Ebook Sleepy or sleepless - Clinical approach to the sleep patient: Part 1

(BQ) Part 1 book Sleepy or sleepless - Clinical approach to the sleep patient presents the following contents: Key history and physical examination findings in the sleepy patient, diagnostic tools and testing in the sleepy patient, central nervous system hypersomnias, sleep deprivation, the sleepy child,...

Editor

Sleepy or Sleepless

Clinical Approach to the Sleep Patient

ISBN 978-3-319-18053-3 ISBN 978-3-319-18054-0 (eBook)

DOI 10.1007/978-3-319-18054-0

Library of Congress Control Number: 2015942895

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2015

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed

The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use

The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors

or omissions that may have been made

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media ( www.springer.com )

Editor

Raman K Malhotra, MD

Director, Neurology Residency Program

Co-Director, SLUCare Sleep Disorders Center

Director, Sleep Medicine Fellowship

Assistant Professor of Neurology

Saint Louis University School of Medicine

St Louis , MO , USA

It is with this in mind that this book is strategically divided into two sections: Part

I focuses on “The Sleepy Patient” and is subdivided into seven chapters addressing history and physical fi ndings, diagnostic tools and tests, and then proceeds with a discussion of the two key clinical entities: sleep disordered breathing and central nervous system hypersomnias, which most commonly present with excessive sleep-iness The chapter on sleepiness in industry is indispensable given the important contributions of shift work schedule requirements on human sleep Part I concludes with two chapters covering sleep deprivation, a pervasive problem in today’s society

as frequently demonstrated by National Sleep Foundation polls, and the sleepy child, which is an often neglected problem but a recent epidemic for any number of reasons Part II “The Sleepless or Restless Patient” mirrors Part I in its organiza-tional approach covering history, physical exam, and tests in addressing these patients This is followed by a discussion of key causes of sleeplessness including insomnia, circadian rhythm disorders, and movement disorders of sleep Separate discussion is later provided covering the sleepless child and problems with sleep-lessness during and after pregnancy

The authors have done a remarkable job in producing a text that is eloquent, practical, and concise All are authorities on the various topics assigned to them through their intimate knowledge of the subject area, which they have not only researched, but also have contributed to the evidence for diagnostic approaches and management strategies The readership should be aware that the authors’ credibility

as writers is derived from their reputable clinical expertise, as well as serving as key opinion leaders and researchers in the fi eld

Every clinician, whether a busy primary care physician, a subspecialist or a trainee needs to ask patients about their sleep quality Having a “road map” within reach to empower clinicians for making appropriate and well-reasoned decision is critical Given that sleep medicine is underrepresented in graduate medical educa-

tion curriculum, resources such as Sleepy or Sleepless: Approach to the Sleep

Patient are indispensible Dr Malhotra and his fellow authors should be

congratu-lated on delivering this masterful textbook and for their commitment and tion in propelling sleep medicine education and clinical care

February 25, 2015

Foreword

tems such as the International Classifi cations of Sleep Disorders —third Edition that was released in 2014 as well as the Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition (DSM-5)

To further make this text more practical, the content is separated into two tions: (1) The Sleepy Patient and (2) The Sleepless/Restless Patient With a focus

sec-fi rst on the patient’s chief complaint, this layout will provide the reader the proper framework to perform a complete clinical evaluation of their patient’s sleep com-plaint, make the proper diagnosis, and then choose the most effective management for their patient Each of the two sections provides a detailed chapter on proper history-taking and key physical examination fi ndings that will be helpful in the clinical evaluation of sleep patients In addition, I have included a chapter in each section on common screening tools, tests, and “templates” that can be used in the clinical setting to assist in the offi ce visit Much of these tools are validated and used frequently in clinical trials and research Other tools, on the other hand, were

on the individual and society is highlighted in a separate chapter

I hope this book serves useful for learners on the sleep medicine elective or ers on other rotations interested in how patients with sleep disorders present In addition, this book will provide a solid foundation to clinicians who want to better evaluate patients who present to their offi ce with sleepiness or sleeplessness

St Louis, MO, USA Raman K Malhotra, M.D

Preface

I would like to express my gratitude to all the accomplished authors who took time away from their families and friends to contribute to this book I would also like to thank my colleagues and staff at the SLUCare Sleep Disorders Center and in the Department of Neurology and Psychiatry at Saint Louis University for their support and guidance with this project I would like to give my sincere gratitude to my Chairman, Dr Henry Nasrallah, for his input and advice

I would like to thank Dr Ronald Chervin who helped guide me early on in my career and drew me to the exciting fi eld of sleep medicine while I was at the University of Michigan Sleep Disorders Center in Ann Arbor, Michigan I would like to thank Dr Alon Avidan who has provided me invaluable support and guid-ance throughout this project and throughout my career I would like to thank the publishing team from Springer who made this book possible and were wonderful to work with Lastly, I would like to thank my parents, my wife, Shalini, and my two sons, Yash and Sanjay, for their inspiration and understanding while I worked on this important endeavor

St Louis, MO, USA Raman K Malhotra, M.D

Part I The Sleepy Patient

1 Key History and Physical Examination Findings

in the Sleepy Patient 3 Raman K Malhotra

2 Diagnostic Tools and Testing in the Sleepy Patient 13 Douglas Kirsch

3 Sleep-Related Breathing Disorders 29 Joseph Roland D Espiritu

4 Central Nervous System Hypersomnias 53 Lourdes M DelRosso and Romy Hoque

5 Sleepiness in High-Consequence Industries 59 Matthew Uhles

6 Sleep Deprivation 75 Pradeep C Bollu , Munish Goyal , and Pradeep Sahota

7 The Sleepy Child 91 Suresh Kotagal

Part II The Sleepless or Restless Patient

8 Key History and Physical Examination Findings

for the Sleepless or Restless Patient 101

John Harrington and Kelly Marie Newton

9 Diagnostic Tools and Testing in the Sleepless

and Restless Patient 107

Fouad Reda

10 Assessment and Management of Insomnia 113 Edward D Huntley and J Todd Arnedt

11 Sleepless Patient: Circadian Rhythm Sleep–Wake Disorders 133

Hallie Kendis and Phyllis C Zee

12 Restless Legs Syndrome: The Devil Is in the Details 151

Paul J Sampognaro , Rachel E Salas , Aadi Kalloo ,

and Charlene Gamaldo

13 The Parasomnias 167

Emmanuel H During and Alon Y Avidan

14 The Sleepless Child 183

Amol Purandare and Shalini Paruthi

15 Sleeplessness During and After Pregnancy 195

Louise M O’Brien and Leslie M Swanson

Index 205

Contents

J Todd Arnedt , Ph.D Sleep and Chronophysiology Laboratory, Behavioral Sleep Medicine Program, Department of Psychiatry and Neurology , University of Michigan Health System , Ann Arbor , MI , USA

