a continuing medical education supplement to mpr … final monograph.pdfscreening & treating...

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SCREENING & TREATING PATIENTS WITH

DECEMBER 2009

Release date: December 2009Expiration date: December 31, 2010

FACULTYJulianne Blythe, MPA, PA-CPhysician AssistantUniversity of California, San Francisco Sleep Disorders CenterSan Francisco, California

Paul P. Doghramji, MD, FAAFPFamily PhysicianCollegeville Family PracticeCollegeville, Pennsylvania

Carla R. Jungquist, PhD, RN,FNP-C

Nurse PractitionerUniversity of Rochester Sleep and

Neurophysiology Research LaboratoryRochester, New York

Marc B. Landau, PAPhysician AssistantGaylord Sleep MedicineNorth Haven, Connecticut

Teresa D. Valerio, MSA, MSN,APN, FNP-BC

Advanced Practice Nurse, Certified Nurse Practitioner

Illinois Neurological Institute Sleep Center at OSF Saint Francis

Medical CenterPeoria, Illinois

Program Advisor:Sonia Ancoli-Israel, PhDProfessor of Psychiatry Director, Gillin Sleep and

Chronomedicine Research CenterUniversity of California,

San Diego School of Medicine San Diego, California

Course Advisor:Sanford H. Auerbach, MDDirector, Sleep Disorders CenterBoston Medical CenterBoston University School of MedicineBoston, Massachusetts

SLEEP/WAKE DISORDERS

A Continuing Medical Education Supplement to MPRwww.PrescribingReference.com

Supported by an educational grant fromCephalon, Inc.

CME/CE Activity

2 DECEMBER 2009

SCREENING AND TREATING PATIENTS WITH SLEEP/WAKE DISORDERS

STATEMENT OF NEEDSleep/wake disorders, which affect as many as 70 million Americans, are often unrecognized and undi-agnosed in primary care. They can have a dramatic and negative impact on daily life.1 These disorders cancause difficulty in concentrating and performing daily tasks; impair psychosocial, cognitive, and psychomo-tor functioning; and result in injuries or fatalities due to accidents.2-5 Among the most common sleep/wakedisorders in adults are obstructive sleep apnea (OSA), insomnia (inadequate or poor-quality sleep), circa-dian rhythm disorders, and restless legs syndrome (RLS).

Many clinicians rarely ask their patients about their sleep habits.6 Clinicians need to be alert to symp-toms and ask patients specific questions about their nighttime and daytime sleep symptoms as part of thehistory-taking process. If a sleep/wake disorder is suspected, the simple Epworth Sleepiness Scale can helpevaluate patient-perceived levels of drowsiness.

The physical examination can help diagnose or rule out underlying medical conditions. Laboratory testingmay involve a complete metabolic panel, thyroid screen, complete blood count (CBC), and iron/ferritin levels.Sleep-related problems should also be considered in patients with high-risk comorbidities. In some cases, refer-ral to a sleep clinic or laboratory may be necessary for polysomnography or further diagnostic tests.

The first step in any management strategy is establishing proper sleep/wake hygiene.Nonpharmacologic options may include behavioral therapies, continuous positive airway pressure (CPAP),oral appliances, oropharyngeal surgery, aggressive weight loss (including bariatic surgery), and positioningmethods. Pharmacologic options include sleep-promoting agents and wakefulness-promoting agents.Patients need to be educated about their sleep/wake disorder and regularly monitored for compliance,adverse events, and response to treatment.

A comprehensive program educating primary care clinicians about current diagnostic and managementstrategies for sleep/wake disorders and interventions for practice improvement can help them better iden-tify and treat these common disorders and improve sleep quality, outcomes, and quality of life for theiradult patients.

REFERENCES1. Colten HR, Altevogt BM. Sleep disorders and sleep deprivation: An unmet public health problem. 2006. The National Academies Press.http://books.nap.edu/catalog.php?record_id =11617. Accessed December 5, 2008.2. Drake C, Nickel C, Burduvali E, et al. The pediatric daytime sleepiness scale (PDSS): sleep habits and school outcomes in middle-schoolchildren. Sleep. 2003;26:455-458.3. National Highway Traffic and Safety Administration. Wake up and get some sleep. www.nhtsa.dot.gov/ people/injury/drowsy_driv-ing1/human/drows_driving. Accessed December 5, 2008.4. Pack AI, Maislin G, Staley B, et al. Impaired performance in commercial drivers: role of sleep apnea and short sleep duration. Am J RespirCrit Care Med. 2006;174:446-454.5. Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses’ work hours on vigilance and patients’ safety. Am J Crit Care.2006;15:30-37.6. National Sleep Foundation 2005. Sleep in America Poll. Washington, DC: National Sleep Foundation; March 2005. http://www.sleep-foundation.org/site/c.huIXKjM0IxF/b. 2419039/k.14E4/2005_Sleep_in_America_Poll.htm. Accessed April 18, 2007.

TARGET AUDIENCEPrimary care physicians

LEARNING OBJECTIVESAfter completing this activity, participants should be better able to:• Describe common sleep/wake disorders in adults such as obstructive sleep apnea, insomnia, circadian

rhythm sleep disorders, and restless legs syndrome • Explain techniques for screening and diagnosing common sleep/wake disorders• Identify nonpharmacologic and pharmacologic treatment strategies for common sleep/wake disorders• Outline optimal approaches for patient monitoring and follow-up, including criteria for referral to a

sleep specialist

ACCREDITATION STATEMENTBoston University School of Medicine is accredited by the Accreditation Councilfor Continuing Education to provide continuing medical education for physicians.

Boston University School of Medicine designates this educational activity for amaximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate withthe extent of their participation in the activity.

Estimated time to complete this activity is 1 hour

Program Code: E.SLEEPHAYM09

Release Date: December 2009 Expiration Date: December 31, 2010

DISCLOSURE POLICYBoston University School of Medicine asks all individuals involved in the development and presentation of continuing medical education (CME) activities to disclose all relationships with commercialinterests. This information is disclosed to CME activity participants. Boston University School of Medicinehas procedures to resolve any apparent conflicts of interest. In addition, faculty members are asked to dis-close when any unapproved use of pharmaceuticals and/or devices is being discussed.

FACULTY/ REVIEWERS’ DISCLOSURESJulianne Blythe, MPA, PA-C, has nothing to disclose with regard to commercial support.

Paul P. Doghramji, MD, FAAFP, serves as a consultant for Cephalon, Inc. and Wyeth and is on thespeakers’ bureaus for Cephalon, Inc., Pfizer Inc, Solvay Pharmaceuticals, and Takeda PharmaceuticalCompany Limited.

Carla R. Jungquist, PhD, RN, FNP-C, serves as a consultant for Abbott Laboratories and is on thespeakers’ bureau for Pfizer Inc.

Marc B. Landau, PA, has nothing to disclose with regard to commercial support.

Teresa D. Valerio, MSA, MSN, APN, FNP-BC, has nothing to disclose with regard to commer-cial support.

Sonia Ancoli-Israel, PhD, serves as a consultant for Ferring Pharmaceuticals Inc, GlaxoSmithKline,Orphagen Pharmaceuticals, Pfizer Inc, Respironics, sanofi-aventis, Schering-Plough Corporation, and Sepracor, Inc.

Sanford H. Auerbach, MD, is on the speakers’ bureau for Forest Laboratories, Inc.

PUBLISHING STAFF DISCLOSURESLara Zisblatt, MA, Boston University School of Medicine, has nothing to disclose with regard to com-mercial support.

Elizabeth Gifford, Boston University School of Medicine, has nothing to disclose with regard to com-mercial support.

Mary Jo Krey, Haymarket Medical Education, has nothing to disclose with regard to commercial support.

Sharon Hill-Ingram, Haymarket Medical Education, has nothing to disclose with regard to commercialsupport.

Lynne Callea, Haymarket Medical Education, has nothing to disclose with regard to commercial support.

Jeff Gherman, Haymarket Medical Education, has nothing to disclose with regard to commercial support.

DISCLOSURE OF OFF-LABEL USEUnlabeled/investigational uses of commercial products are discussed in this monograph.

DISCLAIMERTHESE MATERIALS AND ALL OTHER MATERIALS PROVIDED IN CONJUNCTION WITH CONTINUING MEDICALEDUCATION ACTIVITIES ARE INTENDED SOLELY FOR PURPOSES OF SUPPLEMENTING CONTINUING MEDICAL EDUCATION PROGRAMS FOR QUALIFIED HEALTH-CARE PROFESSIONALS. ANYONE USING THEMATERIALS ASSUMES FULL RESPONSIBILITY AND ALL RISK FOR THEIR APPROPRIATE USE. TRUSTEES OFBOSTON UNIVERSITY MAKE NO WARRANTIES OR REPRESENTATIONS WHATSOEVER REGARDING THE ACCU-RACY, COMPLETENESS, CURRENTNESS, NONINFRINGEMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OF THE MATERIALS. IN NO EVENT WILL TRUSTEES OF BOSTON UNIVERSITY BE LIABLE TO ANYONE FOR ANY DECISION MADE OR ACTION TAKEN IN RELIANCE ON THE MATERIALS. INNO EVENT SHOULD THE INFORMATION IN THE MATERIALS BE USED AS A SUBSTITUTE FOR PROFESSION-AL CARE.

