MH & W Exam 3 sleep disorders

difficulty initiating or maintaining sleep or getting bad sleep. pt says they don’t feel well rested after good amounts of sleep.

insomnia

The people who get insomnia are

Women, advanced age, have med and psychological activity disorders or use alc, drugs, or meds

rem sleep is associated with

Dreaming

Non rem sleep is a period of

Dec physiologic and psychological activity, has four stages based on eeg patterns

What are the stages of sleep

Non rem stage 1, non rem stages 2 to 4, (eeg Dec freq and inc amplitude). Stages 3 and 4 aka slow wave sleep are the most intense early in sleep. REM sleep is inc freq, Dec amplitude eeg, loss of muscle tone in major antigravity muscles, and rems.

aspects of rem sleep (REMs, atonia) are generated in the

Brainstem

Non rem sleep is controlled by the

Hypothalamus, basal forebrain, and thalamus

What neurotransmitters regulate sleep and wakefulness

Ach, norepi, serotonin, dopamine, gaba

What is your circadian rhythm controlled by

one or more internal biological clocks, environmental stimuli, and other processes that promote or inhibit arousal

If time cues didn’t exist humans would have a sleep wake cycle of how long

25 hours

Our circadian rhythm is determined by what

Zeitgebers, like social activities, meals, environmental light

When light reaches my retina it’s conveyed to what part of the body

Suprachiasmatic nuclei in anterior hypothalamus

How does bright light at nighttime/dark hours change your sleep wake cycle

Cause a phase delay in sleep wake cycle so you go to bed later and wake up later.

How does bright light in early morning hours and darkness in the evening change your sleep wake cycle

Advance phase forward so you go to bed earlier and wake up earlier

How does sleep wake cycles states change as you get older

REM latency Dec and length of first rem period inc. after 65 some take more than 30 mins to fall asleep, inc wakefulness after sleeping bc of more breathing and sleep disorders. Older pts more roused by internal and external stimuli

How do your sleep wake cycles change from childhood to adulthood

Inc in childhood, peaks in adolescence, gradually Dec until disappearing. YA spend 15-20% total sleep time in sleep wake state

this insomnia type is from acute stress and resolves on its own. It’s much more common than chronic insomnia.

transient insomnia

this insomnia raises considerations of depression, adjustment d/o, psych d/o. 

persistent insomnia

All patients with chronic insomnia develop what

Learned sleep preventing associations, like a huge over concern that they can’t sleep

Insomnia can be assoc with what other disorders

Sleep related movement disorders like restless leg syndrome

how to tx insomnia w/o drugs

Educate about sleep hygiene and correcting false beliefs (like being afaid of their bed). sleep restriction therapy = improve sleep consolidation by limiting time pt spends in bed (if you sleep 6 hrs be in bed 6 hrs, then slowly add time)

how to tx insomnia with meds

benzos. safe and effective w low dose and short term to get them back on their nl sleep pattern.

Non benzo hypnotics like zolpidem, zaleplon, eszopiclone, ramelteon also can be used and are better for pts who tend to misuse. Dec misuse risk, rebound insomnia, and withdrawal sx.

Zolpidem, zaleplon, eszopiclone are what kind of drug and do what

GABAa receptor agonists so they have less marked motor and cognitive side effects.

Side effects of non benzo hypnotics

Morning hangovers

Long term benzodiazepines are good or bad for sleep insomnia

Bad bc we don’t know what the effects are and you can get a tolerance to it

this drug is considered addiction proof and is a a selective melatonin agonist at MY1 and mt2 sites. They don’t bind to gaba receptors or show activity in brain. They have a fast onset of action and their melatonergic mech is good for initial insomnia with a delayed circadian phase

Ramelteon

What meds do I give to a pt with insomnia with no psych conditions.

Trazodone, other sedating antidepressants, or more sedating atypical antipsychotics. OTC sleeping pills like an H1 receptor antagonist (diphenhydramine) or melatonin.

complications of insomnia tx

tolerance, withdrawl, and abuse from benzos. Withdrawal causes seizures, psychosis, delirium, death. if pt is fearful of other meds drs rx meds with less favorable safety profiles (priapism w trazodone, metabolic complications of atypical antipsychs). Elderly pts prone to anticholinergic s/e of antihistamines like urinary retention, dry mouth, confusion)

what is the problem with using natural products for insomnia

FDA considers them as supplements so they’re unregulated. Problems happen from unsafe processing. Melatonin from stores have wide varying doses and adulterants including benzos.

uncomfortable creepy crawly feeling/pins and needles in the leg. occurs in waking and sleep onset. if pt is lying down inc leg discomfort. they shake their leg to make the feeling go away causing random leg disturbances

restless leg syndrome

Involuntary rhythmic twitches, usually ankle dorsiflexion. Each time they move the pt is aroused and it can cause sleep fragmentation. These pts don’t know they they’re moving and might just complain of hypersomnia. They might present with accidentally kicking their bedmates or disarranging bed linens

Periodic limb movements

Pts with restless leg syndrome and periodic limb movements can have similar sx to what

When someone discontinues illicit substances or meds like antidepressants

How to treat restless leg syndrome and periodic limb movements

tx underlying cause. d/c meds that cause it. Tx reduces muscle activity or sleep disruption. usually dopaminergic agent (ropinerole), GABAergic agent (gabapentin, clonazepam), opioids like codeine preps.

