Evaluation of sleep disturbances

Although two-thirds of Americans have sleep problems, the vast majority of people with sleep disturbances suffer in silence. They enjoy life less, are less productive, and endure more illnesses and accidents at home, on the job, and on the road.

When to seek help

The American Academy of Sleep Medicine recommends seeking medical advice if sleep deprivation has compromised your daytime functioning for more than a month.

Don't hesitate to ask for help when you're sleeping badly following a death in the family or other stressful event. A physician may suggest the short-term use of a sedative to help you sleep at night and thus cope better during the day and prevent development of a long-term sleep disorder.

It's not always easy for people to get evaluation and treatment for a sleep problem. Doctors trained in the United States receive just over two hours of instruction on this topic during four years of medical school. According to a National Sleep Foundation survey, most primary care physicians do not routinely ask their patients about sleep. And while most of the physicians who took part in the survey admitted they had limited knowledge about sleep-related matters, more than half did not consult with an expert in sleep medicine. So it's in your best interest to seek out the help you need.

Your sleep history

A sleep disturbance cannot be accurately diagnosed unless your physician is familiar with your sleep habits and history. This information may be gleaned from an interview or from written questionnaires that you review and discuss with your doctor (see "A sample sleep history questionnaire" and "Screening for sleep apnea"). A bedroom partner may be able to help answer some of these questions and should contribute to the discussion.

Some people are so used to sleep deprivation that they don't realize they're tired; instead, they may see themselves as lazy, lethargic, or not very motivated. Or they may not think it is unusual to fall asleep at a movie or while sitting at dinner with friends. Someone considered by family members to be a "good napper," able to drop off quickly and sleep through anything, may actually be displaying signs of abnormal sleepiness. During a sleep history, a physician may ask how likely you are to doze off in certain situations. The less appropriate the circumstances (such as waiting in traffic while driving or having a conversation), the more dangerously sleepy you are considered to be.

A sample sleep history questionnaire

Your physician may ask you some of the following questions during an evaluation for a sleep problem. You may find it helpful to write down your answers to these questions and bring the completed questionnaire to the exam so you and your doctor can discuss it.

What bothers you most about your sleep habits?

How long have you had trouble sleeping, and what do you think started the problem? Did it come on suddenly?

How would you describe your usual night's sleep?

What time do you go to bed, and when do you wake up?

How long does it take you to fall asleep?

Once you're asleep, do you sleep through the night or wake up frequently?

What's your bedroom like?

What do you do in the few hours before bedtime?

Do you follow the same sleep pattern during the week and on weekends? If not, how are weekends different?

How well do you sleep on the first few nights when you're away from home? At home, do you sleep better in your bedroom or in another room in the house?

Do you often feel sleepy during the day?

Do you fall asleep at inappropriate times or places?

Have you ever been in a car accident or had a close call because you nodded off at the wheel?

Do allergies or nasal congestion bother you at night?

Do you have physical aches and pains that interfere with sleep?

What medications or drugs (including alcohol and nicotine) do you use? Have you ever taken sleep medications? If so, which ones?

Do you often have indigestion at night?

Do you ever feel discomfort or a fidgety sensation in your legs and feet when you lie down? Do you have to get up and walk around to relieve the feeling?

Do you kick or thrash around at night?

Do you ever have trouble breathing when you lie down, or do you awaken because it's hard to breathe?

Does your bed partner or roommate mention that you snore loudly or gasp for air at night?

Do you ever awaken with a choking sensation or a sour taste in your mouth?

Do you wake up with a headache or with cramps in your legs?

How have you been feeling emotionally? Does your life seem to be going as well as you would like?

The psychiatric interview

Sleep disturbances, particularly insomnia, are often related to psychological difficulties that respond well to treatment once they've been identified. Physicians may screen problem sleepers for symptoms of depression, anxiety, childhood physical or sexual abuse, or other psychological problems or traumatic experiences (see "Discovering the cause of sleeplessness"). If one of these conditions is diagnosed, your primary care physician may refer you to a psychologist or psychiatrist for treatment.

