Sleep is so important to the human body. We sleep a third of our lives, yet there is so little attention paid to sleep in most medical programs.
If you suspect that a patient has a sleep disorder, but are unsure of which tests to order, here are a few tips that might help.
- Always do a comprehensive sleep history. It is easy to find good sleep questionnaires and sleep logs online. Do an internet search for universities with sleep labs for examples of good sleep questionnaires. They often have their materials available online. You can also talk to your local sleep lab to see if they have forms that you can use.
- Keep a copy of the International Classification of Sleep Disorders in your office This is detailed information about the different sleep disorders with help on diagnosis and coding. I use mine frequently!
- Have a patient fill out an Epworth Sleepiness Scale and a STOPBANG form. These forms help determine the level of sleepiness and possibility of sleep apnea.
- Keep a copy of the Mallampati classification. This is a simple grading system to help evaluate airway size to help you determine if your patient may be at risk for apnea.
- Have patients keep a sleep log for one to two weeks. You will be able to see if patients are following good sleep hygiene. Often, you will be able to immediately point out where changes in their sleep habits can improve. It is a very useful and underutilized tool.
- Include patients’ bed partner. How can patients really know what’s happening when they’re sleeping? Bed partners can provide so much information. In my clinic, I can’t tell you the number of times bed partners pull out their cell phones and show me video of their spouses snoring!
- Order an overnight polysomnogram. This will offer an overall view of a patient’s sleep. This tool assesses suspected sleep apnea, periodic limb movement disorder, parasomnias, and REM sleep behavior disorder. Polysomnogram results will give you the number of apneas and hypopneas during sleep, the oxygen nadir, sleep efficiency, sleep onset, any cardiac dysrhythmias, and number of limb movements.
- Order a split-night polysomnogram for a patient suspected of sleep apnea. This allows the lab to start continuous positive airway pressure (CPAP) on a patient during the study if a patient has significant apnea. A titration study will often follow a polysomnogram if a patient needs to be treated for sleep apnea if a split night study was not ordered. A titration study is focused on finding the appropriate pressure to set a CPAP, BiPAP, or ASV machine.
- Order an overnight polysomnogram followed by a multiple sleep latency test (MSLT). If a patient presents with excessive daytime sleepiness or possibility of narcolepsy, use these tests. The MSLT is a daytime study. A patient takes a series of naps. The technician watches for how quickly a patient falls asleep, and if they go into REM sleep.
- Order a maintenance of wakefulness test (MWT) for patients who have jobs in the transportation industry. It’s an assessment of a patient’s ability to stay awake. You can also use it to judge the effectiveness of treatments such as CPAP therapy.
There are of course other nuances, but these will help you to get started in ordering the appropriate tests for your sleep patients.
Sharon M. O’Brien, MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.