Sleep and internal medicine. 110 good questions, nicely answered!

Q: How does sleep disturbance relate to CFS and FMS?

Both CFS and FMS are commonly associated with sleep disturbances . Patients often report non-restorative sleep . Polysomnography shows no significant differences from controls. Symptoms are linked to psychosocial factors.

Q: What role do primary sleep disorders (PSD) play in CFS and FMS?

PSDs like obstructive sleep apnea and periodic limb movement disorder are common. They may contribute to daytime dysfunction. Treatment may lead to symptom improvement, but evidence is limited. Screening for PSDs is essential.

What is the effect of the ICU environment on sleep for critically ill patients?

The ICU environment significantly disrupts sleep due to:

Frequent sleep alterations
Major sleep loss stressor
Replacement of normal sleep patterns with atypical EEG patterns
Need for specific scoring rules

What are the main characteristics of Chronic Fatigue Syndrome (CFS) and Fibromyalgia Syndrome (FMS)?

Both conditions are defined by symptom scores.
Primary symptoms include abnormal fatigue and chronic pain.
They result in significant health impact and are disabling.
Sleep disturbances are prominent in both syndromes.

What are common sleep disturbances experienced by patients in critical care?

Critically ill patients often face:

Severe sleep loss
Sleep fragmentation
Increased light sleep
Minimal stage N3 and REM sleep
Persistence of disturbances after discharge

What is the prevalence of insomnia in cancer patients prior to treatment?

Pre-treatment insomnia complaints can range widely among cancer patients.

46% to 80% report insomnia complaints
Higher rates in younger age, female gender, and advanced cancer stages
Over 50% may still experience issues after 18 months

How does sleep disturbance relate to CFS and FMS?

Both CFS and FMS are commonly associated with sleep disturbances.
Patients often report non-restorative sleep.
Polysomnography shows no significant differences from controls.
Symptoms are linked to psychosocial factors.

What factors contribute to the abnormalities in sleep for ICU patients?

Multiple factors can cause sleep issues, including:

Patient-related (severity of disease)
Environmental (light, noise)
Continuous care and medications
Mechanical ventilation and sedation

What are some types of cardiovascular diseases (CVD)?

Heart failure
Coronary artery disease
Arrhythmias
Hypertension
Bidirectional relationships with sleep-disordered breathing

What psychological factors contribute to the development of insomnia in cancer patients?

Various factors may precipitate acute insomnia in patients with cancer.

Cancer-induced psychological distress
Treatment-associated stress
Predisposing traits of individuals
Possible maladaptive behaviors and dysfunctional thoughts

What role do primary sleep disorders (PSD) play in CFS and FMS?

PSDs like obstructive sleep apnea and periodic limb movement disorder are common.
They may contribute to daytime dysfunction.
Treatment may lead to symptom improvement, but evidence is limited.
Screening for PSDs is essential.

How can sleep in critically ill patients be measured?

Sleep assessment can involve:

Quantity and quality measures
Full polysomnography (PSG) as gold standard
Use of questionnaires for subjective sleep perception
Actigraphy for activity-rest rhythm

How does obstructive sleep apnea (OSA) impact cardiovascular health?

Altered blood gas chemistry
Increased arousals
Large negative pressure swings
Leads to hypertension, arrhythmias, heart failure, coronary artery disease, and stroke

How can untreated insomnia affect cancer patients?

Insomnia has numerous negative effects on cancer patients if left untreated.

May lead to mood disorders
Causes functional impairments
Results in cognitive deficits
Affects treatment response, immune function, and survival

What is recommended for managing CFS and FMS patients?

A multimodal biopsychosocial management approach is advised.
It accounts for biological, somnological, psychological, and social factors.
Patients should be screened for primary sleep disorders.
Cognitive Behavioral Therapy (CBT-I) can enhance sleep quality.

What are some limitations of using actigraphy in assessing sleep in ICU patients?

Actigraphy can have limitations such as:

Overestimation of total sleep time
Limited wrist movements due to conditions
Inability to quantify sleep directly

What effects does continuous positive airway pressure (CPAP) therapy have on blood pressure (BP) in OSA patients?