What is the approved tx for restless leg syndrome

Dopaminergic agents like ropinirole. On alternate nights pt should use benzos or opioids.

Pathologically inc sleep duration (like a pt with atypical depression sleeping for 14 hours). Sleep attacks where there is abrupt onset, excessive daytime sleepiness, or both. Assoc with bad sleep at night (sleep disturbed by PLMs) and circadian rhythm disorders. M/c cause is chronic lack of sleep

Hypersomnias

how to tx hypersomnia

Correct the pathophysiology of the dz itself. Supportive therapy to adjust to the illness and social change, early tx to minimize fatal results like falling asleep while driving.

abnl ventilation during sleep presenting as excessive daytime sleepiness or insomnia. sleep apnea and central alveolar hypoventilation.

breathing related dosirders

This dz is the m/c cause of excessive daytime sleepiness

OSA

pt has abnl breathing during sleep, assoc w snoring and gasping for air.

Breathing related sleep d/o

What does polysomnography show in a to with a breathing related sleep d/o

Apneas (stop breathing) and hypopneas (shallow bad breaths)

What is the respiratory disturbance index in a pt with breathing related sleep d/o and what is abnormal

Total amount of these events per hour. > or equal to 10 is abnormal, > or equal to 15 needs tx.

If a pt that has a breathing related sleep D/o goes untreated then what

Inc risk of pulmonary htn, right sided hf, cva, mi, sudden death, impotence, cognitive problems, and a depressive syndrome that stops with tx.

Respiratory drive governed by the brainstem shuts ff during sleep, occurs in neuro and CV d/o

central sleep apnea

this respiratory sleep d/o occurs with mechanically normal lungs, producing hypoxia and hypercarbia even without apneas or hypopneas, usually in morbidly obese pts.

central alveolar hypoventilation

this respiratory sleep d/o is assoc w conditions causing airway turbulence like a deviated septum

snoring

pts with a respiratory sleep d/o can also have what other sleep d/o

PLMs. if it doesn’t go away with apnea tx then tx PLMs specifically

how to tx obstructive sleep apneas

CPAP machine delivered via mask. dental devices to hold the tongue forward and the airway open. surgery like uvulopalatopharyngoplasty (UPPP) to enlarge upper airway by removing soft tissue

how to tx snoring

have pt sleep more upright w pillows if it’s positional. laser assisted uvuloplasty (LAUP) can be performed if needed to control snoring

complications of sleep apnea

CV/respiratory sequelae, early daytime sleepy accidents. non adherence w CPAP. if pt gets LAUP without polysomnography OSA can still be undiagnosed after snoring is fixed

uncontrollable sleep attacks in wrong time at wrong environment, even during driving for 15-20 mins usually. can have other sx like cataplexy (loss of muscle tone), hypnagogic hallucinations, (dreamlike experience when falling asleep) sleep paralysis

narcolepsy

pts with narcolepsy get what specific sx

daytime sleepiness, cataplexy triggered by surprise and anger emotions, hypnagogic hallucinations, sleep paralysis

why does narcolepsy happen

defective REM sleep regulation. Cataplexy and sleep paralysis = atonic w/o REM, hypnagogic hallucinations and sleep attacks linked to REM intrusion.

pts with narcolepsy have also had a hx of

TBIs

narcolepsy like syndromes withOUT cataplexy are produced by

comorbid neuro d/o

how to dx narcolepsy

pos multiple sleep latency test (MSLT), where pt has REM onset during 2 daytime naps after a night of polysomnography to r/o other causes

what is the drug of choice for a pt with early daytime sleepiness bc of neuro d/o, meds like sedating antipsychotics, and OSA w persistent EDS 

modafinil

how to tx narcolepsy

modafinil drug of choice. anti cataplectic meds like MAOIs, TCAs, SSRIs can also be used. Sodium oxybate only approved for cataplexy… but used for drug facilitated assault

complications of narcolepsy

withdrawal sx, psych tolerance, psychosis with amphetamines and sometimes methylphenidate. Dramatic cataplexy rebound happens if anti-cataplectic agent is stopped

unusual events or behaviors occurring during sleep or sleep-wake transitions.

parasomnias

non rem sleep parasomnias are described as

being difficult to wake up, confused when awakened, lack of memory.

