2 B P 270-277

Question 1

What are the actions recommended as part of the Lifestyle prescription for sleep?

BR 273

Answer 1

1. Use bed for sleep and sex only
2. Establish regular sleep cycle for bedtime and wake time
3. Increase bedtime peripheral cutaneous vasodilation with bath/shower, socks or
   heating pad for cold feet, and/or non-caffeinated tea/beverages.
4. Allow air temperature to gradually warm extremities using bedding, socks, heating
   pad, blankets
5. Minimize/eliminate bedroom noise and lights, removing digital displays, charger
   lights, keep alarm clock out of sight.
6. Keeping power naps to 30min or less

Question 2

What are the recommended light exposures for the Lifestyle prescription for sleep?
BR 273

Answer 2

1. Increase daytime exposure to sunlight, ideally outdoors, open sky.
2. Increase daytime physical activity. Get up and move at least once an hour. Increase
   physical activity in late afternoon and early evening.
3. Decrease light at night. Turn off or dim unnecessary lights at least one hour before
   bedtime, especially blue light, compact fluorescent, halogen lights, and backlit
   screens. Use 2500 Kelvin color warm spectrum lights.

Question 3

What are the dietary adjustments recommended as part of the Lifestyle prescription for
sleep?

BR 273

Answer 3

1. Eliminate nighttime caffeinated beverages.
2. Limit daytime caffeinated beverages.
3. Avoid alcohol within three hours of bed.
4. Eliminate after dinner and late night snacking.
5. Avoid high sodium foods, especially at dinner because it affects vascular tone and
   vasodilation.
6. Assure adequate daytime fluid intake, especially late afternoon because it affects
   vascular tone and vasodilation.
7. Weight reduction is BMI is elevated.

Question 4

What are ways to minimize stress recommended as part of the Lifestyle prescription for
sleep?

BR 273 & 274

Answer 4

1. Start settling down one hour before bed, include active relaxation. Examples
   bath/shower, meditation, guided imagery, music with 60 bpm.
2. Develop a wind down routine for segue from daytime concerns to rest fullness. Stop
   working or doing stimulating activities 90 minutes before bed.
3. Mitigate night time worrying, planning, ruminating. Try mindfulness-based stress
   reduction and meditation.
4. Practice cognitive behavioral therapy techniques for insomnia.

Question 5

Which of the following is recommended as first line treatment for chronic insomnia over
medications?
A) CBT
B) Sleep restriction
C) Stimulus control
D) Relaxation training therapy
E) Sleep hygiene

BR 274

Answer 5

A- CBT is recommended as first-line treatment of chronic insomnia over medications. It’s
more likely to produce sustained benefit. It has less risk of tolerance or side effects.
Cognitive therapies combine with behavioral therapies have shown to facilitate getting off
sleep medications and sustaining sleep over time. There’s also limited evidence that they
reduce daytime fatigue.
Sleep restriction meets evidence-based psychological treatment criteria for adults > 60 y/o
and is shown to be effective in moderate to high quality randomized controlled trial.
Stimulus control partially meets evidence-based psychological treatment criteria for adults >
60 y/o and is shown to be effective in moderate to high quality randomized controlled trial.
Although relaxation training therapy is shown to be effective in moderate to high quality
randomized controlled trial, it did not meet evidence-based psychological treatment criteria
for adults > 60 y/o.
Sleep hygiene did not meet evidence-based psychological treatment criteria for adults > 60
y/o.

Question 6

How does cognitive restructuring help with sleep?

BR 274

Answer 6

It addresses anxiety producing or erroneous beliefs about sleep or lack of sleep.

Question 7

Which of the following statements is false regarding melatonin supplementation?
1) Melatonin is efficacious for jet lag mitigation and circadian rhythm disorders

2) Melatonin is efficacious for insomnia.
3) There is no evidence for adverse effects at typical doses of melatonin 1 to 6 mg.
4) Supplementation does not appear to suppress endogenous melatonin.
5) Sublingual melatonin may have better bio availability.

