INTRODUCTION — Sleep-related breathing disorders such as obstructive sleep apnea (OSA) and central sleep apnea (CSA) occur with increased frequency in certain inpatient populations and may be associated with worse short-term outcomes. OSA is common in the general population, is often undiagnosed, and may first be identified in the inpatient setting. These and other primary sleep disorders are important to recognize, as acute illness and other aspects of hospital admission may aggravate chronic symptoms or bring to light previously unrecognized symptoms.
This topic will discuss the evaluation, consequences, and management of sleep disorders in hospitalized adults. Sleep apnea in the perioperative setting is reviewed separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea".)
An approach to poor sleep and insomnia in the inpatient setting is also reviewed separately. (See "Poor sleep and insomnia in hospitalized adults".)
OBSTRUCTIVE SLEEP APNEA — Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and most patients are undiagnosed. Breathing pauses and intermittent hypoxemia during directly observed and monitored sleep in the hospital may be the first sign of the disorder.
Prevalence — The estimated prevalence of OSA in the general population is approximately 15 percent in males and 5 percent in females [1]. OSA is significantly under-recognized in the outpatient setting [2,3], and most patients are undiagnosed [4].
The prevalence of OSA in the general inpatient population has not been well studied but it is likely to be higher than in the general population, as the inpatient population is enriched with comorbid conditions associated with OSA, such as obesity, diabetes, hypertension, and cardiovascular diseases [5,6]. Studies using screening questionnaires have found that 40 percent of inpatients ≥50 years old and 66 to 87 percent of inpatients with a body mass index (BMI) ≥30 kg/m2 score as high-risk for OSA [7-9].
OSA is particularly common in certain inpatient populations, including the following (table 1) [10-17]:
●Post-stroke and transient ischemic attack (TIA) patients (see "Sleep-related breathing disorders and stroke", section on 'Prevalence after stroke')
●Patients admitted to the cardiac care unit, including those with acute decompensated heart failure, acute coronary syndromes, and atrial fibrillation (see "Sleep-disordered breathing in heart failure", section on 'Prevalence and risk factors')
●Patients admitted with respiratory failure, including COPD exacerbations [18,19], obesity hypoventilation (OHV) exacerbations [20], and COVID-19 pneumonia [21,22]
●Patients admitted who are obese [8] and/or with type 2 diabetes mellitus [23]
●Patients presenting for elective surgery (see "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea")
●Patients admitted to inpatient psychiatry units [24,25]
Evaluation and diagnosis in the inpatient setting — The diagnosis of OSA in the inpatient setting can be logistically difficult due to medical illness, limited resources, and technical challenges with obtaining objective data. Acute illness itself can potentially alter findings on objective testing, and waiting to perform testing until the patient has recovered from their acute illness may yield results more reflective of their chronic disease burden. Nonetheless, there are several options to help stratify risk and prioritize testing in the outpatient or, less commonly, inpatient setting.
History and physical exam — The vast majority of inpatients suspected to have OSA by history and physical examination will, when tested, have OSA confirmed by polysomnogram (PSG) or home sleep apnea testing (HSAT) [26,27]. However, clinicians do not routinely evaluate patients for OSA in clinical practice [8,23,28].
The most common symptoms of OSA are daytime sleepiness, nonrestorative sleep, loud snoring, observed breathing pauses, and waking up choking or gasping (table 2). Physical exam findings that may suggest OSA include obesity, poorly controlled hypertension, large neck circumference, and a crowded or narrow upper airway. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Clinical features'.)
Screening questionnaires — Questionnaires that can be used to screen for OSA include, among others, the Berlin Questionnaire (table 3A-B), the STOP-Bang questionnaire (table 4), and the Sleep Apnea Clinical Score (table 5). Although not rigorously validated in inpatients, several studies have demonstrated their utility in the inpatient setting [8,9,29]. Use of a questionnaire will almost certainly capture more suspected cases than routine clinical care [8]. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Screening questionnaires'.)
Overnight oximetry — Overnight oximetry is commonly used in inpatient settings and often provides initial clues to the presence of previously unsuspected OSA [8,9,30], although use of supplemental oxygen and poor quality signal can limit reliability.
In general, a good tracing showing more than 5 to 10 desaturations per hour in patients who are not on supplemental oxygen should prompt consideration of OSA or central sleep apnea (CSA). Very frequent or severe hypoxemia during sleep may signal a need to prioritize diagnostic sleep apnea testing and treatment, depending on the specifics of the clinical situation.
