John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
The diagnosis of narcolepsy is based on a clinical evaluation, specific
questionnaires, sleep logs or diaries, and the results of sleep laboratory
tests.
Clinical evaluation
Clinical evaluation includes a detailed medical history and physical examination by a physician.
Questionnaires
Questionnaires may be used in the assessment of patients with symptoms that suggest narcolepsy. The Stanford Narcolepsy Questionnaire is an extensive questionnaire that can provide the physician with valuable information on all symptoms of narcolepsy, but especially on cataplexy. The Epworth Sleepiness Scale is a brief self-administered questionnaire that provides an estimate of the degree of daytime sleepiness.
A person rates the likelihood of falling
asleep during specific activities. Using the scale from 0-3 below, the person ranks
their risk of dozing in the chart below.
0 = Unlikely to fall asleep
1 = Slight risk of falling asleep
2 = Moderate risk of falling asleep
3 = High likelihood of falling asleep
Situation
Risk of Dozing
Sitting and reading
Watching television
Sitting inactive in a public place
As a passenger in a car riding for an hour, no breaks
Lying down to rest in the afternoon
Sitting and talking with someone
Sitting quietly after lunch, without alcohol
In a car, while stopped for a few minutes in traffic
After ranking each category, the total score is
calculated. The range is
0-24, with the higher the score the more sleepiness.
Scoring:
0-9 = Average daytime sleepiness
10-15 = Excessive daytime sleepiness
16-24 = Moderate to severe daytime sleepiness
Sleep logs or sleep diaries
Sleep logs or sleep diaries for two to three weeks are recommended in the evaluation of any patient with
excessive daytime sleepiness. Sleep diaries record the patient's usual sleep patterns (sleep deprivation, irregular sleep/wake pattern, interrupted sleep), alcohol and/or drug use, and common behaviors that cause the patient to lose sleep (for
example, Internet syndrome - surfing the Internet until late at night, causing sleep deprivation and daytime sleepiness.) This information may be helpful in the evaluation of a patient with
excessive daytime sleepiness.
Sleep laboratory tests
Sleep laboratory tests ("sleep studies") for narcolepsy include polysomnography (PSG) and the multiple sleep latency test (MSLT). Polysomnography (PSG) is a full night recording of several different physiological factors of a patient's sleep. The PSG is followed the next day by the multiple sleep latency test (MSLT), which is a recording of the patient's tendency to fall asleep during the day. These procedures provide objective measures of daytime sleepiness and REM sleep abnormalities.
Daytime sleepiness is measured in the MSLT by the sleep latency (SL) time.
This is the time from the beginning of the recording to the onset of sleep. In
healthy individuals, the SL time is more than 10 minutes, whereas in narcolepsy,
it could be as short as 0.5 minutes (an almost immediate onset of sleep).
REM sleep
REM sleep is named for the rapid eye movements (REM) that characterize this phase of sleep. In REM sleep dreams are vivid, muscle activity is suppressed, and brain activity is high. The REM sleep abnormality that is characteristic of narcolepsy is referred to as sleep onset REM periods. In healthy individuals, the first REM sleep period occurs about 80 to 120 minutes after the onset of sleep. By contrast, in narcolepsy, the initial REM sleep period usually occurs within 15 minutes of the onset of sleep. In addition, narcolepsy patients will have two or more sleep onset REM periods during the multiple sleep latency test (MSLT) in the daytime.
PSG is also helpful in excluding other causes of daytime sleepiness, such as
sleep apnea syndrome (SAS),
periodic limb movements in sleep (PLMS), and sleep disruptions. In some cases, repeat tests may be recommended if there is worsening of the symptoms of narcolepsy despite treatment or if an additional sleep disorder is suspected (for example, sleep apnea syndrome).
Maintenance of wakefulness test (MWT)
Maintenance of wakefulness test (MWT) may be used to evaluate the effects of the treatment for narcolepsy. This test is a recording that measures the ability of a subject to stay awake during the day.
The diagnostic criteria for narcolepsy are described in the
International Classification of Sleep Disorders. These criteria indicate that the diagnosis may be based on clinical symptoms alone if both
excessive daytime sleepiness and cataplexy are present. If cataplexy is not present, however, the diagnosis should be based on the clinical symptoms and polysomnographic findings.
The blood test for a type of HLA
The blood test for a type of HLA (Human Leukocyte Antigen) has been observed to have a very high association with narcolepsy. Certain types of HLA are part of an individual's genetic or hereditary makeup and can be characteristic of certain conditions, especially autoimmune diseases. The particular HLA type associated with narcolepsy is not unique for this condition as it is also found in 20% of the general population. Therefore, HLA typing should not be used for the diagnosis of narcolepsy.
Stress occurs when forces from the outside world impinge on the individual. Stress is a normal part of life. However, over-stress, can be harmful. There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions.
Depression is an illness that involves the body, mood, and thoughts and affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. The principal types of depression are major depression, dysthymia, and bipolar disease (also called manic-depressive disease).
Sleep apnea is defined as a reduction or cessation of breathing during sleep. The three types of sleep apnea are central apnea, obstructive apnea (OSA), and a mixture of central and obstructive apnea. Central sleep apnea is caused by a failure of the brain to activate the muscles of breathing during sleep. OSA is caused by the collapse of the airway during sleep. OSA is diagnosed and evaluated through patient history, physical examination and polysomnography. There are many complications related to obstructive sleep apnea. Treatments are surgical and non-surgical.
A number of vital tasks carried out during sleep help maintain good health and enable people to function at their best. Sleep needs vary from individual to individual and change throughout your life. Not getting enough sleep can hurt memory performance, health, and your mood.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
Insomnia is difficulty in falling or staying asleep, the absence of restful sleep, or poor quality of sleep. Insomnia is a symptom and not a disease. The most common causes of insomnia are medications, psychological conditions, environmental changes and stressful events. Treatments may include non-drug treatments, over-the-counter medicines, and/or prescription medications.
Hypersomnia is a condition where a person has excessive daytime sleepiness and trouble staying awake during the day. Treatment for hypersomnia includes medication, CPAP machines, and lifestyle changes.
Periodic limb movement disorder (PLMD) is a sleep disorder characterized by rhythmic movements of the limbs during sleep. The movements typically involve the legs, but upper extremity movements may also occur. Movements occur periodically throughout the night and can fluctuate in severity from one night to the next. They tend to cluster in episodes that last anywhere from a few minutes to several hours. These movements are very different from the normal spasms, called hypnic myoclonia, that we often experience initially while trying to fall asleep.
When sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called "problem sleepiness." A person can have problem sleepiness without realizing it. Symptoms of problem sleepiness include: consistently don't get enough sleep, or poor quality sleep, fall asleep while driving, struggle to stay awake when inactive (like watching TV or reading), have difficulty paying attention or concentrating at work, school, or home, have poor performance problems at work or school, have difficulty remembering things, have slowed responses, have difficulty controlling your emotions, and/or if you have to take naps on most days.
Sleep needs in children and teenagers depends on the age of the child. Sleep disorders in children such as sleep apnea, parasomnias, confusional arousals, night terrors, nightmares, narcolepsy, and sleepwalking can effect a child's or teen's sleep. Healthy sleep habits and good sleep hygiene can help your infant, toddler, preschooler, tween, or teenager get a good night's sleep.
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