Types of Sleep Disorders
Disruptive sleep-related problems are called parasomnias. The two main types of parasomnias are primary and secondary. Types of secondary parasomnias include seizures, arrhythmias, and GERD.
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Symptoms commonly found in persons with a circadian rhythm disorder related to the sleep-wake cycle can include the following:
Most of the time, a person's biological clock, or circadian rhythm, is in synchronization with the 24-hour day-night environment. In some individuals, however, the biological circadian rhythm of sleep and wakefulness is out of phase with the conventional or desired sleep-wake schedule.
Sensitivity to zeitgebers ("time givers," or time cues such as light and other environmental cues): This sensitivity may be altered or disrupted, which can be demonstrated under certain conditions. Altered or disrupted sensitivity to zeitgebers is probably the most common cause of the circadian rhythm disorder of the sleep-wake cycle. Patient with blindness may experience difficulty with circadian rhythm, because they lack the light cues through the visual system.
Disrupted pacemaker function: A dysfunction may be present in the internal coupling mechanisms of biological pacemakers, for example, the coupling of the sleep-wake cycle with the temperature cycle.
Environment: Light, higher noise levels, and elevated room temperature are not conducive to good sleep and are important variables to consider in both shift workers and night workers.
Travel: The severity of jet lag is related to the direction of travel and is more frequently seen in individuals traveling in an eastward direction. The number of time zones crossed also has an effect on the severity of jet lag, with most individuals experiencing jet lag if they cross 3 or more time zones. The rate of adjustment is 1.5 hours per day after a westward flight and 1 hour per day after an eastward flight.
Neurological disease: Alzheimer disease is one of the more common examples of neurological disease associated with a circadian rhythm disturbance; however, irregular sleep-wake cycles can also be seen in other neurodegenerative diseases. Sundowning, which is a common phenomenon in persons with Alzheimer disease, is characterized by sleep disruptions with awakenings and confusion.
Shift work: Rapid shift changes and shift changes in the counterclockwise direction are most likely to cause symptoms of a circadian rhythm disorder.
Lifestyle and social pressure to stay up late can exacerbate a circadian rhythm disorder.
As always, maintaining good sleep hygiene is important. Good sleep hygiene consists of measures to reinforce the body's natural tendency to sleep, including the following:
Common circadian rhythm disorder treatments can include the these behavioral and environmental therapies.
Therapy for a circadian rhythm disorder is largely behavioral. Light therapy has been shown to be an effective modifier of circadian rhythms. The short-term use of hypnotics (medications that promote sleep) is a useful option in treating a circadian rhythm disorder and has improved the therapeutic response, especially in persons with Alzheimer disease.
Melatonin has been reported to be useful in the treatment of jet lag and sleep-onset insomnia in elderly persons with melatonin deficiency. Melatonin is used for enhancing the natural sleep process and for resetting the body's internal time clock when traveling through different time zones. Melatonin is believed to be effective when crossing 5 or more time zones but is less effective when traveling in a westward direction. Melatonin has also been used in the treatment of circadian rhythm sleep disorder in persons who are blind with no light perception.
Melatonin is available as an over-the-counter (OTC) preparation. Melatonin is still considered a diet supplement, and dosing guidelines have not been established. Because of the effect of melatonin on immune function, persons with immune disorders and those taking systemic corticosteroids or immunosuppressive drugs should be cautioned against taking melatonin. Melatonin may interact with other medications. It is important to consult your doctor before using melatonin.
Melatonin stimulants
Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Melatonin is a hormone produced by the pineal gland during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland (located in the brain) responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep.Short-term use of hypnotics may be beneficial in selected patients. Patients interested in the use of hypnotics for a circadian rhythm disorder should discuss them with their doctor.
Benzodiazepines
Short-acting benzodiazepines are often chosen in the early treatment of a circadian rhythm disorder and are used in conjunction with behavioral therapy. Triazolam (Halcion) is a benzodiazepine frequently chosen for short-term use in addition to behavioral therapy. This short-acting agent is effective in helping persons fall asleep.
Triazolam is not always effective in persons with sleep maintenance issues. For persons with sleep maintenance insomnia, a benzodiazepine with an intermediate half-life (for example, estazolam [ProSom]) or a long half-life (for example, lorazepam [Ativan] or temazepam [Restoril]) may be considered.
Nonbenzodiazepine hypnotics
Nonbenzodiazepine hypnotics are gaining popularity because they do not have a significant effect on sleep architecture and are not associated with the rebound phenomenon seen with benzodiazepines. Zolpidem (Ambien) is a good short-term option for persons with DSPS who require pharmacologic support.
Treatment of sleep disorders associated with shift work
Modafinil (Provigil) is a stimulant indicated to treat workers with sleep disorders caused by their shift work. Modafinil has wake-promoting actions and is taken 1 hour before the start of the work shift.
For more information, see Understanding Insomnia Medications.
Medical care may be necessary if any of the following occur:
A doctor may be able to answer questions about sleep-related issues. The following questions may help in identifying ways to improve sleep:
The following provide an outlook into some sleep disorders:
Disruptive sleep-related problems are called parasomnias. The two main types of parasomnias are primary and secondary. Types of secondary parasomnias include seizures, arrhythmias, and GERD.