Sleep 2

Question 1

Central Disorders of Hypersomnolence

• Be sure to evaluate for ____ prior to dx

Answer 1

Sleep Deprivation

Question 2

Which condition?

• Loss of hypothalamic neurons that produce orexin neuropeptides (hypocretins)
• May have autoimmune component

Answer 2

Central DIsorders of Hypersomnolence

Narcolepsy

Question 3

People w/ narcolepsy have what 3 issues/

Answer 3

• Difficulty sustaining wakefulness
• Poor regulation of REM sleep (immediately enter REM sleep)
• Disturbed nocturnal sleep

Question 4

Which type of narcolepsy?

• w/ cataplexy
• w/o cataplexy

Answer 4

• w/ : type 1
• w/o : type 2

Question 5

Definition:

Sudden muscle weakness w/o LOC, usually triggered by strong emotions

Answer 5

Cataplexy

Question 6

2 alternative presentations of narcolepsy besides with or without cataplexy

Answer 6

• Hypnagogic hallucinations (dream like hallucinations at sleep onset or upon awakening - hypnopompic)
• Sleep paralysis - muscle paralysis upon awakening or just before falling asleep

Question 7

Narcolepsy

• Excessive daytime sleepiness (usually severe)
• Feel ____ upon awakening
• Have episodes of _____
• Epworth sleepiness scale score is typically > __
• Besides excessive daytime sleepiness, also associated w/ what 4 things?

Answer 7

• rested
• “sleep attacks”
• 15

1. Fragmented sleep
2. other sleep disorders
3. psych comorbidities
4. obesity

Question 8

Dx of Narcolepsy

• Start w/ _____
• _____ to r/o other causes
  
  • REM sleep within ___ mins of sleep onset at night

Answer 8

• H&P
• Polysomnogram
  
  • 15 mins

Question 9

Which test for narcolepsy?

• Sleep latency <8 mins
• REM episodes in at least 2 of the naps

Answer 9

Multiple Sleep Latency Test

Question 10

Pts w/ Narcolepsy should avoid what 4 things?

Answer 10

• Benzos
• Opiates
• Antipsychotics
• Alcohol

(BOAA)

Question 11

Pts w/ narcolepsy should get adequate sleep at night, along w/ what type of naps?

Answer 11

1 to 2 well timed 20 minute naps

Question 12

Screen narcolepsy pts for what 3 things?

Answer 12

• depression
• anxiety
• CV risk

Question 13

1st line pharm tx for narcolepsy?

Answer 13

• Wake promoting medication: Modafinil

Question 14

Which drug for narcolepsy?

• CNS stimulant
• Potent wakefulness promoting drug

Answer 14

Methylphenidate

Question 15

Which drug for narcolepsy?

• CNS stimulant
• MOST potent wakefulness promoting drug

Answer 15

Amphetamines

Question 16

Which 2 medications should be prescribed for cataplexy?

Answer 16

• Antidepressants (increase noradrenergic / serotonergic tone)
• Sodium oxybate (CNS depressant)

Question 17

What 3 medications are used in Narcolepsy which suppress REM sleep and Cataplexy?

Answer 17

• Venlafaxine
• Fluoxetine
• Tricyclics

Question 18

Which condition?

• Chronic / recurrent pattern of sleep wake rhythm disruption caused by an alteration in endogenous circadian timing system & desired/required sleep wake schedule
• Sxs duration of at least 3 months
• “shift work disorder”
• Jet lag disorder

Answer 18

Circadian rhythm sleep-wake disorders

Question 19

Which condition?

