Evaluation of Sleep Disturbance with Suspected Sleep Apnea
You need a systematic clinical screening to determine if obstructive sleep apnea (OSA) is causing your sleep problems, followed by objective sleep testing if screening suggests significant risk.
Initial Clinical Screening
Your symptoms of difficulty falling asleep and waking in the middle of the night could represent insomnia, OSA, or both conditions occurring together 1. Start by answering these specific screening questions to assess your OSA risk 1:
Key OSA Screening Questions
- Do you snore loudly (loud enough to be heard through a closed door)? 1
- Has anyone witnessed you gasping or stopping breathing during sleep? 1
- Do you wake up without feeling refreshed or fall asleep during the day? 1
- Do you often wake with a headache? 1
Physical Risk Factors to Assess
Check if you have these predisposing characteristics for OSA 1:
- Body Mass Index (BMI) ≥35 kg/m² 1
- Neck circumference ≥17 inches (men) or ≥16 inches (women) 1
- Craniofacial abnormalities or anatomical nasal obstruction 1
Determining Your Risk Level
If you have signs or symptoms in two or more categories (physical characteristics, airway obstruction history, or daytime somnolence), you have significant probability of OSA 1. The severity matters because untreated moderate-to-severe OSA increases risk of hypertension, cardiovascular disease, stroke, diabetes, and motor vehicle accidents 1, 2, 3.
When OSA is Likely
If screening suggests OSA, you need objective sleep testing—either in-laboratory polysomnography or home sleep testing—to confirm the diagnosis 1. Genetic testing has no role in diagnosing OSA 4.
Addressing the Insomnia Component
Your difficulty falling asleep and returning to sleep after awakening suggests comorbid insomnia, which frequently coexists with OSA 1. The European Urology guidelines recommend asking 1:
Insomnia is diagnosed when you have difficulty falling asleep and/or maintaining sleep at least 3 times per week for at least 4 weeks, accompanied by distress 1.
Essential Medical Evaluation
Before attributing everything to a primary sleep disorder, screen for medical conditions that disrupt sleep 1:
Screening Questions for Other Causes
- Do you experience ankle swelling? (cardiac/renal issues) 1
- Do you get short of breath walking? (cardiac/renal issues) 1
- Have you been feeling excessively thirsty? (diabetes) 1
Baseline Testing Recommended
Obtain these baseline investigations 1:
- Blood tests: electrolytes, renal function, thyroid function, calcium, HbA1c 1
- Blood pressure measurement 1
- Urinalysis 1
Medication Review
Review all medications, as many disrupt sleep 1:
- Diuretics, calcium channel blockers, lithium, NSAIDs 1
- Anxiolytics, antidepressants (especially tricyclics), antihistamines 1
- Caffeine and alcohol (diuretic effects) 1
Recommended Action Plan
If your screening suggests moderate-to-high OSA risk (two or more positive screening categories), pursue sleep testing promptly 1. Sleep studies measure the apnea-hypopnea index (AHI): mild OSA is AHI 6-20/hour, moderate is 21-40/hour, and severe is >40/hour 1.
If OSA is confirmed, continuous positive airway pressure (CPAP) is the treatment of choice, with 60-70% adherence rates 2, 3. CPAP improves sleep quality, reduces daytime sleepiness, and decreases cardiovascular risks 3.
For the insomnia component, treatment includes sleep hygiene education, physical activity, psychosocial interventions, and potentially pharmacologic treatments 1. Improvements in sleep lead to improvements in fatigue, mood, and quality of life 1.
Critical Pitfall to Avoid
Do not assume your sleep problem is "just insomnia" without screening for OSA 1. Undiagnosed OSA masquerading as insomnia is common, and treating insomnia alone while missing OSA leaves you at risk for serious cardiovascular consequences including hypertension, heart failure, stroke, and increased mortality 1, 2, 3. Referral to a sleep specialist is recommended for comprehensive evaluation 1, 4.