Center Sleep Disorders Articles

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A Good Nights Sleep Sleep Medicine & NEA Baptist Clinic Center for Sleep Disorders Strange Events During Sleep Sleep Terror: Parasomnias Is it a Sleep Disorder?

Insomnia Your Internal Clock VS The Punch Clock Obstructive Sleep Apnea Sleep Disorders & Neurological Conditions

www.neabaptistclinic.com

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A Good Night’s

Sleep S

lowly your eyes open, and for a moment you are still on that sunset sail on the calm still waters of the Caribbean, but then it hits, you’re not there, this is your own bed and another night of sleep is over. A quick check of the time confirms you’ve been asleep 7 ½ hrs. Further assessment finds that you feel pleasantly refreshed with a renewed sense of alertness, energy, and vitality making you eager to meet the challenges of the new day. You recall hardly anything from your sleep except those last memories of your sailing experience, but know you’re ready for the new day.

That is a good night’s sleep! Have you ever wondered about: What is sleep? What is good sleep? Why do we sleep? What or who controls when I sleep? How do you know when you had enough sleep, or when you haven’t? Why can we fail to get it? These are all important questions that many of us never stop long enough to ponder. If you want to know more, then read on.

What is Sleep?

If you turn to the dictionary you find that sleep is “a state of partial or full unconsciousness in people and animals, during which voluntary functions are suspended and the body rests and restores itself.” Not bad, but not a fully complete answer. Sleep is essential for survival. Animal models have shown prolonged deprivation causes death (rare in humans), and sleep loss in humans causes many fatal vehicle crashes annually. Although we don’t fully understand sleep we do know that it is a period when the body is in a state of reduced environmental awareness but the brain is actively processing information and regulating critical body functions. The brain actively and cyclically moves through multiple stages of sleep throughout the night. These stages are divided into rapid eye movement sleep (REM) and 3 stages of non-rapid eye movement sleep (N1, N2, and N3). The stages each have distinctive findings that identify them during sleep studies.

Body and brain activities like dreaming, hormone regulation, storing recently learned information into the brain circuits, and regulating of blood pressure and breathing are but a few examples. Sleep stage shifting and process regulation is achieved through neuro-transmitters (chemicals) and nerve pathways in the brain.

What is “good” sleep?

Good sleep is perhaps best described by thinking about the sequence. As night falls you develop an increasing sense of sleepiness, the feeling of heavy eyes, a mind that is not focusing and a desire to lie down. In the comfort of your bed you drift into sleep within 15-20 minutes and have very little remembered disturbance during the night. Then you awaken without the use of an alarm and feel as I described above. You are restored, recharged and refreshed. The day-time finds you sharp and alert

functioning well until the night begins to fall again. This should be the same day after day with only rare exceptions. The one exception is a normal brief dip in alertness during the “siesta time” occurring in the early afternoon. The amount of sleep to achieve this, like every human process follows a bell shaped distribution, and ranges from short sleepers of 5-6 hrs, average at 7-8 hrs and long sleepers 8-10 hrs. If you sleep in on weekends one should suspect that your choice of sleep length is less than your need.

How do you know if you sleep enough or too little?

Having the good sleep pattern described above is a good indication that the sleep duration has been sufficient. Coming from the opposite view, perhaps the very best way to know if you have gotten adequate sleep is to be very aware of the signs of sleep deficit. In our high tech, 24 hour society, sleep has a low priority for many. I have had numerous patients seen in the sleep center tell be that they see sleep as lost opportunity to get things done, a waste of time. While expressing this belief, they are usually totally unconscious of the signs of sleep loss. A brain that has been unable to get enough sleep will usually show symptoms in three distinct areas. First and the most obvious is the pressure to sleep that has not been dissipated. This symptom is sometimes difficult to appreciate because we can overcome it with stimulation from activity, complex tasking, or the use of caffeine. But let there be a lull in activity, and the sleep will come on. The second area is mood stability. A sleepy person can be irritable and hard to deal with, depressed or even excessively anxious. Cognition or the ability of the brain to be alert, exercise good judgment and perform tasks with skill and accuracy can be affected. Sleep loss is typically associated with loss of motor skills, reflex response and coordination. Many of these things are not apparent to the sufferer.

Why do we sleep?

Although we may not know exactly, it is clear that almost all living animals do sleep. It is an essential process to life and is determined in our genes. The arguments over this question have spanned several decades and have spawned several theories. The adaptive theory proposes sleep increases the chances of survival. Support for this theory comes from the observations that animals adjust their sleep/wake cycles to take advantage of their unique biologic capabilities and expose themselves only when things like their vision and other senses and other physical capabilities promote their survival in the harshness of nature. The energy conservation theory suggests that sleep is a mechanism of conserving energy in animals. The support comes from the observation that animals with high metabolic rates sleep longer. The last theory that has perhaps the best support is the restorative theory of sleep.

This places emphasis on the restorative role of sleep. It further suggests that there is a neurotoxin (sleep promoting) that builds up in the brain and that during sleep the levels decrease thus creating the restoration in vitality and alertness. In addition other chemical changes promoting the sleep-wake cycle take place.

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What regulates human sleep?

The sleep-wake cycle is one of many bio-rhythms in animals. We have cells in our brain that serve us like an internal clock or timer. They have a genetically determined ability to create repeating cycles over periods of time in a very accurate and reproducible manner. These rhythms can occur in less than, greater than or about equal to a 24 hrs period. Therefore a process may cycle in periods of a month or longer like the female menstrual cycle, in a 24 hour day cycle like sleep, or less than a day like periods of REM sleep every 90 minutes within the sleep period. The sleep-wake rhythm occurs within the 24 hour period and is set to our environment by the light dark cycle of the 24 hour day. If left unaffected by our behavioral changes the human body wants to wake to light and sleep with darkness in a consistent pattern (or times).The main clock effect is an alerting stimulus to our brain.

A second influence on our times to sleep or wake is what is called the homeostatic mechanism of sleep. Put simply the longer we are awake the more the “pressure” on the brain to want to return to sleep. This “pressure” is believed to be caused by a building of the sleep promoting neurotransmitters in the brain mentioned previously. Sleep at any time of the day or night has the ability to reduce this pressure to sleep. The internal

clock drive for alertness is working against the building pressure to sleep throughout the day and we usually succeed in being alert until this stimulus is gradually reduced as night time arrives. Then the pressure to sleep dominants and sleep onset normally occurs.

What can interfere with sleep?

It pretty much follows Murphy’s Law: “Anything that can go wrong will go wrong”. There are countless ways that normal sleep can be disrupted.

Primary sleep disorders (e.g. sleep apnea, insomnia, restless legs, parasomnias, and periodic limb movement disorder), psychiatric conditions (e.g. hyperactivity, depression, generalized anxiety, bereavement, and psychosis), medical conditions (e.g. asthma, congestive heart failure, reflux esophagitis, urinary symptoms, pain conditions of arthritis, neuropathy, leg cramps, fibromyalgia, and many others) or just everyday life stresses or changes. Perhaps the least obvious factor can be our own behavioral choices. We can, unwittingly, be very destructive to the maintenance of good sleep, all the while complaining that we have poor sleep and don’t understand why.

What is sleep hygiene & why is it important?

The rules of good sleep hygiene are just another list of good suggestions (e.g. personal hygiene, oral hygiene), that are known to make our health and in this case our sleep better. They are all focusing on strengthening the regulation of the sleep wake cycle and to reduce unwanted interference with that process.

1. Maintain a regular bedtime and wake time schedule for all days of the week.

- This means know your real sleep need and plan to get it. It is most important to get up at the same time each day and get light exposure.

It is also what helps set the internal clock. If you find it difficult to wake in the morning you may be getting too little sleep and need an earlier bedtime.

2. Utilize a “wind-down” time prior to sleep onset.

- Everyday stresses can create anxiety and the inability to allow the sleep pressure to “take over” at bedtime. Plan to solve your issues early in the evening and find relaxing, enjoyable things to do the hour or two prior to bedtime.

- It is important that this is not done in the bedroom. It is a place that is not for anything except sleeping and sex. No work, arguments, problem solving sessions or brain storming,TV or computers.Take it to the study, living room or home office.

3. Never attempt to make yourself go to sleep based on the clock time.

If not falling asleep within 20-30 minutes consider that you are not ready to sleep and resume your “wind down” activity until you are. But remember to still get up at the same time in the morning. It may be just one of those nights, bedtime the next night will come easier.

4. Avoid alcohol, nicotine, and caffeine prior to bedtime or if awakening during the night.

- Each of these chemicals can interfere with sleep. Alcohol although it can put you to sleep often as it is metabolized causes later awakening.

Nicotine can interfere with sleep onset and when levels decrease during

the night may cause awakenings. Caffeine is a direct sleep antagonist.

It keeps one awake. People vary greatly in how fast the body eliminates it. Good practice would be no caffeine within 6 hours of bedtime. (coffee, soft drinks, power drinks, tea, chocolate and some over the counter pain medications are common sources).

