Common Sleep Disorders
Snoring
It is estimated that 60% of middle aged men, and 40% of middle aged women snore. Snoring in children has been shown to contribute to performance problems in school, and should be evaluated further. The sound of snoring is produced by the vibration of soft tissues of the upper airway during sleep. The intensity of snoring may vary due to upper airway anatomy, position in bed, stage of sleep, degree of nasal obstruction, and ingestion of sedatives, or alcohol before sleep. Smoking may contribute to louder snoring. In children, nasal congestion, and adenoidal, and tonsillar enlargement commonly contribute to snoring.
Though mild snoring is not typically associated with serious health effects in adults, loud snoring can be associated with obstructive sleep apnea that can have adverse health effects. Treatment for snoring ranges from simple measures such as avoidance of alcohol or sedatives before sleep, to positioning in bed (generally off one’s back), to upper airway procedures aimed at reducing the volume, and vibration of the tissues, or relieving nasal obstruction. The use of palatal stiffening supports (palatal pillars) has also been shown to reduce snoring.
Obstructive Sleep Apnea (OSA)
The hallmark symptoms and findings of obstructive sleep apnea are loud snoring, “stop-breathing” events during sleep, and daytime sleepiness. This common sleep disorder, estimated to affect more than 20 million Americans, is typically unrecognized by those affected, and often by physicians and healthcare personnel.
Seen in all age groups, and both sexes, this under-recognized problem can contribute to high blood pressure, and an increased risk of heart attacks and strokes. A number of other symptoms that can be associated with sleep apnea, and that are often not recognized as such, include headaches on awakening, dry mouth on awakening, sweating during sleep, difficulty staying asleep, waking frequently during the night to urinate, mood and memory problems, worsened heartburn and reflux at night, and sexual dysfunction.
The disorder is characterized by obstruction of the upper airway (typically at the level of the throat), that reduces partially, or completely, the flow of air through the throat into the lungs. This process is associated with an increase in breathing effort, and typically a drop in the body’s blood oxygen level, resulting in an arousal, or awakening from sleep. Those with the disorder often complain of being tired and worn out, and not being refreshed by sleep, that results from their sleep being interrupted up to hundreds of times in a night, even without the affected person being aware of these interruptions. Though seen most often in those who are overweight, thin persons are also affected. Sleep testing is usually performed to document the presence of the disorder so that appropriate treatment can be initiated.
Treatment options include the use of a nasal mask device (continuous positive airway pressure, or CPAP), upper airway surgical procedures, and oral appliances. Positioning techniques can be used for some patients. Weight control is useful in all patients who are overweight with OSA.
Insomnia
This disorder refers to a complaint of poor sleep. Three common patterns of insomnia are seen:
- Difficulty falling asleep
- Difficulty staying asleep
- Awakening before a full night of sleep, typically early in the morning, and not being able to return to sleep.
Individuals may complain of more than one pattern. Persons affected by insomnia report impaired daytime functioning and sleepiness. Though nearly everyone may experience an occasional night of sleeplessness due to stress or anxiety, a chronic condition can result if poor sleep habits, and other behaviors detrimental to good sleep, develop and are continued.
Patients with difficulty falling asleep often have a prominent psychological component, associated with issues of depression, or anxiety. Other factors that can cause problems falling asleep include restless legs, pain, and environmental factors (room too cold/hot, uncomfortable bed, restless/noisy bedpartner). Affected individuals can develop frustration with their sleep problems, resulting in additional focus, concern, and pressure that is placed upon their sleep.
Individuals who have difficulty staying asleep often have a sleep fragmenting/interrupting process, including obstructive sleep apnea, or periodic limb movements. Sleep environment factors (temperature, noise, pets, children, TV, noisy bedpartners), medication/substance effects, and medical illness (pain, asthma) also contribute to sleep disruption.
Persons who awaken early in the morning, ie. 3-4 AM with a 10 PM bedtime, and are unable to return to sleep may have depression. Individuals with REM predominant obstructive sleep apnea may also awaken early in the morning as the amount of REM sleep increases.
