Sleep problems

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Primary Sleep Disorders

Insomnia: Difficulty initiating or maintaining sleep despite adequate opportunity, often due to stress or anxiety.
Obstructive Sleep Apnoea (OSA): Snoring, witnessed apnoeas, daytime somnolence, associated with obesity.
Narcolepsy: Excessive daytime sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations.
Restless Legs Syndrome: Urge to move legs, worse at rest, improved by movement.

Secondary Sleep Disorders

Depression: Early morning waking, difficulty falling asleep, poor sleep quality, low mood.
Anxiety Disorders: Difficulty falling asleep due to excessive worrying, restless sleep.
Chronic Pain: Disrupted sleep due to pain, difficulty finding a comfortable position.
Thyroid Disorders: Hyperthyroidism (insomnia, increased energy); Hypothyroidism (hypersomnia).
Substance Use Disorders: Alcohol (initially sedative, but disrupts sleep architecture); Stimulants (e.g., caffeine, amphetamines) causing insomnia.

Medical Causes of Sleep Problems

Chronic Respiratory Conditions: Asthma, COPD – symptoms may worsen at night, causing sleep disruption.
Heart Failure: Orthopnoea, paroxysmal nocturnal dyspnoea, needing to sleep propped up.
Gastroesophageal Reflux Disease (GERD): Nocturnal symptoms, requiring frequent waking.
Neurological Conditions: Parkinson’s disease (REM sleep behaviour disorder, difficulty turning in bed), dementia (fragmented sleep).

Sleep-Related Movement Disorders

Periodic Limb Movement Disorder (PLMD): Repetitive limb movements during sleep, leading to fragmented sleep.
Bruxism: Teeth grinding, leading to jaw pain or headaches upon waking.

Circadian Rhythm Disorders

Delayed Sleep Phase Disorder: Difficulty falling asleep at the desired time, often falling asleep very late and having trouble waking up in the morning.
Shift Work Disorder: Sleep disruption due to work schedule, leading to insomnia or excessive sleepiness.

Key Points in History 🥼

Onset and Duration

Recent onset: Consider acute stress, anxiety, or a new medical condition.
Long-standing: More likely to suggest a chronic disorder such as OSA, chronic pain, or depression.

Sleep Hygiene and Routine

Irregular sleep schedule: May suggest circadian rhythm disorders.
Poor sleep environment: Assess for factors such as noise, light, or an uncomfortable bed that may contribute to sleep difficulties.
Stimulant use before bed: Consider caffeine, nicotine, or recreational drugs as contributing factors.

Symptoms and Sleep Quality

Difficulty falling asleep: May suggest insomnia or anxiety.
Frequent awakenings: Consider OSA, chronic pain, or nocturia.
Early morning waking: Common in depression.
Excessive daytime sleepiness: Consider narcolepsy, sleep deprivation, or OSA.

Background

Past Medical History: Review for chronic conditions that may affect sleep, such as asthma, heart failure, or depression.
Drug History: Consider medications that may affect sleep, such as beta-blockers, corticosteroids, or diuretics.
Family History: Ask about a family history of sleep disorders such as OSA or narcolepsy.
Social History: Assess for alcohol or drug use, occupational factors such as shift work, and lifestyle factors affecting sleep.

Possible Investigations 🌡️

Sleep Studies (Polysomnography)

Indicated for suspected OSA, narcolepsy, or other primary sleep disorders.
Measures various parameters including brain activity, oxygen levels, and muscle activity during sleep.
Helps diagnose conditions such as OSA by identifying apnoea episodes and sleep fragmentation.

Actigraphy

Useful in assessing circadian rhythm disorders and insomnia.
A non-invasive method using a wrist-worn device to monitor sleep-wake cycles over days to weeks.
Provides data on sleep patterns and helps correlate with sleep diaries.

Blood Tests

Thyroid function tests: To rule out hyperthyroidism or hypothyroidism as a cause of sleep disturbances.
Iron studies: To investigate restless legs syndrome, as it may be associated with iron deficiency.
Glucose levels: To check for diabetes mellitus, which may cause nocturia and sleep disruption.

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