obstructive sleep apnea (osa) is the most common sleep-related breathing disorder and is typically associated with obesity. partners of affected individuals commonly describe observing restless sleep and irregular snoring, gasping, or choking episodes. the diagnosis is based on polysomnography or home sleep apnea testing. lifestyle changes such as weight loss, avoidance of precipitating factors (e.g., alcohol), and improvement of sleep hygiene are recommended.
the diagnosis of obstructive sleep apnea requires sleep studies and should not be made based on clinical tools or questionnaires alone. in-laboratory polysomnography is the gold standard for the diagnosis of sleep-related breathing disorders and can also help identify other sleep-related conditions (e.g., seizures).  nocturnal positive pressure therapy is the therapy of choice in osa. the success of therapy is highly dependent on patient adherence.
it is regulated by the circadian rhythm and usually consists of 4–5 sleep cycles that include three stages of non-rapid eye movement sleep (nrem sleep) and one stage of rapid eye movement sleep (rem sleep). sleep disorders can be grouped into primary disorders (i.e., due to an intrinsic disorder of the sleep-wake cycle) and secondary disorders (i.e., due to an underlying medical condition). environmental factors (e.g., long working hours, irregular sleep schedules, alcohol consumption) can also lead to sleep loss. treatment of sleep disorders and sleep loss may include sleep hygiene practice, phototherapy, and sedative pharmacotherapy. “i saw the t(w)ooth fairy fleeing and the three little pigs peeing:” teeth grinding occurs during n2 stage and bedwetting during n3 stage nrem sleep. inpatients frequently experience insomnia due to disruptive changes in routine and the fact that the hospital environment is not always conducive to sleep.
clinicians should avoid them if possible and, when necessary, they should be prescribed carefully, after weighing the risk of potential adverse events and pharmacological interactions. obtain a detailed clinical history, including symptoms and contributing factors; the insomnia severity index or the pittsburgh sleep quality index are commonly used standardized assessment tools. the most common sets of criteria are the international classification of sleep disorders (icsd-3) and the diagnostic and statistical manual of mental disorders (dsm-5), which are largely consistent with one another. cbt-i combines cognitive therapy, stimulus control, and sleep restriction therapy, possibly with the addition of relaxation training.  avoid sleep restriction in patients with seizure disorders or bipolar disorders, as it can lower the threshold for seizures or precipitate manic episodes. avoid the use of benzodiazepine receptor agonists as a first-line medication for the treatment of insomnia in older adults and in patients with a history of substance use disorder or drug dependence.
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