[Differential diagnosis of hypersomnia in surgical sleep medicine-more than just sleep apnea!] / Differenzialdiagnostik der Hypersomnie in der operativen Schlafmedizin ­ mehr als nur Schlafapnoe!

Otorhinolaryngologists play a vital role in the management of patients with obstructive sleep apnea (OSA) in Germany, particularly with regards to outpatient diagnostics as well as conservative and surgical treatment of patients with intolerance to ventilation therapy. Although establishment of differential indications for surgical therapy and performance of additional preoperative drug-induced sleep endoscopy in patients with sleep-disordered breathing are among the core competencies of otorhinolaryngologists, differential diagnostic considerations and detection of comorbid sleep disorders can be challenging, particularly for those without extensive sleep medicine training and experience. However, detection of comorbid sleep disorders is of particular importance when permanent surgical treatment is considered. Daytime sleepiness is the typical leading symptom of OSA; nevertheless, other disorders of hypersomnolence need to be considered in these patients and can easily be overlooked. This may lead to inadequate indications for surgical treatment. Based on two case reports, narcolepsy is presented as a comorbid disorder and differential diagnosis in patients with OSA.

[Prevalence of sleep-related breathing disorders of inpatients with psychiatric disorders]. / Prävalenz schlafbezogener Atmungsstörungen bei stationären Patienten mit psychischen Erkrankungen.

BACKGROUND: Sleep-related breathing disorders seriously impair well-being and increase the risk for relevant somatic and psychiatric disorders. Moreover, risk factors for sleep-related breathing disorders are highly prevalent in psychiatric patients. The aim of this study was for the first time in Germany to study the prevalence of obstructive sleep apnea syndrome (OSAS) as the most common form of sleep-related breathing disorder in patients with psychiatric disorders. METHODS: In 10 psychiatric hospitals in Germany and 1 hospital in Switzerland, a total of 249 inpatients underwent an 8­channel sleep polygraphy to investigate the prevalence of sleep apnea in this group of patients. RESULTS: With a conspicuous screening result of 23.7% of the subjects, a high prevalence of sleep-related breathing disorders was found to occur among this group of patients. Male gender, higher age and high body mass index (BMI) were identified as positive risk factors for the detection of OSAS. DISCUSSION: The high prevalence indicates that sleep apnea is a common sleep disorder among psychiatric patients. Although OSAS can lead to substantial disorders of the mental state and when untreated is accompanied by serious somatic health problems, screening procedures are not part of the routine work-up in psychiatric hospitals; therefore, sleep apnea is presumably underdiagnosed in psychiatric patients. In view of the results of this and previous studies, this topic complex should be the subject of further research studies.

European guideline for the diagnosis and treatment of insomnia

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

[Recommendations for the diagnosis and therapy of insomnia. German Society of Sleep Research and Sleep Medicine DGSM]. / Empfehlungen zu Diagnostik und Therapie der Insomnie. Deutsche Gesellschaft für Schlafforschung und Schlafmedizin DGSM.

There exist a variety of American and European recommendations regarding treatment with hypnotics, especially the duration of treatment. The German Sleep Society now publishes its own view to help physicians to cope with these different recommendations, some of which are contradictory. Therapy with hypnotics must include substantial information on the type of drug, dose, timing and duration as well as information about the possibility of interval treatment. Agonists at the benzodiazepine receptor, like the conventional benzodiazepines and zopiclone or zolpideme, are indicated in short-lasting adjustment insomnia as well as in long-lasting psychophysiological insomnia. Regarding the duration of prescription the German Sleep Society recommends a period of 14 days in de novo patients, which can be repeated once only. In persisting insomnias further approaches should disregard benzodiazepine receptor agonists, but rely on other classes of substances such as tricyclic antidepressants instead. If such approaches are ineffective, the intake of benzodiazepine receptor agonists may be extended to 6 months, when a sleep log and objective observations have documented a true sleep deficit, when daytime impairment arises, when daytime impairment arises, when rebound insomnia, organic or mental insomnias and dependencies have been excluded, and when the indication is monitored at 14-day intervals. If the insomnia persists, during and in spite of therapy a specialist in sleep medicine should be consulted. If therapy is still ineffective after 3 months of daily treatment, a sleep laboratory should be consulted.

[Subjective well-being in obstructive sleep apnea syndrome before and after nCPAP therapy]. / Subjektive Befindlichkeitsparameter beim obstruktiven Schlaf-Apnoe-Syndrom vor und nach nCPAP-Therapie.

18 obstructive sleep apnea patients (mean time of nCPAP-treatment: 412 nights) were asked about their subjective well-being before therapy and under treatment with nCPAP. Also their wifes were asked to give an outer appraisal. Both groups reported a clear reduction of general well-being before therapy and significant improvements in excessive daytime sleepiness, depression, physical and psychical complaints and the rate of patients accidents under nCPAP. In context with a good compliance of therapy these results indicate that the nCPAP-treatment was subjectively experienced as effective.

Test-retest reliability and validity of the Structured Interview for Sleep Disorders According to DSM-III-R.

OBJECTIVE: The purpose of this study was to evaluate the reliability of sleep disorder diagnoses in DSM-III-R by using a newly developed interview, the Structured Interview for Sleep Disorders According to DSM-III-R (SIS-D) and to evaluate the concordance between these diagnoses and sleep laboratory data. In addition, the sources of disagreements between two interviewers in the diagnoses given to the same patient were determined. METHOD: Two different interviewers used the SIS-D to diagnose 68 patients with complaints of sleep disorders. The concordance between these interviewers' diagnoses and polysomnographic findings was investigated by using kappa statistics. RESULTS: There were excellent reliabilities for almost all current main diagnostic categories and good concordance between diagnoses made on the basis of the structured interview and polysomnographic data. The main source of disagreement between interviewers was found in the symptom information given by the patient. CONCLUSIONS: These findings provide support for the utility of DSM-III-R sleep disorder diagnoses and for their retention in DSM-IV. These findings also accord well with a recent literature review of the DSM-III-R diagnosis of primary insomnia by the DSM-IV Work Group on Sleep Disorders. The good concordance between interview diagnoses and polysomnographic data suggests that a structured interview such as the SIS-D may be a useful screening instrument. The authors discuss the implications of these findings for the polysomnographic evaluation of chronic insomnia.