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39 Cards in this Set
- Front
- Back
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What are the characteristics of Restless Legs Syndrome (RLS)?
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1) Clinical syndrome (based on history)
2) PSG not needed for diagnosis 3) Legs are usually involved but arms and trunk can be involved too |
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What are the clinical features of RLS?
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1) Strong, nearly irresistible urge to move
2) Urge to move usually accompanied by unpleasant sensations deep inside the legs 3) Symptoms made worse by rest (lying or sitting) and temporarily resolved or relieved by walking or stretching 4) Symptoms worse in late afternoon or at night and are relatively better in the AM 5) Patient may complain of involuntary jerking or twitching of legs while sitting or laying (periodic leg movements during wakefulness (PLMW)) |
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How does Restless Leg Syndrome affect sleep?
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1) May cause difficulty falling asleep at night or getting back to sleep
2) Easier to fall asleep in the early morning hours 3) Sleep disruption can cause daytime fatigue leading to problems functioning at home or work |
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What are the characteristic of Primary RLS (no other cause RLS)?
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1) more common in women than men
2) symptoms can occur at any age 3) symptoms may be intermittent but gradually get worse 4) Over 40 years of age, more likely to seek help 5) more than 50% of patients with primary RLS report a family member with similar complaints |
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What conditions and medications is Secondary RLS (caused by another condition) associated with?
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1) Iron deficiency
2) pregnancy 3) Severe kidney failure 4) Medications: -sedating antihistamines (Benadryl) -antidepressants- (Elvail or Prozac) -Dopamine receptor blockers (Haldol) |
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How is RLS diagnosed?
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1) Based on clinical symptoms
2) If there are no sleep complaints, no PSG necessary 3) Other complaints such as snoring or sleep walking, PSG necessary to look for other disorders |
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What does RLS look like on PSG?
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1) PLMs can be recorded during wake (PLMW)
2) PLMs can last up to ten seconds 3) >15 PLMWs/Hour of waking on PSG supports clinical diagnosis of RLS 4) tech notes should document pt restlessness and pt comments about uncomfortable sensations |
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How is RLS treated?
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1) Treat Iron Deficiency: low ferritin levels, treat with supplemental iron, can decrease symptoms
2) Medications: -Dopamine agonists-Mirapex -Oipods- coedine, Vicodin, Oxycontin -Benzodiazpines- Klonopin |
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What are the characteristics of Periodic Limb Movement during Sleep/ Periodic Limb Movement Disorder?
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1) Periodic bursts of repetitive stereotypic movements of the legs during sleep
2) May also involve arms and trunk 3) May or may not cause sleep disruption 4) Can be precipitated or worsened by dopamine receptor blockers and many antidepressants 5) Low iron (ferritin) levels may play a role in worsening PLMs |
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What is the presence of other sleep disorders in those with PLMs?
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1) 80-90% of people with RLS
2) 70-75% of people with REM Sleep Behavior Disorder 3) 45-65% of people with narcolepsy |
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What are the PSG EMG settings for diagnosis of PLMs?
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1) Both anterior tibialis muscles should monitored
2) Movements of upper limb can be sampled if clinically indicated 3) EMG activity is predominately in the 50-100Hz range, therefore: - Digital sampling at least 200- -HFF should be at least 100 Hz -Sensitivity settings must be sufficient to record toe twitches |
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What are the PSG findings for PLMs?
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1) highly repetitive stereotypic limb mvmt
2) repetitive contractions of anterior tibialis EMG 3) duration of limb mvmts, 0.5-10 secs 4) Amplitude of 8 micovolts in EMG from resting baseline 5) Limb mvmt onsets are separated by 5-90 sec (typically 20-40 secs) 6) leg mvmts on 2 different legs, separated by less than 5 secs count as a single movement 7) must be 4 mvmts in a sequence, otherwise not PLMs 8) can appear at onset of N1 sleep 9) Frequent during N2 10) Decrease in frequency during N3 11) Usually absent during REM sleep (except for RBD) 12) Typically occur in discrete episodes lasting a few mins/hr |
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How is the PLM index calculated?
