Mind over Mattress - Sleep Disorders Newsletter (December 2022)

Overview Overview

We all remember our childhood, when we were put to bed at 7:30 PM, and how we loved weekends because we were allowed to stay up just an extra hour! Undoubtedly, those "sleep rules" made us angry and we could not understand their purpose. However, as we grew up and had our sleep disrupted by many factors such as assignments, studying and daily stress, we started appreciating the value of healthy sleep.

Sleep disorders occur when sleep, whether its quality or quantity, is disrupted. Normally, the sleep/awake cycle is regulated by the circadian clock that detects variations around us. For instance, at night, it stimulates the secretion of melatonin which alerts the body that it is time to go to sleep.

One of the most common sleep disorders is insomnia, affecting up to 50% of older adults, but there are many others. Regardless of the type of disorder, the consequences of disrupted sleep should not be underestimated. They can be divided into short-term such as emotional distress and reduced quality of life, and long-term such as increased risk of dyslipidemia, cardiovascular diseases, weight-related issues, and gastrointestinal disorders.

In the following newsletter, we will tackle all the details about the most common sleep disorders! Happy reading everyone!

I. Insomnia I. Insomnia

Insomnia is the most common sleep disorder. It is defined as a difficulty to sleep resulting in insufficient sleep of less than 8 hours as well as daytime impairment. It is more prevalent in women and older adults and frequently coexists with other comorbidities including medical, neurological or psychiatric disorders, such as depression. In fact, it was shown that 40% of patients with insomnia suffer from depression.

Insomnia can be classified as:

Short-term insomnia: Is an acute case of insomnia that usually lasts for a few days or weeks but less than 3 months. It occurs in response to a specific stressor that can be either physical, psychological, psychosocial, or interpersonal, such as job loss, death of a loved one, or divorce, and usually resolves by eliminating the stressor or adapting to it.

Long-term insomnia: Or chronic insomnia occurs when insomnia symptoms appear more frequently, at least three times per week, and persist for at least 3 months to many years. They can occur either due to an unresolvable stressful event or an unidentifiable trigger.

Signs & Symptoms Signs & Symptoms

Trouble falling asleep Trouble staying asleep throughout the night Unwanted early morning waking Resisting sleeping at one’s bedtime (for children and teens) Difficulty sleeping without a caregiver’s help (for children and teens)

Having sleep difficu Fatigue or mala Poor attention Social, vocation Mood disturban Daytime sleepin Reduced motiva Increased error Behavioral pro aggression

Ongoing worry

According to the third edition of the International Classification of Sleep Disorders (ICSD-3), insomnia is diagnosed when all four of the following criteria are met:

1. Having difficulty initiating or maintaining sleep, or waking up too early, as well as experiencing resistance to sleep at an appropriate time.

2. Having daytime impairment (fatigue or malaise, poor attention and concentration, social dysfunction, or poor school performance…)

3 Having a sleep-wake difficulty that cannot be better explained by another sleep disorder.

4. Experiencing sleeping difficulties despite appropriate sleep circumstances.

Causes Causes

The second edition of the International Classification of Sleep Disorders (ICSD-2) classifies insomnia into eleven categories:

Inadequate Sleep Hygiene

Such as improper sleep scheduling consisting of frequent daytime napping, routine use of caffeine products especially before bedtime, and frequent use of the bed for activities other than sleep such as studying, reading, watching TV...

Psychophysiological Insomnia

(Primary Insomnia)

Caused by a prolonged period of stress in a patient with agitation.

Insomnia due to Mental Disorder

Such as depression, anxiety disorders and schizophrenia.

Paradoxical Insomnia Occurs when individuals feel awake even while sleeping.

Insomnia due to Drug or Substance Abuse Including excessive use of stimulants, alcohol, or sedativehypnotics.

Idiopathic Insomnia Or insomnia having an insidious onset in infancy or childhood.

Primary Sleep Disorders

Causing Insomnia

Such as Restless Legs Syndrome (RLS), Obstructive Sleep Apnea and circadian rhythm disorders.

Adjustment Insomnia (Acute Insomnia)

Caused by environmental factors (uncomfortable mattress, excessive noise) and stress-related factors (new life events, deadlines, exams, death of a relative).

Behavioral Insomnia of Childhood Related to children’s behavior such as bed-time resistance or frequent night awakening.

