Sleep, Sleep Disorders, and Biological Rhythms
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National Heart, Lung, and Blood Institute
National Center on Sleep Disorders Research

Sleep, Sleep Disorders, and Biological Rhythms

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Teacher's Guide

Lesson 4—Elaborate

Evaluating Sleep Disorders

At a Glance

Figure 4.1. Woman sleeping with electrodes on face and meter next to pillow
Figure 4.1.
Accredited sleep centers evaluate people with sleep disorders, usually with an overnight sleep recording.

Overview

The lesson begins with students reading several short stories about snoring. Students engage in a discussion about sleep disorders. Also, students recall and use information obtained in Lesson 1 (the sleep diary). Students then assume the role of a sleep specialist. They evaluate five fictional case histories involving sleep problems. Using the reference materials provided, students analyze data and arrive at a “diagnosis.” They select a treatment based on their diagnosis. In a written report, students provide the rationale for their diagnosis and treatment selection, and they predict the expected outcome of the treatment.

Major Concepts

Many factors affect the quality and quantity of sleep. Insomnia is the most prevalent sleep disorder. Other major sleep disorders include sleep apnea, restless legs syndrome, and narcolepsy.

Objectives

After completing this activity, students will

Teacher Background

Consult the following section in Information about Sleep:

  1. 4 Sleep Disorders

In Advance

Web-Based Activities
Activity Web Version?
1 No
2 No
Photocopies
Activity 1

Master 4.1, Snoring—Believe It or Not! (Make 1 copy per student.)
Master 4.2, Snoring Survey (Make 1 copy per student.)

Activity 2 (per team of 4 students)
See Preparation for information about number of copies needed.
Master 4.3, Case History 1 (Make 1 copy per team.)
Master 4.4, Case History 2 (Make 1 copy per team.)
Master 4.5, Case History 3 (Make 1 copy per team.)
Master 4.6, Case History 4 (Make 1 copy per team.)
Master 4.7, Case History 5 (Make 1 copy per team.)
Master 4.8, Sleep Specialist’s Evaluation Form (Make 1 copy per student.)
Master 4.9, Sleep Disorders Reference Manual (Make 1 copy per team.)
Materials
Activity 1 no materials needed
Activity 2 no materials needed

Preparation

Activity 2

Students will be working in teams for this activity. Divide the class into teams of four students. Each team will evaluate two case histories. If necessary, have more than one team evaluate the same case histories.

Cut Masters 4.3, 4.4, 4.5, 4.6, and 4.7 along the dotted lines separating the Primary Information, the Secondary Information, and the Discussion Questions for each case history.

Procedure

Activity 1: Snoring—Believe It or Not!

  1. Give each student a copy of Master 4.1, Snoring—Believe It or Not!, and ask them to read it (these are all true stories).
  2. Ask students to comment on their experiences with snoring.

Remind students that they have information from their own sleep diary, as well as information from their class and other classes around the country, that would allow them to gauge the incidence of snoring among high school students using this supplement.

  1. Give a copy of Master 4.2, Snoring Survey, to each student and allow a few minutes for the class to answer the questions.
  2. After the students have completed their surveys, discuss the answers. Steer the discussion toward sleep disorders.

Sample answers to questions on Master 4.2, Snoring Survey.

Student responses will vary. They might use the reported frequency of snoring by their classmates from the sleep diaries as the basis for their answer. In fact, everyone seems to snore a little. A poll taken several years ago indicated that about 50 percent of the American population reported snoring. Half of this group was habitual snorers. Snoring is becoming increasingly common because fatigue and being overweight aggravate the problem. Convey this information and that provided for the other questions to set the stage for evaluating sleep disorders.

Students may simply respond that snoring is a noise made during sleep. Try to elicit from them the idea that snoring involves breathing. Snoring is an indication that air is not flowing freely through the area where the throat joins the nasal passages. In that area, the tongue and upper throat meet the soft palate and the uvula, which is the fleshy structure that dangles from the back of the palate into the throat. Individuals with narrowed or partially blocked airways must pull in air quickly, creating turbulence that makes the structure vibrate, thus resulting in snoring.

Since students know people who snore and don’t appear sick, they might respond that snoring can be a normal part of sleeping. Even though everyone seems to snore at least a little, it is not considered a normal part of sleep; that is, it does not serve a function during sleep. It may or may not be a symptom of a medical problem, depending on its cause and severity.

