Conditions We Treat
Symptoms of Sleep Disorders
Most sleep disorders can be recognized by one or more of the following symptoms:
- Difficulty falling asleep or staying asleep (Insomnia)
- Feeling excessively sleepy, tired, or fatigued (Excessive Sleepiness)
- Unusual or unwanted behavior in sleep
There are many types of sleep disorders, and the symptoms can overlap. Some don’t cause symptoms that are obviously sleep-related but have very important consequences just the same. Some conditions, such as seizures, can mimic sleep disorders.
Insomnia (difficulty falling asleep or staying asleep)
Insomnia comes in many types and is not a single diagnosis. Here are some common types, their features, and treatment options.
This commonly develops as a result of a specific stressor, such as an illness or a personal loss. Difficulty falling asleep, staying asleep, or waking earlier in the morning than desired can occur. The treatment includes, removal or resolution of the stressor, and in some cases, sleep medication.
Inadequate Sleep Hygiene
Insomnia caused by ineffective sleep habits is called “Inadequate Sleep Hygiene.” Healthy Sleep Hygiene not only treats this form of insomnia, but can also improve many other conditions worsened by inadequate sleep, such as headaches and other types of pain.
Conditioned insomnia is also called “psychophysiological insomnia” or “learned insomnia”. It is characterized by difficulty falling asleep in the usual sleep setting at home. Patients often sleep better elsewhere, such as when traveling, or even in a different room in their own home. Some develop an excessive focus on sleep and may worry about sleep both during the day and when trying to fall asleep at night.
It may begin with . If acute insomnia doesn’t resolve on its own in time, even if the original cause is no longer the reason for difficulty sleeping, and sleep becomes the focus of concern, conditioned insomnia can develop. Patients often spend much more time in bed that actual sleep time.
Sleep Restriction is limiting the number of hours in bed to the number of hours you think you actually sleep most nights.
Example 1: You go to bed at 9 pm, fall asleep at 12 midnight, wake up at 5 am, and get up at 7 am. You are in bed for 11 hours but only sleeping about 5 hours. Sleep restriction would be achieved by going to bed at 12 midnight and getting up at 5 am each day.
Example 2: You go to bed at 9 pm, fall asleep at 11 pm, wake up from 2-4 am, go back to sleep from 4-7 am, and get up at 7 am. You are in bed for 11 hours but only sleeping about 6 hours, not all at once. Sleep restriction would be achieved by choosing the 6 hours you are most likely to sleep continuously, such as going to bed at 12 midnight and getting up at 6 am each day.
Once sleep is continuous for about a week of sleep restriction, the time in bed may be increased gradually. We usually recommend no more than an increase of 30 minutes of nightly sleep time for each week of continuous sleep.
Example: You restrict your sleep to 12 midnight to 5 am and in the second week, you sleep well through those 5 hours every night. The following week you may change you schedule to bedtime at 11:30 pm and keep your wake time at 5 am. Once you sleep well for one week on that schedule, you may increase sleep time by another 30 minutes. Time in bed should not exceed 8 hours.
Stimulus Control means limiting the bed and bedroom to be used only for sleep and intimacy, and sleeping only in bed rather than in other locations (unless traveling). This helps condition (train) the brain to fall asleep in bed and be awake everywhere else. It helps the brain unconsciously associate the bed with sleep and not with other activities (such as TV, reading, or using electronics).
Pain and sleep both affect each other. Pain can disrupt sleep. Poor sleep can make pain worse. Pain medications can also cause drowsiness.
If pain disrupts sleep, control of pain is the most important starting point to improve sleep. Pain management is usually provided by a physician or healthcare provider other than the sleep specialist. Pain and sleep are both best improved when the care is coordinated among the healthcare providers. Pain management may involve multiple modes of treatment, including medication, behavioral therapy, physical therapy, and others. If sleep continues to be disrupted by pain, specific treatment of the insomnia may be needed. If medications lead to drowsiness, a sleep specialist may be able to help improve wakefulness during the day with behavioral strategies and, for some patients, medication.
