E. Lee Murray, MD
CHAPTER CONTENTS
OVERVIEW
Sleep disorders are rarely a reason for hospital admission, but they may become an issue during hospitalization for other reasons. Also, many hospitals routinely screen patients for risk of sleep apnea, especially if anesthesia is contemplated. These disorders are detailed below but are briefly described as follows:
•Obstructive sleep apnea (OSA): Episodes of apnea while sleeping resulting in frequent arousals. Predisposes to respiratory difficulty in the hospital and after discharge.
•Narcolepsy: Excessive daytime sleepiness typically with episodes of weakness or paralysis (cataplexy) which can be mistaken for seizure or stroke.
•Periodic limb movement disorder: Repetitive movements during sleep which cause arousals. Can be mistaken for seizure or myoclonus.
•Insomnia and Sleep Deprivation: Almost universal among hospital patients, predisposes to confusion and possibly hospital psychosis.
OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea (OSA) is a common and often undiagnosed disorder. It is most common in middle age, in males, and in patients with elevated BMI. OSA increases the risk of respiratory compromise with sedation and anesthesia.
PRESENTATION is with episodes of apnea while sleeping. Patients often have prominent snoring, frequent arousals during sleep, and excessive daytime sleepiness (EDS). OSA can exacerbate headaches, hypertension, and promote cognitive difficulty.
DIAGNOSIS is considered when a patient has a history of snoring, has elevated BMI, and, in the hospital setting, is being evaluated for a condition with OSA implications such as preoperative evaluation or hypertension. Polysomnography (PSG) is indicated but is seldom performed on acute hospitalization.
Screening for OSA in the hospital setting is usually by a simple evaluation described by the acronym STOP-BANG. If more than two questions in either group are positive, then the risk is substantially increased. If more than two questions are positive in both groups, then the risk of mild sleep apnea is at least 90% and moderate or worse is at least 80%.
◦Neck circumference >17 inches
MANAGEMENT of OSA consists of continuous positive airway pressure (CPAP) for most patients. Weight loss can lower the necessity for CPAP, but the success at persistent weight loss is less than desired. If OSA is suspected on the basis of inhouse consultation, sleep lab referral is strongly recommended.
NARCOLEPSY
Narcolepsy is occasionally diagnosed in the acute hospital setting, usually presenting to the ED with sleep attacks or cataplexy, although they are usually not recognized as such by observers.
PRESENTATION in the hospital setting is usually with observed episodes of sleep attack, or cataplexy—sudden loss of muscle tone. Patients may be thought to have had syncope, seizure, or transient ischemic attack, but there is no focal deficit, no loss of consciousness with cataplexy, and, upon further questioning, associated symptoms are usually noted including excessive daytime sleepiness, sleep paralysis, and hypnagogic hallucinations—sensory experiences during the transition from wake to sleep. In the outpatient arena, excessive daytime sleepiness is often the principal complaint.
DIAGNOSIS is suspected when a patient evaluated for “spell” is felt to have sleep attack or cataplexy. Clinical diagnosis is quite accurate when the other associated features are present. Sleep studies including PSG and MSLT are performed for diagnosis, but can seldom be performed during an acute hospitalization. Once the diagnosis is suspected to the exclusion of life-threatening conditions, prompt referral to a sleep specialist for diagnosis and treatment is recommended.
MANAGEMENT is usually referred to a sleep specialist and includes stimulants such as methylphenidate, modafinil, and use of sodium oxybate for the cataplexy.
PERIODIC LIMB MOVEMENT DISORDER
Periodic limb movement disorder (PLMD) is repetitive movements during sleep that can cause arousals and interfere with sleep. PLMD is related to restless leg syndrome (RLS), and is seldom a reason for hospital consultation.
PRESENTATION in the hospital setting is usually with jerking of the legs, which can be interpreted by family as possible seizure.
DIAGNOSIS is confirmed by PSG, although this is usually not available during acute hospitalization.
MANAGEMENT is usually with dopaminergic agents, especially ropinirole, pramipexole, or levodopa preparations.
INSOMNIA AND SLEEP DEPRIVATION
Insomnia seldom triggers inpatient neurology consultation, but the effects of sleep deprivation often do. Insomnia and sleep deprivation in the hospital setting predisposes to delirium, and sometimes hospital psychosis. Reasons for insomnia in the hospital setting can include:
•Environmental insomnia: Sleep is disturbed by frequent awakenings from monitors, medical treatments, and evaluations. Change in sleep venue also worsens the quality of sleep.
•Stress insomnia: Stresses of many types can cause or exacerbate insomnia; in this context, the stress of hospitalization and concern over the medical condition.
•Medical condition: Innumerable medical conditions are associated with insomnia or sleep fragmentation. Medications also can exacerbate this, not only stimulants but also, from a neurologic perspective, anticonvulsants and sedatives.
MANAGEMENT of insomnia in a hospital setting is difficult. The situation is dynamic and temporary. Elements that can be helpful include:
•Sedative-hypnotics should be avoided if possible. Chronic therapy can exacerbate insomnia, and patients often have cognitive changes and a predisposition to falls exacerbated by sedatives.
•Sleep hygiene should be the first choice for most hospitalized patients. Among these recommendations are:
◦Turn off the lights and TV at sleep-time.
◦Keep patient awake during the day. If possible, the patient should spend time sitting or walking during the day.
◦Minimize night-time awakening for vital signs, phlebotomy, and medication administration.