Insomnia not due to substance or known physiologic condition (unspecified)

Insomnia due to a Medical Condition Such as chronic pain syndromes from any cause (arthritis, cancer), advanced COPD, benign prostatic hypertrophy causing nocturia, or neurologic disorders (Parkinson’s disease).

Treatment Treatment

According to the American Academy of Sleep Medicine (AASM), there are two primary goals of treatment:

1

2.

Improve sleep quality, and Improve related daytime impairments.

Different approaches may be considered before the use of medications:

Sleep Hygiene Education

Or informing patients about the behavioral and environmental factors that improve sleep, such as:

Ensuring an adequate sleep environment.

Establishing a bedtime routine.

Avoiding exercise, excessive fluids, alcohol, or nicotine close to bedtime. Avoiding caffeine in the afternoon and evening.

Limiting naps to one nap of 30 minutes per day.

Limiting screen time or interactive technology to one to two hours before bedtime.

Cognitive Behavioral Therapy

Improves the factors that exacerbate chronic insomnia and helps improve symptoms of coexisting psychiatric conditions, particularly depression.

Its behavioral component includes:

Establishing a stable bedtime and wake time seven days per week. Encouraging the use of the bed only for sleep, trying to sleep only when sleepy and getting out of bed if anxiety occurs while unable to sleep (stimulus control). Sleep hygiene, which includes avoidance of substances that interfere with sleep, avoidance of naps to maximize sleep drive, and optimization of the comfort of the sleep environment.

Its cognitive component tackles:

Anxious and catastrophic thoughts associated with sleeplessness. Inappropriate expectations about hours of sleep. Relaxation through progressive muscle relaxation, mindfulness, and meditation.

II. Sleep Apnea II. Sleep Apnea

Occurs when regular breathing stops and starts during sleep. An indicator for it may be snoring loudly or feeling exhausted after a full night of sleep. The most prevalent type is obstructive sleep apnea, which happens when throat muscles relax, leading to temporary narrowing or closure of the airway and interruption of breathing.

Loud snoring

Episodes of breathing cessation during sleep, reported by another person sleeping in the same room

Waking up with a dry mouth

Morning headache

Insomnia or difficulty staying asleep

Hypersomnia or excessive daytime sleepiness

Irritability and difficulty paying attention while awake

Signs & Symptoms Signs & Symptoms Causes Causes

Although loud snoring may be a sign of a potentially dangerous issue, not all people with sleep apnea snore.

If you experience any sleep apnea symptoms, or you have a sleep issue that makes you tired, sleepy, or irritable, contact your primary care physician!

Heart Failure Hypoxia Injury to the nervous system in areas that control breathing Obesity Smoking

Diagnosis Diagnosis

Nighttime Sleep Research: Polysomnogram

In this overnight test, the patient spends the night in a hospital setting, or a "sleep lab," designed to be as pleasant as possible to induce sleep and monitor the patient's sleep pattern. Sensors monitor respiration, heart rate, blood oxygen levels, brain waves, and more. This test is regarded as the Gold Standard for identifying sleep apnea.

Sleep Apnea Testing at Home

This examination is comparable to an overnight sleep study, but is carried out at home and excludes the use of a brain wave monitor. When doctors suspect more severe sleep apnea or if the patient suffers from other sleep disorders or medical illnesses, this test is not recommended because it cannot identify central sleep apnea.

Treatment Treatment

Depending on the type of sleep apnea and its severity, there are many treatment options. While not a cure, they can help prevent apnea episodes or lessen their frequency or severity.

Non-pharmacological options: Weight loss, changing sleep position, using oral appliances (mouthpieces)...

Positive airway pressure and adaptive ventilation devices to force air into the lungs.

Medications:

Fluoxetine showed limited success while Modafinil showed good efficacy.

III. Restl III. Restl Leg Syndr Leg Syndr

Restless leg syndrome or Willis-Ekbom Disease causes an unpleasant creeping sensation in the legs and an irresistible urge to move them during sleep.

Causes Causes

The main cause of RLS is unknown, but some evidence indicates that it could be due to

Genetic factors; a specific gene was found in families where RLS occurred before the age of 40. Dysfunction in the basal ganglion in the brain. Alcohol and caffeine intake, pregnancy, iron, folate and Vitamin B12 deficiency and hypothyroidism.

