今日の臨床サポート

日中の眠気

著者: 城田祥吾1) 神戸市立医療センター中央市民病院 総合内科

著者: 黒田浩一2) 神戸市立医療センター中央市民病院 感染症科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正/監修レビュー済:2022/09/28
参考ガイドライン:
  1. 睡眠呼吸障害研究会編:成人の睡眠時無呼吸症候群 診断と治療のためのガイドライン、メディカルレビュー社, 2005
  1. 榊原博樹編:睡眠時無呼吸症候群診療ハンドブック. 医学書院, 2010.
  1. 日本睡眠学会認定委員会:睡眠障害診療ガイド. 文光堂, 2011.
  1. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-276. PMID: 19960649
患者向け説明資料

概要・推奨   

  1. 日中の眠気は、文字通り、日中の眠気を訴えることである。英語ではExcessive daytime sleepiness(EDS)と記載され、「日中過眠」「日中の過度な眠気」と訳される。
  1. 日中の眠気を訴える患者に対して、問診と身体所見・既往歴、薬歴から鑑別を進めることが重要である。
  1. 「日中の眠気」に対する鑑別疾患は多岐にわたる。多くの場合、睡眠不足(病気ではない)、睡眠障害、精神疾患、身体疾患、薬剤性、の5つのカテゴリーに含まれる。(:鑑別疾患表を参照)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
城田祥吾 : 特に申告事項無し[2022年]
黒田浩一 : 特に申告事項無し[2022年]
監修:山中克郎 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューとレイアウトの変更を行った。概要、問診内容や身体所見の一部を削除、追記した。

概要

定義・疫学情報・病因  
  1. 日中の眠気は、文字通り、日中の眠気を訴えることである。英語ではExcessive daytime sleepiness(EDS)と記載され、「日中過眠」「日中の過度な眠気」と訳される。EDSの定義は、「少なくとも3カ月以上に渡り、ほとんど毎日、気付かないうちに、もしくは不適切なタイミングで、睡眠をとってしまい、日中の活動時間帯に覚醒を保つことができない状態」である[1]
  1. わが国で行われた調査で、一般人口の15%が日中に眠気の問題を抱えていると報告された[2]。別の調査では、運転中など眠ってはいけないときに眠ってしまう重度の日中の眠気の問題をもつ人は、一般人口の2.5%と報告された[3]
  1. 日中の眠気といびきの症状がある勤労者は、職場の事故が多いことが示されている[4]。また、日中の眠気を起こす代表的な疾患である閉塞型睡眠時無呼吸症候群(obstructive sleep apnea syndrome:OSAS)は、集中力の低下により、自動車事故のリスクファクターであるとされている[5]。OSASは、一般人口対象の報告で、職場での集中力を低下させ、作業効率の低下を起こすとされる[6]
  1. 脳内の覚醒維持機構に何らかの異常があるために生じる一次性過眠症と、何らかの睡眠障害によって発生した睡眠不足の結果として日中の過眠を来す二次性過眠症がある。
  1. 日中の眠気を来す疾患は多岐にわたるが、最も頻度が高いものは閉塞型睡眠時無呼吸症候群(OSAS)である。わが国では、日中の眠気などの症状を有するOSAS患者が約200万人という調査結果がある[7]。自覚症状の有無を問わず無呼吸低呼吸指数(AHI)が5以上に達する睡眠呼吸障害(sleep disordered breathing:SDB)の有病率は、米国(30~60歳を対象)からの報告で、男性24%、女性9%とされ、日中の眠気などの自覚症状を認める睡眠時無呼吸症候群(SAS)は、男性4%、女性2%とされた[8]。韓国(40~69歳を対象)[9]やスペイン(30~70歳を対象)[10]からも、同程度のSDB・SASの有病率が報告され、ありふれた疾患(common disease)と考えられている。
  1. 一次性過眠症のナルコレプシー、特発性過眠症、反復性過眠症、二次性過眠症のOAS(閉塞型、中枢型、混合型)、睡眠不足症候群、むずむず脚症候群、周期性四肢運動障害(periodic limb movement disorder:PLMD)、概日リズム睡眠障害、うつ病などの気分障害、薬剤性、身体疾患(せん妄、その他意識障害を来す疾患)などが鑑別疾患となる。
 