©2009 Haymarket Medical Education LP25 Philips Parkway, Suite 105 Montvale, NJ 07645www.mycme.com

Cover photo: Getty Images

A SUPPLEMENT TO THE CLINICAL ADVISOR

DECEMBER 2009 3

SCREENING & TREATING PATIENTS WITH

Sleep/wake disorders are common, and ev-idence suggests that they are underdiagnosed.Yet sleep/wakedisorders and sleepiness have been associated with serious con-sequences, including increased risk for motor vehicle crashesand medical errors.This monograph will focus on diagnosing,screening, and treating four common sleep/wake disorders:obstructive sleep apnea (OSA), insomnia, circadian rhythmsleep disorders, and restless legs syndrome (RLS). It also intro-duces a practice improvement program that can facilitate andimprove detection and management of sleep/wake disordersin your practice.

SLEEP/WAKE DISORDERS: A COMMON PROBLEMSleep/wake disorders affect an estimated 50 to 70 million Ameri-cans.1 Manifestations of insomnia are so common that more thanhalf (54%) of the 1,506 respondents to a National Sleep Founda-tion general population survey reported experiencing at least oneof the four diagnostic symptoms (trouble getting to sleep,stayingasleep,awakening too early,and nonrestorative sleep) a few nightsper week.2 OSA occurs in an estimated one-fifth of adults,with6% having at least moderately severe disease.3 RLS affects up to10% of the US and northern European population.4 Prevalencedata for circadian rhythm disorders are unknown for the generalpopulation but are available for risk groups.

A Missed Diagnosis?Evidence suggests that sleep/wake disorders often go undiag-nosed. Patients with chronic insomnia rarely see a clinicianfor it (5%) and only infrequently (26%) mention it during vis-its for other problems.5 Less than one-third of 1,506 adults inthe National Sleep Foundation survey reported that their cli-

nician has ever asked them about their sleep.2 Even when pa-tients discussed symptoms of RLS, primary care physiciansdiagnosed only 6.2% of cases.6

To address this issue, Boston University and HaymarketMedical Education have developed a program to facilitate de-tection and management of sleep/wake disorders in yourpractice.This program, called the Sleep/Wake Practice Cir-cles Initiative,was created with leading experts in sleep/wakedisorders and quality improvement. A few of the practice-improvement tools are mentioned in this monograph. Partici-pants can earn up to 9 complimentary AMA PRA Category 1Credits™ or 4 Continuing Nursing Education Contact Hoursdepending on their level of participation. Access to faculty is available through teleconferences, e-mail, and telephone,to ask questions and receive guidance in developing and im-plementing an Action Plan to improve your practice.Furtherdetails and downloadable practice-improvement tools areavailable at www.sleeppracticecircles.com (see ad at back).

Initial data collected from the Practice Circles Programshow that an average of 67% of participants who completed an

SLEEP/WAKE DISORDERS

Get

ty Im

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4 DECEMBER 2009


initial assessment survey reported that sleep/wake disorders areunderdiagnosed in their practices, with more than 75% citingOSA as the most underdiagnosed.There were 35% who re-sponded “I don’t know”about the underdiagnosis of circadianrhythm sleep disorders, indicating a lack of awareness of theprevalence of that sleep disorder in their practice.The averageconfidence level for diagnosing circadian rhythm sleep disor-ders was the lowest of all the sleep/wake disorders in the survey(with an average of 3.9 on a scale of 1-10).

When asked about the use of tools for diagnosing sleep/wake disorders,almost 60% of participants were unaware of theEpworth Sleepiness Scale, which can help determine which patients’ sleepiness would be considered excessive. Only 2% of participants said they used any tools to help with diagnosis.Participants also indicated that they distribute patient educationmaterials less than half the time to patients they diagnose with a sleep/wake disorder, an option that helps place patients in aposition to self-manage their issues.

This monograph was written in response to gaps in practiceuncovered through live meetings educating physician assistantsand nurse practitioners about sleep/wake disorders as well assome Practice Circles Initiative and other data, showing a needfor further education among providers. The Practice CirclesInitiative further helps close these gaps by offering participantsstrategies for improving systems in their practice to help thembetter identify and care for patients with sleep/wake disorders.

IMPORTANCE OF RECOGNIZING AND TREATINGSLEEP/WAKE DISORDERSSleep, along with diet and exercise, is a cornerstone of health.Yet many people are unaware of what constitutes normalsleep.Following are some features of normal sleep:• Fall asleep in 15-20 min• Some brief awakenings• Sleep 7-9 hr• Feel refreshed upon awakening

Sleepiness or sleep/wake disorders have been associatedwith increased risk for death, medical and psychiatric condi-tions,safety consequences,and poor quality of life.Increased risk for mortality in sleep-disordered breathing. Pres-ence of severe sleep-disordered breathing was associated withhigher risk for all-cause death in the Sleep Heart HealthStudy (N = 6,441 men and women aged ≥40 years), even after adjustment for age, sex, race, body mass index (BMI),smoking status, and medical conditions.7 Severe sleep-disor-dered breathing was defined as ≥30 apnea or hypopnea eventsper hour.Obesity, type 2 diabetes, hypertension, heart failure, stroke, andOSA. All of these conditions have been associated with OSA.Figure 1 shows the elevated prevalence of OSA among peoplewith some of these comorbidities,based on a literature review;8

the highest is with type 2 diabetes.Impaired glucose metabolism and sleep apnea.Higher respirato-ry disturbance index was significantly associated with impairedfasting glucose (IFG), impaired glucose tolerance (IGT), andoccult diabetes in a cross-sectional analysis (n = 2,588) of theSleep Heart Health Study.9 The respiratory disturbance in-dex, although similar to the apnea-hypopnea index, also in-cludes respiratory events that do not technically meet thedefinitions of apneas or hypopneas but do disrupt sleep.Theadjusted odds ratio for all subjects was 1.3 (95% CI 1.1–1.6)for IFG, 1.2 (1.0 –1.4) for IGT, 1.4 (1.1–2.7) for IFG plusIGT,and 1.7 (1.1–2.7) for occult diabetes.Cardiovascular disease and RLS. The Sleep Heart HealthStudy (1,559 men and 1,874 women) also has identified an association between RLS symptoms and cardiovascular disease(coronary artery disease,stroke,heart failure).10

Cognitive dysfunction.A small study (N = 28) found that com-pared with control subjects, people with OSA showed lessbrain activation in regions involved in attention tasks.11

Depression. Onset or increased severity of sleep-related

0

20

40

60

80

Generalpopulation

— men(AHI>15)

Per

cent

age

of p

atie

nts

with

OS

A

Generalpopulation— women(AHI>15)

Type 2diabetes

Polycysticovary

syndrome

Coronaryartery disease

Stroke Congestiveheart failure

FIGURE 1. OSA Prevalence in Medical Conditions

The prevalence of OSA (defined as either AHI ≥10 or 15) in various medical disorders. Comparedto three population-based prevalence studies (20-23), patients with Type 2 diabetes [68,69],polycystic ovary syndrome [70, 72], coronary artery disease [74–76], congestive heart failure[77–79], and stroke [80–82] have a much higher prevalence of OSA. Each bar in the figure represents an individual study.AHI = apnea-hypopnea index, an index of severity that combines apneas and hypopneas.Used with permission from Lee W, et al. Expert Rev Respir Med. 2008;2:349-364.

breathing disorder was significantly associated with higherrisk for developing depression in a general population cohort(N = 1,408).12

Glaucoma. Prevalence of glaucoma among patients withOSA was 27% (27/100) in one study (N = 100).13

Menopause. Perimenopausal women are at elevated risk forOSA and RLS.14 OSA is more common in men by a 1.5- to3-fold margin, but in one study of middle-aged and olderadults (N = 397;175 men and 222 women),sleep disturbancewas associated with poor health-related quality of life in bothmen and women.8 At least one general population study reported higher chronic insomnia rates among peri- andpostmenopausal women (56.6% and 50.7%, respectively)compared with premenopausal women (36.5%). Severe hotflashes were significantly associated with chronic insomnia.15

Asthma, chronic obstructive pulmonary disease, and gastro-esophageal reflux are examples of relatively common condi-tions that can disturb sleep.14,16

Poor quality of life.Reporting one symptom of insomnia (dif-ficulty falling asleep, frequent awakenings with trouble get-ting back to sleep, or daytime tiredness) was significantlyassociated with poorer health-related quality of life on multi-ple SF-36 measures in a general population of 397 adults aged≥40 years old. Measures on which subjects with sleep prob-lems were likely to have significantly poorer quality of life included physical health problems,body pain,general health,mental health,vitality,and social functioning.17

SAFETY ISSUESSpending ≤4 hours in bed had an effect equivalent to that oflegal intoxication (Figure 2), according to one study.18 Usingan objective measure (the multiple sleep latency test), investi-gators equated the levels of sleepiness in sleep deprivation tothose associated with various breath ethanol levels.18

Motor vehicle accidents. Data suggest that people with OSA aremore likely to be involved in motor-vehicle crashes com-pared with controls.19 During the 3 years prior to referral forthe polysomnography (PSG) that led to the OSA diagnosis,patients with OSA (n = 643) had a roughly 2-fold increasedrisk for motor-vehicle crashes compared with age- and sex-matched controls.The elevated risk was higher (~3- to nearly5-fold) for crashes involving personal injury.Medical errors.For critical care nurses, the risk of making an errornearly doubled when working ≥12.5 consecutive hours.20 In

view of that, it is alarming that 62% of critical care nurse shiftslasted >12.5 hours in one study.20 Similarly, medical interns in intensive care units made 35.9% more errors while scheduled forlonger shifts (77 to 81 hours per week,working up to 34 consec-utive hours) than when scheduled for less-demanding ones (60 to 63 hours per week,working up to 16 consecutive hours).21

Major disasters. Sleepiness has been listed as a possible factor incausing major disasters such as the Exxon Valdez oil spill, theChernobyl and Three Mile Island nuclear power plant melt-downs, and the Union Carbide plant poison gas release inBhopal,India.1

SCREENING TECHNIQUES IN PRIMARY CARETo detect sleep problems,ask a few screening questions at everyannual visit (during the review of systems), and at visits when thepatient presents with conditions and physical findings with in-creased risk of sleep problems.Suggested screening questions are:• Do you have any sleep problems?• Do you feel well-rested during the day?If a patient screens positive for those questions, following aresome suggested additional questions to further clarify the prob-lem,first about nighttime and then about daytime symptoms:

Ask About Nighttime Symptoms• How many hours are you sleeping each night?

