Chapter 028. Sleep Disorders (Part 5) potx

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
d sleep,
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
b
enzodiazepine 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.