Ebook Sleepy or sleepless - Clinical approach to the sleep patient: Part 2

(BQ) Part 2 book Sleepy or sleepless - Clinical approach to the sleep patient presents the following contents: Key history and physical examination findings for the sleepless or restless patient, assessment and management of insomnia, the parasomnias, the sleepless child, sleeplessness during and after pregnancy,...

Part II The Sleepless or Restless Patient Chapter Key History and Physical Examination Findings for the Sleepless or Restless Patient John Harrington and Kelly Marie Newton Sleeplessness, restlessness at night, and insomnia are a common clinical complaint for the primary care patient Patients may present with insomnia as the chief complaint, but insomnia will commonly be present as part of another illness or complaint Insomnia has been reported and is observed worldwide In the adult population, 33–50 % will complain of insomnia in their lifetime, and 10–15 % will associate these symptoms with distress or impairment Identifiable risk factors include increasing age, female sex, comorbid disorders, shift work, and potentially lower socioeconomic status [1, 2] Patients with psychiatric and chronic pain disorders have insomnia rates that are reported to be as high as 50–75 % [2] Insomnia is often chronic; over the course of several years, 50–85 % of individuals will report persistence in symptoms [2] The International Classification of Sleep Disorders, Third Edition, defines insomnia as repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate sleep opportunity, a persistent sleep difficulty, and associated daytime dysfunction [1] Patients often complain of extended periods of nocturnal wakefulness or insufficient sleep that are associated with daytime symptoms of fatigue, decreased mood, irritability, malaise, or some kind of cognitive impairment to include impaired concentration and memory [1] Table 8.1 lists some common consequences and impairments associated with insomnia J Harrington, M.D., M.P.H (*) Division of Pulmonary/Critical Care/Sleep/Allergy, 985990 Nebraska Medical Center, Omaha, NE 68198-5990, USA e-mail: john.harrington@unmc.edu K.M Newton Division of Critical Care and Hospital Medicine, Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA e-mail: newtonk@NJHealth.org © Springer International Publishing Switzerland 2015 R.K Malhotra (ed.), Sleepy or Sleepless, DOI 10.1007/978-3-319-18054-0_8 101 102 Table 8.1 Consequences of insomnia J Harrington and K.M Newton Fatigue or malaise Cognitive impairment (attention, concentration, memory issues) Poor work or school performance Mood disturbance or irritability Daytime sleepiness Decreased work performance Lack of motivation or initiative reduction Errors or accidents at work or while driving Muscle tension Headaches GI upset Patient History The evaluation of the patient complaining of sleeplessness begins with a careful history and physical exam that addresses both sleep and waking behaviors The history should include questions designed to evaluate the possibility of common medical, psychiatric and medication, or substance abuse-related issues [2] Taking a good history from a patient with sleeplessness or restless sleep can be time consuming, but is critical to making a correct diagnosis and in guiding the treatment plan A good sleep history includes characterizing the insomnia complaints such as the type of complaint (falling asleep, staying asleep, early morning wakings, or nonrestorative sleep), severity, impact on daytime functioning, frequency (how many nights a week), duration (how long has this been occurring), type of course (intermittent or progressive), aggravating or ameliorating symptoms, treatment attempts, and response to therapy [2] Discussing the patient’s bedtime behaviors such as characterizing the sleeping environment, the patient’s emotional state, and whether the patient senses dread regarding sleep and sleep behaviors can provide insight [2] Understanding the patients’ sleep-wake cycle to include sleep latency (time to fall asleep), number of awakenings, length of awakenings, sleep duration, and napping can all provide clues to the patient’s insomnia Day-to-day variability should also be examined [2] Patterns of sleep can be ascertained which may provide clues to circadian rhythm disorders, and assessing the amount of sleep can provide clues that the patient has too much or too little sleep opportunity [2] In assessing insomnia, it is important to screen for comorbid sleep disorders such as restless leg syndrome, obstructive sleep apnea, and parasomnias (sleep walking/ sleep talking) [2] Comorbid medical complaints such as chronic pain, untreated reflux, uncontrolled nocturnal asthma, headaches, and paroxsysmal nocturnal dyspnea may contribute to the patient’s complaint of insomnia [2] A complete insomnia history includes medical, psychiatric, medication/substance, and family/social/occupational histories (Table 8.2) Not only are medical and psychiatric illnesses often comorbid or even causative for insomnia, but direct effects Key History and Physical Examination Findings for the Sleepless or Restless Patient 103 Table 8.2 Topics to cover when taking a patient history for compliant of insomnia Sleep patterns Activities and habits Substance use Note amount and time of day used Past medical history Medication/supplement use Environment Social history Bedtime Time the patient tries to go sleep How long it takes to fall asleep Frequency and cause of nighttime awakenings How long it takes to return to sleep after waking Time of final awaking Time the patient gets out of bed for the day Frequency and timing of daytime naps How many says per week insomnia occurs Pre-bedtime activities Activities in bed besides sleep and sex Caffeine intake Tobacco use Alcohol use Recreational drug use Current and past medical disorders Current and past psychiatric disorders Note doses and timing of administration Note any prescription or nonprescription sleep aids that have been tried Noise and light level in bedroom Comfort of bed and surrounding Disruption from bed partner, children, pets Current life and social stressors Life and social stressors at time of insomnia onset of prescription or over-the-counter medications may impact sleep and daytime functioning [2] For example, a patient taking an over-the-counter sleep headache remedy containing caffeine may be sabotaging their ability to fall asleep A careful evaluation of their caffeine intake and smoking/tobacco history can be illuminating Many patients with insomnia use cigarettes before bed as a way to “relax,” yet few patients realize the