Epilepsy and Seizure Disorders

Sleep problems, including snoring, sleep apnea, insomnia, sleep deprivation, and restless legs syndrome, are common. Good sleep is necessary for optimal health and can affect hormone levels, mood and weight.

The amount of sleep a person needs depends on many factors, including age. For example, in general:

Infants require about 14-15 hours a day.
Teenagers need about 8.5-9.5 hours on average.
Most adults need 7 to 9 hours a night for the best amount of sleep, although some people may need as few as 6 hours or as many as 10 hours of sleep each day.
Women in the first 3 months of pregnancy often need several more hours of sleep than usual.

Insomnia is by far the most common sleep disorder, affecting nearly 60 percent of U.S. adults at least one night each week. Common symptoms of insomnia include difficulty getting to sleep and waking before it is time to get up. There are many factors that can contribute to insomnia including stress and underlying medical conditions. Typical treatments include sleeping pills and behavior therapy. Practicing good sleep habits can often be effective for treating mild cases of insomnia.

This is one of the most common sleep disorders. Most people experience insomnia at least once in their lives, and as many as 9% to 15% of the general population reports chronic symptoms that cause significant daytime impairments. Not only can it affect daytime functioning, but it has also been implicated in mood disorders and work related accidents. Insomnia is often treated with a combination of sedative hypnotics (sleeping pills) and a behavioral program call cognitive behavioral therapy.

Of all the sleep disorders, obstructive sleep apnea (commonly referred to as Sleep Apnea) is certainly the most talked about. Sleep apnea is one of the most serious sleep disorders, leading to high blood pressure, heart disease, strokes, motor vehicle accidents, and strained relationships. Sleep apnea can be diagnosed with a sleep study and there are effective treatment options such as CPAP, surgery, oral appliance therapy, and medical management. Sleep Apnea:

Sleep apnea is the second most common sleep disorder and affects approximately 20 million Americans. This disorder causes people to stop breathing abruptly while they are asleep. During this brief period, carbon dioxide builds up in the blood and the sleeper wakes suddenly to gasp for breath. The length of time that the sleeper stop breathing can vary from a few seconds to so long that the individuals skin actually turns blue from oxygen deprivation.

There are three different types of sleep apnea: obstructive sleep apnea (OSA), central sleep apnea, and mixed sleep apnea. These types differ in their causes and potential treatments. In all the types of sleep apnea, some part of the respiratory system narrows, impairing the amount of oxygen a person takes into his or her lungs.

An Introduction to the Types of Sleep Apnea

In all cases of sleep apnea, some part of the respiratory system narrows, decreasing the amount of oxygen a person takes into his or her lungs. Lowered blood oxygen levels then trigger the brain to prompt the person to breathe again. The sleeper gasps, jump-starting the breathing process until the next halt in breathing occurs. Doctors distinguish three different types of sleep apnea:

Obstructive sleep apnea
Central sleep apnea
Mixed sleep apnea

Types of Sleep Apnea:

Obstructive Sleep Apnea

This is the most common and severe form of sleep apnea. A typical person with this form of sleep apnea is an overweight male between 35 and 50 years old who usually has a small jaw, a small opening to the airway at the back of the throat, and a large tongue or tonsils. During sleep, the muscles of the soft palate, the muscles at the base of the tongue, and the uvula (the tissue that hangs from the middle of the back of the mouth) relax and sag, blocking the airway, which then collapses. Approximately 4-percent of American men and 2-percent of women suffer from obstructive sleep apnea. The condition temporarily blocks breathing in the upper airways during sleep, causing loud, labored snoring and stressful sleep interruptions frequently throughout a single night, and resulting in severe daytime drowsiness, depression, moodiness, and inability to concentrate during the waking hours.

As breathing stops, the diaphragm and chest muscles strain until the block is literally uncorked, and a noisy gasp -- the snore -- is made. When breathing stops, blood oxygen levels fall, forcing the heart to work harder. As a result, blood pressure rises, and the heartbeat may even become irregular. What is low oxygen saturation? This occurs when air is not getting into the lungs, when the sleep apnea patient is asleep and blood oxygen levels fall. The researchers found that when oxygen saturation goes below 78%, the risk of sudden cardiac death goes up by 80%.