Alon Y Avidan , M.D., M.P.H Sleep Disorders Center, Department of Neurology, University of California , Los Angeles , CA , USA

Pradeep C Bollu , M.D Department of Neurology , University of Missouri , Columbia , MO , USA

Lourdes M DelRosso , M.D The Children’s Hospital of Philadelphia , University

of Pennsylvania School of Medicine , Philadelphia , PA , USA

Emmanuel H During , M.D Department of Psychiatry and Behavioral Sciences, Stanford Center for Sleep Sciences and Medicine, Stanford University , Redwood City , CA , USA

Joseph Roland D Espiritu , M.D., F.C.C.P., F.A.A.S.M Division of Pulmonary Disease, Critical Care, and Sleep Medicine, SLUCare Sleep Disorders Center, Saint Louis University School of Medicine , St Louis , MO , USA

Charlene Gamaldo , M.D Department of Neurology, Johns Hopkins University, School of Medicine , Baltimore , MD , USA

Munish Goyal , M.D., M.Ch Department of Neurology , University of Missouri Healthcare , Columbia , MO , USA

John Harrington , M.D., M.P.H Division of Pulmonary/Critical Care/Sleep/Allergy , Nebraska Medical Center , Omaha , NE , USA

Romy Hoque , M.D Department of Neurology , Louisiana State University of School of Medicine , Shreveport , LA , USA

Edward D Huntley , Ph.D Sleep and Chronophysiology Laboratory, Department

of Psychiatry , University of Michigan Health System , Ann Arbor , MI , USA

Aadi Kalloo , B.A Department of Molecular Microbiology and Immunology , Johns Hopkins School of Public Health , Baltimore , MD , USA

Department of Neuroscience, Johns Hopkins University, School of Medicine, Baltimore, MD, USA

Hallie Kendis , M.D Northwestern University Feinberg School of Medicine , Chicago , IL , USA

Douglas Kirsch , M.D Sleep Disorders Center, Carolinas HealthCare System , Charlotte , NC , USA

Department of Medicine, University of North Carolina School of Medicine, Charlotte, NC, USA

Suresh Kotagal , M.D Division of Child Neurology and Center for Sleep Medicine , Mayo Clinic , Rochester , MN , USA

Raman K Malhotra , M.D SLUCare Sleep Disorders Center, Department of Neurology and Psychiatry, Saint Louis University School of Medicine , St Louis ,

MO , USA

Kelly Marie Newton Division of Critical Care and Hospital Medicine, Department

of Medicine, National Jewish Health , Denver , CO , USA

Louise M O’Brien , Ph.D., M.S Sleep Disorders Center, Department of Neurology, Obstetrics and Gynecology, and Oral and Maxillofacial Surgery , University of Michigan , Ann Arbor , MI , USA

Shalini Paruthi , M.D Pediatric Sleep and Research Center, Department of Pediatrics and Internal Medicine , St Louis University School of Medicine ,

St Louis , MO , USA

Amol Purandare , M.D Department of Pediatrics , Saint Louis University School

of Medicine , St Louis , MO , USA

Fouad Reda , M.D SLUCare Sleep Disorders Center, Department of Neurology and Psychiatry , St Louis University School of Medicine , St Louis , MO , USA

Pradeep Sahota , M.D Department of Neurology, Sleep Disorder Center , University of Missouri School of Medicine , Columbia , MO , USA

Rachel E Salas , M.D Department of Neurology , Johns Hopkins University, School of Medicine , Baltimore , MD , USA

Paul J Sampognaro Department of Neurology , Johns Hopkins University, School

of Medicine , Baltimore , MD , USA

Contributors

Leslie M Swanson , Ph.D Department of Psychiatry , University of Michigan , Ann Arbor , MI , USA

Matthew Uhles , M.S., B.S Clayton Sleep Institute , Maplewood , MO , USA

St Louis University , St Louis , MO , USA

Phyllis C Zee , M.D., Ph.D Sleep Disorders Center, Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine , Chicago ,

IL , USA

Part I

The Sleepy Patient

© Springer International Publishing Switzerland 2015

R.K Malhotra (ed.), Sleepy or Sleepless, DOI 10.1007/978-3-319-18054-0_1

Key History and Physical Examination

Findings in the Sleepy Patient

Raman K Malhotra

Excessive daytime sleepiness (EDS) is defi ned as “the inability to stay awake and alert during the major waking episodes of the day, resulting in unintended lapses into drowsiness or sleep” [ 1 ] This symptom is common among the population; National Sleep Foundation (NSF) polls have suggested that more than 30 % of the surveyed population has daytime sleepiness that interferes with their quality of life [ 2 ] Daytime sleepiness can have signifi cant consequences, particularly when combined with activities requiring alertness for safety, such as operating a car Drowsy driving

is an unfortunate, but common, occurrence; 52 % of polled subjects had driven while drowsy in a recent NSF poll [ 3 ] Patients may not use the words “daytime sleepiness” to describe the way that they feel; some will use other terminology, such

as “drowsiness,” “tendency to fall asleep,” and “decreased alertness” [ 4 ]

Behaviorally induced insuffi cient sleep, or more simply put—not getting enough sleep, is the most common reason for daytime sleepiness in the general population According to the NSF’s Sleep in America 2011 poll, 39 % of subjects self reported less than 7 h per night on typical work or school days [ 5 ] In a sleep clinic referral population, EDS is the most common presenting complaint; although, in contrast, obstructive sleep apnea (OSA) is the most common cause of hypersomnia [ 6 ] Several other causes of hypersomnia exist; selected sleep disorders with the effect

of hypersomnia are listed below

• Behaviorally induced insuffi cient sleep syndrome

• Sleep-disordered breathing

R K Malhotra , M.D ( * )

SLUCare Sleep Disorders Center, Department of Neurology and Psychiatry ,

Saint Louis University School of Medicine , St Louis , MO , USA

e-mail: rmalhot1@slu.edu

• Narcolepsy

• Idiopathic hypersomnias

• Periodic limb movement disorder

• Kleine–Levin Syndrome (recurrent hypersomnia)

• Circadian rhythm disorder

Selected medical disorders that cause hypersomnia are listed here:

• Cancer

• Congestive heart failure

• Central nervous system disorders (brain lesions, hydrocephalus, multiple sclerosis, stroke)

