Sleep Disorders Guidance for Primary Care National Advisory Group for Respiratory Managed Clinical Networks
Presentation Patient complaining of difficulty sleeping, ongoing fatigue, poor concentration and/or irritability Assessment Patient History In diagnosing patients with sleep problems it is important to take a good history (Appendix I) Diagnostic Tools Sleep Diaries (Appendix II) Epworth Sleepiness Scale (ESS) to measure day time sleepiness can be useful to support diagnosis and inform onward referral, the questionnaire can be accessed via the British Lung Foundation Website (http://www.blf.org.uk/page/epworth-sleepiness-scale) Diagnosis Sleep disorder linked to adjustable factors prescribed medication use of stimulants (such as caffeine, alcohol, cigarettes, drugs) vigorous exercise before bed important recent life events (such as bereavement) Sleep disorders linked to depression, worry and anxiety, nocturnal panic attacks Sleep disorder linked to parasomnias Sleep disorder linked to obstructive sleep apnoea Management Sleeping disorder linked to adjustable factors Sleep hygiene Sleep disorders linked to depression, worry and anxiety, nocturnal panic attacks Treat depression or anxiety e.g. drug or cognitive behavioural therapy Management of patients with secondary insomnia Sleep hygiene Sleep disorder linked to parasomnias For restless legs check ferretin, consider non-drug based measures or non-ergot dopamine antagonist drugs for severe cases For other parasomnias consider referral to sleep service as per local protocol Sleep disorder linked to obstructive sleep apnoea Referral on to sleep service as per local protocol 2 Sleep Disorders - Guidance for Primary Care
Insomnia Patients with insomnia may report difficulty falling asleep, trouble staying asleep or frequent wakening, wakening too early and being unable to get back to sleep, or still feeling tired after waking. Insomnia can be grouped into primary and secondary (or co-morbid) insomnia. Patients can have more than one diagnosis. Depression and anxiety underpin insomnia in up to 50% of cases, and they frequently coexist. Primary insomnia is a sleep disorder which is usually diagnosed after excluding other causes such as a medical, psychiatric, or environmental cause. Secondary causes of insomnia and appropriate treatments Secondary Cause Depression Anxiety Obstructive Sleep Apnoea Excess alcohol Physical health problems (such as pain or dyspnoea) Treatment Treat depression (antidepressants, cognitive behavioural therapy) Treat anxiety (drug or psychological therapies, eg CBT) CPAP or mandibular advancement device (Refer to Respiratory Medicine if history compatible) Interventions to reduce intake or promote abstinence Treat symptoms Delayed sleep phase disorder Change work hours; melatonin in the evening and light box (a circadian rhythm abnormality) in the morning Illicit drug use Parasomnias (restless legs, other abnormal activities during sleep) Interventions to reduce drug use For restless legs check ferritin, consider non-drug-based measures, or non-ergot dopamine antagonists for severe cases; for other parasomnias refer to sleep medicine Taking a good history is important for diagnosing insomnia and identifying underlying causes. Sleep diaries can be useful to provide patients with insight in to their actual sleep habits, and also in reflecting sleep trends, such as erratic schedules, or identifying predominant sleep patterns such as taking a long time to fall asleep, frequent awakenings, or early morning awakenings. They can provide a starting point for the management of sleep problems in a personalised manner, and can be used to monitor progress of certain treatments. Sleep Disorders - Guidance for Primary Care 3
Management of insomnia For all patients, following the basic principles of good sleep hygiene may be beneficial. For patients in whom a cause for insomnia is identified, begin by treating the underlying condition. About 30% of patients with primary insomnia will improve with basic sleep hygiene alone. Cognitive behavioural therapy (CBT) has been shown to be an effective treatment for insomnia. It aims to address the various cognitive and behavioural aspects of insomnia using a combination of interventions such as behavioural strategies (bedtime restriction, stimulus control therapy, and relaxation), education (sleep hygiene), and psychological therapies (including CBT). Pharmacotherapy and psychological or behavioural interventions result in similar short-term improvements, but psychological or behavioural treatments have persisting benefits that can also improve with time. Although drugs have their place in the management of insomnia, CBT or other nondrug based interventions should be considered first. Hypnotic drugs are often used in the management of insomnia in general practice. Different classes of sleep medication are often prescribed. Local prescribing guidelines may vary and should be followed. Drugs commonly used for insomnia Drug Dose Side-effects Melatonin M/R 2mg Usually well tolerated Temazepam 10-20mg Sedation, confusion, amnesia, impaired co-ordination, disinhibition Zolpidem 5-10mg As for temazepam Zopiclone 3.75-7.5mg As for temazepam Melatonin is a pineal hormone that is naturally secreted in darkness. It is thought to signal sleep onset and has some sleep promoting effects. It is licensed for use in adults aged greater than 55 years old for periods of 13 weeks at a time. Please note that this has not been approved