5. Avoid exercise or hot baths or showers with in two hours of bedtime.

- This increases the body core temperature and can delay sleep onset.

6. Bedtime Snacks can be okay if you are hungry, but avoid foods that promote gas, indigestion and reflux.

7. Provide a proper bedroom environment that is promoting of sleep for both bed partners.

- These are very common issues. Environmental factors can be pets, children sharing the bed, mattress or pillow comfort, snoring, temperature, noise (TV, music, outside noises, etc), light, safety concerns, and a number of other things that make it hard to sleep.

These affect everyone in different ways.To deal with these when there are two people in the same bed or room takes an open discussion but is essential to getting all concerned a good night’s sleep. Sometimes the best solution is to choose different rooms for sleeping. Keep in mind that what may be one sleepers comfort may be the others deterrent to sleep.

8. Avoid any naps during the wake period if at all possible. They will only decrease the sleep pressure to sleep at bedtime.

- If you have that over whelming need to sleep at “siesta time”, nap no latter than 2:00 PM and limit it to no longer than thirty minutes.

What to do if you fail to achieve good sleep?

What I hope you will do is recognize that there may be an issue with your sleeping that is causing you some daytime functional or mood issues and potentially health and safety issues. The causes for this are numerous and varied and often times multiple. The best solution if the problems persist past the resolution of contributing stresses or life changes for more than a week to a month would be to seek help. This should involve a good assessment of your health (mental and physical) as well as your sleep habits and quality. The best therapies are those that are directed to the root cause of the problem.

David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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s n io it d n o C l a ic g o l o r Sleep Disorders & Neu

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eurological disorders and sleep disorders often coexist, and their relationships are increasingly recognized. Neurologic disorders may cause a variety of sleep dysfunctions. Conversely, sleep disorders may have profound effects on the natural courses of neurologic diseases. Thus, it is important that we understand, recognize, and diagnose sleep disorders when evaluating patients presenting with neurologic illness, so that these patients can be treated appropriately.

Many neurologic disorders may result in sleep disturbances, which include sleep related breathing disorders, hypersomnia (excessive daytime sleepiness) or insomnia, parasomnias, sleep related movement disorders and circadian rhythm disorders.

The following are just a few examples of many neurologic conditions that present important relationships with sleep disorders.

SLEEP & DEMENTIA Alzheimer’s disease (AD) is the most common cerebral degenerative disorder causing irreversible dementia. Dementia with Lewy bodies (DLB) is now considered the second most common irreversible cause of Dementia. Other causes of Dementia include Pick’s disease, cortical basal degeneration (CBD), and vascular dementia, etc. Sleep disturbances in Dementia include sleep related breathing disorders, movement disorders, parasomnias, insomnia, circadian rhythm disorders and hypersomnia.

• Although the relationships between obstructive sleep apnea (OSA), cognitive status, and dementia are still being defined, there appears to be an association between OSA and Dementia.

OSA should be considered one of the treatable contributors to and causes of Dementia. Treatment of OSA, particularly with nasal continuous positive airway pressure (CPAP) may improve cognitive performance, excessive daytime sleepiness (EDS), mood and overall quality of life. Central sleep apnea (CSA) can also occur in patients with primary central nervous system dysfunctions. The dysregulation of the brainstem respiratory neuronal networks is presumed to be responsible for CSA in degenerative dementia.

• Restless legs syndrome (RLS) is one of the common movement disorders and occurs quite frequent in patients with Dementia. RLS often results in Insomnia. The treatment of RLS with dopaminergic agents may also lead to Insomnia in some dementia patients. Patients with cognitive impairment and RLS can be challenging to treat.

Cognitively impaired patients may have difficulty preparing meals with adequate nutrition, leading to inadequate iron intake. Iron deficiency should be considered since iron deficiency can precipitate or aggravate RLS. • The associations of rapid eye movement (REM) sleep behavior disorder (RBD, a type of parasomnia) with Neurodegenerative disease are well established. Patients with RBD experience violent dream-enacting behavior during

REM sleep, often causing self-injury or injury to bed partners. The most prominent finding in polysomnography (PSG) recording in these patients is REM sleep without muscle atonia.

• Circadian dysrhythmias are common in patients with AD. The degenerative changes in a brain structure named suprachiasmatic nucleus, and the decreased melatonin production are thought to be contributing factors in the circadian dysrhythmic abnormalities in patients with AD and other dementing conditions. Sleep disturbance may lead to nocturnal wandering. Nocturnal wandering in Dementia may reflect insomnia secondary to night/day reversal, medication effects, emotional distress, or restless legs syndromes.

• Hypersomnia is quite evident in patients with dementia, especially in patients residing in chronic care facilities.

Hypersomnia may reflect untreated OSA, CSA, RLS, circadian dysrhythmia, or some combination of above.

SLEEP & STROKE Sleep disturbances and complaints are common in stroke patients.

Sleep apnea, snoring, and stroke are intimately related. Stroke may predispose patients to sleep apnea; sleep apnea may predispose patients to stroke. It is important to diagnose sleep apnea in stroke patients, because untreated sleep apnea may adversely affect their short-term and long-term outcomes. Effective treatment for sleep apnea may decrease risk of future stroke. Insomnia is another disturbance observed in stroke patients. The associated depression, spasticity, and immobility from stroke may result in Insomnia.

Brain stem infarction may cause the syndrome known as Ondine’s curse, or primary failure of automatic respiration. These patients become apneic during sleep.

SLEEP & EPILEPSY A reciprocal relationship exists between sleep and epilepsy (i.e., sleep affects epilepsy, and epilepsy affects sleep). Sleep facilitates epileptic activity and seizures. Most of the time, seizures are triggered during Nonrapid Eye Movement (NREM) Stages N1 and N2 sleep, occasionally during NREM Stage N3 sleep. In contrast, during REM sleep, epileptic activity decreases. Some epileptic syndromes have a

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marked tendency to occur only or predominantly during sleep. Sleep related epilepsy range from 10% to 45% of epileptic patients. Sleep deprivation, which increases cortical excitability, is also an important seizure trigger. OSA may also exacerbate sleep related seizures and complicate their treatment.

SLEEP & HEADACHE Epilepsy affects the structure and stages of sleep. These include delay in sleep-onset, increase in waking after sleep onset, reduced REM sleep and NREM Stage N3 sleep, and an increase of stage N1 and N2 sleep.

Headache and sleep complaints are common.

Sleep related headaches are a group of headaches that occur during sleep or upon awakening from sleep. Most sleep related headaches occur daytime as well as during sleep. These include migraines, cluster headache and chronic paroxysmal hemicrania (a type of headache which presents as frequent, short-lasting attacks of unilateral headache).

Hypnic headaches (a benign type headache), on the other hand, only occur in sleep. Patients with hypnic headache are usually awakened from sleep at a constant time each night. Sleep related headaches may cause sleep disruption and insomnia with decreased sleep efficiency. Other sleep disorders including obstructive sleep apnea (OSA) and snoring may also result in sleep related headaches.

Treatment of OSA may improve headache.

SLEEP & NEUROMUSCULAR DISORDERS Sleep disorders have been described in many patients with neuromuscular disorders, including motor neuron disease (such as amyotrophy lateral sclerosis, ALS), polyneuropathies, myasthenia Gravis, myotonic dystrophy and other primary muscular diseases.

The most common sleep complaints among these patients are excessive daytime sleepiness resulting from frequent arousal or awakening from sleep, associated with sleep apnea and hypoventilation. Sleep disturbance in these conditions usually results from the weakness of respiratory muscles, caused by the diseases of these muscles, nerves or the junctions between the nerves and the muscles. Some patients may have insomnia, especially in those with painful neuropathies, muscle pain, muscle cramps and immobility due to muscle weakness.

EVALUATION & MANAGEMENT • A detailed patient history and physical examinations are essential, and lab tests should be conducted as an extension of history and physical examinations. Tests should be directed at diagnosing primary neurological disorders and assessing sleep disturbances that are resulted from neurologic diseases. Common tests that assess primary neurologic conditions include neurophysiologic tests (EEG, NCS/EMG, and video-EEG monitoring, etc.), Neuroimaging studies (CT, MRI, etc.), cerebrospinal fluid examinations, and general lab tests.

Lab tests which are available in most sleep centers to investigate sleep and sleep-related breathing disorders in neurologic conditions include overnight PSG, multiple sleep latency test (MSLT), maintenance of wakefulness test, actigraphy, and video-PSG. • In order to manage sleep dysfunctions in neurologic disorders, primary neurologic disorders should be properly diagnosed, followed by treatment and monitoring of the neurologic illness.

Treatment of underlying causes may improve sleep disturbances.

When a satisfactory treatment is not available for a primary neurologic condition or does not resolve the problem, treatment should be direct to the specific sleep disturbance. Treatment modalities for sleep disorders include general measures, pharmacologic agents, mechanical devices (nasal CPAP and other ventilatory supports), supplemental oxygen, and surgical treatment.

