sleep disorders

Question 1

Stage 0 sleep characteristics

Answer 1

Wakefulness w eyes closed just before sleep onset
EEG: alpha waves over occiput, decreases w inc drowsiness
Increase mm tone

Question 2

Stage 1 sleep characteristics

Answer 2

Sleep-onset or drowsiness, transition from wake to sleep
EEG: less than 50% alpha waves, mixed beta and theta waves
5% total sleep period

Question 3

Stage 2 sleep characteristics

Answer 3

EEG: theta waves, sleep spindles, and K complexes
K complex may represent CNS response to internal stimuli
Increased mm tone, no eye mvmts
45-55% total sleep time

Question 4

Stage 3 sleep characteristics

Answer 4

Slow wave or deep sleep
EEG: high-voltage delta waves
Increased mm tone, no eye mvmts
15-20% total sleep time

Question 5

REM sleep characteristics

Answer 5

EEG: similar to stage 1 (a waves)
Bursts of rapid conjugate eye movements, reduced mm tone, resp and cardiac rate fluctuations, penile or clitoral engorgement
20-25% total sleep time

Question 6

REM latency

Answer 6

Waking through NREM sleep, preceding REM sleep

Usually about 90 minutes

Question 7

Neurophysiological control of sleep

Answer 7

Pontine nuclei regulate REM sleep
Perilocus ceruleus inhibits motor activity
Inc ACh promotes REM
Dec DA, NE, 5HT a/w REM sleep
NREM sleep a/w dec ACh and adrenergic NTs, controlled by ventral arterial preoptic area

Question 8

Insomnia disorder criteria

Answer 8

1- dissatisfaction w sleep or sleep quality a/w 1+ of: difficulty initiating sleep, maintaining sleep, or early morning awakening (can't go back to sleep)
2- causes distress or impairment
3/4- at least 3 nights/w for 3 months
5- occurs despite opportunity for sleep
6/7/8- not d/t another d/o or substance

Question 9

Tx for insomnia d/o

Answer 9

Sleep hygiene- consistent schedule, avoid bed when not sleeping, don’t nap, exercise 3-4x/w, reduce EtOH, caffeine, nicotine, anxiolytics, and sedative hypnotics
Pharm: temporary use of sedative hypnotics, BZDs, z-drugs, chloral hydrate, antihistamines, trazodone, doxepin (TCA)

Question 10

Hypersomnolence disorder criteria

Answer 10

1- self-reported excessive sleepiness despite sleeping 7+ hours with 1+ of: recurrent periods of sleep w/i same day, unrestorative sleep 9+ h/day, difficulty feeling awake w abrupt awakening
2- at least 3x/w for 3 months
3- distress or impairment
4/5/6- not better explained by other condition or substance

Question 11

Sleep drunkenness

Answer 11

Excessive grogginess on awakening that may last several hours, experienced by up to 50% of hypersomnolence d/o patients

Question 12

EEG findings of hypersomnolence

Answer 12

Reduced REM latency, decreased delta sleep, increased # awakenings

Question 13

Tx of hypersomnolence d/o

Answer 13

Sleep hygiene, naps

Stimulant rx: dextroamphetamine, methylphenidate, modafinil

Question 14

narcolepsy criteria

Answer 14

1- recurrent periods of irrepressible need to sleep, falling asleep, or napping in same day for 3x/w for 3 mos
2- 1+ of: cataplexy (brief loss of mm tone after laughter/joking or spontaneous grimaces or jaw-opening episodes w tongue thrusting and global hypotonia w no emotional triggers), hypocretin deficiency (less than 1/3 normal), or REM sleep latency less than or = 15 min or MSLT shows mean sleep latency less/= 8 minutes

Question 15

narcolepsy epidemiology

Answer 15

1/2000 people, M=F

may be hereditary

Question 16

biology of narcolepsy

Answer 16

loss of hypothalamic hypocretin-producing cells -> CSF hypocretin-1 deficiency
*hypocretin regulates arousal, wakefulness, appetite

