Center for Sleep Medicine

Obstructive sleep apnea, or simply ‘sleep apnea,’ is a disorder in which breathing is briefly and repeatedly interrupted during sleep. OSA occurs when the muscles in the back of the throat fail to keep the airway fully open, despite efforts to breathe. When the body realizes this, it reacts by waking the person momentarily to take a breath and reopen the airway. This is what causes the gasping that bed partners recognize between bouts of snoring.

OSA is a serious, potentially life-threatening breathing disorder which affects an estimated 20 million Americans, equally as common as asthma and diabetes. Estimates suggest that up to 85-90% of individuals with sleep apnea go undiagnosed and untreated.

Cardiovascular disease, diabetes and stroke are all commonly known health concerns. OSA can play a major role in the development of these conditions.

A patient with insomnia is characterized as having issues falling asleep or having a consistent sleeping pattern. Those with insomnia exhibit one or more of the following symptoms:

• Difficulty falling asleep
• Waking up often during the night and having trouble going back to sleep
• Waking up too early in the morning
• Feeling tired upon waking

Typically there are two types of insomnia: primary insomnia and secondary insomnia. Primary insomnia occurs when a patient is having sleep problems that are not directly associated with any other health condition or problem. Secondary insomnia involves a patient who is having sleep problems that are attributed to a specific cause, such as a health condition (like asthma, depression, arthritis, cancer, or heartburn); pain; medication they are taking; or a substance they are using (like alcohol). Insomnia also varies in how long it lasts and how often it occurs. It can be short-term (acute insomnia) or can last a long time (chronic insomnia). It can also come and go, with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has insomnia at least three nights a week for a month or longer.

Narcolepsy is a neurological disorder caused by the brain’s inability to self regulate sleep patterns. The hallmark traits of narcolepsy include excessive daytime sleepiness and cataplexy. The disease is also often associated with sudden sleep attacks, insomnia, dream-like hallucinations, and a condition called sleep paralysis. Its prevalence in the developed world is approximately the same as that of multiple sclerosis or Parkinson’s disease. However, with increased public education about narcolepsy and physician training in the diagnosis and treatment of sleep disorders, these figures are expected to rise.

Narcolepsy affects both sexes equally and develops with age; symptoms usually first develop in adolescence or young adulthood and may remain unrecognized as they gradually develop. The instance of family history with narcolepsy is quite small but a combination of genetic and environmental factors may be at the root of this sleep disorder.

The main symptoms associated with narcolepsy are:

• Excessive daytime sleepiness – this is usually the first symptom to appear in people who have narcolepsy. Unless they’re being treated for the disorder, the need to sleep can be overwhelming for narcolepsy patients. Someone who has narcolepsy is proned to falling asleep while engaging in ordinary tasks such as conversation, driving, eating dinner, or at other inappropriate times. The sleepiness occurs in spite of a full night’s sleep and may persist throughout the day.
• Cataplexy – cataplexy is a sudden loss of muscle tone, usually triggered by emotional stimuli such as laughter, surprise, or anger. It may involve all muscles and result in collapse. It may only affect certain muscle groups and result in slurred speech, buckling of the knees, or weakness in the arms. Consciousness is maintained throughout the episode but the patient is usually unable to speak.
• Hypnogogic hallucinations – during transition from wakefulness to sleep, the patient has bizarre, often frightening dream-like experiences that incorporate his or her real environment.
• Sleep paralysis – a temporary inability to move during sleep-wake transitions. Sleep paralysis may last for a few seconds to several minutes and may accompany hypnagogic hallucinations.
• Disturbed nocturnal sleep – waking up repeatedly throughout the night.
• Leg jerks, nightmares, and restlessness.

Treatment

In order to make a determination of narcolepsy, your doctor will ask you for a complete medical and family history and may refer you to a sleep center for evaluation. You should keep a sleep diary as well as a record of your symptoms and their severity for at least a week or two.

Bring this information with you when you visit your doctor.

There is currently no widely-accepted cure for narcolepsy but symptoms can be alleviated to the point of near-normal functioning in many patients. Treatment for narcolepsy includes the use of medication as well as behavioral therapy.

Behavioral therapies may help control symptoms, including taking three or more scheduled naps throughout the day. Patients should also avoid heavy meals and alcohol, which can disturb or induce sleep.

Counseling is very important for people with narcolepsy. The particular symptoms of this disorder are not widely understood by the general public and this may cause patients to feel uncomfortable, alienated, or depressed. The disease can also be quite frightening and the fear of falling asleep inappropriately often significantly alters life for people with narcolepsy.

In treating narcolepsy, doctors typically prescribe stimulants to improve alertness and diminish excessive daytime sleepiness. Antidepressants are also often used to treat cataplexy, hypnagogic hallucinations and sleep paralysis. Finally, sodium oxybate, a strong sleep-inducing agent, may be given at night to improve disturbed nocturnal sleep and reduce daytime sleepiness and cataplexy. All these treatments may have side effects. Stimulants can cause headaches, irritability, mood changes, nervousness, insomnia, anorexia, and irregular heartbeat. Side effects from the use of antidepressants vary and can include nausea, weight gain, anxiety or decreased emotions, drowsiness, sexual dysfunction and changes in blood pressure. Sodium oxybate can induce nausea, excessive sedation, mood changes and enuresis.

The goal in using medications to treat narcolepsy is to achieve normal alertness with minimal side effects.

