Sleep Disturbance

Sleep disorders encompass a range of conditions that affect sleep quality, timing, or duration and can lead to dysfunction during the daytime. Diagnosis and management of sleep disorders often require a multidisciplinary approach.

Diagnosis:

  1. Clinical Evaluation:
    1. A detailed medical and sleep history (including sleep patterns, environmental factors, and bedtime routines).
    2. Use of sleep questionnaires and diaries (e.g.,
      1. Epworth Sleepiness Scale
      2. Pittsburgh Sleep Quality Index
  2. Physical Examination:
    1. To identify any physiological conditions that might interfere with sleep (e.g., obesity suggesting sleep apnea).
  3. Sleep Studies:
    1. Polysomnography (PSG): An overnight sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye and leg movements.
    2. Multiple Sleep Latency Test (MSLT): Measures how quickly a person falls asleep during quiet daytime situations, often used to diagnose narcolepsy.
    3. Home Sleep Apnea Testing (HSAT): A simplified version of PSG used to diagnose obstructive sleep apnea (OSA) in uncomplicated adult patients.
  4. Specialist Referral:
    1. Referral to a sleep specialist or sleep center may be warranted for complex cases or when initial management fails.

Differential Diagnosis:

  1. Primary Sleep Disorders:
    1. Insomnia.
    2. Narcolepsy.
    3. Restless legs syndrome (RLS).
    4. Circadian rhythm sleep disorders.
  2. Sleep-Related Breathing Disorders:
    1. Obstructive sleep apnea (OSA).
    2. Central sleep apnea.
    3. Sleep-related hypoventilation disorders.
  3. Other Medical Conditions:
    1. Endocrine disorders (e.g., hyperthyroidism).
    2. Neurological disorders (e.g., Parkinson’s disease).
    3. Psychiatric conditions (e.g., depression, anxiety).
  4. Substance-Related:
    1. Medication effects.
    2. Substance abuse or withdrawal.

Management:

  1. Behavioral Interventions:
    1. Cognitive Behavioral Therapy for Insomnia (CBT-I): First-line treatment for chronic insomnia.
    2. Sleep hygiene education: Regular sleep schedule, a comfortable sleep environment, and avoidance of caffeine and electronics before bedtime.
  2. Pharmacological Treatment:
    1. May include the use of hypnotics, antidepressants, or antihistamines for insomnia.
    2. Stimulants or wakefulness-promoting agents for narcolepsy.
    3. Dopaminergic agents for RLS (ie pramipexole)
    4. CPAP (Continuous Positive Airway Pressure) therapy is the standard treatment for OSA.
  3. Device Therapy:
    1. CPAP, BiPAP, or other forms of non-invasive ventilation for sleep-related breathing disorders.
  4. Surgical Options:
    1. For OSA, procedures such as uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement, or nasal surgeries may be considered.
  5. Management of Comorbid Conditions:
    1. Addressing underlying medical or psychiatric conditions that may be contributing to the sleep disorder.
  6. Lifestyle Modifications:
    1. Weight loss for overweight individuals, especially those with OSA.
    2. Exercise, although not close to bedtime, can improve sleep quality.
    3. Limiting alcohol and tobacco, both of which can disrupt sleep.
  7. Follow-Up:
    1. Regular follow-up to monitor treatment efficacy and adherence.
    2. Reevaluation of sleep studies if symptoms persist or worsen.

It’s important to tailor the management plan to the individual patient, considering the specific type of sleep disorder, its severity, the presence of comorbid conditions, and the patient’s preferences and responses to treatment. Collaboration with a sleep specialist is often necessary for complex cases or when initial treatment strategies do not yield satisfactory results.

Insomnia

Insomnia is characterized by difficulty falling asleep, staying asleep, or impaired daytime function. It can have a variety of causes and its treatment is multifaceted. Here’s a general outline of the causes and best practice treatments:

Causes of Insomnia:

  • Psychological Issues: Stress, anxiety, and depression are among the leading causes of insomnia.
  • Behavioral Factors: Poor sleep habits or sleep hygiene, such as irregular sleep schedules, stimulating activities before bed, or an uncomfortable sleep environment, can contribute to insomnia.
  • Physical Health Conditions: Chronic pain, acid reflux, hyperthyroidism, asthma, allergies, neurological conditions, and menopause can lead to insomnia.
  • Medications and Substances: Certain medications, caffeine, alcohol, and drugs can interfere with sleep.
  • Neurological Disorders: Conditions like Parkinson’s disease and Alzheimer’s disease can affect sleep patterns.
  • Hormonal Changes: Fluctuations in hormones during menstruation, pregnancy, or menopause can cause sleep disturbances.
  • Other Sleep Disorders: Sleep apnea, restless legs syndrome, and circadian rhythm disorders can lead to insomnia.
  • Lifestyle: Shift work and irregular schedules can disrupt the body’s circadian rhythm.

