Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
99 Cards in this Set
- Front
- Back
|
What are Cicadian rhythms regulated by?
|
Suprachiasmatic nucleus of the hypothalamus
|
|
|
What regulates the circadian rhythms?
|
Light input from retinothalamic tract
Endogeneous oscillator 24 hour period -genetically determined -sends signals to cycle sleep/wake. temp, hormones, ect |
|
|
Where is Melatonin produced?
|
In the pineal gland
|
|
|
When is Melatonin secreted?
|
At night regardless of wakefulness
Can induce daytime sleep |
|
|
What is the pathway of Melatonin
|
A neural pathway from the suprachiasmatic nucleus to the pineal
|
|
|
Of the 2 intrinsic systems to manage sleep which one generates sleep?
|
The thalamus
The pons is important in REM sleep and muscle inhibition |
|
|
Of the 2 instrinsic systems to manage sleep which one plays a role in wakefulness and EEG arousal?
|
The brainstem reticular formation
|
|
|
Responsible for Cortical activatio
sleep spindle EEG syncronization |
Thalamus
|
|
|
Ascending cortical activation
REM/SWS switch |
Brainstem
|
|
|
Circadian Clock
|
SCN
|
|
|
Sleep /Wake Switch
|
Hypothalamus
|
|
|
Sleep promoter
|
Serotonin
|
|
|
Wakefulness promoter
|
Catecholamines
|
|
|
Sleep Cycle
3 States of Consciousness |
1. Wakefulness
2. Non REM sleep : stages 1-4 3. REM sleep |
|
|
How long does each sleep cycle last?
|
Approximately 90-110 minutes so about 4-6 cycles in a nights sleep
|
|
|
How is the sleep cycle define?
|
By changes in the EEG,EOG,and EMG
|
|
|
What 2 sleep cycles alternate throughout the night?
|
REM and non REM
|
|
|
What percentage of sleep is REM in an adult?
|
25% (decreases over time)
|
|
|
What is non REM sleep based on?
|
4 stages of arousal
stages 3,4 slow wave sleep with delta waves |
|
|
How soon after falling asleep do you enter REM
|
normall after one hour
|
|
|
What 4 things can an early onset of REM indicate?
|
1.Depression
2.Narcolepsy 3.Circadian rhythm disorders 4. Drug withdrawls |
|
|
What is the definition of insominia?
|
Difficulty initiating or maintaining sleep depite adequate opportunity to sleep
|
|
|
What define chronic insomina?
|
Greater than 1 month
|
|
|
Who is insomina more prevalent in?
|
Women
unemployed divorced/widowed/separated Lower SES those w family hx chronic pain |
|
|
Clinical Features of insomnia
|
Difficulty falling asleep or staying asleep
Greater than 30 mins to fall asleep Sleep less than 6 hours 3 nights a week |
|
|
Consequences of insomnia
|
Fatigue/daytime sleepiness
Poor attention Social or vocational dysfunction Mood disturbance Increased errors or accidents Depression |
|
|
Causes of secondary insomnia
|
Asthma
Sxs increase at night due to periodicity Theophylline and steroids also disrupt sleep COPD Menopause GERD Hyperthyroidism Caffeine Alcohol Psychiatric and Neurologic Disease Altitude insomnia |
|
|
Causes of primary insomnia
|
No definable cause
Dx of exclusion Multifactorial. Sleep hygiene Behavior issues Negative conditioning Psychiatric issues |
|
|
Treatment of insomnia
|
Treat disorder causing it
Improve sleep hygiene Consider behavioral therapies Relaxation Cognitive behavioral Sleep restriction therapy Medication |
|
|
What gives the best results in the treatment of insomnia
|
BEST RESULT WITH COMBINED MEDS AND BEHAVIORAL THERAPY
|
|
|
What define chronic insomina?
|
Greater than 1 month
|
|
|
Who is insomina more prevalent in?
