Sleep/Wake Disorders Flashcards
(104 cards)
1
Q
2 types of primary sleep disorders according to DSM-5?
A
- dyssomnias
- parasomnias
2
Q
What is the most common dyssomnia?
A
primary insomnia
3
Q
What kind of sleep disorder are nightmares, sleep terrors, and sleepwalking?
A
parasomnias
4
Q
2 major phases of sleep cycle?
A
- REM (25%)
- NREM (75%)
5
Q
How long is is one sleep cycle?
A
70-120mins
6
Q
Which NREM stage is a transition to sleep (0.5-7mins), low voltage EEG?
A
stage 1
7
Q
Which NREM stage is associated with sleep spindles 10-16Hz EEG?
A
stage 2
8
Q
Which NREM stage has high amplitude slow waves?
A
stage 3 and 4
9
Q
Which sleep phase is low voltage, mixed frequency?
A
REM
10
Q
How many sleep cycles/night?
A
4-6
dreams occur in the last part
11
Q
Which neurotransmitter in the locus ceruleus maintains normal sleep pattern, causing increased activity and decreased REM sleep?
A
NE
12
Q
5 brain regions involved in NREM?
A
- hypothalamus
- basal forebrain
- thalamus
- medulla
13
Q
Cholinergic cells in what three areas affect REM?
A
- mesencephalic
- medullary
- pons
14
Q
Which neurotransmitter is involved in sleep regulation?
A
serotonin
15
Q
Does a decrease in 5HT/dorsal raphe damage increase or reduce sleep?
A
reduce
16
Q
Which neurotransmitter has an alerting effect?
A
dopamine
increase causes wakefulness, decrease causes sleepiness
17
Q
The DSM5 describes primary insomnia as difficulty falling asleep, maintaining sleep, or non restorative sleep for at least ___ months and ___ nights/week.
A
3, 3
18
Q
6 Pharmacological causes of insomnia?
A
- anticonvulsants
- central adrenergic blockers
- diuretics
- SSRIs
- steroids
- stimulants
19
Q
What sleep agent was removed by the FDA?
A
L-tryptophan
caused 27 deaths to eosinophilia-myalgia
20
Q
Diphenhydramine is a potent inhibitor of what CYP?
A
2D6
21
Q
How long does it take for max diphenhydramine sedation?
A
1-3hrs
duration of sedation: 3-6hrs
22
Q
Which non-benzo is the oldest agent metabolized to trichloroethanal with a half life of 8hrs?
A
chloral hydrate
REM/NREM not markedly altered
23
Q
What kind of agents are glutethimide, methyllprylon, and ethchlorvynol?
A
barbiturate-like agents
24
Q
Low dose __ 3-6mg is FDA approved for insomnia maintenance?
A
doxepin
25
Sleep apnea pts that are still sleep with CPAP can be given what two drugs?
- modafinil
| - armodafinil
26
Venlafaxine, fluoxetine, sodium oxybate, imipramine, protriptyline, or selegiline are given for narcolepsy, excessive daytime sleepiness or sleep paralysis/cataplexy/hypnagogic hallucinations?
sleep paralysis/cataplexy/hypnagogic hallucinations
27
What is given if no adequate response to initial short term insomnia Tx?
- trazodone
- different BZDRA
- suvorexant
28
3 Tx options for jet lag (circadian rhythm disorder)?
- short acting benzo
- ramelteon
- melatonin
29
Zolpidem is metabolized by what CYP?
3A4
interactions with ketoconazole and rifampin; no interactions with cimetidine
30
Does zolpidem cause tolerance?
no
no tolerance, no rebound insomnia, no next day psychomotor activities
31
___ binds to the BZ-1 receptor producing minimal anxiolytic effects and no muscle relaxant and antiepileptic effects?
zolpidem
32
Duration of zolpidem?
6-8hrs
33
Should zolpidem be taken with food?
no
decreases AUC, take on empty stomach
34
Do women or men need lower zolpidem doses?
women
50% lower than men
CYP3A4 activity lower in women, but this is one of few drugs shown to have PK difference
pronounced PD effects
35
Which Z drug is metabolized by aldehyde oxidase?
zaleplon
duration only 4-5hrs
36
What effect do cimetidine and rifampin have on zaleplon?
cimetidine: increases Cpss
rifampin: decreases Cpss
37
Which Z drug binds to GABA receptor allosterically close to benzo receptors?
eszopiclone
38
Eszopiclone is metabolized by what two CYPs?
- 3A4
| - 2E1
39
Which Z drug causes unpleasant taste, HA, and sedation?
eszopiclone
40
Eszopiclone is FDA approved for up to __ months
6
41
What is eszopiclone dose for elderly pts?
< 2mg
42
What nonbenzo is a melatonin receptor agonist with one active metabolite?
ramelteon (Rozerem)
43
Which sleep drug should be dosed carefully in pts with liver problems, but not renally impaired pts?
ramelteon
metabolized by CYP1A2, 2C, and 3A4
44
Ramelteon recommended dose is __mg and take within __ mins of bedtime.
8, 30
45
Should ramelteon be taken with food?
no
increases AUC 31%
decreases Cmax 22%
delay of Tmax by 45mins
46
What drug causes a 190 fold AUC increase and 70 fold Cmax increase in ramelteon?
fluvoxamine
47
Benzos increase what sleep stage?
stage 2
48
Benzos decrease the durations of what sleep stages?