– Does this vary from weekday to weekend day? • Do you have any trouble getting to sleep? Why?


DECEMBER 2009 5

Tim

e (H

ou

rs) i

n B

ed

Adult

.190 BrEC

As measured objectively, ≤4 hours of sleep per nighthas a sedative effect equivalent to legal intoxication

.102 BrEC

.095 BrEC

.045 BrEC

FIGURE 2. Does Sleep Deprivation Sedate Like Alcohol?

N=32 healthy subjects without prior sleep deprivation and with ≥85% sleep efficiency.Each subject in the sleep group (n=12) was tested in all 4 conditions, with 3 to 7 days’ recovery time between tests.Blood alcohol level of 0.08% = legal intoxication in all states for drivers ≥21 years old,which is illegal.2

BrEC = breath ethanol concentration.1. Roberts T, et al. Sleep. 2003;26:981-985. 2. CDC. http://www.cdc.gov/alcohol/faqs.htm.

– Does your mind start to race upon lying down?– Do aches or pains prevent you from sleeping?– Do you feel an urge to move around at night?

• Do you have any trouble staying asleep? Why?– If you awaken,how long does it take to return to sleep?– Do you wake up gasping?– What does your bed partner say about your sleep? Does

he/she say you snore loudly or kick?• How long have you had this problem?

– Has this happened before? What did you do about it then? What are you doing about it now?

Ask About Daytime Symptoms• Do you feel like you’ve had a good night’s sleep when you

wake up and throughout the day?• Do you find yourself feeling drowsy and needing naps?

– Do you doze off at inappropriate times/places?– Do naps help?– Do you often miss the ending to movies because you

cannot stay awake?• Do you have a headache upon arising?• In the evening,do you have an urge to move your legs,along

with uncomfortable sensations in your legs,when at rest?• Are you having difficulty with concentration or memory?• Are you experiencing problems with mood (eg,irritabili-

ty,depression)?

Screening ToolsEpworth Sleepiness ScaleThe Epworth Sleepiness Scale (Table 1) is a self-administered,validated, brief tool for quantifying the severity of daytimesleepiness.22 It asks: “How likely are you to doze off or fall asleepin the following situations, in contrast to just being tired? This refers to your usual way of life in recent times.”A score >10 indicates significant sleepiness.23

Sleep/Wake Diary or LogAt times,patients may not recall sleep symptoms and times ac-curately,and a diary may reveal issues that did not surface duringquestioning.To assess sleep patterns, consider asking patientswho report sleep issues to keep a sleep/wake diary or log oftheir bedtimes and awakening/arousal times and perception ofsleep quality for at least one week. Ask patients to record:• Bedtime• Wake time• Total hours slept• Time to fall asleep• Number of awakenings,with time spent awake• Daytime alertness level• Daytime napping• Use of medicationsIt may also record caffeine and nicotine use,exercise,stress-relat-ed events, comments, and other factors. In patients for whomanxiety is a factor in their insomnia, the demands of keeping


6 DECEMBER 2009


TABLE 1. Epworth Sleepiness Scale:Measuring Daytime Sleepiness (ESS)1

SituationChance of Dozing

(0 -3)Sitting and reading 0 1 2 3Watching television 0 1 2 3Sitting inactive in a public place – for example, a theater or meeting

0 1 2 3

As a passenger in a car for an hour withouta break

0 1 2 3

Lying down to rest in the afternoon 0 1 2 3Sitting and talking to someone 0 1 2 3Sitting quietly after lunch (when you havehad no alcohol)

0 1 2 3

In a car, while stopped in traffic 0 1 2 3Total Score

0 = would never doze; 1 = slight chance of dozing; 2 = moderate chance of dozing;3 = high chance of dozing.ESS total score >10 indicates significant sleepiness2

1. Johns MW. Sleep. 1991;14:540-545.2. Panossian LA, Avidan AY. Med Clin North Am. 2009;93:407-425.

Practice Improvement: Using the Screening ToolsClinicians often can spend only 5 to 10 minutes withpatients during visits for acute problems and must covermany issues during an annual physical. Keeping a checklistof a few screening questions can help remind busy practi-tioners to ask about sleep. Hanging a poster aboutsleep/wake issues in the reception area and exam roomsmay prompt patients to bring up sleep problems they otherwise might not have mentioned.

Standardizing office systems can facilitate the use of the written tools. Consider keeping a folder of EpworthSleepiness Scales and patient sleep/wake diaries or logs onfile to facilitate their use. Placing copies in patient examrooms may work better for some practices. The program atwww.sleeppracticecircles.com can help you find anoption tailored to your practice.


an accurate diary may be a further hindrance and might be reconsidered.A link to one example of such a diary is availablefrom the Sleep/Wake Practice Circles Initiative Web site.

EDUCATE PATIENTS ABOUT NORMAL SLEEP ANDSLEEP HYGIENEPatients who have become accustomed to maladaptive sleephabits and patterns may view them as normal and not reportthem in answer to clinician questions.Educating patients aboutnormal sleep and good sleep hygiene can help elicit accurate in-formation about sleep issues.

Consider making educational materials about good sleephygiene available in your reception area and/or exam rooms.The Sleep/Wake Practice Circles Initiative (www.sleepprac-ticecircles.com) offers downloadable resources for patients.

Good sleep hygiene should be advocated for all patients andincludes the following principles:24

• Sleep only as long as needed to feel refreshed during the entire wake period (usually 7 to 9 hours/night for adults)

• Keep a regular sleep/wake schedule,do not vary on weekends

• Do not drink caffeine from at least 6 hours before bedtime and minimize daytime use

• Do not smoke,especially close to bedtime or if you awaken during the night

• Avoid alcohol and heavy meals in the late evening before sleep

• Exercise regularly but avoid vigorous exercise within 3 to 4 hours of bedtime

• Minimize noise,light,and excessively hot and cold tempera-tures where you sleep

• Avoid television and computer use in the bedroom,especial-ly if you awaken in the middle of the night

• Take a hot bath before retiringThese principles need to be modified to the individual patient.

OBSTRUCTIVE SLEEP APNEAPatients with OSA experience an anatomic obstruction of theirairway multiple times each night.The reduction of airway mus-cle tone that occurs during sleep leads to airway narrowing orclosure, requiring greater respiratory effort to move air.Airflowinterruptions can cause oxygen saturation to fall and carbondioxide levels to rise. Patients experience apneas, defined ascomplete cessation of airflow for ≥10 seconds; and/or hypop-

neas, ≥30% reduction in airflow compared to baseline for ≥10seconds plus a ≥4% decrease in oxygen saturation.25 They thenawaken,often so briefly the patient is unaware of it,and may ormay not return to sleep.26

Patients with OSA often complain of excessive daytimesleepiness and may awaken snoring, gasping, or choking.Theirbed partners may report that the patient snores loudly (oftenheard outside the bedroom) and falls asleep at inappropriatetimes. Diabetes and cardiovascular disorders such as hyperten-sion,stroke,atrial fibrillation,and congestive heart failure are as-sociated with this sleep disorder,and their presence should raisethe suspicion of OSA.Men are generally at greater risk for OSAthan women until menopause, but OSA is also seen in pre-menopausal women.Patients are often overweight (large neck,upper body) and may have craniofacial abnormalities. Twoscreening tools for OSA are the Berlin Questionnaire27 and theSTOP-BANG method.28

An OSA diagnosis is based on a polysomnogram showing atleast 5 apnea or hypopnea events per hour of sleep plus symp-toms,or at least 15 apnea or hypopnea events per hour of sleepregardless of symptoms (Figure 3).26 Presence of medical condi-tions associated with OSA should raise suspicion of this sleep/wake disorder (see page 4 and Figure 1).17,29,30

Evaluating Suspected OSASpecifics of the physical examination in suspected OSA varywith the clinical picture. Evaluation of the head, nose, throat,

DECEMBER 2009 7

Repetitive episodes of complete (apnea) or partial (hypopnea) reduction of airflow during sleep, lasting

≥10 sec (hypopneas must be associated with hypoxemia)

Diagnosed by PSG recording AHI ≥5/hr (must also have daytimesymptoms) or AHI ≥15/hr without symptoms.1Consider important comorbidities: HTN, stroke, atrial fibrillation,CHF, diabetes.2–4

Daytime Symptoms:Excessive sleepiness,fatigue, unrefreshingsleep, headache on waking, insomnia

Nighttime Symptoms:Awakens snoring,

gasping, or choking;nocturia, frequent

awakenings; patient oftenunaware of awakening

Bed Partner Complaints:loud snoring, pauses

or stopping breathing,falling asleep at

inappropriate times

FIGURE 3. OSA Diagnostic Criteria

PSG=polysomnogram; AHI=apnea/hypopnea index; HTN=hypertension; CHF=congestive heart failure.1. The International Classification of Sleep Disorders: Diagnostic & Coding Manual, revised.Westchester, IL: American Academy of Sleep Medicine; 2005. 2. Shahar E, et al. Am J Respir Crit Care Med. 2001;163:19-25. 3. Newman AB, et al. Am J Epidemiol. 2001;154:50-59. 4. University ofTexas, School of Nursing, Family Nurse Practitioner Program. Screening for obstructive sleep apnea in the primary care setting. University of Texas, School of Nursing; 2006.