Restless Legs Syndrome (RLS)
Restless legs syndrome is an urge to move the legs, and sometimes the arms, often with an uncomfortable sensation (but not pain) that makes you have to move to get comfortable. It may be hard to describe, but some call it a “creepy crawly” feeling, “restlessness” or the legs feel “anxious” or “just want to move”. It occurs or worsens in the evening, and comes on when you are at rest. It is relieved by moving your legs or arms or tensing your muscles. While movement or tensing of the muscles helps at the moment, the symptoms may return as soon as you relax again.
RLS is common – about 1 in 10 people have it. RLS affects men and women, children and adults. It tends to run in families, but not always.
Many conditions can worsen RLS, including pregnancy, iron deficiency, and even other sleep disorders such as sleep apnea. Caffeine and alcohol may also aggravate it.
Strategies to treat RLS include some things you can try on your own: get plenty of sleep, cut back on or stop using caffeine and alcohol, exercise, and treat iron deficiency or sleep apnea if present. Medication can also be very effective.
Sleepiness (feeling sleepy, tired, or fatigued)
The causes of sleepiness fall into 4 groups:
Quantity: Without enough sleep, daytime sleepiness, fatigue, or tiredness occurs. Most adults need about 7-8 hours to feel refreshed. Children need more. Individual tolerance to sleep deprivation varies, so that some people may feel refreshed with less sleep and some may need more than 8 hours to feel alert.
Quality: Even with enough hours of sleep, if sleep quality is poor, sleepiness or fatigue can develop. Common causes of poor sleep quality are sleep apnea, caffeine, and a noisy environment (including a snoring bed partner!)
Timing: Your brain has an internal clock called the Circadian Rhythm. It makes your brain most ready to sleep at night and be awake in the daytime. If the Circadian Rhythm doesn’t line up with the times you need to sleep (such as in shift work or jet lag) then sleepiness occurs when you need to be awake and vice versa. There are many different Circadian Rhythm disorders. Treatments include gradually adjusting the time of sleep, adjusting light exposure before bedtime and at wake time, and in some cases, medications.
Drive: If you are sleepy despite getting enough sleep of good quality at the right time, then you have an increased “drive” to sleep. This can be due to some sleep disorders, such as narcolepsy. It can also result from illness (from something as common as the flu, or more serious conditions), from medications, and other causes.
Sleep apnea is characterized by repeated episodes of stopping breathing during asleep. Obstructive sleep apnea is the most common type. It is due to collapse of the upper airway and is often associated with snoring. Each episode causes an arousal from sleep, which can happen hundreds of times a night without the patient knowing it. Sleep apnea can reduce the blood oxygen level and make the heart work much harder.
Sleep apnea can cause daytime sleepiness, fatigue, difficulty concentrating, mental fog, and irritability. Some people awaken with morning headaches. It increases blood pressure after each apneic episode in sleep and can lead to increased blood pressure during the day. It is a well-known cause of high blood pressure (hypertension), especially when the blood pressure is hard to control with medications.
Sleep apnea also increases the risk of:
- abnormal heart rhythms, such as atrial fibrillation (a-fib)
- Heart attack
Diagnosis of Sleep Apnea
A detailed medical history and physical examination should be performed to determine if testing is needed, and if so, what type.
Testing in the Sleep Laboratory
If sleep apnea is suspected, it is usually diagnosed with an overnight sleep test in the INI Sleep Center. This test gives the sleep specialist physician the most information about stages of sleep, breathing, snoring, body position, movements, and heart rhythm.
Home sleep apnea testing
While the INI Sleep Center is designed to provide a very comfortable home-like sleep setting and provide the most thorough information for the sleep specialist to make a diagnosis, some patients can be tested for obstructive sleep apnea in their own homes. A simpler test that records only breathing, oxygen levels, and heart rate provides enough information to diagnose sleep apnea for many people. Home testing can only diagnose obstructive sleep apnea, and is not helpful for other sleep disorders. It is also not appropriate for patients with some other medical conditions, and is not used for children. For the right patient, however, it provides a simpler alternative to traditional in-lab sleep testing.