鑑別疾患表

 
睡眠関連呼吸障害群
  1. 閉塞型睡眠時無呼吸症候群(最多)
  1. 中枢型睡眠時無呼吸症候群
  1. 混合型睡眠時無呼吸症候群
中枢性過眠症群
  1. ナルコレプシー
  1. 反復性過眠症(Kleine-Levin 症候群など)
  1. 特発性過眠症
  1. 睡眠不足症候群
睡眠関連運動障害群
  1. むずむず脚症候群
  1. 遺伝的素因
  1. 二次性:鉄欠乏性貧血、透析、妊娠など
  1. 周期性四肢運動障害
概日リズム性睡眠障害群
  1. 概日リズム睡眠障害
  1. 睡眠相後退症候群
  1. 非24時間睡眠覚醒症候群
  1. 交代勤務睡眠障害
精神疾患に伴う睡眠障害
  1. 気分障害(うつ病など)
  1. 統合失調症
  1. 身体表現性障害
身体疾患による睡眠障害
  1. パーキンソン病
  1. 脳腫瘍
  1. 中枢神経系の感染症
  1. てんかん
  1. 頭部外傷
  1. 甲状腺機能低下症
  1. 肝性脳症
  1. 副腎不全
  1. GERD
薬剤性
  1. 抗ヒスタミン薬
  1. ドパミンアゴニスト
  1. 総合感冒薬
  1. 鎮咳薬
  1. 抗てんかん薬
  1. 睡眠薬
  1. 抗精神病薬
  1. 抗うつ薬

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文献 

Pradeep C Bollu, Sivaraman Manjamalai, Mahesh Thakkar, Pradeep Sahota
Hypersomnia.
Mo Med. 2018 Jan-Feb;115(1):85-91.
Abstract/Text Adequate alertness is necessary for proper daytime functioning. Impairment of alertness or increase in sleepiness results in suboptimal performance and adversely affects the quality of life. While some causes of somnolence are intrinsic to the brain circuitry and neurochemical architecture, others are due to maladaptive behaviors and disorders affecting the normal sleep homeostasis. Identification of the problem and understanding the underlying etiology is the key to timely treatment and better outcomes.

PMID 30228690
X Liu, M Uchiyama, K Kim, M Okawa, K Shibui, Y Kudo, Y Doi, M Minowa, R Ogihara
Sleep loss and daytime sleepiness in the general adult population of Japan.
Psychiatry Res. 2000 Feb 14;93(1):1-11.
Abstract/Text There are few epidemiological studies on sleep loss and daytime sleepiness in the general adult population of Japan. A total of 4000 adult people, aged 20 and over, were randomly drawn from five areas of Japan, and 3030 individuals were interviewed and completed a questionnaire including information about sleep duration and sleep problems. Overall, 29% slept less than 6 h at night, 23% reported having insufficient sleep, and 6% took sleep enhancing medications. The prevalence rates were 21% for symptoms of insomnia and 15% for excessive daytime sleepiness. Symptoms of insomnia were more prevalent in the elderly, whereas young people were more likely to report short sleep duration, subjective insufficient sleep and excessive daytime sleepiness. A multiple logistic regression model revealed that excessive daytime sleepiness had significant associations with young people, short sleep duration, insomnia symptoms, subjective insufficient sleep and sleep enhancing medication use. Short sleep duration was the strongest predictor of excessive daytime sleepiness. The findings indicate that sleep loss and excessive daytime sleepiness in the Japanese adult population are common, and comparable to those reported in Western countries. Excessive daytime sleepiness in the general adult population seems more likely to be attributed to short sleep duration.

PMID 10699223
Yoshitaka Kaneita, Takashi Ohida, Makoto Uchiyama, Shinji Takemura, Kazuo Kawahara, Eise Yokoyama, Takeo Miyake, Satoru Harano, Kenshu Suzuki, Yuko Yagi, Akiyo Kaneko, Takako Tsutsui, Tsuneto Akashiba
Excessive daytime sleepiness among the Japanese general population.
J Epidemiol. 2005 Jan;15(1):1-8.
Abstract/Text BACKGROUND: Excessive daytime sleepiness is one of the principal symptoms of sleep disturbances, and is often associated with serious consequences including traffic and industrial accidents, decreased productivity, and interpersonal problems. However, there are few epidemiologic studies on excessive daytime sleepiness in a large scale sample targeting Japanese general population.
METHODS: The survey was performed using a self-administered questionnaire in June 2000, targeting a population randomly selected from among 300 communities throughout Japan. This questionnaire included information about sleep habits and sleep problems. Excessive daytime sleepiness measured according to a question "Do you fall asleep when you must not sleep (for example when you are driving a car)?"
RESULTS: A total of 28,714 subjects completed the questionnaire. The prevalence of excessive daytime sleepiness was 2.5% (male=2.8% and female=2.2%). Backward elimination analysis showed that the following were associated with excessive daytime sleepiness: male sex, young age, short sleep duration, subjective insufficient sleep, loss of deep sleep, disagreeable sensations in the legs, interruption of sleep by snoring or dyspnea, and feeling psychological stress. Interruption of sleep by snoring or dyspnea was the strongest associated factor (adjusted odds ratio=2.46, 95% confidence interval=1.76-3.43) of excessive daytime sleepiness.
CONCLUSIONS: These results suggest that excessive daytime sleepiness in Japanese is associated with several sleep problems. These findings may be useful in attempts to prevent excessive daytime sleepiness in the general population of Japan.