by SMC. Hypnotic drugs (benzodiazepines or z drugs such as zopiclone) are often prescribed for insomnia. Tolerance and dependence are common concerns despite the contradictory evidence in many clinical trials. Shorter acting hypnotics (zolpidem) are preferred for insomnia with delayed sleep latency (difficulty getting to sleep). Medium acting hypnotics (temazepam or zopiclone) are preferred for patients who wake in the middle of the night. To limit risk of dependence or tolerance, prescribers can tell patients to use hypnotics as needed, with a maximum frequency per week (ie no more than three nights per week). Benzodiazepines have significantly fewer side effects than sedating anti-depressants and sedating antipsychotics. Sedating anti-depressants and anti-psychotics are often used as they generally do not result in physical dependence, tolerance, or misuse. They do however have more side effects, and are more toxic in overdose. There is also less evidence for their use in insomnia. 4 Sleep Disorders - Guidance for Primary Care
Obstructive sleep apnoea/hypopnoea syndrome Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disorder characterised by excessive daytime sleepiness resulting from disturbed breathing during sleep; the primary causative factor is obstruction of the airway. It affects about 4% of those reporting poor sleep in primary care and is more common in people who are obese. In the absence of intrusive daytime sleepiness (ESS<11), patients cannot have obstructive sleep apnoea syndrome and only those with significant co-morbid vascular pathology should be considered for investigation or treatment. Patients often present with: Snoring Witnessed pauses Intrusive daytime sleepiness (ESS 11) Physical signs: BMI >25Kg/m 2 Neck size 17 inches or larger Nasal congestion/blockage (permanent) Receding lower jaw Other causes of daytime sleepiness (in addition to primary and secondary insomnia): Shift work Sleep deprivation (quantity of sleep) Narcolepsy Hypothyroidism Prescribed medication Neurological conditions Episodic partial or complete upper airway obstruction is usually associated with oxygen de-saturations and arousals from sleep. Symptoms include chronic snoring, insomnia, gasping and breath holding, un-refreshing sleep and daytime sleepiness. The Epworth Sleepiness Scale (ESS) is a useful tool to use to see if people have excessive daytime sleepiness. It is important to remember that the ESS is only a guide, and that patients can still be sleepy, with a normal ESS score. There is an obligation for health professionals to advise professional drivers and machine operators of falling asleep at work. Informing patients that they should never drive, or operate machinery, whilst sleepy is important until the diagnosis is made. Once the diagnosis is confirmed, it is the patient s legal responsibility to inform the DVLA and their insurance company. Once on treatment, and using it with good effect, there will be no issue with them driving. The diagnosis is usually made from a home sleep study, although a minority of patients will require a more complex in-patient sleep study to confirm the diagnosis. Management of obstructive sleep apnoea/hypopnoea syndrome The treatment of OSAHS depends on the severity of the abnormality on the sleep study and how symptomatic the patient is. For all overweight patients, weight reduction is of utmost importance, as reducing weight can reduce the severity of the OSAHS. For patients with mild symptoms and a mildly abnormal sleep study, a combination of weight reduction and a custom made mandibular advancement splint would be the first line treatment. For those with severe symptoms, and a compatible sleep study, continuous positive airways pressure (CPAP) at night would be the mainstay of therapy. Sleep Disorders - Guidance for Primary Care 5
Complex sleep disorders Many complex sleep disorders are seen at the tertiary Sleep Clinics. Many patients present with sleepiness, and so Respiratory Physicians have gained experience in investigating and treating these conditions, even though these disorders may well have a neurological basis. These conditions include Narcolepsy, Circadian Rhythm abnormalities and Parasomnias. Referral for specialist assessment When referral on for support or further investigation is required, the flow chart below is intended to steer referral to the most appropriate service. Patient presentation possible adult sleep disorder GP assessment Features of primary insomnia Features of neurological disease (e.g. parkinsons, myotonic dystropy) Underlying condition evident (e.g. anaemia, hypothyroid, sedative medications Snoring, possible apnoeas, or daytime sleepiness Other sleep problems (dream sleep symptoms, shift work, restless legs) Exclude symptoms of other sleep disorder Discuss sleep hygiene Avoid caffeine Consider anxiety/ depression Refer neurology Assess and treat BMI? Cardiovascular profile? Driving or occupational issues? Discuss associated sleep symptoms* Patient complete ESS questionnaire Refer sleep medicine Consider referral to Community Mental Health Team Snoring Occasional witnessed pauses in breathing ESS <11 No additional sleep symptoms ESS 11 and/or Significant associated sleep symptoms Sleep symptoms suggestive of OSAHS Intrusive daytime sleepiness Unrefreshing sleep Poor concentration Accidents associated with sleepines Nocturia Throat discomfort or headache in morning Simple snoring Reassure about cause Advise weight loss Address any ENT issues Patient can consider dental splint Possible OSAHS Refer sleep medicine 6 Sleep Disorders - Guidance for Primary Care
