Section 5 Circadian Rhythm Disorders
A 22-year-old Man with Excessive Daytime Sleepiness
The patient is a 22-year-old man who recently graduated from Georgia Tech in Atlanta with an engineering degree. He presents to the clinic with severe excessive daytime sleepiness, which has resulted in poor work performance. He has a history of sleepiness dating back to his early teen years. Although the sleepiness has been present for about 6 years, it has gotten worse since he graduated and began working. To combat the sleepiness he drinks 8 to 10 high-caffeine energy drinks per day, mostly before noon. He reports that on weekends he feels “pretty alert” the rest of the day. When he lived at home his parents used to think he was lazy because on weekends he slept until 3 PM. However he was able to get good grades in school. His medical history is unremarkable. He has a history of depression, which is currently being treated with fluoxetine 20 mg hs. He has no history suggesting cataplexy or sleep paralysis.
A 68-year-old Woman with Early Morning Awakening
A 68-year-old woman presents to the clinic with a 5-year history of insomnia. Her final awakening is usually at 3:30 AM, at which time she becomes frustrated and cannot return to sleep. The problem with waking too early coincided with the death of her husband. She is 5 feet 3 inches and weighs 185 lb. She is unaware of snoring but does complain of fatigue in the daytime. Current medications include metoprolol 50 mg, esomeprazole 20 mg at bedtime, atorvastatin 10 mg at bedtime, trazodone 100 mg at bedtime. The patient denies depression but has occasional bouts of intense anxiety, especially in crowds and on airplanes.
Sleep latency = 4 minutes; total sleep time = 5 hours; sleep efficiency = 72%; apnea–hypopnea index = 8 events per hour; PLM arousal index = 3 per hour
No cardiographic or EEG abnormalities were seen. Based on these findings you should:
The 42-year-old Man Who Cannot Keep a Job
A 42-year-old man comes to the clinic with a complaint of an irregular sleep schedule. He was recently fired from work for tardiness. To assess his sleep–wake schedule, you ask him to wear an actigraph for 2 weeks. The results are shown in Figure 5–1.
A 12-year-old girl with insomnia and daytime sleepiness
A 12-year-old girl presents to the clinic with difficulty initiating and maintaining sleep as well as involuntary sleep episodes in school. The problem began about a year ago after she was the passenger in a car that was involved in a head-on collision. She suffered trauma to her head and was subsequently hospitalized for 2 weeks. Before the accident she was a good student without any sleep complaints. She has fully recovered from the accident and has only a small scar on her forehead from the head injury. Her mother thinks the sleep problem is somewhat due to hormonal changes associated with puberty. Actigraphy shows a highly variable sleep–wake schedule that is divided up into four short blocks throughout the day.
A Case of Hating the Night Shift
A 27-year-old women working a local hospital as a nurse began working a rotating shift about 6 months ago. Her rotation schedule was days to evenings to nights. Her schedule is to work three 12-hour days per week and then rotates to the next later shift. At first the new schedule was working out great for her family. Initially she had no trouble adapting to the rotating shift although she stated that the overnights were the hardest because she has to fight off sleepiness. After a few months of rotating she found it increasingly difficult to stay awake all night on the night shift. A coworker found her asleep in the nurse’s station recently, and now the patient is worried about losing her job.
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