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Sleeping Disorder

• Obstructive Sleep Apnea

• Narcolepsy

• Insomnia

• RLS (Restless legs syndrome)

• CRSD (Circadian Rhythm Sleep Disorders)

• Nightmares

• Sleep Deprivation

• Sleepwalking & Sleep Talking

   

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that involves a decrease or complete halt in airflow despite an ongoing effort to breathe. It occurs when the muscles relax during sleep, causing soft tissue in the back of the throat to collapse and block the upper airway. This leads to partial reductions (hypopneas) and complete pauses (apneas) in breathing that last at least 10 seconds during sleep. Most pauses last between 10 and 30 seconds, but some may persist for one minute or longer. This can lead to abrupt reductions in blood oxygen saturation, with oxygen levels falling as much as 40 percent or more in severe cases.
 
The brain responds to the lack of oxygen by alerting the body, causing a brief arousal from sleep that restores normal breathing. This pattern can occur hundreds of times in one night. The result is a fragmented quality of

sleep that often produces an excessive level of daytime sleepiness.
 

Most people with OSA snore loudly and frequently, with periods of silence when airflow is reduced or blocked.  They then make choking, snorting or gasping sounds when their airway reopens.

A common measurement of sleep apnea is the apnea-hypopnea index (AHI). This is an average that represents the combined number of apneas and hypopneas that occur per hour of sleep.
 

Prevalence

• OSA with resulting daytime sleepiness occurs in at least four percent of men and two percent of women.
• About 24 percent of men and nine percent of women have the breathing symptoms of OSA with or without daytime sleepiness.
• About 80 percent to 90 percent of adults with OSA remain undiagnosed.
• OSA occurs in about two percent of children and is most common at preschool ages.

Effects

• Unrefreshing, fragmented sleep
• Severe daytime sleepiness
• Morning headaches
• Fluctuating oxygen levels
• Increased heart rate
• Chronic elevation in daytime blood pressure
• Increased risk of stroke
• Higher rate of death due to heart disease
• Impaired glucose tolerance and insulin resistance
• Impaired concentration
• Mood changes
• Increased risk of being involved in a deadly motor vehicle accident
• Disturbed sleep of the bed partner

Treatments

Sleep apnea must first be diagnosed at a sleep center or lab during an overnight sleep study, or

“polysomnogram.” The sleep study charts vital signs such as brain waves, heart beat and breathing.
 

• Continuous positive airway pressure (CPAP): CPAP is the standard treatment option for moderate to severe cases of OSA and a good option for mild sleep apnea. First introduced for the treatment of sleep apnea in 1981, CPAP provides a steady stream of pressurized air to patients through a mask that they wear during sleep. This airflow keeps the airway open, preventing pauses in breathing and restoring normal oxygen levels. Newer CPAP models are small, light and virtually silent. Patients can choose from numerous mask sizes and styles to achieve a good fit. Heated humidifiers that connect to CPAP units contribute to patient comfort.
• Oral appliances: An oral appliance is an effective treatment option for people with mild to moderate OSA who either prefer it to CPAP or are unable to successfully comply with CPAP therapy. Oral appliances look much like sports mouth guards, and they help maintain an open and unobstructed airway by repositioning or stabilizing the lower jaw, tongue, soft palate or uvula. Some are designed specifically for snoring, and others are intended to treat both snoring and sleep apnea. They should always be fitted by dentists who are trained in sleep medicine.
• Surgery: Surgery is a treatment option for OSA when noninvasive treatments such as CPAP or oral appliances have been unsuccessful. It is most effective when there is an obvious anatomic deformity that can be corrected to alleviate the breathing problem. Otherwise, surgical options most often address the problem by reducing or removing tissue from the soft palate, uvula, tonsils, adenoids or tongue. More complex surgery may be performed to adjust craniofacial bone structures. Surgical options may require multiple operations, and positive results may not be permanent. One of the most common surgical methods is uvulopalatopharyngoplasty (UPPP), which trims the size of the soft palate and may involve the removal of the tonsils and uvula. Adenotonsillectomy, the surgical removal of the tonsils and adenoids, is the most common treatment option for children with OSA. Other children with sleep apnea may benefit from CPAP.
• Behavioral changes: Weight loss benefits many people with sleep apnea, and changing from backsleeping to side-sleeping may help those with mild cases of OSA.
• Over-the-counter remedies: Although some external nasal dilator strips, internal nasal dilators, and lubricant sprays may reduce snoring, there is no evidence that they help treat OSA. They may even mask the problem by muting the loud snoring that is a warning sign for sleep apnea.

