Sleep Medicine

Question 1

Insomnia diagnosis

Answer 1

clinical diagnosis based on detailed sleep history included time needed to fall asleep, number and duration of awakings, estimated time in bed, total sleep time, description of sleep environment, habits and associated symptoms (snoring, kicking during the night, anxiety, depression)

Question 2

To diagnosis insomnia and tx 1st step is

Answer 2

2 wk sleep diary that provdies detailed information about pts quantity and quality of sleep, bedtime routien, daytime symptoms, causative substances, relationship to environmental factors and psychosocial stressers

Question 3

Benefits of sleep diary

Answer 3

confirms insomnia identifies sleep patterns and contributing factors allows Dr to make sleep hygiene recs and targeted behavioral guidance (stimulus control and lseep restriction) and other recs (CBT for insomnia or psychiatric eval)

Question 4

Remember the people who have OSA also have

Answer 4

fatty liver disease

Question 5

New onset insomnia, anxiety, fear, interpersonal conflicts, and escalating substance use

Answer 5

screen for PTSD as a reason for sleep disturbance

Question 6

How to deal with excessive daytime somnolence?

Answer 6

Determine if it’s due to insufficient sleep time, sleep apnea, narcolepsy, recurrent hypersomnia (Kleine Levin Syn)

Question 7

How to treat insufficient sleep time?

Answer 7

increase sleep time, improve sleep hygiene treat underlying insomnia

Question 8

Symptoms of insufficient sleep time?

Answer 8

inadequate amt of sleep, poor sleep hygiene, may be caused by insomnia

Question 9

Symptoms of sleep apnea

Answer 9

loud snoring, witnessed apneic spells, disrupted sleep

Question 10

Tx of sleep apnea

Answer 10

CPAP, weight loss, avoid supine sleep

Question 11

Symptoms of Narcolepsy?

Answer 11

severe daytime somnolence, sleep paralysis, hypnagogic hallucinations, disrupted nocturnal sleep, cataplexy, onset in teens and 20’s

Question 12

Tx for narcolepsy

Answer 12

stimulants (modafinil) venlafaxine, fluoxetine, atomoxetine, sodium oxybate for cataplexy

Question 13

Symptoms of recurrent hypersomnia (Kleine Levin syn)?

Answer 13

Recurrent episodes of hypersomnia hyperphagia hypersexuality onset as teen

Question 14

Treatment for recurrent hypersomnia (Kleine Levin Syn)

Answer 14

no effective tx

Question 15

Cataplexy definition

Answer 15

sudden loss of muscle tone associated with laughing or intense emotions

Question 16

When does narcolepsy present?

Answer 16

20 yrs

Question 17

Initial screening test for narcolepsy??

Answer 17

overnight polysomnogram then having a multiple sleep latency test (MSLT)

Need to have both. Cannot diagnose with multiple sleep latency test alone.

narcolepsy has a high incidence of coexisting sleep disorders like OSA and REM sleep disorder and restless leg syndrome

Need to get the PSG first to ensure that the patient had adequate sleep the night before the multiple sleep latency test (otherwise it invalidates findings if lack of sleep).

Question 18

What is a multiple sleep latency test

Answer 18

pts are given several opportunities to nap and time to sleep onset (sleep latency) is measured

Question 19

What is seen on a multiple sleep latency test with patients who have narcolepsy?

Answer 19

shorter sleep latency (time to sleep) than normal controls and evidence of rapid eye movement (REM) shortly after falling asleep.

Question 20

1st line tx for daytime somnolence from narcolepsy?

Answer 20

modafinil (1st line) - good relief of daytime sleepiness and well tolerated and has a low potential for abuse. Mechanism is not understood. preferred over methylphenidate or amphetamines due to side effect and safety profile. (hypertension, tachycardia, decreased appetite and addiction) and avoid for ppl who are risk for sudden cardiac death

Question 21

Does increasing sleep time for narcoleptic patients help?

Answer 21

no. Naroleptic pts sleep the same time as unaffected pts.

Question 22

What protein is low in CSF fluid of narcoleptic patients?

Answer 22

CSF hypocretin 1 levels are low

Question 23

What is a REM behavior disorder?

Answer 23

parasomnia disorder where there are dream enactment behaviors that occur during a loss of normal REM sleep atonia; behaviors are triggered by the dream

Question 24

REM behavior presentation

Answer 24

violent trashing, punching, kicking to avoid threats related to dream content. Usually come seek advice because of partner concern for injury.

Question 25

Who gets REM behavior disorder?

Answer 25

middle age older men

Question 26

What happens with REM behavior disorder

Answer 26

may be a prodromal syndrome of neurodegeneration w/ vast majority develop Parkinson’s dx or dementia iwth Lewy body about 50% every decade

Question 27

Treatment of REM behavior sleep disturbance

Answer 27

melatonin remove sharp and breakable objects, place cushion next to bed. Low dose clonazepam is effective in refractory cases.

