Postreading

SELF-ASSESSMENT
AND CME

Self-Assessment
and CME Test
By D. Joanne Lynn, MD, FAAN; James W. M. Owens Jr, MD, PhD

SLEEP NEUROLOGY
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POSTREADING TEST

ARTICLE 1: NEUROBIOLOGY AND NEUROPROTECTIVE BENEFITS OF SLEEP

1 Which of the following types of neurons demonstrates the highest

activity during wakefulness and rapid eye movement (REM) sleep?

A cholinergic
B dopaminergic
C glutamatergic
D histaminergic
E serotonergic

2 The potent wake-promoting effect of orexin (hypocretin)–producing

neurons is likely due to innervation of which of the following nuclei?

A dorsal raphe
B lateral dorsal tegmental
C locus coeruleus
D parabrachial
E pedunculopontine

3 The most prominent impairments of consciousness are seen with

lesions of which of the following regions or nuclei?

A dorsal raphe nuclei

B lateral dorsal tegmental
C parabrachial
D tuberomammillary
E ventral lateral pre-optic

4 An increase in which of the following substances is implicated in the

homeostatic sleep drive?

A adenosine
B cortisol
C dopamine
D hypocretin
E melatonin

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ARTICLE 2: EVALUATING THE SLEEPY AND SLEEPLESS PATIENT

5 Which of the following findings on physical examination is correlated

with an increased risk of obstructive sleep apnea?

A history of adenotonsillectomy
B macroglossia
C neck circumference of 38 cm (15 in) in a man
D orthostatic hypotension
E prognathia

6 A 24-year-old man has had problems with excessive daytime

sleepiness for the past 3 months. He reports 8 hours of sleep each night
but still finds himself falling asleep in class, during quiet times, and
even while driving. He has experienced sleep paralysis and cataplexy
several times in the past few months. Which of the following
diagnostic tests will be most helpful?

A brain MRI
B EEG
C home sleep apnea test
D maintenance of wakefulness test
E multiple sleep latency test

7 A home sleep apnea test is indicated for evaluation of patients at

increased risk of which of these diagnostic possibilities?

A central sleep apnea

B moderate obstructive sleep apnea
C narcolepsy
D nocturnal hypoxemia
E sleep-related movement disorders

8 Morning headaches are a common symptom of which of the following

sleep disorders?

A circadian rhythm disorders

B narcolepsy
C obstructive sleep apnea
D periodic limb movement disorder
E restless legs syndrome

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POSTREADING TEST

ARTICLE 3: CENTRAL DISORDERS OF HYPERSOMNOLENCE

9 Which of the following clinical features distinguishes between

narcolepsy type 1 and type 2?

A cataplexy
B daytime sleep attacks
C disrupted nocturnal sleep
D sleep paralysis
E sleep-related hallucinations

10 A 32-year-old man has a long history of excessive sleepiness. For the

past 12 years, he has slept 11 to 12 hours every night yet remained
sleepy during the day, usually resulting in at least one nap lasting
more than an hour. He does not feel refreshed when awakening in the
morning or from one of his daytime naps. On the contrary, he
typically feels very groggy and cognitively “foggy” upon awakening.
He does not report a history of unexplained falls. He has
hypertension, adult-onset diabetes, and hypercholesterolemia, all
under good control with medications. His neurologic examination is
normal except for his very sleepy appearance. Which of the following
conditions is most likely in this patient?

A hypersomnia due to a medical disorder

B idiopathic hypersomnia
C insufficient sleep syndrome
D Kleine-Levin syndrome
E narcolepsy type 1

11 A 16-year-old boy has had several episodes of hypersomnolence

lasting for 2 to 3 weeks followed by a return to his
neurodevelopmentally normal baseline. During these episodes, he
sleeps for 16 to 18 hours per day with periods of wakefulness
characterized by apathy and hyperphagia. He has no other medical
problems, and between these episodes, his neurologic examination is
entirely normal. Which of the following medications could help to
decrease the frequency of these attacks of hypersomnolence?

