Sleep Disorders Flashcards
- AD is a 58-year-old man who presents to your clinic with the complaint that he “just
can’t sleep at night.” Upon further questioning, he reports that he typically falls asleep without problem but wakes up multiple times throughout the night. Which of the following sleep disorders could AD possibly have?
A. Insomnia
B. Obstructive sleep apnea
C. Narcolepsy
D. Restless legs syndrome
E. All of the above
E
- RS is a 28-year-old man with a history of obsessive-compulsive disorder who reports
that he kicks his legs during the night, which wakes him up. He reports that he does not really have any symptoms of restless legs syndrome, but the leg kicking frequently awakens him in the middle of the night and causes him to be sleepy during the daytime. RS has a body mass index of 21 kg/m2 and is normotensive, and his wife says he does not snore or stop breathing during sleep. What would you recommend for RS?
A. Temazepam 15 mg at bedtime
B. Polysomnography
C. Pramipexole 0.5 mg at bedtime
D. Multiple sleep latency test
E. Gabapentin 300 mg at bedtime
A
- Regarding therapies for the treatment of insomnia all of the following are correct except:
A. Sedating antidepressants are commonly used to treat insomnia despite few good
studies that document efficacy for insomnia.
B. Nonbenzodiazepines (zolpidem, zaleplon, eszopiclone) are generally associated with less rebound insomnia than traditional benzodiazepines.
C. Based on efficacy studies, BZDRAs and ramelteon are the drugs of choice for the
treatment of insomnia.
D. Suvorexant is an orexin receptor antagonist used for insomnia that is novel
because it is not a controlled substance.
E. All of the above are correct.
D
- Which of the following is a consequence of unidentified and untreated sleep disorders?
A. Hypertension
B. Motor vehicle accidents
C. Excessive daytime sleepiness
D. Irritability
E. All of the above
E
- BB is a 48-year-old man with a history of RLS. Over the past year, his RLS has gotten
worse, and he has increased the dose of his pramipexole therapy to 1 mg prior to
bedtime. His symptoms started appearing earlier in the day, and he had new symptoms in his arms. What strategy should be implemented to manage his symptom augmentation?
A. Switch to a shorter-acting dopaminergic agent
B. Switch to a longer-acting dopaminergic agent
C. Increase the dose of pramipexole
D. Check serum ferritin and replete iron if necessary
E. Both B and D
E
- TQ is a 51-year-old woman who presents to your clinic today with a complaint of
difficulty initiating sleep. She goes to bed at 10 PM and awakens at 6 AM but frequently
does not fall asleep for 1.5 to 2 hours. This problem has persisted for 9 months. TQ also has a history of alcohol abuse. Based on the available information, which agent would be the best choice to treat TQ’s complaint?
A. Ramelteon
B. Temazepam
C. Flurazepam
D. Eszopiclone
E. Amitriptyline
A
- BL is a 24-year-old college student with narcolepsy (no cataplexy) who is taking
methylphenidate 20 mg/day (he takes this at 8 AM before his first class). Currently, this works well at reducing sleepiness in the morning, but next semester, BL will have morning and late afternoon classes and is worried he will not be able to stay awake for afternoon classes. Which of the following might be the best strategy for the upcoming semester?
A. Methylphenidate 10 mg twice daily (8 AM and 6 PM)
B. Methylphenidate 20 mg SR twice daily and 10 mg prn afternoon sleepiness
C. Dextroamphetamine 10 mg/day (8 AM)
D. Sodium Oxybate 2.25 g at bedtime and 3 hours later
E. Selegiline 10 mg/day at 8 AM
B
- JM is a 38-year-old man traveling to Europe on business. He asks you for a
recommendation to treat jet lag upon his arrival. Based on the available evidence, which agent would you recommend?
A. Valerian
B. Diphenhydramine
C. Mirtazapine
D. Melatonin
E. Quazepam
D
- A patient presents to the clinic and tells you that he is looking for something to help him fall asleep at night. He reports that he frequently goes to bed and cannot fall asleep for 2 or 3 hours, so he lies in bed and watches television. Upon further questioning, he relays the following information about his sleep and medical history:
SH: Retired and married with two grown children. No tobacco use. Does not drink
alcohol or caffeine. He exercises at the health club in the mornings.
Sleep patterns:
Goes to bed on average at 11 PM and awakens with alarm at 6 AM but frequently does not fall asleep until 1 or 2 AM. No awakenings after he is asleep. No reports of limb restlessness. Tired in the daytime and naps for about an hour each afternoon but thinks it is related to inadequate sleep time. What would you recommend to the patient to improve his sleep hygiene?
