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Sleep Disorders In Adults

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

<a href="https://merisehat.pk/article/how-you-sleep">Sleep</a> disorders in adults refer to a range of conditions that disrupt normal sleep patterns and can lead to difficulties in falling asleep, staying asleep, or achieving restorative sleep. 
&nbsp;

Adults typically need 7-8 hours of sleep every day. According to the NIH, around 50-70 million US adults experience a sleep disorder, with reportedly 35% of them claiming their sleep quality is only fair or poor<a href="#accordion">[1][2]</a>. 
&nbsp;

There are nearly 90 different conditions that qualify as sleep disorders, affecting the quantity and quality of sleep, and leading to various physical, mental, and emotional health problems<a href="#accordion">[1]</a>.

<ul>
	<li>Insomnia is one of the most common sleep disorders, affecting around 33-50% of the adult population. If it persists for at least three months, it is referred to as chronic <a href="https://merisehat.pk/disease/insomnia">insomnia</a><a href="#accordion">[1]</a>. 
	&nbsp;</li>
	<li>Obstructive Sleep Apnea is estimated to affect around 13% of adult men and 6% of adult women. The prevalence of undiagnosed sleep apnea is higher, with some estimates suggesting that up to 80-90% of cases go undiagnosed<a href="#accordion">[3]</a>. 
	&nbsp;</li>
	<li>Narcolepsy with cataplexy, a subtype of narcolepsy, is less common and is estimated to affect about 0.02-0.04% of the adult population<a href="#accordion">[2]</a>. The prevalence of narcolepsy without cataplexy is higher, but exact numbers are not well-defined. 
	&nbsp;</li>
	<li>Restless Legs Syndrome affects around 7-10% of the adult population, with a higher prevalence in older adults<a href="#accordion">[1]</a>. 
	&nbsp;</li>
	<li>Periodic Limb Movement Disorder is estimated to affect around 4-11% of adults, and its prevalence increases with age<a href="#accordion">[8]</a>. 
	&nbsp;</li>
	<li>The prevalence of Parasomnias varies widely. Sleepwalking, for instance, affects around 1-5% of the adult population. Parasomnia usually affects children, and its prevalence decreases as kids grow. For instance, only about 2% of adults get night terrors, compared to 37% of 18-month-olds<a href="#accordion">[2]</a>. 
	&nbsp;</li>
	<li>REM Sleep Behavior Disorder is estimated to affect less than 1% of adults, and it mostly affects men older than 50<a href="#accordion">[2]</a>. 
	&nbsp;</li>
</ul>

It&#39;s important to remember that these prevalence figures can vary depending on factors such as geographical location, study methodologies, and changes in diagnostic criteria. Additionally, sleep disorders often go undiagnosed, so the actual prevalence could be higher than the reported figures. 
&nbsp;

Signs and Symptoms

There are numerous types of sleep disorders, each with its specific characteristics and effects. Some common examples include:

<ul>
	<li>Insomnia: It is characterized by difficulty falling asleep, staying asleep, or experiencing non-refreshing sleep. Insomnia can lead to daytime fatigue, irritability, and impaired cognitive function. 
	 
