Sleep Disorder Overview
Sleep disorder describes any condition that involves any trouble related to sleep, including the difficulty of falling or staying asleep, excessive sleepiness, issues with staying awake or falling asleep at inappropriate times or abnormal muscle activity and behaviors associated with sleep. More than 100 different disorders of sleeping and waking can be identified in these categories:
- Problems with falling and staying asleep (insomnia)
- Problems with staying awake (sleep apnea, narcolepsy, excessive daytime sleepiness and restless legs syndrome)
- Problems with sleep schedules (circadian rhythm disorders)
- Unusual behaviors, or parasomnias during sleep (such as nightmares, night terrors, dream enactment and sleepwalking)
Symptoms and signs of sleep disorders vary widely, depending upon the disorder. Insomnia, a common medical complaint that occurs in as many as 15-30% of adults, most often stems from some other problem, such as stress and anxiety; depression; certain medications; use of caffeine, nicotine or alcohol; aging; or poor sleep habits or changes to sleep schedule.
Symptoms of insomnia include:
- Difficulty falling or staying asleep at night
- Waking too early
- Daytime fatigue or sleepiness
- Irritability, depression or anxiety
- Tension headaches
- Diminished cognitive skills (short term memory, concentration)
Disorders of excessive sleepiness or hypersomnia include sleep apnea, narcolepsy, idiopathic hypersomnia and restless legs syndrome.
Sleep apnea is a common, but potentially dangerous disorder, in which breathing repeatedly stops and starts. The two main types are: Obstructive sleep apnea, in which the airway collapses due to excessive relaxation of the throat muscles, and central sleep apnea, in which the brain fails to send proper signals to the muscles that control breathing. Complex sleep apnea is a combination of the two. A serious condition, sleep apnea can increase risk of high blood pressure, heart disease and stroke.
Symptoms of sleep apnea include:
- Loud snoring
- Episodes of breathing cessation during sleep
- Moodiness, irritability
- Morning headaches
- Poor concentration, decreased short-term memory
- Excessive daytime sleepiness
Narcolepsy describes a chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep. The exact cause is unknown, but symptoms include:
- Excessive daytime sleepiness
- Sudden loss of muscle tone (cataplexy)
- Sleep paralysis
Restless legs syndrome is a condition in which the legs feel extremely uncomfortable while you are sitting or lying down. The cause is unknown, but in some cases there may be a hereditary component. Pregnancy, neuropathy from advanced kidney disease or diabetes, or iron deficiency may trigger the symptoms.
Symptoms are often described as unpleasant sensations and movements in the calves, thighs, feet or arms and fluctuate in severity, usually worsening at night. Typically described as an urge to move the limbs, it is often relieved by walking.
Other sleep disorders occur when a consistent sleep/wake schedule is not maintained (e.g. regular traveling between time zones or shift work with rotating schedules), signs of which include excessive sleepiness, fatigue, headaches and poor concentration. Abnormal sleep behaviors, called parasomnias (nightmares, night terrors, sleepwalking), usually manifest symptoms as described by their names.
Your Wellstar sleep specialist is uniquely qualified to diagnose and explain any issues involving your sleep habits.
As with symptoms, the risk factors for sleep disorders vary greatly depending upon the specific disorder. Often in disorders without a known cause, it is difficult to assess risk factors. For many parasomnias, the risks are greatest in children.
With insomnia, however, women are twice as likely to experience the disorder, and the risk for both genders increases with age, especially over the age of 60. Stress, schedule changes and mental health issues also escalate the risk of insomnia. Conversely, men are twice as likely to have obstructive sleep apnea. Other risks include excessive weight, high blood pressure (hypertension), aging, alcohol and drug use, smoking, family history and physical attributes such as a large neck circumference or narrowed airway.
How to Reduce Your Risk of Sleep Disorders
Some sleep disorders cannot be prevented and are often only diagnosed after the onset of symptoms. Regular, consistent sleep and a healthy lifestyle may prevent many sleep disorders.
- Observe regular sleep habits, such as going to bed and waking at the same time every day
- Allow for adequate sleep time, average of eight hours each night
- Create a quite sleep environment
- Avoid alcohol and large meals close to bedtime
- Engage in regular exercise
Sleep Disorder Diagnosis
Your Wellstar sleep medicine specialist will take a careful medical history that includes a questionnaire about your sleep habits and perform a relevant physical examination. Some sleep disorders may be diagnosed on the basis of the history and exam, while others might require tests or evaluation including:
- Blood tests or muscle/nerve studies to exclude other possible causes for your symptoms.
