Sleep Hygiene
Educating patients in good sleep hygiene is the keystone of treatment. The following advice should be given to patients:
Barbiturates and chloral hydrate are seldom used now, because of safety concerns related to their undesirably low therapeutic indexes.
Drugs that block the histamine type 1 receptor are used primarily in over-the-counter preparations, which are inexpensive and help some patients. However, in view of the anticholinergic properties of these agents, they should be used cautiously in older patients and in patients who have conditions such as prostatic hypertrophy, cognitive disorders, and constipation. In addition, most of these drugs have a long duration of action, and their sedative effects may persist well into the following day.
Zolpidem and zaleplon[6] are the newest and, arguably, the safest agents that have been approved by the US Food and Drug Administration (FDA) for short-term hypnotic use. Zolpidem is available an extended-release version that lasts slightly longer than the original preparation. In addition, the FDA has approved eszopiclone as the first agent for long-term use in the management of chronic insomnia.
Diet and Activity No special diet is needed to treat insomnia, but large meals and spicy foods should be avoided in the 3 hours before bedtime. Patients should avoid sleep-disturbing substances such as alcohol, nicotine, and caffeine. Alcohol creates the illusion of good sleep, but it adversely affects sleep architecture. Nicotine and caffeine are stimulating and should be avoided in the second half of the day, from late afternoon on. Consumption of tryptophan-containing foods may help induce sleep; the classic example is warm milk.
Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia. Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus.
Sleep disorders - overview <span>To use the sharing features on this page, please enable JavaScript.</span>
Email this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version
Sleep disorders are problems with sleeping, including trouble falling or staying asleep, falling asleep at the wrong times, too much sleep, or abnormal behaviors during sleep.
Causes There are more than 100 different sleeping and waking disorders. They can be grouped into four main categories:
Insomnia includes trouble falling asleep or staying asleep. Episodes may come and go, last up to 3 weeks (be short-term), or be long-lasting (chronic).
PROBLEMS STAYING AWAKE
People with excessive daytime sleepiness feel tired during the day. Symptoms that are not caused by a lack of sleep or interrupted sleep are called hypersomnia.
Causes of this problem include:
PROBLEMS STICKING TO A REGULAR SLEEP SCHEDULE
Problems may also occur when you do not stick to a regular sleep and wake schedule. This occurs when people travel between time zones and with shift workers who are on changing schedules, especially nighttime workers.
Disorders that involve a disrupted sleep schedule include:
Abnormal behaviors during sleep are called parasomnias. They are fairly common in children and include:
Poor sleep habits (referred to as hygiene) are one of the most common problems encountered in our society. We stay up too late and get up too early. We interrupt our sleep with drugs, chemicals, work, and we overstimulate ourselves with late-night activities such as television. Click here to for more information on sleep hygiene, which may provide useful tips on attaining a normal night's sleep. Many of the tips in this site are "common sense," but it is surprising how many people fail to follow these.
Insomnia
Insomnia is the inability to sleep or inability to sleep well at night. Many different medical and mental health problems cause insomnia. Insomnia may be situational, lasting a few days to weeks, or chronic, lasting for more than 1 month.
Around 9-12 percent of the American population report chronic insomnia. In severe cases, patients experience fatigue, sleepiness, difficulty concentrating and difficulty with thinking. Many sufferers feel that they have been robbed of the joy of life. Insomnia may be a symptom of breathing problems at night like sleep apnea, of medical illness like heart failure, a side effect of medications, or a symptom of severe anxiety or depression illness.
While short-lasting insomnia periods are well treated with medication, chronic or long-lasting insomnia may not respond well to medications. Thus, throwing sleeping pills at many patients with chronic insomnia is not an effective way to treat the problem.
An evaluation by the patient's personal physician or a sleep specialist often helps get to the root of the problem. Many patients respond well to what is called "cognitive behavioral therapy." In this form of therapy, incorrect ideas about sleep are corrected. In addition, relaxation and behavioral techniques may be used to help patients fall asleep. This combined with treatment of any underlying disorders is often the best way to treat the devastating symptom of insomnia. Click here for more information on treatments for insomnia.
Sleep Apnea
Sleep apnea is a common and potentially devastating sleep disorder. It is the most common reason that patients are referred to sleep centers around the country.
The word apnea means "not breathing." Patients with the usual form of sleep apnea actually close off their airway at night.
This airway closure occurs either behind the tongue or behind the nose. Patients continue to make efforts to breathe. Then after 10 to 120 seconds, the brain, realizing it is not getting any oxygen, actually "wakes up." The brain then tells the upper airway to open to let some air in.
