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Sleep Disorders in the

Elderly
Matthew J. Beelen, M.D.
November 17th, 2010

Why am I so tired all of the time?


I dont have any energy
I just cant sleep well anymore
My husbands always falling asleep,

doesnt do anything anymore


I wish I could just get some rest
I dont have any get up and go
I just lie awake, I cant get back to
sleep
I think my memory is slipping

Sound Familiar?

he

A bodily disease which we look upon as


whole and entire within itself, may, after
all, be but a symptom of some ailment of
the spiritual part.
-Nathaniel Hawthorne (1804-1864)

Objectives
Understand

normal sleep physiology


and age-related changes
Appropriately recognize and diagnose
sleep disorders
Understand indications for formal sleep
studies
Recommend appropriate treatment
measures

Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
(Sleep-disordered breathing)
Other sleep disorders

Significance of Sleep Disorders


Survey of 9000 people > age 65
No sleep complaints (12%)
Difficulty initiating/maintaining (43%)
Nocturnal waking (30%)
Insomnia (29%)
Chronic sleep difficulties (>50%)
Daytime napping (25%)
Trouble falling asleep (19%)
Waking too early (19%)
Waking without feeling rested (13%)
Ancoli-Israel S. JAGS 2005;53:S264-S271.

Significance of Sleep Disorders


>50%
In age

of sedatives are used by people age > 65


70-100, 19% of patients were taking a
sleep medicine (in one study)
Disturbed sleep is a strong predictor of ECF
placement, especially in patients with dementia
Mortality due to common conditions is 2 times
higher in elderly with sleep disorders than in those
without.
Daytime somnolence can interfere with activities
and function
Sleep disorders negatively impact quality of life
Sleep disorders can lead to depression and
cognitive impairment

Agenda
Significance

of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Normal Physiology - Basics


Non-REM

sleep

Stage 1: very light, easy to arouse


Stage 2: most of the nights sleep
Stage 3,4: slow wave, deeper sleep

REM

sleep

EEG similar to stage 1


Low/absent muscle tone
Dreaming occurs here
Greatest cardiac and respiratory instability

Normal Physiology - Basics


Sleep

Architecture

REM latency is about 90 minutes (wide


variation)
Very short in narcolepsy

REM normally occurs every 90 to 120


minutes
More stage 3,4 in first half of night, more
REM 2nd half
Brief awakenings (30 sec) common, not
usually remembered
Brief arousals (3 sec) are normal

An 83-year-old woman who resides in a longterm care facility complains of chronic


insomnia. She is bedridden and is legally
blind secondary to diabetes mellitus. Which
of the following age related changes most
likely contributes to this patients sleep
disturbances?
A.
B.
C.
D.
E.

Reduction in total sleep time


Reduction in melatonin secretion
Reduction in stage 3 or 4 sleep
Increase in percentage of REM sleep
Breakdown of the segregation of sleep and
wakefulness

Age-Related Changes
Non-REM

Less slow wave sleep (stage 3 and 4), may


be entirely absent, easier to awaken

REM

Shorter REM latency


Decreased REM percentage and duration

Architecture

Increased overall sleep latency


More awakenings/arousals = less sleep
efficiency
Less sleep in 24 hour period*
Reduced sleep latency during day harder
to stay awake

Espiritu JR. Clin Geriatr Med 2008;24:1-14.

Age-Related Changes
Circadian

cycle shifted earlier

Decreased melatonin levels at night


Decreased modulation of circadian rhythm
between day and night
More

naps during the day (1 hour)

May have little impact on night-time sleep


May enhance cognitive and psychomotor
performance due to increase total sleep

Espiritu JR. Clin Geriatr Med 2008;24:1-14.

Age Related Changes


Less

physiologic flexibility with


schedule changes
More comorbidities that can interfere
with sleep
It is hard to know if sleep problems are
more common independent of other
conditions
The ability to get restorative sleep gets
worse with age, the need for sleep does
not.

