Keywords

Case 1: Difficulty Staying Asleep

A 52 -year-old woman presents with a history of difficulty maintaining sleep. She reports that symptoms have been present since the birth of her first child when she was 35; however, they have worsened since menopause started 2 years ago.

Sleep Routine

Weekdays:

  • Bedtime: She typically is able to fall asleep easily around 10 pm.

  • Number of awakenings – She finds herself waking up approximately every 2 hours.

  • Wake after sleep onset – Earlier in the evening, she is able to fall back to sleep within about 10 minutes; however, on most nights she will wake up around 3 am, and it will take her at least 2 hours to fall back to sleep. Some mornings she does not fall back to sleep at all, and will eventually just give up and get up for the day.

  • Wake up time – On weekdays her alarm is set for 6 am, though she typically is awake before the alarm goes off.

On weekends, she notes that she is often exhausted.

  • Bedtime – falls asleep on the couch around 9 pm.

  • Wake up time – stays in bed until 8 am in order to get more sleep, however feels like she is generally just tossing and turning, and not actually sleeping for the last 2–3 hours. If she is unable to sleep, she will generally just lay in bed trying to relax and make herself fall back to sleep.

Initial sleep logs are provided in Fig. 2.1.

Fig. 2.1
figure 1

Example sleep log from case 1, prior to initiating treatment. Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. A = alcohol, C = caffeine

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She reports daytime sleepiness, with an Epworth Sleepiness Scale score of 12.

She drinks two cups of coffee in the morning, nothing after noon. She works full time, so generally does not have time to nap, and is not aware of whether she would be able to fall asleep if she did try. She notes that she used to enjoy exercising, but has been finding it harder to motivate herself to do it recently. She has gained ~20 pounds in the past year, which she attributes to a combination of decreased exercise and poor diet choices.

Past Medical History

  • Hypertension

  • Occasional migraine headaches

  • Seasonal allergies

Past Surgical History

  • None

Allergies

  • None

Medications

  • Metoprolol

  • Multivitamin

Family History

  • Insomnia in her mother, and sleep apnea in her father.

  • She also notes that she comes from a family of “early birds.”

Social History

  • Two glasses of wine/night, one with dinner, and one while reading before bed.

Review of Symptoms

  • Mild snoring

  • Occasional morning headaches

Vital Signs

Blood pressure:

120/80 mmHg

Heart rate:

70/minute

Respiratory rate:

14/minute

BMI:

29 kg/m2

Physical Examination

She has mild nasal congestion and a Mallampati III airway.

Neck circumference is 16 inches.

Rest of the exam was unremarkable.

Differential Diagnosis

  • Chronic Insomnia

  • Obstructive sleep apnea

  • Untreated depression

  • Advanced sleep wake phase disorder

Assessment

At this point, she presents with symptoms of chronic insomnia, with difficulty maintaining sleep, and waking up earlier than desired that have been present for greater than 3 months. Initial precipitating factors appear to be the birth of her son, with perpetuating factors including spending excessive amount of time in bed on weekends to try to “catch up” sleep. However in addition to the typical symptoms of insomnia, she has several other factors that merit further evaluation. First, she does note excessive daytime sleepiness, snoring, and morning headaches in the context of recent weight gain, and is now post-menopausal, so it is possible that untreated sleep apnea may be contributing to her difficulty maintaining sleep. Many women also experience an increase in insomnia symptoms following menopause. In addition, she recently started taking metoprolol , which can be associated with sleep difficulties. She also notes a loss of interest in activities that she previously enjoyed, so it will be important to explore whether untreated depression is contributing to her symptoms. She also notes alcohol intake immediately prior to bed, which could be causing rebound insomnia. Finally, she does note that she comes from a family of “early birds” so it is important to consider whether her difficulty with sleep maintenance may be secondary to advanced sleep-wake phase disorder.