Of note, overnight oximetry, which can provide an oxygen desaturation index (ODI, number of desaturations per hour of recording), is not considered an adequate diagnostic test by most, if not all, insurers in order to obtain a prescription for positive airway pressure therapy. This technology is therefore best used as a risk-stratifying tool rather than a diagnostic tool. Additional variables that can affect performance include the degree of oxygen desaturation required to determine an event (3 versus 4 percent), the ODI cut-off used (ie, >5, >10, or >15) to identify significant sleep-disordered breathing, the definition of hypopnea used on the confirmatory PSG, whether or not the patient obtains adequate sleep on the testing night, and technical and interpreter variability [31,32]. Use of a high-resolution pulse oximeter may help to reduce some of the technical issues [33]. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults", section on 'Measures of sleep-disordered breathing severity'.)
Portable sleep apnea testing — Home sleep apnea testing (HSAT) using a portable, unattended device is a valid alternative to in-laboratory PSG for diagnosing uncomplicated OSA in the outpatient setting, primarily when pre-test suspicion for moderate to severe OSA is high [34].
HSAT may be available in some centers for inpatient testing. Pending additional validation studies in patients with significant comorbidities, selection of inpatients for HSAT should be approached on a case-by-case basis in conjunction with a pulmonologist or sleep specialist.
Importantly, HSAT has not been extensively studied or validated in outpatients at risk for more complicated types of sleep-disordered breathing (eg, CSA and/or hypoventilation), including those with heart failure, obstructive lung disease, and neuromuscular disease with respiratory impairment [35]. (See "Home sleep apnea testing for obstructive sleep apnea in adults".)
Despite these caveats, limited data in the acute cardiac disease population, in post-stroke patients, and in general medical patients suggest that testing with type III HSAT devices is feasible in the inpatient setting and may be reasonably accurate [10,36-40]. Type III devices include monitoring of at least four channels, including two that assess respiration (figure 1). HSAT devices using peripheral arterial tonometry have been compared with type III devices in patients admitted with myocardial infarctions and found to have moderate levels of agreement [41], though further study is needed. (See "Home sleep apnea testing for obstructive sleep apnea in adults", section on 'Sleep monitoring devices'.)
Polysomnography — PSG remains the gold standard for diagnosing OSA and determining the severity of OSA (as measured by the apnea-hypopnea index [AHI]), but implementing PSG testing in the hospital environment can be challenging. A full PSG may be considered intrusive in patients already suffering from poor sleep, thus limiting sleep time available for analysis. Additional challenges include disturbances to sleep due to ongoing inpatient care (especially if support sleep staff are not directly on site), resource requirements, logistics, and issues of reimbursement.
Nonetheless, inpatient PSG may be an option in some institutions. A number of studies have shown the feasibility of performing PSG in a range of inpatient settings [10,26,42,43]. Local institutional policies and resources may determine whether or not inpatient PSG is practical.
Adverse inpatient outcomes — There are robust data linking a known diagnosis of OSA to worse short-term outcomes in the postoperative and post-stroke settings. (See "Sleep-related breathing disorders and stroke", section on 'Complications' and "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea", section on 'Perioperative complications'.)
In addition, at least two large database studies have found worse inpatient outcomes in patients who carry a diagnosis of OSA compared with those without OSA [44,45]. In a study of over 55 million pregnancy-related inpatient discharges in the Nationwide Inpatient Sample database, OSA was associated with increased risk of multiple adverse outcomes, including preeclampsia (odds ratio [OR] 2.5), eclampsia (OR 5.4), cardiomyopathy (OR 9), pulmonary embolism (OR 4.5), and in-hospital mortality (OR 5) [44]. (See "Obstructive sleep apnea in pregnancy", section on 'Outcomes'.)
In another multicenter retrospective study of >250,000 patients admitted for pneumonia, 6 percent of patients had an established diagnosis of OSA [45]. After adjusting for potential confounders, OSA was associated with higher rates of ICU transfer (OR 1.5), intubation (OR 1.7), and a longer length of stay, but lower mortality (OR 0.9). Further studies are needed to better understand the mechanisms underlying these risks, including potentially modifiable factors such as exposure to opioids or other drugs that may acutely worsen OSA disease severity.
Evidence also suggests that a new diagnosis of OSA by objective testing made during hospital admission is associated with worse outcomes, including:
●Higher rates of rapid response team activation during admission [46].
