Mahmood I. Siddique, D.O., FACP, FCCP, FAASM
Medical Director, SleepCare Center at RWJ Hamilton
Clinical Assistant Professor of Medicine
UMDNJ-Robert Wood Johnson Medical School

HYPERSOMNIA - PROBLEM SLEEPINESS

• Evaluation of hypersomnia includes confirmation of chief complaint (sleepiness vs. fatigue), with the use of sleepiness scales such as Stanford Sleepiness Scale or Epworth Sleepiness Scale. Complete sleep/wake history, medical/psych/neuro history, drug history, complete ROS are essential. Occupational and driving history are also relevant. Family history, physical examination, and screening labs can be helpful in certain conditions.
• Sleep disorders associated with hypersomnia include insufficient sleep, environmental or extrinsic sleep disorders, circadian rhythm sleep disorders, obstructive sleep apnea, narcolepsy, idiopathic hypersomnia, periodic limb movement disorder and restless legs syndrome.
• Other disorders/conditions that should be considered include hypothyroidism, hydrocephalus, previous head trauma, pregnancy, disrupted sleep due to conditions such as COPD, Parkinson's, arthritis, menopause etc.
• True hypersomnolence almost always has an identifiable and treatable physiologic cause.
• Polysomnography is indicated if sleepiness persists despite adequate nocturnal sleep time (primarily to rule out sleep-disordered breathing and periodic limb movement disorder (PLMD)). Polysomnography is not routinely indicated for the insomnias, restless leg syndrome (RLS), circadian rhythm disorders, or insufficient sleep.
• Multiple sleep latency test (MSLT) is indicated if polysomnography fails to explain the hypersomnia.
• General approach to treatment of hypersomnia includes education, safety precautions especially with regard to driving and other hazardous activities, adequate sleep time, sleep hygiene, general countermeasures, treatment of the underlying condition, and follow-up.
• Factors leading to hypersomnolence can, and frequently do, coexist.

OBSTRUCTIVE SLEEP APNEA

• In obstructive sleep apnea, the upper airway repeatedly closes off during sleep. The resulting hypoxia or respiratory effort briefly arouses the person, but when he, or she falls asleep again, the cycle repeats itself, sometimes up to hundreds of times per night.
• Sleep is fragmented; i.e., the person does not go through the normal cycles and stages of sleep, and wakes up still feeling tired and sleepy.
• The major daytime symptom of obstructive sleep apnea is excessive daytime sleepiness. Other symptoms include morning headaches and less-specific symptoms such as depression and decreased libido. The major nighttime symptom is snoring; very often the bed partner notices that the patient stops breathing for a few seconds and then resumes with a loud snort.
• Examination of the upper airways may show redundant neck tissue, macroglossia, retrognathia or micrognathia, or other malformations.
• Obstructive sleep apnea is serious, currently underdiagnosed, and associated with increased risk of hypertension, stroke, myocardial infarction, and death. Most persons with obstructive sleep apnea snore, and the condition is particularly common in overweight persons.
• Excessive daytime sleepiness combined with either obesity or snoring warrants further investigation with polysomnography.
• Screening for hypothyroidism is useful in OSA.
• Sleep apnea should be suspected in patients who are obese, hypertensive, habitual snorers, and hypersomnolent.
• In a primary care setting, patients with a high risk of sleep apnea were those who met two of the following three criteria: snoring, persistent daytime sleepiness or drowsiness while driving, and obesity or hypertension. Combinations of clinical variables such as neck circumference or body-mass index, snoring, reports of nocturnal breathing disturbances, and hypertension have been used to predict which patients will have abnormal results on sleep tests. The sensitivity of this approach can be high (78 to 95 percent), but the specificity tends to be low (41 to 63 percent).
• Polysomnography. Polysomnography is the recommended method of assessing patients with suspected sleep disorders, including sleep apnea. Sleep is recorded and the stage of sleep is determined by electroencephalography, electrooculography, and electromyography.
• Episodes of apnea and hypopnea are defined by a clear reduction in airflow or tidal volume, often accompanied by a decrease in oxygen saturation and terminated by an arousal (an interval of three seconds or longer in which the electroencephalographic pattern indicates that the patient is awake). In addition, breathing and limb movements and an electrocardiographic lead are monitored.
• Short rapid eye movement (REM) latency can be seen in insufficient sleep, late timing of PSG relative to patient's bedtime, sleep disorders that fragment sleep (e.g. OSA), withdrawal of REM suppressing meds/drugs (TCA's, SSRI's, cocaine, amphetamines, etc.)