PMID 15678919
E Lindberg, N Carter, T Gislason, C Janson
Role of snoring and daytime sleepiness in occupational accidents.
Am J Respir Crit Care Med. 2001 Dec 1;164(11):2031-5. doi: 10.1164/ajrccm.164.11.2102028.
Abstract/Text To establish whether snoring and excessive daytime sleepiness (EDS), the main symptoms of obstructive sleep apnea syndrome, influence the risk of occupational accidents a population-based, prospective study was performed. In 1984, 2,874 men aged 30-64 answered questions on snoring and EDS. Ten years later 2,009 (73.8% of the survivors) responded to a follow-up questionnaire including work-related questions and potential confounders. Information on occupational accidents during 1985-1994 was obtained from national register data. A total of 345 occupational accidents were reported by 247 of the men (12.3%). Multivariate analysis revealed that men who reported both snoring and EDS at baseline were at an increased risk of occupational accidents during the following 10 yr, with an adjusted odds ratio of 2.2 (95% CI 1.3-3.8) after adjusting for age, body mass index, smoking, alcohol dependence, years at work, blue-collar job, shift work, and exposure to noise, organic solvents, exhaust fumes, and whole-body vibrations. However, no significant increased risk was found for snorers without EDS or nonsnorers with EDS. We conclude that sleepy, male snorers have an increased risk of occupational accidents. The results indicate that early identification and treatment of sleep-disordered breathing may reduce the number of injuries at work.

PMID 11739131
Charles F P George
Sleep apnea, alertness, and motor vehicle crashes.
Am J Respir Crit Care Med. 2007 Nov 15;176(10):954-6. doi: 10.1164/rccm.200605-629PP. Epub 2007 Sep 6.
Abstract/Text Sleep apnea causes impairment in performance and is associated with an increased risk of motor vehicle crashes compared with the general population of drivers. Despite this increased risk, the actual number of accidents is still quite low, although the implications are significant in commercial vehicle drivers. It is difficult for physicians to assess risk and ability to drive in many patients with sleep apnea, yet physicians are often mandated to make these assessments with obvious implications for patients. Because many patients may never have a crash, it is not practical or feasible to restrict all untreated patients from driving, unless they operate commercial vehicles. Thresholds of disease severity that prompt driving restriction need to be established for sleep apnea much like they have been for alcohol. Until more data emerge, continued educational efforts about sleep apnea are needed to convince government and insurance organizations to provide appropriate resources for diagnosis and treatment of sleep apnea, because apnea risk is minimized with successful apnea treatment.

PMID 17823357
Abstract/Text STUDY OBJECTIVE: To evaluate excessive daytime sleepiness (EDS) at work and effects on reported work performance among men in the general population and male patients suffering from snoring and obstructive sleep apnea syndrome (OSAS).
DESIGN AND PARTICIPANTS: A cross-sectional study of Swedish men between the ages of 30 and 64 years in the county of Kopparberg, in mid-Sweden. A random sample of the general population (n = 285) and consecutive patients referred to a sleep laboratory who fulfilled objective diagnostic criteria (snorers = 289, OSAS = 62) responded to a questionnaire. Responders from the general population were divided into 2 groups, nonsnorers (n = 223) and snorers (n = 62). To validate a question on snoring in the questionnaire, 50 men, randomly selected from the sample of the general population, underwent sleep apnea screening in their homes.
RESULTS: The specificity of the questions about snoring was 83% and the sensitivity was 42%. The risk ratios for reporting EDS at work were 4-fold for snorers in the general population, 20-fold for snoring patients, and 40-fold for patients with OSAS as compared with nonsnoring men in the general population. Patients with OSAS and snoring patients both showed increased ratios on measures of difficulties with concentration, learning new tasks, and performing monotonous tasks when compared with nonsnorers.
CONCLUSION: Snoring and sleep apnea were highly associated with excessive EDS at work and subjective work performance problems. The results provide additional evidence that snoring is not merely a nuisance.