The 3P Model of Insomnia

The “3P” model of insomnia is a framework used to understand the development and maintenance of chronic insomnia. It was proposed by Arthur Spielman, and the “3Ps” stand for:

  • Predisposing Factors: These are the individual characteristics that make a person more vulnerable to insomnia. They can include genetic traits, personality characteristics (such as being a “light sleeper”), or the presence of other medical or psychiatric conditions.
  • Precipitating Factors: These are events or circumstances that trigger the onset of insomnia. They can be acute stressors like the loss of a loved one, job stress, a medical illness, or any significant life change or event that disrupts normal sleep patterns.
  • Perpetuating Factors: These are the behaviors and patterns that develop in response to insomnia and unintentionally sustain the problem over time. For example, spending too much time in bed while awake, worrying about sleep, and irregular sleep schedules can all perpetuate insomnia.

Understanding these factors is important in the treatment and management of insomnia, as it allows for a comprehensive approach to address not just the symptoms, but also the underlying causes and maintaining behaviors. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a common treatment that addresses these factors in a structured way.

Assessment of Insomnia

The assessment of insomnia typically involves a comprehensive evaluation that includes the patient’s medical history, a physical exam, sleep history, and sometimes the use of sleep diaries and questionnaires. Here’s a brief discussion of the key components of insomnia assessment:

  • Medical and Psychiatric History: A thorough medical and psychiatric history helps to identify any underlying conditions that may contribute to insomnia, such as depression, anxiety, chronic pain, or a medical illness.
  • Sleep History: This includes the patient’s usual sleep patterns, bedtime routines, and environmental factors that may affect sleep. The clinician may ask about sleep latency (time to fall asleep), frequency and duration of awakenings, total sleep time, the regularity of the sleep schedule, and symptoms of other sleep disorders (like sleep apnea or restless legs syndrome).
  • Sleep Diary: Patients may be asked to keep a sleep diary for a couple of weeks. This diary should track bedtime, wake time, total sleep time, time to fall asleep, number and length of awakenings, and perceived sleep quality.
  • Questionnaires: Standardized questionnaires such as the
    • Insomnia Severity Index (ISI),
    • Pittsburgh Sleep Quality Index (PSQI), or the
    • Epworth Sleepiness Scale (ESS)
    • can help quantify sleep disturbances and daytime dysfunction.
  • Physical Examination: Although there are no physical signs specific to insomnia, a physical examination can help identify any physical conditions that might contribute to sleep disturbances.
  • Specialized Sleep Studies: In some cases, when the diagnosis is unclear or when there is a suspicion of other sleep disorders, the patient may be referred for polysomnography (a sleep study) or actigraphy. Polysomnography is an overnight study that records brain waves, blood oxygen levels, heart rate, breathing, and eye and leg movements. Actigraphy involves wearing a small wristwatch-like device that measures movement and can provide information about sleep patterns over several days.
  • Psychological Evaluation: Sometimes, psychological evaluation is recommended to assess for mental health disorders that can cause or worsen insomnia.
  • Behavioral and Lifestyle Factors: Assessment includes a review of lifestyle and behaviors that can affect sleep, such as caffeine and alcohol consumption, exercise, smoking, and screen time before bed.
  • Medication Review: A review of all current medications and supplements is important, as some substances can contribute to insomnia.

Based on this assessment, the healthcare provider can diagnose the type of insomnia and its possible causes, which guides the development of an appropriate treatment plan. Treatment may involve cognitive behavioral therapy, medication, and addressing any underlying medical or psychological conditions.