●Higher CHADS2 score during atrial fibrillation admission [12] and increased rates of arrhythmias (two- to threefold) in patients >60 years old admitted with subacute myocardial infarction [47].
●Worse composite cardiovascular outcomes after admission for myocardial infarction (HR 5.4 for patients with AHI >30) [48].
●Higher rates of readmission and mortality at 14 months following congestive heart failure (CHF) admission (hazard ratio [HR] 2.9 for patients with an ODI 4 percent >5) [49].
●Greater mortality at three years following CHF admission (OR 1.5) [11].
●Higher rates of readmission at 30 days after a COPD exacerbation (OR 6 to 10 for moderate to severe OSA) [18].
Management — Positive airway pressure (PAP) therapy is the mainstay of treatment for OSA. For most patients with OSA, continuous positive airway pressure (CPAP) is the first-line treatment; alternative modes such as bilevel positive airway pressure (BPAP) can be used in selected patients. (See "Management of obstructive sleep apnea in adults", section on 'Positive airway pressure therapy'.)
Emerging data support earlier intervention with PAP therapy in patients admitted to the hospital who are found to have sleep apnea. Potential benefits include reduced rapid response team activation and decreased post-discharge readmissions for patients with heart disease and chronic obstructive pulmonary disease (COPD) [9,11,46].
Patients with known OSA who use PAP at home — Inpatients with a previously established diagnosis of OSA who use CPAP or BPAP at home should be encouraged to use it in the hospital, as their condition allows. While some acute medical issues may preclude PAP therapy (eg, nausea and vomiting, use of a nasogastric tube in some cases, upper gastrointestinal bleeding, facial trauma or infection, mental status changes), most others do not. Oxygen therapy does not preclude use of PAP, as oxygen can be delivered in conjunction with PAP.
However, studies suggest that inpatient CPAP use in those with known OSA on PAP therapy is quite variable, ranging from 6 to 64 percent depending on the study [6,50-52]. Aside from acute medical issues, factors that may contribute to a low rate of inpatient CPAP use include lack of awareness or understanding of OSA and PAP therapy on the part of clinicians and respiratory therapists and a lack of available PAP settings during admission [53].
Patients with known OSA who use other therapies at home — Most patients who use an alternative therapy for OSA at home, such as oral appliances or implanted hypoglossal nerve stimulation, should be encouraged to use the device in the inpatient setting.
In some cases, PAP therapy may be preferable during hospitalization. Examples include patients whose OSA is poorly controlled with their home therapy, patients who did not bring their oral appliance or hypoglossal nerve stimulator activator to the hospital with them, and patients with conditions associated with worsening of their underlying OSA, for which the home therapy may not compensate (eg, new stroke, substantial new opioid requirement).
Patients with newly diagnosed or previously untreated OSA — Inpatient initiation of PAP therapy in patients with newly diagnosed or previously untreated OSA can be considered on a case-by-case basis, but there are limited outcomes data to support widespread adoption of this practice [46,54]. There are also several potential drawbacks to consider in the inpatient setting.
●One of the major problems with CPAP therapy in the outpatient setting is adherence, and similar problems may be encountered in the hospital setting. Data in surgical patients suggest that adherence with CPAP initiated perioperatively is quite poor following surgery [55-57]. Poor compliance with newly initiated PAP therapy during admission has also been reported in medical patients [58].
●Patients may not be inclined to start new CPAP therapy during acute medical illness. In addition, hospitals may lack optimal staff support for first-time CPAP initiation. CPAP is often administered in the hospital by nursing personnel or respiratory therapists, who may not have the time or expertise of a sleep technician for mask fittings, pressure adjustments, and other troubleshooting techniques. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea", section on 'First-line interventions'.)
●Determining and optimizing PAP pressure settings may be challenging. While auto-adjusting pressure devices may be appropriate for some patients, those at risk for CSA or hypoventilation may not be well suited for this approach unless advanced technologies are available (eg, adaptive servo-ventilation or volume-assured pressure support). (See "Mode selection for positive airway pressure titration in adult patients with central sleep apnea syndromes".)
●There is a financial cost associated with starting CPAP therapy in the hospital, and data on the economics of inpatient initiation of PAP therapy are lacking.