8 DECEMBER 2009


neck, and mouth may reveal risk factors.A deviated septum ornasal polyps can obstruct the nasal passages and contribute tosnoring.31 Micrognathia, retrognathia, and a short and thickneck (circumference >16 inches in women or >17 inches inmen) are associated with OSA.31,32

The Mallampati score offers a tool for examining the mouthand throat (Figure 4).Originally developed to assess the difficul-ty of endotracheal intubation, this tool has been validated forevaluating suspected OSA prior to polysomnography.33 Instructthe patient to open the mouth as wide as possible and extend thetongue as far as possible,without making sounds.A higher scoreindicates a more crowded airway.Every 1-point increase in theMallampati score is associated with more than 2-fold increasedodds of having OSA.33

Ultimately, the only way to exclude the possibility of OSAwhen it is suspected is to obtain an overnight sleep study.Thiscan involve 2 nights,one to determine diagnosis of OSA and theother appropriate CPAP pressure, or both evaluations can becombined in one “split-night”sleep study.

Laboratory testing should include a complete blood countand complete metabolic panel, as well as thyroid-stimulatinghormone and T3/T4. Hypothyroidism has been associatedwith OSA.14,32 Consider performing a cardiovascular exam giv-en the frequency of cardiovascular comorbidities.

When to Refer for Sleep Testing A patient who admits to waking up gasping or choking,or whosebed partner has witnessed any apneas, should be referred to an accredited sleep specialist/sleep center.The following risk factors,especially when >2 are present,are considerations for referral:

• Snoring• Excessive daytime sleepiness34

• BMI >3034

• Neck circumference >16 inches for females or >17 inches for males32

• Mallampati score of 3 or 433

• Hypertension,type 2 diabetes,coronary artery disease,stroke,recurrent atrial fibrillation34

The Centers for Medicare & Medicaid Services (CMS) re-quire a face-to-face clinical sleep evaluation prior to a poly-somnogram.25 Medicare covers home sleep testing for diagnosisof OSA under some circumstances.35

Treatment for OSAThe first-line, most effective treatment for OSA is continuouspositive airway pressure (CPAP).23,36 CPAP therapy serves as apneumatic splint to maintain airway patency.It has been shownto improve daily functioning and reduce the rate of subjectivedaytime sleepiness,as well as lower the rate of motor-vehicle ac-cidents.36,37 CPAP therapy also has decreased blood pressure inpatients with OSA,38 and improved left ventricular ejectionfraction in patients with OSA and heart failure.39

Three general types of masks are available for use with CPAP:a mask that fits in the nose (also called nasal pillows), a mask thatcovers the nose (also called a nasal mask), and a mask that coversthe nose and mouth (also called full-face mask) (Figure 5).Choice


Class 1Entire tonsil

clearly visible

Class 2Upper halfof tonsil

fossa visible

Class 3Soft and

hard palateclearly visible

Class 4Only hard

palate visible

FIGURE 4. Mallampati Score and OSA Evaluation

Higher score is associated with greater risk for OSA.Used with permission from Walls RM, Murphy MF. The difficult airway in adults. In: Rose BD, ed.UpToDate. Waltham, MA: UpToDate; 2008. Copyright ©2008 UpToDate, Inc. For more information,visit: www.uptodate.com.Nuckton TJ, et al. Sleep. 2006;29:903-908.

Practice Improvement: Educating Patients Promotes AdherenceEducation and support can play important roles in facili-tating treatment success. Providing patient handouts orWeb sites about CPAP can increase treatment knowledge.Referring to durable medical equipment (DME) supplierthat provides good instruction and follow-up about howto use and clean the equipment is part of assistingpatients in managing their OSA. Medicare requires thatthe patient and/or the patient’s caregiver receive instruc-tion about the proper use and care of the CPAP machinein order to receive reimbursement.25 The Practice CirclesInitiative continuing education program at www.sleep-practicecircles.com offers materials and ideas to facilitate adherence to and benefit from CPAP therapy.

depends on fit and patient preference.Cold,dry air can irritate themucosa;heated humidity often improves comfort and adherenceto treatment and should be prescribed with CPAP.40

Regular Follow-up and Troubleshooting CPAP IssuesRegular follow-up visits to the primary care provider is essentialto accomplish 4 tasks:• Ensure adherence to CPAP. Many patients have difficulty

using the CPAP,with incomplete adherence rates of ≥50%.40

Regular follow-up offers an opportunity to uncover and ad-dress these issues.Refitting or changing the mask,adjusting pressure or humidity,and treating any rhinitis,sinusitis,or nasal obstruction often can improve adherence and effica-cy.40,41Adding a chin strap to close the mouth can help patients reporting dry mouth and continuing symptoms despite adequate CPAP use.Consider whether medications or comorbid conditions complicate CPAP use.Persistent or recurrent symptoms coupled with weight change >15% suggests the need for a sleep study to re-titrate pressure.40

• Managing comorbidities• Encouraging lifestyle changes,such as weight loss,smoking

cessation,and avoidance of alcohol• Assessing level of alertness

Residual sleepiness despite optimal CPAP therapy occursin some cases, depending on the parameter tested.36 In thiscase, the clinician should consider other causes of sleepiness.Itshould be kept in mind that drowsiness diminishes quality oflife and increases rates of accidents and injuries.After ensuringproper use of CPAP and sufficient time spent using it during

sleep,and after ruling out other causes of drowsiness,clinicianscan consider offering patients a trial of wake-promoting stim-ulants, such as non-amphetamine stimulants modafinil or ar-modafinil that carry a formal FDA indication,or,alternatively,one of the amphetamine stimulants.The latter should be con-sidered in patients on birth control pills, or for whom cost isan issue.40,41 Clinicians should consider referral to a specialist inthese cases.

Other Treatments for OSANot all patients can negotiate CPAP successfully. Those who can-not should be offered other options,such as oral appliances and sur-gery.Bariatric surgery for those morbidly obese has been shown tosubstantially improve OSA in some patients. Last, some OSA patients have apneas/hypopneas only when sleeping on their backor stomach;they can be positioned to sleep only on their sides.

INSOMNIAInsomnia is the most prevalent sleep/wake disorder in the gen-eral population.42 Symptoms of insomnia are common but a di-agnosis requires adequate opportunity to sleep plus next-dayconsequences as well as one of the symptoms listed in Figure 6.26

Insomnia can be considered acute (<1 month’s duration,often in response to a life event) or chronic (≥1 month’s dura-tion).42 About 10% to 15% of individuals in Western nationshave chronic insomnia,with 80% of those reporting symptomsfor at least 1 year.43 Unhealthy sleep habits that begin in responseto an acute event, such as a death, job loss, or other stressor,sometimes persist and lead to chronic insomnia.


DECEMBER 2009 9

FIGURE 5. Types of CPAP Masks

A mask that covers the nose A mask that fits in the nose A mask that covers the nose andmouth

10 DECEMBER 2009

SCREENING AND TREATING PATIENTS WITH SLEEP/WAKE DISORDERS A SUPPLEMENT TO THE CLINICAL ADVISOR

Insomnia:Impact of Comorbidities and MedicationsPrimary insomnia (ie, insomnia unrelated to other conditions)accounts for a small percentage of chronic insomnia cases. It israrely seen in clinical practice.43 Most cases of insomnia are co-morbid with medical or psychiatric illness.43 Psychiatric diag-noses are common,occurring in 40% of patients with insomniacompared with 16.4% of those with no sleep complaints in onestudy.44 People with hypertension, breathing or urinary condi-tions,chronic pain,and gastrointestinal diseases have statisticallyhigher levels of insomnia compared with those who did nothave these medical disorders.45 Symptoms of these conditionsmay awaken patients at night or interfere with sleep. Considerinsomnia in patients with these conditions who report sleepcomplaints. Other sleep/wake disorders (OSA, RLS, circadianrhythm disorder) also may precipitate,or present as,insomnia.43

Medications or other substances with stimulant properties(such as methylphenidate, amphetamine derivatives, deconges-tants, caffeine, nicotine, modafinil, armodafinil) can contributeto insomnia, and some stimulants contribute as well to risk forhypertension and cardiovascular disease.Ask about medicationsand consider whether the dosage can be reduced or taken earlierin the day to avoid conflict with sleep.

Treatment Strategies for InsomniaA variety of strategies can be useful in the treatment of insomnia.42

• Improve sleep hygiene.Most patients can benefit from counseling about these lifestyle measures (see page 7) but require other therapies as well.

• Psychological and behavioral therapy (usually done by a sleep clinic,but some measures can be done in the primary care clinician’s office)

• Short-term use of hypnotics to facilitate sleep• Treat comorbidity

First-line treatment for chronic insomnia involves at leastone psychological or behavioral measure along with counselingabout sleep hygiene.42 For acute insomnia,start with medicationif needed to provide some relief early,but begin behavioral andhygiene measures immediately. Medication should be consid-ered a bridge therapy while beginning behavioral therapy, andtapered as soon as is practical.