Mechanisms Underlying Sleep Complaints

Vaz Fragoso CA. JAGS 2007;1853-1866.`

Precipitating Factors
Declining

Health Status

Nocturia
Pain (DJD, neuropathy)
Cardiac Disease
Angina, CHF, arrhythmia

Pulmonary Disease
GER
Endocrine: thyroid, menopause, DM polyuria
CKD

Precipitating Factors
Medications

impact sleep architecture


and sleep-disordered breathing
CNS stimulants/depressants
Diuretics, hypoglycemics

Neuropsychological

Impairments

Depression, Anxiety
Cognitive Impairment/Psychosis
Primary

Sleep Disorders

Perpetuating Factors Psychosocial


Caregiving

The work of caregiving


Associated mental and physical health
problems
Social

Isolation

Poorer sleep hygiene


Decline in activity
Bereavement,

Widowhood, Retirement
Loss of zeitgebers* (physical, sensory)

Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Classifying Sleep Disorders


Existing

classifications differ, and many


terms remain inadequately defined, which
leads to diagnostic confusion. Historically,
insomnia has been classified according to
symptom type, symptom duration, and
underlying cause, but these classifications
have not been based on evidence of their
utility, and newer research suggests the
need for change.

Krystal AD. JAGS 53:S258-S263, 2005.

Primary Sleep Disorders


Primary

Insomnia

Sleep onset (Initial)


Sleep maintenance (Middle)
Sleep

disordered breathing

Obstructive sleep apnea


Central sleep apnea
Mixed sleep apnea
Circadian

rhythm disturbances

Primary Sleep Disorders


Restless

Legs Syndrome
Periodic Limb Movements of Sleep
REM Sleep Behavior Disorder
All

primary disorders can be mixed


with other primary and with secondary
causes

Secondary Sleep Disorders


Underlying

conditions that should be


addressed first
Medical Illness causing nocturnal
symptoms
Psychiatric Illness
Medications
Social/behavioral

Secondary Sleep Disorders


Psychophysiologic

Insomnia
(stimulus/response)
Adjustment Insomnia recent stressor
Inadequate Sleep Hygiene
Lack of schedule (retirement!)
Sedentary or naps during daytime
Voluntary sleep deprivation (doctors!)
Mixed-type

insomnia

A 67 y.o. woman asks you for sleeping pills.


She reports initial insomnia and restless
sleep with frequent awakenings. She is
retired and sedentary. Reads, watches TV
in bed, often naps despite caffeine intake
during the day. PE is WNL. Which is most
likely to help her sleep disturbance?
A.
B.
C.
D.
E.

Exposure to early morning daylight


Proper sleep habits
Sustained-release melatonin
Zolpidem
Referral for sleep study

Agenda
Significance

of sleep

disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Sleep Hygiene
The

bed is for sleeping (and sex) only


Increase activity, decrease naps
Avoid late meals
Avoid caffeine, ETOH, cigarettes
Environmental control (light, noise,
temp)
Decrease stress
Establish a routine

Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Evaluation - History
Is

there a sleep disorder (fatigue)?

Or normal age-related change?


False beliefs about sleep?

What

is the nature of the problem?

Initial, middle, early awakening, EDS

Assess impact on daily life/function


Identify contributions from secondary

causes
Look for clues of primary disorders
Consider sleep diary and
partner/caregiver interview

Polysomnography
Formal

Sleep Test indications

Diagnosis of sleep-disordered breathing


CPAP titration
Suspected narcolepsy
Suspected REM sleep movement disorder
Difficult to diagnose parasomnias (e.g. PLMS)
Not usually for:
RLS
Circadian rhythm disorders
Primary insomnia

Agenda
Significance

of sleep

disorders
Physiology: Normal and
Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep
disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Insomnia - Definition
Difficulty

with initiation, maintenance,


duration, or quality of sleep that
results in the impairment of daytime
functioning, despite adequate
opportunity and circumstances for
sleep.
Can lead to fatigue, mood disturbance,
interpersonal and job problems, and
reduced quality of life.
From DSM-IV

Insomnia - Definitions
Sleep latency usually > 30 minutes
Sleep efficiency < 85%
Transient: less than 1 week
Short-term: 1-4 weeks
Chronic: > 1 month

May be perpetuated by worrying in bed or


unrealistic expectations of sleep duration
More common in women, elderly, and
chronic disease (medical and psychiatric)

83 y.o. woman who has HTN and DJD


has 3 wk h/o difficulty falling asleep
and several awakenings per night.
Has symptoms related to
psychosocial stressors. You decide to
try short course hypnotic agent.
Which is most appropriate?
A.
B.
C.
D.
E.

