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88 Cards in this Set
- Front
- Back
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circadian process is regulated by what of the hypothylmas
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suprachiasmatic nucleus
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what else is regulated with the circadian rhythm
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temperature
hormones cortisol, sex hormones BP changes |
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what is produced in the pineal gland
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melatonin - secreted at night no matter if awake or asleep
can induce sleep in daytime |
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what parts of the brain generates sleep
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thalmus
pons is important in REM sleep and muscle inhibition |
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what part of the brain will wake you up and EEG arousal
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brainstem, reticular formation
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what happens when there is an issue in the SCN
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encephalitis lethargica - from a virus, antibodies attack the reticular activating center - cause statue like state
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what hormone is a sleep promotor
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serotonin - can cause anxiety, irritability, impulse - emotion, cognition, function
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what hormone causes wakefulness
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catecholamines - norepi - energy, interest, motivation, anxiety
dopamine = motivation, sex, aggression, drive, mood and emotion |
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how many states of consciousness occur in the sleep cycle
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4
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how long is each cycle and how many cycles occur at night
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90-110 minutes per night, about 4-6 cycles per night
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this cycle is drowsy, memory stops at this stage
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1
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this is where deep sleep occurs; slow wave sleep with delta waves
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3 and 4
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how long does it take until you get into REM sleep and what is the % of time in REM per night
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about 40 minutes - last part of cycle
25% - increases with every cycle, later in night, longer; decrease overtime |
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what does EMG check
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doesn't cover anything, detects radiculopathies ( spine pinch)
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what does CTS study check
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nerve conduction velocity - for peripheral neuropathies,
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if you entire REM sleep in < 30 minutes means what
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depression
narcolepsy circadian rhythm disorder - genetic drug withdrawl |
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this is a difficulty initiating or maintaining sleep despite adequate opportunity to sleep
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insomnia/DIMS
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how long is insomnia to be chronic
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>1 month
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this is not getting enough sleep because doing to much/ your fault
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sleep deprivation
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what are risk factors for insomnia
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unemployed
divorce/seperated lower SES family history of insomnia - learned chronic pain greater in women and increase with age |
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how long to fall asleep or sleep less than how many hours per night for how many nights are considered insomnia
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>30 minutes to fall asleep
<6 hours 3 times per week |
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what are causes of secondary insomnia
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asthma - bc cyclical nature - increase at night or if on theophylline or steroids
COPD menopause - testosterone and estrogen help with sleep when in balance GERD Hyperthyriod or caffiene - stimulant ETOH - decrease REM Neuro disease |
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what are consequences of insomnia
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fatigue/daytime
poor attention social or vocational work dysfunction mood disturbance increased errors depression |
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why does altitude insomnia occur
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due to hypoxia and hypocapnia - decrease barometric pressure, increase risk for alkalosis, cause HA
resolve in a few days |
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what is the treatment for altitude secondary insomnia
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Diamox (acetazolamide) 25mg before go somewhere with high altitude
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how do you diagnosis primary insomnia
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no cause
diagnosis of exclusion must rule out medical and social issues first can be multifactorial - sleep hygiene, behavior issue, negative conditioning, psych issues |
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how can you improve sleep hygiene
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bed for sleep or sex
keep regular schedule do not exercise <4 hours before bed no caffeine or alcohol before bed don't go to bed hungry no naps deal with your worries before bed do not watch TV or read in bed get out of bed if you cannot sleep after 20 minutes |
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what therapy is best for treatment for insominia
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behavioral and medication - do not go to bed wide awake, use relaxation, cognitive, relaxation, improve sleep hygiene
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why are antihistamines, alcohol not work for insomina
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antihistamine - quick tolerance, stop working after one week, rapid tolerance
alcohol - problem with sleep arousal, inhibit REM sleep, worsening of OSA |
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when does OTC melatonin work for insomnia
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in delayed sleep phase syndrome
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what classes work for treatment on insomnia
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melatonin receptor agonist
benzodiazepines benzodiazepine receptor agonists antidepressants |
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what are the benefits of Roxerem
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melatonin receptor agonist
