Sleep Disorders

normal sleep

regular, recurrent, easily reversible state of unconsciousness

effected by neurotransmitters and circadian rhythm

restorative, homeostatic

Sleep serves what function?

thermoregulation and energy conservation

normal sleep is crucial for what?

NREM and REM

What are the 2 physiological states of normal sleep?

sleep latency

average time to be completely asleep is >20 min, which is abnormal

7-8 hours

average hours of sleep per night?

reduced (lower pulse, RR, episodic involuntary muscle movements)

In NREM sleep most physiological functions are ______

heavy exercise, starvation

NREM sleep increases after?

repairs tissues

regulates hormones

clears out brain toxins

memory consilidation

NREM sleep purpose?

EEG activity

the 3 stages of NREM sleep are judged by what?

delta waves

What is unique about stage 3 of NREM sleep?

disorientation, possible amnesia, specific pathology of enuresis, sleep walking, night terrors

NREM stage 3 arousal causes what?

rapid eye movements

REM sleep is characterized b y?

near total paralysis of skeletal muscle

cortical activation

pupillary dilation

increased HR variability and resp rate

erections

REM sleep presentation?

high level activity similar to wakefulness, saw tooth waves

EEG findings for REM sleep?

body temp varies based on environemnt

what is poikilothermia in REM sleep?

REM sleep

Dreams are usually in NREM or REM?

changes in blood flow in brain

Dreams are due to what?

no

Does dreaming occur in NREM?

consolidation of short-term memory to long-term

process emotional experiences

stimulate areas of brain important for learning

purpose of REM sleep?

NREM

What phase of sleep do we spend most of our time?

90-100 min

Typically REM sleep occurs cyclically every ……

pathology

If REM occurs before 90 min of first falling asleep what is suspected?

ventrolateral preoptic nucleus (VLPO)

The switch for sleep is considered to be the…..

anterior hypothalamus

Where is the VLPO located?

GABA, galanin

The VLPO becomes active during sleep and uses the inhibitory neurotransmitters _____ and ______ to initiate sleep by inhibiting the arousal regions of the brain

aging

Number of neurons in VLPO decrease with….

acetylcholine

What neurotransmitter triggers REM sleep?

NE, serotonin, histamine

What inhibits REM sleep?

NE and serotonin, REM

Antidepressants that increase _____ and _____ often suppress ____ sleep

dopamine

what neurotransmitter stimulates wakefulness?

serotonin

What is neurotransmitter important in regulation of sleep?

melatonin

What helps with circadian rhythm?

pineal gland

Where is melatonin released from?

bright light

melatonin is inhibited by what?

decrease in core body temp

decrease in immune system function as measured by WBC and activity

decrease in release of GH

Sleep deprivation leads to what?

obesity, type II DM

Short-term sleep deprivation has been implicated in contributing to _____ as well poor control of ________

higher-order cognitive tasks

With decreased sleep what cognitive tasks are affected early and disproportionately

<5 hours

increased risky behavior seen when how many hours of sleep?

ego and mood disorganization, hallucinations, delusinos

Sleep deprivation leads to what?

STOP-BANG

what assessment for OSA?

epworth sleepiness scale

STOP-BANG for OSA

Standardized questionnaires for eval of sleep disorders?

Snoring

Tired

Observed

Pressure

BMI

Age

Neck size

Gender

what does STOP BANG stand for?

polysomnography

What is the gold standard testing for sleep?

monitors brain waves, eye movements, muscle tone, heart rate, breathing, pulse ox

PSG monitors what?

sitmulants

glucocorticoids

opioids

SSRI/SNRI

What meds can cause insomina?

parasomnias, dyssominias

what are the two categories of sleep disorders?

parasomnias

unusual experiences of behaviors that occur during sleep

dyssomnias

characterized by abnormalities in amount, quality or timing of sleep

sleep in bed

only use bed for sleep and sex

establish routine before going to bed

get up if not asleep in 20 min

avoid stimulants, caffeine, daytime naps

avoid evening exercise, late large meals

room should be cool and dark

awaken at same time, attempt sleep same time of night

avoid screen time in evening

meditation, relaxation techniques, biofeedback can be helpful

being active throughout the day

satisfying sexual experiences can promote sleep

avoid alcohol

Sleep hygeine?

treat underlying disorder

CBT for insomnia

Meds

Tx for sleep disorders?