Despite these limitations, inpatient initiation of PAP therapy may be justified in selected patients, based on limited data that initiating CPAP following a new diagnosis of OSA may improve outcomes in specific inpatient groups. Such groups include the following:
●Selected postoperative patients with previously untreated OSA. (See "Postoperative management of adults with obstructive sleep apnea", section on 'Positive airway pressure therapy'.)
●Post-stroke patients with newly diagnosed OSA, particularly in those with an AHI >15 events per hour. (See "Sleep-related breathing disorders and stroke", section on 'Management'.)
●Patients with newly diagnosed OSA in the setting of acute decompensated heart failure or other cardiac problems. In a pilot study of 46 patients admitted for acute decompensated heart failure who were diagnosed with OSA (AHI >15) within the first 48 hours of admission, patients randomly assigned to initiation of auto-adjusting bilevel pressure support had improved ejection fraction (by 5 percent) compared with those assigned to standard of care [59]. Follow-up data suggest that this benefit is only realized in those adherent to therapy [58]. Other data suggests that initiation of auto-adjusting CPAP following the diagnosis of OSA (AHI >5) in patients admitted for congestive heart failure, myocardial infarction, or an arrhythmia decreases 30-day [36,60] and 6-month [58] readmission rates in those who were adherent to therapy. (See "Sleep-disordered breathing in heart failure", section on 'Management'.)
Even in these groups, deciding whether or not to initiate PAP therapy requires careful consideration of the underlying illness, the severity of the sleep-disordered breathing as suggested by the frequency of respiratory events and degree of associated hypoxemia (based on objective testing), and the patient's willingness and appropriateness for starting PAP therapy in the hospital. Consultation with a pulmonologist or sleep specialist is encouraged in cases of uncertainty, or when PAP therapy is planned.
Review of concomitant medications — The medication list should be carefully reviewed in patients with known or suspected OSA to ensure that medications that may precipitate or worsen OSA are minimized or eliminated. Specifically, sedatives such as benzodiazepines, barbiturates, and high-dose opioids should be avoided if possible. If required, the lowest effective dose should be used. (See "Management of obstructive sleep apnea in adults", section on 'Alcohol avoidance'.)
Role of nocturnal oxygen — Oxygen may be used to minimize OSA-related hypoxemia but is not considered a primary therapy for OSA. Oxygen therapy has not been shown to alter long-term outcomes in patients with OSA and may increase the duration of apneas and hypopneas [61]. Care should also be used when considering oxygen therapy for OSA in inpatients at risk for hypoventilation (eg, obesity-associated hypoventilation) [62,63]. An evaluation for baseline hypercapnia should be considered before starting nocturnal oxygen in such patients. (See "Treatment and prognosis of the obesity hypoventilation syndrome", section on 'Avoidance of alcohol and sedatives'.)
In the absence of hypercapnia risk, nocturnal oxygen can be considered as a "bridge," pending more appropriate OSA therapy, in order to avoid severe nocturnal hypoxemia in selected cases. This may be most appropriate for patients with conditions that may be aggravated by significant hypoxemia, such as acute stroke or myocardial infarction, though data supporting this strategy are lacking at present.
Post-discharge follow-up — Regardless of whether or not PAP is initiated during an acute hospital stay, patients with OSA require appropriate outpatient follow-up, as OSA is a chronic disease. The urgency with which to initiate PAP or other therapies for OSA in patients with newly diagnosed, untreated OSA depends on several factors, including OSA disease severity and symptoms, comorbidities, and risk factors for adverse outcomes. Patients admitted with heart failure, COPD exacerbation, or stroke should be considered target populations for more aggressive and earlier intervention with PAP therapy [9,11,64,65]. (See "Sleep-related breathing disorders and stroke", section on 'Management' and "Management of obstructive sleep apnea in adults".)
Patients who have been started on PAP during hospitalization should generally be seen by their primary care or sleep medicine clinician within two to four weeks of discharge to review symptoms, assess PAP adherence, and troubleshoot any difficulties with CPAP use. If a diagnostic sleep study has not been performed prior to initiation of therapy, then either an in-laboratory PSG or HSAT should be obtained in order to confirm the type and severity of the sleep-disordered breathing. Patients with persistent symptoms (eg, daytime sleepiness) despite regular use of PAP should undergo a formal titration study via either in-laboratory PSG or HSAT in order to determine the adequacy of therapy. (See "Management of obstructive sleep apnea in adults", section on 'Follow-up'.)
