Sleep Medicine

Narcolepsy is a chronic, neurological sleep disorder that affects the brain's ability to control sleep-wake cycles. Narcolepsy symptoms often start in younger people ages 7 to 25 but also later in life.

Symptoms

• Excessive daytime sleepiness
• Sleep attacks - Occur suddenly
• Cataplexy - Sudden loss of muscle control or tone. It's often triggered by stress or emotion.
• Sleep paralysis - A feeling of not being able to talk or move for a short time. It may occur when a person is falling asleep or waking up.
• Hallucinations
• Other symptoms, such as insomnia, fatigue, poor memory, and concentration, or depression

Rapid Eye Movement and Narcolepsy

REM (rapid eye movement) is the dreaming portion of sleep. REM sleep usually starts after the first 60 to 90 minutes. For people with narcolepsy, REM sleep starts much sooner, usually within 15 minutes of sleep. This can make dreaming so vivid, it seems real. 

Many symptoms of narcolepsy are caused by REM sleep intruding into wakefulness. During REM sleep, people are normally paralyzed. Waking out of REM sleep results in sleep paralysis. Cataplexy is a sudden loss of muscle tone, as would occur during REM sleep. Hallucinations may occur due to dreaming during REM sleep, which then continues when awake.

Disorders such as restless legs syndrome refer to an overwhelming urge to move the legs, usually associated with unpleasant sensations. The urge to move the legs is worse at rest and night and relieved by movement. It disturbs sleep and may include jerking and involuntary movements of the legs during sleep. When restless leg syndrome is not present, a condition called periodic limb movement disorder may be present.

Symptoms range from being barely noticeable and not requiring any treatment to those that make it hard to fall asleep. It also may not be limited to nighttime; it can also happen any time a person is sitting still, like in a car or movie theater.

A condition such as restless leg syndrome is different from the brief muscle twitches that occur during sleep, which are called “hypnic jerks.” The asleep study is unnecessary to diagnose this condition; the diagnosis is based on eliciting symptoms that patients experience through a clinical interview.

Treatment 

• Pharmacologic therapies, including alpha-2-delta calcium channel ligands, dopaminergic agents, opioids, and benzodiazepine
• Iron replacement, including through oral means or by IV
• Behavioral changes, such as physical and mental exercises, reduced caffeine, massaging or soaking limbs, increasing the amount of sleep, avoiding certain medications, stretching before, bed, and staying hydrated

Insomnia is one of the most common sleep disorders and is characterized by the inability to fall asleep. Its occurrence can be influenced by multiple factors, including stress, caffeine use, pain, or medical issues that interrupt sleep. Identification of these factors is at the core of insomnia treatment. People with

Causes

Predisposing or precipitating factors – there may be events or comorbidities, including:

• Pain
• Nocturia
• Shortness of breath
• Sleep disorders other than insomnia, including obstructive sleep apnea or restless legs syndrome
• Psychiatric disorders
• History of childhood trauma or chaotic home environment at night

Medication side effects from such drugs as:

• Antidepressants
• Stimulants
• Glucocorticoids
• Opioids

Behavioral factors also may include:

• Anxiety
• Sleep time consistency
• Mood and anxiety disorders
• Posttraumatic stress disorder
• Substance use disorders

Neurodegenerative brain disorders can also play a role

• Dementia such as Alzheimer’s disease
• Parkinson’s disease
• Brain injury

Types of insomnia

• Acute – Lasting less than one month and is most common
  • A sedative medication can be utilized, which may reduce the development of dysfunctional responses to sleeplessness that could otherwise increase the risk of more chronic insomnia. If the insomnia is persistent, evaluation and treatment with cognitive behavioral therapy for insomnia might be used.
• Chronic – Long-lasting
  • Cognitive-behavioral therapy is a preferred approach to treatment as well as medication.

Management of insomnia requires a stepwise approach, beginning with attempts to eliminate or at least minimize contributing factors and comorbid illnesses that interfere with optimal sleep. Insomnia often responds only partially to the treatment of individual sleep-impairing influences, however, and many patients require medication directed towards sleep itself. Successful behavioral and pharmacologic approaches to insomnia can only be devised once all contributing factors are recognized and addressed.

