0863 A Unique case of sleep state misperception in an elderly patient

Abstract

Abstract Introduction Insomnia is a widespread condition, especially in the elderly population. While the International Classification of Sleep Disorders (ICSD) third edition appropriately removed primary insomnia subtypes from the classification, our case illustrates the importance of these factors in considering a chronic insomnia disorder diagnosis. We present a case of severe subjective insomnia with no apparent objective findings, instead with evidence of excellent sleep efficiency on the contrary. Report of Cases: A 76-year-old male with a past medical history of anxiety and a recent diagnosis of early Parkinson's disease presented to the Sleep medicine clinic with two years of insomnia which started after his retirement. The patient felt difficulty with falling asleep every night. He underwent a sleep study and was found to have sleep-disordered breathing, which responded well to Bilevel positive airway pressure (BiPAP) therapy. However, insomnia symptoms persisted and were resistant to multiple medications, including Mirtazapine, Melatonin, and Suvorexant. He was referred for Cognitive Behavioral Therapy with minimal to no improvement in his symptoms. Conversely, a one-week Actigraphy recording on Bipap therapy surprisingly revealed an excellent sleep efficiency with near-continuous seven to eight hours of sleep every night. The etiology of chronic insomnia is poorly understood but is typically multifactorial, as described in the second edition of ICSD. In this case, paradoxical insomnia played a significant role in the patient's clinical presentation. Paradoxical insomnia is defined as thoughts or perceptions of time asleep as wakefulness, with objective measures documenting normative amounts of sleep. Previous work suggests that alterations in the sleep/arousal system may contribute to this apparent mismatch between conventional objective sleep measures and subjective reports. Conclusion This case demonstrates the challenge of effectively diagnosing and managing chronic insomnia. While the new classification guidelines from the ICSD appropriately remove insomnia subtypes from the diagnostic paradigm, familiarity with these previously described subtypes may aid clinical decisions. Crucial to this discussion is that previously described "secondary" or "subtypes" of primary insomnia may develop an independent clinical course that may require further attention. Support (If Any) ICSD 2nd,3rd editions.