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Flashcards in Sleep Disorders and Pharm Deck (32):
1

What neurotransmitters are thought to play a role in the sleep-wake cycle

Serotonin: arousal promoting

NE: arousal promoting

GABA: sleep promotig
Histamine:arousal promoting

Orexin: regulates arousal, wakefulness, and appetite

Ach
Dopamine

2

SLeep is divided into two categories, what are they? Describe each.

1. REM (increase in eye movement, heart rate, breathing, HR, BP, & temp)

2. Non-REM (4 stages)
*REM + Non-REM = 90minute cycles

Description:
Non-REM: stages 1 &2 cyclic waxing and waning of TV and RR, have periodic breathing (periods of apnea), stage 3&4 breathing becomes more regular.

REM: resp become irregular and may include short periods of apnea.

3

What are the types of Sleep Disorders?

-Insomnia
-Hypersomnolence
-narcolepsy
-breathing-related sleep disorders
-circadian rhythm sleep wake disorders
-Non-REM sleep arousal disorders
-REM sleep Behavior disorder
-Movement Disorder

4

Insomnia:
-what is this?
-most common in who?
-risk factors

What: difficulty initiating, maintaining sleep, or waking up early in the AM without the ability to return to sleep.

-most common in women

-Risk factors: Stress, caffeine, physical discomfort, daytime napping, early bedtimes, alcohol abuse, heavy smoking, depression, & manic disorders

5

Etiologies of Insomnia

Medical Conditions: cardiac, neurological, pulmonary, GI (acid reflux), substances (stimulants, caffeine, alcohol, corticosteroids, bronchodilators

Psychiatric Conditions: depression*, Anxiety*, PTSD, Panic disorder, psychotrophic meds

Environmental problems:
-bereavement, shift work, jet lag, changes in altitude

6

Sx of insomnia

-difficulty falling asleep and staying asleep
-daytime sleepiness
-irritability
-fatigue/malaise
-increased errors or accidents
-poor social or educational dysfunction

7

Dx and Tx of Insomnia

Dx:
-sleep hx; # of awakenings, duration of awakening, duration of the problem
-sleep log: bedtime, duration until sleep onset, final awakening time

Tx:
-Before therapy most patients are asked to maintain sleep log for 2-4wks, perform good sleep hygiene, avoid caffeine, nicotine, alcohol 6-8hrs before bedtime

-Meds: *short term use is preferred to restore normal sleep pattern, hypnotic drugs are used for 2wks or less

8

Insomnia Medications:
-for each what is the half life, preg category, and MOA
-trouble getting to sleep
-trouble maintaining sleep
-other
-orexin receptor antagonists

Trouble getting to sleep:
-Ambien 1st line: half life 1.5-2.4hrs, Preg B, MOA: GABA

-Zaleplon(Sonata): alternative

Trouble Maintaining SLeep:
-Lunesta: Half life 5-7hrs, Preg C, MOA: GABA

Other:
-Benzodiazepines (Triazolam, lorazepam, estazolam); MOA: GABA
*be careful in those with breathing difficulties (COPD)

-Melatonin Agonists (Ramelteon); half life: 1.5-5hrs

Orexin receptor antagonists: Belsomra, MOA: inhibits orexin, Preg C

9

Hypersomnolence Disorder
-what is this?
-commonly affects who?
-sx

What: recurrent epidsodes of excessive daytime sleepiness or prolonged nighttime sleep that is not caused by medications, medical conditions, not getting enough sleep, or insomnia.

-Most commonly affects adolescents and young adults

-Sx: anxiety, increased irritation, decreased energy

10

Hypersomnolence Disorder:
-diagnostic criteria

-excessive sleepiness for at least 1 mo (acute) or at least 3 mo (persistent) as evidence by either prolonged sleep episodes or daytime sleep episodes that occur at least 2 times per week.