1, 3, 4
49
Typical use FDA approved duration of benzos for sleep is __ to __ days.
14, 28
50
How should benzos be taken for transient insomnia?
3-4 nights/week for 3-4 weeks
stressors > 1 week
51
5 FDA approved benzos for sleep?
- estazolam
- eszopiclone
- flurazepam
- quazepam
- temazepam
52
3 flurazepam metabolites?
- desalkyl (up to 100hrs half life)
- hydroxyethyl
- aldehyde
53
Which orexin receptor antagonist decreases hyperarousal and improves sleep?
suvorexant
54
Stay in bed how long with suvorexant and lemobrant?
7hrs
take 30mins before sleep
55
Do obese women have higher or lower suvorexant AUC?
higher 46%
56
Do not take > __mg of suvorexant.
20
57
Avoid strong/moderate CYP__ inhibitors with lemobrant?
3A4
max 5mg dose with weak 3A4 inhibitors
58
Orexin antagonists should be used with caution in __ pts
narcolepsy
59
Primary hypersomnia is excessive sleepiness for at least ___, prolonged sleep episodes or daytime sleepiness almost daily.
1 month
60
Primary hypersomnia is average sleep time of > __hrs
9
evaluate over 10-14 days
61
What is Kleine-Levin syndrome?
primary hypersomnia
sleep as along as 18020hrs/day
usually in males
62
Treatment with ___ is effective in 3/4 of Kleine-Levin syndrome
stimulants
63
Mild sleep apnea AHI?
5-15/hr
64
Moderate sleep apnea AHI?
15-30/hr
65
Severe sleep apnea AHI?
> 30/hr
66
Severe obstructive sleep apnea is > __ apneas/hr and excessive daytime sedation.
20
moderate: 5-10 apneas/hr
67
For obstructive sleep apnea avoid all CNS depressants except possibly __
zaleplon
68
__ is indicated for obstructive sleep apnea at 200-400mg/day
modafinil (Provigil)
69
What is treatment for central sleep apnea?
PAP and ventilatory O2
< 10%, temporary loss of respiration during sleep
70
3 drug choices for Tx of mild OSA?
- SSRIs (fluoxetine)
- clonidine
- TCAs (protriptyline)
71
Narcolepsy is sleep attacks __ times/week for at least __ months
3, 3
72
Narcolepsy:
__ is brief seconds-minutes sudden bilateral loss of muscle tone with consciousness precipitated by laughter or joking
cataplexy
73
Narcolepsy is hypocretin < __ pg/mL
110
74
EEG narcolepsy is sleep latency REM < __mins
15
75
What chromosome is associated with narcolepsy?
4P13-q21
76
What HLA antigen is associated with narcolepsy?
Dq6/DQB1
| DR2
77
In narcolepsy the neuropeptide orexin (hypocretin) is found only in the posterior or lateral __
hypothalamus
78
Do increased or decreased levels of orexin cause sleepiness?
decreased orexin = sleepy
79
What drug was used to treat canine narcolepsy/cataplexy?
venlafaxine
80
Narcolepsy daytime sleep attacks last up to ___ mins
30
84% occur before age 30
81
Narcolepsy:
Sleep paralysis occurs during falling asleep and upon awakening and lasts up to __ mins
10
82
Narcolepsy:
__ hallucinations occur when falling asleep and are usually visual, but can be auditory/tactile and bizarre?
hypnagogic
occur weekly
83
Narcolepsy:
__ hallucination occur upon awakening and last < 10 mins
hypnopompic
84
What is gamma-hydroxybutyrate a Tx for?
narcolepsy
85
Narcolepsy:
All stimulants are ineffective for ___ symptoms.
cataplectic
86
What is the least sedating agent for cataplexy?
protriptyline
87
___ is effective for hypersomnia and cataplexy
selegiline
88
What SNRI is used for cataplexy?
venlafaxine
89
The FDA approved ___ in 2002 in oral solution (CIII) for excessive daytime somnolence?
sodium oxybate
90
Is GHB Cmax higher or lower with food?
lower
70% higher Cmax while fasted
91
Which narcolepsy drug has risk management program?
GHB
orphan and FDA worked out a system to minimize diversion
92
GHB risk management program MDs are allowed to write for __ months and reevaluate pts. Refills for only __ months.
3, 3
93
What type of dyssomnia is common among the blind and pts with traumatic brain injury?
non-24hr sleep wake type
94
What MT1/MT2 receptor agonist is used to treat non-24hr sleep wake type dyssomnia?
tasimelton
95
Should tasimelton be taken with food?
no
96
Tasimelton is metabolized by what 2 CYPs?
- 1A2
| - 3A4
97
What is Ekbon's syndrome?
restless legs syndrome (dyssomnia)
98
___ are defined as acute, episodic, and physical phenomena occurring during sleep.
parasomnias
99
Somnambolism (parasomnia) occurs within first ___ hours of sleep
3
100
Are violent behaviors associated with somnambolism/
no
101
Are violent behaviors associated with sleep terrors?
yes
102
3 things used to Tx sleep related eating disorder?
- opiates
- dopaminergic agents (L-dopa)
- topiramate
103
Parasomnias are often self limiting.
a. true
b. false
a. true
104
What are the two most common Sx found in persons with narcolepsy?
- daytime sleepiness
| - cataplexy