Question 17

tx for narcolepsy

Answer 17

stimulants- methylphenidate, dextroamphetamine, modafinil (minimal CV effects)
for cataplexy: sodium oxybate (CNS depressant, careful w EtOH), TCAs

Question 18

obstructive sleep apnea hypopnea cause

Answer 18

airway muscles relax and airway narrows, lowering blood oxygen, low O2 sensed by brain causes brief arousal from sleep

Question 19

obstructive sleep apnea hypopnea criteria

Answer 19

either:
1- evidence by polysomnography of 5+ obstructive apnea/hypopnea per hour of sleep and either nocturnal breathing disturbance (snoring, gasping, pause in breathing) or daytime sleepiness/fatigue not explained by other d/o
OR
2- evidence by polysomnography of 15+ obstructive apneas/hypopneas per hour of sleep regardless of other sx

Question 20

obstructive sleep apnea hypopnea clinical

Answer 20

middle aged-older adults, overweight people
sx: excessive daytime sleepiness, loud snoring, observed episodes of breathing cessation during sleep, abrupt awakening w shortness of breath, sore throat or dry mouth on waking, morning headache, difficulty staying asleep, difficult-to-control HTN

Question 21

tx for obstructive sleep apnea hypopnea

Answer 21

weight loss, avoid sedative-hypnotics, sleep position training (don’t sleep supine), oral appliances to keep airway opening
CPAP (continuous + airway pressure)
uvulopalatopharyngeoplasty if redundant oropharyngeal tissue
life-threatening or unresponsive: tracheostomy

Question 22

apnea and hypopnea definitions

Answer 22

apnea: pause in breathing
hypopnea: decrease in airflow during breathing

Question 23

central sleep apnea criteria

Answer 23

1- evidence by polysomnography of 5+ central apneas/hour of sleep
2- not better explained by another sleep disorder

Question 24

cause of central sleep apnea

Answer 24

idiopathic

medical: heart failure, stroke, renal failure - Cheyne-Stokes breathing (crescendo-decrescendo tidal volume variation)
* can also be d/t substance, like chronic opioid use

Question 25

central sleep apnea tx

Answer 25

similar to obstructive sleep apnea tx | also meds: acetozolamide, theophylline may be prescribed to stimulate breathing

Question 26

sleep-related hypoventilation cause

Answer 26

decreased response to CO2 during sleep, characterized by frequent episodes of shallow breathing lasting longer than 10 sec a/w lung disease or neuromuscular or chest wall disorders

Question 27

sleep-related hypoventilation criteria

Answer 27

1- polysomnography shows dec respiration a/w inc CO2 levels (or persistently low levels of O2 sats) 2- not better explained by another sleep d/o

Question 28

congenital central alveolar hypoventilation

Answer 28

rare congenital d/o in which individual presents in perinatal period w shallow breathing or cyanosis and apnea during sleep

Question 29

sleep-related hypoventilation sx

Answer 29

insomnia or excessive sleepiness, orthopnea, headaches on awakening may have consequences of ventilatory insufficiency: pulm HTN, cor pulmonale (RHF), polycythemia, neurocognitive dysfunction w progression, blood gas abnormalities may persist in wakefulness

Question 30

tx of sleep-related hypoventilation

Answer 30

correct underlying d/o theophylline (stimulate respiratory center and diaphragm contractility) avoid respiratory depressants (EtOH, BZDs) weight loss, including bariatric surgery if indicated some pts need ventilatory assistance

Question 31

circadian rhythm sleep-wake d/o criteria

Answer 31

1- persistent/recurrent pattern of sleep disruption d/t altered circadian system or misalignment w sleep-wake cycle required by environment or professional schedule 2- leading to excessive sleepiness, insomnia, or both 3- causes distress or impairment of functioning