PMID 8797408
T Young, M Palta, J Dempsey, J Skatrud, S Weber, S Badr
The occurrence of sleep-disordered breathing among middle-aged adults.
N Engl J Med. 1993 Apr 29;328(17):1230-5. doi: 10.1056/NEJM199304293281704.
Abstract/Text BACKGROUND: Limited data have suggested that sleep-disordered breathing, a condition of repeated episodes of apnea and hypopnea during sleep, is prevalent among adults. Data from the Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of cardiopulmonary disorders of sleep, were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health.
METHODS: A random sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep (the apnea-hypopnea score). We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score (> or = 5, > or = 10, and > or = 15); we used logistic regression to investigate risk factors.
RESULTS: The estimated prevalence of sleep-disordered breathing, defined as an apnea-hypopnea score of 5 or higher, was 9 percent for women and 24 percent for men. We estimated that 2 percent of women and 4 percent of men in the middle-aged work force meet the minimal diagnostic criteria for the sleep apnea syndrome (an apnea-hypopnea score of 5 or higher and daytime hypersomnolence). Male sex and obesity were strongly associated with the presence of sleep-disordered breathing. Habitual snorers, both men and women, tended to have a higher prevalence of apnea-hypopnea scores of 15 or higher.
CONCLUSIONS: The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women. Undiagnosed sleep-disordered breathing is associated with daytime hypersomnolence.

PMID 8464434
JinKwan Kim, KwangHo In, JeHyeong Kim, SeHwa You, KyungHo Kang, JaeJeong Shim, SangYeub Lee, JungBok Lee, SeungGwan Lee, Chan Park, Chol Shin
Prevalence of sleep-disordered breathing in middle-aged Korean men and women.
Am J Respir Crit Care Med. 2004 Nov 15;170(10):1108-13. doi: 10.1164/rccm.200404-519OC. Epub 2004 Sep 3.
Abstract/Text With many epidemiologic studies made to establish the prevalence of sleep-disordered breathing (SDB) and obstructive sleep apnea syndrome (OSAS) in Western countries, no such data have been reported in Korea. The purpose of this study was to examine the prevalence of SDB and OSAS, and their related factors in Korean adults aged 40-69 years. Among the total of 5,020 participants at the baseline examination of the Korean Health and Genome Study, a random sample of 457 men and women was studied with employment of overnight full polysomnography to determine the prevalence of SDB and OSAS. The prevalence of SDB (apnea-hypopnea index > or = 5) was 27% and 16% in men and women, respectively. When OSAS was defined by an apnea-hypopnea index > or = 5 plus excessive daytime sleepiness, its prevalence was 4.5% in men and 3.2% in women. Logistic regression analyses showed that sex, body mass index, and hypertension were closely associated with the risk of SDB. Our findings show that SDB is a common problem in the Korean adult population. Understanding and treatment of SDB may be essential in terms of intervention to reduce the risk of related medical problems.

PMID 15347562
J Durán, S Esnaola, R Rubio, A Iztueta
Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.
Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):685-9. doi: 10.1164/ajrccm.163.3.2005065.
Abstract/Text The prevalence and related clinical features of obstructive sleep apnea-hypopnea (OSAH) in the general population were estimated in a two-phase cross-sectional study. The first phase, completed by 2,148 subjects (76.9%), included a home survey, blood pressure, and a portable respiratory recording, whereas in the second, subjects with suspected OSAH (n = 442) and a subgroup of those with normal results (n = 305) were invited to undergo polysomnography (555 accepted). Habitual snoring was found in 35% of the population and breathing pauses in 6%. Both features occurred more frequently in men, showed a trend to increase with age, and were significantly associated with OSAH. Daytime hypersomnolence occurred in 18% of the subjects and was not associated with OSAH. An apnea-hypopnea index (AHI) > or = 10 was found in 19% of men and 15% of women. The prevalence of OSAH (AHI > or = 5) increased with age in both sexes, with an odds ratio (OR) of 2.2 for each 10-yr increase. AHI was associated with hypertension after adjusting for age, sex, body mass index, neck circumference, alcohol use, and smoking habit. This study adds evidence for a link between OSAH and hypertension.

