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The Sleep Centre at OneWelbeck Lung Health
Sleep disturbance is highly prevalent and a widely discussed a sign of the times. With greater awareness of its consequences, and specialist multidisciplinary evaluation becoming more accessible, it is no longer the unspoken symptom to be accepted. Rather, there is a chance to understand what reversible factors are present to be dealt with straightforwardly, whilst identifying those sleep disorders that require specialist input. At OneWelbeck we have the multispecialty expertise in all aspects of sleep disorders. Referrals are welcome from self-referrals, primary care, and various specialties including respiratory medicine, cardiology, ENT, neurology, pain medicine, bariatric pathways, women’s and men’ s health and haematology.
As the opportunity for sleep diminishes in an increasingly busy work-life schedule, and with sleep confounders frequently going unrecognised or undervalued, a detailed sleep history, with corroborative information is an important starting point.
Short-term sleep disturbance
Short-term sleep disturbance is highly prevalent, up to 30% in some primary care cohorts. A thorough sleep history, understanding potentially reversible factors to improve the sleep/wake schedule, and adherence to sleep hygiene rules underlies effective management.
Insomnia is defined as inability to initiate or maintain normal sleep more than 3 times per week, with a notable daytime impact, despite an adequate opportunity and conducive environment or circumstances. It may be short term or chronic if over 3 months. There may be primary insomnia or more commonly secondary to a particular episode or circumstances – medical or medicinal, psychological or social. Factors explored should include precipitating, perpetuating and predisposing. It often has a bidirectional relationship with psychological aspects and consequently, if diagnosed, Cognitive Behavioural Therapy for Insomnia (CBTi) is the most effective management. OneWelbeck offers these assessments and treatment.
Obstructive Sleep Apnoea (OSA)
Obstructive sleep apnoea (OSA) is a condition in which people breathe shallowly or stop breathing for short periods while sleeping. This can occur many times at night, leading to frequent arousals and disturbed sleep. These in turn can cause excessive daytime sleepiness, impaired concentration and hypoxaemia.
The consequences of untreated OSA include impaired daytime mental functioning, personality changes and social impairment. Importantly, it can have serious consequences on activities requiring alertness. Thus, there is up to a 12 fold increase in road traffic accidents (RTAs) in patients with OSA . Sleepiness at the wheel may cause up to 20% of motorway accidents, with each fatal accident estimated to cost £1.25 million to society.
Furthermore, there is now strong and emerging evidence that OSA is an independent risk factor for coronary heart disease, hypertension and Stroke (estimated 2-4x increased risk). Moreover, there is also evidence that successful treatment of OSA can reduce diastolic blood pressure by up to 5 mmHg in trials. Over time, this might have a profound impact on cardiovascular and cerebrovascular risk, as part of a collective risk reduction strategy [2,3]. OSA is emerging as a significant public health problem, with a large and increasing demand for sleep service facilities due to the high prevalence and growing public awareness of its existence. Conservative estimates of the prevalence of OSA in middle aged men (30-65y) are between 0.3-2%, which are similar to Type 1 diabetes mellitus . The prevalence in women may be more than half that of men. The gold standard treatment is nocturnal continuous positive airway pressure (CPAP), delivered easily at home.
The diagnosis and treatment of sleep apnoea are now recognised as important national requirements endorsed by NICE and other healthcare organisations (e.g The British Thoracic Society). Thus capacity of services to accommodate an emerging healthcare requirement provides both a pressure and opportunity.
Risk factors include high body mass index, weight gain, short stature, oronasal conditions, sedo-analgesic medications for pain or psychiatric conditions, large tongue or tonsils, and craniofacial variants, to name a few. Cardiac heart rhythm abnormalities or heart failure and certain neurological conditions also have bi directional relationships, whilst a percentage of those with chronic obstructive pulmonary disease may have concomitant Sleep apnoea.
Nocturnal Hypoventilation Syndrome
Nocturnal hypoventilation syndrome is associated with, different from but often coexistent with sleep apnoea. It is characterised by relative under-breathing at night, chronic high carbon dioxide levels, associated headaches and/or ankle swelling which may indicate a weakness of the right side of the heart.
Other sleep disorders
Other primary sleep disorders that require the kind of specialist advice offered at OneWelbeck include:
- Central disorders of hypersomnolence – such as Narcolepsy or idiopathic hyersomnolence
- Circadian rhythm sleep-wake disorders including phase shift disorders, shift-work disorders or chronic jet lag
- Parasomnias and movement disorders like night terrors, sleep walking REM behaviour disorder, cathathrenia, Restless legs syndrome and Periodic limb movement disorder, as well a range of disorders exacerbated by medical illness or medications (e.g. Parkinson’s, chronic benzodiazepines)
Referral pathway, evaluation and treatment
If a patient is referred for evaluation of possible sleep apnoea with sleep disturbance, excessive daytime sleepiness/tiredness, loud snoring or concerns about irregular night time breathing patterns, then a standard protocol is followed. An initial detailed medical consultation is arranged. During that visit, a full history and examination, preferably with an accompanying partner (although not essential), are performed with specific questionnaires, and if necessary a sleep diary for review.
The next stage is usually an overnight sleep study. This may be as an inpatient or at home. The results are analysed, and this report together with other investigations are discussed at a follow up appointment. At this stage, the diagnosis is usually available, and treatment with a device &/or other management strategies are discussed and arranged. Occasionally, sleep studies require repeating for reasons of technical quality assurance. Furthermore, certain other investigations that are important for health may be undertaken.
At OneWelbeck we offer a full specialist evaluation, and a range of home diagnostic sleep studies including sleep apnoea screening devices, home video-polysomnography, actigraph watch and sleep diary for insomnia, and follow-up treatments such as CPAP (continuous positive airway pressure devices which are the gold standard) for sleep apnoea, mandibular advancement devices, chin straps, and CBTi for insomnia. A more detailed multispecialty assessment with ENT, Orthodontics and drug-induced sleep endoscopy are also available when deemed necessary to discuss alternative definitive therapies for sleep apnoea such as surgical approaches. If necessary other positive airway pressure devices like bilevel (BIPAP) are also available for OSA and Nocturnal Hypoventilation syndrome. If Insomnia is being managed then links with Sleep Psychology are provided, as needed.
We welcome referrals to the Sleep Centre at OneWelbeck for a comprehensive evaluation of sleep disturbance.