Alternative therapies for OSA, such as surgical intervention, oral appliances, nasal resistive valves, and negative pressure devices, are generally not feasible to initiate in acutely ill patients but can be considered in the outpatient setting once the patient is stable. (See "Management of obstructive sleep apnea in adults".)
CENTRAL SLEEP APNEA — Central sleep apnea (CSA) is much less common than obstructive sleep apnea (OSA), and the therapeutic options are highly varied, depending on the underlying cause. As such, the literature regarding the prevalence, diagnosis, consequences, and management of CSA in hospitalized patients remains quite sparse.
CSA can be a primary disorder, the manifestation of a variety of underlying medical conditions (eg, stroke, congestive heart failure, neuromuscular disease), the result of certain medications (eg, opioids), or even the result of positive airway pressure (PAP) therapy itself in patients with predominantly obstructive sleep apnea OSA (eg, treatment-emergent CSA). (See "Central sleep apnea: Risk factors, clinical presentation, and diagnosis".)
High-risk groups — The prevalence of CSA in the general medical inpatient population is unknown. Specific inpatient groups with an increased risk of CSA include the following:
●Post-stroke patients – Like OSA, CSA occurs with increased frequency in post-stroke patients compared with expected rates in the general population. Meta-analyses of sleep apnea following stroke found CSA or Cheyne-Stokes breathing as the primary form of sleep-disordered breathing in 7 to 10 percent of patients [14,66]. (See "Sleep-related breathing disorders and stroke".)
●Patients with congestive heart failure (CHF) – CSA with Cheyne-Stokes breathing is common in outpatients with CHF and in patients hospitalized with acute decompensated heart failure [10,36,67,68]. Prevalence rates in inpatient samples range from 18 to 76 percent, with the wide range likely reflecting differences in heart failure severity, whether scoring of central hypopneas was included, and the study population size. (See "Sleep-disordered breathing in heart failure".)
●Patients who chronically use opioids – In a study of 70 consecutive patients admitted to the hospital for buprenorphine/naloxone therapy to treat opioid dependency, 63 percent exhibited predominantly CSA, including 39 percent with at least moderate to severe ataxic breathing, also known as Biot's respiration [69]. (See "Sleep-disordered breathing in patients chronically using opioids", section on 'Prevalence'.)
Diagnosis in the inpatient setting — Establishing an accurate diagnosis of CSA in the inpatient setting can be more difficult than diagnosing OSA, not only for the logistical reasons reviewed above (see 'Evaluation and diagnosis in the inpatient setting' above), but also due to the unreliability of many screening and testing modalities for CSA. There are limited options:
●History and physical exam – Aside from recognizing clinical conditions and medications that may increase the risk of CSA, history and physical examination are generally poorly predictive of CSA. Symptoms of CSA overlap significantly with those of OSA as well as those of underlying comorbidities, and there are no defining physical examination findings (with the exception of witnessed Cheyne-Stokes respirations). (See "Central sleep apnea: Risk factors, clinical presentation, and diagnosis", section on 'Clinical findings'.)
●Screening questionnaires – There are no validated inpatient screening questionnaires for CSA.
●Overnight oximetry – Nocturnal oximetry with continuous recording can provide an oxygen desaturation index (ODI) that can help to identify sleep-disordered breathing, but it is not reliable for distinguishing central from obstructive respiratory events [68,70]. (See 'Overnight oximetry' above.)
●Home sleep apnea testing (HSAT) – Validation studies of HSAT devices have generally excluded patients at risk for CSA, including patients with significant heart failure and neuromuscular disease with respiratory impairment [35]. In addition, the American Academy of Sleep Medicine (AASM) clinical guideline on the use of HSAT devices currently recommends against the use of HSAT to diagnose CSA [34].
Nonetheless, there are limited data in patients with acute decompensated heart failure suggesting that testing with type III HSAT devices (which include monitoring of at least four channels, of which two assess respiration) is feasible and may be reasonably accurate for CSA [39,71]. However, additional validation of these devices for the diagnosis of CSA is warranted before routine use can be recommended.
●Polysomnography (PSG) – PSG is the gold standard method for diagnosing CSA. As reviewed above, there are potential logistical and financial limitations to performing inpatient PSG; however, studies suggest that inpatient PSG may be feasible in a range of inpatient settings [10,26,42,43], including in cardiac patients with CSA [72], though availability may be limited by institutional resources. (See 'Polysomnography' above.)
