Running head: Polysomnography 1

Polysomnography Questions

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(Total words: 2470)

Polysomnography Questions

Question 1: Evaluation, Procedure, Data for patients with Insomnia (827 words)

In various medical literature, the term insomnia is used to define the presence of patient

reporting difficulties falling asleep. Due to the fact that the definition is not very clear and is

subject to interpretation, this paper will focus on the disorder characterized by the following

criteria: difficulties falling or staying asleep, this issue arises even though the adequate

circumstances for the sleeping process are provided, it leads to daytime distress and it occurs for

a minimum of 3 days each week.

In order to understand how to correctly diagnose these cases, it is important to have some

basic pathophysiology knowledge. Most of the cases of insomnia seem to be related to

hyperarousal experiences during the day. Cognitive theories state that patients who are passing

through a stressful period will experience insomnia due to disrupting the mechanism which

initiates this process. The neuroendocrine system is highly involved in this process because it

represents the key to the patient's hypervigilance. Previous studies pointed out that these patients

experience a higher than normal level of free cortisol. This is known as the stress hormone which

in normal patients increases during mornings and start to decline during the evening. (Hein, et

al,2017)

The initial evaluation should focus on the patient's history in order to determine if there are

any factors that can be attributed to this. It is important to discuss with the patient his or her

previous sleeping patterns and determine which was the point where the disruption took place.

This represents the first step in evaluating a patient and is the most easily approached technique

because it is based purely on communication. In case psychological stressful factors are

identified, the patient can receive support for therapies to find ways to cope with the issues in the

cause.

Acute forms of insomnia are usually treated this way and do not require further

investigations. Even so, the chronic forms are frequently managed by sleep specialists who

perform different tests such as a polysomnography. This method is usually conducted in a sleep

laboratory and uses various recordings such as an electrooculogram, electroencephalogram, leg

and submental electromyograms and nevertheless electrocardiogram, to provide the required

data. The disadvantage of this technique is represented by the fact that many of the patients

actually experience subject symptoms of insomnia while their results from the test remain

normal. Due to that, polysomnography is not the first approach when a patient presents with any

symptoms of insomnia. Criteria that indicated some sleep disturbance in the data retrieved

include the following: an increase in the wake after the sleep onset (WASO) period, a dramatic

decrease in the efficiency of sleep (SE), and an elongation of the sleep latency (SL). These three

parameters can be considered a form of indirect markers for the hyperarousal state of the patient.

The study usually presents with increased brain activating both during non-REM and REM sleep

which makes the patient prone to stay awake and creates a drastic instability in terms of the

different sleeping stages. The hyperarousal state induces an increase in the WASO period and a

decrease in both the non-REM and REM. Even though polysomnographic represent a good

method of diagnosis different sleep pathologies, its application in the real-life practice for the

patient with insomnia remains limited due to lack of clear markers. As it was demonstrated in

these paragraphs, the diagnosis is presented based on the symptomatology of the patient and the

indirect indicator of the hyperarousal state. (Rundo,2019)

The elements required to adequately diagnose insomnia are continually evolving based on

the latest researchers. Due to that, it is essential for the care providers to be aware of the changes

which occur. An alternative to the polysomnography is represented by the actigraphy test which

is conducted at the home of the patient. A sensor will be placed on the patient's ankle and wrist

which will determine their sleep patterns. In comparison with the sleep study which usually takes

around a day, the actigraphy test usually requires at least 14 consecutive days. In addition, this

diagnostic test also checks for circadian rhythm disorder or sleep apnea. When there is no

psychological factor that can be attributed to the pathology, the care provider can recommend

various blood tests such as thyroid hormone dosage to determine if a form of hyperthyroidism

isn't the cause of the disease.(Corlateanu et al,2017)

Usually, acute insomnia has clear reasoning for its initiation. On the other hand, the

chronic form is more complex and as this answer pointed out, it tends to require a

multidisciplinary approach. There are various tests available, but most of them lack both

sensitivity and specificity. Most frequently, an adequate assessment of the sleeping pattern can

be enough. Due to that various guidelines have been implemented in regard to standard

assessments which should be used by the care providers in order to standardize the diagnosis.

Until more objective factors are identified, insomnia remains more a subjective sleep issue which

raises many questions in terms of its diagnosis process.

