Sleep Disorders

The word insomnia is pretty simple in origin — it comes directly from the Latin, the “in” signifying “no” and “somnia” meaning sleep. That said, this condition that’s easy to define is not easy to experience, as it can cause irritability, depression, errors, exhaustion, impatience, lack of focus, headaches, and more.

Symptoms

Insomnia can be short-term or temporary, when your sleep patterns are affected by stress or trauma. Or, you can experience long-term insomnia, which may be a symptom of an underlying disorder or an effect of medication you take for another condition.

Either way, insomnia is characterized by:

• Difficulty falling asleep
• Difficulty staying asleep
• Waking up in the middle of the night or too early and being unable to get back to sleep
• Not feeling rested after a night’s sleep
• Daytime tiredness

Causes

Short-term insomnia is often caused by outside stresses that you internalize: changes in job or family situation, disruptions in your travel or work schedule, worries about things you can’t control.

Poor sleep habits contribute to insomnia, as well. If you’re watching a screen (phone, tablet, television or computer) before bedtime, that is going to affect your ability to fall asleep. When you go to sleep at 10 and wake up at seven during the week, but wait until midnight to go to sleep and wake at noon on the weekend, that’s going to have an effect as well. (See our Top Ten Sleep Tips for information about creating a better sleep environment.)

Causes of both short and long-term insomnia include:

• Eating too much, too late
• Caffeine, nicotine, and alcohol
• Gastroesophageal reflux disease (GERD)
• Conditions such as nasal or sinus allergies and asthma, which affect your breathing
• Conditions such as thyroid problems or Parkinson’s
• Sleep disorders including apnea or restless leg syndrome

Aging, gender, napping unhealthy sleep routines, medications and health changes can also factor into insomnia. Also, women are more likely to experience insomnia as a result of hormonal changes from menstrual cycles, pregnancy and menopause.

Living better

No matter what the cause of your insomnia, one of the most important things to do to prevent it is to follow good sleep hygiene: know when to tune out the screens, stop eating heavy food, stop the caffeine and more. St. Luke’s has put together a list of sleep rules that can be found here.

At St. Luke’s, your doctor may recommend that you take a certain dose of melatonin each night. Melatonin, a hormone made in your pineal gland, helps control your sleep and wake cycles. Though it is present in small amounts in some foods, it can be found as a supplement. Because it can cause interactions with other medicines you use, only take melatonin under a doctor’s advice, after discussing your other medications.

Exercise forms such as yoga and tai chi may help relieve any stress you carry, while giving your muscles a gentle workout and stretch. Meditation can also help you find a way to separate daily stresses and relax your brain.

Exams and tests

At St. Luke’s, your physician will give you a thorough physical and take a complete medical history. Your doctor will also ask you about any life changes or stresses, to see what outside conditions may be manifesting themselves in insomnia. If the cause is not determined, a blood test for thyroid problems or other conditions may be administered.

Your health care professional will also discuss with you the importance of healthy sleep habits. You may be asked to keep a sleep diary, recording the times you go to bed versus when you fall asleep; how often and for how long you wake up during the night; when you wake up; how you feel when you awaken; and how you feel during the day. (If you record this information for a week or so before you see your doctor, it will be helpful in narrowing down a problem and a solution.)

You may be advised to take a sleep study, which you can schedule at the St. Luke’s Sleep Disorders Center. There, you will undergo several non-invasive tests over a period of time. Based on the results of the study, your doctor will provide a recommendation for treatment.

Treatments

Treatments for insomnia range from lifestyle changes and therapy to medication.

Lifestyle changes

As your sleep habits are a major contributor to insomnia, no matter what the other causes are, adjusting them to be healthy is a great step in the right direction. Maintaining strict going-to-bed and waking times and getting daily aerobic exercise can help you sleep better at night, which can prevent daytime sleepiness. Not smoking, and avoiding caffeine and alcohol at night is also important. Find the rules for a healthy sleep environment here.

Cognitive Behavior Therapy

Proven to be equally or more effective as medication in certain circumstances, this practical, goal-oriented therapy can help you find the attitudes, thinking and behavior behind your insomnia, change those patterns and so change the way you feel. It can teach you how to eliminate and control the negative thoughts and actions that keep you awake.

