Sleep / Wake Disorders & Weight Loss (Part 3)
November 21, 2000: NEW YORK (Reuters Health) – Night owls and insomniacs are missing out on precious learning time, it seems. Researchers have found that sleep is vital to holding on to certain types of memory.
According to two reports in the December issue of Nature Neuroscience, getting a good night’s sleep helps people retain some of what they learned that day. In experiments, investigators found that well-rested study participants were more adept at picking up new skills than their sleep-deprived counterparts were. Catching some Z’s on the first night after learning the skills turned out to be crucial.
In one study, researchers at Harvard Medical School in Boston, Massachusetts, had healthy young people learn a task in which they had to distinguish visual targets set in a distracting background on a computer screen. One group was allowed to sleep as normal the night after the test, while the other group stayed awake through the first night and day after learning the task. They were then allowed to sleep as long as they wanted during the next 2 nights before being re-tested.
This second series of tests revealed that while the first group’s skills had improved, those who got no sleep the first night showed no improvement. This indicates that people cannot make up for that critical night of sleep by sleeping late on other days, Dr. Robert Stickgold told Reuters Health.
Sleep loss did not appear to make study participants forget what they learned, he noted. Instead, they seemed to miss out on a window of time in which sleep helps the brain mold information into lasting memories.
Sleep, Stickgold said, helps people “deal with information overload.” A growing body of research is showing that during the body’s dormant state, the brain is busy establishing connections that lay down memories.
“There has to be a transformation of information to a form where it can be useful”, Stickgold said. The type of memory his team tested is known as procedural memory–the type used in learning to play a piano or hit a baseball.
Other researchers, at the Medical University of Lubeck in Germany, found that the early stages of sleep were particularly important to learning. Steffen Gais and his colleagues found that study participants’ skills improved after 3 hours of “early” sleep–known as slow-wave sleep. Skills did not improve when participants got only “late” (REM) sleep. However, improvements were greatest when participants got a full night’s rest.
This, according to Gais and colleagues, suggests that while early sleep is essential to memory formation, later stages are also involved.
“It looks like all stages play subtly different roles”, Stickgold said. This is why a restless or shortened night’s sleep is as bad as a sleepless night. Moreover, Stickgold noted, sleeplessness likely affects all types of memory formation.
“We’re only touching the tip of the iceberg with this research”, he added.
By Martin Finucane, The Associated Press
BOSTON – Tuesday, December 05, 2000: Drifting somewhere along the border between reality and the dream world, the sleeping 10-year-old girl said, “Jorge, get off me. Jorge, get off me”.
Prosecutors say it was evidence that was rightfully allowed at the trial of the man convicted of sexually assaulting the girl.
But defense attorneys say it was wrong to let the jury hear sleep talk, or “somniloquence”. The defense argues there is no evidence that people speak the truth in their sleep.
Now Massachusetts’ highest court will decide.
The state Supreme Judicial Court will hear oral arguments tomorrow. The case is the first of its kind in the state. Courts around the country have confronted similar issues and have not been able to agree.
The Massachusetts case began in 1996 when two girls in Milford, 30 miles outside Boston, asked their neighbor, Jorge Almeida, to let them into the cage in his back yard where he kept rabbits. Prosecutors say that Almeida joined the girls in the pen and then grabbed and fondled them before they escaped.
The father of one of the girls testified that on the night of the attacks, after he had brought the girls back from the police station, he heard the other girl, who was sleeping at their house, having a nightmare.
“She was repeating, – Jorge, get off me. Jorge, get off me-, in her sleep”, the father testified.
In 1998, Almeida was convicted of two counts of indecent assault and battery on a child under 14. He was sentenced to five years in jail.
The utterance was not the only piece of evidence; the girl herself took the stand and accused Almeida of fondling her.
Almeida appealed, challenging the judge’s decision to allow the sleep-talk evidence.
Neither defense attorneys nor Worcester County District Attorney John Conte returned a message seeking comment Monday.
In court papers, the defense argued that the father’s testimony “created prejudice and undue emotion in the jury”. The defense suggested that allowing the sleep-talk testimony denied Almeida his constitutional right to confront his accuser, because the little girl could not be cross-examined about something she couldn’t even remember saying.
Prosecutors argued, on the other hand, that the evidence was properly allowed in the trial, not as proof that the incident actually happened, but as corroboration of the testimony the girl gave in person in court.
In a 1981 case in Minnesota, the sleep talk of a 6-year-old about her fear of another attack by the defendant was allowed at a trial. In 1980 in New York, a court threw out a manslaughter and arson conviction of a man whose girlfriend had testified about what he said while he was asleep.
Sam Dash, a professor at Georgetown University who is an expert on criminal law, was skeptical about the admissibility of sleep talk. He said it is unknown whether there is any truth to the things people say in their sleep.
“Our degree of knowledge and science has not permitted us to answer that question. There’s a big hurdle here and it’s got a tremendous danger to it”, he said.
“We don’t know how the mind works in sleep. It’s inviting the jury to speculate as to the meaning of the words – when nobody knows what they mean in any event”.
Experts on sleep were also leery of the idea of sleep talk being allowed as evidence.
“Being able to say which is real and which is fantasy – that’s a coin toss”, said D. Alan Lankford, vice chairman of Sleep Sciences Inc. in Atlanta, which conducts sleep disorder research, education and treatment.
Dr. Mark Mahowald, director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center and a professor at University of Minnesota Medical School, said those who talk in their sleep are essentially half asleep and half awake.
“I think it would be very, very unlikely that all sleep talking was talking the truth”, he said. “Clearly, consciousness is clouded during sleep talking. You wouldn’t want to put a lot of credence to what somebody said during sleep talking”.
By Laurie Barclay, MD
Jan. 12, 2001 — Are you a morning lark or a night owl? The answer may be in your genes, according to research published in the Jan. 12 issue of Sciencexpress. Discovery of a specific genetic mutation in a large family of “morning larks” is shedding light on this sleep disorder, and on the dramatic influence of molecular biology on behavior.
“This outstanding study takes a big step — it shows us how dramatically human behavior can be changed by a single [mutation]”, says Michael W. Young, PhD, who reviewed the study for WebMD. “This is the first time that a genetic variation has been linked to the sleep-wake cycle in humans”. Young is head of the genetics laboratory at Rockefeller University in New York City.
“This research gives us a window to look into the biological clock and see what makes it tick”, says Louis J. Ptacek, MD, a co-author of the study. “We have to understand how the human clock mechanism works before we can approach treatment of sleep disorders”. Ptacek is a professor of neurology and human genetics at the University of Utah, and an associate investigator at the Howard Hughes Institute in Salt Lake City.
In 1999, a large family whose members complained of being “morning larks” came to the attention of study author Christopher R. Jones, MD, PhD, medical director of the University Health Sciences Sleep Disorders Center in Salt Lake City.
Compared with most people, the biological clock in affected members of this family ticks four hours ahead, so they fall asleep around 7:30 PM and wake up around 2:30-4:30 AM. Affected family members carry a specific genetic mutation that is autosomal dominant, meaning that odds of inheriting the trait from a single affected parent are 50:50.
“It’s not a disease, but some find it disabling”, Ptacek tells WebMD. “Some family members don’t like waking up when it’s cold, dark, and lonely, and falling asleep when everyone else is still socializing and having a good time”.
On the other hand, some family members find that their unique biological clock gives them a distinct advantage, citing old adages like “The early bird gets the worm,” and “Early to bed and early to rise, makes a man healthy, wealthy, and wise”.
“Behaviors like sleep are subject to different perceptions, different psychological and sociocultural values — not just genetic and environmental influences”, Ptacek says.
Young is curious to know the full range of behaviors associated with this mutation, and suspects that the effects may be more far-reaching than just the effects on sleep. “Studying behavior in any organism is tricky, and studying the interaction between human behavior and genetics is even more difficult”, he explains.
