Sleep Disorders

Question 1

Area of brain that regulates sleep

Answer 1

• suprachiasmatic nucleus
• pineal gland

blue light to retina, projects to SCN, projects to pineal gland and inhibits melatonin production

Question 2

List 7 general causes of insomnia

Answer 2

1. poor sleep hygiene
2. Psychiatric conditions
3. medical conditions
4. acute stressors
5. circadian rhythm disorders
6. medications
7. primary sleep disorder

Question 3

Examples of poor sleep hygiene that can cause insomnia

Answer 3

alcohol
caffeine
nicotine
sleep schedule

Question 4

examples of psychiatric conditions that can cause insomnia

Answer 4

anxiety

depression

Question 5

Examples of medical conditions that can cause insomnia

Answer 5

lung disease
heart failure
neuro disorders
pain disorders

Question 6

Examples of acute stressors that can cause insomnia

Answer 6

bereavement
relocation
marriage/divorce

Question 7

Examples of circadian rhythm disorders that can cause insomnia

Answer 7

• advanced or delayed sleep phase

- irregular sleep/wake

Question 8

Examples of medications that can cause insomnia

Answer 8

• BB
• bronchodilators
• CNS stimulants
• corticosteroids
• decongestants

Question 9

Examples of primary sleep disorders that can cause insomnia

Answer 9

sleep apnea

Question 10

primary therapy for insomnia

Answer 10

cognitive behavioral therapy

Question 11

Online program that is as effective as face-to-face CBT for insomnia

Answer 11

www. cbtforinsomnia.com

- 5 weeks, 5 sessions, all online CBT

Question 12

Drug categories that have been evaluated for insomnia management

Answer 12

• BZDs
• Orexin receptor antagonists
• Melatonin (Ramelteon)
• off label (Trazodone MC, TCAs like amitriptyline, mirtazapine, quetiapine, hydroxyzine

Question 13

Define narcolepsy

Answer 13

Sleep disorder characterized by excessive sleepiness, sleep paralysis, hallucinations, possible cataplexy

Question 14

Define cataplexy

Answer 14

Partial or total loss of muscle control, often triggered by strong emotion like laughter

Question 15

State role of orexin/hypocretin receptors in sleep

Answer 15

• Interact with all wake-promoting areas of the brain and spinal cord
• Pts with narcolepsy (esp with cataplexy) are deficient in orexin
• Thought is if can antagonize orexin, can put person to sleep

Question 16

What is the role of orexin/hypocretin receptors in therapy of narcoplepsy

Answer 16

Thought is if can antagonize orexin (which is low in people with narcolepsy), can put person to sleep

Question 17

What wavelength of light stimulates the retina and ultimately affects melatonin levels?

Answer 17

blue light

Question 18

Define mixed apnea

Answer 18

combo of OSA and CSA

Question 19

Define treatment induced CSA

Answer 19

can be caused by inappropriately titrated CPAP settings

Question 20

What is GS dx test for sleep apnea

Answer 20

polysomnogram

aka “sleep testing”

Question 21

What is PSG, how is it used in testing/management of apnea

Answer 21

polysomnogram

• Record of sleep activity.
• Includes EEG to determine stages of sleep, EKG to look for arrhythmias (bradycardia and afib most common)
• Determines how many episodes of apnea happen in the session

Question 22

What is PAP titration, how is it used in testing/management of apnea

Answer 22

positive air pressure titration

• Everyone’s pressure requirement is different
• Procedure to change the pressure of the CPAP until enough pressure to tx sleep apnea but not too high (can confuse RAS and cause “induced central apnea”)

Question 23

What is split night, how is it used in testing/management of apnea

Answer 23

half the night’s testing is to figure out the dx, the second half of the night is to figure out a tx plan

Question 24

What is MSLT, how is it used in testing/management of apnea

Answer 24

• multiple sleep latency testing
• For excessive sleepiness syndromes (like narcolepsy)
• Go to lab during day, have 5 scheduled 20 minute nap sessions
• Look for sleep latency and how quickly pt entered REM sleep
• Considered abnl if pt enters REM in 2 or more of the naps

Question 25

What is MWT, how is it used in testing/management of apnea

Answer 25

- maintenance of wakefulness - Put pt in a boring room, tell pt not to sleep - Used for truck drivers and pilots to prove pt is appropriately treated and will stay awake when necessary

Question 26

GS tx for sleep apnea

Answer 26

PAP therapy

Question 27

What is the utility of mandibular advance devices in managing sleep apnea

Answer 27

not good, don't use

Question 28

Restless limb syndrome - MC secondary cause - best way to dx - recommended therapy

Answer 28

- iron deficient anemia - test for ferritin levels - iron supplement to tx OR anti-da drugs bc is a muscular movement disorder

Question 29

Define periodic limb movement disorder. how is it usually IDed?

Answer 29

- Kick all night but not aware | - often IDed by spouse who is sick of being kicked

Question 30

What is the site of endogenous circadian cycle control?

Answer 30

Suprachiasmatic nucleus

Question 31

What is the primary determinant of circadian phase

Answer 31

nadir (lowest part) of core body temp

Question 32

what is definition of entrainment

Answer 32

Process by which light synchronizes the SCN to a 24 hour cycle

Question 33

What happens to phase response curve when there is light exposure before the nadir of core body temp

Answer 33

leads to phase delay (light later in the day) | - example is to treat advanced sleep phase

Question 34

What happens to phase response curve when there is light exposure after the nadir of core body temp

Answer 34

leads to phase advance (light in the morning) | - example is to treat delayed sleep phase

Question 35

Delayed sleep phase

Answer 35

- Delay in the phase of sleep period in relation to desired sleep time - Chronic or recurrent complaint of inability to fall asleep at a desired time and inability to awaken at a desired/socially acceptable time - Classic teenage sleep pattern

Question 36

Advanced sleep phase

Answer 36

- Converse of delayed sleep phase - Go to bed early and wake up early - Middle aged and elderly

Question 37

Jet lag

Answer 37

- Insomnia and excessive daytime sleepiness associated with jet travel - Impairment of daytime function, general malaise, GI disturbance - Occur bc endogenous circadian rhythm is misaligned to external clock

Question 38

Shift work sleep disorder

Answer 38

- Constant state of circadian misalignment | - Work and sleep at the wrong circadian phase

Question 39

Therapy for delayed sleep phase

Answer 39

- Blue light 30 minutes following rise time, advance 30 minutes earlier every few weeks until desired wake time is achieved - Melatonin: given 12 hours prior to light exposure

Question 40

Therapy for advanced sleep phase

Answer 40

- Blue light 30-60 min prior to patient’s bed time - Melatonin not effective - Possibly pharm options and caffeine

Question 41

Therapy for jet lag

Answer 41

- Blue light (using process for delayed and advanced sleep phases) - Avoidance of light - Melatonin 12 hours prior to light therapy like for delayed sleep phase

Question 42

Therapy for shift work sleep disorder

Answer 42

- Light therapy - Melatonin - Hypnotics to improve sleep quality - To improve alertness: caffeine, modafinil/armodafinil, scheduled naps

Question 43

What is the dual mechanism interaction of sleep

Answer 43

Homeostatic - accumulates as a function of wakefulness - important factor in sleep quality Endogenous - core temp and melatonin - important for sleep quantity