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109 Cards in this Set
- Front
- Back
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What % of adults have CHRONIC sleep disturbances that affect their daytime functioning and / or exac med / psych conditions?
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20%
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What regulates our circadian processes? Be Specific.
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The Suprachiasmatic nucleus of the hypothalmus
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Is the SCN's internal clock genetically programmed?
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Yes
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Where is melatonin produced?
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pineal gland
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Is melatonin only secreted when we sleep?
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No, it is secreted at night regardless of wakefulness or sleep. It can induce sleep in the daytime too.
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What instrinsic system GENERATES sleep ?
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The thalamus generates sleep and the PONS is impt for REM sleep and muscle inhibiition
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What instrinsic system plays a role in WAKEFULNESS & EEG arousal?
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brainstem reticular formation; reticular activating formation - aka the "awake center."
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What does the reticular activating formation do?
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it plays a role in wakefulness and EEG arousal
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What does the PONS do r/t sleep?
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It is impt in REM sleep and muscle inhibition
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What does the thalamus do r/t sleep?
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it generates it
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What are the 3 states of the sleep cycle?
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1. wakefulness
2. Non REM (4 stages) 3. REM |
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At what stage of the non REM sleep are memories NOT created?
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stage 1
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At what stage of sleep are we paralyzed?
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REM
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How long does each sleep cycle last?
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90-110 minutes
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How many sleep cycles do we usually get in a night?
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4-6
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What % of sleep is REM sleep in an adult? An infant?
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25% adult; 50% infant
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What occurs in stages 3 and 4 of non REM sleep?
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slow wave sleep with delta waves
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What do we normally enter REM sleep?
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definitely by 1 hour, usually 40-60 minutes
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According to class notes, what 4 conditions can cause entry into REM sleep EARLY (< 30 minutes)?
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1. Depression
2. Drug withdrawal 3. circadian rhythm d/o 4. narcolepsy |
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Define insomnia
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difficulty initiating or maintining sleep despite opportunity to sleep
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What percent of adults have OCC insomnia?
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50%
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What percent of adults have chronic (>1 mos) insomnia?
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19%
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Which sex has more problems with insomnia?
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F
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List the 3 main clinical features of insomnia?
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1) diff falling asleep or staying asleep
2) > 30 min to fall asleep 3) < 6 hr / nt for 3 nights weekly |
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What 9 conditions from class notes can cause SECONDARY insomnia?
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1. asthma
2. COPD 3. Caffeine 4. ETOH 5. Menopause 6. GERD 7. Hyper thyroid 8. psych / neuro px 9. altitude insomnia |
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What ABG features might you see with altitude insomnia?
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hypoxia and hypocapnia
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What med is used to tx altitude insomnia?
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DIamox
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How is Primary insomnia dx?
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it is a dx of exclusion
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How is insomnia treated?
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with med and behavioral therapy
-sleep hygiene - BT including relaxation, CBT, sleep restriction tx |
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Antihistamines for insomnia . . .
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- rapid tolerance
- no controlled studies |
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ETOH for insomnia . . .
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-worsens OSA
-inhibits REM sleep |
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antipsychotics for insomnia . . .
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no controlled studies
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barbituates for insomnia . ..
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NOT recommended
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Valerian root for insomnia . ..
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only improves sleep onset x 1 minute
- hepatotoxic |
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Melatonin for insomnia . . .
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safe but ONLY effective for those with delayed sleep phase syndrome
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What class of drug is Ramelteon (Rozerem)?
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Melatonin receptor agonist
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What does dose Ramelteon come in?
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8 mg
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How does Ramelteon work?
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decreases sleep onset by 15 minutes and increases duration by 15 minutes
-no abuse potential -no sedative effect - not a scheduled drug |
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How do benzos work for insomnia?
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- decrease sleep onset x 10 min
-increase sleep time by 30-60 minutes |
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What receptor do benzodiazepine receptor agonists effect and why is this significant?
