SLEEP DISORDERS III

PARA TERMINAR Y QUE TODOS TENGAMOS UNA CLARA IDEA DE ESTE PROBLEMA LES DEJO EL FINAL DEL ARTICULO, ESPERANDO QUE A TODOS LES SEA DE UTILIDAD.
EXCLUI EL TRATAMIENTO MEDICO, ESE QUE SE LOS INDIQUE SU PROFESIONAL DE SALUD...

DIFFERENTIALS

Alcoholism
Anxiety Disorders
Bipolar Affective Disorder
Breathing-Related Sleep Disorder
Chronic Obstructive Pulmonary Disease
Depression
Emphysema
Hyperthyroidism
Hypoparathyroidism
Obstructive Sleep Apnea-Hypopnea Syndrome
Opioid Abuse
Posttraumatic Stress Disorder

Lab Studies:

Hemoglobin and hematocrit
Thyroid function tests
Drug and alcohol toxicology screening
Imaging Studies:

Although no imaging studies are indicated directly for the workup of insomnia, underlying medical conditions require appropriate investigation using suitable studies.
Other Tests:

Oximetry may be performed during sleep to examine blood oxygen levels for clinically important desaturations.
Procedures:
Subjective measures of sleep are obtained by means of a sleep journal.
A sleep journal kept for approximately 2 weeks may help determine the extent of the sleep disturbance.
Patients should record the total hours slept per night, frequency of nighttime awakenings, and level of restfulness provided after sleep.
Further objective history might be available if patients have a sleep partner who keeps a 2-week journal or provides history.
Objective measures of sleep may be obtained using EEG monitoring or polysomnography.
The criterion standard is polysomnography, which includes EEG, electrooculogram, and chin electromyogram. This study can help the physician discriminate between REM and NREM sleep.
Polysomnogram may be useful in determining the etiology of the sleep disturbance.
These studies may be helpful in determining sleep and wakefulness in the intensive care unit or in the sleep laboratory.
TREATMENT

Medical Care: Evaluate patients for other primary sleep disorders (eg, sleep apnea) and for underlying medical, psychiatric, and substance abuse disorders, and institute appropriate treatment. Sleep hygiene and behavioral strategies are used in combination with medication to treat insomnia, particularly primary insomnia.

Education about good sleep practices is essential for effective treatment of insomnia.
Use the bed for sleep and sex only (no television watching or reading in bed).
Do not watch the clock while in bed. Practice relaxation techniques before bedtime. Avoid stimulating activities during the 3 hours before bedtime, such as heavy exercise, tense or thrilling reading or television, or arguments.
Maintain a regular schedule for bedtime and wakening; avoid naps. Early to rise and early to bed is the most effective schedule. A "night owl" schedule is poor sleep hygiene.
Avoid struggling to fall asleep in bed. Instead, get up and spend quiet time out of bed until sleep comes.
Light-phase shift therapy is useful for sleep disturbances associated with circadian rhythm abnormalities. Patients may be exposed to bright light, from either a light box or natural sunlight, to help normalize the sleep schedule.
Surgical Care: Surgical referral may be indicated to correct some underlying medical conditions that cause insomnia, such as for palate surgery in some cases of sleep apnea.

Consultations: Consultation can help evaluate patients for medical (including psychiatric) causes of insomnia. The evaluation team optimally should include a psychiatrist, neurologist, pulmonologist, sleep medicine specialist, and dietitian.

Diet:

No special diet is needed to treat insomnia, but large meals and spicy foods should be avoided in the 3 hours before bedtime.
Patients should avoid sleep-disturbing substances such as alcohol, nicotine, and caffeine. Alcohol creates the illusion of good sleep, but sleep architecture is affected adversely. Nicotine and caffeine are stimulating and should be avoided in the second half of the day, from late afternoon on.
Consumption of tryptophan-containing foods may help induce sleep. The classic example is warm milk.
Activity:

Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia.
Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus.

MEDICATION Many agents are useful in treating insomnia. Short-term drug therapy is preferred to restore a normal sleep pattern. Generally, hypnotic drugs are approved for 2 weeks or less of continuous use. In chronic insomnia, longer courses may be indicated, which require long-term monitoring to ensure ongoing appropriate use of the medication.

Barbiturates and chloral hydrate seldom are used now because of safety concerns related to their undesirably low therapeutic indexes.

Drugs that block the histamine type 1 receptor are used primarily in over-the-counter preparations, are inexpensive, and are helpful to some patients. However, in view of the anticholinergic properties of these agents, caution should be exercised in their use with older patients and with those who have disorders such as prostatic hypertrophy, cognitive disorders, and constipation.

Zolpidem and zaleplon are the newest and, arguably, the safest agents FDA approved for short-term hypnotic use.

Further Inpatient Care:

This is rarely, if ever, required for treatment of insomnia. Only a severe underlying medical, psychiatric, or substance abuse disorder would warrant inpatient care.
Further Outpatient Care:

Given the complexity of diagnosing sleep disorders, with multiple possible medical etiologies, regular appropriate follow-up care is necessary until final diagnosis and successful treatment of the condition. Involvement of one or several medical specialists for care and consultations, if needed, can be coordinated by the patient's internist or other personal physician or by the medical sleep specialist.
In/Out Patient Meds:

Once appropriate medication, if needed, is in use successfully, regular follow-up should be provided, even if infrequently.
Deterrence/Prevention:

In addition to specific treatment for diagnosed sleep disorders, good sleep hygiene should be taught to every patient (and this information should be publicly available). Just as with dental hygiene, appropriate sleep habits should be cultivated by all individuals all the time.
See Medical Care for more information.
Complications:

Mood and anxiety disorders may develop from untreated sleep disturbances, and current medical literature supports the theory that these brain-based mental status changes are risk factors for morbidity and mortality from a host of medical conditions (eg, cardiovascular disease).
Prognosis:

The prognosis varies widely depending on the etiology of the insomnia or other sleep disorder. For example, insomnia due to obstructive sleep apnea resolves with successful treatment of the apnea, while insomnia due to refractory major depression is itself refractory until a successful treatment can be found for the depression.
Patient Education:

Use the bed for sleep and sex only (no television watching or reading in bed).

Patients should be warned to not drive or operate machinery while taking sedative-hypnotic medications. Document these admonitions clearly in the medical record.
Caution is advised in the treatment of patients who are elderly and others who may be at increased risk for falls.

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