11

Hypersomnolence disorder:
-Tx

-non-pharm: takes naps whenever possible, maintain regular sleep schedule, avoid alcohol and meds that cause drowsiness

Pharm:
1st line: Provigil, Preg C
2nd line: Dextroamphetamine; stimulates CNS, Preg C, BBW: high potential for abuse

12

Narcolepsy
-what is this?
-most common in what age?
-causes

What: daytime sleepiness

Most common in teens and early twenties

-Causes: loss of orexin(hypocretin)
-genetic
-brain lesion

13

Narcolepsy:
-sx and symptoms

-extreme drowsiness during the day with a strong urge to sleep, often followed by a short nap (sleep attack)
-naps last about 15minutes each, may happen after eating, while driving, talking to someone, etc. Wake up feeling refreshed

Tetrad of Sx:
-sleep paralysis (generalized flaccidity of muscles)

-cataplexy: sudden loss of muscle tone in muscles while awake that makes them slump to the floor unable to move; may be triggered by strong emotions. usually last less than 30seconds

-hypnagogic hallucinatinos: visual or auditory which may precede or occur during the sleep attack

-excessive daytime sleepiness

14

Narcolepsy:
-dx
-tx

Dx:
-hx of daytime sleepiness
-absence of underlying nocturnal sleep disorders
-epworth sleep scale
-polysonogram (EEG, eye movements, EMG, EKG)
-multiple sleep latency test (series of naps 2hrs apart and measure the REM cycle for each nap)

Tx:
-good sleep hygiene
-take 1-3 planned 15-20min naps/day
-Meds:
--1st line: Provigil, Preg C
--2nd line: Dextroamphetamine; Preg C, BBW: abuse potential

15

Sleep related Breathing Disorders:
-what are the 3 types?

-obstructive sleep apnea hypopnea
-central sleep apnea
-obesity hypoventilation syndrome

16

Obstructive Sleep Apnea:
-most common in who?
-presentation
- results in...
-risk factors

Most common in middle aged or elderly men

Presentation:
-obese
-loud snoring
-multiple arousals during night
-gasping for breath

Result in:
-daytime sleepiness
-morning HA
-impaired performance
-exacerbated by alcohol use at bedtime

Risk Factors:
-Obesity (BMI greater than 30)
-Neck circumference is greater than 17 inches
-narrow airway
-large tongue

17

Obstructive Sleep apnea
-screening and dx
-tx

Screening and Dx:
-Epworth Sleepiness scale
-Sleep studies:
--Polysomnography (PSG)
---Electrooculogram
---electromyelogram
---electroencephalogram
---electrocardiogram
---tracheal noise
---nasal and oral airflow
---thoracic and abd resp effort
---leg movement
---pulse ox, capnography, tidal CO2

Tx:
-weight loss
-smoking cessation
-CPAP
-oral appliances
-Surgery: mandibular advancement, uvulopalatopharyngoplasty

18

Central Sleep Apnea
-what is this:
-cause
-tx

What: repetitive cessation or decrease of both airflow and ventilatory effort during sleep

Cause:
-stroke/brain tumor
-Afib, CHF
-neuromuscular disorder

Tx:
-treat underlying cause
-CPAP = 1st line ... did he mean BIPAP?
-Meds: acetazolamide, Theophylin

19

Pickwickian Syndrome:
-aka
-what?
-dx
-tx

Aka: obesity hypoventilation syndrome

What: combo of brains control over breathing and obesity. (blunted ventilatory drive and increase mechanical load on the chest by obesity)

-often tired d/t sleep loss/poor sleep quality/chronic low blood O2 levels.

Dx: PSG polysomnogram

Tx:
-weight loss
-BiPAP
- resp stimulants: theophylline, acetazolamide
-O2
-Tracheostomy in severe cases

20

Circadian Rhythm Disorders
-what?
-what are the common disorders?

WHat: a disruption in a persons internal body clock that regulates a 24hr cycle of biological processes.
--disruption may result from either a malfunction in "internal clock" or mismatch between "internal body clock" and the external environment.

Disorders:
-delayed sleep phase disorder
-advanced sleep phase disorder
-non-24hr sleep wake disorder
-irregular sleep-wake disorder
-shift work disorder

21

Delayed Sleep Phase disorder:
-most common in who?
-characteristics

Advanced Sleep Phase Disorder:
-most common in who?
-characteristics

Delayed SLeep phase disorder:
-most common in adolescents/young adults
-characteristics: "night owl", sleeps in, most alert, productive, and creative late at night.


