When Treating Sleep Disorders Doctors Must Rule Out Other Diagnoses First
Consider Dan, a 23-year old male complaining of insomnia. He can't fallasleep at night and habitually arrives at work later than his employer's 8a.m. starting time. Does Dan have depression, situational insomnia,obstructive sleep apnea or a circadian rhythm disturbance? Or does he justwant to start work late?
"When someone claims he's constantly late to work due to chronic sleepproblems, a doctor must eliminate other possibilities first," said Dr. SkipFreedman, executive medical director at AllMed Healthcare Management, aleading Independent Review Organization (IRO). (http://www.allmedmd.com)
According to Freedman, circadian rhythm sleep disorder is a disturbance ofa patient's sleep-wake cycle. Patients with circadian rhythm sleep disordersare unable to sleep or stay awake during work, school or social events.Circadian rhythm sleep disorders include jet lag, shift work sleep disorder,irregular sleep wake phase, advanced sleep phase disorder (ASPD) and delayedsleep disorder (DSPD).
Rule out other disorders
"Doctors need to decide whether patients like Dan don't like to go to workon time, are depressed, have situational insomnia or circadian rhythm sleepdisturbance," said Freedman.
Once Dan's doctor rules out depression using a depression questionnaire,he can refer Dan to a sleep medicine specialist. Using a polysomnogram (sleeptest), the specialist can check for other common sleep problems. Ruling themout, he can check Dan's circadian clock markers next.
One technique is to measure Dan's melatonin level, the hormone secreted bythe pineal gland. Melatonin is the primary influencer of sleep and thus asleep marker. During daylight, the gland produces less melatonin, becauselight suppresses melatonin production. As the light fades, the gland increasesmelatonin production to induce sleep.
Therapies for circadian disorders
Delayed sleep-phase syndrome and early sleep-phase syndrome are circadianrhythm disturbances treated by combining melatonin and phototherapy. Althoughphototherapy is standard of care for circadian disturbance, melatonin isn'tFDA approved. However, it is available as a supplement in the United States.
In Dan's case, the specialists discovered his melatonin levels were lowduring the times he'd normally sleep. This signaled a delayed sleep phase, andDan took off two weeks from work to receive treatment.
Working back about an hour each day, the doctor's treatment used melatoninto make Dan sleepy and exposed him to 2,500 lux of light for two to threehours. (Lux is a unit of brightness emitted by candle to the eye one meteraway.) The treatment pushed back Dan's sleep-cycle pattern an hour a day fortwo weeks until he began falling to sleep at normal hours and could get towork on time.
More information about the medical necessity review services offered byIROs can be found on AllMed's web site at http://www.allmedmd.com.
SOURCE AllMed Healthcare Management
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