This is associated with loud bothersome snoring, often described as snorting and gasping. Patients may take a few breaths of air, the brain goes to sleep again and the cycle may repeat itself several hundred times a night. Patients are often not even aware that they are doing this (although the bed partner is).
Sleep apnea is dangerous, common, relative easy to diagnose, and treatable. Patients with sleep apnea are at great risk for heart disease, heart attacks, strokes and high blood pressure. In addition, since the sleep is poor quality (remember the brain keeps waking up), patients are often sleepy during the day. Sleepiness is associated with inability to concentrate, remember or think. There is also increased risk in falling asleep while doing vital tasks such as driving or using heavy machinery.
Medical treatment involves weight loss if the patient is overweight, avoidance of drugs, which increase the risk of apneas such as sleeping pills, alcohol and sedative medicines, and sometimes sleeping semi-upright. However, in most cases additional treatment is warranted.
In some cases we use Continuous Positive Airway Pressure (CPAP for short) to treat patients. For this treatment a mask is fit over the nose or over the nose and mouth. The mask is pressurized slightly to hold the airway open and allow the patient to sleep normally. Newer technology has made the masks relatively comfortable to use.
Some patients may be candidates for surgery on the upper airway. In the usual upper airway surgery the uvula (that punching bag in the back of the throat) and some of the surrounding soft tissue is removed to enlarge the air passage. In other cases a dental device designed to move the lower jaw down and outwards slightly may be worn at night.
In a few cases, treatment is begun with an emergent tracheostomy when sleep apnea is considered to be immediately life-threatening. The decision about which form of treatment to use should be decided by the patient and his/her physician on the basis of the sleep studies and rest of the clinical data.
Narcolepsy
Narcolepsy is a chronic sleep disorder that commonly begins during adolescence and is characterized by excessive daytime sleepiness with the occurrence of sleep attacks. Narcolepsy can run in families, but can occur in the absence of any family history as well. There are several other characteristic symptoms that may or may not be present, including cataplexy, sleep paralysis and hypnogogic hallucinations.
•Cataplexy is the sudden loss of muscle tone, commonly associated with strong emotions. It may be a subtle sensation of weakness or a complete loss of strength with a fall to the ground.
•Sleep paralysis is a sensation of not being able to move on waking, usually for a few seconds.
•Hypnogogic hallucinations are very vivid and sometimes violent or bizarre sensations, almost dreamlike, that occur on waking or falling asleep.
The treatment of narcolepsy and its associated symptoms commonly requires a combination of behavioral modification and drug therapy. Many patients with narcolepsy will do well with naps scheduled at specific times during the day. Stimulant medication may be used to alleviate symptoms of daytime sleepiness. Other medications, such as certain anti-depressants, are used to treat cataplexy. A new promising treatment for cataplexy using a drug called sodium oxybate has recently become available. Treatment for each patient must be individualized and each patient with his/her physician needs to discuss this on a case-by-case basis.
Restless Legs Syndrome and Periodic Limb Movement Disorder
Restless legs syndrome (RLS) is characterized by an intolerable, internal itching sensation occurring in the lower extremities that causes an almost irresistible urge to move the legs. The sensation is commonly described as a "creepy" or "crawly" sensation and is typically relieved by movement of the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours.
In some patients, this problem persists into the nighttime and may prevent patients from getting a restful night's sleep. Pregnancy and iron deficiency are associated with an increased frequency of this disease. In many patients, RLS is extremely distressing. Further, RLS is more common than previously thought, affecting 5-10% of adults and increasing with age.
Almost all patients with restless legs syndrome have a problem called period limb movement disorder. In this, there are leg (sometimes arm) movements occurring at regular intervals during the night. These movements may fragment sleep, leading to poor quality, non-refreshing sleep. Periodic limb movement disorder can also occur as an isolated problem, often reported by the bed partner.
Luckily, in most people, restless legs syndrome and periodic limb movement disorder are relatively easily treated. Treatment commonly includes the incorporation of both aerobic and leg stretching exercises. Leg stretching or even yoga exercises can be done prior to bedtime to alleviate symptoms and may be all that is needed in mild cases. Iron replacement therapy is used if patients are iron deficient. Drugs used to treat Parkinson's disease are very effective in treating most cases. These include the drug pramipexole (Mirapex®) and ropinirole (Requip®). Medications, such as valium-type medications, such as clonazepam (Klonopin®) or analgesic medications related to morphine and opium, can be also be used. In some cases, anti-seizure medications may be effective.
