MCQ Quiz: Management of Sleep-Wake Disorders

The effective management of sleep-wake disorders is a key competency for pharmacists, requiring a nuanced understanding of both non-pharmacological and pharmacological strategies. As outlined in the Patient Care VII: Brain and Behavior curriculum, managing conditions like insomnia, narcolepsy, and restless legs syndrome involves a patient-centered approach that begins with behavioral interventions and progresses to carefully selected medications. This quiz will test your knowledge on FDA-approved hypnotic agents , treatments for narcolepsy , therapeutic options for restless legs syndrome , and the appropriate use of OTC and herbal products for sleep, preparing you to provide safe and evidence-based care.

1. What is the first-line, foundational treatment for chronic insomnia that should be recommended for all patients?

• A. A prescription benzodiazepine receptor agonist
• B. Cognitive behavioral therapy for insomnia (CBT-I) and proper sleep hygiene
• C. An over-the-counter antihistamine
• D. A low-dose stimulating antidepressant

Answer: B. Cognitive behavioral therapy for insomnia (CBT-I) and proper sleep hygiene

2. A patient asks for an OTC sleep aid. The active ingredient in products like Unisom SleepTabs and ZzzQuil is typically:

• A. Melatonin
• B. Diphenhydramine or Doxylamine
• C. Valerian root
• D. Ibuprofen PM

Answer: B. Diphenhydramine or Doxylamine

3. The non-benzodiazepine hypnotics, or “Z-drugs,” are effective for sleep. What is their primary mechanism of action?

• A. They are positive allosteric modulators at the benzodiazepine site on the GABA-A receptor
• B. They are agonists at melatonin receptors
• C. They are antagonists at orexin receptors
• D. They are antagonists at histamine H1 receptors

Answer: A. They are positive allosteric modulators at the benzodiazepine site on the GABA-A receptor

4. A patient needs a hypnotic for sleep-onset insomnia but must be fully alert for work in 6 hours. Which agent has an ultra-short half-life, making it suitable for this scenario?

• A. Eszopiclone
• B. Zolpidem CR
• C. Zaleplon
• D. Temazepam

Answer: C. Zaleplon

5. Suvorexant (Belsomra) is a hypnotic that works by which novel mechanism?

• A. Potentiating GABA
• B. Agonizing melatonin receptors
• C. Antagonizing orexin receptors to suppress wakefulness
• D. Blocking serotonin reuptake

Answer: C. Antagonizing orexin receptors to suppress wakefulness

6. Which hypnotic agent is not a controlled substance and works by selectively agonizing MT1 and MT2 receptors?

• A. Zolpidem
• B. Eszopiclone
• C. Ramelteon
• D. Suvorexant

Answer: C. Ramelteon

7. A significant counseling point for a patient starting zolpidem is to take it immediately before getting into bed due to the risk of:

• A. Hypertensive crisis
• B. Severe nausea and vomiting
• C. Complex sleep-related behaviors (e.g., sleep-driving)
• D. A severe drug-food interaction

Answer: C. Complex sleep-related behaviors (e.g., sleep-driving)

8. The use of older OTC antihistamines like diphenhydramine for sleep is discouraged in elderly patients due to:

• A. Their high cost.
• B. Their potent anticholinergic side effects.
• C. Their lack of efficacy.
• D. Their abuse potential.

Answer: B. Their potent anticholinergic side effects.

9. Which class of medication is considered first-line for managing the excessive daytime sleepiness associated with narcolepsy?

• A. Benzodiazepines
• B. Wakefulness-promoting agents like modafinil
• C. Tricyclic antidepressants
• D. Orexin receptor antagonists

Answer: B. Wakefulness-promoting agents like modafinil

10. Sodium oxybate (Xyrem) is a highly effective treatment for which specific symptom of narcolepsy?

• A. Insomnia
• B. Sleep paralysis
• C. Cataplexy
• D. Excessive daytime sleepiness

Answer: C. Cataplexy

11. The first-line treatment for Restless Legs Syndrome (RLS) often involves:

• A. High-dose antihistamines.
• B. Dopamine agonists (e.g., pramipexole) or alpha-2-delta ligands (e.g., gabapentin enacarbil).
• C. Benzodiazepine receptor agonists.
• D. Stimulants like methylphenidate.

