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Chapter 028. Sleep Disorders (Part 5)

Disorders of Sleep and Wakefulness Approach to the Patient: Sleep Disorders Patients may seek help from a physician because of one of several symptoms: (1) an acute or chronic inability to initiate or maintain sleep adequately at night (insomnia); (2) chronic fatigue, sleepiness, or tiredness during the day; or (3) a behavioral manifestation associated with sleep itself. Complaints of insomnia or excessive daytime sleepiness should be approached as symptoms (much like fever or pain) of underlying disorders. Knowledge of the differential diagnosis of these presenting complaints is essential to identify any underlying medical disorder. Only then can appropriate treatment, rather than. | Chapter 028. Sleep Disorders Part 5 Disorders of Sleep and Wakefulness Approach to the Patient Sleep Disorders Patients may seek help from a physician because of one of several symptoms 1 an acute or chronic inability to initiate or maintain sleep adequately at night insomnia 2 chronic fatigue sleepiness or tiredness during the day or 3 a behavioral manifestation associated with sleep itself. Complaints of insomnia or excessive daytime sleepiness should be approached as symptoms much like fever or pain of underlying disorders. Knowledge of the differential diagnosis of these presenting complaints is essential to identify any underlying medical disorder. Only then can appropriate treatment rather than nonspecific approaches e.g. over-the-counter sleeping aids be applied. Diagnoses of exclusion such as primary insomnia should be made only after other diagnoses have been ruled out. Table 28-1 outlines the diagnostic and therapeutic approach to the patient with a complaint of excessive daytime sleepiness. Table 28-1 Evaluation of the Patient with the Complaint of Excessive Daytime Somnolence Finding s on History and Physical Examination Diagnostic Evaluation Diagnosis Therapy Obesity snoring hypertension Polysomnograp hy with respiratory monitoring Obstructi ve sleep apnea Continuous positive airway pressure ENT surgery e.g. uvulopalatopharyngoplast y dental appliance pharmacologic therapy e.g. protriptyline weight loss Cataplex y hypnogogic Polysomnograp hy with multiple sleep Narcoleps y-cataplexy Stimulants e.g. modafinil hallucinations sleep paralysis family history latency testing syndrome methylphenidate REM-suppressant antidepressants e.g. protriptyline genetic counseling Restless legs disturbed sleep predisposing medical condition e.g. iron deficiency or renal failure Assesment for predisposing medical conditions Restless legs syndrome Treatment of predisposing condition if possible dopamine agonists e.g. pramipexole ropinirole Disturbe d sleep predisposing .