Narcolepsy
 

Narcolepsy is a neurological sleep disorder that causes a potentially disabling level of daytime sleepiness. This sleepiness may occur in the form of repeated and irresistible “sleep attacks.” In these episodes a person suddenly falls asleep in unusual situations, such as while eating, walking or driving. Narcolepsy affects less than one percent of men and women, typically appearing in teens and young adults and then persisting for a lifetime. It is classified as a hypersomnia, which is a group of sleep disorders that all have daytime sleepiness as a primary symptom.

Sleepiness in narcolepsy is not the result of inadequate sleep; people with narcolepsy still experience daytime sleepiness even when they sleep well at night. Scientific research shows instead that the cause of most cases of narcolepsy is the brain’s loss of neurons that contain hypocretin, which is a protein that helps your brain stay alert. About 90 percent of people with narcolepsy have low levels of hypocretin in their cerebrospinal fluid.

Sleep specialists measure the severity of daytime sleepiness with the Multiple Sleep Latency Test (MSLT). The MSLT is a daytime nap study that is performed after an overnight sleep study (polysomnogram). It documents how quickly people fall asleep during quiet daytime situations. During the MSLT most people with narcolepsy fall asleep in an average of less than eight minutes, and often in less than five minutes. They also show a tendency to enter the stage of rapid eye movement (REM) sleep much faster than normal sleepers.
 

• Excessive daytime sleepiness (EDS)
  EDS usually is the most disabling of the symptoms and the first to occur. Daytime sleepiness is defined as the inability to stay awake and alert during the major waking periods of the day. Excessive sleepiness produces repeated naps or lapses into sleep across the daytime. In narcolepsy these naps tend to be short and refreshing, but sleepiness reoccurs in two or three hours. This repetitive pattern varies in severity and can be hard to distinguish from the sleepiness caused by sleep deprivation or other sleep disorders. 
   
  In severe cases of sleepiness another symptom called “automatic behavior” may appear. This occurs when a person continues an activity without any conscious realization of what he or she is doing. The resulting work tends to make no sense, and the person has no memory of what took place.
  
• Cataplexy
  Cataplexy involves a sudden loss of muscle tone that occurs most often in the knees, face and neck. These episodes of muscle weakness usually are provoked by strong emotions such as laughter, excitement or surprise. A mild occurrence may cause a person’s head to drop or knees to buckle. A severe episode may cause his or her legs to give out and body to collapse. These episodes are brief, tending to last only for seconds or a few minutes. Recovery usually is immediate and complete.

Three other symptoms are common in narcolepsy, although each one also can be found in normal sleepers and in people with other sleep disorders. These symptoms are:

•  Sleep paralysis
  For a few minutes a person is unable to speak or move as he or she falls asleep or wakes up. It also may involve the feeling of being unable to breathe.
  
•  Hypnagogic hallucinations
  These are vivid perceptual experiences that occur as a person falls asleep. He or she has a realistic awareness of the presence of someone or something that really is not there. Hallucinations tend to produce feelings of fear or dread, and they often occur together with sleep paralysis.
•    Disturbed nighttime sleep
  People with narcolepsy often have the problem of waking up during the night.

Prevalence

• Less than one percent of people have narcolepsy.
• About five percent of patients seen at accredited sleep centers and labs have narcolepsy.

