Sleep disorders

Question 1

Which hormone secretion increases during sleep and is suppressed by bright light?

Answer 1

Melatonin

Question 2

Sleep-promoting neurotransmitters

Answer 2

GABA

Question 3

Wakefulness-promoting neurotransmitters

Answer 3

NE, DA, acetylcholine, histamine, orexin

Question 4

Which stage do restorative sleep occur?

Answer 4

3&4

Question 5

Brief description of insomnia

Answer 5

Inability to initiate/maintain sleep, associated with daytime problems (fatigue, impaired concentration/memory etc)

Question 6

DSM-5 Insomnia (A)

Answer 6

Primary complain of unsatisfying sleep quantity or quality, with presence of 1 or more of the following
1. Difficulty with sleep initiation
2. Difficulty with sleep maintenance
3. Early-morning awakening

Question 7

DSM-5 Insomnia (B)

Answer 7

Sleep compliant is associated with social, occupational, academic, educational, behavioral or functional distress or impairment

Question 8

DSM-5 Insomnia (C)

Answer 8

Sleep complaint occurs at least 3 nights per week and has been present for at least 3 months

Question 9

DSM-5 Insomnia (D)

Answer 9

Sleep difficulties happen even with ample opportunity to sleep.

Question 10

DSM-5 Insomnia (E)

Answer 10

Sleep complaint is not attributed to or explained by another sleep- wake disorder, the adverse effect of a medication or substance, or a coexisting psychiatric illness or medical condition

Question 11

DSM-5 Insomnia (F)

Answer 11

Episodic - lasting 1 month to < 3 months
Persistent – lasting ≥ 3 months
Recurrent – experiencing ≥ 2 episodes within 1 year

Question 12

Management of acute insomnia (1 night - few weeks)

Answer 12

Transient <1 week: Sleep hygiene
Short-term <4 weeks: Sleep hygiene + short PRN course of hypnotic

Question 13

Management of chronic insomnia (≥3 nights/week
for ≥ 1 month)

Answer 13

Likely secondary/underlying psychiatric/medical problems, investigate!

Question 14

Pharmacological

Answer 14

Fast-acting anxiolytics/sedatives/hypnotics
Adjunct for SHORT TERM relief! PRN!
At lowest effective dose, short course

Question 15

Sleep hygiene 1

Answer 15

Avoid use of caffeine content products, nicotine & alcohol especially later in the day

Question 16

Sleep hygiene 2

Answer 16

Avoid heavy meals within 2 hours of bedtime

Question 17

Sleep hygiene 3

Answer 17

Avoid drinking fluids after dinner to prevent frequent night-time urination

Question 18

Sleep hygiene 4

Answer 18

Avoid environments that will make you really active after 5pm (i.e. avoid noisy environments).

Question 19

Sleep hygiene 5

Answer 19

Only use your bed for sleep. Sit in your chair when you just want to relax.

Question 20

Sleep hygiene 6

Answer 20

Avoid watching television in bed.

Question 21

Sleep hygiene 7

Answer 21

Establish a routine for getting ready to go to bed.

Question 22

Sleep hygiene 8

Answer 22

Set time aside to relax before bed, and utilise relaxation techniques.

Question 23

Sleep hygiene 9

Answer 23

Create an atmosphere conducive to sleep:
Keep yourself at a comfortable temperature by modifying the number of blankets you use.
Use earplugs if it is too noisy.
Make the room darker if there is too much light (e.g. close the door).
Put an extra mattress on your bed if is uncomfortable.

Question 24

Sleep hygiene 10

Answer 24

When in bed, relax and think pleasant thoughts to help you fall asleep.

Question 25

Sleep hygiene 11

Answer 25

Get up at the same time every day, including weekends. Use an alarm clock if it will help.

Question 26

Sleep hygiene 12

Answer 26

Avoid taking daytime naps. If you have to take them, make sure you do so before 3.00 pm and that
the total napping time does not exceed one hour.

Question 27

Sleep hygiene 13

Answer 27

Pursue regular physical activities like walking or gardening but avoid vigorous exercise too close to
bedtime.

Question 28

What classes of drugs are hypnotics?

Answer 28

Benzodiazepines
Z-hypnotics
Antihistamine
Lemborexant

Question 29

MOA of benzodiazepines

Answer 29

Potentiates GABA; relieves anxiety and insomnia

Question 30

Side effects of benzodiazepines

Answer 30

Sedation, drowsiness, amnesia

Question 31

Which benzodiazepines are useful for insomnia?

Answer 31

1. Lorazepam
2. Diazepam

Question 32

Dose of Lorazepam

Answer 32

0.5-2mg PRN (limit to 2 weeks)

Question 33

Dose of diazepam

Answer 33

2-15mg PRN (limit to 2 weeks)

Question 34

MOA of z-hypnotics

Answer 34

Preferentially binds to benzodiazepine-binding
sites with Y and a1 subunits (causes sedation).

Question 35

Side effects of z-hypnotics

Answer 35

Taste disturbance (Zopiclone)
Complex sleep behaviours (sleep walking)

Question 36

Which z-hypnotics are useful for insomnia?

Answer 36

1. Zolpidem
2. Zopiclone

Question 37

Dose of Zolpidem

Answer 37

> 18y/o: 10mg PRN
Females: half

Question 38

Dose of Zopiclone

Answer 38

> 18y/o: 7.5mg PRN
Elderly: 3.75mg PRN

Question 39

Antihistamines for insomnia

Answer 39

Promethazine
Hydroxyzine

Question 40

Dose of Promethazine or Hydroxyzine

Answer 40

25-50mg ON PRN

Question 41

What drug class is Lemborexant?

Answer 41

OX1 & OX2 orexin receptor antagonist
- Turns off wake signal instead of induce sleepiness

Question 42

Side effects of Lemborexant

Answer 42

Somnolence, nightmare

Question 43

Contraindication of Lemborexant

Answer 43

Narcolepsy
Severe hepatic impairment
Moderate-strong CYP3A4 inducer/inhibitors

Question 44

CYP3A4 inducers

Answer 44

Phenytoin
Phenobarbital
Rifampicin
St John’s wort
Glucocorticoids

Question 45

CYP3A4 inhibitors

Answer 45

Clarithromycin
Erythromycin
Ditiazem
Itraconazole
Ketoconazole
Ritonavir
Verapamil

Question 46

Antidepressant (off-label) for insomnia

Answer 46

Trazodone (inhibits 5HT reuptake, antagonise 5HT2A, H1, a1 receptors)

Question 47

Dose of Trazodone

Answer 47

20-50mg PRN

Question 48

Benzodiazepines & Z-hypnotics should NOT be administered in?

Answer 48

1. Acute narrow angle glaucoma,
2. Acute pulmonary insufficiency, respiratory depression, myasthenia gravis