Answer: B. Dopamine agonists (e.g., pramipexole) or alpha-2-delta ligands (e.g., gabapentin enacarbil).

12. A patient with depression and comorbid insomnia might benefit from a low dose of which sedating antidepressant at bedtime?

• A. Bupropion
• B. Fluoxetine
• C. Trazodone
• D. Sertraline

Answer: C. Trazodone

13. Which Z-drug has the longest half-life, making it suitable for sleep maintenance but also carrying a higher risk of next-day impairment?

• A. Zaleplon
• B. Zolpidem IR
• C. Eszopiclone
• D. Indiplon

Answer: C. Eszopiclone

14. What is a key principle of good “sleep hygiene”?

• A. Using electronic devices in bed until you fall asleep.
• B. Maintaining a consistent sleep-wake schedule, even on weekends.
• C. Drinking a large amount of fluid right before bed.
• D. Taking long naps in the late afternoon.

Answer: B. Maintaining a consistent sleep-wake schedule, even on weekends.

15. A patient should be counseled to avoid which substance when taking any hypnotic due to the risk of additive CNS depression?

• A. Vitamin C
• B. Caffeine
• C. Alcohol
• D. Water

Answer: C. Alcohol

16. Which benzodiazepine is specifically FDA-approved for insomnia and has a relatively short half-life?

• A. Diazepam
• B. Clonazepam
• C. Chlordiazepoxide
• D. Temazepam

Answer: D. Temazepam

17. The use of benzodiazepines for the management of insomnia is generally limited to:

• A. Long-term, indefinite use.
• B. Short-term use, due to the risks of tolerance and dependence.
• C. Use in elderly patients only.
• D. Use in patients with a history of substance abuse.

Answer: B. Short-term use, due to the risks of tolerance and dependence.

18. A patient taking zolpidem reports that the medication is less effective if they take it after a large, high-fat meal. This is due to:

• A. An increase in the drug’s metabolism.
• B. A delay in the drug’s absorption.
• C. A direct chemical reaction with the food.
• D. An increase in the drug’s protein binding.

Answer: B. A delay in the drug’s absorption.

19. What is the primary role of melatonin as an OTC supplement in managing sleep disorders?

• A. It is a potent sedative for middle-of-the-night awakenings.
• B. It can help regulate the circadian rhythm, making it useful for jet lag or sleep-onset insomnia.
• C. It is a powerful muscle relaxant.
• D. It is the most effective treatment for sleep apnea.

Answer: B. It can help regulate the circadian rhythm, making it useful for jet lag or sleep-onset insomnia.

20. The orexin neurotransmitter system is a primary regulator of:

• A. Sleep
• B. Wakefulness
• C. Mood
• D. Appetite

Answer: B. Wakefulness

21. When a patient abruptly stops taking a hypnotic like eszopiclone, they may experience what phenomenon?

• A. Improved sleep quality.
• B. Rebound insomnia.
• C. A reduction in anxiety.
• D. Increased energy the next day.

Answer: B. Rebound insomnia.

22. Which tricyclic antidepressant is approved at very low doses (3mg, 6mg) for sleep maintenance insomnia?

• A. Amitriptyline
• B. Imipramine
• C. Nortriptyline
• D. Doxepin

Answer: D. Doxepin

23. A patient with BPH and insomnia should be counseled to avoid OTC sleep aids containing diphenhydramine because of its:

• A. Stimulant properties.
• B. Anticholinergic properties, which can worsen urinary retention.
• C. Dopaminergic properties.
• D. Serotonergic properties.

Answer: B. Anticholinergic properties, which can worsen urinary retention.

24. The management of sleep-wake disorders is an explicit topic in which Patient Care course?

• A. Patient Care V: Endocrinology and Women’s and Men’s Health
• B. Patient Care VII: Brain and Behavior
• C. Patient Care VI: Skin and Musculoskeletal Disorders
• D. Patient Care IV: Gastrointestinal and Renal Disorders

Answer: B. Patient Care VII: Brain and Behavior

25. A patient should be advised to take ramelteon:

• A. With a high-fat meal to increase absorption.
• B. About 30 minutes before bedtime and not with or immediately after a high-fat meal.
• C. In the morning to prevent daytime sleepiness.
• D. As needed for middle-of-the-night awakenings.