When a person does not get an adequate amount of sleep his or her ability to function is affected. As listed below their coordination is impaired, have longer reaction time, impairs judgment, and memory is impaired.

Obstructive sleep apnea is made worse by drinking alcohol or taking tranquilizers, antihistamines, or sleeping pills.

Central Sleep Apnea

In this rarer form of the disorder, the airway remains open, but the diaphragm and chest muscles temporarily fail. The dropping blood oxygen levels signal the brain, which prompts the person to awaken and gasp in a breath. Because the airway is typically open, this apnea sufferer does not snore loudly but does have daytime sleepiness.

Central sleep apnea is more common among people over 60, and is often seen in nursing homes and among the ill.

Mixed Sleep Apnea

Some people experience long periods of obstructive sleep apnea interspersed with brief periods of central sleep apnea. This is called mixed sleep apnea.

Sleep-deprived driving (commonly known as tired driving, drowsy driving, or fatigued driving) is the operation of a motor vehicle while being cognitively impaired by a lack of sleep. Sleep deprivation is a major cause of motor vehicle accidents, and it can impair the human brain as much as alcohol can.[1] According to a 1998 survey, 23% of adults have fallen asleep while driving.[2] According to the United States Department of Transportation, male drivers admit to have fallen asleep while driving twice as much as female drivers.[3]

In the United States, 250,000 drivers fall asleep at the wheel every day, according to the Division of Sleep Medicine at Harvard Medical School and in a national poll by the National Sleep Foundation, 54% of adult drivers said they had driven while drowsy during the past year with 28% saying they had actually fallen asleep while driving. According to the National Highway Traffic Safety Administration, drowsy driving is a factor in more than 100,000 crashes, resulting in 1,550 deaths and 40,000 injuries annually in the USA.[4]

When a person does not get an adequate amount of sleep his or her ability to function is affected. As listed below their coordination is impaired, have longer reaction time, impairs judgment, and memory is impaired.

"Treating sleep apnea in one person can improve the quality of life of both bed partners and may have the added benefit of helping to prevent cardiovascular disease. If the spouse sees the bed partner stop breathing repeatedly during sleep, this is an important clue that he or she probably has sleep apnea."

MADISON - A continuing study of sleep problems in the general population shows some alarming findings: over an 18-year period, people with severe, untreated sleep apnea died a rate more than three times that of those without apnea.

Sleep apnea, a condition of repeated episodes of breathing pauses during sleep, is measured by the number of complete or partial halts in breathing per hour of sleep. In a paper published in the August issue of SLEEP, researchers found that the higher the number of breathing pauses, the greater the risk of death.

The conclusion comes from a study led by University of Wisconsin-Madison epidemiologist Terry Young, PhD, of the School of Medicine and Public Health.

"We have been studying the effects of sleep apnea in the Wisconsin Sleep Cohort for more than a decade and have reported links between sleep apnea and hypertension, stroke and depression," said Young, a professor in the department of population health sciences at UW-Madison.

"However, our new findings of a strong and significant decrease in survival with severe, untreated sleep apnea show most dramatically the serious health risk sleep apnea poses."

In addition, Young and her co-authors found the risk of cardiovascular death was strikingly high for participants with severe sleep apnea who had not reported being treated for it. People who had 30 or more breathing pauses per hour of sleep, compared to those who had fewer than five, had five times the risk of cardiovascular death over the 18-year period.

The good news is that people who reported that they had used continuous positive air pressure therapy (CPAP) for their sleep apnea fared better. After the participants who had reported CPAP treatment were excluded from the analysis, the cardiovascular mortality risk jumped from a three-fold risk to a five-fold increase in death.

Young is principal investigator of the Wisconsin Sleep Cohort Study, a longitudinal, community-based epidemiology study of sleep apnea and other sleep problems. The study, begun in 1989, is based on a random sample of 1,522 Wisconsin state employees. The participants undergo overnight sleep studies that include polysomnography – an all-night recording of sleep and breathing – and many other tests at four-year intervals. The studies are conducted in a specially designed unit at the federally funded UW Institute for Clinical and Transitional Research Center (ICTR).

Based on the results from participants' first polysomnography studies, Young found that 63 people (or four percent of the group) had severe sleep apnea, 20 percent had mild or moderate sleep apnea, and 76 percent had no sleep apnea.

