Top Five Sleep Medicine No-Nos

If you are a person who suffers from a sleep disorder or chronic insomnia, you might think that any kind of testing or medication that a physician might provide to help you alleviate your symptoms would be a good thing But according to the American Academy of Sleep Medicine (AASM), there are some tests and treatments that should not be provided in specific circumstances.

The AASM’s “Choosing Wisely” list is the result of actions taken by the American Board of Internal Medicine Foundation back in the year 2009. At that time, the board invited clinicians to put together lists of tests and procedures that should be avoided within their particular practice, and many different groups have responded. The AASM’s list specifically indicates that chronic insomnia is a very specific diagnosis that requires clinical evaluation, and that is best done by conducting a complete sleep history as well as a physical examination. They say that pointed questions should be asked about substance use and psychiatric history, and suggest that patients be asked to complete questionnaires and keep sleep journals at home in order to detect specific patterns and symptoms. What does the AASM say should NOT be done for chronic insomnia? Here are their top five, as well as explanations for why.

Sleeping pills aren't always the best option for insomnia, Here are some reasons why:

1. Polysomnography

Though polysomnogaphy may be the gold standard in sleep testing, the AASM says that unless the symptoms that a patient is sharing indicate that there may also be a sleep disorder involved, the test would really only confirm self-reported symptoms. “PSG is indicated in some specific circumstances, for example when sleep apnea or sleep-related movement disorders are suspected, the initial diagnosis is uncertain, behavioral or pharmacologic treatment fails, or sudden arousals occur with violent or injurious behavior.”

2. Hypnotics

The AASM indicates that hypnotic medications are to be avoided in the treatment of chronic insomnia, and that instead of writing prescriptions for drugs, physicians should be providing the option of cognitive behavioral therapy. Numerous studies have shown that cognitive behavioral therapy, or CBT, is the most effective and long-lasting treatment for insomnia, and has the added benefit of lacking any negative side effects. It has been shown to improve sleep after a short period of time. The AASM does acknowledge that if patients have already been prescribed hypnotics and have been on them for an extended period of time, it may be appropriate to allow them to continue their use while beginning CBT.

3. Any Medication for Childhood Insomnia

It is important to remember that the Food and Drug Administration (FDA) has not approved any type of hypnotic or medication for the treatment of chronic insomnia in children. It has been shown that in most cases, insomnia in children is the result of interactions between the parent and the child, and is best treated through behavioral interventions. “As childhood insomnia usually arises due to parent-child interactions, treatment should involve efforts to improve relevant parent and child behavior, establish better sleep hygiene and manage expectations,” is the AASM recommendation. “Basic environmental, scheduling, sleep practice and physiological features should be optimized before hypnotic use is considered for children. When necessary, hypnotics should be used short term with caution and close monitoring for efficacy and side effects. Some children with significant developmental delay or cognitive impairment may not respond to behavioral management and may benefit from judicious use of hypnotics.”

4. Polysomnography for the diagnosis of Restless Leg Syndrome

Restless Leg Syndrome (RLS) is a chronic sleep disorder that is neurological in its origin. Its symptoms include throbbing, creeping and pulling sensations in the legs that are accompanied by an overwhelming need to move them. It occurs almost exclusively at night, and worsens as the night wears on. Moving the legs provides relief, but is extremely disruptive of sleep. The AASM says that polysomnography should not be used for the diagnosis of Restless Leg Syndrome, as it is easily diagnosed based on the symptoms that the patient describes. The only time that the AASM says that polysomnography is warranted is when documentation is required or the diagnosis is unclear. PSG “generally does not provide additional information necessary to make a diagnosis. If a patient’s clinical history for RLS is ambiguous, PSG to assess for periodic leg movements may be useful to help confirm an RLS diagnosis.”

5. Positive Airway Pressure Retitration for Specific Sleep Apnea Patients

Physicians who have patients who have been previously diagnosed with obstructive sleep apnea are frequently tempted to order new testing or retitration for these patients, but according to the AASM, it is not appropriate for those who are of stable weight, who are adherent to their continuous positive airway pressure treatments and have become asymptomatic. The AASM says that if the treatment is being followed and a patient’s weight has stabilized and symptoms are well controlled, there is no need for further testing. “Follow-up PSG or retitration is indicated for adult patients who are again symptomatic despite the continued, proper use of PAP, especially if they have gained substantial weight (e.g. 10% of original weight) since the last titration study. A new diagnostic PSG or retitration may be indicated for patients who have lost substantial weight, to determine whether PAP treatment is still necessary.”

Though this list represents the top five recommendations that the AASM received from their membership, they represent only a portion of the total recommendations that were submitted by AASM members. In total there were 21 different recommendations, ranging from the proper way to reduce medical waste from sleep laboratory settings to a number of recommendations for improved care for patients who have been diagnosed with sleep disorders. The final list that was submitted for the AASM’s contribution to the “Choosing Wisely” campaign was approved by the full board of the Academy.