Sleep disorders

Question 1

Alpha rhythm is associated with ____

Answer 1

awake with eyes closed

Question 2

vertex waves are associated with ______

Answer 2

NREM N1

Question 3

K complex is associated with

Answer 3

NREM N2

Question 4

Sleep spindles are associated with

Answer 4

NREM N2

Question 5

Slow wave sleep is associated with

Answer 5

NREM N3

Question 6

Saw tooth waves are associated with

Answer 6

REM

Question 7

In _____ sleep, there is an increase in parasympathetic activity

Answer 7

NREM

Question 8

In ___ sleep, there is an increase in sympathetic activity, dreaming, paralysis of skeletal muscle

Answer 8

REM

Question 9

Differentiate between NREM parasomnias and REM parasomnias

Answer 9

NREM: overlap between wake and NREM sleep, behaviors are not under conscious control and not remembered upon awakening, most common in children who often “grow out of them”

REM: loss of paralysis, acting out dreams, eyes are closed, rapid alertness and recall on awakening, common in elderly men

Question 10

List the differential diagnosis for a child with sleep terrors

Answer 10

NREM parasomnia

nocturnal panic attacks, nocturnal frontal lobe seizure, delerium, REM sleep behavior disorder

Question 11

Describe the three step model for treatment of NREM parasomnias

Answer 11

1. modify predisposing factors (avoid sleep deprivation, stress)
2. improve safety of sleep environment
3. pharmacotherapy (BZDs)

Question 12

REM sleep behavior disorder is associated with ______ in young people

Answer 12

nacrolepsy

Question 13

Among older men with REM sleep behavior disorder, there is an increased risk for developing ________

Answer 13

Parkinson’s

Question 14

Describe management of REM sleep behavior disorder

Answer 14

1. verify diagnosis with sleep study (elevated muscle tone)
2. treat co-morbid sleep disorders
3. remove iatorgenic causes (ex antidepressants)
4. pharmacology: BZDs, melatonin, pramipexole

Question 15

List major symptoms of narcolepsy

Answer 15

• excessive daytime sleepiness
• sleep paralysis
• hypnagogic imagery
• cataplexy
• automatic behaviors

Question 16

Define cataplexy

Answer 16

Loss of muscle tone in response to emotional stimuli

Question 17

Describe the cause of narcolepsy with cataplexy

Answer 17

Loss of hypocretin/orexin containing neurons in the lateral hypothalamus
Likely autoimmune

Question 18

Describe treatment for narcolepsy

Answer 18

• avoid sleep deprivation
• scheduled naps
• stimulants to reduce daytime sleepiness
• antidepressants for cataplexy
• sodium oxybate for sleepiness and cataplexy

Question 19

Restless leg syndrome is more common in (women/men), (young/elderly), and people of ________ descent

Answer 19

elderly women

Northern European descent

Question 20

List major criteria of restless leg syndrome

Answer 20

URGE
U: urge to move legs, usually with other uncomfortable sensations
R: rest-induced
G: get better with movement
E: evening and night are worse; clear circadian rhythm to symptoms

Question 21

What is the primary cause of restless leg syndrome?

Answer 21

Dysfunction of CNS iron metabolism

Question 22

Describe non-pharmacologic therapy of restless leg syndrome

Answer 22

mental alerting activities
abstinence from nicotine, alcohol, caffeine
Iron replacement
remove medications that contribute

Question 23

Describe pharmacologic therapy of restless leg syndrome

Answer 23

Dopamine agonist: pramipexole, ropinirole, rotigitine

calcium channel ligand: gabapentin, pregabalin

Question 24

Shift work sleep disorder is considered an _____ circadian rhythm disorder

Answer 24

exogenous

Question 25

Describe treatment for shift work sleep disorder

Answer 25

1. increase sleep duration: sleep hygiene, hypnotic medications 2. increase alertness: prophylactic naps, caffeine, wake-promoting drugs 3. re-align circadian rhythm: adjust light exposure, melatonin

Question 26

Delayed sleep phase syndrome is more common in ____ and advanced sleep phase syndrome is more common in ____

Answer 26

delayed in adolescents | advanced in elderly

Question 27

90% of cases of chronic insomnia are caused by _____

Answer 27

comorbid conditions, not primary insomnia

Question 28

List some risk factors for insomnia

Answer 28

``` older age female gender divorce/ widowhood psychiatric illness medical conditions cigarette smoking alcohol or caffeine consumption prescription drugs ```

Question 29

List some psychological factors that contribute to insomnia

Answer 29

More reactive to stressors Worries and intrusive thoughts prior to sleep Over time may develop negative associations with bedtime/environment Maladaptive responses may perpetuate insomnia

Question 30

List common medical comorbidities seen with chronic insomnia

Answer 30

Cardiac, pulmonary, rheumatologic, neurologic, endocrine, gastrointestinal, renal, pain syndromes

Question 31

Insomnia itself is a risk factor for incident ____

Answer 31

MDD

Question 32

List medications linked to insomnia

Answer 32

``` Antidepressants Stimulants Steroids Decongestants Antihypertensives Caffeine Alcohol ```

Question 33

List the 3 Ps used in the behavioral model of chronic insomnia

Answer 33

- predisposing - precipitating - perpetuating

Question 34

Describe components of sleep hygiene

Answer 34

``` Avoid watching clock, stimulants, heavy meals before bedtime Keep the room dark, cool, quiet Increase daytime light exposure Practice relaxing routine Reduce time in bed ```

Question 35

List pharmacologic approaches to insomnia

Answer 35

- BZDs - melatonin agonists - orexin antagonists (suvorexant) - doxepin- TCA re-marketed for sleep, strong H1 affinity

Question 36

List antidepressants used off label to treat insomnia and their advantages/ disadvantages

Answer 36

Mirtazapine, Trazodone, Nefazodone, Amitriptyline, Trimipramine little abuse liability some daytime sedation, weight gain, anticholinergic side effects

Question 37

List anticonvulsants used off label to treat insomnia and their advantages/ disadvantages

Answer 37

gabapentin, pregabalin little use liability and help with co-morbid RLS Less effective than BZDs, cognitive impairment, daytime sedation, weight gain, edema

Question 38

List antipsychotics used off label to treat insomnia and their advantages/ disadvantages

Answer 38

Olanzapine, Quetiapine, Risperidone, Ziprasidone anxiolytic and help stabilize co-morbid bipolar disorder less effective than BZDs, side effect profile, should not be used unless patient has underling psychotic disorder