decreases sleep onset by 15 minutes and increases duration by 15 minutes not abusive no sedation not a scheduled drug |
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what are the benefits of triazolam halcion verses ativan, dalmane, or valium
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trizolam is short acting, good if cannot fall asleep, onset insomnia only
ativan and dal mane are intermediate acting - for those who cannot fall or stay asleep but drowsy in the AM , increased abuse potential Valium - long acting, should avoid in elderly, should be for anti-anxiety and seizures only fast acting increased street value |
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what are the benefits of benzo receptor agonists
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newer and better, used only for sleep
does not help with anxiety - doesn't work on that receptor specific action on GABA type A receptor therefore less anxiolytic and anticonvulsant get rebound insomnia can use up to 6 months |
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what are the differences between
Sonata Ambien Lunest |
Sonata - short half life - one hour, good for falling asleep
Ambien - short half life - one to two hours. CR - slower release so last longer, not generic, increase drowsiness Lunesta - 5-7 hour half life, good for onset and maintenance, expensive |
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what are benefits of antidepressants for insomnia
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for psych issues
sedating because of anticholinergic and antihistamine properties Trazadone - less SE Elavil or amitryptaline - more for neuropathy Doxepin - increased SE rebound insomnia not for chronic use |
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this is dysesthesia in calves or feet causing irresistible urge to move limb
inherited |
RLS
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what are secondary causes of RLS
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iron deficiency
DM rheumatic disease venous insufficiency ESRD PD in 20% of 60 year olds treated with dopaminergic drugs worse at night usually by a secondary cause |
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what are patient complaints of RLS
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urge to move legs associated with unpleasant feeling
'crawling, creepy' worse at night partially or totally relieved by movement FMH |
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what are causes of secondary causes of insomnia
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related to psych or pulmonary causes
always treat underlying issue first |
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how many minutes of reclining back does RLS occur
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within 15-30 minutes
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what is the treatment for RLS
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iron - if deficient
stretching Medications - dopaminergic drugs - levodopa, mirapex opiods, Neurotin or lyrica BEFORE FALL ASLEEP if this does not work then get polysynomogram not painful |
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what is periodic limb movement disorder
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periodic extension of great toe or dorsiflexion of foot - RHYTHMIC
occurs every 5-20 seconds, disturbs sleep not painful can cause insomnia |
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what is the treatment for periodic limb movement
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dopaminergic meds - mirapex or levodopa
Benzos Diagnosis on PSG or EMG |
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what is nocturnal leg cramps
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painful - can be LE or foot, common 50% over 50 years old
disturbs sleep idopathic no known trigger |
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which can you use Meripex and is not painful but can disturb sleep****`
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RLS
periodic limb movement disorder |
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how do you treat nocturnal leg cramps
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Quinine - in tonic water, no longer available
vitamin B - OTC exercise before bed rule out hypocalemia CCB - increase calcium availability RX: TUMS and Tonic water before bed |
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this is when elements of REM sleep intrude into wakefulness and elements of wakefulness intrude into REM sleep - go right into REM sleep
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narcolepsy
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what are symptoms of narcolepsy
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excessive daytime somnolence
intrusion of REM sleep - sudden weakness often elicited by emotion - cateplexy hallucinations at sleep onset - hypnogogic, or hallucinate at end of sleep muscle paralysis upon awakening - you awaken but you cannot move |
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this is sudden weakness that is elicited by emotion
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cataplexy
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how do you diagnose narcolepsy
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polysomnogram - REM sleep within 20 minutes of falling asleep
Multiple step latency test - see how fast they can nap, will be <5 minutes, usual is 10-15 minutes, will have REM sleep at onset HLA testing - genetic Maintance of wakefulness test - see how long you can last awake |
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what are some treatments for narcolepsy
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daytime naps - do help
Stimulants - nuvagil or provigil Ritalin - abuse potential REM suppressing meds - TCA or SSRI - need to wean, if stop will have night terrors, vivid dreams |
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what are secondary causes of narcolepsy
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lesions of hypothalamus
trauma to hypothalamus - stroke |
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what is the treatment of cataplexy
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REM suppressing agents:
Effexor - for depression and anxiety, hard to wean Prozac TCA - Elavil, Pamelor - hard to tolerate Treat as you would narcolepsy |
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most common sleep disorder, repetitive episodes of upper airway obstruction during sleep, last at least 10 seconds and associated with reduction in O2 saturation and/or arousal
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OSA
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why should you rule out OSA when prescribe sedative
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because it will worsen OSA
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for daytime sedation and weird dreams, what should you get
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sleep study - see where REM sleep is at in the sleep cycle
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what are RF for OSA
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25% of population
increase with age, esp over 65 years more in blacks - structural common in men 80% undiagnosed witnessed period of apnea by partner independent of weight - bc structural |
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what are the 3 cardinal features of OSA
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>5 obstructive apnea, hypopnea, or respiratory effort related arousal per hour
