Sleep Disorders Part II: Adults

ABSTRACT

A good night’s rest is vital for people of all ages. Sleep deprivation in the
adult population can occur when a regular and expected night of rest does
not occur, often due to circumstances beyond a person’s control. There are
several known and understood reasons for sleep, with many more being
uncovered through continued research and study about sleep habits and
processes. A sleep disorder will interfere with essential health benefits
derived from good sleep, such as consolidation of memories, regulation of
immune function, body growth, and energy conservation. The patient with
sleep issues may undergo a number of tests to confirm a diagnosis.

Introduction

Every person requires sleep as a normal part of daily activity and for
continued health and stability. Almost everyone experiences disrupted sleep
at one time or another. There may be some nights when sleep is hard to get,
while on other nights, sleep cannot come soon enough. For a percentage of
the population, sleep is continuously disrupted as a result of sleep disorders.
These conditions impact the ability to achieve good, quality sleep and lead to
chronic sleep deprivation, exhaustion, and possibly long-term health
consequences.

Normal Sleep Patterns

Most people extend themselves so much every day that their sleep suffers,
even without the presence of other underlying medical conditions or sleep
disorders. Many adults view sleep as an option, rather than an essential
activity. They schedule many tasks and items of things to do, believing that
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they can cut back on sleep to get everything done. Despite feeling
productive in their daily tasks, many people are often risking their health
and wellness to lose sleep over getting other things done. Sleep is a critical
component of daily living and ultimately affects focus and concentration,
memory, emotional stability, and even weight.1 The reality for many people
is that, although they believe that they are making up time for other more
important activities instead of sleeping, they are missing out on a critical
element for their health.

The optimal amount of time needed for sleep among adults is less than that
for children and adolescents, although adults still need between 7.5 and 9
hours of sleep each night. Most people get by on less sleep, believing that
they can adequately function on only 5 or 6 hours each night. A person may
sleep 6 hours each night, yet continue to function during the day; however,
it does not necessarily mean that the person would not perform and feel
better during the day if they slept more.1 The optimal amount of time to
sleep often varies considerably from the actual amount of time.

Adults who get enough sleep at night should feel alert and awake throughout
the day. For someone who has a lag during the day, must take naps, or
consistently feels tired and less energetic, sleep needs are most likely not
being met. Because each person requires different amounts of sleep, it will
do no good to make comparisons between what one person can accomplish
on a few hours of sleep. Instead, each person should best determine the
amount of sleep needed, not just how much to get by on, and aim to get
that much sleep each night.

The exact reasons for why people sleep are still not fully identified; however,
researchers have concluded that there are several known and understood

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reasons for sleep, with many more being uncovered through continued
research and study about sleep habits and processes. Some of the reasons
why people need sleep include the consolidation of memories, regulation of
immune function, body growth through the release of growth hormone while
sleeping, and energy conservation.2

NREM

Non-rapid eye movement (NREM) sleep is considered to be deep, restorative

sleep. It is classified into 4 stages, each of which has different characteristics
and lasts for different lengths of time. NREM sleep accounts for
approximately 75 to 80 percent of total sleep each night.2 NREM and REM
sleep form a cycle that makes up the sleep architecture; the stages and
cycles of sleep throughout the course of a night. People typically move back
and forth between stages of NREM and REM sleep throughout the night in
cycles that last approximately 90 minutes. A person may have 4 to 6 sleep
cycles each night.1

The first stage of NREM sleep is known simply as stage 1 sleep. It is during
this stage that a person is first falling asleep, but the sleep is very light.
During stage 1 sleep, a person may be awakened easily or may feel sleep
did not occur much at all. For the person who has ever felt as if they’ve
“dozed off” in the middle of an activity or while trying to sleep, they may
have been in stage 1 sleep. Stage 1 lasts only about 5 minutes.13 After stage
1 sleep, a person progresses to stage 2 of NREM sleep.

Stage 2 is considered something of a transitional stage of sleep in which the

person moves between the light sleep of stage 1 and the deep sleep of stage
3. Stage 2 sleep is deeper than stage 1 and, during the initial cycle, it lasts
approximately 10 to 15 minutes. Later sessions of stage 2 are much shorter

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than this and may only last about 7 minutes.13 Stage 2 sleep is important
because of some of the biological processes that occur during this stage. The
heart rate slows and body temperature drops; eye movements that may
have happened occasionally during stage 1 slow and come to a halt, and
brain waves slow down. The brain waves are also affected during stage 2 by
the production of spindles,13 which appear similar to spikes on an
electroencephalogram (EEG) and are thought to be the period of time when
brief bursts of brain activity signify memory and thought processing.

The later stages of NREM sleep, stages 3 and 4, are classified as deep sleep
or slow wave sleep. It is during deep sleep that the body is making most
repairs to the tissues and gaining energy to get up and stay awake the next
day. When a person has interrupted sleep, whether due to wakening during
the night or a lack of total sleep because of a sleep disorder, the most
damaging effects occur with a lack of deep sleep.1

Stages 3 and 4 produce slow brain waves that are also called delta waves. A
person who is in these deep stages of sleep can be very hard to awaken;
consequently, when awakening from this stage of sleep, a person feels very
groggy and disoriented as compared to waking up from a different stage of
sleep. The amount of oxygen that the body takes in decreases during these
stages and the body ceases production of cortisol and increases secretion of
growth hormone during this time.13

Deep sleep is important for memory consolidation because memories are

stored during this time.13 NREM sleep varies in its consistency and quality of
sleep, as well as the amounts of time a person spends in each phase. Deep
sleep is an essential component of the sleep cycle and a person who misses
out on adequate amounts of deep sleep may suffer greatly from harmful

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physical and cognitive issues. After progressing through NREM sleep, the
body then transitions toward the next stage in the cycle, which is rapid eye
movement, or REM sleep.

REM

Rapid eye movement sleep, or REM sleep, is the stage at which a person
dreams while asleep. After falling asleep, a person progresses through the
stages of NREM sleep and ultimately enters the REM stage of sleep after
approximately 70 to 90 minutes. During this phase, a sleeping person can be
seen to have rapid eye movements going on under the surface of the
eyelids.1 As the night progresses, a normal sleeper will have longer periods
of REM sleep and shorter periods of NREM sleep. However, REM sleep still
accounts for approximately 20 to 25 percent of total sleep time each night.2
REM sleep is important for recharging the mind and processing what
occurred during the day. It is during REM sleep that many memories are
consolidated, neural connections are strengthened, and neurotransmitters
such as serotonin and norepinephrine are restocked to provide ample
amounts that will be needed. If a person is lacking in REM sleep, it is more
likely that memory problems or mood disorders associated with altered
levels of neurotransmitters in the brain will develop.

Compared to NREM sleep, REM sleep is a time of increased activity in the

brain as well as other physiological processes that occur due to the increased
brain activity. The heart rate and blood pressure increases; blood pressure
may actually rise by up to 30 percent during REM sleep. There is an increase
in sympathetic nerve activity and increased blood flow to the brain. A
person’s respiratory rate increases and sexual arousal is at its highest.
Alternatively, muscle activity decreases during REM sleep, to the point of

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muscle atonia or paralysis.2 This is thought to occur during REM sleep to
prevent the person from acting out what is dreamt.

Although a sleeping person will progress through a sleep cycle of NREM and
REM sleep after initially falling asleep, a person tends to spend more time in
REM sleep during the later part of the night with more time in NREM in the
earlier parts of the night. Because NREM is so important for deep,
restorative sleep, a person’s body will achieve as much NREM as needed
early on. Once the need for deep sleep has been met, the person may then
spend more time in REM sleep.13

Common Sleep Disorders

Sleep deprivation can occur in almost anyone when a regular and expected
night of rest does not occur. This may be due to circumstances beyond the
person’s control, such as an emergency situation that keeps someone awake
all night, environmental noise that is so loud that it prevents decent sleep
from happening, or traveling through different time zones that disrupt
normal sleep patterns. Typically, a person that is sleep deprived for these
types of reasons is able to catch up on sleep again at the next opportunity.

There are some people who become chronically sleep deprived because of
sleep disorders. While sleep disorders can be common, there is an impact
upon the sleep of affected individuals and their bed partners or roommates.
Sleep disorders may range from mild conditions that are more annoying to
other members of the household rather than to the affected person, to such
severe conditions that the person becomes chronically sleep deprived and
suffers from exhaustion, physical illness, and psychological harm.

Breathing Disorders
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Some people develop difficulties with breathing while trying to sleep. Sleep-
disordered breathing is a term used to describe several situations that can
impact a person’s ability to breathe while sleeping, causing insufficient
breathing patterns or complete absence of breathing. Sleep-disordered
breathing (SDB) causes various symptoms depending on the underlying
disorder, but most people experience frequent snoring, which may impact
the sleep patterns of not only the affected person but also the sleep habits of
a bed or room partner. People with SDB may also suffer from disrupted
sleep at night and excessive daytime sleepiness as a consequence of
impaired sleep habits. Some types of sleep-disordered breathing may
include obstructive sleep apnea (OSA), central sleep apnea, and upper
airway resistance syndrome.5

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is one of the most common types of sleep
disorders and types of sleep-disordered breathing. It is characterized by
interrupted breathing that is manifested as pauses in breath or the
appearance of breath holding. In reality, these pauses are periods of apnea,
in which the affected person is not breathing at all. Obstructive sleep apnea
has characteristic sleep patterns that may be more likely to be identified by
the patient’s bed partner, such as significant snoring, pauses in breathing
while asleep, and choking or gasping upon awakening.

Snoring is one of the most prevalent symptoms associated with obstructive

sleep apnea, although not everyone who snores would be considered to have
sleep apnea. It occurs as noise generated from the back of the throat and
the upper airway when a person breathes in while sleeping. Snoring may
also occur when a person breathes out while sleeping; it is not associated
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with apnea or decreased oxygenation, and many people snore without being
impacted in any other manner.6 That is, for many people without OSA,
snoring is a routine part of sleeping that does not typically cause them to
awaken at night, and it does not cause alterations in sleep patterns or
breathing disturbances. In these cases, snoring is often more disruptive to
the bed partner than the person who snores.

Snoring is a symptom associated with obstructive sleep apnea, however, and

a person who snores and who exhibits other symptoms of sleep loss may
need further testing to determine if an underlying sleep disorder is not
present. Testing for and diagnosis of obstructive sleep apnea is done
through a polysomnogram (PSG), often called a sleep study. The PSG can
measure how often the patient experiences apnea while sleeping, whether
oxygen desaturation is present with the apnea, and any other responses that
the body undergoes during the apneic episode.

It is estimated that approximately 5 to 10 percent of adults in the United

States have obstructive sleep apnea. There are numerous risk factors for the
development of OSA, however, obesity is the most common cause of the
condition in adults. Other risk factors for OSA include enlarged tonsils
(particularly in cases of OSA among children), use of tobacco, alcohol, or
sedatives for sleeping, an underactive thyroid gland, nasal obstruction, and
menopause among women. People who have jaw structures that involve
either a receding jaw or a jutting jaw or chin, and those with enlarged or
protruding tongues, are also at increased risk.7 Men are more likely to
develop OSA than women, and certain ethnic groups, including African
Americans, Asians, and Native Americans, are at higher risk of developing
the condition as well.5

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Obstructive sleep apnea occurs when a person stops breathing while
sleeping because of an obstruction of airflow through the airway passages
leading to the lungs. Apnea occurs when a person stops breathing for more
than 10 seconds. The obstruction that causes the absence of breathing
usually occurs when the structures in the neck and the back of the throat
collapse during the relaxation that occurs with sleep. All people experience
the relaxation of the muscles of the airway during sleep, but not everyone
develops a blockage of the airway. People with OSA have airway structures
that collapse inward, causing a blockage of the airflow. Obese individuals
may have more fat tissue in the neck and face, which can contribute to the
obstruction. Furthermore, some people have narrow airways that collapse
easily during sleep, contributing to periods of apnea.

When a sleeping person enters a state of apnea because of obstruction,

breathing stops for more than 10 seconds at a time. Because the patient is
not taking in more oxygenated air, the blood saturations of oxygen begin to
fall and carbon dioxide levels rise. The brain eventually senses this rise in
blood carbon dioxide, known as hypercapnia, and stimulates the body to
take in air. The person may suddenly gasp or make a choking sound while
awakening slightly to breathe and stopping the apnea. Often, the person is
unaware that they have awakened and the episode occurs relatively quickly.

At times, instead of going into complete apnea, the person with OSA may
experience hypopnea. When hypopnea occurs, similar events lead up to the
reduction in breathing; the person is asleep and somehow the structures of
the airway collapse upon themselves, causing a blockage in airflow. Instead
of entering a state of complete absence of breathing, the person still
breathes in a very shallow manner. The person may snore and take very
slow breaths that are so shallow that they do not provide enough oxygen to

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the body. This experience is known as hypopnea. Although there is not
complete absence of breathing with hypopnea, the person still suffers from
oxygen desaturations in the blood due to decreased gas exchange through
breathing.7

Obstructive sleep apnea is diagnosed when a person has more than five
episodes of either apnea or hypopnea per hour while asleep.7 Often, people
with OSA can have dozens or sometimes even hundreds of episodes of
apnea and hypopnea through a single night of sleep. Although individuals do
not remember waking up to continue breathing, they can suffer from
significantly disrupted sleep with this many episodes of awakening. If left
untreated, OSA can lead to significant complications for the affected patient.
According to the University of Maryland Medical Center, obstructive sleep
apnea has been linked with complications associated with many different
conditions, from excessive daytime sleepiness to alterations in circulation
that could lead to death.7 Excessive daytime sleepiness is a core component
of OSA; in fact, diagnosis of OSA is often made based on the results of the
sleep study as well as the patient’s reports of excessive daytime sleepiness.7
Feeling drowsy and tired during the day, from a lack of sleep due to OSA, is
annoying and can be extremely dangerous. Many people who are excessively
tired from sleeping poorly at night because of OSA can become sleepy
enough during the day that they should not drive or be responsible for
caring for others. They may be so tired that they forget what they should be
doing, have slowed reaction times, or they may fall asleep in the middle of
tasks.

