Insomnia

Front

A 32-year-old female presents with a 6-month history of difficulty sleeping, occurring 4–5 nights per week, often taking more than 2 hours to fall asleep. What is the first-line therapy for this condition? Options: Diphenhydramine (Benadryl Allergy), 25–50 mg before bed; Lorazepam (Ativan), 0.5 mg before bed; Zolpidem (Ambien), 5 mg before bed; Positive airway pressure therapy; Cognitive behavioral therapy.

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Cognitive behavioral therapy

Answer explanation

This patient meets diagnostic criteria for insomnia. She has prolonged sleep latency (>30 minutes) for at least 3 nights per week for at least 3 months. First-line therapy for chronic insomnia is a trial of cognitive behavioral therapy; if this is not effective a trial of pharmacologic therapy may be considered.

Antihistamine therapy is often used but the American Academy of Sleep Medicine notes the benefits are essentially equal to the harms and does not recommend this for insomnia treatment. Benzodiazepines have dependency issues and can also increase the risk of falls in elderly patients. Benzodiazepine receptor

agonists (zolpidem, eszopiclone, and zaleplon) have shown limited effectiveness but are approved only for short-term use. Positive airway pressure is used for treatment of sleep apnea but not insomnia.

Ref: Holder S, Narula NS. Common sleep disorders in adults: diagnosis and management. Am Fam Physician. 2022;105(4):397-405.

Front

The parents of a healthy 5-year-old girl express concern that their daughter appears to be having bad dreams one or two nights per week. During these episodes, they hear her screaming and find her sitting straight up in her bed, diaphoretic and hard to arouse. They note that she seems very confused and disoriented after the episodes and that she cannot recall what occurred. What is the most appropriate next step in this child's care?

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Reassure the parents

Answer explanation

This patient is experiencing sleep terrors (also known as night terrors), a problem that affects approximately 1% to 6% of children between the ages of 4 and 12. Sleep terrors occur during sleep and typically begin with a cry or loud scream that is accompanied by autonomic nervous system activation (tachycardia, diaphoresis, and flushing) and behavioral manifestations of intense fear (muscle stiffening). The child is usually difficult to arouse during these episodes and usually has amnesia of the event.

Sleep terrors are usually more concerning for the parents than for the child, and reassurance is the most appropriate management. Children typically grow out of sleep terrors by adolescence. If the episodes occur nightly, parents may try scheduled waking before the usual time of events.

Key learning point: The most appropriate management for sleep terrors in childhood is reassurance.

Front

A medical resident, who is completing her week of overnight shifts, confuses the medical history of several of her patients. She is also slow in formulating answers to questions and in completing tasks. Which one of the following responses is most appropriate in this situation? Options: The observations should be discussed with the resident, sick-relief replacement should be arranged, and the resident should go home to rest before returning to work, The residency director should be informed about the resident’s inability to function properly in a stressful work environment, The resident should be allowed to take a coffee break before returning to work, The observations should be discussed with the resident, and monitoring of the resident’s order entry should be increased for the remainder of the shift, The resident’s pager or phone should be held to allow time for a 3-hour nap before the resident returns to work

Back

The observations should be discussed with the resident, sick-relief replacement should be arranged, and the resident should go home to rest before returning to work.

Answer explanation

Sleep deprivation in a clinician can cause significant harm to both the clinician and their patients. In a study on the effects of sleep deprivation and altered sleep schedules, nearly 41% of internal medicine residents cited sleep deprivation as the cause of their most serious medical mistake. Sleep deprivation in clinicians should not be trivialized, given the potential risk to patients.

Although sleep deprivation is associated with a significantly increased rate of serious medical errors, the best way to prevent acute and chronic sleep deprivation in residents is not clear. Randomized trials comparing traditional work schedules with schedules that were designed to reduce sleep deprivation have not shown consistent benefit in terms of patient safety outcomes and, in some cases, have even shown higher rates of serious medical errors. As a result, a variety of recommendations have been made, including protected time for napping and strategic intake of caffeine, as well as general lifestyle advice such as good nutrition, regular exercise, and management of insomnia and other sleep-related disorders.

When sleep deprivation has occurred, as in this case, the best management strategy is to allow the resident to go home to obtain uninterrupted sleep — and to seek a backup clinician as a replacement. The exact duration of rest is unclear, but given that sleep deprivation requires catch-up sleep, guidelines suggest a minimum of 14 hours away after 24 continuous hours of duty.

Importantly, if the resident plans to drive home, an alternative should be proposed, such as a taxi ride home, a ride home from a friend, or overnight accommodations in the hospital. Sleep deprivation among residents has been demonstrated to increase the risk of motor vehicle crashes.

Key learning point: Sleep deprivation can have negative effects on a clinician’s work performance, including slowed cognitive processing, lapses in attention, depressed mood, and increased risk for medical errors.

Front

A 62-year-old male presents with daytime fatigue, sleepiness, snoring at night, and a BMI of 41 kg/m2. You are concerned that he may have obesity hypoventilation syndrome (OHS) in addition to possible obstructive sleep apnea. Which one of the following tests is most appropriate for establishing a diagnosis of OHS? Options: Daytime awake serum HCO3–, Daytime awake PaCO2, Daytime awake PaO2, Nighttime serial measurement of peripheral oxygen saturation during sleep, Nighttime serum HCO3– within 2 minutes of awakening

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Daytime awake PaCO2

Answer explanation

Obesity hypoventilation syndrome (OHS) is characterized by obesity and alveolar hypoventilation while awake, which is defined by an awake PaCO2 level >45 mm Hg. Ninety percent of patients have coexistent obstructive sleep apnea (OSA). The pathogenesis is related to the increased physical demands on breathing

caused by obesity. While decreased PaO2 or oxygen saturation is often present, it is not part of the diagnostic criteria. In obese patients with lower risk (often with lower BMIs), a serum HCO3

– level <27 mmol/L may obviate the need for an arterial blood gas measurement as OHS becomes very unlikely. If the HCO3– level is 27 mmol/L (a renal compensatory mechanism for hypoventilation-induced acidosis), a PaCO2 measurement should be obtained to establish the diagnosis. The first-line treatment for ambulatory patients with this condition is CPAP. Nighttime measurement of peripheral oxygen saturation during sleep is a key component of sleep studies that are used to diagnose OSA, but it is not used to diagnose OHS.

Ref: Mokhlesi B, Masa JF, Brozek JL, et al. Evaluation and management of obesity hypoventilation syndrome. An official

American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2019;200(3):e6-e24.