Issue Overview

Sleep Neurology, Volume 26, Number 4, August 2020

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay

abreast of advances in the field while simultaneously developing lifelong self-directed learning

skills.

Learning Objectives

Upon completion of this Continuum: Lifelong Learning in Neurology Sleep Neurology issue,

participants will be able to:

Describe the neurobiology underlying the sleep-wake states and circadian rhythms

 Recognize key findings in the history and examination of patients and objective sleep testing

available in patients presenting with sleepiness or sleeplessness complaints

 Discuss the central disorders of hypersomnolence, summarize available evidence regarding

pathophysiology, and formulate a diagnostic and treatment plan for patients with these

disorders

 Discuss the appropriate screening mechanisms for obstructive sleep apnea, when to refer

patients to be diagnosed, and the importance of treating obstructive sleep apnea

 Diagnose and manage rapid eye movement (REM) sleep behavior disorder and recognize this

disorder as a prodromal neurodegenerative syndrome of disorders of Lewy body pathology

 Diagnose and manage different parasomnias of non–rapid eye movement (REM) sleep

 Describe the clinical symptoms, differential diagnosis, and management of restless legs

syndrome and other sleep-related movement disorders

 Discuss the common presentations, etiology, and treatment recommendations for the

circadian rhythm sleep-wake disorders

 Evaluate and manage patients with chronic insomnia disorder

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 Recognize neurologic patients who are at increased risk of primary sleep disorders

 Recognize the presentations and treatments of common pediatric sleep issues and when to

refer a patient to a pediatric sleep specialist

 Discuss the use of rapid eye movement (REM) sleep behavior disorder as a defense by the

accused in a criminal trial

 Provide patients with evidence-based recommendations on approaches to improve their sleep

health behaviors to maximize their sleep quality and sleep health

Core Competencies
This Continuum: Lifelong Learning in Neurology Sleep Neurology issue covers the following

core competencies:

 Patient Care

 Medical Knowledge

 Practice-Based Learning and Improvement

 Interpersonal and Communication Skills

 Professionalism

 Systems-Based Practice

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Contributors

Charlene Gamaldo, MD, FAAN, FAASM, Guest Editor

Professor, Vice-Chair, Faculty Development, Department of Neurology, Johns Hopkins
University School of Medicine, Baltimore, Maryland
Relationship Disclosure: Dr Gamaldo has served on the board of directors for the American Academy of Neurology,
has received personal compensation as a consultant for Jazz Pharmaceuticals, Inc, and has received publishing
royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Gamaldo reports no disclosure.

Sabra M. Abbott, MD, PhD

Assistant Professor of Neurology, Northwestern University Feinberg School of Medicine,
Chicago, Illinois

Relationship Disclosure: Dr Abbott has received personal compensation for serving as a member of the American
Board of Internal Medicine’s Sleep Medicine Exam Writing Committee, research/grant support from the American
Sleep Medicine Foundation (155-JF-16), and publishing royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Abbot discusses the unlabeled/investigational use of
melatonin for the treatment of circadian rhythm sleep-wake
disorders.

Sara E. Benjamin, MD
Clinical Associate, Instructor in Neurology, Johns Hopkins University School of Medicine,
Baltimore, Maryland

Relationship Disclosure: Dr Benjamin has received personal compensation for a grand rounds presentation for
Mercy Medical Center; as a narcolepsy agent formulary review consultant for OptumRx, Inc; and for occasional
surveys for BioPharm, Compass, Inc, Everyday Health Group, GLG, InCrowd, Inc, J Reckner Associates, Inc, M3
Global Research, Olson Research Group, Research Now Group, LLC, Schlesinger Group, and WebMD, LLC.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Benjamin reports no disclosure.

Diego Garcia-Borreguero, MD, PhD

Medical Director, Sleep Research Institute, Madrid, Spain
Relationship Disclosure: Dr Garcia-Borreguero has received grant support from Merck & Co, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Garcia-Borreguero reports no disclosure.

Celia Garcia-Malo, MD
Specialist in Neurology, Sleep Research Institute, Madrid, Spain
Relationship Disclosure: Dr Garcia-Malo has received grant/research support from Accord Healthcare and the
International RLS Study Group.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Garcia-Malo reports no disclosure.

Michael J. Howell, MD, FAAN

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Vice-Chair, Education, Department of Neurology, University of Minnesota, Minneapolis,
Minnesota
Relationship Disclosure: Dr Howell has received personal compensation for serving as an editor for MedLink
Corporation, as a speaker for the American Academy of Dental Sleep Medicine, and as a speaker and consultant for
the Sleep Performance Institute. Dr Howell has received grant support from the National Institute of Neurological
Disorders and Stroke (1R01NS110613-01) and publishing royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Howell discusses the unlabeled/investigational use of
clonazepam for the treatment of rapid eye movement sleep behavior disorder.