BR 274

Answer 7

2- There is mixed evidence for the effectiveness of melatonin and insomnia. It is effective for
jet lag, especially westward jet lag with sustained preparation, but it may cause morning
drowsiness. There is no evidence for adverse effects, but there is possible interaction with
some cytochrome P450 drugs and vitamin B6 may cause acute altering effects in some
individuals

Question 8

Medications that are used to induce and/or maintain sleep can be prescription strength
(Benzos, Ambien) or over-the-counter (Benadryl, doxylamine). What are the risks associated
with prescription strength hypnotic medications?

BR 274

Answer 8

Prescription strength hypnotic medications are associated with a significant increase in
death rates in adults age 18 to 55. An increased risk of all cause mortality in all age groups
that use hypnotics from overdose, car accidents, falls, depression, cancer, and suicide.

Question 9

What are the 7 parts of the mini sleep assessment?

BR 276

Answer 9

1. Typical weekday hours of sleep
2. Typical weekend hours of sleep
3. Perceived sleep quality
4. Red flags present
5. Frequency of daytime fatigue, sleepiness and/or difficulty waking up
6. Frequency and type of sleep disturbance.
7. Attitude towards sleep and sleep barriers, such as cavalier about sleep need (“I don’t
   have time to sleep”) or highly distressed by any sleep disturbance.

Question 10

In the mini sleep assessment, what are the red flags to insufficient or poor quality sleep?

BR 276

Answer 10

1. Less than 7hrs duration
2. One or more hours weekday-weekend difference
3. Irregular sleep timing, duration (ex. Shift work)
4. Poor sleep quality despite 7 or more hours in bed
5. More than 9hrs

Question 11

In the mini sleep assessment, what are the sleep disturbance types?

BR 276

Answer 11

1. Fall asleep more than 8hrs before ideal wake up time
2. Sleep onset more than 15 to 20min after lights out
3. Prolonged wakefulness after initial sleep onset.
4. Awaking less that 7-8hrs after bedtime

Question 12

Which of the following is not part of the STOP assessment for obstructive sleep apnea?
A) Loud snoring
B) Fatigue, tired, daytime sleepiness that inhibits functioning
C) Observed apnea episodes
D) Obesity
E) Elevated Blood pressure or taking hypertension meds
F) 2 or more positives is high risk for OSA and refer for sleep study
BR 276

Answer 12

D- Obesity is not part of the STOP assessment. S- snoring, T- tired, O- observed apnea P-
pressure (blood pressure). Less than 2 positives is low risk for OSA.

Question 13

Sleep hygiene assessment includes questions of what activities?

BR 276

Answer 13

1. Daytime naps of >30min
2. Poor daytime hydration
3. Variations in sleep onset/offset
4. Prolonged non-sleep periods in bed
5. Stimulating activities pre-bedtime
6. Going to bed stressed, angry, upset
7. Reading, watching TV, eating in bed
8. Uncomfortable bed and/or bedroom
9. Think, plan or worry in bed
10. Caffeine, alcohol within 3 hrs of bedtime

Question 14

Regarding lifestyle adjustments for delayed sleep onset or difficulty with sleep initiation,
which of the following statements is false?

A) Read in bed until sleepy
B) Increase early morning sunlight
C) Avoid nighttime caffiene
D) Eat a low carb dinner
E) Meditation before bedtime
BR 275

Answer 14

A64
A- Use bed only for sleep and sex. Other adjustments include minimize noise and lights,
allow natural cooling of temp through night, warm extremities at ideal bedtime (clothing,
bathing, warm beverage). Increase afternoon physical activity, afternoon outdoor light,
decrease light at night. Avoid alcohol, high sodium foods, carb rich breakfast. Start winding
down at least one hour before bed and include active relaxation including bathing,
meditation, guided imagery.

Question 15

Regarding lifestyle adjustments for sleep fragmentation and difficulty maintaining sleep,
which of the following statements is false?
A) Allow bedroom to cool gradually through night
B) Increase morning and midafternoon sunlight exposure
C) If one wakes up in the middle of night, avoid turning on the lights
D) Stay hydrated by drinking diuretic beverages in the evening
E) Mitigate night time worrying, planning, and ruminating

BR 275

Answer 15

D- Increase late afternoon hydration but avoid evening beverages like soda, caffeine,
alcohol. Other adjustments include darken bedroom, keep a glass of cool water at bedside.
Increase physical activity preferably outdoors. Use red toned ightlights if light is necessary.

