New Trend I see Happening not mentioned in usual education- OSA.

[whopper]

Overweight, snores, problems falling asleep but not staying asleep.

When I see patients have all 3 of the above, and referred them for an OSA test so far 100% of those patients had OSA. How many have I referred for an OSA test? Literally several dozen and well over a hundred in the last few years. Despite this I see the typical patient with the above, and their PCP or other psychiatrist puts the patient on a sleep med and not address the OSA at all.

I believe this has been more a trend now because of increasing trends in obesity, increasing electronic use, and doctors still pulling the Ambien out more so than appropriate. This was not seemingly as much a problem when I was in training. Yes the electronic use doesn't allegedly increase OSA as far as we know but we do have more insomnia in general. Decreased physical activity, more screen time ==> less sleep. It's forced me to pay more attention to sleep than I did in my training.

I don't see physicians in general considering a sleep test when patients are having sleep problems. The doc simply prescribes something that isn't addressing the OSA which in theory could make things worse. In OSA the person is waking up cause they're not breathing. So what? You want them to not wake up and continue to not breathe? The only reason why I believe this isn't killing a lot of patients is cause then it'd be on the news and there'd be more efforts to educate providers on this issue.

At least I don't see as many doctors flippantly prescribing Zolpidem like it's candy although this is still going on. I just see it far less than I did before.

---

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[Sushirolls]

I refer to Sleep Medicine a lot. Like a lot.
Snores gets a consult. I let the sleep doc filter out if inappropriate, and so far none haven't been tested with HST. So far the only people who've been tested that game back no OSA on HST, were the young and female (2-3 in past 7 years), which already is protective factors. I had one guy recently with witnessed apneas, and was just primary snoring, blew my mind. Couldn't believe his risk factors yielded a negative test.

For ADD folks I won't touch stimulants if I have OSA concerns until they've had the consult and HST. Ticks off a few patients, or they do it, get a postive diagnosis but then don't want to treat it...

So much untreated OSA. PCPs are missing so many, Psychiatrists just aren't referring.

Thankfully I got a good one I refer to who also does their own CBTi.

 

[Taddy Mason]

In my experience, sleep disorders are grossly underdiagnosed which I think is due largely to lack of education. Just a PGY4, but in the past 15 months I’ve referred 28 patients to sleep medicine and am batting 100. Primarily OSA, and a number not fitting the stereotypical demographic (e.g., overweight, inactive, middle aged/older, male), but also one CSA, two with narcolepsy, and a handful of NREM and REM disorders. Initially I had patients go through their PCP (if in house) for the referral (because doing anything outside of scheduling and seeing patients in our outpatient department is a logistical nightmare, and even that routinely gets f-ed up), but got push back a couple of times from PCPs who disagreed that there could be a sleep issue and if I felt that strongly about it I could make the referral myself. Since then I’ve made all the referrals myself, have gotten to know our sleep department fairly well, and apparently am the first person from psychiatry to have made a sleep referral in 3-4 years. All in all, I think this just highlights the lack of education around sleep disorders and sleep medicine in general and how easily they go un or misdiagnosed. It’s both satisfying and frustrating (because often the diagnoses went missed for years by PCPs and other psychiatrists) when someone’s anxiety, depression, etc. all of a sudden go away by addressing the underlying cause and they no longer need to follow with psych. Having a sleep disorder myself that went undiagnosed for decades I think has made me biased/more vigilant in screening patients.

 

[whopper]

I've noticed a lot of ADHD patients when they take a dopamine increasing med actually become tired. So far any patient that tells me they sleep better on coffee (or a stimulant, Bupropion, or pseudoephedrine) whenever tested for ADHD turned out they had it. This isn't true of all ADHD patients. I do have ADHD patients where a stimulant has the expected effect of making the person feeling more awake and alert, but when these meds make the person tired? All had ADHD.

Again I'm shocked how many doctors are not investigating OSA with so much obesity going on.

 

[watto]

I really like Barry Krakow's work on insomnia and sleep-related breathing disorders. He goes so far as to estimate that ANY patient who complains of sleep disruption and is treatment-resistant to sleep meds likely has OSA (or at the very least, some level of respiratory-event-related arousal). Even those without typical symptoms of apnea like snoring or witnessed events.

