Sleep Disorders (Behave)

Sleep

regular, recurrent, easily reversible state of unconsciousness

What is the function of sleep

restorative, homeostatic function

thermoregulation

energy conservation

What are the two states of sleep

Non-rapid eye movement sleep (NREM)

Rapid eye movement sleep (REM)

What is the average sleep need per night

7-8 hours

Sleep latency

average time to be completely asleep

Sleep latency above what time is considered abnormal

more than 20 min is abnormal

What are the stages of sleep

NREM 1

NREM 2

NREM 3

REM

NREM Stage 1

The transition period from wakefulness and sleep

Usually around 5-10 minutes

What occurs in NREM 2

Body temp drops

HR slows

Brain begins to produce sleep spindles

How long does NREM 2 take

20 min

What occurs in NREM 3

Muscles relax

BP drop

RR drop

What stage of sleep is the deepest

NREM 3

What can increase the amount of NREM sleep

Heavy execrise

Starvation

Purpose of NREM Sleep

Repairs tissues

Regulates hormones

Clears out brain toxins

Memory consolidation

How do we judge the stage of NREM a patient is in

EEG activity

What can be caused by arousal from NREM 3

disorientation,

possible amnesia,

enuresis,

sleep walking,

night terrors

What are the wave types of NREM

Stage 1 → Theta Waves

Stage 2 → Sleep Spindle

Stage 3 → Delta Wave

What occurs during REM

rapid eye movements

Near total paralysis of skeletal muscle

Cortical activation

Pupillary dilation

Increased heart rate variability and resp. rate

Erections

High level of brain activity and physiological activity similar to wakefulness

Poikilothermia

Dreams

What areas of the brain get more blood during REM

Thalamus

Visual Motor

Sensory Cortex

What is the EEG finding of REM

Saw tooth waves

Poikilothermia

body temperature varies based on the environment

Sign of REm

Failure to shiver or sweat in response to environmental temperature in sleep is a normal sign for

REM (Poikilothermia)

How does dreams differ in REM and NREM

REM → abstract and surreal

NREM → lucid and purposeful

What is the theory on dreams

changes in blood flow in the brain theory of why dreams so vivid yet unquestioning acceptance with bizarre content

Purpose of REM sleep

Consolidation of short-term memory to long-term

Process emotional experiences

Stimulate areas of the brain important for learning

What is the typical percent of sleep spent in NREM vs REM

NREM → 75%

REM → 25%

When does REM typically occur in sleep

Cyclically every 90 min to 100 min

First is the shortest (10 min) and increases to 40 min

If a patient is able to achieve REM prior to 90 min, this indicates

Pathology

What structures is considered the sleep “switch”

ventrolateral preoptic nucleus (VLPO)

ventrolateral preoptic nucleus (VLPO)

An area in the anterior hypothalamus that becomes active during sleep

What occurs in VLPO when active for sleep

uses the inhibitory neurotransmitters GABA and galanin to initiate sleep by inhibiting the arousal regions of the brain

How does the VLPO change with age

Decreases amount of neuron

What neuro condition has been shown to affect the VLPO

Alzheimer’s

What neurotransmitter triggers REM

Acetylcholine

What neurotransmitters inhibit REM

Norepinephrine

Serotonin

Histamine

What medications decreases REM sleep

Anticholinergics

Antidepressants that increase norepinephrine and serotonin

What neurotransmitter stimulates wakefulness

Dopamine

How does serotonin affect sleep

Important for regulation

Lack of serotonin → Sleep Reduction

L-tryptophan reduces nocturnal awakening

L-tryptophan

Precursor to serotonin

What neurotransmitter affects the circadian rhythm

Melatonin

What produces melatonin

Pineal Gland

What inhibits melatonin

Bright light

What effects does sleep deprivation have on the body

decrease in core body temperature,

decrease in immune system function

decrease in the release of growth hormone

cause of increased heart rate variability

contributing to obesity

poor control of type II diabetes

both speed and accuracy demonstrate considerably slowed speed (< 7 hrs sleep) before accuracy begins to fail (< 5 hrs sleep)

Increased risky behavior

ego and mood disorganization,

hallucinations and delusions

debilitated appearance, weight loss,

eventual death

When do accuracy and speed for cognitive tasks slow due to sleep deprivation

Speed → < 7 hours

Accuracy → < 5 hours

When does sleep deprivation cause increase in risk behavior

< 5 hour

STOP-BANG

A screening assessment for OSa

Trouble falling asleep is typically associated with

Anxiety

Nocturnal awakening is typically associated with

Depression

Epworth Sleepiness Scale (ESS)

A standardized questionnaire for sleep disorders

What are the components of STOP-BANG

Snoring

Tireed

Observed (Stop breathing, choke, or gasp)

Pressure (High)

BMI (>35)

Age (>50)

Neck Circumference (> 16 in / 40 cm )

Gender (Male)

What is the gold standard for sleep disorders

Polysomnography (PSG)

What does polysomnography record

EeG

Eye movement

Muscle tone

HR

Breatthing

Pulse Ox

Home sleep apnea testing (HSAT)