Best Practice Treatment:

  • Cognitive-Behavioral Therapy for Insomnia (CBT-I):
    • Sleep Hygiene Education: Establishing a regular sleep-wake cycle, avoiding caffeine and alcohol before bedtime, and creating a comfortable sleeping environment.
    • Stimulus Control Therapy: Creating a sleep environment that promotes sleep and using the bed only for sleep and sex.
    • Sleep Restriction: Limiting the amount of time spent in bed to actual sleep time, gradually increasing it as sleep efficiency improves.
    • Relaxation Techniques: Mindfulness, meditation, deep breathing exercises, and progressive muscle relaxation to reduce stress and promote relaxation.
    • Cognitive Therapy: Addressing negative thoughts and worries that can interfere with sleep.
  • Pharmacological Treatments:
    • These are generally considered when non-pharmacological methods have failed and are typically not intended for long-term use due to potential for dependency and tolerance.
    • Benzodiazepine Receptor Agonists: Such as temazepam, zolpidem and zopiclone
    • Orexin A/B Antagonist: Suvorexant (Belsomra), Lemborexant (Dayvigo)
    • Melatonin: Such as Circadin
    • Antidepressants: Especially when insomnia is comorbid with depression, such as endep or mirtazapine.
    • Over-the-Counter (OTC): Sedating antihistamines, doxylamine (though these are not recommended for long-term use due to side effects).
  • Lifestyle and Behavioral Changes:
    • Regular Exercise: Moderate-intensity exercise during the day can promote better sleep at night.
    • Diet: Avoiding heavy meals, caffeine, and nicotine close to bedtime.
    • Mindfulness and Stress Management: Techniques such as yoga and meditation.
  • Environmental and Sleep Routine Adjustments:
    • Regular Sleep Schedule: Going to bed and waking up at the same time every day.
    • Optimal Sleep Environment: Dark, quiet, and cool environment; comfortable mattress and pillows.
  • Education and Counseling:
    • Informing patients about the nature of sleep and the factors that affect sleep quality.
  • Addressing Underlying Medical Conditions:
    • Treatment of any physical or mental health issues that may be causing or exacerbating insomnia.

Best practice for treating insomnia involves a patient-centered approach, usually starting with non-pharmacological methods and considering medication as an adjunctive treatment when necessary. Each patient’s treatment should be individualized based on the underlying causes, the severity of symptoms, the presence of comorbid conditions, and the patient’s preferences. It’s crucial to avoid self-medication and to consult healthcare professionals for a tailored treatment plan.

BBT-i

BBT-i stands for Brief Behavioral Therapy for Insomnia. It is a short-term, non-pharmacological treatment approach designed to improve sleep in individuals with insomnia. BBT-i is based on principles similar to those in Cognitive Behavioral Therapy for Insomnia (CBT-i), but it is delivered in a more condensed format. It is specifically structured to be more accessible and typically involves fewer sessions, which makes it a practical option for a variety of settings and populations, including primary care.

The core components of BBT-i usually include:

  1. Sleep Education: Patients receive information about sleep regulation, the effects of sleep deprivation, and the role of circadian rhythms, as well as the influence of behaviors and habits on sleep patterns.
  2. Sleep Hygiene Education: Patients are taught about behaviors that can improve sleep, such as maintaining a regular sleep schedule, avoiding caffeine and alcohol before bedtime, creating a comfortable sleep environment, and engaging in relaxing activities before bedtime.
  3. Stimulus Control Instructions: Patients are instructed to use the bed and bedroom only for sleep and sex, establishing a strong association between the bed and sleep. This includes going to bed only when sleepy and getting out of bed when unable to sleep for a specified amount of time.
  4. Sleep Restriction Therapy: This involves limiting the amount of time spent in bed to the actual sleep time, as indicated by a sleep diary. The goal is to increase sleep efficiency by creating a mild sleep debt to promote faster sleep onset and reduced night awakenings.
  5. Relapse Prevention: Education on how to maintain good sleep practices and how to manage potential relapses in insomnia.

BBT-i is typically delivered in four to six sessions, which can be conducted in person or via telehealth. The sessions are structured and focused, with an emphasis on behavioral changes and the development of good sleep habits. The therapist works collaboratively with the patient to tailor the intervention to the patient’s specific needs and to troubleshoot any difficulties with implementing the strategies.

Research has shown that BBT-i can be effective in reducing the time it takes to fall asleep, reducing the time spent awake after sleep onset, and improving overall sleep quality. It is considered a first-line treatment for insomnia by many sleep specialists and healthcare providers.

