sleep disorders Flashcards by caleb markusic

breathing related sleep disorders

Obstructive sleep apnea hypopnea
Central sleep apnea
Sleep related hypoventilation

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parasomnias

Non-rapid eye movement sleep arousal disorders

Nightmare disorder

Rapid eye movement sleep behavior disorder

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Subjective estimates of sleep duration and pattern tend to (overestimate, underestimate) degree of disturbance

overestimate

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t/f Transient insomnia very common (few nights) so the duration of the insomnia is very important to elucidate

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3 types of insomnia that need to be differentiated

For a formal diagnosis

) Difficulty initiating or
) maintaining sleep or
) early awakening and can’t fall back asleep

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how often must insomnia occur to be dx

who is it most common in

At least 3 nights a week for 3 months

More common in elderly, women, chronic medical problems, lower income, less education

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tx for insomnia disorder

Start with sleep hygiene measures

Sleep medications/hypnotics

combo works best

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why are benzo’s not first line for insomnia

tolerance

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name some non benzo’s that are commonly used

eszopiclone
ramelteon
zaleplon
zolpidem

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Targeted insomnia meds, have less day time sleepiness, less tolerance and less potential for abuse

zolpidem, eszopiclone, belsomra (suvorexant)

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Excessive daytime sleepiness/somnolence

Usually involves prolonged nocturnal sleep and continual daytime drowsiness

Often 1-2 long naps (1 hour) during the day

At least 3 nights a week for 3 months

Hypersomnolence Disorder

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A diagnosis of exclusion

Patients have diminished delta sleep (stage 3) and short latency to REM sleep (MSLT)

Hypersomnolence Disorder

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Hypersomnolence Disorder tx

No effective cure

Treatment is symptomatic
Sleep hygiene
Sleep therapy
Stimulants
Dextroamphetamine- short half-life

Methylphenidate- short half-life (3.6 hrs)

Take in multiple, divided doses throughout the day

Modafinil- usually used for narcolepsy, single dose in AM

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how can you estimate how long a drug will remain active

rules of 5

drug eliminated by 5x the half life

at 3 times the half life drug no longer having therapeutic effect

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Recurrent episodes of an irrepressible need to sleep

Sleep attacks (seconds to 30 minutes or longer) occur with one or more of the following: 
Cataplexy (long-standing versus new onset criteria)

CSF hypocretin (Orexin) deficiency

Nocturnal polysomnography with REM latency <15 min or a MSLT sleep latency less than 8 minutes

Narcolepsy Disorder

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does Narcolepsy Disorder have a known etiology

who is affected

Affects 1 in 2000, men and women equally represented, runs in families

One of the only diagnoses with known etiology

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narcolepsy tx

Stimulants
Dextroamphetamine- short half-life
Methylphenidate- short half-life

Take in multiple, divided doses throughout the day

Modafinil- single dose 200-400 mg in AM

Sodium oxybate is prescribed for cataplexy, can reduce frequency of episodes
Considerable social, occupational and mental support
Safeguards in place for travel/driving
May require naps during day at work to reduce symptoms

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what are the two definitions of cataplexy

1) long standing disease, brief sec to min episodes of b/l muscle tone loss. brought on by emotions
2) within 6 mo of onset, spontaneous grimaces or jaw opening episodes with tongue thrusting or global hypotonia w/o emotional triggers

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Most common breathing-related disorder

obstructive sleep apnea hypoapnea disorder

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what is Apnea

pause in breathing/breathing stops

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what is Hypoapnea

decrease in airflow during breathing

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t/f Patient usually unaware of these events on waking

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who is obstructive sleep apnea hypoapnea disorder most common in

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Most common in overweight, middle-aged and older adults

Obstructive Sleep Apnea Hypoapnea Disorder tx

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Obtain a sleep study

Weight loss

Sleep position training

CPAP (continuous positive airway pressure) device

Surgery to remove excess oropharyngeal tissue

Tracheostomy at extreme end of the spectrum

what do you aviod using with Obstructive Sleep Apnea Hypoapnea Disorder

Avoid sedative/hypnotic meds

There is no upper airway obstruction The pathophysiology in CNS control Brain fails to up-regulate breathing during periods of relative hypoxia Snoring is not uncommon Cheyne-Stokes and Opioid variants - Associated with heart failure, stroke, renal failure and chronic opioid use, respectively

Central Sleep Apnea Disorder

Central Sleep Apnea Disorder tx

Obtain a sleep study Treat underlying medical conditions CPAP Supplemental oxygen Adaptive servo ventilation (ASV)- provides positive expiratory airway pressure (EPAP) and inspiratory pressure support (IPAP), which is servocontrolled based on the detection of central sleep apnea

what do you avoid with Central Sleep Apnea Disorder

Avoid sedative/hypnotic meds

Decreased response to high levels of CO2 Frequent episodes of shallow breathing, >10 secs

Sleep-related Hypoventilation Disorder

t/f OSA and CSA may occur along with SHD

true

with sleep related hypoventilation Persistent hypoventilation may result in what????!!!

pulmonary hypertension, polycythemia, right heart failure

what is Sleep-related Hypoventilation Disorder associated with

Frequently associated with lung disease, neuromuscular disorders, chest wall disorders Patients often have headaches upon waking, insomnia, daytime sleepiness, etc.

