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Sleep disorders are common. According to the National
Sleep Foundation, more than 50 million Americans suffer
from a sleep disorder at some time in their lives. These disorders
have a significant impact on the daytime functioning, quality
of life, and health of the sufferer. For example, research
data have shown that people with insomnia report more problems
with attention, concentration, and memory than healthy individuals;
and they are more likely to suffer from psychiatric disorders
like depression and anxiety. Those who suffer from sleep apnea,
a sleep-related breathing disorder, are at greater risk for
high blood pressure, cardiac arrhythmias (irregular heartbeats),
stroke, and death. The significant health consequences of
sleep disorders have led experts to agree that these problems
warrant medical attention.
There are more than 80 different sleep disorders identified
in the International Classification of Sleep Disorders. Some
of the most common disorders and their treatments are described
below.
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| Insomnia |
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Insomnia is characterized by difficulty falling asleep, difficulty
staying asleep, or poor quality sleep. People who suffer from
insomnia often take 30 minutes or longer to fall asleep, awaken
frequently throughout the night, awaken for long periods during
the night, or experience “non-restorative” sleep
that is not refreshing. The nighttime symptoms of insomnia may
result in significant distress for the sufferer who may spend
hours tossing and turning in bed.
Insomnia is associated with impairments in daytime functioning.
People with insomnia commonly report daytime fatigue or daytime
sleepiness that interferes with their lives. Symptoms can be
so severe that the insomnia sufferer cannot engage in productive
activity, or finds that temporary relief comes only after retreating
to a quiet place to nap.
Sleepless nights commonly take their toll in family, social,
and work settings. People with insomnia say that they have more
difficulties dealing with minor stress, and more problems relating
to others in social and work settings, than those without insomnia.
One study has shown that the “quality of life” of
people with insomnia is markedly poorer than people who do not
have sleep difficulties.
The problems associated with insomnia have a real impact on
daytime performance. People with insomnia report greater impairment
in mental functioning than healthy sleepers, including problems
with attention, concentration, and memory. They also are at
greater risk for accidents or injuries due to fatigue. Research
data have shown that people with insomnia are 2.5 times more
likely to be involved in a fatigue-related motor vehicle accident
than healthy sleepers, and 4.5 times more likely to be involved
in an accident in the workplace than healthy sleepers.
One survey conducted by the Louis Harris organization has shown
that people with insomnia report more problems on the job than
those without. There are significant declines in both work quality
and work quantity on the days following a bad night of sleep.
These findings are consistent with other data showing that people
with insomnia have higher rates of absenteeism on the job and
are less likely to be promoted than healthy sleepers.
One of the most concerning findings about insomnia is that it
may be a risk factor for the development of depression. Several
studies have now shown that an episode of insomnia that occurs
early in life may precede the development of depressive symptoms
later in life. There also may be other health consequences of
insomnia, such as altered glucose metabolism or increased risk
for heart disease, although studies to further examine these
relationships are ongoing.
Insomnia may be a transient problem that occurs only occasionally,
or it may be a more chronic condition that occurs nightly or
almost every night. Approximately 36% - 56% of the adult population
of the United States reports problems with occasional insomnia,
while 9% - 17% report longstanding or chronic problems with
their sleep. Whatever is the case, insomnia sufferers can tell
when the problem is causing distress at night or interfering
with daytime functioning. Even an occasional bad night can be
serious when they happen at the wrong times.
What causes insomnia? There are multiple factors that contribute
to the occurrence or maintenance of insomnia. These factors
include stress, medical conditions (e.g., pain, arthritis),
psychiatric conditions (e.g., depression), medications (e.g.,
stimulants, beta-blockers, and some antidepressants), the use
of alcohol and drugs, or environmental conditions. Insomnia
also may be due to underlying sleep disorders such as sleep
apnea, restless legs, or periodic limb movement disorder. Identifying
the underlying cause of one’s insomnia can be important
to finding relief, and can genuinely help to guide medical treatments.