Figure 4.2. Man sleeping wearing mask over nose connected to machine next to bed
Figure 4.2.
People being treated for sleep apnea sometimes wear a medical mask that helps keep their airways open.

Snoring is often associated with certain sleep disorders. Students might be asked if there appears to be an association between the incidence of snoring and some of the entries in the sleep diaries (Lesson 1) such as total sleep time or number of awakenings at night. At this point, the discussion should begin to focus on sleep disorders.

Sleep disorders can be life threatening, as in the case of sleep apnea. Even mild insomnia, if causing problem sleepiness, can contribute to injury such as workplace accidents and auto crashes.

Student responses will vary. Some may not realize that occasional trouble sleeping is a mild form of insomnia and is considered a sleep disorder. By this measure, most students have some experience with a sleep disorder.

Activity 2: Diagnosis Unknown

National Science Education Standards icon
Content Standard F:
Personal choice concerning fitness and health involves multiple factors. Personal goals, peer and social pressures, ethnic and religious beliefs, and understanding of biological consequences can all influence decisions about health practices.
  1. For this activity, divide the class into teams of four students. Each team will receive two case histories to evaluate.
  2. Explain to the class that they will assume the role of specialists in sleep medicine. They will review case histories of patients, make diagnoses, and recommend treatments.
  3. Give each team a copy of the primary information for the two case histories they are to evaluate. The primary information is the top portions of Masters 4.3, 4.4, 4.5, 4.6, and 4.7. Ask students to read the primary information for each case history.
  4. Give each student a copy of Master 4.8, Sleep Specialist’s Evaluation Form. Instruct the students to write down what they consider to be the key aspects of their patients’ sleep disorders in the appropriate box.
  5. Give each team a copy of Master 4.9, Sleep Disorders Reference Manual. Instruct students to make a preliminary diagnosis for each case history by using information contained in the Sleep Disorders Reference Manual. Have students enter their preliminary diagnoses in the appropriate boxes on their evaluation form.
  6. Students should list the matching symptoms of the sleep disorders that match the key aspects of their case histories.
  7. Ask students if they are certain about their diagnoses.

Some students may indicate that they are not completely sure about their conclusions about a case. Ask them what steps they could take to either support or refute their diagnosis. Depending on the specifics of the case, there are a number of ways to obtain additional information relevant to the patient, including a physical exam, observation in a sleep clinic, additional patient history, and interviews with bed partners.

National Science Education Standards icon
Content Standard A:
Formulate and revise scientific explanations and models using logic and evidence.

Content Standard A:
Communicate and defend a scientific argument.

assessment icon
Assessment:
Encourage all team members to participate in their reports to the class. This will help you assess how well each student understands the information.
  1. At this point, explain to the class that some additional information regarding each case has come to light. Give each team the middle portions of the appropriate case histories that contain the Secondary Information.
  2. Ask students to read the Secondary Information for each case and use this new information to reevaluate their diagnoses. They should indicate on the evaluation form whether they want to confirm their initial diagnoses.
  3. If students have changed a diagnosis, they should enter the new diagnosis, together with the reason for the change, in the appropriate boxes on the evaluation form.

At the bottom of the evaluation form is space to recommend a treatment and indicate its expected outcome. Ideally, students should indicate how the treatment(s) might affect the patient’s symptoms. However, students may respond simply that the treatment they have selected will correct or manage the patient’s disorder. This type of response is acceptable. The purpose of asking students to provide this information is two-fold. First, students become aware that sleep disorders can be managed and that the expertise of a specialist is required for proper diagnosis and treatment. Second, it requires students to focus on treating or managing specific symptoms.

  1. Give each team the bottom portion of the appropriate case histories that contains discussion questions, and instruct the students to answer them.
  2. Discuss each of the case histories in turn, asking the students how they arrived at their diagnoses.

The questions are designed to help guide the student to the information that is important to making an accurate diagnosis. If students disagree on a diagnosis, allow each to explain their rationale and make an argument for their point of view. Allow students to consider what additional information, not included in the activity, might help to confirm a diagnosis.

