The five most commonly encountered sleep disorders we encounter in our practice are the sleep apnea hypopnea syndrome (SAHS), the upper airway resistance syndrome (UARS), the restless legs syndrome (RLS), the periodic limb movement disorder (PLMD), and narcolepsy. The key to diagnosis begins with clinical suspicion and involves a thorough history, a directed examination, and a diagnostic polysomnogram (PSG) when necessary.
Patients with SAHS may experience breathing disturbances, difficulty maintaining sleep, excessive daytime somnolence (EDS), fatigue, personality changes, and impaired general function. Risk factors for SAHS include male gender, obesity, ethanol use, use of sedatives, familial factors, craniofacial features, snoring, sleep deprivation, and tobacco use. We feel that the treatment of SAHS should be individualized, but for all patients it should include weight loss and improved sleep hygiene. Other treatment options include oral devices, NCPAP, BiPAP, and surgical options.
UARS was described in 1991 and is a syndrome characterized by hypersomnolence, polysomnogram revealing an AHI of less than 5, and abnormal sleep architecture. The EEG shows abnormal arousals that occur because of increased airway resistance. These patients are generally young (20-40 years of age) but can be of any age. They are generally not obese and snoring may or may not be a complaint. Rhinitis is common. UARS is treated with NCPAP, therapy for rhinitis, and improved sleep hygiene. Occasionally nasal surgery is necessary.
PLMD is very common and may occur in up to 29% of patients over the age of 50. PLMD is best diagnosed by a polysomnogram revealing a PLM index of greater than 5 plus evidence of arousals and sleep fragmentation. We have found that the treatment of PLMD is most effective when it involves anti-Parkinson medication (Sinemet) and benzodiazepines (clonazepam). Occasionally, we find it necessary to use opiates (oxycodone).
RLS is a syndrome characterized by vague and difficult to describe leg discomfort. It is most prominent during times of inactivity. It is relieved by movement. Patients often experience insomnia and arousals from sleep causing sleep fragmentation. RLS is very common and affects up to 5-10% of the population. RLS is made worse by antidepressants (TCAs and MOIs). The treatment of RLS is identical to the treatment of PLMD described above.
Narcolepsy is a disorder of unknown origin. It is characterized by abnormal sleep tendencies including EDS, disturbed nocturnal sleep, and pathological manifestations of REM sleep. Narcolepsy is usually seen in patients in their teens to 20s that complain of EDS. The diagnosis is made by finding a relatively normal polysomnogram and a diagnostic multiple sleep latency test (MSLT). We have found that the treatment of narcolepsy is most efficacious when it involves scheduled naps, stimulants, and agents to combat cataplexy.