• Endocrine disorders (growth hormone defi ciency, hypothyroidism)

• Genetic disorders (fragile X syndrome, myotonic dystrophy, Prader–Willi)

• Hypersomnia due to drug, toxin, or other substance

• Posttraumatic hypersomnia

• Pulmonary disorders (chronic obstructive pulmonary disease)

• Sleeping sickness (protozoan infection)

• Chronic renal insuffi ciency

• Hepatic encephalopathy

History-Taking

Many patients will not appropriately recognize their degree of daytime ness Family members or coworkers may be the fi rst to recognize the severity of the problem and may sometimes be better resources to the clinician than the patient For example, a patient may only begin to recognize the problem when it markedly affects their work productivity or they have a motor vehicle accident because they fell asleep behind the wheel The symptoms of sleepiness may have been chronic and ongoing for years, which make it diffi cult for the patient to know what “normal” alertness and energy levels are supposed to be Furthermore, the sleep disorders have an effect on the brain’s ability to self-assess performance and may lead to inaccurate judgments by the patient in their ability to perform an activity

It is important to ask the patient and any family members the level of sleepiness and how it affects different aspects of their life, such as their job, school, driving, or social activities There are standardized forms and questionnaires that can be uti-lized to measure subjective sleepiness, and will be discussed in the subsequent chapter ( Appendix ) It is helpful to inquire how their level of sleepiness changes throughout the day and which days of the week are worse than others Patients may

R.K Malhotra

have other ways that their “sleepiness” may present itself, such as hyperactivity, inattention, poor behavior, irritability, or fatigue Many patients suffering from sleep disorders may deny EDS, and describe their symptoms as “fatigue,” “tiredness,” or

“lack of energy” [ 7 ]

The following questions will assist in a comprehensive evaluation of a sleepy patient They have been divided into the typical sections of patient presentations

History of Presenting Illness (HPI)

The clinician should ask bedtimes, wake times, and elicit nap start and stop times, frequency for school or work days and also days off (usually weekends) Ask about bedtime routine, latency to sleep, awakenings at night, and wake after sleep onset Find out any unusual motor activities that may be occurring during sleep If a patient reports having to sleep much later in the morning on off days or having to set mul-tiple alarms on work days, this may be a sign of insuffi cient or unrefreshed sleep Patients may frequently oversleep in the morning, or frequently press the “snooze” button every morning Inquire about sleep habits such as exposure to light before bed (i.e., tablets, computers) and sleep environment (noise, temperature, and roommate)

Ask if the patient falls asleep during inappropriate times such as at the table during dinner or during religious services Patients may fall asleep in unusual positions such as standing up Assess if the patient has had any near-miss driving incidents, car crashes or work accidents due to sleepiness Assess typical work hours, if patient has daytime work hours or is the patient a shift worker Shift workers tend to sleep poorly due to trying to sleep during the day and may not have consecutive work nights, thus keeping a fairly irregular schedule Utilizing standardized question-naires, sleep diaries, or actigraphy can also be helpful

The clinician should ask the patient regarding common etiologies for nia, such as OSA, restless legs syndrome, narcolepsy, shift work disorder, and insuf-

hypersom-fi cient sleep, by asking them about signs and symptoms of these disorders Different methods and tools for diagnosing these conditions will be discussed in the subse-quent chapters in the book with each respective disorder It is important to ask both the patient and other family members about snoring, noisy breathing, or pauses in breathing during sleep which could be indicative of OSA Other symptoms of sleep apnea may include nocturia, acid refl ux during sleep, night sweats, and mouth breathing Restless legs syndrome can be evaluated by asking the patient about leg discomfort or an urge to move their legs in the evening or at night that disrupts their sleep and improves with movement In patients with severe daytime sleepiness, it is necessary to ask about sleep paralysis, sleep-related hallucinations, and cataplexy that may be seen in narcolepsy

Past Medical History

Clinicians should ask the patient about any past medical or psychiatric history, as these may place patients at risk for certain sleep disorders or can cause some EDS For example, a history of heart failure or stroke may put the patient at high risk for central or OSA Patients with craniofacial disorders or midface hypoplasia, such as patients with cleft palate or Down syndrome are at higher risk of sleep-related breathing disorders Renal disease or peripheral neuropathy can put the patient at risk for restless legs syndrome

Past Surgical History

Assess for previous airway surgeries; some patients will present with residual OSA

Social History

Inquire about any tobacco, alcohol, or drug use given the signifi cant effects use or withdrawal of these substances can have on sleep and energy levels A history of smoking puts the patient at risk for sleep-disordered breathing In addition, it is essential to ask about use of caffeine, as many patients with sleepiness will try and mask their symptoms with the alerting properties of caffeine In addition to whether

or not they use caffeine, the clinician should carefully document the amount of caffeine that is being used (i.e., size of coffee, type of caffeinated beverage) Occupational history is signifi cant, as certain occupations come with specifi c regulations in regards to sleepiness (i.e., pilots, truck drivers), but may also make the clinician aware of overnight or shifts during nontraditional hours or frequent oversea travel Depending on their job, it may be necessary for the clinician to rec-ommend time away from their work until an evaluation is complete if there is risk

of injury to the patient or the public due to their sleepiness

Family History

A careful family history in regards to known sleep disorders such as sleep apnea, restless legs syndrome, or narcolepsy may aid the clinician in diagnosis since there

is a higher risk of these conditions with fi rst degree family members It is important

to ask not only if they have a formal diagnosis in their family, but about signs and symptoms of these conditions, as many people’s sleep disorders are yet to be diag-nosed or treated For example, many patients know there are other family members that snore, but may not have been formally diagnosed by sleep study

R.K Malhotra

Medications

Inquiring about medications that the patient may be taking (both prescription and over the counter) is important, as sleepiness and fatigue are common side effects of many medications

