apt medication effects in polysomnography

Medication Effects in Medication Effects in PolysomnographyPolysomnography

Midwest Sleep and Midwest Sleep and Neurodiagnostic InstituteNeurodiagnostic Institute

Midwest Sleep and Neurodiagnostic Institute

What the technologist What the technologist needs to knowneeds to know

Possible effects on sleepPossible effects on sleep Basic concepts of pharmacokineticsBasic concepts of pharmacokinetics Specific effects of classes of medicationsSpecific effects of classes of medications Specific effects of commonly used Specific effects of commonly used

substancessubstances– Withdrawal effects alsoWithdrawal effects also

ResourcesResources


Medication Effects on Sleep ArchitectureMedication Effects on Sleep Architecture

Sleep LatencySleep Latency REM LatencyREM Latency SWS sleepSWS sleep TSTTST REMREM Stage 1Stage 1 WASOWASO


Medication Effects on Other Medication Effects on Other Aspects of SleepAspects of Sleep

Arousals – Sleep disruptionArousals – Sleep disruption PLM’sPLM’s Fast activity / spindlesFast activity / spindles SREMSSREMS Apnea duration & severityApnea duration & severity Improve or disturb subjective sleepImprove or disturb subjective sleep daytime sleepinessdaytime sleepiness


PharmacokineticsPharmacokinetics DosageDosage Terms to knowTerms to know

– Onset of action - AbsorptionOnset of action - Absorption– Elimination half lifeElimination half life– WithdrawalWithdrawal

Age relatedAge related– Paradoxical effects in childrenParadoxical effects in children– Much slower elimination in patientsMuch slower elimination in patients

» Who are olderWho are older» have compromised liver or kidney functionhave compromised liver or kidney function


HypnoticsHypnotics

All decrease sleep latencyAll decrease sleep latency– BarbituratesBarbiturates– BenzodiazepinesBenzodiazepines– NonbenzodiazepinesNonbenzodiazepines


BarbituratesBarbiturates

Increased TSTIncreased TST Potent REM suppressionPotent REM suppression

– Increased REM latencyIncreased REM latency May increase sleep spindlesMay increase sleep spindles May increase slow wave sleepMay increase slow wave sleep Decreased WASODecreased WASO Decreased TST and subjective sleep Decreased TST and subjective sleep

upon withdrawalupon withdrawal


Benzodiazepines (BZD)Benzodiazepines (BZD)

–Indicated for insomniaIndicated for insomnia

–Short term treatmentShort term treatment

–Works best with combination of Works best with combination of Sleep Hygiene measuresSleep Hygiene measures



– Effect on SleepEffect on Sleep Decrease arousals & decrease WASODecrease arousals & decrease WASO Reduce general body movementsReduce general body movements Increase TSTIncrease TST Increase stages 1 and 2Increase stages 1 and 2 Increase fast EEG activity incl. spindlesIncrease fast EEG activity incl. spindles May increase REM latency and decrease May increase REM latency and decrease

REMREM Decrease SWSDecrease SWS Improves subjective sleepImproves subjective sleep



– Classified according to their half-life and durationClassified according to their half-life and duration» Short-acting(initiating sleep)Short-acting(initiating sleep)

Triazolam (Halcion-actingTriazolam (Halcion-acting Temazepam (Restoril)Temazepam (Restoril) Estazolam (Prosom)Estazolam (Prosom)

» Long-acting (maintaining sleep)Long-acting (maintaining sleep) Fluazepam (Dalmane)Fluazepam (Dalmane) Quazepam (Doral)Quazepam (Doral) Clonazepam (Klonopin)Clonazepam (Klonopin) [May produce daytime sleepiness][May produce daytime sleepiness]


Non-BenzodiazepinesNon-Benzodiazepines

– Zolpidem (Ambien), Zalepon (Sonata)Zolpidem (Ambien), Zalepon (Sonata)Short acting Short acting Rapid onsetRapid onsetdoes not accumulate with once a day does not accumulate with once a day

dosingdosing Induces sleep pattern similar to Induces sleep pattern similar to

physiologic sleepphysiologic sleepNo tolerance or withdrawal symptomsNo tolerance or withdrawal symptoms


OTC Substances OTC Substances

– L-Tryptophan (amino acid)L-Tryptophan (amino acid)»May decrease sleep latencMay decrease sleep latenc

– MelatoninMelatonin»Decreases sleep latencyDecreases sleep latency»May decrease WASOMay decrease WASO

»May produce daytime sleepiness May produce daytime sleepiness and altered sleep patternsand altered sleep patterns


OTC SubstancesOTC Substances

AntihistaminesAntihistamines– Shorten sleep latencyShorten sleep latency– REM suppressionREM suppression– Daytime somnolenceDaytime somnolence


AntidepressantsAntidepressants

Wide variance in effects across and within Wide variance in effects across and within categoriescategories

»TricyclicsTricyclics»MAO’sMAO’s»SSRI’sSSRI’s»OthersOthers



Tricyclics Tricyclics [Hard to classify as a group][Hard to classify as a group]

