Sleep DO

Question 1

Normal sleep: in a fit young person the ideal is
7.5–8 hours; latency_______minutes; wakefulness
within sleep usually_______ of time

Answer 1

<30

<5%

Question 2

People with _______ usually present with the TATT
syndrome—‘tired all the time’. These patients are
often unaware of waking or becoming aroused
during the night

Answer 2

OSA

Question 3

The majority of cases of excessive somnolence are

caused by ____ and _____

Answer 3

OSA and narcolepsy

Question 4

untreated moderate to severe OSA has an_______ 5-year mortality and a ____ 8-year mortality, mainly from cardiovascular and motor vehicle accident related deaths

Answer 4

11–13%

37%

Question 5

______is defined as the inability to initiate or

maintain sleep.

Answer 5

Insomnia

Question 6

Pharma Tx of insomnia

It is advisable to avoid hypnotic agents as firstline
treatment. If any form of continuous agent is
necessary it is best to limit it to _____

Answer 6

2 weeks

Question 7

Tricyclic antidepressants with sedative effects
(e.g. ________) are often used as hypnotics
but should generally be avoided in the absence
of depressive disorders

Answer 7

amitriptyline

Question 8

The term ‘________ is used to describe cyclical brief
interruptions of ventilation, each cycle lasting 15–90
seconds and resulting in hypoxaemia, hypercapnia
and respiratory acidosis, terminating in an arousal
from sleep (often not recognised by the patient).

Answer 8

sleep apnoea’

Question 9

Sleep apnoea is broadly classified into ___ and ____

Answer 9

obstructive

and central types

Question 10

________ refers to the
presence of apnoeas and hypopnoeas during sleep
together with daytime dysfunction, predominantly
excessive daytime sleepiness. The effects include
snoring

Answer 10

Obstructive sleep apnoea (OSA)

Question 11

Predisposing factors to OSA

Answer 11

• diminished airway size (e.g. macroglossia obesity,
tonsillar-adenoidal hypertrophy)
• upper airway muscle hypotonia (e.g. alcohol hypnotics, neurological disorders
• nasal obstruction

Question 12

Effects of sleep apnea syndromes

Answer 12

• excessive daytime sleepiness and tiredness
• nocturnal problems (e.g. loud snoring, thrashing,
‘seizures’, choking, pain reactions)
• morning headache
• subtle neuropsychiatric disturbance—learning
difficulties, loss of concentration, personality
change, depression
• sexual dysfunction
• occupational and driving problems

Question 13

\_\_\_\_\_\_ is currently the most effective treatment
for OSA (consider it for CSA).

Answer 13

CPAP

Question 14

MOA of CPAP

Answer 14

Provides an air splint to the upper airway and

prevents pharyngeal collapse

Question 15

In children, OSA is usually due to t____ and _____ and is relieved by surgery

Answer 15

onsillar and/

or adenoid hypertrophy

Question 16

There are no reliable drug treatment options for
OSA.

Consider:
1
2

Answer 16

• amitriptyline 25–100 mg (o) nocte, in severe
cases during REM sleep and intolerance of CPAP
• trial of corticosteroid sprays in children with
mild OSA

Question 17

______ is a specific, permanent neurological
disorder that is characterised by brief spells of
irresistible sleep during daytime hours in inappropriate
circumstances, even during activity and usually
at times when the average person simply feels sleepy

Answer 17

Narcolepsy

Question 18

Tetrad of Sx of Narcolepsy

• __________: sudden brief sleep
attacks (15–20 minutes).
• _________: a sudden decrease or loss of muscle
tone in the lower limbs that may cause the
person to slump to the floor, unable to move.
These attacks are usually triggered by sudden
surprise or emotional upset.
• _________: a frightening feeling of inability to
move while drowsy (between sleep and waking).
• _________

Answer 18

Daytime hypersomnolence

Cataplexy

Sleep paralysis

Hypnagogic (terrifying) hallucinations on falling asleep or waking up (hypnopompic hallucination).

