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. . Chapter 028. Sleep Disorders (Part 5) Disorders of Sleep and Wakefulness Approach to the Patient: Sleep Disorders Patients may seek help from a. 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. 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