Medication

Over-the-counter medication for insomnia is not intended for long-term use, and can cause side effects as well as becoming addictive.

You and your physician at St. Luke’s will determine if any prescription medications might work for your insomnia, knowing that, as always, the benefits must outweigh the risks. Short-term medication might be prescribed while you learn to adjust your sleep environment or go through CBT for long-term results.

Narcolepsy is a disorder in which the normal boundary between being awake and being asleep is blurred, causing excessive sleepiness during the day. According to the National Institute of Neurological Disorders and Stroke, about 175,000 to 200,000 people — men and women are equally affected — in the United States suffer from this disorder. This number may be low, because the condition often goes undiagnosed.

Diagnosis is critical, because without the recognition of the condition, many of the symptoms have an effect on how you are treated by your family, at your workplace and within society in general.

Symptoms

Symptoms often appear in childhood and young adulthood, but the disorder can occur at any time.

Symptoms include:

• Excessive sleepiness, which results in unplanned napping during the day
• Sleep paralysis, where you are unable to move or speak when in the state of awakening or falling asleep
• Hallucinations when not quite awake
• Cataplexy, or the partial or total loss of muscle control caused by extreme emotion; laughter is the most common trigger. Not everyone who has narcolepsy experiences all of these symptoms; the most common symptom is the overwhelming need to sleep during the day. Many of the symptoms relate to the confusion of the sleep and awake states and where the rapid eye movement (REM) stage of sleep appears.

Causes

The root cause of narcolepsy when cataplexy is present is the loss of a chemical in the brain called hypocretin. Hypocretin’s role is to act as an alerting system in the brain, and it works to help regulate sleep and wake cycles. There is an autoimmune disorder component: this chemical is located in cells in the hypothalamus, and in people with narcolepsy, it is thought that the body is attacking itself, and those cells are damaged or destroyed.

Other factors can be family history, as some people with narcolepsy have clusters of relatives who also have the condition; many people with it, though, do not.

Current research has determined that there is a genetic factor that is most likely triggered by an environmental factor.

Living better

One of the best ways to live better with narcolepsy is to make sure that the important people in your life know about your condition and have the same facts that you do. This is critical in both the home and work environments, because the way you function throughout the day is not necessarily going to be similar to the way the rest of your family does or your coworkers do.

If your child has been diagnosed with narcolepsy, talk to his or her teachers and school nurse about what it means. As with many conditions, knowledge is a tool and a great reliever of stress and anxiety. Support groups, counseling, and educational networks can be of great help.

Sleep hygiene, important for the general public, is also of great importance to you if you have narcolepsy. Find tips for better sleep here. Sticking to a strict sleep schedule; taking preemptive naps; avoiding heavy meals in the middle of the day; and exercising should all be part of your routine.

Exams and tests

At St. Luke’s, your health care provider will perform a physical exam and take a family history. You’ll talk about your symptoms and decide what the best plan of action might be. You may be asked to keep a sleep diary, and your physician may determine that a sleep study would provide the best information and give you a starting point on which to base the correct treatment.

For diagnosis of narcolepsy, there are two sleep tests that are generally administered:

• A polysmonogram (PSG) measures nighttime sleep; it records brain and muscle activity, breathing pattern, and eye movement.
• A multiple sleep latency test (MSLT) measures daytime sleepiness; the test is administered a few times during the day, with planned naps around periods of wakefulness.

In both tests, attention is paid to when the REM stage of sleep begins. In those with narcolepsy, it often starts very quickly, without the precursor stage found in those with normal sleep patterns.

Treatments

A combination of medicine and lifestyle treatments can make life with narcolepsy smoother.

Medication

Medicines that act on the central nervous system are generally turned to first; these work to improve alertness and reduce sleepiness and include midafinil and armodafinil, both thought to affect dopamine production. Certain amphetamines have a similar affect, and can be given in both short-acting and long-acting forms.
Sodium oxybate can improve the quality of sleep at night, and also works to control cataplexy. Antidepressants, because they suppress REM sleep, may also be used to control cataplexy.

Lifestyle Changes

Scheduling naps, maintaining strict going-to-bed and waking times, and getting daily aerobic exercise can help you sleep better at night, which can prevent daytime sleepiness. Not smoking, and avoiding caffeine and alcohol at night is also important.

