Common Sleep Disorders

• Obstructive sleep apnea(OSA) is a sleep-related breathing disorder that where a person stops breathing in their sleep. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway. This leads to partial reductions (hypopneas) and complete pauses (apneas) in breathing that last at least 10 seconds during sleep. This can lead to low oxygen levels in the blood. The brain responds to the lack of oxygen by alerting the body, causing a brief arousal from sleep that restores normal breathing. This pattern can occur hundreds of times in one night. The result is a fragmented quality of sleep that often produces an excessive level of daytime sleepiness. Most people with OSA snore loudly and frequently, with periods of silence when airflow is reduced or blocked. They then make choking, snorting or gasping sounds when their airway reopens. This is a life-threatening disorder and should be diagnosed and treated.
• Sleepwalking is a sleep disorder that tends to occur during the first third or first half of a person’s sleep period. Sleepwalking consists of a series of complex behaviors that result in walking around with an altered state of consciousness and impaired judgment.  If left untreated, the patient is at risk of causing physical harm to themselves such as falling off of balconies; walking out into traffic; walking outside of a home into extremely cold temperatures; and other endless possibilities.
• Restless legs syndrome (RLS) is a sleep-related movement disorder that involves an almost irresistible urge to move the legs at night. This urge tends to be accompanied by unusual feelings or sensations that occur deep in the legs. These uncomfortable sensations often are described as a burning, tingling, prickling or jittery feeling. In some people these unpleasant feelings become painful. The symptoms of RLS worsen when lying or sitting still and can be relieved at least temporarily, and often immediately, by walking or moving the legs.  In children, RLS often is misdiagnosed as “growing pains.” It can be especially difficult for young children to describe the unpleasant sensations involved with RLS. Symptoms are most common in the legs but may occur in the arms and other parts of the body.
• Periodic Limb Movements, People with RLS often have periodic limb movements, a closely related sleep disorder that occurs when muscles involuntarily tighten, twitch or flex while you are still. A husband or wife may tell their spouse that they kicked them in their sleep all night.  Periodic limb movements in sleep occur in 80% to 90% of people who have RLS.
• Narcolepsy is a neurological sleep disorder that causes a potentially disabling level of daytime sleepiness. This sleepiness may occur in the form of repeated and irresistible “sleep attacks.” In these episodes a person suddenly falls asleep in unusual situations, such as while eating, walking or driving. Narcolepsy affects less than one percent of men and women, typically appearing in teens and young adults and then persisting for a lifetime. Sleepiness in narcolepsy is not the result of inadequate sleep; people with narcolepsy still experience daytime sleepiness even when they sleep well at night. Sleepiness is more likely to occur in boring, monotonous situations that require no active participation (such as watching television).
• Insomnia is a common sleep complaint that occurs when you have a hard time going to sleep, you go to sleep but have a hard time staying asleep, and/or you tend to wake up too early and are unable to go back to sleep. These symptoms of insomnia can be caused by a variety of biological, psychological and social factors. They most often result in an inadequate amount of sleep, even though the sufferer has the opportunity to get a full night of sleep. Insomnia is different from sleep deprivation, which occurs when an individual does not have the opportunity to get a full night of sleep. A small percentage of people who have trouble sleeping are actually short sleepers who can function normally on only five hours of sleep or less. There are two types of insomnia – primary and secondary. Primary insomnia is sleeplessness that cannot be attributed to an existing medical, psychiatric or environmental cause (such as drug abuse or medications). Secondary insomnia is when symptoms of insomnia arise from a primary medical illness, mental disorders or other sleep disorders. It may also arise from the use, abuse or exposure to certain substances.
• Circadian rhythm sleep disorders all involve a problem in the timing of when a person sleeps and is awake. The human body has a master clock in a control center of the brain. This internal clock regulates the timing of body rhythms such as temperature and hormone levels. The primary circadian rhythm that this body clock controls is the sleep-wake cycle. The circadian clock functions in a cycle that lasts a little longer than 24 hours and is set mostly by visual cues of light and darkness. This keeps the clock synchronized to the 24-hour day. Other time cues, such as meal and exercise schedules, also can influence the clock’s timing.  Circadian rhythms and their sensitivity to time cues may change as a person ages.
• Hallucinations: Sleep-related hallucinations are detailed perceptual experiences that occur as a person falls asleep (hypnagogic) or wakes up (hypnopompic). The person has a realistic awareness of the presence of someone or something that really is not there. Hallucinations tend to produce feelings of fear or dread. Although primarily visual, they may involve sensations of sound, touch or movement.
• Rapid eye movement (REM) sleep behavior disorder: REM sleep behavior disorder, or RBD, occurs when a person begins to physically act out a dream during the REM stage of sleep. These dreams tend to be unpleasant, action-filled or violent. Often the dreamer is being confronted, attacked or chased by a person or animal.
• Sleep terrors:  Sleep terrors, sometimes called night terrors, is a sleep disorder that occurs when a person sits up in bed with a loud scream or cry and a look of intense fear. Adults may jump out of bed and run and try to “get away”. The person tends to be unresponsive and will be confused and disoriented if awakened. Attempts to console the person may prolong or intensify the episode. There usually is no memory of the episode, although adults sometimes recall fragments of a dream. It tends to occur during the first third of the sleep period.