For example, antiepileptics, dopamine agonists, pain medications, and beta blockers can make patients feel sleepy or fatigued Patients taking a diuretic medication at bedtime may need to get up to the restroom several times a night, thus disrupting sleep further

examina-in the waitexamina-ing room , or dozexamina-ing off durexamina-ing your history and physical exam, this can give insight into their level of sleepiness during the day Their overall mood, affect, and mental status may point to a psychiatric diagnosis such as depression

or anxiety Portions of the physical exam are described in the following sections

Vital Signs and General Appearance

It is necessary to obtain vital signs as this may assist in the diagnosis of the sleep complaint Patients with hypertension are at high risk for sleep apnea Any abnormal respiratory signs or low oxygen saturations put the patient at risk for sleep- related breathing disorders Look for extremes in weight and BMI, such as failure to thrive

in children as an indication to further pursue evaluation of sleep-disordered breathing due to excessive work of breathing On the other hand, an overweight or obese patient

is also at high risk for OSA

Head and Neck

Males with a neck circumference >17 in and women with a neck circumference

>16 in are at high risk for OSA

Eyes

Patients with OSA may have fl oppy eyelid syndrome

Ear, Nose, and Throat Exam

Certain signs on physical exam lead to a higher risk of OSA: crowded upper airway exam, dental malocclusion, craniofacial abnormalities, and enlarged neck circum-ference The clinician should document the Mallampati classifi cation palatal length, and presence and size of tonsils on otolaryngological examination as specifi c fi nd-ings put the patient at high risk for OSA Adenoids can be best visualized by nasal endoscopy, usually performed by an otolaryngologist

The Mallampati classifi cation or score was fi rst described to assist clinicians in determining ease of intubation by grading the size of the airway This grading scale has also correlated with risk of OSA and serves as a useful tool in describing the pos-terior pharyngeal structure and airway The score is obtained by asking the patient while sitting to open their mouth and fully protrude their tongue (no phonation) and examining the airway [ 8 ] Mallampati 1 classifi cation is when you can view the soft palate, hard palate, uvula, and tonsillar pillars A Mallampati 2 classifi cation is when you can see the other three structures, but not the tonsillar pillars In a Mallampati class 3, only the soft and hard palate, and base of the uvula is seen In a Mallampati class 4, only the hard palate is visualized, suggesting a crowded airway putting the patient at highest risk for sleep apnea Most patients with OSA have a high arched hard palate and low lying soft palate

Other notable features on exam that may suggest OSA include mouthbreathing, noisy breathing while awake, drooling, adenoidal facies (elongated face), microgna-thia, retrognathia, macroglossia, scalloping of the tongue, and signifi cant overjet

Cardiovascular

It is important to listen to heart sounds closely for the presence of murmurs and possible arrhythmias Cardiac disease and sleep-related breathing disorders often co- occur Patients with congestive heart failure are at risk for central sleep apnea, OSA and Cheyne-Stokes respirations Patients with arrhythmias are at high risk for OSA

R.K Malhotra

Lungs

An abnormal pulmonary exam (i.e., crackles, wheezes) suggests an underlying pulmonary condition which puts the patient at high risk of sleep-disordered breathing (obstructive or central sleep apnea, sleep-related hypoventilation/hypoxemia)

Neurologic Exam

A complete neurological examination is helpful as many neurological conditions put patients at risk for hypersomnia and sleep disorders Findings on exam of a resting tremor, cogwheel rigidity, and bradykinesia suggest Parkinson’s disease, putting the patient at risk for dream enactment behavior (Rapid eye movement [REM] sleep behavior disorder) Focal defi cits may be a sign of demyelinating disease or stroke, putting the patient at risk for central sleep apnea or central ner-vous system hypersomnias A good peripheral nerve exam, including strength, refl exes, and a sensory exam, is necessary in evaluating patients with possible rest-less legs syndrome

Thus, in summary, the history and physical exam of your patient are key to a prehensive evaluation of the sleepy patient Subsequent chapters will cover common questionnaires and diagnostic tests that can be administered to patients who present with sleepiness and then discuss specifi c sleep disorders in greater detail

Appendix Saint Louis University Sleep Clinic Evaluation Form

Age Race

M/F

Sleepy: Y/N Sleep schedule:

Symptoms Tired: Y/N Work days

Snoring: Y/N Fatigue: Y/N Bedtime: _ am/pm Frequent snoring Y/N Sleepy during day

with:

Time to sleep _

Heard outside room Y/N – Sitting & Reading Wake time: _am/pm Bothering bed partner Y/N – Watching TV/movie Total sleep time _

Wake up gasping for air? Y/N – Driving Alarm Y/N

Witnessed apnea: Y/N – Passenger in car Off days

Mouth breathing Y/N – At work/school Bedtime: am/pm Nasal congestion Y/N – Poor concentration Wake time: am/pm

AM headaches Y/N – MVA’s from EDS

(#)

Alarm Y/N

GERD Y/N – Close calls

(#) Sweating at night Y/N

Supine or lateral sleep Epworth sleepiness

score

Arousals: Y/N; _x/night

Fatigue severity

score _

Time to fall back asleep: _

Refreshed in am: Y/N Cause of arousals?

Time most tired

Naps: Y/N Naps: _day/

MEDS : Tob: Y/N Etoh Y/N

Caffeine Y/N _cups/day Occupation:

Exercise:

FH: OSA/RLS/insomnia

Snore/narcolepsy/heart disease

ROS : Sleep review of systems:

RLS (creepy/crawly,

twitchy)

Y/N Act out dreams Y/N

(better with walking) Y/N Sleepwalking Y/N

(worse at night) Y/N Bruxism Y/N

PLMs (kick at night) Y/N Hallucination Y/N

Nightmares Y/N Cataplexy Y/N

Ruminating thoughts Y/N Sleep paralysis Y/N

Clock-watching Y/N Insomnia Meds History:

R.K Malhotra

PHYSICAL EXAM:

VITALS : BP HR R Neck circ BMI

General appearance/mental status

CN -PERRLA, pupil size, CV-RRR w/o murmur

EOMI, visual fi elds full Carotid bruits Y/N, pulse amplitude Face sensation/strength intact Lungs-CTA B

Hearing intact bilaterally

Palate elevates symmetrically

Tongue protrudes to midline

SCM/traps full strength

Motor -5/5 throughout, normal bulk/tone

Refl exes (R/L) biceps, triceps, brach, patellar, achilles, toes

Sensory -intact to PP/LT/vibr

7 Chervin RD Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea Chest 2000;118(2):372–9

8 Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL A clinical sign to predict diffi cult tracheal intubation: a prospective study Can Anaesth Soc J 1985;32(4):429–34

© Springer International Publishing Switzerland 2015

R.K Malhotra (ed.), Sleepy or Sleepless, DOI 10.1007/978-3-319-18054-0_2

History taking is of primary importance when assessing a patient who presents with daytime sleepiness; however, subjective or objective assessments are often helpful in making the correct diagnosis or in tracking the patient’s symptom severity over time to assess treatment outcome Evaluation via subjective testing is faster and cost effective, though it may not provide enough specifi city to make an accurate diagnosis Objective evaluations can be time consuming and are signifi cantly more expensive, but may help to effectively guide the clinician to an appropriate treat-ment strategy Knowing how and when to utilize assessment tools is critical to good clinical outcomes