simulating effects of the nicotine Alcohol is commonly used prior to bed to help initiate sleep by many suffering with insomnia, without realizing that alcohol can cause frequent and prolonged nighttime awakenings Finally, evaluating and offering suggestions regarding waking and bedtime behaviors may improve symptoms For example, the light from using electronic devices in bed is counterproductive to sleep and may cause or perpetuate insomnia Physical Examination There are no specific features of the physical exam associated with insomnia or restless sleep However, a thorough physical exam may provide clues to comorbid conditions The physical exam should evaluate for risk factors for sleep apnea to include 104 J Harrington and K.M Newton obesity, increased neck circumference, and a crowded airway [2] The practitioner should look for signs of comorbid medical conditions to include pulmonary disease (cyanosis, clubbing, hypoxemia), cardiac (clubbing, heart murmur, crackles, peripheral edema), rheumatologic, endocrine (thyroid), and/or gastrointestinal symptoms The mental status exam should include an insight to mood, anxiety, memory, concentration, and alertness [2] Additional Tools There are other tools that can be utilized to form a working differential diagnosis for the etiology of insomnia A dedicated prospective sleep log can help identify issues such as insufficient sleep and circadian rhythm disorders such as advanced or delayed sleep phase A standardized scale such as an Epworth can provide insight to how severe the impact on daily functioning is [2, 3] Patients who may have a pretest probability of obstructive sleep apnea or periodic limb movement disorder may be appropriate for polysomnogram Differential Diagnosis Conceptually, chronic insomnia can be grouped into three categories: (1) insomnia associated with other sleep disorders, particularly sleep-disordered breathing, movement disorders, or circadian rhythm disorders; (2) comorbid medical or psychiatric illnesses to include medications/substances; and (3) primary insomnia [2] (Table 8.3) Table 8.3 Causes of transient and chronic insomnia Etiology Characteristics Causes of transient insomnia Acute life stresses, Normal sleep prior to and alterations in familiar following the transient sleep routines or changes disturbance in sleep scheduled Causes of chronic insomnia Primary insomnia Insomnia is not due to another sleep, medical, neurologic, or psychiatric disorder, nor due to substance abuse or withdrawal Alterations in circadian rhythms Insomnia is related to disorders of the timing of sleep periods secondary to desynchrony between endogenous circadian rhythms and the environment Sleep disorders Adjustment sleep disorder Jet lag Shift work sleep disorder Idiopathic insomnia Paradoxical insomnia (sleep state misperception) Psychophysiologic insomnia Advanced sleep-phase syndrome Delayed sleep-phase syndrome Irregular sleep-wake pattern Non-24-h sleep-wake syndrome (continued) Key History and Physical Examination Findings for the Sleepless or Restless Patient 105 Table 8.3 (continued) Etiology Behavioral disorders Environmental factors Sleep disorders Movement disorders Medical disorders Characteristics Insomnia is associated with behaviors that are arousing and not conducive to sleep Sleep disorders Inadequate sleep hygiene Limit-setting sleep disorder Sleep-onset association disorder Nocturnal eating/drinking syndrome Insomnia is due to environmental Altitude insomnia conditions or external factors Environmental sleep disorder that are not conducive to sleep Food allergy insomnia Toxin-induced sleep disorder Insomnia is associated with Central sleep apnea sleep-related breathing disorders Obstructive sleep apnea or parasomnias Parasomnias Confusional arousals Sleep terrors Sleepwalking Rhythmic movement disorder Sleep starts Nocturnal leg cramps Nightmares REM sleep behavior disorder In some individuals, periodic Periodic limb movement disorder limb movements of sleep may be Restless legs syndrome associated with arousals, awakenings, and sleep disruption Restless legs syndrome can give rise to sleep-onset insomnia Insomnia may result from Respiratory disorders physiologic alterations involving Asthma the respiratory, cardiac, COPD gastrointestinal, and Central alveolar hypoventilation musculoskeletal systems syndrome Cardiac disorders Nocturnal angina Congestive heart failure Pain syndromes Gastrointestinal syndromes GERD Peptic ulcer disease Sleep-related abnormal swallowing Dermatologic syndromes Pruritus Cancer Infectious disorders (continued) 106 J Harrington and K.M Newton Table 8.3 (continued) Etiology Neurologic disorders Psychiatric disorders Menstruation and pregnancy Medication and substance abuse Characteristics Neurologic disorders can prevent sleep onset and disrupt its continuity Sleep disorders Cerebral degenerative disorders Dementia Fatal familial insomnia Nocturnal paroxysmal dystonia Parkinson’s disease Sleep-related headaches Sleep-related seizures Many people with insomnia have Alcoholism an underlying psychiatric Anxiety disorders disorder Conversely, among this Mood disorders patient group, there is an Panic disorders increased risk of developing a Personality disorders new psychiatric illness Psychoses Somatoform disorders Both pregnancy and the Menstrual-associated sleep disorder menstrual cycle can produce Pregnancy-associated sleep disorder insomnia among women The use and abuse of hypnotic Alcohol-dependent sleep disorder agents, stimulants, and alcohol are important causes of insomnia The effects of these and other Hypnotic-dependent sleep disorder medications are also influenced Stimulant-dependent sleep disorder by the possible development of tolerance, withdrawal symptoms, and drug interactions Adapted with permission from Lee-Chiong, Teofilo Sleep Medicine Essentials 2008 New York, New York: Oxford University Press, USA, 2008, with permission Summary Insomnia remains a common and pervasive problem in the adult population with a significant impact on health, well-being, and daytime functioning A careful history and physical exam can provide valuable clues into the etiology of the insomnia and therefore guidance regarding the treatment plan References American Academy of Sleep Medicine International classification of sleep disorders 3rd ed Darien, IL: American Academy of Sleep Medicine; 2014 Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M Clinical guideline for the evaluation and management of chronic insomnia in adults J Clin Sleep Med 2008;4(5):487–504 Johns MW A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale Sleep 1991; 50–55 