Surgical options exist for OSA. The most common procedures are uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP). Other procedures in use include tongue reduction and mandibular advancement.
The response rate to OSA surgery averages around 50% but varies on the patient’s characteristics and procedure selected.9 Positive outcomes are most likely for thin patients with obvious upper airway obstruction, including a deviated nasal septum, large tonsils, a low-hanging palate, and large uvula. Potential complications include nasal regurgitation, voice change, postoperative pain, bleeding, infection, tongue numbness, and snoring without apnea (silent apnea).
Oral appliances have a vital niche in OSA treatment. Multiple devices have been developed that open the oropharynx by moving the mandible and tongue out of way. A growing body of data shows that oral appliances improve sleep and reduce EDS and promote patient satisfaction more effectively than nasal CPAP.10 Several studies also show that patients with mild to moderate OSA accept these devices well.
Oral devices do have drawbacks, however. In most settings, effectiveness cannot be observed during a “split-night” laboratory sleep study because the patient has not yet purchased the device. Also, multiple visits sometimes are required to custom fit the oral appliance; this can pose a hardship to patients who live a distance from the provider.
Restless legs syndrome, periodic limb movement disorder
The patient with restless legs syndrome typically reports a restless painful feeling in the limbs that occurs in the evening and at night, disrupting sleep. This condition, which affects 10% of the population, is associated with aging, blood loss, anemia, peripheral neuropathies, and pregnancy.11 Patients can have childhood onset and in some cases there is a familial tendency.
Most patients with restless legs syndrome have periodic limb movements (repetitive leg jerks or twitches). The clinical significance of periodic limb movements with no subjective disagreeable feelings in the limbs is controversial. Typically, treatment is not instituted in these cases.
The history usually confirms the diagnosis without a sleep study. Sleep studies are used only if a co-existing sleep problem is suspected or if the diagnosis is not clear-cut.
One suspected mechanism of restless legs syndrome is a dopamine-deficient state. A serum ferritin level can help detect a relative iron deficiency, iron being a cofactor for dopamine synthesis.12
Treatment can include iron repletion when indicated. Medications include dopaminergic agents, most notably pramipexole and levodopa/carbidopa. Other options include gabapentin, benzodiazepines, and narcotics. Antidepressants have been suspected to worsen this condition but definitive studies are lacking.13
Identifying, correcting circadian rhythm disorders
Instead of compromising the quality or quantity of sleep, circadian rhythm disorders cause sleep to occur at inappropriate times. Adolescents or young adults are most likely to confront these disorders.
The delayed sleep phase disorder—that is, a persistent pattern of staying up late and “sleeping in” the next morning—is the most common example. A careful assessment will reveal that the patient is getting a satisfactory amount of sleep that occurs at a socially unacceptable time, sometimes to the extreme that his or her nights and days are reversed.
Patients can be reluctant to acknowledge the severity of their problem, which can lead to both inaccurate sleep diaries and interviews. A portable device called a wrist actigraph provides data about limb movement, thus more objectively measuring the patient’s sleep schedule.
Psychiatrists frequently encounter patients with delayed sleep phase disorder because of a high degree of comorbidity with depressive disorders.14 The cause of this syndrome is unclear, but environmental factors including light exposure, social patterns, psychological issues, and possibly a genetic substrate, are known to contribute.
A less common circadian rhythm disorder, advanced sleep phase disorder, can also cause EDS. Patients have an inappropriately early time of sleep onset and then are fully awake in the middle of the night. A recent report describes a large family with a severe form of this disorder that is linked to an abnormality on chromosome two.15
Relatively few effective treatments have been identified for circadian rhythm disorders. Some patients elect not to pursue therapy, instead selecting activities that fit around their unconventional sleep schedules. Sometimes individuals with delayed sleep phase cannot arrange their education or work hours around their atypical sleep schedules. These patients experience poor early morning academic or work performance due to sleepiness.
The internal circadian clock can be gradually readjusted with either phototherapy or gradual shifting of the major sleep period (Box 4). Stimulant or hypnotic medications generally are not utilized.
Insufficient sleep syndrome
Studies indicate that more people are attempting to burn the candle at both ends and are consequently developing a newly identified condition, insufficient sleep syndrome.16 In our 24-hour society, people often are trying to make do with less than the required 7-1/2 hours sleep per day. This may have adverse consequences to their health. When people are required to perform shift work, the problem is compounded because of the difficulty in obtaining sufficient quality sleep during daylight hours.