More data is needed to understand the exact cause of RLS.

Signs & Symptoms Signs & Symptoms

Symptoms commonly occur in the evening and are most severe at night when the patient is sleeping. They include:

Irresistible urge to move.

Uncomfortable sensation in one or both lower limbs.

Difficulty falling asleep and staying asleep.

II. Restless II. Restless eg Syndrome eg Syndrome

IV. Narcolepsy IV. Narcolepsy

Not all naps are power

naps!

Some naps are induced by a chronic neurological sleep disorder known as Narcolepsy. Narcolepsy is a condition in which patients experience overwhelming urges to sleep throughout the day and difficulty sleeping at night. Daytime urges are also known as sleep attacks and can last from a few seconds to hours.

There are many types of Narcolepsy:

TYPE I NARCOLEPSY

Is characterized by sudden loss of muscle control while being awake, better known as cataplexy.

Patients typically have low levels of hypocretin, a hormone in the brain that regulates wakefulness, which triggers muscle weakness and sleep attacks.

SECONDARY

This type of Nar injury to the hy from neurologica amounts of sleep:

Signs & Symptoms Signs & Symptoms

Whether patients individual had had a sufficient amount of sleep at night or not, they may find themselves drowsy throughout the day.

Excessive Daytime Sleepiness (EDS) Causes Causes

Cataplexy Sleep Paralysis Hallucinations

Loss of muscle control that is set off by strong emotions like laughter, anger, fear or excitement.

The short-term inability to move or speak while falling asleep or waking up. It usually lasts from seconds to minutes.

Most commonly vivid visual images that occur at the onset of sleep or upon awakening.

Researchers are still conducting studies on the causes of Narcolepsy but most hypotheses state that it may be caused by the following:

Brain injuries, tumors & diseases

Loss of brain cells that produce hypocretin (for narcoleptic patients with cataplexy)

This loss may be due to autoimmune disorders that are activated because of genetic and environmental components, resulting in the immune system attacking healthy hypocretin-producing cells.

These complications may cause loss of hypocretin-containing cells.

Narcoleptic antecedents

10% of Type I Narcolepsy patients have family members that express similar symptoms, but genetic conclusions require more research.

1

Diagnosis Diagnosis

Overnight polysomnogram (PSG) that records brain and muscle activity, breathing and heart rate, as well as eye and leg movement.

Multiple sleep latency test (MSLT) that determines the extent of daytime sleepiness. The day after the PSG, the patient is asked to:

Take five naps separated by 2 hours each, throughout the day. Record the time it took for him/her to fall asleep during these naps. If it is less than 8 minutes, it indicates excessive daytime sleepiness

Test to measure the levels of Hypocretin, performed by a physician that will extract a sample of the cerebrospinal fluid and evaluate it for the level of hypocretin-1.

Treatment Treatment

The Behavioral Approach (Establishing Good Habits)

Taking brief naps throughout the day to ease excessive daytime sleepiness. A sleep specialist can help with a nap schedule. Avoiding caffeine, alcohol and smoking before bedtime. Avoiding heavy meals before bedtime. Going to sleep and waking up at the same time every day. Adopting a relaxing routine before bedtime such as having a warm bath and avoiding distractions and loud music

2 The Pharmaceutical Approach

Modafinil/Armodafinil:

Methylphenidate: Amphetamine-like stimulant that reduces excessive daytime sleepiness.

Sodium Oxybate: Alleviates cataplexy and excessive daytime sleepiness and stabilizes nighttime sleep.

Pitolisant: Promotes wakefulness and reduces cataplexy.

It is important to note that different patients may react differently to the medications.

V. Non-24-Hour V. Non-24-Hour Sleep-Wake Disorder Sleep-Wake Disorder

Is characterized by a circadian rhythm that is shorter or, more often, slightly longer than 24 hours. As a result, sleep and wake periods are gradually pushed earlier or later, typically by one or two hours at a time and the circadian rhythm drifts away from standard daylight hours over the course of days or weeks.

Signs & Symptoms Signs & Symptoms

Having a sleep cycle that drifts later and later. Exhibiting unnatural changes in hunger, mood and attentiveness.

Preferring to sleep during the day and having trouble falling asleep at night because the biological clock is severely out of synchronization.

