Chapter 028. Sleep Disorders (Part 5)

Disorders of Sleep and WakefulnessApproach to the Patient: Sleep DisordersPatients 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...
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Chapter 028. Sleep Disorders (Part 5) 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 severalsymptoms: (1) an acute or chronic inability to initiate or maintain sleep adequatelyat night (insomnia); (2) chronic fatigue, sleepiness, or tiredness during the day; or(3) a behavioral manifestation associated with sleep itself. Complaints of insomniaor excessive daytime sleepiness should be approached as symptoms (much likefever or pain) of underlying disorders. Knowledge of the differential diagnosis ofthese presenting complaints is essential to identify any underlying medicaldisorder. Only then can appropriate treatment, rather than nonspecific approaches(e.g., over-the-counter sleeping aids), be applied. Diagnoses of exclusion, such asprimary 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 acomplaint of excessive daytime sleepiness. Table 28-1 Evaluation of the Patient with the Complaint of ExcessiveDaytime Somnolence Finding Diagnostic Diagnosis Therapys on History Evaluationand PhysicalExamination Obesity, Polysomnograp Obstructi Continuoussnoring, hy with respiratory ve sleep apnea positive airway pressure;hypertension monitoring ENT surgery (e.g., uvulopalatopharyngoplast y); dental appliance; pharmacologic therapy (e.g., protriptyline); weight loss Cataplex Polysomnograp Narcoleps Stimulants (e.g.,y, hypnogogic hy with multiple sleep y-cataplexy modafinil,hallucinations, latency testing syndrome methylphenidate); REM-sleep paralysis, suppressantfamily history antidepressants (e.g., protriptyline); genetic counseling Restless Assesment for Restless Treatment oflegs, disturbed predisposing medical legs syndrome predisposing condition, ifsleep, conditions possible; dopaminepredisposing agonists (e.g.,medical pramipexole, ropinirole)condition (e.g.,iron deficiencyor renal failure) Disturbe Sleep-wake Insomnias Treatment ofd sleep, diary recording (see text) predisposing conditionpredisposing and/or change in therapy,medical if possible; behavioralconditions therapy; short-acting(e.g., asthma) benzodiazepine receptorand/or agonist (e.g., zolpidem)predisposingmedicaltherapies (e.g.,theophylline) Note: ENT, ears, nose, throat; REM, rapid eye movement; EMG,electromyogram. A careful history is essential. In particular, the duration, severity, andconsistency of the symptoms are important, along with the patients estimate of theconsequences of the sleep disorder on waking function. Information from a friendor family member can be invaluable; some patients may be unaware of, or willunderreport, such potentially embarrassing symptoms as heavy snoring or fallingasleep while driving. Patients with excessive sleepiness should be advised to avoidall driving until effective therapy has been achieved. Completion by the patient of a day-by-day sleep-work-drug log for at least2 weeks can help the physician better understand the nature of the complaint.Work times and sleep times (including daytime naps and nocturnal awakenings) aswell as drug and alcohol use, including caffeine and hypnotics, should be notedeach day. Polysomnography is necessary for the diagnosis of specific disorders suchas narcolepsy and sleep apnea and may be of utility in other settin ...