OSA Treatment

• Continuous Positive Airway Pressure (CPAP). Polysomnographic studies obtained before and after treatment clearly demonstrate that CPAP immediately reverses apnea and hypopnea. In randomized, placebo-controlled trials, CPAP has been shown to decrease somnolence and to improve the quality of life, mood, and alertness.
• Short-term compliance with CPAP ranges from 50 to 80 percent, and the duration of average use ranges from 3.4 to 4.5 hours per night. Some patients find CPAP obtrusive and become frustrated by frequent mask leaks and nasal congestion. Long-term use is more likely in patients with a history of snoring, a high apnea-hypopnea index, and severe daytime sleepiness.
• Intensive support of patients when CPAP is initiated is important to maximize the likelihood of long-term use. Assessment of symptoms and the quality of life after initiation of continuous positive airway pressure is particularly important in patients in whom the relation of symptoms to abnormal sleep patterns is unclear.
• Patient education can improve CPAP compliance.
• If patients fail to respond to CPAP, consider equipment problems, inadequate titration, noncompliance, insufficient sleep, inadequate sleep hygiene, coexistent sleep disorders.
• Conservative Treatment and Weight Loss. Conservative treatment strategies include the use of a lateral sleeping position, avoidance of alcohol or sedative medications, and weight loss. Studies have shown that the frequency of apnea and hypopnea is greater with a supine sleeping position and after use of a benzodiazepine or alcohol.
• A 10 percent weight loss was associated with a 26 percent decrease in the apnea-hypopnea index in a population-based study. There are no controlled trials comparing medically and surgically induced weight loss as a treatment for sleep apnea. In an observational study, an average weight loss of 10 kg reduced the mean apnea-hypopnea index from 55 to 29. Surgically induced weight loss (ranging from 27 to 100 kg) reduced the mean apnea-hypopnea index in 15 patients from 97 to 11.
• Weight loss should be recommended for all obese patients with sleep apnea; however, weight loss takes time, and only a minority of patients successfully maintain it. As a primary treatment, weight loss should be targeted toward patients with mild-to-moderate disease, especially if they are not interested in other options.
• Mandibular and Tongue Advancement. Many types of oral appliances have been designed for the treatment of sleep apnea; most are custom fit to the teeth of both dental arches to reposition the mandible and, hence, to modify the retropalatal and retrolingual airway space. This treatment is sometimes effective. In practice, however, the evidence to support its use is limited to one placebo-controlled trial, in which it was more effective than placebo, and trials in which this approach was compared with surgery and continuous positive airway pressure and found to be less effective than continuous positive airway pressure in reducing the frequency of apnea and hypopnea. On the basis of the available data, mandibular advancement appears to be a possible but suboptimal alternative to continuous positive airway pressure in patients with mild-to-moderate sleep apnea.
• Surgery. Surgical procedures for sleep apnea include uvulopalatopharyngoplasty(UPPP), laser-assisted uvulopalatoplasty (LAUP), tonsillectomy, partial resection or ablation of the tongue, major reconstruction of the mandible or maxillae, and tracheostomy.
• UPPP involves resection of the tonsils (if present), uvula, and posterior palate and reorientation of the tonsillar pillars.
• LAUP is performed while the patient is under local anesthesia and involves partial resection of the uvula and soft palate without resection of the tonsils or tonsillar pillars.
• A recent Cochrane review concluded that the data needed to conduct a systematic review of surgical procedures were lacking.
• The reported rates of improvement in the apnea-hypopnea index with UPPP vary; the rate of long-term effectiveness (as evidenced by a reduction in the apnea-hypopnea index of at least 50 percent and a postoperative apnea-hypopnea index below 10) is less than 50 percent.
• The procedure has been associated with complications, including postoperative pain, bleeding, nasopharyngeal stenosis, changes in the voice, and in rare cases, death.
• A randomized trial comparing UPPP with mandibular advancement reported a response (defined by an apnea index of less than 5 [the total number of episodes of apnea per hour of sleep] or an apnea-hypopnea index of less than 10) in 51 percent of surgical patients, as compared with 78 percent of patients who received a mandibular-advancement appliance.