A Missing Link: Dr Barry Krakow's Research on Insomnia and SDB

Dr Barry Krakow’s findings on the relationship between insomnia and sleep-disordered breathing have far-reaching implications for diagnosis and treatment.

www.sleepreviewmag.com

For me, the important piece to remember is that CBT-I may appear to be effective for improving sleep efficiency, but if they are still having respiratory events, you may be masking an underlying problem.

 

[deleted1100659]

probably 3/4 of my patients are obese, which of course is a risk factor for OSA. Im quick to push for a sleep study; however, they're really hard to obtain my area. Not many places that patients can go, and my patient population is generally people that don't have financial means.

But yeah, a large number of patients have undiagnosed sleep apnea, completely agree with that.

 

[Monocles]

So far any patient that tells me they sleep better on coffee (or a stimulant, Bupropion, or pseudoephedrine) whenever tested for ADHD turned out they had it.

Can you explain the sudafed part? Is it like a norepinephrine thing?

 

[whopper]

I'm not sure, but I noticed this and this even happened with myself when I tried Wellbutrin XL. It made me really darned tired. I know I have ADHD so I got a prescription for Wellbutrin XL. I fell asleep the first few days I was on it.

My theory is this. Stimulants if given to a hyperactive ADHD person calms them down. This person may be too used to hyperactive component oft the disorder giving them energy. Well now that the dopamine (and perhaps norepinerphrine) is more normalized that source of energy is gone. ADHD hyperactive kid that wants to touch everything now can sit still while on the right med and right dosage.

I got another theory that akathisia really is medication induced ADHD. Why? You block dopamine, a key chemical that's involved with ADHD, and guess what? Akathisia looks like hyperactive ADHD. What calms it? Everything that treats ADHD such as Clonidine or Dopamine.

 

[aim-agm]

At one system I rotated through, policy was to reflex to sleep medicine for most (maybe all) types of positive cardiology diagnosis/consults since 50%+ of the heart patients would also turn out to have OSA. I wonder if we should do the same for psychiatry diagnosis/consults...is there a good way of screening broadly for OSA that's cheap and straightforward?

 

[whopper]

There's cheaper home tests that are specific only for OSA instead of the sleep-in-the-lab tests that are much more expensive.

A problem with those sleep-in-the-lab tests is despite that these are supposed to be more comprehensive I always get the same end report. OSA or not OSA. So what's the damned point? Just do the cheaper test is the case. I never got someone to explain this to me.

 

[Taddy Mason]

...is there a good way of screening broadly for OSA that's cheap and straightforward?

Actually bothering to do a careful review of sleep disturbances, patterns, and behaviors which really isn't that much more work or time consuming yet rarely done.

Epworth Sleepiness Scale.

Taking 10 seconds to look in a patient's mouth/throat with a pen light, especially if they don't fit the stereotypical outward demographics associated with OSA.

Review comorbidites in the context of the overall clinical picture.

 

[watto]

There's cheaper home tests that are specific only for OSA instead of the sleep-in-the-lab tests that are much more expensive.

A problem with those sleep-in-the-lab tests is despite that these are supposed to be more comprehensive I always get the same end report. OSA or not OSA. So what's the damned point? Just do the cheaper test is the case. I never got someone to explain this to me.

You can ask them for more parameters - ask for AHI, RERAs, arousal index, periodic limb movements, etc. Ask for a hypnogram so you can see their pattern of getting to NREM 3 / deep sleep, if they are getting it at all. The computer provides a lot of this data so the sleep physician should be able to provide it, even if they are not interested in doing a deep dive into the study.

I love full attended studies because of the sheer bulk of data, but home tests are fine if there is a high pre-test probability for some level of obstruction. Even a WatchPAT is fine.

 

[Taddy Mason]

There's cheaper home tests that are specific only for OSA instead of the sleep-in-the-lab tests that are much more expensive.