rem sleep parasomnias are described as

waking clearly and fast with recall for an event

if your circadian rhythm is messed up pts complain of

insomnia or hypersomnia

what are the 2 processes that mediate your propensity to sleep

homeostatic process, where ability to sleep is directly related to duration of prior wakefulness. and your circadian process that regulates your ability to sleep thru a 24 hr day

major sx of prolonged sleep latency and hard waking up at a certain time is what type of parasomnia

delayed sleep phase type

sleepiness and alertness out of sync with new time zone, may be encountered w delayed or advanced sleep phase is what type of parasomnia

jet lag type

involves insomnia, hypersomnia or both at bad times in work schedules. pts usually have inc alc intake, low morale, hi absenteeism, or have ptsd. they don’t adjust to a new schedule bc they try to revert back to their original schedule on weekends. this parasomnia is

shift work type

early evening sleepiness, early sleep onset, and early morning awakening. this is what parasomnia

advanced sleep phase syndrome

pt doesn’t go to bed when its night time and goes to bed when it daytime. theri circadian rhythm doesn’t align with the 24 hour day. this parasomnia is

non 24 hour sleep wake syndrome

how to tx parasomnias

try to sync sleep and wakefulness w underlying phase position of circadian clock. have appropriate time cues to do this. maintain darkness during sleep period. melatonin can be a resynchronizing agent to help w jet lag. bright light, melatonin, hypnotics, caffeine, modafinil to manage shift work sleep disorder

complications of trying to correct parasomnias

maladaptive behaviors from trying to self treat (like using alc). excessive melatonin ca triger free running circadian rhythms that are hard to tx

subjective hypersomnia is m/c in pts with what psych d/o

atypical bipolar depression

what do pts with mania show in terms of their sleep

dec total sleep time and other abnl things on polysomnography

what do pts with MDD show in terms of their sleep

dec REM latency, inc REM, dec slow wave sleep, dec total sleep time

how to tx depression pt w mild insomnia and what’s the SE

antidepressants, bc they suppress REM sleep and affect slow wave sleep. SE of RLS and PLMs

. sedating antidepressants for severe insomnia. activating antidepressants for hypersomnic or anergic depressions

how to tx a depression pt with severe insomnia

sedating antidepressants like trazodone, mirtazapine, TCAs

how to tx a depression pt with severe hypersomnia or anergia

activating antidepressants like SSRIs, bupropion, venlafaxine, MAOIs. given early in the day

how to tx bipolar depression w insomnia

antidepressants + mood stabilizers or atypical antipsychs

what mood stabilizer does not cause early daytime sleepiness, esp when combined with other meds

lithium

complications of antidepressants to tx insomnia

unwanted sedation, some antidepressants worsen insomnia

what sleep d/o are found in PTSD pts

nightmares or phobic avoidance of sleep

what sleep d/o are found in a pt with panic d/o

panic attacks during slow wave sleep

what anxiety disorders have reported polysomnographic abnormalities

GAD, panic d/o, PTSD, OCD

how to tx anxiety with insomnia

psychotherapy, SSRIs and venlafaxine (SNRI) m/c, benzos good for acute anxiety sx but don’t always resolve insomnia

complications of anxiety + insomnia tx

benzo addiction leading to withdrawal, tolerance, abuse.

what psychotic disorders have sleep disturbances as a common sx

schizophrenia and schizoaffective d/o that gets more severe when an acute ep develops

what is the most freq used sleeping aid in general population

alc

if you drink alc to go to bed how does your sleep patterns change

dec sleep latency, inc non rem sleep, dec rem sleep. you get a mini withdrawal in the middle of the night with shallow disrupted sleep and REM rebound

what sleep sx do alcoholics have

insomnia, hypersomnia, parasomnias, and even circadian rhythm disturbances. sleep disordered breathing and PLMs common long into abstinence.

how to tx alc withdrawal and in detox programs

benzos. not used much bc of inc abuse risk

how does cocaine and stimulants (amphetamines) affect your sleep

activates dopaminergic arousal system. withdrawal = hypersomnia dn depression. Insomnia SE, tolerance, physiological withdrawal occurs with use of amphetamines and methylphenidate (for narcolepsy and ADHD)

appropriately tx ADHD in children/teens does what to your risk of abusing substances

dec, by enhancing impulse control

caffeine effects last in the body for how long

8-14 hours

chronic nicotine use is assoc with what sleep sx

inc sleep latency and arousals in smokers. withdrawal causes insomnia or hypersomnia, but generally mild vs other sx. if heavy dependence then withdrawal sx awakens smokers until you take more.

a smoker has inc dreaming and insomnia, you tx with

nicotine patches

how do opioids affect sleep

indirectly improves sleep in pts with pain.

how to tx sleep disorders bc of opioid use

methadone used in detox, but chronic use disrupts sleep and inc freq of central apneas. methadone, buprenorphrine, and maltrexone are used long term for tx of opioid dependence

how does benzo abuse affect sleep

pts abuse benzos when they abuse alc of drugs. dec sleep latency, improve continuity, elevate stage 2 sleep, dec slow wave sleep and REM sleep. withdrawal is diff than rebound or re emergence of anxiety or insomnia. don’t stop benzos completely without medical guidance

if im taking benzos for short term use to tx acute insomnia or PLM/RLS what should i be aware of

don’t take on consecutive nights, pt should alternate. when you taper chronic use insomnia comes back. switching to longer acting benzos helps with taper and used to detox from barbiturates and benzos

what do i give to a pt who is weening off of benzos and is now at risk of seizures

anti convulsants