If you have narcolepsy, you also have to take proper safety precautions. If you have to take a long drive, make sure you have scheduled breaks for a nap and that your medicine schedule allows for it so that you don’t fall asleep at the wheel. If you experience cataplexy, make sure that those around you are aware of what happens, and keep your environment safe for a sudden fall.

Also known as Willis Ekborn disease (or RLS/WED), restless legs syndrome causes such unpleasant sensations in your legs when you are resting or falling asleep that you are forced to move them to alleviate the feelings. It affects seven to 10 percent of the United States population — women more than men — and worsens as you age.

Symptoms

The leg sensations themselves have been described in a number of ways, from crawling, creeping and pulling, to itchy, throbbing and achy. There are two commonalities. The first is that they are felt when you are just going to sleep, in a prone position, or after sitting or resting for a long period of time, as when you are in a movie theatre or plane. The second is that you feel an overwhelming need to move to try to ease the sensations.

Although the syndrome lasts all night long, there is a period of time towards early morning when it goes away, leaving you with a small window of time to get better sleep. It usually affects both legs.

Secondary symptoms are those related to lack of sleep. These include increased irritability, daytime sleepiness and an inability to focus.

Causes

The condition has no known cause, although there are several theories that are being explored. It is thought to be related to an imbalance of dopamine in the brain, as this neurotransmitter is responsible for sending messages that control movement. Iron deficiency has been recognized in patients that have restless legs syndrome, and it may cause or worsen the condition. Other minerals that may be deficient are folate and magnesium. Kidney failure might also be a culprit, because if your kidneys are not working properly it lowers the stores of iron in your blood and may cause other chemical changes.

If the onset of the condition is before age 40, a hereditary factor is noted. Women also sometimes experience restless legs syndrome beginning with pregnancy, but the syndrome goes away after delivery.

Living better

As with other sleep-related disorders, decreasing or eliminating caffeine, alcohol and tobacco, especially within four to six hours of bedtime, is recommended for better sleep.

It’s possible that your symptoms can improve if you take iron, magnesium or folate supplements. However, you need to check with your health care provider at St. Luke’s before you take any vitamins or supplements; too much iron, for example, can be dangerous. Blood work should be done to determine if your levels of these minerals need improvement.

Taking a hot bath, getting a massage, and using a heating pad or ice packs can also relieve any muscular or other stress and prove beneficial in relieving symptoms.

Exams and tests

At St. Luke’s, your physician will give you a thorough physical examination and take your medical history. Generally, a diagnosis of restless legs syndrome is made if no other condition can explain the following:

• You feel an overwhelming need to move your legs in response to the unpleasant feelings they have.
• These sensations start when you are just going to sleep or when you have been resting for a period of time.
• The symptoms can be partially relieved by walking, stretching, or similar motion.
• The symptoms occur at night.

Your physician may refer you for a neurological exam, to rule out any other causes. You may also be asked to take a blood test, to check for iron or other mineral deficiency.

Treatments

There is no known cure for restless legs syndrome, but it is important to treat because it interferes so severely with sleep that your ability to function and cope with life is compromised.

Your health care professional at St. Luke’s will talk with you about the treatment options that work best for you.

Medication

It’s been found that, when there is an iron deficiency, taking an iron supplement helps alleviate the symptoms. Always check with your health care provider before taking supplements.

There are four types of medication that may be given, based on the results of tests you take.

• Anti-seizure medicines have been shown to have a positive effect on the condition, without a need to worry about a buildup of resistance or a boomerang effect where the condition worsens.
• Medicines that increase the level of dopamine in your brain can decrease the leg sensations at night. However, these medicines can have side effects, including an increase in impulsive behavior, like gambling or shopping. This connection is being researched.
• Medicines that target calcium channels can also be effective.
• Muscle relaxants may help you sleep better at night, but can leave you with a different kind of drowsiness the next day.

It’s important to talk about all the medicines you take with your physician, because a medication you take for a separate condition may intensify the symptoms of restless leg syndrome.

Devices

Two recent developments may be beneficial for your condition. Both are devices that you wear at night. One is a foot wrap that is designed to put pressure under your foot. The other is a pad that delivers vibration to the backs of your legs.

Sleep apnea is defined as sleeping broken by pauses that last at least 10 seconds.