Answer: B. About 30 minutes before bedtime and not with or immediately after a high-fat meal.

26. The term “hypnotic” refers to a class of drugs that:

• A. Reduce anxiety.
• B. Improve mood.
• C. Induce or maintain sleep.
• D. Increase wakefulness.

Answer: C. Induce or maintain sleep.

27. For a patient with both depression and insomnia, the most logical initial approach would be:

• A. Prescribing a separate hypnotic and a stimulating antidepressant.
• B. Choosing a sedating antidepressant like trazodone or mirtazapine to address both conditions.
• C. Prescribing a benzodiazepine only.
• D. Focusing only on sleep hygiene.

Answer: B. Choosing a sedating antidepressant like trazodone or mirtazapine to address both conditions.

28. Which of the following is an example of good sleep hygiene?

• A. Exercising vigorously right before bed.
• B. Having a large, heavy meal just before sleep.
• C. Ensuring the bedroom is dark, quiet, and cool.
• D. Watching television in bed to relax.

Answer: C. Ensuring the bedroom is dark, quiet, and cool.

29. The primary safety concern with sodium oxybate is its high potential for abuse and:

• A. Severe liver toxicity.
• B. Potent CNS and respiratory depression.
• C. Hypertensive crisis.
• D. Agranulocytosis.

Answer: B. Potent CNS and respiratory depression.

30. Before recommending any sleep aid, it is critical for the pharmacist to:

• A. Guarantee the patient will sleep for 8 hours.
• B. Assess for underlying medical or psychiatric conditions that could be causing the insomnia.
• C. Insist on the most expensive option.
• D. Recommend the highest possible dose.

Answer: B. Assess for underlying medical or psychiatric conditions that could be causing the insomnia.

31. Augmentation, a common side effect of long-term dopamine agonist use for RLS, refers to:

• A. The medication becoming more effective over time.
• B. The worsening of RLS symptoms, which start earlier in the day and spread to other body parts.
• C. A complete resolution of symptoms.
• D. The development of tolerance.

Answer: B. The worsening of RLS symptoms, which start earlier in the day and spread to other body parts.

32. The “Beer’s Criteria” lists benzodiazepines and Z-drugs as potentially inappropriate for use in the elderly due to the increased risk of:

• A. Improved cognition.
• B. Falls, fractures, and confusion.
• C. Hypertension.
• D. Weight loss.

Answer: B. Falls, fractures, and confusion.

33. What is the most appropriate management for a patient who develops tolerance to a Z-drug they have been taking nightly?

• A. Continue to increase the dose indefinitely.
• B. Recommend a gradual dose reduction and discontinuation, while reinforcing CBT-I.
• C. Add a second hypnotic from the same class.
• D. Switch to a short-acting barbiturate.

Answer: B. Recommend a gradual dose reduction and discontinuation, while reinforcing CBT-I.

34. The primary role of the pharmacist in OTC management of sleep disorders is:

• A. To sell the most expensive product.
• B. To help the patient select an appropriate product, counsel on its safe use, and identify when a referral to a physician is necessary.
• C. To recommend long-term use of antihistamines for sleep.
• D. To diagnose the underlying cause of the insomnia.

Answer: B. To help the patient select an appropriate product, counsel on its safe use, and identify when a referral to a physician is necessary.

35. A patient reports success with the herbal supplement valerian root for sleep. The pharmacist should counsel them that:

• A. It is a potent, FDA-approved hypnotic.
• B. It is completely free of side effects and drug interactions.
• C. Its quality can be inconsistent, and it may cause a “hangover” effect or, paradoxically, stimulation in some individuals.
• D. It should be combined with alcohol for best results.

Answer: C. Its quality can be inconsistent, and it may cause a “hangover” effect or, paradoxically, stimulation in some individuals.

36. A key part of managing sleep-wake disorders is patient education. This falls under which step of the Pharmacists’ Patient Care Process?

• A. Collect
• B. Assess
• C. Plan
• D. Implement

Answer: D. Implement

37. Which of the following is a key feature of narcolepsy?

• A. An inability to fall asleep at night.
• B. Overwhelming daytime sleepiness and sleep attacks.
• C. An uncontrollable urge to move the legs.
• D. Acting out dreams while asleep.