Sleep-related Hypoventilation Disorder tx

Obtain a sleep study Treat underlying disorder For example, bronchodilators for patients with obstructive lung disease Supplemental oxygen But as underlying disorder progresses, may require more extreme support and ultimately mechanical ventilation/tracheostomy

what do you avoid in Sleep-related Hypoventilation Disorder

Avoid sedative/hypnotic meds

Circadian Rhythms Influenced/integrated by:

Light exposure Sleep wake/centers of the brain Genetics

Sleep disturbances from altered sleep-wake cycle May be delayed (night-owls) or advanced phase ”morning people” Or their schedule, job, other factors may interfere (shift-work), morning light exposure constantly “resets” their clock

Circadian Rhythm Sleep-Wake Disorders

t/f with Circadian Rhythm Sleep-Wake Disorders Sleep itself is of normal quality and patients can usually sleep enough if allowed to

Circadian Rhythm Sleep-Wake Disorders tx

Delayed sleep phase - Delay sleep on successive nights for 30 min to 3 hours unit full 24 hr period of wakefulness achieved. Then sleep at “normal” time. Shift work - stop working the night shift or there is an FDA approved stimulant drug, Nuvigil (armodafinil) Jet lag (not DSM-5) - Zolpidem or melatonin short term; keep normal sleep schedule if possible

Sleep walking and sleep terrors, usually during first 1/3 of major sleep episode Complex motor behavior without conscious awareness during NREM sleep, little to no memory

NREM Sleep Arousal Disorders

Sleep walking

very hard to arouse patient, blank stare, amnesia upon awakening. STAGE 3 NREM

Sleep terrors

partial arousal from delta sleep, usually with screaming in terror, motor activity, may not fully awaken and will not remember episode

Both are familial, most common in children, usually outgrown by adolescence

sleep walking, sleep terrors

NREM Sleep Arousal Disorders

Keep them safe!!! Identify triggers, stressors Avoid caffeine/alcohol Benzodiazepines promote stage 3 sleep TCAs, SSRIs and melatonin have been used but no controlled studies proving effectiveness Sleep hygiene

Vivid, terrifying dreams, usually focused on imminent threat to one’s survival Well-remembered, immediately alert after waking In children, they may not be able to distinguish between reality and the dream

Nightmare Disorder

what do you need to rule out with Nightmare Disorder

Rule out substance abuse, withdrawal, other mental illness

when does Nightmare Disorder occur

Usually occurs during 2nd half of a sleep period Usually occur during REM sleep

t/f Body movements and vocalizations are typical

f they are not typical

Nightmare Disorder tx

Treat underlying cause if clear - - EtOH withdrawal, benzodiazepine withdrawal Treat underlying mental illness - depression, trauma counseling Judicious use of hypnotics/sedatives

Arousal during sleep associated with vocalizations and/or complex motor movements Often dream of being attacked or escaping Can usually recall dream content Complex motor activity has the ability to cause injury to the patient or others, and often does

REM Sleep Behavior Disorder

when does REM Sleep Behavior Disorder occur

During REM sleep | Usually later in sleep cycle (> 90 minutes)

what is REM Sleep Behavior Disorder associated with

Association with PD, Lewy Body Dementia, and multiple system atrophy 50% of those presenting to sleep clinics will develop a neurodegenerative disorder

REM Sleep Behavior Disorder tx

Keep them safe!!! May have to have partners sleep in different rooms Identify triggers, stressors if possible TCAs, SSRIs and beta-blockers have been associated with this disorder, minimize/stop if possible Clonazepam is the drug of choice, but symptoms will often return if meds are stopped

drug of choice to treat REM Sleep Behavior Disorder

clonazepam

Desire to move legs associated with unpleasant sensations, tingling, “creeping, crawling” Symptoms at least 3x a week for 3 months Sensations and movements delay sleep or wake patients from sleep Movement of their legs relieves the unpleasant sensations

Restless Legs Syndrome

Restless Legs Syndrome tx

Dopamine agonists are mainstay: Ropinirole 0.25 mg -4.0 mg/day Pramipexole 0.125 mg -0.5 mg/day

what do you need to rule out for Restless Legs Syndrome

``` Rule out medical conditions such as: Leg cramps Positional ischemia/PAD Arthritis Myalgias Peripheral neuropathy ```

sleep disorders Flashcards

(56 cards)