A lithium
B methylphenidate
C pitolisant
D sodium oxybate
E solriamfetol

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12 Scheduled naps and regular nocturnal sleep scheduling can provide
significant benefit in which of the following disorders?

A chronic insomnia
B idiopathic hypersomnia
C insufficient sleep syndrome
D Kleine-Levin syndrome
E narcolepsy type 1

ARTICLE 4: OBSTRUCTIVE SLEEP APNEA

13 Women with obstructive sleep apnea are more likely to present with
which of the following symptoms compared with men with a similar
severity of disease?

A apneas
B delirium
C gasping
D insomnia
E snoring

14 The presence of which of the following characteristics on visual

inspection of the tongue might suggest an increased risk for
obstructive sleep apnea?

A fissuring
B geographic tongue
C leukoplakia
D lichen planus
E scalloping

15 The respiratory disturbance index is a measure of obstructive sleep

apnea severity that differs from the apnea-hypopnea index in that it
includes which of the following in addition to apneas and hypopneas?

A changes in sleeping position

B episodes of oxygen desaturation
C periodic leg movements
D respiratory arousals on EEG
E runs of ventricular ectopy

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POSTREADING TEST

16 Which of the following is the most common surgical intervention for

the treatment of obstructive sleep apnea in adults?

A adenotonsillectomy
B implantation of a phrenic nerve stimulator
C implantation of an upper airway stimulator
D mandibular advancement
E uvulopalatopharyngoplasty

ARTICLE 5: RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER AND

OTHER RAPID EYE MOVEMENT PARASOMNIAS

17 People with rapid eye movement (REM) sleep behavior disorder are
at the highest risk of developing which of the following
neurodegenerative diseases?

A Alzheimer disease
B amyotrophic lateral sclerosis
C corticobasal degeneration
D dementia with Lewy bodies
E Huntington disease

18 Which of the following is postulated to be one of the functions of

rapid eye movement (REM) sleep?

A clearance of metabolic wastes

B conservation of energy
C consolidation of emotionally laden memories
D motor skill learning
E pruning of synapses

19 Which of the following is first-line pharmacotherapy to decrease

rapid eye movement (REM) motor activity in patients with REM sleep
behavior disorder?

A alprazolam
B baclofen
C donepezil
D gabapentin
E melatonin

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20 The presence of rapid eye movement (REM) sleep behavior disorder in
a patient with Parkinson disease is associated with which of the
following?

A absence of hallucinations
B fewer motor fluctuations
C indolent less aggressive course
D less autonomic instability
E non–tremor-predominant presentation

ARTICLE 6: PARASOMNIAS OCCURRING IN NON–RAPID EYE MOVEMENT

SLEEP

21 A 27-year-old woman comes to clinic with a several-year history of

nocturnal episodes. The events are characterized by sitting up in bed
with feelings of shortness of breath, palpitations, paresthesia of her
fingers bilaterally, and a feeling of dread. The events tend to occur in
the first half of the nocturnal sleep period. She does not recall any
associated dream imagery preceding the event but fully recalls the
experience of the event itself. When asked by her bed partner what is
happening, she is able to say that she is having a “spell” and describe
what she is feeling. After the event, she is eventually able to return to
sleep. She has a history of a generalized anxiety disorder, for which she
is pursuing cognitive-behavioral therapy. Her neurologic examination
is entirely normal. Which of the following disorders is most likely
responsible for her events?

A confusional arousals
B nightmares
C nocturnal panic attacks
D rapid eye movement (REM) sleep behavior disorder
E sleep terrors

22 For a patient with a history of potentially injurious behaviors during

sleepwalking episodes, which of the following medications would be
most appropriate?

