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Sleep Disorders & Treatments

In order to diagnose some sleep disorders, a sleep study or other medical testing may be required. Treatment is then based on the diagnosis. If left untreated, some sleep disorders increase the risk of accidents or other medical problems.


What Is a Sleep Disorder?
Sleep disorders are common and can affect males and females of all ages. There are more than 80 specific sleep disorders. They can be grouped into 5 categories:

Insomnia includes trouble falling asleep, staying asleep or non-restful sleep. Almost everyone has experienced insomnia on occasion but when insomnia persists beyond 1 month it is considered a chronic sleep disorder.

Daytime sleepiness can be caused by disrupted sleep, inadequate sleep time, or other underlying disorders. Common sleep disorders causing daytime sleepiness include:

  • Sleep apnea
  • Narcolepsy
  • Insufficient sleep syndrome

Sleep periods may be shifted so that sleep occurs partly or mostly during daytime hours. This shift often causes insomnia and daytime sleepiness. Common disorders that involve a shift in the sleep schedule include:

  • Shift work sleep disorder
  • Delayed sleep phase

Sleep-related movement disorders can disturb sleep or delay its onset. Common sleep-related movement disorders include:

  • Periodic Leg Movements
  • Restless Legs Syndrome
  • Bruxism

Abnormal behaviors during sleep are common in children but can also occur in adults. The most common include:

  • Sleep terrors
  • Sleepwalking
  • Bedwetting
  • Acting out of violent dreams in adults (REM Behavior Disorder)


Sleep Disorders & Treatments

Description
Bedwetting is common in children but it is typically outgrown by adolescence. It is not considered a disorder under the age of 5. Although generally benign, it can cause social embarrassment for children and result in the avoidance of peer group activities such as sleepovers or camping. In adults, bedwetting is often symptomatic of other medical conditions such as sleep apnea, diabetes, dementia, congestive heart failure, and urinary tract infections and should be evaluated by a physician.

Causes
Bedwetting is often hereditary. It can be associated with difficulty awakening from sleep, an overactive bladder, or increased urine production during the night. The factors that determine whether bedwetting will occur on any given night are unknown but are amplified but sleep deprivation and increased fluid intake.

Treatment
Treatment for bedwetting can involve behavioral measures or medication. Behavioral measures include: withholding liquid in the evening, awakening about 2 hours after sleep to urinate, and increasing liquid intake during the day and delaying urination to expand the bladder.

Description
Delayed Sleep Phase Disorder refers to a significant delay in the timing of sleep resulting in inability to fall asleep at the desired time and difficulty awakening in the morning at the desired time. This is common in adolescence where the inability to fall asleep at a reasonable time at night results in short sleep time and daytime sleepiness that impacts school performance. When allowed to sleep ad lib, these individuals go to bed very late and sleep very late but have normal quantity and quality of sleep.

Causes
Delayed Sleep Phase Disorder is due to the shifting of the body's sleep wake rhythm later than the normal or desired sleep time.

Treatment
Treatment of Delayed Sleep Phase typically involves behavioral approaches that include reducing light and stimulating activities in the early evening, enforcing a set wake-up time in the morning even on weekends, and exposure to sunlight or bright light in the morning.

Description
Insomnia refers to the inability to fall asleep, stay asleep or non-restorative sleep resulting in poor daytime functioning. Insomnia may be a lifelong problem, a side effect of medication, or due to a medical or mental condition. In most cases, it develops after a stressful life event, such as a death in the family. Insomnia is more common in females and older individuals and has been associated with increased health risks.

Causes
Insomnia can develop due to poor sleep habits or increased activity in the body's arousal system.

Treatment
Insomnia is typically treated with behavioral therapy or medication, which may be used in combination with behavioral therapy. Behavioral therapy includes a number of components such as good sleep hygiene and cognitive behavioral therapy. When insomnia is present with other associated medical or mental conditions, effective treatment of associated conditions is also needed. If insomnia is a side effect of medications, a change in dosage, timing or type of medication may be needed.

Description
Narcolepsy refers to daily periods of irresistible sleep attacks. Other symptoms may include: cataplexy (the sudden loss of muscle tone in emotional situations, such as when laughing or angry), sleep paralysis (a brief inability to move upon awakening) or dreams occurring when sleepy but still awake. The severity and combination of symptoms varies among individuals. Brief naps of 5-15 minutes are often very refreshing. In most cases, narcolepsy is hereditary with symptoms beginning between 15 and 30 years of age.

Causes
Narcolepsy is due to the loss of hypocretin producing cells in the brain. The reason for the loss of these cells is unknown. In addition to a hereditary link, narcolepsy can be caused by traumatic head injury.

Treatment
Narcolepsy treatment depends on the severity and types of symptoms present. Brief naps during the day and medications are often used independently or together.