Discovering the cause of sleeplessness
Are you depressed?	Yes		No
1. I feel downhearted, blue, and sad.
2. I don't enjoy the things I used to.
3. I have felt so low I've thought of suicide.
4. I feel that I'm not useful or needed.
5. I notice that I'm losing/gaining weight.
6. I have trouble sleeping through the night.
7. I am restless and can't keep still.
8. My mind isn't as clear as it used to be.
9. I get tired for no reason.
10. I feel hopeless about the future.
You may be suffering from depression if you answered yes to at least five of these questions, you answered yes to either question 1 or question 2, and these symptoms have persisted for at least two weeks. You should seek professional help immediately if you answered yes to question 3.
Are you anxious?		Yes		No
1. Do you feel upset or tense, maybe without even knowing why?
2. Does your heart often race uncontrollably?
3. Are your hands often sweaty, clammy, or extremely cold?
4. Do you often have a lump in your throat?
5. Do you have difficulty slowing down or relaxing?
6. Do you often feel insecure or anxious?
7. Do you often feel ill at ease?
8. Do you often feel tired without any reason?
9. Do you often worry about things you've said that might have hurt somebody's feelings?
10. Do you tend to worry, even over things that you realize don't matter?
11. Are you presently worrying over a possible misfortune?
12. Do you often feel nervous, jittery, or high-strung?
13. Are you more apprehensive about the future than other people are?
If you answered yes to five or more of these questions, you are probably more anxious or tense than other people, and you may need to seek professional help.
Reprinted with permission from No More Sleepless Nights by Peter Hauri, Ph.D., and Shirley Linde, Ph.D.

Sleep laboratory evaluation

Most people with sleep problems don't need to visit a sleep laboratory. Insomnia and circadian rhythm disorders, for example, can be diagnosed by a thorough history and physical examination. However, when a doctor suspects a sleep disorder such as narcolepsy, periodic limb movement disorder, sleep apnea, or one of the parasomnias (see "Parasomnias"), he or she may recommend formal sleep testing.

Fees depend on the level of testing required. Some people require a one-time consultation with a sleep specialist, which may run a few hundred dollars. Staying overnight in a sleep laboratory costs between $800 and $1,500. Check with your insurance company in advance because reimbursement varies and may depend on your diagnosis.

The American Academy of Sleep Medicine has a listing of more than 1,100 accredited sleep disorder centers and more than 3,000 board-certified sleep specialists (see "Resources"). Some centers will make an appointment directly with you, while others require a physician referral. The center will request medical records and may send you a sleep questionnaire or diary to use before your visit. You may also be asked to change your sleep habits in certain ways before scheduling the visit. Sometimes these changes alone correct the problem.

Overnight sleep tests

When you spend the night in a sleep laboratory, you'll wear your own nightclothes and you can use a pillow from home. You can take your regular medications, but the clinicians will need to know what they are. The lab usually provides a regular bed in a private room with a bathroom attached. The room is kept as quiet as is possible.

After a technician sets up the sleep-monitoring equipment, you'll be left alone to relax until bedtime. Throughout the night, laboratory staff will monitor the instruments in a nearby control room. Some of the tests and equipment used include polysomnography, audiotape, videotape, and daytime sleep tests.

Polysomnography. In this procedure, small wafer-thin electrodes and other sensors are pasted on specific body sites to take a variety of readings during the night. They may be placed on your scalp to track brain waves; under your chin to measure fluctuations in muscle tension (called an electromyogram, or EMG); near your eyes to measure eye movements; near your nostrils to measure airflow; on your earlobe or finger to measure the amount of oxygen in your blood (using a device called an oximeter); on your chest or back to record heart rate and rhythm; on your legs to record twitches or jerks; and over your rib muscles or around the rib cage and abdomen to monitor breathing.

