para>Melatonin has a weak sedating effect, and individuals should be counseled not to drive/operate dangerous machines after taking the medication. Other side effects include headache and unusual taste in mouth.
ISSUES FOR REFERRAL
- Referral for evaluation and testing at a sleep clinic is not necessary in most cases of DSWPD. The chief indications for referral are suspicion of the following comorbid disorders:
- Obstructive sleep apnea: indicated by loud snoring, obesity/large neck, witnessed apneas, and history of hypertension
- Narcolepsy: indicated by severe levels of daytime sleepiness, despite adequate sleep quantity, and sometimes accompanied by cataplexy (bouts of sudden muscular weakness triggered by strong emotions)
- Parasomnias: undesirable experiential/behavioral phenomena that arise out of sleep, such as dangerous sleepwalking or dream-enactment behavior
- In addition, many individuals with the complaint of insomnia/sleepiness have comorbid mental health disorders, primarily depression and possibly substance abuse. Referral for mental health disorders/substance abuse treatment is indicated if these are present.
ADDITIONAL THERAPIES
- Chronotherapy is an older strategy in which the individual is instructed to delay sleep and wake times by 2 to 3 hours every 2 to 3 days, shifting the sleep cycle across the 24-hour day, until the individual reaches a desired bedtime. Carried out over several weeks, this protocol is extremely disruptive to daytime schedules and also has not been demonstrated to be effective. It is seldom used (4).
- Some early reports suggest that vitamin B12 has circadian phase-shifting properties. This finding has not been confirmed in subsequent investigations, and presently, no evidence seen of benefit to the use of this supplement in CRSDs (3)[B].
- Use of sedative-hypnotic medications to treat the insomnia component and stimulant medications to treat daytime sleepiness has not been shown to be effective in the context of DSWPD (3)[C].
ONGOING CARE
Remind patients to practice healthy sleep behaviors (see "General Prevention") if they wish to maintain an earlier sleep/wake pattern.
PATIENT EDUCATION
http://www.aafp.org/afp/1999/0401/p1918.html
REFERENCES
11 Wyatt JK, Stepanski EJ, Kirkby J. Circadian phase in delayed sleep phase syndrome: predictors and temporal stability across multiple assessments. Sleep. 2006;29(8):1075-1080.22 Ebisawa T, Uchiyama M, Kajimura N, et al. Association of structural polymorphisms in the human period3 gene with delayed sleep phase syndrome. EMBO Rep. 2001;2(4):342-346.33 Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007;30(11):1445-1459.44 Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review. Sleep. 2007;30(11):1484-1501.
ADDITIONAL READING
- Barion A, Zee PC. A clinical approach to circadian rhythm sleep disorders. Sleep Med. 2007;8(6):566-577.
- Kanathur N, Harrington J, Lee-Chiong TJr. Circadian rhythm sleep disorders. Clin Chest Med. 2010;31(2):319-325.
- Kripke DF, Rex KM, Ancoli-Israel S, et al. Delayed sleep phase cases and controls. J Circadian Rhythms. 2008;6:6.
- Wilson SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24(11):1577-1601.
CODES
ICD10
G47.21 Circadian rhythm sleep disorder, delayed sleep phase type
ICD9
327.31 Circadian rhythm sleep disorder, delayed sleep phase type
SNOMED
80623000 Sleep-wake schedule disorder, delayed phase type
CLINICAL PEARLS
- The tendency to become "night-owlish" with adolescence is, to a large extent, a biologically programmed phenomenon, not strictly a behavioral choice. Enlightened public policy would recognize this and allow for later start times for high schools.
- DSWPD can be diagnosed with careful history taking and sleep logs; referral for formal sleep studies is usually not indicated.
- Use of light and melatonin can shift habitual sleep onset and offset time by their action on the human circadian rhythm.
- To maintain a desirable sleep phase, individuals with DSWPD usually need to maintain meticulous attention to sleep hygiene, including a regular sleep/wake schedule 7 days/week, to avoid lapsing into a delayed phase pattern.