Description
Periodic Limb Movement Disorder (PLMD) refers to repetitive limb movement during sleep. This movement can be as small as wiggling of the toes or as big as a full kick of the leg. The individual is unaware of the movement or the brief arousal that fragments sleep. Sleep disruption from the movements can cause difficulty falling asleep, staying asleep or unrestful sleep that results in daytime sleepiness.

Causes
Almost everyone with Restless Legs Syndrome also has PLMD. PLMD is more common in females and may be hereditary. PLMD may be caused by low iron levels, decreased blood flow to the extremities, or medications including certain antidepressants, dopamine agonists and lithium.

Treatment
Treatment depends on the cause of PLMD if known. Iron supplements are used if appropriate. Otherwise, PLMD is typically treated with medication.

Description
REM Behavior Disorder (RBD) refers to abnormal behaviors during REM sleep (dream sleep) that can cause injury. Episodes usually involve enactment of unpleasant and violent dreams in which the sleeper feels they are being attacked. Injuries can occur to the dreamer when they “defend’ themselves during the attack. Typically there is a sudden awakening after the event and the individual reports a coherent dream story. RBD is more common in males over the age of 50 and is often progressive. Due to the high likelihood of injury and progressive nature of the disorder, medical evaluation is needed.

Causes
REM Behavior Disorder is due to absence of muscle paralysis that normally accompanies REM sleep. This may be due to degeneration in certain areas of the brain, other neurologic disorders, or some medications.

Treatment
Treatment typically involves medication to control the episodes along with management of any associated neurological disorders.

Description
Restless Legs Syndrome refers to an uncomfortable sensation in the legs and sometimes arms that occurs during periods of inactivity or rest such as sitting or lying down at bedtime. It occurs almost exclusively in the evening or night. The sensation could range from tingling, creeping or crawling to pain. The sensation is accompanied by an irresistible urge to move the limbs and movement temporarily relieves the sensation. Restless legs syndrome can significantly delay sleep onset and result in sleep deprivation and daytime sleepiness.

Causes
Restless legs syndrome is more common in females and maybe hereditary in many cases. The prevalence of RLS increases with age. It can occur in association with iron deficiency, pregnancy and chronic renal failure. Decreased blood flow to the limbs has also been associated with Restless Legs Syndrome. Stimulant medications or caffeine can increase symptoms of restless legs. Often a specific cause cannot be found.

Treatment
Treatment of Restless Legs Syndrome depends on the underlying cause. Iron supplements are used if appropriate; otherwise, RLS is typically treated with medication. Almost everyone with Restless Legs Syndrome also has Periodic Limb Movements, and the treatment is the same.

Description
Shift Work Sleep Disorder can occur when work schedules overlap with the usual time for sleep. This results in a complaint of insomnia or excessive sleepiness when sleep time is shifted to the daytime or normal wake hours. It is common in workers on night shifts, early morning shifts and rotating shifts. The condition usually persists only for the duration of the shift work schedule.

Causes
Shift Work Sleep Disorder is caused by the misalignment of the sleep period with the body's normal sleep wake pattern.

Treatment
Treatment depends on the severity of symptoms, as there is great variability in the ability to adapt to shift work. Options for treatment include behavioral approaches and medication. Behavioral approaches include stabilizing sleep periods as much as possible, napping, using caffeine and controlling light exposure.

Definition and types
Sleep apnea refers to repeated pauses in breathing during sleep. There are two types of sleep apnea, obstructive and central. Obstructive sleep apnea is the most common and due to blockage of the upper airway. Central sleep apnea is due to the lack of respiratory effort.

Symptoms
The symptoms of obstructive and central sleep apnea often overlap. Generally, obstructive sleep apnea is associated with loud snoring while central sleep apnea is frequently associated with insomnia. Other common symptoms of obstructive and central sleep apnea include:

  • Daytime sleepiness
  • Morning headaches
  • Awakening with a dry mouth
  • Impaired memory and concentration
  • Awakening choking or gasping for air
  • Moodiness

Causes
Obstructive sleep apnea is due to blockage or collapse of the airway during sleep. During sleep, the muscles of the upper airway relax and may not be able to support the structures in the upper airways such as tonsils, adenoids, uvula or soft palate. If these structures are relatively large compared to size of the airway, they can block the airway. In addition the tongue is a muscle, and, when it relaxes during sleep it can fall back across the airway and block it, especially when an individual sleeps on their back. Central sleep apnea is due to loss of signals from the brain to the diaphragm to trigger breathing. Although the airway is open, the chest does not move to pull in air. Central sleep usually occurs in individuals who have heart failure, neuromuscular disease, cardiac or pulmonary disease, or have had a stroke.

Diagnosis
Sleep apnea is diagnosed from a sleep study. The many physiological parameters monitored during a sleep study include airflow, chest movement and oxygen saturation. These are used to determine if sleep apnea is present. The number of apneas (pauses in breathing) and hypopneas {shallow breathing episodes causing oxygen decrease) that occur during sleep are counted and divided by the total hours of sleep. This results in the Apnea and Hypopnea Index or AHI, which can vary from 0-160 and possibly higher. The higher the AHI, the more severe is the sleep apnea.

