Years ago I used to simply ask “How is your sleep?” to screen for red flags and find out if pain was the culprit. I didn’t think of sleep as a hallmark of good health and I certainly didn’t have follow-up questions. Things have changed.
Although it’s a good start, asking “How is your sleep?” is not enough.
Since 35% of adults and 69% of teenagers in the US are not getting adequate sleep you need to be prepared for replies like “Not great” or even “Terrible.” (1)
Why you? Because sleep disorders are under-diagnosed and most primary care physicians don’t routinely screen for them. (2)
YOU can be a part of the change and you don’t need to be a sleep doctor to help. If you are a physical therapist, personal trainer, chiropractor or coach it’s highly likely that your patient/client will discuss their sleep issues with you before their personal doctor.
It’s not even just about the folks who are up for a couple hours each night. People might not know that regular snoring is not normal and a potential health hazard. They probably won’t mention it unless you ASK them.
Having more one-on-one time than traditional doctors we can use that to our advantage and ask specific questions. These questions will guide your care and may serve as the impetus for a necessary referral.
How do you know what questions to ask? To guide your process I find it helpful to look at the categories of potential sleep disorders.
The International Classification of Sleep Disorders recognizes six general categories of Sleep Disorders that are listed below: (3)
Insomnia
Sleep-related Breathing Disorders
Central Disorders of Hypersomnolence
Parasomnias
Circadian Rhythm Sleep-Wake Disorders
Sleep-related Movement Disorders
By asking the questions I have outlined below you can START to get a sense of what is going on. I have also provided links to Questionnaires that you might find beneficial.
Insomnia is characterized by either difficulty falling asleep, difficulty staying asleep or general dissatisfaction with sleep quality. Insomnia can be a sequelae of other conditions or diseases. Having multiple potential causes makes it difficult to know what to do.
Questions to ask include:
Do you feel well-rested during the day?
How many hours do you sleep each night?
Do you have trouble initiating sleep?
Do have frequent awakenings?
Do you wake up in the middle of the night and have trouble falling back to sleep?
Does your sleep disturbance affect your mood, concentration or ability to function?
Questionnaire
As the name suggests, sleep-related breathing disorders are characterized by abnormal respiration while sleeping. They include obstructive sleep apnea (OSA), central sleep apnea, complex sleep apnea, sleep-related hypoventilation, and sleep-related hypoxemia disorder. Obstructive sleep apnea is the most common form of sleep-disordered breathing.
Questions to ask include:
Do you snore?
Do you often feel fatigued, tired, or lack energy during the day?
Do you ever experience (or have been told) that you stop breathing or gasp for air while sleeping?
Do you have high blood pressure?
Do you have morning headaches?
Questionnaire
Several of the questions above are asked in the STOP-BANG questionnaire
Hypersomnolence refers to the symptom of excessive daytime sleepiness. Central Disorders of Hypersomnolence affect less than 1% of the population. The most common disorder in this category is narcolepsy and like many sleep disorders its presentations span a scale of severity.
Questions to ask include:
Do you doze off at inappropriate times/places? (eg, social situations or when driving)
Do you ever feel paralyzed or excessively stiff while sleeping or upon waking up?
Do you ever feel suddenly weak after an emotional reaction like laughing? (cataplexy is a symptom)
Questionnaires
Parasomnias are disruptive sleep disorders that usually occur during arousals from REM sleep or partial arousals from NREM sleep. They include abnormal movements, behaviors, perceptions and dreams.
Questions to ask include:
Do you sleep walk or sleep talk?
Do you have frequent nightmares or sleep terrors?
Questionnaire
Circadian rhythm sleep-wake disorders result from either intrinsic factors (altered circadian cycle), extrinsic factors (travel, shift work) or a dysfunction in the brain’s clock circuitry.
Questions to ask include:
Are you a late night shift worker?
Do you fall asleep or wake up extremely late/early?
Do you often travel over multiple time zones?
Questionnaire
The two most common sleep-related movement disorders are Restless Leg Syndrome (RLS) and Sleep Bruxism.
RLS, also known as Willis-Ekbom disease, is a complex condition that impacts sleep with unpleasant or odd sensations, often causing an irresistible urge to move one’s limbs (most often but not limited to legs.)
Sleep Bruxism is condition characterized by rhythmic masticatory muscle activity that is associated with grinding and clenching.
Questions to ask include:
Do you have an urge to move your legs at rest?
Do you have odd sensations in your legs that disturb your sleep?
Have you been told by a dentist or partner that you grind your teeth at night?
Do you awaken with a headache or painful jaw?
Questionnaire
Get Started!
I believe everyone can benefit from education on sleep hygiene but how do you know if someone needs more?
This post focuses on the subjective part of a sleep assessment; where we begin. It’s important to note that many of these disorders co-exist. For example, sleep bruxism can occur concomitantly with sleep disordered breathing and circadian rhythm disorders usually present with nighttime insomnia and hypersomnolence during the day.
The realm of sleep science is not limited to one profession. Asking better questions will help guide your decision making and may lead to a referral to specialists such as a myofunctional therapist, a dentist, a psychologist, an ENT or a M.D. trained in sleep medicine.
If you think your patient/client needs more than what you can offer don’t hesitate to make the referral and build your multi-disciplinary team. Better sleep for all requires more people on board caring and asking questions. It starts with you.
If you found this helpful please give it a share on one of the links below!
REFERENCES
1. Centers for Disease Control and Prevention Sleep Statistics online
2. Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep disorders in the primary care setting: history taking compared to questionnaires. J Clin Sleep Med. 2011;7(1):41–48.
3. Ibáñez V, Silva J, Cauli O. A survey on sleep assessment methods. PeerJ. 2018;6:e4849. Published 2018 May 25.
Photo credits: Shane Avery, Alexandra Gorn, Danny G, Kinga Cichewicz, and Nathan Dumlao from Unsplash