renal/hepatic disease

alcohol consumption

pulmonary disease/sleep apnea

pregnancy

nighttime decision makers

patients >75 y/o

use with opioids

known parasomnias

cautions with sleep meds?

melatonin

this is produced by the pineal gland, increased secretion with dark, decreased with light

thought to regulate sleep-wake cycles, circadian rhythm

tryptophan converts serotonin to this

ramelteon

this binds w/ much high affinity to melatonin receptors than melatonin

ramelteon

what med is best for sleep onset issues?

liver insufficiency, taking fluvoxamine

avoid ramelteon in who?

tasimelteon

this is FDA approved for non-24-hour sleep wake disorders in completely blind

non-benzo receptor agonists, modulate GABA receptors making GABA more selective

Z-drug MOA?

does not have muscle relaxant or anticonvulsant effect

Since z-drugs cause GABA receptor to be more selective what is the result?

IV

what is the schedule of z-drugs?

zolpidem (ambien)

what z-drug is not approved for long term use?

zalepon (sonata)

z-drug

• take immediately before bed

• decreases sleep latency, short ½ life, less AM drowsiness

zolpidem (ambien)

z-drug

• take 20-30 min prior to bed

• decrease sleep latency, not good for frequent awakenings

zolpidem extended release

decreases sleep latency and sleep maintenance

need at least 7-8 hours before planned awakening

eszopiclone

take immediately before bed

need to at least 7-8 hours before planned awakening

headache, dizziness, somnolence

parasomnias

non-retrograde amnesia

depending on ½ life: sleep hangover

falls in elderly

side effects for z-drugs?

contraindicated in patients who have previously experienced complex sleep behaviors after taking any of these meds

advise all patients that although rare, the behaviors caused by these meds have led to serious injuries or death

FDA black box for z-drugs?

orexin A and B

What are hypothalmic neuropeptides that play a key role in promoting wakefulness and regulating sleep-wake cycle?

IV

schedule for DORAs?

suvorexant

lemborexant

daridorexant

DORA examples?

daytime somnolence, parasomnias

rebound insomnia when stopped

metabolized by P450

S/E of DORAs

narcolepsy

DORAs contraindicated in who?

doxepin

What tricyclic can be used for sleep?

doxepin

enhances sleep-maintenance, at low doses approved for insomnia, no abuse potential

somnolence, nausea, anticholinergic

S/E of tricyclics

acute angle glaucoma, urinary retention

tricyclic contraindications?

benzos

these reduce time to onset of sleep

prolong stage 2 NREM sleep

prolong total sleep time

reduce relative amount of REM sleep

habit forming/abuse, short term

Benzos can be _____/_____ potential, and only used for what period of time?

elderly, alcohol/opioids

caution with benzos …

temazepam

what benzo is used most for sleep initiation?

clonazepam

what benzo is is also used for sleep initiation and to sustain sleep?

lorazepam, alprazolam

what benzos are better for problems with sleep intiation, but have higher abuse potential?

respiratory depression

daytime drowsiness

dizziness

dementia

increased risk of falls

s/e benzos?

caution with opioid use

benzo black box warning?

diphenhydramine

doxylemine

hydroxyzine

antihistamines for sleep?

decreased alertness/cognitive function, delirium, dry mouth, blurred vision, urinary retention, constipation, prolonged QT and increased intraocular pressure and dementia risk

s/e of antihistamines?

trazodone

mirtzapine

quetiapine

off label meds for sleep?

trazodone

antidepressant off label med for sleep

priapism, prolonged QT, syncope, edema, blurred vision, diarrhea, serotonin syndrome

S/E trazodone?

MAOIs

avoid trazodone use with what?

mirtazapine

tricyclic antidepressant off label med used for sleep

hunger, weight gain, somnolence, dizziness

s/e mirtazapine

increased risk of suicidal ideation in children

black box for mirtazapine?

quetiapine

atypical antipsychotic off label used for sleep

EPS, neuroleptic malignant syndrome, hypoTN, weight gain, prolonged QT

s/e of quetiapine?

increased mortality in pt with dementia related psychosis; increased suicidality in children

black box warning

difficulty initiating sleep

difficulty maintaining sleep; frequent awakenings or problems returning to sleep

early morning awakening with inability to return to sleep

insomnia dx sx?

one or more

how many sx needed for insomnia dx?

3 nights per week

how often must sleep difficulty occur to dx insomnia?

3 months

insomnia present for how long?