Question 32

types of circadian rhythm sleep-wake disorders

Answer 32

``` delayed sleep type: "night owl" advanced sleep type: "morning people" irregular sleep-wake type: variable cycles non-24-hour sleep-wake type shift-work type ```

Question 33

tx for circadian rhythm sleep-wake d/o

Answer 33

delayed sleep type: delay sleep time by 30m-3h on successive nights, delay for almost 24 hours to induce sleep at acceptable time shift work: stop shift work or armodafinil (stimulant)

Question 34

non-rapid eye movement sleep arousal disorder criteria

Answer 34

1- recurrent episodes of incomplete waking from sleep during first 1/3 of major sleep episode, accompanied by sleepwalking or sleep terrors 2- no/little dream imagery recalled 3- amnesia for episodes 4- distress/impairment 5/6- not d/t substance or other condition

Question 35

sleepwalking

Answer 35

repeated episodes of rising from bed and walking about with blank, staring face; unresponsive to efforts by others to communicate or rouse from sleep occurs in stage 3 NREM sleep *onset in adults = search for specific etiology like breathing-related sleep d/o, nocturnal seizures, or med effect

Question 36

sleep terrors

Answer 36

recurrent episodes of abrupt arousal from sleep, usually w panicky scream, intense fear and signs of arousal (sweating, rapid breathing, tachycardia, mydriasis); relative unresponsiveness to attempts to comfort individual *usually no recall of event upon awakening

Question 37

tx for NREM sleep arousal d/o

Answer 37

BZDs - suppress stage 3 sleep, dec sleepwalking and sleep terrors TCAs, SSRIs, melatonin better sleep hygiene *protect from injury by installing alarms, staying on first floor, latching windows, removing breakables from room

Question 38

nightmare d/o criteria

Answer 38

1- repeated episodes dysphoric and well-remembered dreams involving threat to security, survival, or physical integrity usually occurring during second 1/2 major sleep episode 2- rapidly oriented and alert on awakening 3- distress or impairment 4/5- not d/t substance or other condition

Question 39

causes of nightmares

Answer 39

``` febrile illness and delirium in elderly and chronically ill drug withdrawal (esp BZDs; barbs or EtOH d/t inc REM; SSRIs) ```

Question 40

tx nightmare d/o

Answer 40

treat underlying mental illness if present | counseling or short-term use sedative hypnotics if d/t psychologically traumatic events (MVA, sexual assault)

Question 41

REM sleep behavior d/o criteria

Answer 41

1- repeated episodes of arousal during sleep w vocalization or motor behaviors 2- occurs during REM sleep (after 90 m sleep onset), more frequent later in sleep, not common in daytime naps 3- upon awakening, not confused or disoriented; alert and completely awake 4- either REM sleep w/o atonia or established synucleinopathy dx (PD, multiple system atrophy) w consistent hx 5- distress/impairment 6/7- not d/t substance or other condition

Question 42

causes of REM sleep behavior d/o

Answer 42

relationship w neurodegenerative d/o (PD, Lewy body dementia, multiple system atrophy) also w TCAs, SSRIs, SNRIs, BBs - these may just unmask underlying condition and not be a true cause

Question 43

tx REM sleep behavior d/o

Answer 43

clonazepam may be effective | protect dreamer and bed partner by sleeping in separate rooms

Question 44

restless leg syndrome criteria

Answer 44

1- urge to move legs d/t unpleasant sensations: worse at periods of rest, partially/totally relieved by mvmt, and worse in evening/night or only occurs at evening/night 2- 3x/w for 3 months 3- distress or impairment 4/5- not d/t substance or other condition

Question 45

mimics of restless leg syndrome

Answer 45

cramps, positional discomfort, arthralgia, arthritis, myalgia, positional ischemia, leg edema, peripheral neuropathy, radiculopathy, habitual foot tapping

Question 46

tx restless leg syndrome

Answer 46

DA agonists: pramipexole, ropinirole

Question 47

possible causes of restless leg syndrome

Answer 47

1- low Fe w/o anemia, low ferritin (less than 50 ng/mL) 2- pregnancy 3- neuro lesion - SC or peripheral nerve lesion, degenerative disk disease 4- uremia 5- drug-induced