Tips to help you detect common sleep disorders
From the March ACP Observer, copyright © 2005 by the American College of Physicians.
By Margie Patlak
Although general internist Joyce E. Wipf, FACP, didn't know it, a patient whom she'd been treating for 15 years had developed a reputation for falling asleep during the day at his Rotary Club meetings.
"He had a long list of medical problems—including hypertension, aortic stenosis, venous stasis edema and back pain with spinal stenosis—that I had managed for years, but sleep never came up as an issue," said Dr. Wipf, of Seattle's VA Puget Sound Health Care System. He did not snore, and no apnea had been observed during a coronary care unit admission for chest pain a year earlier. It wasn't until her 80-year old patient started dozing off at meals that he finally let her know about his excessive sleepiness, which had been going on for about five years.
From there, diagnosis and treatment were fairly straightforward: After an evaluation, Dr. Wipf found he had all the symptoms of both restless legs syndrome and sleep apnea, and referred him to a nearby sleep lab. The lab diagnosed both conditions—as well as serious arrhythmias triggered by the apneic events.
Dr. Wipf's case is a good reminder that physicians may not be detecting patients' sleep problems. Research has found those problems contribute to public health disasters and traffic accidents. Even more importantly, there is growing evidence that sleep helps regulate blood pressure, insulin metabolism and other vital functions, and that it can have as profound an effect on patients' health as exercise and nutrition. (See "For more information.")
Studies have linked snoring to diabetes, and sleep apnea to hypertension, cardiovascular disease and heartburn. And findings published in the Dec. 7, 2004, Annals of Internal Medicine found an association between lack of sleep and excess eating, which contributes to obesity.
That evidence, combined with a shortage of sleep medicine experts in some parts of the country, means it's up to general internists to recognize and treat many sleep disorders. But many physicians don't ask about patients' sleep habits. (See "The nation's pool of sleep specialists is small, but growing.")
"It's a long discussion to do a thorough assessment on sleep," noted Dr. Wipf who typically asks patients a dozen different questions on sleep patterns, sleep environment and snoring history before suspecting a sleep disorder diagnosis. Many internists feel they don't have the time to do an in-depth evaluation. But Michael Sateia, MD, a sleep medicine specialist at Dartmouth-Hitchcock Sleep Disorders Center in Lebanon, N.H., claims there are streamlined ways to screen for sleep disorders.
"If physicians have a clear understanding of the five or six major categories that cause chronic insomnia, they can conduct an effective screening in just five minutes," he said. Because many sleep problems result from underlying disorders or medications already recorded in a standard health history, it's often a matter of connecting the dots. And three short questions can provide clues to the three most common sleep disorders: insomnia, sleep apnea and restless legs syndrome.
The first question sleep experts say physicians should ask patients is: How much are you sleeping at night?
Recent surveys by the National Sleep Foundation found that most people don't get enough sleep, often sleeping less than seven hours a night on a regular basis. Some people don't have trouble falling or staying asleep, but just don't allot enough time in their day for sleep.
But about one-third of American adults claim some level of insomnia within any given year, according to the National Heart, Lung, and Blood Institute (NHLBI), while 10%-15% indicate their insomnia is chronic or severe. Patients are considered to have insomnia if they can't stay asleep, wake up too early in the morning or suffer non-restorative sleep. The prevalence of insomnia increases with age and is more common in women.
The NHLBI recommends asking patients with suspected insomnia or other sleep problems to keep a sleep log for one to two weeks. Every day, they should record factors such as their quality and quantity of sleep, how long it took them to get to sleep, and how sleepy they feel during the day. Those entries may reveal bad sleep habits that could be the underlying cause. (See "Practicing good sleep hygiene." )
Common medications—decongestants, steroids, beta-blockers and theophylline—can disrupt sleep. (Selective serotonin reuptake inhibitors can trigger or exacerbate restless legs syndrome, another common sleep disorder.) Insomnia can also be caused by a wide range of medical and psychiatric disorders, or patients may have a hard time staying asleep because of arthritis pain or breathing problems linked to asthma or chronic obstructive pulmonary disease, which worsen at night. Reviewing the patient's history and improving treatment for those conditions can lead to a better night's sleep.
And sleep problems are often short-term, triggered by stressful situations such as a divorce or a death in the family. You should rule out or treat episodes of acute insomnia before diagnosing patients with a primary chronic sleep disorder.
Short-acting hypnotics can effectively treat insomnia on a limited basis. (See "When are sleeping pills appropriate?") But probably the best treatment for acute insomniacs? "Get them out of bed if they can't sleep," said Dr. Sateia. "Otherwise, they associate the bed with not sleeping and develop sleep-preventing anxiety when they hit the pillow"—a vicious cycle that can lead to chronic insomnia.
Patients who can't fall asleep within 20-30 minutes should do something relaxing outside the bedroom, like quiet reading. And patients with refractory insomnia that occurs three nights a week for more than a month should be referred to a sleep specialist. Those patients can often be helped with cognitive behavioral therapy, offered by most sleep centers.