Appendix I: History taking questions Can you describe your problem with sleeping? Does it interfere with your function the next day (for example, feeling unrefreshed in the morning, fatigued, having poor concentration or irritability)? Can you tell me about your bedtime routine starting with the time you get into bed? Time that you get to bed Time to fall asleep Awakenings (number, duration, do you know what causes you to awaken? Do you have any associated symptoms, such as heartburn, coughing, shortness of breath, pain, anxiety or full bladder?) Last awakening time in the morning Time of rising from bed Usual duration of sleep How is your routine different at the weekends or during holidays? Do you have the same bedtime? Do you do vigorous activity in the evening? Information gained Some patients think they do not get enough sleep but function well the next day. Technically they do not have insomnia because the definition of insomnia includes results in some form of daytime impairment. Frequent changes in routine and vigorous activity just before bedtime can cause sleep problems. Physical health problems are a significant cause (43%) of insomnia in primary care and will require attention. If the time in bed greatly exceeds the time asleep (for example, by a few hours), the patient may have primary insomnia if no other causes are present. Spending less time in bed can lead to a dramatic improvement in sleep quality and may decrease the fragmentation of sleep. Exposure to computer screens in the hours before bed can delay sleep onset. Sleep Disorders - Guidance for Primary Care 7
How do you feel on awakening? Unrefreshed and still sleepy? Any symptoms such as headaches or dry mouth? Day sleepiness falling asleep in waiting rooms, as a passenger in a car, or during lectures. Information gained Needs to consider obstructive sleep apnoea. Considering asking the patient to fill out the Epworth Sleepiness Scale, which measures levels of daytime sleepiness. Are there any symptoms of obstructive sleep apnoea (ask bed partner too if possible)? Such as heavy snoring, pauses in breathing, and gasping. Information gained Provides information on obstructive sleep apnoea. What other factors may interfere with sleeping? Use of stimulants (such as caffeine, alcohol, cigarettes, drugs). Other drugs may interfere with sleep. Important recent life events (such as bereavement). Information gained Ideally avoid use of stimulants after 6pm and if appropriate refer to smoking cessation. Oral decongestants (e.g. pseudoephedrine), asthma medications (e.g. short and long-acting bronchodilators), amphetamines and anti-depressants can cause insomnia. A trial without them is simple and can be potentially diagnostic. Do you take any naps? Ask about frequency, timing and duration. Where are you sleeping when you have the problem? Is the problem persistent when you sleep elsewhere (for example, when on holiday?) Is it persistent throughout the week and year? Information gained Long naps during the day can affect the quality of sleep at night. If the patient sleeps better when on holiday or at weekends, think of delayed sleep phase disorder, especially if he or she goes to bed after midnight. 8 Sleep Disorders - Guidance for Primary Care
Do you experience any of the following: Low mood or lack of pleasure in some or most activities Worrying a lot Nocturnal panic attacks Restless sleep Leg or body twitching Leg jerking (consider restless legs syndrome) Shaking fits Sleep walking or talking Waking up in terror Unusual night time behaviours Information gained Patients who answer yes to the first question may have depression and anxiety; consider using the formal inventories for case finding. The other symptoms may be related to parasomnias. Sleep Disorders - Guidance for Primary Care 9
9 Appendix II: Two week sleep diary Instructions 1. Write the date, day of the week and type of day: Work, School, Day off or Vacation. 2. Put in the letter C in the box when you have coffee, cola or tea. Put M when you take any medicine. Put A when you drink alcohol. Put E when you exercise. 3. Put a line ( ) to show when you think you fell asleep. Shade in the box that shows when you think you fell asleep. 4. Shade in all the boxes that show when you are asleep at night or when you take a nap during the day. 5. Leave boxes unshaded to show when you wake up at night and when you are awake during the day. Today s date Day of the week Type of day Work, School, Off, Vacation Noon 1pm 2 3 4 5 6pm 7 8 Sample Mon Work E A 10 Sleep Disorders - Guidance for Primary Care
Sample entry below: On a Monday when I worked, I jogged on my lunch break at 1pm, had a glass of wine with dinner at 6pm, fell asleep watching tv from 7 to 8pm, went to bed at 10.30pm, fell asleep around midnight, woke up and couldn t get back to sleep at about 4am, went back to sleep from 5 to 7am and had coffee and medicine at 7am in the morning. Reprinted with permission from the American Academy of Sleep Medicine, www.aasmnet.org 9 10 11pm Midnight 1am 2 3 4 5 6am 7 8 9 10 11am C M Week 1 Week 2 Sleep Disorders - Guidance for Primary Care 11
Pub. date: July 2015 Review date: July 2017 Issue No: 03 Authors: Dr Eric Livingston, NHS Greater Glasgow and Clyde; Dr Tom MacKay, NHS Lothian Sleep Studies Working Group (NAGRMCNs) PIL.SLEEPC.02663.O Design - Medical Illustration, NHS Lanarkshire