Question 28

How to treat jet lag?

Answer 28

choose daytime flights, drink water, avoid caffeine, alcohol, large meals during normal sleep period consider melatonin if crossing >4 time zones avoid importnat meetings, long distance driving, or sedentary behavior on 1st day exercise in daytime.

Question 29

Symptoms of Jet lag

Answer 29

sleep disturbance, daytime fatigue, reduced performance, malaise, GI (constipation)

Question 30

manifestations of narcolepsy

Answer 30

daytime sleepiness,

falling alseep at inappropriate times,

vivid dreams when falling asleep or waking up.

Paralysis when waking up

cataplexy (fainting or facial paralysis) with strong emotion as laughing.

most common symptom is daytime sleepiness.

Question 31

diagnosis of narcolepsy:

Answer 31

3 months of severe daytime sleepiness with cataplexy and mean sleep latency time <8 minutes and at least two lseep onset REM sleep latency test for type 1- narcolepsy with cataplexy

or

2 an overnight polysomnogram plus next day multiple sleep latency tests with MEN latency time <8 minutes and at least two sleep onset REM sleep periods can see low orexin A in CSF for type one

Question 32

Cataplexy treatment?

Answer 32

Cataplexy seen in type 1 nacrolepsy.

rarely needs treatment.

Options include drugs that suppress REM (venlafaxine, atomoxetine, fluoxetine and sodium oxybate)

Question 33

pt presents with urge to move legs and unpleasant sensations on legs before bed.

Answer 33

Restless leg syndrome reports having sensations which are worse with inactivity and relieved by movement

Question 34

secondary causes of restless leg syndrome

Answer 34

Fe deficiency uremia DM2 MS and parkinson’s dx pregnancy drugs (SSRI and metoclopramide)

Question 35

Treatment of RLS

Answer 35

iron supplementation if serum ferritin is <75 ug/L leg massage heating pads, lowering caffeine intake, and exercise dopamine agonists (pramiprexole) gabapentin and pregabalin

Question 36

when should exercise be done to promote good slep?

Answer 36

at least 20 minutes and done >4-5 hrs prior to bedtime exercising before bedtme can be activating and further disrupts sleep

Question 37

Restricting time in bed to help one’s sleep is only used in:

Answer 37

people who are insomniacs and try to stay in bed longer in attempt to make up for lost sleep (pt who says in bed for 9 hrs but only sleeps for 5 hrs) by limiting to 5-6 hrs then the sleep efficiacy can improve

Question 38

non pharmacological treatment of insomnia

Answer 38

Question 39

non pharmacological treatment of insomnia is broken down into

Answer 39

sleep hygiene - encourage good sleep habits

stimulus control - break the link between bedroom and fear and frustration

relaxation- reduce tension and stress

sleep restriction - improve sleep efficiency

cognitive therapy - change maladaptive beliefs.

Question 40

what is narcolepsy?

Answer 40

disorder of sleep-wake control in which the line between the two is blurred.

sleep can invade into wakefulness by causing sudden onset sleep during inappropriate times or by causing cataplexy - sudden loss of control of face or entire body with strong emotion like laughter.

wakefulness invades sleep by c_ausing vivid dreams at the onset of or offset of sleep._

can be categorized into

type 1: cataplexy

type 2: no cataplexy

Question 41

Shift work sleep disorder

Answer 41

common phenomenon where pts have difficulty sleeping during the day

need to make sure no sleep apnea and optimize sleep hygeine habits by

sleeping in dark room,

avoiding bright screens like computers or televisions before bed

avoiding caffeine 8 hrs before bed

can give a stimulant modafinil prior to shift.

melatonin and light therapy don’t help

Question 42

1st line treatment for narcolepsy?

Answer 42

modafinil - good relief of daytime sleepiness and is generally well tolerated and low potential for absue

it does decrease effectiveness of oral contraception in women.

can also use methylphenidate and amphetamines as dextroamphetamine)

Question 43

how to treat cataplexy?

Answer 43

seldom requires treatment but if it does, options include medications that suppress REM (venlafaxine, atomoxetine, fluoxetine and sodium oxybate) sodium salt of a gamma hydroxybuytrate)

Question 44

Treat insomnia with cognitive behavioral therapy

Answer 44

1st line treatment to insomnia is cognitive behavioral therapy for insomnia.

combines sleep hygeine with behavioral interventiosn and cognitive behavioral therapy.

melatonin and diphenydramine are OTC remedies that don’t have enough evidence to recommend their use before a CBT-I. also sedating medications like anti-histamines are associated with anticholinergic side effects and carry over daytime sleepiness.