Sleep Disorders

Sleep disorders involve any difficulties related to sleeping, including difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. Take this quiz to determine if you may have a sleep disorder.

Causes
More than 100 different disorders of sleeping and waking have been identified. They can be grouped in four main categories:

  • Problems with falling and staying asleep (insomnia)
  • Problems with staying awake (excessive daytime sleepiness)
  • Problems with sticking to a regular sleep schedule (sleep rhythm problem)
  • Unusual behaviors during sleep (sleep-disruptive behaviors)

PROBLEMS WITH FALLING AND STAYING ASLEEP

Insomnia includes any combination of difficulty with falling asleep, staying asleep, intermittent wakefulness and early-morning awakening. Episodes may come and go (be transient), last as long as 2 to 3 weeks (be short-term), or be long-lasting (chronic).

Common factors associated with insomnia include:

  • Physical illness
  • Depression
  • Anxiety or stress
  • Poor sleeping environment such as excessive noise or light
  • Caffeine
  • Alcohol or other drugs
  • Use of certain medications
  • Heavy smoking
  • Physical discomfort
  • Daytime napping

Counterproductive sleep habits:

  • Early bedtimes
  • Excessive time spent awake in bed

Disorders include:

  • Psychophysiological insomnia: a condition in which stress caused by the insomnia makes it even harder to fall asleep
  • Delayed sleep phase syndrome: your internal clock is constantly out of synch with the "accepted" day/night phases; for example, patients feel best if they can sleep from 4 AM to noon
  • Hypnotic-dependent sleep disorder: insomnia that occurs when you stop or become tolerant to certain types of sleep medications
  • Stimulant-dependent sleep disorder: insomnia that occurs when you stop or become dependent on certain types of stimulants

PROBLEMS WITH STAYING AWAKE

Disorders of excessive sleepiness are called hypersomnias. These include:

  • Idiopathic hypersomnia (excessive sleepiness that occurs without an identifiable cause)
  • Narcolepsy
  • Obstructive and central sleep apnea
  • Periodic limb movement disorder
  • Restless leg syndrome

PROBLEMS STICKING TO A REGULAR SLEEP SCHEDULE

Problems may also occur when you do not maintain a consistent sleep and wake schedule. This occurs when traveling between times zones and with shift workers on rotating schedules, particularly nighttime workers.

Sleep disruption disorders include:

  • Irregular sleep-wake syndrome
  • Jet lag syndrome
  • Natural short sleeper (the person sleeps fewer hours than normal but has no ill effects)
  • Paradoxical insomnia (the person actually sleeps a different amount than they think they do)
  • Shift work sleep disorder

SLEEP-DISRUPTIVE BEHAVIORS

Abnormal behaviors during sleep are called parasomnias and are fairly common in children. They include:

  • Sleep terrors
  • Sleep walking
  • REM sleep-behavior disorder (a type of psychosis in which a person "acts out" dreams so violently that they may injure the person sleeping with them)

Symptoms
The symptoms vary and depend on the specific sleep disorder.

Exams and Tests
Tests vary and depend on the specific sleep disorder. A sleep study (polysomnography) may be done.

Treatment
Treatments vary and depend on the specific sleep disorder.

When to Contact a Medical Professional
Call for an appointment with your health care provider if lack of sleep, too much sleep, or unusual sleep behaviors are interfering with daily living.

Sleep apnea should be suspected in people who snore loudly, wake frequently to urinate at night, and wake up in the morning unrefreshed.

Prevention
The following can help prevent many sleep disorders.

  • Regular sleep habits (such as going to bed and waking at the same time every day)
  • A quiet sleep environment
  • Regular exercise
  • Staying generally fit and healthy
     

Children and Sleep

The amount of sleep a child needs varies based upon a number of factors, including their age.  A general guideline by age is as follows:

  • 1-4 Weeks Old:  15-16 hours per day
  • 1-4 Months Old:  14-15 hours per day
  • 4-12 Months Old:  14-15 hours per day
  • 1-3 Years Old:  12-14 hours per day
  • 3-6 Years Old:  10-12 hours per day
  • 7-12 Years Old:  10-11 hours per day
  • 12-18 Years Old: 8-9 hours per day

Coping with Shift Work

Working odd or inconsistent shifts may present additional challenges to get a good night's rest.  These helpful sleep tips for shift workers can help get you on track to better sleep.

Insomnia

If you experience difficulty falling asleep, staying asleep, or enjoying a restful night's sleep, you may be suffering from insomnia. Insomnia is defined as the perception or complaint of inadequate or poor-quality sleep because of one or more of the following:

  • difficulty falling asleep
  • waking up frequently during the night with difficulty returning to sleep
  • waking up too early in the morning
  • non-refreshing sleep

Causes

Insomnia may be caused by many factors, including:

  • stress
  • depression
  • anxiety
  • physical illness
  • caffeine intake
  • irregular schedules
  • drugs (including alcohol and nicotine)
  • occasional or chronic pain

Check out these tips for getting a good night's sleep.