However, not all people with insomnia can easily identify an
underlying cause.
For more information about insomnia, please download
the Insomnia Fact Sheet, which you can print and take to
your doctor. Or go to www.americaninsomniaassociation.org.
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| Treatment Options for Insomnia |
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Medication
There also are effective and safe drug treatments for insomnia.
Prescription medications such as zolpidem (Ambien®)
and zaleplon (Sonata®)
are effective in many cases of transient and chronic insomnia.
These medications fall into a relatively new category of drugs
known as “non-benzodiazepine benzodiazepine receptor agonists
(BZRAs).” They have been extensively tested in healthy
subjects and people with insomnia, and have been approved for
the treatment of insomnia. These medications are effective,
safe, and do not appear to be habit forming. They also are not
associated with many of the adverse effects of older sleep medicines.
Ambien generally is appropriate for use at bedtime. Sonata may
be used at bedtime or later, provided that one has at least
four hours of sleep time left.
There are two new non-benzodiazepine BZRA medications under
development that may be available by prescription within the
coming months. One medication, Indiplon®,
is a sleep aid that is being developed by Neurocrine Biosciences
and Pfizer. Another medication, Estorra®,
is a sleep aid that is being developed by Sepracor. If approved,
both of these medications will offer important new choices for
those who suffer from sleep problems.
Prior to the newer class of sleep aids, medications known as
the benzodiazepines were widely used. The first of these medications
was discovered in the late 1950s, leading to the synthesis of
more than 300 benzodiazepine drugs. Drugs in this class used
for sleep induction and maintenance include triazolam (Halcion®),
temazepam (Restoril®),
estazolam (Prosom®), and flurazepam (Dalmane®).
Other medications in this class, not approved as sleep aids,
also have been commonly used to treat insomnia. These medications
include drugs such as diazepam (Valium®),
clonazepam (Klonopin®),
and lorazepam (Ativan®). While physicians continue to use
these medications, and a number of people find them to be effective
and safe, they are used less commonly than in the past. This
primarily is due to reports of dependence, tolerance, and adverse
effects (e.g., increased risk of falling, memory impairment)
of these drugs.
Behavioral Therapies
There are many good non-drug treatments for insomnia. These
treatments include sleep hygiene therapy, behavioral therapy,
relaxation therapy, and cognitive-behavioral therapy. Such
treatments may be delivered by a primary care physician or
family doctor, but commonly are performed by a sleep specialist
or psychologist with special training in the field. Scientific
evidence supports the use of many of these techniques, and
sleep specialists commonly use them alone or in combination
with medication therapy.
Sleep Hygiene
The term “sleep hygiene” refers to one’s
sleep habits. People who experience problems falling asleep,
staying asleep, or getting good quality sleep may benefit
from practicing good sleep hygiene. However, many people aren’t
aware of the good sleep hygiene principles advocated by most
sleep specialists. The list below provides an overview.
Stimulus Control Therapy
Stimulus control therapy is based on the idea that people
with insomnia develop negative associations between the sleep
environment and sleep. This idea, essentially, is that people
who lie awake in bed for extended periods begin to associate
the bed and bedroom with “hyperarousal,” rather
than comfort and relaxation. So getting into bed is thought
to be a stimulus that provokes insomnia. Many people with
insomnia can attest to this phenomenon, and describe their
ability to fall asleep easily on their sofas or in their favorite
recliners, but not in their own beds!