Complete analysis of biological and behavioral differences in this family may eventually lead to treatment that will help control differences in the wake-sleep cycle, for those that wish to do so.
What makes this discovery even more striking is that the mutated gene is similar to a specific gene in the hamster — and even in the fruit fly– that control the biological clock in these simpler creatures.
Young explains that this genetic similarity allows researchers to transfer information learned in animal models to better understanding of sleep-wake cycle regulation in humans. In the hamster, for example, a similar gene affects seasonal changes in the sleep-wake cycle. Knowing how this gene works might help scientists understand seasonal affective disorder, a type of depression related to decreased exposure to sunlight in winter.
Knowledge of similar genes may eventually lead to better understanding of other disorders of the biological clock, including jet lag, sleep problems in workers changing shifts, and change in sleep patterns with aging.
“When we reach our late 60s or early 70s, many of us may fall asleep earlier and wake up earlier”, Ptacek says. He estimates that it will take at least five years for drugs to be developed specifically for this type of sleep disorder.
“So many of us consider ourselves to be morning or evening people”, Young says. “If a single gene can have such a dramatic effect on sleep behavior in this family, it makes me wonder if there are larger groups with subtler variations in sleep patterns”.
As different genes may be involved in regulating different aspects of the biological clock, other families with different sleep disorders will need to be studied to determine the role of each gene.
When WebMD asked Jones to summarize the importance of these findings, he paraphrased Alfred J. Lewy, MD, PhD, director of the Sleep and Mood Disorders Lab at Oregon Health Sciences University in Portland: “Through their contribution to our genes, our parents are still telling us when to go to bed at night, and when to get up in the morning”.
Source: © WebMD Medical News
New York, New York and Haifa, Israel, January 29, 2001: The Food and Drug Administration has approved a novel device that inexpensively and accurately screens for sleep apnea at home. Characterized by the temporary cessation of breathing during sleep, sleep apnea could affect as many as 18 million people in the United States alone, particularly men over the age of 35.
The patient fastens the 4-inch long plastic strip to his upper lip before bed. Three tiny temperature sensors attached to the strip record when the patient stops breathing, which in a sleep apnea sufferer can happen 200 to 300 times a night. In the morning, the patient removes the strip and returns it to the doctor who reads the results directly from the built-in display. The device is powered by a tiny eight-hour battery.
SleepStrip™ was developed at the Sleep Research Laboratory at the Technion-Israel Institute of Technology in Haifa by renowned sleep expert Dr. Peretz Lavie and Noam Hadas, head of research and development for SLP, a sister company of the laboratory. Researchers in Germany, Belgium, France, Italy, Israel, Canada and the United States have used SleepStrip™ to successfully screen patients with sleep apnea after one-night tests.
“It’s important to detect sleep apnea as soon as possible because it can be a precursor to hypertension, ischemic heart disease, heart attack and stroke,” says Dr. Lavie, who heads the Technion Sleep Research Laboratory. “With SleepStrip™ we can scan entire segments of the population, such as severely obese people and those with high blood pressure.”
The National Center on Sleep Disorders Research reports that as many as two to four percent of middle-aged American men and two percent of middle-aged American women suffer from sleep apnea. Only 10 percent of those with sleep apnea are actually diagnosed, according to the National Sleep Foundation. This may be due to lack of awareness of sleep apnea, as well as the inconvenience, lack of privacy, discomfort and expense of spending a night in a sleep lab, which can cost from $1,100 to $4,000. While the SleepStrip™ doesn’t replace a night in a sleep clinic, the patent-pending device can identify patients who need to go to one.
Dr. Yosef Krespi, chairman of the Department of Otolaryngology at St. Luke’s-Roosevelt Hospital in New York, has tested more than 50 of the devices and says patients are responding favorably to it.
“Patients find the SleepStrip™ convenient and easy to use,” Dr. Krespi says. “Most people don’t like to be tested in a sleep laboratory overnight, and most sleep labs are located in hospitals, making it even more inconvenient. This device is inexpensive, reliable, small and disposable.”
The Technion Sleep Research Laboratory has signed a marketing and distribution agreement with Influ-ENT, an Israel-based manufacturer and distributor of medical equipment. SleepStrip™ is available by prescription or can be bought from Influ-ENT by calling 1-800-564-7077 from the U.S. or Canada.
UPTON, NY — Two studies by researchers at the U.S. Department of Energy’s Brookhaven National Laboratory provide evidence for the first time that abuse of methamphetamine the drug commonly known as “speed” — is associated with physiological changes in two systems of the human brain. The changes are evident even for abusers who have not taken the drug for a year or more. The studies also found that methamphetamine abusers have reduced cognitive and motor functions, even at one year after quitting the drug. The findings appear in the March issue of the American Journal of Psychiatry.
“These studies provide some of the first clear evidence that methamphetamine at dose levels taken by human abusers leads to dopamine transporter reduction,” said Brookhaven psychiatrist Nora Volkow, lead investigator on the study. “For the first time we can also see that this transporter reduction is associated with motor and cognitive impairment.” Previously, in animal studies and two small human studies, researchers documented reductions in dopamine transporters. Past studies did not test whether these reductions were associated with changes in cognitive and motor function. “We also have the first evidence that methamphetamine affects circuits of the brain other than those regulated by dopamine, and that the drug causes changes that are consistent with inflammation throughout the brain,” Volkow continued. “This is objective evidence that methamphetamine is damaging to the brain. These changes are much greater than what wehave seen with heroin, alcohol, or cocaine. We need to further study whether these changes are long-lasting and result in long-term impairment of memory and motor functions, such as motor speed and motor coordination.”
Reduced dopamine transporters, cognitive and motor function
In the first study, Volkow and colleagues tested both dopamine transporter levels and motor and cognitive function in 15 detoxified methamphetamine abusers and 18 control subjects who had not previously used methamphetamine. Dopamine transporters help transport “used” dopamine, a neurotransmitter that contributes to feelings of satisfaction and pleasure, back into the nerve cells that produce it, thus terminating the pleasure signal.
Each study volunteer was given an injection called a radiotracer, a radioactive chemical “tag” designed to bind to dopamine transporters in the brain. The researchers then scanned the subjects’ brains using a positron emission tomography (PET) camera. The PET camera picks up the radioactive signal of the tracer and shows where it is bound to dopamine transporters. The strength of the signal indicates the number of transporters.
Within two weeks of the PET scans, the researchers administered a battery of neuropsychological tests. These included tests of fine and gross motor function and tests of attention and memory.Methamphetamine abusers showed a significant reduction in dopamine transporters in the caudate (27.8%) and putamen (21.1.%) two areas of the striatum, a section of the brain that controls movement, attention, motivation, and other higher functions — compared with non-abusers in the study. The reduction was evident even in abusers who had been detoxified for 11 months or more. Study subjects with reduced dopamine transporters also exhibited memory impairment and slowed motor function.
Increased brain glucose metabolism and inflammation
In the second study, Volkow’s team looked at brain glucose metabolism in order to see if there was any functional change in regions of the brains of methamphetamine abusers other than those in which dopamine cells are active. The same 15 detoxified methamphetamine abusers who participated in the first study, and 21 non-abusers, received PET scans following administration of a radioactive tracer. The scans showed a 14% higher whole brain metabolism in abusers than in non-abusers. Differences were most accentuated in the parietal cortex an area of the brain that regulates sensation and coordinates information on space and spatial relations where abusers showed a 20% higher rate of metabolism.
“This finding was a complete surprise,” Volkow says. “Most drug studies have shown decreased metabolism. The increased metabolism we saw is consistent with an inflammatory response. This result, taken together with our other findings, indicates that this is a very toxic drug.” The presence of inflammation signals that there is a physical insult to the brain.