Obstructive sleep apnea also increases the risk of developing cardiovascular

complications such as high blood pressure, heart failure, myocardial
infarction, and stroke. A patient with OSA develops an increased risk of

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hypertension. This may be a factor if the patient is already overweight or
obese to begin with and that is contributing to the OSA, and, ultimately, to
hypertension. However, researchers have found that people with OSA who
are not overweight are still prone to develop hypertension as a result of
sleep apnea.7

Heart failure is a complication that develops in approximately one-third of

patients who have obstructive sleep apnea. Heart failure occurs when the
heart is unable to meet the body’s needs for blood supply and cannot pump
fast enough or with enough force to provide adequate oxygenated blood.
Repeated periods of apnea and their accompanying desaturations in the
blood may cause circulatory changes that can eventually change the
structure of the heart. The damaged heart is unable to pump blood
efficiently and heart failure worsens.7 Similarly, patients with OSA are at
increased risk of myocardial infarction, irregular heart rhythms, and of death
from a stroke.7 Beyond cardiac disease risk, OSA may be associated with a
myriad of other conditions, the connection between some of which is not
entirely clear. Examples of other conditions that a patient with OSA may be
at higher risk of developing include diabetes, asthma, pulmonary
hypertension, high-risk pregnancy, glaucoma, headaches, and seizures.7

Obstructive sleep apnea is also associated with mental health disturbances,

and people diagnosed with post-traumatic stress disorder have been shown
to have worse periods of stress and disturbances when they have coinciding
obstructive sleep apnea. OSA has also been shown to worsen symptoms of
depression;7 often people who cannot achieve adequate sleep and who have
become significantly sleep deprived are unable to overcome depression
because many of the symptoms — altered sleep patterns, insomnia, fatigue,

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lethargy, and difficulties with concentration — may overlap between OSA
and depression.

Diagnosis of obstructive sleep apnea is made according to several factors:

the affected person has excessive daytime sleepiness to the point that it
impacts his or her ability to perform work or other duties and significantly
disrupts quality of life; and, if a bed or room partner reports disruptive sleep
on the part of the patient by observing significant snoring, gasping, choking,
or frequent awakenings. Based on the patient’s symptoms and physical
exam to either rule out or support the diagnosis, the physician may order a
polysomnogram (PSG) or sleep study to determine how well the patient is
able to sleep or has sleep patterns associated with sleep apnea.7

The most common treatment of obstructive sleep apnea is continuous

positive airway pressure (CPAP), in which the patient sleeps with a mask
that provides pressurized air into his or her mouth and nose through the
night while asleep. The air forces the tissues to remain open instead of
collapsing onto themselves and causing an obstruction. Use of CPAP has
been shown to significantly improve the quality of sleep among patients with
OSA, thereby leading to increased quality of life overall because of
decreased sleep deprivation.

Beyond using CPAP for the treatment of OSA, the patient may also make
some lifestyle changes that can impact how well he or she sleeps. The
physician may recommend weight loss for a patient who is overweight or
obese, since this can contribute significantly to OSA symptoms. In some
cases, weight reduction may reduce apnea episodes enough that other
medical measures are not necessary.7

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Because apneic episodes may occur more frequently when a person sleeps
on their back, the person could also try repositioning him or herself to sleep
in order to reduce the frequency of obstructions. A person with sleep apnea
who sleeps on his or her back may experience more episodes of apnea when
compared to someone who sleeps on their side. Changing positions to lie on
the side may change the pull of gravity that causes some of the structures in
the airway to collapse and may keep the airway open.7 A patient may try to
use various pillows or even sleep with the head of the bed elevated in order
to reduce the amount of apneic episodes by changing position alone.

Finally, reducing or eliminating certain lifestyle habits may have an impact

on sleep quality and could affect the number of apneic episodes that a
person has each night. The patient should be instructed to avoid alcohol in
the evening before going to bed, as alcohol acts as a depressant and can
affect breathing and sleep patterns. People who smoke are advised to quit;
those who smoke more than two packs each day are 40 times more likely to
develop obstructive sleep apnea when compared to those who do not
smoke.7 Finally, avoiding caffeine, sugar, or liquids in the last few hours
before bedtime may make sleeping a little easier; the patient may be more
likely to fall asleep without any stimulants and may have less awakenings
during the night to get up to use the bathroom.

Other forms of treatment for obstructive sleep apnea include medications,

dental devices, and even surgery if the condition is significant enough.
Although some people try to use medications to help them sleep when they
have OSA, such as sedative-hypnotics, some drugs may actually worsen
sleep apnea symptoms because they relax the muscles and the structures in
the mouth too much and can further worsen an airway obstruction. Patients
should be instructed to avoid over-the-counter sleep medications, sedative-

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hypnotic drugs prescribed for sleep, and even the depressant effects of
alcohol to try and induce sleep in this manner.

Alternatively, there is one type of medication, modafinil, that has been

approved for use by the U.S. Food and Drug Administration (FDA) to
manage the excessive sleepiness that may occur with OSA. It was originally
prescribed, and is still used for the treatment and management of sleepiness
associated with narcolepsy; however, researchers have found that modafinil
is beneficial for patients with OSA. Ultimately, though, modafinil is most
effective when it is used in conjunction with other treatments of OSA, such
as CPAP. In fact, if modafinil is prescribed for OSA, many clinicians ensure
that the patient has another form of breathing management to use alongside
the medication.7
Dental appliances are another option for treatment of OSA, and may be
prescribed for some patients who do not tolerate CPAP or who have not
otherwise benefitted from CPAP therapy. Dental devices are often created
and prescribed by a dentist or orthodontist and, typically, the patient must
be fitted with the device that is specific for the structure and contours of his
mouth. A dental appliance can be a non-invasive method of managing sleep
apnea; many patients who do not tolerate CPAP may successfully use dental
appliances instead, although their overall effectiveness is less than that of
CPAP.

One of the most common types of devices is a mouth guard called a

mandibular adjustment device, which keeps the mouth slightly open and
pulls the jaw forward. The patient places the device in his or her mouth
before going to bed and wears it throughout the night while sleeping. This
type of appliance seems to work best among those who sleep on their backs.
By bringing the jaw forward slightly and opening the mouth, the structures

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in the mouth are less able to collapse and completely obstruct the
airway.7

A tongue-retaining device is another dental appliance that may be used for

obstructive sleep apnea. This device is placed in the mouth, where it pulls
the tongue forward and holds it in place while the patient sleeps. It is
designed to keep the tongue from falling to the back of the mouth and
obstructing the airway, particularly among those patients who sleep on their
backs.7 A study in the Journal of Clinical Sleep Medicine found that among
patients who used the tongue-retaining device and who have obstructive
sleep apnea, 71 percent had partial or complete resolution of symptoms and
68 percent had a reduction in snoring.8

Finally, surgery may be indicated among some patients who have severe
and persistent obstructive sleep apnea. Surgery may be indicated for
removal of enlarged tonsils or adenoids that have grown enough that they
block the flow of oxygen through the airway. Alternatively, other types of
surgery may change the structure of the back of the mouth so that occlusion
of the structures due to relaxation during sleep may be less likely to happen.

Central Sleep Apnea

Similar to obstructive sleep apnea, central sleep apnea is a sleep disorder in

which a person has periods of apnea and hypopnea while sleeping, which
results in oxygen desaturations. However, the causes of the apnea are not
due to obstructions in the airway that prevent airflow. Instead, the part of
the brain that stimulates a person to breathe does not function in a normal
manner. This part of the brain is found in the pons and the medulla; it sends
messages to the respiratory system to take a breath on a regular basis.9
This activity almost always occurs while a person is unaware of it; in other

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words, the person does not regularly have to think and remember to
breathe, the brains sends these messages anyway.

For the person with central sleep apnea, the brain either does not signal the
body to take a breath on a regular basis, or the body does not respond in a
normal manner by taking a breath. Either cause results in periods of apnea
and hypopnea that result in loss of oxygen coming into the body, and
increased levels of carbon dioxide building up in the bloodstream. After a
period of time, the body responds by taking a breath and the person is
aroused from sleep to correct the situation. Again, the person may or may
not be aware that they are waking up to breath and correct the
deoxygenation. If this happens multiple times during the night, the person
can become significantly sleep deprived.
Central sleep apnea is more likely seen among people who have conditions
that cause increased amounts of carbon dioxide to develop in the
bloodstream or conditions that affect the depth and amount of breathing
that occurs, resulting in low oxygen levels in the bloodstream. Some
examples of situations in which a person may be more likely to develop
central sleep apnea include heart failure, periodic breathing associated with
higher altitudes, and the use of some medications, such as opioids or
anesthetics that depress the brain’s ability to send breathing messages to
the body. Additionally, some people who have had damage to parts of the
brain, including those with lesions found high on the spinal cord, may also
develop central sleep apnea if the parts of the brain that send messages to
breathe are impacted.9

The person with central sleep apnea will often suffer from many of the same
symptoms as the person with OSA. This is primarily because both conditions
cause apnea, although due to differing cause. People with central sleep

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apnea may experience excessive daytime sleepiness, fatigue, morning
headaches, and disrupted and poor sleep habits.10

Treatment of central sleep apnea differs from OSA because there is not an
obstruction present that needs to be eliminated or modified. Treatment of
central sleep apnea may include use of CPAP, particularly if the patient has a
condition known as mixed apnea, which is a combination of obstructive and
central sleep apnea. Sometimes, by treating the OSA, the clinician and the
patient may discover that central sleep apnea exists as well. In other cases,
the positive air pressure from CPAP alone is enough to continue to stimulate
the patient with central sleep apnea to breathe.10

Another type of pressurized air delivery system may also be used with
patients who have central sleep apnea. It is a system that is set up in a
method similar to CPAP, but instead of delivering a constant stream of
pressurized air to the patient, it is programmed to distribute the air for a
breath as needed when the machine senses that the patient has stopped
breathing. This method is known as adaptive servo-ventilation (ASV). The
ASV machine is designed to deliver a breath after a certain amount of time if
the patient is not breathing at certain points while asleep. The ASV
effectively monitors the patient on a breath-by-breath basis to ensure that
enough air is breathed in while sleeping.10

Other forms of treatment are also available for central sleep apnea. If the
patient has an underlying disorder that is contributing to the sleep apnea,
treating the disorder may reduce a number of symptoms. For example, if
central sleep apnea develops because of hypoventilation that sometimes
occurs among people when they travel to high altitudes, the central apnea
should disappear when the person returns to normal altitude. In other

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situations, such as in cases of central apnea that develops because of a
brainstem or spinal cord injury, treatment of the underlying disorder to
improve apnea may not always be possible.10

Some medications may help with central sleep apnea by stimulating the
patient to breathe. The most common medications used for treatment of
central sleep apnea are acetazolamide and theophylline. Acetazolamide is
often used to treat altitude sickness and its debilitating symptoms. It works
to inhibit certain enzymes that can impact carbon dioxide levels in the body,
which may change how much carbon dioxide enters the bloodstream and
how the body responds to it.11 Theophylline is sometimes used for treatment
of heart failure and works as a bronchodilator to increase the size of the
airway, making breathing easier. Both drugs may be prescribed in various
situations for treatment or management of central sleep apnea, whether on
their own or in conjunction with other forms of treatment.

Upper Airway Resistance Syndrome

Less common than OSA, upper airway resistance syndrome (UARS) occurs in
a manner similar to OSA in that the affected person experiences a resistance
or obstruction in the airway that can affect breathing, but the patient with
UARS does not experience oxygen desaturation while sleeping. The affected
person has increased airway resistance that disrupts airflow while sleeping,
causing multiple arousals during the night. Compared to OSA, upper airway
resistance syndrome does not lead to periods of apnea and desaturations in
oxygen levels. Instead, the person awakens slightly when resistance to
breathing occurs while sleeping. The individual may or may not be aware of
being awakened frequently because of the airway obstruction.6

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A further distinction between UARS and OSA is that the pauses and arousals
that occur with UARS are typically much shorter in duration than the apneic
episodes that develop in OSA. An event that occurs in UARS may only last
for a length of 1 to 3 breaths. Upper airway resistance syndrome may occur
in approximately 15 percent of the adult population. It affects people of
average weight and is not necessarily associated with obesity. Further, UARS
may occur more in younger people rather than developing as a person gets
older. People with UARS often have upper airway structures that may be
more likely to become obstructed, such as by having narrow nasal passages,
deviated septum, or nasal valve collapse. Upper airway resistance syndrome
seems to be more common among women than men, although the reasons
for this are not entirely clear.6

People with UARS typically experience excessive daytime sleepiness similar

to that felt with obstructive sleep apnea. They may be unaware that they are
waking so frequently during the night but they may feel just as tired. This
can be characterized by falling asleep easily, even in certain situations such
as while at work, feeling tired and less energetic throughout the day, and
feeling irritable. Affected patients may also complain of difficulties with
concentration, memory loss, morning headaches, and impotence.6

Treatment of UARS includes CPAP therapy to promote airflow through the

respiratory tract. Although a complete obstruction of the airway does not
occur in patients with UARS, the CPAP will still promote continuous airflow
and reduce the incidence of breathing pauses, as well as snoring that may
accompany the upper airway restriction.

Insomnia

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Most individuals in the U.S., do not get enough sleep, often because of
choosing to go without sleep in order to complete deadlines or pursue other
activities. However, there are some people who struggle to get enough sleep
because they are unable to get to sleep or stay asleep at night due to
insomnia. Many people have occasional nights where they do not sleep well.
They may stay awake worrying, feel pressure and stress to complete certain
tasks and lie awake thinking about them, have medical conditions or have
consumed food or a beverage that caused them to stay awake longer than
necessary, or they may continually awaken due to environmental noises that
they cannot control. Occasional lack of sleep occurs in almost everyone,
however consistent lack of sleep due to insomnia can quickly lead to
problems associated with sleep deprivation and its effects on the physical
and emotional condition of individuals.
Insomnia occurs when an individual consistently has difficulties falling
asleep, staying asleep, waking up too much during the night, or generally
having poor quality sleep and feeling as if a full night sleep barely happened.
Insomnia can develop for a number of reasons and is associated with certain
illnesses and physical conditions. However, there are some people who
develop insomnia that is unrelated to any other underlying disorder.

Approximately 50 percent of cases of insomnia have no identifiable cause.

There are many other conditions that can predispose a person to developing
insomnia. Some conditions that may increase the risk include advancing age,
substance use, menopause in women, gastroesophageal reflux, changes in
body temperature due to illness, altered hormone secretion or function, or
other sleep disorders, including circadian rhythm sleep disorders.12 People
who suffer from insomnia may toss and turn much of the night in an effort
to achieve sleep. They may fall asleep briefly but never truly feel as if they
are getting restful and restorative sleep. Consequently, the person with

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insomnia may awaken and face the day without feeling refreshed or
experiencing a decent night’s sleep. The person may suffer from daytime
fatigue, irritability, headaches, and difficulties concentrating. When going to
bed at night, he/she may still be unable to sleep despite feeling exhausted.12

Insomnia can lead to mental health issues, most commonly anxiety and
depression related to lack of sleep. Often, when insomnia occurs every night,
the affected person may become more anxious as evening approaches. It
can be very difficult to lie in bed awake while trying to get to sleep; if the
situation has continued for many nights, anxiety may increase due to
worrying that another sleepless night will happen. Further, while lying
awake, a person often feels anxious and worries about getting too little sleep
to face the day. This further compounds anxiety and may make getting to
sleep more difficult.12

Insomnia may also be a cause of depression, although the cause-and-effect

relationship between the two conditions is not always clear. Some people
with chronic insomnia may be more likely to develop depression because
they typically feel isolated when they cannot sleep and others can. They may
feel as if no one else understands how difficult insomnia can be, and it truly
can be difficult for a person who normally has no trouble sleeping to
understand insomnia. A person may also develop depression due to
frustration from not being able to achieve sleep or not finding an appropriate
treatment to resolve sleep deprivation. Alternatively, people who suffer from
depression often develop insomnia and have difficulties sleeping. The
insomnia that occurs may happen because of pre-existing depression, and
could be managed with treatment of depression through medications or
other conventional means. Depression is so widely associated with insomnia

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that studies have shown up to 60 percent of people with insomnia also have
depression.12

Diagnosis of insomnia is made by taking a medical history, including any

underlying medical conditions and the use of medications and substances, as
well as performing a physical exam to measure vital signs and basal
metabolic index (BMI). In some cases, the health clinician may order a sleep
study if the patient’s history suggests the presence of another underlying
sleep disorder. If the polysomnogram reveals another sleep disorder, the
insomnia is often resolved with treatment of that disorder.

