Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of "Major Recommendations" field.
Subjective Assessment
- Chief complaint(s) and/or clinical manifestations
- Complaints of frequent nocturnal awakenings
- Complaints of difficulty concentrating
- Complaints of problems with memory
- Complaints of snoring and/or apnea by patient or significant other
- Complaints of daytime sleepiness or fatigue
- Complaints of depression
- Sleep Assessment
- Review of Systems
- General
- Head, eyes, ears, nose, and throat (HEENT)
- Endocrine
- Heart
- Lungs
- Genitourinary (GU)
- Gastrointestinal (GI)
- Musculoskeletal (MS)
- Neurological
- Psychiatric
- History of present illness
- Onset and duration of symptom complaints
- Body weight changes
- Lifestyle habits, such as diet, exercise, smoking, alcohol or drug use
- Quantity and quality of sleep
- Past medical history
- Note hospitalizations, surgeries, and any/or procedures
- History of any trauma
- Co-morbid conditions such as: diabetes, hypertension, congestive heart failure (CHF), arrhythmias, cardiovascular disease, hypothyroid, depression, gastroesophageal reflux disease, nocturnal cardiac ischemia, asthma
- Medications
- Current prescription medications
- Any or all over the counter medications, including alternative medicines or herbal treatments
- Note previous sleep treatments, including use of sedatives or sleeping aids and response
- Family history
- Obstructive sleep apnea (OSA)
- Diabetes
- Hypertension
- Hypothyroid
- Coronary artery disease
- Cerebrovascular accident (CVA)
- Depression
- Psychosocial history
- Assess for depression, suicidal ideations, irritability, personality changes, and cognitive impairment
- Mental illness
- Support systems, coping strategies
(If OSA is suspected, important to inquire on type of job, if operating heavy machinery, counseling regarding potential dangers, i.e., increased risk of motor vehicle crashes secondary to sleep deprivation) (Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield & Naughton, 2005)
Objective Assessment/Physical Examination
Diagnostic Procedures
- Laboratory studies
- Sleep questionnaire (e.g., Epworth Sleepiness Scale), screen for sleep abnormalities (Elliott, 2001) (Strength of Recommendation: A; Quality of Evidence: Good)
- Diagnostic tests
- NPSG Sleep Study: Nocturnal polysomnographic diagnostic testing (Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield & Naughton, 2005; Hamilton, Solin, & Naughton, 2004; Rodsutti et al., 2004) (Strength of Recommendation: A; Quality of Evidence: Good)
Differential Diagnoses
- Narcolepsy
- Idiopathic daytime hypersomnolence
- Inadequate sleep time
- Depressive episodes
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- CHF
- Panic attacks
- Gastroesophageal reflux disease (GERD)
- Sleep associated seizures
- Anemia
- Fibromyalgia
- Restless leg syndrome
(Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield & Naughton, 2005; Hamilton, Solin, & Naughton, 2004; Rodsutti et al., 2004)
(Strength of Recommendation: C; Quality of Evidence: Fair)
Management/Treatment
Referral to pulmonologist, sleep specialist (Strength of Recommendation: B; Quality of Evidence: Fair)
Patients should be referred for abnormal polysomnogram results and/or sleep complaints consistent for 3 to 6 months with restless leg syndrome, periodic limb movements, narcolepsy, or complex motor activity. (Elliott, 2001) (Strength of Recommendation: B; Quality of Evidence: Fair)
Follow Up
Obtain records from referral physician, and assess patient's adherence to recommendations of management/treatment. (Strength of Recommendation: I; Quality of Evidence: Poor)
Definitions:
Quality of Evidence (Based on U.S. Preventive Services Task Force Ratings)
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
Strength of Recommendations (Based on U.S. Preventive Services Task Force Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify general recommendation.
D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