Reduces blood pressure
Most effective in resistant hypertension
Efficacy linked to adherence to therapy
RCTs fail to show improvement in cardiovascular outcomes

What are the recommended assessment methods for sleep disturbances in clinical settings?

Assessing sleep disturbances requires a multifaceted approach.

Structured clinical interviews for diagnosis
Sleep diaries for additional insights
Objective sleep studies may be necessary for other disorders

How are CFS and FMS defined clinically?

CFS requires incapacitating fatigue for at least months.
Diagnosis includes various minor criteria such as malaise and pain.
FMS is defined by widespread pain and symptom severity scores.
Both require evaluation of sleep disturbances.

What sleep EEG patterns are often observed in ICU patients?

Many ICU patients exhibit:

Atypical EEG patterns
Inability to follow conventional scoring rules
Proposed new classification (pathological wake, atypical sleep)
Abnormalities common in sedated patients

What is the prevalence of cardiovascular disease in adults aged over 20 years?

Approximately 48%
122 million affected in 2016
Increases with age
9% prevalence excluding hypertension

What treatment options are recommended for cancer-related insomnia?

A combination of pharmacological and non-pharmacological options is advised.

Hypnotics for acute insomnia episodes
Cognitive behavioural therapy (CBT-I) for non-pharmacological intervention
Exercise and mind-body interventions showing positive effects

What are the implications of insomnia in CFS and FMS?

Insomnia may indicate a distinct phenotype in these syndromes.
Cognitive Behavioral Therapy for Insomnia (CBT-I) shows benefits.
Treatment can help alleviate fatigue and pain levels.
Randomized trials are needed for better understanding.

How does total sleep time in ICU patients typically compare to normal standards?

In ICU patients:

Total sleep time can be decreased (2-3 hours less)
A normal range (6-8 hours) may be reported
Sleep quality is generally very low

What are the acute consequences of central sleep apnea (CSA) compared to obstructive sleep apnea (OSA)?

Similar effects, less severe
Most observed in heart failure patients
Effectiveness shown for adaptive servoventilation
RCT for cardiovascular outcomes showed neutrality

How prevalent is insomnia among cancer survivors compared to the general population?

Survival from cancer does not guarantee relief from insomnia.

36% of cancer survivors report sleep disturbances
25% of the general population experience similar issues

Why is systematic screening for PSD important in CFS and FMS?

Screening helps identify primary sleep disorders prevalent in these conditions.
Techniques include questionnaires and polysomnography.
Objective sleep assessments complement clinical evaluations.
It aids in tailored treatment approaches.

What are the characteristics of sleep architecture in critically ill patients?

Sleep architecture in ICU patients often displays:

Absent sleep cycle organization
Consecutive sleep bouts with variable durations
High proportion of short sleep episodes
Significant day-time sleep

How does sleep duration affect cardiovascular disease risk?

Short sleep (

What demographics show variability in insomnia prevalence among cancer patients?

Insomnia prevalence varies by demographic factors.

Lower rates in male and older patients
Higher rates in younger female patients
Breast, gynecological, and lung cancers report more disturbances

What are the main symptoms of chronic fatigue syndrome (CFS) and fibromyalgia syndrome (FMS)?

Both conditions are primarily characterized by:

Abnormal fatigue
Chronic pain
Sleep disturbances
Significant health impact
Disabling effects on daily functioning

How is circadian rhythm affected in critically ill patients?

Circadian rhythm disturbances include:

Altered core body temperature rhythms
Variability in timing of acrophase
Abnormal melatonin production
Irregular excretion patterns post-surgery

What is the relationship between heart failure (HF) and sleep-disordered breathing (SDB)?

Bidirectional relationship present
OSA linked to incident HF
CSA prevalent among HF patients
Underdiagnosis common, especially in non-obese patients

What are some normal sleep parameters in cancer patients?

Objective sleep measurements reveal significant alterations in sleep patterns.

Normal sleep onset latency but reduced duration and efficiency
High awakenings index
Disrupted sleep architecture with altered REM patterns

How are sleep disturbances connected to CFS and FMS?

Disturbed sleep is a key feature, with:

Highly prevalent unspecified sleep disturbance
Biologically disturbed sleep hypothesized as a contributor
Insomnia phenotype observed in both conditions

What endogenous factors might affect sleep quality in the ICU?