Psychological and Behavioral StrategiesOptions typically prescribed by primary care clinicians includestimulus control, sleep restriction, and/or relaxation training.Stimulus control involves breaking any association between thebedroom and difficulty sleeping, wakefulness, frustration, orworry. Patients are instructed to leave the bedroom if they donot fall asleep within about 20 minutes.This also involves turn-ing the clock around or getting rid of all timepieces, reducinglight, and using the bedroom only for sleep and intimacy.Thelast measure helps build the association between the bedroomand sleep. Patients who tend to read, watch television, or usetheir laptops,cell phones,or other electronic devices in bed maybenefit from this approach.Sleep restriction limits time in bed at night and bans daytime nap-ping in an effort to promote sleep consolidation.Consider this op-tion for patients who spend too much time in bed in a misguidedattempt to facilitate sleep.Relaxation training, including guidedimagery, progressive muscle relaxation, yoga, or meditation, is in-tended to lower physical and mental activation prior to sleep.

Relaxation training often accompanies cognitive therapy,which addresses unproductive beliefs about sleep such as “Ishould stay in bed if I cannot sleep”or “My life will be ruined ifI cannot sleep.”42 Some patients may benefit from referral forpsychotherapy to address non-sleep-related issues that interferewith sleep.This is especially true of those with comorbid depres-sion and anxiety.42

Pharmacotherapy for InsomniaMatching choice of medication to sleep symptom involves con-sideration of drug half-life.Trouble falling asleep without other sleep symptoms.Zaleplon has a

Next-day Consequences: Fatigue or malaise; difficulty with attention, concentration, or memory; social/vocational dysfunction or poor school performance; irritability/mood disturbance; daytime sleepiness; low motivation, initiative, energy; prone to errors/accidents; tension, headaches, GI symptoms in response to sleep loss; worries about sleep

Difficultyfallingasleep

Difficulty staying asleep(eg, inability to

return to sleep after awakening)

Poor qualityof sleep

Wakingtoo early

Primary and Comorbid Insomnia(Requires ≥1 symptoms below

with adequate opportunity to sleep + next-day consequences)

FIGURE 6. Insomnia Diagnostic Criteria

The International Classification of Sleep Disorders: Diagnostic & Coding Manual, revised.Westchester, IL: American Academy of Sleep Medicine; 2005.


DECEMBER 2009 11

very short half-life and therefore is used to reduce time to sleeponset.Ramelteon,a melatonin receptor agonist,may be appro-priate for patients who have a history of substance-use disordersor who do not wish to use a Drug Enforcement Administra-tion-scheduled agent.42 Zolpidem is a short- to intermediate-acting agent also used for difficulty falling asleep.Triazolam is ashort-acting hypnotic but is not a first choice because of its asso-ciation with rebound anxiety.42

Trouble staying asleep,with or without sleep initiation problems. Insome patients, the clinician may want to consider agents with alonger half-life.For instance,zolpidem CR has a slightly longerhalf-life than zolpidem. Although both may be helpful for sleepmaintenance,it is possible that the CR formulation may be a bitmore helpful in selected patients.Temazepam and eszopiclonehave longer half-lives and should be considered in such cases. A2005 National Institutes of Health did not recommend usingother benzodiazepines for insomnia.46Temazepam is pregnancycategory X and so should be avoided or used with caution inwomen of childbearing age.Avoid off-label therapy for insomnia. Some antidepressants (eg,trazodone,amitriptyline,doxepin,mirtazapine) and antipsychot-ic agents (eg,quetiapine,olanzapine) are used off-label to treat in-somnia.The 2005 National Institutes of Health panel advisedagainst this practice due to an unfavorable risk/benefit ratio.46

CIRCADIAN RHYTHM SLEEP DISORDERSCircadian rhythm sleep disorders may develop when the physicalenvironment demands a sleep schedule that is different from thatof the individual’s internal circadian rhythm.These disorders arecharacterized by difficulty sleeping (and complaints of insomnia)and/or sleepiness during the major wake period.They includedelayed or advanced sleep-phase disorder, irregular sleep/wakedisorder, shift work sleep disorder and jet lag type,and free-run-ning (nonentrained) sleep disorder (Figure 7).26,47

Diagnostic criteria require that this misalignment leads to sleepproblems (insomnia, excessive daytime sleepiness, or both) anddaytime consequences (social, occupational, or other dysfunc-tion).The diagnosis is based on identifying the patient’s sleep-wake schedule and daytime functioning through patient historyor the use of a sleep diary or log.Actigraphy, involving a motionsensor typically worn on a watch, is an optional method that is usually done only by sleep clinics.The presence of motion pro-vides a gauge of sleep and wakefulness.26,47

Delayed-sleep phase: Patients generally fall asleep in the early-

morning hours; then often,especially when circumstances per-mit (eg,on the weekend),they do not wake until the late morn-ing to early afternoon. This is most commonly seen inadolescents and young adults.Some cannot function during theweek because they go to bed at or after midnight but must rise at6 AM or 6:30 AM for school. On the weekend, they often sleepuntil noon or later.Advanced-sleep phase: Patients, often older adults, typically fallasleep in the early evening and wake earlier than desired in themorning.This occurs because a person who goes to sleep by 8 PM,for example,will have had 8 hours’sleep by 4 AM.Irregular sleep-wake rhythm: Patients have no discernible sleeppattern and tend to sleep for multiple 1- to 4-hour periods over24 hours.Shift work sleep disorder: Patients work an imposed schedule be-tween the hours of 7 PM and 7 AM and may have difficulty fallingand/or staying asleep during the sleep period and staying awakeduring the work period.Jet lag type: Also called desynchronosis, patients temporarilyhave fatigue, insomnia, and other symptoms as a result of airtravel across time zones.Free-running type: With this type, the circadian rhythm is notentrained to the 24-hour day.This disorder affects about 50% ofblind people and is rare in patients with normal vision.47

Treatment Strategies for Circadian Rhythm Sleep DisordersTherapy revolves around use of bright-light therapy duringperiods when wakefulness is necessary or desirable but diffi-cult, in order to reset the sleep-wake rhythm. The timing

Consequences include both complaints of insomnia and/or excessive daytime sleepiness and wake time dysfunction (social, occupational, other). Diagnosis based on history, sleep diary, actigraphy (optional)

Delayed orAdvanced

Sleep-Phase Type

IrregularSleep-Wake

Type

Free-Running(Nonentrained)

Type

Shift WorkType,

Jet LagType

Persistent or recurrent sleep disturbance due to either intrinsic (altered circadian rhythm, blindness) OR extrinsic (travel, daytime

sleep schedule) factors WITH consequences

FIGURE 7. Circadian Rhythm Sleep DisordersDiagnostic Criteria

1. The International Classification of Sleep Disorders: Diagnostic & Coding Manual, revised.Westchester, IL: American Academy of Sleep Medicine; 2005. 2. Morgenthaler TI, et al. Sleep.2007;30:1445-1459.

12 DECEMBER 2009


of light therapy varies with the disorder – eg,morning use fordelayed-sleep phase,evening use for advanced-sleep phase dis-order, during night-shift work for shift work sleep disorder,and during wake times upon destination for jet lag.Converse-ly, avoiding bright light near bedtime and using dark shadeswhile sleeping during daylight hours may improve sleep qualityand depth.

For delayed sleep-phase disorder, melatonin, a nutritionalsupplement (which therefore does not require FDA approval),issometimes used 4-5 hours before sleep onset, although there isno published evidence for its efficacy. Melatonin must be usedin combination with morning bright light.

Patients with irregular sleep-wake disorder may benefit fromincreased structured activities,exercise,and daytime light exposure.


CASE STUDYA 51-YEAR-OLD MAN WITHDIABETES AND HYPERTENSIONJohn B, a 51-year-old white constructionworker, presents for a 3-month follow-upof type 2 diabetes and hypertension. Inaddition to those conditions, John B hashypercholesterolemia, gastroesophagealreflux disease, and seasonal allergic rhinitis.He also is obese (body mass index [BMI]34.4; weight 240 lb, height 5’10”). Hedenies alcohol use, drinks 3 to 4 cups ofcoffee daily, chews tobacco, and has highblood pressure (140/96 mm Hg) despiteantihypertensive therapy (lisinopril). Othermedications are metformin, atorvastatin,ranitidine, and cetirizine. His father had dia-betes, experienced a myocardial infarctionin his 50s, and died in his 70s.

In reviewing diet, physical activity, andsleep habits, you learn that John B hasgained 6 lb since his last visit. He works 9to 10 hours a day and walks on his job butreports no time for formal exercise.Screening questions about sleep/wakesymptoms elicit the following:

Nighttime symptoms:• Feels “dead tired”and falls asleep after

dinner; gets up to go to bed at 9 PM

and falls right back to sleep• Awakens 3-4 times/night to urinate,

returns to sleep most nights

• Used to have acid reflux but stopped with use of ranitidine

• Wife sleeps in guest bedroom most nights because of his loud snoring

• Arises at 5 AM with alarm, usually has dry mouth

Daytime symptoms:• Reports feeling “not bad” upon awak-

ening but tiring in late morning• Tries to catnap here and there if he has

the time• Nearly dozed off a few times driving

home from work, so usually stops for coffee on the way

• Jokes that wife complains that he can-not stay awake to watch the end of anymovie

• Has no work injuries or car accidents.John B’s daytime symptoms suggest that his sleepiness could endanger himself or others.You decide to performa sleep workup and advise him to stopdriving until evaluation is complete andsuccessful treatment is initiated.

