11. Sleep disorders

Question 1

Describe: Excessive daytime sleepiness (4)

Answer 1

• is a symptom of sleep disorders, where the patient has trouble staying awake and alert during the day and may sleep unintentionally and/or inappropriately on a daily basis for at least 3 mo. It is an indication for a more thorough evaluation for other sleep disorders:
• Sleep-related breathing disorders include central and obstructive sleep apnea, and sleep-related hypoventilation—which are all characterized by abnormal respiration during sleep.
• When the sleep–wake cycle is not in sync with the environment, such as the case with shift work or jet lag, or when the sleep phase is delayed or advanced, there may be circadian sleep disorders.
• Parasomnias refer to undesired movements during sleep, and they could be non- rapid eye movement or rapid eye movement related.

Question 2

Define: Insomnia disorder (3)

Answer 2

• characterized by difficulty with initiating or maintaining sleep, or where there is poor sleep quality at least 3 nights/wk for at least 3 mo,
• and causes significant distress or impairment, and the insomnia is not better ac- counted for by another sleep disorder.
• While tiredness and fatigue may be associated with insomnia disorder, excessive daytime sleepiness is not.

Question 3

Name DDX of sleep disorders (13)

Answer 3

• Central sleep apnea
• Circadian rhythm sleep-wake disorders
• Sleep-related hypoventilation
• Substance/medication induced sleep disorder
• Obstructive sleep apnea
• Rapid eye movement sleep behavior disorder
• Restless legs syndrome
• Psychiatric comorbidity
• Insomnia disorder
• Physical disorders
• Poor sleep environment
• Hypersomnolence disorder
• Narcolepsy

Question 4

Describe HX of sleeping disorders (8)

Answer 4

• Conduct a thorough sleep history, use a sleep log
• Obtain collateral history: ask about loud snoring, parasomnias, witnessed apneas
• Differentiate excessive daytime sleepiness from fatigue
  
  • Excessive daytime sleepiness is the inability to stay alert at daytime. There may be inappropriate daytime sleeping (e.g., nodding off while driving).
  • Fatigue is a subjective lack of energy to perform mental or physical tasks.
• Screen for safety concerns related to excessive daytime somnolence (e.g., driving, heavy machinery)
• Screen for obstructive sleep apnea
• Medical history, medications, substance use, over-the-counter products, caffeine intake
• Screen for psychiatric comorbidity such as depression
• Medical review of systems

Question 5

How to screen for obstructive sleep apnea? (8)

Answer 5

“STOP BANG”

• snoring
• tired
• observed apneas
• blood pressure
• BMI over 35 kg/m
• age over 60 yr
• neck circumference over 40 cm
• male gender.

High risk if yes to three or more items.

Question 6

Describe general observation and physical exam: Sleep disorder (4)

Answer 6

• Patients may yawn, fall asleep in the clinic.
• Perform vital signs, obtain BMI, inspection of neck and airway, and perform cardiopulmonary physical exam
• Patients with obstructive sleep apnea may have obesity, large neck circumference, and hypertension.
• Often, patients with excessive daytime sleepiness will not show specific physical exam findings.

Question 7

Name investigations for sleep disorders (3)

Answer 7

• Polysomnography
• Home sleep apnea testing
• Multiple sleep latency testing

Question 8

Polysomnography is recommended when? (6)

Answer 8

for patients with excessive daytime sleepiness when there is suspicion

• obstructive sleep apnea
• periodic limb movement disorder
• sleep-related breathing disorders
• narcolepsy
• central hypersomnias
• seizures during sleep

used to assess for central sleep apnea, periodic leg movement disorder, and narcolepsy.

Question 9

Home sleep apnea testing may be used for patients with a high suspicion of what? (1)

Answer 9

• obstructive sleep apnea when there are no complicating medical conditions and there is little suspicion for other sleep disorders.

Question 10

Multiple sleep latency testing can be performed in sleep laboratories to assess for what? (2)

Answer 10

narcolepsy or idiopathic hypersomnia.

Question 11

Describe management: Sleep disorders (8)

Answer 11

• Counsel the patient on the management of the sleep disorder, depending on the underlying cause
• Counsel the patient that excessive daytime sleeping is a safety risk for driving and operating machinery
• Be aware of provincial laws on reporting medical unfitness to drive
• Arrange for specialized testing as warranted (i.e., patients with excessive daytime sleepiness)
• Treat psychiatric comorbidity
• For patients with insomnia disorder (i.e., no excessive daytime sleepiness and no safety concerns), review sleep hygiene measures:
  
  • Avoid napping
  • Avoid stimulants
  • Exercise early in the day
  • Establish routine bedtimes
  • Associate bed with sleep—use the bed for only sleep and intimacy
• Medications for sleep are for short-term use, and may cause dependency and rebound insomnia on cessation of use.
• CBT may be recommended for insomnia disorder (but is contraindicated for other disorders such as uncontrolled obstructive sleep apnea).