Assessment

Assessment is the initial step in management strategies. Assessment data should include documentation of predisposing factors, sleep patterns, emotional status, exercise and activity levels, diet, symptoms, medications, and caregiver routines.[1] The sections below outline recommendations for a sleep history and physical examination. Data can be retrieved from multiple sources: the patient’s subjective report of sleep difficulty, objective observations of behavioral and physiologic manifestations of sleep disturbances, and reports from the patient's significant others regarding the patient's quality of sleep.[2] Use of the Insomnia Severity Index is suggested to screen for insomnia in clinical settings.[3,4]

The diagnosis of insomnia is primarily based on a careful, detailed medical and psychiatric history. The American Academy of Sleep Medicine has produced guidelines for the use of polysomnography as an objective tool in evaluating insomnia. The routine polysomnogram includes the monitoring of electroencephalography, electro-oculography, electromyography, effort of breathing and air flow, oxygen saturation, electrocardiography, and body position. Polysomnography is the major diagnostic tool in sleep disorders and is indicated in the evaluation of suspected sleep-related breathing disorders and periodic limb movement disorder, and when the cause of insomnia is uncertain or when behavioral or pharmacologic therapy is unsuccessful.[5][Level of evidence: IV]

Risk Factors for Sleep Disorders

• Disease factors, including paraneoplastic syndromes with increased steroid production; and symptoms associated with tumor invasion (e.g., obstruction, pain, fever, shortness of breath, pruritus, and fatigue).
• Treatment factors, including symptoms related to surgery (e.g., pain, frequent monitoring, and use of opioids); chemotherapy (e.g., exogenous corticosteroids); and symptoms related to chemotherapy.
• Medications such as opioids, sedatives/hypnotics, steroids, caffeine/nicotine, some antidepressants, and dietary supplements, including some vitamins, diet pills, and other products promoting weight loss and appetite suppression.
• Environmental factors.
• Physical and/or psychological stressors.
• Depression (refer to the PDQ summary on Depression ¹ for more information).
• Anxiety (refer to the Anxiety Disorders: Description and Etiology ² section in the PDQ summary on Adjustment to Cancer: Anxiety and Distress ³ for more information).
• Delirium (refer to the PDQ summary on Cognitive Disorders and Delirium ⁴ for more information).
• Daytime seizures, snoring, and headaches.

Characterization of Sleep

• Usual patterns of sleep, including usual bedtime, routine before retiring (e.g., food, bath, and medications), length of time before onset of sleep, and duration of sleep (awaking episodes during night, ability to resume sleep, and usual time of awakening).
• Characteristics of disturbed sleep (changes following diagnosis, treatment, and/or hospitalization).
• Perception of significant others as to quantity and quality of patient's sleep.
• Family history of sleep disorders.

References

1. American Academy of Sleep Medicine.: The International Classification of Sleep Disorders: Diagnostic & Coding Manual. 2nd ed. Westchester, Ill: American Academy of Sleep Medicine, 2005. 
   
   
2. Perlis ML, Jungquist C, Smith MT, et al.: Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer Science+Business Media LLC, 2008. 
   
   
3. Bastien CH, Vallières A, Morin CM: Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2 (4): 297-307, 2001.  [PUBMED Abstract]
   
   
4. Savard MH, Savard J, Simard S, et al.: Empirical validation of the Insomnia Severity Index in cancer patients. Psychooncology 14 (6): 429-41, 2005.  [PUBMED Abstract]
   
   
5. Littner M, Hirshkowitz M, Kramer M, et al.: Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep 26 (6): 754-60, 2003.  [PUBMED Abstract]