|
Women
unemployed divorced/widowed/separated Lower SES those w family hx chronic pain |
|
|
10 elements of sleep hygiene
|
1.Bed is for sleep and sex
2.Keep regular sleep schedule even on weekends 3.Do not exercise within 4 hours of bedtime 4.No caffeine or alcohol before bed 5.Do not go to bed hungry 6.Comfortable bedroom environment 7.Deal with your worries before bed 8.No naps 9.Do not watch TV or read in bed 10.Get out of bed if you cannot sleep for 20 min |
|
|
6 treatments of insomnia
|
1.Anithistamines: however rapid tolerance and no controlled studies
2.Alcohol: problem with sleep arousal due to inhibition of REM sleep, worsening of OSA 3.Antipsychotics: no controlled studies 4.Barbiturates: not recommended 5.Valerian root: improved sleep onset by 1 minute; hepatotoxic 6.Melatonin OTC: safe but effective only for those with delayed sleep phase syndrome |
|
|
Clinical Features of insomnia
|
Difficulty falling asleep or staying asleep
Greater than 30 mins to fall asleep Sleep less than 6 hours 3 nights a week |
|
|
Consequences of insomnia
|
Fatigue/daytime sleepiness
Poor attention Social or vocational dysfunction Mood disturbance Increased errors or accidents Depression |
|
|
Causes of secondary insomnia
|
Asthma
Sxs increase at night due to periodicity Theophylline and steroids also disrupt sleep COPD Menopause GERD Hyperthyroidism Caffeine Alcohol Psychiatric and Neurologic Disease Altitude insomnia |
|
|
Causes of primary insomnia
|
No definable cause
Dx of exclusion Multifactorial. Sleep hygiene Behavior issues Negative conditioning Psychiatric issues |
|
|
Treatment of insomnia
|
Treat disorder causing it
Improve sleep hygiene Consider behavioral therapies Relaxation Cognitive behavioral Sleep restriction therapy Medication |
|
|
What gives the best results in the treatment of insomnia
|
BEST RESULT WITH COMBINED MEDS AND BEHAVIORAL THERAPY
|
|
|
10 elements of sleep hygiene
|
1.Bed is for sleep and sex
2.Keep regular sleep schedule even on weekends 3.Do not exercise within 4 hours of bedtime 4.No caffeine or alcohol before bed 5.Do not go to bed hungry 6.Comfortable bedroom environment 7.Deal with your worries before bed 8.No naps 9.Do not watch TV or read in bed 10.Get out of bed if you cannot sleep for 20 min |
|
|
6 treatments of insomnia
|
1.Anithistamines: however rapid tolerance and no controlled studies
2.Alcohol: problem with sleep arousal due to inhibition of REM sleep, worsening of OSA 3.Antipsychotics: no controlled studies 4.Barbiturates: not recommended 5.Valerian root: improved sleep onset by 1 minute; hepatotoxic 6.Melatonin OTC: safe but effective only for those with delayed sleep phase syndrome |
|
|
What is Rozerem(Ramelteon), its dosage and action?
|
Melatonin Receptor Agonist
8mg tablet Decreases sleep onset by 15 minutes and increases sleep duration by 15 minutes No abuse potention No sedative effects Not a scheduled drug |
|
|
Action of benzodiazepines
|
Decrease sleep onset by 10 min
Increase sleep time by 30-60 min |
|
|
Sort acting benzo
|
halcion( triazolam
|
|
|
2 intermediate acting benzos
|
ativan lorazepam
dalmane flurszepam |
|
|
Long acting benzo
|
valium diazepam
*** avoid in the elderly |
|
|
Benzodiazepine Receptor Agonists action and indication
|
Specific action on GABA type A receptor therefore less anxiolytic and anticonvulsant properties
Indicated for 7 days or less but long term use (6 months) has been shown to improve sleep, concentration and work performance vs placebo Get rebound insomnia |
|
|
3 Benzodiazepine Receptor Agonists and their dosage
|
Zaleplon SONATA:
5-20 mg; short half life (1 hour). Good for difficulty with sleep initiation Zolpidem AMBIEN 5-10 Short half life (1.5-2.4 hours) Ambien ER 6.25 and 12.5 Eszopliclone LUNESTA 5-7 hour half life Good for sleep onset and sleep maintenance insomnia |
|
|
How do antidepressants assist with sleep?
|
Sedating due to antihistaminic and anticholinergic properties
|
|
|
Contraindications in antidepressants for sleep
|
Rebound insomnia
None intended for chronic use as effects short lived and poor tolerance |
|
|
4 antidepressants commonly used for sleep and their dosages
|
Heterocyclic antidepressants
Trazadone DESYREL 25-100 mg Amitriptyline ELAVIL 10, 25 mg Nortriptyline PAMELOR 10, 25 mg Doxepin SINEQUAN 10, 25, 50 mg |
|
|
What is Restless leg syndrome?