“We cannot reach any definite conclusions about long-term effects, because only three of the subjects had been detoxified for an extended period. But our three primary findings — dopamine transporter loss, whole brain inflammation, and loss of motor and cognitive abilities — document the adverse effects of methamphetamine to the human brain. We believe more studies must be done to assess if there is long-term damage from this drug,” says Volkow. “We can say unequivocally that methamphetamine abusers need to be watched by their physicians as they age to determine whether they begin seeing any effects of neurodegenerative diseases like Parkinson’s.” The reduction in brain dopamine that occurs as these subjects age, in addition to the loss they experience from use of methamphetamine, may result in symptoms similar to those seen in Parkinson’s disease, a severe movement disorder that results from a loss of dopamine in the brain.
Methamphetamine is a highly addictive stimulant that dramatically affects the central nervous system. Long reported as a dominant drug problem in southern California, methamphetamine abuse has recently become a substantial problem in other areas of the West and Southwest as well. Usage has also recently increased in areas of the Midwest and South. According to a survey by the National Institute on Drug Abuse, an estimated 4.9 million Americans have tried methamphetamine at some point in their lives.
Brookhaven scientists have done extensive research on addiction. Studies by Dr. Volkow and colleagues have shown that dopamine plays an important role in addiction to cocaine, nicotine, alcohol, heroin, and other drugs. Previous research at Brookhaven has shown that addictive drugs increase the level of dopamine in the brain while the subject is intoxicated, and that addicts have fewer dopamine receptors than non-addicts.
This study was funded by the U.S. Department of Energy; the National Institute on Drug Abuse, part of the National Institutes of Health; the Office of National Drug Control Policy; and the General Clinical Research Center at University Hospital Stony Brook. It was done in collaboration with researchers from the State University of New York at Stony Brook and the University of California, Los Angeles.
The full text of these studies will appear on the American Journal of Psychiatry web site at: http://www.ajp.psychiatryonline.org.
The U.S. Department of Energy’s Brookhaven National Laboratory creates and operates major facilities available to university, industrial and governmental personnel for basic and applied research in the physical, biomedical and environmental sciences and in selected energy technologies. The Laboratory is operated by Brookhaven Science Associates, a not-for-profit research management company, under contract with the U.S. Department of Energy.
Source: Science Daily Magazine
Sleep disorders occur during — and may be modified by — pregnancy.
Knowledge about sleep has been obtained almost exclusively from men, and the need is critical to correct the imbalance, particularly for pregnant women, suggest these authors.
Meanwhile, to assume that snoring, insomnia and daytime somnolence are expected events in pregnancy may well be a self-fulfilling fallacy.
There is a possibility that the descriptive term pregnancy associated sleep disorder may cause attribution of undiagnosed sleep disorders in pregnant women to presumed physiologic mechanisms unique to pregnancy, suggests this extensive review.
As for patients with already diagnosed sleep disorders who are contemplating becoming — or are — pregnant, doctors should counsel them to adhere to regular sleep schedules, practice good sleep hygiene and continue conservative therapy, such as stimulus control or relaxation techniques.
If discontinuation of therapy with a hypnotic drug is not possible, zolpidem or diphenhydramine should be prescribed.
Patients with narcolepsy also need to be advised to accept less stringent control of their daytime sleepiness both because of the somnogenic effects of early pregnancy and the advisability of using weaker but safer stimulants.
If possible, employed women should consider taking disability or maternity leave early or else requesting employers to allow more day time naps.
Ideally, treatment with benzodiazepine or other pharmacotherapy for periodic leg movements or somnambulism should be discontinued.
Patients with known sleep-disordered breathing will probably experience no greater risks during pregnancy if they are receiving therapy with nasal continuous positive airway pressure.
In all patients, such conservative measures as avoiding excessive weight gain and sleeping in a lateral instead of a supine position will help to control sleep-disordered breathing.
This extensive review used the MEDLINE database for relevant studies by using the term pregnancy combined with a wide range of terms related to sleep. These terms included sleep, wakefulness, sleeping, insomnia, parasomnia, hypersomnia, pulmonary, lung, circadian rhythms, REM, NREM, polysomnogram, apnea, OSA, narcolepsy, snoring, desaturation, sleepwalking, CPAP, movement disorders, restless legs, and PLMS.
Main criterion for inclusion of articles was relevance to the physician caring for pregnant patients with sleep-related problems and sleep disorders.
Contributors were from the Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson University Hospital, and St. Peter’s University Hospital, New Brunswick, New Jersey, United States.
Source: © Doctor’s Guide
By Suzanne Rostler
NEW YORK (Reuters Health) – As men enter middle age, they may find themselves lying awake at night worrying about family, work, money or any number of concerns. Now a team of researchers reports that these stressors may not be directly to blame.
The investigators found that men appear to become more sensitive to the stimulating effects of corticotropin-releasing hormone (CRH) as they age. This hormone plays a role in how the body responds to stress, with higher levels associated with arousal.
“We conclude that middle-aged men show increased vulnerability of sleep to stress hormones, possibly resulting in impairments in the quality of sleep during periods of stress”, according to Dr. Alexandros N. Vgontzas, of Pennsylvania State University in Hershey, and colleagues.
Their findings are published in the April issue of the Journal of Clinical Endocrinology and Metabolism.
In an interview with Reuters Health, Vgontzas suggested that middle-aged men who are under stress try to exercise, use relaxation techniques or do yoga. The researcher also recommended avoiding coffee, alcohol and cigarettes–all of which can disturb sleep.
“Finally, if sleep disturbance persists for more than a few days, seek medical advice to prevent development of chronic insomnia,” Vgontzas said. “Chronic insomnia is a difficult problem to treat.”
The researchers monitored the sleep patterns of 12 middle-aged men and 12 young men over 4 nights. On one night they administered CRH 10 minutes after the men had fallen asleep.
Both groups of men produced higher levels of other types of stress hormones in response to the CRH. Younger men, in fact, produced more cortisol, another hormone involved in the ”fight-or-flight” response, than their older counterparts did.
But middle-aged men remained awake longer and had less slow-wave, or deep, sleep than younger men did, indicating that ”middle-aged men showed increased vulnerability to stress hormones,” the authors report.
“The increased prevalence of insomnia in middle-age may, in fact, be the result of deteriorating sleep mechanisms associated with increased sensitivity to arousal-producing stress hormones, such as CRH and cortisol”, Vgontzas and colleagues explain.
About 75% to 80% of sleep is considered slow-wave, with the rest comprising rapid eye movement (REM) sleep. Previous studies have found that people who spend less time in slow-wave sleep may also be more prone to depression.
The current findings may help to explain why major depression is associated with insomnia in middle age, but often with sleepiness in younger people, the researchers add.
The report may also shed light on why older people seem to be more affected by caffeine, while young people can enjoy a double espresso before heading off to a good night’s sleep.
Up to 40% of the general population report sleep problems, compared with about 20% of the younger population. While increased stress is common during middle age, the research team notes, greater sensitivity to the physiological effects of stress may also be to blame.
Source: Yahoo News
Narcolepsy is a neurological syndrome characterized by daytime somnolence and cataplexy which often begins in childhood. This disorder can be particularly crippling in young patients, affecting both the social and academic progress of the child affected and creating self esteem and emotional problems. With early diagnosis, education and appropriate behavioral and pharmacological intervention, serious problems can be avoided and patients can maintain participation in everyday personal and academic activities. Wake-promoting agents such as methylphenidate, mazindol and modafinil can be used to alleviate somnolence, and antidepressant agents such as fluoxetine and clomipramine effectively control cataplexy.
Sleep is irresistible in narcolepsy
Narcolepsy is a chronic neurological disorder in which the boundaries between the awake, sleeping and dreaming brain are blurred. This is a relatively uncommon disorder which has a prevalence of about 0.04% of the general population. Excessive daytime sleepiness and irresistible sleeping episodes usually occur as the first symptoms of narcolepsy. These may occur independently or in association with one or more other symptoms such as hypnagogic hallucinations, disturbed nocturnal sleep and manifestations of paroxysmal muscular weakness, cataplexy and sleep paralysis. Unwanted sleep episodes recur several times daily and may vary from a few minutes to over an hour.