A problem with those sleep-in-the-lab tests is despite that these are supposed to be more comprehensive I always get the same end report. OSA or not OSA. So what's the damned point? Just do the cheaper test is the case. I never got someone to explain this to me.

Home sleep tests aren't as sensitive and when they come back negative the next step is for an in-lab study. The home tests honestly seem more pointless and a greater waste of money in that regard.

 

[Sushirolls]

Yes there is variability in HST.
More often in women than men.

The sleep doc who subleases from me doesn't have an in lab, and the has rarely had patients they needed to reflex to in lab. To the point the person is questioning the grand goal desire to have a lab and just keep referring these people to other labs when needed.

So in summary I don't believe HST is a waste of money. One could argue the alternative that in labs are more of a waste of money, which the insurance companies know, and have big hurdles for Prior Auths for all sleep studies whether HST/PSG.

 

[Mad Jack]

Overweight, snores, problems falling asleep but not staying asleep.

When I see patients have all 3 of the above, and referred them for an OSA test so far 100% of those patients had OSA. How many have I referred for an OSA test? Literally several dozen and well over a hundred in the last few years. Despite this I see the typical patient with the above, and their PCP or other psychiatrist puts the patient on a sleep med and not address the OSA at all.

I believe this has been more a trend now because of increasing trends in obesity, increasing electronic use, and doctors still pulling the Ambien out more so than appropriate. This was not seemingly as much a problem when I was in training. Yes the electronic use doesn't allegedly increase OSA as far as we know but we do have more insomnia in general. Decreased physical activity, more screen time ==> less sleep. It's forced me to pay more attention to sleep than I did in my training.

I don't see physicians in general considering a sleep test when patients are having sleep problems. The doc simply prescribes something that isn't addressing the OSA which in theory could make things worse. In OSA the person is waking up cause they're not breathing. So what? You want them to not wake up and continue to not breathe? The only reason why I believe this isn't killing a lot of patients is cause then it'd be on the news and there'd be more efforts to educate providers on this issue.

At least I don't see as many doctors flippantly prescribing Zolpidem like it's candy although this is still going on. I just see it far less than I did before.

As a former respiratory therapist, it's one of the first things on my mind if I've got a patient that's overweight, tired all the time, has difficulties with focus/concentration, and has memory issues in addition to their depressive symptoms and anxiety. Asking about whether they have early morning headaches (due to changes in vascular tone from CO2 elevation) or if they wake up frequently at night with their heart racing or feeling like they have to catch their breath can also be additional clues. Often I'll have patients that have responded well to antidepressants from other providers but which feel like they just can't shake feeling tired and residual cognitive issues that are completely unwilling to entertain the idea that they might have OSA for whatever reason and insist they need a pill rather than a sleep eval

 

[Mad Jack]

You can ask them for more parameters - ask for AHI, RERAs, arousal index, periodic limb movements, etc. Ask for a hypnogram so you can see their pattern of getting to NREM 3 / deep sleep, if they are getting it at all. The computer provides a lot of this data so the sleep physician should be able to provide it, even if they are not interested in doing a deep dive into the study.

I love full attended studies because of the sheer bulk of data, but home tests are fine if there is a high pre-test probability for some level of obstruction. Even a WatchPAT is fine.

The problem around where I was at when I last ordered the tests was that they didn't have equipment for all of this at any of the local labs, they had the most basic setups possible because they were reimbursed the same regardless of what equipment they used, or so that was my understanding when I talked to them. They would love to have all of the fancy toys but toys that don't pay for themselves tend to not fly in the budget of most labs

 

[Dr.MONO]

OSA is underdiagnosed.

 

[hallowmann]

In my experience, sleep disorders are grossly underdiagnosed which I think is due largely to lack of education. Just a PGY4, but in the past approximately year and a half I’ve referred 28 patients to sleep medicine and am batting 100. Primarily OSA, and a number not fitting the stereotypical demographic (e.g., overweight, inactive, middle aged/older, male), but also one CSA, two with narcolepsy, and a handful of NREM and REM disorders. It’s both satisfying and frustrating (because often the diagnoses went missed for years by PCPs and other psychiatrists) when someone’s anxiety, depression, etc. all of a sudden go away by addressing the underlying cause and they no longer need to follow with psych. Having a sleep disorder myself that went undiagnosed for decades I think has made me biased/more vigilant in screening patients.