Chapter Diagnostic Tools and Testing in the Sleepless and Restless Patient Fouad Reda In addition to a thorough history and physical, there are a variety of tools available for the clinician to evaluate a patient who comes in with complaints of insomnia, sleeplessness, or restless sleep Sleep Diaries Sleep diaries are valuable tools in assessing sleepless or restless patients (Fig 9.1a) A sleep diary is designed to get the information about a patient’s sleep pattern It has the potential of reducing recall or report bias The patient self-monitors his/her sleep every night and records it This helps in the initial assessment as well as in tracking treatment effect of different interventions It provides valuable information which includes some or all of the following: • Bedtime • Sleep onset latency (SOL)—time taken to fall asleep following bedtime • Wake after sleep onset (WASO)—sum of wake times from sleep onset to final awakening • Time in bed (TIB)—time from bedtime to getting out of bed • The presumed cause, number, time, and length of any nighttime awakenings and activities during these moments • Total sleep time (TST)—time in bed minus SL and minus WASO • Sleep efficiency (SE)—TST divided by TIB times 100 • Wake up time F Reda, M.D (*) SLUCare Sleep Disorders Center, Department of Neurology and Psychiatry, St Louis University School of Medicine, 1465 S Grand Blvd, St Louis, MO 63104, USA e-mail: freda@slu.edu © Springer International Publishing Switzerland 2015 R.K Malhotra (ed.), Sleepy or Sleepless, DOI 10.1007/978-3-319-18054-0_9 107 sample Mon Work E A I 11AM 10 6AM 1AM Midnight 11PM 10 6PM Day Type of Day of the Work, School, week Off, Vacation Today’s Date a 1PM F Reda Noon 108 CM Wed Fri Sat Sun week Thurs Mon Tues Wed Fri Sat Sun week Thurs Mon Tues b Fig 9.1 Example of a sleep diary (a) and actigraphy (b) for patient with insomnia due to delayed sleep phase disorder Diagnostic Tools and Testing in the Sleepless and Restless Patient 109 • Whether the person woke up spontaneously, by an alarm clock, or because of other (specified) disturbance • Quality of sleep • Nap times (frequency, timing, and duration) • A few words about how the person felt during the day (mood, tiredness, etc.) • The name, dosage, and time of any drugs used including medication, sleep aids, caffeine, and alcohol • The time and type/heaviness of evening meal • Activities the last hour before bedtime, such as meditation, watching TV, playing games • Stress level before bedtime A study done on 50 subjects (25 narcoleptics and 25 matched control subjects) comparing the sleep diary and polysomnography found out that the sleep diary is reliable with high sensitivity and specificity (92.3 and 95.6 %) [1] Actigraphy Actigraphy utilizes a wristwatch-like portable device which contains an accelerometer, a clock, internal memory, and a photo sensor It records the rest/activity cycle which may correspond to the sleep/wake cycle It may assist to determine the sleep patterns in normal healthy adult population, to evaluate patients suspected of advanced sleep phase syndrome (ASPS), delayed sleep phase syndrome (DSPS), shift work sleep disorder, and other circadian sleep disorders including jet lag and non-24 h sleep/wake syndrome It is used to determine the circadian rhythm patterns in patients with insomnia (including insomnia associated with depression) and hypersomnia When sleep diaries are used in conjunction with actigraphy, more information can be obtained in regard to sleep/wake cycle of the subject being studied But there may be discrepancy between both these studies especially in young males whose actigraphic estimates of wake after sleep onset (WASO) were substantially greater than sleep diary estimates (74 actigraphy vs sleep diary) [2] In children, actigraphic estimates of total sleep time is substantially less than sleep diary and parental report (6 h 51 actigraphy vs h 16 sleep diary v h 51 parent report) Questionnaires Insomnia Severity Index The insomnia severity index assesses the patient’s perception of insomnia in a seven-item questionnaire Less than or equal to seven is considered normal The full index and directions for use can be found at https://www.myhealth.va.gov/mhvportal-web/anonymous.portal?_nfpb=true&_pageLabel=healthyLiving&contentPa ge=healthy_living/sleep_insomnia_index.htm 15 Sleeplessness During and After Pregnancy 199 to wait until after delivery, despite that treatment of SDB may be beneficial to both mother and baby Another reason for non-referral is the wait time for a sleep study, which can be several months in some facilities Although studies are limited in pregnant women, available data from small studies show that use of PAP during pregnancy is associated with improved blood pressure (in women with hypertension) [19, 20] It is unclear whether the improvement in blood pressure is as a direct result of treatment of underlying SDB or whether PAP alters the cardiovascular system independently of SDB Recent data from women with preeclampsia suggest that PAP use is also associated with improvements in fetal movements [21], a known sign of fetal well-being Studies are currently underway to further address these novel and important findings Major treatment options for insomnia include pharmacotherapies (prescription and over-the-counter hypnotic medications) and non-pharmacological treatments Scant data are available on the safety and efficacy of many prescription and nonprescription hypnotic medications during pregnancy and lactation Many hypnotic medications are assigned a category X designation by the Food and Drug Administration and are therefore contraindicated for use during pregnancy Zolpidem, one of the most frequently prescribed hypnotics, is a category C drug, with no adequate or well-controlled studies in pregnancy Although available evidence does not link zolpidem to teratogenicity, use during pregnancy may increase risk for adverse outcomes (e.g., low birth weight, preterm delivery, small for gestational age, cesarean delivery) [22] Thus, providers and patients should carefully weigh risks and benefits before using medications for sleep Data from the few available studies of non-pharmacological options for insomnia in pregnant women suggest that acupuncture, yoga, and exercise may improve sleep during pregnancy [23] Cognitive–behavioral therapy for insomnia (CBTI) has well-established efficacy and is recommended as a first-line treatment for chronic insomnia However, although there are no contraindications to its use during pregnancy, CBTI has not been studied in pregnancy A relatively brief treatment, lasting between and 10 