What are the essential questions to ask a patient to evaluate and diagnose their sleep complaints?

Comprehensive Sleep History Assessment

You have covered most essential elements of a comprehensive sleep history, but several important areas require additional attention to ensure thorough evaluation and avoid missing critical diagnoses.

Critical Missing Elements

Nocturia Assessment

• Ask specifically about frequency of nighttime urination 1
• This is a common complaint that can significantly disrupt sleep and may indicate underlying cardiac, renal, endocrine, or neurological conditions 1
• Distinguish between waking to urinate versus urinating because already awake 1

Restless Legs Syndrome (RLS) Screening

• "Do you have the urge to move your legs or experience uncomfortable sensations in your legs during rest or at night?" 1
• Follow up with specific RLS diagnostic criteria questions 1:
  • What does it feel like?
  • Does it vary over the day and worsen in evening?
  • Is it relieved by movement?
  • Does it return minutes after sitting/lying back down?
  • Does your bed partner notice kicking movements during sleep?

Recent Life Stressors and Losses

• "Have you suffered any personal losses recently?" 1
• This question addresses psychosocial precipitants of insomnia that may require specific therapeutic attention 1

Physical Activity Assessment

• "How much physical activity or exercise do you get daily?" 1
• Exercise timing and intensity can significantly impact sleep quality and circadian rhythm 1

Bed Partner Observations

• Obtain collateral history from bed partner whenever possible 1
• Partners may observe symptoms the patient is unaware of, including snoring patterns, breathing pauses, limb movements, and parasomnias 1, 2

Additional Screening Questions for Specific Disorders

Sleep Apnea Clarification

• "Do you often wake with a headache?" 1
• This is a specific indicator of obstructive sleep apnea that you haven't explicitly included 1

Parasomnia Details (if positive screen)

• Age of first occurrence 1
• Recall of events and dreams during episodes 1
• Eyes open or closed during episodes 1
• Time of night episodes occur 1
• Whether patient stays in bed or gets out 1
• History of injury to self or others 1

Hypersomnia Evaluation (if excessive sleepiness present)

• Symptom response to napping 1
• Presence of dreaming during naps 1
• Hypnagogic hallucinations 1
• Sleep paralysis 1
• Automatic behaviors 1
• Cataplexy symptoms 1

Objective Documentation Tools

Sleep Diary Requirements

• Request a minimum 2-week sleep diary 1, 3, 4
• Should include: sleep quality ratings, sleep parameters, napping details, daytime impairment, medications, activities, evening meal timing, caffeine/alcohol consumption, and pre-bedtime stress levels 1

Consider Actigraphy

• At least 7 days of actigraphy for objective sleep-wake pattern measurement 3, 4
• Particularly important when circadian rhythm disorders are suspected, as objective data may differ significantly from self-reported patterns 3

Functional Impact Assessment

Quality of Life Domains

• Impact on employment and work performance 1
• Effect on relationships 1
• Social withdrawal or limitations 1
• Ability to drive safely 1
• Cognitive difficulties beyond general "daytime functioning" 1

Distinguish Fatigue from Sleepiness

• These are different constructs requiring different evaluation approaches 3
• Patients with circadian rhythm disorders may report morning sleepiness but increased alertness later in the day 3

Medical Comorbidity Screening

Specific Symptom Queries

• "Do you experience ankle swelling?" (cardiac/renal) 1
• "Do you get short of breath walking certain distances?" (cardiac/renal) 1
• "Do you get lightheaded on standing?" (cardiac/neurological) 1
• "Have you been feeling excessively thirsty?" (endocrine) 1
• "Have you noticed changes in your periods?" (for females of relevant age - endocrine) 1
• "Do you have problems controlling your legs, slowness of movement, or tremor?" (neurological) 1

Physical Examination Elements

• Check for reduced salivation and scleroderma 1
• Assess for peripheral edema 1
• Evaluate for lower limb weakness, gait abnormalities, speech changes, and tremor 1

Baseline Investigations to Order

• 72-hour bladder diary (if nocturia present) 1
• Blood tests: electrolytes/renal function, thyroid function, calcium, HbA1c 1
• Urine dipstick with albumin:creatinine ratio 1
• Blood pressure assessment 1
• Pregnancy test where applicable 1

Common Pitfalls to Avoid

• Failing to obtain bed partner input - critical observations may be missed 1, 2
• Relying solely on subjective reports without objective measures like sleep diaries or actigraphy 3
• Not distinguishing between primary and comorbid insomnia - most insomnia in clinical practice is comorbid and requires treatment of both conditions 1
• Missing multiple coexisting sleep disorders - 70% of patients have more than one sleep diagnosis with mean of 2.2 diagnoses per patient 5
• Inadequate assessment of daytime consequences beyond simple "tiredness" 1