There are various approaches to treatment of insomnia. Some patients use

medications to help them sleep and, while these may work, often a change
in certain lifestyle factors can be even more successful. In some cases,
lifestyle changes alone may be enough to promote sleep such that insomnia
is resolved. Some patients also choose complementary and alternative
therapies in an effort to reduce or resolve their insomnia.

Medications to induce sleep and treat insomnia include both prescription and
over-the-counter varieties. Prescription sedative-hypnotics are often given
by health clinicians to improve sleep. These medications typically change the
levels of neurotransmitters in the brain, which can induce drowsiness. A
class of drugs known as non-benzodiazepine and benzodiazepine-receptor
agonists are often prescribed because they have low levels of addiction
among users and are less likely to lead to a substance use disorder when
compared to some other types of sleep medications. Examples of these
medications include zolpidem and eszopiclone. Other medications that are
benzodiazepines may also be used for inducing sleep associated with
insomnia, however, these drugs may be more likely to lead to inappropriate

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substance use and addiction. They do have a depressant effect that can
cause a person to fall asleep. Examples include temazepam and triazolam.12

Some patients have success with using over-the-counter medications that

may be either indicated for sleep or may have side effects that cause a
person to feel sleepy. Non-prescription medications that could be used
include pain relievers that contain extra sleep aids. People who experience
difficulties sleeping because of increased pain often take these drugs, but
they may also be used if insomnia is present and related to other factors. An
example of this type of medication is diphenhydramine ibuprofen.
Additionally, using non-prescription drugs that have been designed for other
purposes may also induce sleep because their side effects cause drowsiness.
One of the most commonly used medications is diphenhydramine.
Diphenhydramine is sometimes combined with other medications into a pill
that is designed to be a sleep aid.12 For example, acetaminophen
diphenhydramine is marketed as a sleep aid, although the diphenhydramine
is labeled for use in the treatment of allergies.

Changing certain lifestyle factors can make a big difference in treating

insomnia and improving sleep. At times, some patients may be unaware that
their choices and lifestyle habits are contributing to lack of sleep and
through proper education and awareness, may be able to sleep better when
making some changes in their routines. Patients should be encouraged to
avoid taking naps during the day, especially closer to dinnertime in the
evening when bedtime is approaching. Avoiding other activities and
substances late in the day, such as alcohol, caffeine, and exercise, can all
help a person to better “wind down” while getting ready for bed. Alcohol has
an initial depressant effect but can later cause a person to awaken more,
ultimately having the opposite effect. Caffeine acts as a stimulant, which can

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inhibit sleep and should be avoided while trying to get to sleep. Exercise is
beneficial and should be done during the day to improve circulation and
flexibility; however, exercise late in the day may cause a person to feel more
awake and have difficulty sleeping at bedtime.

Some people spend time working on computers or watching television in the

evening before bed. Reducing or eliminating these activities can also help to
promote sleep. The bright light from the screen often keeps the body awake
longer and the person may have difficulties slowing down into a state of
sleep after significant exposure to bright light. This is why bright light
therapy is sometimes used in the treatment of certain sleep disorders; the
light stimulates the brain to believe that it is time to be awake and helps the
person to arise. However, this has the opposite effect when used in the
evening when a person is trying to go to sleep.

For some people with insomnia, it may also help to establish a solid bedtime
routine, in which certain activities are performed each night that help to
promote relaxation and restfulness. The bedroom should be designed as a
place used only for sleep, and the person should not spend significant
amounts of time in bed reading or working on a computer. The body may
later have difficulties transitioning to sleep when the individual has already
been in the same place and position for hours doing other activities. It may
also help to have slow, soothing activities before bed, such as taking a bath
or listening to soft music, which can help to slow down the pace of the day
and help a person feel relaxed.

Finally, treatment and management of other disorders that may be

contributing to insomnia can be extremely helpful in improving sleep for the
affected person. For example, a patient who suffers from sleep apnea and

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has concurrent insomnia may sleep much better when the sleep apnea is
treated. Medical conditions that contribute to insomnia, such as
gastroesophageal reflux or fibromyalgia, can be treated or managed using
outside therapies and medications, which can further improve sleep when
these conditions are managed.

There are a number of options for the treatment of insomnia, which may
depend on concurrent conditions. For people who struggle to sleep because
of insomnia, talking to a health clinician and trying different methods of
treatments and lifestyle changes can often improve sleep enough that a
person feels more rested.

Circadian Rhythm Disorders

The circadian rhythm, or internal 24-hour clock that keeps track of when to
be awake and asleep, is deeply affected by outside and environmental
circumstances to either help a person sleep or arouse to an awakening state.
When the circadian rhythm is altered, the affected individual will have
difficulties falling asleep or staying asleep at an otherwise normal time.

The circadian rhythm in the body is managed by a part of the brain called
the supra-chiasmatic nucleus (SCN). The SCN is found in the hypothalamus
region of the brain and it is this part that responds to external stimuli such
as environmental light levels to keep the internal clock at a pace that
promotes sleep at the appropriate time.2 In the evening when the
environmental light becomes dim and the sun goes down, the internal clock
of the circadian rhythm responds to the changes in light and secretes
melatonin, a hormone that is sent into the body from the pineal gland in the
brain.

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Melatonin is a hormone that essentially tells the body that it is tired and that
it should sleep. It is released into the bloodstream and as serum levels
increase, the person feels more and more sleepy.1 The body secretes
melatonin for approximately 12 hours at a time to promote sleep, which is
typically at night. During the day, blood melatonin levels may be quite low,
because sunlight inhibits melatonin production. This is why most people do
not easily sleep during the day, even if they have been awake all night.

Normal melatonin production keeps the circadian rhythm in check and

promotes a routine cycle of sleep and wakefulness, however, there are
factors that can disrupt melatonin production, resulting in sleep difficulties.
These factors may be modifiable, because a person who recognizes
behaviors that impact sleep can make changes to promote more melatonin
production and therefore more sleep. For instance, exposure to bright lights
in the evening may inhibit production of melatonin, such as when a person
consistently works at a computer screen late at night or watches television.
If an affected person recognizes the effects of artificial light on sleep habits
and the circadian rhythm, lifestyle changes may be made to in the evening
to reduce certain activities and to ultimately promote better sleep.

Alternatively, some conditions that are known as circadian rhythm disorders

occur when the body’s internal clock is thrown off and melatonin production,
as well as sleep, does not occur at a routine or normal time. Circadian
rhythm disorders are patterns of sleep disturbances that occur due to
alterations in the internal clock that acts as a sleep regulator. Primarily, a
circadian rhythm disorder occurs when a person’s cycle of sleeping and
wakefulness is less than optimal and they are unable to function at a normal
sleep/wake cycle to produce adequate sleep.2 Some examples of circadian
rhythm disorders include advanced sleep phase disorder and delayed sleep

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phase disorder, as well as other circumstances that contribute to circadian
rhythm disruptions, such as shift work and jet lag.

Advanced Sleep Phase Disorder

Advanced sleep phase disorder (ASPD) is a less-common circadian rhythm

disorder that is characterized by a shift in sleeping times several hours
earlier than normal. A person with ASPD may fall asleep early in the evening
and awaken very early in the morning. While an individual with ASPD may
be considered a “morning person,” there may be difficulties adjusting to
sleeping at later times and to fall asleep or awaken later. ASPD leads the
affected person to feel sleepy in the late afternoon or early evening and
often sleep occurs between 6 and 9 pm. The disorder then causes the person
to awaken at an earlier time as well, sometimes between 2 and 5 am.2 The
exact amount of time that is shifted when falling asleep with ASPD differs
among patients and there is no set time amount of shifting required for
diagnosis. Consequently, people diagnosed with ASPD may have various
time shifts forward in their sleeping hours and the diagnosis is partly based
on the degree of difficulty the shift in sleep time may cause.3

Advanced sleep phase disorder essentially shifts the circadian rhythm back
by several hours. Affected individuals may feel socially isolated because they
usually sleep at different times than others; they may be falling asleep when
others are still active and social in the evening, and, alternatively, may be
awake and feel alone because others are still sleeping during early morning
hours. ASPD is impacted by age and advancing age causes an increased risk
of development of the disorder. Often, ASPD may be masked by depression,
or the person seeking help for sleep problems may have coinciding
depression along with ASPD.2

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Advanced sleep phase disorder is treated through a number of options to
alter the sleep cycle so the affected individual may eventually sleep on a
normal schedule. Chronotherapy involves adjusting the time of going to
sleep slightly over the course of several days, weeks, or months, until the
affected person has reached a sleep schedule that is acceptable. For
example, if a person with ASPD normally falls asleep at 6:30 pm each
evening and awakens at 3 am each morning, chronotherapy may be used to
adjust sleep habits slightly to change the time of going to sleep. This is
typically done in very short intervals to allow the person to adapt. For
instance, the person may try to go to bed 15 minutes later than normal,
attempting to stay up until 6:45 pm instead of 6:30 pm. After adjusting to
this time, the time for going to sleep may be moved back again to 7 pm and
so on. On the other end of the spectrum, by going to sleep later, a person
may be more likely to sleep a little later, thereby adjusting both the time of
going to sleep and of waking up.

Bright light therapy may be another option for a person suffering from ASPD.
Because bright light, often from artificial sources, can keep a person awake,
the person with ASPD may expose themselves to bright light sources in the
evening for a period of time to attempt to stay awake. By increasing
exposure to bright light during the time that the person would normally fall
asleep, the body is essentially tricked into thinking that it is still time to be
awake. Light therapy is performed for set periods of time each evening; for
instance, a person who goes to sleep at 7 pm may use bright light therapy
for 30 minutes to an hour each evening to stimulate wakefulness, helping
with falling asleep later than the normal time. As with chronotherapy, bright
light therapy takes time to adjust the circadian rhythm into a normal sleep
pattern for the person with ASPD.

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Delayed Sleep Phase Disorder

In contrast to ASPD, delayed sleep phase disorder (DSPD) occurs when a

person’s sleep rhythm is shifted to a later sleep/wake time than normal or
desired. The person with DSPD may not fall asleep until after 2 am and may
wake up later in the morning or afternoon, between 10 am and 12 pm.2
Although the individual with DSPD may be considered a “night owl,” he/she
may not desire to sleep on this particular schedule and may wish for sleep to
come earlier in the evening. Individuals with DSPD may try to go to bed at a
normal time, but may simply lie in bed unable to sleep until the time that
their body is regulated to do so.

Delayed sleep phase disorder causes difficulties with social and work
obligations for people who must get up at certain times. For example, if a
person is consistently unable to fall asleep before 1 am but must get up
every morning at 6 am to get ready for work, this quickly leads to sleep
deprivation. Although catching up on sleep on the weekends may be possible
to some extent for a few people with DSPD, regular routines of work and
school often begin again on Monday and they must go back to a routine of
sleep deprivation. When allowed to sleep without waking up at a standard
time, most people with DSPD experience restful sleep that is appropriate in
length; they are not candidates for insomnia. Alternatively, the difficulties
with sleep deprivation come from shifted cycles of sleep time that are
interrupted by obligations to get up earlier than desired, resulting in a lack
of overall sleep.2

Delayed sleep phase disorder is more common than advanced sleep phase
disorder. DSPD also occurs more commonly among adolescents, although it
can develop in someone of any age. Like ASPD, delayed sleep phase disorder
can be treated through chronotherapy or bright light therapy, and both

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forms of treatment can be quite successful in resetting the circadian rhythm
to a normal sleep time. The difference in using these therapies for DSPD
when compared to ASPD is that, for people with delayed sleep phase
disorder, the time setting is adjusted back rather than forward. For instance,
a person who uses chronotherapy for DSPD may attempt to fall asleep 30
minutes earlier than normal; the person using bright light therapy may use it
in the morning after waking up rather than in the evening as for someone
with ASPD.

Jet Lag

Jet lag is a temporary circumstance in which a person’s circadian rhythms

are disrupted because of travel across several time zones.2 A person who
has an adjusted sleep pattern to particular time zone but travels to a
different time zone that is significantly different may develop difficulties
sleeping due to a disruption in the circadian rhythm. If the time zone
differences are significant enough, the person experiences the feeling of
attempting to stay awake during a time when he/she would normally be
asleep. Alternatively, the person may also need to sleep during a time when
they are usually awake.

Jet lag not only causes difficulties with sleeping, the affected person may
experience problems with memory and concentration, fatigue, malaise,
mood changes, and gastrointestinal disturbances. The individual may feel
tired and sleepy throughout the day yet has insomnia at night while trying to
sleep. Studies have shown that jet lag may be worsened depending on the
direction of the time change. For example, a person who is traveling

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eastward or forward into new time zones may have a harder time adjusting
to the time change than someone traveling westward or backward into time
zones.2 Despite the degree of difficulty regarding the direction of travel, jet
lag can be difficult to manage and live through regardless of the shift of the
body’s internal clock.

Jet lag is typically temporary as the affected person eventually adjusts to the
new time period. It may last several days before slowly resolving. Some
people have had success with using supplemental melatonin to help with
sleep patterns associated with jet lag. Although it can be successful, non-
prescription melatonin is not technically approved for use in people with jet
lag.2
Melatonin is the only hormone that is available for use without a
prescription. Its action mimics the melatonin released by the brain when the
body is preparing to sleep. People who take melatonin should consider its
use very carefully as it is not regulated by the U.S. Food and Drug
Administration. There is not one set dose recommended for age or condition
for which to take melatonin for sleep; however, a general recommendation is
to take 2 to 5 mg before the desired time of going to sleep and repeat the
process for up to 4 days as necessary.2

Shift Work

Shift work disorders develop among people who work during times in which
they would normally be asleep. Shift work often involves working late at
night, overnight, or very early in the morning. The person may work shifts
on occasion, such as in the case of being on call or being scheduled for night
shifts sporadically. Alternatively, many people regularly work at night and
may have overnight schedules of 3 to 5 nights per week, requiring them to
sleep during the day.

