Sleep Disorder Awareness -- March 24, 2008 -- Dr. Michael Bolds - | Nashville News, Weather & Sports

Sleep Disorder Awareness -- March 24, 2008 -- Dr. Michael Bolds


Sleep Disorder Awareness
Medical Mondays

Michael Bolds, M.D pulmonologist
DATE: March 24, 2008


What is a Sleep Disorder?

There are more than 85 recognized sleep disorders, the most recognizable of which may be (1) insomnia, (2) sleep apnea, (3) narcolepsy, and (4)restless leg syndrome. These and others may manifest themselves in various ways.


Up to about one-third of the population have symptoms of insomnia. Those with insomnia typically experience:

  • Sleepiness
  • Fatigue
  • Poor concentration
  • Decreased alertness and performance
  • Muscle aches
  • Depression during the day and night
  • An over-emotional state (tense, worried, irritable, and depressed)

Many of us experience temporary insomnia from a few days to a few weeks. This kind of insomnia usually results from normal events in our lives such as:

  • A stressful event
  • Emotional stress
  • Illness
  • Temporary pain
  • Disturbances in sleep hygiene (environmental factors under your control that may contribute to disturbed sleep and insomnia)
  • Disruptions to circadian rhythm (the 24-hour rhythmic regulation of our body processes)

When stressful situations resolve, when you recover from illness, when the pain goes away, when sleep hygiene improves -- then sleep usually improves.

Circadian rhythm disruptions like shift work and jet lag may contribute to insomnia because the times you fall asleep and wake up are temporarily shifted. Proper sleep hygiene, particularly the amount of and timing of light, can help re-set your circadian rhythm and improve the symptoms of insomnia from these causes.




You actually stop breathing, for 10, then 20, then 30 seconds. Then, you begin to gasp for air, as if it were your last breath. This cycle repeats itself over and over, all night long. For your part, you may be totally unaware of all of that, as the alarm clock rings. You may wake with a dry mouth, a headache, and feeling hungover. You may also be sleepy during the day, have significant memory loss, concentration, attention, mood and other related problems. This rather horrifying scenario is typical for a disorder called sleep apnea There are two types of sleep apnea, obstructive (OSA) and central (CSA).

In OSA the throat collapses during sleep, preventing the flow of air to your lungs. As your oxygen levels decrease, your brain gets an alert message to "wake up and breath." These apnea episodes may occur 20 to 60 to 100 or more times per hour.

CSA is far less common, occurring in less than 10% of cases. Here, the brain fails to send a signal to breath. This can occur in various heart and neurological disorders.

Present in about 7% of the population, the prevalence of sleep apnea is on par with diabetes and asthma. It is also a primary risk factor for high blood pressure. Fortunately, with the proper diagnosis, it can be treated quite effectively.

How is Sleep Apnea treated?

There are three categories of treatment for obstructive sleep apnea:

  1. Physical or mechanical therapy
  2. Surgery
  3. Non-specific therapy


Physical or mechanical therapies only work at the time they are properly used. Apnea episodes return when they are not utilized.

  • Continuous positive airway pressure (CPAP) is the most common treatment. With the use of a snugly fitted face mask or nasal plug, air is blown into the nasal passages, forcing the airway open and allowing air to flow freely. The pressure is continuous and constant and is adjusted so that it is just enough to open the airway.
  • Dental or oral appliances reposition the lower jaw and tongue, moving them outward, creating something akin to a pronounced "underbite." Used in mild to moderate sleep apnea, this physically opens the airway, allowing the free flow of air. They are custom-made devices usually fitted by a dentist or orthodontist.
  • Surgery opens the airway by removal of tissues, like tonsils, adenoids, nasal polyps, and structural deformities that may obstruct it. There are several types of procedures, but none are completely successful and without risk. It is also difficult to predict the outcome and side effects.
  • One procedure, called uvulopalatopharyngoplasty, removes tissue at the back of the throat. In addition to having low success rates of between 30%-60%, it is difficult to predict exactly which patients will benefit, as well as the long-term outcome and side effects.
  • Other procedures include tracheostomy (creating a hole directly in the windpipe, for those with severe obstruction),surgical reconstruction for those with deformities, and procedures to treat obesity, which contributes to apnea.

Non-specific therapy addresses the behavioral aspects that may be an important part of a treatment program.

  • If you are overweight, weight loss can reduce the number of apnea episodes. One should avoid depressants, like alcohol and sleeping pills, which can increase the likelihood of and prolong apnea episodes. Some people have apnea events only when lying on their back. So placing a pillow or other device to help keep you on your side may also help.



Falling asleep spontaneously may indicate the syndrome of narcolepsy. Excessive daytime sleepiness is typically the first symptom. It's the overwhelming need to sleep when you prefer to be awake. Narcolepsy is associated with cataplexy, a sudden weakness or paralysis often initiated by laughter or other intense feelings, sleep paralysis, an often frightening situation, where one is half awake yet cannot move, and hypnagogic hallucinations, intensely vivid and scary dreams occurring at the onset or end of sleep. One may also experience automatic behavior, in which one performs routine or boring tasks without full memory later.