PMID 11254524
Lawrence J Epstein, David Kristo, Patrick J Strollo, Norman Friedman, Atul Malhotra, Susheel P Patil, Kannan Ramar, Robert Rogers, Richard J Schwab, Edward M Weaver, Michael D Weinstein, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine
Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.
J Clin Sleep Med. 2009 Jun 15;5(3):263-76.
Abstract/Text BACKGROUND: Obstructive sleep apnea (OSA) is a common chronic disorder that often requires lifelong care. Available practice parameters provide evidence-based recommendations for addressing aspects of care.
OBJECTIVE: This guideline is designed to assist primary care providers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA by providing a comprehensive strategy for the evaluation, management and long-term care of adult patients with OSA.
METHODS: The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline. For areas not covered by the practice parameters, the task force performed a literature review and made consensus recommendations using a modified nominal group technique.
RECOMMENDATIONS: Questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment. Once the diagnosis is established, the patient should be included in deciding an appropriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treatment option, appropriate outcome measures and long-term follow-up are described.

PMID 19960649
Abstract/Text The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.

PMID 1798888
J W Winkelman, H Goldman, N Piscatelli, S E Lukas, C M Dorsey, S Cunningham
Are thyroid function tests necessary in patients with suspected sleep apnea?
Sleep. 1996 Dec;19(10):790-3.
Abstract/Text Thyroid evaluation is frequently performed in patients with sleep apnea because of a suspected causal relationship between hypothyroidism and obstructive sleep apnea (OSA). The aim of this study was to determine the actual prevalence of hypothyroidism in patients referred for polysomnography and evaluate whether its rate was higher in patients with OSA than those without OSA. Ultrasensitive thyroid stimulating hormone (TSH) was performed on 255 of 279 consecutive patients referred for polysomnography from the neurology service of a large HMO. Hypothyroidism was detected in 1.6% (4/243) of all patients, 1.5% (3/194) of patients referred to evaluate OSA, and 2.0% of patients referred to evaluate the presence of periodic leg movement disorder (PLMD)/narcolepsy/parasomnia. There was no significant difference in rates of hypothyroidism in patients with documented OSA (2.9%, 3/103) compared to those without OSA (0.7%, 1/135). Two of the four patients with elevated TSHs had previously documented hypothyroidism and were on thyroxine replacement. Rates of hyperthyroidism were as high or higher than those of hypothyroidism in all groups. We conclude that thyroid screening does not appear to be appropriate for patients with suspected, or confirmed, OSA in the absence of signs or symptoms consistent with hypothyroidism or unless they are in a high risk group (women over the age of 60).

PMID 9085487
Richard P Allen, Daniel Picchietti, Wayne A Hening, Claudia Trenkwalder, Arthur S Walters, Jacques Montplaisi, Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health, International Restless Legs Syndrome Study Group
Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health.
Sleep Med. 2003 Mar;4(2):101-19.
Abstract/Text BACKGROUND: Restless legs syndrome is a common yet frequently undiagnosed sensorimotor disorder. In 1995, the International Restless Legs Syndrome Study Group developed standardized criteria for the diagnosis of restless legs syndrome. Since that time, additional scientific scrutiny and clinical experience have led to a better understanding of the condition. Modification of the criteria is now necessary to better reflect that increased body of knowledge, as well as to clarify slight confusion with the wording of the original criteria.
SETTING: The restless legs syndrome diagnostic criteria and epidemiology workshop at the National Institutes of Health.
PARTICIPANTS: Members of the International Restless Legs Syndrome Study Group and authorities on epidemiology and the design of questionnaires and scales.
OBJECTIVE: To modify the current criteria for the diagnosis of restless legs syndrome, to develop new criteria for the diagnosis of restless legs syndrome in the cognitively impaired elderly and in children, to create standardized criteria for the identification of augmentation, and to establish consistent questions for use in epidemiology studies.
RESULTS: The essential diagnostic criteria for restless legs syndrome were developed and approved by workshop participants and the executive committee of the International Restless Legs Syndrome Study Group. Criteria were also developed and approved for the additional aforementioned groups.