Treatment
The treatment of sleep apnea depends on the type and cause of sleep apnea. Treatments can range from behavioral measures to surgery and may be done in combination.

  • Positive Airway Pressure (PAP) is the most common treatment for sleep apnea. There are different types of PAP therapy but all involve wearing a mask over the nose or nose and mouth. The mask is connected by a tube to a machine that blows pressurized room air into the nose and airway to keep the airway open. The pressure needed can be determined by a titration study.

    • CPAP (continuous positive airway pressure) blows a single pressure of air continuously.
    • Bi-Level PAP blows one level of pressure with every inspiration and a lower pressure during each exhalation.
    • Auto PAP automatically adjusts the pressure needed to open the airway based on airway resistance detected by the machine.
    • ASV (Adaptive Servo-Ventilation) is used for central sleep apnea and delivers a steady airflow but will increase and decrease pressure to deliver a breath when there is a pause in respiration.

  • Behavioral Treatments will help most patients with sleep apnea and they are often used in combination with other treatments. Behavioral treatments include avoiding: the supine sleep position, alcohol, sleeping pills, and sleep deprivation.
  • Weight Loss. Overweight sleep apnea patients will benefit from weight loss, as even modest weight loss can reduce the AHI.
  • Oral Appliances are used to pull the tongue or jaw forward to prevent the tongue from falling back and blocking the airway. Oral appliances are used for patients with mild to moderate sleep apnea.
  • Surgical Treatment may be recommended to remove obstructions, extra tissue in the nose or airway or certain facial abnormalities. Surgical procedures include: tonsillectomy, adenoidectomy, uvulopalatopharyngoplasty (UPPP removes the uvula and part of palate), nasal septum surgery for deviated septum and mandibular advancement surgery.

Description
Insufficient Sleep Syndrome, or lack of sleep, refers to the failure to obtain a sufficient amount of sleep to remain alert during the day. This reduced time in bed causes sleep deprivation resulting in daytime sleepiness. Sleep is often shortened by the use of alarm clocks or being awakened by others in order to meet work, school or social schedules. Characteristically, these individuals sleep longer when such measures are not used such as on weekends, holidays or vacation. Extending the time in bed can reverse the symptoms.

Causes
There is no underlying pathology in insufficient sleep syndrome. It is caused by the voluntary decision of an individual to limit their time in bed below their sleep need.

Treatment
Insufficient Sleep Syndrome is treated by increasing time in bed to meet the body's sleep need. The amount of sleep that an individual needs can be determined by waking up naturally for about a week and determining the average hours of sleep per night for the week. This is used to determine the amount of time in bed that is needed every night.

Description
Sleep Terrors are common in children and usually outgrown by adolescence. Typical episodes consist of an abrupt terror beginning with sitting up in bed and letting out a piercing scream. The eyes are wide open with a glassy stare and there might be some incoherent vocalizations or shouting, although dreamlike activity is not associated with the event. A rapid heart rate, rapid breathing, flushing of the skin and sweating accompany the intense fear. Most episodes are short but some can last up to 40 minutes. The individual does not have memory of the event. In adults, the episodes could progress into bolting out of bed and also violent behavior if attempts are made to intervene.

Causes
Sleep Terrors are the result of incomplete awakening from deep sleep. Episodes can be triggered by sleep deprivation and stress and in rare situations may be due to some medical conditions.

Treatment
Treatment for Sleep Terrors can involve behavioral measures or medication when needed. Behavioral measures involve getting adequate sleep and napping.

Description
Sleepwalking is common in children and usually outgrown by adolescence. There is often a family history of sleepwalking. Complex behaviors can be carried out during the sleepwalking episode, but there is minimal cognitive functioning and no remembrance of the event. Sleepwalkers can injure themselves during these episodes, and there may be inappropriate responses if others try to intervene. The occurrence of sleep walking in adults needs medical evaluation.

Causes
Sleepwalking is the result of incomplete awakening from deep sleep. Episodes can be triggered by sleep deprivations, stress, sound, touch or other stimuli. Sleepwalking can also be a side effect of medication.

Treatment
Treatment for sleepwalking can involve behavioral measures or medication when needed. Behavioral measures involve getting adequate sleep, napping and making the sleep environment safe and secure.

Description
Tooth grinding includes grinding or clenching the teeth during sleep. The friction from tooth grinding makes a grinding sound that can be quite loud. Tooth grinding can cause abnormal tooth wear and damage to tooth enamel. Both tooth grinding and clenching may cause temporary jaw pain, headache or jaw locking on awakening in the morning.

Causes
Tooth grinding and clenching during sleep are due to muscle contractions of the jaw. The specific cause is not known, although it has been associated with Temporomandibular joint (TMJ) problems, stress and anxiety.

Treatment
Treatment for bruxism usually involves the use of oral appliances, such as a mouth guard, to protect the teeth