Sleep Disorders in the Elderly — MCQs
A 72-year-old woman with insomnia participates in a sleep study. As part of the study protocol, she has EEG leads attached, then goes to sleep. At one point during the evening, 12-16 Hz sleep spindles and K-complexes are observed. Which stage of sleep is associated with this pattern?
Which anxiolytic acts through 5-HT1A receptor partial agonism without exhibiting significant anticonvulsant or muscle relaxant properties?
A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
In which of the following psychiatric conditions is floccillation seen?
In narcolepsy, the polysomnographic recording typically shows which of the following patterns?
Intense nihilism, somatization and agitation in old age are the hallmark symptoms of -
What is the primary characteristic feature of Klein-Levin syndrome?
Which of the following statements about narcolepsy is false?
Alzheimer's disease is associated with:
Which of the following statements is NOT true about delirium?
Sleep Disorders in the Elderly Indian Medical PG Practice Questions and MCQs
Question 1: A 72-year-old woman with insomnia participates in a sleep study. As part of the study protocol, she has EEG leads attached, then goes to sleep. At one point during the evening, 12-16 Hz sleep spindles and K-complexes are observed. Which stage of sleep is associated with this pattern?
- A. REM
- B. Stage 1
- C. Stage 2 (Correct Answer)
- D. Stage 3
Explanation: ***Stage 2*** - **Sleep spindles** (12-16 Hz bursts) and **K-complexes** (high-amplitude negative deflection followed by a positive component) are the definitive EEG markers of **Stage 2 non-REM sleep**. - This stage represents a deeper level of sleep than Stage 1, where the body begins to relax more, and eye movements cease. *REM* - **REM sleep** is characterized by low-voltage, mixed-frequency EEG activity resembling wakefulness, along with **rapid eye movements** and muscle atonia. - While dreaming is prevalent during REM, **sleep spindles** and **K-complexes** are notably absent. *Stage 1* - **Stage 1 (N1 non-REM sleep)** is the transition from wakefulness to sleep, marked by the disappearance of alpha waves and the appearance of **theta waves** (3-7 Hz). - It does not contain **sleep spindles** or **K-complexes**, which are characteristic of deeper sleep stages. *Stage 3* - **Stage 3 (N3 non-REM sleep)**, commonly known as **deep sleep** or **slow-wave sleep**, is defined by the presence of **delta waves** (0.5-2 Hz) accounting for 20% or more of the EEG. - Although it is a deeper stage of sleep, **sleep spindles** and **K-complexes** are not the primary defining features; **delta wave activity** predominates.
Question 2: Which anxiolytic acts through 5-HT1A receptor partial agonism without exhibiting significant anticonvulsant or muscle relaxant properties?
- A. Diazepam
- B. Zolpidem
- C. Phenobarbitone
- D. Buspirone (Correct Answer)
Explanation: ***Buspirone*** - **Buspirone** is a unique anxiolytic that primarily acts as a **partial agonist at 5-HT1A receptors**. - Unlike benzodiazepines, it lacks significant **anticonvulsant**, **muscle relaxant**, or **sedative-hypnotic properties** and does not lead to physical dependence or withdrawal. *Diazepam* - **Diazepam** is a **benzodiazepine** that acts by enhancing the effect of **GABA** at GABA-A receptors, leading to significant anxiolytic, sedative, muscle relaxant, and anticonvulsant effects. - It does not primarily act via **5-HT1A receptor partial agonism**. *Zolpidem* - **Zolpidem** is a **non-benzodiazepine hypnotic** that selectively binds to the **GABA-A receptor** subunit, primarily mediating sedative effects. - While it's used for insomnia, it doesn't primarily act as a **5-HT1A partial agonist** and is not typically used for its anxiolytic properties in the same way as buspirone. *Phenobarbitone* - **Phenobarbitone** is a **barbiturate** that acts by prolonging the opening of **chloride channels** associated with GABA-A receptors, leading to strong sedative, hypnotic, and anticonvulsant effects. - Its mechanism of action is distinct from **5-HT1A receptor partial agonism**, and it carries a high risk of dependence and overdose.
