Circadian Rhythm Disorders
Obstructive Sleep Apnea
Pediatric Sleep Disorders
Periodic limb movement disorder and restless leg syndrome
Principles of Sleep Hygiene
Sleep disorders among older patients
Circadian rhythm disorders
These are conditions in which the internal biological clock is not in synchrony with the 24-hour cycle of the external world. One common example is jet lag, which occurs when someone travels rapidly across time zones. Other examples include shift worker syndrome, in which a job, personal obligations, or lifestyle choices produce difficult, changing sleep schedules. Teenagers and young adults often experience delayed sleep phase syndrome, causes difficulty falling asleep at night and waking up in the morning. Older adults may experience the opposite, advanced sleep phase syndrome, in which they fall asleep and wake up earlier than desired. Circadian rhythm disorders can disrupt lifestyles and interfere with work and school. They can be treated with behavioral techniques to improve sleep habits, and with light therapy under the guidance of a sleep specialist. The use of melatonin generally is not advised because it is a hormone that is not an FDA-approved medication, and it has not been tested adequately for safety.
Insomnia is a common symptom with a wide variety of forms, causes, and treatments. Insomnia refers to difficulty in initially falling asleep, frequent awakenings during the night, awakening too early, or unsatisfactory quality of sleep. Duration and time course can range from transient and situational to continuous and chronic. Some of the wide range of causal factors that may be involved include poor sleep hygiene, stress, anxiety, depression, conditioned arousal, psychological conflict, sleep-wake schedule problems (e.g. shift work or jet lag), various medical conditions, and use of certain medications. Treatments can include sleep hygiene improvements, cognitive-behavioral therapy, medications, psychotherapy or intervention that addresses underlying psychiatric or medical problems.
Narcolepsy was among the first sleep disorder to be characterized, and it remains among the leading neurological causes of excessive daytime sleepiness. Narcolepsy affects about 1 in 4000 individuals but commonly remains undiagnosed.
The typical features include excessive daytime sleepiness, sleep paralysis (temporary inability to move upon awakening), sensation of dreaming at times while still awake and sleep disruption during the night. Another feature of this disorder can be cataplexy, the sudden onset of muscle weakness in response to laughter or strong emotion.
The diagnosis requires a clinical evaluation, as well as a nocturnal sleep laboratory study. A multiple sleep latency test (MSLT), may also be helpful. This is a series of naps recorded at the Sleep Laboratory during the daytime.
The treatment of narcolepsy often includes a combination of behavioral recommendations and medications.
(National Women's Health Information Center)
Nocturnal or sleep-related seizures can cause abnormal movement or behavior during sleep. Activity may range from awakening from sleep for no clear reason, sometimes multiple times a night, to violent movements of the arms and legs with biting of the tongue and loss of urine. Someone having a nocturnal seizure may thrash around or act confused. Nocturnal seizures are a form of epilepsy, a disorder caused by abnormal electrical activity within the brain. Nocturnal seizures frequently occur in people with epileptic seizures during the day, but may also occur only at night. If you suspect that you or your bedpartner may have nocturnal seizures, the first step is to see a physician, neurologist, or sleep specialist. An overnight sleep study with video monitoring may be recommended. These Nocturnal seizures often can be controlled with medication.
Obstructive Sleep Apnea
Obstructive sleep apnea is a common condition in which throat closes repeatedly during sleep. Each time, breathing stops for 10 to 30 seconds, or longer, usually until a brief arousal occurs. The throat then opens, breathing resumes, and the patient falls back asleep, only to repeat the same cycle. Some patients stop breathing hundreds of times each night without remembering any of these episodes because arousals from sleep are so brief. Untreated, obstructive sleep apnea may lead to high blood pressure, stroke, heart attack, heart failure, or shorter life span. However, one of the most common consequences is excessive daytime sleepiness. Thinking ability, including concentration and decision-making ability, can also be affected. In children, obstructive sleep apnea often occurs in association with large tonsils. Children with obstructive sleep apnea may show inattention, hyperactivity, sleepiness, or other behavioral problems.
Once identified, obstructive sleep apnea can be successfully treated in most instances. The most common from of treatment is continuous positive airway pressure, or CPAP. The patient sleeps with a mask over the nose. The mask is connected by a long, flexible tubing to a machine that is about the size of a large shoebox. The CPAP unit transmits pressurized air through the nose and into the throat, where the walls of the airway are splinted open. The patient can then breathe normally, without apneic pauses. The CPAP therapy is usually highly effective if used properly every night. For patients who cannot tolerate CPAP, surgery or a dental appliance may be reasonable alternatives. Children are often treated by removal of the tonsils and adenoids.
