Approach to the Patient: Sleep Disorders

Pts may complain of (1) difficulty in initiating and maintaining sleep at night (insomnia); (2) excessive daytime sleepiness or tiredness; (3) unusual behaviors during sleep (parasomnias); or (4) circadian rhythm disorders associated with jet lag, shift work, and delayed sleep phase syndrome. Careful history of sleep habits and reports from the sleep partner (e.g., heavy snoring, falling asleep while driving) are a cornerstone of diagnosis. Pts with excessive sleepiness should be advised to avoid driving until effective therapy achieved. Completion of a day-by-day sleep-work-drug log for 1-2 weeks is often helpful. Work and sleep times (including daytime naps and nocturnal awakenings) as well as drug and alcohol use, including caffeine and hypnotics, should be noted each day. The physical examination may show a small airway, large tonsils, or a neurologic or medical disorder that contributes to the complaint. Objective sleep laboratory recording is necessary to evaluate specific disorders such as sleep apnea, periodic limb movements, and narcolepsy.