The 5T method for working up a sleep complaint

Why a framework helps

The most common reflex when a patient complains about sleep is to prescribe something.

For most patients that is not the best first move. Most of us got only a couple of hours of sleep education across medical school and residency, so we never learned how to work sleep up properly.

Sleep is multifactorial, which is what makes it interesting and also what makes it easy to miss things. Patients end up misdiagnosed, underdiagnosed, or placed on treatments that do not match what is actually going on.

A simple framework you can go to in your mind prevents most of that. Mine has five steps: talk, test, treat, track, and tune up.

Talk

Take a real sleep history by talking to the patient.

As you may remember from learning history taking, the patient will tell you the diagnosis if you listen closely enough and ask the right questions.

Ask what time they go to bed and wake up, whether they nap, what their sleep quality is like, and how the schedule differs on weekdays and weekends.

Then ask about the symptoms they did not think to mention. Obstructive sleep apnea symptoms, kicking or movements during the night, frequent trips to the bathroom, mood or anxiety symptoms, and whether a bed partner is disrupting their sleep.

Why this matters: a patient who says “insomnia” may not have insomnia. It can be a sign of another underlying sleep disorder.

Even hypersomnias and narcolepsy can present with insomnia complaints, because of the sleep disruption that goes along with them.

Talking also gets you their buy-in, which is what makes them engaged in the treatment plan.

If you do not have time for a long history, an intake form or screening questionnaire sent before the appointment gives you a jumping off point.

Test

Testing covers three different things.

Rating scales come first: STOP-BANG, the Epworth Sleepiness Scale, the Insomnia Severity Index, and mood scales such as the PHQ-9 and GAD-7.

Then a sleep diary. I like the free one-page grid from the American Academy of Sleep Medicine. It gives a really nice visual of what is going on, and circadian misalignment often shows up on it at a glance.

Then baseline labs, to look under the hood. A CBC and CMP, vitamin D, B12 and folate, and thyroid function.

In patients with restless legs symptoms, periodic limb movements, or heavy menstrual periods, check ferritin and iron studies. In our practice, optimizing iron levels has had a significant effect on energy and on sleep quality.

Finally there is sleep testing itself. Baseline polysomnography or a home sleep test, titration studies, a study to check that an oral appliance is working, and studies to assess for narcolepsy.

Treat

Once you have a differential and some data, you can treat the underlying issue.

If the study showed sleep disordered breathing, that is what you treat. If iron is low and there are restless legs symptoms, optimize the iron.

One point worth knowing here: patients with restless legs syndrome who are not anemic can still benefit from iron supplementation. The Restless Legs Syndrome Foundation has more information on that.

If it does look like a primary insomnia issue, start CBT-I techniques or refer for CBT-I, which is the gold standard first line treatment for insomnia. Sleep restriction or compression, circadian regulation and lifestyle work all sit here.

Medication can have a role short term, to get a patient back on track while you continue investigating.

The key point is that whatever you implement should follow the differential you built in the first two steps. Treatment is not the opening move.

Track

Now you track whether the treatment worked.

Wearables can help, with one caveat. Patients who are struggling with sleep sometimes get fixated on the data, and that adds anxiety. That is orthosomnia, and it is worth watching for.

The sleep diary and the rating scales both work well for tracking. If a patient has hypersomnia, the Epworth gives you a baseline and a way to follow daytime sleepiness over time.

Patient self-report matters just as much. They will tell you whether they have more energy, better focus, less brain fog, or fewer complaints from a bed partner.

Tune up

This is where you fine-tune. Day-to-day habits, apnea treatment, titration and compliance data.

Even asking a patient what their compliance data shows gets them thinking and engaged in their own treatment.

If they are on sleep medication, this is the point to think about deprescribing, or a longer term plan that supports sleep without external sleep aids.

Relapse prevention belongs here too. It is normal for people to have sleep issues from time to time, so agree in advance on what you will both do if things slip again.

The five T’s are a cycle rather than a checklist. You can go around it again as the plan gets refined, or if the patient runs into trouble later.

Clinical pearls

• Prescribing before talking and testing is the most common misstep in a sleep complaint.
• “Insomnia” is a complaint, not a diagnosis. Screen for apnea, movement disorders and circadian issues before taking it at face value.
• Check ferritin and iron studies with restless legs symptoms and with heavy menstrual bleeding. Iron can help even without anemia.
• Watch for orthosomnia in patients who track their own sleep.
• Build relapse prevention into the plan while things are going well, not after they slip.

Sleep problems are highly treatable, and a patient who has been told to live with them usually has not had a systematic work-up yet.

Disclaimer: This information is for educational purposes only and is not intended to replace individualized medical advice, diagnosis, or treatment.