	Chronic psychophysiological insomnia (also called conditioned or learned insomnia) ensues when a stressor is combined with the fear of being unable to sleep. A hallmark sign is individuals cannot sleep when they&rsquo;re not in their own beds<a href="#accordion">[5]</a>. 
	&nbsp;</li>
	<li>Sleep Apnea: This disorder involves interruptions in breathing during sleep, leading to repeated awakenings throughout the night. It can cause loud snoring, gasping, or choking during sleep, daytime sleepiness, headaches, and an increased risk of cardiovascular problems. 
	&nbsp;</li>
	<li>Narcolepsy: Narcolepsy is a neurological disorder where individuals experience sudden, uncontrollable episodes of falling asleep. It can also cause muscle weakness (cataplexy), hallucinations when falling asleep or waking up, and sleep paralysis. 
	&nbsp;</li>
	<li>Restless Legs Syndrome (RLS): RLS is characterized by uncomfortable sensations in the legs and an irresistible urge to move them, often leading to difficulty falling asleep or staying asleep. 
	&nbsp;</li>
	<li>Periodic Limb Movement Disorder (PLMD): This disorder involves repetitive movements of arms, legs, or both during sleep, which can cause frequent awakenings and fragmented sleep. 
	&nbsp;</li>
	<li>Circadian Rhythm Disorders: These disorders involve disruptions in the body&#39;s internal clock, leading to difficulty falling asleep or waking up at the desired times. Examples include jet lag and shift work sleep disorder. 
	&nbsp;</li>
	<li>Parasomnias: These are abnormal behaviors or experiences that occur during sleep or while falling asleep. Examples include sleepwalking, sleep talking, night terrors, and sleep-related eating disorders. 
	&nbsp;</li>
	<li>Hypersomnia: Individuals have difficulty staying awake during the day, even after getting sufficient nighttime sleep. 
	&nbsp;</li>
	<li>REM Sleep Behavior Disorder: In this disorder, the normal muscle paralysis that occurs during rapid eye movement (REM) sleep is absent, leading to physically acting out dreams during sleep. As such, this can involve movements, talking, or even violent actions, potentially leading to injuries or sleep disruptions for the individual or their bed partner. 
	&nbsp;</li>
	<li>Sleep-Related Movement Disorders: These disorders involve abnormal movements or behaviors during sleep, such as rhythmic movement disorders or sleep-related leg cramps. 
	&nbsp;</li>
</ul>

Causes

These include:

<ul>
	<li>Stress; academic or occupational</li>
	<li>Fatigue, e.g., due to parenting responsibilities</li>
	<li>Lifestyle Habits, including irregular sleep schedules, excessive use of screens before bedtime, and irregular eating habits or consumption of caffeine or alcohol before bedtime</li>
	<li>A Side Effect of a medication</li>
	<li>(Age-related) Health Issues, such as iron deficiency, pregnancy, and neuropathy</li>
	<li>A symptom of Medical Conditions like asthma</li>
	<li>A symptom of Mental Health condition like anxiety disorder</li>
	<li>Rapid Travel across time zones 
	&nbsp;</li>
</ul>

Diagnosis

Screening and diagnosing sleep disorders in adults typically involves a combination of medical history assessments, sleep questionnaires, sleep diaries, and, in some cases, objective sleep tests conducted in sleep laboratories. 
&nbsp;

<ul>
	<li>
	<h5>Medical History And Clinical Assessment</h5>
	</li>
</ul>

The healthcare provider will start by discussing the individual&#39;s sleep patterns, daily routines, and any specific sleep-related complaints or symptoms.

Information about medical history, medications, and potential underlying conditions that might contribute to sleep problems will also be collected. 
&nbsp;

<ul>
	<li>
	<h5>Sleep Questionnaires And Diaries</h5>
	</li>
</ul>

Various sleep questionnaires may be used to gather detailed information about sleep quality, sleep duration, and sleep-related behaviors.

Keeping a sleep diary for a week or more can provide insights into sleep patterns, bedtime routines, and potential triggers for sleep disturbances. 
&nbsp;

<ul>
	<li>
	<h5>Actigraphy</h5>
	</li>
</ul>

Actigraphy involves wearing a wristwatch-like device that monitors movement to assess sleep-wake patterns over several days. This can provide a rough estimate of sleep duration and timing. 
&nbsp;

<ul>
	<li>
	<h5>Polysomnography (PSG)</h5>
	</li>
</ul>

PSG is a comprehensive sleep study conducted in a sleep laboratory. It involves monitoring various physiological parameters during sleep, including brain activity (EEG), eye movements (EOG), muscle activity (EMG), heart rate, respiratory effort, and oxygen levels.