A protocol for stimulus control therapy was developed several
years ago. This protocol usually is followed under the supervision
of a professional who can tailor it to a specific patient’s
needs. However, the basic outline of the protocol is provided
below:
| 1. |
Go to bed only when sleepy |
| 2. |
Allow yourself 15 – 20 minutes to fall asleep |
| 3. |
If not asleep within 15 – 20 minutes, get out
of bed, go to another room, and engage in a sedentary
activity (e.g., reading) until you feel sleepy |
| 4. |
Repeat steps 1 – 3 as often as necessary |
| 5. |
Get up at the same time each morning, even if you had
a difficult night |
| 6. |
Avoid hazardous activity if you are sleepy during the
day |
Sleep Restriction Therapy
Sleep restriction therapy is a treatment that is based on
the idea that people with insomnia spend too much time in
bed. Time spent awake in bed is thought to contribute to subsequent
nights of wakefulness, sleep fragmentation, or poor quality
sleep. Therefore, treatment is the process of reducing the
sleeper’s time in bed to be roughly equivalent to his
or her reported sleep time. For example, if a person reports
lying in bed for eight hours per night, but sleeps only six
hours per night, the sleep restriction therapist might recommend
that the sleeper remain in bed for only six hours per night.
Sleep restriction therapy usually is administered by a healthcare
professional who can tailor the therapy to a patient’s
individual needs. However, the basic sleep restriction protocol
is provided below.
| 1. |
Determine your usual rise time (e.g., 6:00 AM) |
| 2. |
Determine the average number of hours that you spend
asleep in bed (e.g., 5.5 hours) each night. This can be
done using a sleep log. |
| 3. |
Work backwards to determine what your bedtime should
be. For example if you normally rise at 6:00 AM and you
sleep 5.5 hours each night, your bedtime should be 12:30
AM. |
| 4. |
Go to bed at your new “prescribed” time
each night for one week. |
| 5. |
If you do not fill your night with sleep, repeat steps
1 – 3 to identify an appropriate, later bedtime. |
| 6. |
Continue this plan until your time in bed is mostly
filled with sleep, or until you reduce your time in bed
to 4 hours |
| 7. |
If you fill your time in bed with sleep, wait for several
days and then begin increasing your time in bed each night
by 15 minutes. Do this as long as you can continue to
fill your time in bed with sleep |
| 8. |
Avoid hazardous activity if your are sleepy during the
day
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Over-the-Counter Medications
There are many over-the-counter (OTC) medications that are
available to treat insomnia. These medications include drugs
such as Sominex®,
SleepEze®,
and Unisom®
that contain antihistamines such as diphenhydramine or doxylamine
as the active ingredient. They also include pain-reliever/sleep-aid
combinations such as Tylenol
PM®. Such medications may be appropriate for the relief
of short-term insomnia. However, patients should be aware
that OTCs may fail to produce the desired result, and also
may be associated with some unwanted adverse effects (e.g.,
dry eyes, dry mouth, next day “hangover”).
Melatonin
There is little scientific evidence to suggest that melatonin
is valuable as a sleep aid in people with insomnia.
Herbal Remedies
There is little scientific evidence to suggest that herbal
remedies are valuable as sleep aids in people with insomnia.
For more information about insomnia, please download
the Insomnia Fact Sheet, which you can print and take
to your doctor. Or go to www.americaninsomniaassociation.org.
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| Snoring |
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Snoring is an audible and typically recurrent sound that is
produced by some sleepers. It is more common in men, and is
much more likely to occur as we get older. One study has shown
that more than 60% of men and more than 40% of women over the
age of 60 describe themselves as regular snorers. While gentle
snoring usually doesn’t give rise to many complaints,
loud snoring can be quite annoying to one’s spouse or
bed partner, and can be the source of strained relationships.
Historical sources note that some men have been shot in their
sleep by neighbors who could no longer tolerate their snoring!
Snoring sounds are produced by air passing over the soft tissue
in the upper airway as the sleeper breathes in and out. Snoring
occurs during sleep, and not during wakefulness, because the
muscles that keep the upper airway open automatically relax
during sleep. The soft tissue in the airway (areas such as the
uvula, tonsils, and soft palate) actually sag down into the
airway opening, and the air passing over these areas causes
them to vibrate and make that unmistakable snoring sound.