Question 19

In Narcolepsy,

____________
are of proven effectiveness in increasing alertness

Answer 19

Central nervous system psychostimulants

Question 20

Examples of Central nervous system psychostimulants for narcolepsy

Answer 20

1. dexamphetamine 5–10 mg (o), half an hour
   before breakfast and lunchtime; up to 40 mg
   daily may be required in slowly increasing doses
2. methylphenidate (Ritalin) 10–20 mg (o) half an
   hour before breakfast and lunchtime; up to 60
   mg daily may be required

Question 21

Important to consider for Central nervous system psychostimulants for narcolepsy

Answer 21

Drug holidays from these drugs may be necessary

Question 22

Tricyclic antidepressants are used to treat
______, ________, ______ (e.g. clomipramine 20–100 mg (o)
daily)

Answer 22

cataplexy, sleep paralysis and hypnagogic

hallucinations

Question 23

This type of excessive daytime sleepiness (EDS) can
present similarly to narcolepsy without cataplexy.
The condition, which accounts for 5–10% of patients

Answer 23

Idiopathic hypersomnia

Question 24

Difference between Idiopathic hypersomnia and narcolespy

Answer 24

They usually have non-refreshing deep nocturnal sleep but, unlike narcolepsy, naps are not refreshing.

Question 25

Tx of idiopathic narcolepsy

Answer 25

Treatment is usually based on psychostimulant | therapy to improve EDS.

Question 26

_________ is a sonorous sound with breathing during sleep, caused by vibrations in the upper airways from the nose to the back of the throat. It is caused by partially obstructed breathing during sleep

Answer 26

Snoring

Question 27

When does snoring need medical intervention?

Answer 27

Generally harmless, but if very severe, unusual or associated with periods of no breathing (>10 s) assessment is advisable

Question 28

Periodic limb movements (PLMs) and restless legs syndrome are important causes of insomnia and excessive ________

Answer 28

daytime sleepiness

Question 29

Periodic limb movements, which are also referred to as nocturnal myoclonus or ‘leg jerks’, tend to occur usually in the ________of the leg but can occur in the upper limbs

Answer 29

anterior tibialis | muscles

Question 30

Dx of PLM

Answer 30

The diagnosis is often made during sleep studies

Question 31

Mx of PLM

Answer 31

levodopa plus carbidopa (e.g. Sinemet 100/25, 2 tablets before bedtime) or clonazepam 1 mg (o) nocte increasing to 3 mg (o) nocte or sodium valproate 100 mg (o) nocte

Question 32

_______ also known as Ekbom syndrome, is a rather common movement disorder of the nervous system where the legs feel as though they want to exercise or move when the body is trying to rest

Answer 32

RLS,

Question 33

What are the sensations felt in RLS

Answer 33

Sensations that may be experienced include ‘twitching’, ‘prickling’ and ‘creeping’.

Question 34

Dx of RLS

Answer 34

The diagnosis is made from the history—there | are no special diagnostic tests.

