Case 044: Sleep Disorders

PATIENT PRESENTATION

Chief Complaint

“I’m up all night since he passed away”

History of Present Illness

Zella Pechette is a 50-year-old female with complaints of trouble getting to sleep after the death of her husband 2 months ago. She reports going to the emergency room last week after taking several Tylenol PM^® to get better rest at night.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. How does Mrs. Pechette meet the diagnostic criteria for insomnia?

   Hint: See Epidemiology and Etiology in PPP

2. What are the dangers of taking OTC medications for sleep aids?

   Hint: See Treatment in PPP

3. What pharmacologic options are available for the treatment of insomnia in Mrs. Pechette?

   Hint: See Treatment in PPP

4. What pharmacologic options are available for treatment of restless leg syndrome in Mrs. Pechette?

   Hint: See Treatment in PPP

5. What lifestyle changes would you recommend to Mrs. Pechette to treat her insomnia? Include a monitoring and follow up plan.

   Hint: See Treatment and Table 42-1 in PPP

FOLLOW-UP

Mrs. Pechette returns to your clinic 3 weeks later to follow-up on your previous interventions. She reports that she’s getting better sleep and that her restless leg has improved since changes to her pharmacologic therapy. She states that she bought a new herbal medication called melatonin. What patient counseling and possible intervention can you supply Mrs. Pechette regarding the use of melatonin?

Hint: See Treatment in PPP

CASE SUMMARY

Global Perspective

There are about 70 million adults in the United States who suffer from a sleep disorder.¹ Insomnia is the most common specific sleep disorder, with short term issues reported by about 30% of adults and chronic insomnia by 10%.² A strong association between sleep disturbance and major depression has been identified.³ Seventy-five percent of patients who report being depressed have symptoms of insomnia.³ Over-the-counter first-generation antihistamines, such as diphenhydramine and doxylamine, are frequently used for difficulty sleeping. Many OTC products contain diphenhydramine that can aid in sleep, however, taking in excess can lead to harmful overdoses. Unintentional acetaminophen overdose accounted for nearly 25 percent of the emergency department visits, 10 percent of the hospitalizations, and 25 percent of the deaths.⁴ It is important to identify all patient factors, lifestyle habits, and concurrent medications when determining the appropriate management for sleep disorders.

Key References