The Early Riser

A78-year-old man complains of early morning awakenings. History reveals early awakenings started approximately 1 year ago, 7 months after his wife of 35 years died. He admits the first few months were difficult, but for the past year he has fallen into a routine which includes shopping on line in the early morning, playing golf and cards with friends during the day, and going out to dinner in the late afternoon or early evening. He occasionally has up to 2 alcoholic drinks with dinner and up to 2 cups of caffeinated coffee during the day. The patient occasionally feels sleepy during the day with an Epworth Sleepiness Scale score of 5, but does not snore loudly or complain of insomnia. Other than prostatic hypertrophy, which awakens him briefly twice each night, he does not have any medical problems, and his physical exam is remarkable for a physically well-appearing elderly man. The patient is eager to visit his grandchildren next month. When questioned further, the patient tells you he read on-line that “not getting enough sleep can kill you.” He provides the sleep diary shown in Figure 1. Figure 1 SLEEP DIARY What is the next appropriate step? a. Reassurance b. Counseling and consideration of antidepressant therapy c. Early morning light therapy d. Elimination of all caffeinated beverages e. Overnight polysomnography with CPAP titration in split-night format (if needed) CORRECT ANSWER: a. Reassurance This patient has a history and sleep pattern consistent with advanced sleep phase disorder. Reassurance (answer a) is all that is required. Indeed, the patient's sleep diary shows he obtains a “normal amount” (nearly 8 hours) of sleep each night. Although patients may be concerned that awakening early in the morning is detrimental to their well-being, the condition is benign. When advanced sleep phase syndrome has an impact on social functioning, specific interventions should be considered. The first step in the evaluation of a patient with a presumed circadian rhythm disorder should be assessment of the sleep cycle via sleep logs followed by actigraphy if the diagnosis remains unclear. Treatment centers on delaying sleep onset and includes behavior modification, sleep-wake scheduling, and early evening light exposure. Hence, answer c is incorrect as early morning light exposure would treat a delayed sleep phase. Although early morning awakenings are a frequent complaint when patients are depressed, our patient does not have features of depression and is looking forward to visiting his grandchildren (answer b is incorrect). While elimination of caffeinated beverages is a recommendation given to many patients with sleep disturbances, particularly those with sleep onset insomnia, it is likely not a factor in our patients circadian rhythm disturbance (answer d is incorrect). Finally, our patient does not snore or have excessive daytime sleepiness by history or Epworth. Thus, a polysomnography to rule in obstructive sleep apnea or other sleep disorder is unlikely to assist in the diagnosis (answer e is incorrect). The next appropriate test would be actigraphy, which is not listed, but indicated to substantiate the diagnosis or follow treatment efficacy.