Sleep Disorders

Question 1

EEG findings characteristic of Stage 2 sleep

Answer 1

Sleep spindles

K complexes

Question 2

Treatment for circadian rhythm disorders

Answer 2

Melatonin or bright light therapy

Question 3

Restless legs syndrome

Answer 3

• Sleep disorder characterized by an urge to move legs, usually during periods of rest or inactivity
• Patients describe uncomfortable “crawling” that worsens with stillness and improves with movement
  
  • Accompanied by periodic involuntary leg movements that last 2-3 seconds
• Etiologies:
  
  • Genetic (autosomal dominant)
  • Iron deficiency anemia
• Diagnosis:
  
  • Polysomnography can confirm the diagnosis, but often a clinical diagnosis is sufficient. Iron studies should be ordered to screen for iron deficiency anemia.
• Treatment:
  
  • If IDA is present, give iron
  • Otherwise, dopamine agonists ropinirole or pramipexole are the preferred treatments, given 2-3 hours prior to symptom onset

Question 4

Augmentation in treatment of restless leg syndrome

Answer 4

Symptoms develop progressively earlier in the day rather than stop when starting a pro-dopaminergic medication

If this occurs, or if there is another contraindication to pro-dopaminregic medications (induced gambling disorder, psychosis) second-line options include gabapentinoids, levodopa, opioids, benzodiazepines.

Of the pro-dopaminergics, trans-dermal rotigotine is less likely to produce augmentation.

Question 5

IDA and restless leg syndrome

Answer 5

IDA is a risk factor for the development of IDA. But, when IDA is corrected, the restless leg syndrome may persist

Question 6

Four components of narcolepsy/cataplexy

Answer 6

• Excessive daytime sleepiness with:
  
  • Narcolepsy
  • Cataplexy
  • Sleep paralysis
  • Hypnagogoic hallucinations

Question 7

Narcolepsy

Answer 7

The irresistable urge to sleep, often taking the form of “sleep attacks”

Question 8

Cataplexy

Answer 8

Characterized by sudden oss of muscle tone, often in the setting of laughter or other strong emotions

Question 9

Hypnagogic hallucinations

Answer 9

Those that occur immediately upon falling asleep

Question 10

Onset of narcolepsy/cataplexy syndrome

Answer 10

Usually onsets in late teens-20’s

Question 11

Pathophysiology of narcolepsy

Answer 11

Related to loss of hypocretin-secreting neurons in the hypothalamus

CSF hypocretin level < 110 pg / mL is diagnostic in the appropriate clinical setting

Question 12

Multiple sleep latency test

Answer 12

Special type of polysomnography used to diagnose narcolepsy/cataplexy

Involves several short naps and monitoring of the latency to sleep onset and latency to REM onset

Latency < 8 minutes or with more than two epsiodes of REM at sleep onset is diagnostic for narcolepsy/cataplexy

Question 13

Treatment for narcolepsy

Answer 13

• Modafinil is first-line
  
  • Mechanism unclear, stimulant
• Amphetamines are second-line
  
  • Methylphenidate, dextroamphetamine

Question 14

Treatment for cataplexy

Answer 14

• Sodium oxybate (a GABA agonist) is first-line
• Second line options:
  
  • Tricyclics (clomipramine)
  • SSRIs (fluoxetine, venlafaxine)

Question 15

SSRIs that are most likely to be “activating”

Answer 15

Fluoxetine (most by far)

Sertraline (less so)

Question 16

Confusion arousals

Answer 16

A form of parasomnia and arousal disorder

When patients awaken from sleep with disorientation, slow speech, and incoordination

Question 17

Sleep terrors

Answer 17

A form of parasomnia and arousal disorder

Involve rapid reawakening from sleep with featful behavior, often beginning with a scream

Associated with autonomic hyperactivity such as facial flushing, diaphoresis, tachycardia.

Often seen in children and self-resolves with age.

Question 18

Preventing episodes of REM sleep behavior disorder in Lewy body diseases

Answer 18

Clonazepam at bedtime prevents these episodes

Question 19

Nocturnal cramps

Answer 19

• Painful tightness, most often in leg muscles
• Should be differentiated from restless legs syndrome
• Treatments include:
  
  • Gentle exercise before bedtime,
  • potassium and magnesium supplementation,
  • antihistamines,
  • anticonvulsants,
  • quinine.

Question 20

Sleep starts / hypnic jerks

Answer 20

Commonly experienced myoclonic jerks that occur with sleep onset

Question 21

Treatment for insomnia

Answer 21

• Behavioral:
  
  • Sleep hygiene
  • Facilitation of relaxation before bedtime
• Pharmacologic:
  
  • Melatonin
  • 1st generation antihistamines
  • Benzodiazepines
  • Nonbenzodiazepines (zolpidem, zaleplon, eszopiclone)
  • Ramelteon (selective melatonin receptor agonist)
    
    • Note: Many of these have addictive properties, and they should NOT be used every night – just PRN for severe difficulty sleeping

Question 22

Restless leg syndrome is worsened by ____ and improved by ____

Answer 22

Restless leg syndrome is worsened by antidopamienrgics (often 1st generation antihistamines) and improved by prodopaminergics (pramipexole, ropinirole)