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Studies have shown that people with jobs that require shift work do not
adjust to the altered sleep cycles required, even if they regularly work
opposite hours. Most people’s circadian rhythms are programmed for them
to sleep at night instead of to go to work. Consequently, people who work at
night may feel sleepy, and they may have difficulties staying awake to
perform tasks and may be more prone to make mistakes while on the job.2
Alternatively, working at night makes it difficult to sleep during the day,
particularly when sleep is necessary to repeat a shift the next night. A
person who works overnight and must return to work to repeat the shift the
following night may feel obligated or even anxious about getting enough
sleep during the day to avoid feeling exhausted when at work later.
It may be very difficult to sleep during the day in order to stay awake at
night to work. Social obligations, family activities, or even medical
appointments create times when sleep is disrupted in order to attend these
activities. Further, the person who works alternate shifts may sometimes be
required to shift back and forth between sleeping during the day and at
night. After a stretch of three night shifts in a row that includes sleeping
during the day for three days in a row, a night-shift worker may desire to
sleep at night again on a night off. However, when the person must return to
work a few nights later, a need to readjust to staying awake again during
the night and sleeping during the day again will occur.

Some people have had success with achieving sleep through the changing
sleep patterns of shift work by taking medications that induce sleep when
necessary. Some prescription sedative-hypnotics, as well as over-the-
counter sleep aids, may help shift workers to sleep during the day in order
to stay awake longer at night. However, some of these medications can have
negative side effects, such as grogginess upon awakening, and those who

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take them may not wish to continue their use long term. The use of
medications to induce sleep to maintain a night shift schedule is individual
for each person. Some people have little trouble with taking medication to
sleep on a regular basis and must continue with their chosen jobs as shift
workers, while others struggle to maintain a schedule of sleep during the
day and try to stay awake at night.

Limb Disorders

Limb disorders develop as conditions that affect sleep because of

inappropriate movement of the extremities. Typically, the affected person
has little to no control over the limb movements and may become quite
frustrated with an inability to control body movement and the disruptions
that the limb disorder has on quality of sleep.

Restless Legs Syndrome

Restless legs syndrome (RLS) is one of the most common limb disorders that
cause sleep deprivation. People with RLS report a significant impact on their
quality of sleep and often develop symptoms that are severe enough that
medical intervention is required. Restless legs syndrome is characterized by
a feeling of unpleasant sensations in the lower limbs such as buzzing,
tingling or burning, along with an almost irresistible need to move the legs.
Moving the legs may relieve some of the sensations but the relief is usually
temporary. The sensations in the legs can cause problems getting to sleep
and difficulties staying asleep for the person who must spend each night in
discomfort.

Many people consider RLS to be an imagined condition, and do not recognize

the impact the condition can have on diagnosed patients. RLS may develop
in up to 10 percent of the population, with 2.7 percent having severe enough
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symptoms that they need medical evaluation and treatment.24 RLS can
significantly disrupt quality of life by causing sleep deprivation that further
contributes to depression, excessive daytime sleepiness, decreased focus
and attention, memory deficits, and anxiety.24

Risk factors for the development of RLS consist of both preventable and non-
preventable factors. Knowing these factors may help some people who suffer
from the condition to make changes in order to improve symptoms and
quality of life. Examples of preventable risk factors of RLS include obesity,
an inactive lifestyle, alcohol use, and smoking. Alternatively, RLS is more
common in women and may be more likely to develop as a person ages, and
is also associated with a lower socioeconomic status. Despite the presence of
these risk factors, researchers have yet to find one specific cause as to why
some people develop RLS.24

The incidence of episodes of RLS also varies among people. Some people
report very mild and infrequent symptoms that do not have much impact on
sleep. Alternatively, some unfortunate people have periods of RLS several
nights a week for long periods of time. Of those diagnosed with RLS,
approximately 20 percent have symptoms every night or almost every night,
40 percent have symptoms at least once per week, and another 40 percent
report symptoms every few weeks or months.24

Diagnosis of RLS is basically subjective, depending on what the patient

describes is happening, as there is no specific test that can otherwise
determine its presence. Criteria to help the clinician in the diagnosis of RLS
has been developed. Firstly, the patient experiences symptoms underneath
the skin of the lower extremities that are typically described as crackling,
buzzing, tingling, or crawling. The most common occurrence is in the space

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between the knee and the ankle. The sensations are sometimes difficult to
describe and are almost always accompanied by an irresistible urge to move
the legs. Secondly, the patient experiences these sensations, as well as the
urge to move the legs, most often during times of lying down or trying to
sleep. Thirdly, the unpleasant sensations are temporarily relieved by moving
the legs or getting up to move, walk around, or shake the legs in response.
Finally, the criteria states that the sensations almost always occur in the
evening or at night; if they occur during the day, they are much less
noticeable when compared to their appearance at night.24

Restless legs syndrome can be successfully treated with medications and

other lifestyle changes. Currently, there are four different medications
available in the U.S., approved by the FDA in the treatment of restless legs
syndrome, which are ropinirole, pramipexole, and rotigotine patch. These
medications are all dopaminergic agonists that are currently used.
Gabapentin enecarbil, a type of anticonvulsant medication, is another
medication that has been specifically approved by the FDA for RLS.25 Other
medications may also be prescribed for RLS symptoms, but they are not
necessarily intended for the treatment of RLS; however, their off-label use
has been shown to relieve some symptoms in affected patients and they
may be prescribed to alleviate RLS. Examples include other anticonvulsant
medications, such as lamotrigine and carbamazepine, benzodiazepine-
hypnotics, such as eszopiclone, and alprazolam, and opioid analgesics such
as hydromorphone and meperidine.25

Many people with RLS find relief of symptoms by combining medication use
with changes in some lifestyle factors. Examples of changes that may be
incorporated into treatment of RLS symptoms include avoiding caffeine
intake, as well as that of alcohol and nicotine, massaging the legs regularly,

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taking a hot bath in the evening before bed, and getting regular exercise.
Studies have shown that taking supplements of iron, magnesium, and folate
may also be helpful in relieving some symptoms, particularly if these mineral
deficiencies are present.26

Periodic Limb Movement Disorder

Somewhat similar to restless legs syndrome, periodic limb movement

disorder (PLMD) is another type of limb disorder that can significantly disrupt
sleep. Periodic limb movement disorder occurs as a series of limb
movements during sleep that happen approximately every 20 to 40 seconds.
The affected limbs are most commonly the lower legs and the movements
may be described as jerking or twitching; additionally, the affected patient
may repeatedly flex the feet up and down. These uncontrollable movements
of the extremities can disrupt sleep of affected individuals and their bed
partner. They can cause significant sleep disruption that can lead to
excessive daytime sleepiness, lethargy, irritability, and lack of concentration
when awake during the day.27

Many people with PLMD also have restless legs syndrome, although the
reverse is not typically true. There has not been one identifiable cause that
is associated with PLMD that explains why some people develop these limb
movements that can affect them so significantly. In addition to causing
complications associated with sleep deprivation, individuals with PLMD are
also at an increased risk to develop other chronic conditions, such as kidney
disease, diabetes, and anemia.27

Many of the treatments and lifestyle changes recommended for restless legs
syndrome can work well in the management of PLMD. Affected patients
should see a health clinician for a full history and physical exam to rule out

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other disorders that may be present, including medical conditions such as
Parkinson’s disease or vitamin or mineral deficiencies that could be causing
muscle twitching similar to PLMD.

Sleep-related Leg Cramps

A further limb disorder that may develop in some people is episodes of

sleep-related leg cramps. These cramps develop when the muscles of the
lower leg tighten involuntarily while a person is asleep, often causing severe
pain and forcing the person to wake up. Sleep-related leg cramps usually
begin quite suddenly and can last for a few seconds to several minutes,
depending on the person’s response to the cramp and efforts at relieving the
pain. Leg cramps may occur in some people only sporadically, developing
once or twice a year; alternatively, some people have leg cramps every
night or even more than once per night of sleep.28

People with diabetes, blood vessel disease, nerve or endocrine disorders, or

electrolyte imbalances may be more likely to develop sleep-related leg
cramps. Additionally, some other conditions, such as excessive exercise
during the day, dehydration, use of some types of medications, and
immobility may also contribute to the development of leg cramps. They may
increase in frequency with advancing age, although anyone of any age can
develop sleep-related leg cramps. There is also an increased association of
leg cramps with pregnancy; and up to 40 percent of pregnant women have
reported suffering from leg cramps while sleeping.28

When a leg cramp occurs during sleep, the affected individual typically
awakens quickly in response. The pain can be sharp and intense, causing the
person to sit up or get up out of bed. The muscle often feels very tight,
stretched, or throbbing, and massaging or stretching the muscle relieves the

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pain. Even after the initial pain has gone away and the acute cramp has
been resolved, the person may feel soreness in the muscle for hours to days
afterward.28 If the muscle cramps occur several times at night, sleep can be
disrupted as the person continuously awakens from their sleep and exerting
effort to eliminate the pain.

Unfortunately, there is not one specific treatment aimed at stopping leg

cramps from occurring. Most patients are advised to implement lifestyle
interventions that can improve circulation and flexibility of the muscles,
which may prevent leg cramps from occurring at night. A patient who wants
to incorporate exercise must know that exercise should be performed during
the day and not closer to bedtime. Exercising late in the day may lead to
sleep difficulties and the body may have more trouble calming for sleep.
However, regular exercise is extremely beneficial in controlling weight and
improving sleep, and can reduce the incidence and severity of sleep-related
leg cramps.

Nighttime Sleep Behaviors

Nighttime sleep behaviors, in which a person acts in an abnormal manner

while asleep, are known as parasomnias. These behaviors often develop
during childhood but they can actually be apparent at any age, including
during adulthood. When nighttime sleep behaviors occur consistently, they
can significantly impact the affected individual’s quality of sleep.

Hypersomnias

Hypersomnias are sleep disorders in which affected people suffer from

sleeping too much. They often feel very tired, drowsy during the day, and
struggle with excessive daytime sleepiness. At times, people with

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hypersomnias can fall asleep at inappropriate times, leading to difficulties
with maintaining activities, jobs, or relationships.

Narcolepsy

Narcolepsy is one type of sleep disorder classified as a hypersomnia sleep

disorder that is characterized by excessive daytime sleepiness and
abnormalities in the REM period of sleep. The part of the brain that regulates
sleep is impaired and the affected patient may experience a sudden loss of
muscle control in addition to excessive sleepiness. Consequently, the patient
with narcolepsy may fall asleep at inappropriate times when the brain is
triggered, leading to out of place behaviors, such as falling asleep while
performing specific activities or during times when the affected person is
supposed to be working.

Narcolepsy most commonly presents between ages 10 and 25. Beyond

excessive daytime sleepiness, people with narcolepsy suffer from other
symptoms that may be triggered by emotional responses. Cataplexy is a
condition that involves a sudden loss of muscle function; and, the person
with narcolepsy who experiences cataplexy may suddenly lose muscle
control and drop items or fall down. Often cataplexy is triggered by
significant emotions, such as crying or fear.

Narcoleptics may also experience sleep paralysis, in which they may have
periods of being unable to move at all just after awakening or just prior to
falling asleep. It is thought that sleep paralysis occurs more often in people
with narcolepsy because of the altered transition to REM sleep that
commonly occurs with the disorder. After falling asleep, most people go
through a cycle of NREM sleep before transitioning to REM sleep
approximately 90 minutes later. However, people with narcolepsy often fall

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asleep straight into REM sleep, rather than going through the deep, slow-
wave sleep of the NREM cycle. Because muscle atonia or paralysis often
occurs with REM sleep to prevent people from acting out their dreams, the
narcoleptic may also quickly go into or revert out of muscle paralysis
associated with REM sleep. If the person is not quite asleep or not quite
awake, but the body still believes it is in the stage of REM sleep, the muscles
may be paralyzed and the person will be unable to move.4

People with narcolepsy may experience other symptoms as well.

Hallucinations are more common in this population, and narcoleptics may
see visions or hear sounds that are not truly there just before falling asleep
or just after waking up. Nighttime wakefulness may also occur when the
person tries to sleep at night but may wake up repeatedly. Finally,
narcoleptics also often have periods of microsleep, where they fall asleep
while performing routine activities, although they wake up quickly and may
be unaware that they were ever asleep.4

The exact cause of narcolepsy is unknown, although research has uncovered

several theories that are attributable to the condition. People with
narcolepsy are more likely to lack a substance in the brain known as
hypocretin, which helps to regulate sleep and can help a person to wake up.
The cells that secrete hypocretin are known as Hcrt cells, and scientists
believe that people with narcolepsy have a decreased number of these cells
overall, thereby producing less hypocretin overall. This results in the
person’s inability to control how much sleep occurs as well as the ability to
wake up after sleeping.4

Narcolepsy can cause significant difficulties for the affected person. The
narcoleptic patient may feel isolated and alone, believing that no one else

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understands their condition or the difficulties that they must face with the
disorder. Many people with narcolepsy are unable to continue with activities
that are otherwise considered routine for most people. Activities such as
driving or cooking could become dangerous if the affected person falls asleep
while performing them, so they are often avoided. Narcolepsy may cause
sleep to become very disrupted and the affected patient then becomes sleep
deprived. Chronic sleep deprivation can lead to memory impairment,
difficulties with concentration and focus, and decreased power of the
immune system.

Narcoleptics may also struggle in some social relationships and the potential
for avoiding others can be high if they fear falling asleep or losing muscle
control in social situations. Others may not understand the physical causes
associated with narcolepsy and may end up being judgmental of the affected
person, believing that there is a neglect of self-care, not enough sleep being
obtained, or that the person is slow or lazy.4 Often, support groups are
available for people with narcolepsy and are opportunities to meet with
others who struggle with the same condition and to gain insight about some
remedies and lifestyle changes that can make a difference in their quality of
life. Support groups are also important for building friendships and reducing
the isolation that someone may feel when diagnosed with narcolepsy.