- Sleep diary to maintain a detailed record of your sleep pattern for a week or two.
- Home sleep apnea test (HSAT) to measure selected body signals during sleep, which is done in your own home.
- Polysomnogram to measure a variety of signals during sleep. The test, which requires an overnight visit to one of the Wellstar Sleep Disorders Centers, measures multiple parameters, including the breathing pattern, the electrical activity of the brain (electroencephalogram) and the heart (electrocardiogram), and the movement of chin and limb muscles (electromyogram) and eyes (electro-oculogram). Your Wellstar sleep physician will review the study and provide a report.
Sleep Disorder Treatment
Treatments vary and depend on the specific sleep disorder. In general, treatment often involves maintaining an active and healthy lifestyle, a regular sleep schedule and, sometimes, medication. In more severe instances, treatment may require ongoing positive airway pressure (PAP) therapy or even surgery.
Insomnia and related sleep disorders
For many patients suffering from insomnia, changing sleep habits—such as keeping the same bedtime and waking time—can be enough to improve quality sleep and increase daytime alertness. If those measures do not work, your Wellstar physician may prescribe behavioral therapies to teach you new sleep methods and improve your sleep environment. These may include:
- Optimizing sleep hygiene (keeping a regular sleep/wake schedule, avoiding alcohol and eating late at night, quitting smoking, avoiding reading or watching TV in bed)
- Relaxation techniques, such as progressive muscle relaxation or breathing exercises designed to reduce tension and heart rate and control breathing and mood.
- Cognitive therapy, which replaces worries about sleep with positive thinking.
- Stimulus control, where you limit the time awake in bed so you only associate the bed and bedroom with sleep or intimate relations.
- Sleep restriction, a treatment that decreases your time in bed and makes you more tired for the following night, creating a temporary sleep deprivation. As sleep improves, the time in bed is gradually increased.
- Light therapy, which uses natural or artificial light to affect your internal clock and control when you need to go to sleep and when you need to wake.
- Referral to a psychologist for cognitive behavioral therapy for insomnia (CBT-I)
Ongoing care for insomnia
For most cases of insomnia, making changes to your lifestyle and improving your sleep habits go a long way to reducing symptoms of sleeplessness. Such changes may include:
- Sticking to a sleep schedule by making your bedtime and wake time consistent, even on the weekends
- Finding ways to relax and reduce stress, such as a warm bath before bed or a soothing bedtime ritual, such as reading, listening to music, yoga, prayer or breathing exercises
- Maintaining a sleep environment, such as reserving the bedroom only for sleeping or intimate relations, keeping the bedroom cooler and dark during sleep and creating subtle background noises
- Avoiding or limiting naps
- Avoiding nicotine, caffeine, alcohol and certain medications
- Maintaining a healthy diet and exercise
Keep track of your questions, and never be afraid to ask your Wellstar sleep specialist for clarification regarding your condition or your treatment.
Your Wellstar sleep medicine specialist may also prescribe various sleeping pills, such as zolpidem (Ambien®), eszopiclone (Lunesta®), zaleplon (Sonata®) or ramelteon (Rozerem®), but usually for no more than a few weeks or months. When insomnia is diagnosed along with depression, your doctor may prescribe an antidepressant with a sedative effect, such as trazodone (Desyrel®), doxepin (Sinequan®, Adapin®) or mirtazapine (Remeron®).
Several over-the-counter medications may induce drowsiness. However, they contain antihistamines, which may reduce the quality of your sleep and may cause side effects such as daytime sleepiness, dry mouth and blurred vision.
Obstructive sleep apnea
For milder cases, your Wellstar physician may recommend lifestyle changes, such as losing weight or quitting smoking. If symptoms do not improve, or, if your apnea is severe, your doctor may suggest a variety of therapies, including:
- Continuous positive airway pressure (CPAP): This is a machine that delivers pressurized air through a mask placed over your nose or whole face while you sleep. The pressurized air ensures that the upper airway passages remain open, preventing apnea and snoring.
- Additional airway pressure devices: For patients who find CPAP too uncomfortable or who fail to respond fully to CPAP, your sleep specialist may recommend a different device that automatically adjusts the pressure during the two phases of the breathing cycle. For example, a bi-level positive airway pressure (BiPAP®) machine provides more pressure when you inhale and less when you exhale. Other patients may respond well to auto-CPAP, where the unit adjusts the pressure during the course of the night based on the variable need to keep the airway open.
