INSOMNIA
One in three people suffer from some form of insomnia during their lifetime. It can be experienced as difficulty falling asleep, difficulty staying asleep, waking up too early, or waking up feeling unrefreshed. There are many possible causes of insomnia, including stress, environment, mood/anxiety/depression, pain and discomfort, circadian rhythm issues, medical disorders such as sleep apnea, medication, substance side effects, or just plain bad sleep habits. Most often, there is a combination of factors involved. To determine how to help, we perform a careful review of your health history and habits in addition to asking you to keep a sleep diary. Sleep testing is sometimes needed but not always. Our goal for each insomnia patient is to first try to clear up medical, behavioral, and circadian rhythm issues. After that, we have a frank discussion about the pros and cons of different lifestyle, cognitive-behavioral, therapeutic, herbal/over the counter, and pharmaceutical approaches.
SNORING
Snoring is a noise made from turbulent airflow through the nose and upper airway. It can lead to social embarrassment and be bothersome to bed partners. Most patients with sleep apnea report that they snore, but there are many people who snore and do not have sleep apnea. This can include people who snore when they have a virus, eat certain foods, drink alcohol, suffer from allergies, or have a deviated septum. The first goal of evaluation is determining if the snoring is associated with sleep apnea. Treatment for primary snoring might involve lifestyle changes, trial of medication for nasal congestion, consultation with an allergist or ENT specialist, use of an oral appliance made by a dentist, or use of a device or exercises to help activate and train the tongue and upper airway muscles.
SLEEP APNEA
There are many types of disorders that can affect breathing during sleep, but the most common one is obstructive sleep apnea (OSA). OSA happens when there is a partial or complete collapse of the soft tissues of the airway during sleep, causing patients to intermittently gasp or struggle for air. Most often these patients will report snoring, but not always. Sometimes they present just with feeling that their sleep is restless, and they are having poor concentration during the day. Screening questionnaires can be helpful in identifying possible cases, but sleep testing is needed for confirmation. Treatment for sleep apnea can range from lifestyle adjustments, treatment for allergies, weight loss strategies, use of pillows to encourage optimal body positioning, an oral appliance made by a dentist, CPAP machines, to even surgical interventions by ENT and oral surgeons.
NARCOLEPSY/HYPERSOMNIA
Feeling excessively sleepy during the day is a common complaint in the modern era. Sometimes it is due to just not getting enough sleep or having very disrupted sleep (such as by sleep apnea or restless legs). It can be related to other imbalances in the brain chemistry. Narcolepsy is one very specific example of this where there are lower than normal levels of orexin/hypocretin in the brain. If a neurological cause of sleepiness is suspected, all other sleep issues need to be addressed. Then specific testing is done in a sleep laboratory (diagnostic polysomnography and multiple latency sleep testing). If we do identify a condition such as narcolepsy, sometimes lifestyle modifications can help improve sleepiness. Other times medications are needed and can require multiple careful adjustments to optimize the timing and duration of wakefulness while minimizing side effects.
RESTLESS LEGS SYNDROME
Some people are troubled by an uncomfortable sensation in their legs, difficult to describe, but often occurring around bedtime and preventing them from falling asleep because the only way to ease the discomfort in their legs is to move. This disorder can affect the arms too, but most often just the legs. Sometimes people find that these symptoms are worse when they do not maintain adequate iron levels in their diet. Other people experience restless legs due to underlying diabetes or neuropathy. Medication and substance side effects are always important to consider, including nicotine, alcohol, antidepressants and antihistamines. We try to identify if simple lifestyle changes can help, but some patients need to pursue medications. A thorough evaluation is needed for this diagnosis. Sleep testing is not typically needed.
CIRCADIAN RHYTHM DISORDERS
When your circadian rhythm is out of alignment with your life’s schedule, it can make it hard to fall asleep even when you are tired. It also becomes hard to stay awake in the middle of your workday. A common example of this is jet lag, which thankfully is usually short lived. However, many people experience circadian rhythm malalignment every day. This can include people who work odd hours or are “night owls” or “morning larks.” A careful review of your sleep history and a sleep diary can help identify these factors. Often, strategic timed use of bright light exposure followed by properly timed avoidance of light sources can help adjust your brain’s inner clock. Sometimes medications are needed as well. Sleep testing is not usually needed.
SLEEPWALKING/PARASOMNIAS
Parasomnias refer to a wide range of disorders where people experience undesirable activities or movements during sleep. Some of the more common examples include sleep walking, sleep eating and bedwetting. With these issues, it is important to undergo a thorough evaluation for any possible contributing medical issues or side effects of a substance or medication. Depending on the primary cause of the parasomnia, symptoms can sometimes be improved with changes to sleep habits, but occasionally medications are needed. Sleep testing is usually recommended.
NIGHT SWEATS
For some people, the symptom that brings them into the doctor’s office is an uncomfortable amount of sweating during sleep without a clear reason. Potential causes include environmental factors, medication side effects, hormonal fluctuations, low blood sugar, indigestion, and illness. Often, we find out that the person was suffering from sleep apnea. In fact, night sweats may be three times more common in patients with sleep apnea than in the general population. Not everyone with sleep apnea snores loudly, but the intermittent gasping or struggling for air during sleep can lead to swings in adrenaline, which in turn can lead to excessive sweating. A sleep consultation can help narrow down potential causes of night sweats and prompt the appropriate testing.
TEETH GRINDING/BRUXISM
Grinding or clenching your teeth while awake may be related to anxiety, stress, or frustration. Sometimes it is a habit, or even a coping strategy. However, grinding teeth during sleep is considered a sleep-related movement disorder. The concern is that people do not control these movements during sleep, and significant damage to teeth may result, as well as disrupted sleep, headaches, earaches, sore jaw muscles, or TMJ. Dentists are usually the first health care provider to identify the grinding, and they will review possible contributing factors such as alcohol, smoking, stress, poor teeth/jaw alignment, and medications and discuss devices to protect the teeth from further damage.
Occasionally, the dentist will ask the patient to consult with a sleep specialist to see if sleep apnea might be a factor. Several studies have shown that people with sleep apnea are prone to grinding their teeth. There are theories to explain why sleep apnea and teeth grinding during sleep might influence each other’s frequency, but nothing has been proven. Regardless, if sleep apnea is present, the dentist can alter the design of the teeth protective device to also help treat underlying sleep apnea.
SLEEP PARALYSIS
Sleep paralysis is usually described as the feeling of being awake and conscious but unable to move. It can normally occur as a person is falling asleep or waking up, during the transition between sleep and wake states. It often occurs when a person is waking up from rapid eye movement (REM) sleep, and their muscles are still “turned off” or “partially paralyzed.” It can be frightening, and some people even fear they are experiencing supernatural or out-of-body phenomena. Sleep doctors always consider whether the patient might have narcolepsy. However, the most common factor linked to sleep paralysis is sleep deprivation. Substance use and certain medications can increase the frequency of events. A careful review of your sleep history and habits will usually help identify possible culprits and guide further recommendations.