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Toronto Notes 2019 Common Presenting Problems
Etiology
• primarysleepdisorders
■ primary insomnia, narcolepsy, obstructive sleep apnea, restless leg syndrome, periodic limb
movements of sleep • secondarycauses
■ medical: COPD, asthma, CHF, hyperthyroidism, chronic pain, BPH, menopause, GERD, PUD, pregnancy, neurological disorders
■ drugs: alcohol, caffeine, nicotine, nicotine replacement therapy, β-agonists, antidepressants, steroids
■ psychiatric: mood and anxiety disorders
■ lifestyle factors: shift work, jet-lag
Investigations
• completesleepdiaryeverymorningfor1-2wk
■ record bedtime, sleep latency, total sleep time, awakenings, quality of sleep
• ruleoutspecificmedicalproblems(e.g.CBCanddifferential,TSH)
• referforsleepstudy,nocturnalpolysomnogram,ordaytimemultiplesleeplatencytestifsuspicionof
sleep apnea or periodic leg movements of sleep
Management of Specific Problems
• Primaryinsomnia
■ person reacts to insomnia with fear or anxiety around bedtime or with a change in sleep hygiene, which can progress to a chronic disorder (psychophysiological insomnia)
■ treat any suspected medical or psychiatric cause
■ exercise regularly, avoid heavy exercise within 3 h of bedtime
■ first-line treatment (CBT)
◆ sleep hygiene: avoid alcohol, caffeine, nicotine; comfortable sleep environment; regular sleep schedule; no napping
◆ relaxation therapy: deep breathing, meditation, biofeedback
◆ stimulus control therapy: re-association of bed/bedroom with sleep, re-establishment of a
consistent sleep-wake schedule, reduce activities that cue staying awake
◆ sleep restriction therapy: total time in bed should closely match the total sleep time of the patient ◆ address inappropriate beliefs and attitudes that perpetuate dysfunctional sleep
■ pharmacologic treatment (used to supplement CBT; short-term prescription of <14 d with appropriate follow-up in 7-14 d):
◆ short-acting benzodiazepines (e.g. lorazepam) are used to:
– break the cycle of chronic insomnia
– manage an exacerbation of previously controlled insomnia
◆ non-benzodiazepines: zoplicone, zolpidem, melatonin, sedating anti-depressants (e.g. amitriptyline, trazadone)
◆ if no progress or limited improvement on pharmacotherapy, consider referral to sleep medicine program
■ other treatment: exercise regularly, avoid heavy exercise within 3 h of bedtime • Snoring
■ results from soft tissue vibration at the back of the nose and throat due to turbulent airflow through narrowed air passages
■ physical exam: obesity, nasal polyps, septal deviation, hypertrophy of the nasal turbinates, enlarged uvula and tonsils
■ investigations (only if severely symptomatic): nocturnal polysomnography and airway assessment (CT/MRI)
■ treatment
◆ sleep on side (position therapy), weight loss
◆ nasal dilators, tongue-retaining devices, mandibular advancement devices
■ at risk of developing obstructive sleep apnea
• ObstructiveSleepApnea(OSA)
■ apnea (no breathing for ≥10 s) resulting from partial or complete upper airway obstruction due to collapse of the base of the tongue, soft palate with uvula, and epiglottis; respiratory effort is present
■ leads to a distinctive snorting, choking, awakening type pattern as the body rouses itself to open the airway
■ apneic episodes can last from 20 s-3 min and occur 100-600 episodes/night
■ diagnosis is based on nocturnal polysomnography: >15 apneic/hypopneic episodes per hour of sleep
■ consequences
◆ daytime somnolence, non-restorative sleep
◆ poor social and work performance
◆ mood changes: anxiety, irritability, depression
◆ sexual dysfunction: poor libido, impotence
◆ morning headache (due to hypercapnia)
◆ HTN (2x increased risk), CAD (3x increased risk), stroke (4x increased risk), arrhythmias ◆ OSA is an independent risk factor for CAD
◆ pulmonary HTN, right ventricular dysfunction, cor pulmonale (due to chronic hypoxemia) ◆ memory loss, decreased concentration, confusion
Family Medicine FM45
Risk Factors for Obstructive Sleep Apnea
• 2% of women, 4% of men between ages 30-60
• Obesity (due to upper airway narrowing). BMI >28 kg/m2 present in 60-90% of cases
• Children (commonly due to large tonsils and adenoids)
• Aging (due to decreased muscle tone)
• Persistent URTIs, allergies, nasal tumours,
hypothyroidism (due to macroglossia),
neuromuscular disease • Family history