Search

To enhance physicians' knowledge of the prevalent problem of sleep disorders, a 50-minute videotape program designed as a learning and self-assessment experience in evaluating and treating these disorders was coproduced with the Network for Continuing Medical Education. The program has been presented nationally to about 25,000 medical professionals. The mean correct score was 50% for the pretest, 69% for the instructional section, and 79% for the posttest; the composite score on the posttest was 59% higher than that on the pretest. Physicians' responses indicated strengths and weaknesses in their knowledge of sleep disorders, thus delineating future directions for medical education in insomnia, narcolepsy/cataplexy, nightmares, night terrors, sleepwalking, and enuresis. All of these sleep disorders can be best evaluated and treated by the general physician.

The most thorough and clinically relevant approach to hypnotic drug evaluation is one that balances the strengths and weaknesses of clinical trials and sleep laboratory evaluations. Advantages of clinical trials include the ability to evaluate large numbers of subjects and specific target groups and to thoroughly assess and quantify a drug's side effects, whereas sleep laboratory studies are very limited in all of these areas. Sleep laboratory studies however provide a rigorous, precise, and comprehensive profile of a drug's activity since there is more control over experimental variables and measurements are objective as well as continuous throughout the night. These benefits offset the shortcomings of clinical trials, which include a lack of objective measurements, less control over experimental variables, failure to evaluate a drug's effectiveness with continued use, and inattention to drug interaction and withdrawal effect. Several basic principles derived from sleep laboratory findings have been incorporated into both the clinical trials and sleep laboratory evaluations recommended in the new FDA Guidelines for the Clinical Evaluation of Hypnotic Drugs. These principles include provision for adequate baseline and withdrawal periods, use of multiple consecutive drug nights to assess a drug's effectiveness with continued use, and inclusion of an adequate washout period when a cross-over design is used. The guidelines do not emphasize either clinical trials or sleep laboratory studies at the expense of each other, but rather stress their complementary utilization.

Although the initial sleep disorders classifications provided a framework for categorizing diagnoses, these early instruments had a number of limitations. Among their shortcomings were a lack of specific diagnostic criteria, limited clinical validation, and an overreliance on sleep laboratory findings. As a result, many of the diagnoses were not only poorly substantiated, but they lacked clinical relevance. Also, because of a fusing of diagnoses, a causal relationship was implied that may have been nonexistent and could misdirect the treatment focus. The ICD-10 represents a clinically based diagnostic classification. Furthermore, this classification system includes diagnostic criteria and encourages multiple diagnoses for a more complete description of the patient's clinical presentation. In addition, the ICD-10 allows for differentiation of psychogenic, developmental, and organic factors. Finally, it can be fully applied in the office setting, which allows physicians to maximize their interviewing and assessment skills to complete the diagnoses and subsequent treatment plans. Thus, this classification system strongly reinforces the doctor-patient relationship. It also facilitates consideration of the entire scope of the patient's problems in a truly biopsychosocial perspective. The prevalence of insomnia ranges across studies from 20 to 30% of the adult population. Before adulthood, its prevalence is below 2%. About 5% of adults complain of excessive daytime sleepiness. Among the conditions of excessive daytime sleepiness, narcolepsy has a prevalence of 0.1% and sleep apnea not more than 1% in the general adult population. Nightmares have a prevalence of about 5% in adulthood and 20% in childhood. Sleepwalking and night terrors have a prevalence of less than 1% in adulthood and 15 and 5%, respectively, in childhood.(ABSTRACT TRUNCATED AT 250 WORDS)

In treating the symptomatology of patients who are chronically ill, it is likely that the physician will encounter a significant number of patients who have sleep disorders. This article has described an approach for the assessment, differential diagnosis, and clinical management of the most prevalent sleep disorders, which are often chronic in nature and have significant psychosocial or medical consequences for the patient and his or her family. We have emphasized the importance for the physician to complement his general medical and diagnostic skills by taking a careful sleep history from the patient (and, in some instances from the bed partner or caretakers). There is no justification for the physician to routinely request costly sleep laboratory hypnopolygraphic evaluations to screen patients with sleep disorders. However, in those instances where the sleep history is highly suggestive of sleep apnea, a sleep laboratory evaluation is indicated. By incorporating the use of the sleep history in the general evaluation of patients with sleep disorders, the physician is better able to develop rational pharmacologic and non-pharmacologic approaches to managing these patients, including the judicious use of medication as an adjunctive treatment.