A clonazepam
B haloperidol
C sodium oxybate
D trazodone
E zolpidem

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POSTREADING TEST

23 A 6-year-old boy has nightly episodes that are stereotyped and brief,
usually lasting less than 60 seconds. His parents first noted something
was amiss when he began to wet the bed again after a year of being dry
at night. The parents moved him to their bed so they could monitor the
episodes. The episodes occur at any time of night and begin with a
moan and brief stiffening followed by shaking of his limbs, during
which enuresis occurs. This is followed by a brief arousal and return to
sleep. The patient does not recall anything specific about the nocturnal
events but does remember that “he had one.” Given this description,
which of the following types of nocturnal events is most likely?

A confusional arousal
B rapid eye movement (REM) sleep behavior disorder
C rhythmic movement disorder
D seizure
E sleep terror

ARTICLE 7: RESTLESS LEGS SYNDROME AND OTHER COMMON

SLEEP-RELATED MOVEMENT DISORDERS

24 A 45-year-old man with restless legs syndrome has continued to have

bothersome symptoms despite adequate trials of increased exercise
and improved sleep hygiene. He has also tried iron therapy resulting in
a serum ferritin level of 500 ng/mL and transferrin saturation of 60%.
He has gastroesophageal reflux disease, for which he takes ranitidine
and metoclopramide, as well as hypertension that is well controlled
with lisinopril. He has a long-standing history of initiation insomnia
treated with a combination of melatonin and zolpidem. Which of the
following interventions would be best to try next?

A begin clonazepam
B begin pramipexole
C stop metoclopramide
D stop zolpidem
E switch lisinopril for another antihypertensive

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25 A 57-year-old patient comes to sleep clinic with restless legs
syndrome symptoms that have been gradually worsening despite
nonpharmacologic interventions. A sleep study reveals that the patient
also has frequent periodic limb movements that are not associated
with arousals. He has hypertension, which was well controlled but is
now more variable and less responsive to medication. His serum
ferritin level is 80 ng/mL with a transferrin saturation of 28%. Which
of the following therapeutic interventions would be best to try next?

A clonazepam
B gabapentin
C IV iron
D oral iron supplementation
E pramipexole

26 A 52-year-old returns to sleep clinic after an overnight sleep study. He

had initially come to clinic with excessive daytime somnolence that
proved unresponsive to improved sleep hygiene measures. He was
diagnosed with restless legs syndrome several years ago, and his
daytime symptoms are well managed with gabapentin, but he feels
that he is a “restless sleeper.” His sleep study revealed an
apnea-hypopnea index of 15 events per hour and a periodic limb
movement index of 5. Which of the following disorders is most likely
responsible for this patient’s excessive daytime somnolence?

A obstructive sleep apnea

B periodic limb movement disorder
C propriospinal myoclonus
D rapid eye movement (REM) sleep behavior disorder
E sleep-related rhythmic movement disorder

27 An 18-month-old boy is brought to clinic for head banging at night. His

parents report that, soon after falling asleep, he will get on all four
limbs and then rock back and forth with his head repetitively hitting
the headboard of his crib. He has awoken with forehead bruising, and
his parents feel that he is more irritable during the day since these
behaviors have begun. Once he falls asleep, he generally sleeps well,
and there are no other nocturnal episodes of concern. He is otherwise
neurodevelopmentally normal with a normal neurologic examination.
Which of the following treatments would be most appropriate in
this case?

A clonazepam
B gabapentin
C iron
D levodopa
E pramipexole

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POSTREADING TEST

ARTICLE 8: CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS

28 A 67-year-old man with progressive retinal degeneration has

developed more difficulties with sleep. Initially, he experienced
trouble falling asleep at night and difficulties awakening as early as he
wished in the morning. More recently, his sleep has grown more
disturbed and appears to follow a non–24-hour pattern. What
medication is US Food and Drug Administration (FDA) approved for
this disorder?

A caffeine
B lemborexant
C melatonin
D modafinil
E tasimelteon

29 Which of these sleep disorders has been associated with an increased

risk of breast cancer?

