STUDY - Technical - New Dacian's Medicine
Sleep
and circadian rhythm disorders (3)
Translation Draft
"Stop" this position in the position "of duty"...
"Stop" this position in the position "of duty"...
I mean, I'm going to write
it sometime, as I've told you, but not today...
I'll start this post with the patient's approach with a sleep disorder. Patients may seek medical help for: 1. chronic or acute incapacity to sleep properly at night, 2. chronic fatigue, exhaustion or a state of fatigue during the day and 3. manifestations of behavior associated with sleep itself. Interruption or disturbance of night sleep is directly related to reduced mental state and disturbance of psychomotor and cognitive performance during the day, which is a serious concern for the patient in most cases.
A careful examination of the history is essential in the evaluation of the patient with sleep disorders. In particular, the duration, consistency and severity of the disorder are important in relation to the patient's estimation (in case of insomnia) in terms of the effect of sleep deprivation on subsequent wakefulness functions.
Information obtained from a friend or family member can be extremely useful in assessing the severity of the disorder during the day, especially since some patients report the embarrassment caused by loud snoring or fall ill driving.
Retrospective completion, by doctor and patient, of drug-induced sleepiness in the daily work-sleep cycle in reverse chronological order, can help the doctor better understand the nature of the disorder. Working hours must be specified every day. The use of medicines and alcohol, including caffeine and hypnotics should be noted daily.
These daily records should be compared with a prospective schedule of sleep-work-medication activities (including daily sleep-sweating and night-time awakenings) of the patient for at least 2 weeks. Sleep periods should be plotted to facilitate recognition of circadian sleep disorders, such as delayed sleep phase syndrome.
Laboratory evaluation of objective sleep measurements is necessary for the diagnosis of specific conditions such as narcolepsy and sleep apnea and may also be useful under other conditions. In addition to the three electrophysiological variables used to define sleep states and its stages, the standard clinical polysomnogram includes breathing measurement (respiratory effort, air flow and oxygen saturation), anterior tibial EMG and ECG. Assessment of penile tumescence during night sleep can also be used to help determine whether the etiology of erectile dysfunction of the patient is psychogenic or organic.
Let's talk a little bit about the daytime consequences of sleep disorders. While suffering caused by discontinuation of night sleep may be the most important symptom for patients with sleep disorders, especially those with insomnia, the impact of this sleep disruption on daily function is the most important aspect for clinical and public health prospects. Road accidents associated with drowsiness, for example, constitute an important risk to the health of the patient with interrupted sleep.
Daily sleep loss impairment can be difficult to quantify in the clinical context due to several reasons. Firstly, drowsiness is not necessarily proportional to subjectively assessed sleep deprivation. In obstructive sleep apnea, for example, repeated short sleep interruptions associated with resuming breathing at the end of apnea episodes cause significant impairment of wakefulness, despite the fact that the patient may be unconscious of sleep fragmentation.
Secondly, subjective descriptions of sleep impairment vary from patient to patient. Patients can describe themselves as "sleepy," "tired" or "tired" and have a clear definition of these terms, while others may use these terms to describe a completely different condition.
Thirdly, drowsiness, especially when deep, can affect judgment in an alcohol-like manner, so subjective awareness of the condition and cognitive and motor alterations is reduced. Finally, patients may be reluctant to admit that drowsiness is a problem, both because they are generally unaware of what constitutes the normal state of attention, and because drowsiness is generally viewed pejoratively, most often attributed to a deficit in motivation and less to an inadequately satisfied physiological need.
In assessing clinical sleepiness, specific questions about the occurrence of sleep episodes during normal waking hours, both intentional and non-intentional, may imbalance the contradictions of subjective characterizations and simultaneously provide an indication of the adverse impact of sleepiness on daily activity.
Specific areas of discussion include the occurrence of episodes of inadequate sleep while driving or other conditions associated with safety, sleepiness during work or school (and the relationship between drowsiness and work and school performance) and the effect of sleepiness on social and family life. The evidence of significant daily impairment (especially in association with the diagnosis of primary sleep disorder, such as narcolepsy or sleep apnea) raises the question of the doctor's responsibility to notify the traffic authorities of the increased risk of road accidents associated with drowsiness.
As with epilepsy, legal requirements vary from state to state and the existence of legal precedents does not typically provide a consistent interpretation of the balance between the responsibility of the doctor and the patient's right to secrecy. At least the doctor should direct the discussion with the patient towards the increased risk of driving a vehicle and recommend that driving be suspended until successful treatment is established.
Differentiating fatigue sleepiness can be difficult, especially due to the imprecise use of these terms by patients in describing these symptoms. The distinction may be useful in differentiating patients with accusations of fatigue or fatigue in the case of conditions such as fibromyalgia, chronic fatigue syndrome or endocrine deficits such as hyperthyroidism or Addison's disease.
