A Synopsis of AFP's "Management of Common Sleep Disorders"

Management of Common Sleep Disorders
KANNAN RAMAR, MD, and ERIC J. OLSON, MD, Mayo Clinic, Rochester, Minnesota
Am Fam Physician. 2013 Aug 15;88(4):231-238.
http://www.aafp.org/afp/2013/0815/p231.pdf

     Most people get about 6.9 hours of sleep a night. The recommended amount is 7-9 hours a night. The four types or sleep disorders are
those who cannot sleep,
those who won't sleep,
those with daytime sleepiness, and
those with increased movements during sleep.
     For those who cannot sleep, the two causes are insomnia and restless leg syndrome. Insomnia is described as difficulty with sleep initiation, duration, quality, and consolidation (amount of uninterrupted sleep). A proper insomnia history include asking questions about onset, frequency, sleep and wake times, sleep environment, evening activities, comorbid psychiatric/ medical conditions, and medications. CBT with hypnotics and sleep hygiene, in combination, have been shown to be synergistic for treatment. Sleep hygiene includes not have pets in the bedroom, no caffeine, no nicotine, no late night exercising, no staring at the bedroom clock, and keeping the bedroom cool. Patients should only lay in bed when they are tired and sleepy.  Antihistamines and melatonin for insomnia have limited effectiveness.  Restless leg syndrome has four parts;
uncomfortable sensation and
intense urge to move legs,
worsening during rest,
worse at night, and
relieved by movement.
If the patient has a low ferritin, then the syndrome can be fixed when the iron deficiency is fixed. Otherwise, the patient can try dopaminergic agonists (ropinirole or pramipexole), opiates, gabapentin, or pregabalin.
     Patients who "will not sleep" have a delayed sleep phase syndrome. These people go to bed late and get up late. They develop daytime sleepiness, insomnia, and functional impairment. The treatment is giving the patient melatonin  before bed and bright light exposure upon awakening. The goal is to gradually give the melatonin and bright lights earlier each week to create a more appropriate schedule.
     Excessive daytime sleepiness is seen in narcolepsy and obstructive sleep apnea (OSA). Narcolepsy has a classic tetrad of;
sleepiness,
cataplexy,
hallucinations upon falling asleep,
hallucinations upon awakening, and
sleep paralysis.
Patients with narcolepsy should be referred to a sleep clinic, which includes polysomnography and a multiple sleep latency test. Medications for narcolepsy include antidepressants (venlafaxine), SSRIs, and stimulants (methylphenidate). OSA is obstruction or the upper airway  during sleep, despite the patient trying to breath. It can cause hypertension, sleepiness, hypoxia, and cognitive impairment. Risk factors include obesity, CHF, diabetes, pulmonary hypertension, stroke, atrial fibrillation, and bariatric surgery. The treatment calls for CPAP or BIPAP.
     Patients who complain of increased movement during sleep usually have REM sleep behavior disorder or periodic limb movement. REM sleep behavior disorder is characterized by elevated muscle tone, causing the patient to act out dreams. It is associated with parkinsonian syndromes. The spouse may notice the patients movements during sleep. Treatment consists of moving dangerous items that the patient may fall on. Melatonin or clonazepam may be helpful. Periodic limb movements are repetitive and stereotypic actions during sleep. Diagnosis is made by polysomnography, finding a movement index greater than 15 per hour (5 per hour in children). Treatment is the same as for RLS.