Narcolepsy is typically diagnosed through a series of tests that include an

initial history and physical exam to rule out other causes of excessive
daytime sleepiness and cataplexy, such as the presence of other medical
conditions. A polysomnogram may be performed to determine the patient’s
sleep patterns, brain activity, and muscle movements while asleep. The
patient may also need to undergo a multiple sleep latency test, in which they
sleep for short periods during the day and the provider determines if there

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are abnormalities in the patient’s abilities to fall asleep or if they have
periods of REM sleep at inappropriate times, which is thought to contribute
to the cataplexy and sleep paralysis associated with narcolepsy.17

There is no cure for narcolepsy, but many people are helped by taking
certain medications that act as stimulants to protect them from falling asleep
at inappropriate times. The two most common medications prescribed to
treat excessive daytime sleepiness associated with narcolepsy are modafinil
and sodium oxybate. These drugs are unfortunately associated with higher
levels of use and addiction because of their effects. However, when
combined with lifestyle changes, use of medications may be very effective in
controlling symptoms.17 Another class of drugs that may be prescribed for
the treatment of some symptoms associated with narcolepsy is
antidepressants, including tricyclic antidepressants and selective serotonin
and noradrenergic-reuptake inhibitors (SSRIs). These drugs are helpful in
reducing and controlling the symptoms of cataplexy in people with
narcolepsy.17

Finally, lifestyle modifications, particularly when paired with medication, can

be effective in helping to treat symptoms of narcolepsy and for reducing the
incidence of accidents or injuries that can occur from excessive daytime
sleepiness and cataplexy. The patient with narcolepsy may benefit from
avoiding certain substances in the evening, including caffeine and alcohol, in
order to get a better night of sleep. It is also important to engage in regular
exercise to manage weight, to improve circulation and to regulate body
systems that may promote sleep at night. If a patient does exercise during
the day, it is best to engage in the exercise at least 4 hours before the
normal bedtime. Developing a bedtime routine that promotes sleep is also
helpful, which may include relaxing activities in the evening, sleeping in a

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warm and comfortable environment, and going to bed and getting up at the
same time every day.17

Idiopathic Hypersomnia

Idiopathic hypersomnia is another form of excessive sleepiness that differs

from narcolepsy, but still leads a person to feel frequently drowsy and to fall
asleep quickly. Idiopathic hypersomnia most often develops during childhood
or young adulthood and the affected individual may struggle with the
condition throughout their life. It is classified into two main types of
1) idiopathic hypersomnia with long sleep time and 2) idiopathic
hypersomnia without long sleep time.15 The description of “idiopathic” means
that the entire cause of the hypersomnia is not really known.

Researchers have yet to be able to pinpoint a genetic, environmental, or

physical reason why the person exactly feels so much excess sleepiness and
the condition is not attributed to another disorder. Idiopathic hypersomnia
with long sleep time is characterized by excessive daytime sleepiness and
the need for naps during the day, which are often long. Despite taking one
or two long naps during the day, the person continues to feel tired and
drowsy, and may also sleep for great lengths at night and be very difficult to
arouse in the morning. After awakening, the affected individual is likely to
have confusion upon arousal, also known as sleep drunkenness, in which
there is confusion, disorientation, and sometimes aggressive or
inappropriate behavior for a time after awakening. Often, the person does
not remember such an episode.

Idiopathic hypersomnia with long sleep time may also lead to periods of
sleep paralysis, hypnagogic hallucinations, which involves the patient seeing
or hearing things that are not real during the period of time transitioning

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between sleep and wakefulness; and, headaches, lightheadedness, and
occasional fainting during such episodes may be experienced. In contrast to
narcolepsy, the patient does not experience symptoms of cataplexy with this
type of idiopathic hypersomnia.15 Idiopathic hypersomnia without long sleep
time is a little more similar to narcolepsy in that the affected patient still
experiences excessive daytime sleepiness and is irresistibly drawn to taking
short daytime naps.

The daytime sleeping episodes may be more frequent than idiopathic

hypersomnia with long sleep time, usually because they are shorter in
duration. The patient often has more of a sense of feeling refreshed after a
daytime nap. In contrast to idiopathic hypersomnia with long sleep time, the
patient with this type of hypersomnia usually does not sleep for great
lengths at night and does not have as many difficulties with awakening.15

Idiopathic hypersomnia with long sleep time is diagnosed through a patient

history and physical exam to rule out the potential of other conditions that
could be contributing to excessive daytime sleepiness. The patient may need
to keep track of how many hours they sleep, as well as naps taken, time of
going to bed at night and of morning awakening, and the overall quality of
their sleep. Additionally, a polysomnogram may be necessary to determine
whether other factors such as sleep-disordered breathing are present.15

The patient with idiopathic hypersomnia may experience severe frustration

at an inability to get enough sleep. While many people who become sleep
deprived can improve their conditions by catching up on sleep and improving
overall sleep habits, the person with idiopathic hypersomnia seems to never
get enough sleep, and continues to feel drowsy despite 10 or more hours of
sleep at night and with napping during the day.

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Unfortunately, there are few treatments available for idiopathic
hypersomnia. Many health clinicians prescribe stimulant medications similar
to those used in the treatment of narcolepsy and some patients have had
success using these drugs. For those who use prescribed stimulant
medications, many may still continue with having more than the average
amount of sleep. Often, sleep must be scheduled or considered as a normal
way of life for those diagnosed with this condition, and they need to make
others aware of their disorder and the need for extra sleep every day.16

Sleepwalking

Sleepwalking, also referred to as somnambulism, is a condition that occurs

when a person gets up, walks, or performs other activities while asleep.
Sleepwalking most commonly develops during childhood and may be
prevalent in up to 40 percent of children for occasional episodes. It peaks
between 11 and 12 years of age and then often diminishes during
adolescence. Between 0.5 and 4 percent of adults continue to sleepwalk and
never outgrow the condition.19

While sleepwalking the person may be transitioning between NREM and REM
sleep, which is when the brain is active but the rest of the body is acting out
some of what is being dreamt. Typically, the person has no awareness of
what they are doing while sleepwalking. It most commonly occurs during the
first half of the night and in stages 3 and 4 of NREM sleep; however, it can
occur at any time of night and in other stages of sleep.19 Sleepwalking is
characterized by activity that is abnormal, such as, when a sleeping person
gets out of bed, walks around the room or the house, performing routine
activities that would be performed during the day, or talking.

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Some people also perform more bizarre activities, such as placing items in
inappropriate locations or urinating on the floor. Contrary to its portrayal in
the media, a sleepwalking person typically does not stumble around the
room with their arms held out in front. The person does have slower
movements and may appear clumsy, often with their eyes open, having a
blank stare, and typically they do not track or follow what is going on in
front of them. Attempts to talk to people who are sleepwalking may be
unsuccessful or may be met with inappropriate or confusing responses.19

While many professionals believe that sleepwalking is a benign condition that

does not hurt anyone, other researchers have disagreed. A study noted by
the American Academy of Sleep Medicine found that adults who sleepwalk
have higher instances of excessive daytime sleepiness, insomnia,
depression, and anxiety when compared to people who do not sleepwalk.
Sleepwalking can also be dangerous if the person becomes engaged in
activities that are hurtful toward others or themself. For instance, some
studies have revealed that people who sleepwalk, or their bed partners,
have been injured enough during the episode that they required medical
treatment.18 Clearly, in these situations, sleepwalking and its associated
activities is not a benign behavior.

The most common cause of sleepwalking among adults is sleep deprivation.

People who are stressed and who are chronically sleep deprived are more
likely to have episodes of sleepwalking if they have had them in the past.
Other causes of sleepwalking episodes include using alcohol or certain
psychotropic medications, chronic sleep deprivation, and the presence of
other sleep disorders, such as obstructive sleep apnea. Illnesses that cause
a fever can also precipitate a sleepwalking episode. Some people who have
medical conditions, such as hypothyroidism or migraine headaches, may also

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be more likely to sleepwalk. The concept that sleepwalking is more
commonly associated with mental illness is not true; sleepwalking has not
been associated with a greater level of psychological disorders among
affected people.19

Sleepwalking is often not treated with medications or therapies and it is

usually diagnosed based on the patient’s history alone. The most prominent
part of managing sleepwalking is managing and improving sleep. A
polysomnogram may be indicated for some people if there is a risk of
another underlying disorder, such as obstructive sleep apnea. Otherwise, the
management of sleep by increasing the amount of sleep at night to avoid
sleep deprivation, managing stress, and avoiding the use of certain
substances, such as alcohol or sedatives, can help to reduce instances of
sleepwalking.19

Some people who are known to have sleepwalking episodes benefit from
taking safety precautions in the home to avoid accidents and injuries. While
most sleepwalkers are able to navigate within their rooms and homes
without difficulty, taking safety precautions can help to prevent a severe
injury from occurring. This includes removing sharp objects, locking doors
and windows, and getting rid of any items that could cause injury or be used
to hurt someone else. In cases where a sleepwalker has become injured or
violent, or in other cases where episodes occur so frequently that the person
is suffering from severe sleep deprivation, some medications should be
prescribed to stop the frequency of episodes. Some types of medications
that have been successfully used for sleepwalking include antidepressants,
such as tricyclic antidepressants and selective serotonin reuptake inhibitors,
and low-dose benzodiazepines.19 Treatment is most effective when

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medications are combined with other lifestyle changes, such as good sleep
hygiene habits (discussed later).

Confusional Arousals

While more common among children, confusional arousals occur in

approximately 4 percent of adults. Confusional arousals are a type of
parasomnia that is characterized by disoriented, confused, inappropriate or
even violent behavior upon awakening. They most often occur when the
affected patient is forced to awaken or otherwise wakes up spontaneously
from stages 3 or 4 of NREM sleep.19 Because the person usually has
awakened during the stages of deep sleep, it may take time to become
reoriented to time and place.

Among adults, confusional arousals are classified into two different types of
severe morning sleep inertia and sleep-related abnormal sexual behaviors.
Severe morning sleep inertia is also referred to as sleep drunkenness and is
most likely to occur with morning awakenings. The patient may exhibit
bizarre behaviors or appear disoriented, may thrash around in bed, exhibit
similar behavior to sleepwalking, cry, scream, or even become aggressive.
Typically, the affected person does not remember the event after becoming
fully awake and any attempts to calm them or alter their behavior are
unsuccessful. Most episodes last between 5 and 15 minutes, although some
episodes have been shown to last for over an hour.19 Alternatively, sleep-
related abnormal sexual behaviors are characterized by inappropriate sexual
behaviors that occur when a person is just waking up. They often happen
when the affected person is forced to awaken from sleep and has been in a
deep stage of sleep. These behaviors may include sexualized behaviors, such
as acting out sexual activity, masturbation, and talking in a sexually
suggestive manner.19

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Confusional arousals affect both men and women equally; however, like
other types of parasomnias, they are most often associated with chronic
sleep deprivation and stress. Other factors that also contribute to more
episodes of confusional arousals include use of alcohol, which acts as a
central nervous system depressant, and the presence of other sleep
disorders, including obstructive sleep apnea and periodic limb movement
disorders. Additionally, conditions or circumstances that change the rhythm
and schedule of sleep, including shift work or altered sleep routines, may
lead to episodes of confusional arousals.19
Diagnosis of confusional arousals takes time and often includes more than
one sleep study. A polysomnogram can detect changes in the transition
between NREM and REM sleep, as well as the presence of short bursts of
sleep, called microsleeps. However, not all patients experience episodes of
confusional arousals with one sleep study, which may indicate the need for
successive studies. Many patients and their families keep sleep journals, in
which the patient can track how much and how often they slept, as well as
the quality of sleep. The family can report the patient’s behavior of when
they had a confusional arousal. It may also be necessary to complete video
recordings of the patient’s behavior that can be used in conjunction with
polysomnogram findings to determine a diagnosis.19

Treatment of confusional arousals involves lifestyle modifications and

medication, if necessary. Often, getting higher quality sleep and sleeping for
longer periods can reduce the effects of sleep deprivation that contributes to
confusional arousals. The patient should determine what areas of life are
causing the most stress and work to adapt those situations so that they may
experience better sleep and fewer confusional arousal episodes. Severe
cases of confusional arousals have also been managed with complementary

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and alternative medicine (CAM) therapies, such as hypnosis and progressive
relaxation.19

Medications that may be used for treatment typically include antidepressants

or benzodiazepines. Use of antidepressants does not necessarily indicate
that the patient is depressed when treating confusional arousals; the use of
antidepressants is considered to be successful in off-label methods for
treatment of the condition. The antidepressants may help with stress levels
and can work to alter levels of neurotransmitters in the brain that could
contribute to some of the confused activity. Alternatively, benzodiazepines
promote sleep and work to eliminate sleep deprivation, which is a common
source of the confusional arousals.19

REM Behavior Disorder

Another type of parasomnia, REM behavior disorder, occurs with bizarre or

sometimes aggressive behavior patterns that appear to be of a person acting
out his or her dreams. REM behavior disorder occurs when the individual is
in the stage of REM sleep but often does not have muscle paralysis or atonia
that is normally associated with the stage.19 Instead, while the person
dreams, he/she may be physically able to move and act on some of the
occurrences that are happening in dreams. The episodes may be more likely
to occur later in the night or in late morning when there is a greater amount
of REM sleep.

People who experience REM behavior disorder may get up out of bed, move
around the room, scream, cry, or become aggressive toward others. In some
instances, REM behavior disorder has been associated with violence toward
and injury of a bed partner or roommate. The affected person has closed
eyes and often acts in a defensive manner. The episode ends when the

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person abruptly awakens and stops the behavior, and can usually recall
much of what the dream was about at that time.19

REM behavior disorder is classified into three different types; subclinical REM
behavior disorder, parasomnia overlap syndrome, and status dissociatus.
The subclinical REM behavior disorder type is usually only determined during
a polysomnogram, when the person has brain and muscle activity associated
with the disorder but does not act out. This subtype is associated with later
development of full-blown behaviors that are characteristic of the disorder.

Parasomnia overlap syndrome includes REM behavior disorder that is also

associated with other types of parasomnias, including sleepwalking, night
terrors, and confusional arousals. It may be difficult to determine the
difference between REM behavior disorder and some other types of
parasomnias because often their behaviors may mimic each other. However,
each parasomnia does have distinct differences that classify them
accordingly. For example, sleepwalking and REM behavior disorder may
appear similar initially, particularly if the sleepwalker is showing aggressive
behavior, but a sleepwalker typically has open eyes with a blank stare and
may or may not remember the event or wake up. Alternatively, an individual
acting out through REM behavior disorder usually has closed eyes and wakes
up from the episode with memory of the dream that was occurring.19

Status dissociatus is usually caused by an underlying medical disorder that

contributes to the behavior. This type of REM behavior disorder has been
shown to appear during different stages of NREM and REM sleep, and
activities are not well correlated with a specific sleep stage. Status
dissociatus is most likely seen with conditions such as Parkinson’s disease,

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narcolepsy, alcohol withdrawal, and dementia. Approximately 60 percent of
causes are considered idiopathic.19

REM behavior disorder more commonly develops in adults and can actually
be considered a condition that progressively worsens with aging, particularly
when underlying conditions, such as Parkinson’s disease, are present.
Diagnosis includes a history and physical, a polysomnogram test, and a
brain MRI to rule out other brain abnormalities or underlying medical
conditions that contribute to the behaviors. The patient may need more than
one sleep study to determine changes that occur with the REM behavior
disorder episodes, particularly if an episode does not happen during the first
polysomnogram.19 Video recording of the events may also be helpful to
distinguish some of the actions or characteristics of the REM behavior
disorder from other types of parasomnias, such as sleepwalking.

