Advanced sleep phase syndrome (ASPS)

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Family Medicine

Family Medicine 03: 65- year-old woman with insomnia

Author:Author: William Hay, MD; Associate Editor: Martha P. Seagrave RN, PA-C; Case Editor: William Hay, MD

INTRODUCTION HISTORY

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

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You meet with Dr. Lee during your afternoon clinic to discuss your nextYou meet with Dr. Lee during your afternoon clinic to discuss your next patient.patient.

!

You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”

Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”

Question What are common causes of insomnia in the elderly?

The suggested answer is shown below.

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Letter Count: 0/1000

SUBMITSUBMIT

Answer Comment Common causes of insomnia in the elderly:

1. Environmental problems 2. Drugs/alcohol/caffeine 3. Sleep apnea 4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder 5. Disturbances in the sleep-wake cycle 6. Psychiatric disorders, primarily depression and anxiety 7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure) 8. Pain or pruritus 9. Gastroesophageal reflux disease (GERD) 10. Hyperthyroidism 11. Advanced sleep phase syndrome (ASPS)

Common Causes of Insomnia in the Elderly

TEACHING POINTTEACHING POINT

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Common Causes of Insomnia in the Elderly

1. Issues that may lead to an environment that is notenvironment that is not conducive to sleepconducive to sleep.

Specific examples include: noise or uncomfortable bedding. You can teach the patient sleep hygiene techniques that will

increase the likelihood of a restful night’s sleep.

2. The use of prescription, over-the-counter, alternative,prescription, over-the-counter, alternative, and recreational drugsand recreational drugs might affect sleep.

Patients should be counseled to avoid caffeine and alcoholavoid caffeine and alcohol for four to six hours before bedtime.for four to six hours before bedtime.

3. Sleep apneaSleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

4. In restless leg syndromerestless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.

5. In periodic leg movementperiodic leg movement and REM sleep behaviorREM sleep behavior disorderdisorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.

As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.

6. Disturbances in the sleep-wake cycleDisturbances in the sleep-wake cycle include jet lag and shift work.

7. Patients with depression and anxietydepression and anxiety commonly presenthttp://www.aafp.org/afp/2015/1215/p1058-s1.html

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with insomnia.

Any patient presenting with insomnia should be screened for these disorders.

8. Patients with shortness of breath due to cardiorespiratorycardiorespiratory disordersdisorders often report that these symptoms keep them awake.

9. Pain or pruritusPain or pruritus may keep patients awake at night.

10. Those with GERDGERD may report heartburn, throat pain, or breathing problems.

These patients may also have trouble identifying what awakens them.

Detailed questioning may be needed to elicit the symptoms of this disorder.

11. Elderly patients with hyperthyroidismhyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.

12. Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phaseadvanced sleep phase syndrome (ASPS)syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.

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