Mark Borigini M.D.

Overcoming Pain

The Sixth Vital Sign

Afar into the land of Nod.

Posted Mar 30, 2012

Now that most of us have recovered from the time change of earlier in the month, it is a good time to reconsider that a large percentage of Americans are slowly dying from a lack of sleep.

According to the American Academy of Sleep Medicine, over 70 million people in this country suffer from a sleep disorder, which is causing many health care providers to call for the memorialization of one more vital sign in the medical record: a measurement of the degree of sleepiness when a patient presents for primary care evaluations. Chronic insomnia is the most prevalent sleep disorder, and is associated with a variety of health consequences. The National Institutes of Health (NIH) reports that 50 percent of patients seen by doctors report symptoms of insomnia; 10 percent of patients have impaired daytime functioning.

An insomnia patient is more likely to experience anxiety, depression and chronic pain. Conversely, patients diagnosed with at least one other medical condition, such as arthritis or heart disease, are more likely than healthy patients to be at risk for restless leg syndrome, daytime sleepiness and have at least one symptom of insomnia. The personal and societal burden due to insomnia begs for the tools to yield an early diagnosis, and this could be accomplished with one or two questions posed by doctors or their assistants.

A sleep screening questionnaire on a new patient intake form could be very helpful. Researchers reported in the journal Neuropsychiatric Disease and Treatment on new assessment tools that measure sleep vital signs: the SleepMed Insomnia Index (SMI) and the Sleep Matrix. The SMI scores were found to allow clinicians to structure patient interviews to more quickly focus on potential sleep problems. The Sleep Matrix allows for the visual display of the sleep complaint.

Once patients screen positively for a sleep disorder, the physician should attempt to classify the condition: If a patient is tired during the day, then that patient might have sleep apnea; if the patient is unable to fall asleep, perhaps stress or anxiety is playing a major role in that individual's life. Unfortunately, there are many other possible conditions causing sleep disorder; therefore, the screening should contain queries into the following:
• Sleep environment: is the mattress uncomfortable?
• Sleep hygiene: does the patient use high amounts of caffeine?
• Medications: are certain medications adversely affecting sleep?
• Mood disorders: is depression causing a loss of sleep?
• Intrinsic sleep disorders: does the patient have restless leg syndrome?
• Medical disorders: is arthritis pain keeping the patient awake?
Circadian rhythm disorders: age can cause this.
• Psychological conditions: bipolar disease could keep a patient awake.

Awareness on the part of patient and physician of the prevalence and the possibility of a sleep disorder with every visit to the clinic is the first step in reducing the huge number of sleep pathology seen in the United States. It follows that the identification of the condition and the initiation of treatment for that condition will be rewarding for both parties. This country cannot afford to lose any more sleep. "Catching up" on sleep is a pipe dream.

As Robert Louis Stevenson wrote in The Land of Nod:

Try as I like to find the way,
I never can get back by day.............