Chapter 028. Sleep Disorders (Part 5) potx

Sleep Disorders Part 5 Disorders of Sleep and Wakefulness Approach to the Patient: Sleep Disorders Patients may seek help from a physician because of one of several symptoms: 1 an acu

Chapter 028 Sleep Disorders

(Part 5)

Disorders of Sleep and Wakefulness

Approach to the Patient: Sleep Disorders

Patients may seek help from a physician because of one of several symptoms: (1) an acute or chronic inability to initiate or maintain sleep adequately

at night (insomnia); (2) chronic fatigue, sleepiness, or tiredness during the day; or (3) a behavioral manifestation associated with sleep itself Complaints of insomnia

or excessive daytime sleepiness should be approached as symptoms (much like fever or pain) of underlying disorders Knowledge of the differential diagnosis of these presenting complaints is essential to identify any underlying medical disorder Only then can appropriate treatment, rather than nonspecific approaches (e.g., over-the-counter sleeping aids), be applied Diagnoses of exclusion, such as primary insomnia, should be made only after other diagnoses have been ruled out

Table 28-1 outlines the diagnostic and therapeutic approach to the patient with a complaint of excessive daytime sleepiness

Table 28-1 Evaluation of the Patient with the Complaint of Excessive Daytime Somnolence

Finding

s on History

and Physical

Examination

Diagnostic Evaluation

Diagnosis Therapy

Obesity,

snoring,

hypertension

Polysomnograp

hy with respiratory monitoring

Obstructi

ve sleep apnea

Continuous positive airway pressure; ENT surgery (e.g., uvulopalatopharyngoplast y); dental appliance; pharmacologic therapy (e.g., protriptyline); weight loss

Cataplex

y, hypnogogic

Polysomnograp

hy with multiple sleep

Narcoleps y-cataplexy

Stimulants (e.g., modafinil,

hallucinations,

sleep paralysis,

family history

latency testing syndrome methylphenidate);

REM-suppressant antidepressants (e.g., protriptyline); genetic counseling

Restless

legs, disturbed

sleep,

predisposing

medical

condition (e.g.,

iron deficiency

or renal failure)

Assesment for predisposing medical conditions

Restless legs syndrome

Treatment of predisposing condition, if possible; dopamine agonists (e.g., pramipexole, ropinirole)

Disturbe

predisposing

medical

conditions

(e.g., asthma)

Sleep-wake diary recording

Insomnias (see text)

Treatment of predisposing condition and/or change in therapy,

if possible; behavioral therapy; short-acting benzodiazepine receptor

and/or

predisposing

medical

therapies (e.g.,

theophylline)

agonist (e.g., zolpidem)

Note: ENT, ears, nose, throat; REM, rapid eye movement; EMG,

electromyogram

A careful history is essential In particular, the duration, severity, and consistency of the symptoms are important, along with the patient's estimate of the consequences of the sleep disorder on waking function Information from a friend

or family member can be invaluable; some patients may be unaware of, or will underreport, such potentially embarrassing symptoms as heavy snoring or falling asleep while driving Patients with excessive sleepiness should be advised to avoid all driving until effective therapy has been achieved

Completion by the patient of a day-by-day sleep-work-drug log for at least

2 weeks can help the physician better understand the nature of the complaint Work times and sleep times (including daytime naps and nocturnal awakenings) as well as drug and alcohol use, including caffeine and hypnotics, should be noted each day

Polysomnography is necessary for the diagnosis of specific disorders such

as narcolepsy and sleep apnea and may be of utility in other settings as well In addition to the three electrophysiologic variables used to define sleep states and stages, the standard clinical polysomnogram includes measures of respiration (respiratory effort, air flow, and oxygen saturation), anterior tibialis EMG, and electrocardiogram