1485 Reviving the Sleep-Wake Cycle: Integrated Approaches to Circadian Rhythm and RLS Management in a Complex Case

Likhita Shaik; Daniel Rongo; Janey Dudley; Anna Wani; Abha Patel

doi:10.1093/sleep/zsaf090.1485

Introduction Circadian rhythm disorders, often misdiagnosed as primary insomnia, can be challenging to treat with medications alone. Effective management requires an integrated approach that combines behavioral therapy, circadian rhythm interventions, and lifestyle modifications[1,2]. This case details the treatment of a 59-year-old male with an irregular sleep-wake pattern, severe social anxiety, and restless legs syndrome (RLS). His treatment involved behavioral strategies and circadian rhythm interventions, resulting in significant improvements in his sleep and overall well-being. Report of case The patient presented with severe sleep disturbances, including spending up to 20 hours in bed per day, with a highly fragmented sleep schedule. His typical sleep pattern involved sleeping at 11:00 PM and waking at 3:15 AM, averaging 6–7 hours of broken sleep nightly, compounded by excessive daytime naps. Initial home sleep apnea testing revealed a total sleep time (TST) of 4 hours and 26 minutes, an apnea-hypopnea index (AHI) of 0.7/hr, and a minimum oxygen saturation of 91%. Follow up polysomnography showed a TST of 175.5 minutes, with a sleep efficiency of 56%, an AHI of 1.0/hr, and a periodic limb movement index of 83.4/hour. An integrated treatment plan was initiated, combining cognitive behavioral therapy for insomnia (CBT-i), sleep environment modifications, and lifestyle changes. The patient was encouraged to adhere to a consistent sleep-wake schedule and reduce time spent in bed during the day. Additionally, he started an exercise program to help manage his RLS symptoms and joined a senior center for increased social engagement. Several sedative medications, including melatonin, hydroxyzine, and trazodone were gradually discontinued. The patient now uses doxepin for insomnia and gabapentin a few times per week for RLS symptoms. Following these interventions, he was able to maintain consolidated nighttime sleep. His RLS symptoms also improved with regular physical activity. Conclusion This case illustrates the effectiveness of an integrated treatment approach combining behavioral therapy, circadian rhythm interventions, and lifestyle changes in managing complex sleep disorders like circadian rhythm dysfunction and RLS. The patient’s use of CBT-i, exercise, and improved sleep hygiene led to a significant reduction in sleep fragmentation and a more regular sleep-wake cycle, as reflected in the improvement in patient’s symptoms.

1485 Reviving the Sleep-Wake Cycle: Integrated Approaches to Circadian Rhythm and RLS Management in a Complex Case

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