A thorough but focused physical examination, including neurologic and mental status assessment, should seek confirmation of conditions suggested in the history, including evidence of comorbid, insomnia-promoting conditions listed in Table 2.
When history and physical suggest sleep apnea, restless leg syndrome, or narcolepsy, or when the diagnosis is uncertain, treatment fails, or wakening is associated with violent or injurious behavior, further testing such as survey tools and polysomnography3 should be used. Referral ma