Sleep Wake Disorders

Question 1

What is the deepest stage of sleep?

Answer 1

N3

Question 2

Which stage of sleep is important for memory consolidation?

Answer 2

Rem

Question 3

Which sleep wake disorder has the predominant complant of dissatisfaction with sleep quality or quantity, associated with difficulty maintaing or initiating sleep and or early morning awakening

Answer 3

Insomnia disorder

Question 4

Which sleep wake disorder presents with excessive sleepiness at least 3 times per week for at least 3 months despite a main sleep period lasting at least 7 hours

Answer 4

Hypersomnolence disorder

Question 5

Which sleep wake disorder presents with recurrent periods of an irrepressible need to sleep or lapse into sleep, or napping occurring in the same day

Answer 5

Narcolepsy

Question 6

Name 3 examples of breathing related sleep wake disorders

Answer 6

• Obstructive sleep apnea/hypopnea
• central sleep apnoea
• Sleep related hypoventilation

Question 7

Which sleep wake disorder presents with repeated episodes of arousals during sleep associated with vocalisation and or complex motor behaviours

Answer 7

Rem sleep behaviour disorder

Question 8

Name 3 examples of parasomnias

Answer 8

• Non-rem sleep arousal disorder :confusional arousals, sleepwalking (n 3 ), bruxism (n 2) sleep terrors (n3)
• nightmare disorder
• Rem sleep behaviour disorder

Question 9

Which sleep wake disorder presents with an urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in legs

Answer 9

Restless legs syndrome

Question 10

Time period of insomnia disorder?

Answer 10

At least 3 nights per week for 3 months

Question 11

Define difficulty initiating steep

Answer 11

Subjective sleep latency greater than 20-30 minutes

Question 12

Pharmacological treatment options for insomnia disorder? (5)

Answer 12

Short term < 2 weeks to restore normal sleep pattern

• Melatonin! receptor agonists : tasimelteon, ramelteon , agomelatine
• benzos (mainstay!)
• non-benzo hypnotics : “z” - zolpidem, zaleplon, zopiclone, eszopiclone
• Sedative hypnotics, gaba r agonists
• trazadone (sari)
• Sedating antipsychotics: quetiapine (atypical)
• antihistamines

Nb first line is sleep hygiene , light phase shift therapy , sleep diary etc

Question 13

Time period of hypersomnolence disorder?

Answer 13

Excessive sleepiness at least 3 times per week for at least 3 months

Question 14

Hypersommolence disorder symptoms? ( 3)

Answer 14

At least 1 of following:
• recurrent periods of sleep in same day
• prolonged non restorative sleep episode lasting at least 9 hours, wake up not refreshed
• Sleep inertia- difficulty being fully awake, feel groggy after waking

Despite a main sleep period lasting at least 7 hours

Question 15

3 specifiers according to time period of hypersomnolence disorder?

Answer 15

• acute: Less than month
• subacute: 1-3 months
• persistent: more than 3 months

Question 16

What is mild Hypersomnolence disorder?

Answer 16

Difficulty maintaining daytime alertness 1-2 days per week

Question 17

What is moderate hypersomnolence disorder?

Answer 17

Difficulty maintaining daytime alertness 3-4 days per week

Question 18

What is severe hypersomnolence disorder?

Answer 18

Difficulty maintaining daytime alertness 5-7 days per week

Question 19

Name 5 risk and prognostic factors for hypersomnolence disorder

Answer 19

1. stress
2. Alcohol
3. Viral infections
4. Head trauma
5. Familial ad

Question 20

Time period of narcolepsy?

Answer 20

At least 3 times per week for 3 mouths

Question 21

Name 3 diagnostic features of narcolepsy

Answer 21

At least 1:

1. episodes of cataplexy
2. Hypocretin deficiency in csf
3. Nocturnal sleep polysomnogram showing rem sleep latency 15 or less minutes , or a multiple sleep latency test showing mean sleep latency 8 minutes or less and 2 or more sleep-onset rem periods

Question 22

First line drug treatment of narcolepsy? (3)

Answer 22

Stimulants to help stay awake:
• modafinil (provigil)
• methylphenidate (ritalin)
• Atomoxetine

( Can use ssri for hallucinations)

Question 23

Name 2 examples of non-rem sleep arousal disorders

Answer 23

• Sleepwalking
• sleep night terrors
Both n3.

Question 24

Which sleep wake disorder is described by repeated dysphoric, well remembered dreams involving efforts to avoid threats to survival/security or physical integrity.

Answer 24

Nightmare disorder - one of the parasomnias

Question 25

Which sleep wake disorder is described by repeated episodes of arousals during sleep associated with vocalisation and or complex motor behaviours?

Answer 25

Rem sleep behaviour disorder- type of parasomnias

Question 26

Which group sleep wake disorders is described by abnormal behaviour or physiological events during sleep?

Answer 26

Parasomnias

Question 27

Time period of restless legs syndrome?

Answer 27

At least 3 times per week for 3 months

Question 28

Name 5 risk or prognostic factors for restless legs syndrome

Answer 28

* Family history * trauma * iron deficiency * uraemia * pregnancy * chronic renal failure

Question 29

Name 5 drugs that can cause medication or substance induced sleep disorder

Answer 29

• Antipsychotics : daytime sedation, increased appetite risk osa, impact on sleep architecture and decreased rem sleep, da antagonism aggravates plmd / rls • ssri :rem suppress, increased rem latency • alcohol • ampetamine • tobacco Cocaine, caffeine, cannabis, opioids...

