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Do you have trouble sleeping? Learn about some common sleep disorders.
Insomnia People who have insomnia report that their sleep is inadequate or poor quality. It may be characterized by one or more of the following: - Difficulty falling asleep - Awakening too often and having trouble returning to sleep - Awakening too early - Awakening unrefreshed Insomnia cannot be simply defined by the "facts" about sleep, such as how many hours someone sleeps or how long it takes to get to sleep. People have variable needs for and perceptions of their sleep. Consequences of insomnia can include excessive sleepiness, fatigue, irritability, and problems with tasks such as maintaining attention, organizing, and remembering. About 30 to 40 percent of adults report insomnia in any given year. For 10 to 15 percent of these people, their insomnia is chronic and/or severe. Our ability to sleep decreases with age. Insomnia is more common in women, especially after menopause.  Insomnia may be transient (i.e., lasting from one night to several weeks), intermittent, (i.e., recurrent bouts of transient insomnia), or chronic, (i.e., occurring most nights and lasting a month or more). Transient insomnia is often triggered or perpetuated by stress or discomfort. Common disturbances include life crises, acute illness, a change in the sleep environment, uncomfortable temperature, and irregular sleep/wake schedule (e.g., shift work schedules, jet lag), and medications that impact sleep. Chronic insomnia may be due to ongoing factors, including those that cause transient insomnia, or mental or physical disorders. An irregular sleep-wake schedule can perpetuate poor sleep. Chronic sleep disturbance can reflect abnormal sleep-wake regulation or physiology during sleep. Excessive napping reduces the likelihood of sustained night sleep. Some sleep disorders, including restless legs syndrome (RLS), periodic limb movement disorder (PLMD), sleep apnea, and disturbances of circadian rhythms disrupt sleep. Psychiatric problems frequently trigger chronic insomnia but account for less than half of cases. Depression, anxiety, and mood instability are often associated with insomnia. Medical and neurologic illnesses that disturb sleep include asthma, chronic lung disease, arthritis, heart failure, Parkinson's disease, and Alzheimer's disease. Sleep is disrupted by immobility, difficulty breathing, and pain. Hormonal changes that are associated with pregnancy, peri-menopause, and menopause disrupt sleep. Some medical problems are worse during sleep, either due to increased vulnerability because of underlying sleep physiology (e.g., asthma), and/or because they are worsened by recumbence (e.g., gastro-esophageal reflux). When identifiable causes of insomnia are excluded or successfully treated, persisting insomnia may be classified as primary. Chronic stress, hyper-arousal, poor sleep habits, and negative conditioning may underlie primary insomnia. Many over-the-counter prescriptions and drugs of abuse can worsen sleep quality. Individuals are variably susceptible to the effects of these agents. Activating antidepressants (e.g., buproprion), steroids, stimulant decongestants (e.g., pseudoephedrine), beta blockers (e.g., atenolol), caffeine, alcohol, nicotine, and recreational drugs degrade sleep. If you have any questions regarding Insomnia please contact us for further information. Narcolepsy The symptoms of narcolepsy Narcoleptics are very sleepy except during the minutes after they awaken from sleep. Their nighttime sleep is fragmented by repeated awakenings. In cataplexy emotional excitement triggers the abrupt onset of twitching of small face muscles, inarticulate speech, drooping of upper eyelids, limpness of the neck, sagging in a chair or sinking to the floor with preserved consciousness. Laughter, surprise, and anger are common precipitants. Muscle weakness typically occurs for seconds or minutes. The narcoleptic is likely to fall asleep if this weakness persists for more than two minutes. Sleep paralysis is the temporary inability to talk or move while falling asleep or awakening. It is commonly accompanied by dream-like images or, less frequently, accompanied by hallucinations of touch, voices, or the sense that there is an intruder in the sleep environment. These are called hypnogogic when they occur as one is going to sleep or hynopompic when awakening. The symptoms of narcolepsy, except for cataplexy, which occurs only very rarely in non-narcoleptics, also occur in people who do not have narcolepsy. They tend to persist throughout life from the time of onset. Most often excessive sleepiness begins months or years before the onset of cataplexy. The prevalence of narcolepsy 200,000 Americans have narcolepsy, however, only a quarter are diagnosed. Often there is an interval of many years between the onset of symptoms and the establishment of the correct diagnosis. During this time, incorrect diagnoses are often made and inappropriate treatments initiated. Sex and age distribution of narcoleptics Narcolepsy occurs in a roughly equal number of males and females and may begin at any age. However, the most common age of onset is the teens or twenties. The sleep of narcoleptics Unlike non-narcoleptics who typically develop dreaming or rapid eye movement (REM) sleep an hour or more after they fall asleep, narcoleptics tend to enter REM sleep within minutes of sleep onset. REM sleep is characterized by paralysis of voluntary muscles except for the small muscles that move the hands, toes, and eyes. Dreams are more likely to occur during REM compared with non-REM sleep. The sleep paralysis and cataplexy of narcoleptics along with the hallucinations, closely resemble the normal events of REM sleep.