In this potentially dangerous disorder, your breathing repeatedly stops and starts while you are sleeping. The most common type is called obstructive sleep apnea. As apparent by its name, in this type, your breathing is obstructed by something; usually, it is the relaxation of muscles at the back of your throat.

The rarer form is called central sleep apnea. In this type, your breathing isn’t physically obstructed; rather, your brain is not sending the proper signals to the muscles that control your breathing. Yet another form is called complex sleep apnea syndrome. This is caused by a combination of the first two types.

Symptoms

Sleep apnea is characterized by the following signs:

• Loud snoring (particularly in obstructive sleep apnea), especially if surrounded by periods of silence
• Episodes when you stop breathing while sleeping
• Abrupt awakenings at night when you are gasping or short of breath (particularly in central sleep apnea)
• Waking frequently at night to urinate (what wakes you is the fact that you stopped breathing)
• Waking in the morning with a dry mouth or sore throat 

As a result of the difficulty you have in breathing during the night — even if you don’t remember it — you’ll often have a headache in the morning, become very sleepy during the day, have attention problems and act irritably.

Causes

Obstructive Sleep Apnea

Obstructive sleep apnea is caused by exactly that: an internal obstruction that stops you from breathing. Especially prevalent when you sleep on your back, the muscles in the back of your throat can relax. These muscles support your tonsils, your tongue, your uvula and the side walls of your throat.

Your airways are therefore narrowed, and you can’t breathe adequately. This lowers the oxygen level in your blood. Your brain, aware of this, wakes you up so you can reopen the airway. It happens so quickly that you don’t remember it. In fact, it can repeat up to five to 30 times an hour!

What causes the obstruction? Obesity is a major factor. People who are obese have four times the risk of obstructive sleep apnea than the general population. This may be due to excessive fat deposits around the airway. Similarly, people with thicker necks often have narrower airways; and a narrow airway might be inherited, or might be caused by enlarged tonsils or adenoids, particularly in children. Nasal congestion, whether caused by a deviated septum or allergies, can also be a factor.

Smokers have three times the risk of sleep apnea than non-smokers. And because alcohol, sedatives and tranquilizers relax the throat muscles, you are at higher risk for apnea if you use these substances or medicines.

Central Sleep Apnea

Central sleep apnea is caused by the failure of the brain to send signals to your breathing muscles. This itself can stem from various other medical conditions, such as congestive heart failure, or if you’ve had a stroke. Age is a factor, as well; the aging process may impair your brain’s signaling ability. Narcotic pain medications can also have this effect.

Living better

The most important thing you can do to combat your sleep apnea is to use the tools you and your physician at St. Luke’s have agreed on. Often, a breathing “machine” is given to you. It may take time to get adjusted to wearing a mask at night and being hooked up to a machine; it may also take time for the fit to be correct. Persevere. Once you’ve gotten used to it, the machine can improve your sleep and therefore your life.

Aside from following doctor’s orders, you can try sleeping on your side to prevent your tongue and soft palate from blocking the back of your throat and hence your airway. Avoid sedatives and alcohol, especially four to six hours before bedtime, as these can also cause your throat muscles to relax.

Losing weight, if you are obese, will also greatly improve your sleep apnea. Exercising at least 30 minutes every day will help with both weight loss and sleep. Stop smoking if you do; smokers are at much higher risk for sleep apnea. If you suffer from allergies, try using a saline spray or nasal rinse to keep your nasal passages open at night.

Exams and tests

After performing a physical examination and taking a family history, your health care practitioner at St. Luke’s may want you to see an ear, nose and throat (ENT) specialist to rule out blockage in your nose or throat, such as large tonsils or adenoids or a deviated septum.

If central sleep apnea is suspected, you may be referred to a cardiologist or neurologist for testing.

Your physician may also think it best for you to undergo a sleep study at one of St. Luke’s sleep centers. with sleep apnea, one of the benefits of a sleep study, particularly the nocturnal sleep test, is that the test measures your muscle action and your breathing. your rate of breathing as recorded during the test can be used to set up any necessary breathing apparatus that is deemed necessary as a result.