Potential consequences — Observational studies of patients with CSA due to heart failure suggest that CSA is associated with impaired quality of life [73] and increased mortality [74,75], although the data are not entirely consistent [76,77]. Little is known about the prognosis for patients with CSA secondary to other comorbid diseases.
Studies in heart failure patients with a new diagnosis of CSA during inpatient admission have found an association between CSA and more frequent and complex arrhythmias [78], six-month cardiac readmission rates [71], risk of cardiovascular death at two years (hazard ratio [HR] 1.3) [78], and all-cause mortality [11].
Management — Patients with a known diagnosis of CSA who are admitted to the hospital should be encouraged to continue with their primary therapy, whenever possible. Like OSA, PAP therapy is the most common treatment for CSA. (See "Central sleep apnea: Treatment".)
Definitive statements about whether or not to intervene for newly diagnosed CSA during an inpatient admission are not possible, due to the varied underlying etiologies that can lead to CSA as well as the considerable uncertainty regarding the optimal therapy for many types of CSA. Management considerations in specific patient populations include the following:
●For inpatients with CSA associated with heart failure, primary interventions include optimizing cardiac function and use of oxygen therapy if patients are hypoxemic at night [79]. Initiation of PAP therapy upon discharge may improve short-term outcomes [11]. Caution is recommended when considering the empiric initiation of certain modes of PAP therapy, based on data showing worse outcomes with adaptive servo-ventilation (ASV) in patients with symptomatic heart failure and reduced ejection fraction [80,81]. (See "Sleep-disordered breathing in heart failure".)
●For post-stroke patients with primarily newly diagnosed CSA, close observation is reasonable for most patients in the inpatient setting, as the CSA often resolves during recovery from the stroke [82]. Initiation of PAP therapy can be considered in the inpatient setting on an individual basis. (See "Sleep-related breathing disorders and stroke", section on 'Management'.)
●For patients with CSA associated with opioid use, minimizing or discontinuing opioid therapy is considered first-line therapy, where possible. If this is not feasible, PAP therapy is an option in selected patients, although given the complexities of care and paucity of data regarding benefits, this should generally be addressed and coordinated on an outpatient basis. (See "Sleep-disordered breathing in patients chronically using opioids", section on 'Treatment'.)
OTHER SLEEP DISORDERS — A variety of other primary sleep disorders may be encountered in the inpatient setting. These fall into the broad categories of central disorders of hypersomnolence (eg, narcolepsy), circadian rhythm sleep-wake disorders (eg, delayed sleep-wake phase syndrome), parasomnias (eg, sleep walking, rapid eye movement [REM] sleep behavior disorder), and sleep-related movement disorders (eg, restless legs syndrome [RLS]). (See "Classification of sleep disorders".)
While some of these conditions are common in the general population and occur with increased frequency in patients with multiple comorbidities (eg, RLS), others have low prevalence rates and may rarely be seen in the inpatient setting (eg, narcolepsy). There are sparse data on inpatient prevalence, consequences during hospitalization, or management strategies during admission to help guide care. Select issues to consider and some common sense approaches include the following:
●Central disorders of hypersomnolence such as narcolepsy – Patients with narcolepsy may have increased symptoms during hospitalization and may be at risk for cardiopulmonary complications in the perioperative setting [83-86]. Potential mechanisms include disease-related autonomic instability, altered pain sensitivity, medication interactions, and medication withdrawal [87]. Based on these considerations, the following are recommended:
•Continue stimulant therapy unless otherwise contraindicated by the clinical situation.
•Resume stimulant therapy early in the postoperative period.
•Continue medications for cataplexy unless otherwise contraindicated by the clinical situation. Abrupt withdrawal of certain medications can lead to a state of status cataplecticus [88] or significant mental status changes [89]. (See "Treatment of narcolepsy in adults", section on 'Antidepressants for cataplexy'.)
•Evaluate safety and use fall risk precautions in patients with frequent cataplexy.
●Circadian sleep-wake rhythm disorders
•Be attuned to how a delayed or advanced sleep phase may affect sleep during admission. Patients with an underlying circadian sleep-wake rhythm disorder (eg, delayed sleep-wake phase syndrome in adolescents or young adults, advanced sleep-wake phase syndrome in older adults) may develop significant sleep deprivation during admission when sleep is limited to conventional nighttime hours not in line with their usual sleep habits. (See "Overview of circadian sleep-wake rhythm disorders".)