Cataplexy is no laughing matter
Cataplexy is an abrupt and reversible decrease or loss of muscle tone, most frequently bought on by strong emotions such as laughter, anger or surprise. The severity and frequency of cataplexy varies considerably between individuals. In some patients, the only sign may be a transient sagging of the jaw whereas in others, all the voluntary muscles may be paralyzed for a period of minutes.
Night-time sleep can be disturbed
Hypnagogic hallucinations and sleep paralysis do not affect all patients and can be transitory. Disturbed nocturnal sleep seldom occurs initially and generally worsens during adulthood.
Difficult to diagnose in children
It is not uncommon for a child to be symptomatic for several years before the diagnosis of narcolepsy is even considered. Symptoms such as excessive daytime sleepiness may not be recognized as abnormal in young children and these patients are often mislabeled as lazy, depressed or even as learning disabled. Furthermore, cataplexy may be disregarded as clumsiness or misdiagnosed as atonic seizures (drop attacks) in young children.
If and when the child does come to medical attention, an objective sleep study such as a Multiple Sleep Latency Test and an all-night polysomnogram is necessary to confirm a diagnosis. Cataplexy may also serve as diagnostic criteria although this should be, and rarely is, witnessed by an examiner.
Develop a therapeutic plan
Once an accurate diagnosis of narcolepsy has been made, most children face the prospect of lifetime treatment. The goal of managing narcolepsy is to control the narcoleptic symptoms and to allow the patient to continue full participation in personal and academic activities. The therapeutic plan must include behavioral as well as pharmacological interventions (see patient care guidelines). Regular follow-up is required to monitor disease progression, response or tolerance to drug therapy as well as the development of abnormal liver function, psychosis, irritability, hypertension, depression, insomnia or anorexia associated with the medication or the disease itself.
Behavioral intervention important
In children, nonpharmacological treatment is preferred, particularly in the early stages of the disease when sleepiness is mild and before there is any decrease in performance at school. Good sleep patterns need to be instilled by establishing a regular sleep-wake schedule; a 20-minute nap 3 times a day will help maintain vigilance.
Narcolepsy is a disorder often poorly understood by patients, family members, teachers and peers. Education about the disease and provision of emotional and academic support is an integral part of the management of these patients to maintain self esteem as well as academic and social progress.
Drug therapy depends on symptoms
If a child does not respond to behavioral modification or if sleepiness worsens, pharmacological treatment should be initiated (see patient care guidelines). Despite a lack of controlled trials investigating the use of anti-narcoleptic medication specifically in children, a number of agents are used in clinical practice.
Old and new treatments for somnolence
The drugs most commonly used to treat excessive day time sleepiness are stimulants, which are generally considered to be well tolerated in children. Amphetamines such as dexamphetamine and methamphetamine have been used to treat somnolence for over 50 years. Although effective, the use of these agents is limited by a number of adverse effects including irritability, anxiety, nervousness, headache, psychosis, tachycardia, hypertension, nocturnal sleep disturbances, tolerance and drug dependence.
Methylphenidate (to a maximum daily dose of 30mg) is an effective and frequently used stimulant in children. This agent is generally preferred over amphetamines due to a lower incidence of similar adverse events. Another stimulant, pemoline, was previously widely used in children but is now discouraged due to the risk of severe liver damage. Mazindol, an imidazoline derivative, has also been shown to reduce daytime sleepiness but it is not considered as effective as amphetamines.
Modafinil is a relatively new agent for the treatment of somnolence which has shown good efficacy in adults. This agent has a different mode of action and is considered more as a ‘somnolytic’ than a nonspecific stimulant. Although direct comparative data are lacking, modafinil may offer advantages over amphetamines and methylphenidate because of its good tolerability profile, its lack of rebound phenomena after treatment withdrawal and its low abuse potential. The drug has been used in teenagers, although data specifically in children appear to be lacking. The initial dose should be relatively low (100 mg) to avoid headaches. The dosage can be later increased to 200 to 300 mg/day divided twice daily.
Antidepressants for cataplexy
The other symptoms of narcolepsy, such as cataplexy, are typically treated with different medications from those used for excessive daytime sleepiness. Apart from mazindol, most stimulants have limited anticataplectic activity. The standard treatment for cataplexy has been low doses of tricyclic antidepressants such as clomipramine, imipramine or protriptyline; selective serotonin reuptake inhibitors such as fluoxetine and femoxetine have also shown efficacy. Post-pubertal teenagers are typically treated as young adults and clomipramine and fluoxetine are commonly used in this group of patients. Although very effective at controlling cataplexy, tricyclic antidepressants have anticholinergic effects which may produce a sedatory effect. This may be useful in patients who also suffer from insomnia, but can be problematic in some patients and lead to treatment withdrawal.
A relatively new agent, sodium oxybate (-hydroxybutyrate), may also be useful for cataplexy, particularly if insomnia is present. However, this medication may be abused and the future role of this agent is uncertain.
Treatment for other symptoms
In patients with insomnia, short-acting benzodiazepines taken in the evening can also be used to improve nocturnal sleep. Clonazepam or levodopa may be used to reduce periodic limb movement or REM sleep behavior disorder.
© 2001 Adis International Limited
Frequent flyers who repeatedly suffer jetlag could be permanently affecting their brain power, claim researchers.
The study, published in the journal Nature Neuroscience, examined the brains of aircrew, but suggests that any worker who swaps from night to day shifts over a short period may be at risk.
Jet lag happens when a traveller passes over a number of time zones and disrupts the normal “circadian” rhythms which help humans wake up in the morning and go to sleep at night.
Sufferers feel exhausted, disorientated and often cannot sleep.
Dr. Kwangwook Cho of the University of Bristol conducted a small study of 20 women, aged between 22 and 28, who had worked for at least five years for an airline, and regularly flew across at least seven time zones.
Half of the women, however, had on average least a fortnight to recover from their jetlag – the rest had only a week.
Women were chosen for the test because, in general, they suffer far worse jetlag than their male counterparts.
Dr. Cho not only scanned their brains to look at their physical characteristics, but also measured their performance in memory and understanding tests.
He found that the aircrew given the shorter period to “turn around” after a jet-lagging flight had an area of the brain called the temporal lobe which was noticeably smaller than the others.
Dr. Cho said: “I found there was no deficit of language, but certain short-term objective memory and very simple abstract cognition was quite bad.”
It is not known whether the temporal lobe will “recover” given time away from such sleep-disrupting working patterns.
Brendan Gold, from the Transport and General Workers Union, told the BBC: “We’re going to have to look at some more research – perhaps even commission some ourselves, to look at the long term effects on crew, including those who have retired from the occupation.”
Dr. Robert Sack, of the Sleep Disorders Medicine Clinic at the Oregan Health Sciences University in Portland, said: “It’s interesting because we think of jet lag as a kind of nuisance, but this study would suggest that it may have more serious consequences.”
The study, although small, could have implications for a variety of workers whose hours switch backwards and forwards from day to night, such as police officers and doctors.
Previous studies have suggested a link between working night-shifts and both heart disease and breast cancer.
Source: BBC News
NEW YORK, Aug 16 (Reuters Health) – Scientists have found increased blood levels of stress hormones in people with chronic insomnia, suggesting that these individuals suffer from sustained, round-the-clock activation of the body’s system for responding to stress.
For this reason, the researchers suggest, doctors who treat insomnia should go beyond improving the quality or quantity of their patients’ sleep and seek to reduce this hyperarousal, which is a risk factor for both psychiatric and medical illness.
Dr. Alexandros N. Vgontzas, of Pennsylvania State University College of Medicine in Hershey, and associates monitored the sleep of 11 patients with insomnia and 13 people without sleep disturbances (the “control” group). Blood was collected every 30 minutes for 24 hours, and levels of stress hormones–adrenocorticotropic hormone (ACTH) and cortisol–were monitored.
Average levels of both hormones were significantly higher in the insomniacs than in the control group, the researchers report in the August issue of The Journal of Clinical Endocrinology and Metabolism.