In March 2008, researchers examined state death records and found that about 19 percent of participants with severe sleep apnea had died (12 deaths), compared with about four percent of participants with no sleep apnea (46 deaths).

Participants in the study were not selected because they were patients with known sleep problems. After the testing, researchers contacted participants with severe sleep apnea, and explained the condition, its health risks, and recommended seeing their doctor. Despite this information, most failed to seek diagnosis or treatment for their apnea. Furthermore, their primary care doctors may have been unaware of the need for further evaluation of reports of loud, irregular snoring and breathing pauses.

While intervention and treatment for sleep apnea was not part of this study, it is offered at an increasing number of health facilities in the U.S. In Madison, treatment is available at Wisconsin Sleep, located in the University Research Park. Young’s report in the journal, SLEEP, underscores the need for diagnosis of sleep apnea.

"I think many people who wrote off their snoring or apnea as a minor problem will be stunned by these findings, as the sleep-research community is," said Dr. Ruth Benca, medical director of the Wisconsin Sleep Clinic.

"The silver lining is that treatment for sleep apnea seems to help decrease the risk of death and serious complications."

The Wisconsin Sleep Cohort study is funded by the National Institutes of Health.

"In addition to strengthening the evidence that, over time, sleep-disordered breathing (sleep apnea) can increase the risk of death in adults, these findings suggest that treatment may help lessen the risk of dying from cardiovascular disease," noted Michael J. Twery, PhD, director of the NIH National Center on Sleep Disorders Research.

Restless Legs Syndrome (RLS) has probably received the most media attention of all the sleep disorders. In 2005, the first FDA approved medication for RLS was released, and seemingly overnight many patients were being diagnosed. Sleep disorders clinics were suddenly filled with RLS patients, even though it has been known about for centuries. Restless Legs Syndrome occurs in approximately 5% to 10% of the population. Oftentimes it can be related to low iron levels or to substances like caffeine or Benadryl, but frequently it is actually a genetic disorder that requires a medication. Fortunately, we now have a number of medication options for treating RLS. Restless Leg Syndrome (or RLS) causes the lower legs to burn, ache, itch, twitch, and tingle upon falling sleep. It disrupts sleep mostly in middle-aged sufferers who have a family history of RLS. In order to reduce symptoms of RLS, patients are told to cut their caffeine intake and alcohol consumption.

Restless Legs Syndrome/Periodic Limb Movements in Sleep

RLS is a condition characterized by leg dysesthesia that occurs when the patient is in a relaxed awake or restful state and, thus, is more common during the evening or at night. Patients typically describe RLS as an uncomfortable sensation in their legs that is accompanied by the urge to move. Movement provides temporary relief of this uncomfortable sensation. Other terms that are used to describe this sensation include: creepy-crawly, electric current, crazy legs, worms moving, ants crawling or pain. Similar to PLMS, the etiology of RLS is unknown but is associated with iron deficiency states (including pregnancy), uremia, peripheral neuropathy and radiculopathy. Diagnosis of RLS is done on the basis of history alone. Table ​outlines the 4 essential features of RLS, according to the International Restless Legs Syndrome Study Group. Asking the question, ‘When you relax in the evening, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?’, could be sufficient for diagnosis.

Four essential questions required to make the diagnosis of RLS.

PLMS, often related to RLS, are characterized by clusters of repetitive leg jerks or kicks during sleep. These leg movements characteristically occur every 20–40 s and recur throughout the night. Each jerk or kick may result in an arousal or a brief awakening which causes sleep fragmentation and might lead to complaints of EDS. Since the patients are not aware of these kicks, the complaints might be wrongly interpreted as insomnia. For assessment, a bed partner might be helpful since they are most likely aware of their partner's excessive movements during the night. Diagnosis of PLMS should be based only on an overnight polysomnogram showing a calculated periodic limb movement index (the number of limb movements per hour of sleep) ≥5. The etiology of PLMS is unknown. In the absence of RLS, there may be little clinical significance to PLMS.

PLMS and RLS are both common in the older adult. The prevalence of both RLS and PLMS increases significantly with age.

