What is the best approach to evaluate and manage a patient's sleep complaints?

Comprehensive Approach to Evaluating and Managing Sleep Complaints

The evaluation of sleep complaints requires a structured clinical interview focusing on specific symptom patterns, comorbidities, and behavioral factors, followed by a 2-week sleep diary and validated screening tools, with polysomnography reserved only for suspected sleep apnea, movement disorders, or treatment failure. 1

Initial Screening Questions

Start with two critical screening questions to determine if further evaluation is warranted: 2

• "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?"
• "Does the problem with your sleep negatively affect your daytime functioning?"

If both answers are yes, proceed with comprehensive assessment. 2

Core Sleep History Components

Primary Sleep Complaint Characterization

Identify the specific insomnia phenotype: 1

• Sleep onset insomnia: Difficulty falling asleep initially
• Sleep maintenance insomnia: Frequent awakenings during the night
• Early morning awakening: Terminal insomnia with inability to return to sleep
• Non-restorative sleep: Unrefreshing sleep despite adequate duration

Document sleep onset latency (how long to fall asleep), frequency of nighttime awakenings, and total sleep time. 1

Temporal Pattern and Course

Assess the evolution of symptoms over time, including: 1

• Duration of symptoms (acute vs. chronic)
• Precipitating factors at onset
• Progression or fluctuation of symptoms
• Day-to-day variability in sleep patterns
• Menstrual cycle or seasonal variations 3

Sleep-Wake Schedule Details

Document specific timing patterns: 1

• Bedtime and wake time on weekdays and weekends
• Weekend drift (delayed sleep phase on weekends suggests circadian component)
• Napping frequency, duration, and timing 3
• Shift work history and travel across time zones 1

Pre-Sleep Behaviors and Environment

Critical behavioral factors to assess: 1

• Clock watching: Explain to patients that looking at the clock at 3:00 AM triggers mental math calculations ("I only have 4 hours left!"), activating the amygdala and releasing adrenaline, making deep sleep biologically impossible for 20-40 minutes
• TV or phone use before bed (screen time and blue light exposure)
• Eating, exercising, or smoking within 2-3 hours of bedtime
• Caffeine and alcohol consumption timing and quantity 1

Sleep environment assessment: 1

• Noise levels
• Light exposure (including morning light dose)
• Temperature
• Bed comfort

Previous Treatment History

Document all prior interventions and responses: 1

• Behavioral therapies attempted (stimulus control, sleep restriction, relaxation)
• Medications tried (prescription and over-the-counter)
• Duration of each treatment
• Efficacy and side effects experienced
• Reasons for discontinuation

Screening for Comorbid Sleep Disorders

Obstructive Sleep Apnea Screening

Use the STOP questionnaire to stratify OSA risk in all patients with sleep complaints. 1

Specifically assess for: 1

• Snoring patterns (obtain bed partner input)
• Witnessed apneas or gasping
• Morning headaches 3
• History of cardiovascular or cerebrovascular events, congestive heart failure
• Chronic prescription opioid use

Restless Legs Syndrome Screening

Ask: "Do you have the urge to move your legs or experience uncomfortable sensations in your legs during rest or at night?" 3

Parasomnia and Movement Disorder Screening

Query about: 1, 3

• Limb movements during sleep
• Sleep walking, talking, or other complex behaviors
• Violent or injurious behaviors during sleep
• Dream enactment behaviors

Other Nocturnal Symptoms

Assess for: 1, 3

• Gastroesophageal reflux symptoms
• Palpitations
• Coughing
• Frequency of nighttime urination (nocturia may indicate cardiac, renal, endocrine, or neurological conditions) 3

Daytime Consequences Assessment

Distinguish between fatigue and sleepiness, as these require different evaluation approaches. 3, 2

Document impact on: 1, 3

• Mood disturbances
• Cognitive difficulties (concentration, memory)
• Quality of life
• Work performance and employment
• Social functioning and relationships
• Driving safety
• Ability to stay awake during passive activities

Medical and Psychiatric Comorbidity Evaluation

Medical Conditions

Screen for conditions commonly causing insomnia: 2

• Cardiovascular diseases
• Pulmonary conditions
• Neurological disorders
• Chronic pain conditions
• Gastrointestinal disorders
• Endocrine disorders (thyroid, diabetes)

Ask specific symptom queries: 3

• Ankle swelling
• Shortness of breath
• Lightheadedness on standing
• Excessive thirst
• Changes in menstrual periods

Psychiatric Conditions

Assess for psychiatric disorders commonly associated with insomnia: 2

• Depression
• Anxiety disorders
• Post-traumatic stress disorder
• Bipolar disorder

Ask about recent personal losses to identify psychosocial precipitants requiring specific therapeutic attention. 3

Medication and Substance Review

Conduct thorough review of: 2

• Medications that may disrupt sleep: Beta-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs
• Over-the-counter sleep aids
• Caffeine, alcohol, nicotine use patterns
• Recreational drug use