“We found that the insomniacs with the highest degree of sleep disturbance secreted the highest amount of cortisol, particularly in the evening and nighttime hours,” Vgontzas said in a prepared statement. “This means that insomniacs are experiencing hormonal changes in their bodies, which prevents them from sleeping.”
Vgontzas and colleagues propose that the physical mechanism of chronic insomnia differs from that of sleep loss, with chronic insomnia being a disorder of hyperarousal present throughout the 24-hour sleep/wake cycle. Increased production of stress hormones is likely to lead not only to depression, but also to high blood pressure, obesity and the bone-thinning disease osteoporosis, the researchers suggest.
“This information could help doctors who are treating insomniacs refocus their therapeutic goals,” Vgontzas said in the statement. “Instead of aiming to simply improve nighttime sleep, doctors may now work to decrease the levels of physiologic arousal.”
Toward that end, medications that downregulate the activity of the stress system, such as antidepressants, may be of more help to patients than hypnotic drugs, the investigators remark.
Source: Journal of Clinical Endocrinology & Metabolism 2001;86:3787-3794.
Sleep and sleep-related problems play a role in a large number of human disorders and affect almost every field of medicine. For example, problems like stroke and asthma attacks tend to occur more frequently during the night and early morning, perhaps due to changes in hormones, heart rate, and other characteristics associated with sleep.
Sleep also affects some kinds of epilepsy in complex ways. REM sleep seems to help prevent seizures that begin in one part of the brain from spreading to other brain regions, while deep sleep may promote the spread of these seizures. Sleep deprivation also triggers seizures in people with some types of epilepsy.
Neurons that control sleep interact closely with the immune system. As anyone who has had the flu knows, infectious diseases tend to make us feel sleepy. This probably happens because cytokines, chemicals our immune systems produce while fighting an infection, are powerful sleep-inducing chemicals. Sleep may help the body conserve energy and other resources that the immune system needs to mount an attack.
Sleeping problems occur in almost all people with mental disorders, including those with depression and schizophrenia. People with depression, for example, often awaken in the early hours of the morning and find themselves unable to get back to sleep. The amount of sleep a person gets also strongly influences the symptoms of mental disorders. Sleep deprivation is an effective therapy for people with certain types of depression, while it can actually cause depression in other people. Extreme sleep deprivation can lead to a seemingly psychotic state of paranoia and hallucinations in otherwise healthy people, and disrupted sleep can trigger episodes of mania (agitation and hyperactivity) in people with manic depression.
Sleeping problems are common in many other disorders as well, including Alzheimer’s disease, stroke, cancer, and head injury. These sleeping problems may arise from changes in the brain regions and neurotransmitters that control sleep, or from the drugs used to control symptoms of other disorders.
In patients who are hospitalized or who receive round-the-clock care, treatment schedules or hospital routines also may disrupt sleep. The old joke about a patient being awakened by a nurse so he could take a sleeping pill contains a grain of truth. Once sleeping problems develop, they can add to a person’s impairment and cause confusion, frustration, or depression. Patients who are unable to sleep also notice pain more and may increase their requests for pain medication. Better management of sleeping problems in people who have other disorders could improve these patients’ health and quality of life.
NEW YORK (Reuters Health) – Research on drowsy fruit flies is helping scientists get a closer look at the genetics of sleep.
Researchers at the University of Pennsylvania in Philadelphia found that a gene known as CREB may be key to staying awake and to getting a good night’s sleep. The finding was in fruit flies, but since the gene is also found in mammals it may offer insight into human sleeping behavior, Dr. Joan C. Hendricks told Reuters Health.
To tackle sleep disorders or to figure out ways to help people stay awake other than loading up on caffeine, scientists have to first understand why we need sleep and what regulates it, Hendricks explained in an interview.
“We’re trying to get a handle on the genetics of the sleep-like state,” she said.
That starts with the lowly fly, which, like humans, needs its beauty rest and gets drowsy when sleep-deprived. More importantly, it carries many of the same genes related to human sleep and neurological function.
Hendricks and her colleagues studied CREB (for cAMP response-element binding protein) because of its proposed involvement in sleep, as well as neurological functions like learning and memory. Sleep is believed to help recharge the neural circuitry behind these functions, Hendricks noted.
But for all the sleeping humans do, surprisingly little is known about why we need it and why it goes wrong for some people. According to Hendricks, her team’s findings on CREB show the body has an “appetite for sleep.”
In experiments with genetically altered flies, they found that increasing CREB activity in the flies increased their time awake, and decreasing CREB activity did the reverse. When CREB activity was blocked, the flies needed more rest to recover from periods of sleep deprivation. In addition, the researchers found that in normal fruit flies, periods of sleep deprivation caused their CREB activity to rise, and this elevation remained during their rest recovery.
The findings were published Monday in the online early edition of the journal Nature Neuroscience.
All of this, according to the study authors, suggests that CREB is key in both staying awake and in recovery from sleep deprivation. Whether CREB’s role in sleep has something to do with maintaining neurological function requires further study, they note.
For now, according to Hendricks, CREB appears to be involved in “good, quality sleep.” Studying CREB and the other molecular players behind sleep, she said, should help researchers find better ways to treat sleep disorders–and possibly uncover ways to help people who need to stay awake do so by means other than “stimulating the nervous system.”
CREB is what is known as a transcription factor, which means it helps regulate other genes. Hendricks and her colleagues now plan to figure out what some of these other genes are.
Source: Nature Neuroscience Online, 22 October 2001;10.1038.
By Suzanne Leigh
Are you waking up in the wee hours of the morning, struggling to return to sleep? If so, scientists speculate that what you’re experiencing is a decline in your body’s production of melatonin, a hormone implicated in the regulation of the body clock.
Blame aging, but don’t make the mistake of thinking that poor-quality sleep has to be the price we pay for getting older. A combination of lifestyle changes, perhaps supported initially with drug therapy, may be the key to restoring healthy, satisfying sleep patterns.
In a Canadian study, insomniacs who received training and support for behavioral changes improved their sleep patterns almost as much as the study participants who received both drug therapy (Restoril) and the same training in behavior modification (cognitive-behavior therapy or CBT).
Below are the results reported by Charles M. Morin of Laval University, Quebec. The percentages represent a decrease in time spent awake after falling asleep, the sleep pattern that befalls many middle-aged people. Morin tested 78 insomniacs in four groups:
- Restoril Behavior Therapy: 63 percent drop in sleeplessness.
- Behavior Therapy Alone: 55 percent drop in sleeplessness.
- Restoril Alone: 46 percent drop in sleeplessness.
- Placebo Pills: 17 percent drop in sleeplessness.
Another sleep researcher, James K. Walsh believes that emotional upheavals and stress, rather than age, are the prime causes of insomnia. About 40 percent of patients with chronic insomnia suffer from psychiatric disorders, but once these disorders are treated it’s usually relatively easy to establish a healthy sleeping pattern, claims Walsh, Executive Director of the Unity Sleep Medicine and Research Center at St. Luke’s Hospital in St. Louis.
Source: My PrimeTime
January 24, 2002: LONDON, England — Insomniacs are more likely to fall asleep by imagining a relaxing scene than by counting sheep, scientists have found.
Researchers at Oxford University discovered that the traditional cure for sleeplessness, believed to date from the 19th century, does not work because it is just too boring to keep the mind off problems and concerns.
In an experiment, 50 insomniacs were asked to try different techniques to see which helped them to fall asleep more quickly. One group imagined a relaxing, tranquil scene like a waterfall or a beach. The second tried counting sheep while a third were left to their own devices.
Those who conjured up the relaxing scene fell asleep more than 20 minutes earlier than if they did nothing. Those who counted sheep and the controls took slightly longer than normal to drop off.
“Picturing an engaging scene takes up more brain space than the same dirty old sheep,” Allison Harvey, who conducted the study with Suzanna Payne, told New Scientist magazine in which details of the research were published on Thursday. “Plus it’s easier to stay with it because it’s more interesting.”