- Oral appliances: These devices may or may not be more comfortable than the airway pressure devices but tend to be less effective. They are designed to reposition your jaw and mouth to enable better breathing during sleep. They may be likened to the effect of a “shoe tree” in the mouth which helps reposition and advance the mandible (lower jaw).
Taking care of obstructive sleep apnea with surgery
If your Wellstar sleep specialist recommends surgery, the goal is to remove excess tissue from the nose and throat that may be vibrating or blocking the upper airway passages. Surgeries for obstructive sleep apnea include:
- Uvulopalatopharyngoplasty (UPPP), involves removal of tissue from the rear of your mouth and top of the throat, as well as the tonsils and adenoids (usually performed by an ENT surgeon). This is usually reserved for very few select cases in adults and is the standard of care for pediatric OSA.
- Maxillomandibular advancement (MMA), involves breaking the jaw bone and repositioning it forward from other facial bones. Often done in step treatment with Genioglossus advancement & hyoid myotomy (the front of the chin bone is advanced, with stretching of the tongue). This enlarges the space behind the tongue and soft palate to make obstruction less likely. Oro-maxillofacial surgeons usually perform these complex procedures.
- Tracheostomy, a procedure preformed when other treatments have failed or if the apnea is life threatening. In this procedure, the surgeon makes an opening in the neck and inserts a breathing tube directly into the windpipe (trachea). The opening is covered during the day and uncovered at night to allow air to bypass the blocked air passage in the throat.
- Nasal surgery to remove polyps or to straighten the crooked partition between the nostrils (deviated nasal septum).
- Hypoglossal nerve stimulation (HGNS), a procedure Wellstar ENT surgeons are specially trained to implant in the upper right chest and attach a stimulating wire to the right tongue muscle. Once fully healed (about 4 to 5 weeks), the device is activated by one of our Wellstar sleep specialists.
Central and complex sleep apnea
As with obstructive sleep apnea, your Wellstar physician may recommend therapy or more invasive procedures if lifestyle and sleep habit changes do not work for these types of apnea. In addition to CPAP and BiPAP, your Wellstar sleep specialist may prescribe supplemental oxygen or an adaptive servo-ventilation (ASV), an airflow device that learns your normal breathing pattern and, during sleep, normalizes your breathing pattern to prevent apnea.
Phrenic nerve stimulation (PNS) with the Remede device is also available at Wellstar. This involves having the device implanted by a catheter inserted into a heart vein by a cardiac electrophysiologist (EP). After adequate healing (usually 5 to 6 weeks), the Remede device is activated by your sleep specialist.
Ongoing care for sleep apnea
As with other sleep disorders, changes to your lifestyle, diet and sleep habits can significantly reduce the symptoms associated with sleep apnea. In addition, your Wellstar sleep specialist may also suggest that you:
- Lose excess weight. Even a slight loss in weight may help constriction in your throat and air passages, and in some cases, your apnea may be cured by a return to a healthy weight.
- Avoid alcohol, tranquilizers and sleeping pills. These relax the muscles in the back of your throat and inhibit breathing during sleep.
- Sleep on your side or abdomen rather than on your back. Sleeping on your back may cause your tongue and soft palate to rest against the back of your throat and block your air passages.
- Keep your nasal passages open at night. Your doctor may suggest a nasal spray to ensure that your nasal passages remain open and do not restrict breathing.
- Keep track of your questions, and never be afraid to ask your Wellstar sleep specialist for clarification regarding your condition or your treatment.
- Maintain minimum of annual check up at the CPAP clinic (a function of the sleep specialist office, where patients can get their CPAP units checked & updated regularly). This will improve the long-term success and compliance with CPAP.
Narcolepsy or severe daytime sleepiness
Narcolepsy has no known cure, although medications and lifestyle changes have been found to reduce the symptoms of this disorder. Some medications your Wellstar sleep specialist may consider include:
- Stimulants: Drugs designed to stimulate the central nervous system are the primary treatment to help people with narcolepsy stay awake during the day. Armodafinil (Nuvigil®) and Modafinil (Provigil®) tend to be the most common prescriptions because they are not addictive, and are not actually stimulants. These drugs activate the “wake” centers of the brain. Unlike the traditional stimulants, these agents produce fewer highs and lows. Solriamfetol (Sunosi) is a newer wake promoting agent that may be more effective than modafinil. More severe cases of narcolepsy often require true stimulants, such as methylphenidate (Concerta® and Ritalin®) and some amphetamine mixtures, like Adderall. These may be more effective, but they tend to have more side effects, such as nervousness and heart palpitations, and can be addictive.