Endogenous factors that impact ICU sleep quality include:

Poor sleep prior to ICU admission
Use of sleep medications at home
Pain and breathing difficulties
Anxiety and illness severity

How does sleep architecture differ in patients with heart failure?

Excessive light sleep
Insomnia and frequent arousals
Normal apnea-hypopnea index despite poor sleep quality
Symptoms like cough and nocturia impact sleep

What factors increase the likelihood of insomnia in cancer patients?

Various factors are linked to higher insomnia rates, including:

younger age
female gender
advanced stage
Primary sites such as breast, gynaecological, or lung cancer

What role does cognitive behavioral therapy for insomnia (CBT-I) play in CFS and FMS?

CBT-I has proven effective by:

Improving sleep quality
Reducing fatigue scores
Diminishing pain scores

What is the role of the Intensive Care Unit (ICU) in relation to sleep for critically ill patients?

The ICU environment hinders sleep restoration due to:

Frequent sleep alterations
Major stressor from sleep loss
Dependence on specific sleep analysis techniques

What is the economic cost associated with cardiovascular disease (CVD)?

Estimated at $351 billion
CVD impacts high morbidity and mortality
Annual updates provide prevalence statistics
Leading cause of death globally

What are some psychological and physiological factors that contribute to insomnia in cancer patients?

Key factors include:

psychological distress caused by cancer
treatment-associated stress
predisposing traits leading to acute insomnia
Maladaptive behaviours that perpetuate the disorder

Which primary sleep disorders (PSD) are commonly found in patients with CFS and FMS?

Commonly detected PSD include:

Chronic insomnia
Obstructive sleep apnea (OSA)
Periodic limb movement disorder (PLMD)

How are sleep EEG patterns typically altered in ICU patients?

Patients in ICU often exhibit:

Atypical sleep EEG patterns
Inadequate standard scoring application
Severe reductions in deep sleep and REM sleep

What types of cardiovascular diseases (CVD) are commonly associated with sleep-disordered breathing?

Common CVD types include:
- Heart failure
- Coronary artery disease
- Arrhythmias
- Hypertension

How can insomnia in cancer patients affect their overall health?

Untreated insomnia may lead to:

mood disorders
functional impairments
cognitive deficits
Negative impact on treatment response and survival rates

What is recommended for managing patients with CFS and FMS?

A multimodal biopsychosocial management approach is advised, which includes:

Acknowledging biological, psychological, and social factors
Addressing relevant individual patient history
Screening for primary sleep disorders

What are the main factors contributing to sleep disruption in critically ill patients?

Key contributors include:

Patient-related factors (e.g., disease severity)
Environmental factors (e.g., light, noise)
Health support techniques (e.g., sedation, ventilation)

How does obstructive sleep apnea (OSA) affect cardiovascular disorders?

Repeated exposure to OSA consequences leads to:
- Hypertension
- Heart failure
- Coronary artery disease
- Stroke

What assessment methods are recommended for diagnosing insomnia in cancer patients?

Recommended assessment methods include:

structured clinical interviews
sleep diaries for tracking patterns
objective sleep studies if needed to rule out other disorders

What are the criteria for diagnosing chronic fatigue syndrome (CFS)?

Diagnosis requires:

At least 6 months of incapacitating fatigue
Four out of eight minor criteria, including:

1. Post-exertional malaise

Unrefreshing sleep
Memory and concentration impairment

What specific sleep measures can be taken to protect sleep in ICU patients?

Implementing strategies may include:

Reducing light and noise exposure
Managing medications that disrupt sleep
Regular sleep assessments by intensives

What effect does continuous positive airway pressure (CPAP) therapy have on blood pressure in OSA patients?

CPAP therapy reduces blood pressure, especially in:
- Resistant hypertension
- Patients with high adherence to therapy

How does the concept of insomnia phenotype relate to CFS and FMS?

Insomnia phenotype in both conditions involves:

Subjective sleep difficulties
Not clearly defined as a comorbid disorder
Requiring a specific approach in treatment

What is the relationship between sleep disturbances and weaning from mechanical ventilation?

Sleep disturbances lead to:

Increased morbidity
Prolonged weaning periods
High levels of fragmentation and poor sleep quality

Why have randomized controlled trials (RCTs) not shown that CPAP improves cardiovascular outcomes?

