An otherwise healthy 19-year-old man presented with new onset “sleep attacks” leading to multiple minor motor vehicle accidents over the past 8 months. His Epworth Sleepiness Scale score (ESS) was 15/24 (normal ≤ 10), and excessive daytime sleepiness was present for 2–3 years. There was no reported antecedent viral illness or head injury. He recalled a single episode of sleep paralysis lasting less than 5 minutes several months prior to presentation, but denied symptoms of cataplexy, hypnagogic/hypnopompic hallucinations, and sleep fragmentation. He also reported loud snoring, but was unaware of snorting, gasping or choking. He denied symptoms of other sleep disorders—parasomnia, insomnia, or movement disturbances. He reported the following wake/sleep schedule: on weekdays, bedtime was 23:00 to midnight, falls asleep in 15 min, and wake time was 06:00 if working or 09:00 if not working. On weekends, bedtime was similar, but wake time was 09:00. He endorsed napping at least once per day either during school hours or after 17:00 for 1–3 hours. He was a part-time student and also worked part-time at a restaurant. He denied recreational drugs, alcohol, or caffeine use. He used nasal fluticasone intermittently for allergic rhinitis. He had a body-mass index of 29.2 kg/m2 and a crowded airway oropharynx (Mallampati 3) without tonsillar hypertrophy. He was counseled on health sleep habits and agreed to regularize his wake sleep schedule and extend sleep. He was scheduled for polysomnography (PSG) to rule out obstructive sleep apnea (OSA), but PSG did not support that diagnosis. The apnea-hypopnea index was 3.0 with no significant hypoxemia or sleep fragmentation. He slept 416 min with a sleep latency of 23 min, REM latency of 61.5 min, 92% sleep efficiency, and an arousal index of 9/h. At the follow-up visit, he still complained about excessive sleepiness, so investigation turned to the possibility of a primary hypersomnolence disorder. Before considering multiple sleep latency testing (MSLT), actigraphy was obtained using an Actiwatch-2 (Philips Respironics, Bend, OR). The study was autoscored with manual editing as needed to remove inconsistent or artifactual data (Figure 1). The patient was asked to keep a sleep log during this time (Figure 2).
Two week actigraphy summary.
Patient did not wear the actigraphy on 3 nights of the recording period: nights 8, 11, and 12. On average, bed time is 02:00 and wake time is 07:00. His average time in bed is only 5 h and average estimated sleep time is only 3.75 h.
Two week actigraphy summary. Patient did not wear the actigraphy on 3 nights of the recording period: nights 8, 11, and 12. On average, bed time is 02:00 and wake time is 07:00. His average time in bed is only 5 h and average estimated sleep time is only 3.75 h.
Summary of the patient-reported wake-sleep schedule at the time of the actigraphy in log format.
Of note, there were no reported naps.
Summary of the patient-reported wake-sleep schedule at the time of the actigraphy in log format. Of note, there were no reported naps.
QUESTION: What is going on with this patient's sleep? What is the diagnosis?
ANSWER: Actigraphy showed significantly irregular and insufficient sleep, the most likely cause of the patient's “sleep attacks” and an important contributor to his motor vehicle accidents. The objective actigraphy data were in contrast to the patient reported wake-sleep schedule by history and by sleep log during actigraphy.
Hypersomnia is a common complaint in sleep clinic. A sleep medicine specialist formulates a differential diagnosis and outlines plans for further evaluation based on history, physical examination, and results of validated screening tools. One usually relies on the patient/family reports for pretest probability and justifying PSG and/or MSLT to third party payers. In our patient, there was a collection of symptoms that warranted a PSG to exclude OSA and the degree of functional sleepiness that needed explanation. Once OSA was ruled out, a primary hypersomnolence disorder was reconsidered. Consistent with the latest recommendations in the third International Classification of Sleep Disorders (ICSD-3),1 we performed actigraphy to objectively confirm the patient's sleep wake timing prior to scheduling the MSLT. While actigraphy is supported by American Academy of Sleep Medicine practice guidelines and has a billable procedure code, in our practice area, none of third-party payers either pre-authorize or reimburse for this procedure.1,2 In spite of these barriers, many sleep centers will provide actigraphy as needed for best patient care. For this patient, actigraphy provided the objective data to establish the true nature of this patient's symptoms and prevented over-use of more expensive diagnostic testing that was not indicated. Our case provides clear evidence to support the new recommendation in the ICSD-3 for at least 1 week of actigraphy recording with a sleep log before PSG/MSLT to establish whether the results could be biased by insufficient sleep, shift work, or another circadian disorder.1 In our patient, objective actigraphy showed insufficient opportunity for sleep which was not clearly evident from the initial face-to-face consultation and led to the correct diagnosis of insufficient sleep syndrome, which now listed as a diagnosis under central disorders hypersomnolence in the ICSD-3.
Adolescents and young adults often complain of daytime sleepiness, commonly due to chronic sleep loss.3 Excessive sleepiness can have a profound negative effect on school or work performance, cognitive function, mood, and increase the risk of accidents. Factors associated with chronic insufficient sleep in teens and young adults include biological factors pre-disposing to a more evening type circadian phase preference, electronic media, early school start times, after school and evening work, and high caffeine use.4,5
Excessive daytime sleepiness due to insufficient sleep has been associated with other serious consequences such as increased incidence of automobile crashes. Sleepiness while driving is a common complaint among adolescence and college students with 40% reporting sleepiness while driving and 11% reported having an automobile crash in which sleepiness was the main cause.4 Young male drivers are more likely to be involved in sleep related crashes than are young female driver.6 It is very important to counsel patients on drowsy driving, particularly in this age group who are more vulnerable to motor vehicle accidents. Countermeasures that may potentially help in this age range include avoidance of driving when sleep deprived, discourage drinking alcohol and planned napping.6
In follow-up, the results of the actigraphy were shared with the patient. We explained that his actual sleep time was much less than his reported or perceived sleep time. At this time, the patient did admit to using electronic media in bed. He was re-counseled on good sleep hygiene and advised to increase his sleep duration to at least 7 to 8 hours, regularly. He was seen six weeks later and declared that his daytime sleepiness improved significantly, which was supported by his ESS falling from 15/24 to 6/24. He denied having anymore “sleep attacks” and no longer required naps during the day.
SLEEP MEDICINE PEARLS
Actigraphy is an important adjunct for the evaluation of excessive daytime sleepiness
Electronic media use is an important “sleep stealer” in teens and young adults.
Insufficient sleep is a significant problem in teens and young adults and an important contributor to car accidents in this age group.
This was not an industry supported study. Dr. Strohl has consulting agreements with Inspire Medical, Vivus, Seven Dreamers Laboratories and GlaxoSmithKline. In addition Dr. Strohl has grant/research support with Inspire medical, Veteran Affairs research service and the National Institutes of Health. Dr. Rosen has consulting agreements with Jazz Pharmaceuticals and Advance Medical and grant/research support with Jazz Pharmaceuticals and National Institutes of Health (NIH). The other authors have indicated no financial conflicts of interest. There was no investigational or off label use device use. The work was performed at University Hospitals-Case Medical Center, Cleveland, OH.
Lewis O, Morkous S, Strohl KP, Rosen CL. Actigraphy as a “truth-buster.” J Clin Sleep Med 2015;11(12):1466–1469.
American Academy of Sleep Medicine. International classification of sleep disorders. Darien, IL: American Academy of Sleep Medicine, 2014.
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