In all age groups, the recommended treatments for RLS/PLMS are dopamine agonists. Ropinirole and pramipexole are the only drugs that are FDA-approved for RLS, but the off-label use of other dopamine agonists (e.g. carbidopa-levodopa) have also been shown to be effective.

Periodic limb movement disorder (PLMD), previously known as nocturnal myoclonus, is a sleep disorder where the patient moves limbs involuntarily during sleep, and has symptoms or problems related to the movement.

PLMD should not be confused with restless leg syndrome (RLS). RLS occurs while awake as well as when asleep, and when awake, there is a voluntary response to an uncomfortable feeling in the legs. PLMD on the other hand is involuntary, and the patient is often unaware of these movements altogether.

Patients with PLMD will complain of excessive daytime sleepiness (EDS), falling asleep during the day, trouble falling asleep at night, and difficulty staying asleep throughout the night. Patients also display involuntary limb movements that occur at periodic intervals anywhere from 20–40 seconds apart. They often only last the first half of the night during non-REM sleep stages. Movements do not occur during REM because of muscle atonia.

Diagnosis

People with PLMD often do not know the cause of their excessive daytime sleepiness and their limb movements are reported by a spouse or sleep partner. PLMD is diagnosed with the aid of a polysomnogram or PSG. PLMD is diagnosed by first finding PLMS (periodic limb movements of sleep) on a PSG, then integrating that information with a detailed history from the patient and/or bed partner. PLMS can range from a small amount of movement in the ankles and toes, to wild flailing of all four limbs. These movements, which are more common in the legs than arms, occur for between 0.5 and 5 seconds, recurring at intervals of 5 to 90 seconds. A formal diagnosis of PLMS requires three periods during the night, lasting from a few minutes to an hour or more, each containing at least 30 movements followed by partial arousal or awakening.

Causes

It is mostly unknown what causes PLMD, but in many cases the patient also suffers from other medical problems such as Parkinson's disease or narcolepsy. Factors that increase the likelihood of PLMD in the absence of restless leg syndrome include being a shift worker, snoring, coffee drinking, stress, and use of hypnotics, particularly in the case of benzodiazepine withdrawal. For women, the presence of musculoskeletal disease, heart disease, obstructive sleep apnea, cataplexy, doing physical activities close to bedtime and the presence of a mental disorder were significantly associated with having a higher risk of both PLMD and restless legs syndrome.

Treatment

PLMD is often treated with anti-Parkinson medication; it may also respond to anticonvulsants, benzodiazepines, and narcotics. Patients must stay on these medications in order to experience relief, because there is no known cure for this disorder. PLMs tend to be exacerbated by tricyclic antidepressants, SSRIs, stress and sleep deprivation. It is also advised to not consume caffeine, alcohol or antidepressants as these substances could worsen the PLMD symptoms.

Other medications aimed at reducing or eliminating the leg jerks or the arousals can be prescribed. Non-ergot derived dopaminergic drugs (pramipexole and ropinirole) are preferred.[4] Other dopaminergic agents such as co-careldopa, co-beneldopa, pergolide, or lisuride may also be used. These drugs decrease or eliminate both the leg jerks and the arousals. These medications are also successful for the treatment of restless legs syndrome.

In one study, co-careldopa was superior to dextropropoxyphene in decreasing the number of leg kicks and the number of arousals per hour of sleep. However, co-careldopa and, to a lesser extent, pergolide may shift the leg movements from the nighttime to the daytime.[5] Clonazepam, (Klonopin), in doses of 1 mg has been shown to improve objective and subjective measures of sleep.

Of all the sleep disorders, Narcolepsy is probably the most "famous". It has been made fun of in popular television and is part of our popular cultures vernacular, but few understand that this is probably one of the most devastating sleep disorders. It causes frequent uncontrollable bouts of sleepiness throughout the day, and can be accompanied by episodes of paralysis caused by emotional triggers. Narcolepsy remains on of the most difficult to treat sleep disorders, although new medications like Xyrem and Nuvigil offer hope.

Narcolepsy is one of the most dangerous sleep disorders. It’s rare, affecting only roughly 100,000 Americans. The condition itself causes a dysfunction in the brain mechanisms that manage sleeping and waking—causing a person to instantly fall asleep while conversing, walking, driving, climbing stairs, working, etc. Most narcoleptics are extremely fatigued during the daytime hours, and suffer from hallucinations, muscle deterioration, sleep paralysis, and fainting.

