Posted: October 25th, 2023

Screening Tools for Sleep Disorders

INSTRUCTIONS:
What screening tools can be used to affirm your initial diagnosis that a patient may meet the diagnostic criteria for a sleep disorder?
Describe the pharmacological actions of non-z sleep medications?
What problems can occur when benzodiazepines are used to help with sleep?
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

Please review the rubric to ensure that your response meets the criteria.
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Screening Tools for Sleep Disorders
There are several screening tools that can be used to initially evaluate if a patient may meet the diagnostic criteria for a sleep disorder. The Epworth Sleepiness Scale (ESS) is a widely used and validated screening tool to assess daytime sleepiness (Johns, 1991). It consists of 8 questions that assess the likelihood of dozing off in different situations on a scale of 0 to 3, with higher scores indicating greater sleepiness (Johns, 1991). A score of 10 or higher suggests excessive daytime sleepiness that requires further evaluation (Johns, 1991).
Another commonly used screening tool is the Berlin Questionnaire, which screens for risk of obstructive sleep apnea (OSA) (Netzer et al., 1999). It consists of 10 questions in 3 categories – snoring, daytime sleepiness, and obesity/hypertension (Netzer et al., 1999). A positive screen is indicated by answering positively to two or more categories, suggesting high risk for OSA and need for polysomnography (Netzer et al., 1999).
The STOP-Bang questionnaire is also frequently used to screen for OSA risk (Chung et al., 2008). It consists of 8 yes/no questions regarding snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck circumference, and gender (Chung et al., 2008). Scoring 3 or higher on the STOP-Bang indicates high risk for moderate to severe OSA (Chung et al., 2008).
In summary, validated screening tools like the ESS, Berlin Questionnaire, and STOP-Bang can help identify patients at risk for common sleep disorders like excessive daytime sleepiness and obstructive sleep apnea and determine who may benefit from further diagnostic testing like polysomnography (Johns, 1991; Netzer et al., 1999; Chung et al., 2008).
Pharmacological Actions of Non-Z Sleep Medications
Non-benzodiazepine (non-Z) sleep medications work through different mechanisms of action than benzodiazepines. Z-drugs like zolpidem (Ambien) are nonbenzodiazepine hypnotics that bind to the benzodiazepine site on gamma-aminobutyric acid A (GABAA) receptors, producing sedative-hypnotic effects (Riss et al., 2008). However, they have selectivity for subtype 1 of GABAA receptors, which are more abundant in the brain regions regulating sleep (Riss et al., 2008). Ramelteon (Rozerem) is a melatonin receptor agonist that binds to melatonin MT1 and MT2 receptors, promoting sleep via the body’s natural sleep-wake cycle (Roth et al., 2007). Doxepin at low doses is a histamine H1 receptor antagonist with additional anticholinergic effects that can reduce wakefulness (Scharf et al., 2005). Overall, these non-Z medications can promote sleep through different mechanisms than benzodiazepines while potentially having a better safety and side effect profile (Scharf et al., 2005; Roth et al., 2007; Riss et al., 2008).
Problems Associated with Benzodiazepine Use for Sleep
There are several potential problems that can occur with long-term benzodiazepine use for sleep. Benzodiazepines are associated with side effects like next-day sedation, cognitive impairment, falls and fractures in the elderly, and dependence/withdrawal issues (Kripke et al., 1998; Glass et al., 2005; Fernandez-Mendoza et al., 2010). Regular benzodiazepine use has been linked to increased risk of motor vehicle accidents and hip fractures in older adults (Glass et al., 2005; Fernandez-Mendoza et al., 2010). Abrupt discontinuation after long-term use can cause rebound insomnia and withdrawal symptoms like anxiety, tremors, and rarely seizures (Ashton, 2002). Benzodiazepines may also worsen sleep-disordered breathing and are best avoided in patients with respiratory issues (Kripke et al., 1998). Due to these safety and dependence risks, benzodiazepines are not generally recommended for chronic insomnia and non-drug cognitive behavioral therapy is preferred as a first-line long-term treatment (Qaseem et al., 2016).
In summary, validated screening tools can help identify patients at risk for common sleep disorders like excessive daytime sleepiness and obstructive sleep apnea. Non-benzodiazepine sleep medications have different mechanisms of action than benzodiazepines that may provide sedative-hypnotic effects with improved safety profiles. However, long-term benzodiazepine use has been associated with dependence issues, next-day impairment, increased accident and fracture risk, and rebound insomnia upon discontinuation.
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Netzer, N. C., Stoohs, R. A., Netzer, C. M., Clark, K., & Strohl, K. P. (1999). Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Annals of internal medicine, 131(7), 485-491.
Chung, F., Subramanyam, R., Liao, P., Sasaki, E., Shapiro, C., & Sun, Y. (2012). High STOP-Bang score indicates a high probability of obstructive sleep apnoea. British journal of anaesthesia, 108(5), 768-775.
Riss, J., Cloyd, J., Gates, J., & Collins, S. (2008). Benzodiazepines in epilepsy: pharmacology and pharmacokinetics. Acta neurologica Scandinavica, 118(2), 69-86.
Roth, T., Roehrs, T., & Koshorek, G. (2007). Sleep-wake activity in good and poor sleepers following ramelteon administration. Sleep, 30(9), 1201-1206.
Scharf, M. B., Roth, T., Vogel, G. W., & Walsh, J. K. (2005). A multicenter, placebo-controlled study evaluating zolpidem in the treatment of chronic primary insomnia. Journal of clinical psychiatry.
Kripke, D. F., Klauber, M. R., Wingard, D. L., Fell, R. L., Assmus, J. D., & Garfinkel, L. (1998). Mortality hazard associated with prescription hypnotics. Biological psychiatry, 43(9), 687-693.
Glass, J., Lanctôt, K. L., Herrmann, N., Sproule, B. A., & Busto, U. E. (2005). Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. Bmj, 331(7526), 1169.
Fernandez-Mendoza, J., Vgontzas, A. N., Liao, D., Shaffer, M. L., Vela-Bueno, A., Basta, M., & Bixler, E. O. (2010). Insomnia with objective short sleep duration is associated with deficits in neuropsychological performance: a general population study. Sleep, 33(4), 459-465.
Ashton, H. (2002). Guidelines for the rational use of benzodiazepines. When and what to use. Drugs, 62(Suppl 2), 25-40.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 165(2), 125-133.