A take home screening test for sleep disorder

If a HSAT is positive, what is the next step

Polysomnography to confirm

What medications have insomnia as a side effect

Stimulants

Glucocorticoids

Opiodis

SSRI/SNRI

How do we reduce insomnia from stimulants

Decrease dose

Change to short acting

Dose earlier in the day

How do we reduce steroid induced insomnia

Decrease dose

Dose earlier in the day

How does opioids cause insomnia

While sedating changes sleep architecture and leads to nocturnal awakenings

How do we reduce insomnia with SSRI/SNRI

Dose in the AM

What is considered “trouble falling alseep”

Longer than 30 min

What is considered trouble staying asleep

Frequent awakenings

Early morning awakenings

What are the broad categories of sleep disorders

Parasomnia

Dyssomnia

Parasomnias

unusual experiences or behaviors that occur during sleep

Dyssomnias

characterized by abnormalities in the amount, quality, or timing of sleep

Types of Parasomnia

Sleep terror disorder

Sleepwalking

Nightmare disorder

Restless Leg Syndrome

Non-Rapid Eye Movement Sleep Arousal Disorders

Rapid Eye Movement Sleep Behavior Disorder

Types of Dyssomnai

Insomnia Disorder

Hypersomnolence Disorder

Narcolepsy

Breathing-Related Sleep Disorders

Circadian Rhythm Sleep Disorders

Types of Breathing-Related Sleep Disorder

Obstructive Sleep Apnea Hypopnea

Central Sleep Apnea

Sleep-Related Hypoventilation

What are the aspects of sleep hygeine

Sleep in a bed

Use bed only for sleep and sex

Establish a routine before going to bed

Get up if not asleep in 20 minutes

Avoid stimulants, caffeine, daytime naps

Avoid evening exercise, late large meals

Room should be cool and dark

Attempt sleep same time of night, awaken same time

Avoid screen time in the evening

Meditation, relaxation techniques, biofeedback can be helpful

Being active throughout the day

Satisfying sexual experiences can promote sleep

Avoid alcohol

Cognitive Behavioral Therapy for Insomnia

A special type of CBT made for chronic insomnia

What are medications options for sleep disorders

Melatonin/melatonin receptor agonists

Z-drugs

Antihistamines

Dual orexin receptor antagonists

Benzodiazepines

Who do we need to be cautionous about treating sleep disorders with medication?

Renal/hepatic disease

Alcohol consumption

Pulmonary disease/sleep apnea

Pregnancy

Nighttime decision makers

Patients greater than 75 years old

Use with opioids

Known parasomnias

What increases melatonin production

Dark enviroment

What is the production path of melatonin

Tryptohan

Serotonin

Melatonin

OTC Melatonin is best for helping with

sleep initiation

Ramelteon (Rozerem)

Melatonin Receptor Agonist

MOA of Ramelteon (Rozerem)

Binds with much higher affinity to melatonin receptors than melatonin

What type of sleep disorders does Ramelteon best treat

Sleep onse

When is Remelteon taken

30 min before sleep

Benefits to Using Ramelteon (Rozerem)

Less side effects

Does not appear to be habit forming or have rebound insomnia

Contraindications for Ramelteon (Rozerem)

Liver insufficency

Taking Fluvoxamine (Luvox)

Tasimelteon (Hetlioz)

Melatonin Receptor Agonist

Indication for Tasimelteon (Hetlioz)

non-24-hour sleep wake disorders in the completely blind

Z-Drugs

Non-benzodiazepine receptor agonists

MOA of Z-Drugs

Modulates GABA receptors

Action on GABA receptor is more selective

don’t have muscle relaxant or anticonvulsant effect you have with benzos

What is needed to prescribe Z-drugs

DEA (Scheudle IV)

Zalepon (Sonata),

Z-Drugs

Zolpidem (Ambien)

Z-Drugs

What Z-Drug cannot be taken long term

Zolpidem (Ambien)

Zolpidem ext release (Ambien CR)

Z-Drug

Eszopiclone (Lunesta)

Z-Drug

When is Zalepon (sonata) taken

Immediatly before bed

Benefits of Using Zalepon (Sonata)

Decreases sleep latency,

short ½ life = less am drowsiness

When should Zolpidem (Ambien) be taken

20-30min prior to bed

Use for Zolpidem (Ambien)

Decreases sleep latency,

not good for frequent awakenings

Use for Zolpidem ext release (Ambien CR)

Decreases sleep latency

sleep maintenance

When is Eszopiclone (Lunesta) taken

Take immediately before bed

What Z-drugs need to be taken 7-8 hours before planned awakening

Zolpidem ext release (Ambien CR)

Eszopiclone (Lunesta)

Side Effects of Z-drugs

Headache, dizziness, somnolence

Parasomnias

Non-retrograde amnesia

Depending on ½ life: sleep hangover

Falls in elderly

BLACK BOX: behaviors caused by these medicines have led to serious injuries or death

Contraindication for Z-drugs

BLACK BOX: patients who have previously experienced complex sleep behaviors after taking any of these medicines

What needed to prescribe DORAs

DEA (Schedule IV)