Question 3: A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
- A. ERG (Correct Answer)
- B. Retinoscopy
- C. Dark adaptometry
- D. EOG
Explanation: ***ERG*** - **Electroretinography (ERG)** measures the electrical responses of various retinal cells, including **rods** and **cones**, to light stimuli. - In conditions like **retinitis pigmentosa** which cause night blindness and delayed dark adaptation, ERG will show characteristic abnormal or extinguished responses, confirming retinal dysfunction. *Retinoscopy* - **Retinoscopy** is an objective method to assess the refractive error of the eye by observing the light reflex from the retina. - It does not directly evaluate the functional integrity of photoreceptors or diagnose conditions causing **night blindness**. *Dark adaptometry* - **Dark adaptometry** measures the time it takes for the eye to adapt to dim light after exposure to bright light, quantifying the function of **rod photoreceptors**. - While it can *detect* delayed dark adaptation, it is a functional test that assesses the symptom, not the underlying cause provided by ERG. *EOG* - **Electrooculography (EOG)** measures the potential difference between the cornea and the retina, primarily assessing the function of the **retinal pigment epithelium (RPE)**. - While useful for conditions like **Best's disease**, it is less direct for evaluating generalized rod dysfunction causing night blindness compared to ERG.
Question 4: In which of the following psychiatric conditions is floccillation seen?
- A. Mania
- B. Depression
- C. Anxiety disorders
- D. Delirium (Correct Answer)
Explanation: ***Delirium*** - **Floccillation**, or carphologia, is specifically characterized by **purposeless plucking at bedclothes or imaginary objects**, indicative of severe agitation and altered consciousness. - It is a classic sign of **severe delirium**, often seen in critically ill, elderly, or demented patients. *Mania* - Mania presents with elevated mood, increased energy, and racing thoughts, but typically does not involve the disoriented, purposeless movements characteristic of floccillation. - While extreme agitation can occur in mania, it is usually goal-directed or related to the patient's grandiosity or irritability. *Depression* - Depression is characterized by low mood, anhedonia, and psychomotor retardation or agitation, but not by picking at bedclothes. - Psychomotor agitation in depression usually involves pacing or restless movements associated with distress, rather than the disoriented floccillation. *Anxiety disorders* - Anxiety disorders involve excessive worry and fear, with symptoms like restlessness, tension, and hypervigilance. - While patients can be agitated, they generally maintain awareness of their surroundings and typically do not exhibit meaningless motor behaviors like floccillation.
Question 5: In narcolepsy, the polysomnographic recording typically shows which of the following patterns?
- A. REM intrusion during inappropriate periods (Correct Answer)
- B. An absence of REM sleep in midcycle
- C. Extreme muscular relaxation
- D. Spike-and-wave EEG recording
Explanation: ***REM intrusion during inappropriate periods*** - In narcolepsy, the hallmark polysomnographic finding is **sleep-onset REM periods (SOREMPs)** - the occurrence of REM sleep within 15 minutes of sleep onset. - The **Multiple Sleep Latency Test (MSLT)** in narcolepsy typically shows **≥2 SOREMPs** along with a mean sleep latency of ≤8 minutes. - Clinically, this **REM sleep intrusion** manifests as **sudden, irresistible sleep attacks** during the day, **cataplexy** (sudden muscle weakness triggered by strong emotions), **sleep paralysis**, and **hypnagogic/hypnopompic hallucinations**. - These represent features of REM sleep (muscle atonia, dreams) occurring at inappropriate times. *An absence of REM sleep in midcycle* - This statement is incorrect as narcolepsy is characterized by an **abnormal presence and early onset of REM sleep**, not its absence. - Individuals with narcolepsy enter REM sleep much faster than normal (often within minutes rather than the typical 90 minutes). *Extreme muscular relaxation* - While **cataplexy** (present in Type 1 narcolepsy) involves sudden loss of muscle tone due to REM-related atonia during wakefulness, this is a clinical symptom rather than a continuous polysomnographic finding. - Polysomnography focuses on **sleep architecture** and the timing of **REM sleep onset**, not general muscle relaxation patterns. *Spike-and-wave EEG recording* - **Spike-and-wave patterns** on EEG are characteristic of **absence seizures** (a form of epilepsy), not narcolepsy. - Narcolepsy is a primary **sleep disorder** with distinct polysomnographic features related to **REM sleep dysregulation**, not epileptiform activity.