PMID 14592341
A Chesson, K Hartse, W M Anderson, D Davila, S Johnson, M Littner, M Wise, J Rafecas
Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine.
Sleep. 2000 Mar 15;23(2):237-41.
Abstract/Text Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.

PMID 10737341
S Redline, V K Kapur, M H Sanders, S F Quan, D J Gottlieb, D M Rapoport, W H Bonekat, P L Smith, J P Kiley, C Iber
Effects of varying approaches for identifying respiratory disturbances on sleep apnea assessment.
Am J Respir Crit Care Med. 2000 Feb;161(2 Pt 1):369-74. doi: 10.1164/ajrccm.161.2.9904031.
Abstract/Text Varying approaches to measuring the respiratory disturbance index (RDI) may lead to discrepant estimates of the severity of sleep-disordered breathing (SDB). In this study, we assessed the impact of varying the use of corroborative data (presence and degree of desaturation and/or arousal) to identify hypopneas and apneas. The relationships among 10 RDIs defined by various definitions of apneas and hypopneas were assessed in 5,046 participants in the Sleep Heart Health Study (SHHS) who underwent overnight unattended 12-channel polysomnography (PSG). The magnitude of the median RDI varied 10-fold (i.e., 29.3 when the RDI was based on events identified on the basis of flow or volume amplitude criteria alone to 2.0 for an RDI that required an associated 5% desaturation with events). The correlation between RDIs based on different definitions ranged from 0.99 to 0.68. The highest correlations were among RDIs that required apneas and hypopneas to be associated with some level of desaturation. Lower correlations were observed between RDIs that required desaturation as compared with RDIs defined on the basis of amplitude criteria alone or associated arousal. These data suggest that different approaches for measuring the RDI may contribute to substantial variability in identification and classification of the disorder.

PMID 10673173
Clete A Kushida, Michael R Littner, Timothy Morgenthaler, Cathy A Alessi, Dennis Bailey, Jack Coleman, Leah Friedman, Max Hirshkowitz, Sheldon Kapen, Milton Kramer, Teofilo Lee-Chiong, Daniel L Loube, Judith Owens, Jeffrey P Pancer, Merrill Wise
Practice parameters for the indications for polysomnography and related procedures: an update for 2005.
Sleep. 2005 Apr;28(4):499-521.
Abstract/Text These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.

PMID 16171294
Nancy A Collop, W McDowell Anderson, Brian Boehlecke, David Claman, Rochelle Goldberg, Daniel J Gottlieb, David Hudgel, Michael Sateia, Richard Schwab, Portable Monitoring Task Force of the American Academy of Sleep Medicine
Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine.
J Clin Sleep Med. 2007 Dec 15;3(7):737-47.
Abstract/Text Based on a review of literature and consensus, the Portable Monitoring Task Force of the American Academy of Sleep Medicine (AASM) makes the following recommendations: unattended portable monitoring (PM) for the diagnosis of obstructive sleep apnea (OSA) should be performed only in conjunction with a comprehensive sleep evaluation. Clinical sleep evaluations using PM must be supervised by a practitioner with board certification in sleep medicine or an individual who fulfills the eligibility criteria for the sleep medicine certification examination. PM may be used as an alternative to polysomnography (PSG) for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA. PM is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions that may degrade the accuracy of PM. PM is not appropriate for the diagnostic evaluation of patients suspected of having comorbid sleep disorders. PM is not appropriate for general screening of asymptomatic populations. PM may be indicated for the diagnosis of OSA in patients for whom in-laboratory PSG is not possible by virtue of immobility, safety, or critical illness. PM may also be indicated to monitor the response to non-CPAP treatments for sleep apnea. At a minimum, PM must record airflow, respiratory effort, and blood oxygenation. The airflow, effort, and oximetric biosensors conventionally used for in-laboratory PSG should be used in PM. The Task Force recommends that PM testing be performed under the auspices of an AASM-accredited comprehensive sleep medicine program with written policies and procedures. An experienced sleep technologist/technician must apply the sensors or directly educate patients in sensor application. The PM device must allow for display of raw data with the capability of manual scoring or editing of automated scoring by a qualified sleep technician/technologist. A board certified sleep specialist, or an individual who fulfills the eligibility criteria for the sleep medicine certification examination, must review the raw data from PM using scoring criteria consistent with current published AASM standards. Under the conditions specified above, PM may be used for unattended studies in the patient's home. Afollow-up visit to review test results should be performed for all patients undergoing PM. Negative or technically inadequate PM tests in patients with a high pretest probability of moderate to severe OSA should prompt in-laboratory polysomnography.

