Sleep Disorders; Diagnosis
As a first step in gauging the severity of your sleepiness and fatigue symptoms, consider answering the questions on the Epworth Sleepiness Scale (available online at www.healthywomen.org/healthtopics/sleepdisorders/ess) and the Fatigue Severity Scale (available online at www.healthywomen.org/healthtopics/sleepdisorders/fss). These are self-administered tests designed to measure your general level of daytime sleepiness and fatigue. They are useful screening tools but shouldn’t be used to diagnose a condition.
If you have a sleep-related problem, a diagnosis may be as simple as talking to your primary health care professional about the amount of sleep you’re getting and taking simple steps, such as going to bed earlier and avoiding caffeine and alcohol, to sleep longer and better each night.
However, if you experience long-term sleep and fatigue issues that don’t improve with lifestyle changes, you should probably see a sleep specialist. The American Board of Medical Specialties certifies physicians and researchers in sleep medicine.
You may need to stay overnight in a sleep disorders center to have your sleep monitored. You can find a list of accredited sleep disorder centers and laboratories from the American Academy of Sleep Medicine at www.aasmnet.org.
The following outlines the typical diagnostic procedures for the most common sleep disorders:
The key to accurately diagnosing insomnia is talking with your health care professional about your overall health. If you experience chronic insomnia, one or more of the following conditions may be the cause:
medical, emotional and psychological problems.
depression, anxiety and emotional crises, such as a death, illness, divorce or other stressful events.
physical conditions such as arthritis, kidney disease, heart failure, heartburn, asthma, Parkinson’s disease and hyperthyroidism
circadian rhythm disruptions such as shift work
prescription or non-prescription medications
stimulants such as caffeine and nicotine
alcohol and other drugs
other specific sleep disorders such as restless legs syndrome or sleep apnea.
Intermittent and transient insomnia (insomnia that lasts only for a few nights and returns from time to time) can result from:
temporary changes in the surrounding environment
circadian rhythm disruptions such as jet lag
side effects from medication taken on a short-term basis
If you’re suffering from insomnia, your health care professional may need a sleep history as well as a medical history. The sleep history comes from a sleep diary you complete at home or via an interview with a health care professional about the quantity and quality of your sleep.
Your bed partner may participate in the evaluation to provide insight into snoring, movements or other symptoms you might not be aware of.
Your health care professional may also recommend specialized sleep studies to diagnose or rule out another primary sleep disorder.
It’s not unusual for people suffering from narcolepsy to visit a variety of health care professionals for years before they receive an accurate diagnosis. To get an accurate diagnosis, you should be seen in an accredited sleep center by a sleep specialist. The following tests are used to diagnose narcolepsy:
The nocturnal polysomnogram (“sleep study”). This test involves continuous recording of brain waves and several nerve and muscle functions during nighttime sleep. It also includes monitoring your breathing pattern and oxygen levels while you sleep. When tested, people with narcolepsy fall asleep rapidly, enter REM (rapid eye movement) sleep early and may wake often during the night. The polysomnogram also helps detect other possible sleep disorders such as sleep apnea that could cause daytime sleepiness.
The Multiple Sleep Latency Test (MSLT). This test measures the degree of daytime sleepiness and detects when REM sleep occurs. During this test, you’re given a chance to sleep every two hours during normal wake times. A sleep specialist observes how long it takes you to fall asleep. People with narcolepsy fall asleep rapidly and enter REM sleep very early in their sleep cycle.
If you suffer from sleep apnea, you may have as many as 100 or more involuntary interruptions in airflow, or “apneic events,” each night. It’s important that you get a diagnosis and treatment as soon as possible because the condition is associated with heart rhythm problems, high blood pressure (experienced by an estimated 50 percent of sleep apnea patients) and a higher risk of heart attack and stroke. Other possible consequences of sleep apnea include depression, irritability, sexual dysfunction, nocturia (the need to urinate several times a night), learning and memory difficulties and falling asleep while at work, on the phone or driving. Recent studies also suggest that sleep apnea may negatively affect blood sugar control in people with diabetes.
Sleep partners often are the first to suspect that something is wrong, usually because of their partner’s heavy snoring and apparent struggle to breathe. If you suffer from sleep apnea, you may not realize you aren’t sleeping normally and may not believe it when someone tells you. For proper diagnosis, consult a health care professional with special training in sleep disorders.
A nocturnal polysomnogram is the standard test to diagnose sleep apnea.
Restless Legs Syndrome (RLS) and Periodic Limb Movements (PLM) in Sleep
Although the cause is unknown in most cases, certain factors may be associated with RLS:
Family history. RLS seems to run in some families with parents passing on the condition to their children
Pregnancy. Some women experience RLS during pregnancy, especially in the last months. The symptoms usually disappear after delivery.
Low iron levels or anemia. If you have low iron levels or anemia, you are prone to developing RLS. The symptoms may improve once the iron level or anemia is corrected. Low ferritin levels (a protein used to carry iron in the blood) have also been associated with RLS. Some studies find that supplementing with iron can improve symptoms. Don’t supplement on your own, however; too much iron can be dangerous and cause damage to vital organs such as the liver and heart.
Chronic diseases. KKidney failure and other chronic diseases such as diabetes, rheumatoid arthritis and peripheral neuropathy.
Caffeine intake. Reducing your intake of caffeine can improve symptoms.
how they affect day-time functioning
No specific laboratory test can diagnose RLS, so it usually depends on your symptoms.
To help make a diagnosis, your health care professional may ask about all current and past medical problems, family history and medications. You may need basic laboratory tests to assess your general health and a blood test to rule out anemia. A complete physical, a neurological exam and additional diagnostic and/or serum chemistry testing may help identify other conditions that may be associated with RLS.
These other causes include kidney failure, diabetes, nerve damage and certain medications including antiseizure drugs such as phenytoin (Dilantin) or droperidol (Inapsine); antinausea drugs such as prochlorperazine (Compazine) or metoclopramide (Reglan); antipsychotic drugs such as haloperidol (Haldol); and most antidepressant medications, including widely prescribed ones such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). Some cold and allergy medications may also aggravate symptoms.
In some cases, your health care professional may suggest an overnight sleep study to determine whether you have PLMS or other sleep problems. Most people with RLS, however, have no medical problems.
Circadian Rhythm Disorders
Circadian rhythm disorders, like insomnia, can be categorized as either temporary (transient) or chronic. Transient circadian rhythm disruptions are typically caused by temporary disturbances to sleep patterns, such as jet lag, or altered sleep schedules due to work, social responsibilities or illness.
A common type of circadian rhythm disorder is delayed sleep-phase syndrome (DSPS). Those with DSPS have a persistent inability (more than six months) to fall asleep and wake up at normal times. They tend to go to bed very late and get up in the late morning or early afternoon. Once asleep, they have normal total sleep times and normal sleep. Another type is advanced sleep-phase syndrome (ASPS). Those with ASPS go to sleep in the early evening (between 6 and 9 p.m.) and wake up early, generally between 2 and 5 a.m. As with all sleep disorders, a thorough medical history is the first step to accurately diagnose circadian rhythm disorders. Be prepared to discuss your symptoms, including how long they last, their severity and how they affect your ability to function during the day.
Your health care professional will also want to know what, if any, medications you’re taking; what you’ve tried to improve your sleep; and any medical or mental health conditions that could affect sleep.
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