Mosopefoluwa Smith
HLTD22: Special topics in Health (Sleep)
Professor Mollayeva
August 8th, 2021
Abstract
Sleep studies has increasingly grasped the attention of scientist and researchers. Good quality sleep is part of the fundamental Advanced Sleep Phase disorders presents itself in form of tiredness early in the evening and early morning awakenings. This is more prevalent in adult populations and may represent an extreme of normal advancement of circadian rhythm that occurs with aging. For this current case study, we are presented with a 70-year-old man who complains of early morning awakening. He complained of finding it difficult to stay up late and sleep disruptions at night caused by nocturia. Asides these symptoms he notes the use of diuretic to treat hypertension and no other medications being used. The patient specifies that the problem has worsened since his retirement, when he wakes up intermittently at night (between midnight and 2am) due to nocturia, he is able to fall back asleep quickly but afterwards he wakes up spontaneously between 4am and 5am and is unable to fall back to sleep. The patients age and complain about early morning awakening are two factors that are plausible indicators of advanced sleep phase disorder. This disorder is common amongst older adults as we know, also the patient he wakes up more than twice per night to use the bathroom and this will disrupt the sleep.
Introduction
Good quality sleep is necessary for efficient functioning, poor sleep affects us in many ways including psychologically and physically. For us to get good quality sleep, it is important to know the major process that regulates sleep. Sleep is regulated by the interaction between homeostatic and the endogenous circadian process(citation). The homeostatic process is regulated based on prior wakefulness (therefore, the longer you stay awake the deeper your next sleep) the circadian factor plays a key role in sleep quantity and is usually determined by the time an individual goes to bed. These two processes show us the importance of being awake for a solid amount to time for us to get the best quality of sleep and the importance of falling asleep at a good time (bedtime) to enable to have a stable sleep cycle and duration. In this case study, the patient (a 70-year-old man) is reporting symptoms like feeling sleepy early in the evening and awakening as early as 5am with disruptions during his sleep, either to urinate(nocturia) or inability to continue in his state of sleep. Nocturia (sleep disruption from having to urinate more than once or twice each night) affects most people above the age of 30 and the rate of people affected increases with age. This can be triggered by a host of factors including drinking too much water, behavioural patterns and the dose and timing of medication like cardiac glycosides, propoxyphene and water pills (diuretics).
The quality and quantity of sleep can be negatively affected by these symptoms that the patient presents. He is not getting sufficient quality or quantity of sleep because the circadian and homeostatic processes of regulating sleep are not at optimum due to behavioural factors, in this case taking diuretics and taking a nap during the day can affect the sleep pattern. Due to his age (70 years) he notes he has been retired for 5 years, therefore there is probably less physical and/or mental activity in the daytime.
Case
A 70-year-old man with early morning awakening
A 70-year-old patient was seen for complaints of early morning awakening. The problem has worsened since his retirement 5 years ago. His typical bedtime was 9pm; he often fell asleep withing 5 minutes and has difficult staying up late. At night the patient awakens twice with nocturia, usually at midnight and 2am, but can return quickly to sleep. Afterwards he is awakened spontaneously between 4am and 5am and typically was unable to fall back to sleep but will remain in bed till 6:30am. This inability to enjoy quality sleep past 4am -5am is the patients main concern and cause of distress.
Case History
The patient is currently using a diuretic (water pill) for hypertension. Separate from this the patient has no other complaints, engages in his several hobbies and maintains a good relationship with his wife.
From the information we can infer from this case, it is likely that our this 70-year-old patient is suffering from Advanced Sleep Phase Disorder. This disorder is one of many circadian rhythm sleep wake disorders. Circadian rhythm sleep wake disorders involve any difficulty falling asleep, waking up multiple times during the sleep cycle or early awakening and having trouble falling back to sleep. In the circadian rhythm sleep wake disorder, it encompasses several disorders including delayed sleep phase, advanced sleep phase, irregular sleep-wake rhythm disorder, non-24- hour sleep wake rhythm disorder and shift work disorder.
Advanced sleep phase disorder can be characterised by waking early leaving individuals often with difficulty falling back to sleep state and tiredness early in the evening. Research shows that prevalence of ASPD increases with age. This age-related increased prevalence may be due to low exposure levels to evening light, conversely exposure to high level of morning light exposure can also influences ASPD. The key diagnostic features of ASPD are difficulty staying awake until desired time or excessive early evening sleepiness. In comparison to the other key features of diagnosis in Delayed Sleep Phase Disorder which includes difficulty falling asleep at the desired time, trouble waking in the morning and excessive daytime sleepiness. In this case, the patient does not complain of excessive daytime sleepiness and on the contrary is able to stay awake during the day without difficulty.
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