Sleepwalking is a sleep disorder that mainly afflicts children in deep sleep, causing the brain to continue sleeping, but the body to act as though its awake for short periods of time (i.e., 5- to 10-minute intervals). Sleepwalking is often linked to fever, sickness, medication, or stress, and sleepwalkers almost never remember what they do or say during an episode. With only 10-percent of children affected by sleepwalking, most outgrow it in their teen years.

Sleepwalking & Night Terrors:

While insomnia and sleep apnea are more common in adults, other sleep disorders such as sleepwalking and night terrors are far more common in young children. Sleepwalking, also known as somnambulism, is characterized by periods of getting out of bed while asleep.

Night terrors are most frequently seen in very young children (between the ages of 2 and 6), but people of any age can be affected by this sleep disorder. Typical symptoms include excessive sweating, shaking and obvious fear.

If you’re going to sleep earlier and earlier or waking up later and later, you may have non-24-hour-sleep-wake syndrome, a condition that sets your biological clock to 25 hours or longer. This condition is often linked to blind individuals due to their absence of waking and sleeping light cue

Advanced sleep phase disorder (or ASPD) occurs when the biological clock sets to rise earlier than it should—for instance, the sufferer may feel the need to sleep at 7pm and wake up at 3am. ASPD most commonly affects seniors and is often linked to seasonal affective disorder (or SAD).

Jet lag is a traveler’s sleep condition that affects the body’s internal clock by causing sleep disruptions in a new time zone. The severity of jet lag depends on many factors—including age, quantity of time zones, and the direction of travel—causing the sufferer to become fatigued, nauseated, headachy, and unable to fall to sleep.

Delayed sleep phase disorder is a condition that makes it really difficult to wake up in the morning. It affects the biological clock, causing the body to become out of sync with normal required hours of sleep. Sleep becomes so sound that it’s almost impossible to wake up on time for work or school—even with a loud alarm clock or person waking you up.

Approximately 70 million Americans suffer from one sleep disorder or another. Sleep disorders are characterized by any conditions that prevent a person from getting restful sleep. The dangerous part isn’t the actual sleep loss, but the dysfunction it causes during the waking hour when we are operating motor vehicles, work-associated machinery, and so forth.

RBD is a condition in which the skeletal muscle atonia normally found in REM sleep is absent. Patients with this sleep disorder are often described as ‘acting out their dreams'. This disorder is characterized by the display of elaborate movements during REM sleep. These can include kicking, punching, running and/or yelling. The patient's uncontrolled movements are sometimes aggressive and/or violent, and might result in injuries either to the patient himself and/or the patient's bed partner. The etiology of chronic RBD is currently unknown, yet it appears to be strongly related to a number of underlying neurological or neurodegenerative disorders. Approximately 40% of RBD cases are related to such conditions. Some data suggest that RBD may be the first manifestation and/or indication of a neurodegenerative disease [24]. In one study, 50% of those diagnosed with RBD developed Parkinson's disease or Multiple System Atrophy within 3–4 years [25]. RBD is more common in the elderly, with a significantly higher prevalence in older men.

The diagnosis of RBD requires a thorough sleep history which should be conducted in the presence of the patient's bed partner. Recently, a new screening questionnaire was developed and validated [26]. An overnight polysomnography recording which includes video recording is helpful in confirming the disorder. Close attention should be given to the presence of intermittent elevations in muscle tone or limb movements on the electromyelogram channel during REM sleep. This finding is highly suggestive of RBD.

Delayed sleep phase disorder is a condition that makes it really difficult to wake up in the morning. It affects the biological clock, causing the body to become out of sync with normal required hours of sleep. Sleep becomes so sound that it’s almost impossible to wake up on time for work or school—even with a loud alarm clock or person waking you up.
Approximately 70 million Americans suffer from one sleep disorder or another. Sleep disorders are characterized by any conditions that prevent a person from getting restful sleep. The dangerous part isn’t the actual sleep loss, but the dysfunction it causes during the waking hour when we are operating motor vehicles, work-associated machinery, and so forth.
Here are the eight most common sleep-associated disorders…