#3 Exam Normal Sleep and Sleep-wake disorders

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REM sleep in normal persons

The body musculature resting muscle potential is lower

Narcolepsy

a type of human leukocyte antigen, HLA-DR2 is found in 90 - 100 % of patients with narcolepsy. Deficient in the neurotransmitter hypocretin, which stimulates appetite and alertness.

sleep hygiene

can include: keeping regular hours of bedtime and arousal, avoiding excessive caffeine, not eating heavy meals before bedtime, and getting adequate exercise

Melatonin

endogenous hormone produced by the pineal gland, which is linked to the regulation of sleep

REM sleep

pairs an atonic body with an active brain (capable of creating elaborate dream fantasies)

Characteristics of Insomnia Disorder

-occurs at least 3 nights per week, present for at least 1 month -Episodic: last at least 1 month, but less than 3 -Persistent: last 3 months or longer -Recurrent: Two or more episodes within 1 year

Short sleepers

-require fewer than 6 hours of sleep each night to function adequately - are generally efficient, ambitious, socially adept, and content

long sleepers

-require more than 9 hours of sleep each night to function adequately. - have more REM periods and more rapid eye movements within each period (REM density). -tend to be mildly depressed, anxious, and socially withdrawn.

Sleep deprivation

-with prolonged periods can lead to ego disorganization, hallucinations, and delusions.

Psychophysiological insomnia features

1)excessive worry about not being able to sleep 2)trying too hard to sleep 3)rumination 4)increased muscle tension when attempting to sleep 5)somatic manifestations of anxiety 6)being able to sleep better away from one's own bed 7)being able to fall asleep when not trying to

sleep is made up of

2 physiological states: 1)non-rapid eye movement (NREM) 2)rapid eye movement (REM)

Sleep

About 90 minutes after sleep onset, NREM yields to the first REM episode of the night. This REM latency of 90 minutes is a consistent finding in normal adults; shortening of REM latency frequently occurs with such disorders as narcolepsy and depressive disorders

role of norepinephrine in sleep

NE-containing neurons will cell bodies located in locus ceruleus play important role in controlling normal sleep patterns. drugs that increase the firing of NE containing neurons reduce REM sleep and increases wakefulness

indications for polysomnography

`0diagnosis of sleep-related breathing disorders 2)positive airway pressure titration and assessment of treatment efficacy 3)evaluation of sleep-related behaviors that are violent or may potentially harm the patient or bed partner.

apnea

a period of cessation of breathing for 10 seconds or more during sleep.

during REM sleep

almost every period in men is accompanied by a partial or full penile erection. this is used in sleep studies for diagnosis

A brief period of insomnia is usually associated with

anxiety; either as a sequela to an anxious experience or in anticipation of an anxiety-provoking experience. transient insomnia of this kind may be related to grief, loss, or almost any life change or stress. a psychotic episode or a severe depression sometimes begins with acute insomnia

additional reasons for polysomnography

atypical parasomnias, sleep-related problems secondary to neuromuscular disorders, periodic limb movement disorder, arousals secondary to seizure disorder, those with excessive daytime sleepiness or those who wake up gasping of choking should be referred.

wakefulness

both the body and the brain are active

NREM sleep

both the body and the brain are much less active

Role of acetylcholine (ACh) in sleep

brain ACh involved in production of REM sleep - disturbances in central cholinergic activity are associated with the sleep changes observed in MDD.

sleep state misperception (subjective insomnia)

by a dissociation between the patient's experience of sleeping and the objective polygraphic measures of sleep. diagnosed when a patient complains of difficulty initiating or maintaining sleep and no objective evidence of sleep disruptions is found. can represent a somatic delusion or hypochondriasis.

RLS

check ferritin levels and B12 due to iron or folic acid deficiency anemias causing this. Also thyroid disease check TSH. Diabetes, fibromyalgia, rheumatoid arthritis, and COPD

Persistent insomnia

composed of a fairly common group of conditions in which the problem has difficulty falling asleep or remaining asleep. associated with somatized tension and anxiety and a conditioned associative response. may complain of apprehensive feelings or ruminative thoughts that keep them awake.

