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48 Cards in this Set
- Front
- Back
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2 main categories of problems with sleep. Subcategories
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Inadequate sleep - too much, too little, fragmented
Dysfunctional sleep - Snoring, apneas, limb movement, sleep-related behavior, seizures, poor sleep hygiene Can lead to daytime impairment |
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Problems with wake categories and subgroups
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Disordered or unrefreshing sleep
Increased fatigue - other medical problems, medications Excessive sleepiness - hyperomnia, narcolepsy |
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Parts of the Sleep History
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Onset, duration, aggravating factors, refreshed upon waking?
Bedtimes, arising times, naps Sleep habits, prior to bedtime, do you wake up at night |
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Optimal sleep environments
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Quiet, dark
Not too cold or hot (67 degrees) Move pets to other room Remove non-sleep activities (TV, reading, computer, chores, pay bills, study NOT in sleep room) |
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Why do laptops and TV impair sleep
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BLUE light suppresses melatonin production
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Class I - IV airway
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Class I - clear uvula top to bottom
Class II - can't see bottom Class iII - barely make out arches of throat Class IV - can't see arches III and IV at risk for obstructive sleep apnea |
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Diagnostic Investigations for Sleep Disorders
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Interview sleep partner
Sleep diary (times) Actigraphy - watch measuring movement level in sleep Polysomnography - not usually indicated in insomnia, but can evaluate primary sleep disorders Multiple Sleep Latency Test Maintenance of Wakefulness Test |
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What diagnostic test is not indicated in insomnia
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Polysomnography
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Polysomnography parameters
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EEG (electroencephalography) - brain waves to stages depth of sleep
EOG (electrooculography) - eyes, NREMvsREM EMG (electromyography) - muscle in chin and legs EKG (electrocardiography) Snore - microphone Airflow - nasal pressure and airflow Respiratory Effort - chest and abdominal belts. Apnea Oxygen saturation Body Position |
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Sleep Stages (List)
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NREM - N1, N2, N3
REM Cycle throughout all stages during the night, scored in 30 second pages (epochs) based on EEG features, eye movements |
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Wake EEG, eyes, EMG
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EEG - Alpha (8-13Hz) and Beta (14-25Hz) frequencies. FAST
Eyes - blinks EMG - high muscle tone (particularly chin) |
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N1 EEG, eyes, EMG
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NREM Stage 1 - light sleep
EEG - Slow, more theta (3-7Hz), less alpha. >50% of the epoch is theta Eyes - slow rolling eye movements EMG - muscle tone begins to decrease |
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N2 EEG, eyes, EMG
Hallmarks |
NREM Stage 2 - light sleep
EEG - mixed theta > alpha, Delta (0.5-2Hz) EMG - slightly less than N1 HALLMARKS: Sleep spindles (reticular nucleus of thalamus) - 12-14Hz bursts, K complexes (high amplitude, biphasic or triphasic discharge higher in CENTRAL regions). Less periodicity to K complexes |
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N3 EEG, Eye, EMG, Latency
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NREM stage 3 - slow wave sleep (SWS)
EEG - Delta sleep, deep sleep. DEFINED AS >20% EEG delta waves Eye - usually picks up on EEG EMG - less than N2 Latency is 60 minutes and decreases over night (in the cycles) |
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EEG waves, first stage appearance
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Alpha (8-13Hz) - wake
Beta (14-25Hz) - wake Theta (3-7Hz) - >50% in N1 Delta (0.5 - 2Hz) - First appear in N2 |
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Majority of sleep is what phase
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N2
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Sleep spindles
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12-14Hz periodic bursts in N2 phase of sleep caused by reticular n. of thalamus
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REM EEG, Eye, EMG, Latency
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EEG: theta > alpha
Eye: rapid eye movements, dream consolidation (can dream in all stages though) EMG - flat, muscle atonia (paralysis) Latency is 90 minutes, more in 2nd half of night cycles Also get penile erections in this stage |
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What disorders can be diagnosed by Polysomnography? Mean Sleep Latency Test?