While patients with these conditions can characteristically distinguish their daytime symptoms from sleepiness that occurs with sleep deprivation, substantial overlaps may occur. This is particularly true when the primary condition also causes chronic sleep disruption (e.g. nocturnal apnea from hypothyroidism) or abnormal sleep (e.g. fibromyalgia).
While the assessment of the allegation of excessive sleepiness is generally appropriate, objective quantification is sometimes necessary for diagnostic purposes or for the evaluation of the therapeutic response. The assessment of daily activity as an appropriate sleep index can be carried out by the Multiple Sleep Latency Test (TLMS) which involves repeated measurement of sleep latency (the time from the onset of sleep) under standardized conditions during a day following a quantified night sleep.
The average latency over 4-6 tests (administered every 2 hours over a wake-up day) is interpreted as an objective measure of the daily sleep trend. Sleep disorders that cause pathological daytime sleepiness can be actually distinguished by TLMS. In addition, multiple measurements of sleep onset can directly identify transitions from wakefulness to REM sleep that are suggestive of specific pathological conditions (e.g. narcolepsy).
Now let's move on to insomnia!
Insomnia is accused of unsatisfactory sleep, being classified according to the nature of sleep interruptions and its duration. The nature of sleep disruption provides important information about the possible etiology of insomnia and is also the main, central element in the selection of appropriate and specific treatment.
Insomnia is subdivided into: difficult sleep (insomnia of onset of sleep), frequent or sustained awakenings (insomnia in maintaining sleep), morning awakenings (wake-up insomnia) and persistent sleepiness, despite a sleep of adequate duration (sleep without physical and mental recovery).
Similarly, the duration of the persistence of symptoms is an important indication in determining the nature of appropriate treatment. Insomnia lasting one to several nights (in a single episode) is called transient insomnia. Transitional insomnia is typically the result of a stressful or change in sleep schedule or ambient environment (e.g. time zone change).
Short-term insomnia lasts from a few days to 3 weeks. Disruption of this duration is usually associated with prolonged stress, such as recovery from surgery or acute illness. Long-lasting or chronic insomnia lasts for months or years and normally reflects perpetuation factors associated with primary sleep disorders.
Chronic insomnia may occur in the form of recurrent episodes of insomnia, not necessarily associated with parallel variations of the underlying cause. Although some clinicians refer to these as recurrent insomnia, others suggest that this may be the typical pattern of patients with chronic insomnia. While an occasional night with little sleep, typically under stress or exercise conditions related to external events, is common and without lasting consequences, persistent insomnia can have significant negative effects resulting in daytime function disorders, mood disorders and an increased risk of accident injuries.
In the next post we will discuss the "species" of insomnia...
I'll start this post with the patient's approach with a sleep disorder. Patients may seek medical help for: 1. chronic or acute incapacity to sleep properly at night, 2. chronic fatigue, exhaustion or a state of fatigue during the day and 3. manifestations of behavior associated with sleep itself. Interruption or disturbance of night sleep is directly related to reduced mental state and disturbance of psychomotor and cognitive performance during the day, which is a serious concern for the patient in most cases.
A careful examination of the history is essential in the evaluation of the patient with sleep disorders. In particular, the duration, consistency and severity of the disorder are important in relation to the patient's estimation (in case of insomnia) in terms of the effect of sleep deprivation on subsequent wakefulness functions.
Information obtained from a friend or family member can be extremely useful in assessing the severity of the disorder during the day, especially since some patients report the embarrassment caused by loud snoring or fall ill driving.
Retrospective completion, by doctor and patient, of drug-induced sleepiness in the daily work-sleep cycle in reverse chronological order, can help the doctor better understand the nature of the disorder. Working hours must be specified every day. The use of medicines and alcohol, including caffeine and hypnotics should be noted daily.
These daily records should be compared with a prospective schedule of sleep-work-medication activities (including daily sleep-sweating and night-time awakenings) of the patient for at least 2 weeks. Sleep periods should be plotted to facilitate recognition of circadian sleep disorders, such as delayed sleep phase syndrome.
Laboratory evaluation of objective sleep measurements is necessary for the diagnosis of specific conditions such as narcolepsy and sleep apnea and may also be useful under other conditions. In addition to the three electrophysiological variables used to define sleep states and its stages, the standard clinical polysomnogram includes breathing measurement (respiratory effort, air flow and oxygen saturation), anterior tibial EMG and ECG. Assessment of penile tumescence during night sleep can also be used to help determine whether the etiology of erectile dysfunction of the patient is psychogenic or organic.
Let's talk a little bit about the daytime consequences of sleep disorders. While suffering caused by discontinuation of night sleep may be the most important symptom for patients with sleep disorders, especially those with insomnia, the impact of this sleep disruption on daily function is the most important aspect for clinical and public health prospects. Road accidents associated with drowsiness, for example, constitute an important risk to the health of the patient with interrupted sleep.