NREM

composed of stages 1-4 most physiological functions are markedly lower than in wakefulness

polysmnography

continuous, attended, comprehensive recording of the biophysiological changes that occur during sleep.30-sec segment of the recording is an epoch. looks at brain wave activity, eye movement, submental electromyography activity, nasal-oral airflow, respiratory effort, oxyhemoglobin saturation, heart rhythm, and leg movements during sleep are measured,

Parasomnias

disorders of partial arousal - a diverse collection of sleep disorders characterized by physiological or behavioral phenomena that occur during or are potentiated by sleep.

Insomina

dissatisfaction with sleep quantity or quality associated with one or more of the following symptoms: difficulty in initiating sleep, difficulty in maintaining sleep and frequent awakenings or problems returning to sleep, and early morning awakening with inability to return to sleep.

role of dopamine in sleep

drugs that increase dopamine produce arousal and wakefulness dopamine blockers increase sleep.

polysomnogram for OSA

episodes of OSA in adults are characterized by multiple periods of at least 10 seconds in duration in which nasal and oral airflow ceases completely (an apnea) or partially (a hypopnea), while the abdominal and chest expansion leads indicate continuing efforts of the diaphragm and accessory muscles of respiration to move air through the obstruction

L-tryphtophan in sleep

essential amino acid needed by the body to produce serotonin; found in protein-based food and dietary proteins (eggs, poultry, milk). ingestion of large amounts increases sleep and reduces nocturnal awakenings. Defenciety reduces REM sleep.

Clinical features of OSA

excessive sleepiness, snoring, obesity, restless sleep, nocturnal awakenings with chocking or gasping for breath, morning dry mouth, morning headaches, and heavy nocturnal sweating. HtN, erectile failure in men, depression, heart failure, nocturia, polycythemia and memory impairment as a result of obstructive sleep apnea hypopnea.

medical conditions known to cause hypersomnia

head trauma, stroke, encephalitis, parkinson's disease, inflammatory conditions, tumors, genetic diseases, and neurogenerative diseases

role of melatonin and sleep

hormone secreted from the pineal gland is inhibited by bright light, so lowest concentrations during the day. the suprachiasmatic nucleus of the hypothalamus may act as the anatomical site of the circadian pacemaker that regulates melatonin secretion and the entrainment of the brain to a 24-hour sleep-wake cycle.

insomnia can be classified

how it affects sleep (sleep-onset insomnia, sleep maintenance insomnia, or early-morning awakening). Can also be classified according to its duration (transient, short term, and long term)

Narcolepsy signs

hypocretin deficiency as measured using CSF hypocretin-1 immunoreactivity values (less than or equal to one third of values obtained in healthy subjects tested using the same assay or less than equal to 100pg/mg). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.

sleep walking and sleep terrors

involve momentary or partial wakeful behaviors suddenly occurring in NREM (slow wave) sleep

REM behavior disorder

involves a failure of the patient to have atonia (sleep paralysis) during the REM stage sleep. The result is that the patient literally enacts his or her dreams. Without this paralysis or with intermittent atonia, punching, kicking, leaping, and running from bed during attempted dream enactment occur.

Narcolepsy

is a condition characterized by excessive sleepiness, as well as auxiliary symptoms that represent the intrusion of aspects of REM sleep into the waking state.

NREM sleep in normal persons

is a peaceful state relative to waking. The pulse rate is typically slowed 5 - 10 bpm below the level of restful waking and is very regular. Respiration is similarly affected, and blood pressure also tends to be low, with few minute-to-minute variations. Episodic involuntary body movements are present, blood flow through most tissues and cerebral blood flow, is slightly reduced. Few if any REMs occur

cyclic nature of sleep

is regular - a REM period occurs about every 90-100 minutes during the night. The first REM period tends to be the shortest, usually lasting less than 10 minutes; later REM periods may last 15-40minutes. Most REM periods occur in the last third of the night, whereas stage 4 sleep occurs in the first third of the night.

REM

isolated sleep paralysis is the persistence of REM sleep atonia (sleep paralysis) into the wakefulness transition, whereas REM sleep behavior disorder is failure of the mechanism, creating paralytic atonia such that individuals literally act out their dreams.

