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.

3. Give a copy of Master 4.2, Snoring Survey, to each student and allow a few minutes for the class to answer the questions.
4. 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.

• Question 1. How common is snoring?

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.

• Question 2. What is snoring?

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.

• Question 3. Is snoring a normal part of sleeping, or is it an indication of a medical problem?

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. People being treated for sleep apnea sometimes wear a medical mask that helps keep their airways open.

• Question 4. Is snoring associated with sleeping problems, that is, with sleeping disorders?

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.

• Question 5. Are sleep disorders life threatening, or are they just annoying?

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.

• Question 6. Have you, or a member of your family, ever experienced a sleep disorder?

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.

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.

Content Standard A:
Formulate and revise scientific explanations and models using logic and evidence.

Content Standard A:
Communicate and defend a scientific argument.


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.

8. 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.
9. 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.
10. 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.

11. Give each team the bottom portion of the appropriate case histories that contains discussion questions, and instruct the students to answer them.
12. 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

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.

2. 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.

3. 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.

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.

2. 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.

3. 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.

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.

2. 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.

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.

2. 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.

3. 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.

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

Symptoms worsen during periods of relaxation and decreased activity.