Sleep Meds Final

Question 1

Sleep disorders are more common in?

Answer 1

Women and older patients

Question 2

One theory on sleep disturbance is increased ______ activation (i.e. ____, ____, ____, ___)

Answer 2

physiological

• cardiac
• metabolic
• hormone
• EEG

Question 3

Sleep disturbance may also arise from increased activation of the _____.

Answer 3

Hypothalamus

Question 4

Risk factors for sleep disturbance include

Answer 4

Older age
female
previous insomnia
FH insomnia
-predisposed to waking easily

Question 5

Psychiatric disorders associated with sleep disturbance

Answer 5

depression
anxiety
substance use disorder
PTSD

Question 6

Pulmonary diseases linked to insomnia

Answer 6

chronic pain
CHF
Parkinson dz
HTN

Question 7

Meds that can cause insomnia

Answer 7

CNS stimulants i.e. caffeine, cocaine, modafinil

• appetite supressants
• antidepressants (MAOIs, some SSRI esp. prozac/wellbutrin is a DNRI
• Glucocorticoids
• Beta blockers
• alcohol
• nicotine

Question 8

What can beta blockers cause that can produce sleep disturbance?

Answer 8

Sleep-onset insomnia, vivid dreams and increased awakening

Question 9

Two main types of insomnia?

Answer 9

Short term < 3 mos

Chronic >/= 3X/week and >/= 3 mos

Question 10

Short term insomnia can also be termed…

Answer 10

Adjustment/acute insomnia

Question 11

Clinically insomnia is classified as taking >/= ___ minutes to fall asleep or spend >/= ___ minutes awake during the night, or wake up >/= ___ minutes prior to desired time.

Answer 11

30, 30, 30

Question 12

What is the first line therapy for insomnia?

Answer 12

CBT-I

Question 13

What are the behavioral components of CBT-I?

Answer 13

• stable bedtime 7 days/wk
• only stay in bed while sleeping or sex
• get out of bed if not sleepy

Question 14

How do you evaluate insomia?

Answer 14

1. Detailed sleep hx & sleep diary
2. Screening tools i.e. Pittsburg sleep quality index
3. Sleep problem questionnaire
4. Ddx

Question 15

Tx for acute?

Answer 15

1. Discuss the stressors

2. +/- short-term intermittent use of sedative (up to 4 wks)

Question 16

List of benzos

Answer 16

Estazolam
flurazepam
lorazepam
temazepam
triazolam

Question 17

List of non benzos

Answer 17

Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopicline (Lunesta)

Question 18

What is the cognitive aspect of CBT-I

Answer 18

treat:
- anxious thoughts about sleeplessness
- inappropriate expectations about hours of sleep
- misbeliefs about the effects of sleeplessness
- relaxation through mindfulness, progressive muscle relaxation and meditation

Question 19

What is the concern with chronic use of sedatives for chronic insomnia?

Answer 19

• abnormal thinking
• behavioral changes
• CNS depression
• rx abuse
• increase sleep-related activities i.e. sleep driving or eating

Question 20

Non controlled meds for insomnia?

Answer 20

Melatonin
Trazodone (off label antidepressant)
Doxepin (Silenor [TCA])
Suvorexant (Belsomra) >orexin receptor antagonist

Question 21

What meds do you want to avoid for insomnia

Answer 21

Antipsychotics
Benadryl
Barbiturates
Alcohol

Question 22

Sequelae of insomnia

Answer 22

Adverse cardiac outcomes from SNS activation i.e. HTN/MI

• Increased SI
• Self medication/substance abuse

Question 23

Narcolepsy is daytime sleepiness with:

Answer 23

Cataplexy (type I with, type II without)

• Hypnagogic hallucinations
• sleep paralysis
• sleep attacks

Question 24

When does narcolepsy usually begin?

Answer 24

Teens - early 20s
M=F
1 in 2000 people

Question 25

Pathophysiology behind narcolepsy?

Answer 25

Loss of orexin-A & orexin-B

Question 26

What the hell is orexin?

Answer 26

released during wakefulness and increase activity of brain regions that keep a person awake

Question 27

Clinical features of narcolepsy

Answer 27

- fall asleep at inappropriate times without warning (sleep attack) - sleepiness improves with nap - usually feel rested in morning - Epworth score >15 - sleep paralysis - hypnagogic hallucinations

Question 28

How to eval narcolepsy

Answer 28

1. Sleep study (polysomnogram) showing spontaneous awakening, reduced sleep efficiency, increased light non-REM sleep - Enters REM sleep quickly w/in 15 min (normal takes 80-100 min) 2. Multiple sleep latency test (falls asleep in < 8 min, normal is 10-15 min) - naps often include REM sleep (>/= 2 naps with REM essential feature of narcolepsy)

Question 29

Non-Rx tx of narcolepsy

Answer 29

1-2 20 min naps/day (around 1 pm best, can reduce sleepiness up to 3 hrs) - maintain regular sleep schedule - avoid alcohol/benzos/opiates - psychosocial support

Question 30

1st line rx for narcolepsy

Answer 30

Modafinil (Provigil) -does not affect sleep s/e: HA, nausea, dry mouth, anorexia, diarrhea

Question 31

2nd line meds for narcolepsy include

Answer 31

Stimulants i.e. ritalin/concerta/amphetamines * s/e: HTN, HA, sudden death, dependency - Newly approved last 2019 solriamfetol

Question 32

What is the narcolepsy medication that has to be taken QHS then 2.5-4 hrs later?

Answer 32

Sodium oxybate (liquid) show results in few days but up to >3 mos for full effect * s/e: weight loss, dizzy, mood swings, worsening depression * overdose potential with respiratory depression

Question 33

What is the most common sleep-related breathing disorder?

Answer 33

OSA

Question 34

Risk factors for OSA

Answer 34

``` getting old M>F Obesity Got a weird face or airway nasal congestion ```

Question 35

What does OSA cause at a cellular level?

Answer 35

Gas exchange disturbances (hypercapnia and hypoxia)

Question 36

Some maybe not so normal sxs of OSA

Answer 36

morning headaches

Question 37

PE findings that might lead you to evaluate OSA

Answer 37

Obesity Crowded airway (Malompati score) Big ol' neck HTN

Question 38

How to dx OSA

Answer 38

First-line is in lab sleep study or secondary home sleep apnea testing (HSAT)

Question 39

Sleep study diagnostic criteria for positive OSA

Answer 39

Need an AHI (apnea hypopnea index) of 5 or more (AHI of 15 diagnostic on its own) per hour AND at least one of these (no shit criteria) - sleepy, fatigue, insomnia - wake up choking/gasping - chronic snoring/apnea observed by partner - HTN, mood disorder, cognitive dysfunction, CAD, CVA, CHF, AF, DM2

Question 40

Complications of OSA besides the obvious

Answer 40

``` MVAs Metabolic syndrome DM2 Perioperative complications NAFLD 2-3 fold increase in all cause mortality ```