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3. sleep disorders

Handbook of Disabilities
Sleep Disorders
Sleep Disorders
(Insomnia, Narcolepsy, Hypersomnia, Sleep Apnea)
Description of the Disability
Sleep is a complex and poorly understood part of our daily lives. There is a distinct
"architecture" in how we sleep, which includes 5 stages (only one of which is Rapid Eye
Movement, or REM sleep) and which changes subtly as we age. Most people need
approximately 8 hours of sleep a night, although some individuals need 2 or 3 less or more.
During sleep, our brain appears to recharge and maintain itself in ways scientists still don't
entirely understand. Missing even a few hours of sleep can interfere with this maintenance and
cause functional difficulties. The only cure is to get enough extra sleep to cancel the "sleep
deficit" resulting from the missed hours.
The amount we sleep varies through life, although the amount of REM sleep stays about the
same. Small children sleep 16 to 20 hours a day. Adults sleep 7 to 8 hours a day. After age 60,
adults sleep around 6 or 7 hours a day. The time spent in the 2 deepest stages of sleep (the most
refreshing stages, which are "non-REM" sleep) declines with age, but the time spent in the
earliest level of sleep (a light dozing) increases with age. So with age, sleep may become more
fragmented and be accented with brief awakenings. The change in sleep patterns with age may
reflect an increase in sleep ability rather than a decreased need for sleep. This does not mean that
it is normal for elderly individuals to be drowsy all day or to wake up extremely early - those are
signs of sleep disturbance for people of any age.
Common sources of sleep problems include:
Side effects of medication (see below)
Medical conditions, including obesity, heart conditions, allergies, acid reflux, menopause,
asthma, seizure disorder, and Parkinson's Disease, among others.
Chronic pain conditions, including headaches, muscular aches and pains, leg cramps,
sinus pain, arthritis, and cancer, among others.
A psychiatric disorder such as depression or anxiety disorder.
A specific sleeping disorder (see below)
Specific Sleeping Disorders
Insomnia
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Handbook of Disabilities
Sleep Disorders
Insomnia is actually a symptom rather than a diagnosis. It is a generic term for difficulty
sleeping, leaving the person with a feeling that they did not sleep well. Either emotional or
physical problems can cause it. Specialists identify several varieties of insomnia:
Initial insomnia - difficulty falling asleep. This is commonly related to an emotional
condition, such as anxiety, a phobia, or depression, or to a stimulant such as coffee.
Early morning awakening - the individual falls asleep normally but wakes up several
hours too early and can't get back to sleep. This can sometimes be related to depression.
Circadian Rhythm Disruption - a sleep cycle that is out of sync with the rest of the world
- sleeping earlier & waking earlier or sleeping later and waking later. Jet lag is one
common but temporary cause of this disruption. Irregular night-shift work can also cause
it. It is often treated with light therapy or chronotherapy: gradually shifting the sleeping
period. Sometimes damage to the sleep areas of the brain, from trauma or disease, can
also cause this kind of disruption.
Hypersomnia
Hypersomnia is a significant increase (25% or more) in the amount time actually spent sleeping
(not just time spent in bed), especially if it interferes with social and job functions. Encephalitis,
depression, or abuse of sedative/hypnotic drugs (see drug entry) can cause hypersomnia.
Sometimes tumors in the hypothalamus or upper brain stem can also cause the problem.
Narcolepsy
Narcolepsy is defined by sudden attacks of sleep during the day, accompanied by persistent
sleepiness during the day even after a good night's sleep. Other possible symptoms include
fragmented nighttime sleep; sudden loss of muscle function or tone during the day for several
seconds or minutes (called Cataplexy); a temporary inability to move or talk when falling asleep
at night or waking up in the morning (called Sleep Paralysis); and vivid, often frightening,
dream-like experiences when dozing or just starting to fall asleep (called Hypnagogic
Hallucinations). Most people with narcolepsy do not have all of these secondary symptoms and
the symptoms can occur by themselves in people who do not have narcolepsy. A tendency to fall
asleep suddenly during the day is the defining characteristic.
Researchers believe narcolepsy involves a disruption of the normal pattern of sleep stages. Most
people go through several non-REM stages of sleep early in the night and do not experience
REM sleep until an hour or so after falling asleep, but people with Narcolepsy appear to move
almost immediately into REM sleep. Sleep paralysis, vivid dreams, and loss of muscle tone are
all characteristics of normal REM sleep, but they seem to be happening at the wrong time for
these individuals. There is no cure for narcolepsy, but antidepressants seem to help reduce the
symptoms by suppressing REM sleep.