Factors contributing to this include:
- Poor adherence to CPAP
- Lack of improvement in downstream cardiovascular consequences

How can sleep quality in ICU patients be assessed?

Sleep quality can be evaluated by:

Total sleep time (TST)
Sleep fragmentation rates
Electroencephalography (EEG) patterns

What is central sleep apnea (CSA) and its relationship with heart failure?

CSA frequently occurs in:
- Patients with heart failure
- Left ventricular dysfunction
Its acute consequences resemble those of OSA.

What is the significance of full polysomnography (PSG) in ICU?

Full PSG is important because it:

Provides reliable sleep measurement
Requires multiple EEG signals
Detects abnormalities affecting sleep fragmentation

What did observational trials reveal about adaptive servoventilation for CSA?

Multiple observational trials showed effectiveness, yet:
- A large RCT on cardiovascular outcomes was:
- Neutral or detrimental
- Showed lack of effectiveness compared to usual care

What are some subjective sleep quality issues faced by ICU patients?

Common complaints include:

Difficulty falling asleep
Insufficient deep and prolonged sleep
Reported as major stressors, ranking high among ICU experiences

What broader implications does sleep quality and duration have on cardiovascular health?

Short sleep duration linked to increased risk of:
- Obesity
- Diabetes mellitus
- Coronary heart disease
- Stroke

How does the composition of sleep differ in critically ill patients?

Sleep composition is characterized by:

Increased light sleep (N1 and N2 >60%)
Decreased deep sleep (N3

What are the economic impacts of cardiovascular diseases (CVD)?

CVD poses significant costs, including:
- Excessive morbidity and mortality
- Estimated economic impact of:
- $351 billion

What impact does continuous care have on sleep in ICU patients?

Continuous care contributes to:

Difficulty achieving restorative sleep
Fragmentation of sleep stages
Impaired circadian rhythm

How prevalent is cardiovascular disease (CVD) among adults over 20 years old?

In 2020, the prevalence of CVD was:
- 48% in adults over 20
- Which equates to 122 million cases

How does circadian rhythm get affected in ICU patients?

There are notable changes in:

Core body temperature oscillations
Melatonin production and excretion
Individual variability in rhythm stability

How common are sleep disturbances in heart failure patients?

Heart failure patients exhibit:
- Poor sleep architecture
- Characteristics like:
- Excessive light sleep
- Insomnia

What physiological changes occur during NREM sleep affecting cardiovascular health?

NREM sleep is characterized by:
- Decreased sympathetic activity
- Elevated parasympathetic tone
- Resulting in reduced blood pressure and heart rate

How does REM sleep impact cardiovascular function?

REM sleep features:
- Increased sympathetic activity
- Intermittent heart rate and BP increases
- Can lead to myocardial ischemia due to heightened demand

What is the relationship between obstructive sleep apnea (OSA) and type 2 diabetes (T2D)?

OSA is common in T2D patients, and this connection includes:

High prevalence of T2D in OSA cohorts (8%-29%).
Increased T2D risk due to OSA severity.
OSA may worsen diabetic complications like retinopathy and nephropathy.

How does OSA affect glycaemic control in patients with diabetes?

Increasing OSA severity deteriorates glycaemic control. Key points include:

Higher adjusted HbA1c levels in patients with severe OSA.
Association with poorer diabetic control.
Links to microvascular complications of diabetes.

What is nocturia and how does it impact individuals' lives?

Nocturia involves waking at least once nightly to urinate.
It's bothersome and reduces sleep quality.
Significantly affects health-related quality of life (HRQoL).
Associated with underlying diseases and age-related factors.

What role does continuous positive airway pressure (CPAP) therapy play in managing diabetes?

CPAP therapy’s effectiveness in diabetes management is debated.

Observational studies suggest possible benefits for glycaemic control.
Randomized controlled trials generally do not support significant HbA1c reduction.
Role in preventing diabetes complications remains unclear.

What underlying factors are known to contribute to nocturia?

Disturbed sleep
Disorders of the lower urinary tract
Overproduction of urine at night (nocturnal polyuria)
Age-related decrease in diurnal variation of urine production

What endocrine disorders are commonly associated with obstructive sleep apnea (OSA)?