Treatments

It is important that your sleep apnea is treated, because an untreated condition can lead to other illnesses. You may be at higher risk for heart problems or high blood pressure, because your lack of breathing will trigger stress hormones. People with sleep apnea are also at higher risk for both insulin resistance and Type 2 diabetes, since the condition changes the way your body uses energy.

Things that you can start on your own include sleeping on your side instead of your back, losing weight, and stopping smoking. You may need to seek treatment for nasal allergies.

The latest treatment for moderate to severe obstructive sleep apnea is hypoglossus nerve stimulation, a big name for a small device that is implanted in your chest to monitor your breathing and stimulate a nerve that keeps your airway passage open. The unit comes with a remote control — you can adjust it, and also turn it on and off so that functions only when you are sleeping.

For most, though, the tried-and-true treatment is a continuous positive airway pressure (CPAP) machine. This apparatus delivers air pressure through a mask you wear when you sleep; the continuous air pressure keeps your throat passage open. It may take time for you to find the most comfortable way to wear the mask.
Other treatments include valved devices you place over each nostril, and oral appliances that realign your jaw, opening the space in the back of your throat.

Depending on the root cause of your sleep apnea, different kinds of surgery may be an option for you and your physician. For example, you may need nasal surgery to move a deviated septum or remove polyps; you may need a tonsillectomy or to have your adenoids removed; weight loss surgery may be your best path forward. The tissue at the back of your throat may be removed; you may need to have your jaw realigned surgically; or you may require rods put into the soft palate. As a last resort, you may require a tracheostomy, where the surgeon will create an opening in your neck with a tube. Covered during the day, the tube is used for breathing at night.

Perhaps you’ve poked your sleeping partner in the ribs a few times to get him or her to stop snoring. Or maybe you’re the one being poked. You’re not alone. Over half of the adults in the United States snore at one time or another.

Snoring happens when the air that usually flows out of your mouth and nose is blocked during sleep. This causes the tissues at the back of your throat, at the top of your airway, to bump into each other and vibrate. Snoring can be self-perpetuating, and even worsen over time, because that “bumping” can cause trauma to those tissues, causing them to swell and compounding the blockage problem.

Symptoms

The noise associated with snoring is one thing; if it is accompanied by other symptoms, however, it make indicate sleep apnea, which can be a serious sleep disorder.

If you are experiencing any of these additional symptoms, visit your health care provider at St. Luke’s to determine if you have sleep apnea or another sleeping disorder:

• Feeling extremely sleepy during the day
• Having difficulty concentrating
• Experiencing morning headaches or sore throats
• Waking at night or in the morning gasping or choking

Causes

Snoring can be caused by the natural anatomy of your mouth or nose, including:

• Having narrow air passages
• The thickness of your soft palate
• The length of your uvula (the tissue that hangs from the soft palate in the back of your throat)
• The size of your tonsils or adenoids
• A deviated septum — when the partition between your nostrils is crooked

Illnesses or conditions, such as allergies or having nasal or sinus polyps, can cause a blockage that results in snoring. Smoking, being obese and drinking alcohol can also cause snoring. Smoking irritates the tissues of your nose and mouth, which can cause inflammation. Obesity often affects the layers of fat around the neck, which can narrow airways. Alcohol relaxes the throat muscles, weakening that natural defense against obstruction.

Living better

Practical solutions to snoring include elevating the head of your bed a little, or sleeping on an inclined pillow. If you’re a back sleeper, this position allows your tongue to fall backward into your throat; try sleeping on your side instead.
Over-the-counter nasal strips that you apply to the bridge of your nose can help increase the size of your nostril passages and hold them open.

If you have a cold or another respiratory condition, such as allergies, make sure it is kept under control so that your nasal passages are clear. Over-the-counter decongestants, both sprays for your nose and medicines, can have a boomerang effect, though, so don’t use them for more than a few days without consulting with your health care practitioner. However, a saline spray can be used regularly, as can saline nasal and sinus washes that you use at the sink or in the shower; these can be helpful in relieving congestion and keeping stuffiness under control.

Sedatives, which you might think would help you sleep better, have an adverse affect on snoring, since, like alcohol, they relax the muscles at the back of the throat. Avoid sedatives and don’t drink alcohol four to six hours before you go to sleep.
As with many other conditions, losing weight and stopping smoking will go a long way in helping you to stop snoring. Weight loss may decrease some of the extra tissue in your throat, and take pressure off your airways. If you stop smoking, you’ll stop irritating your throat and nose with the chemicals in smoke, so they can stop responding by being aggravated.