A. Instruct him not to exercise; it may contribute to his complaint.
B. Instruct him to continue watching television in bed; it will help him fall asleep
more easily.
C. Recommend he drink alcohol in the evening to take the edge off.
D. Instruct him to avoid daytime naps.
E. Recommend all of the above.
D
- GR is a 58-year-old man with obstructive sleep apnea (OSA) and hypertension. He is currently using continuous positive airway pressure (CPAP) therapy (8 cm of water pressure [0.8 kPa]) for his OSA and uses it about 6.5 hours each night. His Epworth Sleepiness Scale score was 19 out of 24 when he first started CPAP, and it has improved, but he is still sleepy (current score, 14 out of 24). He has not gained any weight since starting CPAP therapy. What would be the best recommendation for GR?
A. He should start methylphenidate 20 mg SR in the morning for his daytime sleepiness.
B. He should increase his CPAP pressure to 12 cm water pressure (1.2 kPa).
C. He should start dextroamphetamine/amphetamine 30 mg XR in the morning for his daytime sleepiness.
D. He should start modafinil 200 mg in the morning for daytime sleepiness.
E. None of the above.
D
- In the treatment of restless legs syndrome, which of the following are disadvantages to the various treatments?
A. Levodopa-carbidopa—application site reactions
B. Pramipexole—risk of compulsive behaviors
C. Gabapentin enacarbil—high risk of symptom augmentation
D. Zaleplon—constipation
E. All of the above
B
- DP is a 46-year-old woman who presents with a complaint of difficulty initiating sleep. After a careful sleep history, you rule out other potential sleep disorders and want to start her on drug therapy for her insomnia. Which of the following would be the best
recommendation?
A. Amitriptyline 10 mg at bedtime
B. Flurazepam 15 mg at bedtime
C. Zaleplon 5 mg at bedtime
D. Doxepin 3 mg at bedtime
E. None of the above
C
- A patient with restless legs syndrome has been taking ropinirole 1 mg before bedtime to treat her symptoms. She takes her ropinirole at 7 PM, goes to bed at 9 PM, and wants to awaken at 6 AM for work. She explains that ropinirole helps her before going to bed and for the first few hours of sleep, but her symptoms reemerge around 3 AM, causing her to awaken too early. Her serum ferritin is 88 ng/mL (mcg/L; 198 pmol/L). What is happening with this patient’s therapy?
A. Patient is experiencing tolerance to the ropinirole.
B. Patient is experiencing symptom augmentation.
C. The ropinirole has worn off at 3 AM due to relatively short half-life.
D. Patient is experiencing morning symptoms due to iron deficiency.
E. All of the above.
C
- DH is a 34-year-old woman with a history of narcolepsy with cataplexy. She takes modafinil (Provigil) 200 mg each morning and 200 mg at noon to help control her sleepiness but does not receive much benefit from it. Her Epworth Sleepiness Scale score was 19 out of 24 today in clinic. She reports that she is most sleepy in the middle of the afternoon. She had not previously been on therapy for cataplexy. Today, she reports that her cataplexy has worsened and that she wishes to try something to help. What regimen would you recommend to better control DH’s narcolepsy and cataplexy?
A. Switch to methylphenidate 20 mg SR in the morning and at noon and add
venlafaxine 75 mg/day.
B. Increase her modafinil to 400 mg in the morning and 200 mg at noon.
C. Keep modafinil dose the same and add venlafaxine 75 mg in the morning.
D. Switch to methylphenidate 10 mg taken in the morning.
E. Switch to dextroamphetamine 5 mg in the morning and fluoxetine 10 mg in the
morning.
A
- VF is a 74-year-old man who is accompanied today in your clinic by his wife. She reports that for the past few months, VF thrashes around in bed violently during the latter half of the night (one to two times per week). He has flown out of bed on occasion and bruised his arm by hitting the wall. When asked about these episodes, he replies that he is usually dreaming about a struggle before he wakes up. What is the best diagnosis and matching appropriate therapy for VF?
A. NREM parasomnia—sleep walking—clonazepam
B. NREM parasomnia—night terrors—bupropion
C. REM parasomnia—REM behavior disorder—clonazepam
D. Periodic limb movements of sleep—ropinirole
E. Restless legs syndrome—gabapentin
C
- Which of the following is a consequence of unidentified and untreated sleep disorders?
