Diagnostic and Therapeutic Procedures for Sleep Medicine Disorders
The diagnosis and treatment of sleep disorders should follow standardized procedures established by the American Academy of Sleep Medicine (AASM), with home sleep apnea testing used when clinically appropriate and sleep studies interpreted according to the AASM Manual for the Scoring of Sleep and Associated Events. 1
Diagnostic Procedures
Initial Assessment
- A comprehensive sleep-relevant medical history should be performed for all patients reporting sleep complaints, focusing on common sleep disorders to identify primary and secondary insomnias 1, 2
- For patients with sleep complaints, the STOP questionnaire is recommended to stratify the risk of obstructive sleep apnea (OSA) 1
- Assessment for sleep-disordered breathing should be conducted in patients with history of cardiovascular or cerebrovascular events, congestive heart failure, and chronic prescription opioid use 1
- For evaluating suspected insomnia disorder, the Insomnia Severity Index or Athens Insomnia Scale is recommended as part of a comprehensive sleep assessment 1
Sleep Testing
- Sleep diagnostics should be performed in accordance with standards, clinical practice guidelines, and practice parameters established by the AASM 1
- Polysomnography (PSG) and Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints, but are appropriate for diagnosing specific sleep disorders such as OSA, periodic limb movement disorder, and narcolepsy 2
- For patients with high pretest probability for OSA, a manually scored type 3 home sleep apnea test (HSAT) using an event index (respiratory disturbance index, AHI ≥15 events/h) is recommended to establish the diagnosis of moderate to severe OSA 1
- For patients with high pretest probability for OSA and a nondiagnostic HSAT (technically inadequate or AHI <5 events/h), repeat testing (either HSAT or lab-based polysomnography) is strongly recommended 1
- Documentation of sleep patterns using sleep diaries and/or actigraphy for at least 7 days is required for diagnosing circadian rhythm sleep-wake disorders, with 14 days required for non-24-hour sleep-wake rhythm disorder 1
Therapeutic Procedures
Obstructive Sleep Apnea (OSA) Treatment
- Patients with OSA on positive airway pressure (PAP) therapy should use this treatment for the entirety of their sleep periods 1
- PAP therapy should be continued even if the patient is using treatment for <4 hours/night 1
- Educational, behavioral, and supportive interventions are strongly recommended to improve PAP adherence, especially in patients with comorbid conditions like PTSD, anxiety, or insomnia 1
- For patients with mild to moderate OSA (AHI <30/h), mandibular advancement devices fabricated by qualified dental providers can be offered as an alternative to PAP therapy 1
- For patients with OSA with an AHI of 15–65/h and a BMI <32 kg/m² who cannot adhere to PAP, evaluation for hypoglossal nerve stimulation therapy is recommended 1
- For patients with severe OSA who cannot tolerate other recommended therapies, maxillomandibular advancement surgery may be considered 1
Insomnia Treatment
- Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for chronic insomnia 3, 4
- When pharmacotherapy is indicated, sedative-hypnotics like zolpidem and eszopiclone may be prescribed:
- Zolpidem has been shown to improve sleep latency and sleep efficiency in patients with chronic insomnia 5
- Patients should be warned about potential complex sleep behaviors (sleep-walking, sleep-driving) and next-day impairment with these medications 5, 6
- A full night of sleep (7-8 hours) should be ensured when using these medications to minimize risk of next-day impairment 5
Circadian Rhythm Sleep-Wake Disorders Treatment
- Treatment includes timed light exposure, strategic avoidance of light, and timed administration of melatonin according to phase response curves 1
- Light therapy is strategically timed - evening light before core body temperature minimum leads to phase delays, while morning light after core body temperature minimum leads to phase advances 1
- For delayed sleep-wake phase disorder, morning light therapy and evening melatonin are typically used 1, 7
- For advanced sleep-wake phase disorder, evening light therapy may be beneficial 1
Telemedicine Applications in Sleep Medicine
- Live interactive telemedicine can be used for initial consultations, follow-up visits, and prescription of medications including controlled substances when appropriate 1
- Remote interpretation of sleep studies can be performed using store-and-forward systems, where sleep study data is collected and transmitted to the sleep medicine provider for review 1
- Self-directed care mechanisms (online CBT-I programs, PAP adherence programs, smartphone applications) can be valuable tools in managing sleep disorders 1
- Special consent may be required when physical examination is not performed via telemedicine, and patients should be informed of the limitations of this approach 1
Special Considerations
- Patients with sleep disorders should be evaluated for comorbid conditions, as sleep disturbances may be manifestations of underlying physical or psychiatric disorders 5, 6
- Failure of insomnia to remit after 7-10 days of treatment may indicate a primary psychiatric or medical illness that requires evaluation 6
- When prescribing sedative-hypnotics, be aware of potential risks including complex sleep behaviors, next-day impairment, and worsening of depression in primarily depressed patients 5, 6
- Older patients (>40 years) with insomnia have a significantly higher rate of positive polysomnography findings than younger patients and may benefit from routine PSG 8