Exams and tests

Your physician at St. Luke’s will give you a physical examination and take a complete medical history. To find out more about your snoring pattern, you’ll answer questions about the frequency of waking during the night, what helps your snoring or makes it worse, whether you’ve noticed or been told that you stop breathing during the night or whether you wake up gasping either in the morning or at any time during the night.

Depending on your answers, your health care provider may recommend that you participate in a sleep study.

Treatments

Lifestyle changes, including those given in Living Better, can help your snoring. Additionally, your doctor may recommend certain oral exercises that strengthen your tongue and throat muscles; these exercises are simple, repetitive motions that take little time and can be done easily at home.

An allergist at St. Luke’s can provide medication and remedies for any allergic symptoms you have that are causing snoring. Similarly, a dentist trained in preventing snoring may be able to provide you with an oral device that shifts your jaw and helps to keep the back of your throat open.

An appliance called a continuous positive airway pressure (CPAP) machine may be recommended. Frequently used by people diagnosed with sleep apnea, this apparatus delivers air pressure through a mask you wear when you sleep; the continuous air pressure keeps your throat passage open.

As a last resort, if your snoring is so severe that you get no rest, surgery may be indicated. This is generally surgery to the back of your throat, eliminating extra tissue or removing tonsils or adenoids, but may center on the nose instead; for example, you may benefit from having a deviated septum straightened.

At St. Luke’s, our physicians and other health care professionals treat people with many different kinds of sleep problems and disorders. In addition to the ones presented in detail (insomnia, narcolepsy, restless legs syndrome, sleep apnea, and snoring), there are others that may present differently and have various degrees of severity.

Bruxism

This clenching or grinding of your teeth during sleep can lead to headaches, jaw disorders and damaged teeth. If you wake up in the morning with tired jaw muscles or teeth that ache, or if you have pain that seems to be coming from your ear, but isn’t — you may be grinding your teeth at night. Your dentist may be the first health care professional to pick up on these symptoms.

Circadian Rhythm Disorders

With these types of disorders, your circadian rhythm (internal sleep clock that takes its cues from the day / night cycle) is disrupted so that you can’t follow a regular sleep pattern. These disorders take several forms.

Idiopathic Hypersomnia

This condition can be severe and disabling. Similar to narcolepsy in its effect, you experience extreme sleepiness, constantly and recurrently, even after you’ve had a good night’s sleep.

Night Leg Cramps

Possibly caused by muscle fatigue or nerve problems, this kind of very painful cramp can wake you up at night, and, over time, cause you to have constantly interrupted sleep. (Note: if you experience sudden and constant cramping, see a physician immediately, as this can be a sign of a serious underlying condition.)

REM Sleep Behavior Disorder

Body movement during the rapid eye movement (REM) phase of sleep is uncommon. Your body is designed that way: it goes into a temporary paralysis, called atonia, to keep you from acting out your dreams. If you suffer from this disorder, however, atonia is not present, and you can act out your dreams with sometimes violent motions such as kicking or fighting.

Sleep Talking

Sleep talking can occur in any stage of sleep; the lighter the sleep you are in, the more intelligible your words will be. This condition is sometimes associated with sleep apnea or REM sleep behavior disorder.

Sleep-Related Eating Disorder

Frequent, out-of-control eating while you are sleeping characterizes this disorder. Possibly related to sleepwalking, you generally have no memory of your actions at all.

Sleep Walking

Not just walking, but any form of action that takes place while you are asleep, including, in some cases, driving, occur with this condition.

Some of these disorders can indicate serious underlying health issues. All of them result in interrupted sleep, which can bring on headaches, an inability to focus or concentrate, irritability, and more.

Your physician at St. Luke’s will be able to help you determine the kind of sleep problems you are having and what causes them, and will be able to tell you if these symptoms are associated with any particular sleep disorder. A physical exam and family history will be taken at your appointment, and you may be asked to keep a sleep diary ahead of time or afterwards.

Your health care professional will tell you if he thinks a sleep study, which uses different tests, some overnight, to measure breathing, brain function, and physical movement while sleeping, will be helpful.