The Nutritional Supplement

History:

• 58-year old Patient is a 70-year old Japanese man who presents with an established diagnosis of COPD. He is seeking help with worsening shortness of breath.
• He is also looking for support for insomnia.
• The patient has never smoked, however from the ages of 25 – 55y, he worked at a green tea farm in Japan. The tea was regularly sprayed with organophosphate pesticides.
• In his early 50’s he developed shortness of breath at rest and wheezing. This progressed to dyspnoea and he developed bronchitis several times. He was diagnosed with COPD and retired at the age of 55. He was put on home oxygen (2 litres).
• His symptoms improved in that the shortness of breath persisted only with light activity (such as walking) but no longer at rest.
• At the age of 60, he and his wife relocated to the US. He now lives in an urban environment in a 2nd floor condo overlooking a busy street.
• He continues to get bronchitis most winters and last year had pneumonia diagnosed as well. He has a productive cough in the mornings. He occasionally has wheezing, especially in cold weather and with an upper respiratory tract illness.
• In addition to these symptoms, since moving to the US he has developed insomnia.
• Specifically, he has trouble falling asleep, often taking 1-2 hours to fall asleep. He awakens twice during the night to urinate and takes up to 30 minutes to fall back asleep. He awakens in the morning after being in bed for 8 hours. He does not wake rested. He says that he does dream. He naps for 1 hour in the afternoon.
• Overweight with a BMI of 27 and a waist circumference of 40 inches
• Vitals: bp = 138/86 p= 70; regular rr = 30 t= 990F Pulse oximetry = 90%
• Dark circles under eyes
• Nails with clubbing
• Heart: RRR, no extra sounds
• Pulmonary: Rhonchi heard on auscultation; increased expiratory time
• No recent labs

Review of Systems (pertinent only):

• Mild benign prostatic hyperplasia (BPH) with nocturia and weakened urinary stream
• Fatigue – attributed to the insomnia

Past Medical Hx:

• Annual bronchitis with pneumonia last year – treated with antibiotics and steroids

Family History:

• Father: CVD; deceased age 78 from MI
• Mother: Breast cancer; deceased age 60
• Son: Apparent good health

Medications:

• Home oxygen
• Albuterol inhaler as needed
• Tamsulosin (Flomax) [selective alpha blocker]: 0.4mg daily

Supplements:

• Green tea: 16oz daily
• Vitamin C: 500mg daily
• Vitamin E as alpha tocopherol: 400iu daily

Typical Daily Diet:

• B: white rice, miso soup, natto (fermented soy)
• L: seafood tempura or grilled chicken, soba noodles
• D: vegetable soup, white rice, chicken, beef or fish, salad, ice cream
• Alcohol: Saki nightly
• Water: 2-4 glasses

Activity:

• Walks slowly for 30 minutes every morning

Psychosocial:

• Patient is accompanied by his wife, who provides most of the history. Patient is alert and oriented, but has a relatively flat affect. He says that he enjoys living in the US with his son’s family. He watches TV and reads most of the day.

Assessment Considerations:

• Address urgent medical conditions first. Often, treatment of the underlying disease (here COPD with a probable infection) will help with insomnia.
• Consider nocturnal desaturation with a chronic COPD patient as a cause of sleep disturbance.
• Insomnia or sleep disturbance can be a common manifestation of many chronic diseases. It is useful to include a simple set of questions in your ROS or routine screening of patients.
• Consider sleep apnoea and narcolepsy in your referral.

Insights, Tips and Perspectives:

• Healthy restorative sleep is foundational for optimal wellness.
• Despite the high prevalence of insomnia, it is rarely formally assessed and should be.
• Figure out what stage of sleep is disturbed- latency (time to fall asleep) or sleep maintenance (staying asleep) or early awakening (often associated with anxiety or other mental health issues) and tailor your intervention to the proper stage.
• Begin with cognitive behavioural therapy to correct poor sleep habits and address many sleep latency issues.

Management Considerations:

• Once the underlying illness is optimised, consider other insomnia treatments.
• Avoid sedating therapies which could suppress respiratory drive.
• Use cognitive behavioural therapy to address poor sleep habits.
• Consider therapies such as magnesium, valerian or melatonin to assist with sleep.