Diagnosis of narcolepsy The diagnosis of narcolepsy is highly likely when severe sleepiness is associated with cataplexy. The presence of other cardinal symptoms and positive results of sleep testing support the diagnosis, especially when cataplexy is absent. Diagnostic testing typically includes an overnight polysomnogram (PSG) to investigate other possible causes of excessive sleepiness (e.g., sleep apnea or periodic limb movements during sleep) and to make sure that the patient is not lacking REM sleep. Following the overnight, the patient completes a mean sleep latency test (MSLT) during which the patient is given four to five nap opportunities to sleep. The patient is not allowed to sleep for more than 15 minutes during each nap opportunity. Narcoleptics usually have the onset of Stage REM during two or more of the MSLT naps. Importantly, if there is a lack of Stage REM during the night immediately prior to an MSLT, sleep onset REM activity may represent a normal rebound of Stage REM rather than narcolepsy. Even with a normal amount of Stage REM the night before, as documented by the PSG , narcoleptics tend to have two or more sleep onset REM periods during an MSLT. The genetics of narcolepsy Only one to two percent of narcoleptics with cataplexy have immediate family members with narcolepsy. Eight to twelve percent of people with excessive sleepiness and other associated symptoms of narcolepsy without cataplexy have a higher incidence of hypersomnolence and associated symptoms in their immediate family. Although the genetics of human narcolepsy, as opposed to dog narcolepsy, appear to be complex, 90% or more of narcoleptics with cataplexy, and a smaller majority of those without cataplexy, have a narcolepsy susceptibility gene. When one identical twin has narcolepsy with cataplexy, the other twin has a one of three chance of having narcolepsy. Therefore, genes do not alone determine whether an individual will develop narcolepsy. Treatment of narcolepsy There is no cure for narcolepsy however, the symptoms can be partially relieved. Sleepiness can be reduced by stimulants or by twice nightly doses of oxybate, a natural substance that consolidates sleep. A variety of antidepressant medications can reduce cataplexy however, oxybate is more potent. A regular sleep wake schedule and taking periodic naps during the day and evening can also be helpful. Sleep Apnea Epidemiology, history, definitions, and common symptoms Sleep apnea is a potentially serious and even life-threatening condition that affects up to 18 million Americans according to the National Institutes of Health. Despite its high prevalence, it is often overlooked and undiagnosed. Although sleep apnea was described in ancient Hebrew texts, by William Shakespeare in Falstaff, and by Charles Dickens in The Pickwick Papers, the first contemporary medical description of sleep apnea was only published in 1965. In adolescents and adults, an apnea during sleep is defined as the absence of air flow through the nose and mouth for 10 seconds or more. During non-obstructive apneas, there is no breathing effort either because the brain or spinal cord fails to send an adequate signal to the breathing muscles or because there is a problem with the muscles or nerves that normally convey messages from the brain and spinal cord. Sleep apnea with predominantly non-obstructive apneas tends to be most common in the elderly however, it may occur at any age. Obstructive apneas are characterized by the absence of airflow for more than ten seconds despite ongoing breathing effort. During inhalation the upper airway is sucked closed, typically in the area behind the tongue. Sleep apnea with predominant obstructive apneas is most frequent in preadolescents, adolescents, and young and middle-aged adults. Individuals with sleep apnea syndrome may have many apneas per hour of sleep. Partial breaths called hypopneas, like apneas lasting 10 seconds or more, may occur. They have the same consequences as apneas. Serious consequences Untreated sleep apnea can increase the likelihood of critical medical consequences, such as irregular heartbeat, high blood pressure, heart failure, heart attack, and stroke. In addition, difficulty maintaining vigilant attention, organizing and executing tasks, and remembering can occur. Diagnosis A majority of people with predominantly obstructive sleep apnea are overweight or obese. The severity of the apnea in these individuals is often proportionate to the degree of their obesity. However, people who are not overweight can also have obstructive sleep apnea. Common symptoms of obstructive sleep apnea, aside from excessive sleepiness, include loud snoring, headaches, heart burn, cognitive impairment, and awakening unrefreshed. Choking, coughing, excessive movement, regurgitation, and, in a small proportion of individuals, awakenings triggered by involuntary closure of the vocal cords, may occur. Patients with obstructive sleep apnea often awaken with a dry mouth and, in