Dental sleep medicine series 6: Manifestations of sleep disorders

Sleep is an important part of life; we spend around 1/3 of our lives sleeping. It is important for daily functioning, health and cognitive performance. Manifestations of poor sleep indicate the need for further investigation. Patients may not even be aware of their own problem as manifestations may initially seem to be unrelated to sleep. Clinicians must be vigilant in screening for the signs and questioning patients on the symptoms of sleep disorders to organise the appropriate investigations or referrals. Fundemental symptoms that prompt the need for further investigation include excessive daytime sleepiness, insomnia and unusual events at night. These

From Sleep medicine 6th edition

Insomnia
Difficulty initiating or maintaining sleep combined with daytime sequelae. These may include excessive fatigue, impaired performance or emotional change. Insomnia has to be differentiated from normal variation in the need for sleep (5-9 hours) or the occasional difficult night which may be linked to recent events. Patients with insomnia believe the disruption to sleep causes their excessive sleepiness, fatigue, lack of concentration and depression and a good night sleep would reverse these symptoms. Insomnia appears to be more common in women, older persons, and those with psychiatric or chronic medical illness. Insomnia also is more common in persons of lower socioeconomic status and with less education. Behavioral traits such as obsessive-compulsive nature, frequent rumination, and poor coping strategies and a “hyperalert” baseline state are correlated with greater risk for insomnia. Insomnia may be initiated by sudden changes in environment or challenges to the body or mind however may not be part of the ongoing process in chronic insomnia.

Some patients attempt to improve their sleep by adopting behaviours that can actually perpetuate their insomnia. These may include caffiene or alcohol use, watching television while in bed or even eating or exercising during usual sleep times. A subgroup of patients experience anxiety of the oncoming sleep period.

The timing of the insomnia in the sleep period assists in the evaluation. Circadian rhythm sleep-wake disorders can be hidden by complaints of insomnia or excessive sleepiness or patients with insomnia may develop dysfunction of their circadian rhythm. Diffculty with the onset of sleep suggests an underlying delayed sleep phase or occasionally depression in younger adults. Insomnia with early-morning arousal raises the possibility of underlying depression or advanced sleep phase. Schedule changes, such as from jet lag or shift work, are important clues, and sleep diaries of bedtime and wake time can be useful in determining potential links to schedule or circadian rhythm issues. Timing also may correlate with other issues such as restless legs syndrome or medication or caffeine intake. Specifc questions should explore the patient’s daily routine including the timing of activities that may be stimulating, such as exercise or work or gaming on a computer.

Excessive daytime sleepiness

Fatigue

Snoring

Sleep apnoea

Cataplexy

Sleep paralysis

Hypnagogic and hyponopompic hallucinations

Automatic behaviour

Excessive movement in sleep or parasomnia

RLS and periodic movements in sleep

Morning headache

Systemic features

Pediatric cardinal manifestations