Adult Sleep Disorders
OBSTRUCTIVE SLEEP APNEA
Obstructive Sleep Apnea is a serious sleep disorder, where you stop breathing or your breath becomes very shallow during sleep. These pauses can last 10-20 seconds and can occur frequently during sleep. Obstructive Sleep
Apnea indicates that your airway closes down and you are not able to get adequate air into your lungs. This episode of apnea can be terminated by a loud snort or choking sound.
Obstructive Sleep Apnea is common. It is estimated that more than 12 million Americans have Obstructive Sleep Apnea. It is more common in men but is also seen in women. More than half of the people with Obstructive Sleep Apnea are overweight and snore heavily. Thin people, however, can have Obstructive Sleep Apnea. Frequently, this can be related to their underlying jaw structure.
The most common signs of sleep apnea are:
- Loud snoring
- Choking or gasping during sleep
- Daytime sleepiness
- Dry throat upon awakening
- Frequent urination at night
- Morning headaches
- Mood swings or personality changes
- Concentration difficulty
- Sleepiness while driving
The diagnosis of sleep apnea involves a consultation in which a sleep specialist will obtain your medical and sleep history and will perform a physical exam. Sleep studies, or polysomnograms, are performed to assess if sleep apnea is present.
Sleep apnea can cause oxygen to fall in sleep. In addition, the episodes in which you stop breathing can lead to increases in pulse and blood pressure. These changes in pulse, blood pressure and oxygen saturation over time can cause high blood pressure. Sleep apnea has also been associated with a higher risk of heart disease, including heart attacks, arrhythmias or irregular heart beats, as well as stroke. In addition, insulin resistance, which is a factor in adult onset diabetes, can also be seen with untreated sleep apnea. Untreated apnea causes daytime sleepiness because during these episodes of apnea, you move from deeper sleep to light sleep. Sleep is disrupted leading to non-refreshing sleep and daytime sleepiness.
The goal of treatment for sleep apnea is to prevent these episodes of apnea, improving nighttime sleep and thus resolving daytime sleepiness.
General measures which can be used to treat sleep apnea include weight loss, if you are overweight, avoiding alcohol and sleeping medications, which can cause the airway to collapse during sleep.
CPAP (Continuous Positive Airway Pressure) is the most common treatment for sleep apnea. With this treatment you will wear a mask over your nose or a nasal pillow system which fits in the nose. CPAP puts positive pressure through your nose, which prevents the airway from closing in sleep. This ultimately prevents apnea, snoring and falls in oxygen saturation. The end result is that your sleep improves and daytime sleepiness resolves.
There is also bilevel equipment. Bilevel equipment consists of positive inspiratory pressure which opens the airway. This pressure falls as you exhale. Bilevel equipment opens the airway and prevents snoring, apnea and falls in oxygen saturation. Some people find that bilevel equipment is easier to use than CPAP.
There is also surgery for obstructive sleep apnea. However, surgery is not always 100% effective. If there are enlarged tonsils and adenoids, tonsillectomy and adenoidectomy may be effective for treatment of obstructive sleep apnea. This surgery is especially helpful for children. Uvulopalatopharyngoplasty (UPPP) is a surgery that removes the uvula (the tissue that hangs from the back of the roof of the mouth and part of the soft palate). This surgery improves obstructive sleep apnea by approximately 45%. There are also surgeries which involve the tongue and try to advance the tongue onto the lower jawbone. This is called mandibular osteotomy with genioglossus advancement. Again, this is not 100% effective.
There are oral appliances which may be helpful for mild sleep apnea. These oral appliances should be adjustable appliances and are custom fit. They are made by a dentist, orthodontist or oral surgeon. The mouthpiece attempts to adjust the lower jaw and tongue to keep the airway open. These dental appliances could cause problems with your bite or occlusion. They can be associated with temporal mandibular joint dysfunction (TMJ) and can cause loosening of teeth.
Sleep apnea is a serious disease with many potential complications. It is important to see a specialist for evaluation and treatment of this disorder.
