Sleep Medicine
QUESTIONS
1. What percentage of Americans suffer from insomnia (both acute and chronic)?
A. 10%
B. 40%
C. 90%
D. <1%
E. None of the above
View Answer
1. Answer: B. A survey conducted by the National Sleep Foundation in 2007 estimated 30% to 35% of the US population reported difficulty sleeping in the past year, and approximately 10% suffer from chronic insomnia. Although so many people suffer, only approximately 5% of the chronic insomniacs report it to their physician.
2. A 75-year-old man complains of difficulty falling asleep for the past 2 years. He was started on zolpidem by his primary care physician at that time and has been taking it since then. He states he is not sure if it is still helping and feels fatigued during the day. He goes to bed at the same time every night and lies in bed for hours thinking about things, watching the clock. The patient states he sleeps better at his sister’s house. He denies any depression but does feel some anxiety about going to bed. He does watch TV in bed. About 2 years ago, he mentioned he had a significant amount of stress when his wife was sick, but she is much better now. What is the most likely diagnosis?
A. Sleep apnea
B. Circadian rhythm disorder
C. Idiopathic insomnia
D. Depression
E. Psychophysiologic insomnia
View Answer
2. Answer: E. Psychophysiologic insomnia is a disorder of somatized tension and learned sleep-preventing associations resulting in a complaint of insomnia and daytime fatigue. It usually begins with a prolonged period of stress in a person who previously had no problems. The person tends to respond to this stress with increased tension and aggravation resulting in increased awakenings while in bed.
3. A 22-year-old man comes to the office complaining of difficulty sleeping and daytime tiredness, which started right after college. His usual bedtime is 10:00 PM, but he cannot fall asleep until 1:00 or 2:00 AM, and then he wakes up for work around 6:00 AM. The patient states that on the weekends, he can stay in bed until 11:00 AM or noon, and he goes to bed around 2:00 AM. He does feel better on the weekends. He does not snore, is not obese, and had no problems as a child. The patient also denies any recent stressors. What is the best treatment for him?
A. Light therapy
B. Sedative hypnotic
C. Antidepressant
D. Stop working
E. None of the above
View Answer
3. Answer: A. This patient has delayed sleep phase syndrome. Light therapy along with adjusting his schedule to a regular fixed schedule 7 days a week is the mainstay of his treatment. These steps will need to be done gradually, and chronotherapy is an option.
4. Which of the following disorders is most commonly associated with chronic insomnia?
A. Restless legs syndrome (RLS)
B. Sleep apnea
C. Narcolepsy
D. Depression
E. Obsessive compulsive disorder
View Answer
4. Answer: D. Depression is the most common disorder associated with insomnia. It is usually associated with early morning awakenings and inability to fall back asleep; some studies have shown that insomnia can lead to depression (especially if the insomnia has been present for more than 1 year).
5. A 35-year-old female presents to a sleep specialist for difficulty falling asleep and staying asleep over the course of 1 year. The patient also complains of daytime fatigue. She has been diagnosed with attention-deficit hyperactivity disorder (ADHD) in the past but has never been treated. The patient is diagnosed with primary insomnia. What is the best treatment for her?
A. Stimulant
B. Short-acting sedative hypnotic
C. Cognitive behavioral therapy
D. Antidepressant
E. None of the above
View Answer
5. Answer: C. Behavioral therapy is now considered the most appropriate treatment for patients with primary insomnia. If the patient had secondary insomnia, treating the underlying cause would be the primary focus. Behavioral therapy is based on the notion that the insomnia is associated with physiologic, cognitive, and emotional arousal as well as conditioned arousal in bed.
6. Which of the following is not a behavioral therapy for insomnia?
A. Relaxation therapy
B. Stimulus control
C. Biofeedback
D. Sleep restriction therapy
E. All of the above
7. Of all the treatments for insomnia, sedative hypnotics are commonly used. What length of time is generally recommended for this family of drugs?
A. Six months
B. Less than 1 month
C. At least 1 year
D. Nine months
View Answer
7. Answer: B. Most of the sedative hypnotics are not recommended for use for more than 2 to 3 weeks. Also, continued nightly use should not be recommended, and therapy should always be instituted with small doses and maintained at the smallest effective dose.
8. A 67-year-old man presents with complaints of “acting out his dreams.” He states they are very violent, and his wife has been injured on multiple occasions. He usually recalls the exact dream when his wife wakes him. There are no focal deficits on neurologic examination. He does have an uncle diagnosed with Parkinson’s disease. What is the most likely location of this problem?
A. Cortex
B. Basal ganglia
C. Pons
D. Thalamus
E. None of the above
View Answer
8. Answer: C. The patient has REM behavior disorder. Normally, generalized atonia of muscles occurs during REM. This atonia results from active inhibition of motor activity by the perilocus coeruleus (pons). In REM behavior disorder, the brain stem mechanisms generating the muscle atonia normally seen in REM sleep are interfered with, and therefore patients can “act out their dreams,” which tend to be violent in nature.
9. In the above patient, what is the best line of treatment?
A. Clonazepam
B. Selective serotonin reuptake inhibitors (SSRIs)
C. Gabapentin
D. Carbidopa/levodopa
E. There is no treatment.
View Answer
9. Answer: A. Clonazepam has been shown to be very effective in the treatment of REM behavior disorder.
10. What neurodegenerative disorder may rapid eye movement (REM) behavior disorder be associated with or be the prodrome of?
A. Alzheimer’s disease
B. Huntington’s chorea
C. Mitochondrial myopathy
D. Parkinson’s disease
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