Amitriptyline
Diphenhydramine
Melatonin
Triazolam
Zolpidem tartrate

Insomnia - Treatment
Non-pharmacologic

therapy

Improvement in 70-80% of patients (though


some studies used psychologists)
Stimulus control therapy bed for sleeping
only, same wake time daily, 1 small nap only
Sleep restriction therapy reduce time in bed
to achieve 90% efficiency, gradually increase
(up to 6-7 hours)
Relaxation therapy biofeedback, imagery,
meditation, muscle relaxation
Cognitive therapy beliefs and attitudes
Sleep hygiene education

Joshi S. Clin Geriatr Med 2008;24:107-119.

Insomnia - Medications
Use

lowest effective dose


Use intermittent dosing
Short term use (< 1 month if possible)
Gradual discontinuation (rebound)
Medications with shorter half lives are
preferred to prevent next-day sedation

Insomnia - Medications
Short

acting medications

More improvement with sleep latency


More withdrawal and dependence

Long

acting

More improvement with sleep duration


More next day symptoms (sedation,
cognitive impairment, falls)

Most

medications have not been


studied extensively in the elderly or
more than 6 months

Insomnia - Medications
Benzodiazepines

GABA-A receptors

Benefits: cheap, improve sleep latency, total


sleep time, number of awakenings, sleep
quality
Disadvantages:
More next day effects (drowsy, dizzy)
More dependency/withdrawal
More rebound symptoms
More anterograde amnesia (especially with
shorter acting agents)
Falls and hip fracture risk (long acting)
Tariq SH. Clin Geriatr Med 2008;24:93-105.

Insomnia - Medications
Benzodiazepine

receptor agonists

Advantages
more specific targeting of GABA receptors in
the brain so less side effects

Disadvantages
Not well studied in the elderly (use lower
starting doses)
Not compared against each other
More expensive ($65-100 per month)
Dependence/withdrawal still occur
Still can increase risk of falls and fractures

Zolpidem (Ambien)
Short

half life (2.6 hours, 2.8 for CR)


Better for sleep onset insomnia
Minimal impact on sleep architecture
CR

not directly compared with


Ambien
Can see rebound insomnia, mild next
day drowsiness, mild antergrade
amnesia
CR approved for long term use

Zaleplon (Sonata)
Ultrashort

half-life (1 hour)
Better for sleep onset insomnia
Can increase total sleep time and efficiency
Can

be taken after a middle of night


awakening
Rare rebound and next day effects
Not approved for long term use
But reported to be safe for long term use in
elderly

Eszopiclone (Lunesta)
Medium

half life (5-7 hours)


Better for sleep maintenance insomnia
Increased total sleep time 49 min
Helps

with sleep onset (27min)


Few next day effects (but longer half
life suggest risk for next day effects in
elderly)
Approved for long term use

Sedative-Hypnotics Risk/Benefit
Meta-analysis

of 24 studies, > 2400 patients


older than age 60 treated with benzos or benzo
receptor agonists
Benefits compared to placebo (NNT = 13)
Small improvement in sleep quality
Sleep time increased (25 minutes)
Decrease number of awakenings (0.63)
Harms (NNH = 6)
Cognitive impact (4.78 times more common)
Psychomotor events (2.61 times as common)
Daytime fatigue (3.82 times more common)

Glass et al. BMJ 2005;331:1153-1212.

Other Medications
Ramelteon

(Rozerem)

Melatonin receptor agonist


Small improvement in sleep onset (8 min)
Improved total sleep time (12 min)
Increase prolactin levels, few other side
effects.
Not compared to other drugs or melatonin.
Approved for chronic use.

Sedating

antihistamines BEERS LIST

Other Medications
Sedating

Antidepressants

Tricyclics: they help, but side effects


Trazadone: helps, not as much as Ambien
May improve SWS (stage 3 and 4)

Remeron: increased sleep efficiency,


increases duration of slow wave sleep in
elderly
These drugs are not well studied (or
approved) for insomnia in the elderly
Best used for depression with insomnia

Other Medications - Melatonin


Levels

correlate with circadian rhythm


Deficiency is more common in elderly and
associated with insomnia
Effects (0.1 to 10mg QHS)
7.8 minute latency in primary insomnia
38.8 minute latency in delayed sleep phase
syndrome
No impact on sleep efficiency
Minimal side effects, if any
Nutritional

supplement dosing?

Gooneratne NS. Clin Ger Med 2008;24:121-138.