But the researchers found that a new method for beating insomnia, “thought suppression,” was also ineffective. The idea is to block an anxious or negative thought by burying it as soon as it occurs to achieve a relaxed state of mind that leads to sleep.
Dr. Harvey found that the “suppression” group took 10 minutes longer to nod off than if they did nothing. The results replicate a pyschological study in which telling someone not to think about polar bears only encourages them to think even more about them.
One in 10 people suffer from chronic insomnia, and scientists estimate that sleeplessness costs the U.S. economy $35 billion a year in absenteeism and accidents.
“These studies represent an innovative approach to the management of insomnia,” sleep researcher Charles Morin, from Laval University, Quebec, told New Scientist.
Morin said he was not surprised by the finding about the suppression technique. “The more you fight those intrusive thoughts, the more they want to come back.” Tackling the underlying source of worry is the only solution to insomnia, he recommended.
JANUARY 2, 2002: CLEVELAND — If a nightly symphony of snorers sleeps in your home, chances are they inherited the family’s round-shaped head.
Six researchers at Case Western Reserve University have used the shape of a person’s head as one indicator of potential problems with sleep apnea, a chronic form of snoring. Round-headed individuals tend to interrupt a good night’s sleep with snoring more than long, thin-faced people.
Prior to the study such factors as age, sex, and obesity were used as predictors for chronic snoring, according to Mark Hans, chair of the Department of Orthodontics at the CWRU School of Dentistry.
As an orthodontist, Hans studies face shape and how it can be used in a variety of ways from forensic dentistry to the shape of the head’s role in overall good health.
Chronic snoring, also known as obstructive sleep apnea syndrome (OSAS), is a medical condition, characterized by the blockage of the air passage at the back of the mouth during sleep. This blockage can cause a person to stop breathing hundreds of times a night from seconds to as long as two minutes and intermittently wake up. Chronic snoring can lead to cardiovascular problems or accidents associated with inattention due to sleep deprivation.
Hans was lead researcher for the study, “Subgrouping Persons with Snoring and/or Apnea by Using Anthropometric and Cephalometric Measures.” Sleeping and Breathing, the international journal of the Academy of Dental Sleep Medicine, published the article in a recent issue.
In the first phase of the two-part study, researchers examined craniofacial characteristics of 60 known snorers and compared their features with 60 individuals with little history of snoring or a low respiratory disturbance index.
The researchers examined 25 different parts of the face and did measurements from the front teeth to the esophagus, the length from the tip of the nose to the rear of the nasal passage, and the distance from the top of the cheek bone to the bottom of the jaw. Coupled with other characteristics of a snorer, these measurements formed the new craniofacial risk index (CRI). They constructed the CRI that included age, body mass index, and 14 cephalometric measures.
In the second part of the study, an investigator, unaware of the individual’s snoring history, examined the facial features of 19 heavy snorers and 47 light or non-snorers. Using the new CRI, the researcher tested the hypothesis that head shape could predict sleep apnea problems. Approximately 75 percent of the time, the investigator was able to predict whether the individual was a snorer.
In addition to reducing the cardiovascular problems and accidents snorers suffer, one of the benefits of the study, according to Hans, is that head shape can now be used to find new ways to lower the fortissimo of the nightly music to a soft lullaby.
BRISTOL — A lot of Afghan children — and some American homeless — could be better off because some folks will be sleeping on the job next week.
With NAPapalooza 2002, Yarde Metals is hoping to raise money for homeless children in Afghanistan and homeless people in the United States as well as raise awareness of the benefits of a few winks taken at a strategic moment.
Craig Yarde, president and owner of the metal distribution company, said he wanted to do something special with the annual nap day after the tragedy of Sept. 11.
Trying to tie in his company’s nap-friendly policy with an effort to help Afghan orphans, he thought of collecting sleeping bags and sending them overseas. But the Red Cross felt more comfortable with blankets, Yarde said, so some of the money raised will go to distributing blankets in the war-torn nation.
But because he thought some people “may have some anxiety” about sending aid to Afghanistan, Yarde said, he decided to add the choice to help the homeless in America instead. The company will be working with The Salvation Army on the domestic-aid program.
Yarde Metals employees are encouraged to get family and friends to sponsor them on April 8 with pledges to take a 20-minute nap that day. Sponsors can donate a certain amount per minute of sleep, or simply make a contribution, and the company will match the donations.
The napping event is an annual celebration for Yarde Metals, but Yarde is hoping other companies will embrace the idea, at least for a day.
Any customer or vendor of Yarde Metals that raises $100 or more will be eligible to win tickets to a Major League Baseball game in their area.
In all, about 7,000 other firms were notified of the fund-raiser, he said, but it doesn’t stop there. Pledge forms are available on the Internet at www.yarde.com and www.greaterhartfordredcross.org.
“We’re opening it up, actually, to the world,” said Yarde. “The more money we raise, the better.”
Given the power of the Internet — and his own company’s success in raising money for victims of floods, earthquakes and other disasters — Yarde seemed to think the possibilities are limitless. “You never know where these things go sometimes,” said Yarde.
Through the fund-raiser, Yarde wants to make a difference to the homeless here and in Afghanistan. “We’re hoping that we can have an impact,” he said.
Yarde said the fund-raiser is also open to anyone who wants to take a nap on their own time or just donate to the cause.
The deadline for contribution is April 19. Checks can be made payable to NAPapalooza and sent to John Cookley, Southington Savings Bank, 121 Main St., Southington, CT 06489.
Is too much surfing sending children to sleep? Excessive net-surfing and television are leaving 2-year-olds suffering the symptoms of chronic sleep deprivation, say experts.
And this could, in the worst cases, have a detrimental effect on child development.
Many children now have television and computers even in their bedrooms, and are allowed to stay up late using the internet.
Researchers at Tel Aviv University looked at 140 Israeli schoolchildren aged eight, 10 and 12. Most were from “middle class”, or “upper middle class” families.
Each child was given an actigraph, a tiny wristwatch-sized device which allowed continuous monitoring without interfering with sleep.
They found that the younger children were asleep on average an hour earlier than the older children.
And the older children, questioned about their levels of tiredness, reported feeling much drowsier during mornings.
The authors wrote: “This suggests the age related significant delay in sleep onset and the shortening of sleep leads to chronic partial sleep deprivation and increased day-time sleepiness even in this age group preceding adolescents, where such a tendency has already been established.”
They added that the sleep the 12-year-olds are getting may not “be in accordance with their physiological needs”.
In adolescents, hormonal changes lead to later sleep times, but this does not explain the same effect in younger children.
Lead author Dr. Avi Sadeh said there were several possible explanations.
He said: “There are increased school demands, the need of children to feel more like adults by having a more active night life and the incentives like late-evening or late-night TV shows and internet surfing.”
The research also showed that younger parents tended to enforce earlier bedtimes.
The best way of predicting the quality of sleep, rather than the time spent asleep, were the parents’ education and the general stresses within the family.
Children of parents with better education tended to sleep better.
The research was published in the journal, Developmental Psychology.
Do you suffer from a disturbance of the sleep/wake schedule?
- Do you have trouble sleeping, staying awake, or suffer from early morning headaches?
- Does your spouse/family complain about your loud snoring at night?
- Have you lost a job because you can’t get to work on time, or can’t stay awake during the day?
- Do you fall asleep in class or have difficulty concentrating?
- Is your social calendar empty because you are just too tired to participate?
- Have friends, teachers, or co-workers labelled you as disinterested, inattentive, or unmotivated?
- Have you become wary of driving because you doze off at the wheel?
- Do you lose muscle control – perhaps even collapse – when you laugh or get angry?
- Have you been relegated to the couch because you have a tendency to act out your dreams?
- Do you ever get a crawling sensation in your legs?
- Are your bedclothes in disarray each morning, even though you believe you’ve had a restful sleep?