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Number of PLMs per hour of TST, determined by PSG
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How is the PLM arousal index calculated?
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Number of PLMs associated with EEG arousals per hour of TST, determined by PSG
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What are the characteristics of Periodic Limb Movement Disorder (PLMD)?
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1) characterized by PLMs
2) clinical sleep disturbance that is not due to another sleep disorder 3) Clinical history not enough to diagnose, need PSG 4) PLMs present on PSG 5) Medications for RLS effective in PLMD |
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What are the characteristics of bruxism?
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1) strong muscle contractions that produce clenching of teeth and teeth grinding sounds
2) lends to abnormal wear of teeth, broken teeth, jaw pain, jaw lock on waking, or headache 3) May consist of brief (phasic) or sustained (tonic) elevations of chin EMG that are at least twice the amplitude of the background EMG 4) Pts have normal sleep organization 5) Usually not aware of bruxism or arousals 6) Pts don't complain about poor sleep quality 7) Pts evaluated because of: -complaint of noise from sleeping partner -dental exam shows destruction of teeth |
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What are the characteristics of bruxism in PSGs?
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1) occurs in all sleep stages
2) >80% occur in N1 and N2 sleep 3) EMG activity scored if 0.25-2 sec in duration and at least 3 elevations occur in regular sequence 3) sustained elevation of chin EMG activity scored if duration >2 secs 4) an episode of bruxism after >3 sec intervals of stable background EMG before a new episode can be scored 5) 90% of episodes have PSG arousal followed by onselt of jaw muscle contractions associated with tooth grinding 6) can look like chewing 7) can be scored by audio with PSG by min of 2 audible tooth grinding eps/night of PSG in absence of epilepsy 8) Sleep tech documentation of sounds and pt appearance is essential |
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What are the risk factors and triggers of bruxism?
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1) Family History
2) Other Mvmt Disoders (Parkinson's, Tourette's) 3) RLS 4) OSA 5) Dementia, depression, mental retardation 6) Alcohol 7) Medications and Drugs -amphetamines (Dexedrine) -antidepressants (Prozac, Zoloft) - Dopamine antagonists (Haldol) -Cocaine |
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How is bruxism treated?
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1) no specific cure
2) Prevent damage to teeth and jaw -mouth guard -stabilization bite splint 3) Reduce complaints of pain (analgesics) 4) Medications-short term use and severe cases -Benzos -muscle relaxants -Dopamine agonists -Beta blockers -Botulinum toxin (Botox) |
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What is the definition of parasomnias?
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1) Undesirable physical events experienced as one is going to sleep, during sleep, or during arousals from sleep
2) Results from CNS activation --> skeletal muscles and/or autonomic (fight or flights) nervous system) |
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What are the characteristics of REM Sleep Behavior Disorder (RBD)?
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1) Abnormal behavior during REM sleep
2) Behaviors can cause injury or sleep disruption 3) Abnormal behavior due to the disappearance of normal skeletal muscle atonia (paralysis) during REM 4) Sleep related injury is common, usually why pt seeks medical advice 5) 1st episode approx 90 minutes after sleep onset, occur more frequently in 2nd half of night 6) Assc with long history of disruptive mvmts during sleep 7) more common in men 8) more common after 50 yrs old 9) often underlying neurological disorder -Parkinson's -Narcolepsy 10) Seen in alcohol withdrawal with intense REM sleep rebound 11) Antidepressants can trigger RBD |
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What are the criteria for diagnosing RBD and characteristics of RBD in PSGs?
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1) Time synced video and PSG essential for diagnosis
2) All four limbs must be monitored 3) Excessive sustained EMG activity or intermittent loss of normal EMG atonia during REM sleep 4) PLMs with a few EEG arousals during NREM in 70-75% of RBD patients 5) PLMS can be present during REM |
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How is RBD scored in PSGs?