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Narcolepsy is a term used to describe a specific sleep disorder, characterized by extreme daytime sleepiness along with a tendency for uncontrolled sleep attacks. The condition is due to an abnormality in controlling REM (rapid eye movement) sleep onset. Normally, REM sleep is only seen after an individual is asleep for several hours. In patients with narcolepsy, REM sleep can manifest during the daytime or only after a brief nap. Often patients will have a long history of excessive daytime sleepiness (sometimes dating back to adolescence). Narcoleptics can feel tired for most of the day and they often have uncontrolled urges to take naps during the day. Occasionally, people with narcolepsy experience other symptoms such as muscle weakness with laughter or other emotional expression. Some complain about having vivid dreams during naps or during “daydreaming”.
The diagnosis of narcolepsy involves a consultation and discussion about symptoms and review of one’s sleep history. Sleep studies are performed to measure how rapidly someone can fall sleep during daytime naps. In addition, we look for dreaming or REM sleep during these naps, strengthening the diagnosis. Blood tests suggest the diagnosis but are not definitive. Narcolepsy can be seen in other family members as well.
Treatment for narcolepsy is available and includes medication to help maintain alertness during the day. In addition, newer medication is available to use at night to help improve sleep at night, thereby reducing daytime sleepiness. Understanding the diagnosis can also allow patients to adjust their lifestyle to mitigate symptoms. Scheduled naps during the day can also help to improve symptoms of excessive drowsiness.
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Idiopathic hypersomnia is a term used to describe an individual who feels excessively sleepy during times when he or she should be awake. People with idiopathic hypersomnia often complain that despite sleeping 10 or more hours, they are excessively drowsy in the morning and feel tired throughout the day. Often these symptoms are present for years and may have started in adolescence.
Idiopathic hypersomnia differs from narcolepsy in the fact that REM onsets are not usually seen during naps or daytime sleep. However, in both conditions the complaint of excessive daytime sleepiness is similar. Hypersomnia is also treated with medication to improve alertness.
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Restless legs is a movement disorder in which the individual suffers an almost irresistible urge to move their leg, usually due to disagreeable leg sensations that are worse during inactivity and often interfere with sleep. Restless legs is a common disorder. The exact prevalence is uncertain, however, limited studies have indicated that 2-15% of the population may experience restless legs symptoms (RLS). The prevalence of RLS increases with age. However, it has a variable age of onset and can occur even in children. Restless legs can run in families.
The diagnosis of restless legs is based on the individual’s history. The criteria necessary for the diagnosis of restless legs include:
- A compelling urge to move the legs, usually associated with disagreeable leg sensations.
- Motor restlessness can be seen, such as tossing and turning in bed, pacing the floor and rubbing the legs.
- Symptoms worsen or present exclusively at rest and are relieved by activity.
- Symptoms are worse in the evening and at night.
Restless legs can cause problems with sleep initiation as well as other
sleep disturbance and daytime fatigue.
Restless legs can be seen with iron deficiency. Research indicates that decreased iron stores as indicated by a ferritin level, an iron storage protein, less than 50 can worsen restless legs symptoms.
Restless legs has been reported in end stage kidney disease and has been seen in association with neuropathy. Restless legs can also affect up to 19% of women during pregnancy. Symptoms usually subside within a few weeks post partum.
Finally, restless legs symptoms can be worsened or masked by medications such as antidepressants. Caffeine has also been implicated in the worsening of restless legs symptoms.
If you think you have symptoms of restless legs, you should see your physician, who will take a history and perform a physical exam. Routine blood work, including a ferritin level, should be obtained.
Individuals with occasional or mild symptoms of restless legs may not require any specific treatment. If the individual is on medications that can worsen restless legs, removing that medication, if possible, may help the symptoms of restless legs. In the setting where a ferritin level is less than 50, iron supplementation may significantly improve the symptoms of restless legs. If none of those treatments are effective, there are medications which are effective for the treatment of restless legs. Your physician can discuss that option with you.
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Insomnia is the perception of inadequate or poor quality sleep because of one or more of the following:
- Difficulty falling asleep
- Waking up frequently during the night with difficulty returning to sleep
- Non-refreshing sleep
- Waking up too early in the morning
Insomnia may cause problems during the day such as fatigue, a lack of energy, difficulty concentrating and irritability. Insomnia can be associated with depression or other psychiatric disorders. It can be seen as people age. It can be associated with stress or changes in the surrounding environment. Insomnia can also be a side effect of medication or seen with multiple medical conditions.
Treatment of insomnia can include identifying behaviors that may worsen insomnia. Behavioral techniques can be used to improve the ability to sleep. Sleeping medications can also be used for insomnia. However, these medications generally should be used for just a short period of time.
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