Sleep

Question 1

Delayed sleep phase disorder (DSPD): Dx

Answer 1

• circadium rhythm disorder with late time sleep pattern where sleep onset and wake up times are delayed by 3-6hrs
• occurs in 1% of teens/young adults through:
o delayed circadian rhythm (biological)
o poor sleep habits (staying up late, computer screens)
• Dx criteria
o delay in the phase of the major sleep episode in relation to the desired sleep time and waking time (pt reported)
o Sx present for at least 3 months
o When patients are allowed to choose their own schedule, they show improved sleep quality and duration and maintain a delayed phase of the 24-hour sleep/wake pattern.
o Sleep log monitoring 7-14 days demonstrates a delay in the timing of the habitual sleep period.
o The sleep disturbance is not better explained by another disorder

Question 2

Delayed sleep phase disorder (DSPD): Mx

Answer 2

• Keep sleep log for 7-14 days to determine delayed sleep phase (difference between natural waking up time and desired wake up time)
• Behavioral changes (need motivation)
o Gradually shifting sleep and wake up times by 30mins every few days while maintaining adequate sleep window (ie 8hrs)
o Bright light exposure: 1-2hrs at indicated wake up times
o Evening behavioral changes: no computer 2hrs before bed, relaxing activities in 1-2hrs before bed in dim light (reading, TV show (not computer!), shower etc), avoid caffeine

Question 3

Tiredness/sleep issue: ddx

Answer 3

• mental health causing sleep onset/maintenance issues
• stimulant intake causing delayed onset
• fragmenting sleep disorders (ie insomnia, sleep apnoea, periodic limb mvt, nightmares, RLS)
• disorder of excessive day time sleepiness (ie narcolepsy)
• sleeping at wrong time of day due to body clock- delayed sleep phase disorder (DSPD) or advances sleep phase disorder (ASPD)
• physical: thyroid, fibromyalgia, diabetes

Question 4

OSA Mx

Answer 4

Lifestyle:
• Diet/weight loss program
• Reduce ETOH
• Smoking cessation
• Nasal steroids 4 week trial
• Consider positional therapy: on side, 1 pillow
• Rationalize drugs/treat underlying condition
Dental splints
• Mild-mod OSA
• SE: dental pain, salivation, TMJ pain
CPAP: mod-severe
• automatically tirating vs in lab titrating
• SE: rhinitis, dermatitis, pressure sores from masks
Surgical
• Children: anatomical→surgical intervention (T&As)
• Jaw abnormality or nasal decongestive surgery as indicated
Driving
• Must notify driving license authority due to long term condition likely to affect driving ability- may need conditional license

Question 5

Restless leg syndrome (Willis Ekbom disease)- Dx criteria

Answer 5

Diagnostic criteria (URGES):
• U urge to move limbs – occurs suddenly and is usually accompanied by uncomfortable and unpleasant sensations
• R rest or inactivity precipitates or worsens symptoms
• G getting up or moving improves the situation
• E evening or nighttime appearance or worsening of symptoms
• S not solely accounted for by another medical or behavioral condition

Question 6

Restless leg syndrome (Willis Ekbom disease)- Mx

Answer 6

Conservative
•	Sleep hygiene
•	stretches, compression stockings, exercise
•	abstinence from alcohol, caffeine, nicotine
•	engaging in mentally distracting activities
•	review of medications
•	assess for iron deficiency and institute iron therapy for appropriate patients (aim ferritin >75ng/ml)
•	CBT
Medical: 
1)	alpha 2 ligands (off label use)
•	pregbalin 25-300mg
•	gabapentin
2) dopaminergic agents
•	pramipexole: 125-750ug/day-PBS
•	ropinirole: 4mg/day - not PBS
•	rotigotine: g/day transdermal patch- not PBS
Side effects of dopaminergic meds
•	augmentation: exacerbation of Sx 
•	impulse control disorders
•	hypersomnolence

Question 7

Persistent (chronic) insomnia: Dx criteria

Answer 7

The diagnostic criteria include:
• difficulty initiating and/or maintaining sleep (being awake for > 30 min)
• dissatisfaction with sleep quality (non-restorative sleep) or quantity
• impairment in daytime functioning (eg work, study, social).
• Occurring for at least 3 days per week for 3months

Question 8

Persistent (chronic) insomnia: Management

Answer 8

• CBTi (CBT for insomnia):
• Reduce ETOH, smoking, caffeine
• sleep/bed restriction
• relaxation strategies
• stimulus control therapy (bed is only for sleep/sex, leave if you’re not doing this)
• bright light therapy +/- morning exercise