Sleepwalking/Somnambulism
Sleepwalking, also referred to as somnambulism, is characterized by walking or other physical activities during sleep. Sleepwalking is common in children -- up to 15 percent of children have had this problem -- but can occur at any age. In children, it can be associated with sleep deprivation or anxiety. In adults, it is more commonly associated with other medical disorders, medication use, or anxiety or depressive disorders.
Clinically, the person may simply sit up with their eyes open, appearing to be awake, or they may engage in a complex task. Episodes can last from seconds to minutes. Contrary to popular belief, it is safe to wake a sleepwalker, but they may be confused and disoriented on waking.
There is no specific treatment except to avoid triggers if known, or treat anxiety or depression. If severe, short-term use of sedatives may be considered. Otherwise it is best to keep the person safe and out of harm's way. We often advise families to make sure the windows are closed and that there is no possibility of sleepwalking leading to danger for the patient.
Sleep Disorders in Medical Illnesses
Many medical illnesses are associated with disturbances of sleep. Patients with chronic lung disease may experience low oxygen levels at night that disturb sleep. Patients with asthma may develop wheezing or shortness of breath at night, usually in the early morning hours. Patients with heart failure may develop abnormal breathing at night, which disturbs sleep much in the way that sleep apnea does. Patients with Parkinson's or other neurological diseases may develop disturbed sleep.
Sleep Disorders in Mental Illnesses
Many people with mental illnesses, notably depression, anxiety, post-traumatic stress syndrome, and panic attacks, develop profound sleep disturbances. Insomnia is a common symptom in many people with these problems. Evaluation and treatment by a health care provider skilled in these disorders, usually in conjunction with evaluation by a sleep specialist, often brings about great improvement.
Educating patients in good sleep hygiene is the keystone of treatment. The following advice should be given to patients:
- Use the bed for sleep and sex only (no television watching or reading in bed)
- Avoid caffeine, especially late in the day; avoid activities that will get you stimulated and upset late in the day; practice relaxation techniques before bedtime
- Exercise each day
- Maintain a regular schedule for bedtime and wakening; avoid naps
- Do not watch the clock while in bed; avoid struggling to fall asleep in bed—instead, get up and spend quiet time out of bed until sleep comes
Barbiturates and chloral hydrate are seldom used now, because of safety concerns related to their undesirably low therapeutic indexes.
Drugs that block the histamine type 1 receptor are used primarily in over-the-counter preparations, which are inexpensive and help some patients. However, in view of the anticholinergic properties of these agents, they should be used cautiously in older patients and in patients who have conditions such as prostatic hypertrophy, cognitive disorders, and constipation. In addition, most of these drugs have a long duration of action, and their sedative effects may persist well into the following day.
Zolpidem and zaleplon[6] are the newest and, arguably, the safest agents that have been approved by the US Food and Drug Administration (FDA) for short-term hypnotic use. Zolpidem is available an extended-release version that lasts slightly longer than the original preparation. In addition, the FDA has approved eszopiclone as the first agent for long-term use in the management of chronic insomnia.
Diet and Activity No special diet is needed to treat insomnia, but large meals and spicy foods should be avoided in the 3 hours before bedtime. Patients should avoid sleep-disturbing substances such as alcohol, nicotine, and caffeine. Alcohol creates the illusion of good sleep, but it adversely affects sleep architecture. Nicotine and caffeine are stimulating and should be avoided in the second half of the day, from late afternoon on. Consumption of tryptophan-containing foods may help induce sleep; the classic example is warm milk.
Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia. Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus.
Sleep disorders - overview <span>To use the sharing features on this page, please enable JavaScript.</span>
Email this page to a friend Share on facebook Share on twitter Bookmark & Share Printer-friendly version
Sleep disorders are problems with sleeping, including trouble falling or staying asleep, falling asleep at the wrong times, too much sleep, or abnormal behaviors during sleep.
Causes There are more than 100 different sleeping and waking disorders. They can be grouped into four main categories:
- Problems falling and staying asleep (insomnia)
- Problems staying awake (excessive daytime sleepiness)
- Problems sticking to a regular sleep schedule (sleep rhythm problem)
- Unusual behaviors during sleep (sleep-disruptive behaviors)
Insomnia includes trouble falling asleep or staying asleep. Episodes may come and go, last up to 3 weeks (be short-term), or be long-lasting (chronic).
PROBLEMS STAYING AWAKE
People with excessive daytime sleepiness feel tired during the day. Symptoms that are not caused by a lack of sleep or interrupted sleep are called hypersomnia.
