Tired of waking up tired: Sleep disorders in general practice

Oh, the nights are long
And I’m so tired of waking up tired,
Man, they just drag on and on
And I’m so tired of waking up tired.

                     – Hoodoo Gurus, Waking up tired​

We all know that we feel – and look – a lot better when we’ve had a good night’s sleep. But many can relate all too well to the above lyrics.
 
What many may not realise so clearly, however, is the potentially serious consequences of poor sleep, or the widespread nature of the problem.
 
‘A recent Deloitte Access Economics report suggests that 40% of Australian adults experience inadequate sleep,’ Dr Kirk Kee, a respiratory and sleep physician at the Royal Melbourne and Alfred hospitals, told newsGP.
 
‘This leads to a loss of wellbeing and quality of life, and also increases the risk of accidents – motor vehicle or workplace accidents, for example.
 
‘There is increasing literature that suggests any form of inadequate sleep can be associated with poorer long-term health outcomes. Cardiovascular disease, dementia, depression and even cancer have all been linked to inadequate sleep, and patients who have too much or too little sleep have shorter life-expectancies than those who sleep 6–8 hours per day.’
 
The term ‘sleep disorders’, used to describe any illness that results in insufficient or inadequate sleep, can be divided into two categories, respiratory and non-respiratory.
 
‘The respiratory disorders include obstructive and central sleep apnoea, as well as obesity hypoventilation syndrome, which are the illnesses many doctors think of when they think about sleep disorders,’ Dr Kee explained.
 
‘However, the non-respiratory disorders are also very common and include insomnia, circadian rhythm abnormalities, restless-leg syndrome, primary hypersomnolence, narcolepsy or parasomnias – for example, sleep walking, sleep talking, nightmares.
 
‘Finally, there are sleep disorders which aren’t really illnesses, such as sleep restriction, shift-work disorder or jet lag.’

Research has shown sleep disorders are already quite prevalent. But as the Australian population ages and becomes heavier, the numbers of people experiencing sleep disorders are also likely to rise.
 
‘Many sleep disorders increase in prevalence with age – insomnia, restless legs syndrome, REM [rapid eye movement] behaviour disorder are some examples,’ Dr Kee said.
 
‘As well, the elderly are more likely to have medical conditions which disrupt their sleep, such as orthopnoea, chronic pain or dementia, and many drugs affect both sleep quantity and quality.
 
‘Increasing obesity rates will also result in an increased prevalence and severity of sleep apnoea as well as obesity hypoventilation syndrome.’
 
As a result, GPs are increasingly likely to encounter patients with sleep problems, but this might not always be immediately obvious.
 
‘Many patients won’t or don’t mention issues with their sleep because they don’t think it’s important, or that it can be fixed,’ Dr Kee said. ‘A lot of them blame their poor sleep on their age, weight or general health and don’t realise that often there is a specific cause that can be treated.’

Dr Kirk Kee, a respiratory and sleep physician, believes it is important for GPs to ask patients about the quality of their sleep.
 
Because of the tendency to take sleeplessness for granted, it may be helpful for GPs to include questions about sleep quality as part of a general health check-up.
 
‘Sleep disorders often don’t present with classical symptoms, and there are many causes of sleepiness and fatigue, the most common of which is depression,’ Dr Kee said.
 
‘Some patients, especially women, are more likely to describe a loss of energy or fatigue rather than sleepiness. Also, nocturia is a common symptom of sleep apnoea which is often put down to other causes.’
 
Once a sleep issue has been identified, there are a number of referral steps GPs can take, depending on the particular condition a patient is experiencing.
 
‘Referral to a sleep physician or public hospital sleep clinic should be considered early, especially if symptoms are complex or patients do not respond to initial management,’ Dr Kee said.
 
‘Recent changes to the item numbers for sleep studies mean only patients with a high probability of sleep apnoea and symptoms of excessive daytime sleepiness can be referred directly for a sleep study. Patients who fall outside these criteria should be referred for specialist review.
 
‘For insomnia, referral to a psychologist for insomnia-directed cognitive behavioural therapy might be appropriate.’
 
GPs often also have a critical role after the patient has been to a specialist, particularly in cases of sleep apnoea.
 
‘A sleep study which suggests sleep apnoea doesn’t always necessitate CPAP [continuous positive airway pressure] or a splint,’ Dr Kee said.
 
‘Some patients are best managed conservatively, especially those with milder disease for whom a trial of CPAP does not improve their symptoms.
 
‘In situations where the testing has been done without the clinical input of a sleep physician, the GP has a role in ensuring the patient is not committing to an expensive and often inconvenient piece of equipment from which they are not deriving tangible benefit.’
 
When CPAP is appropriate, GPs also play a vital part in ensuring it is being used correctly.
 
‘GPs should check compliance with CPAP or other therapy as part of a patient’s ongoing care,’ Dr Kee said.
 
‘They should also review symptoms to ensure that treatment has been effective, as sleep issues are often multifactorial.’
 
Overall, Dr Kee believes GPs are key in the identification and management of sleep disorders and helping to improve the lives of a vast number of patients who experience them.
 
‘It is important to be aware of the high prevalence of sleep disorders in the community,’ Dr Kee said.
 
‘Asking about sleep and sleepiness can make a huge difference to a patient’s quality of life, as well as how they might cope with their other co-morbidities.’

insomnia sleep apnoea Sleep disorders