A delayed sleep-wake phase disorder

B insomnia
C jet lag disorder
D non–24-hour sleep-wake rhythm disorder
E shift work disorder

30 In mammals, circadian rhythms are coordinated by which

hypothalamic nucleus structure?

A arcuate
B dorsomedial
C preoptic
D suprachiasmatic
E tuberomammillary

ARTICLE 9: INSOMNIA

31 Which of the following interventions is considered first-line therapy

for adult patients with insomnia?

A bioenergy therapy
B cognitive-behavioral therapy
C energetic sleep hygiene
D melatonin
E zolpidem

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32 Which of the following integrative medicine treatments for insomnia
is associated with potential side effects such as headache, drowsiness,
false memories, and strong emotions?

A acupuncture
B autonomous meridian sensory response
C hypnotherapy
D Reiki
E therapeutic touch

33 Which of the following sleep aid strategies aims at producing a

tinglinglike sensation across the scalp and back of the neck in response
to specific auditory and visual stimuli?

A autonomous sensory meridian response

B healing touch
C Qigong
D Reiki
E tactile therapy

ARTICLE 10: SLEEP IN PATIENTS WITH NEUROLOGIC DISEASE

34 The irregular sleep-wake rhythm and phenomenon of “sundowning”

that occur in Alzheimer disease correlate to a critical loss of neuronal
populations in what brain area?

A lateral hypothalamus
B midbrain reticular formation
C nucleus accumbens
D suprachiasmatic nuclei
E ventral medial hypothalamus

35 Patients with idiopathic rapid eye movement (REM) sleep behavior

disorder have a high incidence of conversion to Parkinson disease. The
risk is further increased by the presence of which of these factors?

A history of smoking
B hypertension
C hyposmia
D negative family history for movement disorders
E younger age

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POSTREADING TEST

36 Which of the following movement disorders is recognized as one for

which abnormal movements typically persist during sleep?

A dystonia
B essential tremor
C Huntington disease
D Parkinson disease
E tardive dyskinesia

ARTICLE 11: SLEEP-WAKE DISORDERS IN CHILDHOOD

37 A child with significant insomnia, which has proved incompletely

responsive to behavioral intervention, is placed on a low starting dose
of a hypnotic medication. After the low-dose hypnotic is initiated, he
seems agitated at bedtime and his insomnia worsens. How should this
response to medication be classified?

A adverse effect
B allergy
C behavioral disorder
D paradoxical reaction
E pharmacogenomic trait

38 A 5-year-old girl is seen in a sleep clinic because of excessive daytime

somnolence. She gets 10 to 10.5 hours of sleep per 24 hours and does not
have difficulty falling asleep. She has confusional arousals every few
weeks, but these seem to be less frequent now. She is described as “a
very active sleeper,” frequently winding up with her head at the foot
of the bed. She finds it difficult to awaken in the morning. There are no
reports of morning headaches, and she does not snore. Her birth
history and past medical history are unremarkable, and her
developmental history is on track with no change in trajectory. Her
general physical and neurologic examinations are normal. She
undergoes overnight polysomnography, which reveals an
apnea-hypopnea index of 0.5 and a periodic limb movement index of
3 events per hour. Which of the following sleep disorders most likely
explains her daytime somnolence?

A chronic insomnia
B idiopathic hypersomnia
C insufficient sleep syndrome
D restless legs syndrome
E restless sleep disorder

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39 For a patient with frequent parasomnias who does not have evidence
of obstructive sleep apnea or periodic limb movement disorder on
overnight polysomnography and who receives an appropriate total
duration of sleep for his or her age, which of the following medications
should be considered?

A baclofen
B clonazepam
C fluoxetine
D gabapentin
E sodium oxybate

40 For patients with Smith-Magenis syndrome, in addition to melatonin

at bedtime, which of the following interventions is recommended?

A beta-blocker in the morning

B clonidine at night
C iron supplementation
D melatonin in the morning
E trazodone at night

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