Risk factors for snoring include: obesity (overweight), hypothyroidism
(low thyroid function), and tobacco use. Some people are born
with a small or narrow airway, while others have conditions
that interfere with normal breathing (such as nasal polyps or
deviated septum). In either case, snoring is more likely to
occur. Snoring also can arise with sleep deprivation, with common
colds or allergies, when sleeping on one’s back, or as
a result of the use of alcohol or certain sleeping pills.
Most snoring probably is not associated with health concerns,
but is a problem that snorers and their loved ones would like
resolved. Simple treatments include weight loss, avoidance of
alcohol or sleep aids that relax muscles, treatment of nasal
congestion or allergies, or the use of over-the-counter devices
such as tape strips that help open your nasal passages. Every
spouse of a snorer can tell you that sleeping on your side also
reduces the likelihood of snoring. Some people can sleep on
their sides at will; others might want to try using an old tennis
ball sewn into the center of the back of a T-shirt, which “reminds”
the sleeper to roll over whenever he’s on his back. Oral
appliances, usually fit by a dentist, may be helpful. Finally,
a variety of surgical procedures provided by Ear, Nose, and
Throat specialists can provide a long-term solution to the problem
of snoring.
Snoring actually may be a health concern for some. Medical reports
have shown that snoring is associated with high blood pressure
and reports of daytime dysfunction. Snoring also may be a “warning
sign” of a sleep-related breathing disorder known as “sleep
apnea.” Approximately five out of every 100 snorers has
sleep apnea, a very serious medical condition that is associated
with breathing pauses during sleep (see Sleep Apnea). People
with sleep apnea often suffer from debilitating daytime fatigue
and sleepiness, and they are at significantly greater risk than
others for stroke, irregular heartbeats, high blood pressure,
and death. The treatment plan for a person with sleep apnea
is quite different from one for an individual with simple snoring,
so medical evaluation and follow-up care is essential.
Treatment Options for Snoring
To jump to Treatment Options for Snoring and Sleep Apnea,
click here.
For more information about snoring, download
the Snoring Fact Sheet, which you can print and take to
your doctor. Additional information may be found at www.sleepapnea.org,
and patient information booklets are available by calling
212-994-5100.
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| Sleep Apnea |
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Sleep apnea is a sleep-related breathing disorder that is thought
to affect between 2 and 4 percent of the adult population. It
is diagnosed more often in men, those over 40, and those who
are overweight.
Sleep apnea is characterized by multiple respiratory pauses
during sleep. These pauses, or “apneas,” are defined
as periods of 10 seconds or longer during which the sleeper
stops breathing altogether. Other, milder respiratory events
during sleep known as “hypopneas” are defined as
periods lasting 10 seconds or longer during which breathing
is significantly reduced. Most people with sleep apnea will
have periods of abnormal breathing that last between 30 and
40 seconds more than 400 times per night. So the average person
with sleep apnea spends more than 3 hours a night when he’s
not breathing normally – or not breathing at all!
People with sleep apnea report a number of symptoms that they
often fail to report as problems, and thus miss detection by
healthcare professionals. (A spouse or bed partner often provides
helpful information about the sleep and daytime functioning
of the sufferer.) Symptoms of sleep apnea include:
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Loud snoring |
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Snoring interrupted by gasping, snorting, or choking |
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Excessive daytime sleepiness, often with the tendency
to fall sleep in inappropriate situations such as while
at work, while watching movies, or while driving |
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Trouble with attention, concentration, or memory |
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Low mood, depression, or irritability |
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Loss of sexual interest, impotence (in men), or menstrual
irregularities (in women) |
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“Acid stomach,” or heartburn at night |
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Dry mouth upon awakening |
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Headaches upon awakening |
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Nausea upon awakening |
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Frequent nighttime urination or even bedwetting |
Sleep apnea is associated with significant health and safety
risks.