D Kirsch , M.D ( * )

Sleep Disorders Center , Carolinas HealthCare System ,

1601 Abbey Place Bldg 2, Suite 200 , Charlotte , NC 28209 , USA

Department of Medicine , University of North Carolina School of Medicine ,

1601 Abbey Place Bldg 2, Suite 200 , Charlotte , NC 28209 , USA

e-mail: douglas.kirsch@carolinas.org

Subjective Tools

Several questionnaires are available to screen patients for the presence of sleep orders and hypersomnia; this section will review several of the most common ones used in today’s clinical practice Selection of the most appropriate questionnaire will vary based on the patient’s symptoms and demographics Thus, this section will

dis-be subdivided into three groups: general sleep, EDS, and obstructive sleep apnea (OSA) Table 2.1 contains the listed questionnaires, and current Internet locations for some of these subjective tools are located in Table 2.2

General Sleep

Patients are often referred to sleep disorder centers with a suspicion of a rare sleep disorder, such as narcolepsy, due to their EDS, when in fact a more commonplace issue is to blame Clinical history taking is paramount, in order to best distinguish amongst the potential causes of hypersomnia General sleep questionnaires can then help guide the clinician in understanding symptom patterns and severity

After an initial visit with the clinician, most patients complaining of nia should be given a sleep diary to complete The sleep diary is an instrument in which the patient would keep track their daily sleep patterns Information may include medications taken, bedtime, time to sleep onset, number of awakenings, time of waking, time out of bed, and length and timing of any naps A sleep diary should typically be used for 1–2 weeks, but it may also be used as a long-term method of assessing a patient’s sleep time, particularly as behaviorally induced

Table 2.1 List of discussed sleep questionnaires by category

General sleep assessments Sleep diary

SF-12, SF-36 Daytime sleepiness Epworth Sleepiness Scale [ 34 ]

Stanford Sleepiness Scale [ 35 ] Functional Outcomes of Sleep Questionnaire [ 36 ] OSA Berlin Questionnaire [ 37 ]

STOP-BANG Questionnaire [ 38 ]

Table 2.2 Internet-based locations of some sleep disorder scales

Epworth Sleepiness Scale http://epworthsleepinessscale.com/

Stanford Sleepiness Scale http://www.stanford.edu/~dement/sss.html

Berlin Questionnaire http://www.aafp.org/afp/2000/0315/p1825.html

STOP-BANG Questionnaire http://sleepapnea.org/assets/fi les/pdf/STOP-BANG%20

Questionnaire.pdf Sleep diary http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf

insuffi cient sleep is a common cause of daytime sleepiness It is worth considering that insuffi cient sleep may be quite subtle; a loss of 30–60 min of sleep per weekday may induce chronic mild sleep deprivation, from which some patients may be clearly symptomatic A sample sleep diary is provided in Fig 2.1 ; another example

is available on the Internet, referenced in Table 2.2

A nonspecifi c assessment of the effect of sleep disorders on the lives of patients may be performed by the Short Form 36 (SF-36), a 36-question survey with “an 8-scale profi le of functional health and well-being scores as well as psychometrically- based physical and mental health summary measures and a preference-based health utility index” [ 3 ] This questionnaire has been used to assess many medical disor-ders, including many sleep disorders The SF-12, a shorter, one-page form, is also available and has been used in sleep research [ 4 ]

Excessive Daytime Sleepiness

The most widely used questionnaire specifi cally for daytime sleepiness is the Epworth Sleepiness Scale (ESS), developed in 1991 by Dr Murray Johns In research studies, the ESS has been shown to be reliable when testing and retesting individuals over time The ESS assesses a patient’s self-report of sleepiness by ask-ing about eight different situations and the likelihood of a patient dozing in each of them The Likert response scale ranges from 0 (“would never doze”) to 3 (“high chance of dozing”) Adding the results from each question determines a total score that measures subjective sleep propensity “in recent times.” Early research demon-strated that ESS scores greater than 15 were observed in patients with narcolepsy,

Fig 2.1 Sample sleep log

2 Diagnostic Tools and Testing in the Sleepy Patient

idiopathic hypersomnolence, or moderate/severe OSA Since the ESS is easy to use,

it has been commonly used in research studies; however confl icting results exist regarding the ability of the ESS to predict objective measures of daytime sleepiness [ 5 , 6 ] These results suggest that in practice, the ESS is best used to assess subjective sleepiness in a standardized manner though it is unlikely to replace objective test-ing Tracking ESS scores longitudinally for individual patients does appear useful

in assessing change or treatment response over weeks to months

The Stanford Sleepiness Scale (SSS) provides an instantaneous subjective sure of sleepiness as a single question on a seven-point scale [ 7 , 8 ] The scale ranges from “feeling active, vital, alert, or wide awake” (1 on the scale) to “no longer fi ght-ing sleep, sleep onset soon, or having dreamlike thoughts” (7 on the scale) This scale, in contrast to the ESS, can be used by the same patient many times in 1 day

mea-to help track sleep drive However, this scale becomes less meaningful over longer time periods (weeks to months), since many factors can impact an instantaneous measure of daytime sleepiness The Karolinska Sleepiness Scale (KSS) is very sim-ilarly designed, with the primary difference being that it has a nine-point scale instead of seven [ 9 ] Both of these immediate-assessment sleep scales are validated with objective sleep measures including EEG and performance [ 10 , 11 ]

The impact of daytime sleepiness on activities of daily living can be assessed by the Functional Outcomes of Sleep Questionnaire (FOSQ) The FOSQ was designed

at a fi fth grade reading level, is designed to take 15 min to complete, and contains

74 questions over six domains (orientation, physical independence, mobility, pation, social integration, and economic self-suffi ciency), as well as assessment of several additional daily endeavors potentially affected by daytime sleepiness Initially, this questionnaire was validated to discriminate between normal subjects and those seeking medical attention for a sleep problem [ 12 ] It has since been shown to change with positive pressure therapy for OSA [ 13], treatment with modafi nil [ 14 ], and with other treatments of OSA [ 15 ] A modifi ed short form of the FOSQ, the FOSQ-10, has also been validated and may be easier for clinical use in following patients over time [ 16 ]

Obstructive Sleep Apnea

OSA is a disorder of repetitive collapse of the upper airway causing oxygen rations and electroencephalographic arousals Fairly common in the general popula-tion (4 % of middle-aged men and 2 % of middle-aged women based on one study) [ 17 ], OSA has been demonstrated to increase risk for developing hypertension, heart disease, and cardiovascular disease [ 18 ] Primary symptoms of OSA include snoring, sleep disruption, and most relevant to this chapter, EDS