Management

The patient was counselled to get into bed when sleepy (rather than falling asleep on the couch), to not stay in bed if she is unable to sleep, to maintain consistent sleep-wake times on work days and non-work days. In addition, she was advised to limit alcohol intake before bedtime. Additional screening for depressive symptoms with the Patient Health Questionnaire (PHQ-9) showed a score of only 4, suggesting a low likelihood for major depression. On discussion with her primary care doctor, she was switched from metoprolol to lisinopril for her blood pressure control. She was also referred for home sleep apnea testing, with the results shown in Fig. 2.2.

Fig. 2.2
figure 2

Example sleep log from case 1 after limiting alcohol intake and working to make sleep-wake times more consistent. Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. C = caffeine

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As the home sleep apnea testing indicated mild sleep apnea (AHI = 12) and the patient has hypertension and daytime sleepiness, she was started on CPAP. At a follow-up visit 1 month after initiating PAP therapy, she notes significant improvement in her daytime sleepiness, and a decrease in some of her middle of the night awakenings, however continues to find it difficult to fall back to sleep after 3 am, noting that after that time she found herself lying awake with racing thoughts. She was referred for cognitive behavioral therapy for insomnia (CBT-I) and sleep logs from that initial appointment are presented in Fig. 2.3.

Fig. 2.3
figure 3

Example sleep log from case 1 after initiating therapy for obstructive sleep apnea . Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. C = caffeine

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Based on her sleep logs demonstrating a slightly earlier bedtime after being instructed to get into bed when sleepy, and her reported family history, there was concern for a component of advanced sleep-wake phase disorder contributing to her early morning awakenings. Evening bright light therapy was recommended. However, in addition, she did also report times of lying awake in bed with racing thoughts, so was also instructed on strategies for stimulus control and scheduled worry. Sleep logs from 2 months later are shown in Fig. 2.4.

Fig. 2.4
figure 4

Example sleep log from case 1 after initiating evening bright light therapy and cognitive behavioral therapy for insomnia . Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. L = light, C = caffeine

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Case 2: Difficulty Falling Asleep

A 25-year-old man who was referred to the sleep clinic by his human resources department at work, due to sleep problems. He reports that he first noted difficulty with his sleep when he started his first job after graduating from college, which required him to be at work by 8 am every morning. He needs to get up for work at 6 am on weekdays, so will try to get into bed by 10 pm. It will typically take several hours to fall asleep, and he has found himself getting increasingly more anxious about getting into bed at night because he finds it so challenging to fall asleep. Once he finally does fall asleep, he notes that he sleeps “too well” having slept through his alarm several times, resulting in difficulty making it to work on time, resulting in disciplinary action. In the past, he has been prescribed several hypnotics to try to help him fall asleep more easily, including zolpidem and trazodone . While they do make it slightly easier to fall asleep, they have not helped with his difficulty sleeping through his alarm. On weekends he will frequently stay out with his friends, going to bed between 2 and 4 am, and notes that it is much easier to fall asleep on those nights. He will typically wake up between 11 am and noon and generally feels refreshed. He does not typically nap on weekends, though will sometimes fall asleep for 1–2 hours after getting home from work.

Sleep Routine

Weekdays:

  • Bedtime – 10:00 pm

  • SOL – several hours

  • wake up time – 6 am, with an alarm

Weekends:

  • Bedtime – 2:00 am and 4:00 am

  • SOL – less than 30 minutes

  • wake up time – 11:00 am to 12:00 pm

On further history, he notes that he may have had similar problems with his sleep during college, but was able to adapt to this. During his first semester of school, he failed out of an 8 am class because he slept through too many of the lectures. However for the rest of his undergraduate time, he was able to schedule classes that started later in the day, and did well in his classes. During this time, he would typically sleep from 2 am to 10 am without difficulty.

Review of Symptoms

  • Denies snoring, witnessed apneas or symptoms of restless legs syndrome.

Past Medical History

  • Mild depression

Medications

  • None now, though he has tried several hypnotics in the past.

Family History

  • Similar sleep problems in his older brother. His father is a shift worker, and has always preferred to work third shift, so primarily sleeps during the daytime.

