AAPA: Most Doctors Don't Ask About Sleep Problems

PHILADELPHIA, May 29 -- Millions of Americans suffer from undiagnosed obstructive sleep apnea, narcolepsy, and other sleep problems, in part because most physicians simply don't ask patients about them.
In fact, 70% of primary care physicians said they did not ask patients about the quality of their sleep, according to a National Sleep Foundation poll published in 2005, said Eric Kirsch, PA-C, of United Sleep Medicine, a provider of sleep and neurology services based in Charlotte, N.C.
The reason doctors don't ask about sleep may be that they have little training in sleep disorders, Mr. Kirsch said at an industry-sponsored symposium held in conjunction with the American Academy of Physician Assistants conference here.
A 1990 study of 126 accredited U.S. medical schools found that students received an average of only 1.6 hours of instruction about sleep disorders, he said. At 37 of these schools, students received less than one hour of sleep disorder education during their first two years, he said.
The result is that sleep disorders are significantly underdiagnosed, said Paul P. Doghramji, M.D., FAAFP, a private practitioner and associate of Pottstown Medical Specialists, Inc., of Pottstown, Pa.
About 30% of men and 21% of women suffer from excessive daytime sleepiness, according to recent research, Dr. Doghramji said. But only 10% to 20% of people with obstructive sleep apnea syndrome and only 15% to 20% of individuals with narcolepsy are ever diagnosed and treated, he said.
Lack of quality sleep can have serious consequences, he noted. For example, from 1% to 4% of U.S. highway automobile crashes are caused by sleepiness, and 4% of fatal crashes are caused by driver drowsiness, according to estimates from the National Highway Traffic Safety Administration, he said.
A person trying to function on only four hours of sleep is as impaired as a person with a blood alcohol level of 0.095, which is above the legal definition of intoxication in many states, said Dr. Doghramji, quoting a study of healthy volunteers that appeared recently in the journal Sleep.
Excessive sleepiness or fatigue have also been linked to endocrine disorders, immunologic disorders, neurological disorders such as Parkinson's disease and multiple sclerosis, and rheumatological disorders including fibromyalgia, Dr. Doghramji said.
Furthermore, nearly half (46.5%) of patients with excessive sleepiness also have a psychiatric disorder, such as anxiety, depression, or bipolar disorder, he said.
Psychiatric disorders such as these may sometimes be the cause of, not the result of, poor sleep quality and excessive sleepiness, Dr. Doghramji noted. Other causes include obstructive sleep apnea, narcolepsy, insomnia, circadian sleep rhythm disorders, and sleep-related movement disorders such as restless legs syndrome and periodic limb movement disorder, he said.
A variety of effective pharmacologic options for treating excessive sleepiness and some of its underlying causes are available to clinicians, said Jonathan R.L. Schwartz, M.D., of the University of Oklahoma Health Sciences Center in Oklahoma City.
Those include central nervous system stimulants such as dextroamphetamine and methylfenidate, which are FDA-indicated for treating narcolepsy, Dr. Schwartz said. These agents promote dopamine, serotonin, and norepinephrine neurotransmission, he said. Side effects may include anxiety, restlessness, insomnia, headache, tachycardia, hypertension, and psychosis, he noted. They are classed as schedule II controlled substances.
The wake-promoting agent modafinil is FDA-approved for treating excessive sleepiness associated with narcolepsy, obstructive sleep apnea, and shift work disorder, said Dr. Schwartz. Shift work disorder is a condition that affects about 32% of workers on the night shift and about 26% of rotating shift workers, he said.
Modafinil is thought to work by increasing activity in the hypothalamus. Side effects include headache, nausea, rhinitis, back pain, diarrhea, dyspepsia, anxiety, dizziness, and insomnia, he said. The drug is classed as a schedule IV2 controlled substance, he said.
If insomnia is the cause of excessive sleepiness, a variety of hypnotic medications can be used to promote sleep, including zolipidem, zaleplon, eszopiclone, and ramelteon, Dr. Schwartz said. If restless legs syndrome is the culprit, on the other hand, pharmacologic options include ropinirole and pramipexole. However, Dr. Schwartz did not discuss the mechanisms of action or potential side effects of the above-mentioned drugs. Iron replacement therapy may also be useful in patients with restless legs who have iron deficiency, he said.