Case Studies in Sleep Medicine
Case Study #1 • Case Study #2
Case Study #1 – Female Realtor, Age 37: Janet’s Insomnia Resolved
Lifestyle/Occupation: Divorced, no children. Commercial real estate professional.
Referred for: Problems initiating sleep.
Past Medical History: Depression, anxiety, back pain, allergic rhinitis, asthma.
Previous Surgical History: None.
Sleep History: Janet has difficulty falling asleep. Goes to bed 9:00-10:00 pm. Falls asleep 11-12 midnight. Rises at 7:15 am on workdays. On days off, she goes to bed at 11 pm, gets up at 9-10 am, although sometimes she can sleep until 2-3 pm. Mild, occasional snoring. Used to have restless legs prior to sleep onset, no restless legs now. Sleep talking 2-3 nights per week.
Frequent episodes of intense, vivid dreams. Mild to moderate daytime sleepiness, Epworth Sleepiness Scale Score: 12.
Medications: Zyrtec, Advair, albuterol, Rhinocort, Cymbalta, Skelaxin, Soma.
Physical Examination: Height: 70 inches Weight: 214 lbs. Body Mass Index (BMI): 30.7. Oropharynx: Uvula, soft palate visible, Class I dental occlusion.
Treatment History: Tried Lunesta, Ambien. Lunesta did not help. Ambien has helped but exacerbates daytime sleepiness. Currently taking Ambien CR 12.5 mg nightly 30 minutes before bedtime.
Initial Diagnostic Impression: Psychophysiological insomnia.
Diagnostic Evaluation: 1 week of ambulatory recording of sleep/wake patterns with wrist actigraphy. Wrist actigraphy is a wristwatch-like monitor that detects motion and provides a technology for long-term assessment of activity patterns that can be used to estimate sleep/wake cycles.
Findings: Actigraphy results were consistent with the patient’s history. Patient typically spent 9.5 hours in bed per night, sleeping 7 hours. Most of the wakefulness and increased motor activity was observed in the first two hours of the nightly sleep period.
Treatment Plan: Cognitive behavioral therapy for insomnia.
Treatment Goals: 1) Reduce sleep onset latency to less than 30 minutes. 2) Improve “sleep efficiency,” calculated as the amount of sleep time over time in bed to greater than 85%. 3) Reduce or eliminate need for sedative hypnotic medications.
Estimated number of visits: 3-6.
Interventions: Sleep restriction therapy: Go to bed no earlier than 11:30 pm, wake up no later than 7:30 am. No daytime naps. Read Dr. Gregg Jacobs’ book, “Say Goodnight to Insomnia,” behavioral self-help guide for sleep problems. Morning exercise program 4 days a week. Morning light exposure 30 minutes per day, avoid UV overexposure. Relaxation training exercise CD to facilitate sleep onset. Total number of visits: 3.
Outcomes: Patient reports that self-monitoring helped her learn that her habit of compulsive listmaking contributed to high arousal levels at night and interfered with sleep onset. Goes to bed at 11:30 pm. Up every day before 7:30 am. Exercises 4 days a week, lost 10 lbs.
Sleep efficiency has improved to 88%, sleep latency 20 minutes or less. Discontinued nightly use of Ambien CR,
now uses it twice a month as needed. Mood improved.
Results: Insomnia resolved with short-term cognitive behavioral therapy. Nightly use of benzodiazepine agonist therapy discontinued, now uses only rarely as needed.
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Case study #2 – Male, Age 51: Albert’s Apnea Ended
Lifestyle/Occupation: Married, one son. Electronics sales professional.
Referred for: Loud snoring and nonrestorative sleep.
Past Medical History: Hypertension, hypercholesterolemia, seasonal allergies.
Previous Surgical History: None.
Sleep History: Albert reports excessive daytime sleepiness. He reports feeling “very sleepy in the afternoon, unable to stay awake after lunch, feeling groggy when I wake up, I don’t sleep well.” He reports a history of snoring, loud enough to disrupt domestic tranquility. His wife does not report observing apneic episodes during his sleep but he has, on occasion, awakened choking and gasping. He awakens frequently and gets up to urinate twice a night. He naps daily but does not feel refreshed. He has had some difficulty maintaining alertness during meetings and is concerned that his productivity at work has gradually fallen off over the past two years. On workdays he goes to bed at midnight and gets up at 8:30 am. On weekends he usually goes to bed at 12:30-1 am, and sleeps until 9:30-10:00 am. Epworth Sleepiness Scale score is 16, consistent with moderately severe excessive daytime sleepiness.