For an appointment to evaluate your sleep and/or neurologic problems, please call (870) 935-8388.

Dr. Bing Behrens is board certified in Neurology and Sleep Medicine. She is a member of the American Academy of Neurology, and the American Academy of Sleep Medicine.

Bing Behrens, MD Neurology & Sleep Medicine NEA Baptist Clinic – 870.935.8388

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Sleep Medicine Sleep Medicine deals with those conditions that result in sleep disturbances capable of creating sleep loss sufficient to interfere with the quality of life. Through accurate diagnosis and appropriate therapy addressing these disorders helps patients to improve the daily quality of life. Some of the common problems are sleep disordered breathing, insomnia, restless leg syndrome, and excessive daytime sleepiness.

Board Certified Physicians and Registered Sleep Technologists

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y name is Dr. David R. Nichols, the medical director of the NEA Baptist Clinic Center for Sleep Disorders (NEAC-CSD), and I am extremely excited and proud to be writing this article for the fall issue of NEA Health. It is my pleasure to formally introduce the center to Jonesboro and North East Arkansas.

The NEAC-CSD opened on November 3, 2008 and is located at 1118 Windover in Jonesboro. The center is an evolution of the Sleep Medicine Department of the NEA Baptist Clinic started with my joining the clinic medical staff in May of 2006. I am a former Fort Smith, AR physician trained and board certified in Internal Medicine with a Pulmonary Disease sub-specialty and a Diplomat of the American Board of Sleep Medicine.

After an active career of 27 years in pulmonary and critical care in Fort Smith, with the last 10 of those years including Sleep Medicine, I decided to change the direction of my professional career and focus exclusively on Sleep Medicine.

Discussions with the NEA Baptist Clinic administration and physician leadership in 2005 included not only opening the Sleep Medicine department but also plans for the future development of a sleep center to support the diagnostic needs of the practice. The clinic had the vision and commitment to add a rapidly growing new medical specialty capable of bringing state of the art treatment and diagnostics to patients suffering with sleep disorders. In this article I will describe our center facility, the technical and clinical staff on site as well as the extended clinical staff off site. I will discuss the scope of the practice as well as our commitment to our patients and the community.

David R. Nichols, MD

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The NEA Baptist Clinic Center for Sleep Disorders is a multi-disciplinary center that meets the American Academy of Sleep Medicine’s (AASM) definition of a sleep disorder center because of its ability to evaluate, diagnose and treat all sleep disorders, and provide follow-up care for these patients. At this time the expertise of the center is focused at the age ranges of adult to age 13. The sleep disorder center definition stands in clear distinction to facilities that are focused on just performance of sleep diagnostic studies. The American Academy of Sleep Medicine has also established standards for centers in the performance of diagnostic studies, and treatment of patients. The AASM is the premier professional organization that accredits sleep centers to be in compliance with standards of excellence set by the professional sleep community. This center has been developed and staffed in a manner that is committed to meet all of the standards set by the AASM. The clinical staff is committed to perform the evaluations and diagnostic studies, and to develop treatment plans that follow the current published evidence based guidelines of care. The center accomplishes this mission by having dedicated physicians, technical and support staff.

The physician staff for the center is the core of what makes it a multi-disciplinary organization. As the field of clinical sleep medicine evolved it was clear that many existing disciplines were involved in the treatment of sleep disorders. The specialties included psychiatry and psychology, pulmonary disease specialists, internal medicine specialists, pediatricians, neurologists, and ear nose and throat surgical specialists (otolaryngologists), dentists, orthodontists and oral surgeons. In recent years, as with all developing specialties board certification processes were developed that allowed a designation of added expertise in the field of sleep medicine for all of these existing specialties, and training programs have also been producing specialists in sleep medicine. The developmental concept of the NEAC-CSD was to become a focal point to bring the NEA Baptist Clinic physicians interested in treatment of sleep disorders together, and to seek interested community physicians.

The goal was to promote an interactive environment which would allow for “learning from and with each other” and create an “audience” for inviting outside speakers. Although the participants become the immediate beneficiaries of their efforts the ultimate goal is to improve the care of patients treated through the center and within the community. The forum allows for the discussion of complicated patient treatment plans that could crossover all the disciplines. At this time I serve as the “resident” sleep specialist at the center. I am seeing patients referred by their physician or self-referred with sleep complaints. The process begins with an evaluation of these complaints with a comprehensive medical history and then adds findings from a physical examination. This process generally produces a suspected diagnosis which will either generate a decision to perform a diagnostic test to confirm or the initiation of an appropriate treatment plan. Dr. Bing Behrens, an NEA Baptist Clinic board certified neurologist and sleep medicine physician and her partner Dr. William Long, certified in Neurology and board eligible in sleep medicine, see their neurology patients with sleep complaints in the NEA Baptist Clinic Neurology Department and send patients to the center as needed for diagnostic testing.

When any of the sleep specialty physicians feel a patient is in need of another medical specialty to treat the sleep disorder a referral is made to that specialist. Dr. Bryan Lansford of the NEA Baptist Clinic ENT Department provides expertise in the surgical management of obstructive sleep apnea (OSA), primary snoring, or nasal conditions that complicate medical management of OSA. He may in turn refer patients he sees in his office

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for either diagnosis or medical management of a sleep disorder. In some patients with obstructive sleep apnea, or snoring a treatment option includes the use of an oral appliance. This would result in the referring of the patient to their dentist. Dr. William Morgan has elected to join with us in the center for our educational meetings as well as to serve as a consultant. His practice as a dentist has focused on the areas of tempro-mandibular joint disease (TMJ) and sleep apnea. In a similar manner patients with underlying mental disorders may be jointly managed by a sleep specialist and a behavioral medicine specialist in the community. Every effort is made to keep everyone involved in the care aware of the treatment plans and progress.

Equally important to the quality of services at the NEAC-CSD are the sleep technologists, nursing and the front office staff. In accordance with the standards set by the AASM, all of our sleep technologists have attained the standards of being a Registered Polysomnography Technologist (RPSGT). They are responsible for performing the sleep study, scoring the results for the sleep specialist to interpret, and in educating and training patients about aspects of treatment. This is a complex job and there are many ways of getting inaccurate data or making inaccurate scoring decisions. For this reason they receive comprehensive training before they are allowed to take the examination to become registered. At the center we have a chief technologist and manager, Rickey Lee, BS, RPSGT and four more technologists: Brock Smith, RPSGT, Coralyne Turner, CRT-SDS, RPSGT, Dalton G. Barber, RPSGT and Colleen Blanchard, RN, RPSGT. With these technicians the center provides studies 7 nights per week and when needed studies during the day. The center provides regular training opportunities to maintain the skills of the technicians and conducts quality assessments to assure consistency of scoring among the technologists and adherence to the scoring recommendations of the AASM. During the day, Stacey Hart, LPN serves as my clinic nurse and assists in the care of the patients being seen for evaluation and in follow-up, handles patient calls, data collection, quality assurance studies and helps with equipment ordering and patient problems. Our customer service representative, Mary Miles is in charge of center phone calls, patient scheduling for day and night evaluations, data processing, billing, quality assurance studies and insurance verification. Clinicians and staff are committed to doing our jobs well and are constantly looking for ways to measure how we are doing and how we can do even better to serve our patients.

Our facility consists of about 3500 square feet, and is designed to meet the needs of both a daytime sleep medicine practice and the needs a diagnostic test site performing over night and daytime sleep testing operations. There are 4 private sleep rooms with private bathrooms. They were designed and furnished to simulate the comforts and privacy of a bedroom at home, but have the needed technical equipment to monitor a night of sleep remotely from the centers control room. Patients have the ability to communicate at all times with the clinic staff in the control room via a two-way intercom. In addition low light video cameras and microphones provide remote monitoring of body position and any movements or sounds associated with some of the common sleep disorders.

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The rooms are also equipped to provide remotely controlled Positive Airway Pressure (PAP) devices that are utilized along with a face mask to treat obstructive sleep apnea. Oxygen is available if needed during the sleep study. There is a showering facility provided for those patients wishing to shower prior to going home or to work the morning after the sleep study. There are 2 exam rooms that serve for daytime sleep evaluations and as hook-up rooms in preparing patients for studies. There are two physician offices and a conference room for staff meetings and education. The center is a fully integrated service of NEA Baptist Clinic and shares a common electronic medical record and uses additional software to manage the sleep practice that helps in scheduling and work flow of studies but also allows building a database of information used for practice analysis and quality assurance studies. These systems facilitate good communication with referring providers, among our staff and with guiding our commitment for improving our practice.