Question 16

Regarding lifestyle adjustments for sleep deficiency from waking up too early, which of the
following statements is false?
A) Sufficient bedcovers to be warm in early morning
B) Increase morning and mid-afternoon sunlight exposure
C) Avoid bright lights until ideal wake up time
D) Use blue spectrum 6500 kelvin lights until one hour before bedtime
E) Shift carbohydrates from breakfast to dinner
BR 275

Answer 16

B- Increase late afternoon and evening sunlight to increase melatonin production, especially
if one tends to gravitate towards early morning light. Other adjustments include avoid bright
lights until ideal wake up time. Avoid eating or drinking caffeine until 30 to 60min after ideal
wake up time.

Question 17

Regarding lifestyle adjustments for jetlag traveling east, which of the following statements is
false?
A) Get late afternoon and early evening bright light, preferably outdoors.
B) Get only dim-light exposure starting one hour before new ideal sleep time
C) Eat a hearty breakfast within 30-45 min of new ideal wake-up time
D) Melatonin 1mg SL one hour before new ideal sleep time
BR 275

Answer 17

A-For eastward jetlag travel, get exposure to bright light, preferably outdoors, close to new
ideal wake-up time.

Question 18

Regarding lifestyle adjustments for jetlag traveling west, which of the following statements is
false?
A) Get late afternoon and early evening bright light, preferably outdoors.
B) Avoid dim-light exposure until hour before new ideal sleep time
C) Eat a hearty breakfast within 30-45 min of new ideal wake-up time
D) Melatonin 1mg SL one hour before new ideal sleep time
E) Eat a complex carb-rich dinner one hour before new ideal sleep time
BR 275

Answer 18

E- Eat a complex carb-rich dinner two to three hours before new ideal sleep time

Question 19

Match the sleep disorder with the accurate statement

a. Behaviorally induced insufficient sleep syndrome (BIISS)
b. Insomnia
c. Obstructive sleep apnea (OSA)
d. Restless Leg Syndrome

1. Classified as Mild, Moderate, Severe
2. Difficulty initiating and/or maintaining sleep with daytime consequences despite
   adequate sleep opportunity, ongoing for at least 3mos at least 3 times/week
3. Feeling an urge to move legs, occurring with uncomfortable sensation in the legs that
   happens when one rests (sitting or lying down), worse in the evenings than day, with
   relief with movement and not due to another primary medical cause
4. Inadequate sleep for functional performance, voluntary restriction of sleep, longer
   sleep duration on weekends, disparity between sleep needed and obtained
5. Associated with younger age, 30-39, alcohol abuse, longer work hours (>40/week),
   Stress, Depression
6. Associated with fatigue, malaise, sleepiness, concentration/memory impairment,
   decreased motivation, mood disturbances/irritability, errors or accidents at work/driving, physical symptoms of headaches, GI distress, persistent worry about
   sleep
7. Associated with periodic movements of sleep (occurs in 85%), disruptions of sleep,
   fatigue, periodic involuntary and jerk movements of limbs while awake or at rest
8. Associated with overweight or obese, metabolic syndrome, HTN, increased neck
   circumference, loud snoring
9. Prevalence of up to 26% general population, with 80% undiagnosed
10. Prevalence of 5-15% of US population
11. Prevalance of 7.3% to 20% general population

BR 270-271

Answer 19

1. C- Mild is Apnea-Hyponea Index (AHI) 5-15, Moderate 15-30, Severe 30+
2. B
3. D
4. A
5. A
6. B
7. D
8. C
9. C
10. D
11. A

Question 20

Match the sleep disorder to the accurate statement

a. Short sleep misperception
b. Secondary insomnia
c. Narcolepsy
d. Periodic limb movements

1. Sudden, uncontrollable mobile onset of sleep; may require a referral for sleep study
   and sleep medicine specialist.
2. Possibly due to medications, vascular dysfunction (peripheral hypoperfusion,
   vasospasm); visual impairment (opacification, retinal degeneration);
   renin-angiotensin dysfunction (fluid balance).
3. Mismatch between sleep duration on polysomnography and interpretation - patient
   perceives less sleep than actual sleep duration.
4. Limb movements occurring at about 30-second interval during sleep; increased
   frequency with age especially after 50 years old; often associated with restless leg
   syndrome; patients may report restless sleep or middle of night awakening with
   increased daytime sleepiness.