Treatment of Sleep Apnea
There are many treatment options for obstructive sleep apnea. Some mild cases can be treated with changes in lifestyle, such as weight loss, reduction in alcohol intake, and not sleeping on your back. Most patients, however, need other treatments.
Positive Airway Pressure (such as CPAP or bilevel PAP):
Positive airway pressure provides air pressure through a fitting in or over the nose, or nose and mouth. The pressurized air keeps the airway open while you breathe normally with your own muscles. This allows you to sleep more continuously and feel more refreshed in the daytime. Although there are several types of PAP, the commonly used term is CPAP.
Most obstructive sleep apnea is easily treated with CPAP (Continuous Positive Airway Pressure). Some patients benefit from a self-adjusting form of PAP (auto-titrating PAP) which delivers air pressure at a set range. The machine senses when the airway begins to close and adjusts the pressure throughout sleep to maintain an open airway. This allows for a lower setting when that is sufficient, and increases to higher settings only when needed.
Another form of positive airway pressure is “bilevel PAP”. This delivers a higher air pressure on inspiration (breathing in) and a lower pressure on expiration (breathing out).
In order to determine what mask settings of CPAP are best for each individual patient, a “CPAP titration” test is usually performed in the INI Sleep Center. This allows you to spend as much time as needed to find just the right mask fit and comfort. While you sleep, the sleep technologist adjusts the air pressure to find just the right setting to keep your airway open so you can breathe.
There are many mask options for CPAP, and treatment at the INI Sleep Center is very individualized. Careful attention to fit and comfort is provided to each patient.
We make getting CPAP very easy
CPAP is prescribed by a physician and provided by a Durable Medical Equipment (DME) company. In order to provide the most convenient service to our patients, the INI Sleep Center offers complete custom CPAP set-up service on the morning after the CPAP titration test. If this option is selected by the patient, the test is read by the sleep specialist physician immediately upon completion. The individual settings and mask details are provided to a respiratory therapist, who then provides them to you right after the test, teaches you how to use PAP, and sends you home with your new CPAP equipment right from the INI Sleep Center.
Although CPAP is most often effective, some patients with mild to moderate sleep apnea are well treated with an oral appliance. Most devices are designed to position the jaw forward, and some reposition the tongue. They are all designed to keep the airway open while you sleep.
Some sleep apnea can be treated with surgery.
Most children with obstructive sleep apnea are effectively treated with removal of the tonsils and adenoids.
For adults, surgical procedures are generally reserved for patients who are not well treated with CPAP or other alternatives.
The UPPP (uvulopalatopharyngoplasty) involves removal of some of the soft tissue at the back of the throat. This is only effective for some people with sleep apnea, but is a valuable alternative to CPAP and other options in carefully selected patients.
Maxillomandibular advancement (jaw surgery) is a procedure that changes the position of the upper and lower jaw in order to create more space in the airway at the throat. It is performed by an oral surgeon and sometimes requires orthodontic treatment in conjunction with surgery.
Tracheostomy, which creates an opening in the throat at the front of the neck, is used for severe, life-threatening apnea that is not well treated with other options.
Narcolepsy is a disorder of sleepiness that is characterized by an intense, often irresistible, urge to sleep. Symptoms usually develop between the ages of 10 and 25, and can include the following:
Excessive sleepiness: People with narcolepsy often fall asleep in the daytime with little warning, feel refreshed after a short nap, and later feel sleepy again.
Cataplexy: This is sudden loss of muscle tone triggered by emotion. Laughter is the most common trigger, but any strong emotion (such as fear, surprise, or anger) may also cause it to occur. It may last seconds to minutes and does not involve sleep or a loss of consciousness. Not everyone with narcolepsy has cataplexy.
Sleep paralysis: This is an inability to move while awake, just before sleep onset or just after waking up. It can last seconds or minutes, and many people find it uncomfortable or worrisome when it happens. People without narcolepsy can have sleep paralysis, especially if they are sleep deprived or under stress.
