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30 Cards in this Set
- Front
- Back
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Describe RLS
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Restlessness and curious sensory disturbances lead to an irresistible urge to move the limbs, especially during relaxation
-disturbed nocturnal sleep and excessive daytime somnolesences may occur |
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Define U.R.G.E.
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U = Urge to move the legs, typically associated with discomfort in the legs
R = The symptoms are worse when the legs are at Rest G = Gets better when legs are in motion E = Evening time is associated with worse symptoms |
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Describe possible etiologies of RLS.
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-May occur as a primary or idiopathic disorder
-Also may occur in relation to pregnancy, iron deficiency anemia, peripheral neuropathy (especially uremic or diabetic) -possibly hereditary |
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Describe treatment for RLS
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- non-ergot dopamine agonists (ie- pramipexole)
- OR benzodiazepines (clonazepam) - Gabapentin may provide relief - opioids or levodopa are last resort treatments |
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Describe Periodic Limb Movement Disorder.
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Periodic Limb Movement Disorder (PLMD) requires
the documentation of PLMS in the presence of daytime neurocognitgive impairment or subjective sleep disruption. Periodic Limb Movements of Sleep (PLMS) is a polysomnographic finding of frequent leg movements during sleep -Leg movements are stereotyped & repetitive |
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Possible etiologies of PLMD and PLMS.
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-PLMS and PLMD may be associated with RLS, but may occur in isolation
-Also associated with iron deficiency and medications, similar to RLS |
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Treatment for PLMD?
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-Treatment options parallel those for RLS
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Describe Sleep related Bruxism.
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-Grinding or clenching of the teeth during sleep, causing…
-Disturbing sounds, which can disrupt bedpartner sleep quality -Abnormal tooth wear -Jaw pain or temporal headaches -Nonrestorative sleep |
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Causes of Sleep related Bruxism
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-Related to an exaggerated response to arousals from sleep
-Tobacco and caffeine use can exacerbate frequency or intensity of the episodes -Stress and anxiety also contribute to severity of symptoms |
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Treament options for sleep related bruxism
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-Dental mouthpieces (to protect against abnormal tooth wear)
-Dopaminergic agents may be of benefit -Clonazepam is often effective -Role of dental malocclusion corrective surgery is controversial |
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Describe sleep related rhythmic movement disorder and the various types.
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-Repetitive, stereotyped and rhythmic motor behaviors (not tremors) that occur during drowsiness or sleep involving large muscle groups
-Most common in infants and children, it can also be seen in adolescents and adults -Rhythmic humming or vocalizations may be heard -To be considered a disorder, the behavior must markedly interfere with normal sleep, cause daytime impairment, or result in injury Body Rocking Type Can involve the entire body, with child on hands & knees, may be limited to the torso (with child sitting) Head Banging Type Child is prone, repeatedly lifting head & upper torso, forcibly banging head back down into pillow or mattress Head Rolling Type Side to side head movements, usually with child in supine position |
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Describe treatment options for sleep related rhythmic movement disorders.
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-In most children, symptoms are likely to resolve before age 5
-Treatment is typically aimed at education & reassurance of the parents, and protection from injury -Some possible benefit from waterbed use! -If symptoms are severe, pharmacologic therapy may be needed (clonazepam? TCAs?) |
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Describe parasomnia conditions.
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-Undesirable physical events or experiences that accompany sleep
-Behaviors are “disconnected” from conscious awareness -May involve complex, apparently purposeful goal-directed behaviors |
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List some predisposing factors to REM Behavior disorder.
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Predisposing factors:
-Male>>Female -Over 50 years old Associated with Neurologic Disease: -Parkinson Disease -Dementia with Lewy Bodies -Narcolepsy Can be precipitated by medications Venlafaxine SSRI’s (particularly in narcolepsy patients!) |
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Describe and list some non-REM parasomnias.
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“Disorders of Arousal”
Typically involve partial awakenings from slow wave sleep Blurring of the sleep-wake border Confusional Arousals Sleepwalking Sleep Terrors Sleep Related Eating Disorder Sexsomnia Confusional Arousals Occurs following an arousal from slow wave sleep, typically in the first part of the night Mental confusion, disorientation Slow speech, blunted response to request: “Sleep Drunkenness” Inappropriate behavior can occur during forced awakenings Sleepwalking Confusional Arousal + Ambulation Eyes typically open, but glassy or blank stare is noted Patient is confused if forcibly awakened, typically amnestic for the episode Inappropriate behavior may be hazardous (eg: driving, climbing out a window) or have disastrous interpersonal effects (sexual, violent) Family history is common Consider other factors which can lead to inappropriate arousals from sleep (eg: apnea, PLMD) and treat appropriately Focus on personal / cohabitant safety Locks on doors No access to weapons Drug therapy is typically benzodiazepine-based (clonazepam, others) Sleep Terrors Arousals from slow wave sleep accompanied by a cry or piercing scream Intense autonomic activation, with tachycardia, flushing, sweating, and increased muscle tone Can be associated by prolonged inconsolability Patient is usually amnestic for the event, but sometimes dream fragments can be recalled Sleep Related Eating Disorder Sexsomnia |
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List 3 types of REM related parasomnias.