Question 6: Intense nihilism, somatization and agitation in old age are the hallmark symptoms of -
- A. Depressive stupor
- B. Atypical depression
- C. Involutional melancholia (Correct Answer)
- D. Somatized depression
Explanation: ***Involutional melancholia*** - This **historical term** (now obsolete in DSM-5 and ICD-11) described a severe depressive episode occurring in late life, characterized by **intense nihilism**, **somatization**, and **agitation**. - In modern psychiatry, this presentation would be diagnosed as **Major Depressive Disorder with melancholic features** or **with psychotic features** (if nihilistic delusions are present). - Though no longer used as a formal diagnosis, this term may still appear in older psychiatric literature and some textbook references, particularly describing the classical triad in elderly patients. - Key features included: severe guilt, nihilistic themes, marked psychomotor agitation (not retardation), and somatic preoccupations in older adults. *Depressive stupor* - This is a rare and severe form of depression characterized by extreme **psychomotor retardation**, where the individual is almost entirely unresponsive, withdrawn, and has minimal or no movement or speech. - The key differentiating feature is **marked retardation** rather than **agitation** - these are opposite psychomotor presentations. - While it involves severe depression, the primary features of **agitation** and active **somatization** as described in the question are not characteristic of depressive stupor. *Atypical depression* - This type of depression is characterized by **mood reactivity** (mood improves in response to positive events), increased appetite or weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity. - Features **reversed neurovegetative symptoms** (hypersomnia and hyperphagia rather than insomnia and anorexia). - The symptoms of **nihilism**, **somatization**, and **agitation** are not typical features; atypical depression often involves anergic features and is more common in younger patients. *Somatized depression* - This refers to depression where psychological distress is primarily expressed through **physical symptoms** such as pain, fatigue, or gastrointestinal issues, often leading to medical consultations. - While **somatization** is the predominant feature, it lacks the specific constellation of **intense nihilism** and severe **agitation in elderly patients** that characterizes the classical involutional presentation. - More commonly seen in cultures where psychological expression of distress is stigmatized.
Question 7: What is the primary characteristic feature of Klein-Levin syndrome?
- A. Insomnia
- B. Anxiety
- C. Depression
- D. Hypersomnia (Correct Answer)
Explanation: ***Hypersomnia*** - **Hypersomnia** is the cardinal and primary characteristic feature of Klein-Levin syndrome, characterized by recurrent episodes of excessive sleepiness lasting days to weeks. - During these episodes, individuals may sleep for **16 to 20 hours a day** and are extremely difficult to awaken. - Episodes are often accompanied by **cognitive disturbances** (confusion, derealization), **behavioral changes** (apathy, hyperphagia, hypersexuality), but **hypersomnia remains the defining feature**. - Normal functioning returns between episodes. *Insomnia* - **Insomnia** (difficulty falling or staying asleep) is the opposite of the key symptom seen in Klein-Levin syndrome. - Klein-Levin syndrome is a disorder of excessive sleep, not sleep deprivation. *Anxiety* - **Anxiety** may occur as a secondary feature or during the distress of episodes, but it is not the primary characteristic feature. - The core pathology manifests as profound sleep disturbance, not an anxiety disorder. *Depression* - **Depression** is sometimes observed during or after episodes of Klein-Levin syndrome, but it is not the primary defining feature. - The diagnostic hallmark is the **recurrent hypersomnia with associated cognitive and behavioral symptoms**, not mood disturbance.
