Posted by Craig on March 27, 2002 at 15:18:44:In Reply to: longcase.1 posted by Sam Shanmugham on February 12, 2002 at 19:52:44:
DDx:
1. Alcohol Dependent Sleep Disturbance
2. OSAs
3. Sleep Disturbance Related to Dementia
4. Sleep Disturbance Related to Depression
5. Post-Traumatic Hypersomnia (remember alcoholics fall)
6. Hypersomnia related to Neurologic Disorder not otherwise stated (Chonic Subdural, CVAs, etc especially with decreasing functional status) and Nocturnal Seizures
7. Inadequate Sleep Hygene ("goes to bed at 6 pm..." not always equivalent to going to sleep at 6 pm and prolonged naps during the day)
8. Narcolepsy (onset during childhood, but life long disease)
9. PLMs (always good to list because they are such a common cause of nonrefreshing sleep in the elderly)Follow-up:
1. Nocturnal Polysomnogram
2. Sleep and Medication Diary/Logs (include when drinks and when smokes)
3. Actinography if available (Is there a prolonged arousal that the wife is not seeing during HER major sleep period...and that we cannot relay upon the patient to report because of his decreasing status)Management:
Will largely depend on the above studies, but for the moment:
1. Education about the risks of driving with excessive sleepiness and alcohol
2. Reconsult primary MD and make plan for discontinuation of alcohol usage and smoking
3. Psychiatric evaluation (since will have difficulty with habitual drug usage and wifes concerns about "depression")
4. Neurologic evaluation including consultation with a specialist and CNS imaging
5. If neurologist does not think there is a high suspicion of seizures, consider buproprion (may decrease smoking cravings, treat depression and act as alerting/insomnogenic agent)
6. Education to rules of sleep hygene
7. Reduce daytime napping (initially taper to less than 30 minutes and then see if can consolidate nocturnal sleep)
8. Daytime activity and exercise
9. Follow-up in one month