Assessing the sleepy patient Flashcards
Reasons someone could struggle with daytime sleepiness
This can vary from a number of medical conditions including sleep disorders, to poor sleep due to other disorders or poor sleep hygiene. Medications can cause sleepiness. It can also be due to external factors such as children, pets, partners and noisy neighbours disturbing sleep. It is therefore important to get a through history as well as diagnostic tests to ensure optimal treatment.
Taking a good sleep history components
- HX of presenting problem - duration/ frequency. Changes in weight, meds or other conditions in this time? Severity of symptoms, impact on patient
- Medical hx - Comorbidities of OSAHS - HTN, T2DM or pain
Fhx - members with diagnosed sleep disorder
-Meds - contribute to poor sleep or daytime impairment
Meds/ drug history
- caffeine/ alcohol/ nictotine
Nicotine, which can disrupt sleep and reduce total sleep time. Smokers report more daytime sleepiness and minor accidents than do nonsmokers, especially in younger age groups.
illicit drugs e.g. cocaine/ amphetamines and methamphetamines
- OTC:
- anti histamines
- cough and cold meds
- non-prescription sleeping tablets
-prescription drugs
- sleeping tablets
- analgesics
- anti-depressants
What are some common sleep disorders
- Narcolepsy
_ Periodic limb movements - OSAHS
- Parasomnia
- Insomnia
- Nocturnal Frontal Lobe epilepsy
STOP BANG - if at risk for OSAHS
Snore
Tired during daytime
Observed apnoeas
Pressure - HTN
BMI > 35 km/m2
AGE >50
Neck circ >40cm
Gender - Male
Score >3 = risk for OSA
When to suspect OSAHS
- snoring
- witnessed apnoeas
-choking during sleep
-sleep fragmentation or insomnias - nocturne
- unrefreshed sleep
-waking headaches - unexplained excessive sleepiness/ tiredness or fatigue
- cognitive dysfunction or memory impairment
RFS for OSAHS
- obesity
- treatment resistant HTN
- cardiac arrhythmia, particularly AF
- stroke or TIA
- chronic HF
- mod or severe asthma
-PCOS - Down’s syndrome
- non-arteritic anterior ischaemic optic neuropathy
- hypothyroidism
-acromegaly
Assessing sleepiness
Epworth sleepiness scale >10 suggests excessive sleepiness
- this is not diagnostic, and must not be used in isolation as not all patients with OSAHS have sleepiness
- cannot predict OSAHS severity
Stanford Sleepiness Score - measure of sleepiness right now
Functional Outcome of Sleep Questionnaire (FOSQ) - assessing effect of sleepiness on QoL
Physical examination
- body habits/neck circumference
- cranio - facial abnormalities
- retrognathia / micrognathia
- macroglossia
- age/ gender
Upper airway
- latency
-deviated septum
-hx of broken nose
- oropharyngeal visualisation
- soft palate and uvula (? elongated)
- tonsil size
- tongue size
Diagnostic tests for OSAHS
- offer home respiratory polygraph to people with suspected OSAHS
- if access limited, consider home oximetry
- take into account, oximetry alone may be inaccurate for differentiating between OSAHS and other causes of hyperaemia in people with HF or chronic lung diseases
- consider Resp polygraph or polysomnography if oximetry results are negative nut person still has significant symptoms
- consider hospital respiratory polygraphs for people with suspected OSAHS if home respiratory polygraph and home oximetry are impractical or additional monitoring needed
- consider polysomnography if Resp polygraphs results negative but symptoms continue
- use results of sleep study to diagnose OSAHS and determine severity but before diagnosing consider social history (e.g. employment, marital status etc)
AHI
No of apnoeas + hypopnoeas/ number of hours sleep study
<5hr = normal AHI
> 5- 14 = Mild
> 15 Mod
>30 severe
OSA is a risk factor for general anaesthetic
- difficult intubation in patients
- difficulty maintaining adequate SpO2
Before recommending CPAP, what are things to consider
- patient claustrophobic
- also offer weight management support and ask to reduce caffeine
- if low sustained periods of SpO2 I would want a blood gas to check for any ventilatory failure. I would also want to review in clinic to explain the findings and why CPAP would be indicated (or NIV might be indicated if pCO2 is raised). Patient has history of claustrophobia so may struggle to tolerate CPAP mask and will need a good explanation of why this is needed in order to for them to have a chance of being successful with therapy.
rEDS
Residual excessive daytime sleepiness
12% of those on CPAP
- higher ESS at diagnosis
- milder OSA
- worse health perception and mood
Causes:
Inadequate treatment pressure/ inadequate compliance
Sleep disturbance
Sleep hygiene
Comorbities;
Depression
Neurological conditions
Hypothyroidism
Poorly controlled T2DM
Iron deficiency
Vitamin deficiency (B!@, D)
Treatment:
correct deficiencies in CPAP therapy
Advice and support with sleep hygiene
Treatment of comorbidities
Medication review
- Sleep promoting or wake promoting meds