Types

• Narcolepsy with cataplexy 
• Narcolepsy without cataplexy

Risk groups

• Onset tends to occur between the ages of 15 and 25 years.
• Narcolepsy affects both men and women, with a slightly higher risk among men.
• There does appear to be a genetic link, but families that have more than two
  members with narcolepsy are extremely rare.

Effects

• When left untreated, narcolepsy can be socially disabling and isolating.
• It often leads to the onset of depression.
• Type 2 diabetes mellitus may occur more often in people with narcolepsy.

Treatment

Making lifestyle changes can help manage the symptoms. Examples include maintaining a consistent sleep schedule and planning to take short naps during the day. Otherwise, treatment for narcolepsy typically involves a combination of medications. Because narcolepsy is a lifelong illness, treatment is ongoing. These medications commonly are used to treat narcolepsy:

• Modafinil
  This stimulant is a unique chemical compound that has replaced amphetamines as a first-line treatment for EDS. Modafinil (Provigil) is an effective, FDA-approved treatment for narcolepsy with few side effects and a low potential for abuse.
• Other stimulants
  Amphetamines were formerly the most common treatment option for EDS in narcolepsy, but they carry a strong risk of addiction. Methylphenidate, pemoline and mazindol also have been used. Selegiline (Eldepryl) is a methamphetamine derivative. It may treat both sleepiness and cataplexy. Relatively few side effects have been reported with its use. 
• GHB (gamma-hydroxybutyrate)
  GHB (Xyrem) can improve alertness and also reduce cataplexy. It tends to take about six weeks to nine weeks before it consistently reduces sleepiness. It is a preferred option to treat cataplexy because it has few side effects. Although the FDA approved Xyrem in 2002 for the treatment of cataplexy, all other uses of GHB are banned by the U.S. government’s controlled-substance laws.
• Other anticataplectic drugs
  Tricyclic antidepressants formerly were the first treatment option for cataplexy. Severe side effects now make them a last resort. Other antidepressants (atomoxetine, clomipramine, fluoxetine, venlafaxine, zimeldine) have been effective and have produced fewer side effects. The use of antidepressants to treat cataplexy is not approved by the FDA.

Insomnia

Insomnia is a common sleep complaint that occurs when you have one or more of these problems:

• You have a hard time initiating sleep. 
• You struggle to maintain sleep, waking up frequently during the night.
• You tend to wake up too early and are unable to go back to sleep.
• Your sleep is nonrestorative or of a poor quality.

These symptoms of insomnia can be caused by a variety of biological, psychological and social factors. They most often result in an inadequate amount of sleep, even though the sufferer has the opportunity to get a full night of sleep. Insomnia is different from sleep deprivation, which occurs when an individual does not have the opportunity to get a full night of sleep. A small percentage of people who have trouble sleeping are actually short sleepers who can function normally on only five hours of sleep or less.

Prevalence

• About 30 percent of adults have symptoms of insomnia. 
• About 10 percent of adults have insomnia that is severe enough to cause daytime consequences.
• Less than 10 percent of adults are likely to have chronic insomnia.

Types

Insomnia is considered a disorder only when it causes a significant amount of distress or anxiety, or when it results in daytime impairment. The International Classification of Sleep Disorders, 2^nd Edition, documents the following types of insomnia:

• Adjustment insomnia: This is also called acute insomnia or short-term insomnia. It is usually caused by a source of stress and tends to last for only a few days or weeks.
• Behavioral insomnia of childhood: Two primary types of insomnia affect children. Sleep-onset association type occurs when a child associates falling asleep with an action (being held or rocked), object (bottle) or setting (parents’ bed), and is unable to fall asleep if separated from that association. Limit-setting type occurs when a child stalls and refuses to go to sleep in the absence of strictly enforced bedtime limits.
• Idiopathic insomnia: An insomnia that begins in childhood and is lifelong, it cannot be explained by other causes.
• Inadequate sleep hygiene: This form of insomnia is caused by bad sleep habits that keep you awake or bring disorder to your sleep schedule.
• Insomnia due to drug or substance, medical condition, or mental disorder: Symptoms of insomnia often result from one of these causes. Insomnia is associated more often with a psychiatric disorder, such as depression, than with any other medical condition.
• Paradoxical insomnia: A complaint of severe insomnia occurs even though there is no objective evidence of a sleep disturbance.
• Psychophysiological insomnia: A complaint of insomnia occurs along with an excessive amount of anxiety and worry regarding sleep and sleeplessness.

