Patrick Hanley (identical twin of John Hanley) gave an excellent overview of common sleep disorders. Like rheumatologists, sleep physicians use multiple different tools to evaluate and differentiate the variety of sleep disorders, in order to determine the best treatment. Patient tools include sleep logs and actigraphy (watch-like devices that monitor sleep). Nocturnal sleep can be monitored with home sleep study and polysomnography. Daytime sleepiness can be monitored with the multiple sleep latency test (MSLT) and the maintenance of wakefulness test (MWT).
The first step when evaluating patients for potential sleep disorders is to differentiate fatigue from sleepiness. The Epworth Sleepiness Scale is one tool that can be used, with a score above 10 consistent with sleepiness. Sleepiness is involuntary, unplanned, can have potential consequences (e.g. falling asleep while driving) and can be qualified as active or passive. The differential diagnosis for sleepiness includes medication side effects, medical disorders, psychiatric disorders, sleep restriction and sleep disorders.
How do we know if someone is sleep restricted? We all have our own individual sleep requirements. Someone who is sleep restricted will be alarm clock dependent, will have a different sleep schedule on weekends or holidays, and will feel better with more sleep. Fatigue, on the other hand, is reported as unrefreshing sleep, poor motivation, voluntary naps, and lack of interest, and has a broader differential diagnosis.
Of all the sleep disorders, sleep apnea is likely the most common. Symptoms include snoring, witnessed apnea, and nocturnal choking/gasping. Evaluation of severity includes clinical symptoms, BMI, neck circumference, age and gender. The STOP-BANG questionnaire and adjusted neck circumference can be used to determine the likelihood of having sleep apnea. Home testing is becoming more common and readily available as an alternative to sleep labs. Sleep apnea severity is determined by the number of apnea events per hour of sleep. For those with mild disease and without hypoventilation, treatment options include weight reduction and dental appliances. For more severe disease, CPAP is the treatment of choice, and can be fixed or auto-adjusting. In those with hypoventilation, BIPAP is appropriate.
There are conditions that can result in false positive results, and a common example of this is restless legs. A good screen for restless legs is URGE -- Urge to move limbs, Rest worsens, Gets better with moving around, Evening and night makes symptoms worse. Treatment includes behaviour modification, avoiding caffeine, treating sleep apnea or low iron if present, and identifying contributing medications (particularly antidepressants, benzodiazepines, dopaminergic agents, gapapentin/pregabalin, and opiods).
Although I admit that I did not know much about sleep disorders prior to the workshop, it is important for us to have at least a basic understanding of this issue that commonly affects our patients.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio