Sleep

Question 1

4 components of CBT-i?

Answer 1

• Sleep restriction: limiting the time in bed
• Stimulus control: extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry; bed is for sleep and sex only
• Relaxation training: reduce arousal in bed
• Cognitive therapy
• Sleep hygiene education: regular schedule, maintaining a healthy diet, getting regular daytime exercise, having a quiet sleep environment, avoiding all napping, and avoiding caffeine, etc.
• Acceptance and commitment therapy
• Mindfulness
• Brief behavioral treatments for insomnia

Question 2

6 components of sleep hygiene

Answer 2

a. Leave room if cannot fall asleep within 30min
b. Enviro dark
c. No screen time 2 hours before
d. Consistent routine
e. Only go when tired
f. Limit caffeine
g. Don’t go hungry
h. Avoid ETOH

Question 3

nocturnal leg cramps management

Answer 3

Hydration
Stretching
Diltiazem
Vit B
Vit K
?Compression stockings

Discontinue donepezil
Discontinue hydrochlorothiazide
Minimize/avoid alcohol caffeine
Wear supportive footwear during day

Question 4

DORAs mechanism? How does it affect the sleep cycle?

Answer 4

OX1R and OX2R antagonist, orexin promotes wakefulness

Decr sleep latency, wake after sleep onset (WASO)

Incr total sleep time, REM sleep (mild), faster transition from wake to REM sleep

Question 5

What are other possible diagnoses mimicking RBD?

Answer 5

Periodic Limb Movement Disorder (PLMD/nocturnal myoclonus): Only occurs during NREM sleep, unrelated to dreams

OSA: Parasomnia-like behaviours resolve once sleep-disordered breathing is treated

Sleep-related hypermotor epilepsy (SHE): Usually adolescence, up to 20 episodes per night, unaware of nighttime behaviours

Non-RME parasomnia: Sleepwalking / sleep terrors

Question 6

3 effects of melatonin on sleep

Answer 6

Decr sleep latency
Incr total sleep time
Incr sleep quality

Question 7

Restless leg syndrome (RLS) diagnostic criteria? Name 4

Answer 7

Urge to move, what makes it better or worse, not related to other condtion

▪ Urge to move the legs, usually associated with discomfort
▪ Begins or worsens during periods of rest or inactivity (e.g. sitting, lying down)
▪ Decreases with movement, as walking or stretching
▪ Worse or present only at night
▪ These features are not solely accounted for as symptoms primary to another medical or behavioral condition (e.g. myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, habitual foot tapping, etc.)

Question 8

Four classes of medications for RLS?

Answer 8

iron
gabapentinoid (gabapentin)
dopamine agonist (pramipexole)
levodopa
benzodiazepine (clonaz)

Question 9

How is RLS different from nocturnal myoclonus?

Answer 9

Periodic limb movement disorder (aka nocturnal myoclonus): Repetitive LE movements, highly stereotyped, last 1-2 seconds, occur q20-40 seconds. Occur during sleep. Awakenings caused by movement.

• repetitive stereotyped movements
• people usually NOT aware
• needs sleep study to diagnose

Question 10

6 causes of hypersomnolence other than metabolic etiology

Answer 10

Dementia (e.g. LBD, end-stage)
Depression
Delirium
Obstructive sleep apnea
REM sleep disorder
Periodic limb movement disorder
Seizures
Sedative medications
Thalamic stroke

Question 11

Two most common conditions associated with REM sleep disorder?
What is the pathology of the subgroup of disorders associated with RBD?

Answer 11

PD, DLB

Alpha-synuclein

Question 12

6 components of an insomnia history to elicit risk factors?

Answer 12

6 P’s – pain, PND, pills, pee, partner, physical environment
Chun 2016 CME Journal

Question 13

4 conditions associated with RLS

Answer 13

– CKD with hyperuricemia
– Peripheral neuropathy - diabetes, alcohol, amyloid, among others
– Myelopathy
– Multiple Sclerosis
– Idiopathic Parkinson’s
– Medication: antidepressants (SSRI, mirtazapine; except bupropion), antipsychotics, dopamine-blocking antiemetics (e.g. metoclopramide), antihistamines, caffeine