For a while, the issue was cost and convenience which was prohibitive for a lot of patients. Now with home sleep studies, I think it is a bit easier, but I feel like the threshold/criteria for ordering it is too strict from an insurance/healthcare system standpoint probably due to the excessive prior cost. As a result, virtually everyone who is sent for a sleep study is found to have OSA. In primary care and psychiatry I have ordered over a hundred sleep studies. I can only recall 1 that was borderline and 1 that was negative, using the criteria of my institution.

OSA is underdiagnosed.

100% agree. Not just in adults as well, way more kids have it than you would expect (big tonsils, increasing obesity, etc.).

 

[robellis]

I've noticed a lot of ADHD patients when they take a dopamine increasing med actually become tired. So far any patient that tells me they sleep better on coffee (or a stimulant, Bupropion, or pseudoephedrine) whenever tested for ADHD turned out they had it. This isn't true of all ADHD patients. I do have ADHD patients where a stimulant has the expected effect of making the person feeling more awake and alert, but when these meds make the person tired? All had ADHD.

Again I'm shocked how many doctors are not investigating OSA with so much obesity going on.

I agree with this but am confused why you started discussing adhd randomly

 

[robellis]

I'm not sure, but I noticed this and this even happened with myself when I tried Wellbutrin XL. It made me really darned tired. I know I have ADHD so I got a prescription for Wellbutrin XL. I fell asleep the first few days I was on it.

My theory is this. Stimulants if given to a hyperactive ADHD person calms them down. This person may be too used to hyperactive component oft the disorder giving them energy. Well now that the dopamine (and perhaps norepinerphrine) is more normalized that source of energy is gone. ADHD hyperactive kid that wants to touch everything now can sit still while on the right med and right dosage.

I got another theory that akathisia really is medication induced ADHD. Why? You block dopamine, a key chemical that's involved with ADHD, and guess what? Akathisia looks like hyperactive ADHD. What calms it? Everything that treats ADHD such as Clonidine or Dopamine.

Very interesting but Propranolol treats akathisia but doesn’t target dopamine

 

[clausewitz2]

I generally have people get their PCP to order HSTs for them as they seem to get them covered much more routinely, but I do coach them on exactly what to tell the PCP to get them to do it. Batting a thousand there so far. For folks who really need an MSLT I haven't had problems getting them approved but I am fanatical about ESS tracking and sleep diaries.

Not everyone wants to bother with this but 'sleeping 14 hours a day on a regular basis is something most healthy human adults actually find impossible' is a line that works well.

 

[hamstergang]

I got another theory that akathisia really is medication induced ADHD. Why? You block dopamine, a key chemical that's involved with ADHD, and guess what? Akathisia looks like hyperactive ADHD. What calms it? Everything that treats ADHD such as Clonidine or Dopamine.

Do psychostimulants treat akathisia? Does Strattera?

Does Dopamine treat ADHD?

 

[Lexanoob]

I totally agree with this! I also specifically wish we also got more formal teaching on parasomnias. I've had some patients that complain of psychiatric symptoms of dissociation, disorientation, and/or auditory/ visual hallucinations only at night, in the setting of interrupted sleep, with history of OSA/symptoms of OSA, one of which got admitted to the psych unit and treated with antipsychotics! Luckily, my friend has sleep training, so she's my informal consulting provider for a ton of my patients 🤪

 

[calvnandhobbs68]

In outpatient private practice, I’m not really sure I can order a sleep study for most of my patients since I’m not affiliated with any health system…so no way to integrate an order into a system or make sure it’s going to get approved by insurance or whatever.

Honestly I just end up giving patients the contact info for sleep medicine at the local hospitals or having them see if their PCP can order it but I’m not sure if there’s a better way around this in terms of actually physically ordering the study somehow in a way that a sleep lab/hospital system will recognize as valid.

