Sleep apnea primary

FIGURE 38-1. Primary assessment and initial treatment for complaint of excessive daytime sleepiness. RLS, restless-legs syndrome NPSG, nocturnal polysomnography OSA, obstructive sleep apnea DA, dopamine agonist MSLT, multiple sleep latency test BZDRA, benzodiazepine receptor agonist SNRI, serotonin and norepinephrine reuptake inhibitor TCA, tricyclic antidepressant CPAP, continuous positive airway pressure. 

BZDs may offer temporary symptomatic relief for transient and short-term insomnia. They generally are not recommended as a long-term primary treatment for chronic insomnia or in patients with sleep apnea. Several of these agents are currently marketed in the United States or elsewhere for use as hypnotics ( Table 12-5), but other BZDs can also serve the same purpose. 

Sleep disorders are common, and are generally underdiagnosed. The two major complaints related to sleep are insomnia ( I can t sleep ) and excessive daytime sleepiness (EDS, I can t stay awake ). EDS is a relatively nonspecific symptom. It can be the end result of any factor that causes sleep disruption, and it can be caused by primary or intrinsic sleep disorders. Insomnia of any cause can result in sleep deprivation and subsequent EDS. The most common cause of EDS in the general population is self-imposed sleep deprivation, or insufficient sleep syndrome. By contrast, the most common causes of EDS seen in a sleep center are primary (intrinsic) disorders of EDS. The American Academy of Sleep Medicine (AASM, formerly the American Sleep Disorders Association) classification of sleep disorders includes over 80 diagnoses that are associated with EDS, but the majority of patients evaluated at sleep centers have sleep apnea, narcolepsy, idiopathic hypersomnia, or periodic limb movements of sleep. 

Sleepiness is a primary symptom of narcolepsy, often preceding the onset of the other well-known symptoms of the disease, namely cataplexy, sleep paralysis, and hypnagogic hallucinations (44). Evaluation of the MSLT of narcoleptic patients has demonstrated a short sleep latency (<5 min) and multiple sleep-onset REM periods (SOREMPs). The more specific finding in the MSLT of narcoleptic patients is more than 2 SOREMPs, shown to reach a specificity of 99% by Amira et al. (45), which further increased to 99.2% if 3 SOREMPs were recorded (46). On the other hand, more than one SOREMP can occur in nonnarcoleptic patients, such as those with sleep apnea, sleep deprivation, depression, periodic limb movements, circadian rhythm disruption, or withdrawal from REM-suppressing medications (5,47). Thus, the findings of the MSLT, which is always performed for suspected narcoleptic patients, must be interpreted in view of the clinical history and nocturnal PSG. 

Moreover, there is evidence for increased rates of ADHD symptoms in clinical populations of children with sleep disorders, including children with the obstructive sleep apnea syndrome (OSAS), periodic limb movements of sleep (PLMS), narcolepsy, and sleep-wake schedule disorders. Studies indicate that treating the primary sleep disorder can produce significant improvement in ADHD symptoms (103). 

Finally, sleep disorders per se can have the same outcome on operator performance as sleep loss or alcohol intoxication. It does not make sense that commercial truck drivers must be screened for arterial hypertension but not for obstructive sleep apnea syndrome. The need for general screening of commercial and public operators for obstructive sleep apnea syndrome is highlighted by the fatal train accident in Clarkston, Michigan on November 15, 2001, in which the engineer s untreated and conductor s insufficiently treated sleep apnea were determined as the probable primary cause of the accident. 

The effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders, such as sleep apnea and periodic limb movement disorder, are essential steps in the management of insomnia [8],... 

In addition to the sleep disturbances that result from normal aging or brain disease, sleep quality may be impaired by primary sleep disorders, some of which occur with increasing prevalence with age. Sleep disordered breathing (sleep apnea), restless legs syndrome (RLS) and REM sleep behavior disorder (RBD) are three such primary sleep disorders that are more prevalent in older adults. 

Although it might be expected that the incidence of the primary sleep disorders would increase in demented patients relative to age-matched controls because of the CNS dysfunction underlying these disorders, studies comparing the rates of sleep apnea in dementia patients and aged controls have not found consistent differences. Nevertheless, these conditions may interact with the dementia syndrome to further worsen sleep quality as well as cognitive and functional abilities. For example, some studies have shown that sleep apnea is associated with increased morning confusion in AD patients. 

If insomnia does nof improve affer 7-10 days, it may be a manifestation of a primary psychiafric or physical illness such as obstrucfive sleep apnea or restless leg syndrome, which requires independent evaluation... 

Chronic kidney disease Cushing s syndrome Coarctation of the aorta Obstructive sleep apnea Parathyroid disease Pheoc h ro mocyto ma Primary aldosteronism Renovascular disease Thyroid disease... 

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