Sleep Evaluation and Management PlanJohn B’s Epworth Sleepiness Scale score is 18,when >10 indicates significant sleepiness.23

His physical examination is noteworthy for alarge neck size (18 inches), Mallampati class4, and slight retrognathia. Cardiorespiratory

and peripheral vascular and neurologic eval-uations are within normal limits. Cholesterollevels (total cholesterol [TC] 160 mg/dL,low-density-lipoprotein-cholesterol [LDL-C]80 mg/dL) are controlled by medication.HbA1c level (6.8%) is within the goal of<7% for people with diabetes.

John B appears to be at high risk forOSA. He is obese and has diabetes andhypertension. He reports that his wife oftensleeps in another room because of his loudsnoring. His excessive sleepiness may resultfrom sleep apnea, nocturia, or caffeine use.

Following documentation of clinicalfindings, you refer John B for a polysomno-gram at a sleep laboratory.You discuss withhim why you are referring him, what yoususpect, and what he can expect at thesleep lab.You provide some education aboutOSA and its health consequences, reinforcethe need for weight loss and exercise, reiter-ate prior advice to stop chewing tobacco,and educate about CPAP treatment.

Sleep Lab FindingsJohn B fell asleep rapidly (3 minutes) andslept slightly more than 7 hours at the sleeplaboratory. His apnea-hypopnea index of33.4/hour far exceeds the threshold of5/hour that is diagnostic for OSA with symp-toms. He experienced periods of oxygendesaturation as low as 76% with apnea.Normal sinus rhythm was present. John B

In patients with shift work sleep disorder, patients may betreated for either drowsiness during the shift, and/or insomniawhen they try to go to bed.Any sleep medication before bedtimeis an option that can also be used.Recommendations are to take10 hours off after working 8 hours;12 hours off after working 12hours; and 24 hours off when transferring to or from a night shiftwhenpossible.48Taking short naps of about 20 minutes each when

possible may help alleviate the effects of sleepiness.49 Two wake-promoting FDA-approved agents, armodafinil and modafinil,may be used to help maintain wakefulness and alertness.

In patients with jet lag, changing one’s schedule, being ex-posed to bright light,and avoiding caffeine and alcohol can helpadjust to the new time zone.There are no approved wake-pro-moting therapies for jet lag;melatonin is not very effective,as it


DECEMBER 2009 13

meets the diagnostic criteria for OSA. Hissplit-night polysomnogram recorded effec-tive control of OSA at a CPAP pressure of10 cm and, following CPAP titration, hewas prescribed CPAP therapy at 10 cmwater pressure with heated humidity and anasal mask.

FIRST FOLLOW-UP VISIT (AT THE SLEEPLAB): 9 DAYS AFTER CPAP INITIATIONEach follow-up visit includes an assessmentof adherence and experience with theCPAP therapy and a repeat of the EpworthSleepiness Scale. Most CPAP devices havebuilt-in meters recording duration of use.Clinicians review the same nighttime anddaytime sleep symptoms, related comor-bidities, and sleep screening tool that led tothe sleep laboratory referral to determinewhether the patient has improved.

John B is using the CPAP every night foran average of 6.8 hours/night but reportsthat the mask “doesn’t fit” and his mouthis dry. You schedule a mask fitting with hisdurable medical equipment supplier andadd a chin strap; the dry mouth could signalthat the jaw is opening at night.

Even during this brief treatment period,John B’s Epworth Sleepiness Scale andblood pressure have fallen, from 18 to 14and from 140/96 to 128/82, respectively.He awakens less often to urinate (twicerather than 3 to 4 times per night). He

reported some dozing at lunch, after work,and in the evening. He is adhering to ther-apy and responding well.

SECOND FOLLOW-UP VISIT (ATCLINICIAN OFFICE): 4 TO 6 WEEKSAFTER CPAP INITIATIONJohn B reports that the new mask and chinstrap are comfortable and that his mouth isno longer dry. He still uses the CPAP everynight, for a longer period than indicated atthe 9-day follow-up (an average of 7.6hours/night, up from 6.8 hours/night). Heno longer snores, his wife has returned totheir bedroom, and he awakens less oftento urinate (not at all or once per night,down from twice each night). He has lost 5 lb. Both symptom reports and EpworthSleepiness Scale score (down from 14 to12) indicate that his daytime sleepiness hasimproved. He no longer dozes at lunch. Ifhis Epworth score remains >10 with reportsof dozing 3 to 4 times per week after workand in the evening, you look for other caus-es of sleepiness, such as inadequate titra-tion, poor compliance, depression.

THIRD FOLLOW-UP VISIT (ATCLINICIAN OFFICE): 3 MONTHSAFTER CPAP INITIATIONJohn B’s CPAP adherence remains high,at 95% of nights at 7.8 hours/night.With continued CPAP use, his daytime

sleepiness as measured by the EpworthSleepiness Scale has fallen from a score of12 to 6. He has no trouble falling asleepand is not dozing during the day. He haslost another 6 lb since his visit 6 weeksago, for a total of 11 lb lost since start-ing CPAP therapy. His blood pressurehas normalized, to 118/80 mm Hg.HbA1c has fallen to 6.2% from 6.8%prior to CPAP therapy.

Medicare RequirementsA visit within the first 3 months is im-portant for Medicare reimbursement.In order to cover CPAP use in OSAbeyond the first 90 days, Medicarerequires a face-to-face re-evaluation ofthe patient documenting improvementof OSA symptoms and objective evi-dence of adherence to CPAP use.Minimum adherence is defined as usingthe CPAP at least 4 hours per night on70% of nights during a consecutive30-day period within the first 3 monthsof CPAP use.25 This minimal level ofadherence to CPAP therapy may not besufficient to reduce symptoms andhealth risks. Advise your patients towear CPAP whenever sleeping to maxi-mize the benefit they will receive fromtherapy.At this point, yearly follow-up issufficient as long as the symptoms donot return.

14 DECEMBER 2009


does not provide therapeutic benefit quickly enough for peoplewho switch time zones rapidly.Armodafinil is under FDA re-view as a treatment for improving wakefulness in jet-lag patientswith excessive sleepiness.

For individuals with free-running disorder, patient educa-tion about good sleep hygiene is recommended.50

RESTLESS LEGS SYNDROME Restless legs syndrome (RLS) is a disorder with sensory andmotor components.A clinical diagnosis,it requires 4 criteria: thepatient has the urge to move,usually accompanied by unpleasantsensations in the legs;this urge occurs or worsens during inactiv-ity, and occurs or worsens during the evening or night; and it ispartly or temporarily relieved by movement (Figure 8).51

Supportive criteria that may further strengthen the diagnosisinclude family history, response to dopaminergic therapy, andperiodic limb movements in sleep (which can be diagnosed onlywith an overnight sleep study).Prevalence of RLS among first-degree relatives of patients with RLS is 3 to 5 times higher thanthat of those without such a family history. Nearly all patientswith RLS will respond at least initially to dopaminergic therapy.At least 85% of patients with RLS also experience periodic limbmovements during sleep.51

RLS occurs twice as often in women as men.4 Prevalence in-creases with age up to 79 years old,then decreases.6 RLS is mostoften primary (75%) but can also be secondary to pregnancy,end-stage renal disease, iron deficiency, and medications.4,52 Ex-amples of medications and substances that can induce or aggra-vate RLS symptoms include selective serotonin reuptakeinhibitors, tricyclic antidepressants, caffeine, nicotine, alcohol,

and agents with antidopaminergic effects.4 As suggested by itsresponse to dopaminergic and antidopaminergic agents, RLSmay be associated with abnormalities of the dopamine system.4

A neurologic and vascular examination will help rule outother conditions,such as peripheral arterial disease or neuropa-thy. Patients with RLS tend to describe their symptoms as “Coca-Cola bubbles,”“arrows,” or “spiders” crawling on theirlegs rather than mentioning cramping or pain as a predominantsymptom. RLS also differs from leg cramps in that stretchingusually relieves the latter but not the former.The diagnosis ofRLS is made clinically; a neurologic test is not necessary. Nei-ther is a sleep test necessary unless you suspect periodic limbmovement disorder as well.

Treatment for RLSTherapy for RLS includes relaxing exercise or a warm bath be-fore bedtime and avoiding medications that may worsen symp-toms.53 Patients with a ferritin level <50 µg/L should receiveferrous sulfate 325 mg with vitamin C twice or 3 times daily.23,53

Investigate the cause of iron deficiency in patients with low fer-ritin levels.

The only FDA-approved medications to treat RLS are thedopamine agonists pramipexole and ropinirole.23 Both shouldbe started at the low end of their approved dose range and titrat-ed upward as needed to the maximum recommended dose. Inan evidence-based review analyzing literature up to and includ-ing 2006, ropinirole, pramipexole, and the unapproved agentslevodopa and gabapentin were noted as effective for RLS, andbromocriptine, oxycodone, carbamazepine, valproic acid, andclonidine as likely effective.54

The Johns Hopkins restless legs severity scale55 or the Interna-tional RLS Rating Scale56 may help evaluate ongoing management.When to Refer Table 2 indicates when you might consider referral to a sleepclinic or a sleep specialist.57-60


Supportive criteria: Family history, positive response to dopaminergictherapy, and periodic limb movements in sleep

Urge to move, usually with

uncomfortable, unpleasant sensations

in legs

Occurs or worsens

when inactive

Relieved partly and temporarily

with leg movement

Occurs only in or

worsens in evening/night

Movement disorder with sensory and motor components; Clinical diagnosis with 4 criteria

FIGURE 8. Restless Legs Syndrome Diagnostic Criteria

Allen RP, et al. Sleep Med. 2003;4:101-119.