|
Dysesthesia in calves or feet causing irresistible urge to move limb
Worse at night worsened by inactivity: relieved by movement |
|
|
What is treatment of RLS
|
dopaminergic drugs
Iron replacement Stretch Drugs Benzodiazepines Dopaminergic drugs Levodopa Pramipexole MIRAPEX Opioids Gabapentin NEURONTIN |
|
|
Possible causes of RLS
|
dominantly inherited( idiopathic type)
Possibly due to hypothalamic dopamin distrubance |
|
|
Possible causes of secondary RLS
|
Iron deficiency
DM Rheumatologic diseases Venous insufficiency ESRD PD |
|
|
Clinical manifestations RLS
|
Discomfort in legs worsened by rest and relieved by movement
Bilateral, lower leg Occur within 15-30 min of reclining Pulling, creeping, itching, drawing |
|
|
Periodic limb movement disorder
|
In 17% of insomniacs
? Chicken or egg Periodic extensions of great toe or dorsiflexion of foot STEREOTYPICAL Occurs q 5-20 seconds Disturbs sleep Dx with PSG and EMG Rx with dopaminergic meds or benzos |
|
|
Nocturnal Leg Cramps
|
Differs from Restless leg and PLMD
Common: 50% over 50 yoa Painful Disturb sleep Majority idiopathic |
|
|
Nocturnal Leg Cramps Treatment
|
Quinine—works great. Not available
Vitamin B Exercise before bed Rule out hypocalcemia Calcium channel blockers Tonic Water ( contains quinine) |
|
|
Narcolepsy
|
Elements of REM sleep intrude into wakefulness and elements of wakefulness intrude into REM sleep
|
|
|
Narcolepsy tetrad”
|
Excessive daytime somnolence
Intrusion of REM sleep characteristics Sudden weakness often elicited by emotion “cataplexy” Hallucinations at sleep onset: hypnogogic halluncinations Muscle paralysis upon awakening (sleep paralysis) |
|
|
Second most common cause of disabling daytime sleepiness
|
Narcolepsy
|
|
|
Diagnosis of Narcolepsy
|
Polysomnogram
REM sleep within 20 minutes of sleep onset Multiple Sleep Latency Test Give opportunities to nap Sleep latency less than 5 minutes Normal 10-15 minutes REM sleep with sleep onset HLA testing—DQB1*0602 Research tool |
|
|
Treatment of Narcolepsy
|
Treatment
Daytime naps Stimulants Modafinil Provigil Non amphetamine 200-400mg qAM Armodafinil Nuvigil Methylphenidate Ritalin but very sympathomimetic Amphetamines – Dextroamphetamine; methamphetamine REM suppressing meds Tricyclics SSRI |
|
|
Causes of Secondary Narcolepsy
|
Lesions of hypothalamus
Trauma to hypothalamus |
|
|
What is Cataplexy?
|
Cataplexy is a sudden and transient episode of loss of muscle tone, often triggered by emotions
|
|
|
What is the treatment for cataplexy?
|
Treat with REM suppressing drugs
Effexor especially Effexor XR Prozac Tricyclic antidepressants but poorly tolerated |
|
|
Definition of Obstructive Sleep Apnea
|
Repetitive episodes of upper airway obstruction during sleep, lasting at least 10 seconds, and associated with reduction in O2 saturation and/or arousal
|
|
|
Epidemiology of OSA
|
One quarter of adults are at high risk
Prevalence increases with age up to age 65 Blacks > Whites independent of body weight Men > Women 8:1 80% are undiagnosed |
|
|
OSA cardinal features 3
|
More than 5 per hour of obstructive apneas, hypopneas or respiratory effort-related arousals
Daytime sleepiness, fatigue or poor concentration Snoring or resuscitative snorts |
|
|
8 Predisposing Factors of OSA
|
Age
Obesity Craniofacial abnormality & airway obstruction ETOH Hypothyroid Smokers Nasal congestion Alcohol ingestion |
|
|
10 Sequelae of OSA
|
Daytime sleepiness
Depression Poor libido Poor concentration Angina Anxiety Cognitive impairments Cerebral anoxia CVAs Cardiac arrhythimas |
|
|
Pathophysiology of OSA
|
Hypoxemia
Hypercapnia Respiratory acidosis Pulmonary Hypertension => Cor pulmonale > 10% have pulmonary HTN |
|
|
OSA Presentation 6
|
Excessive Daytime Sleepiness
Snoring Nocturnal choking/gasping at times Morning headaches Fatigue upon waking WITNESSED PERIODS OF APNEA |
|
|
Relationship of OSA and HTN
|
33% of OSA pts. have systemic HTN & 33% of HTN pts. have OSA
|
|
|
8 possible findings on a Physical examination of an OSA pt
|
Obesity
HTN Narrow airway Retrognathia; micrognathia Large neck Collar size > 17 inches men Collar size > 16 inches women Macroglossia Nasal obstruction Enlarged tonsils |
|
|
3 possible addition findings in OSA
|
Polycythemia
Proteinuria Hypercapnia |
|
|
What does a Polysomnogram PSG measure ?