Drugs vs No Drugs
Unclear if cognitive behavioral therapy or
medication therapy is better
Both help
Medications may work more quickly
CBT may have more lasting benefit

Hard for PCPs to do cognitive therapy


Medications not studied more than 6 months
It is best to attempt education and nonpharmacologic therapy first, and continue even if
medications are used

Other Treaments for Insomnia


Bright

Light Therapy

Light -> suprachiasmatic nucleus -> inhibits


production of melatonin by pineal gland
Threshold between 200-400 lux (normal indoor
fluorescent light)
Treatment uses 2000-10,000 lux

Cochrane: no trials focused on elderly, but


benefit seen with younger patients
Dosing, timing, duration, effectiveness not
established in the elderly
Best evidence for SAD in younger people
Gammack JK. Clin Geriatr Med 2008;24:139-149.

66 year old man asks for Viagra. Has DM2,


HTN, CHF, obesity. Takes digoxin, lasix,
norvasc, insulin. ROS: +for ED, fatigue,
frequent daytime sleepiness. 510,
250#. BP 160/90, poorly alert. Wife
says he drinks 1-2 beers/night, snores
loudly, is sleepy during the day. Which
would be most beneficial:
A.
B.
C.
D.
E.

Avoid alcohol
CPAP
Methylphenidate
Oropharyngeal surgery
Viagra

Agenda
Significance of sleep disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

Sleep-disordered Breathing
Usually

present with daytime


somnolence
Snoring: alone is not usually a problem
Hypopnea
Apnea increased incidence in the
elderly, can be seen in 10-40%
Obstructive
Central
Mixed

Sleep-disordered Breathing
Significance,

Signs, and Symptoms

Daytime somnolence, effect on function


Decreased cognition, dementia may be
worse
CHF, arrythmias, HTN, cor-pulmonale
Polycythemia
Nocturia
Personality changes
Morning headaches
Decreased libido, impotence
May increase mortality

Sleep-disordered Breathing
Other

Symptoms

Snoring
Restless sleep
Choking/gasping during sleep
Witnessed apnea

Obstructive Sleep Apnea (OSA)


Definition:

repetitive episodes of uper


airway obstruction with continued
movement of chest and abdominal
walls, leads to desaturations and
arousals.
Risk factors: people with classic
symptoms and:

Male
Large neck circumference (>18 inches)
Obesity
Crowding of oropharynx

OSA - Diagnosis
Classic

Symptoms and
Polysomnography

EEG (at least 2 channel)


EMG (muscle activity chin)
EOG (eye movements)
ECG
Respiratory airflow and effort
Oxygen saturation
Snoring intensity and body position
Reports an Apnea-Hypopnea Index - AHI

OSA - Stages
Mild:

sleepiness when sedentary, little


attention required, not daily, minor
impairment of function
Mean sat >90 and min sat >85, AHI 6-20

Moderate:

daily sleepiness when


minimaly active and moderate
attention required (driving, meetings,
movies)
Mean sat >90 and min >70, AHI 21-40

OSA - Stages
Severe

daily sleepiness during tasks


that require significant attention
(driving, conversation, eating, walking),
marked impairment in function
Mean sat <90 or min <70, AHI > 40

OSA - Treatment
Unclear

benefit to treating mild or


minimally symptomatic patients
Treatment is likely to improve:

HTN
CHF
Daytime function
Cognition and health-related quality of life

OSA - Treatment
Weight

loss, avoid supine position (tennis

balls)
Avoid sedating drugs
Prescription drugs not helpful
CPAP/BIPAP Most efficacious
Compliance issues

Oral

appliance less effective, use for


mild cases or if CPAP not tolerated
Surgery trach, uvuloplasty, bariatric
surgery not first line, various
effectiveness

Central Sleep Apnea - CSA


Definition

Periodic complete cessation of


airflow and respiratory effort, followed by
desaturations and arousals.
Related to chemoreceptors and CO2
physiology.
Hypercapneic underlying hypoventilatory
disorders blunts chemoreceptor
responsiveness
Nonhypercapneic underlying
hyperventilatory disorder causing periodic
hypocapnea which turns off respiratory
drive

CSA Associated Conditions


Congestive

heart failure
Prior Stroke and cerebrovascular
disease
Other neurologic disorders ALS,
mucular dystrophy
Chronic renal failure
Hypothyroidism
Baseline CO2 retainers (COPD,
kyphoscoliosis)

CSA Diagnosis and Treatment


Diagnosis

Polysomnography

Treatment

CPAP/BIPAP can help


Nocturnal Oxygen can help (offsets
overshoot)
Consult your local pulmonologist

Agenda
Significance

of sleep disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders

A 66 y.o. man reports excessive daytime


sleepiness and an intense, irrisistable urge
to move about, especially in evening. He is
nervous, tense, irritable, has initial
insomnia. Wife notes he is restless during
night, moves legs abnormally. Which med
is most likely to be beneficial?
A.
B.
C.
D.
E.

