Sleep wake disorders Part 1

How many stages are there in the sleep cycle?

5

When do you experience beta waves?

stages 1 and 2

What stage do you experience delta waves

stage 3

25% of total sleep time is spent in what stage

stage 5 in R.E.M

Non REM is what % of total sleep time?

75%

About how long does it take to go through a sleep cycle?

90 minutes

Infants spend up to ___ hours/day sleeping

20

differentiation of sleep stages occurs between what months of age

3-6 months

By what age is the circadian rhythm established?

3 years

What are the four major neurotransmitters to focus on?

melatonin, histamine, orexin, GABA

What are the 2 sub types of primary sleep disorders?

1. parasomnia

2. dyssomnia

Define insomnia

unsatisfying sleep quality or quantity associated with at least one of the following:

• difficulty initiating sleep

• difficulty maintaining sleep

• early morning awakenings

Medications that can induce insomnia

• alcohol

• caffeine

• corticosteroids

• diuretics

• thyroid preparations

What are some factors that are associated with insomnia?

• initiation

• duration

• consolidation

• quality

Transient insomnia usually lasts how long?

last 2-3 nights

acute/short-term insomnia can last how long?

<4 weeks

Treatment goals of insomnia include

• consolidate sleep

• avoid ADR

• lowest effective dose

• improve daytime functioning and sleepiness

• correct underlying complaint

What are some behavioral interventions

• stimulus control therapy

• sleep restriction therapy

• relaxation training

True or false: we have an ideal hypnotic

false

Tolerance for antihistamines can develop if used longer than ____

10 days

Kava Kava is not recommended due to ______

hepatotoxicity

Valerian root can mimic what

benzo withdrawl

chamomile can interact with what type of drug class

anticoagulants

Benzos decrease time in what stage of sleep?

REM

Which type of zolpidem is used for night time awakenings

intermizzo

What sleep cycle is described: brain waves resemble stage 1 but there is complete paralysis of skeletal muscles

REM

Which stages of sleep are spent mostly in a deep sleep

1 and 2

Where is the suprachiasmatic nucleus located?

hypothalamus

Melatonin secretion is regulated by ____

daylight

Define parasomnia

abnormal physiological behaviors either occurring during sleep or exaggerated by sleep

Define dyssomnia

abnormalities in the amount, quality or timing of sleep

Dose of Benadryl

50 mg

Dose of doxylamine

25mg

Dose range for melatonin

5-10mg

MOA of this OTC herbal appears to increase GABA concentrations

valerian root

These drugs reduce sleep latency, increase total sleep time, and decrease stage 3, 4, and REM sleep

Barbs

For barbs, loss of efficacy occurs after ___ weeks of use

2

These drugs reduce sleep latency, increase total sleep time, increase stage 2 sleep, decrease REM, stage 3 and 4

benzos

Key ADR of benzos

• anterograde amnesia

• daytime cognitive impairment and sedation

• rebound insomnia

• abuse and misuse

• increased risk of falls

What drug therapy preserves sleep stages and has lower incidence of tolerance or rebound insomnia?

non-benzos

What non-benzo has complaints of unpleasant taste?

eszopiclone

Clinical pearls for non-benzos

• take on an empty stomach

• avoid alcohol

Best agents to help maintain sleep are

• zolpidem CR

• eszopiclone

Agents used in case of middle-of-the-night awakenings (may use as long as >4 hours sleep left)

• zaleplon

• low-dose zolpidem SL

How long should non-benzos be used?

14 days or less

Which non-benzos have been shown to be safe and effective for at least 6 months?

• eszopiclone

• zolpidem CR

Name of melatonin agonist

Ramelteon (rozerem)

Ramelteon is selective for what melatonin recepetors?

1 and 2

Melatonin 1 receptor does what?

blocks alertness and firing

Melatonin 2 receptor does what?

synchronizes sleep-wake phases

Dosing for ramelteon

8mg 30 minutes before bedtime

True or false: ramelteon is effective for sleep onset and maintenace?

false; just sleep onset

Counseling points for ramelteon

• do not take after high-fat meal

• 30 minutes before bed

• most effective when used nightly vs PRN

• avoid alcohol

What are the sedating tricyclic antidepressants?

• amitriptyline

• doxepin

What are the sedating 5-HT2 receptor blockers

• trazodone (low dose)

• mirtazapine

What are the orexin receptor antagonists?

• suvorexant

• lemborexant

counseling points for orexin receptor antagonists

• only take if you have at least 7 hours to sleep

• report any temporary weakness in legs

• don’t drink alcohol

Evaluate after _____ week of treatment to assess

1

A sedating antidepressant may be considered in patients with what?

concurrent depression or anxiety or history of substance use disorder

Orexin receptor antagonists are good for?

sleep onset and maintenance

What is the dosing for Zolpidem?

adult male: 5-10mg

female and elderly: 5mg

What is the dosing for Zolpidem CR?

adult male: 6.25-12.5

female and elderly: 6.25

What is the dosing for SL Zolpidem?

adult male: 1.75-3.5mg

female and elderly: 1.75mg

What is the dosing for Lunesta?

adult: 1-3mg

elderly: 1-2mg

What is the dosing for Temazepam?

adults: 7.5-30mg

elderly: 7.5-15mg