Practice Improvement: Cheat Sheets forMedicationIf you have trouble remembering which medication worksbest for which symptom, keep a cheat sheet on hand. Asimple list of medications and their indications can beuploaded to your electronic medical record (EMR) or keptavailable with the patient handouts about sleep.

THE PRACTICE CIRCLES INITIATIVE This monograph presents current standards of care forsleep/wake disorders and illustrates how to apply quality im-provement interventions in this area.The Sleep/Wake PracticeCircles program is available online to guide you as you imple-ment these and other interventions in practice.

Boston University and Haymarket Medical Education havedeveloped the Practice Circles Program in conjunction withleading experts in sleep/wake disorders. It offers structure, sup-port, and continuing education credit for attempting to im-prove the care of patients with sleep/wake disorders. It isavailable at www.sleeppracticecircles.com and includes thefollowing elements:• Step 1: Complete a Practice Profile Survey to assess your

current practice (~10 minutes) • Step 2: Choose educational interventions. These include

4 radio-style teleconferences with opportunities to ask ques-tions of the faculty.You will receive 1 CME or CEU for every teleconference in which you participate.

• Step 3: Create and implement an Action Plan that involves quality-improvement tools.You will receive 5 CME credits for documenting this step.

• Step 4: Complete a Follow-up Practice Profile Survey to assess the effectiveness of your changes.Participants can earn a maximum of 9 complimentary AMA

PRA Category 1 Credits™ or 4 Continuing Nursing EducationContact Hours for completing all 4 steps.All information aboutyour practice remains anonymous.Through the Practice CirclesInitiative,you can access downloadable tools and expert supportfor patient education about sleep and detection of sleep/wakedisorders, and develop an Action Plan aimed to improve yourpractice. Through the structure and support of this program,you can enhance the care of sleep/wake disorders,assess the ef-fectiveness of those changes, and help improve your patients’sleep and quality of life.

SUMMARYSleep/wake disorders are common, underdiagnosed, and asso-ciated with serious consequences.Patients tend not to mentionsleep problems and clinicians often do not ask about them.Us-ing a few simple screening questions and tools can uncoversleep/wake disorders that will respond to treatment. Considerasking about sleep during annual physicals and regular visits forchronic conditions.This is especially relevant when following

patients with conditions linked to sleep/wake disorders.Educating patients about normal sleep and good sleep hy-

giene may improve sleep and prompt mention of unhealthysleep/wake patterns.The use of CPAP leads to beneficial out-comes in OSA.Psychological and behavioral measures offer thebest choice for patients with chronic insomnia.Bright light canhelp retrain the circadian rhythm in patients with circadianrhythm sleep disorders. Dopamine agonists are approved fortreatment of RLS.

Through a greater awareness of sleep/wake disorders andtaking a proactive approach to patient questioning, diagnosis,education, and management, clinicians can better detect andtreat sleep/wake disorders and improve patient outcomes andquality of life.

REFERENCES 1.Colten HR,Altevogt BM,eds.Committee on Sleep Medi-cine and Research.Sleep Disorders and Sleep Deprivation:An Unmet Public Health Problem.Washington,DC:National Academies Press;2006.http://books.nap.edu/openbook.php?record_id=11617&page=20#p2000f7ef8960020002.Accessed September 16,2009.2.National Sleep Foundation.2005 Sleep in America Poll.Summary of findings.March 2005.http://www.sleepfoundation.org/_content/hottopics/2005_summary_of_findings.


DECEMBER 2009 15

TABLE 2. When to Refer to a Sleep Clinic or SleepSpecialist

Suspected obstructive sleep apnea syndrome or narcolepsy1-3

Violent behaviors or unusual parasomnias1-3

Severe daytime sleepiness1

Periodic limb movements or certain neurologic disorders2,3

Insomnia fails to respond to behavioral and/or pharmacologic thera-py after an appropriate interval1,3

Psychiatric or substance-related comorbidity4

Significant problems described as related to the sleep disorder4

– Cognitive – Sensory– Attentional – Perceptual– Communicative – Amnestic

1. Doghramji PP. J Clin Psychiatry. 2001;62(suppl 10):10-26.2. Sateia MJ et al. Sleep. 2000;23:243-308.3. Kushida CA et al. Sleep. 2005;28:499-519.4. Schneiders J. CNI Rev. 1999;10: Available at: http://www.thecni.org/reviews/

10-1-19-schneiders.htm.


16 DECEMBER 2009


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20.Scott LD,Rogers AE,Hwung W-T,Zhang Y.Effects of critical care nurses’work hours on vigilance and patients’ safety.Am J Crit Care.2006;15:30-37.21.Landrigan CP,Rothschild JM,Cronin JW,et al.Effect of reducing interns’work hours on serious medical errors in intensive care units.N Engl J Med.2004;351:1838-1848.22.Johns MW. A new method for measuring daytime sleepi-ness: the Epworth Sleepiness scale.Sleep. 1991;14:540-545.23.Panossian LA,Avidan AY.Review of sleep disorders.MedClin North Am.2009;93:407-425.24.National Heart,Lung,and Blood Institute Working Groupon Insomnia;1998.Insomnia:Assessment and Management inPrimary Care.National Institutes of Health;Bethesda,MD.No.98-4088.25.LCD for Positive Airway Pressure (PAP) Devices for theTreatment of Obstructive Sleep Apnea (L11528).http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11528_2009-09-01_PA_2008-03_rev_ 2008-09.pdf. Accessed August 7,2009.26.The International Classification of Sleep Disorders:Diagnostic &Coding Manual, revised.Westchester,IL: American Academy of Sleep Medicine;2005.27.Netzer NC,Stoohs RA,Netzer CM,et al.Using the BerlinQuestionnaire to Identify Patients at Risk for the Sleep Apnea Syndrome. Ann Intern Med.1999;131:485-491.28.Chung F,et al.STOP questionnaire:A tool to screen patientsfor obstructive sleep apnea. Anesthesiology.2008;108:812-821.29.Newman AB,Nieto FJ,Guidry U,et al.Relation of sleep-disordered breathing to cardiovascular disease risk factors. TheSleep Heart Health Study. Am J Epidemiol.2001;154:50-59.30.Shahar E,Whitney CW,Redline S,et al.Sleep-disorderedbreathing and cardiovascular disease.Cross-sectional Results of the Sleep Heart Health Study.Am J Respir Crit Care Med. 2001;163:19-25.31.Nuñez-Fernandez D,et al.Snoring and obstructive sleepapnea,upper airway evaluation.eMedicine Specialties.UpdatedJune 16,2008.http://emedicine.medscape.com/article/868925-overview.Accessed August 7,2009.32.University of Texas,School of Nursing,Family Nurse Prac-titioner Program.Screening for obstructive sleep apnea in the primary care setting. Austin (TX):University of Texas,School of Nursing;May 2006.http://www.guideline.gov/summary/summary.aspx?doc_id=9436. Accessed June 5,2009.33.Nuckton TJ,Glidden DV,Browner WS,Claman DM.Phys-ical examination:Mallampati score as an independent predictorof obstructive sleep apnea.Sleep. 2006;29:903-908.34.Institute for Clinical Systems Improvement.Diagnosis andtreatment of obstructive sleep apnea.June 2008.http://www.icsi.org/guidelines_and_more/gl_os_prot/respiratory/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_ 3.html. Accessed July 26,2009.


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35.Centers for Medicare & Medicaid Services.CMS Manual System.Pub 100-03 Medicare National Coverage Determina-tions.Transmittal 96.October 15,2008.http://www.cms.hhs.gov/ Transmittals/Downloads/R96NCD.pdf. Accessed June 5,2009.36.Weaver TE,Maislin G,Dinges DF, et al.Relationship between hours of CPAP use and achieving normal levels ofsleepiness and daily functioning.Sleep. 2007;30:711-719.37.Gay P,Weaver T,Loube D,et al.Evaluation of positive airwaypressure treatment for sleep related breathing disorders inadults.Sleep. 2006;29:381-401.38.Becker HF, Jerrentrup A,Ploch T,et al.Effect of nasal con-tinuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea.Circulation.2003;107:68-73.39.Kaneko Y,Floras JS,Usui K,et al.Cardiovascular effects ofcontinuous positive airway pressure in patients with heart failure and obstructive sleep apnea.N Engl J Med. 2003;348:1233-1241.40.Chowdhuri S.Continuous positive airway pressure for thetreatment of sleep apnea.Otolaryngol Clin North Am.2007;40:807-827.41.Black J.Sleep and residual sleepiness in adults with obstruc-tive sleep apnea.Respir Physiol Neurobiol.2003;136:211-220.42.Schutte-Rodin S,Broch L,Buysse D,et al.Clinical guideline for the evaluation and management of chronic insomnia inadults. J Clin Sleep Med. 2008;4:487-504.43.Sateia MJ,Pigeon WR.Identification and management of insomnia. Med Clin North Am.2004;88:567-596.44.Ford DE,Kamerow DB.Epidemiologic study of sleep disturbances and psychiatric disorders.An opportunity for prevention? JAMA. 1989;262:1479-1484.45.Taylor DJ,Mallory LJ,Lichstein KL,et al.Comorbidity ofchronic insomnia with medical problems.Sleep. 2007;30:213-218.46.National Institutes of Health State of the Science Confer-ence statement.Manifestations and management of chronic in-somnia in adults, June 13-15,2005.Sleep. 2005;28:1049-1057.47.Morgenthaler TI,Lee-Chiong T,Alessi C,et al.Practice pa-rameters for the clinical evaluation and treatment of circadianrhythm sleep disorders.An American Academy of Sleep Medi-cine Report.Sleep. 2007;30:1445-1459.