sessions, CBTI targets the factors believed to perpetuate insomnia A typical course of CBTI includes behavioral components (sleep restriction, stimulus control, relaxation training) and may also include cognitive strategies (i.e., identification and restructuring of maladaptive beliefs about sleep) Equally effective to medications in the short term, CBTI is superior to medications in the long term, as remission is typically sustained for years following treatment RLS typically resolves around delivery and during the puerperium As medications typically prescribed for RLS are contraindicated in pregnancy, non-pharmacological behavioral strategies such as regularization of the sleep–wake schedule, relaxation techniques, limiting nighttime exercise, stretching, massage, warm baths, and warm pads are commonly employed to address symptoms Supplementation with ferrous sulfate may also reduce symptoms in women with low serum ferritin levels (less than 50 ng/mL), and all women should be encouraged to take folic acid not only for RLS but also to decrease the incidence of neural tube defects 200 L.M O’Brien and L.M Swanson Poor Sleep Postpartum Common Reasons for Poor Sleep Postpartum Normal postpartum sleep is characterized by marked sleep fragmentation due to infant care, which continues until the infant sleeps through the night Relative to pregnancy, women sleep less at night and more during the day and are awake more during the night in the early postpartum Maternal sleep does not appear to differ by nighttime feeding method (i.e., breastfeeding vs bottle feeding) [24], and results from one study suggest that women who breastfeed exclusively sleep more during early postpartum relative to women who use formula some of the time [25] Of note, while sleep is significantly disrupted in postpartum women, total sleep time is preserved, and thus women experience sleep fragmentation rather than sleep deprivation Certainly other sleep disorders may continue following delivery although RLS generally resolves Since SDB is related to excess weight, many women continue to have SDB symptoms in the postpartum period while they still carry excess weight However, SDB does not necessarily resolve in the immediate postpartum period in women in whom it was moderate–severe during pregnancy It is typically these women who seek treatment following delivery Many factors unique to the postpartum period may trigger insomnia and perpetuate it over time Rapid hormonal changes following delivery, particularly the precipitous decline of progesterone (known for its hypnotic effects), may contribute to wakefulness Caring for an infant who is not yet entrained to a 24-h day may lead to dysregulation of circadian rhythms via variable bed and wake times, low light levels during the day, and exposure to bright light at night Anticipation of infant awakenings can contribute to hyperarousal and difficulty falling asleep Behaviors to manage sleep loss experienced during the postpartum may perpetuate insomnia by weakening sleep drive, dysregulating circadian rhythms, and conditioning the bed as a place for wakefulness Such behaviors include spending long periods of time in bed awake, use of the bed for activities other than sleep, irregular sleep–wake times, excessive use of caffeine, and reliance on medications for sleep Consequences of Poor Sleep Postpartum The sleep fragmentation and significant fatigue that affect almost all women in the postpartum period are major contributors to the onset of mood disturbance In the early postpartum period, infant sleep is evenly distributed across the day and night; thus, the caregiver’s sleep is significantly fragmented during this time Sleep fragmentation is associated with daytime sleepiness, fatigue, neurobehavioral deficits, and postpartum depression While total sleep time remains constant across the initial postpartum months, sleep efficiency appears to improve Although sleep 15 Sleeplessness During and After Pregnancy 201 fragmentation constitutes normal development during the postpartum period, persistent difficulty in falling asleep or returning to sleep when the infant is sleeping may signal insomnia Insomnia during the postpartum period is associated with depression and anxiety symptoms Difficulty falling asleep may be more closely linked to postpartum depression than other insomnia symptoms [26] Poor sleep quality in the first months postpartum significantly increases the risk of relapse to postpartum depression in women with a past history of depression [27] In rare cases, sleep loss may precipitate postpartum psychosis, an uncommon but serious psychiatric illness Maternal depression subsequently increases the risk for negative parent–infant interactions, adverse infant emotional and cognitive outcomes, as well as failure to thrive Thus, it is important to consider sleep disruption as a precipitating factor when addressing postpartum depression Assessment of the Sleepless Postpartum Patient Understanding the influence of the infant is important in assessing sleep disturbances in postpartum women For example, women who report sleep problems that occur due to their infant’s sleep may benefit from infant-focused interventions In contrast, women who describe difficulty falling asleep or staying asleep when the infant is asleep or not otherwise a factor may be experiencing a sleep disorder such as insomnia Light exposure during the day and at night should also be assessed Many postpartum women remain in dim light during the day and are exposed to short bursts of bright light at night when caring for their infant Exposure to bright light at night suppresses melatonin, a hormone secreted during the night that provides the body’s internal biological signal of darkness Exposure to light resets the circadian rhythm of melatonin and acutely inhibits melatonin synthesis Thus, patterns of low light levels during the day, combined with periods of bioactive light at night, may cause dysregulation of circadian rhythms Encouraging postpartum women to spend time with their infant in bright light during the day and to limit bright light exposure at night—such use of red light (which is believed to prevent melatonin suppression)—may improve sleep as well as mood Postpartum Treatment Options It should again be emphasized that disrupted maternal sleep in the postpartum period is a normal developmental trajectory While there is a high prevalence of parent-reported infant sleep problems during this time, it is most likely that it is not the infant with sleep problems per se, but rather the unrealistic expectations by the parents of normal infant sleep patterns