Question 30

Name the 2 diagnostic features of osa

Answer 30

One of following; 1. Evidence by polysomnography of at least 5 osa or hypopneas per hour of sleep, with either of these symptoms • nocturnal breathing disturbances: snoring, snorting, breathing pauses during sleep • day time sleepiness, fatigue or non-refreshing sleep despite sufficient opportunity 2. Polysomnogram shows 5 or more osa and or hypopneas per hour of sleep regardless of symptoms

Question 31

Name 5 common comorbidities of osa

Answer 31

``` • Cad • heart failure • CVA • diabetes • parkinsons Depression ```

Question 32

Name 10 causes sleep disorders

Answer 32

SLEEP WAKE - substances: alcohol, opioid, caffeine, stimulant - lungs: asthma, copd, central alveolar hypoventilation - environment: hot, noisy - endocrine: hyperthyroid, hormone fluctuations eg menopause, hypogonadism - Psychiatric: MDD , anxiety, PTSD, panic disorder, stress, bereavement - withdrawal - aging - kidney: paroxysmal nocturnal haemoglobinuria - employment: shift work - drugs: antidepressants, benZos, bronchodilators

Question 33

Name 6 specifiers insomnia disorder

Answer 33

- Episodic: 1-3 months - persistent: 3 or more months - recurrent: 2 or more episodes in 1 year - with non-sleep disorder mental comorbidity (including sud) - with other medical comorbidity - with other sleep disorder

Question 34

Name 3 types insomnia

Answer 34

- Initial insomnia: sleep onset difficulty > 20-30 minutes - middle: maintenance - late /terminal: early morning awakening + inability to return to sleep

Question 35

Name 9 differential diagnoses insomnia

Answer 35

- Normal sleep variation - insomnia disorder - situational/ acute insomnia (for a few days,associated life events) - delayed sleep phase + shift work: circadian rhythm shift work disorder - breathing related sleep disorders - restless leg syndrome - Narcolepsy - parasomnias - substance/ medication induced sleep disorder, insomnia type

Question 36

Name 5 subtypes narcolepsy

Answer 36

- Narcolepsy without cataplexy but with hypocretin deficiency - narcolepsy with cataplexy but without hypocretin deficiency - autosomal dominant cerebellar ataxia, deafness and narcolepsy - autosomal dominant narcolepsy,obesity and type 2 diabetes - narcolepsy secondary to AMC

Question 37

Name 3 features non-rem sleep arousal disorders

Answer 37

- Incomplete awakening from sleep during N3 with sleepwalking/ sleep terrors - no/little dream imagery recalled - amnesia for the episodes

Question 38

Name 2 criteria of nightmare disorder

Answer 38

- Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical in­ tegrity and that generally occur during the second half of the major sleep episode. - On awakening from the dysphoric dreams,the individual rapidly becomes oriented and alert.

Question 39

Name 4 criteria of REM sleep behaviour disorder

Answer 39

- Repeated episodes of arousal during sleep associated with vocalization and/or com­plex motor behaviors. - These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later por­tions of the sleep period, and uncommonly occur during daytime naps. - Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented. - Either of the following: 1. REM sleep without atonia on polysomnographic recording. 2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson’s disease, multiple system atrophy)

Question 40

Which medications should be used and avoided in REM sleep behaviour disorder (5)

Answer 40

Avoid: - mirtazepine ( ttad ) - SsRI - venlafaxine (snri) Use: - clonazepam - tad - melatonin - da agonists

Question 41

Name 2 specifiers of substance/medication induced sleep disorder

Answer 41

- With onset during withdrawal - with onset during intoxication

Question 42

Name 3 types central sleep apnoea

Answer 42

- Idiopathic: variability in respiratory effort - Cheyne -stokes breathing: crescendo-decrescendo variation in tv - central sleep apnoea comborbid with opioid use: affect resp rhythm generators in medulla

Question 43

Define sleep-related hypoventilation

Answer 43

Decreased respiration episodes associated with elevated co2 levels

Question 44

Name 3 specifiers for sleep-related hypoventilation

Answer 44

- Idiopathic hypoventilation - congenital central alveolar hypoventilation - comorbid sleep related hypoventilation ( eg substance use, neuro disorders)

Question 45

Define apnoea

Answer 45

Absence breathing > 10 seconds

Question 46

Define hypopnea

Answer 46

Excessive decrease rate/ depth breathing ( > 50% reduction in ventilation for > 10 seconds)

Question 47

Name 3 specifiers obstructive sleep apnoea hypopnea

Answer 47

- Mild: apnoea hypopnea index < 15 - moderate: 15-30 - severe: >30

Question 48

Name 15 sleep-wake disorders

Answer 48

- Insomnia disorder (3/week for 3 mo for all) - hypersomnolence disorder - narcolepsy - obstructive sleep apnoea hypopNoea - central sleep apnoea - sleep-related hypoventilation - circadian rhythm sleep- wake disorders - "s/m" induced sleep disorder - other specified insomnia disorder - unspecified insomnia disorder - other specified hypersomnolence disorder - unspecified hypersomnolence disorder - other specified sleep-wake disorder - unspecified sleep- wake disorder Parasomnias: - restless legs syndrome - non-rapid eye movement sleep arousal disorders - rapid eye movement sleep behaviour disorder - nightmare disorder