Central disorders of hypersomnolence — MCQs

An otherwise healthy 55-year-old woman comes to the physician because of a 7-month history of insomnia. She has difficulty initiating sleep, and her sleep onset latency is normally about 1 hour. She takes melatonin most nights. The physician gives the following recommendations: leave the bedroom when unable to fall asleep within 20 minutes to read or listen to music; return only when sleepy; avoid daytime napping. These recommendations are best classified as which of the following?

A 20-year-old female presents to student health at her university for excessive daytime sleepiness. She states that her sleepiness has caused her to fall asleep in all of her classes for the last semester, and that her grades are suffering as a result. She states that she normally gets 7 hours of sleep per night, and notes that when she falls asleep during the day, she immediately starts having dreams. She denies any cataplexy. A polysomnogram and a multiple sleep latency test rule out obstructive sleep apnea and confirm her diagnosis. She is started on a daytime medication that acts both by direct neurotransmitter release and reuptake inhibition. What other condition can this medication be used to treat?

A 16-year-old girl is brought to the physician because of generalized fatigue and an inability to concentrate in school for the past 4 months. During this period, she has had excessive daytime sleepiness. While going to sleep, she sees cartoon characters playing in her room. She wakes up once or twice every night. While awakening, she feels stiff and cannot move for a couple of minutes. She goes to sleep by 9 pm every night and wakes up at 7 am. She takes two to three 15-minute naps during the day and wakes up feeling refreshed. During the past week while listening to a friend tell a joke, she had an episode in which her head tilted and jaw dropped for a few seconds; it resolved spontaneously. Her father has schizoaffective disorder and her parents are divorced. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate initial pharmacotherapy?

A 23-year-old woman is seen by her primary care physician. The patient has a several year history of excessive daytime sleepiness. She also reports episodes where she suddenly falls to the floor after her knees become weak, often during a laughing spell. She has no other significant past medical history. Her primary care physician refers her for a sleep study, which confirms the suspected diagnosis. Which of the following laboratory findings would also be expected in this patient?

An 18-year-old man presents to his primary care physician with a complaint of excessive daytime sleepiness. He denies any substance abuse or major changes in his sleep schedule. He reports frequently dozing off during his regular daily activities. On further review of systems, he endorses falling asleep frequently with the uncomfortable sensation that there is someone in the room, even though he is alone. He also describes that from time to time, he has transient episodes of slurred speech when experiencing heartfelt laughter. Vital signs are stable, and his physical exam is unremarkable. This patient is likely deficient in a neurotransmitter produced in which part of the brain?

A 72-year-old man presents to his primary care physician complaining of increasing difficulty sleeping over the last 3 months. He reports waking up frequently during the night because he feels an urge to move his legs, and he has a similar feeling when watching television before bed. The urge is relieved by walking around or rubbing his legs. The patient’s wife also notes that she sometimes sees him moving his legs in his sleep and is sometimes awoken by him. Due to his recent sleep troubles, the patient has started to drink more coffee throughout the day to stay awake and reports having up to 3 cups daily. The patient has a past medical history of hypertension and obesity but states that he has lost 10 pounds in the last 3 months without changing his lifestyle. He is currently on hydrochlorothiazide and a multivitamin. His last colonoscopy was when he turned 50, and he has a family history of type II diabetes and dementia. At this visit, his temperature is 99.1°F (37.3°C), blood pressure is 134/81 mmHg, pulse is 82/min, and respirations are 14/min. On exam, his sclerae are slightly pale. Cardiovascular and pulmonary exams are normal, and his abdomen is soft and nontender. Neurologic exam reveals 2+ reflexes in the bilateral patellae and 5/5 strength in all extremities. Which of the following is most likely to identify the underlying etiology of this patient's symptoms?

A 21-year-old man presents to the clinic complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. What is this patient's diagnosis?

A 50-year-old man with severe obstructive sleep apnea (AHI 65 events/hour) and CPAP intolerance despite multiple mask trials undergoes maxillomandibular advancement surgery. Three months post-operatively, he continues to report excessive daytime sleepiness and his bed partner reports persistent snoring. Post-operative polysomnography shows AHI of 28 events/hour. He has a BMI of 38 kg/m² (unchanged from pre-surgery) and crowded posterior pharynx. Evaluate the next management strategy.

A 70-year-old man with newly diagnosed Parkinson disease and REM sleep behavior disorder is being considered for treatment. His neurologist is concerned about medication interactions and disease progression. He also has mild cognitive impairment, orthostatic hypotension, and a history of visual hallucinations. Evaluate the optimal therapeutic approach considering his complex medical profile.

A 25-year-old medical resident presents with excessive daytime sleepiness and difficulty maintaining wakefulness during lectures. Polysomnography shows normal sleep architecture with a sleep latency of 8 minutes. Multiple Sleep Latency Test (MSLT) shows a mean sleep latency of 4 minutes with 1 sleep-onset REM period (SOREMP). She works rotating shifts, sleeps 4-5 hours on workdays, and has no cataplexy. Evaluation of this clinical scenario suggests which diagnosis best accounts for all findings?