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-REM-Behavior Disorder
-Recurrent Isolated Sleep Paralysis -Nightmare Disorder |
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What should you rule out when you suspect REM behavior disorder.
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OSA
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Describe REM behavior disorder.
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-Abnormal presence of ability to move volitional muscles during REM sleep.
Polysomnogram will reveal a lack of REM-related atonia on EMG -Patients “act out” dream content, which typically has a high action component -Protection of spouse or home is common theme -Eyes usually remain closed -Spouse can be injured during “rescue” attempts -High risk of personal or bedpartner injury |
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Describe Recurrent isolated sleep paralysis
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-Awakening from sleep with inability to move skeletal muscles
-Patient is often intensely afraid -Hallucinations: visual, tactile, auditory, formed or abstract; sense of evil presence in the room -Dyspnea/breathlessness, sense of weight or heaviness in chest -Excessive daytime sleepiness and cataplexy (symptoms of narcolepsy) are not present -Many people experience sleep paralysis, but frequent episodes are relatively rare -Can occur once in a lifetime or many times a week -Can be precipitated by stress, sleep deprivation, alcohol -Treatment usually aimed at education, elimination of known precipitants. SSRI’s may be of benefit in severe cases. |
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Describe REM related nightmare disorder
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-Recurring episodes of awakenings from sleep with recall of intensely disturbing dream content
-Full alertness on awakening -Delayed return to sleep -Can be associated with traumatic experience (PTSD) |
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List some possible different diagnoses for a patient with parasomnias.
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The following conditions can minic a parasomnia:
1.Nocturnal seizures. History of seizure disorder, loss of bladder/bowel continence, post-ictal confusion, history of predisposing problem (such as structural CNS lesion, stroke, etc) 2.Confusional arousals due to primary sleep disorder, particularly OSA! 3. Sleep Related Movement Disorder |
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Describe the augmentation phenomenon when treating RLS and what you should do to prevent it.
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In treating RLS, beware of augmentation (specific for dopaminergic agents; symptoms worsen at an increased dosage of drug)
Dopaminergic agonists (such as Levodopa, Mirapex, Requip) are first line drug therapies To avoid augmentation, start with a low dose, ~2-3 hours before bedtime, then increase dose every 5-7 days |
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Identify medications that can worsen the symptoms of RLS.
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SSRI’s (prozac, paxil)
Tricyclic antidepressants (elavil) Antipsychotics Anticholinergic medications (old-fashioned antihistamines, such as Benadryl) |
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Given a patient with symptoms of restless leg syndrome, identify appropriate screening requirements for co-morbid conditions
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-check iron level first
-check medication list for drugs that can make RLS symptoms worse (then possibly change meds if list includes the following): SSRI’s (prozac, paxil) Tricyclic antidepressants (elavil) Antipsychotics Anticholinergic medications (old-fashioned antihistamines, such as Benadryl) -can be related to pregnancy -can be related to peripheral neuropathies |
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Describe primary hypersomnia.
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-Conditions which produce severe sleepiness, but no source for sleep disruption can be identified
-Narcolepsy (with or without cataplexy – loss of muscle tone associated with emotional stimuli) -Idiopathic CNS Hypersomnia |
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List the classical clinical diagnostic tetrad of narcolepsy.
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-Inappropriate Excessive Daytime Sleepiness
-Sleep paralysis -Hypnogogic hallucinations -Cataplexy |
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Describe idiopathic CNS hypersomnia
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Clinical complaint of excessive daytime sleepiness
May be associated with long sleep time (>10 hrs per 24h period) Naps usually non-restorative Patient is often difficult to awaken Cataplexy is not seen No other explanation for sx’s are found Thorough sleep schedule history, evaluation for OSA, movement disorders, depression, medical disorders essential MSLT mean sleep latency of <8 min Unpredictable response to stimulant medications |
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Describe the modern polysomnographic diagnosis of narcolepsy.
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Patient complains of clinically severe excessive daytime sleepiness
MSLT: Mean sleep latency of < 8 min Two SOREMPs are recorded Narcolepsy without cataplexy: All of the above Narcolepsy with cataplexy: All of the above with symptoms of cataplexy |
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List the three common types of sleep disorders (excluding OSA) and possible conditions that fall under these types.
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Sleep Related Movement Disorders:
Restless Legs Syndrome Periodic Limb Movement Disorder Sleep Related Bruxism Sleep Related Rhythmic Movement Disorder Parasomnias: Confusional Arousals Sleepwalking Sleep Terrors Sleep Related Eating Disorder Sexsomnia Primary Hypersomnias: Narcolepsy Idiopathic CNS hypersomnia |
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Describe sleep terrors.
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Arousals from slow wave sleep accompanied by a cry or piercing scream
Intense autonomic activation, with tachycardia, flushing, sweating, and increased muscle tone Can be associated by prolonged inconsolability Patient is usually amnestic for the event, but sometimes dream fragments can be recalled |