Readings are collected on a single printout (called a polysomnogram) and analyzed by a technician and physician. If a breathing problem is detected early on, you may be awakened and given treatment, such as PAP, during the second half of the night. This allows the sleep experts to monitor how well the treatment works for you. Sometimes this process requires two nights. A standard polysomnogram cannot diagnose sleep-related epilepsy. If your doctor suspects that you may have a seizure disorder, you may undergo a full electroencephalogram (EEG) during the night.

Audiotape and videotape. Audiotape equipment may be used to record snoring, talking during sleep, or other sounds. A video may also be taken to compare with the polysomnogram. This may show, for example, that you snore only when in a certain position. Signs of movement disorders (such as periodic limb movement disorder) or parasomnias will probably be apparent on the videotape.

Daytime sleep tests. Daytime sleep tests may be administered after a night in the sleep lab. The multiple sleep latency test measures how long it takes you to fall asleep while lying down in a quiet room and what stages of sleep occur during a brief nap. The procedure is usually repeated four or more times during the day at two-hour intervals. This test measures sleepiness and looks for signs of narcolepsy. Falling asleep within five minutes each time indicates extreme sleepiness.

In the maintenance of wakefulness test, which is less commonly used, you're given the opposite instructions: Try to stay awake. This ability is also affected by the degree of sleepiness. People are sometimes given both tests at different times.

Home-based tests

Some sleep-monitoring equipment can be used at home. Physicians, however, disagree about whether the information collected is reliable enough to use for diagnosis and treatment. Portable recordings may be useful when polysomnography is not available and symptoms indicate that immediate treatment is needed, or when a patient is bedridden or medically unstable and cannot be moved. Home-based tests may also be used when a physician wishes to evaluate the effectiveness of treatment.

Apnea detectors. To detect breathing disturbances during sleep, a patient is sometimes equipped with apnea detectors that can measure heart rate, snoring sounds, body position, nasal airflow, and the amount of oxygen in the blood. Although these devices have been used to estimate how many people suffer from breathing disturbances, the information they provide isn't as accurate as sleep lab evaluations and may not be complete enough to diagnose and plan treatment for an individual.

Wrist actigraphy. A wristwatch-sized monitoring device that automatically records arm or leg movements can be used to track periods of sleep and wakefulness at night. Although it cannot determine the stage of sleep, it can help clarify ambiguous aspects of a sleep diary — such as entries reporting long hours of sleep but exhaustion the next day — or assess the effectiveness of medical treatment. The actigraphy device may reveal that brief awakenings during the night are unknowingly disturbing sleep. In some studies, wrist actigraphy accurately determined whether a person was asleep almost 90% of the time.

The American Academy of Sleep Medicine recommends polysomnography, done in a sleep lab, as the best method for diagnosing sleep apnea and determining its severity. Portable home devices can miss mild apnea and other sleep disruptions, and they don't provide the sleep stage information needed to rule out other sleep disturbances. Accordingly, they should only be used when the patient's physician is familiar with the devices' benefits and limitations and has experience interpreting the results.

How sleepy are you?

Sleep specialists often use this measure, called the Epworth Sleepiness Scale, to gauge a patient's level of daytime sleepiness.

Imagine yourself in the following situations, and then select your likelihood of dozing using the 0–3 scale below. Add up these numbers. If you score 10 points or more, consider seeing a physician for an evaluation.

Scale:

0 = would never doze
2 = moderate chance of dozing
1 = slight chance of dozing
3 = high chance of dozing

Situation:

______ Sitting and reading

______ Watching TV

______ Sitting inactive in a public place, like a theater or meeting

______ As a passenger in a car for an hour without a break

______ Lying down to rest in the afternoon

______ Sitting and talking to someone

______ Sitting quietly after lunch (when you've had no alcohol)

______ In a car while stopped in traffic

Review Date: 2007-10-01