Education regarding normal sleep patterns of both the infant and the new mother should be provided during pregnancy so that 202 L.M O’Brien and L.M Swanson the mother has realistic expectations of sleep in the initial postpartum period Although education is important, alone it may not be sufficient in many cases Women with residual symptoms of SDB should be evaluated and, if obstructive sleep apnea is present, treated with PAP Insomnia and poor sleep quality are the most common sleep problems in the postpartum period In non-lactating women, medications can be used to address insomnia symptoms on a short-term basis Hypnotic medications are not indicated for long-term use in chronic insomnia, as hypnotic-dependent insomnia may develop, and many patients develop tolerance to such medications when used regularly Further, insomnia typically returns once the medications are discontinued CBTI is the recommended first-line treatment for chronic insomnia Although there are no randomized controlled trials (RCTs) of CBTI for postpartum insomnia, data from small pilot studies suggest that the treatment is likely effective for this population and holds promise for improving both mood and sleep in postpartum women with insomnia and depression [28] New mothers can also be encouraged to spend time in bright light during the day and to limit light exposure at night Of note, techniques aimed at improving the sleep of the infant lead to improvement in maternal depression scores Most RCTs of sleep interventions have focused on promotion of infant sleep by recommending strategies to enhance day–night entrainment and improvement of the infant’s self-soothing ability While the majority of studies have not specifically sought to investigate the impact on parental sleep, several have reported that more consolidated infant sleep is associated with improved maternal sleep quality, longer total sleep time, better sleep efficiency, and reduced nighttime awakenings One pilot study designed to improve maternal and infant sleep in the early postpartum period enrolled women into a behavioral–educational intervention that involved a meeting with a nurse, a booklet, and weekly telephone calls to reinforce the behavioral strategies to increase nighttime sleep [29] This pilot study, which employed actigraphy for objective measures of sleep, found that women slept more than a control group and had less problematic sleep However, a larger trial powered from this pilot did not find significant differences [30] The authors suggested that the newborn period may be too early to implement maternal and infant sleep strategies Conclusion In summary, sleep disruption during pregnancy and the postpartum period is common and consequential In addition to the high prevalence of clinical sleep disorders such as SDB, RLS, and insomnia, sleep fragmentation is a characteristic of maternal sleep particularly in the postpartum period Sleep disruption is associated with significant maternal morbidity, yet few women are referred for evaluation during pregnancy despite available and effective treatment options Interventions in the postpartum period may improve maternal mood and consequently parent–infant attachment 15 Sleeplessness During and After Pregnancy 203 References Bourjeily G, Raker CA, Chalhoub M, Miller MA Pregnancy and fetal outcomes of symptoms of sleep-disordered breathing Eur Respir J 2010;36(4):849–55 O’Brien LM, Bullough AS, Owusu JT, Tremblay KA, Brincat CA, Kalbfleisch JD, Chervin RD Pregnancy-onset 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Schwartzman K, Kimoff RJ Maternal sleepdisordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis Am J Obstet Gynecol 2014;210(1):52.e1–14 Luque-Fernandez MA, Bain PA, Gelaye B, Redline S, Williams MA Sleep-disordered breathing and gestational diabetes mellitus: a meta-analysis of 9,795 participants enrolled in epidemiological observational studies Diabetes Care 2013;36(10):3353–60 10 Louis JM, Mogos MF, Salemi JL, Redline S, Salihu HM Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009 Sleep 2014;37(5): 843–9 11 O’Brien L, Bullough AS, Owusu JT, Tremblay KA, Brincat CA, Chames MC, Kalbfleisch JD, Chervin RD Habitual snoring during pregnancy and delivery outcomes: prospective cohort study Sleep 2013;36(11):1625–32 12 Louis J, Auckley D, Miladinovic B, Shepherd A, Mencin P, Kumar D, Mercer B, Redline S Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women Obstet Gynecol 2012;120(5):1085–92 13 Fung AM, Wilson DL, Lappas M, Howard M, Barnes M, O’Donoghue F, Tong S, Esdale H, Fleming G, Walker SP Effects of maternal obstructive sleep apnoea on fetal growth: a prospective cohort study PLoS One 2013;8(7):e68057 14 O’Brien L, Owusu J, Swanson LM Habitual snoring and depressive symptoms during pregnancy BMC Pregnancy Childbirth 2013;13(1):113 15 Skouteris H, Germano C, Wertheim E, Paxton S, Milgrom J Sleep quality and depression during pregnancy: a prospective study J Sleep Res 2008;17(2):217–20 16 Lee KA, Gay CL Sleep in late pregnancy predicts length of labor and type of delivery Am J Obstet Gynecol 2004;191(6):2041–6 17 Micheli K, Komninos I, Bagkeris E, Roumeliotaki T, Koutis A, Kogevinas M, Chatzi L Sleep patterns in late pregnancy and risk of preterm birth and fetal growth restriction Epidemiology 2011;22(5):738–44 18 Okun ML, Hall M, Coussons-Read ME Sleep disturbances increase interleukin-6 production during pregnancy: implications for pregnancy 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systematic review J Can Chiropr Assoc 2013;57(3): 260–70 24 Montgomery-Downs HE, Clawges HM, Santy EE Infant feeding methods and maternal sleep and daytime functioning Pediatrics 2010;126(6):e1562–8 25 Doan T, Gay CL, Kennedy HP, Newman J, Lee KA Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum J Clin Sleep Med 2014;10(3):313–9 26 Swanson LM, Pickett SM, Flynn H, Armitage R Relationships among depression, anxiety, and insomnia symptoms in perinatal women seeking mental health treatment J Womens Health (Larchmt) 2011;20(4):553–8 27 Okun M, Hanusa B, Hall M, Wisner K Sleep complaints in late pregnancy and the recurrence of postpartum depression Behav Sleep Med 2009;7(2):106–17 28 Swanson LM, Flynn H, Adams-Mundy JD, Armitage R, Arnedt JT An open pilot of cognitivebehavioral therapy for insomnia in women with postpartum depression Behav Sleep Med 2013;11(4):297–307 29 Stremler R, Hodnett E, Lee K, MacMillan S, Mill C, Ongcangco L, Willan A A behavioraleducational intervention to promote maternal and infant sleep: a pilot randomized, controlled trial Sleep 2006;29(12):1609–15 30 Stremler R, Hodnett E, Kenton L, Lee K, Weiss