daytime sleepiness, fatigue, or poor concentration snoring or resuscitative snorts #1 is apnea |
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what are predisposing factors
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age
obesity craniofascial abnormality ETOH hypothyriod smoker nasal congetsion |
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what is the sequelae of untreated OSA
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daytime sleepiness
depression poor libido poor concentration angina anxiety bc lack sleep cognitive impairments cerebral anoxia CVA arrythmias - increased pressure on arteries of heart and lungs |
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what physiology occurs with OSA
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hypoxemia
hypercapnia acidosis pulmonary hypertension - cor pulmonale right CHF |
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what other disease goes hand in hand with OSA
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HTN
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what are some symptoms a patient with OSA would tell you
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excessive sleepiness
snoring nocturnal choking/gasping at times morning HA - CO2 build up fatigue upon wakening witnessed periods of apnea *ask spouse |
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what are some PE findings in OSA
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obesity
HTN narrow airway - best predictor if you do not see UVULA Micrognathia or retrognathia - recessed jaw Macroglossia Nasal obstruction Enlarged tonsils Swollen uvula - by vibration at night insult with snoring or from GERD |
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what lab values will be seen in OSA
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polycythemia - hypoxia
Protienuria - bc vascular insult by hypoxemia - hit on renal - damages everything hypercapnia |
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how do you diagnose OSA
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PSG
measures: sleep stages respiratory effort and frequency of apnea airflow oxygen saturation EKG Body position Limb movements checks index - apnea # |
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this measures severity of OSA, measures the number of apneas or hypopneas in an hour
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apnea hypopnea index
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the PSG AHI is 5-15, have daytime sleepiness is considered what
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mild OSA
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the PSG AHI is 15-39, have HTN and increased risk of MVA is considered what
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moderate OSA
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the PSA AHI is >30 with O2 sat <90%
can have HF Cor Pulmonale Polycythemia |
severe OSA - must intervene and use PAP machine
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this is a PSG where the first half is regular then they put you on a CPAP machine and titrate it there
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split night PSG
its cheaper, easier and less time to titrate |
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can occupational people use in home studies
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NO, must get fitted by MD, with occupational have to monitor use because its a safety issue - Driver or Pilot
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what is the treatment of OSA
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Behavioral - weight loss, avoid ETOH smoking, sleep on side
Mechanical - masks O2 Surgery |
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What is CPAP
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continuous pressure, simple, cheap, tight fitting mask
can be timed after 10-20 minutes after put on so its when you fall asleep pressure 5-20mmHg |
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what is BPAP
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deliver different pressure during inspiration and expiration
augment respiratory rate augment TV more comfortable can augment RR like ventilator |
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what are risk benefits of surgery
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for severe OSA only
try other treatments first use if obstructive lesion UPPP scars after 6 years - will eventually drop down and cause obstruction |
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what are the mediations for treatment of OSA
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no medications used
Modafinil or Armodafinil will help daytime sleepiness but should only be ordered if apnea addressed |
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what are some oral appliances for OSA
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preferred by patients
mandibular advancement splint tongue retaining device NOT for severe OSA NOT as effective for mild to severe OSA but will improve compliance |
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what are the sequelae of OSA
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3-6x increase risk of all cause mortality
Daytime sleepiness MVA - 2-3x more common HTN CVD decrease memory and performance |
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this is a failure of normal respiratory drive
can be caused by altitude - increased RR or Cheyne strokes breathing - in CHF |
central sleep apnea
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who are more common to have central sleep apnea
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elderly
male HF - common - secondary cause CVA - acute, does not matter location |
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what are the pathogenesis of OSA
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secondary usually due to hyperventilation
when inhibitory input to the respiratory center of the brain exceeds excitatory input |
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how do you treat central sleep apnea
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treat the condition
trial of CPAP - will not help Nocturnal O2 |
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this is caused by 3d shift working, sleep and wake cycle is off, does not stabilize, causes chronic insomnia
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shift work sleep disorder
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what are some consequences of SWSD
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cognitive deficit and attention
depression or anxiety increased all cause mortality increased risk of CAD and HTN - vascular stress decreased immune function sleep deprivation increases appetite |
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what is the pathophysiology of SWSD
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fight urge to sleep at 4am, body makes cortisol, increase weight, hunger, vascular changes, HTN response
increase glutamate - hormone trigger hunger tend to eat, increase risk for DM - confusion of SCN |
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what is the treatment for SWSD
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nap during shift no more than 40 minutes - if longer than 40 minutes go into deep sleep and more tired
sunglasses when you drive home bright light at work - SCN provigil or nuvigil for sedation |
