A Structure for the Sleep Consultation
Build a picture of bedtime, night and morning then screen for what else is there
Consultations are fluid and there is no single model. This is the framework I use for all sleep-type consultations. It will not always name the disorder. It will usually give you a reasonable idea of the likely diagnosis and enough information to write a genuinely useful referral letter.
It takes a full appointment, and often more than one. The value is in the structure: the same walk through the night, every time, so that nothing routinely gets missed.
1. Walk through the night
Bedtime. What time do they get into bed intending to sleep?
Falling asleep. How long does it take them to get off to sleep?
Waking in the night. Do they wake after initially falling asleep? How many times, what do they do, and how long does it take to get back to sleep?
Morning. What time do they wake, and is that an alarm — or several alarms?
Onset. When did the symptoms start? Was there a change in medication, or a new illness, around that time?
2. Then screen
Sleep problems travel together. Screen routinely, even when the presenting complaint looks clear.
Restless legs. Unpleasant sensations in the legs, or an urge to move them, in the evening or before sleep. Ask particularly where they struggle to get off to sleep.
Sleep-disordered breathing. Witnessed apnoeas, snoring, waking with a choking sensation.
Parasomnias. Nightmares, sleep terrors, sleepwalking, acting out dreams, kicking or punching in sleep.
3. Don't miss
Cataplexy: sudden loss of muscle tone triggered by emotion, often laughter
Falling asleep without warning
Daytime sleepiness severe enough to put them at risk driving or at work
Ask directly about sleepiness at the wheel. Where there is a real risk of falling asleep while driving, advise against driving and check the current DVLA standard on notification.
4. Work, days off and habits
Shifts. Are they working shifts, and on what pattern?
Days off, weekends and holidays. When the alarm comes off and sleep is unrestricted, what time do they fall asleep and wake, and how much do they need to feel well? Marked catch-up points to chronic restriction rather than an inability to sleep, and in shift workers it shows you where the body clock actually sits.
Caffeine and alcohol. Ask about timing, not just quantity.
Sleep hygiene has often been covered already, or they have read about it themselves.
5. Where to go next
Ferritin and iron studies, particularly where restless legs is a possibility
Bloods for reversible causes of tiredness
What else is interrupting the night? For example nocturia, pain, itching.
Use this freely. Copy it, print it, put it in your teaching. No permission needed and no attribution required.
A consultation structure, not a clinical guideline. Clinical judgement and local referral pathways apply.
I'm a GP and sleep medicine specialist (MSc, Oxford) and a trustee of The Sleep Charity. I write about sleep, primary care and health policy at The Missing Variable.