- Selective serotonin or norepinephrine reuptake inhibitors (SSRIs, SNRIs): These medications suppress REM sleep to help alleviate the symptoms of muscle tone loss (cataplexy), hallucinations and sleep paralysis. They include atomoxetine (Strattera®), fluoxetine (Prozac® and Sarafem®) and venlafaxine (Effexor®).
- Tricyclic antidepressants (TCAs): These older antidepressants, such as protriptyline (Vivactil®) and imipramine (Tofranil®) help with muscle tone loss (cataplexy) but have side effects such as dry mouth and constipation.
- Sodium oxybate (Xyrem®): Prescribed for cataplexy, sodium oxybate improves and stabilizes nighttime sleep, thus reducing daytime drowsiness. Although effective, this medication can have infrequent serious side effects such as nausea, bed-wetting and sleepwalking, and in excessive doses, can lead to impaired breathing, coma and death. Newer formulations of the oxybate compound include Xywav (calcium, magnesium, potassium, sodium oxybate) and Lumryz (once nightly formulation).
Ongoing care for narcolepsy
As with other sleep disorders, changes to your lifestyle, diet and sleep habits can significantly reduce the symptoms associated with narcolepsy. In addition, your Wellstar sleep specialist may also suggest that you:
- Stick to a sleep schedule by making your bedtime and wake time consistent, even on the weekends
- Take naps. A series of short naps through the day may reduce sleepiness.
- Avoid nicotine and alcohol
- Get regular exercise
- Keep track of your questions, and never be afraid to ask your Wellstar sleep specialist for clarification regarding your condition or your treatment.
Restless legs syndrome (RLS)As with other sleep disorders, lifestyle changes, improved sleep habits and diet changes (particularly if you are diagnosed with an iron deficiency) may reduce symptoms of restless legs syndrome (RLS). Your doctor may order a ferritin blood test and suggest a daily over-the-counter oral iron tablet (with vitamin C) if the level is in the lower normal range.
Most selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) as well as first generation antihistamines (e.g. Benadryl), can exacerbate RLS. Your doctor may be advise to consider weaning off such agents if cleared by your prescribing physician. If those methods do not work, your Wellstar sleep specialist may recommend medications, such as:
- Gabapentin (Neurontin®) or Pregabalin (Lyrica): These agents are used in some patients with RLS associated with severe renal or diabetic neuropathy.
- Parkinson’s disease medication: These medications reduce the amount of motion in your legs by affecting the level of dopamine in your brain. Two drugs designed for Parkinson’s patients—ropinirole (Requip®) and pramipexole (Mirapex®)—are approved by the Food and Drug Administration to treat restless legs syndrome. RLS has no connection with Parkinson’s disease.
- Muscle relaxants and sleep medications: These medications, known as benzodiazepines, improve sleep but do not necessarily eliminate leg movement.
- Opioids: Narcotic medications have been proven to relieve moderate to severe symptoms of restless legs syndrome, but they can be highly addictive. Some common medications include codeine, oxycodone, combinations of oxycodone and acetaminophen (Percocet® and Roxicet®) and combinations of hydrocodone and acetaminophen (Lortab® and Vicodin®).
In most cases of parasomnia, your Wellstar physician will not recommend special medical treatment, but coping measures. If the conditions are associated with stress or a medical condition, your doctor will make recommendations based on the issues leading to the parasomnia.
Ongoing Care for Sleep Disorders
Wellstar’s world-class, community-based physicians utilize state-of-the-art medical centers and hospitals with the latest technologies and medical resources. Our clinicians are dedicated to:
- Helping you create and maintain healthy lifestyles
- Offering advice to prevent illness and injuries
- Providing early and appropriate care of acute illness to prevent its progression
Sleep disorders labs
Wellstar sleep specialists are uniquely qualified to assess and treat all aspects of sleep medicine for adults, adolescents and children with the prime focus of assisting you in obtaining a good, quality night of sleep. Patients are evaluated and studied at state-of-the-art sleep disorders centers.