 

[Sushirolls]

I was glad that my residency had us rotate with Sleep Medicine.

There are numerous ways to order and get an HST done, even with the Sleep Med doc interpretation. The real pain is writing the CPAP prescription and all the hiccups that happen at the DME.

1) Refer to an independent Sleep Medicine doc in private practice in your local area
2 or 3) Refer to a local Big Box Shop health system Sleep Med department
2 or 3) Do a google search in your state to find the independent Sleep Medicine practices, call them, set up a tele meeting, discuss how many potential referrals you'll have and if they will be willing to do mail in kits following their telemedicine consult to be your go to referral.
4) Refer to national conglomerate company that does telemedicine *consults and mailed home sleep study kits
5) Refer to PCP and request they deal with it (they'll either do Big Box shop #2, or #4), they may even have an arrangement with a national sleep tele firm where there is no consult, but the HST is done out of the PCP office (i.e. they bill for it!!) and a sleep doc some where random does the report read for near pennies...

*those consults will be abbreviated and super focused on OSA and not all the parasomnias and other sleep behaviors that a full routine consult would be in a traditional office.

 

[whopper]

Propranolol-there's literature saying it treats Akathisia-but never seen it happen in clinical practice and I've tried dozens of times.
Do psychostimulants treat akathisia? I've seen this happen clinically. E.g. patient has akathisia, and prescribing a low dose stimulant relieved it. I haven't seen literature on it. Reason why I tried a stimulant was out of desperation cause everything the literature stated to do was tried and didn't work.

Does dopamine treat ADHD? In theory it's one of the key neurotransmitters although as we know almost everything in our field is theory.

I agree with this but am confused why you started discussing adhd randomly

Me being a little over-random. I have a lot of ADHD patients who have sleep problems. IMHO the relationship between ADHD, anxiety and insomnia should be better explored. I never once, for example, was taught that some ADHD patients sleep better on stimulants or other dopamine enhancing meds and why is this happening? Or that stimulants can cause significant anxiolytic effect in those with ADHD. Yet I see this often in clinical practice.

 

[PsyDr]

Thoughts on OSA being in the DSM?

 

[clausewitz2]

Thoughts on OSA being in the DSM?

I agree that it is an odd fit at present, but only because of the history of any condition with reliably discernable physiological mechanisms or causes being immediately partitioned off into another medical specialty (cf. epilepsy), regardless of the burden of psychiatric sequelae. It also does violate the DSM's initial guiding principle of being agnostic about etiology but that ship sailed with PTSD.

 

[comp1]

OSA would not fit well in the DSM, but fortunately we are physicians first and psychiatrists second. I order sleep tests on a lot of psychiatric inpatients who screen as likely. It's great, we can get all of it done in house and they leave with a CPAP.

 

[splik]

OSA would not fit well in the DSM, but fortunately we are physicians first and psychiatrists second. I order sleep tests on a lot of psychiatric inpatients who screen as likely. It's great, we can get all of it done in house and they leave with a CPAP.

um, it is in the DSM

 

[watto]

Yeah, the DSM-V did right by trying to more closely match the International Classification of Sleep Disorders v. 3 and to emphasize that these phenomena need to be treated as separate disorders, even if overlap of symptoms exists.

Then again, you haven't lived until you have treated someone with OSA, circadian rhythm disorder, bruxism, and depression. It's like a 9921infinity every session.

 

[comp1]

um, it is in the DSM

Right, sorry.

 

[futureapppsy2]

FWIW, I'd be shocked if my dad didn't have OSA--history of terrible (and I mean terrible) snoring from young adulthood on, witnessed apneas, choked himself awake multiple times a night. His PCP ordered an at home sleep oximeter study, which showed frequent considerable drops in O2 levels over the course of the night but somehow said that it read as "normal" (???). Interestingly, the sleep issues went away when had a tonsilectomy a few years ago for an unrelated reason.

 

[shotgunlagoon]

FWIW, I'd be shocked if my dad didn't have OSA--history of terrible (and I mean terrible) snoring from young adulthood on, witnessed apneas, choked himself awake multiple times a night. His PCP ordered an at home sleep oximeter study, which showed frequent considerable drops in O2 levels over the course of the night but somehow said that it read as "normal" (???). Interestingly, the sleep issues went away when had a tonsilectomy a few years ago for an unrelated reason.