PSG is often used to diagnose disorders like sleep apnea, periodic limb movement disorder, and narcolepsy. 
&nbsp;

<ul>
	<li>
	<h5>Home Sleep Apnea Testing (HSAT)</h5>
	</li>
</ul>

HSAT involves using a simplified sleep monitoring device at home to assess breathing patterns and oxygen levels during sleep.

It is primarily used for diagnosing obstructive sleep apnea in individuals with a high likelihood of having the disorder. 
&nbsp;

<ul>
	<li>
	<h5>Multiple Sleep Latency Test (MSLT)</h5>
	</li>
</ul>

MSLT measures daytime sleepiness by assessing the time it takes to fall asleep during scheduled daytime naps.

It is commonly used to diagnose narcolepsy and evaluate excessive daytime sleepiness. 
&nbsp;

<ul>
	<li>
	<h5>Maintenance Of Wakefulness Test (MWT)</h5>
	</li>
</ul>

MWT evaluates an individual&#39;s ability to stay awake during quiet and sedentary situations, providing insights into daytime sleepiness.

It is often used to assess the effectiveness of treatment for sleep disorders like narcolepsy. 
&nbsp;

Note: Sleep disorders can have a significant impact on overall health and quality of life, so seeking professional help is essential if sleep problems are affecting daily functioning. The choice of diagnostic tests depends on the specific sleep disorder suspected and the individual&#39;s symptoms. 
&nbsp;

Treatment

The treatment of sleep disorders in adults varies based on the specific disorder, its underlying causes, and the individual&#39;s overall health. If it&rsquo;s a side effect of another medication, the doctor may prefer changing the medicine or its dosage at first before proceeding to treat it using other modalities.

Here are some common treatment approaches for different sleep disorders: 
&nbsp;

<ul>
	<li>
	Insomnia
	</li>
</ul>

<ol>
	<li>Cognitive Behavioral Therapy For Insomnia (CBT-I): A structured therapy that helps individuals develop better sleep habits and address negative thought patterns related to sleep.</li>
	<li>Sleep Hygiene Education: Promoting good sleep practices such as maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulating activities close to bedtime.</li>
	<li>Medications: In some cases, short-term use of medications (e.g., alerting agents or sleeping pills) might be recommended. These should be used under medical supervision due to potential side effects and the risk of dependency. Examples include: Zolpidem, Ramelteon, Lemborexant, Eszopiclone, and Suvorexant<a href="#accordion">[4]</a>.</li>
	<li>Mind And Body Approaches: While yoga, mindfulness, acupuncture, and massage therapy need more research, they are generally considered safe and effective to help relax or destress<a href="#accordion">[2]</a>. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	Sleep Apnea
	</li>
</ul>

<ol>
	<li>Continuous Positive Airway Pressure (CPAP): The most common treatment for obstructive sleep apnea, CPAP involves wearing a mask over the nose or mouth during sleep to deliver a continuous flow of air that keeps the airway open.</li>
	<li>Lifestyle Changes: Weight loss, avoiding alcohol and sedatives, and sleeping on one&#39;s side can help reduce the severity of sleep apnea.</li>
	<li>Oral Appliances: Some individuals may benefit from dental devices that reposition the jaw and tongue to keep the airway open. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	Narcolepsy
	</li>
</ul>

<ol>
	<li>Stimulant Medications: Medications like modafinil are often prescribed to improve wakefulness and reduce daytime sleepiness.</li>
	<li>Antidepressant Medications: These can help manage cataplexy and other symptoms.</li>
	<li>Scheduled Naps: Short, scheduled naps throughout the day can help manage excessive daytime sleepiness. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	RLS And PLMD
	</li>
</ul>

<ol>
	<li>Lifestyle Modifications: Regular exercise, avoiding caffeine and nicotine, and maintaining a regular sleep schedule can help alleviate symptoms.</li>
	<li>Medications: Dopamine agonists and other medications can help relieve the discomfort associated with RLS and PLMD. Examples include: gabapentin, pregabalin, and gabapentin enacarbil<a href="#accordion">[4]</a>. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	Circadian Rhythm Disorders
	</li>
</ul>