Parasomnias are disorders that usually involves some type of abnormal behavior during sleep.
||Sudden partial awakening, usually from deep non-REM sleep, that is associated with confusion and disorientation
||Arousal with complex motor behavior,
walking, running, talking, or eating may occur
||Sudden arousal with fearful agitated behavior, often with screaming or crying and inconsolability
Rhythmic movement disorder
|Repetitive head or/body rocking, rolling, or other movement during sleep
||Talking during sleep can occur from any sleep stage and is often normal
||Frightening dreams can be a problem with they are excessively frequent or bothersome to the patient
||Paralysis occurring near the onset or end of sleep or during awakenings
|REM sleep behavior disorder
||Dream-enacting behavior with loss of muscle paralysis that usually helps prevent people from acting out their dreams during REM sleep
||Repetitive grinding or clenching of the teeth during sleep
Pediatric Sleep Disorders
Snoring or obstructive sleep apnea are common problems in children. Boys and girls are equally affected. Children with sleep apnea have symptoms such as loud snoring, difficulty breathing (their chest seems to "suck in" often while trying to breathe), and intermittent snorts and gasps. The disrupted sleep can lead to symptoms of excessive daytime sleepiness, hyperactivity, irritability, or difficulties in school because of decreased concentration. Other problems that can be caused by sleep apnea include high blood pressure or failure to gain weight. In children, the most common cause of sleep apnea is large tonsils and adenoids.
Narcolepsy is a disorder that can cause children to have severe daytime sleepiness, though inattention hyperactivity, and problems at school can also occur. Although narcolepsy can begin before the age of 10 or as late as the age of 50, gradual onset between 15 and 35 years is usual.
Sleepwalking, talking, screaming, and other behaviors during sleep may be frightening and disruptive to the family. All of these behaviors occur during partial arousal from non-REM sleep. Until age five or six years, most of these behaviors are "developmental." This means that they are not usually caused by physical or emotional problems, but instead only reflect normal maturation of a child's sleep. In an older child, these behaviors may no longer be "developmental." Underlying emotional factors may now be relevant, especially if the behaviors are frequent. Sometimes, another primary sleep disorder, such as sleep apnea, can trigger nocturnal sleepwalking or other behaviors.
Periodic leg movements and restless leg syndrome
Periodic leg movements are repetitive leg jerks lasting only a few seconds or less, typically occurring every 20 to 40 seconds and sometimes resulting in awakenings. Restless leg syndrome appears in some patients with periodic limb movements. Conversely, almost all patients with restless leg syndrome also have periodic leg movements during sleep.
Restless leg syndrome has four cardinal symptoms: uncomfortable sensation in the legs; motor restlessness; worsening during the night; and improvement with movement of the legs or walking. Patients with restless leg syndrome experience significant restlessness, which can cause insomnia.
Sometimes restless leg syndrome is associated with other medical conditions such as iron deficiency anemia, pregnancy, diabetes mellitus, chronic renal failure, or rheumatoid arthritis. Caffeine and some medications can exacerbate the disorder.
A sleep study is called a polysomnogram. It requires an overnight stay in a private room in a Sleep Laboratory.
Patients are asked to follow their usual daily activities on the day of the study. However, they are encouraged to avoid naps, caffeine and alcohol on the day of their polysomnogram. Patients usually arrive at the Laboratory around 8 or 9 PM bringing their sleeping clothes, toiletries, and any medications, much as they would do on a trip away from home.
Once in the room, monitoring devices will be applied to collect the type of information requested by your doctor. Sensors applied will monitor your brain waves (EEG activity), heart rate (EKG), eye movements, leg muscle activity, and chest and stomach movement. Air flow from your nose and mouth will be recorded as will your oxygen levels. The amount of oxygen in the blood is monitored by a sensor that clips onto your finger.
Specific questions from your doctor may require other monitors.
Usually a polysomnogram ends around 6 AM and the patients can return to their usual daytime routine.
Principles of Sleep Hygiene
- Go to bed and arise from bed at the same time each day
- Avoid daytime naps or limit them to one mid-afternoon nap
- Avoid evening alcohol use
- Avoid caffeinated drinks late in the day
- Eliminate tobacco use, especially at night or in the evening
- Exercise regularly during the day, but avoid evening exercise
- Use the bedroom only for sleep or marital relations; avoid school work, business affairs, TV, exercise, or other activities that could teach you to associate your bedroom with these activating experiences
- Keep the bedroom dark, quiet, and comfortable
- Avoid stress and worrisome thoughts in the evening before sleep; ; a regular bedtime routine may help signal your mind that the time to relax and sleep is approaching.
Sleep disorders among older patients
Sleep disorders are very common among older patients. As individuals age their sleep architecture changes. Deep non-REM sleep and sleep efficiency decline. The older individual can be more sensitive to noises. The latency to REM sleep, total sleep time, and the percentage of time spent in REM sleep all are reduced.
Sleep disturbances may be due to primary sleep disorders such as apnea or restless leg syndrome. Sleep disturbances may also occur because of medical conditions such as Parkinson's disease, diabetes, polyneuropathy, polypharmacy, psychiatric disorders, or psychosocial malfunctioning. Chronic sleep disturbance may affect thinking ability, concentration, or mood.