Sleep disorders

Question 1

insomnia

Answer 1

difficulty initiating sleep, maintaining sleep or early morning awakenings occur at least three times per week for a minimum duration of at least 3 months
-freq triggered by stress and resolves when the stress resolves

Question 2

causes of insomnia

Answer 2

• med conditions (pain, thyroid abnormalities, asthma, GERD)
• meds (SSRIs, steroids, stimulants, diuretics, b-agonists)

Question 3

narcolepsy

Answer 3

less prevalent than insomnia
-onset: in childhood and adolescens

Question 4

restless legs syndrome (RLS)

Answer 4

5-15% w/ 2.5% needing medical tx
-increases w/ age and various med conditions such as end-stage renal disease, pregnancy, and iron deficiency
-more common in W than M
-genetic

Question 5

obstructive sleep apnea (OSA)

Answer 5

-common in M (4:1 ratio to W)
-link to obesity

Question 6

parasomnias

Answer 6

sleep talking, bruxism (teeth grinding), sleepwalking, sleep terrors, and enuresis occur more frequently in childhood than in adulthood

Question 7

neurotransmitters controling NREM sleep

Answer 7

serotonin

Question 8

neurotransmitters controling REM sleep

Answer 8

cholinergic and adrenergic transmitters

Question 9

neurotransmitters playing a role in wakefulness

Answer 9

dopamine, norepinephrine, hypocretin, substance P, and histamine

Question 10

RLS patho

Answer 10

reduced serum ferritin levels and dopamine

Question 11

OSA associated with

Answer 11

hypertension, arrhythmias, heart failure, stroke, and ischemic heart disease

Question 12

PSG

Answer 12

overnight polysomnography or sleep study
-gold standard for dx and identifying sleep-disordered breathing, parasomnias, and nocturnal sleep irregularities r/t narcolepsy

Question 13

first-line therapy for insomnia

Answer 13

non-pharmacological: cognitive-behavioral therapy for insomnia (CBT-I); sleep hygiene, behavioral, cognitive, and stimulus-control interventions

Question 14

second-line intervention

Answer 14

pharmacologic tx
intermediate-acting NBRAs: eszopiclone or zolpidem
or
benzodiazepine: temazepam

Question 15

patients w/ sleep onset difficulty

Answer 15

zaleplon (limit to 30 days), ramelteon (6mo), or triazolam (6mo)

Question 16

patients difficulty maintaining sleep

Answer 16

doxepin or suvorexant

Question 17

BZD carry a black box warning regarding concomitant use with

Answer 17

opioids (greater level of sedation, respiratory depression, coma, and death)

Question 18

ramelteon

Answer 18

a melatonin receptor agonist; for difficulty w/ sleep onset

Question 19

suvorexant and lemborexant

Answer 19

oxerin receptor antagonist: 1st meds to turn off wakefulness mechanism instead of stimulating pathways that induce sleepiness

for difficulty initiating and maitaning sleep, like BZD and NBRA classified as Schedule IV controlled substances

Question 20

OTC agents

Answer 20

first-generation antihistamines: diphenhydramine and doxylamine
-produce undesirable anticholingeric effets and carryover sedation esp in elderly
-limit to 10 days

Question 21

sleep latency

Answer 21

time it takes for person to fall asleep after turning the lights out

Question 22

RLS tx

Answer 22

dopamine agonists (DAs) levodopa-carbidopa (longer half-lives to cover overnight symptoms)
-check iron levels and replete if nec
-switch to gabapentin (ropinirole, pramipexole,(1st line) and rotigotine)

Question 23

gabapentin dose

Answer 23

600mg taken w/ food at dinnertime

Question 24

clonazepam

Answer 24

reduces the amt of sleep time spent in stage 3 of NREM sleep when most NREM parasomnias occur

0.5-2mg at bedtime or melatonin 3-12 mg at bedrime

Question 25

antidepressants

Answer 25

may alleviate depressive sxs but exacerbate sxs of RLS

Question 26

follow-up for insomnia

Answer 26

in 3 wks