Causes of this problem include:
- Medical conditions such as fibromyalgia and low thyroid function
- Mononucleosis or other viral illnesses
- Narcolepsy and other sleep disorders
- Obesity, especially if it causes obstructive sleep apnea
PROBLEMS STICKING TO A REGULAR SLEEP SCHEDULE
Problems may also occur when you do not stick to a regular sleep and wake schedule. This occurs when people travel between time zones and with shift workers who are on changing schedules, especially nighttime workers.
Disorders that involve a disrupted sleep schedule include:
- Irregular sleep-wake syndrome
- Jet lag syndrome
- Paradoxical insomnia (the person sleeps a different amount than they think they do)
- Shift work sleep disorder
Abnormal behaviors during sleep are called parasomnias. They are fairly common in children and include:
- Sleep terrors
- Sleepwalking
- REM sleep-behavior disorder (a person moves during REM sleep and may act out dreams)
Poor sleep habits (referred to as hygiene) are one of the most common problems encountered in our society. We stay up too late and get up too early. We interrupt our sleep with drugs, chemicals, work, and we overstimulate ourselves with late-night activities such as television. Click here to for more information on sleep hygiene, which may provide useful tips on attaining a normal night's sleep. Many of the tips in this site are "common sense," but it is surprising how many people fail to follow these.
Insomnia
Insomnia is the inability to sleep or inability to sleep well at night. Many different medical and mental health problems cause insomnia. Insomnia may be situational, lasting a few days to weeks, or chronic, lasting for more than 1 month.
Around 9-12 percent of the American population report chronic insomnia. In severe cases, patients experience fatigue, sleepiness, difficulty concentrating and difficulty with thinking. Many sufferers feel that they have been robbed of the joy of life. Insomnia may be a symptom of breathing problems at night like sleep apnea, of medical illness like heart failure, a side effect of medications, or a symptom of severe anxiety or depression illness.
While short-lasting insomnia periods are well treated with medication, chronic or long-lasting insomnia may not respond well to medications. Thus, throwing sleeping pills at many patients with chronic insomnia is not an effective way to treat the problem.
An evaluation by the patient's personal physician or a sleep specialist often helps get to the root of the problem. Many patients respond well to what is called "cognitive behavioral therapy." In this form of therapy, incorrect ideas about sleep are corrected. In addition, relaxation and behavioral techniques may be used to help patients fall asleep. This combined with treatment of any underlying disorders is often the best way to treat the devastating symptom of insomnia. Click here for more information on treatments for insomnia.
Sleep Apnea
Sleep apnea is a common and potentially devastating sleep disorder. It is the most common reason that patients are referred to sleep centers around the country.
The word apnea means "not breathing." Patients with the usual form of sleep apnea actually close off their airway at night.
This airway closure occurs either behind the tongue or behind the nose. Patients continue to make efforts to breathe. Then after 10 to 120 seconds, the brain, realizing it is not getting any oxygen, actually "wakes up." The brain then tells the upper airway to open to let some air in.
This is associated with loud bothersome snoring, often described as snorting and gasping. Patients may take a few breaths of air, the brain goes to sleep again and the cycle may repeat itself several hundred times a night. Patients are often not even aware that they are doing this (although the bed partner is).
Sleep apnea is dangerous, common, relative easy to diagnose, and treatable. Patients with sleep apnea are at great risk for heart disease, heart attacks, strokes and high blood pressure. In addition, since the sleep is poor quality (remember the brain keeps waking up), patients are often sleepy during the day. Sleepiness is associated with inability to concentrate, remember or think. There is also increased risk in falling asleep while doing vital tasks such as driving or using heavy machinery.
Medical treatment involves weight loss if the patient is overweight, avoidance of drugs, which increase the risk of apneas such as sleeping pills, alcohol and sedative medicines, and sometimes sleeping semi-upright. However, in most cases additional treatment is warranted.
In some cases we use Continuous Positive Airway Pressure (CPAP for short) to treat patients. For this treatment a mask is fit over the nose or over the nose and mouth. The mask is pressurized slightly to hold the airway open and allow the patient to sleep normally. Newer technology has made the masks relatively comfortable to use.
Some patients may be candidates for surgery on the upper airway. In the usual upper airway surgery the uvula (that punching bag in the back of the throat) and some of the surrounding soft tissue is removed to enlarge the air passage. In other cases a dental device designed to move the lower jaw down and outwards slightly may be worn at night.
In a few cases, treatment is begun with an emergent tracheostomy when sleep apnea is considered to be immediately life-threatening. The decision about which form of treatment to use should be decided by the patient and his/her physician on the basis of the sleep studies and rest of the clinical data.