48.Hughes R,Stone P. The perils of shift work:evening shift,night shift,and rotating shifts:Are they for you? Am J Nurs.2004;104:60-63.49.Agency for Healthcare Research and Quality.MakingHealth Care Safer: A Critical Analysis of Patient Safety Prac-tices.Evidence Report/Technology Assessment:Number 43.AHRQ Publication No.01-E058,July 2001. Agency forHealthcare Research and Quality,Rockville,MD.(chapter 46).http://www.ahrq.gov/clinic/ptsafety/.Accessed January 11,2007.50.Lu BS,Zee PC.Circadian rhythm sleep disorders.Chest.2006;130:1915-1923.51.Allen RP,Picchietti D,Hening WA,et al.Restless legs syndrome:diagnostic criteria, special considerations,and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health.Sleep Med.2003;4:101-119.52.Allen RP,Earley CJ.Restless legs syndrome.A review ofclinical and pathophysiologic features. J Clin Neurophysiol.2001;18:128-147.53.Hening WA.Current guidelines and standards of practice forrestless legs syndrome. Am J Med.2007;120(1A):S22-S27.54.Trenkwalder C,Hening WA,Montagna P,et al.Treatment of restless legs syndrome:an evidence-based review and implications for clinical practice.Mov Disord.2008;23:2267-2302.55.Allen RP,Earley CJ.Validation of the Johns Hopkins restlesslegs severity scale. Sleep Med.2001;2:239-242.56.Walters AS,LeBrocq C,Dhar A,et al; International RestlessLegs Syndrome Study Group.Validation of the InternationalRestless Legs Syndrome Study Group rating scale for restlesslegs syndrome.Sleep Med.2003;4:121-132.57.Doghramji PP.Detection of insomnia in primary care.J Clin Pyschiatry.2001;62(suppl 10):18-26.58.Sateia MJ, Doghramji K,Hauri PJ,et al.Evaluation ofchronic insomnia.Sleep. 2000;23:243-308.59.Kushida CA,Littner MR,Morgenthaler T,et al.Practice parameters for the indications for polysomnography and relatedprocedures:an update for 2005.Sleep.2005;28:499-519.60.Schneiders J.Clinical Management of Adult Insomnia.CNI Rev.1999;10.http://www.thecni.org/reviews/10-1-p19-schneiders.htm.

The content of this educational activity has been developed with faculty through an ongoing PracticeCircles initiative on the topic of sleep/wake disorders that is being conducted by Boston University Schoolof Medicine and Haymarket Medical Education.

To join this Practice Circles program and earn additional CME credits while improving your practice outcomes, please see the detailed information on the next page.

Screening and Treating Patients With Sleep/Wake Disorders

Improving Clinical Proficiency through Practice-Based Learning

EARN UP TO 9 COMPLIMENTARY CME/CE CREDITS

INTERACT WITH FACULTY AND YOURPEERS THROUGH A COMPLIMENTARYVIRTUAL PRACTICE CIRCLE

• Download patient handouts

• Participate in Discussion Board

• E-mail faculty

• Attend virtual Office Hours with faculty

HOW TO PARTICIPATESTEP 1 STEP 3 STEP 4STEP 2

Take a Practice Profile

survey to assessyour practice

Attend 4educational

teleconferences and earn 4 credits

Implement an Action Plan

to improve your practice and

earn 5 credits

Take a follow-up

Practice Profile survey to

measure the success of your

Action Plan

Supported by an educational grant fromCephalon, Inc.

Jointly sponsored by

Go to http://www.sleeppracticecircles.com for more information and to register.

Target AudiencePhysician assistants, nurse practitioners, nurses, and physicians in primary care

Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areasand policies of the Accreditation Council for Continuing Medical Education (ACCME)through the joint sponsorship of Boston University School of Medicine and HaymarketMedical Education. Boston University School of Medicine is accredited by the ACCME toprovide continuing medical education for physicians.

Boston University School of Medicine designates this educational activity for a maxi-

mum of 9 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commen-surate with the extent of their participation in the activity.

ACCME is one of the organizations that approve CME, which can be submitted asCategory I credit by Physician Assistants.

Nursing StatementContinuing Nursing Education Provider Unit, Boston University School of Medicine isaccredited as a provider of continuing nursing education by the American NursesCredentialing Center’s Commission on Accreditation.Contact hours: 4

Learning Objectives• Identify at least one barrier in your organization to the identifi-

cation and treatment of adult patients with common sleep/wake disorders

• Establish an Action Plan to facilitate improvements in your office-based practice for the identification and management

of adult patients with common sleep/wake disorders • Create and implement a general management plan for

adult patients with common sleep/wake disorders, taking into consideration available agents

CME/CE POST-TEST

1. The prevalence of obstructive sleep apnea (OSA)is highest among individuals with A. Coronary artery diseaseB. Polycystic ovary syndromeC. Type 2 diabetesD. Congestive heart failure

2. According to one general population study, whichperi-/postmenopausal symptom is significantly associated with chronic insomnia?A. Mood swingsB. Severe hot flashesC. HeadachesD. Decreased libido

3. The Epworth Scale is a self-administered tool toquantifyA. Number of hours slept at nightB. Factors that interfere with sleepC. Problems with moodD. Severity of daytime sleepiness

4. Which physical examination finding is associated with suspected OSA?A. Absence of tonsilsB. Impacted cerumenC. Thick neck circumferenceD. Edentulousness

5. Which medication could be considered to lessen drowsiness associated with shift work sleep disorder?A. ModafinilB. MethylphenidateC. PemolineD. Bupropion

6. Onset or increased severity of sleep-relatedbreathing disorder was significantly associatedwith higher risk for developing which of the fol-lowing in a general population cohort? A. Panic disorder B. Cognitive dysfunction C. Depression D. Substance abuse

7. Which medication for insomnia may be appropriate for patients who have a history of substance-use disorders?A. TriazolamB. ZolpidemC. ZaleplonD. Ramelteon

8. An example of good sleep hygiene for everyoneisA. Using the weekends to catch up on sleep

missed during the weekB. Avoiding watching television in the bedroomC. Having an alcoholic drink before bedtime to

induce drowsinessD. Napping regularly during the day

9. The presence of which medical condition that isassociated with OSA should raise the suspicion of OSA?A. Spinal stenosis B. Congestive heart failure C. Hypothyroidism D. Migraine headaches

10. One of the FDA-approved medications to treat RLS isA. GabapentinB. Clonidine C. RopiniroleD. Sertraline

DECEMBER 2009 19

To participate in this activity, please read the monograph and take the test. Fill in the answer andevaluation sheets and submit them to BUSM CME before December 31, 2010. CME or CE creditwill be awarded if a score of 70% or better is achieved. Or participate online to receive your certificate instantly at www.bucmetest.com.



ANSWER SHEET

PROGRAM EVALUATION AND ANSWER SHEETPlease read the monograph and take the test. Fill in the answer sheet and submit it to BUSM CME before December 31, 2010. CME credit will be awarded if a score of 70%or better is achieved. Submit the answer sheet via mail or fax to: Boston University School of Medicine, Continuing Medical Education, E.SLEEPHAYM09, 72 East Concord St.,A305, Boston, MA 02118. Fax 617-638-4905. Your certificate will be mailed to you in 4-6 weeks. To participate online and receive your certificate instantly, go to www.bucmetest.com. Enter E.SLEEPHAYM09 in the Test Code Search Field. For questions, please contact BUSM CME at 617-638-4605.

Boston University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Boston University School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participa-tion in the activity.

Darken the circle with the correct answer to each question in the CME activity.

Please type or print clearly

First name Middle initial Last name Degree Specialty

Mailing address

City State ZIP + 4-digit code

Phone FAX E-mail address

The amount of time I spent on this activity was ___________ (max of 1 hour).

1. How would you rate this activity overall?(5 = excellent, 1 = poor; please circle one)

5 4 3 2 1

2. Do you feel each of the learning objectives listed on page 2 was met?

Objective 1 o Yes o Partially o No o N/AObjective 2 o Yes o Partially o No o N/AObjective 3 o Yes o Partially o No o N/AObjective 4 o Yes o Partially o No o N/A

3. In your opinion, did you perceive any commercial bias?

o Yes o No If yes, please specify:

4. Please rate the content of this activity.(5 = excellent, 1 = poor; please circle one)

4a.Timely, up to date? 5 4 3 2 14b. Relevant to your practice? 5 4 3 2 1

5. Do you feel that the information in this activity was based on the best evidence available? o Yes o No If no, please explain:

6. Do you intend to make changes in your practice asa result of this activity? o Yes o No

If yes, please explain:

7. Which of the following competency areas do you feel

have been improved as a result of this activity?

(Mark all that apply)

o Patient care o System-based practice

o Medical knowledge o Practice-based learning

o Professionalism o Communication skills

8. Please make suggestions for future programs.

Program Evaluation

1 . A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

Exam Answer Form

a continuing medical education supplement to mpr … final monograph.pdfscreening & treating...

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