The sleep center is seeing and treating patients with obstructive sleep apnea, insomnia, restless leg syndrome, periodic limb movement disorder, narcolepsy and other causes of excessive daytime sleepiness, and a variety of parasomnias conditions such as sleep walking, talking, sleep movement disorders, or other strange activities occurring during or around the sleep period. Not all of these conditions require treatment but are worth evaluating to determine if treatment or reassurance is needed. Patients who are self or physician referred often complain of loud snoring, daytime fatigue or tiredness, excess sleepiness during the day, poor quality of sleep or strange behaviors during the night. The center can also offer help with conditions called circadian rhythm disorders. Examples are shift workers sleep disorder, Jet lag, or sleep phase disorders (delayed or advanced). These disorders often arise because of the conflict created when we attempt to sleep or remain awake at times that proves to be at odds with the way our internal body clock is set. Many times the most important aspect of the sleep evaluation is gaining an understanding of how to improve sleep habits to get better sleep and learning about some of the myths and misconceptions that can develop about sleep.

One of the clear missions undertaken by the NEAC-CSD is sleep education. This may be directed at our patients, staff, or other healthcare providers. We firmly believe that patients do best with a deeper understanding of their sleep problem as well as its treatment. We in the center are willing to come out into the community to address groups or businesses interested in sleep issues related to most any topic. In the center we keep some education materials for distribution and have a resource center that provides access to recommended sleep education websites.

The physicians and staff of the NEA Baptist Clinic Center for Sleep Disorders are excited to be a new addition to the healthcare resources of Jonesboro and the region and are already working hard to help improve the quality of sleep for our patients. We pledge to continue our efforts to bring state of the art sleep medicine technology and treatment to the citizens of North East Arkansas.

David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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A Message from a Sleep Medicine Specialist/Neurologist Regarding

OBSTRUCTIVE SLEEP APNEA

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bstructive sleep apnea is the most common sleep disorder affecting millions of American people. Although it may appear to be just a simple breathing problem during sleep, a sleep breathing disorder will cause many complications affecting your brain, in addition to the heart. A brief review is listed below and I hope this will be substantially beneficial to readers who are outside of the medical area.

LACK OF CONCENTRATION AND POOR PERFORMANCE: The patients often feel tired.

Some patients subconsciously get accustomed to drinking a lot of caffeine to counteract the fatigue.

Although some individuals may do well in their work, they very likely perform significantly below their potentials. Obstructive sleep apnea will significantly increase the risk of having a serious accident including death and long-term disability when driving and operating machines.

POOR MEMORY: In function, patients were found to have delayed response latency and reduced accuracy in registration of information/message due to poor concentration and reduced alertness.

In pathology, there is a significant decline of capacity of neuronal reservation due to the possible chronic insult to the brain caused by complicated biochemical cascades secondary to oxygen desaturation/hypoxia and multiple inflammation mediators. Furthermore, if the brain does not get enough rest (restorative) on an almost daily basis, the result is a "wearing-tearing� effect, that continues to exist long term (deterioration).

DEPRESSION AND MOOD SWINGING: Patients frequently feel tired and have difficulty enjoying life. They may easily lose their temper and then apologize later. They may have decreased interest in many things simply due to fatigue.

SIGNIFICANTLY INCREASED RISK OF HAVING STROKE: Obstructive sleep apnea is an independent risk of stroke, like diabetes and hypertension. The mechanism that causes stroke by obstructive sleep apnea is complicated and not fully understood. In addition to raising sympathetic tone at night, causing elevated blood pressure during sleep (in normal sleep there should be a significant drop of blood pressure called "dippers"), the very complicated inflammation cascades are associated with significant small vessel arteriosclerosis (hardening of the arteries) and increased viscosity of the blood. Therefore, the screening and treatment of obstructive sleep apnea are the important part of stroke prevention.

STRONG ASSOCIATION WITH SEVERE AND INTRACTABLE HEADACHES INCLUDING MIGRAINE STATUS: Obstructive sleep apnea can either induce headaches or make headaches much worse. It can be the main aggravating factor in constant migraine sometimes.

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Sleep Tip!

INCREASED SEIZURE ACTIVITY IN PATIENTS WITH EPILEPSY: Obstructive sleep apnea can significantly reduce patient’s seizure threshold. It appears somewhat equivalent to sleep deprivation, which is a well known risk of breakthrough seizure.

BEING ASSOCIATED WITH SOME NEUROLOGICAL DISORDERS: Statistically, patients with stroke, Parkinson disease, REM behavior disorder, vascular dementia, Down's syndrome and congenital myotonia have shown a much higher incidence of developing obstructive sleep apnea, compared to the normal population.

MIMICKING SOME OTHER SLEEP DISODERS WITH SOME SIMILAR SYMPTOMS: Obstructive sleep apnea may mimic narcolepsy because its severe hypersomnia mimics a sleep attack. Patients with undiagnosed obstructive sleep apnea may complain of having restless leg syndrome due to tossing around. Severe obstructive sleep apnea patients may complain of insomnia rather than hypersomnia due to difficulty in falling asleep or maintaining sleep due to frequent arousals, gasping for air and/or cessation of breathing.

It may sound surprising that obstructive sleep apnea can be so extensively related to many neurological disorders. It is my desire to bring formal and updated information from specialty references to our patients and staff for more healthy brains.

Symptoms and signs of obstructive sleep apnea include snoring during sleep, excessive daytime sleepiness, significantly short and thick neck, overweight, gasping for air or awakening from sleep with difficulty breathing. Diagnosis of obstructive sleep apnea is made with clinical presentations with confirmation by a polysomnogram. The treatment of obstructive sleep apnea varies accordingly.

Mild cases can be treated with oral devices, loss of weight or nasal decongestion if an allergy exists. Positional types can be taken care of effectively with sleeping on the side only. Patient with nasal septal deviation, nasal turbinate hypertrophy, enlarged tonsils and prolonged uvular prominence with severe degrees will most likely need surgical correction. However, in the majority of cases; mild, moderate or severe; most can be effectively treated with a CPAP or BiPAP machine. So far, no clinical trial study has proved any other remedy with better efficacy statistically, although the media announces “NoCPAP.com”

Practices conducive to good sleep • Sleep only when drowsy • Minimize light, noise and extreme temperatures • Avoid strenuous exercise six hours before bedtime • Avoid large meals, caffeine, alcohol and nicotine before bedtime • Avoid napping during the daytime • Avoid lying in bed unable to sleep • Maintain a regular arise time, even on days off and on weekend

Do you get the right amount of sleep...

Take a sleep quiz at William Long MD, PhD Neurology & Sleep Medicine NEA Baptist Clinic – 870.935.8388

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I

t was a typical night; John and Mary, a married couple in their 60’s, had been peacefully sleeping when Mary is awakened by a disturbance next to her. John is actively engaged in a loud conversation, and he is not calling out to her! He is warning someone to “look out…take cover now!”

John’s arms begin to swing like a boxer, at first swinging out into the darkness, and then he lands a hard blow to her cheek. Mary, at first stunned, soon feels the intense pain in her face. John continues his active assault, but now he has jumped from the bed in a mad dash to somewhere, all the while yelling, “quick get down, into the foxhole.” Then he runs into the bedroom wall and falls backward hitting his head on the dresser’s edge.

Mary screams “what are you doing?” There is no answer, and she tries several more times before John finally hears his wife’s voice. Mary repeats, “What are you doing?”

John, becoming more aware of his real surroundings, slowly responds, “I was back in Vietnam, I was taking cover and warning my buddies to do the same. I guess it was just a bad dream.”

So, what’s up with that? This event is something that many people are unfortunate enough to endure on an almost nightly basis. John has just suffered from an episode of what is called REM behavior disorder (RBD). John, experiencing a very unpleasant dream about his Vietnam combat experience, begins to “act out” the scenes as they unfold in his dream by swinging out in defense and running for cover, calling to his comrades on the way. To his shock and amazement he finds he has injured his wife and suffered personal injury when falling against the bedroom furniture. This episode is not what happens to a normal person. When we enter rapid eye movement sleep and experience a dream, the brain, in effect, turns off our body muscles with the exception of those for breathing and eye movements.

What happens to John and other patients like

him is that their muscles are not “turned off” and they are able to act out their dreams unaware of any effect on the real environment or its inhabitants.

RBD has an estimated occurrence in the general population of 0.5%.

The first reports of acting out dreams appeared in the 1970’s and the description of the clinical disorder followed in 1986. The overwhelming numbers of patients with this disorder are older men who either have or will develop degenerative disorders of the brain.

Perhaps the most common such disorder is Parkinson’s disease, in which up to 25 % of patients may exhibit the behavior. RBD has also been associated with narcolepsy, autism, multiple sclerosis, stroke patients, brain tumors and other neurological conditions. These conditions produce a chronic form of RBD but an acute type has been associated with alcohol withdrawal and with the use of prescription medications used to treat depression, dementia, anxiety, and Parkinson’s disease to name a few. It has also been implemented in the excessive consumption of caffeine and chocolate. When the cause is related to the medications, women and younger patients have been seen with the disorder. The chronic form can also occur as an idiopathic (unknown cause) disorder. The cases will present with either the complaints of violent sleep behavior or with the resulting injuries to self or bed partner.