some cases, headaches. Breathing interruptions disrupt sleep and contribute to the excessive sleepiness that is a cardinal symptom of sleep apnea syndrome. In addition to being overweight, many patients with obstructive sleep apnea have high blood pressure, a recessed chin, or narrow or shallow upper airway. Obstructive sleep apnea tends to run in families. Patients with obstructive sleep apnea and other conditions that cause chronic excessive sleepiness often tend to underestimate their degree of sleepiness. Family members or other observers often provide more accurate assessments of the patient's sleepiness. Individuals with obstructive apnea often believe their sleep is uninterrupted. Their sleep however, is usually interrupted by awakenings that are so brief that the patients are unaware of them. A care provider who is aware of the symptoms and signs of sleep apnea may suspect the diagnosis from the history and examination of the patient. Unfortunately, other physicians may miss the diagnosis. For this reason and because patients with apnea often do not complain to their doctors about their sleep-related symptoms, the majority of patients go undiagnosed and untreated. If the diagnosis is suspected most patients should complete an overnight recording of their sleep in a qualified sleep laboratory. Brain and muscle activity, eye movements, heart rate and rhythm, breathing effort, air flow, and blood oxygen levels are routinely recorded. A test the next day, called a multiple sleep latency test (MSLT), is sometime necessary to investigate other disorders that may mimic or compound sleep apnea. During the MSLT, sleep is recorded during four or five brief nap opportunities. While normal individuals fall asleep after an average of 10 to 20 minutes, people likely to benefit from treatment for underlying sleep problems are likely to fall asleep in less than five minutes. Treatment All patients with sleep apnea benefit from avoiding or limiting alcohol intake and smoking. They should avoid sleeping pills and other sedating medications unless directed to use them by a knowledgeable care provider. Depending on the dose consumed, alcohol, hypnotics, and sedatives may make a patient's upper airway more likely to collapse during sleep and interfere with the arousals that terminate these airway collapses. Certain medications, such as trazodone and theophylline, may slightly reduce the severity of apneas in some patients. Nasal continuous positive airway pressure (CPAP) is the most effective treatment for obstructive sleep apnea. Sufficient air pressure is introduced into the nose to inflate the upper airway enough to prevent collapse during sleep. The air pressure is generated by a flow generator , which is attached to a tube that connects to an air tight nasal or nasal/oral mask or a tube with branches that insert into the outer parts of the nostrils. This tube is similar to the one commonly used for applying nasal oxygen through the nostrils. Dental appliances that fit onto the teeth and hold the jaw and tongue forward widen the airway and can be helpful for mild sleep apnea. Dentists with appropriate expertise can fit these devices. A variety of surgical procedures have been used to treat obstructive sleep apnea. When large tonsils and adenoids are an important contributing factor tonsillectomy and adenoidectomy can be helpful. Surgery that includes removal of soft tissue from above and behind the base of the tongue has been done extensively. Thirty to 50% of patients may derive benefit from this procedure. However, the duration of the benefit is uncertain Also, it is difficult to predict which patients will respond favorably to this procedure. Surgery to correct jaw deformities may improve obstructive sleep apnea. Weight loss can be helpful for overweight patients. Unfortunately, inducing enduring weight loss is often difficult. Restriction of calories and an increase in exercise are helpful, but may be difficult to maintain. Over the past decade, physicians at the Centers for Sleep Medicine have prescribed safe medications that induce frequently substantial weight loss in a majority of overweight patients. REM Sleep Behavior Disorder (RBD) People with REM Sleep Behavior Disorder (RBD) tend to speak and shout and also move vigorously or violently during REM sleep. These episodes of abnormal movements may result in injury to the patient or a bed partner. If the patient awakens during these episodes, the patient reports that the specifics of the observed movements correspond to the violent events taking place in a dream. Muscles, except those that mediate breathing and movement of the eyes, fingers and toes, are paralyzed during normal REM sleep. Electrical activity and oxygen consumption of the brain continues to the same degree as during wakefulness. In some cases, it is sufficient to make the diagnosis of REM sleep behavior based on the patient's history. In other cases, it is difficult to distinguish the symptoms from those of sleep