Daily sleep loss impairment can be difficult to quantify in the clinical context due to several reasons. Firstly, drowsiness is not necessarily proportional to subjectively assessed sleep deprivation. In obstructive sleep apnea, for example, repeated short sleep interruptions associated with resuming breathing at the end of apnea episodes cause significant impairment of wakefulness, despite the fact that the patient may be unconscious of sleep fragmentation.
Secondly, subjective descriptions of sleep impairment vary from patient to patient. Patients can describe themselves as "sleepy," "tired" or "tired" and have a clear definition of these terms, while others may use these terms to describe a completely different condition.
Thirdly, drowsiness, especially when deep, can affect judgment in an alcohol-like manner, so subjective awareness of the condition and cognitive and motor alterations is reduced. Finally, patients may be reluctant to admit that drowsiness is a problem, both because they are generally unaware of what constitutes the normal state of attention, and because drowsiness is generally viewed pejoratively, most often attributed to a deficit in motivation and less to an inadequately satisfied physiological need.
In assessing clinical sleepiness, specific questions about the occurrence of sleep episodes during normal waking hours, both intentional and non-intentional, may imbalance the contradictions of subjective characterizations and simultaneously provide an indication of the adverse impact of sleepiness on daily activity.
Specific areas of discussion include the occurrence of episodes of inadequate sleep while driving or other conditions associated with safety, sleepiness during work or school (and the relationship between drowsiness and work and school performance) and the effect of sleepiness on social and family life. The evidence of significant daily impairment (especially in association with the diagnosis of primary sleep disorder, such as narcolepsy or sleep apnea) raises the question of the doctor's responsibility to notify the traffic authorities of the increased risk of road accidents associated with drowsiness.
As with epilepsy, legal requirements vary from state to state and the existence of legal precedents does not typically provide a consistent interpretation of the balance between the responsibility of the doctor and the patient's right to secrecy. At least the doctor should direct the discussion with the patient towards the increased risk of driving a vehicle and recommend that driving be suspended until successful treatment is established.
Differentiating fatigue sleepiness can be difficult, especially due to the imprecise use of these terms by patients in describing these symptoms. The distinction may be useful in differentiating patients with accusations of fatigue or fatigue in the case of conditions such as fibromyalgia, chronic fatigue syndrome or endocrine deficits such as hyperthyroidism or Addison's disease.
While patients with these conditions can characteristically distinguish their daytime symptoms from sleepiness that occurs with sleep deprivation, substantial overlaps may occur. This is particularly true when the primary condition also causes chronic sleep disruption (e.g. nocturnal apnea from hypothyroidism) or abnormal sleep (e.g. fibromyalgia).
While the assessment of the allegation of excessive sleepiness is generally appropriate, objective quantification is sometimes necessary for diagnostic purposes or for the evaluation of the therapeutic response. The assessment of daily activity as an appropriate sleep index can be carried out by the Multiple Sleep Latency Test (TLMS) which involves repeated measurement of sleep latency (the time from the onset of sleep) under standardized conditions during a day following a quantified night sleep.
The average latency over 4-6 tests (administered every 2 hours over a wake-up day) is interpreted as an objective measure of the daily sleep trend. Sleep disorders that cause pathological daytime sleepiness can be actually distinguished by TLMS. In addition, multiple measurements of sleep onset can directly identify transitions from wakefulness to REM sleep that are suggestive of specific pathological conditions (e.g. narcolepsy).
Now let's move on to insomnia!
Insomnia is accused of unsatisfactory sleep, being classified according to the nature of sleep interruptions and its duration. The nature of sleep disruption provides important information about the possible etiology of insomnia and is also the main, central element in the selection of appropriate and specific treatment.
Insomnia is subdivided into: difficult sleep (insomnia of onset of sleep), frequent or sustained awakenings (insomnia in maintaining sleep), morning awakenings (wake-up insomnia) and persistent sleepiness, despite a sleep of adequate duration (sleep without physical and mental recovery).
Similarly, the duration of the persistence of symptoms is an important indication in determining the nature of appropriate treatment. Insomnia lasting one to several nights (in a single episode) is called transient insomnia. Transitional insomnia is typically the result of a stressful or change in sleep schedule or ambient environment (e.g. time zone change).
Short-term insomnia lasts from a few days to 3 weeks. Disruption of this duration is usually associated with prolonged stress, such as recovery from surgery or acute illness. Long-lasting or chronic insomnia lasts for months or years and normally reflects perpetuation factors associated with primary sleep disorders.
Chronic insomnia may occur in the form of recurrent episodes of insomnia, not necessarily associated with parallel variations of the underlying cause. Although some clinicians refer to these as recurrent insomnia, others suggest that this may be the typical pattern of patients with chronic insomnia. While an occasional night with little sleep, typically under stress or exercise conditions related to external events, is common and without lasting consequences, persistent insomnia can have significant negative effects resulting in daytime function disorders, mood disorders and an increased risk of accident injuries.
In the next post we will discuss the "species" of insomnia...
Have a good day, everyone!
Dorin, Merticaru