For some people, simple tips known as sleep hygiene are enough to improve sleep. For others, however, the situation can be more complicated where they have such negative experiences with sleep that they get caught in a cycle where, each night, the idea of sleep causes stress, which makes it harder to sleep.

It is important to note that beliefs about what is “normal” sleep can impact whether a person seeks treatment, such as thinking it abnormal to awaken during the night or needing eight hours of sleep per night to be healthy. Individual needs vary greatly.

Abnormal movements and behaviors during sleep are part of a larger group of nocturnal events that may occur during sleep, wake, or the transitions into or out of sleep. These nocturnal events are typically divided into simple behaviors, such as single movements or repetitive movements, or complex behaviors like sleep talking, sleepwalking, or sleep terrors. Sleep talking and sleepwalking mainly occur during non-REM (NREM) sleep.

Types

• Simple and periodic movements
  • Teeth grinding or Bruxism
  • Hypnic jerks – Sudden or brief jerks of the body
  • Propriospinal myoclonus – Jerks of the abdomen, neck, or shoulders
  • Exploding head syndrome – Painless sensation of head exploding accompanied by fear
  • Epileptic myoclonus
  • Benign sleep myoclonus – Bilateral and symmetric jerks of the body
  • Leg cramps – Painful muscle contractions
  • Rhythmic movement disorder – Large muscle groups move
  • Hypnagogic foot tremor – Rapid movement of one foot
  • Periodic limb movements
• Complex movements
  • Sleepwalking – Walking, sitting, talking, eyes open but with little to no memory of the event after and ability to interact with others during the event. Can be triggered by a stimulus such as a lack of sleep or stressors.
  • Sleep-related eating disorder – Involuntary eating during sleep where the memory of the event is minimal.
  • Sleep paralysis – Inability to move or make sounds and can be accompanied by hallucinations.
  • Nightmares or night terrors – usually involving disturbing or distressing dreams, these events could also lead to sudden wakefulness and screaming or movements.
  • Vocalization – Talking while sleeping
  • Sleep behavior disorder – The body moves in turn with a dream sequence.

Sleep behavior disorder is of particular significance as individuals who have the disorder may be at an increased risk for the development of neurodegenerative disorders such as Parkinson’s disease and dementia.

Risk factors

• Poor sleep hygiene
• Sleep deprivation
• Circadian rhythm disturbances (i.e., jet lag)
• Fever or other illnesses
• Emotional stress
• Medication use
• Ingestion of alcohol or sedatives before sleep onset
• Other medical conditions, such as obstructive pulmonary disease, and neurologic conditions

Diagnosis

An overnight polysomnography can help determine the reason for the events, along with patient history. The test would incorporate the following:

• Complete respiratory monitoring
• Time-synchronized high definition video monitoring
• Electromyographic recording from all four limbs ("expanded EMG/RBD/parasomnia montage")
• A complete 10-20 set of cephalic EEG electrodes
• Ability to extensively review the electroencephalogram

Treatment

• Medication
• Behavior modification

Our internal “clock” is located in a small part of the brain called the suprachiasmatic nucleus (SCN). For most people, the clock runs on a cycle that is just slightly longer than 24 hours and is synchronized with the light-dark cycle. In fact, light detected by the eyes entrains the clock by sending signals to the SCN. However, for some people the clock does not synchronize properly, causing the person to feel sleepy before or after “normal” bedtimes.

In teenagers and young adults, the most common circadian rhythm disorder is called delayed phase (staying up late and then sleeping late the next morning), while in older adults the advanced phase pattern is more likely (early to bed, early to rise). These patterns can cause difficulty when the person’s social or work schedule is not compatible with the timing of the internal clock. Fortunately, the clock can be entrained to change – this happens when we cross time zones: the clock reacts to light as well as other clues (food, social activity, exercise).

A common sleep disorder is hypopnea, which is both a symptom of other sleep disorders and also a common disorder in which 10 seconds or more of shallow breathing occurs where someone loses 30% to 90% of your normal airflow. Blood oxygen saturation drops by 3% to 4%.