Case Studies in Sleep Medicine

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.