Physical Examination

Vital signs – stable.

BMI of 22 kg/m2.

He has a Mallampati I airway.

Neck circumference is 14 inches.

Differential Diagnosis

  • Delayed sleep wake phase disorder

  • Sleep initiation insomnia

  • Comobid anxiety

  • Central hypersomnia

  • Obstructive sleep apnea

Assessment

At this point, the patient is presenting with symptoms of difficulty with sleep initiation and anxiety related to bedtime. More concerning, he also has difficulty waking up in time for work, resulting in disciplinary action and concerns about his ability to be able to maintain his job. The early morning sleepiness could raise concerns for an underlying disorder of hypersomnia, though he has minimal risk factors for obstructive sleep apnea, and denies any symptoms to suggest a diagnosis of narcolepsy. More importantly, when allowed to sleep during his preferred schedule he denies any sleep complaints. Of note, his family history suggests similar symptoms in his brother, and possibly his father who has self-selected for a third shift position, working at night and sleeping during the daytime. As the primary concern at this point is for delayed sleep-wake phase disorder, the patient was instructed to complete 2 weeks of sleep logs, shown in Fig. 2.5.

Fig. 2.5
figure 5

Example sleep log from case 2, prior to initiating treatment. Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. A = alcohol, C = caffeine

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Management

Based on the clinical history and actigraphy results, the patient was diagnosed with delayed sleep-wake phase disorder, and was given instructions to take a low dose of melatonin and avoid bright light exposure in the evening, in conjunction with morning bright light therapy to gradually advance his sleep-wake schedule. In addition, after discussion of his diagnosis with his work place, he was able to arrange for a more flexible start time. On initial follow-up, while he was able to fall asleep and wake up earlier, he was still experiencing significant anxiety related to bedtime, given his history of difficulty falling asleep in the past. He was referred for cognitive behavioral therapy for insomnia , with significant improvement in his bedtime anxiety. He is now able to sleep from midnight to 8 am and is working from 10 am to 7 pm. His productivity at work has improved significantly, and both he and his employer are pleased with his progress. Figure 2.6 demonstrates the response to treatment.

Fig. 2.6
figure 6

Example sleep log from case 2, demonstrating the use of light and melatonin to advance (week 1) and then stabilize (week 2) the sleep-wake schedule at the desired time. Black shaded boxes indicate subjective reports of sleep time. Down arrows indicate the time of getting into bed, and up arrows indicate the time of getting out of bed. A = alcohol, M = melatonin

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Discussion

For most individuals, the symptoms of insomnia are likely multifactorial and require evaluation of multiple factors that may be contributing to the inability to all asleep and stay asleep. A flow chart demonstrating a general approach to insomnia symptoms is presented in Fig. 2.7.

Fig. 2.7
figure 7

Flow chart demonstrating the process for evaluating a patient with symptoms of insomnia

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As a first step in evaluating patients with insomnia, it is important to screen for the presence of daytime sleepiness. While many patients with insomnia will present with symptoms of daytime fatigue related to difficulty sleeping, the classic description is of someone who is “tired but wired” who would love to be able to nap, but is unable to fall asleep when given the opportunity. The presence of actual daytime sleepiness raises the question of whether additional sleep disorders may be present, with the most common being obstructive sleep apnea . In addition, patients with narcolepsy can present with fragmented nocturnal sleep, in addition to the more classic daytime symptoms of sleep attacks and cataplexy. Patients should also be screened for symptoms of restless legs syndrome, as this can exacerbate difficulties with sleep initiation, and associated periodic limb movements of sleep can potentially disrupt the ability to stay asleep [1].

