An overview of most common sleep disorders, how they are diagnosed, and typical treatments, with an emphasis on how we approach these things at Somnia.

This is where the screening tools help.

History: snoring, gasping, overweight/obese, more males than females (until menopause), retrognathic (recessed chin). If history only used, only 50-60% of those with OSA are diagnosed.

Oximetry: O2 saturation/pulse only. If oximetry only used, only 70% of those with OSA are diagnosed.

HST: O2, nasal flow, respiratory effort, pulse, snoring. If HST used, 90% of those with OSA are diagnosed.

Polysomnography: 14 channels, sleep (EEG, eye movements, chin tone), breathing, O2, legs, EKG (heart). When PSG used, 100% of those with OSA are diagnosed.

OSA=Obstructive Sleep Apnea. To diagnose OSA, must have respiratory effort, pulse oximetry, airflow, and snoring. This is necessary so you can tell the difference between central events (CSA), where the person simply stops trying to breathe, and obstructive events, where the person is trying to breathe but the throat has closed off.

In-lab studies are a the gold standard, in part because the brain waves (EEG) are observed, and if OSA is present, therapy can be started and adjusted during the night. However, they are expensive, and insurance companies often require pre-authorization to do an in-lab study (which is not always given).

Home Sleep Tests (HST) provide a reliable way to screen for OSA if the above parameters (effort, airflow, oxygen level, snoring) are recorded. Nocturnal pulse oximetry alone is inadequate as it cannot differentiate OSA from CSA.

Positive Airway Pressure (PAP) is the gold standard: it's highly effective, reversible, with minimal short-term side effects. However, it is very difficult for claustrophobic patients to tolerate, if not impossible. Aesthetics are hard for many others, especially younger patients. Also inconvenient for travelers. PAP is most often CPAP (Continuous Positive Airway Pressure) or APAP (Auto-titrating Positive Airway Pressure).

Oral Appliance Therapy (OAT) is a first line treatment for mild-moderate OSA, and a secondary treatment for severe OSA (usually need to fail PAP before insurance covers OAT). However, while severe patients may not completely resolve their OSA using OAT, it is better to do something than nothing. When care is taken, side effects are usually manageable: bite changes, soreness, Temporal-Mandibular Joint Disorder (TMJ).

Surgery: Tonsillectomy & Adenoidectomy (T&A), can be effective, especially in children. Nasal/sinus surgery is also an option, although not as frequently done anymore. Bariatric surgery and subsequent weight loss can improve OSA severity.

Weight loss of any kind can improve OSA, but patients do not always get complete resolution. The impact of weight loss is determined in large part by the initial severity of the OSA, and by the amount of weight lost. A 10% weight loss can lead to a significant improvement in OSA (usually one degree: severe->moderate, moderate->mild).

SOMNIA screener.
If customer scores 3 or more "yes" answers, they are at risk for OSA.

Ask them if they want to rent the HST.
If "yes" there is a full, detailed process to follow that we will cover separately.
If "no" let them make that choice, offer them information, invite them to think it over.

If HST positive, we can treat OSA with APAP and/or OAT, or the customer can seek treatment elsewhere, or can choose not to treat. Again our job is to inform and give options, not to shame or terrify them.

OSA is a serious, chronic condition, that leads to serious long-term risks. But it usually doesn't kill you quick.

Insomnia, especially that which is resistant to medication, is HIGHLY correlated with OSA (91%).

Other disorders that can cause insomnia include RLS/PLMD, mood disorders (esp. Bipolar).

Diagnosis is NOT from a sleep test, in-lab or HST. Rather, insomnia is diagnosed from the STORY. "I don't sleep well." "I can't go to sleep." "I wake up in the middle of the night." "I have to pee." "Pain." "Hot flashes."

This is where the Assessment Tool can really help guide customers. Their score will help decide which area of the store will provide the best short-term and long-term solutions.

OSA treatment (PAP and/or OAT). Make sure to ask about headaches, dry mouth, frequent bathroom trips.

Sleep hygiene/environment: dark, cool, quiet.

CBT: as effective as medications, better long-term results

Over The Counter (OTC) medications: Benadryl, melatonin, valerian. Pain medications such as ibuprofen and acetiminophen can have side-effects.

RLS is a wake phenomenon, so patient history important. Again, it is about the story. "Creepy legs."

PLMD is a sleep disorder, so diagnosis requires that you must be able to see sleep staging and arousal to determine severity.

Have doctor check iron (ferritin) levels.

Gets worse with age. Seen more often in women than men.

A tough disorder to treat. Supplemental iron is dangerous if low ferritin/anemia is not diagnosed.

Topical treatments can sometimes help.

CBT has been shown to be effective as it allows the person to focus on things besides how their legs are feeling, which reduces anxiety and allows them to fall asleep.

Medications are better now than they were, but often lose effectiveness over time. In addition, side effects can be significant.

Parasomnias are common in children, probably as a function of their greater percentage of night in N3 sleep. We tend to grow out of them.

If an adult patient has a return of parasomnias, it is likely secondary to another sleep disorder, such as OSA.

REM-behavior disorder is not a parasomnia, but it typically is an adult-onset disorder and is linked with later diagnoses of Parkinson's.

Need to rule out other sleep disorders. Often treatment of OSA will eliminate or reduce parasomnias.

Medications such as Ambien and antidepressants (Selective Seratonin Reuptake Inhibitors--SSRIs) can lead to increased parasomnias.

In-lab testing simply for parasomnias not always useful since patients don't always "perform" the first night.

Some parasomnias have more impact than others. Safety to patient and bed partner are very important. Locks & alarms, secure firearms and car keys, and things that can break.

If someone has a tendency to have parasomnias, lack of sleep and increased stress will tend to cause an increase in these events.

A circadian rhythm disorder.
By using sleep logs, you can ensure that adequate total sleep time occurs, thus confirming it's a sleep phase disorder and not insomnia.

Screen for other sleep disorders.

Delayed: teens. Morning light therapy.
Advanced: elderly. Evening light therapy.

Melatonin can also help to reset the clock. This also can be helpful for those who travel across time zones.

Need overnight test and Multiple Sleep Latency Test (MSLT). The PSG must be negative for OSA. The MSLT must show a mean sleep latency (average time it takes to fall asleep) of less than 5 minutes over 4-5 nap opportunities, and at least 2 of the 15-minute nap opportunities must show REM sleep for a diagnosis of narcolepsy.

OSA can lead to significant and life-threatening sleepiness, which can be mistaken for narcolepsy.

Narcolepsy is pretty rare: 1/2000. Symptoms: Sleepy, cataplexy, sleep paralysis, hallucinations.

Refer to sleep specialist or neurologist.

Screen for other sleep disorders. If overnight test is positive for OSA, you must treat that before further testing is done or you may get false positive. If sleep is disrupted from OSA, or REM is diminished, you may get rapid sleep times or REM periods during naps.

If no OSA, sleep is refreshing and should be utilized for optimal functioning. Somnia offers environmental aids to help provide comfort outside of the bedroom so naps can be managed (neck pillows, eye masks, etc.).

Ritalin, Adderal, Nuvigil are typically used to help increase alertness.

The chemical functioning of the brain is affected in narcolepsy, with proper brain stimulation systems impaired (Reticular Activation System: RAS).