Our last article talked about the importance of getting sufficient, high-quality sleep and how to tackle the ubiquitous problem of sleep deprivation in our globalizing world. Several readers asked: At what point does inadequate sleep become pathological, necessitating medical intervention? To answer this, let’s examine some common sleep disorders.
We can categorize patients with sleep disorders into four groups: (1) Those who can’t sleep, (2) Those who don’t sleep, (3) Those who don’t get restful sleep and still feel sleepy during the day, and (4) Those with increased movements during sleep.
About 10% of Americans suffer chronic insomnia, defined as trouble initiating sleep every night for at least two weeks. Normally it should take 30 minutes or less from your head hitting the pillow to actually falling asleep. Insomniacs may also have difficulty sleeping through the night. Diagnosis is based on a detailed sleep questionnaire.
Cognitive behavior therapy fosters correct beliefs about sleep and reinforces positive behavior. You’re taught how to build an optimal sleep environment, improve sleep hygiene and increase sleep efficiency. Several prescription sedatives are approved for insomnia, including zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata) and triazolam (Halcion). Therapy combined with medication works better than meds alone. Over-the-counter diphenhydramine (Benadryl), doxylamine (Unisom), melatonin, and valerian, have minimal and inconsistent effects, thus not recommended as a regular solution to sleepless nights.
Delayed sleep phase syndrome
Some people have a misaligned circadian rhythm characterized by going to sleep late and waking up late. The grogginess during the day and insomnia at night form a vicious cycle that impairs daytime function. Treatment involves removing stimulating activities at night (computer and Internet use, TV, social interactions), and sleep-cycle adjustment with melatonin a few hours before bed and bright light first thing in the morning.
Narcolepsy is a relatively rare condition that usually begins in youth. Patients have shortened sleep latency, earlier onset of rapid eye movement sleep, hallucinations upon falling asleep or waking, and sleep paralysis. The result is unrefreshing sleep at night and excessive daytime sleepiness. Some suffer cataplexy attacks where their whole body goes limp if they experience intense emotions. Diagnosis requires a clinical sleep study that monitors brain waves, muscle tone, eye movements, and breathing. Narcolepsy is treated with medications that suppress REM sleep, such as venlafaxine (Effexor), and amphetamine-type stimulants such as modafinil (Provigil) and methylphenidate (Ritalin).
Obstructive sleep apnea
We’ve previously written about OSA, an underdiagnosed condition that’s becoming more common with our aging population and increased obesity. The upper airway collapses during sleep, blocking airflow and dropping blood oxygen levels. OSA manifests as snoring, paused breathing, and gasping for air while sleeping. OSA results in daytime sleepiness and cognitive impairment, but more importantly, the oxygen deprivation can lead to heart and lung diseases. Once the diagnosis is confirmed with a sleep study, the patient can be fitted with a continuous positive airway pressure machine that keeps the airway open.
Restless leg syndrome
Patients with RLS feel an intense urge to move their legs, usually accompanied by uncomfortable sensations that are relieved by movement. Symptoms occur during periods of rest (predominantly in the evening). Many patients have episodes of repetitive leg movement during sleep, which can be disturbing not only for themselves but also for their bed partners. Medications that alter nerve conduction, including carbidopa/levodopa (Sinemet), pramipexole (Mirapex), ropinirole (Requip) and gabapentin (Neurontin) are often used.
REM sleep behavior disorder
Normally we’re paralyzed during REM sleep when we dream; however, patients with REM sleep behavior disorder have increased muscle tone and act out their dreams, which can be vivid and violent. This disorder can be a side effect of alcohol and certain psychiatric drugs, or possibly a sign of neurodegenerative diseases such as Parkinson’s and Lewy body dementia. It differs from sleep walking or night terrors, which happen during deep non-REM sleep and are usually seen in childhood. Treatment is mostly supportive – limited to removing dangerous objects nearby. Melatonin and clonazepam (Klonopin) may be helpful.
In all, sleep disturbances affect a quarter of adults in the US Don’t dismiss poor sleep as something you have to live with. Your health, and your bed partner, deserve better.
Qing Yang and Kevin Parker are a married couple and live in Springfield. dr Yang received her medical degree from Yale University School of Medicine and completed residency training at Massachusetts General Hospital. She is an anesthesiologist at HSHS Medical Group. Parker has helped formulate and administer public policy at various city and state governments around the country. He is formerly the group chief information officer for education with the Illinois Department of Innovation and Technology. This column is not intended to be a substitute for professional medical advice, diagnosis or treatment. The opinions are those of the writers and do not represent the views of their employers.