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Polysomnography - Obstructive sleep apnea, central sleep apnea, periodic leg movements in sleep, bruxism (teeth grind), NREM parasomnias, REM sleep behavior disorders
Mean Sleep Latency Test - narcolepsy, Idiopathic hypersomnia |
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Narcolepsy Overview, Symptoms, First symptom (EDS), Cardinal features
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Chronic disabling disorder affecting wakefullness and sleep with REM INTRUSTION INTO WAKING STATE
Symptoms: Pathologic sleepiness with sleep onset REM causing continuous excessive sleepiness and episodic sleep attacks First Symptom: Excessive Daytime Sleepiness that is INDEPENDENT of duration or quality of night sleep, RELIEVED by napping, can occur ANYTIME NORMAL REM in a 24/hr period, TOTAL sleep time is NORM or slightly elevated Cardinal features: Cataplexy - loss of tone associated with emotional response (laughter, anger) Vivid dreams Sleep paralysis Hypnagogic/hypnopompic hallucinations Disrupted sleep |
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Dx requirement for narcolepsy purely clinical
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Definite cataplexy with excessive sleepiness
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Cataplexy signs, timeframe
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Sudden temporary loss of BIL muscle tone triggered by an emotional response (laughter, anger, surprise)
PRESERVED consciousness and memory Eye and diaphragm are NOT impaired Loss of reflexes Lasts seconds to minutes, rarely over 2 minutes |
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Genetic narcolepsy cause
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HLA DQB10602
Loss of hypocretin-1-secreting (Orexin) cells in hypothalamus Can test CSF for Orexin levels (LOW IN NARCOLEPSY) |
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How to approach excessive daytime sleepiness
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Distinguish sleepiness from fatigue, lifestyle factors from a medical illness
Screen for depression Do sleep log Sleep studies: overnight polysomnography and multiple sleep latency test (quantitate wake tiem and evaluate for REM intrusion into nap) |
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Narcolepsy pt naps characteristic
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Have REM sleep in short naps
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Epworth Sleepiness Scale
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8 item questionaire to subjectively measure "sleepiness", more likely to be elevated in sleep disorders
Normal score is <10 |
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Mean Sleep Latency Test and role, considerations
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Followed by an overnight sleep study which must have quality sleep to rule out other causes
Series of 5 naps separated by 2 hours of wakefulness 20 minutes to fall asleep, if do not then must wait 2 hours. If sleep given 15 minutes to see if any REM, if go to REM it is called "sleep onset REM" Considerations: must be off sedating and stimulant meds for 2 weeks prior Role: Mean sleep latency of 10 minutes or over is considered normal, <5 minutes = pathologic sleepiness. |
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Narcolepsy vs Idiopathic hyperosmnia MSLT
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Narcolepsy - MSL < 5 minutes AND 2 sleep onset REM periods
Idiopathic hypersomnia - MSL < 5 minutes but NO or ONLY 1 sleep onset REM periods |
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Narcolepsy Nonpharmacologic
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Nonpharmacologic - good sleep hygeine, treat comorbid sleep disorders, LOW TYRAMINE diet, adequate sleep (increased time and quality, daytime naps (only 1-3 <20 minutes b/c >2 hrs can cause inertia; also nap after a sleep attack)
Caffeine 150mg - 300mg to increase alertness and MSLT score, may be additive with napping BRIGHT light |
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Narcolepsy Pharmacologic treatment
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Non stimulants - Modafinil, armodafinil
Stimulants (indirect sympathomimetics) - Methylphenidate, amphetamines MAO-B inhibitors Nighttime benzodiazepines may improve quality Sodium oxybate may help consolidate nocturnal sleep |
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Only FDA drug for cataplexy
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Sodium oxybate
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Parasomnias def, when can they occur, Associations
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Def: Abnormal sleep related movements, behaviors, emotions, perceptions, dreaming, and ANS functioning
Can occur as falling asleep, NREM, REM or after arousals OR with another sleep disorder and its treatment (ie CPAP for OSA reveals a parasomnia, usually gets better as body adjusts) Associations: spontaneous or with sleep deprivation, stress, medical or neurologic disorder, medications, alcohol, drugs |
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NREM parasomnias common features, precipitating factors
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Common features: Arise from SLOW WAVE SLEEP (N3) and occur in the FIRST HALF of the night
Common in childhood, FHx, AMNESIA Precipitated by: rotating shift work, recovery during sleep (after the deprivation), Alcohol use, other sleep disorders |