The disorder may be treated with medications and there are a variety of
options available for treatment. One of the most common drugs prescribed is
clonazepam, which has been shown to reduce symptoms in up to 87 percent
of people with REM behavior disorder. Other types of drugs that have been
successful with treatment include imipramine and bupropion, which are
types of antidepressants; and, levodopa, which is often used in the
treatment of symptoms associated with Parkinson’s disease and
carbamazepine, which is an anti-seizure medication.19

Sleep Disorders Secondary To Illness/Injury

While some sleep disorders develop as primary conditions, there are many
situations in which underlying health issues contribute to sleep problems and
cause excessive daytime sleepiness or insomnia among affected patients.

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Illnesses and injuries can create pain, discomfort, and changes in body
systems that impact sleep.

Injury and Chronic Pain

People who experience chronic pain as a result of a previous injury or due to

a condition that causes unrelenting discomfort may have considerable
difficulties with achieving adequate sleep at night. Sleep difficulties have also
been associated with medical conditions that cause chronic pain, including
fibromyalgia, arthritis, chronic fatigue syndrome, and cancer. Although many
people who have chronic pain may complain of sleep disturbances, pain by
itself is not a sleep disorder. The presence of pain should not explain all the
reasons why a person is having sleep difficulties; instead, the affected
person should have a sleep study to determine if there is another underlying
disorder present that is causing the sleep difficulties. Additionally, proper
diagnosis and treatment of the syndrome causing the pain can make a
significant different in relieving sleep difficulties.

People who have chronic pain have been shown to have changes in the EEG
portion of the polysomnogram sleep test. Sleep studies of people with
chronic pain have shown that they tend to spend more sleep time in the
lighter stages of sleep, rather than achieving deep NREM sleep that is
restorative. This creates a vicious cycle of further sleep deprivation that
exacerbates chronic pain symptoms. People with chronic pain have also
shown EEG changes that are known as alpha intrusions, which are
characteristic brain wave patterns that have been associated with chronic
fatigue syndromes and chronic pain disorders.21

While treatment of alpha intrusions is not available, people with chronic pain
who are experiencing sleep difficulties would do well to have a pain workup

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that investigates the cause of the pain. The connection between pain and
sleep is profound, as both are impacted by the central nervous system.21
Unfortunately, it may be difficult to determine which condition is causing the
other; whether sleep deprivation is worsening chronic pain or if pain is
causing further sleep problems. Either situation needs a full investigation to
determine underlying cause and may need individual treatment and
management. With treatment of one condition, a relief of symptoms of the
second system will often follow.

Obesity

Obesity can have a significant impact on sleep habits and the volume of
excess weight can affect how much and the quality of sleep a person gets. It
is well known that obesity contributes to a number of health problems,
including cardiovascular disease and diabetes, and some of the symptoms of
these conditions can cause sleep problems. For example, a person who has
diabetes may be at risk of developing diabetic neuropathy, a condition that
leads to numbness, burning pain, and tingling in the extremities, particularly
in the feet. This discomfort can significantly impact the diabetic’s ability to
get quality sleep if the pain is causing him or her to wake up frequently.

Obesity is a significant contributor to obstructive sleep apnea, which affects

approximately 18 million people in the United States. As people continue to
gain weight, fat that accumulates around the neck and face can place more
pressure on the airway and the structures that must normally remain open
while breathing during sleep. Apnea during sleep leads to excessive daytime
sleepiness, which can further promote obesity when the person is too tired
during the day to get in extra activities that could lead to weight loss.22
Unfortunately, lack of proper sleep may contribute to obesity and being
overweight. Some people who lose enough sleep are more prone to weight

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gain, regardless of whether there is an underlying illness or disease present.
According to Harvard Medical School, hormones that the body produces that
control appetite and feelings of fullness can be impacted by lack of sleep.

Ghrelin is a hormone that stimulates appetite and causes a person to feel

like they want to eat. Alternatively, leptin is another hormone that
counteracts the ghrelin by telling the brain to stop eating when satisfied.
When a person is deprived of sleep, ghrelin levels have been shown to
increase, further stimulating a person’s appetite and driving him or her to
eat more. Alternatively, leptin levels drop with sleep deprivation, so the
brain receives fewer messages to stop eating when full. Ultimately, the
sleep-deprived person may be more likely to gain weight because of these
hormone disruptions that impact eating habits.1

Sometimes, the best method of managing obesity is to treat the sleep

problems that are happening at the same time. For example, in the case of
an obese person who has sleep apnea, weight loss efforts may be more
successful after a person has had time treating the sleep apnea with CPAP.
The person may be less likely to have excessive daytime sleepiness because
they are sleeping better at night with the CPAP. Improved sleep then leads
to improved activity during the day, as well as improved feelings of well
being, which can contribute further to weight loss.22

Mental Illness

Sleep problems can be associated with certain mental health conditions. At

times the cause of the sleep disturbance may be the mental illness but, in
some cases, the mental illness may be causing the sleep disturbance. Often,
there is a negative cycle of symptoms of sleep deprivation intertwined with

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negative behaviors and emotions that can make it difficult to determine
which problem started first.

Sleep disturbances are most commonly associated with illnesses such as

depression, anxiety, and bipolar disorder; they are also associated with
attention deficit hyperactivity disorder (ADHD) among children and teens.
One of the classic signs of depression is sleep-related problems, whether
sleeping too much or an inability to sleep or insomnia. Alternatively, the
sleep problems may develop before the mental health crises occur. A study
noted by Harvard University reported that people with insomnia were four
times more likely to develop major depression when the insomnia was not
adequately treated.23
People with depression and who subsequently have sleep problems are less
likely to respond to treatment when compared to people who are depressed
but do not have sleep problems.23 Although sleep difficulties are common
symptoms of depression, they are not common in all patients. However,
many people with depression have difficulties sleeping because of anxiety,
worry, or ruminations about events of the day. Insomnia can also create
feelings of isolation within a person when he or she feels alone in having
sleep difficulties.

Anxiety is another mental health issue that has been associated with sleep
disorders. A person with anxiety may have trouble sleeping because they are
awake at night worrying or thinking, or they may have experienced insomnia
in the past and may feel increased anxiety as bedtime is approaching
because they fear an inability to sleep. Approximately 50 percent of patients
with generalized anxiety disorder have some type of sleep difficulty. Sleep
problems are also associated with other kinds of anxiety disorders including

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obsessive-compulsive disorder, post-traumatic stress disorder, and panic
disorder.23

Various studies have shown an increased risk of sleep problems among

people diagnosed with bipolar disorder; results of a systematic review by
Harvard University have been reported as being between 69 and 99 percent
of patients who claimed that they experienced insomnia during manic
episodes. A lack of sleep and chronic insomnia may contribute to the
development of manic episodes in patients with bipolar disorder.
Alternatively, up to 78 percent of patients experiencing bipolar depressive
symptoms may develop hypersomnia and sleep excessively.23

Treatment of sleep problems associated with mental health disorders is

geared toward treating and managing the underlying disorder and making
positive lifestyle changes. The affected patient can develop good sleep habits
that are more likely to promote sleep, such as a regular bedtime routine and
avoiding certain substances such as alcohol or nicotine before going to bed.
Using other measures, such as hypnosis, guided imagery, or meditation may
also be helpful in reducing anxiety and improving sleep habits.

Patients who are treated for mental illness by using medications may have
resolution of sleep problems through medication. For example, some
patients with depression experience a decrease in sleep problems when they
treat their depression with antidepressant medications. They may experience
relief of depressive symptoms and resolution of sleep problems with one
medication.23 Patients treated with medications for anxiety disorders may
also experience relief of sleep problems by drug use to treat the anxiety
itself. Many anti-anxiety medications work by providing a calming effect,
which may induce sleep in some people. Additionally, patients with bipolar

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disorder who are experiencing manic episodes may need drugs to induce
sleep when they suffer insomnia. Often, some of the drugs prescribed, such
as benzodiazepine medications or anticonvulsants work well to promote
sleep during times when mania is causing sleep deprivation.23

Heart Disease

The heart beats faster or slower at night, depending on the stage of sleep a
person is in; when the heart does not function properly and a person has
developed heart disease, it can increase the risk of some types of sleep
disorders. Alternatively, some pre-existing sleep disorders can increase the
risk of developing certain types of cardiac conditions.

Obstructive sleep apnea is a common denominator associated with a number

of different types of heart disease. People who have OSA are more likely to
develop cardiovascular diseases, including hypertension, heart failure, and
coronary artery disease. When a person with OSA repeatedly has episodes of
apnea, the blood oxygen level drops. The heart, in response, beats faster in
an effort to make up for loss of oxygen. This causes an increased amount of
work for the heart and results in an increase in overall blood pressure. Over
time, blood pressure levels may remain high, leading to chronic
hypertension. Hypertension is a risk factor for the development of coronary
artery disease as well, because of the increased stress placed on the blood
vessels with high blood pressure.20

Heart failure can lead to chronic sleep problems for various reasons; it may
lead to decreased and disrupted sleep because of symptoms, and it may be
associated with specific sleep disorders that also cause sleep deprivation. A
person with heart failure has a heart that does not pump efficiently enough
to provide oxygenated blood to the tissues; excess fluid often builds up in

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circulation and in the tissues, which is why the condition is sometimes
referred to as congestive heart failure. When a patient has congestive heart
failure, significant sleep difficulties may result, particularly if the congestion
has reached the circulation surrounding the lungs. The patient may have
difficulties breathing, obviously impacting sleep and the need to sleep in an
elevated position or use supplemental oxygen to help with breathing.

People with heart failure are more likely to have central sleep apnea, a
disruption between the brain’s signals to breathe and the body’s response to
take a breath. Approximately 40 percent of people with heart failure have
central sleep apnea.20 Unfortunately, for those involved, the two conditions
create a cyclical effect in which each worsens the symptoms of the other.
The heart failure may increase the episodes of central sleep apnea, causing
more pauses in breathing and decreased oxygenation throughout the body.
The heart attempts to compensate against the deoxygenation and works
harder, but because of the heart failure it is already stressed and damaged.
The cycle between the two conditions continues to prolong sleep deprivation
and can worsen cardiovascular disease.

Heart disease overall impacts sleep when the affected patient must make
accommodations for both the disease affecting the heart and the associated
sleep disorders. This often means using medications to treat the heart
disease, using other methods of management, such as supplemental oxygen
or CPAP, and incorporating lifestyle modifications to better manage both
heart disease and sleep problems.

Sleep Tests

Various tests and procedures may be performed as diagnostic tools for

determining if a sleep disorder is present. The patient with sleep issues may
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undergo a number of tests to confirm a diagnosis; some tests are more
invasive than others. The gold standard of sleep testing is polysomnography,
or an overnight sleep study; however, there are a number of other tests that
are also useful for confirming sleep disorders among patients experiencing
excessive sleepiness or sleep deprivation.

Polysomnography

Polysomnography is the technical term for a sleep study, and is a procedure

for diagnosing sleep disorders and other problems that may be causing
difficulties with behavior or mood and may be related to sleep deprivation. It
is typically performed at a sleep center where the patient must attend to be
monitored while asleep.

Most patients undergo overnight polysomnography studies while they spend

the night sleeping at a sleep center. A typical study involves the patient
arriving at the center approximately 2 hours before their normal time for
going to sleep. The sleep center staff connects the patient to a number of
sensors that monitor the patient’s vital signs and sleep cycles. The patient’s
brain activity while they sleep is recorded through an EEG and a sleep
medicine specialist can later read the results to verify if there are
disturbances in sleep patterns, or whether there are other problems affecting
the patient from progressing through the normal stages of sleep.7

Sleep studies are used to diagnose a number of sleep disorders; they allow
the sleep medicine specialist to not only read the results of brain patterns
that occur during sleep, but to watch a recording of the sleeping individual to
look for behaviors that occur during sleep, such as excessive limb
movements, sleepwalking, or sleep talking. A sleep study is also used to
diagnose obstructive sleep apnea after determining if the patient has

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significant episodes of apnea and associated oxygen desaturations. If a
patient is diagnosed with sleep apnea through a sleep study, the health
clinician will then typically prescribe CPAP for use. The patient must then
return to the sleep center to have another sleep study using the CPAP to
determine if it is effective in treating the obstructive sleep apnea and to
adjust the settings if necessary.7

Before starting a polysomnogram, a patient may complete a sleep diary, in

which he or she records such factors as the time they go to bed, the time of
falling asleep, the number of times awakened while sleeping, and the total
time spent asleep. Additionally, the patient may also record other factors
that can influence sleep, such as activities before bed, food intake, or mood.
The patient records this information in the sleep diary over a period of time,
often for several weeks, so that the sleep medicine specialist can review the
information and determine if there are patterns occurring that are impacting
the patient’s sleep. Sometimes, there are obvious situations that a clinician
can find and point out to the patient; when the patient changes these
circumstances then sleep may be improved dramatically with little or no
effort.2

Alternatively, if the sleep diary does not point to problems that can be
readily explained or treated, further management of the patient’s condition
is necessary. It should be noted that the patient’s sleep diary is subjective
and the information included is based on the patient’s expressions,
descriptions, and opinions. Often, diagnosis and treatment of sleep disorders
requires testing that will produce objective results that can be measured in
order to fully facilitate treatment for the patient.

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While sleep studies are very useful, especially in conjunction with a sleep
journal from the patient, they do not diagnose all different kinds of sleep
disorders. In some situations, a sleep study may be unnecessary, such as
with sleep-related leg cramps or other disorders where diagnosis may be
made on the basis of patient description. Further, some people do not sleep
normally in a sleep laboratory, particularly when they are connected to
sensors and someone is watching them attempt to sleep. When this occurs,
the affected patient may not demonstrate a routine night of sleeping that is
comparable to what is experienced at home. Other forms of testing may be
necessary or supplemented with the sleep test. Ultimately, the sleep study
can be very useful in diagnosing many types of sleep disorders, including
circadian rhythm disorders, insomnia, narcolepsy, and most commonly,
obstructive sleep apnea.

Maintenance of Wakefulness

Maintenance of wakefulness (MWT) testing determines how well a person is

able to stay awake in a situation. The MWT is particularly useful for people
who experience excessive daytime sleepiness and fall asleep quickly and
sometimes inappropriately. It may also be required in some situations where
a person with a sleep difficulty needs to stay awake for an important job,
such as with air traffic control or transportation.

During the MWT, the patient attends a sleep lab where he/she is placed in a
darkened room and connected to various sensors that signal when the
patient is asleep and awake. After being connected to the sensors, the
patient lies down in a comfortable bed and is asked to lie on their back and
stay awake for as long as they can. If the patient falls asleep, they are
awakened after 90 seconds. If the patient has not fallen asleep within 40

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minutes, the test is complete. The MWT test is repeated for four trials of
attempting to stay awake.29

According to the American Academy of Sleep Medicine, up to 59 percent of

patients with normal sleep are able to go through the MWT and stay awake
for the 40 minutes of each of the four trials. Over 97 percent of people are
able to stay awake for at least 8 minutes or more during the trials. If a
person falls asleep in less than 8 minutes during one of the sleep trials, it is
significant for further testing of a sleep disorder.