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-act on GABA type A receptors
-therefore less anxiolytic / anticonv effects; essentially just work for sleep |
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How long can benzodiazepine receptors agonists be used?
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they are indicated for less than or equal to 7 days but some benefit has been shown with use for 6 months
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What is the brand name for Zaleplon and what is the dose range?
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-Sonata
-5-20 mg |
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what is the half life of Zaleplon?
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1 hr, therefore good for sleep onset problem
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What is the half life of regular zolpidem?
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1.5 -2.4 hrs
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What might be a good drug for a problem with both sleep initiation AND maintenance?
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Ambien ER
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What is the brand name for Eszoplicione and what is its half life?
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lunesta; 5-7 hrs
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Which type of sleep px is eszoplicione good for?
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onset and maintenance
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What are some problems with using antidepressants for sleep?
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- anticholinergic drying effects
-rebound insomnia -poor tolerance |
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Define restless leg syndrome.
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a DYESTHESIA in calves or feet causing IRRESTIBLE URGE TO MOVE
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How is inherited RLS inherited?
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dominantly inherited
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What are some conditions that can cause secondary RLS?
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-ESRD
-DM -IDA -Parkinson's -Rheum disease -venous insuff |
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What % of 60 yr olds have RLS?
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20%
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What are some other characteristic features of RLS?
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- worse at rest
-relieved with mvmt -family hx -respond positively to dopaminergic drugs -worse at night |
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What descriptive words can be used for RLS?
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creeping, pulling, itching, drawing
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How soon after reclining does RLS usually strike?
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15-30 min
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Is RLS u/l or b/l?
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B/L
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Name 4 drug classes that MAY help RLS?
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benzos
dopaminergic drugs opiods gabapentin |
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what are 2 example of dopaminergic drugs for RLS
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-levodopa
-pramipexole (Mirapex) |
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Define PLMD
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Periods EXTENSIONS OF GREAT TOE or DORSIFLEXION OF FOOT
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How often do symptoms of PLMD occur?
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every 5-20 seconds
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How do you dx PLMD? How do you treat it?
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DX - PSG and EMG
Tx - dopaminergics or benzos |
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What percent of people over 50 have nocturnal leg cramps?
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50%
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What 5 treatment options should be consider for nocturnal leg cramps?
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Quinine (seltzer water)
Vit B 12 supplement r/o hypocalcemia (TUM before bed) Exercise before bed CCBs |
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Define narcolepsy
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REM sleep that intrudes into wakefulness and / or wakefulness that intrudes into REM
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What are the 1st and 2nd most common causes of disabling daytime sleepiness?
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1. OSA
2. Narcolepsy |
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What 4 things are used to dx narcolepsy? AKA the Narcolepsy tetrad
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1. Excessive daytime
2. cataplexy 3. muscle paralysis upon awakening 4. hallucinations at sleep onset (hypnogogic hallucinations) |
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what is the incidence of narcolepsy
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1:2000
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When does narcolepsy usually start?
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puberty
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When attempting to dx Narcolepsy with a PSG, what would you expect to see?
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REM sleep within 20 minutes of sleep onset
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When attempting to dx narcolepsy, what would you expect to find on a multiple sleep latency test?
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- sleep latency - how long it takes to fall asleep when light turned off
- normal is 10-15 min but in narcolepsy is < 5 minutes |
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What 3 consideration for tx for narcolepsy can you do (class notes)?
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-daytime naps
-stimulants -REM suppressing meds |
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What 2 stimulants medications can you use with low abuse potential but still good success?
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Modafinil (provigil)
Armodafinil (nuvigil) |
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what is the normal dose for Modafinil (provigil)
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200-400 mg QAM
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What 2 class of drugs are REM suppressants
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TCA
SSRI |
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why shouldn't you stop REM suppressing meds suddenly
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risk of night terrors / dream rebound
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What percent of pts with narcolepsy also have cataplexy?