Answer: B. Overwhelming daytime sleepiness and sleep attacks.

38. The use of benzodiazepines in a patient with untreated sleep apnea is dangerous because they can:

• A. Improve breathing during sleep.
• B. Worsen respiratory depression and apnea episodes.
• C. Cure sleep apnea.
• D. Reduce daytime sleepiness.

Answer: B. Worsen respiratory depression and apnea episodes.

39. A patient’s hypnotic should be tapered upon discontinuation to prevent:

• A. A severe hypertensive crisis.
• B. Liver damage.
• C. Rebound insomnia and other withdrawal effects.
• D. An increase in medication cost.

Answer: C. Rebound insomnia and other withdrawal effects.

40. Why is buspirone not effective for insomnia?

• A. It is a CNS stimulant.
• B. It lacks any significant sedative or hypnotic properties.
• C. Its half-life is too long.
• D. It must be taken with food.

Answer: B. It lacks any significant sedative or hypnotic properties.

41. The management of shift work sleep disorder often involves:

• A. Taking a long nap immediately before a night shift.
• B. Using short-acting hypnotics for sleep during the day and wakefulness-promoting agents (e.g., modafinil) during the night shift.
• C. Drinking large amounts of coffee throughout the shift.
• D. Avoiding all light exposure during the day.

Answer: B. Using short-acting hypnotics for sleep during the day and wakefulness-promoting agents (e.g., modafinil) during the night shift.

42. The “Assess” step of the PPCP for a patient with insomnia involves:

• A. Immediately recommending a product.
• B. Evaluating the patient’s symptoms, medication history, and lifestyle to identify potential causes and medication therapy problems.
• C. Dispensing the prescription as written.
• D. Documenting the encounter.

Answer: B. Evaluating the patient’s symptoms, medication history, and lifestyle to identify potential causes and medication therapy problems.

43. The FDA warns that taking a Z-drug with which other class of CNS depressants has led to deaths?

• A. Statins
• B. Opioids
• C. Proton pump inhibitors
• D. Beta-blockers

Answer: B. Opioids

44. Which of the following should be ruled out before diagnosing primary RLS?

• A. Hypertension
• B. Iron deficiency anemia
• C. Hyperlipidemia
• D. Gout

Answer: B. Iron deficiency anemia

45. A patient should be counseled to have at least how many hours available for sleep after taking eszopiclone?

• A. 4 hours
• B. 5 hours
• C. 6 hours
• D. 7-8 hours

Answer: D. 7-8 hours

46. A patient is taking modafinil for narcolepsy. What is a key counseling point regarding its interaction with hormonal contraceptives?

• A. It will increase the efficacy of the contraceptive.
• B. It can decrease the efficacy of hormonal contraceptives by inducing their metabolism.
• C. There is no interaction.
• D. It should only be taken with progestin-only contraceptives.

Answer: B. It can decrease the efficacy of hormonal contraceptives by inducing their metabolism.

47. Low-dose doxepin’s hypnotic effect is due to its high potency as a(n):

• A. Serotonin reuptake inhibitor.
• B. Histamine H1 receptor antagonist.
• C. Norepinephrine reuptake inhibitor.
• D. Dopamine receptor agonist.

Answer: B. Histamine H1 receptor antagonist.

48. What is the most common reason for treatment failure in insomnia?

• A. The medications are not effective.
• B. Failure to address poor sleep hygiene and underlying behavioral factors.
• C. The medications are too expensive.
• D. Patients develop tolerance too quickly.

Answer: B. Failure to address poor sleep hygiene and underlying behavioral factors.

49. For which hypnotic is there a specific warning about performing activities the next day that require full mental alertness, even if the patient feels fully awake?

• A. Diphenhydramine
• B. Melatonin
• C. Suvorexant
• D. Valerian root

Answer: C. Suvorexant

50. The comprehensive management of sleep-wake disorders requires the pharmacist to:

• A. Focus only on dispensing the medication.
• B. Act as an educator, counselor, and collaborator within the healthcare team to optimize both non-pharmacological and pharmacological therapy.
• C. Only recommend OTC products.
• D. Defer all questions to the physician.

Answer: B. Act as an educator, counselor, and collaborator within the healthcare team to optimize both non-pharmacological and pharmacological therapy.