This is a 52-year-old gentleman whose height is 60 inches and weight is 240 pounds with a BMI of 34.4.
CHIEF COMPLAINT: Evaluation for abnormal body movements while asleep.
HISTORY: This gentleman goes to bed between 9:00 and 11:00 p.m. and falls asleep within 10-15 minutes and wakes up between 2:30 and 3:30 in the morning and falls back asleep until around 7:00 in the morning and usually takes 1 hour nap in the afternoon. During the night, he snores heavily and has frequent witnessed apneas. He does not offer symptoms suggestive of narcolepsy, but has very frequent leg twitching or kicking during sleep, although no other symptoms suggestive of restless leg syndrome. He has problems falling asleep and maintaining sleep with frequent awakenings during the night. His bedroom is described as conducive to sleep. He smokes 2 packs daily and does not drink alcohol and drinks coffee in the morning. His Epworth Sleepiness Scale is 7.
MEDICATIONS TAKEN REGULARLY: Include lisinopril, citalopram, and until recently clonazepam, but this apparently was stopped. He also used zolpidem for the sleep study night.
PARAMETERS STUDIED: The patient had an overnight attended polysomnogram in accordance with standards of The American Academy of Sleep Medicine. Bilateral extraoculogram, 6-lead electroencephalogram, chin electromyogram, airflow, thoracic and abdominal effort, pretibial EMGs right and left, EKG, SaO2, tracheal sound and snoring, body position, and video monitoring were done during this polysomnography.
SLEEP SUMMARY: Total recording time is 428 minutes with a total sleep time of 342 minutes, resulting in a decreased sleep efficiency of 80%. Sleep onset latency was normal at 22 minutes. REM onset latency was delayed at 176 minutes and he had 63 minutes of wakefulness after sleep onset time, which is increased.
SLEEP STAGE AND ARCHITECTURE: Stage N1 was increased, stage N2 was increased. Slow wave sleep was absent and REM sleep was decreased. He also had 77 arousals with an arousal index of 15 per hour, which is increased. The majority of those were related to sleep disordered breathing events. Overall, his sleep architecture had increased percentage of the lighter stages of sleep. The sleep continuity was disrupted with many arousals and few prolonged awakenings early in the night.
RESPIRATORY SUMMARY: The overall apnea and hypopnea index was 15 per hour with a respiratory disturbance index of 18 per hour, resulting from 21 obstructive apneas, 69 hypopneas and 14 respiratory effort related arousals. REM related index was 31, non-REM related index was 16. The supine RDI was 25 and non-supine RDI was less than 1.
SNORING SUMMARY: He had loud snoring throughout the study, but especially worse in the supine sleeping position.
ELECTROCARDIOGRAM SUMMARY: He was in sinus rhythm throughout the study.
MOVEMENT SUMMARY: This gentleman had a total of 661 periodic limb movements with a very high periodic limb movement index of 115 per hour. Associated arousal index was formerly low at 3 per hour, but upon personal review many of the periodic limb movements were associated with some changes in the EEG consistent with a degree of sleep continuity disruption. Of note, he had upper and lower extremity leads and there did not seem to be any indication of REM without atonia. The few twitches during REM sleep did not mount to the degree of formal scoring of REM without atonia.
OXYGENATION SUMMARY: The mean oxygen saturation was 95%, the lowest was 75% and he spent less than 3 minutes at or below 88%.
ELECTROCARDIOGRAM SUMMARY: He was in sinus rhythm.
IMPRESSION: Abnormal polysomnography consistent with obstructive sleep apnea, adult, ICD G47.33. In addition, this gentleman has a rather severe periodic limb movement disorder, ICD G47.61.
DISCUSSION: 1. This gentleman offers symptoms of severe claustrophobia, given his severity of sleep disordered breathing and symptomatology CPAP is very reasonable therapeutic option.
2. Given the claustrophobia it is recommended that he be evaluated for a CPAP desensitization trial with his DME provider after which an auto set CPAP with a pressure range of 4-12 with heated humidity and a clinical evaluation and a download in 6-12 weeks be provided.
3. If CPAP is not well tolerated, alternatives may include mandibular advancement devices and, significantly, avoiding the supine sleeping position as his apnea was rather severe in the supine sleep, but very mild in the non-supine sleep.
4. In addition, he has a rather violent periodic limb movements involving mostly the lower extremities but also occasionally the upper extremities, further clinical evaluation is recommended to rule out possible contributing factors including SSRI medications and a possible recent withdrawal of clonazepam, which may have contributed to partial control of these movements, iron deficiency and other less common underlying neurological abnormalities may also be contributing, again, clinical correlation is recommended and given the severity medicinal interventions may be warranted.
5. He otherwise should be encouraged to maintain a healthy weight, avoid sedatives and hypnotics close to bedtime and to maintain a good sleep hygiene.
6. He should not drive when