OSA is linked with several endocrine disorders, including:

Type 1 diabetes (T1D) - common and increases microvascular complications.
Hypothyroidism - may cause OSA and can improve with hormone therapy.
Acromegaly - anatomical changes significantly increase OSA risk.
Polycystic ovarian syndrome (PCOS) - one-third may have OSA and lower quality of life.

What is nocturnal polyuria and its relevance to nocturia?

The leading mechanism causing nocturia.
Characterized by excessive urine production at night.
Associated with diurnal variation loss in urine production.
Linked to reduced arginine vasopressin secretion.

What interventions may improve sleep-disordered breathing in patients with hypothyroidism?

Treatment for hypothyroidism can reduce sleep-disordered breathing.

Hormone replacement therapy with levothyroxine is effective.
Improvement in OSA symptoms noted in treated patients.
Unclear if OSA treatment benefits thyroid function.

How is nocturia assessed and diagnosed?

Diagnosis relies on detailed history taking.
Use of a voiding diary to quantify voids.
Identification of contributing factors is essential.
Multidisciplinary approach may be necessary.

How does acromegaly affect the risk of obstructive sleep apnea?

Acromegaly contributes to significant risk elevation for OSA.

Anatomical changes in upper airway due to acromegaly.
Effective treatment may resolve OSA symptoms.
Links with worsening sleep quality highlighted.

What treatment options are available for nocturia?

Targeting underlying or contributing disorders.
Symptomatic treatment with desmopressin.
Causal treatment when the cause is identified.
Supportive care when causes remain unclear.

What is the prevalence of OSA in patients with polycystic ovarian syndrome (PCOS)?

OSA is prevalent in women with polycystic ovarian syndrome (PCOS).

Approximately one-third of women with PCOS have OSA.
Associated with lower quality of life measures.
Increased insulin resistance reported among these patients.

Describe enuresis and its prevalence in different age groups.

Enuresis refers to urinary incontinence during sleep.
Common in children, prevalence can reach 25% in 5-year-olds.
Decreases with age, affecting only 0.5%-2% of adults.

What is the prevalence of OSA in patients with type 2 diabetes?

OSA is highly prevalent in those with type 2 diabetes:

8% to 29% presence in moderate-severe OSA patients
Greater than twofold likelihood of type 2 diabetes in OSA
Significant relationship persists despite adjusting for confounding factors.

What physiological mechanisms are involved in urination and diuresis?

Glomerular filtration (GF)
Osmotic diuresis
Free-water reabsorption, mainly regulated by vasopressin.
Daily urine production is significantly reduced overnight.

How does OSA severity relate to diabetic control in patients with type 2 diabetes?

Increased OSA severity correlates with worse glycaemic control:

Higher HbA1c levels linked to more severe OSA
OSA severity associated with poor diabetes management
OSA impacts metabolic health significantly.

What is the impact of aging on diuresis?

Aging reduces glomerular filtration rate (GFR).
Results in increased nocturnal free-water production.
Alters circadian rhythms of vasopressin and RAAS.
Leads to excessive nocturnal urine production.

What role does intermittent hypoxia play in the relationship between OSA and diabetes?

Intermittent hypoxia may negatively impact glucose metabolism:

Associated with sympathetic excitation
Influences adipose tissue function
Particularly detrimental if occurring during REM sleep.

What is nocturia and what conditions can it affect?

This condition involves waking at least once during the night to urinate. It can interfere with:

Sleep quality
Health-related quality of life
Sleep disorders

What is the relationship between type 1 diabetes and OSA?

OSA is commonly co-occurring with type 1 diabetes:

Increased risk of microvascular complications
Less studied compared to type 2 diabetes
OSA prevalence noted in T1D patients.

How is nocturia related to sleep disturbances?

Sleep disturbances can provoke or worsen this condition, specifically:

Insomnia
Obstructive sleep apnea (OSA)
Reciprocal effects with insomnia

How is hypothyroidism linked to OSA?

Hypothyroidism can lead to OSA development:

Hormone replacement therapy with levothyroxine can improve sleep-disordered breathing
Relationship between treating OSA and thyroid function is unclear.

