Common Sleep Disorders
Snoring
Snoring is extremely common and can either be a benign problem that is socially serious or evidence of a more important primary sleep disorder such as sleep apnea. It is more common in men and patients who are overweight. Excessive alcohol intake and sleeping on the back in the supine posture can make snoring worse. You should seek medical attention as soon as you become aware that you snore. A complete history and physical examination are performed, including a detailed examination of the upper airway. Patients are asked to complete an Epworth Sleepiness Scale to see if they are excessively tired during the day which might suggest that snoring is related to sleep apnea.
Snoring is caused by turbulent airflow due to obstruction occurring anywhere from the tip of the nose down the back of the throat. Medical treatment of benign snoring includes weight reduction, avoiding sleeping in the supine position, avoidance of excessive alcohol and may include the use of various nasal sprays or nasal strips to relieve nasal obstruction. If there is suspicion of sleep apnea, a noninvasive sleep study may be ordered. If medical therapy fails and surgery is being considered, a sleep study is usually performed to exclude sleep apnea before proceeding. A variety of surgical techniques ranging from office procedures to more involved operative procedures requiring the use of general anesthesia are sometimes indicated and may be beneficial.
Obstructive Sleep Apnea (OSA)
Obstructive Sleep Apnea (OSA) is a sleep disorder that affects at least 18 million people in the United States. Most are undiagnosed. People with OSA literally stop breathing repeatedly during their sleep for 10 seconds or longer and sometimes as many as a hundred times or more in a single night. This occurs because their airway collapses and prevents air from getting into the lungs. It disrupts healthy sleep, puts a strain on the heart, and can lead to a number of life-threatening health conditions, including heart disease, increased high blood pressure, stroke, and even a heart attack. Patients are often sleepy and tired all day with an increased risk for motor vehicle accident.
Warning Signs of OSA
- Loud snoring or a pattern of snoring with pauses
- Excessive daytime sleepiness
- Difficulty concentrating, irritability, forgetfulness, or depression
- Gasping or choking during sleep
- Headache or dry mouth upon waking
- Waking up at night frequently for unclear reasons, sometimes to urinate
A thorough history and physical examination is performed, including a history from the bed partner, if possible. Patients are usually scheduled for an overnight noninvasive sleep study. If results suggest the need for treatment, the preferred form of treatment is the use of continuous positive airway pressure. Patients are asked to wear a comfortable but snug fitting mask over the nose or nose and mouth connected through some tubing to a small machine weighing less than 5 pounds that prevents snoring and airway obstruction. They must use this equipment all night every night to achieve benefit and to avoid potentially life-threatening complications. Patients are scheduled for a full night of CPAP titration to determine how much positive pressure is required to prevent their airway from collapsing. CPAP works for 80-90% of patients and the current generation of masks and machines are very comfortable to get used to. Weight reduction may be helpful. Patients with mild to moderate disease are sometimes treated with a dental appliance designed to pull the lower jaw forward and prevent airway obstruction from occurring. Positional therapy can be useful in selected cases and surgery is sometimes indicated for those who cannot tolerate medical treatment or do not respond well to it.
Insomnia
Insomnia is one of the most common sleep disorders. Patients have difficulty getting to sleep, staying asleep, or wake up feeling unrefreshed. Insomnia is more common in women and the elderly. There may be genetic factors involved. It is responsible for workplace accidents, work disability and significant impairment in the quality of life. It has been estimated that direct healthcare costs for insomnia in the United States for one year in the mid-1990s may have been between $3 and $14 billion and indirect costs were $80 billion. Medical conditions such as heart failure, lung disease, arthritis and others may be contributory factors as are depression and anxiety. Medications can contribute to insomnia. After obtaining a complete history and physical examination and a list of all medications, a detailed sleep history is obtained and patients are often asked to complete a two-week sleep diary. Cognitive behavioral therapy and sleep hygiene therapy designed to eliminate habits that may be contributing to insomnia, as well as relaxation techniques are often tried before resorting to medications.
Restless Leg Syndrome
Restless Leg Syndrome is another common sleep disorder and may affect as many as 5% to 15% of the population. It is more common in women and the elderly. It is sometimes seen during pregnancy or in association with certain forms of renal insufficiency. Patients describe a creepy crawly sensation in the legs, worse in the evening and at bed time which may interfere with sleep. This sensation is relieved by walking and made worse by sitting still. Treatment depends on the severity of the condition and may consist of iron supplements for those who developed restless leg syndrome in association with iron deficiency anemia or a variety of medications.
Narcolepsy
Narcolepsy is the second most common cause of excessive daytime sleepiness after sleep apnea. In narcolepsy, sleep interludes into wakefulness, and patients may have sudden drop attacks into sleep when they become emotionally upset and/or after hearing a joke, called cataplexy. Sleep interludes into wakefulness and patients may have sudden drop attacks into sleep associated with emotional upset or and after hearing a joke, called cataplexy. They may also have sleep paralysis where they are unable to move immediately after awakening. All patients with narcolepsy have chronic sleepiness. There may be genetic factors involved. The diagnosis is established on the basis of a careful history and physical examination followed by an overnight sleep study and a multiple sleep latency test. Other confirmatory tests are sometimes performed. Treatment consists of scheduled naps, avoidance of medications that make the problem worse, and a variety of pharmacologic agents designed to maintain wakefulness and prevent cataplexy.
Circadian Rhythm Disorders
Circadian rhythm disorders are all characterized by an imbalance between sleeping, wakefulness, and the normal internal 24-hour clock. Examples include jet lag syndrome and shift work disorder. Teenagers sometimes develop delayed sleep phase syndrome when they remain awake all night and sleep all day. Middle-aged and elderly adults sometimes develop advanced sleep phase syndrome, going to sleep earlier and earlier and waking up in the early morning to start their day. They may present to a physician with what initially seems like insomnia. These disorders are evaluated by obtaining a complete history and physical examination. Patients are sometimes asked to complete a sleep diary or wear an Actigraph, a motion and light sensor that looks like a wristwatch and is worn for one to two weeks day and night. Data from the Actigraph is downloaded into a computer and analyzed by the physician. Treatment often consists of timed bright light exposure, gradually advancing or delaying sleep time until the patient is back into a normal cycle that corresponds with the clock and sometimes involves the use of melatonin or sleeping medication.
Less Common Sleep Disorders
There are a variety of somewhat less common sleep disorders including sleepwalking, nocturnal eating disorders, REM-related behavior disorders, central sleep apnea and idiopathic hypersomnia which are also treated at this facility.