S, Weston J, Willan A Effect of behaviouraleducational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial BMJ 2013;346:f1164 Index A Accidents due to sleepiness aviation crashes, 60 bus accidents, 61 fatal accidents, police officers, 60 railroad accidents, 59, 60 truck accidents, 61 Actigraphy ASWPD, 140 CRSWDs, 135 DSWPD, 138, 191 insomnia, 108, 117 ASPS, 109 in children, 185 DSPS, 109 paradoxical insomnia, 186 pregnant patient, 198 insufficient sleep syndrome, 57 N24SWD, 142 rest times, 24 SWD, 145 wrist-worn accelerometer, 24 Adaptive support servo-ventilation (ASV), 41 Adolescent sleepiness circadian drive for sleep, 92 electronic media, use of, 91 homeostatic drive for sleep, 92 inadequate sleep hygiene, 94–95 laboratory investigations, 94 physiological changes, 91 sleep disorders, 92–93 sleep-wake function, 92 Advanced sleep phase syndrome (ASPS), 109 Advanced sleep–wake phase disorder (ASWPD) definition, 139 diagnosis, 140 pathophysiology, 140 prevalence, 139 treatment, 136, 140 Angelman syndrome, 189 Apnea–hypopnea index (AHI), 20, 30, 39 B Beck Anxiety Inventory (BAI), 110 Beck Depression Inventory (BDI), 110 Behavioral insomnia limit setting, 187 sleep-onset association, 187–188 Benzodiazepines, 193 insomnia, 119–121 nightmares, 175 NREM parasomnias, 169 OSA, 30 PLMD, 163 RLS, 160, 161 RSWA, 177 SRED, 174 SRHV disorders, 44 SRVH disorders, 42 Berlin Questionnaire, 14, 16–17, 63 Bilevel positive airway pressure (BPAP), 44, 48 Body mass index (BMI), 17, 30, 63 C Cataplexy, 53, 54, 95, 96 CBT-I See Cognitive behavioral therapy for insomnia (CBT-I) Central sleep apnea (CSA) syndromes clinical features of, 39 definition of, 37 © Springer International Publishing Switzerland 2015 R.K Malhotra (ed.), Sleepy or Sleepless, DOI 10.1007/978-3-319-18054-0 205 206 CBT-I See Cognitive behavioral therapy for insomnia (CBT-I) (cont.) diagnosis, 39–40 epidemiology, 37–38 mechanisms, 47 pathophysiology, 38–39 PSG diagnostic criteria, 47 risk factors, 47 therapy of, 40–41, 47 Children and sleepiness (see Sleepy child) and sleeplessness (see Sleepless child) Children’s Sleep Wake Scale, 93 Chronic insomnia See also Insomnia causes of, 104–106 CBT-I, 125–126 DSWPD, 137 economic impact of, 114 hypnotics, 119 Chronic pain syndromes, 81 Chronic sleep deprivation, 76–77, 79 Circadian rhythm disorder, 4, 102, 104, 193 Circadian rhythm sleep–wake disorders (CRSWDs) ASWPD, 139–140 DLMO, 135 DSWPD, 137–139 insomnia, symptoms of, 135 ISWRD, 143–144 jet lag disorder, 146–147 light–dark cycle, 134 N24SWD, 141–142 schematic representation of, 133, 134 sleep–wake cycle, 133–134 SWD, 144–146 symptoms, 133 treatment of, 136 Cleveland Adolescent Sleepiness Scale, 93 Cognitive behavioral therapy for insomnia (CBT-I) benefits, 126 components of, 126 cost-effectiveness of, 125–126 efficacy and safety of, 122 internet-based interventions, 125 limitations of, 124–125 vs pharmacotherapy, 122, 124 postpartum sleeplessness, 202 posttreatment effects of, 125 pregnant women, 199 sleep restriction therapy, 124 telephone-delivered CBT, 125 written and media-based interventions, 125 Index Commercial drivers’ medical examination (CDME), 62, 63 Commercial medical examiners (CME), 66 Confusional arousals (CA), 105, 168–174 Continuous positive airway pressure (CPAP) therapy, 192 CSA syndromes, 40–41 OSA disorders, 30, 33–34, 36 CRSWDs See Circadian rhythm sleep–wake disorders (CRSWDs) “Cry-it-out” method, 188 CSA syndromes See Central sleep apnea (CSA) syndromes D Deep tendon reflexes (DTRs), 54 Delayed sleep phase syndrome (DSPS), 93, 94, 97, 104, 109, 191 Delayed sleep–wake phase disorder (DSWPD) in children, 191 definition, 137 diagnosis, 138 pathophysiology, 137–138 prevalence, 137 treatment, 136, 138–139 Dementia with Lewy bodies (DLB), 178 Diagnostic polysomnography (DPSG), 57, 181 Dim light melatonin onset (DLMO), 135 Disorders of arousal See Non-rapid eye movement (NREM) sleep Driver sleepiness bus accidents, 61 CDME, 62, 63 CME, 66 ESS scores, 62–63 FMCSA, 61, 62, 64, 66 FMCSRs, 62 history and physical examination, 67 JTF criteria, 63–66 medical certification, 62 OCST test, 69 PAP therapy, 70 reasons for, 61 screening and treatment programs, 66–67 self-reporting, 63 sleep apnea, 61–62 truck accidents, 61 DSPS See Delayed sleep phase syndrome (DSPS) DSWPD See Delayed sleep–wake phase disorder (DSWPD) Index E Electroencephalogram (EEG) NFLE, 180 NREM parasomnias, 169 PLMs, 152, 154 Electromyography (EMG) NREM parasomnias, 169 PLMs, 152 Epilepsy, 80, 189 Epworth Sleepiness Scale (ESS), 15–16, 62, 110, 117 Excessive daytime sleepiness (EDS) See Hypersomnia Exploding head syndrome, 168, 179 F Federal Aviation Administration (FAA), 59, 60 Federal Motor Carrier Safety Administration (FMCSA), 61, 62, 64, 66 Federal Motor Carrier Safety Regulations (FMCSRs), 62 Federal Rail Administration (FRA), 60 Firefighters, sleepiness in, 60 Fitbit®, 127 Floppy eyelid syndrome, Functional Outcomes of Sleep Questionnaire (FOSQ), 14, 16 G Growth hormone (GH), 77, 78 H Headaches, 80 History of presenting illness (HPI), Home sleep apnea testing (HSAT), 20–22, 33, 68 Hypersomnia circadian rhythm disorder, definition of, 3, 13 drowsy driving, idiopathic hypersomnia, 4, 56 insufficient sleep syndrome, 3, 57 KLS, 4, 56–57 medical disorders, narcolepsy (see Narcolepsy) OSA, PLMD, terminology, Hypnagogic hallucinations, 54 Hypnotics, 119, 121–122 Hypnotoxin theory, 76 207 I Idiopathic hypersomnia (IH), age of onset, 56 in children, 92, 96 diagnosis of, 56 MSLT, 111 prevalence rates, 56 symptom, 56 treatment of, 56 Idiopathic insomnia, 104, 186 In-service evaluation (ISE), 63, 64 Insomnia in children (see Sleepless child) chronic insomnia, causes of, 104–106 clinical assessment actigraphy, 108, 109, 117 ESS, 117 ISI, 109, 116–117 medical and psychiatric history, 115–116 MSLT, 111 patient’s sleep history, 115 polysomnography, 110, 117 sleep diaries, 107–109, 116 consequences of, 101, 102, 114 CRSWDs, 133 definition, 101, 184–185 diagnostic classification system, 117–118 differential diagnosis, 118–119 economic impact of, 114 Fitbit®, 127 non-pharmacological interventions, 122–126 OSA disorders, 29 patient history, 102–103 pharmacological interventions, 119–122 physical examination, 103–104 postpartum sleeplessness assessment, 201 depression and anxiety symptoms, 201 reasons for, 200 treatment, 202 in pregnant women consequences, 197 daily sleep diary, 198 non-pharmacological treatments, 199 pharmacotherapies, 199 self-report questionnaires, 198 symptoms, 196 prevalence rate of, 113–114 psychiatric and chronic health conditions, 114 societal costs, 114 sociodemographic characteristics, 114 Spielman’s 3-P