"If a psychologist who specializes in sleep disorders isn't available," said Kesavan Kutty, FACP, chair of medicine at Milwaukee's St. Joseph Regional Medical Center, professor of medicine at the Medical College of Wisconsin and ACP's Governor for the Wisconsin Chapter, "the next best option is a psychologist who offers cognitive/behavioral therapy."
Fatigue vs. sleepiness
But many patients, even if they sleep through the night, feel sleepy during the day. That's why a second screening question—Do you have any trouble with daytime sleepiness?—is critical.
For patients who say they feel sleepy, physicians need to distinguish run-of-the-mill tiredness or fatigue from pathological sleepiness.
Patients who are fatigued say they have little energy and find it tough to get themselves in gear. Patients tend not to notice their sleepiness, on the other hand, until they are seated and struggling to stay awake. (Some daytime sleepiness occurs naturally in the early afternoon.) You should suspect a primary sleep disorder such as sleep apnea, narcolepsy or restless legs syndrome in patients who doze off during meetings or movies, or even while driving.
When patients admit to sleepiness, a few more questions can help pinpoint the most common causes:
Do you snore or snort loudly?
Has your bed partner observed pauses in your breathing?
Do you have restlessness in your legs before bedtime, or does your bed partner complain that your legs kick or jerk during the night?
Suspect sleep apnea in regular snorers, especially if they say their breathing stops periodically during the night. Sleep apnea is becoming more common, fueled in part by the current epidemic of obesity, said sleep medicine specialist Nancy Collop, MD, of Baltimore's Johns Hopkins University.
"Primary care doctors should refer patients for an overnight sleep study if they suspect sleep apnea," she said. Such evaluations are usually covered by health insurance.
Patients who run into long lines at a sleep lab can use a portable, home-use device to monitor their sleep and detect sleep apnea.
"The problem with these devices is that they may miss other conditions besides sleep apnea, or may even miss sleep apnea itself because they are not adequately sensitive," said John E. Stevenson, FACP, a sleep disorder consultant for Aurora Baycare Medical Center in Green Bay, Wis.
Besides, if the portable monitor diagnoses sleep apnea, "the patient will often still need a formal sleep lab study to determine the best treatment for the apnea," he said. "Formal sleep center studies may not always be necessary, but the best guide to a patient's needs will be sound clinical evaluation rather than a 'screening' study, which is often an added, redundant expense."
If patients have all the hallmark symptoms of sleep apnea but problems accessing a sleep lab, a diagnosis can be made clinically, said Dr. Kutty. They can then be given autotitration devices to indicate the pressure amount they need for a continuous positive air pressure (CPAP) device—although health plans tend not to cover the costs of these titration devices or the subsequent use of CPAP without a sleep lab evaluation.
At the same time, Dr. Kutty pointed out, initiating CPAP without thorough acclimatization could cause misuse or subsequent poor compliance. The best place to ensure acclimatization, he said, was in a sleep laboratory.
And according to Dr. Sateia, "CPAP is not an easy treatment for patients, and they tend to abandon it prematurely if they don't get the proper oversight and intervention for complications." He recommended that a sleep specialist initiate treatment and follow-up for patients with sleep apnea. Once they're stable, he said, primary care physicians can take over their care. (He also pointed out that his center recently did a survey of accredited and non-accredited sleep centers, and found that waiting times for an evaluation were typically no longer than three weeks.)
Another common cause for daytime sleepiness is restless legs syndrome—a highly treatable condition, now that researchers have pinned down its pathology. Recent studies, including one in the May 11, 2004, issue of Neurology, have found that the syndrome is caused by an iron shortage in the central nervous system, impairing the brain from properly using dopamine. Low doses of dopamine-like drugs, such as pramipexole or pergolide, are generally well tolerated and often relieve patients of their symptoms.
The tricky part of restless leg syndrome, said Dr. Sateia, is detecting it, because patients often can't find the right words to describe their symptoms. "They may use nonspecific terms such as feeling jittery or having creepy-crawly sensations in their legs," he said.
When those sensations are severe enough to interfere with sleep, you can refer the patient to a sleep specialist or a neurologist—or you may feel comfortable diagnosing restless legs syndrome and treating it with dopaminergic medications.
Snoring: more than a nuisance
Sleep medicine experts recommend asking patients a third question—Do you snore?—for two reasons. First, many patients with sleep apnea won't report its signature symptom: daytime sleepiness.
'Most patients tend to deny sleepiness because part of what we identify as success is getting by with less sleep.'
—John E. Stevenson, FACP
"Most patients tend to deny sleepiness," said Green Bay's Dr. Stevenson, "because part of what we identify as success is getting by with less sleep." He did one study published in a supplement to the April 15, 1999, issue of Sleep that found patients' spouses or significant others were much more accurate in reporting patients' daytime sleepiness than patients were themselves. So you can't rule out sleep apnea, even if patients don't complain of daytime sleepiness. That's why sleep apnea's other signature symptom—snoring—is so important to note.