PMID 18198809
G C Man, B V Kang
Validation of a portable sleep apnea monitoring device.
Chest. 1995 Aug;108(2):388-93.
Abstract/Text OBJECTIVE: To assess the sensitivity and specificity of a portable sleep apnea monitoring device (PolyG; CNS Inc; Chantassen, Minn) using standard polysomnography (PSG) as a gold standard.
SETTING: The University of Alberta Hospitals Sleep Disorders Laboratory.
PARTICIPANTS: One hundred and four consecutive patients referred for assessment of sleep complaints.
MEASUREMENTS: Patients underwent simultaneous PSG and PolyG overnight recordings. The PSG included recordings of EEG, Chin electromyogram, electroculogram, ECG, oronasal airflow, thorax and abdomen respiratory movements, bilateral tibialis anterior electromyogram, and ear oximetry. The PolyG monitoring included oronasal airflow (thermistors), chest and abdomen pneumobelts, oximetry, ECG, and body position sensor. The raw data were screened and analyzed separately by two technicians without knowledge of results of the other system.
RESULTS: The coefficient of correlation for apnea index (AI) was 0.94. The r value for apnea-hypopnea index (AHI) was 0.97. Using the criteria of AI more than 5 as diagnostic for sleep apnea syndrome, 23 out of the 104 patients had the disease based on PSG results. Twenty-six patients had AI more than 5 based on PolyG results. The sensitivity was 82.6% and the specificity was 91.4%. The positive predictive value was 73.1% and the negative predictive value was 94.9%. The overall accuracy was 89.4%. Using the criteria of AHI more than 15 as diagnostic for sleep apnea syndrome, 28 of the 104 patients had the disease based on the PSG results. Twenty-four patients had AHI more than 15 based on PolyG results. The sensitivity was 85.7% and the specificity was 94.7%. The positive predictive value was 85.7% and the negative predictive value was 94.7%. The overall accuracy was 92.3%.
CONCLUSION: The PolyG monitoring device is useful in identifying patients without significant sleep apnea.

PMID 7634872
Christopher J Lettieri, Arn H Eliasson, Teotimo Andrada, Andrei Khramtsov, David A Kristo
Does zolpidem enhance the yield of polysomnography?
J Clin Sleep Med. 2005 Apr 15;1(2):129-31.
Abstract/Text STUDY OBJECTIVES: An uncomfortable environment or continuous positive airway pressure (CPAP) intolerance may cause poor sleep efficiency during polysomnography and result in a poor-quality study. Unsatisfactory polysomnograms often must be repeated. Nonbenzodiazepine hypnotics may improve sleep efficiency without disruption of sleep architecture. We hypothesized that premedication with zolpidem improves polysomnogram quality and decreases the need to restudy.
METHODS: We retrospectively reviewed 200 consecutive polysomnograms. Zolpidem premedication was not standardized and was prescribed at the discretion of consulting sleep physicians, who were unaware of this study. We compared the quality of polysomnograms between patients who received zolpidem 10 mg prior to polysomnography and those who did not. A poor-quality polysomnogram was defined as having insufficient sleep time to allow for diagnosis, incomplete CPAP titration with a resulting apnea-hypopnea index > 10 on the highest level of CPAP achieved, or complete CPAP intolerance.
RESULTS: Of 200 records reviewed, 54 patients (27%) received zolpidem. Demographics did not differ between groups. Premedication with zolpidem resulted in improved sleep latency (11.8 +/- 9.5 minutes vs 26.0 +/- 19.9 minutes, p = .002) and sleep efficiency (89.5% +/- 5.6% vs 78.8 +/- 12.3, p < .0001). Zolpidem premedication resulted in significantly fewer studies meeting criteria for poor quality (7.4% vs 33.6%, p = .005). Of the 49 studies meeting criteria for poor quality, 21 were repeated using zolpidem, showing significant improvements in sleep latency (10.8 +/- 7.1 minutes vs 42.8 +/- 30.5 minutes, p = .0004) and sleep efficiency (89.5% +/- 4.9% vs 61.8% +/- 13.7%, p < .0001). No study repeated with zolpidem met criteria for poor quality.
CONCLUSIONS: Pretreatment with zolpidem significantly improved polysomnographic quality and may decrease the need to repeat polysomnograms.