Joseph S. Kass, MD, JD, FAAN

Associate Dean, Office of Student Affairs; Professor of Neurology, Psychiatry, and Medical
Ethics; Director, Alzheimer’s Disease and Memory Disorders Center, Baylor College of
Medicine; Chief of Neurology, Ben Taub General Hospital, Houston, Texas
Relationship Disclosure: Dr Kass serves as associate editor of medicolegal issues for Continuum, as an associate
editor for Continuum Audio, as a neurology section editor of Ferri’s Clinical Advisor for Elsevier, and as co-editor
of Neurology Secrets, Sixth Edition. Dr Kass has received personal compensation for CME lectures from Pri-Med
LLC and as a principal investigator for clinical trials for Alzheimer disease from Biogen, Eisai Co, Ltd, Eli Lily and
Company, National Institutes of Health, Novartis AG, and Roche Diagnostics.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Kass reports no disclosure.

Douglas B. Kirsch, MD, FAAN

Medical Director, Sleep Medicine, Atrium Health, Charlotte; Clinical Professor, UNC School of
Medicine, Chapel Hill, North Carolina
Relationship Disclosure: Dr Kirsch has served as president of the American Academy of Sleep Medicine and
receives publishing royalties from Elsevier and UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Kirsch reports no disclosure.

Amy Licis, MD, MSCI

Associate Professor, Department of Neurology, Washington University School of Medicine in
St. Louis, St. Louis, Missouri
Relationship Disclosure: Dr Licis has received personal compensation for serving as a moderator for Pediatric
Update.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Licis discusses the unlabeled/investigational use of
medications, none of which are approved by the US Food and Drug Administration for pediatric use except for
sodium oxybate and amphetamines for the treatment of narcolepsy.

Raman K. Malhotra, MD, FAAN

Associate Professor, Department of Neurology, Washington University School of Medicine, St.
Louis, Missouri
Relationship Disclosure: Dr Malhotra has received personal compensation for serving on the board of directors for
the American Academy of Sleep Medicine and as a speaker for a boards review course for the American College of
Chest Physicians.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Malhotra reports no disclosure.

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Jason C. Ong, PhD
Associate Professor, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Relationship Disclosure: Dr Ong has served on the board of directors for the Society of Behavioral Sleep Medicine;
on the medical advisory boards for the Hypersomnia Foundation, the Narcolepsy Network, and Wake Up
Narcolepsy, Inc; and on the editorial boards for Behavioral Sleep Medicine, the Journal of Clinical Psychology, and
SLEEP and has received personal compensation for serving as a consultant for Headspace, Inc. Dr Ong has received
grant/research support from the American Academy of Sleep Medicine, Harmony Biosciences, LLC, the National
Institutes of Health (K23AT003678, R21NS081088, R01HL114529, and R3AT009551), and Wake Up Narcolepsy
and publishing royalties from the American Psychological Association.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Ong reports no disclosure.

Sofi a Romero Peralta, MD

Sleep Research Institute, Madrid; Sleep Unit, Respiratory Department, Hospital Universitario
Guadalajara, Guadalajara, Spain
Relationship Disclosure: Dr Romero Peralta reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Romero Peralta reports no disclosure.

Maria Nichole Perez, MD

Affiliate Faculty, The University of Texas at Austin, Dell Medical School, Austin, Texas
Relationship Disclosure: Dr Perez reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Perez reports no disclosure.

Rachel V. Rose, JD, MBA

Attorney, Rachel V. Rose Attorney at Law, PLLC; Affiliated Faculty, Baylor College of
Medicine, Houston, Texas
Relationship Disclosure: Ms Rose serves on the editorial board of BC Advantage and receives book royalties from
the American Bar Association.

Unlabeled Use of Products/Investigational Use Disclosure: Ms Rose reports no disclosure.

Rachel Marie E. Salas, MD, MEd, FAAN

Associate Professor, Director, Interprofessional Education and Interprofessional Collaborative
Practice for School of Medicine, Johns Hopkins University School of Medicine, Baltimore,
Maryland
Relationship Disclosure: Dr Salas has received grant/research support from the American Medical Association and
the Josiah Macy Jr Foundation and publishing royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Salas reports no disclosure.

Logan Schneider, MD
Staff Neurologist, Stanford/VA Alzheimer’s Research Center, Palo Alto; Affiliated Clinical
Assistant Professor of Sleep Medicine, Stanford Sleep Center, Redwood City, California
Relationship Disclosure: Dr Schneider has served as an editorial board member for Practical Neurology and Sleep
and Breathing and has received personal compensation for serving on the speakers’ bureau for Harmony
Biosciences, LLC, and Jazz Pharmaceuticals, Inc, and as a sleep health consultant for Alphabet Inc. Dr Schneider

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

has received research/grant support as a VISN 21 research fellow from the US Department of Veteran Affairs
Mental Illness Research, Education and Clinical Centers.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Schneider reports no disclosure.

Michael H. Silber, MBChB, FAAN

Professor of Neurology, Mayo Clinic College of Medicine and Science; Consultant Neurologist,
Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota
Relationship Disclosure: Dr Silber has served on the scientific and medical advisory board of the Restless Legs
Syndrome Foundation and as a book review editor for Sleep Medicine. Dr Silber has received publishing royalties
from Oakstone and UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Silber discusses the unlabeled/investigational use of
antidepressants, benzodiazepines, pramipexole, and topiramate for the management of non–rapid eye movement
parasomnias.