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High blood pressure. One review of the medical literature
reports that approximately 6 of every 10 people with sleep
apnea suffers from high blood pressure. |
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Irregular heartbeats. Heart rhythms that are either
too slow or too fast, or rhythms that are abnormal (such
as premature ventricular contractions, or PVCs) occur
in about half of those with sleep apnea. |
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Stroke is approximately 10 times greater in those with
sleep apnea than those without. |
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Low blood oxygen, a common occurrence in people with
sleep apnea, appears to be associated with a number of
medical problems. This condition may result in seizure
during sleep. |
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Death rates are higher in those with sleep apnea or
untreated than those without. |
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Excessive daytime sleepiness: Sleepiness is a “hallmark”
of sleep apnea, and often results in impaired daytime
functioning. People with sleep apnea may be at greater
risk of accidents or injuries due to fatigue. For example,
people with sleep apnea are five times more likely to
be involved in a fatigue-related motor vehicle accident
than healthy individuals. |
There are many treatments for sleep apnea. Weight loss is
a common recommendation for overweight people with sleep apnea.
However, most doctors usually recommend treatment with nasal
continuous positive airway pressure (CPAP). CPAP is delivered
using a small bedside machine that is attached to a plastic
hose and nose mask worn by the sleeper. The machine gently
delivers air that helps the sleeper breathe normally. Effective
surgical treatments are available, including those offered
by Ear, Nose, and Throat specialists, and weight loss specialists.
Mild cases of sleep apnea may benefit from the use of an oral
appliance.
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| Treatment Options
for Snoring and Sleep Apnea |
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Weight Loss
Most people with sleep apnea are overweight. Excess weight can
contribute significantly to the occurrence and severity of sleep
apnea. Sometimes weight loss of 5 or 6 pounds can have a significant
impact on the problem. Therefore, weight loss is a common treatment
recommendation made by sleep specialists. There is no linear
relationship between the amount of weight one loses and improvement
in sleep apnea, so it is impossible to predict how much weight
loss is needed in order to be helpful. It is most common to
find that apnea improves once the patient falls below a critical,
“threshold” weight.
Weight loss often is difficult to achieve, and may not result
in the therapeutic outcome desired. Therefore, weight loss recommendations
often are complemented by recommendations for other treatments.
CPAP/BiPAP
People who suffer from sleep-related breathing disorders such
as sleep apnea may be given treatment with nasal continuous
positive airway pressure (CPAP) or bi-level positive airway
pressure (BiPAP). These treatments deliver room air to the sleeper’s
nasal airway through a nose mask at a pressure that is sufficient
to keep the upper airway open and facilitate normal breathing.
Nasal CPAP is one of the most commonly recommended treatments
for sleep apnea because it is effective in almost all cases.
However, the machine must be used on a nightly basis, every
time the patient sleeps, in order for it to be truly effective.
This can be challenging for some people, who find it difficult
to use the system regularly. Others may experience “adverse
effects” associated with nasal CPAP use, such as nasal
congestion, dryness, or feelings of claustrophobia. The difficulties
one has accommodating to nasal CPAP can interfere with treatment
compliance. Studies have shown that 20% - 60% of patients abandon
the use of nasal CPAP despite the health consequences of doing
so.
Surgery
There are several factors that contribute to the occurrence
of sleep apnea. Excessive or redundant tissue in the upper airway
(the part of the airway between the tip of one’s nose
to the base of one’s tongue) can be one important causative
factor. Therefore, some specialists, known as “Ear, Nose,
and Throat” doctors have developed several techniques
that can be used to effectively treat snoring and sleep apnea.
Somnoplasty is a simple, bloodless procedure that is used to
treat snoring by using needle-tip radiofrequency to minimize
the soft tissue in the upper airway. Uvulopalatopharyngoplasty
(UPPP) and laser-assisted uvulopalatoplasty (LAUP) are two procedures
that excise (cut out) or reduce excessive tissue in the upper
airway. Other surgical procedures such as genioglossus advancement,
bimaxillary advancement, also may be attempted during the course
of surgical treatment of sleep apnea. Approximately 1/3 of patients
who undergo surgical treatment for sleep apnea will realize
improvement in respiration during sleep.