Question 8: Which of the following statements about narcolepsy is false?
- A. Day dreaming (Correct Answer)
- B. Cataplexy
- C. Sudden sleep and decreased REM latency
- D. Hypnagogic hallucinations
Explanation: ***Day dreaming*** - While people with narcolepsy experience excessive daytime sleepiness, **daydreaming** is a normal cognitive process and not a characteristic symptom of narcolepsy. - Narcolepsy involves **irresistible urges to sleep** or sudden sleep attacks, which are distinct from simply daydreaming. *Hypnagogic hallucinations* - These are **vivid, often frightening hallucinations** that occur as a person is falling asleep. - They are a common symptom of narcolepsy, along with hypnopompic hallucinations (occurring upon waking). *Cataplexy* - **Cataplexy** is a sudden, brief loss of voluntary muscle tone, often triggered by strong emotions like laughter or anger. - It is a hallmark symptom of **Type 1 narcolepsy** and is caused by the intrusion of REM sleep atonia into wakefulness. *Sudden sleep and decreased REM latency* - Individuals with narcolepsy experience **sudden and irresistible sleep attacks** during the day. - They also have **decreased REM latency**, meaning they enter REM sleep much faster than usual, often within minutes of falling asleep.
Question 9: Alzheimer's disease is associated with:
- A. Delusion
- B. Parkinsonism
- C. Delirium
- D. Dementia (Correct Answer)
Explanation: ***Dementia*** - **Alzheimer's disease** is the most common cause of **dementia**, a chronic and progressive neurodegenerative disorder characterized by a decline in cognitive function. - Key features include **memory loss**, particularly of recent events, along with impairments in language, problem-solving, and other cognitive abilities that interfere with daily life. *Delusion* - **Delusions** are fixed, false beliefs that are not amenable to change in light of conflicting evidence, more commonly associated with **psychotic disorders** like **schizophrenia**. - While individuals with advanced Alzheimer's disease can experience neuropsychiatric symptoms, including delusions, they are not the primary or defining feature of the disease itself. *Parkinsonism* - **Parkinsonism** refers to a group of neurological disorders characterized by motor symptoms such as **tremor**, **bradykinesia**, **rigidity**, and **postural instability**. - It is the hallmark of diseases like **Parkinson's disease** or **Lewy body dementia**, but not the primary feature of Alzheimer's disease, although some individuals with Alzheimer's may later develop parkinsonian features. *Delirium* - **Delirium** is an acute, fluctuating confusional state characterized by a disturbance in attention and awareness. - It is typically caused by an underlying medical condition, medication, or substance withdrawal, and is often reversible, unlike the chronic and progressive nature of Alzheimer's dementia.
Question 10: Which of the following statements is NOT true about delirium?
- A. Preserved attention (Correct Answer)
- B. Disorientation
- C. Hallucination
- D. Disturbed sleep
Explanation: ***Preserved attention*** - A core diagnostic feature of **delirium** is a disturbance of attention, meaning attention is **impaired**, not preserved. - Patients typically struggle to focus, sustain, or shift attention. *Disturbed sleep* - Delirium often involves a **disturbance of the sleep-wake cycle**, leading to insomnia during the night and drowsiness during the day. - This disorganized sleep pattern is a common symptom and can contribute to agitation or lethargy. *Disorientation* - Patients with delirium frequently exhibit **disorientation**, particularly to time, place, or person. - This reflects the global cognitive impairment characteristic of the condition. *Hallucination* - **Hallucinations**, particularly visual ones, are commonly experienced by individuals with delirium. - These perceptual disturbances contribute to the agitated or fearful presentation of some delirious patients.
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