How is  Narcolepsy Treated?

There are both behavioral treatments and medications for this situation, which can make life livable again.

General behavioral measures include:

  • Avoiding shift work
  • Avoiding heavy meals and alcohol intake
  • Regular timing of nighttime sleep
  • Strategically timed naps

Medications typically involve stimulants in attempt to increase the level of alertness and antidepressants to control the associated conditions noted above. The effects of stimulant medications vary widely and their dosing and timing must be individualized.

  • Provigil is a relatively new medication that improves alertness but does not act as a stimulant for other body systems. It has few side effects and low abuse potential.
  • Stimulants include dextroamphetamine sulfate (Dexedrine, Dextrostat), methylphenidate hydrochloride (Ritalin, Concerta, others), and Cylert.
  • Antidepressants include:
    • Multicyclics like Tofranil, Norpramin, Anafranil, and Vivactil.
    • Selective serotonin re-uptake inhibitors (SSRIs). These include Prozac, Paxil, and Zoloft.


Particularly around bedtime, many people (about 15% of the population) experience "pins and needles feelings," an "internal itch," or a "creeping, crawling sensation" in their legs, with a subsequent irresistible urge to relieve this discomfort by vigorously moving their legs. This movement totally relieves the discomfort. These symptoms are classic for restless leg syndrome.


RLS makes if difficult to fall asleep and may also awaken you out of sleep, forcing you to walk around to relieve the discomfort. Though not considered medically serious, symptoms of RLS can range from bothersome to having a severe impact on you and your bed partner's lives.

Most people with RLS also have periodic limb movement disorder (PLMD), repetitive movements of the toe, foot, and sometimes knee and hip during sleep. They are often recognized as brief muscle twitches, jerking movements, or an upward flexing of the feet. As with sleep apnea, sufferers may be unaware that RLS and PLMD disturb sleep and produce symptoms similar to those noted above. Once again, it is often the bed partner that brings this to light, as movements awaken him or her throughout the night. It is important to note that RLS and PLMD are associated with several other medical conditions, including iron-deficiency anemia. So one should, as always, seek proper medical attention.

How is Restless Leg Syndrome Treated?

RLS generally responds well to medication, but since it may occur sporadically with spontaneous remissions, the continuous use of medications is generally recommended for symptoms occurring at least three nights per week. Sleep experts use three types or classes of medications for RLS and PLMD:

  1. Dopaminergic agents: This class enhances a brain chemical known as dopamine. Mirapex and Permax have become first-line medication, over older drugs like L-Dopa with Sinemet.
  2. Benzodiazepines are generally sleep experts' second-line medication. They must be used carefully due to the potential for addiction and the negative impact on sleep. This class includes such drugs as diazepam (Valium, Diastat), Klonopin, Restoril, and Halcion.
  3. Opioids represent the third-line of preferred medication generally and is reserved for those with more severe symptoms. They may be used alone or in conjunction with other medications. This class includes codeine (active ingredient in Tylenol #3), oxycodone (active ingredient in Percocet), Darvon, and methadone (in very severe cases only).

As one would expect, all of these medications are available by prescription only and should be taken only while under a doctor's care.

Seeing a sleep specialist is essential for proper diagnosis and treatment.  Many sleep disorders are secondary to a variety of medical and mental-health disorders, pain, and even the treatments for these disorders. Medical conditions like diabetes, congestive heart failure, emphysema, stroke, and others may have nighttime symptoms that disturb sleep. Depressive illnesses and anxiety disorders are associated with sleep disturbances, as is the pain from conditions like arthritis, cancer, and acid reflux, to name a few.

Recognizing and distinguishing among sleep problems, primary sleep disorders, and those secondary to or associated with medical conditions is critical to proper diagnosis and treatment. It is equally important, however, to realize that they often interact in a complex manner, with each impacting the other. For example, poor sleep can affect your mood, and your mood can affect the quality of your sleep. Poor sleep can contribute to obesity, and obesity can cause sleep disorders. Exactly how all these factors interact is not completely known, but we can target each aspect individually and achieve vastly improved interventions and treatments.

The magnitude of the impact of sleep disorders on our individual and public health, safety, and performance is truly enormous. Fortunately, increasing awareness is leading to more effective treatment, less suffering, and happier, more productive lives.

What are the consequences of Sleep Deprivation?

Sleep deprivation induces significant reductions in performance and alertness. Reducing your nighttime sleep by as little as one and a half hours for just one night could result in a reduction of daytime alertness by as much as 32%.