- Are you a shiftworker who wants to sleep when you can’t, and then can’t when you should?
- Are you often depressed because you don’t have the energy to complete an everyday routine?
If you have answered Yes to any of the above questions, you may wish to read on . . .
Sleep/Wake Disorders Canada (SWDC) is a national self-help association of volunteers dedicated to fostering the interests of people with sleep/wake disorders, and to assisting them in improving their alertness so that they can become more productive and enjoy a better quality of life, by providing:
- accurate and timely information on sleep/wake disorders to people with the conditions, and health professionals.
- assistance to patients, individuals and their families and the broader community, to understand the implications of sleep/wake disorders in the home environment, the workplace, and public areas.
- encouragement and support for research on the underlying causes of these conditions to bring better methods of prevention, diagnosis, and coping skills.
SWDC offers a wide range of programs and services to those seeking information on sleep/wake disorders. They include:
- Self-help chapters and contact representatives across Canada with local access for people seeking information and peer support.
- National Sleep Awareness Week activities (spring and fall) to raise public awareness about sleep/wake disorders.
- Local fund-raising events.
- A national office with a toll-free 1-800 number which can be accessed for information across Canada.
- Information brochures: Insomnia: The facts; Narcolepsy: The facts; Sleep and it’s disorders; Sleep apnea: The facts; and Restless Legs Syndrome.
- Sleep Solutions, a ten-volume information booklet series for general practitioners.
- A Newsletter, Good Night/Good Day, which provides updates on research and chapter activities and serves as a vehicle for people with sleep/wake disorders to communicate with one another across Canada.
- A register of sleep laboratories and sleep specialists from across Canada.
- An annual conference which brings volunteers and medical professionals together to review the current state of sleep/wake research and to plan initiatives for the organization.
- A reference library on sleep/wake disorders which can be accessed by the general public.
- A working relationship with the Canadian Sleep Society, the organization of doctors and researchers specializing in sleep disorders.
- A home page on the Internet which gives access to millions of people world-wide and serves as an information and networking tool.
For your information . . .
It is estimated that:
- Over two million Canadians have sleep disorders.
- Insomnia, the most common of sleep disorders, affects one third of the general population.
- Narcolepsy is estimated to afflict more than 26,000 Canadians, most undiagnosed.
- 1 out of 4 Canadians has a sleep problem.
- In Canada and the US, 200,000 car crashes a year are caused by sleepiness.
- Sixty percent of men over the age of sixty snore.
What is sleep?
Roughly one-third of our time is spent in sleep. Yet, in spite of rapid advances in sleep research during the past decade, there are still many things we don’t understand about this important part of our lives.
Two kinds of sleep?
Basically, there are two kinds of sleep. One is known as Rapid Eye Movement (REM) sleep. It is related to dreaming and occupies about a quarter of our sleeping hours. The second type, known as non-REM sleep, is characterized by light and deep stages, with the deeper stage (slow wave or delta sleep) usually predominating during the first three hours of sleep.
Research suggests that slow-wave, non-REM sleep, might be related to restoration of our physical functioning whereas REM might be part of some psychological process related to the functioning of intellect and memory.
How much is enough?
Perhaps the only measure of the amount of sleep we need is the amount that makes us feel well. Too much or too little makes a person irritable and tired. The old idea that every adult needs eight hours has long since been discounted; some need ten, some four.
Primary sleep disorders all have a physiological basis. Something in the sleep mechanism is amiss.
What are some of the symptoms of sleep disorders?
Excessive Daytime Sleepiness (EDS) can manifest itself as sleep attacks (irresistible sleepiness and/or an unusual, susceptibility to drowsiness.
Sleep apnea involves frequent cessations of breathing during a sleep period. Loud snoring usually accompanies each resumption of breathing. Awake, respiration is normal; asleep, the sufferer is unaware of breathing irregularities.
Cataplexy is a rapidly occurring loss of voluntary muscle tone, usually triggered by emotions such as laughter, anger, elation or surprise. A cataplectic attack can range from a brief experience of partial muscle weakness to an almost complete loss of muscle control lasting several minutes; the victim is conscious, but cannot move.
Disrupted night-time sleep refers to multiple awakenings during each sleep period. Often such awakenings are accompanied by a craving for food.
Hypnagogic hallucinations are intense, vivid, sometimes terrifying experiences which occur at the beginning or end of a sleep period. Any or all of the normal senses may be involved and the experience is often very difficult to distinguish from reality.
Night terrors (not to be confused with nightmares) usually affect young children who awaken in panic and confusion within an hour of falling asleep. Tghe pulse races and there is disorientation, but no memory of dreaming. Nightmares are not a disorder, but a natural dream phenomenon; only if they are recurrent and deeply disturbing is help necessary.
Automatic behavior refers to doing things (usually of a routine nature) with greatly reduced awareness of and intelligent control over the activities involved. One is generally unable to recall the specific details of one’s activities.
Sleep paralysis is an awareness of one’s ability to move despite the desire to do so. It occurs as a person is falling asleep or waking up.
Sleepwalking (somnambulism) episodes occur occasionally in children, typically before the age of 10 and stopping by age 15. Frequent sleepwalking in adults is more serious, begins later in life, occurs more frequently, shows no family history, and is often related to major stress. Although sleepwalkers can avoid objects, they are clumsier than when awake and speech is usually unintelligible.
Bedwetting (enuresis) is found in about 10% of girls and 15% of boys at age five. Cases in older age groups may be related to physical disorders, congenitally small bladders or infections, or may be a result of generalized anxiety.
What are some of the sleep disorders?
Persons with sleep apnea stop breathing several times during each night’s sleep. Each episode ends with a sudden snore. The cause may be a central nervous system problem or an upper airway obstruction. In rare cases, both causes may exist. Symptoms include excessive daytime sleepiness and complaints of poor sleep. In some people, this can be life-threatening and may require a respiratory aid or surgery.
This disorder of excessive sleepiness has four main characteristic symptoms: cataplexy, excessive daytime sleepiness, hypnagogic hallucinations, and sleep paralysis. Symptoms do not appear in any typical order, sometimes appear years apart, and may vary widely in severity. There is a genetic predisposition to inheriting the disorder.
Myoclonus – Periodic Limb Movements (PLM)
This disorder is diagnosed when highly stereotyped leg twitches repeat every 20 to 40 seconds. Episodes generally last from five minutes to two hours and alternate with periods of normal sleep. It is not the same as “hypnic jerks” which startle many of us as we fall asleep. The victim of myoclonus is usually unaware of leg movements, but complains of fragmented and unrefreshing sleep.
Insomnia is a disorder of initiating and maintaining sleep. The insomniac may be totally relaxed and still sleep poorly because of a weakness in the sleep system. This can be manifested as difficulties falling asleep, frequent nocturnal arousals, or earl morning awakenings. Transient insomnia lasts less than three weeks and usually has an emotional cause. Persistent psychophysiological insomnia usually starts with a prolonged episode of stress in a person who slept adequately, but not well, before the stress. Insomnia is often caused by drugs and alcohol. It may also accompany myoclonus (periodic limb movements).
These are dysfunctions associated with sleep or partial arousals and may be associated with a specific stage of sleep or related to the transition between sleeping and waking. Patients may not know if they are awake or asleep and thus confuse activities, demonstrating such symptoms as sleepwalking, bedwetting, etc., or suffering sleep-related headaches, abnormal swallowing, painful erection, or head-banging.
Disorders of the sleep/wake schedule
People whose sleep time is shifted every few weeks may find their daily rhythms cannot adapt and may experience disrupted sleep. Even when circumstances later permit a regular schedule, it may be difficult to re-establish a good sleep schedule. Such people may develop mood changes, cognitive difficulties, and a tendency for peptic ulcers. Insomnia is common.
How are these disorders diagnosed?