• Fragmented sleep
• Difficulty falling asleep
• Difficulty staying asleep
• Poor sleep quality
• Reduced sleep duration

Answer 19

Circadian Rhythm Sleep Wake Disorders

(shift work disorder)

Question 20

2 types of therapies for Circadian Rhythm Sleep-Wake Disorders (shift work disorder)

Answer 20

• CBT
• Therapeutics such as: short acting hypnotic agent, exogenous melatonin, caffeine, wake promoting agents

Question 21

Circadian rhythm sleep wake disorder (shift work disorder)

Prognosis

• RIsk of ____
• Negative impact on ___ resulting in what 4 things?
• ___ concerns

Answer 21

• insomnia
• work ->
  
  • absenteeism
  • reduced productivity
  • increased injuries
  • increased illnesses
• Safety

Question 22

Which condition?

• Undesirable physical events (movements/behaviors)
• Undesirable experiences (emotions, perceptions, dreams)

<—-That occur during ENTRY into sleep / within sleep / or during AROUSALS from sleep

• More common in _____

Answer 22

Parasomnias

• Children

Question 23

4 NREM related disorders of arousal w/ Parasomnias?

Answer 23

• Confusional arousal
• Sleepwalking
• Sleep terrors
• Sleep-related eating disorder

(TWEC)

Question 24

REM related Parasomnias involve intrusion of the features of REM sleep into wakefulness

• 3 disorders of this?
• What is NOT a parasomnia, but is mistaken as such?

Answer 24

• Sleep paralysis
• Exaggerated features of REM sleep (nightmare disorder)
• Aberrations of REM sleep physiology (lack of atonia) atonia = muscles completely relaxed during REM
• Sleep talking (NOT a parasomnia)

Question 25

**Which condition?** * Dysfunction in orchestration of neural pathways regulating wake, NREM, and REM --\> leads to state dissociation

Answer 25

NREM related Parasomnias

Question 26

NREM related parasomnias usually occur during which stage?

Answer 26

**N3** in the first 1/3 of major sleep period

Question 27

**Criteria for what disorder?** * Recurrent episodes of incomplete awakening * Absent / inappropriate responsiveness * Limited or no cognition or dream report * Partial or complete amnesia for event

Answer 27

NREM related parasomnias

Question 28

Dx of NREM related parasomnias is made by what 2 things?

Answer 28

* History * PSG (if comorbid sleep disorder is suspected) -Polysomnography

Question 29

**Precipitating factors of what?** * Sleep deprivation * Emotional stress * Fever, menses, environmental / internal stimuli * Comorbid sleep disorders (OSA, periodic limb movement) * Medications / substances

Answer 29

NREM related parasomnias

Question 30

**Which condition?** * Sudden arousal from sleep associated w/ sitting up in bed, intense fear, piercing scream * Intense autonomic activation (tachycardia, tachypnea, diaphoresis, facial flushing, mydriasis) * Appear frightened / confused / inconsolable * Difficult to arouse * Usually no recollection of events * Lasts ____ mins * Calmly, quietyly return to sleep (do not interfere / try to wake pt)

Answer 30

**Sleep Terrors** | (NREM related Parasomnia)

Question 31

**Which condition?** * Slow quiet ambulation w/ eye open * Possible activities: such as what? * How does the episode end? * Appears confused * _____ when aroused * Self injury common or not common?

Answer 31

Sleep Walking (NREM parasomnia) * preparing food, eating, cleaning, rearranging furniture, driving, inappropriate behavior (urinating in closet) * Terminates spontaneously * agitated/aggressive when aroused * Self injury is NOT uncommon

Question 32

**Which condition?** * Variant of sleepwalking * Involuntary eating associated w/ diminished LOC during an arousal from sleep * NOT linked o daytime eating disturbances

Answer 32

Sleep related eating disorder (NREM parasomnias)

Question 33

How do you manage a pt w/ NREM parasomnias?

Answer 33

* Avoid sleep deprivation * Avoid ETOH Avoid certain meds * Maintain consistent, regular sleep-wake cycles * Safety interventions * Bystanders should allow pt to move freely * Bystanders should ensure safety w/o yelling, screaming, or arousing pt (gently coax pt back to bed) * Anticipatory awakening (wake pt before sleep terror bc you shouldn't wake pt during)