Narcolepsy
Narcolepsy is a chronic sleep disorder that commonly begins during adolescence and is characterized by excessive daytime sleepiness with the occurrence of sleep attacks. Narcolepsy can run in families, but can occur in the absence of any family history as well. There are several other characteristic symptoms that may or may not be present, including cataplexy, sleep paralysis and hypnogogic hallucinations.
•Cataplexy is the sudden loss of muscle tone, commonly associated with strong emotions. It may be a subtle sensation of weakness or a complete loss of strength with a fall to the ground.
•Sleep paralysis is a sensation of not being able to move on waking, usually for a few seconds.
•Hypnogogic hallucinations are very vivid and sometimes violent or bizarre sensations, almost dreamlike, that occur on waking or falling asleep.
The treatment of narcolepsy and its associated symptoms commonly requires a combination of behavioral modification and drug therapy. Many patients with narcolepsy will do well with naps scheduled at specific times during the day. Stimulant medication may be used to alleviate symptoms of daytime sleepiness. Other medications, such as certain anti-depressants, are used to treat cataplexy. A new promising treatment for cataplexy using a drug called sodium oxybate has recently become available. Treatment for each patient must be individualized and each patient with his/her physician needs to discuss this on a case-by-case basis.
Restless Legs Syndrome and Periodic Limb Movement Disorder
Restless legs syndrome (RLS) is characterized by an intolerable, internal itching sensation occurring in the lower extremities that causes an almost irresistible urge to move the legs. The sensation is commonly described as a "creepy" or "crawly" sensation and is typically relieved by movement of the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours.
In some patients, this problem persists into the nighttime and may prevent patients from getting a restful night's sleep. Pregnancy and iron deficiency are associated with an increased frequency of this disease. In many patients, RLS is extremely distressing. Further, RLS is more common than previously thought, affecting 5-10% of adults and increasing with age.
Almost all patients with restless legs syndrome have a problem called period limb movement disorder. In this, there are leg (sometimes arm) movements occurring at regular intervals during the night. These movements may fragment sleep, leading to poor quality, non-refreshing sleep. Periodic limb movement disorder can also occur as an isolated problem, often reported by the bed partner.
Luckily, in most people, restless legs syndrome and periodic limb movement disorder are relatively easily treated. Treatment commonly includes the incorporation of both aerobic and leg stretching exercises. Leg stretching or even yoga exercises can be done prior to bedtime to alleviate symptoms and may be all that is needed in mild cases. Iron replacement therapy is used if patients are iron deficient. Drugs used to treat Parkinson's disease are very effective in treating most cases. These include the drug pramipexole (Mirapex®) and ropinirole (Requip®). Medications, such as valium-type medications, such as clonazepam (Klonopin®) or analgesic medications related to morphine and opium, can be also be used. In some cases, anti-seizure medications may be effective.
Sleepwalking/Somnambulism
Sleepwalking, also referred to as somnambulism, is characterized by walking or other physical activities during sleep. Sleepwalking is common in children -- up to 15 percent of children have had this problem -- but can occur at any age. In children, it can be associated with sleep deprivation or anxiety. In adults, it is more commonly associated with other medical disorders, medication use, or anxiety or depressive disorders.
Clinically, the person may simply sit up with their eyes open, appearing to be awake, or they may engage in a complex task. Episodes can last from seconds to minutes. Contrary to popular belief, it is safe to wake a sleepwalker, but they may be confused and disoriented on waking.
There is no specific treatment except to avoid triggers if known, or treat anxiety or depression. If severe, short-term use of sedatives may be considered. Otherwise it is best to keep the person safe and out of harm's way. We often advise families to make sure the windows are closed and that there is no possibility of sleepwalking leading to danger for the patient.
Sleep Disorders in Medical Illnesses
Many medical illnesses are associated with disturbances of sleep. Patients with chronic lung disease may experience low oxygen levels at night that disturb sleep. Patients with asthma may develop wheezing or shortness of breath at night, usually in the early morning hours. Patients with heart failure may develop abnormal breathing at night, which disturbs sleep much in the way that sleep apnea does. Patients with Parkinson's or other neurological diseases may develop disturbed sleep.
Sleep Disorders in Mental Illnesses
Many people with mental illnesses, notably depression, anxiety, post-traumatic stress syndrome, and panic attacks, develop profound sleep disturbances. Insomnia is a common symptom in many people with these problems. Evaluation and treatment by a health care provider skilled in these disorders, usually in conjunction with evaluation by a sleep specialist, often brings about great improvement.