Narcolepsy symptoms

most common is sleep attacks (cannot avoid falling asleep); Cataplexy sudden loss of muscle tone (jaw drop, head drop, weakness of the knees, or paralysis of all skeletal muscles with collapse; hypnagogic or hypnopompic hallucinations (vivid perceptual experiences, wither auditory or visual occurring at sleep onset or on awakening; sleep paralysis

The classic form of Narcolepsy

narcolepsy with cataplexy - characterized by the tetrad of symptoms 1)excessive daytime sleepiness 2)cataplexy 3)sleep paralysis 4)hypnagogic hallucinations. Abnormal sleep architecture in which REM sleep occurs soon after sleep onset both at night and during the day. Narcolepsy appears to be a REM sleep intrusion syndrome from the dysfunction of REM sleep generator gating mechanisms.

Role of serotonin in sleep

prevention of serotonin synthesis or destruction of the dorsal raphe nucleus of the brainstem, which contains nearly all the brain's serotonergic cell bodies, reduces sleep for a considerable time. Synthesis and release of serotonin by serotonergic neurons are influenced by the availability of amino acid precursors of this neurotransmitter, such as l-tryptophan

during REM sleep

pulse, respiration, and blood pressure are high during this sleep. brain oxygen use increases. thermoregulation is altered - a poikilothermic condition (a state in which animal temp varies with the changes in the temp surround medium) prevails during this sleep.

EEG records

rapid conjugate eye movements that are the identifying feature of the sleep state (no or few rapid eye movements occur in NREM sleep); the EEG pattern consists of low voltage, random, fast activity with sawtooth waves; The EEG shows a marked reduction in muscle tone.

Obstructive Sleep Apnea Hypopnea

repetitive collapse or partial collapse of the upper airway during sleep. During an obstructive apnea episode, respiratory effort continues but airflow ceases due to loss of airway patency. a reduction in breathing for at least 10 seconds (Hypopnea)

Polygraphic measures during REM

show irregular patterns, sometimes close to aroused waking patterns. looks like an active waking state. which is why REM sleep is called paradoxical sleep.

REM

sleep is a qualitatively different kind of sleep, characterized by a high level of brain activity and physiological activity levels similar to those in wakefulness.

Sleep regulation centers

small number of interconnecting systems or centers that are located chiefly in the brain stem and that mutually activate and inhibit one another.

Idiopathic insomnia

start early in life; cause is unknown; possibly neurochemical imbalance in brainstem reticular formation, impaired regulation of brainstem sleep generators (raphe nuclei, locus ceruleus), or basal forebrain dysfunction.

polysomnography

test to monitor brain waves, muscle tension, eye movement, and oxygen levels in the blood as the patient sleeps

NREM sleep

the deepest portions occur in stages 3 and 4. if aroused during this time the person will be disoriented, and their thinking will be disorganized. Brief arousals from slow-wave sleep are also associated with amnesia. the disorganization during arousal from stage 3 or 4 may result in problems such as enuresis, somnambulism, and in state 4 nightmares and night terrors.

during REM sleep

the near-total paralysis of the skeletal (postural) muscles. Because of this motor inhibition, body movement is absent. Dreaming occurs and it the most distinctive feature of this sleep stage

Primary Insomnia

treated with Benzos, zolpidem, eszopiclone (Lunesta), zaleplon (Sonata) and other hypnotics. should only be prescribed for 2 weeks due to tolerance and withdrawal.

Psychophysiological insomnia

typically presents as a primary complaint of difficulty in going to sleep. may have gone on for years and denies associated with stressful periods. objects associated with sleep (bed or bedroom) become conditioned stimuli that evoke insomnia. also called conditioned insomnia.

sleepiness can be caused

use or abuse of sedative hypnotics, sedating antihistamines, sedating antidepressants, antiepileptics, neuroleptics, and opioid analgesics. can be provoked by withdrawal from traditional stimulants, caffeine, or nicotine.

multiple sleep latency test

used for diagnosing narcolepsy. beginning 2 hours after morning awakening, 20 minute nap opportunities are provided during which the patient is instructed to let himself or herself fall asleep and not resist falling asleep. Electroencephalographic, electro-oculographic, and submental electromyography activity is recorded to determine sleep stage. The latency to sleep is used to assess the level of sleepiness, and the appearance of REM sleep on two or more nap opportunities confirms narcolepsy.

stages of sleep defined by

visual scoring of 3 parameters:electroencephalogram (EEG), electro-oculogram (EOG), and electromyogram (EMG)

Primary insomnia

when the chief complaint is non-restorative sleep or difficulty in initiating or maintaining sleep, and the complaint continues for at least a month. the insomnia is independent of any known physical ro mental condition. both difficulty falling asleep and by repeated awakening.


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