eMedicine Specialties > Neurology > Sleep-Related Diseases

Sleeplessness and Circadian Rhythm Disorder: Follow-up

Author: Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Coauthor(s): Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Contributor Information and Disclosures

Updated: Aug 22, 2008

Follow-up

Further Outpatient Care

  • Address associated psychological issues. Patients with delayed sleep-phase syndrome (DSPS) who initially responded to chronotherapy may gradually shift back to their old sleep pattern. Often, chronotherapy must be repeated every few months to maintain long-lasting results.
  • Emphasize importance of good sleep hygiene.
  • Avoid use of alcohol, stimulants (eg, nicotine, caffeine), and strenuous exercise before bedtime.

Inpatient & Outpatient Medications

Transfer

  • The overwhelming majority of patients with insomnia (except elderly patients) are treated as outpatients.
  • In the elderly, in whom numerous other physical, psychiatric, and pharmacological concerns are present, institutional care is often necessary. The presence of significant sleep disruption is often a predictor for which patients require institutionalization.

Deterrence/Prevention

  • Encourage good sleep hygiene.
  • Control of sleep environment with regulation of light/dark exposure has been helpful to shift workers in maintaining sleep.
  • For patients anticipating jet lag, advise scheduling to the time of the new location prior to departure. This can modify effects of jet lag.
  • For shift workers, advise shifting the schedule in a clockwise direction; this is often better tolerated.

Complications

  • Sleeplessness may have various consequences, which have been discussed above. These consequences include poor daytime performance, daytime sleepiness, impaired social interactions, and irritability.

Prognosis

  • Jet lag: This is a transient condition that has a good prognosis.
  • Shift work: Abrupt changes in schedule and counterclockwise shifts are associated with daytime sleepiness and impaired performance. Older patients may not adjust well to shift work.
  • DSPS: This is typically seen in adolescents and young adults. This sleep pattern often resolves in adulthood.
  • Advanced sleep-phase syndrome (ASPS): This is prominent in the elderly and often responds well to a combination of behavioral and pharmacological intervention.
  • Other conditions: Children with special needs, including attention deficit hyperactivity disorder and developmental disabilities, generally respond well to behavioral intervention.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The consequences of poor sleep are well established. Among other symptoms, they include impaired social interactions and psychomotor coordination. The literature supports the relationship of poor sleep to automobile accidents, heavy machinery accidents, and other catastrophes.
  • Failure to diagnose other medical conditions associated with increased daytime sleepiness, such as obstructive sleep apnea (OSA), may also carry significant consequences in terms of added morbidity and mortality.
  • Failure to assess patient risk for motor vehicle accidents is a pitfall. Patients should be advised of risks secondary to sleepiness and have follow-ups after treatment to determine if risk factors have been satisfactorily addressed.

Special Concerns

  • Children and adolescents: Early start times for school coupled with after school activities and homework are associated with sleep deprivation and phase shifting in children and adolescents. Subsequent daytime sleepiness and impaired performance have been documented.
  • Children with special needs: These children have a higher incidence of sleeplessness. This impacts children, parents, and their families. Positive routines are superior to extinction techniques in this population; however, these children may take longer than other children to achieve the desired results.
  • Elderly persons: The decision to institutionalize elderly individuals is often based on sleep disruption. This decision often involves the need for the caregiver to be able to obtain adequate sleep. Concerns about the elderly patient wandering and falling are also important when making the decision to institutionalize the patient
  • Shift workers: Numerous health risks have been described in association with shift work. These include GI symptoms, psychosomatic symptoms, increased alcohol and drug use, and emotional problems.
 


More on Sleeplessness and Circadian Rhythm Disorder

Overview: Sleeplessness and Circadian Rhythm Disorder
Differential Diagnoses & Workup: Sleeplessness and Circadian Rhythm Disorder
Treatment & Medication: Sleeplessness and Circadian Rhythm Disorder
Follow-up: Sleeplessness and Circadian Rhythm Disorder
References
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Further Reading

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Keywords

sleeplessness, circadian rhythms, ultradian rhythm, entrainment, free-running clock, zeitgeber, insomnia, biological clock, jet lag, sleep disorders, sleep deprivation, daytime sleepiness, biological rhythms, delayed sleep-phase syndrome, DSPS, advanced sleep-phase syndrome, ASPS, irregular sleep-wake cycle, suprachiasmatic nuclei, SCN, suprachiasmatic nuclei lesions, SCN lesions, Alzheimer disease, Alzheimer's disease, shift work syndrome, circadian rhythm disorder, motor vehicle accidents, heavy machinery accidents, obstructive sleep apnea, OSA, excessive daytime sleepiness, EDS, upper airway resistance syndrome, congestive heart failure, chronic obstructive pulmonary disease, neurodegenerative disease, chronic lung disease

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Contributor Information and Disclosures

Author

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Coauthor(s)

Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Gila Hertz, PhD, ABSM is a member of the following medical societies: American Academy of Sleep Medicine and American Psychological Association
Disclosure: Nothing to disclose.

Medical Editor

Carmel Armon, MD, MSc, MHS, Professor of Neurology, Tufts University School of Medicine, Chief, Division of Neurology, Baystate Medical Center, Springfield, Massachusetts
Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Norberto Alvarez, MD, Assistant Professor, Department of Neurology, Harvard Medical School; Consulting Staff, Department of Neurology, Boston Children's Hospital
Norberto Alvarez, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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