In patients with insomnia who do not also present with daytime sleepiness, the next step will be to screen for other precipitating factors. A careful history should be taken of daytime behaviors, including caffeine and alcohol intake, exercise (regularity, proximity to bedtime), and bedtime behaviors. All patients should be counseled on good sleep hygiene, including maintaining regular sleep-wake times, avoiding the use of electronics or bright light prior to bedtime, limiting caffeine and alcohol intake prior to bedtime and making sure the bedroom is a cool quiet environment conducive to sleep. In addition, medications should be reviewed, with attention particularly given to those the timing of administration of sedating and alerting medications. In case 1 the patient was taking a beta-blocker, which has been demonstrated to be associated with poor sleep quality, though at least in part to be related to suppression of melatonin production. A small study has demonstrated that administration of a low dose of melatonin at bedtime can improve sleep quality in these individuals [2]. However, in our patient the addition of evening melatonin in a patient who may also have comorbid advanced sleep-wake phase disorder can potentially result in even further phase advances, so the decision was instead made to switch her to an alternate anti-hypertensive.

As demonstrated in both cases, it is important for all patients with insomnia to screen for the presence of circadian rhythm disorders , which may contribute to overall symptoms. Up to 10% of patients presenting to the sleep clinic with complaints of insomnia actually have delayed sleep-wake phase disorder [3]. In the clinical history, it will be important to ask about factors such as duration of symptoms. Patients with ASWPD and DSWPD will often note sleep patterns that have been present since childhood, and will also frequently note a family history of symptoms [4, 5]. In addition, questioning patients about their preferred sleep habits while on vacation or otherwise during times where they have no time obligations can be insightful. A patient with a circadian rhythm sleep-wake disorder may have much less difficulty sleeping when allowed to sleep at their preferred times, but will develop symptoms of insomnia when required to sleep at conventional times. Sleep logs and/or actigraphy can be useful for helping to distinguish individuals with a circadian disorder. In addition, while not readily available, other measures of circadian timing such as salivary dim light melatonin onset can also be useful in distinguishing patients with a circadian rhythm disorder [3]. It is also important to recognize that while the focus of treatment for the CRSWDs is primarily on adjusting circadian timing, many of these individuals will also have developed primary insomnia symptoms, and may also benefit from elements of cognitive behavioral therapy for insomnia , including stimulus control and sleep restriction, with a focus on centering their sleep window around their optimal circadian time for sleep.

Another important factor to consider is the role of depression/anxiety in the presentation of insomnia. Early morning awakenings are a common presenting symptom of depression, and the severity of insomnia often correlates with the severity of depression. In turn, insomnia can be associated with worsening depressive symptoms, with severe insomnia having demonstrated to be an independent risk factor for suicide [6]. Similarly among patients with insomnia, 13% report symptoms consistent with generalized anxiety disorder [7]. Cognitive behavioral therapy for insomnia can be effective at treating the sleep symptoms in comorbid insomnia, and in some cases has also been demonstrated to improve some depressive symptoms [8].

Finally, once other comorbid factors have been addressed, one can move to focusing on addressing the primary insomnia symptoms. Current recommendations are to focus on cognitive behavioral therapy for insomnia . If medications are included in a treatment regimen, treatment should focus on the specific characteristics of the patient’s insomnia (e.g., difficulties with sleep initiation vs. maintenance) and the presence of any comorbid conditions, as this can guide treatment selection. Based on weighing risks and benefits, the American Academy of Sleep Medicine currently recommends the use of either suvorexant, benzodiazepine receptor agonists (eszopiclone, zaleplon or zolpidem), benzodiazepines (triazolam or temazepam), ramelteon, or doxepin. They advise against the use of trazodone, tiagabine, diphenhydramine, melatonin, l-tryptophan, or valerian as a primary treatment for insomnia [9].

Overall, it is important to recognize that the approach to insomnia must be individualized. While CBT-I is often an effective component of treatment for individuals with difficulty falling and staying asleep, it is also important to evaluate and address other factors that may be contributing to a patient’s symptoms.

Key Points

  • Sleep disorders are often multifactorial. Even if the primary presenting complaint is insomnia, it is important to evaluate for other factors that may also be impacting a patient’s sleep

  • Up to 10% of patients presenting to a clinic with complaints of insomnia may have delayed sleep-wake phase disorder