Sleep-wake disorders

Question 1

Sleep disorders are divided into either

Answer 1

Dyssomnias: insufficient (insomnia), excessive (hypersomnia), or altered timing of sleep
Parasomnias: unusual sleep-related behaviors

Question 2

Components of a sleep history

Answer 2

Activities prior to bedtime 
Bed partner 
Consequence on waking function/QOL
Drug regimen, meds
Exacerbating/relieving factors
Frequency/duration
Genetic factors/FH
Habits (EtOH, caffeine, nicotine, etc)

Question 3

What are the main types of symptoms of insomnia disorder?

Answer 3

Difficulty going to sleep (sleep-onset insomnia)
Frequent nocturnal awakenings (sleep-maintenance insomnia)
Early morning awakenings (sleep-offset insomnia)
Nonrestorative sleep

Question 4

Diagnostic criteria for insomnia disorder

Answer 4

• Difficulty initiating or maintaining sleep
• At least 3x/wk for 3 months
• Causes distress or dysfunction
• Occurs despite adequate opportunity to sleep
• Does not occur exclusively during another sleep-wake disorder
• Not from medications, meds, etc

Question 5

Etiology of insomnia disorders

Answer 5

Subclinical mood or anxiety disorder
Preoccupation with perceived inability to sleep
Poor sleep hygiene

Question 6

Management of insomnia disorder

Answer 6

Sleep hygiene
CBT
Drugs: Benzos, zolpidem, eszopiclone, zaleplon, trazodone, amitriptyline, doxepin

Question 7

Diagnostic criteria for hypersomnia disorder

Answer 7

• Excessive sleepiness despite at least 7 hours of sleep with at least one of: multiple times sleeping in the same day; prolonged non-restorative sleep >9hrs; difficulty being fully awake
• At least 3x/wk for at least 3 mos
• Distress or dysfunction
• Etc…

Question 8

Etiology of hypersomnia disorder

Answer 8

Viral infections (HIV, mono, Guillan-Barre)
Head trauma
Genetic

Question 9

Treatment of hypersomnia disorder

Answer 9

Modafinil or stimulants

Scheduled napping

Question 10

What are the characteristics of central sleep apnea?

Answer 10

Five or more central apneas per hour of sleep. Can be idiopathic with Cheyne-Stokes respirations (periodic crescendo-decrescendo variation in tidal volume due to heart failure, stroke, or renal failure) or due to opioid use

Question 11

Treatment for central sleep apnea

Answer 11

Treat underlying condition
CPAP/BiPAP
Supplemental O2
Medications (acetazolamide, theophylline, sedative-hypnotics)

Question 12

Diagnostic criteria for narcolepsy

Answer 12

Recurrent episodes of needing to sleep, lapsing into sleep, or napping during the day, occuring at least 3x/wk for at least 3 months with at least one of:
–Cataplexy
–Hypocretin deficiency in CSF
–Reduced REM sleep latency on polysomnography
Hallucinations and/or sleep paralysis at the beginning or end of sleep episodes are common but not necessary for diagnosis

Question 13

Management of narcolepsy

Answer 13

Sleep hygeine
Scheduled daytime naps
Avoidance of shift work
Amphetamines or non-amphetamine stimulants for excessive daytime sleepiness
For cataplexy: sodium oxybate, TCAs, or SSRIs/SNRIs

Question 14

What is delayed sleep phase disorder?

Answer 14

Chronic or recurrent delay in sleep onset and awakening times with preserved quality and duration of sleep

Question 15

Risk factors for delayed sleep phase disorder

Answer 15

Puberty, caffeine or nicotine use, irregular sleep schedules

Question 16

Treatments for delayed sleep phase disorder

Answer 16

Timed bright light phototherapy in early morning
Administration of melatonin in the evening
Chronotherapy (delay bedtime by a few hours each night)

Question 17

What is advanced sleep phase disorder?

Answer 17

Normal duration and quality of sleep with sleep onset and awakening earlier than desired

Question 18

Risk factors for advanced sleep phase disorder

Answer 18

Old age

Question 19

Treatment for advanced sleep phase disorder

Answer 19

Timed bright light phototherapy prior to bedtime

Question 20

What is shift-work disorder?

Answer 20

Sleep deprivation and misalignment of circadian rhythm 2/2 nontraditional work hours

Question 21

Risk factors for sleepwalking

Answer 21

Sleep deprivation
Irregular sleep schedules
Stress
Fatigue
OSA
Nocturnal seizures
Fever
Meds, including sedatives/hyponotics, lithium, anticholinergics
Family history

Question 22

Management of sleepwalking

Answer 22

Education, reassurance, ensure safe environment, sleep hygiene, low-dose benzos if refractory

Question 23

What are the features of sleep terrors?

Answer 23

Recurrent episodes of sudden terror arousals that occur during slow-wave sleep
Signs of autonomic arousal (elevated BP, RR, diaphoresis)
Difficulty arousing during an episode
Dreams aren’t remembered and there is amnesia for the episode

Question 24

What are the features of nightmare disorder?

Answer 24

Recurrent frightening dreams that occur during the second half of sleep episode
Terminate in awakening with vivid recall
Causes clinically significant distress or dysfunction

Question 25

Management of nightmare disorder

Answer 25

Reassurance
Desensitization/imagery rehearsal therapy
Medications rarely indicated, but can use prazosin and antidepressants

Question 26

Risk factors for REM sleep behavior disorder

Answer 26

Older age, generally >50
Psychiatric meds including TCAs, SSRIs, SNRIs, B-blockers
Narcolepsy
Neurodegenerative disorders: Parkinson’s, multiple system atrophy, Lewy body dementia

Question 27

Treatment for restless leg syndrome

Answer 27

Drugs: pramipexole, ropinirole, or benzos
Iron replacement if ferritin is low
Remove offending agents if possible