  • Decreased alertness and excessive daytime sleepiness impair your memory and your cognitive ability -- your ability to think and process information.
  • Disruption of a bed partner's sleep due to a sleep disorder may cause significant problems for the relationship (for example, separate bedrooms, conflicts, moodiness, etc.).
  • You may experience a poor quality of life. For example, you might be unable to participate in certain activities that require sustained attention, like going to the movies, seeing your child in a school play, or watching a favorite TV show.
  • Excessive sleepiness also contributes to a greater than two-fold higher risk of sustaining an occupational injury.
  • The National Highway Traffic Safety Administration (NHTSA) estimates conservatively that each year drowsy driving is responsible for at least 100,000 automobile crashes, 71,000 injuries, and 1,550 fatalities.

The good news for many of the disorders that cause sleep deprivation is that after risk assessment, education, and treatment, memory and cognitive deficits improve and the number of injuries decreases.

In the long term, the clinical consequences of untreated sleep disorders are large indeed. They are associated with numerous, serious medical illnesses, including:

  • High blood pressure
  • Heart attack
  • Heart failure
  • Stroke
  • Obesity
  • Psychiatric problems, including depression and other mood disorders
  • Mental impairment
  • Fetal and childhood growth retardation
  • Injury from accidents
  • Disruption of bed-partner's sleep quality
  • Poor quality of life

Studies show an increased mortality risk for those reporting less than either six or seven hours per night. One study found that reduced sleep time is a greater mortality risk than smoking, high blood pressure, and heart disease. Sleep disturbance is also one of the leading predictors of institutionalization in the elderly, and severe insomnia triples the mortality risk in elderly men.

Remarkably, sleep loss may also be a contributing factor to obesity. John Winkelman, MD, PhD, medical director of the Sleep Health Center at Brigham and Women's Hospital and assistant professor of psychiatry at Harvard Medical School sums up this finding up nicely: "What most people do not realize is that better sleep habits may be instrumental to the success of any weight management plan." And Michael Thorpy, MD, director of the Sleep-Wake Disorders Center at Montefiore Medical Center in New York adds, "Any American making a resolution to lose weight ... should probably consider a parallel commitment for getting more sleep."

It is also important to realize the huge scope and prevalence of these disorders; more than 85 sleep disorders are recognized by the American Sleep Disorders Association, affecting more than 70 million Americans. Up to one-third of Americans have symptoms of insomnia; however, less than 10% of those are identified by primary care physicians. Sleep-related breathing disorders represent a spectrum of abnormalities that range from simple snoring to sleep apnea (repeated episodes of cessation of breathing during sleep). As highly prevalent as they are, most cases remain undiagnosed and untreated.

  • Chronic snoring, for example, is associated with an increased incidence of heart and brain-related diseases. It is present in about 40% of men and 30% of women, with up to half of those affected having sleep apnea.
  • The prevalence of sleep apnea (at least 2%-4% of the population) is on par with diabetes and asthma.
  • Sleep apnea is a primary risk factor for high blood pressure; as many as 40% of those people are undiagnosed and untreated for high blood pressure. Effective treatment of sleep apnea in patients with high blood pressure leads to a substantial reduction in stroke risk.
  • Patients with moderate to severe sleep apnea perform as poorly as drunk drivers and have up to a 15-fold increased risk of motor vehicle accidents.


Who suffers from Sleep Disorders?

More than two-thirds of older adults suffer from sleep problems, such as insomnia, and losing sleep can only make matters worse for their health, according to researchers. A new poll shows that poor health, not old age, is a major factor behind many of the sleep disorders among people over 55. In fact, not getting enough sleep may merely compound the aches and pains of getting older.

Researchers say the 2003 Sleep in America poll, released today by the National Sleep Foundation (NSF), shows for the first time that health problems such as diabetes and arthritis are more likely to be responsible for poor sleep among older people in the U.S. than old age.

The poll found that insomnia is the most commonly reported sleep disorder, and nearly half of the 1,506 surveyed said they frequently suffer from at least one symptom of insomnia. But only one in eight says sleep disorders have ever been addressed by a doctor.

"In spite of the emerging science linking sleep and health, only a small fraction of the many reported sleep complaints of older adults are actually diagnosed and treated," says NSF President James K. Walsh, PhD, in a news release.

Walsh says the poll shows that doctors need to talk to their patients about sleep, listen to the problems they describe, and treat those problems as part of any medical condition.

Researchers also found a strong link between the number of diagnosed medical conditions reported by the participants and the quality of their sleep. Only about half of those with no reported medical conditions said they suffered from sleep disorders, compared with 80% of those with four or more medical conditions.

Sleep disorders were reported by:

  • 82% of those with depression
  • 81% who have suffered a stroke
  • 76% being treated for heart disease
  • 75% diagnosed with lung disease
  • 72% with diabetes or arthritis
  • 71% of those diagnosed with high blood pressure (hypertension)

Loss of sleep was also associated with other physical problems common among older adults, including frequent pain, excess weight, and lack of mobility.

Compared with younger people, the poll found older adults get slightly more sleep on weeknights (7.0 vs. 6.7 hours/night). But younger adults get more sleep on weekends than their older counterparts, averaging about a half hour more sleep on Saturday and Sunday.

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