Question 2: Medical Interaction and reporting insomnia cases (733 words)

As was depicted in the previous answer, the first step is represented by an adequate

assessment of the patient history which will have to evaluate the severity and impact insomnia

has on the quality of life. Due to the fact that nurses represent the first contact of the patient with

the medical care system, it is essential for them to maintain an up to date knowledge in regard to

the most efficient assessment options. An example of an assessment that can be conducted

during the first visit of the patient is known as the "Insomnia Severity Index". The test consists of

7 different questions which then are added up in order to interpret a final score. Various elements

are approached in this questionnaire such as the difficulty of falling or staying asleep, problems

when trying to wake up early, patient’s satisfaction regarding his or her current sleep pattern,

how noticeable this disease is to the other family members, and how much it interferes with daily

activities. Based on the result there are 4 major categories: stage 1 which is not significant from a

clinical point of view for this disease (score 0 -7 points); stage 2 which indicated a subthreshold

form of insomnia (score 8 -14 points); stage 3 clinical moderate insomnia (score 15-21 points)

and stage 4 which is severe clinical insomnia (score 22-28 points). These results can either guide

the care providers to the other diagnostic tests which were previously mentioned or start the

treatment. Usually, additional tests are required only when the care providers have a suspicion

regarding the origin of the sleep abnormalities and consider it a secondary form of insomnia

rather than a primary one. The nurse needs to be aware of the three types of insomnia when
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discussing with the patient (acute, transient, and chronic) as their approach can differ. (Verma et

al, 2016)

In order for insomnia to be treated efficiently, its mechanism needs to be understood both by

the nurse and the patients. Due to the lack of a standard plan of care for these patients, many

cases are unreported. It is believed that 7 out of 10 person experiences sleep difficulties. Due to

the high prevalence of this disease and due to the fact that it dramatically decreases the quality of

life of the patient, it needs to be approached in an effective manner since the first visit to the

health facility.

During the initial assessment, essential data need to be recorded which can be used to

establish the reasoning behind this condition. The nurse should evaluate how the patient spends

his day if they consume any kind of substances which could induce a hyperarousal state

(including nicotine, caffeinated products, or alcohol), evaluate the family members' opinion in

regard to this condition, and the sleep environment. Sometimes basic maps out of sleep schedule

which include the time when the patient has laid down, when they felt asleep and the moment

when they woke up can be enough. Even so, all these elements are very subjective and hard to be

recorded without external interference which can lead to wrong conclusions. Due to the

increased prevalence of stress, the nurse should focus on these elements during their first visit.

This can include any stress at work due to new projects or even a new job, changed interpersonal

relationships, or traumatic events. Once the assessment is recorded, the next step includes a

physical exam that will determine if there any signs of secondary conditions that can be

attributed to insomnia. When suspicion of obstructive sleep apnoea or restless leg syndromes
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exist, the patient can undergo polysomnography as instructed in the previous question. (Kaur et

al,2020)

Once all this data is retrieved, the physician needs to be informed in regard to the finding.

The nurse should be able to provide a full assessment of the patient so the medical care provider

could take an objective decision. Insomnia is a disease that requires multidisciplinary

investigations which further confirms the need of delivering these data to the other departments

(Such as to the cardiologist or to the endocrinologist). The nurse is an intermediary between the

patient and the physician. Their role is to adequately collect all the information needed to sustain

the diagnosis. Based on this information the physician can continue with the testing process or

can recommend a treatment. Usually, periodic reassessments are needed to determine the

efficiency of the proposed therapy.

References

Corlateanu, A., Covantev, S., Botnaru, V., Sircu, V., & Nenna, R. (2017). To sleep, or not to

sleep - that is the question, for polysomnography. Breathe (Sheffield, England), 13(2), 137–140.

https://doi.org/10.1183/20734735.007717

Hein, M., Lanquart, J. P., Loas, G., Hubain, P., & Linkowski, P. (2017). Similar

polysomnographic pattern in primary insomnia and major depression with objective insomnia: a

sign of common pathophysiology?. BMC psychiatry, 17(1), 273. https://doi.org/10.1186/s12888-

017-1438-4

Kaur H, Spurling BC, Bollu PC.(2020) Chronic Insomnia. In: StatPearls [Internet]. Treasure

Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK526136/

Rundo JV, Downey R 3rd.(2019) Polysomnography. Handb Clin Neurol. ;160:381-392. doi:

10.1016/B978-0-444-64032-1.00025-4. PMID: 31277862.

Verma, R., Nagar, K. K., Garg, R. K., Uniyal, R., Sharma, P. K., & Pandey, S. (2016). Study of

Sleep Disorders and Polysomnographic Evaluation among Primary Chronic Daily Headache

Patients. Journal of neurosciences in rural practice, 7(Suppl 1), S72–S75.

https://doi.org/10.4103/0976-3147.196469