<ol>
	<li>Light Therapy: Exposure to bright light at specific times can help reset the body&#39;s internal clock.</li>
	<li>Behavioral Strategies: Gradually adjusting sleep schedules, avoiding bright light before bedtime, and promoting consistent sleep-wake times.</li>
	<li>Medications: A tiny dose of supplements like melatonin may be prescribed to help shift the cycle<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	Parasomnias
	</li>
</ul>

<ol>
	<li>Creating A Safe Sleep Environment: Minimizing potential hazards for individuals who sleepwalk or experience night terrors.</li>
	<li>Medications: In some cases, medication may be prescribed to manage symptoms, but this is usually a last resort. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	Hypersomnia
	</li>
</ul>

<ol>
	<li>Stimulant Medications: Similar to narcolepsy treatment, stimulants can help improve wakefulness during the day.</li>
	<li>Scheduled Naps: Short, scheduled naps can help manage excessive sleepiness. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	REM Sleep Behavior Disorder
	</li>
</ul>

<ol>
	<li>Medications: Certain medications, such as melatonin, may help reduce the physical movements associated with REM sleep behavior disorder. 
	&nbsp;</li>
</ol>

The complications can range from mild to severe and may vary based on the type and severity of the sleep disorder.

<ul>
	<li>Decreased Attention Span, slower reaction times, and decreased overall cognitive performance, increasing the risk of accidents both at home and in occupational settings</li>
	<li>Mood Disorders, such as depression and anxiety</li>
	<li>Cardiovascular Issues, including hypertension, heart disease, and stroke</li>
	<li>Reduced Quality Of Life with poor physical and emotional health, and strained intimate relationships</li>
	<li>Impaired Immune Function making individuals more susceptible to infections and illnesses</li>
	<li>Conditions like fibromyalgia may be exacerbated</li>
	<li>Neurological Problems like Parkinson&rsquo;s disease and dementia</li>
	<li>Hormonal Imbalances causing chronic issues like type 2 diabetes</li>
	<li>Substance Abuse and dependence 
	&nbsp;</li>
</ul>

Note: While it&rsquo;s rare, some sleep disorders can be life-threatening. 
&nbsp;

Several risk factors can contribute to the development of sleep disorders in adults.

<ul>
	<li>Age</li>
	<li>Genetic mutation</li>
	<li>Family history of sleep disorders</li>
	<li>Gender; women are more likely to experience them than men<a href="#accordion">[4]</a></li>
	<li>Obesity, especially in the neck area, can contribute to obstructive sleep apnea due to the narrowing of the airway during sleep</li>
	<li>Lifestyle factors, such as smoking and excessive caffeine consumption</li>
	<li>Emotional distress</li>
	<li>Anxiety and depression</li>
	<li>Underlying health conditions, such as chronic pain, heart disease, respiratory disorders, gastrointestinal issues, neurological disorders, and allergies</li>
	<li>Certain medications, including antidepressants, antihypertensives, and corticosteroids</li>
	<li>Pregnancy, menopause, and other life stages that cause significant hormonal imbalances</li>
	<li>Irregular work schedules, especially shift work and jet lag</li>
	<li>An uncomfortable sleep environment, such as excessive noise, bright light, and uncomfortable bedding</li>
	<li>Substance abuse, including alcohol, caffeine, and certain recreational drugs</li>
	<li>Trauma or PTSD 
	&nbsp;</li>
</ul>

It&#39;s important to note that having one or more risk factors doesn&#39;t guarantee the development of a sleep disorder, but they can increase the likelihood. 
&nbsp;

It&rsquo;s not possible to prevent every type of sleep disorder. However, improving sleep hygiene can help get better sleep. 
&nbsp;

Avoid the following at least 3-4 hours before the scheduled bedtime:

<ul>
	<li>Tobacco</li>
	<li>Chocolate</li>
	<li>Caffeinated drinks, including tea, soda, and coffee</li>
	<li>Heavy meals</li>
	<li>Naps after 3 pm 
	&nbsp;</li>
</ul>

