Sleep Disorders

Question 1

Genetic component of sleepwalking

Answer 1

HLA gene

Question 2

3 step model for treating NREM parasomnias

Answer 2

• Modify predisposing factors – avoid sleep deprivation / stress
• Improve safety of sleeping environment
• Pharmacotherapy (benzos)

Question 3

What parts of the brain are involved in REM sleep?

Answer 3

The critical structures for initiation of REM sleep are cholinergic neurons in the pons and midbrain.

Question 4

Population for RBD

Answer 4

• Usualy occurs in elderly men. Risk of developing Parkinson’s or dementia.
• Associated w/ narcolepsy in young pxs.

Question 5

Diagnosis and Tx for RBD (5 things)

Answer 5

•PSG is needed to confirm diagnosis. Look for elevated muscle tone.

Treatment
• Remove any causative drugs (antidepressants)
• Optimize safety of sleeping environment
• Benzos (but risky in elderly due to risk of falls)
• Melatonin
• Pramipexole (drug for PD)

Question 6

5 cardinal sxs of narcolepsy

Answer 6

• Excessive daytime sleepiness (EDS)
• Sleep paralysis – mix of REM and wake
• Hypnogogic / hypnopompic imagery – often mixed w/ sleep paralysis
• Cataplexy – Highly specific for narcolepsy. Loss of muscle tone in response to emotional stimuli such as laughter
• Automatic behaviors – may not remember how you just drove somewhere

Question 7

Cause of narcolepsy w/ cataplexy

Answer 7

Loss of hypocretin / orexin neurons in lateral hypothalamus. Most likely an autoimmune rxn due to association w/ HLA gene.

Question 8

Diagnosis of narcolepsy (2)

Answer 8

• PSG

* Multiple sleep latency test (MSLT) – shows fast sleep onset and fast entry into REM, even during naps.

Question 9

Treating narcolepsy (5)

Answer 9

• Avoid sleep deprivation
• Schedule naps – even 10-15 min work well
• Stimulants
• Antidepressants – tx cataplexy
• Sodium oxybate – tx EDS and cataplexy

Question 10

Restless legs syndrome
Population
Criteria
2 types
Tx (4)

Answer 10

• Most common in women, elderly, and northern European descent
• Criteria (URGE)
• Urge to move legs, usually with uncomfortable leg sensations (creepy-crawling, tingling, or itching)
• Rest – Onset or worsening of symptoms at rest or inactivity (lying or sitting)
• Gets better w/ movement
• Evening – Worsening of symptoms in the evening and at night
• 2 types
• Primary – caused by low iron stores in CNS
• Secondary – caused by iron deficiency anemia, renal failure, pregnancy, or meds (antidepressants, antiemetics, antispychotics, antihistamines)
• Treatment – iron replacement if ferritin is less than 50, behavioral strategies, DA agonists (pramipexole / ropinirole), or gabapentin

Question 11

What parts of the brain control circadian rhythms?

Answer 11

Suprachiasmic nucleus of the hypothalamus. Melatonin release from the pineal gland also plays a role.

Question 12

Risk factors for insomnia

Answer 12

Age (older), female (especially post-menopausal), divorce / widow, psychiatric illness (mood, anxiety, substance abuse), medical conditions, other sleep disorder, smoking, alcohol, coffee, meds

Question 13

Meds that may cause insomnia

Answer 13

Antidepressants, stimulants, steroids, bronchodilators, decongestants, antihypertensives / diuretics, alcohol (wake up in middle of night to pee)

Question 14

Psychiatric disorders that may cause insomnia (4)

Answer 14

MDD, bipolar, GAD, PTSD

Question 15

Non-drug treatments for insomnia

Answer 15

Sleep hygiene
CBT - Challenge misconceptions about sleep, relaxation training, sleep restriction, stimulus control (get out of bed if can’t sleep)

Question 16

Drug treatment for insomnia

Answer 16

• Benzos – work well but have many side effects.
• Benzo receptor agonists (BzRAs) – bind to allosteric site on GABA-A receptor. Fewer side effects than benzos, but still present. Include zolpidem, eszopiclone, and zaleplon
• Melatonin agonists (ramelteon) – no cognitive impairment or abuse. Better for sleep initiation than maintenance.
• Orexin antagonists (suvorexant)
• Doxepin – TCA w/ strong H1 affinity. Good for sleep maintenance
• OTC drugs – antihistamines
• Off-label drugs – very commonly used but not much supporting evidence
• Sedating antidepressants, anticonvulsants (gabapentin), and atypical antipsycotics

Question 17

Mechanism of benzo receptor agonists

Which drugs?

Answer 17

Bind ot allosteric site on GABA-A receptor

Zolpidem, eszopiclone, and zaleplon