Diagnosis of RBD is in large part made from the history of the clinical behavior occurring after about 90 minutes of sleep or in pre-dawn hours. Both are typical times for the appearance of REM sleep. Confirmation of the disorder can be achieved with the use of the polysomnogram (sleep study). During this study limb movements are found to occur during periods of REM sleep which would usually show no motor activity at all. Fortunately, treatment can be highly successful with the use of the drug clonazepam.

Response is seen in over 90 % of the patients and they maintain a lasting benefit over years of therapy.

Another experience out of REM sleep that virtually all of us have experienced is a nightmare. We all know that a typical

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nightmare consists of an emotion charged dream (typically anxiety, fear or terror but also anger, rage, embarrassment or disgust). It usually portrays experiences that focus on imminent danger or threat to the individual but may be other distressing themes. Occurrence of nightmares is highest among children and declines with age.

Percentages will vary depending on the reported frequency in all age groups. If one considers the frequency of “at least sometimes” then reports are: 30-90% among children; 40-60% in young adults; and 60-68% in older adults. There has been some suggestion of a familial or genetic predisposition to nightmares. When the occurrence of nightmares takes on a recurrent theme with increased severity, and there is associated sleep disturbance with a delay in return to sleep it begins to satisfy the diagnostic criteria of nightmare sleep disorder.

Some medications have been reported to be associated with increased nightmares. Some examples include the beta-blockers, Calan, Aricept, Halcion, and Prozac. Treatment is not typically required but a variety of treatments are available when it has reached highly disturbing status. Most of the successful therapy modes involve some form of behavioral therapy.

muscles, or speak. Breathing and eye movements are retained. This can be a normal finding or may be part of the symptoms of narcolepsy.

This disorder like the one above occurs because of the residual effects of REM sleep that have not gone away with the onset of wake state. It is estimated that the occurrence of this event is low. It occurs “often or always” in 0%-1% of young adults and “at least sometimes” in 7-8%.

If one looks at the frequency of at least once in a lifetime, it goes up to as high as 40-50% of the population.

I would like to mention one last sleep disorder that occurs as an event during sleep. It is called sleep bruxism. It is characterized as a grinding or clenching of the teeth during sleep. It can cause noise sufficient to disturb the bed partner, but can also be destructive to the teeth and jaws, and be a cause of headache and orofacial pain. It is estimated that 8% of the general population are conscious of teeth grinding sounds during their sleep. Clinical recognition is based upon the history of the grinding, a morning jaw pain or stiffness, or worn teeth on inspection.

Confirmation of the disorder can be seen during a polysomnogram with the increased motor activity of the jaw muscles seen during the sleep period. Causes may relate to increased stresses and anxiety or to increased sleep arousal responses. Treatment may consist of relaxation therapy, improved sleep hygiene, muscle relaxants, or oral appliances to protect the teeth. Many dentists are very familiar with this disorder and check for it during routine dental exams.

There are several disorders that occur during the transition into and out of our sleep. Some of these can be frightening until we understand more about them. One is called the sleeps starts or jerks. It is a sudden jerking of the arms, legs, face or neck that is often associated with the sensation of falling and occurs with The above descriptions of the sleep disorders occurring Occurrence of nightmares...the onset of sleep. It may be out of sleep along with those described in the last issue the frequency of “at least accompanied with a vivid, of this magazine (sleep terrors, sleep walking etc) are sometimes” reports are: 30-90% impactful and brief dream some but certainly not all of the disorders arising among children; 40-60% in young event. This is a normal from sleep. As I have said previously, the study of phenomenon, and may sleep disorders is fascinating. As suggested by adults; and 60-68% in older adults. occur with a frequency as Murphy’s Law “anything that can go high as 60-70 %. At times wrong…will go wrong”. It is very likely many there may be a loud auditory more disorders of sleep are yet to be discovered component of an explosion, thunder clap, cymbal clashes sound and understood. The process of waking and or other similar sound. The emotions of fear or terror associated with sleeping is a highly complex series of biologic events that involve one a racing pulse or cessation of breathing have also been reported. A of the most complex organs in our body, the human brain. I continue terrifying hallucination that occurs with the onset of sleep or to be amazed by the complex interaction of emotional, physical, wakefulness is another example of a transition disorder. It is called environmental, and developmental factors either a hypnagogic (at sleep onset) or hypnopomic (upon awakening) that have the ability to affect the quality of our and consists of the immediate recall of a dream content that is typically sleep and therefore the quality of our life. threatening in nature. It has a very real feeling like the events are actually occurring in the bedroom. It is thought that these represent a delay in the cessation of a REM sleep dream during the immediate period of waking. These can be a normal finding or may occur with the increase in REM sleep associated with the removal of medications known to suppress REM sleep. They are also a feature of narcolepsy.

One last example of a transition disorder is called sleep paralysis. This is the brief experience of awakening and being unable to move your David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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SPARASOMNIAS LEEP TERROR J

ohn and Sue are sitting in their living room for a moment of quiet and relaxation watching their favorite TV program. About an hour ago, their 9 year old daughter Andrea went to bed, and they are confident that by now she is asleep. Suddenly, the peaceful moments are abruptly shattered by a loud, blood-curdling scream coming from Andrea’s bedroom.

John and Sue, their hearts pounding, rush to the bedroom and discover Andrea sitting bolt upright in her bed with a blank stare, her eyes wide with terror, skin flushed and sweating profusely, and her chest heaving with a pounding heart and rapid breathing. It is like she is looking right past her distraught parents. Sue, without pausing, rushes to console her as John looks on in disbelief. But the effort proves to be fruitless, and even seems to aggravate the situation. After what seems a lifetime, Andrea appears to awaken but is confused and mumbling nonsense. After 15 very uncomfortable minutes, she recognizes her mother, and Sue’s efforts to calm her daughter finally meet with success. When asked, Andrea cannot remember anything about the episode and remains shaken for several more minutes.

So…what was that? Andrea and her family just experienced a sleep disorder known as a sleep terror. It is one of several disorders of arousals that arise out of non-rapid eye movement sleep (NREM).The other disorders of arousal are confusional arousals, sleep walking and a specialized form of arousal known as sleep eating disorder. Sleep terror, is unquestionably, the most dramatic of the arousal disorders as this example clearly demonstrates.

These arousal disorders of sleep are part of a group of sleep disorders known as parasomnias. This group is defined as unpleasant or undesirable behavior or experience that occur predominantly or exclusively during a sleep period. Although once thought to be associated with psychiatric disorders, newer research has shown that parasomnias are due to a large number of completely different conditions, most of which are diagnosable and treatable. They are also both more common than previously thought, and are not as limited to the pediatric age group. Parasomnias are categorized as primary (disorders of the sleep states) and secondary (organ system disorders that appear during sleep). Those associated with sleep are further classified

as to the sleep state of origin: NREM sleep, rapid eye movement sleep (REM), or miscellaneous (those not respecting sleep states). The very presence of parasomnias is a good example of how wakefulness, NREM and REM sleep are not always mutually exclusive. They represent complex interactions of our brain cells that are controlled by numerous chemicals in the brain known as neurotransmitters. Just as Murphy’s Law would predict, what can go wrong will go wrong.

Parasomnias represent a “blend” of wakefulness and sleep (either REM or NREM sleep) and therefore what is witnessed appears like someone “half asleep” and doing strange things for the situation. In technical terms this is called state dissociation with wake and sleep overlapping. In the overlap status the patient can accomplish many complex activities common to wakefulness but is usually unaware of what is being done and gives the outward appearance of being “sleepy”. I will use the rest of this article to discuss the other NREM parasomnias with emphasis on the clinical features, aggravating factors and their treatment.

Those that arise out of REM sleep and those that do not respect sleep stages will be the subject of a future article.

A confusional arousal is seen in up to up to 17% of children and can occur in up to 4% of adults. It is characterized by movements in bed, sometimes a thrashing about and may be accompanied by a vocalization or inconsolable crying. The event is mostly seen during the NREM slow wave sleep (Stages 3 and 4) and therefore is most common in the first third of the sleep period. It is often precipitated when attempting to awaken the child from sleep, especially the early portion of sleep and may persist for 15 minutes or longer.

During this arousal the individual is disoriented, has slow speech, diminished mentation, and often amnesia for the event. Behavior can be very complex and on occasions even violent or resistive in nature. The individual may appear to be awake but is still very much asleep. A similar condition can occur with the morning awakening and has been called sleep inertia or “sleep drunkenness”. These are the individuals we all know as impossible to get up and get going. This may well be a variant of the confusional arousal.

Another arousal disorder arising out of NREM sleep is sleepwalking. This like sleep terror can be very dramatic

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depending on the distance traveled and the mood of the individual.

