Sleep Disorders

Question 1

What are parasomnias?

Answer 1

Disruptive sleep-related disorders causing abnormal movements, talking, or behaviours during sleep

Question 2

What is the patient demographic for Non-REM parasomnia?

Answer 2

mostly children, sometimes stressed adults or those with mood disorders

Question 3

What is the patient demographic for REM parasomnia?

Answer 3

mainly men aged 60–70, often associated with neurodegenerative disorders

Question 4

Give examples of Non-REM parasomnias

Answer 4

1. Confusional arousals
2. Sleepwalking
3. Sleep terrors
4. Sleep paralysis

Question 5

How do REM parasomnias typically present?

Answer 5

Enactment of dreams during REM sleep: kicking, punching, talking, sitting up, and often aggressive behaviours

Question 6

How are Non-REM parasomnias managed?

Answer 6

Mostly reassurance, as children usually grow out of them before adolescence

Question 7

What is the first-line treatment for REM parasomnias?

Answer 7

Clonazepam 0.25–1 mg at bedtime

Question 8

What is an alternative treatment for REM parasomnias with fewer side effects?

Answer 8

Melatonin 2–6 mg at bedtime

Question 9

What is narcolepsy?

Answer 9

A chronic sleep disorder causing extreme daytime sleepiness and sudden sleep attacks; can also include cataplexy (sudden muscle weakness triggered by emotions)

Question 10

What is the underlying pathophysiology of narcolepsy?

Answer 10

Dysfunction of hypocretin (orexin), a neurotransmitter that regulates wakefulness and REM sleep

Question 11

What is cataplexy?

Answer 11

Sudden loss of muscle tone triggered by strong emotions (e.g., laughter, surprise) while consciousness is retained

Question 12

What is the first-line sleep study used for narcolepsy?

Answer 12

Overnight polysomnography

Question 13

What are other characteristic features of narcolepsy?

Answer 13

(1) Hypnagogic hallucinations (at sleep onset)

(2) Sleep paralysis (unable to move on falling asleep or waking)

(3) REM sleep behaviour disorder (RBD)

Question 14

What is the diagnostic test used for narcolepsy?

Answer 14

Multiple Sleep Latency Test

Question 15

What non-drug treatments are recommended for narcolepsy?

Answer 15

Sleep education, scheduled naps, exercise, good sleep hygiene

Question 16

What drug treatments are used for narcolepsy?

Answer 16

Modafinil (first-line)

Question 17

What safety advice is critical at diagnosis of narcolepsy?

Answer 17

Patients must cease driving and inform the DVLA until symptoms are satisfactorily controlled

Question 18

What is insomnia?

Answer 18

A condition of unsatisfactory sleep, affecting sleep
1. onset
2. sleep maintenance
3. early waking

Question 19

Explain what initial insomnia is

Answer 19

difficulty falling asleep
→ mania, anxiety, depression, substance misuse

Question 20

Explain what Middle insomnia is

Answer 20

waking during the night
→ medical conditions such as sleep apnoea, prostatism

Question 21

Explain what late insomnia is

Answer 21

early morning waking
→ depression, malnutrition
(eg, anorexia nervosa)

Question 22

Which pharmacological treatments are used for long-term insomnia in adults?

Answer 22

Daridorexant for adults with insomnia ≥3 nights/week for ≥3 months

Question 23

Which hypnotic drugs are used for short-term insomnia relief?

Answer 23

Zopiclone (max 2 weeks) at the lowest effective dose

Question 24

What is recommended for insomnia in patients over 55?

Answer 24

Melatonin

Question 25

A 23-year-old male presents to you in the neurology clinic complaining of excessive daytime somnolence. He describes episodes of sudden onset of sleep during the day, and at night, often wakes with episodes where he is unable to move his arms or legs and describes seeing figures in the far corner of his bedroom. Given the likely diagnosis, what is the most appropriate first-line investigation?

Answer 25

Multiple sleep latency EEG

Question 26

A 22-year-old man has been admitted to the psychiatric ward following concerns from his GP that he was experiencing symptoms of psychosis. The psychiatric team is considering a diagnosis of schizophrenia. What feature in his history would be most consistent with this diagnosis?

Answer 26

Insomnia

Question 27

How to tell in questions if the answer is REM sleep disturbance?

Answer 27

Involves abnormal behaviours during REM sleep, such as acting out dreams, and is not characterised by difficulty falling asleep or early morning awakening

Question 28

A 54-year-old male presents to the GP following trouble falling asleep. He thinks that he may have chronic insomnia, which he has read about on the internet. The patient says that he has tried everything to get to sleep, including meditation and a warm bath before bed. He feels like he has too many thoughts in his head, and cannot 'switch off'. This happens at least three days a week and has been ongoing for one month. What feature would suggest that this patient has self-diagnosed incorrectly?

Answer 28

The duration of insomnia is too brief; it must be over 3 months

Question 29

A 23-year-old man presents to his GP. He describes episodes of leg weakness following bouts of laughing whilst out with friends. The following weekend, his friends described a brief collapse following a similar episode. What is the most likely diagnosis?

Answer 29

Cataplexy

Question 30

Laughter → fall/collapse This sequence of events immediately makes you think of what disease?

Answer 30

Cataplexy

Question 31

REM (Rapid eye movement) sleep is characterised by what?

Answer 31

1. Rapid eye movements! 2. Large muscle paralysis 3. Reduced body temperature 4. Irregular breathing 5. Irregular heart rate

Question 32

Non-REM sleep is associated with what?

Answer 32

1. Reduced muscle tension = but not paralysis, as can still toss and turn 2. (Slightly) reduced body temperature 3. Regular breathing 4. Regular heart rate