1182 Enhancing Primary Care Detection and Referral of Nightmare Disorder: A Quality Improvement Project
James R. Kang, Zahari N. Tchopev, H. Scheuller, W. Frey, Collin Clay, Aaron Burch, Philip Cushman, Amanda Radtke, J. Faulk, M. Peterson, M. Evans, D. Armstrong, Bhavna Lalvani, Matthew S. Brock
Sleep May 1, 2025 DOI: 10.1093/sleep/zsaf090.1182 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Quality improvement project Peer reviewed |
|---|---|
| Sample size | 614 |
| Population | Patients presenting to the Internal Medicine Clinic at a Military Treatment Facility |
| Duration | Screening period from September 6 to October 4, 2024 |
| Measures | Nightmare Disorder Index (NDI) |
| Topics | Dreaming |
| Key points | Integrating the Nightmare Disorder Index into routine primary care intake achieved a 94.5% completion rate and identified possible or probable nightmare disorder in 84 of 580 screened patients (14.5%), plus 25 of 35 previously diagnosed patients still symptomatic. However, only 16 sleep medicine referrals were made, 2 for nightmare disorder concern, indicating that detection greatly exceeded referral. |
Abstract
Nightmare disorder (NDO) is a significant but often under-recognized condition, especially within the military population. We previously reported that 31.2% of patients referred to our military sleep disorders center have NDO, yet only 3.9% were referred for NDO. Despite the general population’s NDO prevalence (2-8%), our center had no referrals for NDO from June 1 to August 31, 2024. This quality improvement (QI) project aimed to improve NDO detection and referral rates using the nightmare disorder index (NDI). From September 6 to October 4, 2024, the Internal Medicine Clinic (IMC) at a Military Treatment Facility (MTF) integrated the NDI into routine patient intake. Patients were categorized into three groups: negative for NDO (no nightmares or nightmares without associated symptoms), possible NDO (nightmares causing symptoms), and probable NDO (nightmares causing significant symptoms, indicated by a score of 2 or greater in each NDI section of sections 2-4). Additionally, patients with a prior NDO diagnosis were classified as symptomatic or asymptomatic. Providers were instructed to review the NDIs and refer patients for NDO as clinically appropriate. Out of 614 patients screened, 580 (94.5%) completed the NDI. Among them, 460 (79.3%) screened negative, 72 (12.4%) screened positive for possible NDO, and 12 (2.1%) for probable NDO. Additionally, 35 patients had a prior NDO diagnosis, with 25 (71.4%) remaining symptomatic. Of these symptomatic patients, 10 were on pharmacologic therapy, 3 engaged in behavioral therapy, 5 received both, and 7 had no treatment. The IMC made 16 referrals to sleep medicine during this period, with 2 referrals indicating concern for NDO. This quality improvement project successfully incorporated the NDI into routine primary care screening, achieving a high completion rate. The detection of possible and probable NDO is clinically significant. However, far more patients were identified than were referred for specialty care. Future planned QI cycles will expand this project to other primary care clinics, such as Family Health and Operational Medicine, to improve referral rates and enhance NDO identification and treatment. These efforts, which are generalizable to civilian populations, aim to reduce NDO under-recognition and improve patient quality of life.