Top tips in managing some common sleep disorders

Continuing our ‘top tips’ series, Consultant Respiratory Physician and Sleep Specialist, Dr John Faul gives his advice on the diagnosis and treatment of sleep disorders

Top Tip 1: Obtain a good history
Since sleep medicine patients are, by definition, unaware of their sleep patterns, valuable information can be gleaned from bed partners or room mates: Is there snoring? Is there gasping, snorting or choking at night? Have there been episodes of sleep walking or collapse? Is daytime sleepiness present?

Patients are often unaware of these sleep problems, but a collateral history may provide essential information.

Many patients read or watch television in bed, so that their time to bed does not necessarily correlate with sleep duration. Other patients wake early in the morning but lie in bed listening to the radio. Hence, it is important to try to establish a patient’s true sleep duration.

Top Tip 2: Sleep hygiene
Sleep hygiene can be defined as behavioural and environmental factors that may influence the duration and quality of sleep. Good sleep hygiene is a term used to describe the various practical environment and lifestyle measures which can be sued to promote better sleep. Simple practical advice on improving sleep hygiene can help sick patients to recover and heal e.g.

a. Improve the environment so that the bedroom is warm, comfortable and quiet.
b. Increase physical activity during the day, particularly during the morning, and try to eat and work at regular times.
c. Avoid caffeine and medications such as steroids and diuretics in the evening.
d. Get up and go to bed at the same time every day
e. Avoid daytime naps

Top Tip 3: Driving
Professional drivers are at particular risk of sleep disorders. In my experience, about 80 per cent of professional drivers have clinically significant sleep apnoea syndrome. It remains unclear whether the sedentary lifestyle of professional drivers causes obesity and increased upper airway compression at night or, alternatively, the sedentary life of the occupation attracts patients with obstructive sleep apnoea syndrome (OSAS) who often complain of exercise intolerance.

Drowsy driving is a serious public health issue that threatens the lives of all road users. Drivers with obstructive sleep apnoea syndrome have an increased risk of motor vehicle crashes. While a nationwide compulsory test for heavy goods vehicle drivers and commercial drivers does not exist in Ireland, most drivers are very aware of the dangers of excessive daytime sleepiness. Many patients report pulling into the side of the road or stopping for a drink of tea or coffee just to take a break on a long drive (more than two hours).

The problem of drowsy driving is relatively neglected in medical practice and little time is spent on this topic in medical school.

Although there is a lack of awareness of sleep quality and driving risk, about 10 per cent of serious motor vehicle accidents and 20 per cent of motorway accidents are due to driver drowsiness, and the number of near misses due to drowsiness is even greater. Young males appear to be particularly poor at recognising their degree of fatigue and are in danger when they drive late at night or after a poor night’s sleep.

Early morning headaches and sleep attacks, particularly when driving, require further investigation. A need for a daily nap might suggest poor quality nocturnal sleep, depression, obstructive sleep apnoea syndrome or periodic limb movement syndrome (PLMS).

Patients who are chronically mildly sleep deprived or those with undiagnosed or untreated sleep disorders are particularly at risk when they are exposed to an additional acute episode of sleep loss. These conditions should be treated.

It is also particularly important to avoid medications that can precipitate accidents by accentuating sleepiness e.g. benzodiazepines, barbiturates, anti-depressants (particularly trazadone and clomipramine), opiates, antihistamines, progesterone (which can have a hypnotic effect), and recreational drugs such as alcohol, cannabis and opiates.

Top Tip 4: Shift work
Shift workers too easily attribute drowsiness to their irregular hours. Many also have intrinsic sleep disorders which only become apparent after careful history taking and a diagnostic sleep study. It is worth remembering that sleep disorders frequently co-exist.

It is important to assess a patient’s caffeine intake (including colas and energy drinks) in addition to alcohol and tobacco consumption. Furthermore, one should assess whether there has been a recent change in levels of sleepiness or a change in occupational activity that may be dangerous e.g. operating cutting machines, driving for longer than four hours etc.

Top Tip 5: Family history
The risk of developing sleep apnoea syndrome is doubled if there is a sibling or parent with OSAS. There may also be important familial factors, such as cranio-facial development, which predispose some family members more than others to obstructive sleep apnoea syndrome.

Thus, a patient who reports that a close family member has been diagnosed with obstructive sleep apnoea syndrome may warrant close history-taking to determine their risk of having a sleep disorder.

A predisposition to obesity is also an important consideration. The familial tendency to obesity is a combination of both eating habits and genetic factors.

Not all patients with sleep disordered breathing are obese and many non-obese patients have significant and treatable sleep disorders e.g. periodic limb movement disorder, narcolepsy.

However, obesity is associated with an increased risk of sleep disorders, although it appears to be less of a risk factor for obstructive sleep apnoea syndrome in children and the elderly.

Top Tip 6: Non-drug therapies
Surgery, including uvulo-pharyngo-palato-plasty (UPPP), tonsillectomy and orthognathic surgery, and mandibular advancement devices can be successful options for treating patients with snoring and/ or mild sleep disordered breathing. Patients often have anxiety about the effectiveness of these strategies and will ask for a second opinion.

While each case is judged on an individual basis, mechanical adjustments often improve the level of sleep apnoea syndrome without abolishing snoring. Patients should be made aware that most of these procedures are less effective, or ineffective, in cases of marked obesity since, in these cases, upper airway compression results in greater airway compromise.

Top Tip 7: Smoking
Smoking cessation is important for all patients, and can also benefit patients sleep disorders. Nicotine dependence is arguably the most common lethal disease of children in Ireland and we need to support patients in their quit efforts. Thankfully there are medications and support services available to provide patients with a plan if they want to quit.

Evidence suggests that counseling by a healthcare professional is an important motivator in a patient’s attempts to quit. Surprisingly, the main motivators for quitting remain traumatic life events such as a myocardial infarction or cancer diagnosis, or calendar events e.g. New Year’s Day, Ash Wednesday etc.

Top Tip 8: CPAP
Continuous positive airway pressure (CPAP) mask therapy is the cornerstone of therapy for patients with severe obstructive sleep apnoea syndrome. Patients generally feel greatly improved energy and a reduction in daytime tiredness while on therapy, but compliance is key to its effectiveness. Patients who use CPAP for less than four hours per night are unlikely to gain a significant health benefit.

It may be useful to remind patients of the wide array of health benefits which can be gleaned from CPAP therapy in an effort to promote compliance.

For example, recent evidence demonstrates that patients who use CPAP regularly can lose weight more easily and diabetic patients show improved glucose control.

Top Tip 9: Do not tolerate snoring
While snoring may be seen in 35 per cent of adults on an occasional basis, regular habitual snoring probably heralds the onset of obstructive sleep apnoea syndrome.

Epidemiological surveys show an increase in daytime tiredness and daytime hypertension in patients who snore. Snorers without sleep apnoea generally do not complain of excessive sleepiness unless the bed partner’s response to the snoring causes sleep disruption.

Top Tip 10: Narcolepsy
The prevalence of narcolepsy is about one in 3,000, but patients still suffer for two or three years on average before a diagnosis is made. Today, patients with narcolepsy have many treatment options available to them apart from caffeine and frequent scheduled naps.

A stimulant and/or wake-promoting agent is now regarded as the first-line medication for narcolepsy.

Ten years ago the only option available to treat cataplexy was behavioural measures such as avoidance of emotion. These days, new medications are also available to treat this condition.

Where there is a suspicion of narcolepsy, a specialist referral is warranted since advances in therapies and modern management can significantly improve quality of life and daytime functioning. – Irish Medical Times