A 54-year-old male patient with hypertension, type 2 diabetes mellitus, obesity, dyslipidemia, and coronary artery disease (CAD) status postcoronary artery bypass graft (CABG) presents to the sleep clinic because his wife is worried that he “stops breathing at night.” He underwent CABG about 3 months prior to his appointment. He had initial difficulty sleeping after his surgery, but this has improved over time. He also found a supplement at a natural foods store that seemed to help.
Insomnia, defined as difficulty falling asleep or staying asleep, is a very common sleep complaint. Some studies estimate that up to 30% of the general population report chronic insomnia, while at least 10% of the general population report insomnia that is “distressing” or that significantly impairs their daytime functioning. Insomnia that occurs after a major life event, including a significant change in health status, a hospitalization, or a medical procedure, is called adjustment insomnia and is usually transient (lasting <3 months). However, in patients with cardiovascular disease, medication side effects must also be considered. In patients with congestive heart failure (CHF) or hypertension, diuretic therapy may lead to overnight awakenings related to nocturia. Cardiac patients are frequently prescribed beta blockers that depress sympathetic tone and thereby produce many positive effects from a cardiovascular perspective, but decreased sympathetic tone also decreases production of melatonin, a neurohormone that is critical for regulating the circadian sleep–wake cycle. For some of these patients, starting a melatonin supplement may help them fall asleep more quickly.
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Clinical Pearl
Many commonly prescribed medications can have deleterious effects on sleep, including selective serotonin reuptake inhibitors (SSRIs) and other antidepressants, antiepileptic medications, and stimulants prescribed to treat attention deficit hyperactive disorder (ADHD). When possible, adjusting medication dosages or timing, changing to a different class of medication, or discontinuing nonessential medications may have a significant impact on sleep quality.
The patient reports that he sleeps from 10 PM to 6 AM. He falls asleep quickly, usually in less than 5 minutes, sometimes on the couch while watching television. He typically awakens one or two times overnight to urinate. He returns to sleep quickly after using the bathroom. He denies excessive daytime sleepiness and has a normal Epworth Sleepiness Scale score of 6/24 (see page 270). He drinks about six cups of coffee each day and sometimes has an “energy drink” in the afternoon.
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Excessive daytime sleepiness may be masked by caffeine intake or by prescription stimulants such as methylphenidate (Ritalin®), dextroamphetamine/levoamphetamine (Adderall®), and modafinil (Provigil®). When evaluating any patient, it is always important to obtain a complete list of current medications and herbal supplements, to assess caffeine and alcohol intake, and to ask about tobacco and substance use.
The patient denies drowsy driving, falling asleep at the wheel, and motor vehicle collisions related to sleepiness. He does not nap.
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When assessing a patient who reports sleep-related difficulties, it is critical to assess safety concerns, including drowsy driving and if his or her occupation involves operating heavy machinery or vehicles involved in mass transit or the long-distance transportation of goods. All patients should be counseled to avoid driving and other high-risk activities when they are drowsy.
The patient is accompanied by his wife, who says that he does not move around much in his sleep and that she has not noticed any sleep talking (somniloquy) or sleep walking (somnambulism). He snores loudly every night, and has done so for about the past 10 years. The snoring is so loud that his wife sometimes has to sleep in a different room, especially on nights when they have had wine or cocktails earlier in the evening. She also reports that her husband “stops breathing” several times each night, and sometimes gasps or chokes. She thinks the pauses in breathing have recently become more frequent, even prior to his CABG.
