Hi. Welcome to the Lexington Sleep Clinic at SleepWell. Here is where you will learn what to expect about sleep evaluation and treatment once you’ve made telephone contact and set up an appointment for your first visit.
Tracking down the cause of your sleep or wakefulness problem then initiating treatment usually takes about three visits. Depending on what we find, there may be more visits as we work together to solve the problem for which you sought help.
More specifically, here is what to expect:
The first telephone contact is where you begin the process of sleep evaluation. At the time of our first contact, you will be asked to go to the Forms page of this website and print out specific forms. Bring the completed forms with you to your first visit. One of the most important forms is the Sleep Questionnaire. Here you will be able to describe in your own words exactly what you would like me to help you with.
The remainder of the questionnaire is designed to let you collect in one place all the things you’ve already done to try to correct the problem. There is also ample space to provide information about all the many things that might be causing it. You will also be asked to have relevant health care providers forward to me reports of any prior sleep studies, and any other medical information that may be pertinent. Your health care providers will ask you to provide written consent to release the information to me. The Consent to Release Information Form in the Formspage can be used for that purpose.
At our first visit, the very most important thing in the process of sleep evaluation will be to establish a provisional diagnosis to guide our further assessment and treatment. My approach is to get to the symptom’s cause, then treat the cause. This is instea of attempting non-specific treatment of the symptom such as with sleeping pills for insomnia or stimulant medication for daytime fatigue or sleepiness. So, in this context, “diagnosis” really means getting to the root cause of your sleep disruption or unsatisfying status when you are awake.
To accomplish this, we will piece together all the information you provided in the sleep questionnaire, whatever medical information has been sent from your health care professionals with, and most importantly, what YOU tell me directly as you sit in my office.
By the end of our first meeting, we should have one or several highly informed ideas about what is at the heart of the sleep-wake problem. In more formal terms, these are referred to as differential diagnoses.
What happens next in the sleep evaluation process depends upon the nature of your sleep or waking difficulty (see Does this describe you? ), and then what we discover lies at the heart of it. It is possible we will develop a treatment plan at our first meeting. In that case you will be given specific recommendations to follow at home. Alternatively, we may discover we need additional objective data (things you record). If so I will explain what we need and how to proceed – and then we go from there
What happens after the first meeting? If at the first meeting we are able together to identify one strong possibility of what is going on, you will be given recommendations on how to proceed at home, You will then be asked to return in a week or so in order that we can see how well the recommendations worked – a follow-up. If all is well, may you SleepWell (and wake well!) – and please contact me if you run into trouble again down the line — your sleep evaluation is complete. A routine follow-up appointment will be scheduled, but may be cancelled if it turns out to be unnecessary.
If the outcome of the treatment trial is not satisfactory, and/or if at the end of the first meeting I/we realize some additional information might be tremendously helpful for full sleep evaluation, following are examples of the kind of information that we may also need:
SLEEP, WAKE AND TEMPERATURE DIARIES In some cases, a Sleep-Wake and temperature diary becomes extremely useful. The Form Sleep, Wake and Temperature Diaries found in the Forms page is used to gather this information on a day by day basis.
AT HOME MONITORING OF CIRCADIAN BIOLOGY. Through the use at home of a watch-like recording device called a Wrist Actimeter in combination with a skin temperature monitor you wear on your finger, we can learn almost to the minute when you were asleep and when you were awake over the course of an entire week. This can prove tremendously useful. If you look carefully at the graphic you will see vertical gray bars which indicate periods of sleep. In that bar, at the top row, you will see the unique signature of skin temperature as it looks when a person is sleeping; and in the bottom row you will see the activity information — decreased or non-existent during sleep.
OVERNIGHT SLEEP STUDY (polysomnograph, or PSG). At times, it is necessary for us to actually SEE what might be causing you to wake up in the middle of the night, or to feel unrefreshed at the end of what seems like it should have been enough sleep, and for a wide range of other reasons. This may be your first sleep study, or I may suggest a repeat sleep study, if you have already had one.
I no longer operate my own sleep testing facility, but I have an outstanding relationship with a specific testing facility. There I can read your record personally and be able to make my own interpretation of how the sleep study results might explain the symptoms you are experiencing.
OTHER. There are a wide range of other kinds of “data collecting” studies that might be suggested in coordination with your own health care professionals, which are too numerous to mention here but which would be discussed with you should they become relevant.
The type of treatment will be tailored to a clear understanding of what is causing the problem, and what your own life situation requires be taken into account. The number of possibilities is quite large since, of course, sleep problems have many potential causes. Of course wherever possible we would like to treat the cause. Here, we talk about specific TYPES of treatment that might be considered:
COGNITIVE BEHAVIORAL THERAPY (CBT). This is most often used for people with insomnia (difficulty falling asleep, difficulty staying asleep, difficulty waking up in the morning, failure of sleep to offer refreshment). Not infrequently, it is also useful for those of you having difficulty with the home CPAP unit or the CPAP mask you were prescribed.
CORRECTING CIRCADIAN RHYTHM DISTURBANCES. This can include, for instance, the use of Broad Spectrum Bright Light (light box, SAD box, BLT – Bright Light Therapy, not Bacon Lettuce and Tomato!). This is used to re-set or stabilize a person’s circadian rhythm. Light treatment (Phototherapy) is most useful for people who are “night owls” (Phase Delayed) but who must follow a daily schedule that requires getting up far too early, and getting to sleep far too early, as compared with how their biological clock is genetically programmed. It is also extremely helpful in other Circadian Rhythm Disorders, such as Shift Work and Jet Lag Disorders.
MEDICATION. Sometimes rather minor but important changes in the medications you are already taking might be recommended. For instance, simply altering the timing of when you take the medications prescribed for high blood pressure (hypertension), or hypothyroidism (“low thyroid”), or for a mood disorder can sometimes make a huge difference. If a previously unknown medical cause of your sleep-wake problem is uncovered during the course of your sleep evaluation, I will contact the health care provider you designate to discuss treatment of the newly identified condition. If it becomes apparent that the sleep-wake disturbance is a result of an underlying anxiety disorder or depression, then medication might be recommended for that.
In line with my focus on treating cause rather than symptom, it is unlikely that a standard “sleeping pill” or “stimulant” will be recommended.
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP). If a sleep-related breathing disorder called Obstructive Sleep Apnea (OSA) is diagnosed, CPAP at the correct pressure is the treatment of choice. Should CPAP already have been prescribed but you are having difficulty with it, assisting you with making CPAP work for you may be our treatment goal. At times, we have found that prescribed CPAP does not work simply because a different treatment might have been more useful. This possibility, too, will be looked at in your sleep evaluation.
Overall, the flow from our first meeting until our final visit is to:
- Get a clear sense of WHAT your symptoms are
- By piecing together all information available by the first or second meeting, end up with a clear and specific set of hypotheses (differential diagnoses) about what might be creating your sleep or waking difficulty.
- Take additional steps that might be necessary, such as one or several objective tests, to be able to choose from among the differential diagnoses.
- Develop and carry out a treatment plan based upon a clear understanding of the root of the sleep-wake difficulty that is problematic.
- Continued follow-up until the problem is resolved.