The MWT test may be used in conjunction with other types of sleep testing;
particularly when confirmation or diagnosis of a specific sleep disorder and
planned treatment is necessary.29 The MWT is useful in recognizing such
disorders as obstructive sleep apnea or narcolepsy. It can also determine the
effectiveness of treatment for some types of sleep disorders when a patient
has started therapy and needs to find out how well it is working.

Multiple Sleep Latency Test

In contrast to situations where people have sleep testing while sleeping at

night, the multiple sleep latency test (MSLT) challenges certain patients
while sleeping during the day. The multiple sleep latency test is typically
used as a diagnostic tool among people who complain of excessive daytime
sleepiness, usually as a result of some type of sleep disorder.

The MSLT studies how quickly a patient falls asleep when taking a nap
during the day. The patient is connected to sensors that measure such items
as eye and chin movements, as well as brain waves through an EEG. The
MSLT can determine how much time a person spends in NREM and REM
sleep stages. It also helps to gain a better idea of whether the affected

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person is having difficulty falling asleep as well as spending abnormal
amounts of time in one or more sleep stages when they do fall asleep.29
Additionally, the MSLT can determine how quickly a person moves through
the phases of sleep and whether REM sleep occurs at an abnormally fast
pace (faster than the average time it usually takes for a sleeping person to
progress to this stage).

The MSLT is often used for the diagnosis of narcolepsy. Because people with
narcolepsy often complain of excessive daytime sleepiness and typically
move quickly into the REM stage of sleep after falling asleep, this test can
act as a diagnostic tool for this condition. Alternatively, the multiple sleep
latency test may also be used to diagnose idiopathic hypersomnia. Although
people with idiopathic hypersomnia do not usually move directly into REM
stage sleep after falling asleep, the MSLT can be diagnostic when evaluating
excessive daytime sleepiness associated with the condition.29

Before the MSLT, the patient may need to keep a sleep journal for at least a
week, which can give the clinician a better idea of the patient’s sleep habits,
periods of awakening, amounts of daytime sleepiness, and quality of sleep
overnight. Before the study, the patient typically must also refrain from such
activities as smoking, drinking caffeine, or taking medications that could
impact the results of the study. The MSLT is also typically performed after an
overnight sleep study, as the results can be compared between nighttime
sleeping and daytime naps.29

During the test the patient has five opportunities to take a nap and is tested
on how quickly sleep occurs. If the patient had an overnight sleep study
prior to the MSLT, the first nap opportunity may come approximately 1 to 3
hours after the completion of the overnight study. The patient is connected

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to the appropriate sensors and then allowed to lie down in a dark room that
is being monitored by professionals who will eventually read the results. The
room is kept dark, quiet, and comfortable in order to better facilitate sleep.
The patient basically lies down and tries to go to sleep. Once the patient has
fallen asleep, their activity is recorded for approximately 15 minutes and
then they are awakened. The nap sessions are then repeated four more
times throughout the day. If the patient is unable to fall asleep after 20
minutes, the session is discontinued, the sensors are removed, and the
patient waits until the next nap trial a couple of hours later.29

After the last nap trial of the day, the patient is free to go home and they
will receive the results later. A sleep medicine specialist who can diagnose
the presence of a sleep disorder, such as a hypersomnia sleep condition,
must read the results. The diagnosis is made by determining how long it
takes for the patient to fall asleep during each of the nap trials. Additionally,
the physician checks for how quickly the patient enters the stage of REM
sleep and how much time is spent in NREM sleep to determine if the sleep
cycles are occurring normally. Deviations from normal in these situations
often indicate the presence of a sleep disorder. Further testing may be
warranted in some situations if the patient is showing signs of sleep
disturbances but the results are not entirely clear through the MSLT.

Actigraphy

Actigraphy is a diagnostic tool that can be used in diagnosing several types

of sleep disorders. Actigraphy involves placement of a sensor on the patient,
who wears the device for several days including during the day and at night
while sleeping. The device records the patient’s activity both while awake
and at rest. The information is downloaded to an electronic program where a
health clinician can review it.

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While not designed to replace an overnight sleep study test, actigraphy can
be a useful tool for documenting sleep patterns. It has been used prior to
performing a multiple sleep latency test and it is useful in evaluating the
presence of specific disorders, such as circadian rhythm disorders. It may
also be used concurrently with treatment methods for sleep-disordered
breathing to determine the effectiveness of such treatments as CPAP.
Furthermore, it has been shown to be useful when evaluating the effects of
sleep on some medical conditions, such as depression and dementia.35

There are certain advantages that actigraphy can provide over certain types
of sleep evaluations, such as a sleep journal. When patients are asked to
keep a sleep journal, they typically record their sleep habits over the course
of several days to weeks. However, this information is sometimes inaccurate
because it relies on the patient’s memory of the situation and it is entirely
subjective information provided by the patient and their family. A study in
the journal CHEST showed that when actigraphy was used in conjunction
with a sleep journal, the results were different between the journal and the
actigraph. For example, in one report, the bedtimes reported by the patient
in the sleep journal were a full hour before the recorded times found in the
actigraphy.35 Most patients do not intend to provide false data, but memory
and recall of events may be distorted when recording items in a sleep
journal, particularly during sleep deprivation.

Actigraph use is prescribed by a physician and is a small monitor that is

worn on the wrist; the average length of time of wear is 1 to 2 weeks. It
continuously monitors activity and sleep habits of the patient while it is worn
and records and downloads the information for the physician to read and
interpret. It can record information constantly while worn, although there

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are certain situations in which it should be removed, such as when
showering or bathing.

An actigraph may also have a light sensor that can record changes in light
levels that indicate when the patient is asleep. If the patient is undergoing
light therapy as a treatment for a circadian rhythm disorder, the light sensor
on the actigraph can record and determine adherence to light therapy
treatment as well. Actigraphy may be used in recording the sleep habits of
people who suffer from insomnia.35 Sleep journals of patients with insomnia
may or may not be entirely accurate for the number of hours of sleep and
for the amount of sleep deprivation that has occurred. This is especially true
in situations where sleep deprivation impacts concentration and memory for
recalling events.

When a person undergoes a sleep study for the first time, he or she may not
go to sleep or may have difficulties following through with the study to
produce “normal” results because of trying to sleep in a lab and not at
home. It may take several sleep studies to gain an example of a routine
night of sleep for someone with insomnia. Alternatively, actigraphy may be
used in place of a polysomnogram in some cases of insomnia to record light
levels in the room and the patient’s actual times of sleeping and
wakefulness.

Sleep actigraphy does not necessarily measure sleep stages accurately

enough to be considered a valid resource for this data. Additionally, if a
person lies completely still at night but is actually awake, the actigraphy
may incorrectly note that the individual is asleep. Actigraphy is typically not
designed to take the place of an overnight sleep study; however, it can be a

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valid and useful device for recording sleep habits, particularly when used in
conjunction with a sleep journal for some patients.

Imaging and Laboratory Tests

Because underlying medical conditions may cause some sleep disorders,

there are situations in which laboratory testing and imaging studies are
warranted to rule out specific conditions. Checking the blood and
determining whether hormone levels are altered or if there are other
indications that a disease is present can detect some diseases that impact
sleep.36 For example, a patient with hypothyroidism may have difficulties
with sleeping that could be diagnosed as insomnia. Laboratory testing to
check thyroid levels and to perform thyroid function tests may pinpoint
hypothyroidism and sleep could then be improved by treating the
hypothyroidism.

Other types of blood tests that could be necessary for ruling out the
presence of other conditions include: arterial blood gases, which measure
the amount of oxygen and carbon dioxide levels in the bloodstream and may
be useful in determining the consequences of sleep-disordered breathing;
tests for glucose levels to determine the presence of diabetes; and tests of
cholesterol levels, triglycerides, and C-reactive protein to confirm the
presence of heart disease or factors that are contributing to decreased
circulation or other problems with the cardiovascular system.

Imaging studies are particularly useful in diagnosing sleep-disordered

breathing; they typically provide an image of the structures of the inside of
the mouth and throat that can confirm problems associated with sleep
apnea, snoring, or upper airway resistance syndrome. A CT scan of the head
and neck may be useful for examining parts of the airway that are difficult to

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see from other types of physical exams. The head and neck CT may
determine if a patient has an enlarged tongue or extensive tissue in the neck
or at the back of the throat that could be contributing to obstructive sleep
apnea.36

A specific type of x-ray known as a cephalometric x-ray may take images of

the head to determine if there are skull or jaw abnormalities contributing to
sleep difficulties. This type of x-ray would be most useful in determining if
there are structural abnormalities in the upper or lower jaw, the nasal
bones, or the hyoid bone that could also contribute to obstructions found in
OSA.

Pharyngoscopy is a procedure that involves inserting a tube with a small

camera on its end into the patient’s pharynx to look at the structures at the
back of the mouth. The pharyngoscopy takes pictures of the structures and
can better determine if the patient has excess tissue or other structures that
would be more likely to collapse during relaxation while sleeping, further
contributing to obstructive sleep apnea.

Imaging studies and laboratory tests are all part of the diagnostic process of
determining the cause of sleep problems. When a patient has sleep
difficulties and the physician has narrowed down possibilities for a diagnosis,
these types of studies may help to confirm one way or another, which type
of sleep disorder is present or if there is another problem that is causing the
sleep difficulties that should be treated differently.

Treatments For Sleep Disorders

Treatments for sleep disorders may vary depending on the type of disorder
and the presence of any underlying medical conditions that accompany it.
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After a patient undergoes diagnostic procedures and has a diagnosis
confirmed of a sleep disorder, there may be a number of treatments
available that can help to induce better sleep. Some treatments may be
combined with others to ensure positive results.

Behavioral Modifications

There are several behavioral modifications that may be included as part of

treatment for sleep disorders. Some sleep problems can be treated with
behavior modifications and lifestyle changes alone, while in other cases,
behavior modification is combined with other forms of medical treatment.

Cognitive-behavioral therapy (CBT) is a behavior modification that may be

used for some types of sleep disorders. It has been effective in the
treatment of insomnia. A therapist serves as a guide for the patient to coach
him in learning to recognize the factors that are contributing to sleep
problems. For example, a patient with insomnia may learn to recognize
those thoughts and ideas that he or she consistently thinks about every
night that sometimes prevent asleep from occurring. After learning to
recognize the cognitive factors that lead to sleep impairment, the patient
then learns behavioral factors that can counteract the cognitive
disturbances.38

Some types of behavioral changes that may be successful include making

changes in sleep hygiene habits, such as by avoiding the bedroom unless
using it for sleep, keeping the bedroom quiet and dark when trying to sleep,
moving the clock to avoid checking the time too frequently, and eliminating
exterior light and noise that can prevent sleep. Other examples of behavior
modifications include progressive relaxation, meditation, prayer, and mental
imagery.

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In a situation where a patient is trying to go to sleep but cannot, using
paradoxical intention may be helpful. Paradoxical intention is the process of
trying to perform the opposite of the intended effect as a method of tricking
the mind into actually getting the body to engage in the opposite behavior.
For example, a patient who cannot sleep because of insomnia due to
continued ruminations might benefit from paradoxical intention by telling
themself not to go to sleep and focusing on trying to stay awake. The
paradoxical intent may trick the mind into going to sleep when the patient
attempts to stay awake.37,38

Finally, sleep restriction therapy may be another option that can help a
person with sleep difficulties to get to sleep. Many people who have difficulty
falling asleep lie in bed for hours, trying to force themselves to sleep. Sleep
restriction therapy uses the guideline that if the person is unable to fall
asleep within a certain amount of time, he or she should get up and leave
the bedroom and rest in another location until ready to try and sleep again.
By doing this, sleep restriction prevents a person from developing anxiety
that may occur while lying in bed and trying too hard to sleep.

Behavioral interventions and modifications can successfully help some

patients with sleep disturbances because these activities alter the sleep
environment as well as the patient’s approach and thoughts about sleeping.
While some people need extensive treatment and therapy for the treatment
of sleep disorders, many others can benefit from cognitive or behavioral
modifications alone to eliminate sleep disruptions.37,38

CPAP and BiPAP

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Continuous positive airway pressure device (CPAP) is used as treatment for
some types of sleep disorders, particularly those associated with sleep-
disordered breathing, such as obstructive sleep apnea and upper airway
resistance syndrome. CPAP is used to deliver pressurized air directly into the
airway through a mask that is worn over the patient’s nose or mouth and
nose. The pressurized air keeps the collapsible structures at the back of the
mouth and the throat from occluding the airway during sleep. Consequently,
the patient who wears CPAP is then less likely to have apneic episodes and
periods of hypopnea due to an occluded airway.7,9,31

CPAP is prescribed by a health clinician and usually is ordered after a patient

has gone through a sleep study for diagnosis of sleep-disordered breathing
or another need for the CPAP machine. If the health clinician determines that
CPAP is necessary after a sleep study, the patient will return for another
sleep study with a trial of CPAP to determine its effectiveness and to adjust
the settings. Once the correct level has been determined and the amount of
pressure necessary for the patient has been discovered, the patient may
then begin to use CPAP at home.

The patient or their family often must obtain a CPAP machine from a medical
service provider that either rents or sells medical equipment. Depending on
the patient’s situation and financial coverage, buying a CPAP machine is
often an option for someone who would need to use it on a long-term basis.
Alternatively, if the patient has other options for treatment of sleep-
disordered breathing, such as weight loss or surgery, rental of a CPAP
machine for a short period of time may be a better fit.7,9,31

The patient typically keeps the machine at the bedside to use at night while
sleeping. The CPAP machine consists of a box that is approximately 3

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pounds in weight and contains the motor, which generates the air and where
the settings can be adjusted. A set of tubing is connected to the machine,
which extends to the patient; the air from the machine flows through this
tubing to reach the patient. Finally, a mask fits over the patient’s nose or
mouth and nose, where air is takin in while sleeping.

The patient typically places the mask on their face and starts the machine
before going to sleep, adjusting the mask as necessary for comfort. Most
masks have a strap that encircles the back of the head to keep the mask in
place and prevent it from slipping off during sleep. For people who are prone
to mouth breathing, a chinstrap may be necessary to keep the mouth closed
and prevent air from entering the nose and escaping through the open
mouth.7 Additionally, a chinstrap can prevent excessive drying of the oral
mucous membranes that may develop from excess airflow.