Lynn Marie Trotti, MD, MSc

Associate Professor of Neurology, Emory University School of Medicine, Atlanta, Georgia
Relationship Disclosure: Dr Trotti has served on the editorial boards for Current Sleep Medicine Reports, Journal of
Clinical Sleep Medicine, and Sleep and has received compensation/honoraria from the American Academy of
Neurology, the American Academy of Sleep Medicine, Associated Professional Sleep Societies, the Kentucky Sleep
Society, Medscape, Oakstone, and the Society of Behavioral Sleep Medicine and research/grant support from the
National Institutes of Health/National Institute of Neurological Disorders and Stroke (NS083748, NS111280, and
NS113912) and the American Academy of Sleep Medicine Foundation.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Trotti discusses the unlabeled/ investigational use of
modafinil/armodafinil, traditional psychostimulants, sodium oxybate, solriamfetol, pitolisant, lithium,
clarithromycin, antiepileptic medications (carbamazepine, valproate, phenobarbital, and phenytoin), and
methylprednisolone for the treatment of idiopathic hypersomnia or Kleine-Levin syndrome; antidepressants,
methamphetamine, and lisdexamfetamine for the treatment of narcolepsy; and pitolisant for cataplexy.

Phyllis C. Zee, MD, PhD

Benjamin and Virginia Boshes Professor in Neurology, Director, Center for Circadian and Sleep
Medicine, Chief, Sleep Medicine Division, Department of Neurology, Northwestern University
Feinberg School of Medicine, Chicago, Illinois

Relationship Disclosure: Dr Zee has received personal compensation for serving on scientific advisory boards for
Eisai Co, Ltd, Jazz Pharmaceuticals, Inc, and Koninklijke Philips NV; on the editorial board for Sleep Medicine; for
providing live and web-based CME lectures for Accredit Education, LLC, Impact Education, LLC, and WebMD
LLC; for providing research and educational programs for Eisai Co, Ltd, Jazz Pharmaceuticals, Inc, Koninklijke
Philips NV, Merck & Co, Inc, Pear Therapeutics, Inc, Sanofi-Adventis US LLC, and Takeda Pharmaceutical
Company Limited; and research/grant support from Apnimed, Harmony Biosciences, LLC, Jazz Pharmaceuticals,
Inc, Koninklijke Philips NV, and the National Institutes of Health (R01 HL140580-03, P01 AG011412-20,
UG3HL140144-02, R01 AG059291-01, R01HL141881-02, R01HL134015-04, R21DK 118503-02, and
R01HD097786). Dr Zee has received publishing royalties from Wolters Kluwer and has held stock in Teva
Pharmaceutical Industries Ltd.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Zee discusses the unlabeled/investigational use of
melatonin for the treatment of circadian rhythm sleep-wake disorders.

Self-Assessment and CME Test Writers

D. Joanne Lynn, MD, FAAN

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Associate Dean for Student Life, Clinical Professor of Neurology, The Ohio State University
College of Medicine, Columbus, Ohio

Relationship Disclosure: Dr Lynn has received book royalties from Lippincott Williams & Wilkins and has held
stock in Abbott Laboratories, AbbVie Inc, Amgen Inc, Bristol-Myers Squibb Company, CVS Health Corporation,
Express Scripts Holding Company, General Electric, Merck & Co, Inc, and Zimmer Biomet.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Lynn reports no disclosure.

James W. M. Owens Jr, MD, PhD

Associate Professor of Neurology, Adjunct Associate Professor of Pediatrics, University of
Washington School of Medicine, Seattle, Washington

Relationship Disclosure: Dr Owens has served as CME co-editor for Neurology and has received publishing
royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Owens reports no disclosure.

Methods of Participation and Instructions for Use

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay

abreast of advances in the field while simultaneously developing lifelong self-directed learning

skills. In Continuum, the process of absorbing, integrating, and applying the material presented is

as important as, if not more important than, the material itself.

The goals of Continuum include disseminating up-to-date information to the practicing

neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills;

encouraging critical thinking; and, in the final analysis, strengthening and improving patient

care.

Each Continuum issue is prepared by distinguished authors who are acknowledged leaders in

their respective fields. Six issues are published annually and are composed of review articles,

case-based discussions on ethical and practice issues related to the issue topic, coding

information, and comprehensive continuing medical education (CME) and self-assessment

offerings. For detailed instructions regarding Continuum CME and self-assessment activities,

visit continpub.com/CME.

The review articles emphasize clinical issues emerging in the field in recent years. Case reports

and vignettes are used liberally, as are tables and illustrations. Audio interviews with the authors

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

of Continuum articles are published alongside each article, and video material relating to the

issue topic accompanies issues when applicable.

The text can be reviewed and digested most effectively by establishing a regular schedule of

study in the office or at home, either alone or in an interactive group. If subscribers use such

regular and perhaps new study habits, Continuum’s goal of establishing lifelong learning patterns

can be met.

Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.