Advanced SLeep:
-most common in elderly
-early bedtimes and early morning wakenings, "morning larks"

22

Non-24hr sleep-wake disorder
-what is this?
-commonly seen in who?
-sx
-tx

What: condition in which a persons day length is longer than 24hrs

Commonly seen in the blind

Sx:
-cognitive dysfunction
-confusion
-extreme fatigue
-HA

Tx:
-bright light therapy, melatonin
-Hetlioz (Tasimelteon): DOC for blind pts.

23

Irregular sleep-wake syndrome:
-what is this?
-sx

What: sleeping without a sleep schedule

sx: sleeping or napping more than usual during the day, trouble falling asleep or staying asleep, waking up often during the night

24

Shift Work Disorder:
-what?
-tx

What; ppl who rotate shifts or work at night, work schedule conflicts with circadian rhythm, results in insomnia or excessive sleepiness

Tx: light therapy, combination of planned sleep schedule, timed light exposure, and timed melatonin
-good sleep hygiene

25

Non-rapid eye movement sleep arousal disorders;
what are the 3 types?

-sleepwalking
-sleep terrors
-enuresis

26

Sleep walking:
-aka
-occurs during what stages of sleep?
-causes
-most common among what ages?

aka: somnambulism

occurs during sleep stages 3-4 of Non-REM and in REM sleep

Cause:
-idiosyncratic drugs (marijuana, ETOH)
-medical conditions (seizures)

Common in ages 8-12yrs old

27

Night terrors
-aka
-occurs during what sleep stages?
-common in who?
-describe these to me.
-tx

aka: Pavor nocturnus

occurs during stages 3&4 Non-REM

common in preadolescent boys

Description: abrupt terrifying arousal from sleep, marked vocalization, hard to wake up, unable to recall event.
*fear, sweating, tachycardia

Tx:
-improve sleep by...
--setting a regular bedtime
--practice relaxation
--limit food or drink before sleep
--establish bedtime routine
--scheduled awakenings

28

Enuresis
-what is this?
-common in who?
-occurs during what stage of sleep?
-tx

What: involuntary micturition during sleep in a person with voluntary control " you pee the bed " - Lauren Theis

Common in children

Occurs during stages 3&4 non REM

Tx:
-simple behavioral interventions are 1st line approaches.
-DDAVP (desmopressin) (clotting promoter and antidiuretic)
-oxybutynin
-imipramine
-alarm system

29

Rapid Eye movement Sleep Behavior Disorder
-what is this?
-potential causes
-dx
-tx

What: dream enactment that happens during a loss of REM sleep atonia, ranges from hand gestures to violent thrashing, punching, and kicking

Cause:
-antidepressants, narcolepsy, or alpha-synuclein neurodegeneration (eldery population)

Dx:
-polysomnography (PSG)

Tx:
-establish safe sleep enviornment
-melatonin = 1st line
-clonazepam

30

Movement Disorder:
RLS
-what is this?
-cause
-tx

What: urge to move legs to stop unpleasant sensations

Cause: DM, Parkinsons, Pregnancy, peripheral neuropathy, iron deficiency,
caffeine, chronic venous insufficiency

Tx:
-stretching, massage, warm baths
-avoid stimulants
-Meds:
--iron supplememnt if iron deficient
--Dopamine agonist (requip)
-alpha-2 delta Ca chennel ligand (Gabapentin)

31

Bruxism
-aka
-common hx complaints
-tx

aka: teeth grinding

Hx: jaw soreness, flattening of teeth radiating AM HAs.

Tx:
-clonazepam
-botox
-nocturnal oral appliances
-relaxation and behavioral therapy

32

Periodic Limb Movement Disorder:
-what?
-dx
-tx

What: pt moves limbs involuntarily during sleep and has sx or problems related to the movements.

Dx: PSG

Tx:
-dopamine agonists = 1st line
-anticonvulsants
-benzodiazepines