BR 271

Answer 20

1. C
2. B
3. A
4. D

Question 21

Which of the following statements is true?
A) Impaired sleep quality and short duration has lower cortisol and glucose levels,
greater insulin sensitivity, higher daytime leptin, reduced food seeking behaviors.
B) Healthy sleep duration in quality has higher nighttime cortisol and glucose levels,
reduced insulin sensitivity, higher glucose levels, lower daytime leptin levels and
higher intake of carbohydrate dense foods
C) Men and women who slept four hours for five nights in a row sought out
approximately 300 cal more, and especially calories from saturated fat, during the
day
D) There is no correlation between short duration and disrupted sleep to metabolic
disorders like elevated BMI, obesity, metabolic syndrome, and type two diabetes.

BR 271

Answer 21

C- Healthy sleep duration in quality has lower cortisol and glucose levels, greater insulin
sensitivity, higher daytime leptin, reduced food seeking behaviors. Impaired sleep quality
and short duration has higher nighttime cortisol and glucose levels, reduced insulin
sensitivity, higher glucose levels, lower daytime leptin levels and higher intake of
carbohydrate dense foods. Short duration and disrupted sleep correlates with elevated BMI,obesity, metabolic syndrome, and type two diabetes.

Question 22

What is the relationship between sleep and cardiovascular disorders?

BR 271&272

Answer 22

• Healthy sleep duration and quality leads to lower sympathetic tone and blood pressure,
  greater nighttime peripheral perfusion and core body temperature cooling, increased stamina
  and faster cardiovascular recovery time.
• Impaired sleep quality and/or short duration leads to elevated sympathetic tone, elevated blood pressure- especially at night, reduced nighttime
  peripheral perfusion, and increased nighttime core body temperature.
• Short sleep correlates with refractory and no-reduction of blood pressure in early morning hours, increased heart attacks, increased risk of cardiovascular disease deaths, and vasospastic disorders.

Question 23

Which of the following statements is false? (More than one)
A) Healthy sleep duration and quality sleep lead to higher proportion of sleep time spent
in slow wave sleep, which is the deepest, most restorative stage of non-REM sleep.
B) Lower proportion of REM sleep leads to enhance learning and memory, faster
cognitive processing, greater anxiety and fear extinguishment.

C) Impaired sleep quality and short sleep lead to less slow wave and REM sleep; and
reduced brain derived neurotrophic factor (BDNF), which is a key substance that
triggers repair and regeneration of nerve tissue.
D) Impaired sleep can cause impaired learning and memory; emotional distress,
impaired moral judgment, misinterpretation of social cues; decreased alertness and
cognitive processing speed; diminished fear extinguishing, as the amygdala is not
able to get rid of the memory of fearful events.
E) Short sleep duration correlates with major depression, bipolar disorder, seasonal
affective disorder, premenstrual syndrome
F) Post traumatic stress disorder (PTSD) is not affected by sleep.
G) Traumatic brain injury (TBI) is not affected by sleep.

BR 272

Answer 23

B- Higher proportion of REM sleep leads to enhance learning and memory, faster cognitive
processing, greater anxiety and fear extinguishment.
F- Post traumatic stress disorder (PTSD) is worsened if sleep deprivation occurs two weeks
prior to traumatic event.
G-Traumatic brain injury (TBI) is worse with sleep deprivation if sleep deprivation occurs
before and/or follows injury.

Question 24

Discuss the relationship between sleep health and cancer.

BR 272&273

Answer 24

Healthy sleep duration quality help with DNA repair and histone remodeling, and apoptosis
and anti-cancer cytokines (IL-1, IL-2), TNF-alpha.
Impaired sleep quality and short duration lead to melatonin and immune system
suppression; increased cancer-stimulating cytokines (IL-10); dysfunction in gene
transcription and cell cycle; aberrant DNA methylation (meaning DNA expression is not
being coded correctly.)
Sleep disruption and short sleep duration correlates with breast cancer, endometrial cancer,
prostate cancer, colorectal cancer, and acute myeloid leukemia.