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Sleep Terrors, Symptoms, Presentation
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NREM parasomnia
Sx: autonomic and behavioral manifestations (intense fear, tachycardia, tachypnea, flushin of the skin, diaphoresis, mydriasis and increased muscle tone) Presentation: sits up in bed, unresponsive to external stimuli and if awakened is confused and disoriented Inconsolable piercing scream/cry, MAY be violent Eventually falls back asleep |
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Confusional Arousals, Symptoms, Presentation
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NREM parasomnia
Symptoms: Disoriented to surroundings, mental confusion, slow speech, slow response to questions, dulled cognition, confusional behavior (simple, non-goal directed, complex, prolonged) May be very inappropriate (vigorous, resistive, sexual, even violent or murderous) WORSE in FORCED awakenings minutes to hours |
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Somnambulism, Symptoms, Presentation, Inducers
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NREM parasomnia
Sx: sleep walking, altered consciousness, impaired judgement Presentation: EYES OPEN, confused "glassy stare". Complex behaviors, urinating in inappropriate places, may leave bed or room, SLEEP DRIVING Inducers: lithium, zolpidem, anticholinergics |
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3 NREM parasomnias
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Sleep terrors, Confusional arousals, Somnambulism
All more prevalent in FIRST part of night |
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4 REM Parasomnias
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REM sleep behavior disorder (RBD)
Recurrent Isolated Sleep Paralysis Nocturnal Groaning - Catathrenia Nightmare Disorder |
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Normal NREM sleep EMG (reasons)
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FLAT
Atonia - due to glycine hyperpolarizing alpha motor neurons EXCEPT eyes and diaphragm Protects from injury during consolidated dream periods |
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REM Sleep Behavior Disorder Symptoms, Presentation, Associations
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Sx: Motor, verbal behaviors during REM sleep, if awoken during event usually RECALLS DREAM
Disruption of normal atonia, impaired modulation motor system Presentation: DREAM ENACTMENT more common in LAST 1/3 of night Associations: neurodegenerative disorders (parkinson's, lewy body dementia) |
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Parasomnia Nonpharmacologic treatment
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Minimize precipitating factors - alcohol, meds
Safe sleep environment - guns away from ammo, remove sharp objects, mattress and boxsprings on floor, bedpartner in other room till behavioral control, door or floor mat alarms, bed away from window Adequate sleep hygiene, normal cycle, good total time |
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How to approach a parasomnia pt
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DO NOT FORCEFULLY AWAKE PATIENT
Gently guide them back to bed |
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Medication for treating parasomnia
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AVOID SSRIs
Use: Benzodiazapines (clonazepam) Best is melatonin +/- clonazepam Imipramine for NREM parasomnias in children |
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Imipramine MOA
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NREM parasomnias in children
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Obstructive Sleep Apnea Def, Symptoms, Presentation, Incidence, Risk Factors, Treatment
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Incidence: 2-4% middle aged women and men. >20% of the ELDERLY, but estimated that 90% population is undiagnosed
Def: Sleep disordered breathing - brief disruptions in breathing during sleep due to obstruction of airway despite continued respiratory effort Apnea = >10 seconds of paradoxical breathing (trying to breath against closed airway) Sx: Difficulty maintaining sleep (snore arousals, unexplained arousals, nocturia), loud snoring, apneic events, unrefreshed awakenings, morning headaches, poor concentration, decreased memory, abnormal daytime sleepiness Risk Factors: Obesity, increased neck size, Males over 50, postmenopausal women, HTN, crowded oropharynx, family history, alcohol, sedative, smoking Treatment: weightloss, positional therapy (DON"T sleep on back), CPAP, oral mandibular device, pharyngeal surgery (+/- jaw advancement), don't drive if drowsy |
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Clinical consequences of OSA
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Consequences: excessive daytime sleepiness, neurocognitive dysfunction, HTN, arrythmias, coronary artery disease, stroke, erectile dysfunction, metabolic dysfunciton, mood disorder exacerbation
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Obstructive sleep apnea vs central sleep apnea
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Obstructive - paradoxial breathing (trying to breath against a closed airway)
Central - no attempt to breath both have absence of airflow |
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What stage of sleep is OSA worst
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REM (lowest EMG)
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