45% when one parent has been affected and 60% when both have It often starts with the individual sitting up in bed, and then drifting been sleepwalkers. All of the arousals are more common during sleep off around the room, house or even outdoors. At times it may start deprivation, but are also more common with hyperthyroidism, with a bolt of activity or a mad dash. The sleep walker may leave the migraine headaches, encephalitis, head injury, and strokes. Sleep house and engage in activities like driving equipment or disorders like obstructive sleep apnea and other forms of sleep automobiles with obvious risks. There can be violent behavior related breathing disorders can make them more likely. Other factors especially in older male children and adults. Reports have been made capable of bringing them on are travel, febrile illnesses, sleep in of individuals walking through windows with resulting harm from unfamiliar surroundings, certain medications, and physical and falls or cuts. The sleepwalker is unaware and if awakened will be emotional stress. confused and sometimes combative with the person attempting to wake them. Because these episodes arise from slow wave NREM In general, the course in children improves with age and may be sleep they appear in the early portion of the sleep period. These gone by adulthood, although some may persist. Persistence into episodes may terminate with the individual returning to bed and to adolescence adds the prospects of some social embarrassment when sleep or may terminate in inappropriate places. The sleepwalking overnight sleep guests are more common. Treatment is often can be associated with loud shouting, or inappropriate activities like supportive in nature. Creating a safe sleep environment with locks moving furniture, urinating in a waste basket, etc. This can occur in on doors and windows, hiding vehicle keys and dangerous tools is children in up to 17% and often with the peak of ages 8-12. There important. Maintenance of good sleep hygiene with adequate sleep is no sexual difference except for violent behavior being more duration and consistency helps to reduce the occurrence. Diagnosis common in adult men. The adult and treatment of any precipitating sleep occurrence rate is up to 4%. Many of the disorder or medical condition can be children who sleep walk had episodes of useful. At times there are medications that confusional arousals at an earlier age. can be used to lower the severity or ...most of the parasomnias offer, frequency of the events. Clonazepam has on the one hand, frightening A unique form of sleep walking is a specialized been useful in sleep terrors, and dopaminergic experiences, but, on the other, form of arousal known as sleep-related eating agents have been helpful in the sleep-related disorder. This is a condition that results in an very interesting examples of the eating disorder. awakening from NREM sleep during which fine line that exists between the individual moves from the bedroom to the These arousals like most of the parasomnias wake and sleep states. kitchen or other place of food storage. The offer, on the one hand, frightening activity could be as simple as eating a candy experiences, but, on the other, very bar or as complex as preparing a meal and eating it. At times, interesting examples of the fine line that exists between wake and individuals may return to their bedroom where the food is sleep states. The conditions can invade each others territory with consumed leaving evidence of the sleep behavior. Individuals have some strange outcomes. Many people are baffled, embarrassed or no recall of the event and often only become aware when finding the frightened by their occurrence and often think them too strange to kitchen mess or the food wrappers in the bedroom. It is often very even talk about. No matter how strange a behavior is, it is very likely disturbing to the individual because of the associated weight gains some form of described, or yet to be and the embarrassment and strangeness of the behavior. described, form of a parasomnia. Don’t hesitate to discuss the problem with your This group of arousal disorder share some common predisposing physician or seek consultation with a sleep and precipitating conditions. Genetic factors and familial tendencies specialist to learn more about it for your appear to play a role. This is especially true in sleep walking. The rate own peace of mind. of children being affected is 22% when neither parent has a history,

David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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Is it a Sleep Disorder?

T

he field of sleep medicine is by most standards a newcomer among the many medical specialties available. Over the past decades it has followed the same developmental path of many of the other specialties. There has been an ever increasing body of medical knowledge from basic science and clinical practice experiences, increased availability of trained clinicians, formation of professional organizations that have developed professional practice standards and guidelines, as well as a board certification process.

Due to the efforts of these organizations and others there are disease classification systems that describe over 80 sleep-related disorders.

Parallel to the growth of the professional organization of sleep medicine there have been huge efforts to increase public knowledge about sleep and its many disorders. Despite these efforts many individuals are unaware of sleep symptoms that may suggest the presence of a treatable sleep disorder or underlying medical or psychiatric disorder contributing to altered sleep efficiency. Even if suspected, what one can or should do may not be clear. In this article I will highlight some of these symptoms (experienced by patients) and signs (observed by others) and discuss their significance and options for their evaluation.

To set the stage for the abnormal, let me take a shot at a simple description of normal sleep. A good sleeper is one that has a consistent bedtime and rise time, and becomes sleepy at or near the same time each night. Sleep is uninterrupted, and wake time is at or near the same time each morning unassisted by an alarm clock, and results in a feeling of being refreshed, restored and ready for the day.

Throughout the day there is a sense of full alertness, with sharp, clear thought and judgment without any desire to sleep. In short, one is running on all cylinders and ready for anything. An expected brief period of decreased alertness typically comes in the early to mid-afternoon due to a dip in the alerting signals from the body’s internal clock. Many cultures deal with this biologic event with their “siesta time.”

As I begin to discuss the symptoms and signs that can be seen, it is important to note that these may occur as a result of a sleep disorder (primary) or may be an effect on sleep that is caused (secondary) by another medical or mental illness. This relationship can be complex with the loss of sleep resulting in a worsening of the primary disorder as well. Depression and fibromyalgia are two examples of this bidirectional relationship. Other times the primary condition

may be the sole cause of the sleep disruption and its consequences.

Examples are the pain of arthritis, nighttime breathing disturbances from asthma, COPD or heart conditions, sleep arousals from the frequent urination of bladder conditions, or the hot flashes of menopause. It is thus clear that a sleep symptom like any other medical symptom may have multiple causes and therefore requires a careful medical history followed with appropriate testing to sort through the list of possible causes (differential diagnosis). Successful completion of these steps ensures the most effective therapy and the desired resolution of symptoms. So, with this in mind let’s look at some common sleep signs and symptoms.

One of the most common sleep symptoms, snoring, offers a potential problem for both the snorer and the bed partner. It is actually an example of both a sign and a symptom. Most often the bed partner is the complainer because of the loud volume and the disruption that occurs in their sleep. The snorer may awaken themselves or feel they have non-restoring sleep and thus produces symptoms that alert them to a problem. This sign/symptom could simply be related to primary snoring, but often it is a tipoff to the more serious problem of obstructive sleep apnea (OSA), or other obstruction in the upper airway.

Excessive daytime sleepiness is defined as a tendency to fall asleep during activities that are most often associated with wakefulness. Often this symptom is overlooked by the individual who instead rationalizes it as boredom, or being tired and worn out from the day’s activities.

Some individuals are fully aware of the symptom and have an uncontrollable need for long sleep periods that never seem to relieve their sleepiness. The excessive sleepiness

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interferes with the ability to work, attend school and enjoy social Have you ever had the sensation of being unable to move when functions with the family. Remember, the well rested sleeper stays falling to sleep or upon awakening? Being unable to speak and only awake until the next bedtime. Sleepiness can be a sign of several able to move your eyes and breathe? Fortunately, the experience sleep disorders, depression, drug or substance use or insufficient dissipates in minutes with things returning to normal. This is very quantity of sleep. The large number of possible causes demands a likely an episode of sleep paralysis. Although it can occur as an detailed sleep history and appropriate testing to infrequent normal phenomenon, it may also determine the root cause and select the best therapy. be symptomatic of a sleep disorder.

Fortunately many causes of excessive sleepiness Sleep disorders may show up are manageable, and improved quality of life Sleep disorders may show up as can be achieved. strange behaviors during the as strange behaviors during the night. These may include The complaint of insomnia is the inability to common ones like sleep talking, night...sleep talking, teeth achieve or maintain sleep or the awakening teeth grinding, grunting and from sleep earlier than desired. The usual result grinding, grunting and moaning, moaning, or sleep walking. The is a sense of non-restorative sleep with a reduced latter may be simply getting up or sleep walking. ability to perform well during the wake period. to the bathroom asleep but may Almost everyone has had the loss of sleep associated be much more complex with with life’s stresses and problems. Resolution of the wandering into the kitchen and fixing stress or problem generally results in correction of the sleep a snack without knowledge of doing it until finding the mess in the complaint. At other times the symptom becomes much more morning. Even more frightening can be leaving the house and chronic and can extend to months or years of suffering. This driving somewhere without being aware of what you are doing. symptom can reflect a primary sleep disorder or be caused by Violent behavior can be seen with the bed partner becoming the numerous medical and mental illnesses, as well as from other sleep victim of unintended injury as the sleeper acts out an often scary disorders. The longer an insomnia complaint goes unresolved the dream, thinking all the times the attack is directed at an assailant. much more likely the sleeper develops maladaptive behaviors and This is known as REM behavior disorder and is important to both thoughts about sleep and the night time. There are many effective recognize and treat. Dreams may take the form of nightmares and ways to deal with the complaint, and most patients can be helped be disruptive to sleep quality. Night terrors occur as an arousal from with medications, behavioral therapy or a combination. A detailed sleep accompanied by loud screams with total disorientation of the history of the insomnia onset and subsequent developments is sleeper and often times amnesia for the event. Many other activities incredibly important to successful management. have described in individuals during sleep, not all requiring treatment but many worth discussing with your physician for Another annoying symptom is to have the tranquility of sleep onset reassurance and to be certain no therapy is required. Varieties of interrupted by the uncontrollable urge to move your legs. This is nocturnal seizures, with associated strange behaviors, have also been typically accompanied by a sensation of numbness or tingling, or a described and are not that uncommon. Medications can be very feeling of something creeping or crawling up the legs. Movement effective in eliminating this frightful and stressing condition. offers temporary and sometimes significant relief. At other times the sensation may be a cramping. This symptom is highly suggestive Human sleep is a fascinating thing. It is far from being as simple as of restless leg syndrome flipping a switch and disconnecting oneself from the environment but can be mimicked until it is flipped again. Sleep is a very active physiologic process by other medical involving complex brain activities that cycle during the night. conditions. Restless legs Adequate quality and quantity is critical to many body systems. Like can be associated with any one of these other processes, sleep can function abnormally and iron deficiency anemia or will result in signs, symptoms, and consequences that can affect the chronic renal disease. quality of life. And, like any other symptom of a dysfunction, sleep Does your spouse symptoms should be adequately evaluated using standard medical complain of being kicked processes to make a definitive diagnosis and initiate the appropriate during the night or that therapy. It is the very promise of providing the bed shakes as you help and relief to the sleep sufferers that makes perform movements that the specialty of sleep medicine both exciting look like you may be and rewarding. riding a bike? You may be suffering from periodic limb movement disorder, a highly treatable condition.