The well-documented relationship between obesity (overweight)
and sleep apnea has led to the use of certain surgeries for
obesity, known as bariatric surgery, used in the interest of
treating some cases of sleep apnea.
Patients who are considering surgical treatments for sleep apnea
should speak to their primary care doctors and/or Ear, Nose,
& Throat doctors. Thorough evaluation in an accredited sleep
laboratory is appropriate before and after surgery in order
to document the problem and improvement with treatment.
Oral Appliances
Snoring and mild sleep apnea may be treated with the use of
an oral appliance. An oral appliance is a device that is worn
over the teeth during sleep in order to keep the sleeper’s
jaw fixed in a “forward” position. Some devices
also aid in maintaining a stationary position of the sleeper’s
tongue. Oral appliances help to open the upper airway and facilitate
airflow during sleep. A dental sleep specialist usually must
fit these devices.
If you think you have sleep apnea, download
the Sleep Apnea Fact Sheet, which you can print and take
to your doctor. Additional information may be found at www.sleepapnea.org,
and patient information brochures may be obtained by calling
212-994-5100.
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Restless Legs
Syndrome and
Periodic Limb Movement Disorder |
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Restless Legs Syndrome
Restless legs syndrome (RLS) is a disorder that often occurs
in otherwise healthy individuals. It is characterized by discomfort
in the lower limbs while at rest, usually just prior to sleep
or during periods of wakefulness at night. People often describe
the discomfort as an aching pain, or as a “tingling,”
“creeping/crawling” or other bothersome sensation.
RLS is more common in older people, but can occur in young adults
as well.
People who suffer from RLS often report difficulties falling
asleep or staying asleep. These difficulties may range from
mild to severe, but in many cases result in significant nighttime
distress and daytime fatigue. Sufferers often report the problem
of “insomnia” to their doctors; however, it is important
to distinguish RLS from primary insomnia because the treatments
are different. RLS does not improve with conventional treatments
for “insomnia.”
One interesting fact about RLS is that symptoms usually occur
when the sufferer is at rest, but are not present during periods
of activity. Therefore, people with RLS often report that the
discomfort in their limbs goes away if they get out of bed and
walk about. Even non-physical activity can seemingly reduce
the symptoms of RLS!
Treatment of RLS can begin at home. Many people find relief
from massage, applied heat, or hot baths before bedtime. A number
of medications also have been found to be effective and safe
in the treatment of RLS. These medications act on the neurotransmitter
substance “dopamine,” such as pramipexole (Mirapex®),
ropinirole (Requip®),
or pergolide (Permax®).
Periodic Limb Movement Disorder
Periodic limb movement disorder (PLMD) is a condition in which
brief movements of the lower limbs occur repetitively during
sleep. These movements usually last between a half second and
five seconds, and repeat once or twice per minute for long stretches
of the night. Movements can be mild, such as the movement of
a toe, or severe, such as a powerful leg jerk or kick. Some
sleepers have reported that they’ve literally made their
spouses black and blue from kicking they’ve done while
asleep!
PLMD is rare in people under 30 years of age, but is more common
in older people. Many people with this condition are unaware
of the problem, unless they also have RLS along with it. Therefore,
a common report from people with PLMD is difficulty falling
asleep and/or staying asleep. Since the movements associated
with PLMD disrupt sleep and prevent the sleeper from enjoying
deep, restful sleep, the sufferer also often feels that sleep
is not restful or restorative.
The treatment of PLMD usually involves the use of medications
that act on the neurotransmitter substance “dopamine,”
such as pramipexole (Mirapex®),
ropinirole (Requip®),
or pergolide (Permax®).
Treatment of underlying causes of PLMD, such as iron deficiency,
also provides relief.