walking, sleep talking, seizures or sleep terrors. For these difficult cases, it is sometimes helpful to do an overnight sleep recording, known as a polysomnogram (PSG). An episode of REM sleep behavior disorder may be recorded during the polysomnogram or there may be one or more awakenings directly from Stage REM sleep. Treatment of REM sleep behavior disorder includes prescription of medications to deepen sleep and/or to suppress Stage REM sleep. Sleepwalking Sleepwalking (Somnambulism) is characterized by complex sometimes semi-purposeful activity that arises from Stages 3 and 4 sleep, usually during the first hour or two of sleep. The affected person may sit up in bed or arise and walk about, occasionally sustaining an injury. When awakened during the episode or after awakening for the day, the patient has no recollection for what occurred. Sleep terrors (pavor nocturnus) are characterized by the affected individual screaming during awakening and then often jumping up from bed in terror. Initially there is disorientation. On questioning, a recollection of experiencing intense fear is described rather than the specifics of a typical dream. Sleep terrors arise from Stage 3 and 4 sleep and, like somnambulism, are therefore most likely to occur during the first hour or two of sleep. Sleep terrors and sleepwalking are more common in childhood than during adult years, but in some cases may begin or persist into adulthood. There is a tendency for these disorders to run in the family. Sleepwalking is diagnosed through a combination of history and sleep studies including actigraphy and polysomnography. Medications, such as bedtime benzodiazepines or sedating antidepressants, can suppress or eliminate episodes of sleepwalking or sleep terrors. Psychotherapy and drug treatment to reduce anxiety may also provide benefit. Restless Legs Syndrome Symptoms of RLS Individuals with restless legs syndrome (RLS) report discomfort in their legs, and less often their arms, that are associated with an irresistible urge to move or rub the affected limbs. This occurs when individuals are immobile, especially at night when they are trying to sleep. During these episodes, the person will get up to walk about to suppress the abnormal sensations. When asked to describe the nature of the discomfort, affected individuals almost always have difficulty. Most often they describe tightening, pulling, or crawling sensations. When these feelings are intense they may interfere substantially with sleep and there is consequent excessive sleepiness during the day. Patients with severe RLS note that their symptoms can make it difficult for them to remain confined to a car or airplane seat for more than a short time. Some patients experience RLS symptoms intermittently, sometimes over a series of nights, but then they may remain symptom-free for days, months, or even years. Associated periodic limb movements Most people with RLS also have periodic limb movements (PLMs) during sleep. These PLMs occur in trains of five or more limb jerks with an interval of 10 to 60 seconds between jerks. Sometimes the PLMs severely disrupt sleep, but more often they do not disrupt sleep substantially, if at all. Associated conditions RLS can be associated with a number of other conditions or it can occur without any underlying medical problem. There is a 50% chance in some families that children of an affected individual will develop RLS. Some women experience RLS only during pregnancy. Iron deficiency may trigger RLS; there appears to be a lack of iron in areas of the brain that exert control of movements. Iron treatment should be considered in RLS patients with serum ferritin levels below 50. Treatment with iron supplements can correct the condition in these individuals. Kidney failure and diabetes cause dysfunction of peripheral nerves and are associated with a relatively high rate of RLS and PLMs. Similarly, sciatic can predispose an individual to RLS. Age and sex prevalence RLS becomes more prevalent and more severe with aging. Both men and women are equally affected. Diagnosis The diagnosis of RLS depends mostly on the individual's history. Laboratory testing can detect PLMs, but not RLS. Treatment A variety of medications have been used successfully to treat RLS. However, none of these are consistently tolerated or helpful to all patients. Dopaminergic drugs that are FDA-approved for treating Parkinsonism can suppress RLS symptoms. A minority of patients who initially experience a successful response to this treatment, note that they begin having a break through of RLS symptoms earlier in the day. This is called augmentation. Narcotics and benzodiazepines can suppress RLS, but these can be sedating and addictive. More recently, certain anti-epilepsy drugs, including gabapentin, topiramate, and zonisamide, have been found to be variably effective for RLS. Of course, iron should be prescribed for patients with underlying iron deficiency. |
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