WBR0432

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D. and Alison Leibowitz [1])]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pharmacology
Sub Category	SubCategory::Neurology
Prompt	[[Prompt::An 72-year-old man presents to the emergency department with a fractured hip following a fall. His daughter states that the patient has fallen twice in the past 3 days. The patient then explains that prior to his symptoms, he could not sleep for the past 8 days, and his neighbor has been giving him left-over benzodiazepine (BZD) pills each day to help him sleep. The patient states that ever since he started taking the new pill, he has been sleepy and dizzy throughout the day. Which of the following BZDs has this patient been receiving?]]
Answer A	AnswerA::Flurazepam
Answer A Explanation	[[AnswerAExp::Flurazepam is a long-acting BZD that is associated with daytime residual effects that may include frequent falls, dizziness, and impaired balance and coordination.]]
Answer B	AnswerB::Alprazolam
Answer B Explanation	[[AnswerBExp::Alprazolam is an intermediate-acting BZD.]]
Answer C	AnswerC::Triazolam
Answer C Explanation	[[AnswerCExp::Triazolam is a short-acting BZD.]]
Answer D	AnswerD::Oxazepam
Answer D Explanation	[[AnswerDExp::Oxazepam is an intermediate-acting BZD.]]
Answer E	AnswerE::Midazolam
Answer E Explanation	[[AnswerEExp::Midazolam is a short-acting BZD.]]
Right Answer	RightAnswer::A
Explanation	[[Explanation::Insomnia is a common sleep problem characterized by insufficient or non-restorative sleep. It is classified by duration as either transient/short-term (duration less than 3 weeks) or chronic/long-term (duration more than 3 weeks). Short-term insomnia is most commonly caused by an identifiable stressor, such as examinations, loss of loved ones, pain, or drugs. In contrast, long-term insomnia requires more elaborate work-up to identify possible underlying diseases, substance abuse, or psychological disorders. Benzodiazepines (BZD) have demonstrated significant anxiolytic and hypnotic properties when used for a short period of time, and they are currently approved for the treatment of anxiety, panic disorders, insomnia, muscular spasms, and some forms of epilepsy. Short-acting BZD are often used to treat patients with insomnia to help initiate sleep with no daytime residual effect. In contrast, long-acting BZD may have a more delayed onset of action and may be associated with daytime residual effect, which may cause patients to experience daytime sleepiness, dizziness, imbalance, and frequent falls. Accordingly, this patient in this vignette has most likely been given long-acting BZD to treat his insomnia and has been experiencing daytime residual effects: Long-acting BZDs include: Diazepam, clonazepam, nitrazepam, flurazepam, chlordiazepoxide, clorazepate, prazepam, and halazepam Short- and intermediate-acting BZDs include: Alprazolam, triazolam, oxazepam, midazolam, lorazepam, and temazepam Educational Objective: Long-acting BZDs, such as diazepam, clonazepam, nitrazepam, and flurazepam, are associated with daytime residual effects, such as frequent falls, impaired balance and coordination, and dizziness. References: Gillin JC, Byerley WF. The diagnosis and management of insomnia. N Engl J Med. 1990;322(4):239-48. First Aid 2014 page 492]]
Approved	Approved::Yes
Keyword	WBRKeyword::Benzodiazepine, WBRKeyword::Flurazepam, WBRKeyword::Side effect, WBRKeyword::Falls, WBRKeyword::Adverse effect, WBRKeyword::Daytime residual effect, WBRKeyword::Insomnia, WBRKeyword::Sleepiness, WBRKeyword::Hip fracture
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::