Evaluation of RLS and PLMD
The evaluation of RLS and PLMD always involves discussion
with your doctor. Your doctor may refer you to a sleep laboratory
for overnight evaluation in order to make the diagnosis of
RLS or PLMD, and to help determine an appropriate treatment
plan.
For information about RLS and PLMD, download
the Restless Legs Syndrome and Periodic Limb Movement Disorder
Fact Sheet, which you can print and take to your doctor.
Additional information may be found at www.rls.org,
and patient information brochures may be obtained by calling
212-994-5100.
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| Narcolepsy |
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Narcolepsy is a rare condition that affects approximately 0.05%
of the population, with symptoms peaking between the ages of
15 and 20. Narcolepsy is marked by excessive daytime sleepiness
which can be so severe that it interferes with functioning and
sometimes results in unexpected “sleep attacks.”
People with narcolepsy often report the associated symptoms
of sleep paralysis, hypnogogic hallucinations, cataplexy, and
automatic behavior.
Sleep paralysis usually occurs when the sleeper is lying in
bed prior to sleep onset or after awakening. He or she is unable
to move for a few seconds, minutes, or longer. Sometimes sleepers
can move only their eyes. The episodes are generally harmless,
although they can result in genuine distress for the sufferer.
Hypnogogic hallucinations also generally occur when the sleeper
is lying in bed prior to sleep onset or after awakening. The
sufferer may experience auditory, visual, tactile, or olfactory
(smell) hallucinations for brief periods. People sometimes describe
these as brief, dreamlike experiences. Although these experiences
are not concerning to many, some people can have terrifying
or disturbing hallucinations that cause them great distress.
Cataplexy is characterized by the sudden loss of muscle tone
while awake. The sufferer may experience a mild, transient drop
in muscle tone (e.g., a droopy arm or periods of clumsiness
associated with dropping things), or may experience severe loss
of muscle tone that literally results in falling to the floor,
and speech can be affected during the attacks. Cataplexy often
is brought on by stress, fatigue, or the experience of intense
emotion such as anger or laughter. Narcolepsy and cataplexy
are so rare that healthcare providers often fail to accurately
diagnose the problem.
Automatic behavior refers to actions for which the person has
no memory. Sometimes the sufferer reports that she is acting
in a “fog.” For example, one woman with narcolepsy
entered her dining room to find a beautiful vase on her table.
She had no idea where it came from until she looked at her checkbook
and realized that she had purchased it on a recent shopping
trip. Both the vase and the shopping trip had been forgotten!
Automatic behavior probably is due to severe sleepiness.
Narcolepsy often is diagnosed in a sleep laboratory facility.
One diagnostic indicator of narcolepsy is the occurrence of
rapid-eye-movement (REM) sleep on daytime nap testing.
Narcolepsy usually is treated with stimulant medication to address
daytime sleepiness, and tricyclic or other medications to address
sleep paralysis, hypnogogic hallucinations, and cataplexy. These
medications include stimulants such as methylphenidate (Ritalin®),
and pemoline (Cylert®)
for sleepiness and fluoxetine (Prozac®)
and venlafaxine (Effexor®)
for cataplexy and associated symptoms. However, effectiveness
is not guaranteed and some people may experience unwanted adverse
effects. Two newer medications include modafinil (Provigil®),
which recently was approved by the FDA to treat sleepiness associated
with narcolepsy, and gamma-hydroxybutyrate (Xyrem®),
which relieves narcolepsy symptoms including cataplexy.
For information about narcolepsy, speak to your doctor. Additional
information may be found at www.narcolepsynetwork.org,
and patient information brochures may be obtained by calling
212-994-5100.
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| Parasomnias |
|
Parasomnias include a variety of disorders such as sleep walking
(somnambulism), night eating, sleep-related bruxism (tooth grinding),
nightmares, night terrors, and REM sleep behavior disorder.
Parasomnias occur most commonly in children, but adults can
experience parasomnias at any age. For example, night eating
appears to occur most commonly in young female patients, and
REM sleep behavior disorder appears to be most common in elderly
men.