Coping

Behavior treatment of narcolepsy includes:

• Several short daily naps (10-15 minutes) to combat excessive sleepiness
• Establish a routine sleep schedule
• Maintain a regular exercise and meal schedule
• Avoid alcohol, caffeine, nicotine

Parasomnias are disruptive sleep condition that are the result of heightened brain activity during REM sleep or partial stimulus from Non-REM sleep. Parasomnias include nightmares, night terrors, sleepwalking, etc.

Nightmares

Nightmares are vivid nighttime events that can create strong feeling of terror or anxiety. Usually, the person having a nightmare is abruptly awakened from REM sleep and is able to describe detailed dream content, with the person also having difficulty returning to sleep. Nightmares can be caused by many factors including illness, anxiety, the loss of a loved one, or negative reactions to a medication. Call the Sleep Center at Raritan Bay Medical Center if nightmares occur more often than once a week or if nightmares prevent you from getting a good night’s sleep for an extended period of time.

Night Terrors

A person experiencing a night terror or sleep terror abruptly awakes from sleep in a terrified state. The person may appear to be awake, but is confused and unable to communicate. They do not respond to voices and are difficult to fully awaken. Night terrors last about 15 minutes, after which time the person usually lies down and appears to fall back asleep. People who have sleep terrors usually don’t remember the events the next morning. Night terrors are similar to nightmares, but night terrors usually occur during deep sleep.

People experiencing sleep terrors may pose dangers to themselves or others because of limb movements. Night terrors are fairly common in children, occurring in approximately 5% of the population, mostly between the ages of three to five. Children with sleep terrors will often also talk in their sleep or sleepwalk. This sleep disorder, which may run in families, can also occur in adults. Strong emotional tension or the use of alcohol can increase the likelihood of night terrors among adults.

Sleepwalking

Sleepwalking occurs when a person appears to be awake and moving around but is actually asleep. They have no recollection of their actions. Sleepwalking most often occurs during deep non-REM sleep (stages 3 and 4 sleep) early in the night and it can occur during REM sleep in the early morning. This disorder is most commonly seen in children aged eight to twelve; however, sleepwalking can occur among younger children, the elderly and adults.

Sleepwalking appears to run in families. Contrary to what many people believe, it is not dangerous to wake a person who is sleepwalking. The sleepwalker simply may be confused or disoriented for a short time upon awakening. Although waking a sleepwalker is not dangerous, sleepwalking itself can be dangerous because the person is unaware of his or her surroundings and can bump into objects or fall down. In most children, it tends to stop as they enter the teen years.

Periodic limb movement disorder (PLMD) is repetitive cramping or jerking of the legs during sleep. It is the only movement disorder that occurs only during sleep, and it is sometimes called periodic leg (or limb) movements during sleep. “Periodic” refers to the fact that the movements are repetitive and rhythmic, occurring about every 20-40 seconds. PLMD is also considered a sleep disorder, because the movements often disrupt sleep and lead to daytime sleepiness.

PLMD may occur with other sleep disorders. It is often linked with restless leg syndrome, but they are not the same thing. Restless leg syndrome is a condition involving strange sensations in the legs (and sometimes arms) while awake and an irresistible urge to move the limbs to relieve the sensations. At least 80% of people with restless legs syndrome have PLMD, but the reverse is not true.

When PLMD was first described in the 1950s, it was called nocturnal myoclonus. Nocturnal means night, and myoclonus is a rapid, rhythmic contraction of a group of muscles similar to that seen in seizures. PLMD movements are not myoclonus, however, and the original name is not used today.

PLMD can occur at any age. Like many sleep disorders, PLMD is more common in middle-aged and older people.

Restless Leg Syndrome (RLS) is a serious condition that has affected people for many years, but it has not always been taken seriously, and is often undiagnosed or misdiagnosed. Approximately 10 percent of American adults suffer from this neurological sensorimotor disorder, which causes uncomfortable and sometimes painful tingling and tugging sensations in the legs.

People with RLS often feel as though they have to move their legs, by walking or stretching, in order to make the uncomfortable feelings go away. These sensations tend to get worse with inactivity, sitting for a long time or even just relaxing, like when watching television or taking a long car ride. Because the symptoms usually intensify in the evening and at night, they often interfere with the ability to sleep.

There are two types of RLS – primary and secondary. And while there is extensive research into the origin of RLS being conducted worldwide, there is no single known cause for the condition.

• Primary RLS is the most common type of RLS. It is also referred to as familial (because it is hereditary) or idiopathic (because the causes are unknown) RLS.
• Secondary RLS, on the other hand, is believed to be caused by a separate underlying medical condition or in association with the use of certain drugs. For example, some of these conditions include kidney failure, low levels of iron or anemia, pregnancy, and peripheral neuropathy (a problem with the nerves that carry information to and from the brain and spinal cord that produces pain, loss of sensation, and inability to control muscles). Stress, diet or other environmental factors can also play a role in developing secondary RLS.

RLS is a condition that can affect anyone; it does not discriminate among age, sex or race. Symptoms can start at any age, and many people with RLS remember their first experience with RLS from childhood and being told they were just having “growing pains.” RLS symptoms tend to get worse and occur more frequently with age, especially if they began in childhood or as a young adult.

While there is currently no cure for RLS, in most cases, the symptoms can be controlled through lifestyle changes, such as diet and exercise, and in some cases medical treatments. People with RLS should speak with a health care professional about how to best manage their symptoms.

Some people with RLS will not seek medical attention, believing that they will not be taken seriously, that their symptoms are too mild, or that the condition is not treatable. Some health care professionals inaccurately attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle cramps or aging.