Signs, Symptoms, and Effects of Sleep Disorders

            Excessive daytime sleepiness

            Morning Headaches

            Snoring

            Bed-wetting

            Swelling in Legs and feet

            Memory Loss and poor concentration

            Depression or Irritability or Anger

            Night time leg pains

            Attacks of muscle weakness when laughing, crying, or during extreme emotions

            Low blood oxygen levels

                        Increased heart rate and/or irregular heart rhythms

                        Increase in daytime blood pressure

                        Increased risk of stroke

                        Higher rate of death due to heart disease

                        Impaired glucose tolerance and insulin resistance  - Diabetes

                        Mood changes

                        Increased risk of being involved in a deadly motor vehicle accident

                        Disturbed sleep of the bed partner

Work Performance issues due to sleepiness

            School performance issues due to sleepiness

Treatments

Continuous positive airway pressure (CPAP):

CPAP is the standard treatment option for moderate to severe cases of OSA and a good option for mild sleep apnea. CPAP blows air into a person’s windpipe at a set, steady pressure. This airflow keeps the airway open, preventing pauses in breathing and restoring normal oxygen levels.

Oral appliances: An oral appliance is an effective treatment option for people with mild to moderate OSA who either prefer it to CPAP or are unable to use CPAP therapy. Oral appliances look much like sports mouth guards, and they help maintain an open and unobstructed airway by repositioning or stabilizing the lower jaw, tongue, soft palate or uvula. Some are designed specifically for snoring, and others are intended to treat both snoring and sleep apnea. They should always be fitted by dentists who are trained in sleep medicine.

Surgery: Surgery is a treatment option for OSA when noninvasive treatments such as CPAP or oral appliances have been unsuccessful. It is most effective when there is an obvious anatomic deformity that can be corrected to alleviate the breathing problem. Otherwise, surgical options most often address the problem by reducing or removing tissue from the soft palate, uvula, tonsils, adenoids or tongue. More complex surgery may be performed to adjust craniofacial bone structures. Surgical options may require multiple operations, and positive results may not be permanent. One of the most common surgical methods is uvulopalatopharyngoplasty (UPPP), which trims the size of the soft palate and may involve the removal of the tonsils and uvula. Adenotonsillectomy, the surgical removal of the tonsils and adenoids, is the most common treatment option for children with OSA. Other children with sleep apnea may benefit from CPAP.

Behavioral changes:

Weight loss benefits many people with sleep apnea, and changing from back-sleeping to side-sleeping may help those with mild cases of OSA.

Position Therapy: A treatment used for patients suffering from mild OSA. Patients are advised to stay off of the back while sleeping and raise the head of the bed to reduce symptoms.

Modafinil:

This stimulant is a unique chemical compound that has replaced amphetamines as a first-line treatment for Excessive daytime sleepiness. Modafinil (Provigil) is an effective, FDA-approved treatment for narcolepsy with few side effects and a low potential for abuse.

Other stimulants:

Amphetamines were formerly the most common treatment option for sleepiness in narcolepsy, but they carry a strong risk of addiction. Methylphenidate, pemoline and mazindol also have been used. Selegiline (Eldepryl) is a methamphetamine derivative. It may treat both sleepiness and cataplexy. Relatively few side effects have been reported with its use.

GHB (gamma-hydroxybutyrate):

GHB (Xyrem) can improve alertness and also reduce cataplexy. It tends to take about six weeks to nine weeks before it consistently reduces sleepiness. It is a preferred option to treat cataplexy because it has few side effects. Although the FDA approved Xyrem in 2002 for the treatment of cataplexy, all other uses of GHB are banned by the U.S. government’s controlled-substance laws.

Other anticataplectic drugs:

Tricyclic antidepressants formerly were the first treatment option for cataplexy. Severe side effects now make them a last resort. Other antidepressants (atomoxetine, clomipramine, fluoxetine, venlafaxine, zimeldine) have been effective and have produced fewer side effects. The use of antidepressants to treat cataplexy is not approved by the FDA.

Cognitive behavioral therapy (CBT): CBT can have beneficial effects that last well beyond the end of treatment. It involves combinations of the following therapies:

Cognitive therapy: Changing attitudes and beliefs that hinder your sleep

Relaxation training: Relaxing your mind and body

Sleep hygiene training: Correcting bad habits that contribute to poor sleep

Sleep restriction: Severely limiting and then gradually increasing your time in bed

Stimulus control: Going to bed only when sleepy, waking at the same time daily, leaving the bed when unable to sleep, avoiding naps, using the bed only for sleep and sex

Over-the-counter products:

Most of these sleep aids contain antihistamine. They can help you sleep better, but they also may cause severe daytime sleepiness. Other products, including herbal supplements, have little evidence to support their effectiveness.

Prescription sleeping pills:

Prescription hypnotics can improve sleep when supervised by a physician. The traditional sleeping pills are benzodiazepine receptor agonists, which are typically prescribed for only short-term use. Newer sleeping pills are nonbenzodiazepines, which may pose fewer risks and may be effective for longer-term use.