model of, 115 symptoms, 101, 113–114 transient insomnia, causes of, 104 Index 208 Insomnia Severity Index (ISI), 109, 116–117 Insufficient sleep syndrome (ISS), 57, 119 International Classification of Sleep Disorders Third Edition (ICSD-3) hypersomnias, 53, 55 insomnia, 101 SRBDs, 29 International Restless Legs Syndrome Study Group (IRLSSG), 156–158 Irregular sleep–wake rhythm disorder (ISWRD) definition, 143 diagnosis, 143–144 pathophysiology, 143 prevalence, 143 treatment, 136, 144 ISI See Insomnia Severity Index (ISI) J Jet lag disorder definition, 146 diagnostic criteria, 146 pathophysiology, 146 treatment, 136, 147 Joint task force (JTF), 62, 66 K Karolinska Sleepiness Scale (KSS), 16 Kleine–Levin syndrome (KLS), 4, 56–57, 96–97 L Limit-setting sleep disorder, 105, 184, 187 M Maintenance of wakefulness tests (MWTs), 24, 62, 69 Mallampati classification, Mandibular advancing devices (MADs), 35, 47 Mean sleep latency (MSL), 23 Morningness-Eveningness Questionnaire (MEQ), 119 Multiple sclerosis, 80 Multiple sleep latency test (MSLT), 54 daytime sleepiness in children, 94 EDS, 23 EEG, 23, 24 insomnia, 111 mean sleep latency (MSL), 23, 24 narcolepsy, 23 patient preparation, 23 recovery sleep, 77 SOREMs, 23 Multiple-system atrophy (MSA), 178 Munich ChronoType Questionnaire (MCTQ), 119 MWTs See Maintenance of wakefulness tests (MWTs) N Narcolepsy, age of onset, 53–54 cataplexy, 54 in children, 95–96, 192 definition, 53 diagnosis of, 55 etiology of, 54 hypnagogic hallucinations, 54 incidence of, 53 sleep paralysis, 54 treatment of, 55 National Sleep Foundation (NSF), 3, 63 National Transportation Safety Board (NTSB), 60, 82, 83 Night eating syndrome (NES), 174 Nightmares, 10, 175, 192–193 Nocturnal frontal lobe epilepsy (NFLE), 168, 180 Nocturnal myoclonus, 153 Non-24 h sleep–wake rhythm disorder (N24SWD) definition, 141 diagnosis, 142 pathophysiology, 141–142 prevalence, 141 treatment, 136, 142 Non-rapid eye movement (NREM) sleep causes, 168–169 confusional arousals, 169, 173 diagnosis, 169 management, 169–172 risk factors, 169 sleep terrors, 173 sleepwalking, 173–174 SRED, 174 O Obesity narcolepsy–cataplexy, 95 OSA disorders, 30 sleep deprivation, 79–80 Index Obesity hypoventilation syndrome (OHS) diagnosis of, 43 epidemiology, 41 pathophysiology, 42 Obstructive sleep apnea (OSA) alcohol intake and smoking, 30 aviation crashes, 60 benzodiazepines, 30 Berlin Questionnaire, 16–17 cardiac disease, cardiovascular complications, 32 in children, 192 in commercial drivers (see Driver sleepiness) craniofacial abnormalities, 30, 31 definition of, 30 diabetes mellitus type 2, 32 diagnosis of, 32–33 endocrine disorders, 30, 32 in firefighters, 60 floppy eyelid syndrome, FOSQ, 16 HSAT, 20 hypersomnia, insomnia, 29 Mallampati classification, mechanism, 47 metabolic syndrome, neck circumference, neurocognitive manifestations, 32 obesity, 30 pathophysiology of, 31–32 polysomnography, 18 prevalence of, 30 RBD, 178 sleep enuresis, 180 SRED, 174 STOP-BANG Questionnaire, 17 symptoms of, 16, 29, 32 therapy for, 47 CPAP therapy, 33–34, 36 exercise training, 37 MADs and TRDs, 35 medications, 36–37 nasal EPAP devices, 35 OP therapy, 35 playing wind instruments, 37 positional therapy, 34–35 surgical therapies, 35–36 OCST See Out-of-center sleep testing (OCST) OHS See Obesity hypoventilation syndrome (OHS) Oral pressure (OP) therapy, 35 209 OSA See Obstructive sleep apnea (OSA) Out-of-center sleep testing (OCST), 68–69 P Paradoxical insomnia, 104, 111, 117, 186 Parasomnias categories, 167–168 definition, 167 differential diagnoses NFLE, 180 PLM, 180 RMD, 181 exploding head syndrome, 179 NREM parasomnias (see Non-rapid eye movement (NREM) sleep) REM parasomnias (see Rapid eye movement (REM) sleep) sleep enuresis, 179–180 sleep-related hallucinations, 179 SRDD, 179 Parkinson’s disease, 9, 80 Partial sleep deprivation, 76, 82 Pediatric Daytime Sleepiness Scale, 93 Pediatric Sleep Questionnaire, 93 Periodic limb movement disorder (PLMD), 4, 152–153, 162–163 Periodic limb movements (PLMs), 180 clinical significance, 154–155 EMG, 152 epidemiology, 154–155 etiology, 154 features, 153–154 history, 153 pathophysiology, 154 patient history, 153 PSG and EEG, 152, 154 Peripheral arterial tonometry (PAT), 21, 22, 33 Pilot sleepiness, 59–60 Pittsburg Sleep Quality Index (PSQI), 110, 198 PLMD See Periodic limb movement disorder (PLMD) PLMs See Periodic limb movements (PLMs) 3-P model, 115 Police officers, sleepiness in, 60 Polysomnography (PSG), 68, 69 advantages of, 20 AHI, 20 CSA syndromes, 39–40 insomnia, 110–111, 117, 185 insufficient sleep syndrome, 57 NREM parasomnias, 169 210 Polysomnography (PSG) (cont.) OSA, 18 PLMs, 152, 153 practice parameters for, 19 RBD, 176–177 SRBDs, diagnostic criteria for, 47–48 Portable monitoring (PM) See Out-of-center sleep testing (OCST) Positive airway pressure (PAP) therapy, 199 CSA syndromes, 40–41 SRVH disorders, 44 workers, 70–71 Postpartum sleeplessness insomnia assessment, 201 depression and anxiety symptoms, 201 reasons for, 200 treatment, 202 RLS, 200 SDB symptoms, 200 treatment, 202 Prader-Willi syndrome, 189 Pregnancy and sleeplessness insomnia consequences, 197 daily sleep diary, 198 non-pharmacological treatments, 199 pharmacotherapies, 199 self-report questionnaires, 198 symptoms, 196 RLS consequences, 197 diagnosis, 198–199 symptoms, 196–197 treatment, 200 SDB consequences, 197 diagnosis, 198 hypertensive disorders, 196 PAP therapy, 199 physiological and hormonal changes, 196 symptoms and signs, 198 Prophylactic nap, 84 PSG See Polysomnography (PSG) Psychomotor vigilance test (PVT), 69 Q Quality of life (QoL) insomnia, 114 parasomnias, 181 RLS patients, 162 Index Questionnaires BDI and BAI, 110 Berlin Questionnaire, 16–17 Epworth Sleepiness Scale, 15–16, 110 FOSQ, 16 ISI, 109 KSS, 16 PSQI, 110 SF-12 and SF-36, 15 sleep diary, 14–15 SSS, 16 STOP-BANG Questionnaire, 17 Quiescegenic nocturnal dyskinesia (QND), 156 R Railroad accidents, 59, 60 Rapid eye movement (REM) sleep characteristic features, 175 management, 169–172 nightmares, 175 RBD, 176–178 recurrent isolated sleep paralysis, 176 REM-off cells, 175 REM-on cells, 175 RBD See REM sleep behavior disorder (RBD) Recovery sleep, 77 Recuperative nap, 84 Recurrent hypersomnia See Kleine–Levin syndrome (KLS) Recurrent isolated sleep paralysis, 168, 176 REM sleep See Rapid eye movement (REM) sleep REM sleep behavior disorder (RBD), 176–178 REM sleep without atonia (RSWA), 177 Respiratory disturbance index (RDI), 33, 68 Respiratory effort-related arousals (RERAs), 31, 33 Restless legs syndrome (RLS) augmentation, 160, 162 brain iron dysregulation, 159 in children, 190–191 clinical