Hypnagogic hallucinations: These are dreams while you are awake, but just about to fall asleep. When they occur just after waking, they are called hypnopompic hallucinations. They can be very vivid, and when paired with sleep paralysis, may be frightening. Like sleep paralysis, people without narcolepsy can have these types of hallucinations, especially if they are sleep deprived or under stress.
Narcolepsy can also cause sleep disruption at night. Although narcolepsy is a disorder of sleepiness, it is also a disorder of sleep-wake instability. People with narcolepsy have a hard time maintaining wakefulness for long periods of time, but they also may have trouble maintaining sleep as well.
Treatment: Narcolepsy is usually treated with medications. Timing a strategic nap at a time sleepiness typically occurs can also be helpful.
Unusual or Unwanted Behavior in Sleep
Unusual or unwanted behavior in sleep can be due to sleep disorders called parasomnias. These can occur at all ages, and are categorized by the stage of sleep from which they arise.
Common in children, but also seen in adults, sleepwalking is one type of parasomnia that arises from NREM (non-rapid eye movement) sleep, also called deep sleep. Most deep sleep occurs in the first half of the night of sleep, so sleepwalking is more common in the first couple of hours after bedtime than in the later hours of sleep. Normally, if a person awakens from deep sleep, they may feel groggy, but awake and oriented. In sleepwalking, a person starts to arouse from deep sleep but doesn’t fully awaken, is disoriented and walks or runs from bed. The person does not have normal perception of the environment, and seem disoriented, slow to speak, or even agitated. The person does not recall the event the next morning.
Confusional arousals are similar to sleepwalking but the person stays in bed and may just involve sitting up in bed, looking around, and returning to normal sleep.
Sleep terrors are also like sleepwalking, but involve crying or screaming and the appearance of fear or terror. The person is inconsolable, may stay in bed or walk around or run. It can be very daunting for a parent to observe a sleep terror in a child. Fortunately, they are not recalled in the morning and they are not thought to be due to stressors, anxiety, or other experiences while awake.
Sleep talking is common and occurs at the transition of sleep and wake. It generally needs no treatment, but should be distinguished from other types of sleep behaviors.
Nightmares are frightening dreams that lead to significant distress upon waking. They arise from REM (rapid eye movement) sleep, which tends to occur more in the second half of the night. Therefore, nightmares are more common later in the night. They can happen at any age, and are often related to stress.
Acting out dreams in sleep
REM sleep behavior disorder (RBD) is a parasomnia in REM (rapid eye movement) sleep. Normally we dream in REM sleep. While the mind is active, experiencing the stories of dreams, the body is quiet and still. In essence, the muscles are “disconnected from the mind” at that time. In RBD, the muscles lose their disconnection from the mind, and the body acts out dreams. Typically, this involves mainly dreams of a violent or defensive nature. The person may exhibit fighting, yelling, kicking, or running behaviors. This can be disruptive to the household, but also dangerous. The patient and sleeping partner may both be injured. This is more common in men than women, and tends to occur after age 50. It is also more common in people with Parkinson’s disease.
Rocking and head banging
Rhythmic Movement Disorder (RMD) commonly develops in infancy or early childhood, but can last into adulthood. It typically involves one or more types of movement, such as body rocking, head banging or rolling, or leg rolling or rubbing just before sleep onset. RMD can last into light sleep. It tends to be benign but can lead to injury in some, particularly if head banging occurs.
Conditions Related to Sleep
Headaches and sleep are linked in many ways.
- Headaches can disrupt sleep
- Sleep disorders and sleep deprivation can lead to or worsen headaches
- Some headache treatments can disrupt sleep
- Healthy sleep may relieve headaches
Headaches that are present on waking in the morning are more likely to occur in people with sleep disorders. While sleep apnea is a known cause of morning headaches in some, many other sleep disorders can also cause morning headaches. Treating the sleep disorder often relieves the headaches.
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder is a common syndrome characterized by inattention and/or hyperactivity or impulsivity. Since poor sleep can cause the same symptoms, ADHD may either be the result of, or be worsened by, a sleep disorder. This includes both children and adults. Patients with ADHD may benefit from a sleep evaluation to determine if a sleep disorder contributes to the condition.