What is the primary mechanism behind nocturia?

The most leading mechanism is:

Overproduction of urine, known as nocturnal polyuria (NP)
Diuresis modulation by circadian rhythms
Vasopressin activity

What effect does acromegaly have on OSA?

Acromegaly increases the anatomical risk of OSA:

Leads to significant upper airway changes
Effective treatment may resolve OSA symptoms.

What factors contribute to nocturnal polyuria?

Several factors are known to cause nocturnal polyuria:

Loss of diurnal variation in urine production
Reduced nocturnal secretion of arginine vasopressin
Decreased circadian activity of the RAAS

How does polycystic ovarian syndrome (PCOS) relate to OSA?

Women with PCOS have a heightened risk of OSA:

Approximately one-third of affected women develop OSA
Associated with decreased quality of life and insulin resistance.

What is the recommended treatment approach for nocturia?

Treatment should focus on:

Identifying underlying disorders
Symptomatic treatment when specific causes are unclear
Desmopressin for specific cases

What percentage of type 2 diabetes patients in studies were found to have OSA?

Studies show varying percentages of OSA in type 2 diabetes patients:

23% in overweight British diabetics
Up to 86% in severely obese US diabetics.

How does age affect nocturia?

Nocturia's prevalence increases with age, often leading to:

More frequent nighttime voiding
Poorer sleep quality
Higher incidence of bladder-related symptoms

What is the adjusted odds ratio for type 2 diabetes in moderate to severe OSA?

The adjusted odds ratio indicates a 1.87 likelihood of diabetes:

Observational studies reveal this relationship
Diabetes prevalence more than doubled with OSA diagnosis.

What is the role of a bladder diary in diagnosing nocturia?

A bladder diary helps quantify:

Number of times urine is passed during sleep
Helps establish nocturia's impact on sleep
Required for proper diagnosis

What findings relate to the progression of diabetic retinopathy in OSA patients?

Diabetic retinopathy risk may increase with OSA:

OSA-linked presence and severity of eye disease
Fivefold increased likelihood of developing advanced retinopathy.

What physiological mechanisms regulate diuresis?

Diuresis arises from:

Glomerular filtration (GF)
Osmotic diuresis
Free-water reabsorption

What is the significance of CPAP therapy in managing type 2 diabetes?

CPAP therapy's benefits for diabetes management remain unclear:

Most randomized controlled trials found no significant benefit
Observational studies suggest potential improvement in glycemic control.

How does OSA contribute to nephropathy in diabetes patients?

OSA may worsen nephropathy in diabetes individuals:

Increased prevalence of nephropathy linked to OSA
Associated with accelerated decline in renal function.

How does the renin-angiotensin-aldosterone system (RAAS) influence diuresis?

RAAS regulates diuresis by:

Maintaining extracellular fluid volume
Facilitating salt-saving mechanisms
Influencing nocturnal osmotic diuresis

What are the learning objectives regarding OSA and endocrine disorders?

Objectives focus on understanding OSA's relationship with endocrine issues:

Evaluate epidemiological links to diabetes
Understand pathophysiological mechanisms involved
Assess CPAP therapy's role in management.

What is the impact of protein intake on nocturia?

Increased protein intake affects nocturia through:

Elevated osmotic diuresis
Hyperfiltration in the kidneys
Delayed peak diuresis

What is the overarching effect of OSA on metabolic health?

OSA appears to have a detrimental impact on metabolic health:

Potential independent effect on metabolic disease evolution
Interventions targeting OSA may benefit metabolic dysfunction.

What age-related changes affect diuresis patterns?

Aging leads to:

Decrease in glomerular filtration rate (GFR)
Flattened nocturnal vasopressin secretion
Increased nocturnal diuresis risk

What mechanisms are associated with impaired glucose metabolism in OSA?

Mechanisms include:

Systemic inflammation
Sympathetic excitation
Interaction with adipose tissue and intermittent hypoxia.

How does the severity of OSA influence prediabetes prevalence?

OSA severity correlates with increased prediabetes prevalence:

Prevalence ranged from 10.8% to 34.2%, based on AHI levels
Higher AHI indicates higher likelihood of prediabetes.

Sleep and internal medicine

110 important questions on Sleep and internal medicine