There is also growing evidence that snoring, even without apnea, can compromise health. A study found that women who snored regularly were twice as likely to develop diabetes as nonsnorers, even if they were not overweight. Other studies suggest that persistent snoring may raise the lifetime risk of developing high blood pressure, heart failure and stroke.
Patients with heavy snoring and conditions linked to it or to sleep apnea—such as cardiovascular disease, hypertension, heartburn and type 2 diabetes—should be monitored overnight for sleep apnea or seen by a sleep specialist, even if patients don't report daytime sleepiness or observed apneas. If patients don't have access to a sleep specialist, consider using a home monitoring device.
The good news is that most sleep problems don't require specialist care, and that even sleep disorders—including the restless legs syndrome and sleep apnea suffered by Dr. Wipf's patient—respond well to treatment. After being placed on CPAP for his sleep apnea and on pramipexole for his restless legs, he happily reported that colleagues at his Rotary Club meetings were amazedthat he was finally able to stay awake.
Given benzodiazepines' track record for causing serious problems, most physicians are reluctant to prescribe hypnotics for insomnia for more than a few weeks. But a new breed of short-acting hypnotics is prompting a reevaluation of sleeping pills' risks and benefits.
In December 2004, the Food and Drug Administration (FDA) for the first time approved a hypnotic for long-term insomnia treatment. In the six- and 12-month studies conducted on eszopiclone (Lunesta) and summarized on the FDA Web site, researchers found no evidence that patients developed tolerance. Patients who stopped treatment suffered rebound insomnia for only the first night or two, and daytime drowsiness was not significant.
"This opens a window for greater consideration of hypnotics for the long term, because it means that with new-generation hypnotics, our conventional fears about addiction, tolerance and dosage escalation may not apply to such a large extent," said Dartmouth Medical School's sleep medicine expert Michael Sateia, MD. But that doesn't mean, he cautioned, "that overnight, the treatment for chronic insomnia should change to longer-term use of sleeping medications."
According to Dr. Sateia, several studies show that cognitive-behavioral therapy produced more sustained improvement than short-term use of sleeping pills. Because hypnotics treat the symptom but not the underlying cause of insomnia, experts recommend prescribing them only to patients whose underlying chronic insomnia is not treatable by other means. This would include some insomnia patients with innate hyperarousal tendencies that foster their lack of sleep, and those whose insomnia is triggered by an incurable disorder, such as Alzheimer's disease.
But not all patients have access to cognitive-behavioral therapists who treat sleep disorders, nor are they willing to commit to the standard three to six hours of therapy needed to treat insomnia.
In fact, most patients don't need long-term treatment because their insomnia is event-triggered. For patients with acute insomnia, physicians may consider prescribing short-acting hypnotics, such as zolpidem and eszopiclone, for a few weeks or less, experts say. These medications are also appropriate for patients experiencing short-term medical or psychiatric problems that interfere with their sleep.
And to prevent long-term problems from developing, any medication should always be accompanied by some education and advice on healthy sleep habits.
The lack of sleep suffered by many patients may be caused by bad habits that are easily remedied. Some examples of poor sleep hygiene that can disrupt sleep include:
Going to bed and rising at different times.
Not leaving enough wind-down time before bedtime, nor enough time for sleep itself.
Exercising three to four hours before bedtime.
Drinking caffeinated beverages or smoking cigarettes in the late afternoon or evening.
Having that nightcap. Once the effects of alcohol have worn off, the patient can wake up and have trouble falling back to sleep.
Sleeping with distractions, such as in brightly lit rooms or with the television on, or in rooms that are too warm.
Taking late afternoon naps.
When it comes to finding sleep experts, there's good news and bad news.
First the bad. There are currently only about 2,000 physicians certified in sleep medicine by the American Board of Sleep Medicine. The good news? That number is growing.
Between 1993 and 2003, the number of physicians certified in sleep medicine increased more than six-fold. And the nation's pool of sleep specialists is expected to grow even more, now that the Accreditation Council for Graduate Medical Education decided this year to start accrediting one-year fellowships in sleep medicine. According to Nancy Collop, MD, of Baltimore's Johns Hopkins University, the American Board of Medical Specialties is expected to follow suit by offering a sleep medicine certification exam within the next year or two.
"Sleep medicine is a fledgling field, but we're coming into the mainstream more," she said. "Now that sleep medicine is becoming more recognized as a specialty, the hope is that people will get formal training."
Despite the current shortage of sleep specialists, experts say you should try to refer patients only to labs accredited by the American Academy of Sleep Medicine. These labs feature American Board of Sleep Medicine-certified specialists who review all sleep studies performed.
National Center on Sleep Disorders Research
National Heart, Lung, and Blood Institute, NIH
6705 Rockledge Drive
One Rockledge Centre, Suite 6022
Bethesda, MD 20892-7993
American Insomnia Association
American Academy of Sleep Medicine
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
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