Symptoms may resolve when the internal clock readjusts to the return of sunshine.

Causes Causes Diagnosis Diagnosis

N24SWD most commonly occurs in people with total blindness, due to the lack of light reaching the internal clock. Other individuals who may be affected include men, people in their teens and early 20s, people with irregular schedules, and those who live or work in low-light areas.

Trouble falling asleep or waking up Experience a progressive delay in the sleep phase, and Be unable to adjust to a typical 24-hour day for at least six weeks

The International Classification of Sleep Disorders (ICSD) indicates that to diagnose N24SWD, the person must have Actigraphy is another technique:

ACTi graphic devices, which resemble wristwatches, record periods of wake and sleep and show the delay in the sleep-wake cycle associated with N24SWD.

1

Treatment Treatment

Melatonin or Melatonin Receptor

& Other Substances

Agonists

Are recommended in blind patients except in elderly patients with dementia according to the 2015 American Academy of Sleep Medicine (AASM).

Tasimelteon is the only FDA approved Melatonin Receptor Agonist for the treatment of N24SWD. Other substances include Orexin Receptor Agonists for patients with difficult-to-treat N24SWD or concomitant illnesses.

2

Light therapy

For both sighted and blind people with functional light pathways and consists of exposure to bright light in the morning.

Traditional light therapy involves spending up to an hour in the morning in front of a light box.

For people without the required room, a wearable gadget may be used.

Experts also advise obtaining natural sunshine in the morning.

For patients with a circadian rhythm shorter than 24 hours (wake up and go to sleep earlier), melatonin may be taken in the morning and bright light therapy at night.

3

Sleep Hygiene & Lifestyle Changes

Such as reducing the number of naps, avoiding screen time before bed, engaging in regular exercise, and modifying eating habits, among other activities.

People with N24SWD should also be treated for co-existing disorders such as anxiety and depression.

DEPRIVATION

Signs & Symptoms Signs & Symptoms

Difficulty staying alert Increased forgetfulness

Diagnosis Diagnosis

It is critical to correctly identify the underlying cause of excessive sleepiness in order to choose the most effective course of action.

The doctor may ask about the patient's lifestyle choices, current medications and mental health status. Some cases however may require diagnostic tests such as:

Polysomnography that tracks body movements, brain waves, and oxygen levels as the patient sleeps. Electroencephalogram, which is a noninvasive test that tracks the brain's electrical activity.

Treatment Treatment

Non-pharmacological treatment:

Treatment depends on the cause, but people may experience healthier sleep after certain lifestyle changes such as adopting healthier eating habits, reducing consumption of alcohol and caffeine, working out, having a warm bath before bedtime, maintaining a regular sleep schedule in addition to others.

Pharmacological treatment:

The first line treatment is Modafinil, which has a low potential for abuse Other medications used are amphetamines (dextroamphetamine and methylphenidate), but they have high abuse potential and many undesirable side effects. Patients who are prescribed sleep medications should not use them regularly in order to avoid tolerance and dependence.

Natural Therapies Natural Therapies & Vitamins & Vitamins for Sleep Disorders for Sleep Disorders

Helps calm the mind and body and relax muscles, making it easier to fall asleep.

Studies show that its relaxing effect may be due to regulation of melatonin production.

Is a hormone naturally produced in the body and helps indicate the time to sleep or to wake up, as levels naturally rise in the evening and fall in the morning.

Melatonin helps with daytime sleep quality and duration and overall sleep quality. Supplements have become a popular sleep aid if taken in doses of 3–10 mg.

Vitamin D deficiency is associated with a higher risk of sleep disorders. It can be obtained from sunlight and certain foods such as eggs, salmon, tuna fish and from supplements as well

Is amino acid found in warm milk and supplements. It is converted into serotonin and melatonin in the body.

Tryptophan and the molecules it produces influence many functions in sleep, mood

Has mild sedatives effect that can help induce and maintain sleep as well as improve its quality. It has also shown to help with sleep problems associated with depression and other mental health issues.

From a From a

Psychologist's Perspective Psychologist's Perspective

A talk with MS. GHIDA SHREIM MS. GHIDA SHREIM Bachelor in psychology Masters in clinical psychology

From a From a Psychologist's Perspective Psychologist's Perspective

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