– Some sedatingSome sedating

– Moderate to strong REM suppressionModerate to strong REM suppression

– Generally increase TSTGenerally increase TST

– May increase PLM’sMay increase PLM’s



MAO’sMAO’s– Strong REM suppressionStrong REM suppression

– Decrease TSTDecrease TST

– Increase WASOIncrease WASO



SSRI’sSSRI’s

–Prosac (Fluoxitine)Prosac (Fluoxitine)

–Paxil (Paroxetine)Paxil (Paroxetine)

–SerazoneSerazone

–Trazadone (Desyrel)Trazadone (Desyrel)



SSRI’sSSRI’s

– No effect on sleep onsetNo effect on sleep onset

– Reduces SWSReduces SWS

– May increase WASOMay increase WASO

– Decreases REM Decreases REM

– May worsen RLSMay worsen RLS

– May increase SREMS in NREM sleepMay increase SREMS in NREM sleep


StimulantsStimulants

Amphetamines/Ritalin/Cylert/CocaineAmphetamines/Ritalin/Cylert/Cocaine TheophyllineTheophylline DecongestantsDecongestants NicotineNicotine Caffeine & other xantheinesCaffeine & other xantheines

– Coffee, teas, soft drinks, chocolate,Coffee, teas, soft drinks, chocolate,

OTC diet and pain medicationOTC diet and pain medication


StimulantsStimulants

– Effects on sleepEffects on sleep»Increase sleep latencyIncrease sleep latency»Decreased TSTDecreased TST»Increase arousals & WASOIncrease arousals & WASO»Increase stage 1Increase stage 1»Decrease SWSDecrease SWS


Stimulants – OverdoseStimulants – Overdose


AlcoholAlcohol

Decrease sleep latencyDecrease sleep latency Decrease REM (leads to REM Decrease REM (leads to REM

rebound and nightmares after rebound and nightmares after elimination)elimination)

Increase WASO (after elimination)Increase WASO (after elimination) May increase deltaMay increase delta Worsen OSAWorsen OSA


ResourcesResources

PDRPDR Nursing & Other drug referencesNursing & Other drug references Principles & Practice of Sleep MedicinePrinciples & Practice of Sleep Medicine Sleep Disorders Medicine (Chokroverty)Sleep Disorders Medicine (Chokroverty) AtlasesAtlases SLEEP (reviews on treating Insomnia)SLEEP (reviews on treating Insomnia) Advanceforsleep.comAdvanceforsleep.com


Exam Content Areas Related to Exam Content Areas Related to Medication EffectsMedication Effects

Domain 1, Task 1Domain 1, Task 1– Review medical information to Review medical information to

become familiar with potential study become familiar with potential study requirements/parametersrequirements/parameters»Consider questions related to:Consider questions related to:

Medication effects on sleep architectureMedication effects on sleep architecture What will you expect to seeWhat will you expect to see

from medication X?from medication X?



Domain 1, Task 2Domain 1, Task 2– Collect data from the patient by Collect data from the patient by

observation & interviewobservation & interview» Consider questions related to:Consider questions related to:

Acute alcohol or caffeine administrationAcute alcohol or caffeine administration Recent medication changesRecent medication changes



Domain 1 Task 3Domain 1 Task 3– Analyze in integrate collected informationAnalyze in integrate collected information

» Consider questions related toConsider questions related to Need for interventions, e.g. nocturnal dosingNeed for interventions, e.g. nocturnal dosing Should study continue?Should study continue? Should medical director be called?Should medical director be called? Withdrawal effectsWithdrawal effects Will the patient wake more, or less?Will the patient wake more, or less? Will there be REM rebound?Will there be REM rebound?



Domain 3 Task 4Domain 3 Task 4– Implement appropriate interventionsImplement appropriate interventions

» Consider questions related toConsider questions related to Possible overdosePossible overdose Adverse reactionsAdverse reactions Severity of apneasSeverity of apneas Severity of PLM’sSeverity of PLM’s Patient self administrationPatient self administration



Domain 4, Task 1Domain 4, Task 1– Score stagesScore stages

» Consider questions related to:Consider questions related to: Sleep architectureSleep architecture Sleep micro architectureSleep micro architecture

– Does the EEG show a medication effect?Does the EEG show a medication effect?– Does the EOG show a medication effect?Does the EOG show a medication effect?


Exam Content Areas Related to Exam Content Areas Related to

Medication EffectsMedication Effects Domain 4, Task 2Domain 4, Task 2

– Score clinical eventsScore clinical events» Consider questions related to:Consider questions related to:

Sleep apnea durationSleep apnea duration Number of arousalsNumber of arousals Prevalence of PLM’sPrevalence of PLM’s


Exam Content Areas Related to Exam Content Areas Related to

Medication EffectsMedication Effects Domain 5, Task 5Domain 5, Task 5

– Educate patientsEducate patients– Consider questions related to:Consider questions related to:

Sleep hygieneSleep hygiene Patient safetyPatient safety Use of OTC sleep aidsUse of OTC sleep aids Use of alcohol & effect on CPAP efficacyUse of alcohol & effect on CPAP efficacy Effect of caffeine on sleep efficiencyEffect of caffeine on sleep efficiency Effect of caffeine & stimulants on PLM’sEffect of caffeine & stimulants on PLM’s

apt medication effects in polysomnography

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