Medications: Benicar, Amlodipine, Lipitor, Rescon-MX, alprazolam, aspirin.
Physical Examination: Height: 72 inches, Weight: 208 lbs. Body Mass Index (BMI): 28.2 (mildly overweight). Oropharynx: uvula, soft palate not visible without use of tongue depressor (Mallampati palate position Class III), Class I dental occlusion.
Treatment History: Used alprazolam intermittently to facilitate sleep onset and maintenance, finds that he falls asleep more readily with alprazolam but still wakes up tired. Has gained 20 lbs. in the past five years; trying to lose weight but no success.
Initial Diagnostic Impression: History and symptoms strongly suggestive of obstructive sleep apnea.
Diagnostic Evaluation: One overnight polysomnography, first segment diagnostic evaluation, second segment CPAP trial.
Findings: No apneas and 56 hypopneas were observed in the diagnostic portion of the recording, yielding an Apnea + Hypopnea Index (AHI) of 48.9/hour, consistent with severe obstructive sleep apnea. O2 desaturations to 83% were observed. Apneas, hypopneas, snoring and arousals were relieved with CPAP at 8 cm H2O.
Treatment Plan: CPAP at 8 cm H2O, with a heated humidifier and nasal mask.
Treatment Goals: 1) Improve daytime alertness. 2) Improve sleep continuity, reduce nighttime awakenings. 3) Reduce or eliminate need for benzodiazepine medication (alprazolam) to facilitate sleep onset. 4) Reduce risk for cardiovascular morbidity.
Outcomes: Sleep continuity greatly improved with CPAP at 8 cm H2O. Sleep efficiency (sleep time over time in bed) = 96.2%. No apneas or hypopneas observed with CPAP at 8 cm H2O. Snoring abolished. O2 saturation averages 97.8%. No O2 desaturations below 96%. Patient rates the quality of his sleep as “good,” reports feeling more rested than usual upon awakening with CPAP. Patient reports improved alertness, “feels great” upon awakening in the morning with CPAP. Sleeps through the night. No more nighttime awakenings. Discontinued use of alprazolam. No snoring with CPAP. Spouse’s sleep improved. Marital harmony restored. Concentration, productivity at work improved.
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Chapter 5: Circadian Rhythm Sleep Disorders
John, a 17-year-old high school student, was referred to the sleep center with the complaint of not being able to fall asleep.
Patient History and Examination
History of Previous Illness: John reports a history of difficulty falling asleep at night that has been present from grade school but has drastically worsened during the past 2 years. He has always been a "night owl" and throughout grade school would resist his bed time and have difficulty waking up in the morning. He was often caught reading in bed with a flashlight after "lights out."
Past Medical History: None significant.
Social History: John was a competent student until about 2 years ago, at which point his grades began to decline. When awakened by his parents, John gets to school on time but falls asleep in his morning classes. If left asleep, he does not awaken until around 1:00 PM and then does not bother to go to school. John is currently on the verge of being expelled from school due to frequent unexplained absences.
Family History: Patient’s father had a similar behavior pattern at John's age.
Review of Sleep Pattern: Typically, John does not fall asleep until 5:00 AM. He sleeps deeply until 7:00 AM, when his parents awaken him for school. His parents report he often surfs the Internet until after 2:00 AM.
Evaluation and Diagnosis
After ruling out other sleep disorders (e.g., sleep-onset insomnia associated with psychological issues) and reviewing a 2-week sleep diary, the patient was diagnosed with delayed sleep-phase disorder.
Treatment and Follow-up
The patient was instructed to get up regularly at noon and undergo 45 minutes of "light therapy" by going outside without sunglasses. In addition, 3 mg of melatonin was prescribed to be taken at 1:00 AM. John was further advised to limit his exposure to bright light after 4:00 PM by wearing wrap-around sun glasses. Each week, the bright light therapy and the melatonin were prescribed to be taken 1 hour earlier until an acceptable wake-up time was achieved (for John, this was 9:00 AM). John’s class schedule was rearranged so that he would start classes in the afternoon and would end the day with a private tutor for the classes he missed in the morning. This tutor would be phased out as John’s wake time advanced. Using this approach, John was able to graduate 6 months after his classmates.
Currently (5 years after starting treatment), John gets up at 10:00 AM for 30 minutes of outdoor light therapy. He works an afternoon/evening job and takes night classes at a local college. He still struggles occasionally with his delayed sleep phase disorder, especially when he does not get light therapy for a few days or when he stays out late on the weekend.