Carbamazepine
Carbidopa-levodopa
Clonazepam
Clonidine
Iron supplementation

Other Sleep Disorders


Restless

Legs Syndrome
Periodic Limb Movements of Sleep
REM Sleep Behavior Disorder
Nocturnal Leg Cramps
Circadian Rhythm Disturbances

Restless Legs Syndrome (RLS)


Sensorimotor

neurologic condition,
possibly caused by abnormal iron
metabolism and dopaminergic
dysfunction unclear
Compelling urge to move limbs
(legs>arms)

Worse at rest
Worse at night
May have dysesthesia or pain
Relieved with movement
Disrupts sleep, alertness, daytime function,
QOL

RLS Facts
5-15%

prevalence, increased in the


elderly, more common in women
Associated features
FH positive in 60%
PLMS in 80% (but 30% PLMS pts have RLS)
Diagnosis

Classic symptoms
Responds to trial of therapy

RLS Associated Conditions


Drugs

Pregnancy
ESRD
Fe

Deficiency

Check ferritin, iron


Parkinsons
Radiculopathy
Neuropathy
Rheumatoid

arthritis

DM
Depression/anxiety

can exacerbate

Sedating antihistamines
Metoclopramide
Calcium channel blockers
Neuroleptics
TCAs
SSRIs
Caffeine
Nicotine
ETOH

RLS Treatment
Non-pharmacologic

Avoid caffeine, ETOH,


associated medications
Sleep hygiene
Bedtime bath
Mild exercise before
bedtime

Pharmacologic

see handout most drugs


used off label
70-100% effective

RLS Treatment
Dopaminergics

Requip/ropinirole and Mirapex/pramipexole


only FDA approved meds)
Use for daily or intermittent symptoms
First line treatment (most studied)

Benzos

intermittent use, klonopin is best

choice
Opioids daily or intermittent use
Neurontin daily use, similar efficacy to
Requip (average dose 800mg)
Neuropsychobiology 2003;48(2):82-6.

Magnesium,

folate have slight evidence

Periodic Limb Movements of Sleep


PLMS:

Periodic episodes of repetitive


and highly stereotypc limb movements
during sleep
34-45% prevalence in the elderly,
increases with age
Associated with RLS, arousals, difficulty
achieving and maintaining sleep
Most are asymptomatic
Unclear significance
Associated conditions similar to RLS

PLMS Diagnosis and Treatment


Diagnosis

Clinical history and response to treatment


Polysomnography can be used
Treatment

Dopamine agonists
Benzos decrease arousals but not
movements
Opioids

REM Sleep Behavior Disorder


Lack

of normally low muscle tone


during REM sleep
Cause unknown
Usually male, onset age 50-60
Act out dreams which can be violent
Vivid memory of dreams
Can diagnose with polysomnography
1/3 of Patients will develop Parkinsons
Treat with benzo (klonopin 90%
effective)

Nocturnal Leg Cramps


Cause

not known
Associated factors
Meds (diuretics, nifedipine, beta agonists,
steroids, morphine, cimetidine, statins,
lithium)
Conditions (uremia, DM, thyroid, electrolyte
d/os)

Diagnosis history, check labs

Nocturnal Leg Cramps


Treatment

Review associated factors


Calf stretching exercises
Quinine (200-300mg QHS)
Evidence of moderate benefit
Toxicity careful in elderly, kidney/liver disease
Digoxin interaction
Hematologic (thrombocytopenia)
Cinchonism
Blindness, arrhythmias, death!
Tonic Water

? Dr. Gott soap

Circadian Rhythm Disturbance


Advanced sleep phase syndrome
Neurologic control of rhythms is altered
Early to bed, early to rise

Can interfere with societal norms


Total sleep time and daytime function
usually not affected

Melatonin

and light therapy are


theorized to help
Reassure patients

Summary
Sleep

problems are very common in


the elderly
Sleep problems have significant impact
on health and quality of life
Be as specific as possible in diagnosing
sleep disorders
Treatment should include all
contributing factors, and should include
counseling
Avoid a pill for every symptom

The way it used to be


Chronic

enlargement of the tonsils


symptoms:

As a result of the obstruction to nasal


respiration the patient snores during sleep.
The facial expression is somewhat dull, and
the mind is often as dull as the face betrays.
Aprosexia, or difficult attention, is a
common symptom.
Eye, Ear, Nose, and Throat. A Manual for
Students and Practitioners. Lea Brothers
and Co. Philadelphia, PA. 1900.