David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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It is 1:00 a.m. and John, a 30-year-old attorney, is lying in his comfortable bed, eyes wide open, and unable to get his mind off the big event that will take place in the morning. He has been unable to get to sleep since his usual 11:00 p.m. bedtime. The big event is his first big jury trial concerning a personal injury claim for his client. He keeps going over the strategy he will employ and cannot get it off his mind. He begins to worry about how he will ever be able to perform if he cannot get some sleep soon. This is not usual for him, as he is usually a very good sleeper and can only remember one other time in his life this has happened. He was 25 years old and was to take his state bar exam the following day. When he awakens the next day he feels like he had a very non-refreshing night of sleep.

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W

hat is John’s problem? He is suffering an episode of acute transient insomnia. He, along with an estimated 30 million other Americans, is experiencing a random sleepless night that is precipitated by a stress or change in his life. This type of insomnia, also known as adjustment insomnia, is fortunately a self-limiting event that is almost always eliminated when the stress is relieved or one adapts to the life change. Just about all of us at one time in our lives have or will experience such an event. However, not all insomnia is this straight forward or goes away that quickly.

These principles will help the situation to be more conducive to the sleep process.

Insomnia is defined by the American Academy of Sleep Medicine’s International Classification of Sleep Disorders as “a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some type of daytime impairment.” Individuals with insomnia usually complain about difficulty in getting to sleep or awakening many times during sleep. Less often the complaint is expressed as having had a poor quality or non-restorative sleep. Daytime 1) Sleeping only as much as you need to complaints consist of fatigue, tiredness, sleepiness, irritability or other mood disturbance, and may involve functional areas. feel well and function the next day; Problems may consist of an inability to concentrate or focus on 2) Get up at the same time each day, 7 the tasks at hand, a sense of mental cloudiness, memory impairment, and periods of “mini-blackout” or “disconnect” from days a week; the immediate environment. Overall there is a feeling of being 3) Exercise regularly (but not within 3 unable to perform to the usual or expected standards. To diagnose hours of bedtime); true insomnia, both the nighttime and daytime features should be present. When these symptoms persist for months, the insomnia 4) Make sure the bedroom is free of light is classified as chronic.

Sleep hygiene principles include:

Behavioral psychologists utilize a model of chronic insomnia suggested by Dr. Arthur Spielman to evaluate their patients. The model suggests there are predisposing factors, precipitating factors and perpetuating factors to chronic insomnia. A patient may have a family history of insomnia, be an excessive worrier or a “light sleeper” and be more susceptible to development of chronic insomnia. Initial episodes of insomnia may be provoked by things like job changes, stressed relationships, or the birth of a child.

Many individuals then, in an effort to “deal” with the insomnia, engage in behaviors that actually end up perpetuating the insomnia and having it appear to develop a “life of its own.” The bedroom, bedtime and the night no longer invite sleep but rather provoke anxiety and worry with a fixation on “making” oneself sleep. When it becomes chronic (lasting months to years), it is time to deal with the problem before it becomes a major disturbance to the quality of life.

Insomnia can exist as a symptom of or as a consequence of another condition; then, it is considered secondary insomnia. It can occur in patients with other sleep disorders, medical conditions, psychiatric illnesses or substance-abuse problems. In these situations it is important to recognize and include treatment of the underlying condition when treatment plans for the

5) 6) 7) 8) 9) 10) 11) 12)

13) 14)

and noise; Regulate temperature to what is comfortable to you during the night; Eat regular meals, and do not go to bed hungry or overstuffed; Avoid excessive liquid in the evening; Cut down or off all caffeine products; Avoid alcohol, especially in the evening; Cut out smoking in the evening prior to bed, and preferably altogether; Don’t take your problems to bed; Do not try to fall asleep; if unsuccessful, get up out of bed and wait until sleepy to return; Put the clock under the bed or turn it so you can’t see it; and Avoid naps.

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Stimulus control and sleep restriction often work together.

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insomnia are developed. Like any medical condition, insomnia is best managed after a careful medical examination because there are multiple possibilities for its cause and different methods of treatment that could be recommended.

So what are possible treatment options if you are found to have chronic insomnia? Option No. 1 would be to do nothing and continue your current path with the knowledge that the insomnia is not likely to be a signal of some serious disease. The upside is no time or money spent on therapy, but the downside is it is very unlikely to go away on its own. Option No. 2 includes several types of sleeping pills or hypnotics that can help promote a nearly normal type of sleep. The most commonly prescribed types are non-benzodiazepine hypnotics (Ambien, Lunesta, Sonata and Rozerem). The upside here is the relatively immediate relief – a 30 to 50 percent improvement in the sleep – and with sustained gains demonstrated from 3 to 6 months to up to one year in clinical studies. The downside is that these medications offer no cure, and, when stopped, the problems have a high recurrence rate. Option No. 3 is to use what are called sedating anti-depressant medications. Upside potential is the offer of some immediate relief, and the gains can be stable for months to years and no withdrawal symptoms. The downside is there is less effect on sleep onset than the hypnotics and the gains achieved may be less. There is also the potential of more unpleasant side effects and the possibility of any long-term benefits after the medication is stopped is unknown. Option No. 4 is a therapy known as cognitive behavioral therapy for insomnia (CBT-I). This involves several different components and begins with an effort to educate the patient about normal sleep and normal sleep mechanisms.

It helps for patients to understand how the body sleeps and how they can maximize behavior that positively affects their sleep. The therapy is conducted over 5 to 8 office visits designed to confirm the diagnosis, introduce the elements of therapy and monitor progress of their application. The therapist and patient work as a team with the therapist as educator and advisor while the patient is the implementer of the plan and recorder of the data that marks progress. Each program is tailored to the patient’s needs, and not all patients are suitable for this approach. Some common components of such therapy include emphasis of good sleep hygiene measures, sleep stimulus control and sleep restriction therapy. Other measures that may be added are relaxation training and cognitive therapy.

Stimulus control and sleep restriction often work together. The underlying concept is that one cannot make oneself sleep, but the failure to sleep can build negative sleep stimuli with the bedroom, bedtime and the night.

Basic principles are that the bedroom has only two purposes, for sleep and intimacy. Any other activity needs to be done elsewhere. Don’t go to bed unless sleepy. If that does not occur within 15 to 20 minutes, then leave and go somewhere else in the house until the drive to sleep returns. This would be repeated as often as needed during the night. Although this sounds counterintuitive, the object is to build the drive to sleep from longer periods of wakefulness away from the bedroom rather than spending the time in bed with thoughts of not being able to sleep. Another cornerstone of this therapy is to set consistent bedtime and wake times while avoiding sleep at other times. The most restorative sleep comes from consolidated periods of sleep, and naps only reduce the drive to sleep during the selected period.

Successful implementation of such therapeutic principles has been shown to reduce the time to get to sleep and the time awake after asleep by 50 percent. There are also benefits seen in the sleep efficiency (the percent of time asleep of the total time in bed.) Upside of this therapy is it offers the possibility of cure. The downside is the effects can take several weeks to achieve, and it requires significant effort on the part of the patient and skill on the side of the clinician.

Perhaps the most important message to leave you with is that insomnia is not an incurable situation. There can be clear benefits of improving the sleep when a structured treatment plan is put in place and implemented by the patient under the guidance and assistance of a qualified therapist.

David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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Having Trouble Sleeping...

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We can help!

Come tour our Sleep Center with comfortable, convenient sleep study rooms.