Required Assessment Tools

Mandatory Baseline Documentation

At minimum, every patient must complete: 1

1. Two-week sleep diary/log documenting: 1, 2

   • Bedtime and wake times
   • Sleep onset latency
   • Number and duration of awakenings
   • Total sleep time
   • Nap frequency and duration
   • Sleep quality ratings
   • Daytime impairment
   • Medications taken
   • Evening activities
   • Caffeine/alcohol consumption
   • Pre-bedtime stress levels

2. General medical/psychiatric questionnaire to identify comorbid disorders 1

3. Epworth Sleepiness Scale to identify excessive sleepiness and comorbid disorders 1, 2

Additional Validated Screening Tools

For insomnia assessment, use the Insomnia Severity Index or Athens Insomnia Scale as part of comprehensive evaluation. 1, 2

Consider additional measures of: 1

• Subjective sleep quality
• Psychological assessment scales
• Daytime function
• Quality of life
• Dysfunctional beliefs and attitudes about sleep

Objective Monitoring

Actigraphy for at least 7 days is indicated to objectively measure sleep-wake patterns, particularly when circadian rhythm disorders are suspected. 1, 4, 2

Collateral Information

Obtain bed partner history whenever possible, as they may observe critical symptoms the patient is unaware of, including snoring patterns, breathing pauses, limb movements, and parasomnias. 1, 3

Ask bed partners about: 3

• Observed breathing abnormalities
• Movement patterns during sleep
• Vocalizations or behaviors
• Timing and frequency of symptoms

Additional Behavioral Assessment

Ask about: 3

• Daily physical activity and exercise patterns
• Number of alarms set in the morning
• How many times snooze button is hit (indicates inadequate sleep or circadian misalignment)

When to Order Polysomnography

Polysomnography is NOT indicated for routine evaluation of chronic insomnia, including insomnia due to psychiatric or neuropsychiatric disorders. 1

Polysomnography IS indicated when: 1

• Reasonable clinical suspicion of obstructive sleep apnea exists
• Movement disorders are suspected
• Initial diagnosis is uncertain
• Treatment fails (behavioral or pharmacologic)
• Precipitous arousals occur with violent or injurious behavior

For patients with high pretest probability for OSA and nondiagnostic home sleep apnea testing, repeat testing (home or lab-based polysomnography) is required. 1

Laboratory Testing

Other laboratory testing (blood work, radiographic studies) is not indicated for routine evaluation of chronic insomnia unless there is suspicion for comorbid disorders. 1

If nocturia is present, order: 3

• 72-hour bladder diary
• Electrolytes/renal function
• Thyroid function tests
• Calcium
• HbA1c
• Urine dipstick with albumin:creatinine ratio
• Blood pressure assessment
• Pregnancy test where applicable

Differential Diagnosis Considerations

Multiple primary and comorbid insomnia disorders may coexist; the presence of one does not exclude others. 1, 4

Consider: 4, 2

• Primary insomnia vs. comorbid (secondary) insomnia
• Other circadian rhythm disorders
• Psychiatric conditions
• Medication effects or substance use

Common Pitfalls to Avoid

Critical errors that compromise diagnosis and treatment: 3, 4

1. Failing to obtain bed partner input: Critical observations of breathing, movements, and behaviors during sleep may be missed 3

2. Relying solely on subjective reports without objective measures: Sleep diaries and actigraphy provide data that may differ significantly from self-reported patterns 3, 4

3. Not distinguishing between fatigue and sleepiness: These require different evaluation and treatment approaches 3, 2

4. Treating the symptom without identifying underlying causes: Insomnia is often secondary to medical, psychiatric, or other sleep disorders that require specific treatment 1, 2

Treatment Framework Based on Assessment

First-Line Treatment

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia. 2

CBT-I components include: 1

• Stimulus control: Go to bed only when sleepy; maintain regular schedule; avoid naps; use bed only for sleep; if unable to sleep within ~20 minutes, leave bed and engage in relaxing activity until drowsy
• Sleep restriction: Initially limit time in bed to match total sleep time from sleep logs, adjusting weekly based on sleep efficiency
• Cognitive therapy: Address dysfunctional beliefs ("I can't sleep without medication," "My life will be ruined if I can't sleep")
• Relaxation training: Progressive muscle relaxation to lower arousal states

Pharmacological Considerations

When non-pharmacological approaches are insufficient: 2

• Short-intermediate acting benzodiazepine receptor agonists as first-line pharmacotherapy
• Ramelteon as alternative first-line option
• Combined therapy (CBT-I plus medication) may be appropriate based on symptom pattern and patient factors

OSA-Specific Management

For patients diagnosed with OSA: 1

• PAP therapy should be used for the entirety of sleep periods
• Continue PAP even if used <4 hours/night while working on adherence
• Offer educational, behavioral, and supportive interventions to improve PAP adherence, especially in patients with PTSD, anxiety, or insomnia
• For mild to moderate OSA (AHI <30/h), consider mandibular advancement devices fabricated by qualified dentist

Treatment Goals

Primary treatment goals regardless of therapy type: 1

• Improve sleep quality and quantity
• Improve insomnia-related daytime impairments