Most parasomnias involve some behavioral abnormality that occurs
during sleep. For example, sleepwalkers may rise from bed, walk
about the house, and finally come to rest somewhere other than
their beds. While most sleep walking is benign, some sleepwalkers
engage in remarkable behaviors during their excursions, such
as eating during sleep. Some parasomnias involve some violent
(e.g., hitting a spouse), bizarre or unhealthy (e.g., eating
large amounts of food or unusual food items), or even criminal
behavior during sleep.
Parasomnias require a careful evaluation by a physician. Behavioral
treatments or medications may be appropriate. One of the doctor’s
primary concerns is the health and safety of the patient, as
well as the safety of others in the patient’s environment.
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| Circadian Rhythm
Disorders |
|
Each of us has an internal “biological clock”
that governs the regular, daily rhythms of sleep and wakefulness.
This rhythm, know as the circadian rhythm, increases the likelihood
that we will sleep at certain time of the day, and that we
will be awake at others. It is so powerful that it is considered
to be one of the most important determinants of sleep, even
continuing to exert its influence in the absence of time cues.
Circadian rhythms can become disrupted. This occurs when the
rhythm that drives sleep and wakefulness falls out of synch
with desired times for sleep and wakefulness. A common type
this condition is known as “jet lag,” which can
occur following high-speed travel over multiple time zones.
For example, a person who lives in Los Angeles, California
and travels by air to New York, New York might feel wide awake
at bedtime following his arrival. While the actual “clock
time” in New York is midnight, the traveler’s
biological clock is still set to California time, telling
his brain that it is only 9:00 PM. There are several types
of circadian rhythm disorders that can be diagnosed and treated:
Advanced Sleep Phase Syndrome: Advanced
Sleep Phase Syndrome is characterized by a tendency to become
sleepy and fall asleep early in the evening, and awaken too
early in the morning. People often find that they are unable
to enjoy evening activity due to their sleepiness, and some
complain of “insomnia” in the morning hours. A
person who is phase advanced might fall asleep at 7:00 PM
and awaken eight hours later at 3:00 AM. In such cases, the
person’s biological clock is set to an earlier bedtime
and rise time.
Delayed Sleep Phase Syndrome: Delayed Sleep
Phase Syndrome is characterized by a tendency to remain awake
and fall asleep late, and awaken late in the morning. People
with this condition often find that they occupy their nighttime
hours with activity, waiting until they feel sleepy enough
to go to bed. Awakening in the morning can be a very difficult
chore, sometimes interfering with the ability to hold down
a job. A person who is phase delayed might fall asleep at
4:00 AM and sleep until Noon. In such cases, the person’s
biological clock is set to a later bedtime and rise time.
Delayed Sleep Phase Syndrome can be seen in young people who
have developed late night habits. Difficulties can arise when
these individuals leave academic environments and transition
into the workforce. Tardiness and daytime sleepiness often
interfere with work performance.
Shift Work: More than 16% of our Nation’s
workforce is engaged in some type of regular shift work. Shift
work includes afternoon, evening, night, rotating, and split
shifts, as well as extended-duty hours. Shift workers may
find that it is difficult to stay awake during work periods,
and that it is difficult to sleep when opportunity allows.
The result is a person who is fatigued, sleepy, and poorly
adjusted to his or her work schedule.
Treatments for circadian rhythm disorders typically include
behavioral management of the sleep problem. Medications used
to treat insomnia are not remarkably effective when used outside
of the context of a behavioral treatment. Data regarding some
wakefulness promoting medications such as modafinil (Provigil®)
suggest that these medications may be helpful in sustaining
arousal during desired periods of wakefulness.
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| Other Sleep Disorders |
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There are more than 80 different sleep disorders identified
by the International Classification of Sleep Disorders. Some
are rare, some quite common, and all can present significant
distress, daytime impairment, or health consequences for those
who suffer from them. Evaluation and treatment hold the keys
to finding relief.
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