Advanced sleep-wake phase disorder

Advanced sleep–wake phase disorder is a circadian rhythm disorder characterised by persistently early sleep onset and wake times (ie at least 2 hours earlier than desired sleep and wake times). Typically, older adults experience advanced sleep–wake phase disorder—they fall asleep between 6.00 and 9.00 pm, before they can complete social, family or work obligations, and wake in the early hours of the morning (between 2.00 and 5.00 am). This causes distress, disruption, reduced sleep time and daytime sleepiness. As such, advanced sleep–wake phase disorder can be misdiagnosed as late (or terminal) insomnia. Early morning awakenings can also be as symptom of major depression, which should be excluded.

Assess advanced sleep–wake phase disorder with a sleep diary. People with sleep–wake phase disorders tend to sleep less on weekdays, but receive sufficient sleep when sleep is not restricted (eg weekends, holidays). Formal actigraphy can assist with the diagnosis of advanced sleep–wake phase disorder.

If a persistently early sleep–wake routine causes daytime sleepiness and dysfunction, treat advanced sleep–wake phase disorder with the following steps to slowly adjust the circadian rhythm to a sleep–wake routine that provides sufficient sleep:

  • increase sleep efficiency (ratio of time asleep to time in bed) by restricting time in bed to times identified from the sleep diary or actigraphy for several days (eg a person who naturally sleeps from 7.00 pm to 3.00 am would start going to bed and getting up at those times)
  • delay bedtime and wake-up time by 15 to 30 minutes—to assist sleep–wake delay, seek exposure to bright natural or artificial light, and exercise in the evening
  • once the person sleeps well in the new schedule (ie time in bed approximates time asleep), continue to delay bedtime and wake-up times by 15 to 30 minutes increments until desired sleep–wake routine is achieved.

To maintain desired sleep–wake routine, advise the patient to:

  • continue to exercise and seek bright light in the evening
  • keep a regular sleep routine (ie go to bed and arise at the same time each day, including on weekends and holidays).

If the above recommendations are not successful, refer the patient to a sleep expert.