brain barrier --> binds to H1 (brain) & H2 (stomach) --> blocks histamine release --> promotes drowsiness
53
1st gen antihistamines ADE
Anticholinergic ADE (blurred vision, dry mouth, constipation, somnolence, dizziness, fatigue)
54
1st gen antihistamines DDI
Other anticholinergic agents, sedating agents, alcohol
55
1st gen antihistamines Precautions
CNS depression, BPH, glaucoma
56
1st gen antihistamines monitoring
Improved sleep, ADE
57
1st gen antihistamines pt education
Avoid activities requiring mental alertness Likely to cause hangover feelings the next day
58
1st gen antihistamines clinical considerations
FDA-approved and OTC sensitivity in elderly and liver disease do not use for > 10 days Doxylamine safe in pregnancy
59
Do not use 1st gen antihistamines for more than ___ due to ___
10 days, tolerance
60
____ is a 1st gen antihistamine that is safe in pregnancy
Doxylamine
61
L-trypotphan/5-HTP
Metabolized into 5-hydroxytryptophan (5-HTP), then converted into serotonin, melatonin, and vitamin B6 HA,N/V/D, sedation found in egg whites, cheese, cod, soybean
62
Valerian
Binds to the beta subunit on the GABA-A receptor; increased GABA Morning drowsiness, HA, anxiety extract, infusion tea, tincture
63
OTC and herbal products
Tart cherry juice Magnesium Lavender Chamomile tea Alcohol Canabinoids
64
Melatonin Receptor Agonists MOA
light-induced activation of SCN prevents the production of melatonin by pineal gland
65
Melatonin
MT1, MT2 & MT3 receptor agonist Dizziness, nausea, headache, drowsiness CNS depressants Take 30 min before bedtime May be most helpful for pts with jet lag, delayed sleep phase syndrome or low endogenous melatonin May help with sleep onset
66
Ramelteon
MT1 & MT2 receptor agonist (more selective) GI upset, increase prolactin in women, decrease testosterone in men DDI: Substrate CYP1A2 (major)/3A4 (minor); contraindicated for use with strong CYP1A2 inhibitors (e.g., fluvoxamine) Take 30 min before bed avoid taking with high fat meal
67
BZD MOA
Non-selectively bind to GABAA interface between the α- and γ-subunits; GABA agonist
68
BZD Triazolam vs Temazepam
Triazolam --> hepatic metabolism, CYP3A4, short half-life, good for sleep onset Temazepam --> conjugation metabolism, long half-life, good for onset and maintenance
69
BZD precautions
Do not use for more than 7-10 days tolerance will develop ~4 weeks
70
BZD clinical considerations
increase risk of fall in elderly avoid in pregnancy, sleep apnea, SUD 7-10 days of use (no more)
71
Z- drugs MOA
Selective binding of GABAA a-1 subunit (the hypnotic subunit)
72
Z drugs
Zaleplon Zolpidem Eszopiclone (Lunesta)
73
Z drugs: Zolpidem
higher affinity for alpha-1 subunit women require lower starting dose
74
Lunesta
Max 2 mg in hepatic impairment or use with CYP3A4 inhibitors
75
Z drugs ADE
similar to BZD withdrawal risk present fatigue, dizziness, N/V, headache, somnolence Eszopiclone has unpleasant taste and headache
76
Z drug DDI
CNS depressants CYP3A4 Cimetidine increases zalepon Rifampin decreases zalepon
77
Z drug monitoring
ADE, sleep improvement, tolerance
78
Z drug patient education
devote ≥ 7-8 hours to sleep for zolpidem ER/lunesta Take on empty stomach
79
Z drug clinical considerations
possibly less tolerance & less rebound insomnia as compared to benzodiazepines Should limit to < 4 weeks to  risk of tolerance & dependence (eszopiclone FDA-approved for up to 6 months)
80
Sedating Anti-Depressants
Doxepin, Trazodone, Mirtazapine
81
Orexin Receptor Antagonists MOA
OX1R & OX2R receptor antagonist
82
Orexin Receptor Antagonists Agents
Suvorexant, lemborexant, daridorexant
83
Orexin Receptor Antagonists cautions
precaution in patients with depression CI in patients with narcolepsy CYP3A4 medications DDI hepatic considerations
84
Tiagabine
MOA: Inhibits GABA reuptake into presynaptic neuron (GAT-1 inhibitor) ADE: Abdominal pain, nausea, asthenia, ataxia, confusion, dizziness, nervousness, somnolence Take with food; avoid driving
85
Total Sleep time
Diphenhydramine Doxepin Eszopiclone Suvorexant Temazepam Tiagabine Trazodone Zaleplon Zolpidem
86
Sleep Latency
Everything but tiagabine
87
Waking after sleep onset
Diphenhydramine Doxepin Eszopiclone Suvorexant Temazepam Tiagabine Trazodone Tryptophan* Zolpidem
88
Sleep onset
Zaleplon Zolpidem SL/oral spray Triazolam Ramelteon
89
Sleep maintenance
Suvorexant Doxepin

CDM 4 Exam 2 (13 decks)

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