Narcolepsy

Narcolepsy is a chronic, neurological sleep disorder with no known cause. It involves the body's central nervous system. Narcolepsy is a genetic disorder, but what causes narcolepsy is not yet known.

The main characteristic of narcolepsy is excessive and overwhelming daytime sleepiness, even after adequate nighttime sleep. A person with narcolepsy is likely to become drowsy or to fall asleep at inappropriate times and places, and sleep attacks may occur with or without warning.

Attacks can occur repeatedly in a single day, drowsiness may persist for prolonged periods of time, and nighttime sleep may be fragmented with frequent awakenings.

 

How to Diagnose

In addition a complete medical history and physical examination, diagnostic procedures may include:

  • combination of EDS and cataplexy provide for preliminary clinical diagnosis
  • laboratory tests - to confirm diagnosis and plan treatment, including:
  • overnight polysomnogram (PSG) - to determine the presence of EDS and perhaps other underlying causes of this symptom.
  • Multiple Sleep Latency Test (MSLT) - to measure sleep onset and how quickly rapid eye movement REM sleep occurs.
  • Genetic blood test - to measure certain antigens often found in people who have a predisposition to narcolepsy.

Symptoms

The following are the most common symptoms of narcolepsy. However, individuals may experience symptoms differently. Symptoms may include:

  • excessive daytime sleepiness (EDS) - an overwhelming desire to sleep at inappropriate times.
  • cataplexy - a sudden loss of muscle control ranging from slight weakness to total collapse.
  • sleep paralysis - being unable to talk or move for about one minute when falling asleep or waking up.
  • hypnagogic hallucinations - vivid and often scary dreams and sounds reported when falling asleep.
  • Secondary or auxiliary symptoms include:
    • automatic behavior - performing routine tasks without conscious awareness of doing so, and often without memory of it.
    • disrupted nighttime sleep, including multiple arousals
  • Other difficulties that may be caused by primary symptoms may include side effects of medication, or result from one's continuing struggle to cope, including:
    • feelings of intense fatigue and continual lack of energy
    • depression
    • difficulty in concentrating and memorizing
    • vision (focusing) problems
    • eating binges
    • weak limbs
    • difficulties in handling alcohol

Treatment Options

Specific treatment will be determined by your physician based on:

  • your age, overall health, and medical history
  • extent of the disease
  • your tolerance for specific medications, procedures, or therapies
  • expectations for the course of the disease
  • your opinion or preference

The goal of treatment of narcolepsy is for the patient to remain as alert as possible during the day and to minimize any recurring episodes of cataplexy, while using a minimal amount of medication.

  • medications - excessive daytime sleepiness and cataplexy are treated separately, with central nervous system stimulants usually prescribed for EDS and tricyclic antidepressants for cataplexy
  • nap therapy - two or three short naps during the day to help control sleepiness and maintain alertness
  • proper diet
  • regular exercise

Restless Legs Syndrome (RLS)

Restless legs syndrome (RLS) is a sleep disorder in which a person experiences unpleasant sensations in the legs, which are described as:

  • creeping
  • crawling
  • tingling
  • pulling
  • painful

These sensations usually occur in the calf area, but may be felt anywhere from the thigh to the ankle. One or both legs may be affected. For some people, the sensations are also felt in the arms. People with RLS have an irresistible urge to move the affected limb when the sensations occur.

Some patients, however, have no definite sensation, except for the need to move. Sleep problems are common with RLS because of the difficulty it causes in getting to sleep.

 

Causes

The cause of RLS is still unknown. Some cases are believed to be inherited; some cases have been associated with nerve damage in the legs due to diabetes, kidney problems or alcoholism. RLS can also be a side effect of a pinched nerve root in the lower back.


Symptoms

Sensations occur when the person with RLS lies down or sits for prolonged periods of time, causing:

  • the need to move the legs for temporary relief of symptoms by:
    • stretching or bending.
    • rubbing the legs.
    • tossing or turning in bed.
    • getting up and pacing.
  • a definite worsening of the discomfort when lying down, especially when trying to fall asleep at night, or during other forms of inactivity, including just sitting.
  • a tendency to experience the most discomfort late in the day and at night.

Sleep Apnea

Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. Sleep apnea occurs in all age groups and both genders. It is more common in men, although it may be under-diagnosed in women and young African-Americans. It is estimated that as many as 18 million Americans have sleep apnea.