|
Sleep stages/architecture
Respiratory effort and frequency of apneas Airflow Oxygen saturation EKG Body position Limb movements |
|
|
What does the Apnea Hypopnea Index measure?
|
Measures severity of OSA
Measures the number of apneas and hypopneas in an hour |
|
|
OSA Treatment
|
Behavioral
wt. loss Avoid alcohol, stop smoking AVOID sedatives Sleep on side Mechanical Pharmacologic – O2 Surgical |
|
|
What is the treatment of choice for OSA?
|
PAP positive airway pressure
CPAP continous cheaper well studied Bilevel PAP |
|
|
Descibe CPAP
|
Fixed
Constant pressure Well studied Autotitrating Pressure varies as a function of airway resistance Result varies per manufacturer 5-20 cmH20 Results Help daytime sleepiness Helps AHI |
|
|
Describe BPAP
|
Delivers different pressure during inspiration and expiration
Can augment respiratory rate Can augment tidal volume Not as well studied as CPAP BiPAP is a brand name by Respironics |
|
|
What is UPPP
|
Uvulopalatopharyngoplasty Surgical benefits in tx of OSA inconsistent
|
|
|
When should surgical interention for OSA be used?
|
Reserved for severe OSA
Other treatments have failed Used if there is an obstructing lesion causing OSA |
|
|
When should you treat for daytime sleepiness
|
Only after apnea has been addressed
|
|
|
Two treatments for daytime sleepiness
|
Modafinil
Armodafinil |
|
|
Sequelae of Sleep Apnea
|
3-6X INCREASED RISK OF ALL CAUSE MORTALITY IN SEVERE UNTREATED OSA
Daytime sleepiness MVA: 2-3 x more common HTN CVD Decreased memory and performance |
|
|
What is the Epworth Sleepiness Scale?
|
Measures sleepiness
Validated scale Used in safety sensitive jobs to measure risk Commercial drivers Pilots |
|
|
What is Central Sleep Apnea?
|
Central sleep apnea is a disorder in which your breathing repeatedly stops and starts during sleep. Central sleep apnea occurs because your brain doesn't send proper signals to the muscles that control your breathing — unlike obstructive sleep apnea, in which you can't breathe normally because of upper airway obstruction
Only 3 – 4% of sleep-related apneas Primary A failure of normal respiratory drive Secondary Cheyne – Stokes breathing in heart failure vs. pure central apneas Central sleep apnea of altitude |
|
|
Epidemiology of Central Sleep Apnea
|
Elderly
Male CHF Central sleep apnea is common in CHF CVA Acute CVA Irrelevant of location of CVA |
|
|
Pathogenesis of CSA
|
When inhibitory input to the respiratory center of the brain exceeds excitatory input
Secondary usually due to hyperventilation |
|
|
CSA Treatment
|
Treat the condition
Trial of CPAP Nocturnal 02 |
|
|
Shift Work Sleep Disorder
|
Sleep wake cycle is circadian
Third shift disrupts this Hard to stay asleep past noon Circadian rhythm never stabilizes due to 2 days off per week Causes chronic insomnia |
|
|
Consequences of SWSD
|
Individualized: early bird or night owl
Cognitive deficit and attention Depression/anxiety Increased all-cause mortality Increased risk of CAD and HTN Decreased Immune function Sleep deprivation increases appetite |
|
|
Liability of SWSD
|
Errors and Poor Performance
Second leading cause of MVA is sleep deprivation |
|
|
Liability of SWSD and Sleep Deprivation
|
Evidence that a person was sleeping while driving is generally sufficient to establish negligence, especially if reckless
Employers are liable for employees’ accidents if within scope of employment Clinicians who fail to inform a patient of his/her risk of injury due to a medical condition (SWSD, OSA) can be held liable |
|
|
Treatment of SWSD
|
Nap during shift no more than 40 minutes
Sunglasses when you drive home Bright light at work Provigil or Nuvigil for sedation |