Treatment for insomnia complaints is directed at the underlying cause, but also includes behavioral measures, and medication to induce, and maintain sleep. Behavioral measures include avoidance of practices detrimental to sleep (sleep hygiene), limiting time in bed to time spent asleep (stimulus control), limiting the total amount of time spent in bed to sleep (sleep restriction) and utilizing relaxation exercises. Medications used to improve the ability to fall asleep, and stay asleep include antidepressants with sleepiness side effects (i.e. Elavil, Desyrel), benzodiazepines (ie. Halcion, Restoril), non-benzodiazepines (i.e. Ambien, Sonata, Lunesta), and agents that work at melatonin sites (melatonin, Rozerem).
Sleep/Wake Schedule Disorder
Shifting sleep schedules due to work or travel can result in problems with sleep. Generally attributed to misalignment of the body’s internal clock, or circadian rhythm, with when one chooses to sleep, this disorder can result in problems getting to sleep, and staying asleep. Approximately 20% of the workforce in the United States performs some type of shift work, putting them at risk for this disorder. The extent to which a person is affected by shift work is dependent on variables such as an individuals prior sleep quality, strength of circadian rhythm, age, and the shifts being worked. How travel, particularly that associated with crossing time zones, affects an individual is dependent on some of the same variables as shift work, along with the direction of travel (i.e. Eastward or Westward). In addition to symptoms associated with not enough sleep, other symptoms associated with circadian rhythm misalignment include those of depression, and gastrointestinal problems.
Narcolepsy
This disorder, often arising in adolescence, is characterized by excessive sleepiness, sleep attacks, and sudden episodes of muscular weakness (cataplexy). Muscular weakness, or paralysis, while falling asleep, or waking up, and vivid visual or auditory experiences while falling asleep (hypnagogic hallucinations), or awakening (hypnapompic hallucinations) are also features of the disorder. Sleepiness is often improved for 2-3 hours at a time by short naps, and nighttime sleep is often interrupted by 1-2 hour awakenings.
This disorder is often unrecognized, or misdiagnosed, resulting in delay of diagnosis. Recent research has identified the cause in classic forms of narcolepsy as being due to destruction of a group of cells within the brain that produce a neurotransmitter (hypocretin/orexin) that regulates wakefulness and sleep. Viral, and autoimmune mechanisms for cell damage have been postulated. Sleep testing is generally needed for diagnosis.
Treatment includes proper sleep habits, strategically timed naps, and medications. The latter includes medications that can reduce the tendency for cataplexy, sleep paralysis, and hypnagogic hallucinations, as well as medications used to improve wakefulness. Xyrem is an effective agent for reducing cataplexy and helps to consolidate sleep at night. The medication can improve daytime wakefulness, though the mechanism of action has not been definitively determined. A combination of REM-suppressing medications (ie. protriptyline, Effexor, Prozac) and stimulants (Provigil, methylphenidate, methamphetamine) has also been used to improve symptoms.
Restless Legs Syndrome/Periodic Limb Movements
A creepy, crawly sensation associated with an irresistible urge to move the legs is often described by those affected by restless legs syndrome (RLS). Typically worse during periods of inactivity, and especially in the evening hours before bed, this disorder is under-recognized, though readily treatable. It is often associated with periodic limb movements (PLMS) during sleep, which are repetitive movements of the legs, or arms, that can disrupt sleep, and leave one feeling worn out and tired, in spite of adequate sleep amounts. Periodic limb movements in sleep can occur without the restless legs syndrome. Diagnosis of restless legs syndrome is typically made by clinical history, though diagnosis of periodic limb movements is made by sleep testing.
Treatment for both disorders is with medications, though avoidance of certain substances (i.e. caffeine for RLS), and some medications (diphenhydramine (active ingredient in Benadryl, and many “PM” products), Reglan) which are associated with worsening of symptoms, is important. Treatment of underlying medical problems often associated with RLS, and PLMS, such as anemia due to iron-deficiency, is also important. Obstructive sleep apnea can also contribute to RLS symptoms that are improved with treatment of the sleep apnea. Medications commonly used to manage symptoms of RLS include Requip (very effective), Mirapex (very effective), Sinemet (effective but more frequently associated with a subsequent increase in leg symptoms (augmentation), Klonopin, Neurontin, and pain medications.
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