In addition to a thorough clinical history, the sleep specialist may request an all-night polysomnograph, requiring the patient to sleep at the lab while equipment records the different stages of sleep which are experienced. This same equipment may be used during the daytime for a multiple sleep latency test (MSLT) in which the patient is given opportunities to nap and the time needed to fall asleep is measured. Whether or not the patient enters REM sleep early is also recorded. Pupillography, which measures the diameter of the pupil of the eye, is also used as an indication of drowsiness.
(from Sleep Solutions, Volume 9)
- The dyssomnias.
Intrinsic sleep disorders
|Psychophysiological insomnia||Sleep state misperception||Idiopathic insomnia||Narcolepsy|
|Idiopathic hypersomnia||Posttraumatic hypersomnia||Obstructive sleep apnea syndrome|
|Central sleep apnea syndrome||Central alveolar hypoventilation||Periodic limb movement disorder (PLM)||Restless leg syndrome (RLS)|
|Intrinsic sleep disorder not otherwise specified (NOS)|
Extrinsic sleep disorders
|Inadequate sleep hygiene||Environmental sleep disorder||Altitude insomnia||Adjustment sleep disorder|
|Insufficient sleep syndrome||Limit-setting sleep disorder||Sleep-onset association disorder||Food allergy insomnia|
|Noturnal eating/drinking syndrome||Hypnotic-dependent sleep disorder||Stimulant-dependent sleep disorder||Alcohol-dependent sleep disorder|
|Toxin-induced sleep disorder||Extrinsic sleep disorder not otherwise specified (NOS)|
Circadian Rhythm Sleep Disorders
|Shift-work sleep disorder||Irregular sleep/wake pattern||Delayed sleep-phase syndrome|
|Advanced sleep-phase syndrome||Non-24-hour sleep/wake disorder||Circadian rhythm sleep disorder not otherwise specified (NOS)|
- The parasomnias
Sleep/wake transition disorders
|Rhythmic movement disorder||Sleep starts
|Sleep talking||Nocturnal leg cramps
(Pavor nocturnus, incubus attacks)
Parasomnias usually associated with REM sleep
|Nightmares||Sleep paralysis||Impaired sleep-related penile erections||Sleep-related painful erections|
|REM sleep-related sinus arrest||REM sleep behavior disorder|
|Sleep-Related Abnormal Swallowing Syndrome||Nocturnal Paroxysmal Dystonia|
|Sudden Unexplained Nocturnal Death Syndrome||Primary Snoring||Infant Sleep Apnea||Congenital Central Hypoventilation Syndrome|
|Sudden Infant Death Syndrome (SIDS)||Benign Neonatal Sleep Myoclonus||Other Parasomnias Not Otherwise Specified (NOS)|
- Sleep disorders associated with medical/psychiatric conditions
Associated with mental disorders
|Psychoses||Mood disorders||Anxiety disorders||Panic disorder|
Associated with neurological disorders
|Cerebral degenerative disorders||Dementia||Parkinsonism||Fatal familial insomnia|
|Sleep-related epilepsy||Electrical status epilepticus of sleep||Sleep-related headaches|
Associated with other medical disorders
|Sleeping sickness||Nocturnal cardiac ischemia||Chronic obstructive pulmonary disease||Sleep-related asthma|
|Sleep-related gastroesophageal reflux||Peptic ulcer disease||Fibrositis syndrome(fibromyalgia)/chronic fatigue|
- Proposed sleep disorders
|Short sleeper||Long sleeper||Subwakefulness syndrome||Fragmentary myoclonus|
|Sleep hyperidrosis||Menstrual-associated sleep disorder||Pregnancy-associated sleep disorder||Terrifying hypnagogic hallucinations|
|Sleep-related neurogenic tachypnea||Sleep-related laryngospasm||Sleep choking syndrome||Low slow-wave sleep syndrome|
Narcolepsy often mistaken for other problems by doctors
To properly diagnose narcolepsy, primary-care physicians must overcome the tendency to tell their patients to simply “get some more sleep,” and instead ask thorough and probing questions to detect the disorder, which affects over 200,000 Americans, sleep specialists said.
Like other sleeping disorders, narcolepsy is often misdiagnosed or ignored by both patients and physicians. One reason for this may be that often, patients are a poor source of information about their own nighttime and daytime sleeping habits.
Of the estimated 30 million adult Americans with moderate to serious sleep disorders, only about 5% are diagnosed and treated. In a recent Gallup survey conducted on behalf of the National Sleep Foundation, in Washington, D.C., approximately 83% of people who reported excessive daytime sleepiness had not discussed the matter with their physicians.
Therefore, it is essential for clinicians to elicit information regarding sleep history and habits. If a patient complains of excessive sleepiness and, particularly, of trouble staying alert while engaged in quiet sedentary activities such as reading, watching a movie or driving a car, the first question that a primary-care physician should ask is whether the patient snores. Since individuals are often uncertain or even in denial about snoring activity, it is helpful to question the bed partner or other family members, said Merrill Mitler, M.D., director of sleep research at the Scripps Clinic and Research Foundation in La Jolla, California.
Even if snoring can be ruled out, the physician should ask questions about work schedule and sleep habits to determine if the excessive fatigue stems from a lack of sleep or from exhaustion associated with a hectic lifestyle.
Michael Thorpy, M.D., Director of the Sleep-Wake Disorders Center at Montefiore Medical Center in the Bronx, N.Y., agreed that such questioning is essential, and commented that physicians too often simply tell the patient to get more sleep without determining if there is a genuine sleep disorder present. If the physician is uncertain, general recommendations can be made.
These can include going to bed around the same time every night and getting up around the same time in the morning; spending enough time in bed; avoiding alcohol, caffeine or chocolate before bed; and trying not to nap during the day at the expense of nighttime sleep. “Initially, the aim should be to try to maximize the person’s quality of sleep at night, and see if that leads to resolution of the symptoms of sleepiness during the day,” Dr. Thorpy said.
A hallmark of true narcolepsy is that no amount of nighttime sleep or napping will prevent the person from falling asleep at inappropriate or unwanted times, he added. Psychiatric conditions such as depression that can interfere with sleep also must be ruled out before the clinician can ask about matters specific to narcolepsy.
Typical symptoms that aid in the diagnosis of narcolepsy are:
- severe muscle weakness (cataplexy) during the day.
- frightening images in the person’s mind as he or she is falling asleep.
- cataplexy that occurs just before falling asleep.
Patients reporting such symptoms may complain of insomnia and may or may not be aware that they regularly fall asleep for short periods during the day.
The reason, according to Dr. Thorpy, is that it takes approximately five minutes of sleep for the brain to recognize the fact that sleep has occurred.
“So, if you are falling asleep for a minute or two at a time and then waking up, you are unlikely to realize that you have been asleep,” Dr. Thorpy said. “People often will say, ‘I just closed my eyes,’ when in fact, they were asleep for one or two minutes. They lose their frame of reference because it doesn’t feel like sleep. But those few minutes are actually refreshing to the narcoleptic patient.”
The standard treatment for narcolepsy has been stimulants, such as ritalin or amphetamines, but clinical trials of an experimental drug called modafinil (Cephalon) have shown promise. The drug has a favorable side-effect profile and has been shown to increase alertness during the day while not interfering with nighttime sleep. Although the exact mechanism of modafinil is unclear, it does not act on dopamine pathways and does not cause the euphoria or addictive behavior seen with amphetamines, Dr. Mitler said.
Cephalon, of West Chester, Pa., has submitted the drug to the Food and Drug Administration for marketing clearance in the United States.
A genetic cause of narcolepsy also is being pursued. The National Narcolepsy Registry has begun the process of collecting blood samples from more than 500 subjects. Dr. Thorpy, who heads the registry, said he hopes to enroll at least 100 families in which at least two children have narcolepsy. “This holds promise that there may be a gene associated with narcolepsy, and if that gene can be discovered, then the potential lies to understand what is wrong with the gene and correct it,” he said. “Genetic research is one of the more exciting areas of research into narcolepsy at the moment.”
L. A. McKeown
Reprint from MedScape