I Imagine enlarged tonsils can contribute to the obstruction, so the fact that his sleep issues resolved after the tonsillectomy makes sense to me. No tonsils, less obstructed airway.

 

[PsyDr]

I Imagine enlarged tonsils can contribute to the obstruction, so the fact that his sleep issues resolved after the tonsillectomy makes sense to me. No tonsils, less obstructed airway.

They grade the tonsils by size, and have surgical decision trees partially based on that grading.

 

[shotgunlagoon]

They grade the tonsils by size, and have surgical decision trees partially based on that grading.

Yeah I scribe for an ENT right now and most people have like 1+ to 2+ tonsils, but when they start getting to 3 or 4, he often comments on them and asks about previous tonsillitis.

 

[hebel]

Actually bothering to do a careful review of sleep disturbances, patterns, and behaviors which really isn't that much more work or time consuming yet rarely done.

Epworth Sleepiness Scale.

Taking 10 seconds to look in a patient's mouth/throat with a pen light, especially if they don't fit the stereotypical outward demographics associated with OSA.

Review comorbidites in the context of the overall clinical picture.

I've stopped using the epworth scale because it isn't sensitive enough. Way too many people with "normal" range scores that end up with an OSA dx.

One sleep clinic would not accept patients with low epworth scales for referral, but I bet they were missing a lot of legit OSA. I think any kind of self-report screener is going to be pretty flawed.

 

[clausewitz2]

I've stopped using the epworth scale because it isn't sensitive enough. Way too many people with "normal" range scores that end up with an OSA dx.

One sleep clinic would not accept patients with low epworth scales for referral, but I bet they were missing a lot of legit OSA. I think any kind of self-report screener is going to be pretty flawed.

It's a screener, not a diagnostic instrument. That clinic was being ridiculous. However, I think it is good for forcing people to hone in on sleepiness instead of just talking about how tired they are (no matter how many times I have that conversation with them, grumble grumble)

 

[Taddy Mason]

I've stopped using the epworth scale because it isn't sensitive enough. Way too many people with "normal" range scores that end up with an OSA dx.

One sleep clinic would not accept patients with low epworth scales for referral, but I bet they were missing a lot of legit OSA. I think any kind of self-report screener is going to be pretty flawed.

I’m not a huge fan of self-report screeners in a vacuum but it’s a datapoint to use in conjunction with everything else and something our sleep lab wants when making a referral for requesting a prior auth. If the score is low/at odds with what the patient is reporting otherwise I point that out and it generally ends up being a fruitful conversation with them reflecting on and possibly better characterizing their sleep issues. Our sleep lab claims to have a hard cutoff for the ESS but in reality is pretty flexible. If a patient’s ESS is still lower despite numerous complaints otherwise suggestive of sleep pathology I just make sure to document more emphatically in my progress note and referral documentation.

 

[hypnorpheus]

I just use the very simple STOP-BANG screen to identify high risk patients. It makes much more sense to me than the ESS.

 

[clausewitz2]

I just use the very simple STOP-BANG screen to identify high risk patients. It makes much more sense to me than the ESS.

Well, the thing is, STOP-BANG is fine for OSA, but a high ESS score is going to clue you in to other potential disorders of hypersomnolence as well, all of which can be fairly debilitating.

 

[ridethecliche]

I agree with this but am confused why you started discussing adhd randomly

I think the answer writes itself here...

 

[psyguru]

A sleep-specialist told me benzos (and possibly z-drugs) are worse than other sleep aids in OSA as they act as a muscle relaxant and can worse the apnea.

 

[adiradirim]

A sleep-specialist told me benzos (and possibly z-drugs) are worse than other sleep aids in OSA as they act as a muscle relaxant and can worse the apnea.