RESTLESS LEG SYNDROME (RLS)

• RLS and PLMD can be causes of insomnia, with or without daytime sleepiness.
• Criteria for diagnosis of RLS include 1) desire to move the limbs, associated with parasthesias (2) motor restlessness (3) sx worse at rest/relief with activity (4) sx worse in the evening/night. RLS is commonly associated with insomnia, and, less likely, with hypersomnia.
• RLS occurs as a primary, early onset, familial form and as a secondary, later onset form. Secondary causes of RLS include anemia (particularly iron deficiency), uremia, peripheral neuropathy, and pregnancy. RLS has also been described in diabetes, hypo/hyperthyroidism, porphyria, COPD, peripheral vascular disease, ADHD, fibromyalgia, rheumatoid arthritis, sjogrens syndrome, carcinoma, obesity, decreased exercise, LS radiculopathy, spinal cord disease, ALS, polio, multiple sclerosis, deficiency states including Mg, folate, B12, Fe and drugs/toxins including lithium, TCA's, SSRI's, caffeine, smoking, benzo withdrawal, spinal anesthesia.

NARCOLEPSY

• Narcolepsy is a common cause of EDS
• Narcolepsy typically presents in adolescents/young adults but can present in later life. There is a significant delay between symptom onset and diagnosis.
• Narcolepsy symptoms include EDS, cataplexy, sleep paralysis, hypnogogic hallucinations, disturbed nocturnal sleep. EDS is the most common symptom. Cataplexy is the most specific. MSLT criteria for diagnosis include mean sleep latency < 5 minutes and 2 + SOREM's (Sleep onset REM), in the absence of other sleep disorders.
• Treatment of narcolepsy includes wake-promoting agents for EDS and tricyclic antidepressants or SSRI's for cataplexy. Other management includes adequate nocturnal sleep, daytime naps, education, support, and safety precautions.
• Acute alcohol increases sleepiness, reduces wakefulness during the first 3 to 4 hours of the night, and fragments early AM sleep. Delta sleep is increased in the first part of the night and wake and REM are increased in the second part of the night. Chronic alcohol initially deepens sleep during first days of use, then is associated with more fragmented sleep over time.
• Abstinence following chronic alcohol use is associated with significant sleep disruption, fluctuations in REM (often increased) and decreased delta sleep.

INSOMNIA

• Insomnia is very prevalent, affecting up to 30% of the adult population. Insomnia is a symptom, and not a disorder, of many underlying medical, psychiatric, and psychological conditions. Insomnia may also be the presenting symptom of other primary sleep disorders.
• Insomnia may be (arbitrarily) categorized as: transient (a few nights), short-term (less than a month), or chronic (longer than a month). Most cases of insomnia can be readily diagnosed and managed in the primary care setting. Once possible underlying medical or psychiatric conditions have been identified and treated, a combination of behavioral and pharmacologic therapy is often very effective. Sedative-hypnotic treatment has a role, particularly in short-term insomnia, and may serve to prevent the development of chronic insomnia.
• Effective agents include the benzodiazepines and a newer non-benzodiazepine, zolpidem (Ambien) and zaleplon (Sonata). The risk of tolerance, dependence, and abuse in this patient population appears to have been greatly overrated. Aggressive management is justified due to the known consequences of insomnia on mood and performance.

References:

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8. Skjodt NM et al. Screening for hypothyroidism in sleep apnea. Am J Respir Crit Care Med 1999; 160:732735

SLEEP EDUCATIONAL RESOURCES:
American Academy of Sleep Medicine (www.aasmnet.org)
National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov/about/ncsdr)
National Sleep Foundation (www.sleepfoundation.org)
American Sleep Apnea Association (www.sleepapnea.org)
Narcolepsy Network (www.narcolepsynetwork.org)
RLS Foundation (www.rls.org)