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Handbook of Disabilities
Sleep Disorders
Sleep Apnea
This is a serious disorder in which a person repeatedly stops breathing for 10 seconds or more
while sleeping, sometimes it happens more than 30 times during an typical night. The lack of
oxygen triggers the brain to rouse from deep sleep and get breathing started again. This
significantly disrupts restful sleep and leads to the most common symptom - chronic daytime
sleepiness. Morning headaches are also common. Most individuals with this disorder have
Obstructive Apnea, in which tissues block the breathing passages in the mouth and nose. The
obstruction may be related to snoring (or not), obesity, abnormalities in the nose or throat, or the
normal relaxation of the tongue during sleep. Less common is Central Apnea, in which the
brain stops sending breathing signals to the chest during sleep. Untreated, sleep apnea can lead to
depression, cardiac abnormalities (such as arrhythmias, slowed heart rate, or fast heart rates),
high blood pressure, and problems with learning and memory.
There is no drug therapy for sleep apnea, and the first treatment is usually weight loss (even 10%
weight loss makes a significant difference). In a few individuals with mild cases, special pillows
to prevent sleeping on their back will help. Similarly, dental appliances to reposition the jaw and
tongue help a few individuals with mild cases. More common is Continuous Positive Airway
Pressure (CPAP) treatment, in which a machine blows air into a facemask which the individual
wears at night, keeping pressure in the airway and preventing its collapse during sleep. Side
effects of this treatment include irritation and dryness of the nose, irritation of the face,
abdominal bloating, and headaches. In serious cases, physicians will perform
Uvulopalatopharyngoplasty (UPPP) to remove tissue at the back of the throat. The success rate
is less than half and the long-term side effects are unknown. Another type of surgery, Laserassisted Uvulopalatoplasty (LAUP), is similar but only helps snoring, not sleep apnea. In
extreme cases, the physician may do a tracheostomy to insert a tube in the throat, which can be
opened at night for breathing.
Periodic Leg Movement - This is a minor disorder in which the person's legs jerk every 20 to
40 seconds during sleep. The jerks disrupt the sleep of the person and any bed partner. Restless
Leg Syndrome is a related problem involving leg discomfort and the urge to move ones legs
when resting, but not when sleeping. The discomfort makes it difficult to sit still long enough to
fall asleep. If either problem is significant, it can be treated with medication.
Drug Induced Sleep Problems
Medications that cause sleep problems include:
Some anti-hypertension drugs, including Beta-adrenergic Blockers
Corticosteroids
Selective Serotonin Reuptake Inhibitors (SSRIs)
Monoamine Oxidase Inhibitors (a type of antidepressant)
Some anti-convulsant drugs
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Handbook of Disabilities
Sleep Disorders
Some chemotherapy drugs
Alcohol, nicotine, and caffeine are also common sources of sleep problems. Alcohol will make
you sleepy, but overall it shortens the amount of time you sleep and disrupts the pattern of your
sleep, leaving you with a sleep deficit. Sleep problems from alcohol abuse can continue for a
while even after alcohol consumption has stopped.
Incidence Statistics
Young children sleep 16 to 20 hours a day, Adults sleep 7 to 8 hours a day, and the
elderly sleep around 6.5 hours per day.
60% of American adults have difficulty sleeping at some time (National Sleep
Foundation Poll).
Stress is considered the main cause of short-term sleeping problems.
Shift workers are 2 to 5 times more likely to fall asleep on the job than other workers.
Up to 200,000 Americans may have narcolepsy, but fewer than 50,000 are diagnosed. It
is estimated to be as common as Multiple Sclerosis or Parkinson's disease.
Sleep Apnea occurs in 4% of middle-aged men and 2% of middle-aged women. Over age
65, the rates are 28% and 24%, respectively.
40% of the adult population snores. The majority does not have sleep apnea.
Sleep apnea and obesity are often linked. Weight loss as low as 10% can significantly
reduce the number of apneic events in the night.
Fatigue and sleepiness cause 100,000 car accidents and 1,500 car deaths annually.
Drivers younger than age 25 are at the highest risk of fatigue-related accidents (US
Highway Traffic Safety Administration).
Students, shift workers, travelers, and persons with acute stress, depression, or chronic
pain are at high risk for sleep disorders.
For people who reported having nighttime pain in a 1996 Gallup Poll, 64% of the pain
was back pain, 30% of the pain was caused by arthritis. Over age 50, the proportion due
to arthritis rose to 60%.
The elderly use prescription and over-the-counter medications much more than the
average population, leading to higher rates of drug interactions and side effects, including
difficulty sleeping.
56 million Americans experience nighttime pain and sleeplessness more than 8 nights a
month. On these nights, they only sleep 4.5 hours on average.
Women are at greater risk for sleeping difficulties than men
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Handbook of Disabilities
Sleep Disorders
On average, women between the ages of 30 and 60 sleep 6.5 hours per night according to
a 1998 National Sleep Foundation poll.
58% of women reported nighttime pain in a 1996 Poll, compared to 48% of men.
Menstruation, menopause, and pregnancy can each cause difficulty sleeping.
50% of menstruating women report bloating which disrupted their sleep.
During menstruation, women with PMS spend around 5% of sleep time in deep sleep
stages, compared to 15-20% for the average sleeper.
