This chapter primarily focuses on sleep and sleep disorders in adults. While many basic and clinical aspects are similar in children, developmental issues and some disorders not present in adults, for example, 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 and Kryger, 1995).
General Approach to the Patient
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 27–1). 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 (see Figure 27–1).
Table 27–1. Office Evaluation of Chronic Sleep Complaints |Favorite Table|Download (.pdf)
Table 27–1. Office Evaluation of Chronic Sleep Complaints
Detailed history and review of the sleep complaint, as well as predisposing, precipitating, and perpetuating factors
Review of the difficulties falling asleep, maintaining sleep, and awakening early
Timing of sleep and wakefulness over the 24-h day
Evidence of EDS and fatigue
Bedtime routines, sleep setting, preoccupations, anxiety, beliefs about sleep and sleep loss, fears about consequences of sleep loss, nightmares, enuresis, and sleepwalking
Medical and neurologic history and examination and routine laboratory examinations
Review of use of prescription and nonprescription medications, hypnotics, alcohol, and stimulants
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)
Abnormal movements during sleep; “jerky legs,” leg movements, myoclonus, “restless legs,” leg cramps, and cold feet
Psychiatric history and examination
Social and occupational history, marital status, living conditions, financial and security concerns, and physical activity
Sleep environment—ambient noise, light, and temperature
Sleep–wake diary for 2 weeks
Typical exposure to light (sunlight and artificial) and darkness across a 24-h day
Interview with bed partners or persons who observe the patient during sleep
Tape recording of respiratory sounds during sleep to screen for sleep apnea
Steps for a sleep disturbance algorithm. (Adapted from Gillin JC, Ancoli-Israel S, Erman M: Sleep and sleep–wake disorders. In: Tasman A, Kay J, Lieberman JA (eds). Psychiatry. 2nd edn. Philadelphia: Saunders, 1996, pp. 1217–1248.)
During the evaluation, the patient's bed partner or other informants should be included whenever ...