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Am Fam Physician. 2022;105(4):397-405

Patient information: Handouts on this topic are available at https://familydoctor.org/condition/insomnia, https://familydoctor.org/condition/sleep-apnea, and https://familydoctor.org/condition/restless-legs-syndrome.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Sleep disorders are common in the general adult population and are associated with adverse effects such as motor vehicle collisions, decreased quality of life, and increased mortality. Patients with sleep disorders can be categorized into three groups: people with problems falling asleep, people with behavior and movement disturbances during sleep, and people with excessive daytime sleepiness. Insomnia, the most common sleep disorder, is defined by difficulty initiating sleep, maintaining sleep, or both, resulting in daytime consequences. Insomnia is diagnosed by history and is treated with cognitive behavior therapy, with or without medications. Rapid eye movement sleep behavior disorder is characterized by increased muscle tone during rapid eye movement sleep, resulting in patients acting out their dreams with potentially harmful effects. Rapid eye movement sleep behavior disorder is diagnosed by polysomnography and treated with melatonin or clonazepam. Restless legs syndrome is defined by an urge to move the legs that worsens when at rest. Restless legs syndrome is treated with gabapentin or dopamine agonists, depending on the severity. Narcolepsy is characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, and sleep hallucinations. Diagnosis is suggested by the history and can be confirmed with polysomnography and a multiple sleep latency test the following day. Narcolepsy is treated with behavior modifications and medications such as stimulants, selective serotonin reuptake inhibitors, sodium oxybate, and pitolisant. Obstructive sleep apnea may be diagnosed in patients with excessive snoring and witnessed apneas and can be diagnosed using overnight polysomnography. Treatment consists of positive airway pressure therapy while sleeping in conjunction with weight loss.

Sleep disorders are common in the United States, with the Institute of Medicine estimating that 50 million to 70 million adults report chronically disturbed sleep.1 Current recommendations for adult sleep duration range from seven to nine hours; however, nearly 40% of Americans sleep six hours or less per night.2 Sleep disturbances have been associated with motor vehicle collisions, hypertension, decreased quality of life, and increased all-cause mortality, which may be linked to increased arousal burden (unconscious wakefulness) with daytime sequelae.3,4 Sleep disorders have been connected to increased health care use and cost more than $94 billion per year.5 Family medicine physicians must regularly inquire about healthy sleep and should be able to diagnose and treat sleep disorders in the primary care setting.6

Clinical recommendationEvidence ratingComments
Cognitive behavior therapy for insomnia is the first-line treatment for chronic insomnia.10,12,13,15 AClinical guidelines from multiple organizations and large systematic review and meta-analysis
Cognitive behavior therapy for insomnia can be administered effectively in a primary care setting to treat chronic insomnia.14,17 BOne randomized controlled trial and a systematic review of good-quality studies
A sleep-wake schedule and melatonin or a bright-light therapy regimen is recommended for treatment of delayed sleep phase syndrome.23,24 BAmerican Academy of Sleep Medicine clinical practice guidelines and two randomized controlled trials
Nonpharmacologic interventions are first-line treatment for restless legs syndrome, followed by the use of alpha-2-delta ligands. Dopaminergic agonists should be used if there is inadequate response.31 CClinical review and expert opinion
Continuous positive airway pressure is the most effective treatment option for obstructive sleep apnea and is recommended in conjunction with weight loss.39,45,48 BClinical practice guideline, clinical review, expert opinion, and original research (multicenter, prospective study)
RecommendationSponsoring organization
Avoid polysomnography in patients with chronic insomnia unless symptoms suggest a comorbid sleep disorder.American Academy of Sleep Medicine
Do not use polysomnography to diagnose restless legs syndrome, except rarely when the clinical history is ambiguous and documentation of periodic leg movements is necessary.American Academy of Sleep Medicine
Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive behavior therapy, and reserve medication for adjunctive treatment when necessary.American Academy of Sleep Medicine

Sleep disorders are classified formally into seven categories by the International Classification of Sleep Disorders, 3rd ed.7 Sleep disorders manifest as problems associated with falling asleep, disturbances occurring during sleep, and excessive daytime sleepiness.7 The most common sleep conditions encountered by family physicians are discussed in this article. Insomnia, delayed sleep-wake phase disorder, and restless legs syndrome (RLS) are common examples of problems that occur while falling asleep. RLS also can interfere with sleep late into the night. Other problems during sleep include parasomnias, such as rapid eye movement (REM) sleep behavior disorder. Parasomnias are disruptive sleep-related disorders that include sleepwalking, nightmares, sleep-related eating disorder, and sleep paralysis. Sleep disorders causing excessive daytime sleepiness include obstructive sleep apnea (OSA) and narcolepsy. Table 1 summarizes common sleep disorders.

