S58 - Sleep Wake Disorders

Question 1

Narcolepsy - Excessive daytime sleepiness

Answer 1

Stimulant: modafinil

Question 2

Narcolepsy - Sleep paralysis, catalexy or hypnagogic hallucinations

Answer 2

venlafexine
fluoxetine
sodium oxybate

Question 3

Obstructive Sleep Apnea - after CPAP therapy still sleepy

Answer 3

modafinil

armodafinil

Question 4

Short Term Insomnia

Answer 4

Sleep hygiene
Short-acting Benzodiazepine receptor agonists
Ramelteon

Question 5

Chronic Insomnia

Answer 5

Sleep hygiene
Treat underlying condition
Benzodiazepine receptor agonists

Question 6

Primary hypersomnia DSM-5 criteria

Answer 6

Excessive sleepiness for at least one month, prolonged sleep episodes or daytime sleepiness almost daily

Question 7

Primary hypersomnia - Kleine-Levin Syndrome – usually males

Answer 7

Binge eating and hypersomnia

Sleep as long as 18-20 hours/day.

About 500 cases world-wide reported.

Disoriented, forgetfulness, depressed mood, irritability, and possibly aggressive behaviors.

Treatment with stimulants reported to be effective in ¾ cases.

Question 8

Obstructive Sleep Apnea (OSA).

Answer 8

Loud snores or brief gasps that alternate with episodes of silence that lasts 20-30 seconds.
Disturbs partner; subject is often unaware.
Cessation of breathing 60-90 seconds with cyanosis.
Most subjects are overweight

Question 9

Obstructive Sleep Apnea (OSA).

Complications –

Answer 9

arrhythmias, hypertension, cor pulmonale, and sudden death.

Question 10

Obstructive Sleep Apnea (OSA).

Symptoms –

Answer 10

daytime HA, poor memory and irritability.
Airflow ceases, episode stops by a reflex action from the decrease in O2 => arousal which breathing resumes.
Severe: > 20/apneas/hr and excessive daytime sedation; moderate: 5-20 apneas/hr.

Question 11

Obstructive Sleep Apnea (OSA).

Non-Pharm Treatment:

Answer 11

nonpharmacologic includes weight loss, remove obstruction (e.g. tonsillectomy).

Question 12

Obstructive Sleep Apnea (OSA).

Pharm Treatment:

Answer 12

Modafinil (Provigil®) is indicated for OSA. Dose is 200-400 mg/day.

Question 13

Narcolepsy

Answer 13

Irresistible sleep attacks of short duration.

DSM-5 criteria: occurs 3 times/week for at least 3 months.

Question 14

Narcolepsy

Pathophysiology –

Answer 14

Neuropeptide orexin or “hypocretin” found only in the posterior or lateral hypothalamus.
Innervate aminergic and cholinergic areas to promote wakefulness.
Decrease orexin levels = > sleepiness in animal models.

Question 15

Narcolepsy
Daytime sleep attacks: lasts up to 30 min.
Cataplexy –

Answer 15

precipitated by laughter (84%), excitement (74%) or surprise (64%).

Question 16

Narcolepsy – Treatment.
Sleep scheduling – routine of bedtime and naps.
Record keeping – daily charting of episodes.
Medications.

Answer 16

Stimulants. Modafinil and armodafinil are FDA approved for EDS in narcolepsy.
Antidepressants.
Gamma - hydroxybutyrate.

Question 17

Narcolepsy – Treatment options

Answer 17

Stimulants – sleep attacks
Drug					Daily Dose
Dextroamphetamine (C-II)		5-60 mg 
Methylphenidate (C-II)		10-60 mg
Modafinil (C-IV)			200-400 mg
Amodafinil (C-IV)			150 mg-250 mg

Question 18

Amodafnil: R-enatiomer of modafinil.

Answer 18

True

Question 19

Narcolepsy – Treatment.

Cataplexy

Answer 19

Tricyclic antidepressants (TCA’s) –protriptyline (< 20 mg/day) least sedating agent.
SSRI’s - fluoxetine and others.
SNRI’s – venlafaxine

Question 20

Gamma - hydroxybutyrate

Answer 20

Used in sexual assaults – “date-rape” drug causes anterograde amnesia leaves victims unable to recall details of the event

Question 21

Circadian rhythm sleep disorders

Answer 21

sleep disruptions either increase. sleepiness or insomnia mismatch in the sleep-wake cycle.

Question 22

Non-24 Hour Sleep-Wake Type (DSM-5).

Common among the blind, visual impairment and patients with a traumatic brain injury (TBI).

Answer 22

Tasimelton (Hetlioz®) MT1 and MT2 receptor agonist

Question 23

Sleepwalking (somnambolism) – rising out of bed and walking about.
Blank, staring face, unresponsive to efforts to wake.
On awakening – amnesia for the episode.

Answer 23

True

Question 24

Treatment of Sleepwalking and Sleep Terrors.

Answer 24

BZ’s, SSRI’s or TCA’s antidepressants.

Question 25

Sleep-related eating disorder – frequent episodes of nocturnal eating without full conscious awareness.
Treatment:

Answer 25

Tx with opiates, dopaminergic agents (L-dopa) or topiramate.

Question 26

Insomnia is the most common sleep problem.

Answer 26

True

Question 27

Parasomnias are often self-limiting.

Answer 27

True

Question 28

What are the two most common symptoms found in persons with narcolepsy?

Answer 28

Daytime sleepiness and Cataplexy

Question 29

What agent used for narcolepsy is available with only by a Risk Management program?

Answer 29

Gamma - hydroxybutyrate GHB

Question 30

What agents is used for “blind” persons with sleep difficulty?

Answer 30

Tasimelton