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30%
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How is cataplexy treated?
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with REM suppressing meds
-Effexor -Prozac -TCA *can tx like narcolepsy |
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What can cause secondary narcolepsy?
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lesions or trauma to hypothalamus
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Define OSA
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repetitive episodes of upper airway obstr during sleep, lasting at least 10 seconds and assoc with decreased sat or / and arousal
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what percent of adults are high risk for OSA?
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25%
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Who has more OSA?
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B > W (regardless of wt)
M > F 8:1 |
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what % of pts with OSA are undiagnosed?
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80%
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What are the 3 cardinal features of OSA?
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1) >5x/hr of obstr apneas / hypopneas / or resp related arousals
2) daytime sleepy / fatigue / poor concentration 3) snoring or resucitative snorts |
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List some OSA predisposing fx?
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- age
-craniofacial abn -obesity -ETOH -hypothyroid -smokers -nasal congestion |
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What kind of acid base distrubance do you see with OSA?
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resp acidosis (hypercapnia)
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What % of pts with OSA have Pulm HTN?
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>10
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List 7 things a pt might present to your office with that should make you think OSA?
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1. naps / sleep not restorative
2. snoring 3. witnessed apnea 4. daytime sleepiness / fatigue 5. nocturnal choking / gasping 6. AM headaches 7. fatigue upon waking |
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What physical findings are common in OSA?
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large tongue
narrow airway obese HTN retrognathia / micrognathia enlarged tonsils collar size >17 men / 16 women |
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What 3 findings more typically are found with OSA as well (different systems)
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-polycythemia vera
-proteinuria -hypercapnia |
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What is the apnea hypopnea index?
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it measure the severity of OSA by measuring the number of apneas and hypopneas in an hr
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On a polysonogram, what does a AHI of 5-15 indicate?
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mild OSA, usually only have daytime sleepiness
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On a PSG, what does a AHI of 15-30 indicate?
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moderate OSA; icreased risk of MVC/ HTN
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on a PSG, what does a AHI of > 30 with a sat of < 90% indicate?
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severe OSA
risk for CHF, cor pulm polycythemia |
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What is included in behavioral tx for OSA?
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-wt loss
-smoking cessation -avoid etoh -side sleep |
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What is different about BPAP vs CPAP?
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- different pressures on I & E
-can augment resp rate -can augment TV -not as well studied |
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what is the name of the surgical procedure for SEVERE OSA?
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UPPP- uvulopalatopharyngoplasty
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When should / could you use med for daytime sleepiness in OSA?
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ONLY WHEN YOU HAVE ADDRESSED APNEA
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What meds can you use for OSA daytime sleepiness?
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provigil (modafinil)
nuvigil (armodafinil) |
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what type of oral appliances are available for OSA?
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- tongue retention appliance
-mandibular advancement splints |
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If untreated, what is the increase in all cause mortality of OSA?
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3-6x more likely
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how does untreated OSA affect cognition?
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decreased memory and performance
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How much more likley are you to have an MVC if you have untreated OSA?
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2-3x
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What percent of sleep apneas are central?
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only 3-4 %
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What causes primary central sleep apnea?
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failure of nml resp drive
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what causes secondary central sleep apnea?
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altitude
- heart failure with cheyne stokes -pure central apneas |
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list 2 pathogenic features of CSA.
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-inhibitory input of resp centers exceeds excitory input
-hyperventilation (secondary) |
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How do you treat CSA?
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-treat condition
-CPAP trial (not likely to work) nocturnal oxygen ` |
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what are some consequences of SWSD
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-cognitive deficits
-depression / anx -incre all cause mort -incr CAD / HTN -decr immune fx increased appetite incr DM |
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how do you treat SWSD?
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-nap during shift of no more than 40 min
-sunglasses on way home -bright lights at work -Provigil or nuvigil |