The Berlin Questionnaire is one of the more frequently used clinical screening

tools for the assessment of OSA: The Berlin Questionnaire was an outcome of the

Conference on Sleep in Primary Care , which involved 120 U.S and German nary and primary care physicians and was held in April 1996 in Berlin , Germany Questions were selected from the literature to elicit factors or behaviors that , across

studies , consistently predicted the presence of sleep - disordered breathing [ 19 ] The questionnaire has three sections Section one evaluates symptoms including snoring and witnessed apneas, section two covers daytime sleepiness severity, and section three assesses the presence of hypertension and calculates a body mass index In sec-tion 1, high risk was defi ned as persistent symptoms (3–4 times/week) in two or more questions about their snoring In section 2, high risk was defi ned as persistent (3–4 times/week) sleepiness In section 3, high risk was defi ned as a history of high blood pressure or a body mass index (BMI) more than 30 kg/m 2 When two of the three sections meet the criteria for high risk, the patient is at high risk for OSA [ 20 ] While many questionnaires are completed solely by the patient, this questionnaire may require clinician input for the BMI calculation or to supply blood pressure status Initially, the STOP-BANG Questionnaire was developed as a short preoperative assessment used by anesthesiologists to screen for OSA The tool covers similar content as the Berlin Questionnaire, containing eight questions in two sections (the tool was originally designed as STOP only; BANG was added at a later date in an attempt to improve specifi city) The name of the questionnaire is developed from

the primary content of each question, including s noring, t iredness, o bserved apneas, blood p ressure, B MI, a ge, n eck circumference, and g ender While the questions on

snoring, tiredness, apneas, high blood pressure, age (over 50 years) and gender are straightforward for patients to complete, questions on BMI (more than 35 kg/m 2 ) and neck circumference (greater than 40 cm) often require clinician interaction A positive answer to three or more questions gives a high probability of OSA [ 21 ] Thus, the STOP-BANG tool is easier to score than the Berlin Questionnaire, but similarly requires some clinical measurements

Objective Testing

While subjective testing for sleep disorders has the advantages of being quick and inexpensive, objective testing is generally considered to be the gold standard Objective testing removes the possibility of reporting biases and allows for an improved assessment of the patient’s symptom severity Objective testing of EDS may include overnight polysomnography, out-of-center sleep tests, multiple sleep latency tests (MSLTs), maintenance of wakefulness tests (MWTs), and actigraphy

Overnight In-Laboratory Polysomnography

The polysomnogram (PSG) is considered the gold standard for objective testing of sleep, evaluating electroencephalography, respiratory parameters, and muscle activity during sleep Current guidelines from the American Academy of Sleep Medicine (AASM) recommend that polysomnography assess the following parameters: electroencephalography (EEG), eye movements (EOG), chin and leg motor activity (EMG), airfl ow parameters (typically nasal pressure transducer and

2 Diagnostic Tools and Testing in the Sleepy Patient

oronasal thermistor ), respiratory effort parameters (both thoracic and abdominal), oxygen saturation, and body position (Fig 2.2 ) [ 22 ] Laboratories performing sleep studies should be accredited by one of several agencies (the Joint Commission, the American Academy of Sleep Medicine, etc.) to ensure that quality metrics are being upheld A technologist places all of the appropriate probes and wires on the patient prior to the study initiation and observes the patient throughout the night, ensuring that the patient is medically stable and that the recorded data is accu-rately obtained

Commonly, patients are sent for in-laboratory polysomnography for evaluation

of OSA, treatment of OSA with positive pressure therapy, or evaluation of treatment for OSA, such as weight loss, oral appliances, or surgical intervention Other rea-sons for polysomnography may include evaluation for periodic limb movements during sleep, assessment of dangerous parasomnias, and differentiation of seizures and parasomnias Patients with insomnia or restless leg syndrome are not typically evaluated with polysomnography, unless clinical evaluation suggests a comorbid sleep disorder A full list of reasons to obtain (or not to obtain) an in-laboratory sleep study from the AASM practice parameters for polysomnography is supplied

in Table 2.3

Fig 2.2 In-laboratory polysomnography This is a 2-min epoch of in-laboratory

polysomnogra-phy (Nihon Kohden) from a 55-year-old man with obstructive sleep apnea The top six leads are EEG (right and left frontal, central, and occipital), followed by two eye leads (right and left), the chin lead, ECG with heart rate below (R-R), two leg leads (right and left), snore channel, oronasal thermistor, nasal pressure transducer, effort bands (thorax and abdomen), and oxygen associated Two obstructive apneas are observed at the boxes in the NAF (nasal airfl ow) signal with absent nasal–oral airfl ow and continued respiratory effort The respiratory events are associated with increased frequency signal (arousals) in the EEG signals and oxygen desaturations

Table 2.3 Practice parameters for polysomnography, 2005

Polysomnography is routinely indicated for :

The diagnosis of sleep-related breathing disorders (standard)

Positive airway pressure (PAP) titration in patients with sleep-related breathing disorders (standard)

A preoperative clinical evaluation to evaluate for the presence of OSA in patients before they undergo upper airway surgery for snoring or obstructive sleep apnea (standard)

The assessment of treatment results in the following circumstances (standard):

1 After good clinical response to oral appliance treatment in patients with moderate to severe OSA

2 After surgical treatment of patients with moderate to severe OSA

3 After surgical or dental treatment of patients with SRBDs whose symptoms return

The assessment of treatment results in the following circumstances (standard):

1 After substantial weight loss or gain (e.g., 10 % of body weight) has occurred in patients on continuous positive airway pressure (CPAP) for the treatment of SRBDs for potential adjustment

of PAP pressures

2 When clinical response is insuffi cient or when symptoms return In these circumstances, testing should be devised with consideration that a concurrent sleep disorder may be present (e.g., OSA and narcolepsy)

Patients with heart failure, if they have nocturnal symptoms suggestive of sleep-related breathing disorders (disturbed sleep, nocturnal dyspnea, snoring) or if they remain symptomatic despite optimal medical management (standard)

Patients with coronary artery disease, if there is suspicion of sleep apnea (guideline)

Patients with history of stroke or transient ischemic attacks, if there is suspicion of sleep apnea (guideline) Patients with signifi cant tachyarrhythmias or bradyarrhythmias, if there is suspicion of sleep apnea (guideline)

Patients with neuromuscular disorders and sleep-related symptoms for the evaluation of symptoms of sleep disorders beyond the sleep history (standard)