References

Salzman C. Pharmacologic treatment of disturbed sleep in the


elderly. Harv Rev Psychiatry 2008;16:271-278.
Glass J. et al. Sedative hypnotics in older people with insomnia:
meta-analysis of risks and benefits. BMJ 2005;331:1153-1212.
Vaz Fragoso CA et al. Sleep complaints in community-living older
persons: A multifactorial geriatric syndrome. JAGS
2007;55:1853-1866.
Ancoli-Israel S et al. Sleep disorders in the geriatric population:
Implications for health. Supplement to Geriatrics Dec. 2005. 115.
Butler JV et al. Nocturnal leg cramps in older people. Post Grad
Med J 2002;78:596-598.
Thorpy MJ. New paradigms in the treatment of restless legs
syndrome. Neurology 2005;64 (supp 3):S28-S33.

References
Silber MH. Chronic insomnia. NEJM 2005;353:803-810.
Ancoli-Israel S et al. Prevalence and comorbidity of insomnia
and effect on functioning in elderly populations. JAGS
2005;53:S264-S271.
Clinics in Geriatric Medicine 2/08: Sleep in elderly adults.

Age-related sleep changes


Evaluation of sleep disturbances in older adults
The effect of chronic disorders on sleep in the elderly
Pharmacotherapy for insomnia
Nonpharmacologic therapy for insomnia
Complimentary and alternative medicine for sleep disturbances in
older adults
Light therapy for insomnia in older adults
Restless legs syndrome in older adults

65

y.o. woman, 5 mo. of difficulty falling/staying asleep.


Notes uncomfortable sensation in legs removed in part
by moving/rubbing legs. Husband notes her kicking legs
and moving arms at night. Not falling asleep until 2 am,
excessive daytime fatigue, impacting function.
Sertraline started 4 weeks ago for mild depression.
What is most likely cause of her symptoms?
A. Primary insomnia
B. Major depressive disorder
C. Anxiety disorder
D. Restless legs syndrome
E. Delayed sleep phase disorder

73

year old man with urinary urgency, nocturia x 3, has


had urologic eval and medications given. Symptoms
improved from nocturia x 6 when switched from
terazosin to tolterodine. Also has loud snoring and leg
kicking at night which distrubs wife. He is moderately
obese and has small prostate. PVR and urine are
normal. Which is the next most appropriate step?
A. Switch from tolterodine to tamsulosin
B. Refer for urologic eval
C. Prescribe furosemide in late afternoon
D. Refer to sleep clinic
E. Prescribe finasteride

71

y.o. man has violent movement in sleep for last 8


months (kicks, punches, yells 2-3 hours after sleep
onset). His wife says he snores lightly occasionally and
has nocturia x 1. He has PD and MDD without
recurrence. Only med is mirapex. Speelp study
confirms the movements and shows no OSA. Best
treatment?
A. clonazepam
B. Venlafaxine
C. Ropinarole
D. Trazodone
E. Gabapentin

72

y.o. man with mild dementia comes to office


saying he has had difficuly falling and staying
asleep for the last 4 months. He has vivid dreams
a few times per month. Problems started after
another MD prescribed a new medication. Which
drug most likely caused his symptoms?
A. Buspirone
B. Trazodone
C. Donepezil
D. Melatonin
E. Ramelteon

82

y.o. man has EDS x 6 mo. Falls asleep during day in


late morning. Falls asleep easily at 8pm, wakes up q23h at night. Social activities limited by his need for
naps. Has h/o CVA, MCI, HTN. Wrist actigraphy testing
shows 3 sleep periods during 24 hour period with no
dominant nocturnal sleep period. Most likely diagnosis?
A. Idiopathic hypersomnia
B. Advanced sleep phase disorder
C. Irregular sleep/wake rhythm disorder
D. Sundowning
E. REM sleep behavior disorder