PMID 17561625
R M Wittig, A Romaker, F J Zorick, T A Roehrs, W A Conway, T Roth
Night-to-night consistency of apneas during sleep.
Am Rev Respir Dis. 1984 Feb;129(2):244-6.
Abstract/Text The consistency of apneas from night to night was examined in 2 groups of patients. The first group had more than 100 apneas per night (frequent apnea) and the second group had less than 100 apneas per night (infrequent apnea). All patients underwent clinical polysomnography for 2 nights, with no significant weight change or treatment occurring between recordings. The frequent apnea group showed a consistent number of apneas on the 2 nights (r = 0.92, p less than 0.01), whereas the infrequent apnea group showed a highly variable number of apneas (r = 0.35, p greater than 0.10). The correlations on apnea index (apneas per hours of sleep) showed a similar result. Apnea duration and type were consistent in both groups of patients.

PMID 6696325
T J Meyer, S E Eveloff, L R Kline, R P Millman
One negative polysomnogram does not exclude obstructive sleep apnea.
Chest. 1993 Mar;103(3):756-60.
Abstract/Text Night-to-night variability of apneas on overnight polymnography exists in patients with documented obstructive sleep apnea (OSA). In this study, we evaluated the possibility that this variability may be severe enough to miss the diagnosis of OSA in patients clinically at risk for the disease. We prospectively studied 11 patients who were deemed on clinical grounds to have probable OSA, but had a negative result on overnight polysomnography. Six of the 11 patients were found to have a positive second study with a significant rise in the apnea/hypopnea index (AHI) from 3.1 +/- 1.0 to 19.8 +/- 4.7 (mean +/- SEM, p < 0.01). The cause of the negative first study in these patients is unclear, but it does not seem related to risk factor pattern, sleep architecture, or test interval. The change in AHI was not found to be rapid eye movement (REM)-dependent. This study demonstrates that a negative first-night study is insufficient to exclude OSA in patients with one or more clinical markers of the disease.

PMID 8449064
F Rosenow, V McCarthy, A C Caruso
Sleep apnoea in endocrine diseases.
J Sleep Res. 1998 Mar;7(1):3-11.
Abstract/Text The pertinent literature on the prevalence, clinical manifestations and pathogenic mechanisms of sleep apnoea (SA) in endocrine diseases, namely acromegaly, Cushing syndrome, hypothyroidism and diabetes mellitus was reviewed. An increased prevalence is well documented in patients with active and treated acromegaly. While most authors report peripheral obstruction, due to hypertrophy of tongue and pharyngeal tissues, to be the cause of SA in acromegaly, some findings argue for a role of hormone-induced changes of central respiratory control. SA is also more common in hypothyroidism, especially when myxedema is present. The associated edema and myopathy appear to be of pathogenic importance. Thyroxin substitution is frequently effective for the treatment of SA but nCPAP can be necessary initially and in some patients even after remission of clinical signs of hypothyroidism. In Cushing disease and syndrome, parapharyngeal fat accumulation can cause SA, but no epidemiological information is available. In non insulin dependent diabetes (NIDDM), obesity is the common risk factor for both, nocturnal hypoxia and insulin resistance. In IDDM, the development of autonomic neuropathy may predispose to SA. Where treatment of the underlying endocrine disease is unable cure the associated SA, nCPAP is usually the treatment of first choice. More prospective studies are clearly needed to establish prevalences and resolve the controversies regarding pathogenesis.

PMID 9613423
J F Pagel
Excessive daytime sleepiness.
Am Fam Physician. 2009 Mar 1;79(5):391-6.
Abstract/Text Excessive daytime sleepiness is one of the most common sleep-related patient symptoms, and it affects an estimated 20 percent of the population. Persons with excessive daytime sleepiness are at risk of motor vehicle and work-related incidents, and have poorer health than comparable adults. The most common causes of excessive daytime sleepiness are sleep deprivation, obstructive sleep apnea, and sedating medications. Other potential causes of excessive daytime sleepiness include certain medical and psychiatric conditions and sleep disorders, such as narcolepsy. Obstructive sleep apnea is a particularly significant cause of excessive daytime sleepiness. An estimated 26 to 32 percent of adults are at risk of or have obstructive sleep apnea, and the prevalence is expected to increase. The evaluation and management of excessive daytime sleepiness is based on the identification and treatment of underlying conditions (particularly obstructive sleep apnea), and the appropriate use of activating medications.

PMID 19275068

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