Patients with suspected narcolepsy in combination with a multiple sleep latency test (standard) Diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure related when the initial clinical evaluation and results of a standard EEG are inconclusive, with additional EEG derivations in

an extended bilateral montage, and video recording is recommended in addition to standard leads (option) For evaluating sleep-related behaviors that are violent or otherwise potentially injurious to the patient

or others in combination with additional EEG derivations and video recording (option)

When evaluating patients with unusual or atypical parasomnias (age at onset, the time/duration/frequency

of behavior, or the specifi cs of the motor behavior) (e.g., stereotypical, repetitive, or focal) (guideline) Situations with forensic considerations (e.g., if onset follows trauma or if the events themselves have been associated with personal injury) (option)

When the presumed parasomnia or sleep-related seizure disorder does not respond to conventional therapy (option)

When a diagnosis of periodic limb movement disorder is considered because of complaints by the patient or an observer of repetitive limb movements during sleep and frequent awakenings,

fragmented sleep, diffi culty maintaining sleep, or excessive daytime sleepiness (Standard)

Polysomnography is NOT routinely indicated for :

In patients treated with CPAP whose symptoms continue to be resolved with CPAP treatment (option)

A multiple sleep latency test is not routinely indicated for most patients with sleep-related breathing disorders (standard)

Diagnosis of chronic lung disease (standard)

In cases of typical, uncomplicated, and non-injurious parasomnias when the diagnosis is clearly delineated (option)

Patients with a seizure disorder who have no specifi c complaints consistent with a sleep disorder (option) Diagnosis or treatment of restless leg syndrome, except where uncertainty exists in the diagnosis (standard) Establishing the diagnosis of depression (standard)

Diagnosis of circadian rhythm sleep disorders (standard)

Adapted from Kushida CA, Littner MR, Morgenthaler T, et al Practice parameters for the tions for polysomnography and related procedures: an update for 2005 Sleep 2005 Apr;28(4): 499–521, with permission

The advantages of the in-laboratory polysomnogram include the assessment of sleep stage changes over the course of the night and the effect of sleep stage upon sleep-disordered breathing, observer reporting and video recording for the evalua-tion of patient behavior, and scoring of EEG-based arousals from sleep Based on Medicare criteria, an apnea–hypopnea index (AHI) of 5 events/hr in association with a symptom (EDS, impaired cognition, mood disorders, insomnia, hyperten-sion, ischemic heart disease, or history of stroke) or an AHI of 15 events/hr without associated symptoms is considered diagnostic of OSA [ 23 , 24 ] However, as there are multiple standards for the scoring of respiratory events, AHI values may have interlaboratory variability

In most cases, the diagnostic test will last a minimum of 6 hrs, however many sleep centers have opted to perform “split-night” studies (fi rst half of the study (2–3 hrs) is diagnostic and the second half is a positive pressure treatment trial) to minimize health care costs in cases of patients with a high likelihood of OSA Overnight testing may also be in the form of an all-night positive airway pres-sure (PAP) titration study, as the technologist adjusts the PAP pressures to eliminate

or minimize sleep- disordered breathing Polysomnography with 16-lead EEG and/

or extra EMG leads may be considered in specifi c circumstances, particularly in the context of epilepsy patients who may be having seizures during sleep or patients who have parasomnias suggestive of potential underlying seizures; however, this study type is often only available in a minority of sleep centers

Home Sleep Apnea Testing

Monitoring of sleep-related breathing at home was reviewed and approved at a national level by the Centers for Medicare & Medicaid Services (CMS) in 2007–2008; many of these portable monitors measure a subset of the measures of a typical polysomnogram (e.g., airfl ow, respiratory effort, heart rate, and snoring) [ 25 ] AASM guidelines (2007) suggest that Home Sleep Apnea Testing (HSAT) may be performed on patients who have moderate-to-high likelihood of OSA in the absence

of comorbid conditions, such as signifi cant intrinsic lung disease or neuromuscular conditions which may cause hypoventilation While the AASM also suggests limit-ing these tests on patients who have comorbid sleep or medical disorders, current utilization management programs run through insurance companies may guide patients who have risk for OSA and another sleep disorder into HSAT rather than allowing an in-laboratory study The 2007 AASM algorithm for use of portable monitoring is provided in Fig 2.3 A limitation for the large majority of home sleep apnea monitors is the lack of EEG leads; absence of brain wave measurement limits accurate sleep staging and identifi cation of cortical arousals [ 26 ]

Home sleep apnea testing is a growing area of sleep medicine, given the large number of patients with likely OSA, the limited number of sleep laboratories across the country, and the cost savings to insurance programs of doing HSAT compared

to an in-laboratory test These tests tend to underestimate OSA severity, as the numerator in the AHI (respiratory events) is lower than an in-laboratory test as subtle respiratory events are diffi cult to score and the denominator in the AHI is elevated because recording time is typically assessed as opposed to sleep time as in

a sleep laboratory In addition, the failure rate of an home sleep apnea test is signifi cantly higher than an in-laboratory test, both due to the absence of a polysomno-graphic technologist fi xing sensors during the test and due to the technological limitations of current home sleep testing (HST) devices

Not all portable testing devices measure the same parameters Most devices will measure airfl ow, respiratory effort, and oximetry via standard signals (oronasal thermistor or nasal pressure, oximetry/pulse rate, respiratory effort belt) (Fig 2.4 ) However, some devices have used alternative signals such as peripheral artery tonometry (PAT) in the WatchPAT device as a substitute for airfl ow and respiratory effort (Fig 2.5 ) or venous pulsation as a surrogate for respiratory effort in some ver-sions of the apnea risk evaluation system (ARES) device If you are selecting a HSAT device for your practice, it would be wise to trial a few devices to understand the pros and cons of each device

Boehlecke B, et al Clinical guidelines for the use of unattended portable monitors in the diagnosis

of obstructive sleep apnea in adult patients Portable Monitoring Task Force of the American Academy of Sleep Medicine J Clin Sleep Med 2007 Dec 15;3(7):737–47, with permission.)

