Announcer: Disturbed Sleep. Five Case Problems.
Robert Rackel, M.D.: We all may see patients who complain about fatigue and then ask us to help them get rid of the insomnia which they feel causes it. Sometimes I personally get stumped by perplexing cases and wish that I could discuss them with a sleep-disorder expert like Dr. Kramer. I'm delighted to have the opportunity to do so now. From time to time, I'll ask multiple choice questions and ask you to participate by answering them. Circle the number of your choice on the NCME medical tv guide.
Milton Kramer, M.D.: After Dr. Rakel outlines each case, I will discuss diagnostic and treatment alternatives based on our experience here at the sleep disorder centre.
Dr. Rakel: Lets begin with a situation that most of us have faced. The patient, like 45 year-old Jack Apple, who complains at the end of a routine check-up that he's not sleeping well and wants medication. His former physician several years ago prescribed secobarbitol which Jack has been using as needed at relatively frequent intervals. He's currently getting a divorce, and can't sleep even though he has increased his bed-time dose of secobaritol to three 100 mg capsules. Jack says that it takes him more than an hour to fall asleep and that he wakes up feeling tired.
Question #1: What therapy would be indicated at this point?
a. prescribe a new drug
b. reduce the dose of the current medication and observe the reaction
c. increase the dose of the current drug
Dr. Kramer: For several years Jack Apple has periodically been on a high level of the drug. He's beyond the reasonable maximum dose and has developed a tolerance to it. The medicine has lost its effect because Jack has adapted to it. The insomnia may even be caused by drug dependency. Many medications have cross-tolerance, so to immediately substitute another drug probably won't help. I recommend that you very slowly withdraw the drug until the patient is off the medication.
Dr. Rakel: Our next case involves insomnia that had lasted for two weeks before Dan Brown, a young executive, came to see me.
Dan Brown: I don't know what the matter is. I can't seem to fall asleep at night.
Dr. Rakel: How are you feeling in general?
Dan Brown: I've had some stomach pains and occasionally diarrhea.
Dr. Rakel: Are the pains worse in the morning or in the evening?
Dan Brown: I'd say in the evening.
Dr. Rakel: Are you taking any medications?
Dan Brown: No, I'm not.
Dr. Rakel: Would you describe what happens when you go to bed at night?
Dan Brown: I just lie there, thinking. I'm about to be transferred to another city and I've been running around tying up some loose ends.
Dr. Rakel: Do you toss and turn much when you're falling asleep or have any tingling in your legs?
Dan Brown: No.
Dr. Rakel: Are you eating okay? How are you eating?
Dan Brown: Mainly its been junk food on the run, mixed in with large business luncheons as well as some farewell dinners with some friends.
Dr. Rakel: Are you drinking much alcohol?
Dan Brown: Some wine with lunch, two or three drinks at dinner time and an occasional brandy later to help me sleep.
Question #3: What is Dan's probable diagnosis?
Dr. Kramer: Dan's stomach problems get worse as the day wears on and may exacerbate his night time sleeplessness. Fortunately, he isn't using stimulant drugs which often contribute to wakefulness. However he'd be better off with a light diet and reduced alcohol intake. If depression had been the problem, its be more likely that Dan would have complained of early morning awakenings and not being able to get back to sleep. Also his stomach pains might well have diminished as the day progressed.
Dr. Rakel: In cases of situational anxiety, I often first prescribe physical exercise or deep muscle relaxation exercizes. I recommend jogging, swimming, handball, or whatever the patient enjoys doing and whats most available. I find that exercise seems to help the patient's whole mental outlook.
The next patient, Jim Bowen, is a 22 year-old master's degree student presented perplexing symptoms which he reluctantly disclosed. On falling asleep Jim complained that his legs sometimes became paralyzed or that he heard frightening noises although no one was there. He often woke up during the night and had difficulty getting back to sleep. Then, unexpectedly, two or three times a day he'd fall asleep for five or ten minutes. And occasionally, when he laughed, he'd feel weak in the knees and have to catch himself to keep from falling.
Question #4: What is Jim's probable diagnosis?
a. primary insomnia
b. night terrors
c. sleep apnea
Dr. Kramer: We observed Jim's sleep in the lab for three nights. We taped electrodes to his head, face and chest to measure brain waves, eye movement, chin and other muscle activity and heart rate.
Dr. Rakel: What characterizes REM sleep? How did you treat Jim's narcolepsy? Here's a case that gave me a problem. Jenny Thompson, a 72 year-old retired school teacher couldn't get to sleep at night because of cramping feelings in her legs. When she did fall asleep, she would often awake, and have difficulty getting back to sleep again.
Jenny: I wake up in the middle of the night with these creepy-crawly sensations in my legs. I can't lie in bed and I get up and walk around. I can't stand it. My husband complains I keep him awake too.
Dr. Rakel: How do you keep him awake, by getting up out of bed?
Jenny: No, by kicking him.
Dr. Rakel: How many times do you get up a night?
Jenny: Oh three or four times.
Dr. Rakel: How long has this been going on?
Jenny: Ten to twelve years.
Dr. Rakel: And how long does it take you to fall asleep at night?
Jenny: One to two hours.
Dr. Rakel: Do your legs feel restless then?
Jenny: Yes. My God, you can't imagine.
Dr. Rakel: Have you ever had epileptic attacks?
Dr. Rakel: Do you drink much liquor?
Jenny: No, just a glass of wine with dinner.
Question #5: What is the probable diagnosis?
Dr. Kramer: Women in the second half of life seem more susceptible to this disorder, nocturnal myoclonus. The best treatment we can offer is benzodiazapenes taken an hour or two before sleep to suppress the jerking movements.
Dr. Rakel: Are there guidelines for dealing with the sleep problems of the elderly?
Dr. Kramer: Yes.
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