What to know about screening for sleep disorders in primary care

Key takeaways:

• Sleep disorders are more prevalent than typically thought, according to a presenter here.
• There are several questionnaires clinicians can use for screening, which is critical in catching sleep disorders.

SAN DIEGO — Asking patients a few questions about sleep could help clinicians catch the vast majority of sleep disorders, according to a presenter at the 2023 ACP Internal Medicine Meeting.

Sleep deprivation affects cognitive functioning, behavior, mental health, chronic pain, diabetes, heart disease, hormone imbalances, inflammatory states and, ultimately, an increase in mortality.

“Sleep has been underestimated in the health arena for many, many years, (but) is now considered the sixth vital sign,” Kimberly Hardin, MD, MS, FAASM, FACCP, professor of clinical internal medicine in the division of pulmonary, critical care and sleep medicine at the University of California, Davis, said during her presentation. “Seven hours is the average minimum amount that most adults need, but in the United States, we see that we certainly do not get that much sleep.”

Between 10% and 30% of adults have chronic insomnia, Hardin said, and women have a higher risk of insomnia — nearly double that to men — throughout their lives. However, obstructive sleep apnea is the most prevalent sleep disorder, being “as common or more common than diabetes and asthma.” Narcolepsy is even “more common than you think,” at a rate of 20 to 67 of every 100,000 people.

Considering the prevalence of sleep disorders that present to primary care, Hardin offered tips on screening.

“If you go through these questions, you will get 90% of patients with their sleep disorder and be able to kind of pigeonhole them into a category a little bit better,” she said.

• What is the patient’s sleep schedule?
• What is their specific complaint? (Falling asleep? Staying asleep?)
• Do they have problems functioning the next day?
• Do they struggle with issues such as: excessive daytime sleepiness, fatigue, memory impairment, irritability, behavioral issues, reduced motivation or energy and errors or accidents?

“They're saying, ‘I'm so tired. I can't get up in the morning.’ Well, you find out that they're bingeing on Netflix until 2 o'clock in the morning and then they have to get up at 6, so then there’s only 4 hours of sleep and then they come home, they're tired so they take a nap, then they can't go to sleep,” she said. “I can't tell you how many times this scenario goes over and over and over again.”

Additional sleep questionnaires include the Epworth Sleepiness Score (measuring the chances of one dozing off during common activities), Insomnia Severity index (measuring how bothersome one’s insomnia is), STOP BANG, URGE and Fatigue Severity Scale.

“These (questionnaires) will get you through a big chunk of the sleep disorders,” she said. “The hardest one I think is the fatigue severity questionnaire because fatigue in itself is all encompassing.”

The Fatigue Severity Scale includes nine questions that patients can rate on a scale of one through seven based on how strongly they agree with statements about what causes fatigue, how much it affects their daily life and more.

The STOP BANG score measures sleep apnea severity, Hardin said. It is very thorough but biased toward middle aged men because, when it was created, it was thought that sleep apnea prevalence was higher in that population.

“If you have a young, thin female, you may underestimate her severity of sleep apnea,” she said. “I just caution you on that.”

Finally, there is URGE, which measures restless leg syndrome. URGE stands for Urge to move, Rest induced, Gets better with activity and Evening and night associated with onset and worsening of symptoms.

“These all have to be present,” Hardin said. “And they cannot have overlapping disease that can explain it such as the neuropathy that is often associated with restless leg-like symptoms.”