Common Treatments, Medications, and Side Effects
Aside from the individual's self-report of sleepiness, there are two common diagnostic tests for
sleep problems. One is the Sleep Study or Polysomnography, in which the individual spends a
night in the sleep lab wired up to monitors which record brain activity, eye movement, muscle
activity, heart rate, respiration, blood oxygen levels, and other things. The second is the Multiple
Sleep Latency Test (MSLT) to measure daytime sleepiness. The individual is asked to lay down
and try to sleep several times during a normal day, and examiner records how long it takes them
to fall asleep each time. An average person will take 10 to 20 minutes. Individuals with sleep
disorders will usually take 5 minutes or so.
The main treatment for most sleep problems is behavior therapy. This is described as "good sleep
hygiene" and includes the following steps:
Reduce or stop the use of nicotine, caffeine and alcohol.
Keep a regular schedule of bedtimes and wake times, even on weekends.
Keep a regular schedule of mealtimes. Do not have a heavy meal before bedtime.
Exercise regularly, but not later than early evening.
Do not use the bed as a place to worry (especially about not sleeping). If you start to
worry in bed, get up and leave the room.
Only use the bedroom for sleep. Don't read, watch television, eat, etc. in bed.
Limit the amount of time you spend in bed to about eight hours.
Avoid daytime naps, or limit them to early afternoon and no more than 30 minutes.
Get regular sunshine, especially in the late afternoon.
Biofeedback techniques and pain management techniques may also be useful.
If the sleep problem is a side effect of medication taken for treatment of other conditions, it may
be useful to try alternative medication or an alternative dosage.
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Handbook of Disabilities
Sleep Disorders
Drugs that promote sleep are called hypnotics. Individuals taking hypnotics have increased
disorientation when getting up to go to the bathroom during the night increasing the risk of
falling. In some cases physicians use medication to treat sleep disorders. This is usually only on a
short-term basis in combination with the behavior therapy steps above. The medication allows
the person to get restful sleep until the behavior therapy can take effect. More commonly,
individuals will self-medicate with over the counter sleep aides. Physicians do not recommend
long-term use of these drugs and, again, behavior therapy is the preferred treatment.
Drugs used to treat sleep disorders include:
Benzodiazapines (see entry in Drug section)
Chloral hydrate (See Drug entry on sedatives/hypnotics)
Hydroxyzine (Atarax) (See Drug entry on sedatives/hypnotics)
Zolpidem (Ambien) (See Drug entry on CNS Depressant)
Over-the-counter drugs include
Diphenhydramine (Nytol, Sleep-Eze, Sominex), Doxylamine (Unisom, Nighttime), and
Diphenhydramine in combination (Anacin P.M., Doan's P.M. Extra Strength, Excedrin
P.M., Tylenol P.M.) (See Drug entry on sedatives/hypnotics)
Melatonin (see Drug entry)
Possible Functional Issues
Falling asleep at inappropriate times during the day, such as while driving, working or
talking
Frustration at sleepiness
Low self-esteem
Depression
Impression by others that individual is lazy or stupid
Difficulty concentrating
Irritability
Memory difficulty
Learning difficulty
Increased risk of car accidents
Difficulty driving long distances
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Handbook of Disabilities
Sleep Disorders
Initial Interview Considerations
Initial Questions
What is the person's typical sleep pattern?
How regular is their bedtime? Are they going to bed at different times each night?
What time do they go to bed? How long after that until they fall asleep?
What time do they wake up in the morning?
What do they feel is causing the sleeping problem? Is it pain, not feeling sleepy,
worrying, restlessness, or something else?
How much alcohol, coffee, soda, or tea do they drink in the afternoon and evening?
Have they talked to their physician about whether the problem might be related to
medications they are taking?
Which, if any, extra vitamins and supplements do they take? (gets at possibility of
accidental drug interactions through self-medication not reported to physician)
Which, if any, over the counter sleep aids are they taking?
When do they find themselves feeling most tired during the day?
How often do they feel sleepy when driving?
How often does the sleepiness seem to be causing memory problems?
Initial Observations
Does the person seem anxious and worried in general?
Does the person seem depressed, rather than just being tired?
Possible Accommodations and Assistive Technology
A schedule allowing several short naps during the day may be helpful
Career Planning Issues
Avoid jobs that involve driving long distances, handling dangerous machinery or
chemicals, or long periods of close concentration
If narcolepsy is involved, the job should accommodate the possibility of a sudden period
of sleep or loss of muscle movement.
Social skills are not usually affected.
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Handbook of Disabilities
Sleep Disorders
Physical coordination may or may not be affected. Physical strength is not usually
affected.
Learning skills may or may not be affected.
Mobility is not usually affected.
Emerging Issues
Awareness of the importance of good sleep habits
Awareness if how common sleep deficits are
Treatment for specific disorders
Additional Information Resources
The National Sleep Foundation: www.sleepfoundation.org
American Academy of Sleep Medicine: www.aasmnet.org
National Center on Sleep Disorders Research: www.nhlbi.nih.gov/about/ncsdr/index.htm
Sleepnet: www.sleepnet.com
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