Key aspects of case studies and answers to discussion questions

CASE HISTORY 1:
From Primary Information
Key aspects
  • Excessive daytime sleepiness
  • Possible genetic connection through mother
  • Vivid dreams
  • Inability to move after waking in the morning
  • Weakness associated with emotion
Diagnosis Narcolepsy
Matching symptoms
  • Excessive daytime sleepiness
  • Cataplexy
  • Sleep paralysis
After reading Secondary Information
Is your initial diagnosis confirmed? Answers will vary.
If no, what is your new diagnosis? Answers will vary.
If no, what caused you to change your mind? Entering REM sleep early is consistent with vivid dreams and hypnagogic hallucinations characteristic of narcolepsy.
Recommended treatment Medication and lifestyle changes such as frequent napping
Expected outcome (effect of treatment on patient symptoms) Control of most symptoms

ANSWERS TO DISCUSSION QUESTIONS

  1. Why is it important to consider that the patient’s mother reportedly had a similar problem?

It establishes the possibility of a genetic link for the patient’s disorder. Genetics is implicated in some sleep disorders and not others. In fact, a gene responsible for narcolepsy in dogs has been discovered.

  1. Of what significance is it that this patient’s sleepiness began during her teen years?

The excessive sleepiness characteristic of narcolepsy usually begins during a person’s teen years or early twenties.

  1. Is it important that this patient experienced feeling weak when laughing or being tickled?

Yes, it is. About 60 percent of those with narcolepsy experience this sudden, brief loss of muscle tone, often following an emotional stimulus.

CASE HISTORY 2:
From Primary Information
Key aspects
  • Excessive daytime sleepiness
  • Snoring
  • Regular breathing (rules out OSA)
Diagnosis Insomnia
Matching symptoms
  • Excessive daytime sleepiness
  • Snoring
After reading Secondary Information
Is your initial diagnosis confirmed? Answers will vary.
If no, what is your new diagnosis? Answers will vary.
If no, what caused you to change your mind? Excessive caffeine consumption, drinking alcohol before bedtime, and awakening during the night are all consistent with insomnia.
Recommended treatment
  • Improved sleep hygiene, especially reducing consumption of caffeine and alcohol
  • Medication if necessary
Expected outcome (effect of treatment on patient symptoms) Improved sleep

ANSWERS TO DISCUSSION QUESTIONS

  1. Why is it important that the patient’s wife confirms that although he snores, his breathing is normal during sleep?

These observations help rule out obstructive sleep apnea (OSA) as the patient’s disorder.

  1. The wife never witnessed any unusual events while the patient was asleep. What “unusual events” might she have noticed?

She might have noticed his sleepwalking, talking in his sleep, excessive body movements, or agitation.

  1. How would you suggest that this patient improve his sleep hygiene?

A number of improvements can be made, including maintaining a regular sleep/wake schedule that allows for adequate sleep, avoiding caffeine after the early afternoon, avoiding alcohol before bedtime, unwinding before bedtime and leaving the day’s troubles behind, and ensuring a good sleep environment.

CASE HISTORY 3:
From Primary Information
Key aspects
  • Patient in generally good health
  • Sleepwalking as a child
  • Vivid dreams that are acted out
  • Sleep-related behaviors acted out late in the sleep period
  • Patient relatively young and female
  • No other apparent sleep disorders present
Diagnosis Parasomnia (REM motor behavior disorder)
Matching symptoms
  • Movement to another location (is excessive for REM motor behavior disorder)
  • Acting out vivid dreams
  • Behavior occurs later in sleep period
  • The patient presents symptoms that do not indicate a clear diagnosis. Both sleepwalking and REM motor behavior disorder are possibilities.
After reading Secondary Information
Is your initial diagnosis confirmed? Answers will vary.
If no, what is your new diagnosis? Answers will vary.
If no, what caused you to change your mind? Secondary information is consistent with diagnosis of REM motor behavior disorder.
Recommended treatment
  • Improved sleep hygiene, getting enough sleep, maximizing safety of sleeping environment, and consulting a specialist for an evaluation
  • Possibly medication
Expected outcome (effect of treatment on patient symptoms) Reduced frequency of parasomnia episodes

ANSWERS TO DISCUSSION QUESTIONS

  1. The patient reports these episodes occurring at 3:30 a.m. and 4:00 a.m. Is this important?

Yes. Sleepwalking, another disorder characterized by walking or moving about during sleep, typically occurs during the first third of a night’s sleep. This patient’s abnormal episodes occur later than that.

  1. In general terms, what would you expect this patient’s EMG during sleep to look like if she is experiencing REM motor behavior disorder and not sleepwalking?