- Board Certified Physicians & Registered Sleep Technologists -

1118 Windover, Jonesboro, AR

870-336-4144 www.neabaptistclinic.com 1S\bS` T]` AZSS^ 2Wa]`RS`a

David R. Nichols, MD Bing Behrens, MD William Long, MD, PhD

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B

eing a member of the 21st Century brings with it many advantages and conveniences in our daily lives. Thanks to scientific and technological advances our lives are made easier and more enjoyable.

Medical research has helped us to live longer and has developed excellent treatment for controlling and reducing the risk of many of society’s chronic illnesses like diabetes, hypertension and heart disease.

But along with these advances has come a continuing push to be a 24/7 society. We have expectations of finding services, shopping, dining, and entertainment available around the clock. More and more of the workforce needed to operate our 24/7 society finds itself expected to work at nontraditional times. This expectation is not limited to the service industry but includes the traditional manufacturing jobs as well. Many companies are forced, for economic and productivity reasons, to utilize an around-the-clock workforce. It is estimated that about 20 percent of our workforce has a job that requires work hours outside the traditional 7 a.m. to 6 p.m. workday on a regular basis. This number is likely to rise as the requirement for mandatory overtime and second jobbing becomes more commonplace.

So, what’s the problem with this picture? One just sleeps at a different time. No big deal, the clock has 24 hours and you take your sleep time where you must, and move on! This philosophy is fine for the 80 percent of workers fortunate enough to work during the daylight and be in their beds during the typical night sleep times.

But those who work the “night and early AM shift times” find themselves either getting up very early to make the pre-dawn start-times, or, even worse, find themselves working all through the night. They soon discover that man

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is not wired to work at night and sleep during the day. Many shift workers find great difficulty with this nontraditional and un-natural schedule.

Their problems fit into a describable medical diagnosis called a circadian rhythm sleep disorder, shift-work type.

understates the magnitude of the problem. It is also known that certain workers are more likely to develop problems coping with the rigors of shift work. Individuals older than 50 years, those with a history of gastrointestinal problems, psychiatric illness, previous sleep disorders, diabetes, epilepsy or heart disease are typically more prone to suffer from this sleep disorder. Also more susceptible are those working second jobs or having heavy domestic responsibilities. An individual’s sleep time preferences can be either a plus or a minus in this situation. The “morning person” suffers with the night shift, while the “night owl” does especially well.

The International Classification for Sleep Disorders tells us that the circadian rhythm sleep disorder, shiftwork type, is characterized by complaints of insomnia or excessive sleepiness occurring in relation to the working of night and early morning shifts. These workers typically report curtailed total sleep times from one to four hours. Their sleep quality is perceived as unsatisfactory. There often is the complaint of difficulty in initiating or sustaining the necessary Why does this happen? The short daytime sleep, and as a result sleep answer is because man is designed to deprivation occurs with the symptoms function alertly during the day and of decreased alertness, loss of sleep at night. To do otherwise is to concentration, decreased motor skills, attempt to change or go against our and irritability as well as increased internal biologic clock or circadian sleepiness during the wake hours. rhythm. We tend to be overcome by the Complications of the disorder have drive to sleep when two different been described with increased mechanisms “kick in.” One, the gastrointestinal symptoms and circadian rhythm, has a daily cycling exacerbations of cardiovascular between sleep and wakefulness and is disorders. It is also recognized that largely set by the environmental cues there are frequent disruptions of the from light. We tend to get sleepy when social and family life that often can the nighttime falls and become alerted lead to fractures in relations and when the sun rises. This clock affects increased tensions within the family not only the drive to sleep but many of unit. All too often individuals who our body systems are tuned into it as suffer the most with this disorder find well. The other drive to sleep is called themselves at greater the homeostatic drive. It is risk of accidents or ...individuals who suffer simply a buildup of the need to the most with this injuries, and due to sleep that comes from their symptoms they disorder find themselves prolonged wakefulness. The at greater risk of bring both safety and longer one goes without sleep, productivity issues to accidents or injuries... the more difficult it is to avoid the workplace. the onset of sleep. Even minor loss of sleep will make this drive cause It is estimated that from 2 to 5 percent us to feel drowsy, even in the daytime. of shift workers may suffer with this The only “fix” for this drive is sleep problem. However, this is a adequate periods of sleep. A person difficult statistic to obtain and the working the night shift must go against estimate may be inaccurate and likely his internal clock and attempt to be

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alert during the night, when his environmental cues are to sleep. Even worse, the worker many times has great difficulty getting sufficient amount of sleep during the daytime or early evening that is capable of suppressing the homeostatic sleep drive. Thus the worker is at risk of having to work in a sleep-deprived state and during a time interval that his body is telling him to sleep.

As if this were not enough to deal with, there are more complicating factors that can affect the situation. Although the worker needs to sleep during the day, society doesn’t always respect this need. The necessity of getting things done often forces a worker to choose between sleep and not getting the task completed. Interruptions to sleep can come from the telephone, loud noises, door knocks, family members, and dozens of other examples. Light and potentially increased daytime temperatures can be problems for daytime sleepers. Family members and their needs, as well as the sense of obligation and desire on the part of the worker to be a part of the family life, further contributes to the likely loss of sleep. This may be from either the time spent in activities or the emotional stress of feeling guilty that then interferes with the attempts to sleep.

Perhaps in an unknowing manner, many times the efforts to be fair with work schedules can further complicate the shift worker’s lot. Everyone has heard of “jet lag” and realizes that when one travels to a distant time zone your body has to adjust, and that there are functional issues that are very similar to what is described above.

With jet lag our internal clock is aided in its time resetting by stimuli that come from a “new” light dark cycle, and from the social cues from the activities around us. These are lacking for the shift worker. His work cycle is the only change. Although there can be some adaptation to the new work time, it is rarely complete during the days allotted to working the shift.

Workplace policies that vary the shifts among groups of workers can keep any complete adaptation from happening.

This, in effect, causes the body to be in a constant need to adapt – a goal made more elusive by these very changes.

Rotating shifts, off times when workers

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rejoin their daytime oriented families, and extended overtime all further complicate the delicate processes attempting to adapt to the un-natural work periods.

workplace can be adapted to help the workers become more successful in their struggle to change. Things like bright lighting, and consideration of authorized power naps, timings of breaks and approving the use of Solutions to this problem, just like the alerting medications may help problem itself, are neither simple nor facilitate the internal clock shift. They within the control of can learn to listen to those any one particular workers who are having Individuals can learn to person or group of trouble adapting to the make a self-assessment of people. They must night shifts and adjust their own tolerance come as a result of schedules where possible. for the shift work... the cooperation They can look to the among workplace research in work shift managers, the family, and society and scheduling and strive for the least from the individual. It is essential for disruptive types of schedules that can everyone involved to be educated still achieve the economic and about the issues that bring about the productivity goals. And perhaps most sleep disorder and its real importantly they can learn to watch consequences that threaten individual for the signs of workplace sleep and public safety, diminish deprivation among their employees. productivity and work quality, and They need to develop methods that contribute to weakening marital and detect quality, safety, absenteeism and family relationships. Education is health issues that can stem from the needed in what the scientific and failure to tolerate the many stresses medical communities know may be created by the work schedules. Doing helpful in reducing the symptoms and this may well uncover currently risks. unappreciated consequences already present in the work place.

Individuals can learn to make a selfassessment of their own tolerance for One reason for strong optimism may the shift work and make decisions on well be that timing may be on our side. whether to continue or find ways to get The discipline of clinical sleep to more tolerable shifts. They can learn medicine is on the rise, and increasing how to better control the daytime sleep numbers of trained sleep physicians are environment and their sleeping habits. becoming available to help educate and They should talk with their physicians treat these individuals. Due to the about medications that can both aid tireless work of many of the early sleep during the day or increase pioneers in sleep medicine, there has alertness during the work shift. They been an ever-increasing awareness of can learn the importance of a regular the importance of good sleep and sleep routine and how to best adapt to the consequences of too little or bad the changing work schedules. Families sleep among the public and practicing can be educated on the importance of physicians. More funding for sleep helping to maintain and research is there, and answers to the not interfere with the quality of the complex questions raised by this worker’s sleep environment and better disorder are being sought. However, understand the stresses that come from undoubtedly the first and most such work schedules. They can become important step is awareness and more knowledgeable and accepting of understanding of the unwanted impact of shift work this sleep upon the ability of their worker to disorder. participate in family outings.

Workplace managers can become educated in the same way as individuals about the sleep disorder but can also learn about ways that the David R. Nichols, MD Sleep Medicine NEA Baptist Clinic – 870.336.4144

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CARDIOLOGY Anthony T. White, MD Michael L. Isaacson, MD Robert D. Taylor, MD, FACP Eumar T. Tagupa, MD D.V. Patel, MD Suresh Patel, MD, FACP Margaret Cooper, APN Jennifer Jarrett, APN 311 E. Matthews (870) 935-4150

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