Interestingly, I've also heard from a psychiatry trained sleep doc that you can use them to suppress the micro-awakenings that come from the apneas and let the patient have uninterrupted sleep lol so who knows

 

[watto]

Interestingly, I've also heard from a psychiatry trained sleep doc that you can use them to suppress the micro-awakenings that come from the apneas and let the patient have uninterrupted sleep lol so who knows

Except when those awakenings keep you from suffocating, they are a good thing. You have to address the underlying problem.

 

[FlowRate]

I've referred a lot of people to sleep med and I have been surprised at how few actually had significant OSA. A typical case like this is that a pt complains of feeling super tired/fatigued during the day, doesn't have trouble falling asleep, may have some brief night time awakenings, their bed partner complains of very loud snoring, they do not feel rested in the morning, they may or may not wake up with headaches, and they have BMI 30+ and usually 35++. Generally other medical causes of fatigue have been ruled out already. Most of these "false positive" (by clinical interview) cases are on the younger end of the spectrum (<40).

Because I referred so many people for HSS over the last 1.5 years who ended up having mild (aka probably not relevant) or minimal/absent OSA, I'm working on changing my practice to include some of the other prognostic factors more strictly. I noticed that when I had time to drill down more specifically and ask some of the questions on the ESS, a lot of patients reported that the fatigue was not THAT severe (so basically no chance of dozing in any situation other than intentionally trying to take an afternoon nap, definitely not while in situations where it would be inappropriate). So now I send a pt a ESS and if it's like <6 I will probably not recommend a sleep med referral (I'm just now starting to figure out how I want to implement this, I think some of the existing guidelines are >10). Also HTN is a big prognostic factor that many of my pts are lacking and I'm working on whether I want to include that in the risk stratification as well.

I just feel like I wasted a good amount of patient time and system resources on what I thought were relatively high likelihood cases based on many of their symptoms and BMI.

It's also fun to watch pts tell me that they're severely fatigued, highly likely to fall asleep, then go to see the sleep doc and they report more mild sx and score low on ESS.

 

[clausewitz2]

(I'm just now starting to figure out how I want to implement this, I think some of the existing guidelines are >10). Also HTN is a big prognostic factor that many of my pts are lacking and I'm working on whether I want to include that in the risk stratification as well.

Yeah, 10 is the number at which I start pushing people to consider a sleep study to be honest. I ask a lot of questions about this but one crucial one for interpreting some of these ESS scores is "how many times did you fall asleep unintentionally in the last week", and if 0, "so when was the last time you fell asleep when you didn't mean to?" If their ESS is 14 but this hasn't happened to them in years, clearly the score is suspect as a genuine indicator of sleepiness. Often carefully and repetitively returning to the distinction between sleepy and tired/fatigued/exhausted is helpful; the one is fairly specific and the other is anything but. I have to train most of my patients not to use them as synonyms.

It's also fun to watch pts tell me that they're severely fatigued, highly likely to fall asleep, then go to see the sleep doc and they report more mild sx and score low on ESS.

I will sometimes elicit really horrible sleep schedules from some people and then when I send them to sleep medicine, suddenly they sleep in a very routine and reasonable fashion and don't need to nap and sleep doc seems a little confused as to why they are there.

 

[mistafab]

I essentially stop bang every patient that has a sleep complaint. OSA can explain lots of MDD symptoms. Sleep referral is so high yield for low hanging fruit - plus patients think you are a genius if you fix them with a cpap.

 

[clausewitz2]

The one caveat that I recall from a lecture given by a pulmonologist ages ago was that while screening for and treating OSA is important, especially for reducing the risk of fatal accidents and lowering blood pressure, optimal CPAP on average does not have a tremendously large effect on the cognitive/mood complaints that come along with OSA in many cases. So like Vit D supplementation if someone is low, it's not a bad idea at all and should probably be addressed, but miraculous improvements may have a substantial non-specific component to them.

 

[aim-agm]

optimal CPAP on average does not have a tremendously large effect on the cognitive/mood complaints that come along with OSA in many cases.

Is the thinking that the persistent cognitive/mood effects are because of residual apnea/sleep disturbance, the damage has already been done, there's more of a correlation from common cause (e.g. obesity causing mood changes and OSA), or something else?