significance, 160 dopamine and neurotransmitter dysfunction, 159 epidemiology, 160 history, 156 IRLSSG diagnostic criteria for, 156–158 patient history, 155, 159 pharmacologic treatment, 160–162 postpartum sleeplessness, 200 in pregnant women consequences, 197 diagnosis, 198–199 Index symptoms, 196–197 treatment, 200 primary vs secondary, 158 prognosis, 162 QoL deficits, 162 SRED, 174 thalamic glutamate, 159 Rhythmic movement disorder (RMD), 105, 168, 181 RLS See Restless legs syndrome (RLS) S SDB See Sleep-disordered breathing (SDB) Shift work disorder (SWD) definition, 144 diagnosis, 145 pathophysiology, 145 prevalence, 145 treatment, 136, 145–146 Short Form 36 (SF-36), 15 Short-term insomnia, 118, 190 Sleep debt, 77 Sleep deprivation and chronic pain syndromes, 81 diabetes and obesity, 79–80 as diagnostic tool, 82 driving and accidents, 82–83 history, 76 life expectancy, 75 in medical profession, 83 and neurological diseases, 80 non-pharmacological treatments, 84 pharmacological therapies, 84 physiological functions, effect on hormonal profile, 77–78 immune function, 78–79 thermoregulatory function, 78 in psychological and psychiatric illnesses, 80–81 as treatment, 81–82 types of chronic sleep deprivation, 76–77 recovery sleep, 77 total/partial sleep deprivation, 76 and vascular disease risk, 79 Sleep diaries, 107–109, 116 Sleep-disordered breathing (SDB) postpartum sleeplessness symptoms, 200 treatment, 202 in pregnant women consequences, 197 diagnosis, 198 211 hypertensive disorders, 196 PAP therapy, 199 physiological and hormonal changes, 196 symptoms and signs, 198 Sleep Disturbance Scale for Children, 93 Sleep enuresis (SE), 179–180 Sleepiness See also Sleepy patient commercial drivers, OSA in bus accidents, 61 CDME, 62, 63 CME, 66 ESS scores, 62–63 FMCSA, 61, 62, 64, 66 FMCSRs, 62 JTF criteria, 63–66 medical certification, 62 physical examination, 67 reasons for, 61 screening and treatment programs, 66–67 self-reporting, 63 truck accidents, 61 firefighters, 60 pilot sleepiness, 59–60 police officers, 60 workers, OSA in additional evaluation, 72 MWT, 69 OCST test, 68–69 overnight shifts, 72 PAP therapy, 70–71 PSG, 68, 69 surgical interventions, 71 wake-promoting agents, 72 Sleepless child insomnia in children, 183, 184 actigraphy, 185 behavioral insomnia, 187–188 drug/substance, 189–190 DSWPD, 191 excessive time in bed, 191 idiopathic insomnia, 186 inadequate sleep hygiene, 186–187 medical comorbidities, 185 medical condition, 189 medications, 193–194 mental disorder, 189 narcolepsy types and 2, 192 nightmares, 192–193 OSAS, 192 paradoxical insomnia, 186 physical exam, 185 psychophysiological insomnia, 185–186 restless legs syndrome, 190–191 short-term insomnia, 190 212 Sleepless child (cont.) sleep diaries, 185 symptoms, 185 treatment, 185 sleep duration in children, 184 treatment, 194 Sleep-onset association disorder, 105, 184, 187–188 Sleep-onset REM periods (SOREMs), 23 Sleep paralysis (SP), 54, 176 Sleep-related breathing disorders (SRBDs) CSA syndromes (see Central sleep apnea (CSA) syndromes) excessive daytime sleepiness, 29 OSA disorders (see Obstructive sleep apnea (OSA)) SRHO disorder, 44–46 SRHV disorders, 41–44 Sleep-related dissociative disorders (SRDD), 168, 179 Sleep-related eating disorder (SRED), 168, 174 Sleep-related hallucinations, 168, 179 Sleep-related hypoventilation (SRHV) disorders clinical features of, 43 definition of, 41 diagnosis of, 43–44 epidemiology, 41 mechanism, 48 pathophysiology, 42 PSG diagnostic criteria, 48 risk factors, 48 therapy of, 44, 48 Sleep-related hypoxemia (SRHO) disorder, 48 clinical features of, 45 definition of, 44 diagnosis of, 45–46 epidemiology, 45 pathophysiology, 45 treatment of, 46 Sleep-related movement disorders definition, 151 PLMD, 152–153, 162–163 PLMs (see Periodic limb movements (PLMs)) RLS (see Restless legs syndrome (RLS)) Sleep restriction therapy (SRT), 82, 122, 124 Sleep terrors (ST), 105, 168, 170–173 Sleepwalking (SW), 173–174 Sleepy child circadian drive for sleep, 92 clinical features, 93 delayed sleep-phase syndrome, 97 electronic media, use of, 91 Index homeostatic drive for sleep, 92 idiopathic hypersomnia, 96 inadequate sleep hygiene, 94–95 Kleine–Levin syndrome, 96–97 laboratory investigations, 94 medications, 94, 97–98 narcolepsy, 95–96 physiological changes, 91, 97 prevalence, 91 public health hazard, 91 sleep disorders, 92–93 sleep-wake function, 92 Sleepy patient history-taking, 13 family history, HPI, medications, past surgical history, review of symptoms, social history, standardized forms and questionnaires, objective assessment tools actigraphy (see Actigraphy) Fitbit activity and sleep tracker, 26 HSAT, 20–22 in-laboratory polysomnography (see Polysomnography (PSG)) MSLT (see Multiple sleep latency test (MSLT)) MWTs, 24 PAT, 21, 22 physical examination abdominal exam, cardiovascular, ear, nose, and throat exam, extremities, eyes, head and neck, lungs, neurologic exam, Saint Louis University Sleep Clinic Evaluation Form, 10–11 vital signs and general appearance, subjective assessment tools Berlin Questionnaire, 16–17 ESS, 15–16 FOSQ, 16 internet-based locations, 14 KSS, 16 SF-12 and SF-36, 15 sleep diary, 14–15 SSS, 16 STOP-BANG Questionnaire, 17 Index 213 Somnambulism See Sleepwalking (SW) SRBDs See Sleep-related breathing disorders (SRBDs) SRHO disorder See Sleep-related hypoxemia (SRHO) disorder SRHV disorders See Sleep-related hypoventilation (SRHV) disorders Stanford Sleepiness Scale (SSS), 14, 16 STOP-BANG Questionnaire, 14, 17, 32 Suprachiasmatic nuclei (SCN), 133–134 SWD See Shift work disorder (SWD) Tracheostomy, 36, 71 Transient insomnia, 104, 193 Type II diabetes mellitus (DM) OSA disorders, 32 sleep deprivation, 79–80 T Thyroid-stimulating hormone (TSH), 77–78 Tongue-retaining devices (TRDs), 35, 47 Total sleep deprivation, 76, 80–81 W Wake after sleep onset (WASO), 107, 109 Willis-Ekbom disorder (WED) See Restless legs syndrome (RLS) U Upper airway resistance syndrome (UARS), 33 Uvulopalatopharyngoplasty (UPPP), 36 ... Advanced sleep- phase syndrome Delayed sleep- phase syndrome Irregular sleep- wake pattern Non -2 4 -h sleep- wake syndrome (continued) Key History and Physical Examination Findings for the Sleepless or Restless... characteristics Sleep 20 00 ;23 (1):71–9 29 Carney CE, et al The consensus sleep diary: standardizing prospective sleep self-monitoring Sleep 20 12; 35 (2) :28 7–3 02 30 Buysse DJ, et al Recommendations for a standard... disorders, and assessing the amount of sleep can provide clues that the patient has too much or too little sleep opportunity [2] In assessing insomnia, it is important to screen for comorbid sleep