/* Clinical Guidelines for Sleep Disorder Screening and Referral in Primary Care */ SLEEPEZ CLINICAL GUIDELINES Evidence-based guidelines for sleep disorder screening and referral in primary care INTRODUCTION ----------- Sleep disorders are highly prevalent but often underdiagnosed in primary care settings. These evidence-based guidelines are designed to help primary care providers identify patients who may benefit from sleep disorder evaluation and treatment. Early identification and intervention for sleep disorders can significantly improve patient outcomes and quality of life. GENERAL SCREENING RECOMMENDATIONS -------------------------------- 1. All adult patients should be screened for sleep disorders during annual wellness visits 2. Targeted screening should be conducted for high-risk populations: - Patients with obesity (BMI ≥30) - Patients with hypertension, cardiovascular disease, or stroke - Patients with type 2 diabetes - Patients reporting daytime sleepiness, fatigue, or cognitive impairment - Patients with treatment-resistant depression or anxiety - Commercial drivers and shift workers OBSTRUCTIVE SLEEP APNEA (OSA) SCREENING --------------------------------------- Clinical Presentation: - Snoring, witnessed apneas, gasping/choking during sleep - Excessive daytime sleepiness - Morning headaches - Unrefreshing sleep - Nocturia - Mood disturbances Recommended Screening Tools: - STOP-BANG Questionnaire (preferred for general population) - Berlin Questionnaire - Epworth Sleepiness Scale (to assess daytime sleepiness) Referral Criteria: - High-risk STOP-BANG score (≥5) - Moderate-risk STOP-BANG score (3-4) with comorbidities - ESS score ≥10 with symptoms suggestive of OSA - Any patient with witnessed apneas regardless of questionnaire scores INSOMNIA SCREENING ----------------- Clinical Presentation: - Difficulty falling asleep, staying asleep, or early morning awakening - Daytime fatigue, concentration difficulties, or mood disturbances - Sleep difficulties occurring ≥3 nights per week for ≥3 months - Sleep difficulties causing significant distress or impairment Recommended Screening Tools: - Insomnia Severity Index (ISI) - Sleep diary (2-week minimum) Referral Criteria: - ISI score ≥15 (moderate to severe insomnia) - Insomnia with comorbid psychiatric disorders - Insomnia unresponsive to first-line behavioral interventions - Suspected complex insomnia or comorbid sleep disorders RESTLESS LEGS SYNDROME (RLS) SCREENING ------------------------------------- Clinical Presentation: - Urge to move legs, usually accompanied by uncomfortable sensations - Symptoms begin or worsen during periods of rest or inactivity - Symptoms partially or totally relieved by movement - Symptoms worse in the evening or night Recommended Screening: - International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria - RLS severity scale for diagnosed patients Referral Criteria: - Moderate to severe symptoms (RLS severity scale ≥15) - Symptoms causing significant sleep disruption - Symptoms unresponsive to iron supplementation (if iron deficient) - Atypical presentation or uncertain diagnosis NARCOLEPSY SCREENING ------------------- Clinical Presentation: - Excessive daytime sleepiness (EDS) despite adequate sleep - Cataplexy (sudden loss of muscle tone triggered by emotions) - Sleep paralysis - Hypnagogic/hypnopompic hallucinations - Disrupted nighttime sleep Recommended Screening: - Epworth Sleepiness Scale (ESS) - Swiss Narcolepsy Scale - Detailed sleep history focusing on cataplexy and other associated symptoms Referral Criteria: - ESS score ≥10 with unexplained excessive daytime sleepiness - Any suspected cataplexy - Sleep attacks or irresistible sleep episodes - Persistent hypnagogic/hypnopompic hallucinations or sleep paralysis CIRCADIAN RHYTHM DISORDERS SCREENING ----------------------------------- Clinical Presentation: - Chronic or recurrent sleep disturbance due to misalignment between desired/required sleep time and circadian rhythm - Common types: Delayed Sleep Phase Disorder, Advanced Sleep Phase Disorder, Shift Work Disorder, Irregular Sleep-Wake Rhythm Recommended Screening: - Sleep diary (2-week minimum) - Morningness-Eveningness Questionnaire - Detailed history of sleep-wake patterns Referral Criteria: - Significant impairment in social, occupational, or other important areas of functioning - Symptoms persisting despite adequate sleep hygiene measures - Shift work sleep disorder with significant impairment REFERRAL PROCESS --------------- When to Refer: - Positive screening results meeting referral criteria - Suspected sleep disorder with significant impact on quality of life - Sleep symptoms with significant comorbidities - Treatment-resistant sleep disorders - Diagnostic uncertainty Referral Information to Include: - Screening questionnaire results - Relevant medical history and medications - Previous treatments attempted - Impact of sleep symptoms on daily functioning - Specific sleep-related concerns FOLLOW-UP RECOMMENDATIONS ------------------------ - Schedule follow-up within 4-6 weeks after referral - Assess adherence to recommended treatments - Monitor for improvement in symptoms and quality of life - Coordinate care with sleep specialists for complex cases - Annual reassessment for patients with treated sleep disorders IMPLEMENTATION STRATEGIES ------------------------ - Incorporate sleep disorder screening into electronic health records - Provide staff education on sleep disorder recognition - Use waiting room screening questionnaires - Develop clear referral pathways to sleep specialists - Consider telehealth options for sleep consultations REFERENCES ---------- 1. Kapur VK, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(3):479-504. 2. Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-33. 3. Sateia MJ, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. 4. Garcia-Borreguero D, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. Sleep Med. 2016;21:1-11. 5. Scammell TE. Clinical features and diagnosis of narcolepsy in adults. UpToDate. Accessed 2023. 6. Auger RR, et al. Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders. J Clin Sleep Med. 2015;11(10):1199-236. © 2025 SleepEz. All rights reserved. These guidelines are intended for healthcare professionals only.