Some patients use a humidifier that provides moist air and prevents
excessive drying of the nasal passages. This can help particularly if CPAP
causes nasal stuffiness or congestion, which is a side effect of use. Although
CPAP typically provides pressurized air only, there are some people who also
need supplemental oxygen. A physician must order this to be used in
conjunction with the CPAP and it requires an extra tank to fit with the
machine. The amount of oxygen to deliver can be set and then blended in
with the air coming in from the CPAP. Even though it can be very effective
for treating sleep-disordered breathing, CPAP takes a little time to adjust.
Many people struggle a bit at first by immediately starting to wear a mask to
sleep all night because it is a different sensation. Some people may have a
feeling of being enclosed or suffocating while using the mask, so short
periods of wearing the mask may help to adjust. CPAP is most effective
when it is used at least 6 to 7 hours at a time during sleep.7,9

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Occasionally, the CPAP mask may cause irritation to the face; this occurs
primarily when the mask does not have a proper fit. A patient with facial
irritation from the mask should see their prescribing provider for adjustment
of the mask to avoid further skin irritation. Some moisturizers or skin balms
may help to soothe chafed skin.7

People who wear CPAP for months or years for treatment of sleep-disordered
breathing often must have periodic readjustments to the CPAP settings to
determine if it is continuing to be effective for the patient. This may include
another periodic sleep study where the patient wears the CPAP device; if the
study determines that adjustments need to be made, the clinician can then
prescribe a change in settings, such as by increasing or decreasing the
amount of pressure delivered.

Many people who use CPAP for sleep-disordered breathing find that once
they adjust to the machine and wear it on a nightly basis, they have
considerably improved sleep habits. They feel better during the day and are
not as sleepy, they have improved memory and better concentration, and
they are less irritable. Some other associated health problems may also
resolve or at least improve with the use of CPAP. Its use has been shown to
decrease the risks of heart disease that may be more likely to develop in
patients with OSA and in some cases, it has been shown to reduce chronic
high blood pressure.7,9,31

Another form of treatment for sleep-disordered breathing is bi-level positive

airway pressure, or BiPAP. This method is similar to CPAP in that it provides
air to keep the structures of the mouth and throat open for breathing, but
the method of delivery is slightly different than CPAP. Instead of providing a

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constant air pressure that has been programmed at a set level, BiPAP
adjusts the amount of air pressure delivered during both inspiration and
expiration.

A higher amount of air pressure is typically delivered as the patient breathes

in and a smaller amount of air delivered when the patient breathes out with
the use of BiPAP. This method is designed to decrease mean airway pressure
overall, particularly when CPAP pressure is too constant or too high for the
patient to tolerate on a continuous basis. A patient with a sleep disorder and
another type of medical condition, such as COPD, may more likely benefit
from BiPAP over CPAP. The patient does not have to work as hard to exhale
against higher pressures of air with the use of BiPAP; instead, he or she can
breathe out against a lower amount of pressure for exhalation, which may
help the patient’s breathing patterns overall.

BiPAP may be more expensive in some cases when compared to CPAP. It is

not necessarily recommended as a first line of treatment for someone with
sleep apnea; however, in certain situations, such as COPD or other types of
barotrauma that are contributing to sleep difficulties, it may be a positive
option to improve sleep.

Medications

Various medications are used in the treatment of sleep disorders, whether

they are prescribed to help reduce excessive daytime sleepiness or to assist
patients with getting to sleep at night. Medications work in a variety of ways.
A healthcare provider prescribes medications to patients in order to help
them to better manage a sleep disorder. However, the consistent use of
medications, particularly over-the-counter drugs known as sleep aids, will
not necessarily fix the situation causing the sleep disorder. While

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medications can be beneficial, a diagnostic workup is important to get to the
root of the problem and to determine what treatments, including
medications, may be necessary.39,40

Medications that may be prescribed for insomnia, circadian rhythm

disorders, or other situations whereby a patient has difficulties falling asleep,
include sedative-hypnotics, which include benzodiazepines and non-
benzodiazepines. They are classified as controlled substances because of
their risk of abuse. These drugs cause a person to feel sleepy and may help
people to stay asleep longer; they are also used in the treatment of anxiety,
whether or not it leads to sleep problems.

Melatonin is a supplement that is available over the counter and can be

taken to induce sleep in some people who have difficulties getting to sleep.
Melatonin may be most effective in certain types of sleep disorders, such as
circadian rhythm disorders.40 The body naturally produces melatonin from a
gland in the brain, but if environmental factors are disrupting the body’s
natural rhythm, it may have difficulties secreting enough melatonin to
induce sleep. Melatonin is a hormone that makes a person feel sleepy during
a normal time in the evening when sleep would naturally begin.

Although melatonin can be purchased without a prescription, people who

take it as a sleep aid should consult with a health clinician for dosage
instructions and side effects. There is not one exact dose that is
recommended; additionally, because the U.S. Food and Drug Administration
(FDA) does not regulate supplements, the exact amount listed on the bottle
may not be the same as what the patient is taking. Many over-the-counter
supplements are prone to toxic elements within their products as well, which
could lead to harmful effects.

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When taken appropriately, melatonin can improve sleep in people who are
sleep deprived and who need assistance with getting to sleep. When taken in
the evening approximately one hour before going to bed, melatonin often
helps a person to feel sleepy enough to fall asleep. In some cases, such as
hypersomnias, a patient has more trouble staying awake instead of falling
asleep. When this happens, a different type of medication may be necessary
to help the patient feel more alert and to reduce excessive daytime
drowsiness. These drugs have stimulant effects and typically work by
impacting the effects of neurotransmitters in the brain to help keep the
affected person awake longer. People who take stimulants to stay awake
may also suffer some of the side effects of these drugs; they may make the
person who takes them feel wide awake and eventually have difficulty
sleeping. Other side effects may include tremor and irritability.

Medications may cause some problems when used over a long period of
time. Some medications are at higher risk of being abused or causing
dependence among users, particularly prescription drugs that contain
sedatives or opioids. Over time, a patient may also develop a tolerance to a
drug, so that although it worked well in the beginning, the effects slow over
time and are not as successful. Medications can also be dangerous because
they can cause drug interactions with other prescription or over-the-counter
drugs and they may have undesirable side effects. To determine the most
effective method of treatment, a healthcare provider should monitor
medications used in the treatment of sleep disorders, such as prescription,
over-the-counter, and herbal preparations.

Surgical Treatment

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Surgical treatment of some sleep disorders may be available, depending on
the patient’s health status and the significance of the sleep disorder on his or
her life. Often patients go through other forms of treatment first to
manage sleep disorders, or other underlying diseases that may affect sleep,
and then turn to surgery as another option.

Surgical treatment is most commonly performed among patients with sleep-

disordered breathing, particularly obstructive sleep apnea. Often, an ear-
nose-throat (ENT) physician performs surgical procedures after the patient
has typically tried other forms of treatment, such as CPAP, before resorting
to surgery. Because obstructive sleep apnea may be caused by enlarged
tissues in the mouth and throat or the collapse of throat structures that
block the airway during sleep, some surgical procedures can change these
structures so that they no longer impede airflow.7,39

One such procedure is uvulopalatopharyngoplasty (UPPP), in which the

surgeon removes some of the soft tissues of the uvula, the soft palate, and
the pharynx at the back of the mouth. If the patient has enlarged tonsils or
adenoids, they may be removed during this procedure as well. The UPPP is
meant to enlarge the space at the back of the mouth to avoid the risk of the
structures enclosing around the airway and blocking airflow. It may also help
to improve muscle tone in the airway, which can further help to keep the
airway open while the patient sleeps.7 The UPPP is obviously an invasive
procedure and the patient requires anesthesia and usually an overnight stay
in the hospital. The patient may be at higher risk of bleeding in the back of
the mouth and the throat because the structures that have been altered are
made of very delicate and soft tissue. Many patients complain of significant
pain with the UPPP procedure as well.7

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If a patient has sleep-disordered breathing as a result of nasal problems,
such as a deviated septum or nasal valve collapse, nasal surgery may be
warranted. Nasal surgery often involves straightening the structures that
contribute to disrupted airflow, such as the nasal septum and the nasal
turbinates. The septum may be moved to a slightly different position and the
nasal turbinates may be reduced in size if they are large enough that they
are blocking air passage through the nose. For most people who have nasal
surgery for sleep disorders, the procedure is well tolerated and short; it
usually includes an outpatient stay in the hospital and a fairly rapid recovery
time.14

Another type of procedure that may be used in the treatment of obstructive

sleep apnea is called the pillar palatal implant, or the pillar procedure.
During this procedure, the surgeon inserts three small pillars, or rods, into
the soft palate. The body responds to the presence of the rods as foreign
objects and typically develops inflammation in the area. This inflammation of
the soft tissues that surround the rods may make the soft palate firmer and
a little stiffer. Because this happens, the tissue is less likely to collapse or
otherwise contact the back of the throat to cause an obstruction while
breathing when the tissues are relaxed during sleep. The pillar procedure
can be done on an outpatient basis and is often even performed in a clinic or
physician’s office using local anesthesia.7,14

For patients who have sleep-disordered breathing due to an enlarged tongue

or the tongue muscle falling against the back of the throat and obstructing
the airway, there are a couple of surgical procedures that may be options for
treatment. A hyoid advancement procedure involves surgically moving the
hyoid bone slightly forward to prevent airway collapse. The hyoid bone is
found in the neck where the muscles that control the base of the tongue

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meet with the pharynx. The hyoid advancement procedure is fairly
straightforward and most patients experience few complications; they are
often able to go home soon after surgery.14

Another procedure that involves the tongue is the tongue advancement

procedure. This type of surgery is more invasive than the hyoid
advancement and recovery time may be longer for the patient. The surgeon
moves the genioglossus muscle, one of the main muscles that controls
tongue movement, and pulls it slightly forward to prevent the tongue from
falling backward during sleep and obstructing airflow. Despite the fact that
this procedure is more invasive, it has a fairly high success rate with
improving breathing for patients affected with sleep apnea.14

Summary

Sleep deprivation in the adult population can occur in almost anyone when a
regular and expected night of rest does not occur, and may be due to
circumstances beyond the person’s control. The patient with sleep issues
may undergo a number of tests to confirm a diagnosis. The gold standard of
sleep testing is polysomnography, which is an overnight sleep study. Other
tests that are also useful for confirming sleep disorders have also been
discussed.

Despite the numbers of people who struggle with sleep deprivation as a

result of sleep disorders, there are treatments available that can help. Those
who must spend their days with excessive sleepiness and their nights
drained of sleep do have some options for testing and treatment. These
measures can provide hope for those who may wonder if they will find
restful sleep again.

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 References Section

The References below include published works and in-text citations of

published works that are intended as helpful material for your further
reading. [References are for a multi-part series on Sleep Disorders].

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UpToDate. Retrieved online at
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wake-rhythm-
disorders?source=search_result&search=circadian%20rhythm%20diro
serds&selectedTitle=1~101.
3. Auger, R. (2017). Delayed sleep-wake phase disorder. UpToDate.
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sleep-wake-phase-
disorder?source=search_result&search=delayed%20sleep%20phase&s
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4. Robinson, L., Segal, J. (2014). Narcolepsy. Retrieved online at
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s.htm
5. American Thoracic Society. (n.d.). Sleep-disordered breathing.
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america/index.php
6. Garcha, P. S., Aboussouan, L. S., Minai, O. (n.d.). Sleep-disordered
breathing. Retrieved online at

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 http://www.clevelandclinicmeded.com/medicalpubs/diseasemanageme
nt/pulmonary/sleep-disordered-breathing/
7. University of Maryland Medical Center (2017). Obstructive sleep
apnea. UMMC. Retrieved online at
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apnea
8. Paruthi, S. (2017). Management of obstructive sleep apnea in children.
UpToDate. Retrieved online at
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sleep-apnea-in-
children?source=search_result&search=sleep%20apnea%20and%20to
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10. American Sleep Apnea Association. (n.d.). Central sleep apnea. ASSA.
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sleep-apnea.html
11. Badr, M.S. (2017). Central sleep apnea: Risk factors, clinical
presentation, and diagnosis. UpToDate. Retrieved online at
https://www.uptodate.com/contents/central-sleep-apnea-risk-factors-
clinical-presentation-and-
diagnosis?source=search_result&search=central%20sleep%20apnea&
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12. University of Maryland Medical Center (2017). Insomnia. UMMC.
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13. Kirsch, D. (2017). Stages and architecture of normal sleep. UpToDate.
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14. American Sleep Apnea Association. (n.d.). Varieties of OSA surgery.
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options/surgery.html
15. Thorpy, M. J., Billiard, M. (Eds.) (2011). Sleepiness: Causes,
consequences, and treatment. New York, NY: Cambridge University
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16. National Sleep Foundation. (n.d.). Extreme sleepiness. Retrieved
online at http://sleepfoundation.org/sleep-disorders-
problems/idiopathic-hypersomnia-and-sleep
17. National Institute of Neurological Disorders and Stroke (2014).
Narcolepsy fact sheet. Retrieved online at
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18. American Academy of Sleep Medicine (2013). Adult sleepwalking is a
serious condition that impacts health-related quality of life. [News
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19. Lee-Chiong, T. (2008). Sleep medicine: Essentials and review. New
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20. UCLA Sleep Disorders Center. (n.d.). Heart disease. Retrieved from
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21. Shives, L. (2012). Why you can’t sleep when you’re in pain. Retrieved
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22. National Sleep Foundation. (n.d.). Obesity and sleep. Retrieved online
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legs syndrome. Jones and Bartlett Learning. London, UK.
25. Willis-Ekbom Disease Foundation. (n.d.). Medications for Willis-Ekbom
disease/restless legs syndrome. [Patient handout]. Retrieved online at
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26. National Institute of Neurological Disorders and Stroke (2014).
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27. National Sleep Foundation. (n.d.). Periodic limb movements in sleep.
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instead of sleeping pills. Mayo. Retrieved online at
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depth/insomnia-treatment/art-20046677
33. Sharma, M. P., Andrade, C. (2012). Behavioral interventions for
insomnia: Theory and practice. Indian Journal of Psychiatry 54(4):
359-366. Retrieved online at
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ment.htm
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actigraphy?source=search_result&search=actigraphy&selectedTitle=1
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36. Auckley, D. (2017). Sleep disorders in hospitalized adults: Evaluation
and management. UpToDate. Retrieved online at
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adults-evaluation-and-
management?source=search_result&search=sleep%20disorder%20an
d%20imaging&selectedTitle=10~150
37. Schlarb, A., et al (2017). Sleep problems in university students.
Neuropsychiatr Dis Treat; 13:1989-2001. Retrieved online at
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38. Herbert, V., et al. (2017). Does cognitive behavioural therapy for
insomnia improve cognitive performane? A systematic review and
narrative synthesis. Sleep Med Rev. Retrieved online at
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39. Bonnet, M. and Arand, D. (2017). Treatment of insomnia in adults.
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40. Physician’s Desk Reference (2017). Retrieved online at
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