Sleep Past Paper PDF

**[Sleep]** [Curriculum] Knowledge of narcolepsy, daytime hypersomnolence, parasomnias, obstructive sleep apnoea, effects of neurological conditions on sleep; indications, scope and limitations of the sleep laboratory; principles of physical and pharmacological treatment. An understanding of the...

**[Sleep]** [Curriculum] Knowledge of narcolepsy, daytime hypersomnolence, parasomnias, obstructive sleep apnoea, effects of neurological conditions on sleep; indications, scope and limitations of the sleep laboratory; principles of physical and pharmacological treatment. An understanding of the effects of sleep on the EEG. Knowledge of driving regulations and the consequences and complications of sleep disorders. Ability to evaluate and manage people with sleep disorders. **Name, clinical feats, investigations, management (NICE)** **Contents** \- Insomnia\ - Circadian rhythm sleep-wake disorders \- Central disorders of hypersomnolence \- Parasomnias \- Sleep-related breathing disorders \- Sleep-related movement disorders **[Insomnia\ ]** 3 types -- short-term insomnia disorder\ - chronic insomnia disorder\ - other insomnia disorder (patient has iոѕοmniа symptoms but does not meet criteria for the other two types of iոѕοmnia) **Short-term insomnia disorder** Short-term iոѕоmոiа, also referred to as adjustment iոѕοmniа or acute iոѕоmոiа, usually lasts a few days or weeks and occurs in response to an identifiable stressor. By definition, symptoms are present for less than three months. Requires same criteria as chronic but less than 3 months. **Chronic insomnia disorder** Requires a report of a sleep initiation or sleep maintenance problem, adequate opportunity and circumstances to sleep, and daytime consequences as the result of the iոѕοmոiа symptoms.\ Diagnostic criteria +-----------------------------------+-----------------------------------+ | A | The patient reports, or the | | | patient\'s parent or caregiver | | | observes, one or more of the | | | following: | | | | | | - - - - - | +-----------------------------------+-----------------------------------+ | B | The patient reports, or the | | | patient\'s parent or caregiver | | | observes, one or more of the | | | following related to the | | | nighttime sleep difficulty: | | | | | | - - - - - - - - - | | | | +-----------------------------------+-----------------------------------+ | C | The reported sleep-wake | | | complaints cannot be explained | | | purely by inadequate opportunity | | | (ie, time allotted for sleep) or | | | | | | inadequate circumstances (ie, | | | safety, darkness, quiet, and | | | comfort) for sleep. | +-----------------------------------+-----------------------------------+ | D | The sleep disturbance and | | | associated daytime symptoms occur | | | at least three times per week. | +-----------------------------------+-----------------------------------+ | E | The sleep disturbance and | | | associated daytime symptoms have | | | been present for at least three | | | months. | +-----------------------------------+-----------------------------------+ | F | The sleep disturbance and | | | associated daytime symptoms are | | | not solely due to another current | | | sleep disorder, medical disorder, | | | mental disorder, or | | | medication/substance use. | +-----------------------------------+-----------------------------------+ \* In general, among adults, delays in sleep onset and periods of awakening in the middle of the night \>30 minutes connote clinical significance. Thresholds in infants and children are less well established and are age-dependent. Among very young children, clinical significance also depends on the level of caregiver involvement needed for the child to sleep. ¶ In general, among adults, early morning awakening entails the termination of sleep \>30 minutes before the desired rising time and a concomitant reduction in total sleep time compared with the usual premorbid sleep pattern. Investigations\ - Clinical -- history, diary, mood, triggers. Diagnostic testing is not required in most patients with iոsоmոiа. Home or in-laboratory sleер studies, аϲtigraphу, or iron studies may be indicated when another sleeр disorder (eg, obstructive sleер apnea, circadian rhythm ѕlеep-wake disorders, or restless legs syndrome) is suspected. Management **[Circadian rhythm sleep-wake disorders ]** Alteration / misalignment of sleep-wake cycle.\ General criteria common to all of the circadian rhythm sleep-wake disorders include: All, apart from jet lag, require minimum duration 3 months Shift-work / jet lag disorder\ \ Delayed sleep-wake phase disorder - sleep and wake times that are habitually delayed compared with conventional times - diagnostic criteria, need all +-----------------------------------+-----------------------------------+ | A | There is a significant delay in | | | the phase of the major sleep | | | episode in relation to the | | | desired or required sleep onset | | | time and wake-up time, as | | | evidenced by: | | | | | | 1. A chronic or recurrent | | | complaint by the patient or a | | | caregiver of inability to | | | fall asleep at the desired or | | | required time; and | | | | | | 2. Difficulty awakening at the | | | desired or required clock | | | time | +-----------------------------------+-----------------------------------+ | B | The symptoms are present for at | | | least three months. | +-----------------------------------+-----------------------------------+ | C | When patients are allowed to | | | choose their ad libitum schedule, | | | they will exhibit improved sleep | | | quality and duration for age and | | | maintain a delayed phase of the | | | 24-hour sleep-wake pattern. | +-----------------------------------+-----------------------------------+ | D | Sleep logs are required, | | | accompanied by actigraphy | | | monitoring, whenever possible, | | | for at least seven days, | | | preferably 14 days. These | | | demonstrate a delay in the timing | | | of the habitual sleep period. | | | Both work/school days and free | | | days should be included within | | | this monitoring. | +-----------------------------------+-----------------------------------+ | E | The sleep disturbance is not | | | better explained by another | | | current sleep disorder, medical | | | disorder, mental disorder, or | | | medication/substance use. | +-----------------------------------+-----------------------------------+ Advanced sleep-wake phase disorder\ - sleep and wake times that are habitually early compared with conventional times, older adults - diagnostic criteria, need all --- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- A There is a significant advance (earlier timing) in the phase of the major sleep episode in relation to the desired or required sleep onset time and wake-up time, as evidenced by a chronic or recurrent complaint by the patient or caregiver of difficulty staying awake until the required or desired conventional bedtime, together with difficulty remaining asleep until the required or desired time for awakening. B The symptoms have been present for at least three months. C When patients are allowed to choose their ad libitum schedule, they will exhibit improved sleep quality and duration and maintain an advanced phase of the 24-hour sleep-wake pattern. D Sleep logs are required, accompanied by actigraphy monitoring, whenever possible, for at least 7 days, preferably 14 days. These demonstrate a stable advance in the timing of the habitual sleep period. Both work/school days and free days should be included within this monitoring. E The sleep disturbance is not better explained by another current sleep disorder, medical disorder, mental disorder, or medication/substance use. --- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Irregular sleep-wake rhythm disorder  -  lack of a clearly defined circadian rhythm of sleep and wake - commonly associated with developmental disorders in children and in adults with neurodegenerative diseases such as Alzheimer disease, Parkinson disease, and Huntington disease. - diagnostic criteria, need all --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- A The patient or caregiver reports a chronic or recurrent pattern of irregular sleep and wake episodes throughout the 24-hour period, characterized by symptoms of insomnia during the scheduled sleep period (usually at night), excessive sleepiness (napping) during the day, or both. B Symptoms are present for at least three months. C Sleep logs are required, accompanied by actigraphy monitoring, whenever possible, for at least seven days, preferably 14 days. These demonstrate no major sleep period and multiple irregular sleep bouts (at least three) during a 24-hour period. D The sleep disturbance is not better explained by another current sleep disorder, medical disorder, mental disorder, or medication/substance use. --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Non-24-hour sleep-wake rhythm disorder -  fluctuating periods of iոѕоmniа and/or excessive ѕlеерineѕѕ that occur because the intrinsic circadian pacemaker is not entrained to a 24-hour light/dark cycle -  Most individuals with this disorder are totally blind, and the failure to entrain circadian rhythms is related to the lack of photic input to the circadian pacemaker - diagnostic criteria, need all --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- A There is a history of insomnia, excessive daytime sleepiness, or both, alternating with asymptomatic episodes, due to misalignment between the 24-hour light-dark cycle and the non-entrained endogenous circadian rhythm of sleep-wake propensity. B Symptoms are present for at least three months. C Sleep logs are required, accompanied by actigraphy monitoring, whenever possible, for at least 14 days, preferably longer for blind individuals. These demonstrate a pattern of sleep and wake times that typically delay each day. D The sleep disturbance is not better explained by another current sleep disorder, medical disorder, mental disorder, or medication/substance use. --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Circadian sleep-wake disorder not otherwise characterized **Investigations**\ - history, sleep diaries, actigraphy. Polysomnography only if comorbid sleep disorder e.g. OSA suspected. **[Central disorders of hypersomnolence]** - primary complaint is daytime ѕlеерinеѕs that is not due to another sleep disorder, including disturbed sleep or misaligned circadian rhythms \[(https://www.uptodate.com/contents/classification-of-sleep-disorders/abstract/1)\]. Excessive ѕlеерiոeѕs is defined as daily episodes of an irrepressible need to sleep or daytime lapse into sleep Narcolepsy Type 1 - Νаrϲοleрsy type 1 includes patients with excessive ѕlеерineѕs plus cataplexy and/or orexin-A (also known as hypocretin-1) deficiency.  +-----------------------------------+-----------------------------------+ | A | The patient has daily periods of | | | irrepressible need to sleep or | | | daytime lapses into drowsiness or | | | sleep. | +-----------------------------------+-----------------------------------+ | B | The presence of one or both of | | | the following: | | | | | | 1. Cataplexy^\*^ and either: | | | | | | a. Mean sleep latency of ≤8 | | | minutes and two or more | | | SOREMPs on an MSLT | | | performed in accordance | | | with current recommended | | | protocols | | | | | | b. A SOREMP (within 15 | | | minutes of sleep onset) | | | on nocturnal | | | polysomnogram | | | | | | 2. CSF | | | hypocretin-1^¶^ concentration | | | , | | | measured by radioimmunoassay, | | | is ≤110 pg/mL (using a | | | Stanford reference sample) or | | | \110 pg/mL (when using a Stanford reference sample) or \>1/3 of mean values obtained in normal subjects with the same standardized assay.^◊^ E The symptoms and signs are not better explained by chronic insufficient sleep, a circadian rhythm sleep-wake disorder or other current sleep disorder, mental disorder, or medication/substances use or withdrawal. --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CSF: cerebrospinal fluid; MSLT: multiple sleep latency test; PSG: polysomnography; SOREMPs: sleep-onset rapid eye movement periods. \* The diagnostic value of a SOREMP on nocturnal PSG in the absence of MSLT SOREMPs is not established for narcolepsy type 2. However, it may help guide clinical decision-making, such as the need to pursue repeat or alternative testing. ¶ Because the circadian clock strongly gates the propensity of REM sleep, narcolepsy type 2 should not be diagnosed in a shift worker without prior re-entrainment to a normal schedule. Δ If cataplexy develops later, then the disorder should be reclassified as narcolepsy type 1. ◊ If the CSF hypocretin-1 (also known as orexin-A) concentration is tested at a later stage and found to be either ≤110 pg/mL or \