•Continue any chronic chronotropic therapy during the admission, such as melatonin or light therapy where possible. (See "Delayed sleep-wake phase disorder", section on 'Management'.)
●Parasomnias – Parasomnias may be seen in the inpatient setting resulting from an illness (eg, stroke) or medication side effect, the cause for admission (eg, serious injury in sleep), or may manifest or worsen during admission for a separate medical illness [90]. (See "Approach to abnormal movements and behaviors during sleep".)
•Encourage adequate sleep and consider need for fall risk prevention from sleep-related behaviors. Avoid sleep disruption as much as possible, as sleep deprivation is a common trigger for parasomnias.
•Continue medications used for control of a known parasomnia unless otherwise contraindicated by the clinical situation. Abrupt withdrawal of these medications can precipitate the parasomnia [91], which can place the patient at risk for injury. (See "Disorders of arousal from non-rapid eye movement sleep in adults" and "Rapid eye movement sleep behavior disorder".)
•For patients with REM sleep behavior disorder, use melatonin 5 to 10 mg at night when benzodiazepines cannot be given. (See "Rapid eye movement sleep behavior disorder", section on 'Management'.)
●Sleep-related movement disorders such as RLS – RLS symptoms can worsen in the inpatient and perioperative setting due to medication changes, forced immobilization, blood loss, and sleep deprivation. Worsening symptoms can adversely impact recovery from illness and/or surgery and increase length of stay [86,92]. We suggest the following approach:
•Continue medications used for control of the movement disorders, such as dopamine agonists, gabapentin, or pregabalin, unless otherwise contraindicated by the clinical situation. Take care to administer at the correct time and avoid skipping doses.
•Avoid medications known to precipitate or aggravate RLS (eg, first-generation antihistamines, metoclopramide, haloperidol, selective serotonin reuptake inhibitors).
•Limit blood draws whenever feasible, as phlebotomy-induced iron deficiency can worsen RLS and periodic limb movements in sleep. (See "Management of restless legs syndrome and periodic limb movement disorder in adults".)
•Encourage ambulation, stretching, and use of sequential compression devices.
•Avoid immobility, sleep disruption/deprivation, and inadequate pain control.
Many of the common sleep disorders may be aggravated by acute illness, as well as by substance abuse or withdrawal. If a known sleep disorder becomes a significant problem during inpatient admission, consultation with a specialist in sleep medicine should be considered. Similarly, if a primary sleep disorder is suspected during inpatient admission, involvement of a sleep specialist may be useful to aid in diagnosis and management. Specifics of the clinical situation should dictate whether this occurs while the patient is an inpatient or as an outpatient.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults" and "Society guideline links: Parasomnias, hypersomnias, and circadian rhythm disorders".)
SUMMARY AND RECOMMENDATIONS
●Obstructive sleep apnea
•Prevalence and impact – Obstructive sleep apnea (OSA) is increasingly recognized in the inpatient setting and may be associated with worse short-term outcomes. This may be especially true for patients admitted with cardiovascular disease and stroke. (See 'Prevalence' above and 'Adverse inpatient outcomes' above.)
•Evaluation and diagnosis – The majority of inpatients suspected of having OSA by history and physical examination will be confirmed to have OSA once tested by polysomnography (PSG) or home sleep apnea testing (HSAT). Inpatient diagnostic sleep testing is logistically challenging but can be accomplished at some centers. (See 'Evaluation and diagnosis in the inpatient setting' above.)
•Management – Inpatients with a previously established diagnosis of OSA who use positive airway pressure (PAP) therapy at home should be encouraged to use it in the hospital, as their condition allows.
Inpatient initiation of PAP therapy in patients with newly diagnosed or previously untreated OSA can be considered on a case-by-case basis, but there are inadequate outcomes data at this time to support widespread adoption of this practice. (See 'Management' above.)
●Central sleep apnea – Though less common than OSA, central sleep apnea (CSA) occurs with increased frequency in certain inpatient groups, including post-stroke patients, patients with acute decompensated heart failure, and patients who chronically use opioids. Management of CSA in the hospital varies according to the underlying cause. (See 'Central sleep apnea' above.)
●Other sleep disorders – Many other less common primary sleep disorders may potentially require attention during inpatient admission. Consultation with a specialist in sleep medicine may be useful if there is uncertainty about how best to evaluate and manage existing or suspected sleep disorders in the inpatient setting. (See 'Other sleep disorders' above.)
