Insomnia

Question 1

Name 5 sleep disorders

Answer 1

1) Not enough sleep (i.e. insomnia)
2) Too much sleep (i.e. hypersomnolence disorder, narcolepsy)
3) Busy sleep (i.e. restless legs syndrome, obstructive sleep apnea hypopnea, nightmare disorder)

Question 2

What should you screen for with insomnia and what tool?

Answer 2

depression with a PHQ-2:
“Over the last 2 weeks, how often have you been bothered by the following problems:
1. Little interest or pleasure in doing things?
2. Feeling down, depressed or hopeless?”

Question 3

Sleep study types:

Answer 3

Level 3 sleep study is done in the patient’s home with monitors for heart rate, oxygen levels and snoring.

Level 1 study (polysomnography) is a more intensive, overnight sleep study in a lab setting; measuring brain wave activity, limb movements, oxygen levels with electrocardiography.

Question 4

Name 5 ways to ensure sleep hygiene

Answer 4

• sleep rx- limit time in bed to what sleeping
  No caffeine/alcohol within 6h of bedtime
  Alcohol helps with sleep initiation but impairs sleep maintenance
  No nicotine (including replacement) close to bedtime
  No excessive liquids or heavy evening meal before bedtime
  Moderate physical activity, avoid heavy exercise within 3h of bedtime
  Minimize noise and light
  Temperature (avoid too warm)
  Avoid watching/checking clock

Question 5

Name 4 pharmacologic options for sleep aids. Which one for elderly?

Answer 5

1. Doxepin 10mg (generic) may be cheaper
2. Zopiclone 3.75-7mg PO qHS (short half life)
3. Zolpidem 5-10 mg SL qHS
4. Temazepam 15-30mg PO qHS
5. Trazadone: 25-100 mg shorter half-life, minimal tolerance, risk orthostatic hypot., cardiac conduction issues)
6. Non benzo hypnotic (Lunesta)
7. (dual orexin antagonist (Dayvigo)

Question 6

What other options for insomnia are there with comorbidities?

Answer 6

Antidepressants: e.g., mirtazapine, amitriptyline, nortriptyline

Antipsychotics: e.g., quetiapine, (Seroquel), methotrimeprazine (Nozinan)

Muscle relaxants: e.g., cyclobenzaprine

Question 7

List sleep disorders (at least 5)

Answer 7

Hypersomnolence disorder

Narcolepsy

Circadian rhythm sleep-wake disorders

Delayed sleep-wake phase disorder (sleep normally if go to bed later and wake up later)

Advanced sleep-wake phase disorder (sleep normally if go to bed earlier and wake up earlier)

Non-REM Sleep Arousal Disorders: Sleep terrors, Sleep walking, Restless legs syndrome, Obstructive Sleep Apnea**

Question 8

DDX for insomnia

Answer 8

Alcohol or other medication/drug use
Parkinsons 
Depression 
Cushings 
Hyperthyroid

Question 9

List one safety concern in insomnia

Answer 9

Driving

Question 10

List two things a patient should stop doing for their sleep hygiene

Answer 10

Drinking caffeine

Napping

Question 11

Non pharm treatments

Answer 11

CBT-I
Auricular acupuncture
Remove tech from the bedroom

Question 12

Non prescription treatments for restless leg (5)

Answer 12

Iron 
Magnesium 
Stretches 
Exercise 
Avoid caffeine 
Massage 
Heat

Question 13

Restless legs prescriptions

Answer 13

Non ergot dopamine agonists - pramipexole, ropinorole

Alpha-delta ca channel ligand (gabapentin, pregabalin)

Question 14

How to do sleep apnea questionnaire

Answer 14

STOP BANG
Snore
Tired
Observe apnea
Htn
BMI > 35
Age older than 50
Neck Size large
Gender male