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1) Sustained (tonic) muscle activity in REM in chin EMG
-50% of epoch as chin amp > min chin amp seen in NREM 2) Excessive transient muscle activity during REM in the chin or limb EMG -divide 30 sec epoch --> 10 sequential 3 second epochs -at least 5 contain bursts of transient muscle activity at 4 times the amp of the background EMG activity |
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What is the differential diagnosis for RBD?
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Differentiate from:
-NREM parasomnias -Nocturnal Seizures -Violent activity during arousals induced by OSA -Other rhythmic movement disorders during sleep |
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How RBD managed/treated?
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1) Neurologic eval to exclude underlying neuro disorders
2) Remove potentially dangerous objects from the bedroom 3) place cushions, mattress around bed 4) cover mirrors and windows 5) Medications at bedtime -Klonopin -Melatonin |
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What is the definition of confusional arousals?
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mental confusion or confusional behavior during or after arousals from sleep
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What are the characteristics of confusional arousals?
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1) Usually occur in 1st part of night but can occur on attempted awakening in am
2) Marked mental confusion during or after arousals from sleep, slow speed, disorientation to time and space 3) Pt may: -move slowly -incomplete responsiveness -mumble and moan -automatic behavior such as picking at bed clothes -become agitated if outsider tries to help 4)Pt may not remember anything that happened during arousal 5) most common in SWS 6) can occur in N2 |
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What are the predisposing factors to confusional arousals?
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1) Family history
2) Rotating shift work 3) Night shift work 4) Other sleep disorders 5) Insufficient sleep 6) Anxiety 7) Depression |
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What are the precipitating factors to confusional arousals?
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1) Recovery from sleep deprivation
2) Alcohol 3) OSA 4) PLMD 5) Drug abuse 6) Forced awakening 7) Psychotropic medication |
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What are the characteristics of sleepwalking?
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1) kids with confusional arousals often walk in their sleep
2) Behaviors are inappropriate 3) potentially violent 4) pts can be hard to wake or are confused if awakened 5) people often don't remember in am 6) No sex difference in kids 7) Occurs in families 8) Most common in children 8-12 yrs old 9) Usually spontaneously stops during puberty 10) Assc. with injury and violence more common in adult males |
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What are the characteristics of sleepwalking in PSGs?
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1) Usually begins after arousals from SWS, near end of 1st or 2nd eps of SWS
2) Occasionally N2 3) Multiple arousals from SWS w/out the behavior 4) Time synched video essential 5) Post-arousal EEG: partial or complete persistence of sleep 6) PSG document precipitating events (ex. OSA) 7) PSG document normal REM atonia and exclude RBD 8) EEG should be normal to exclude seizures 9) Sleep tech notes pt behavior during arousals essential |
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What is the definition of sleep terrors?
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abrupt awakening from sleep, usually beginning with a cry or loud scream
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What nervous system are sleep terrors associated with?
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autonomic (fight or flight)
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What physical autonomic nervous system responses are associated with sleep terrors?
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1) Tachycardia
2) Tachypnea 3) Sweating 4) Flushing 5) Dilated pupils 6) Increased chin tone |
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What are the characteristics of sleep terrors?
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1) Pt sits up in bed
2) if awakened, confused and disorients, potentially dangerous 3) Usually cannot recall event in AM 4) Occurs in families 5) Usually begins in childhood 6) Stops spontaneously during teens 7) can begin in adulthood 8) Injury can occur if pt tries to escape from bed and fight |
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What are the characteristics of sleep terrors in PSGs?
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1) Typically start after sudden arousal from SWS
2) Usually occurs at the end of the 1st or 2nd eps of SWS 3) findings can be the same as sleepwalking |
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What is the PLM index needed for children to diagnose PLMD?
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>5hr/sleep
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What is the PLM index needed for adults to diagnose PLMD?
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> 15/hr sleep
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How should PLM indexes be intepreted?
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1) in the context of the pts sleep related complaint of disturbed sleep or daytime fatigue in order to diagnose
2) Not better explained by another cause -sleep disorder -medication -neurological, psychiatric, medical disorder |