One would expect to see periods during REM sleep in which muscle activity increases if the patient is experiencing REM motor behavior disorder. Sleepwalking occurs during NREM sleep.

CASE HISTORY 4:
From Primary Information
Key aspects
  • Patient is male and relatively young
  • Has no trouble falling asleep
  • Has multiple awakenings during the night
  • Excessive daytime sleepiness
  • Recently gained weight
Diagnosis Obstructive sleep apnea
Matching symptoms
  • Has multiple awakenings during the night
  • Excessive daytime sleepiness
  • Obesity
After reading Secondary Information
Is your initial diagnosis confirmed? Answers will vary.
If no, what is your new diagnosis? Answers will vary.
If no, what caused you to change your mind? Patient snores, and stops breathing for up to 30 seconds.
Recommended treatment Use a positive airway pressure device, weight loss, avoid alcohol, avoid sleeping on back, possibly surgery
Expected outcome (effect of treatment on patient symptoms) More normal breathing during sleep and less snoring

ANSWERS TO DISCUSSION QUESTIONS

  1. Why is it significant that the patient has gained 55 pounds in the past two years?

Being overweight is a major risk factor for sleep apnea. Thickening of airway walls and soft tissue in the neck also increase risk, and this is related in part to excess fatty tissue.

  1. Why do patients with sleep apnea wake up feeling unrefreshed?

Sleep apnea is associated with multiple awakenings during the night, thus causing sleep to be fragmented. Also, because breathing stops many times per night, less oxygen is available for body tissues.

  1. Would you expect naps to be helpful in treating obstructive sleep apnea?

No. Naps generally are of little help to those with sleep apnea because the sleep quality is not sufficient to be beneficial. Extra sleep will not eliminate the apnea episodes and the risk of cardiovascular problems.

CASE HISTORY 5:
From Primary Information
Key aspects
  • Difficulty sitting for prolonged periods
  • Excessive daytime sleepiness
  • Difficulty getting to sleep
Diagnosis Restless legs syndrome
Matching symptoms
  • Sitting still for long periods is difficult.
  • Symptoms interfere with sleep.
After reading Secondary Information
Is your initial diagnosis confirmed? Answers will vary.
If no, what is your new diagnosis? Answers will vary.
If no, what caused you to change your mind? Patient complaint that he feels as though bugs are crawling under his skin on his arms and legs is characteristic of restless legs syndrome.
Recommended treatment possibly medication Exercise, massages, avoid alcohol and caffeine
Expected outcome (effect of treatment on patient symptoms) Lessening of symptoms and better sleep

ANSWER TO DISCUSSION QUESTION

  1. Why is it significant that the patient has difficulty in the classroom?

Symptoms worsen during periods of relaxation and decreased activity.


Lesson 4 Organizer
Activity 1: Snoring—Believe It or Not!
What the Teacher Does Procedure Reference

Give each student a copy of Master 4.1, Snoring—Believe It or Not, and instruct them to read it.

  • Have students comment on their experiences with snoring.
master icon Steps 1 and 2

Give each student a copy of Master 4.2, Snoring Survey, and instruct them to complete it.

  • Discuss the students’ responses and relate them to sleep disorders.
master icon
Steps 3 and 4
Activity 2: Diagnosis Unknown
What the Teacher Does Procedure Reference

Divide the class into student teams and have each team review two case histories. For each case history, hand out

  • preliminary information (top portion of Masters 4.3, 4.4, 4.5, 4.6, and 4.7) and
  • Master 4.8, Sleep Specialist’s Evaluation Form.
master icon Steps 1–4
Instruct student teams to use Master 4.9, Sleep Disorders Reference Manual, to make preliminary diagnoses for their case histories. master iconSteps 5 and 6
Ask students if they feel confident about their diagnoses. Step 7

Give each student the secondary information parts of their case histories (the middle portion of Masters 4.3, 4.4, 4.5, 4.6, and 4.7) and ask them to read them.

  • Students should reevaluate their diagnoses in light of this new information.
  • Students should enter final diagnoses on the Sleep Specialist’s Evaluation Form where indicated.

master icon Steps 8–10

Give each student the discussion questions for their case histories (the bottom portion of Masters 4.3, 4.4, 4.5, 4.6, and 4.7) and instruct them to answer them. master icon Step 11

Discuss the case histories.

  • Ask students how they answered the discussion questions.
  • Ask students how they arrived at their diagnoses.

Step 12

master icon= Involves copying a master.  

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