Assessing Sleep
Sleep is essential for both mental and physical health. I personally treat it like pain or the “5th vital sign” of mental health. In my experience, treating sleep disorders i.e. insomnia alone is more effective than as an additional symptom of a mental disorder like depression. Insomnia may or may not be related to an underlying condition (which still needs to be ruled out), but a lack of sleep in itself has been linked to multiple health problems:
- Sleep is involved in the healing and repair of your heart and blood vessels, ongoing sleep deficiency is linked to an increased risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke.
- Sleep deficiency also increases the risk of obesity.
- Sleep helps maintain a healthy balance of the hormones that make you feel hungry (ghrelin) or full (leptin). When you don’t get enough sleep, your level of ghrelin goes up and you’re level of leptin goes down. This makes you feel hungrier than when you’re well-rested.
- Sleep also affects how your body reacts to insulin, the hormone that controls your blood glucose (sugar) level. Sleep deficiency results in a higher than normal blood sugar level, which may increase your risk for diabetes.
- Ongoing sleep deficiency can change the way in which your immune system responds. For example, if you are sleep deficient, you may have trouble fighting common infections.
–NIH
Thus, it’s important to assess sleep and identify disorders. Almost everyone has a sleep problem but just start by asking a simple question, such as how are you sleeping? (try to avoid feeding the patient answers). Don’t ask “you’re having a hard time falling asleep aren’t you?” i.e. the patient may not understand how to answer the question or simply saying yes/no can also be confusing.
“My Sleep is Horrible”
More than likely the patient or even yourself will complain of having poor sleep. Most patient visits are short on time but at least assess general issues that are associated with sleep. According to ANCC, the sleep assessment consists of obtaining the following information, which is also crucial for improving sleep hygiene and (med) management:
- A detailed history of present insomnia, including a time frame, progression, and associated symptoms.
- Social history, including present living situation; marital status; occupation; education; and alcohol, tobacco, or illicit drug use.
- Medication use, including prescription, over-the-counter, alternative, supplements,
and home remedies. - Initial and periodic functional history and assessment.
- The number of hours in the usual sleep pattern.
- Initial- or middle-phase insomnia; early morning awakening.
- Use of sleep aids.
- Bed position, use of pillows.
- Environment: temperature, sound, light.
Modifying the Behaviors
This is attempted before the use of pharmacological treatment, typically for at least 2-3 weeks. The main goal is to improve sleep habits and be LESS dependent on medications. The different sleep methods used are:
Improving Sleep Hygiene (not shown to be particularly effective on its own, though has been seen to be very critical to improving the efficacy of other non-pharmacological treatments):
- Improving comfort when sleeping
- Decrease Ambient Noise
- Go to bed/wake up at a constant time
- Reduce Lighting
- Think Positively
Stimulus Control Therapy (this method has been seen to be very effective if used over a prolonged period of time):
- Learn to associate the bedroom with sleep alone
- Don’t go into the bedroom unless going to sleep
- Do not go to bed unless tired
- Leave the bedroom if haven’t fallen asleep in 15 minutes
- Be completely relaxed when in bed
Sleep Restriction Therapy (shown the most promising results of all the non-pharmacological therapies and is even more effective when sleep hygiene is improved):
- Restrict sleep during the day
- Cut sleep short during certain nights
- The goal is to be excessively tired when the time to sleep at night
The Most Serious CONCERN
If a person has breathing-related problems, they must get a sleep study (a polysomnograph) before prescribing hypnotics/tranquilizers/sleep meds. Sleep apnea affects younger and older populations, and people are becoming more unhealthy. Weight loss and avoiding a supine position may alleviate sleeping and breathing problems and other times, it may not be good enough…
Sleep apnea is diagnosed by a specialist who also can order a continuous positive airway pressure (CPAP) or a bi-level (BiPAP) machine and discuss other options such as surgery. Understanding this information is imperative before prescribing sedative medications.
If the sleep hasn’t improved, make sure the patient is adherent to using the sleep machine. Be very cautious with prescribing a sleep aid or at least collaborate with the PCP to rule out or treat any conditions and not worsen the situation.
About Obstructive Sleep Apnea (OSA)
- The hallmark of OSA is snoring and repeated apnea during sleep.
- Daytime sleepiness or sense of feeling unrefreshed despite an adequate sleep period is
prominent. - Headache upon awakening is common.
- Consequences include panic attacks (waking up “gasping”), attention-deficit hyperactivity disorder, depression, hypertension, and motor vehicle and workplace accidents.
- Affects up to 2% of children, up to 15% to 20% of adults
- Etiology due to an abnormally small nasopharynx, tonsillar tissue in children; obesity
-ANCC
Stop Bang Questionnaire (Screening for OSA)
CPAP is effective and remains the first-line treatment for OSA.
–AAFP
Medical and Legal Considerations
Legal requirements for reporting excessive daytime sleepiness that may impair driving vary from state to state. The physician treating patients with excessive daytime sleepiness (or patients using drugs likely to affect driving performance) has the responsibility to make a clinical assessment of the patient’s overall risk of unsafe driving and to document driving recommendations and precautions. A physician should report patients who fail to comply with treatment, particularly high-risk persons such as airline pilots, truck, bus, and occupational drivers, and those with a history of recent sleepiness-associated incidents.
–AAFP
Obtain a Drug Screen
The last major consideration is to get a drug screen at least at baseline. It should be discussed during the intake or initial assessment and even if the patient categorically denies everything, it’s ensuring that the provider and the patient are practicing safe care. In addition, people will claim they were given someone else meds or accidentally did heroin…etc. before prescribing medications discuss developing a standard of care for prescribing medications.
Drug abuse is often stigmatized and most people will not admit they have a problem. Therefore, try to address the topic from a standard of care not because someone “looks like an addict”. Staying consistent (doing regular drug screens) helps establish trust and reduces the harm and consequences of medications. Hard illegal substances i.e. heroin are grounds to not be prescribed any sleep meds or consider sending the patient to rehab, whereas using marijuana/tobacco isn’t as risky and may even encourage the patient to remain drug-free with screenings.
DSM V Categories
The DSM-5 Sleep-Wake Disorders Work Group worked closely with other nosology systems (eg, International Classification of Sleep Disorders, third edition [ICSD-3]) to incorporate changes in diagnosis. DSM-5 sleep-wake disorders are now more in sync with other medical disorders and sleep disorders classificatory systems.
In DSM-5, the pathological and etiological factors associated with sleep-wake disorders are taken into consideration, as is the increase in awareness and knowledge gained from sleep studies. The aim is to increase uniformity and consistency among health care professionals when they are assessing and treating patients with various sleep disorders. Sleep-wake disorders comprise 11 diagnostic groups:
- Insomnia disorder
- Hypersomnolence disorder
- Narcolepsy
- Obstructive sleep apnea-hypopnea
- Central sleep apnea
- Sleep-related hypoventilation
- Circadian rhythm sleep-wake disorders
- Non–rapid eye movement (NREM) sleep arousal disorders
- Nightmare disorder
- Rapid eye movement (REM) sleep behavior disorder
- Restless legs syndrome and substance-/medication-induced sleep disorder
Growing evidence has shown that sleep disorders coexist with other medical and psychiatric disorders and may not be mutually exacerbating. DSM-5 underscores the need for independent clinical attention of a sleep disorder regardless of mental or other medical problems that may be present. DSM-5 also recognizes that coexisting medical conditions, mental disorders, and sleep disorders are interactive and bidirectional. Two previous diagnoses have been eliminated: sleep disorder related to another mental disorder and sleep disorder related to another medical condition.
Additional Information
