The 5 biggest sleep medicine no-no’s

You might think that any kind of treatment for a sleep disorder is better than none, but according to some of the world’s leading sleep medicine professionals, some treatments, in specific circumstances, should be avoided completely.

As part of a continued commitment to providing high-quality, patient-centred care, the American Academy of Sleep Medicine (AASM)  has published a list of five common tests and treatments that are not always necessary in sleep medicine, in order to promote better conversation between doctors and patients, reduce medical waste and provide the most appropriate care.

The top 5 were voted the most popular out of 21 candidate recommendations put forward by the Executive Committee of the AASM. The list was published as part of the Choosing Wisely,  an initiative by the ABIM Foundation which aims to ‘improve health care through the advancement of medical professionalism.’

Here’s a rundown of the top five:

1) Most insomniacs don’t need a sleep study

A polysomnogram (PSG) is the gold standard of sleep testing and is vital to perform accurate diagnoses on a wide range of sleep disorders. However, the AASM says that patients with chronic insomnia should avoid a PSG, unless symptoms suggest a co-morbid sleep disorder.

“Chronic insomnia is diagnosed by a clinical evaluation that includes a thorough sleep history along with a medical, substance and psychiatric history……..Although polysomnography may confirm self-reported symptoms of chronic insomnia, it does not provide additional information necessary for diagnosis of chronic insomnia.”

2) Medication is not the first choice for treating insomnia

Sleeping pills (hypnotics) such as benzodiazepines and Z-drugs, generally, should not be the first choice of treatment for chronic insomnia, according the the AASM. Although some long-term hypnotic users may be unwilling to give up their medication, the preferred first-option for treating insomnia is cognitive behavioural therapy (CBT), a non-drug approach, which has none of the side-effects or dependency issue of pharmaceuticals.

“In clinical trials, CBT is generally as effective as or more effective than hypnotics at improving sleep, and can be effective over an extended period of time without side-effects associated with hypnotics.”

3) Don’t give kids sleeping pills

In the US there’s a growing trend of parents giving sleep meds to kids. Although some treatments, such as melatonin are considered to be an effective and harmless quick fix for sleep challenged kids, it’s important to remember that there are no approved medications in the US for childhood insomnia, which is why the AASM strongly recommends behavioural treatment over hypnotics.

“As childhood insomnia usually arises due to parent-child interactions, treatment should involve efforts to improve relevant parent and child behavior, establish better sleep hygiene and manage expectations. Basic environmental, scheduling, sleep practice, and physiological features should be optimized before hypnotic use is considered for children.”

4) You don’t need a sleep study to diagnose Restless Legs Syndrome

Restless legs syndrome (RLS), one of the most common sleep problems, is a neurological disorder that causes sensations in the legs, resulting in an irresistible urge to move. However, unless the patient’s clinical record is ambiguous, the AASM doesn’t recommend PSG as a means to diagnose the condition.

Restless Legs Syndrome (RLS) is a neurologic disorder that can be diagnosed based on a patient’s description of symptoms and additional clinical history.

5) Sleep apnea patients with stable weight and no symptoms don’t need a re-titration study

The most common treatment for sleep apnea – a breathing disorder affecting millions – is known as continuous positive airway pressure (CPAP, or PAP). Although highly effective, the patient must wear a mask at night whilst air is blown into the breathing passage.

A titration study, performed in a sleep lab, is used to determine the correct settings for a patients PAP device. Some patients demand a ‘re-titration’ study when they feel their treatment is not performing adequately. The AASM, however advises against re-titration,

“for adult obstructive sleep apnea patients with stable weight whose symptoms are well controlled by their current PAP treatment. Follow-up PSG or re-titration is indicated for adult patients who are again symptomatic despite the continued, proper use of PAP, especially if they have gained substantial weight (e.g. 10% of original weight) since the last titration study.”

You can read the full list at Choosing Wisely here.

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  1. This is a valuable list. Efficiency and effectiveness are both important components of patient care. It would be interesting if the AASM published a list of the most under-prescribed treatments–that is, treatments that are required in patients with sleep disorders that are not received because of misdiagnosis or not being aware of having the disorder. I think a lot of people are not receiving the care they need (especially for sleep apnea) because they are not officially diagnosed.

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