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Chapter 26: Sleep Disorders

Camellia P. Clark; Polly J. Moore; J. Christian Gillin

INTRODUCTION

This chapter primarily focuses on sleep and sleep disorders in adults. Although many basic and clinical aspects are similar in children, developmental issues and some disorders not present in adults, such as sudden infant death syndrome, are beyond the scope of this chapter. For further information the reader is referred to Principles and Practice of Sleep Medicine in the Child (Ferber & Kryger, 1995).

GENERAL APPROACH TO THE PATIENT

Office Evaluation

Clinicians should ask routinely about sleep and wakefulness. A thorough sleep history lays the foundation for accurate diagnosis and effective treatment of sleep disorders (Table 26–1). Patients' sleep complaints will usually fall into four general categories: complaints of difficulty initiating sleep or staying asleep (insomnia); difficulty staying awake during the day (hypersomnia); abnormal movements or behavior during sleep (parasomnia); timing of the sleep–wake cycle at undesired or inappropriate times over a 24-hour day (circadian rhythm disorder); or a combination of the above (Figure 26–1).

Figure 26–1

Steps for a sleep disturbance algorithm. (Adapted with permission from Tasman A, Kay J, Lieberman JA. Psychiatry, 2nd ed. Philadelphia: Saunders; 1996.)

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Table 26–1Office Evaluation of Chronic Sleep Complaints
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Table 26–1 Office Evaluation of Chronic Sleep Complaints

  1. Detailed history and review of the sleep complaint, as well as predisposing, precipitating, and perpetuating factors

  2. Review of the difficulties falling asleep, maintaining sleep, and awakening early

  3. Timing of sleep and wakefulness over the 24-h day

  4. Evidence of excessive daytime sleepiness and fatigue

  5. Bedtime routines, sleep setting, preoccupations, anxiety, beliefs about sleep and sleep loss, fears about consequences of sleep loss, nightmares, enuresis, and sleepwalking

  6. Medical and neurologic history and examination and routine laboratory examinations

  7. Review of use of prescription and nonprescription medications, hypnotics, alcohol, and stimulants

  8. Evidence of sleep-related breathing disorders: snoring; orthopnea, dyspnea; headaches; falling out of bed; nocturia; obesity; short, fat neck; enlarged tonsils; narrow upper oral airway; and foreshortened jaw (retrognathia)

  9. Abnormal movements during sleep; "jerky legs," leg movements, myoclonus, "restless legs," leg cramps, and cold feet

  10. Psychiatric history and examination

  11. Social and occupational history, marital status, living conditions, financial and security concerns, and physical activity

  12. Sleep environment—ambient noise, light, and temperature

  13. Sleep–wake diary for 2 weeks

  14. Typical exposure to light (sunlight and artificial) and darkness across a 24-h day

  15. Interview with bed partners or persons who observe the patient during sleep

  16. Tape recording of respiratory sounds during sleep to screen for sleep apnea

Adapted from Gillin JC, Ancoli-Israel S. The impact of age on sleep and sleep disorders. In: Salzman C, ed. Clinical Geriatric Psychopharmacology. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2005:492.

During the evaluation, the patient's bed partner or other informants should be included whenever possible. Because the patient may be unaware of ...

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