Question 35

Cause of RLS

Answer 35

unclear

Question 36

Secondary causes of RLS

Answer 36

``` • anaemia (common) • iron deficiency (common) • uraemia • hypothyroidism pregnancy (usually ceases within weeks of delivery) ```

Question 37

What drugs cause RLS

Answer 37

antihistamines, anti-emetics, selective antidepressants, lithium, selective major tranquillisers and antihypertensives

Question 38

What to do if Fe deficiency is the cause of RLS

Answer 38

Iron studies should be performed and, if low, treat | with iron and vitamin C tablets

Question 39

T or F getting out of bed and going for a walk or run seem to help RLS.

Answer 39

F getting out of bed and going for a walk or run does not seem to help RLS.

Question 40

Good exercise of RLS

Answer 40

a popular treatment is gentle stretching of the legs, particularly of the hamstring and calf muscles, for at least 5 minutes before retiring.

Question 41

Tx of mild RLS

Answer 41

clonazepam 0.5–1 mg (o) 1 hour before retiring or levodopa ( + benserazide or carbidopa) 100–200 mg (o) (especially if limb movements at sleep onset are infrequent

Question 42

Tx of severe RLS

Answer 42

pramipexole 0.125 mg (o) daily, increasing as tolerated to 0.75 mg or ropinirole 0.5 mg (o) → 4 mg daily

Question 43

______ is the habit of grinding, clenching or tapping teeth, which may occur while awake (especially in children) or more commonly while asleep

Answer 43

Bruxism

Question 44

What is the result of Bruxism?

Answer 44

It may result in headaches and TMJ dysfunction in the person during the day.

Question 45

_______ are defined as dysfunctional episodes associated with sleep, sleep stages or partial arousal. They are more common in children.

Answer 45

Parasomnias

Question 46

Drugs associated with nightmares/ dream anxiety

Answer 46

alcohol, barbiturates, drugs such as zolpidem, SSRIs, β -blockers, benzodiazepines

Question 47

Mx of dream anxiety

Answer 47

Psychological evaluation with cognitive behaviour therapy (CBT) is appropriate. Medication that may help includes phenytoin, clonazepam or diazepam

Question 48

A feature is complex and elaborate motor activity associated with dreams. The behaviour may be violent with profane verbalisation

Answer 48

REM sleep behaviour disorder

Question 49

Tx of REM sleep behaviour disorder

Answer 49

Diagnosis is by sleep studies and treatment is low-dose clonazepam

Question 50

This is a complex motor activity in which the person performs some repetitive activity in bed or walks around freely while still asleep. There is amnesia for the event

Answer 50

Somnambulism (sleepwalking)

Question 51

In Somnambulism, Benzodiazepines such as_______ may be useful but withdrawal usually leads to rebound problems.

Answer 51

diazepam

Question 52

Sleep disorders in children are very common in _______, _______, ______

Answer 52

late | infancy, toddlerhood and early preschool age groups

Question 53

Toddlers begin to have dreams coinciding with | _________in the second year of life

Answer 53

language development

Question 54

Why not use sedative meds for sleep disturbances in children?

Answer 54

Not recommended for children <2 years although the judicious use of a sedative/hypnotic for a short term may break the sleepless cycle

Question 55

What sedative hypnotic drug can be given to children?

Answer 55

Such drugs include promethazine 0.5 mg/kg (max. 10 mg) and trimeprazine (Vallergan) 1–2 mg/kg per dose (not for infants under 6 months)

Question 56

These are not true sleep disorders or night-time | arousals. They occur in deep non-REM sleep

Answer 56

Parasomnias

Question 57

Desrcibe the event clusters happening in each age group * ________4–8 years * _______8–12 years * _______ 6–10 years * _______3–6 years

Answer 57

sleep terrors sleep walking sleep talking nightmares

Question 58

A study of elderly patients with insomnia showed that: • 25% had insomnia either coexisting with or related to other sleep disorders, such as sleep apnoea or periodic limb movement disorder • 10% had insomnia related to _______ • 13% had insomnia associated with an _____

Answer 58

medical or psychiatric conditions inability to stop taking sedative–hypnotic agents

Question 59

There are three types of stratified squamous epithelium in the oral mucosa: 1 ________—surface layer, cornified (orthokeratinised), attached to underlying periosteum (e.g. hard palate and gingivae) 2 ________—(e.g. lip and buccal mucosa, alveolar mucosa, floor of mouth, soft palate and tongue— lateral and undersurface) 3 ______—with taste buds and papillae e.g. on dorsum of tongue

Answer 59

masticatory lining specialised

Question 60

_________ is an important cause of many oral mucosal disorders, such as ulceration, bleeding gums and hyperplasia

Answer 60

Dental trauma or neglect

Question 61

Non-healing oral ulcers warrant biopsy to exclude | ______

Answer 61

squamous cell carcinoma (SCC

Question 62

________ persisting for 3 weeks after injury, e.g. sharp tooth or denture, should have an incisional biopsy

Answer 62

Erythroplasia or leucoplakia

Question 63

Any oral ulcer or soft-tissue lesion that persists ______ after the apparent cause has been removed should be biopsied.

Answer 63

3 weeks

Question 64

Consider ________infection with unusual faucial ulceration and petechial haemorrhages of the soft palate.

Answer 64

Epstein–Barr virus (EBV)

Question 65

______ are usually 3–5 mm in diameter— | minor ones have an erythematous margin

Answer 65

Aphthous ulcers

Question 66

______, other than palatal and | mandibular tori, are often variations from normal

Answer 66

Intraoral bony exostoses

Question 67

Histology of oral ulceration

Answer 67

The histology of oral ulceration is usually non-specific, with fibrin slough covering granulation tissue, and the aetiology is varied