Sleep complaints are among the commonest in medical practice and can be simply categorised as:
▶disturbances of getting to sleep or staying asleep, or unrefreshing sleep, that is insomnia,
▶excessive daytime (or more properly wake-time) sleepiness, that is, hypersomnia; and
▶things that disturb the individual's sleep commonly said to be “things that go bump in the night”, or parasomnias.
Although insomnia and parasomnias are prevalent, the hypersomnias are considered more prominently because of the potential impact on the household and on society.
Conditions that will produce excessive wake-time sleepiness are also relatively few, specifically
▶interrupted sleep such as might be caused by Restless Legs with Periodic Limb Movements or breathing problems, and
▶intrinsic sleepiness or narcolepsy and its equivalents.
Restless Legs Syndrome (RLS) common with a general prevalence of 3–4%. It is a waking complaint easily diagnosed by history (discomfort usually in the legs, occurring at rest, relieved by movement and confined mostly to the evening), associated 80% of the time with periodic limb movements in and disturbing sleep which might result in sleep complaints such as insomnia or hypersomnia. RLS may be secondary to renal failure and occurs in pregnancy and is promoted by anti-dopaminergis medicines such as the antihistamines. RLS is highly heritable and the genetic associations have recently been identified. The diagnosis of periodic limb movements in sleep usually requires polysomnography, although we have recently reported pulse rate variability on oximetry to be very useful. Treatment of both with a licensed dopa-agonist is common and second line treatment with codeine derivatives or clonazepam possible. Breathing problems are ubiquitous, the common form being snoring with obstructive sleep apnoea which affects some 5% of the population. The hallmark symptoms are snoring, witnessed apnoeas and excessive sleepiness with resulting sleep related vehicle accidents. Medical consequences include cardiovascular disease particularly hypertension, atrial fibrillation, stroke, along with neurocognitive abnormalities such as poor concentration, depression. Diagnosis is by history supplemented by a sleep study, often oximetry. When associated with symptoms such as sleepiness treatment with continuous positive airway pressure is usually advised along with weight loss in the obese. An alternative therapy would be an oral appliance for mandibular advancement. Both are successful mechanical treatments aimed at making the collapsing pharyngeal airway more patent. Surgery is rarely used.
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