A. Hypertension
B. Motor vehicle accidents
C. Excessive daytime sleepiness
D. All of the above
D
- Which of the following are important principles to improve sleep hygiene?
A. Exercise is helpful for sleep but try to avoid exercising right before bedtime
B. Use bed for sleep and intimacy only
C. Avoid drinking alcohol
D. All of the above are important principles of sleep hygiene
D
- Which of the following medications are indicated for treatment of residual daytime sleepiness in patients with OSA who are treated with CPAP?
A. Armodafinil
B. Methylphenidate
C. Venlafaxine
D. Nasal fluticasone
A
- What medication is a histamine-3 antagonist/inverse agonist that works to increase wakefulness?
A. Lemborexant
B. Pitolisant
C. Solriamfetol
D. Sodium oxybate
B
- Which of the following medications is not a controlled substance?
A. Ramelteon
B. Suvorexant
C. Armodafinil
D. Zaleplon
A
- Which of the following medications requires a lower dose in females as compared to males due to pharmacokinetic differences?
A. Clonazepam
B. Temazepam
C. Zolpidem
D. Eszopiclone
C
- Which lab should be checked in an individual complaining of symptoms of RLS?
A. Liver function
B. Hemoglobin A 1C
C. Magnesium level
D. Iron panel
D
- All NBRAs have a boxed warning for:
A. Risk of seizures due to reduction in the seizure threshold
B. Risk of life-threatening rash if slow titration is not followed
C. Risk of malignancy
D. Risk of complex sleep behaviors
D
- Prevalence of RLS is greater in individuals with certain medical conditions. Which of the following is a condition associated with higher RLS rates?
A. Menopause
B. End-stage renal disease
C. Congestive heart failure
D. Prostate cancer
B
- A 48-year-old man with a history of RLS has progressive worsening of symptoms over the past year. His RLS symptoms started appearing earlier in the day, and he had new movements in his arms. He has increased the dose of his pramipexole therapy to 1 mg prior to bedtime. What
strategy should be implemented to manage his symptom augmentation?
A. Switch to a shorter-acting dopaminergic agent
B. Increase the dose of pramipexole
C. Check serum ferritin and replete iron if necessary
D. Switch to levodopa/carbidopa
C
- A 44-year-old man presents today in your clinic with his wife. She reports that for the past few months, he thrashes around in bed violently during the latter half of the night (one to two
times per week). He has flown out of bed on occasion and bruised his arm by hitting the wall. When asked about these episodes, he replies that he is usually dreaming about a struggle before
he wakes up. What is the best diagnosis and matching appropriate therapy for VF?
A. NREM parasomnia—sleep walking—clonazepam
B. NREM parasomnia—night terrors—bupropion
C. REM parasomnia—REM behavior disorder—clonazepam
D. Restless leg syndrome—ropinirole
C
- A 53-year-old woman presents to the pharmacy for an over-the-counter recommendation for the treatment of insomnia. Upon further assessment, she is noted to have good sleep hygiene and denies any other chronic medical conditions. The pharmacist recommended her to start taking diphenhydramine 25 mg at bedtime. Which treatment duration best fits this recommendation?
A. Six months
B. Ten days
C. Indefinitely
D. Three months
B
- A 47-year-old man with OSA uses his CPAP daily. Despite good control of his OSA, he continues to have significant symptoms of insomnia. He presents to his primary care provider for treatment recommendations to help him sleep. He also takes oxycodone 30 mg daily for chronic pain. What medication is most appropriate for this patient given his medical history and current complaint?
A. Flurazepam
B. Modafinil
C. Ramelteon
D. Sodium oxybate
C
- A 35-year-old woman was diagnosed with RLS about 1 year ago. She was initially started on pramipexole but was unable to tolerate therapy due to the development of an impulse control disorder as well as augmentation. In addition to RLS, her only other medical condition is fibromyalgia. What would be the most appropriate treatment for the patient?
A. Rotigotine
B. Ropinirole
C. Gabapentin enacarbil
D. Carbidopa/levodopa
C
- A 13-year-old adolescent boy presents to the pediatric sleep specialist due to his poor academic performance secondary to falling asleep multiple times during class. In addition to these episodes, he gets into trouble with his teacher for falling out of his chair anytime he laughs hard in class. What is the most likely diagnosis and associated treatment for this patient?
A. Chronic insomnia—quazepam
B. Restless leg syndrome—ropinirole
C. REM sleep behavior disorder—melatonin
D. Narcolepsy—sodium oxybate
D
