6.1 Primary care: Sub-optimal health conditions prior to clinical manifestation of a disease
Long periods of bed rest and low levels of physical activity are associated with increased cardiovascular risk [79] and mortality [80]. It is extremely difficult to comprehensively assess the daily habits of patients in a short period of time in a GP's brief contact. In particular, the survey of regular physical activity according to the recommendations of the World Health Organisation remains a challenge [53]. The activity behaviour among middle-aged adults remains highly insufficient [54].
The 45-year-old patient was referred by his general practitioner with the core symptoms of therapy-resistant sleep disturbance and non-restorative night sleep. The focus of the problem at the time of referral was the poor quality of sleep, attempts at improvement with sedating substances were unsuccessful.
The 14-day actigraphy initiated after taking the patient's history showed a predominantly sedentary lifestyle with almost complete avoidance of physical activity. Significant deconditioning was present, and physiotherapy was indicated.
The patient underwent a cycle of outpatient medical training therapy and reported an improvement in his daily well-being as well as a decrease in the sleep problem that initially led to his presentation.
The use of actigraphy in this case enabled the support of sustainable behaviour change. The patient's original focus on a health disorder (“sleeping sickness”) could be expanded to a broader understanding of the concept of health (“I can be more active in my everyday life and live healthier”).
6.2 Secondary care (to avoid complications and cascading pathologies)
A careful family history opens additional perspectives in the context of therapy, as does the use of objective diagnostics, which can be of importance for therapy [81].
A 65-year-old pensioner was referred by his family doctor because of his sleep disturbances attributed to a decrease of the benzodiazepine effect of the hypnotic therapy prescribed for many years.
After a prolonged actigraphy was performed over 4 weeks, an unusual pattern of sleep fragmentation was revealed. An extended family history was taken to adjust the intended behavioural therapy for insomnia (CBT-I).
Considerable computer gaming activity and imminent indebtedness became evident. Specialist psychiatric treatment for the underlying disorder "gambling addiction" was initiated. A rapid change in the patient's behaviour has been achieved through 24-hour support by family members. Medium-term psychiatric therapy was not desired by the patient.
The relationship between insomnia symptoms and obsessive-compulsive symptoms was also postulated in the context of the corona pandemic [82]. In the presented patient case, however, no increased psychological stress was subjectively reported due to the corona crisis.
If we transfer the patient case to the age group of adolescents, there are connections between media consumption, playing video games and the development of sleep disorders [83, 84]. Prolonged media consumption can cause or complicate the course of psychiatric illnesses through sleep time reduction and social isolation [85].
6.3 Tertiary care
57-year-old patient with chronic pain syndrome on escalated opiate therapy was referred because of significant daytime fatigue combined with pain and sleep disturbances.
Actigraphy shows a predominantly abolished circadian rhythm with rest phases distributed throughout the day. Painkillers and sedative substances are taken in medium to high doses only when needed. General practitioner prescription schemes are no longer observed. The patient was hospitalised for reduction of pain medication and readjustment of medication.
In our case, the use of the actigraphy method in cooperation with the pain physician led to a changed view of the subjective patient information regarding pain experience and prevented the further escalation of pain therapy.
From a sleep- and chronomedical point of view, light therapy in the morning (breakfast on the balcony) was recommended, as well as retarded melatonin added to the basic therapy in the evening [86].
Finally, the establishment of an outpatient service led to a pain therapy based on medical and pharmacological criteria [87]. With a reduced total medication, an improved patient condition has been achieved.
6.4 Help in adolescence: A psychiatric patient with suspended day-night structure
Adolescents frequently complain of academic and personal difficulties in psychiatric outpatient clinics, which often leads to a standard psychiatric diagnosis. Especially in the presence of relevant sleepiness and fatigue, the use of actigraphy can provide complementary and high relevant information towards circadian rhythm disorders [88, 89].
Taking into account the principles of chronomedical therapy and the two-process model of sleep [90], an improvement of the day-night rhythm can be achieved through regular eating times, improvement of the activity level with simultaneous light exposure and melatonin administration [91].
After normalisation of the day-night rhythm, the patient has been admitted to long-term psychiatric therapy.