2 Diagnostic Tools and Testing in the Sleepy Patient

Fig 2.4 A 2-min epoch of home sleep apnea testing (Stardust II) This is a 5-min epoch from a

Stardust II home sleep testing device of a 64-year-old woman with obstructive sleep apnea The top channel is oximetry, followed by heart rate, nasal pressure, respiratory effort, snoring, patient event marker (PEM), and position (in this case, supine) The epoch demonstrates repetitive apneas with absent nasal pressure and continuous respiratory effort

Fig 2.5 Image from a WatchPAT device This is a 10-min epoch of a WatchPAT 200 sleep test in

the testing of a 53-year-old gentleman with obstructive sleep apnea The top channel is the eral arterial tonometry (PAT) signal, followed by the PAT amplitude, pulse rate, oxygen saturation, actigraphy, estimate sleep stage, body position, and snore channel The epoch demonstrates fre- quent snoring with intermittent respiratory events (defi ned in part by the increased PAT signal)

Preparation is essential prior to a patient undergoing the MSLT It is recommended that the patient obtain 2 weeks of regular sleep prior to the test; use of actigraphy and/

or sleep diaries may help track the patient’s sleep patterns Stimulants, stimulant-like medications, and REM-suppressing medications (such as many antidepressants) should be discontinued, if safe to do so, at least 15 days or fi ve half-lives before the patient undergoes the MSLT Urine drug screening is often performed the morning after the overnight study and before the MSLT to ensure that fi ndings of the test are not altered pharmacologically Caffeine and alcohol may have dramatic effects on sleep; these substances should not be used immediately prior to or during the test Withdrawal from caffeine and alcohol may also alter test results; tapers should be discussed with the patient when scheduling testing [ 28 ] The night prior to the MSLT, an in-laboratory polysomnogram is performed to document quality and duration of the patient’s sleep

At least 6 h of documented sleep should occur prior to the administration of the MSLT

to ensure an accurate daytime test Patients with abnormalities of circadian phase may require an altered test schedule, though this may be diffi cult in typical sleep practices

A standard MSLT montage includes a referential electroencephalogram (EEG) from frontal, central, and occipital locations, two electrooculograms (left and right) at the outer canthi, a mental or submental electromyogram, and an electrocardiogram (Fig 2.6 ) These leads will allow determination of sleep onset, sleep stage, and the patient’s heart rhythm The nap attempts should take place in a bedroom that is dark, quiet, and at a comfortable temperature setting Five nap opportunities begin 1.5–3 h after the end of the overnight polysomnogram and continue every 2 h No sleeping should be allowed between the nap tests, nicotine use should be avoided 30 min before each test, and vigor-ous activity should be suspended 15 min before each trial Prior to each attempt, the patient is told to “please lie quietly, assume a comfortable position, keep your eyes closed, and try to fall asleep” [ 29 ] The results of the test demonstrate two things: the mean sleep latency (MSL), which is the arithmetic average of how quickly the patient had an epoch scored as sleep in each nap, and the number of sleep-onset REM periods (SOREMs), which is the number of naps in which the patient had at least one epoch scored as REM sleep Based on the International Classifi cation of Sleep Disorders, Third Ed., a diagnosis of narcolepsy requires a MSL of less than 8 min and two SOREMs [ 30 ]

A REM sleep onset (REM sleep latency less than 15 min on overnight sleep study) can count as one of the two SOREMs However, physicians should recognize that other sleep disorders (including OSA, behaviorally induced insuffi cient sleep, and circadian rhythm disturbances, for example) may cause similar fi ndings, so assessment of the results from

a MSLT should always be performed within a clinical context

2 Diagnostic Tools and Testing in the Sleepy Patient

Maintenance of Wakefulness Test (MWT) is effectively the inverse of the MSLT Though similar in that the patient is tested four times over the course of a day for

40 min per “nap” episode in a dim room while reclining, the subtle, but important, difference in the instructions is the patient should attempt to “remain awake as long

as possible” [ 31 ] The MWT has been used by the Federal Aviation Administration

to test pilots who have been diagnosed with OSA and treated, assessing if they are alert enough to return to work safely [ 32 ] While this test evaluates the ability of patients to stay awake in a circumscribed set of conditions, it has not been clearly demonstrated to be predictive of motor vehicle accidents or other activities where reduced alertness may impact safety It is also a diffi cult test to interpret, as the meaning of the result is unclear when the test does not demonstrate either “no sleep/clearly alert” or “clearly abnormally sleepy.” Table 2.4 demonstrates the normative data from the MWT to aid in result interpretation

Actigraphy and Similar Monitoring Devices

Actigraphy uses a wrist-worn accelerometer to track activity over time; this tool has been demonstrated to be a reasonably accurate refl ection of states of activity and rest [ 33 ] Care should be taken when analyzing data from this device, as rest times do not always refl ect sleep time (sitting quietly with minimal movement is often scored as rest) Sleep diaries should be used simultaneously to provide comparisons of subjective sleep times and more objective rest times This device is most useful in assessing patients for circa-dian patterns and in tracking approximate sleep times in patients with insomnia or hyper-somnia Figure 2.7 provides an example of typical actigraphy data from a clinical device

Fig 2.6 A 30-s epoch of a multiple sleep latency test This is a 30-s image from a mean sleep

latency test (MSLT) of a 20-year-old woman with daytime sleepiness The layout is more limited than a full polysomnogram and demonstrates from top to bottom: left and right eye leads, six EEG leads (right and left frontal, central, and occipital), chin EMG lead, ECG lead, and heart rate (R-R) This image demonstrates rapid eye movements in the eye leads, mixed-frequency EEG signal, and low chin EMG tone, all of which suggest stage R sleep

Table 2.4 40-min MWT normative data

Sleep onset defi nition

Mean (min)

Standard deviation

2 SD below (min) First epoch any stage 32.6 9.9 12.9 Three epochs stage 1 or one epoch any other stage 35.2 7.9 19.4 Adapted from Doghramji K , Mitler MM , Sangal RB et al A normative study of the maintenance

of wakefulness test (MWT) Electroencephalogr Clin Neurophysiol 1997 Nov;103(5):554–62, with permission

Fig 2.7 Actigraph, 7-day display This is an Actiware actigraphy report The shaded areas are

scored as rest time; in this patient’s case, they have an approximate bedtime from 11 pm–12 night to a wake time of about 6 am One nap is observed on day 3 in the middle of the afternoon

mid-2 Diagnostic Tools and Testing in the Sleepy Patient

Many currently used electronic devices contain similar accelerometer ogy (smartphones, activity monitors); a sample download from a Fitbit activity and sleep tracker is seen in Fig 2.8 Clinicians should understand how patients may benefi t from quantifying their own wake and rest periods with these devices, but should be wary about the clinical correlation of that data with the patient’s reported symptoms as the algorithms for sleep monitoring have not been clinically tested

Fig 2.8 Fitbit activity and sleep monitor download This is a Fitbit download image from a

40-year-old female with hypersomnia The device reports that she was in bed for 10 h and 36 min and reports that she slept for 6 h and 12 min, was restless for 3 h and 27 min, and was awake for 33 min