Obstructive Sleep Apnoea

Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, leading to disrupted sleep and decreased oxygen levels in the blood. Here’s a detailed overview of its causes, diagnosis, differential diagnosis, and management:

Causes:

  • Anatomical Factors: Enlarged tonsils or adenoids, obesity (especially neck and abdominal obesity), retrognathia (receding jaw), or other structural abnormalities that narrow the upper airway.
  • Functional Factors: Muscle relaxation during sleep can lead to airway collapse, especially in the presence of anatomical predispositions.
  • Risk Factors: Include obesity, male gender, older age, smoking, alcohol use, family history of OSA, and use of sedatives or tranquilizers.
    • Snoring
    • Tiredness during the day
    • Observed Apnoea
    • Pressure (BP)
    • BMI > 35
    • Age > 50
    • Neck > 40cm
    • Gender: male

Diagnosis:

  • History (Hx):
    • Symptoms: Loud snoring, observed episodes of breathing cessation during sleep, abrupt awakenings accompanied by shortness of breath, morning headache, daytime sleepiness, attention problems, irritability.
    • Risk Factors: Assessment of body mass index (BMI), neck circumference, and medical history of conditions associated with OSA (e.g., hypertension, diabetes).
  • Examination (Ex):
    • Physical Examination: Focus on the upper airway, including nasal passages, oropharynx, and neck. Assessment of body habitus, particularly obesity and craniofacial abnormalities.
    • Neck Circumference: A large neck circumference is a significant risk factor (greater than 40 cm in men and 35 cm in women).
  • Investigations (Ix):
    • Polysomnography (Sleep Study): Gold standard for diagnosis. Measures various physiological parameters during sleep, including airflow, blood oxygen levels, heart rate, brain activity, and muscle activity.
      • Hypopneas
      • Apnoeas
      • Home Sleep Apnea Testing (HSAT): An alternative to in-lab sleep studies for some patients.

Differential Diagnosis (DDx):

  • Central Sleep Apnea: Characterized by a lack of effort to breathe during sleep, not obstruction of airflow.
  • Primary Snoring: Snoring without apnea episodes.
  • Nocturnal Asthma: Can mimic some symptoms of OSA but has different treatment.
  • GORD: Gastroesophageal reflux disease can worsen or mimic OSA.
  • Hypothyroidism: Can have similar symptoms like fatigue and weight gain.
  • Chronic Obstructive Pulmonary Disease (COPD): Overlapping symptoms may occur.

Management (Mx):

  • Lifestyle Modifications:
    • Weight Loss: Especially if obese.
    • Avoid Alcohol and Sedatives: Particularly before bedtime.
    • Positional Therapy: Sleeping on the side instead of the back if OSA is position-dependent.
  • Continuous Positive Airway Pressure (CPAP):
    • The mainstay of treatment for moderate to severe OSA. Delivers air through a mask to keep the airway open.
    • Requires use 4+ hours a night at least 5 days a week to meet minimum standards for driving.
      • Drivers can only be licenced if they meet this standard
  • Oral Appliances:
    • Dental devices that adjust the lower jaw and tongue position to keep the airway open.
  • Surgery:
    • Options include uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement, or tracheostomy in severe cases.
  • Management of Comorbid Conditions:
    • Addressing conditions like obesity, hypertension, and diabetes.
  • Follow-Up and Monitoring:
    • Regular follow-up to assess symptom improvement, CPAP adherence, and manage side effects.

In summary, OSA is a multifactorial disorder with significant health implications. Diagnosis involves a thorough clinical assessment and often requires confirmatory polysomnography. Management is tailored to the individual, with CPAP therapy being the cornerstone of treatment for many patients.

The Apnoea-Hypopnea Index (AHI)

The Apnoea-Hypopnea Index (AHI) is a measure used to assess the severity of sleep apnea, a condition characterized by repeated episodes of partial or complete airway obstruction during sleep. The AHI quantifies the number of apneas (complete cessation of airflow) and hypopneas (partial reduction of airflow) that occur per hour of sleep.

AHI = Number of Apneas + Hypopneas / Total Hours of Sleep

The AHI is used to categorize the severity of sleep apnea:

  • Normal: AHI < 5
  • Mild Sleep Apnea: AHI 5-15
  • Moderate Sleep Apnea: AHI 15-30
  • Severe Sleep Apnea: AHI > 30

Importance of AHI

  1. Diagnosis: The AHI helps diagnose sleep apnea and determine its severity.
  2. Treatment Decisions: It guides treatment decisions, such as lifestyle changes, the use of continuous positive airway pressure (CPAP) therapy, or surgical interventions.
  3. Monitoring: AHI can be used to monitor the effectiveness of treatment over time.