DisorderSymptoms and signsMost effective treatment
Problems falling asleep
Delayed sleep-wake phase disorderDelayed sleep onset and late wake-up timeMelatonin before bed and bright light therapy at awakening for adolescents
InsomniaDifficulty initiating or maintaining sleep, daytime sleepiness with inability to nap, daytime impairmentCognitive behavior therapy for insomnia, benzodiazepine receptor agonists
Behavior and movement disturbances during sleep
Rapid eye movement sleep behavior disorderMotor activity during sleep, acting out of dreams, polysomnography showing increased muscle toneBehavior modification, clonazepam (Klonopin), melatonin
Restless legs syndromeUncomfortable sensation in both legs, symptoms are worse in the evening, improve with movement such as walking or stretchingNonpharmacologic treatments, alpha-2-delta ligands, dopamine agonists
Excessive daytime sleepiness
NarcolepsyExcessive daytime sleepiness, cataplexy, hallucinations when falling asleep or awakeningModafinil (Provigil), armodafinil (Nuvigil), stimulants, gamma hydroxybutyric acid (sodium oxybate [Xyrem]), pitolisant (Wakix), selective serotonin reuptake inhibitors (venlafaxine, fluoxetine [Prozac], clomipramine [Anafranil])
Obstructive sleep apneaSnoring, witnessed apneas, gasping or choking, excessive daytime sleepinessPositive airway pressure therapy

Diagnosis

Many sleep disorders can be diagnosed by history alone; however, overnight polysomnography (PSG) may help diagnose certain sleep disorders such as OSA.6 PSG monitors brain wave activity, eye movements, muscle activity, heart rate and rhythm, and respiration. Brain wave activity is used to assess sleep stages, sleep latency, and arousals. Eye movements are monitored to assess REM sleep, and muscle activity is monitored to assess for parasomnias and RLS. Vital signs are monitored to assess for apneas that would indicate a diagnosis of OSA. PSG is commonly performed in a sleep laboratory, but home sleep apnea tests are sometimes used for the diagnosis of sleep apnea in patients with less severe sleep problems.8 Table 2 lists the most common indications for PSG.6

Diagnosis of a sleep disorder
 Narcolepsy
 Parasomnias
 Periodic limb movement disorder
 Rapid eye movement sleep behavior disorder
 Sleep-related breathing disorders (e.g., obstructive, central sleep apnea)
 Sleep-related seizure disorders
Evaluation of sleep-related symptoms
 Sleep maintenance insomnia
 Snoring
 Unexplained daytime fatigue or sleepiness
Treatment of sleep-related breathing disorders (i.e., positive airway pressure titration)

Problems Falling Asleep

INSOMNIA

Insomnia is the most common sleep disorder, with approximately 33% of the adult population experiencing symptoms and 6% to 10% meeting diagnostic criteria for insomnia disorder.9 Chronic insomnia is classified as the report of difficulty initiating sleep (less than 30 minutes for people without insomnia [i.e., sleep latency]), maintaining sleep, or waking up too early with daytime consequences that occur at least three times per week for at least three months.7 Daytime consequences can involve symptoms of fatigue; difficulty with memory and concentration; and disturbances in mood or irritability.9

Diagnosis is often determined by the patient’s history and should include an evaluation for medical or psychiatric conditions that could be contributing. Approximately 40% to 50% of individuals presenting with insomnia have a comorbid mental illness.10 If the diagnosis is not clear from the history, other tools such as a sleep diary or actigraphy may be helpful.11 Actigraphy is a procedure where the patient continuously wears a relatively unobtrusive device on the wrist or ankle for days to weeks. The device measures the occurrence and degree of limb movements over time to provide information on sleep phases, sleep duration, daily patterns, and efficiency of sleep.11 PSG is not recommended for the diagnosis of chronic insomnia except to evaluate concurrent sleep disorders or look for other causes of the sleep disturbance when treatment has been ineffective.10

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