Early recognition and treatment of sleep apnea is important, as it may be associated with:

  • irregular heartbeat
  • high blood pressure
  • heart attack
  • stroke

Causes

Certain mechanical and structural problems in the airway cause the interruptions in breathing during sleep. Apnea occurs:

  • when the throat muscles and tongue relax during sleep and partially block the opening of the airway.
  • when the muscles of the soft palate at the base of the tongue and the uvula relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether.
  • in obese people when an excess amount of tissue in the airway causes it to be narrowed.
  • with a narrowed airway, the person continues his/her efforts to breathe, but air cannot easily flow into or out of the nose or mouth.

Characteristics

Sleep apnea is characterized by a number of involuntary breathing pauses or "apneic events" during a single night's sleep - may be as many as 20 to 30 or more events per hour. These events are almost always accompanied by snoring between apnea episodes (although not everyone who snores has sleep apnea). Sleep apnea may also be characterized by choking sensations. The frequent interruptions of deep, restorative sleep often lead to early morning headaches and excessive daytime sleepiness.

During the apneic event, the person is unable to breathe in oxygen and to exhale carbon dioxide, resulting in low levels of oxygen and increased levels of carbon dioxide in the blood. The reduction in oxygen and increase in carbon dioxide alert the brain to resume breathing and cause an arousal. With each arousal, a signal is sent from the brain to the upper airway muscles to open the airway; breathing is resumed, often with a loud snort or gasp. Frequent arousals, although necessary for breathing to restart, prevent a person from getting enough restorative, deep sleep.


How to diagnose

Diagnosis of sleep apnea is not simple because there can be many different causes. Primary care physicians, pulmonologists, neurologists, or other physicians with specialty training in sleep disorders may be involved in making a definitive diagnosis and initiating treatment. Several tests are available for evaluating a person for sleep apnea, including:

  • Polysomnography - a test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, air flow, and blood oxygen levels.
  • Multiple Sleep Latency Test (MSLT) - a test that measures the speed of falling asleep. People without sleep problems usually take an average of 10 to 20 minutes to fall asleep. Individuals who fall asleep in less than 5 minutes are likely to require some type of treatment for sleep disorders.

Diagnostic tests usually are performed in a sleep center, but new technology may allow some sleep studies to be conducted in the patient's home.


Treatment Options

Specific treatment will be determined by your physician based on:

  • your age, overall health, and medical history
  • extent of the disease
  • your tolerance for specific medications, procedures, or therapies
  • expectations for the course of the disease
  • your opinion or preference

Medications are generally not effective in the treatment of sleep apnea. Therapy for sleep apnea is specifically designed for each individual patient, and may include the following:

  • Oxygen administration may safely benefit certain patients, but does not eliminate sleep apnea or prevent daytime sleepiness. Its role in the treatment of sleep apnea is controversial.
  • Behavioral changes are an important part of a treatment program, and in mild cases of sleep apnea, behavioral therapy may be all that is needed. The patient may be advised to:
    • avoid the use of alcohol.
    • avoid the use of tobacco.
    • avoid the use of sleeping pills.
    • lose weight if overweight (even a 10 percent weight loss can reduce the number of apneic events for most patients).
    • use pillows and other devices to help sleep in a side position.
  • Physical or Mechanical Therapy

Nasal continuous positive airway pressure (CPAP) is a procedure in which the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages.

Dental appliances that reposition the lower jaw and the tongue have been helpful to some patients with mild sleep apnea, or who snore but do not have apnea.

  • Surgery: Some patients with sleep apnea may need surgery. Examples of these procedures include:
  • Common surgical procedures to remove of adenoids and tonsils, nasal polyps or other growths or tissue in the airway, and correction of structural deformities.
  • Uvulopalatopharyngoplasty (UPPP) - a procedure used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate).
  • Surgical reconstruction for deformities of the lower jaw may benefit some patients.
  • Surgical procedures to treat obesity are sometimes recommended for sleep apnea patients who are morbidly obese.

Types of Sleep Apnea

Sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. There are two types of sleep apnea:

  • central - occurs when the brain fails to send the appropriate signals to the muscles to initiate breathing. Central sleep apnea is less common than obstructive sleep apnea.
  • obstructive - occurs when air cannot flow into or out of the person's nose or mouth although efforts to breathe continue.

Who it affects

Sleep apnea seems to run in some families, suggesting a possible genetic basis. People most likely to have or develop sleep apnea include those who:

  • snore loudly.
  • are overweight.
  • have high blood pressure.
  • have some physical abnormality in the nose, throat, or other parts of the upper airway.

Use of alcohol and sleeping pills increases the frequency and duration of breathing pauses in people with sleep apnea.

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