Additionally, good sleep habits should include:

<ul>
	<li>Maintaining a regular schedule, i.e., going to bed and waking up at the same time each day.</li>
	<li>Exercising regularly. However, avoid doing it right before bedtime.</li>
	<li>No reading, no phone, no watching television in bed.</li>
	<li>Maintaining a dark and calm environment in the bedroom.</li>
	<li>Avoid struggling to fall asleep in bed. Either change the bed, or simply get up and try again later. 
	&nbsp;</li>
</ul>

According to a recent study, the composition of microbes in the gut can positively or negatively affect the individual&rsquo;s health by producing either beneficial metabolites or toxins respectively. It also found that particular species of microbes are linked to a particular risk of long-term health conditions, including heart disease, diabetes, and obesity.

For instance, 3 out of 6 microbiota species that were more abundant in the jet-lagged group have negative implications for health. They are associated with obesity, cardiovascular risk, and higher levels of inflammation among others<a href="#accordion">[6]</a>.

Another recent survey found that more than 50% of older adults are under the impression that poor sleep is part of aging. These underreported, undiagnosed, and untreated sleep problems occur despite the fact that the National Sleep Foundation and the American Academy of Sleep Medicine have recommended at least 7 hours of sleep per day for all adults. It&rsquo;s imperative to educate and increase awareness of the importance of quality sleep among both the older patients and their healthcare providers<a href="#accordion">[7]</a>. 
&nbsp;

Key Points

<ul>
	<li>Sleep disorders encompass various conditions that disrupt normal sleep patterns, impacting the quantity and quality of sleep.</li>
	<li>Common sleep disorders in adults include insomnia, sleep apnea, narcolepsy, restless legs syndrome, circadian rhythm disorders, and parasomnias.</li>
	<li>Symptoms vary based on the disorder but can include difficulty falling asleep, waking up frequently during the night, waking up too early and being unable to fall back asleep, feeling tired upon waking, irritability, difficulty concentrating, and impaired daytime functioning.</li>
	<li>Diagnosis involves medical history assessment, sleep questionnaires, sleep diaries, and sleep studies such as polysomnography or home sleep apnea testing.</li>
	<li>Treatment varies by disorder and may include behavioral interventions, lifestyle changes, medication, CPAP therapy, light therapy, and cognitive behavioral therapy for insomnia (CBT-I).</li>
	<li>Practicing good sleep hygiene, such as maintaining a consistent sleep schedule, creating a comfortable sleep environment, and managing stress, can help prevent and manage sleep disorders.</li>
	<li>Sleep disorders can lead to mood disturbances, cognitive impairment, increased accident risk, cardiovascular issues, metabolic disruptions, and reduced overall quality of life.</li>
	<li>Risk factors include age, gender, obesity, stress, medical conditions, medications, genetics, lifestyle habits, and sleep environment.</li>
</ul>

[1] The six types of sleep disorders. Cedars.

[2] What are sleep disorders? Psychiatry.org - What are Sleep Disorders?

[3] Santilli M, Manciocchi E, D'Addazio G, et al. Prevalence of Obstructive Sleep Apnea Syndrome: A Single-Center Retrospective Study. Int J Environ Res Public Health. 2021;18(19):10277. Published 2021 Sep 29. doi:10.3390/ijerph181910277

[4] Sleep disorders: Conditions that prevent you from getting restful sleep. Cleveland Clinic.

[5] Key sleep disorders - sleep and sleep disorders. Centers for Disease Control and Prevention.

[6] Irregular sleep patterns associated with harmful gut bacteria. ScienceDaily.

[7] Gordon, N.P., Yao, J.H., Brickner, L.A. et al. Prevalence of sleep-related problems and risks in a community-dwelling older adult population: a cross-sectional survey-based study. BMC Public Health

[8] Drakatos P, Olaithe M, Verma D, et al. Periodic limb movements during sleep: a narrative review. J Thorac Dis. 2021;13(11):6476-6494. doi:10.21037/jtd-21-1353