Risk groups

• A high rate of insomnia is seen in middle-aged and older adults. Although your individual sleep need does not change as you age, physical problems can make it more difficult to sleep well.
• Women are more likely than men to develop insomnia.
• People who have a medical or psychiatric illness, including depression, are at risk for insomnia.
• People who use medications may experience insomnia as a side-effect.

Effects  

• Fatigue
• Moodiness
• Irritability or anger
• Daytime sleepiness
• Anxiety about sleep
• Lack of concentration
• Poor memory
• Lack of motivation or energy
• Headaches or tension
• Upset stomach
• Mistakes/accidents at work or while driving

Severe daytime sleepiness typically is an effect of sleep deprivation and is less common with insomnia. People with insomnia often underestimate the amount of sleep they get each night. They worry that their inability to sleep will affect their health and keep them from functioning well during the day. Often, however, they are able to perform well during the day despite feeling tired.
 

Treatments

• Cognitive behavioral therapy (CBT): CBT can have beneficial effects that last well beyond the end of treatment. It involves combinations of the following therapies:

o Cognitive therapy: Changing attitudes and beliefs that hinder your sleep

o Relaxation training: Relaxing your mind and body

o Sleep hygiene training: Correcting bad habits that contribute to poor sleep

o Sleep restriction: Severely limiting and then gradually increasing your time in bed

o Stimulus control: Going to bed only when sleepy, waking at the same time daily, leaving the bed when unable to sleep, avoiding naps, using the bed only for sleep and sex

• Over-the-counter products: Most of these sleep aids contain antihistamine. They can help you sleep better, but they also may cause severe daytime sleepiness. Other products, including herbal supplements, have little evidence to support their effectiveness.

• Prescription sleeping pills: Prescription hypnotics can improve sleep when supervised by a physician. The traditional sleeping pills are benzodiazepine receptor agonists, which are typically prescribed for only short-term use. Newer sleeping pills are nonbenzodiazepines, which may pose fewer risks and may be effective for longer-term use.

• Unapproved prescription drugs_ Drugs from a variety of classes have been used to treat insomnia without FDA approval. Antidepressants such as trazodone are commonly prescribed for insomnia. Others include anticonvulsants, antipsychotics, barbiturates and nonhypnotic benzodiazepines. Many of these medications involve a significant level of risk.

Restless legs syndrome

Restless legs syndrome (RLS) is a sleep-related movement disorder that involves an almost irresistible urge to move the legs at night. This urge tends to be accompanied by unusual feelings or sensations, called “paresthesia,” that occur deep in the legs. These uncomfortable sensations often are described as a burning, tingling, prickling or jittery feeling. In some people these unpleasant feelings become painful.
 

The symptoms of RLS worsen when lying or sitting still and can be relieved at least temporarily, and often immediately, by walking or moving the legs. The urge to move the legs increases in the evening or at night, with relief tending to arrive in the morning. Onset occurs at all ages, from early childhood to late adult life. In children, RLS often is misdiagnosed as “growing pains.” It can be especially difficult for young children to describe the unpleasant sensations involved with RLS.
 

Symptoms may vary widely from one day to the next, and they are provoked by long periods of inactivity. Symptoms are most common in the legs but may progress to the arms and other parts of the body. In mild cases, RLS may occur with great irregularity and long periods of remission. Symptom progression involves greater intensity, more rapid provocation by rest, and the expansion of symptoms to involve more nights and more time during each night.
 

Prevalence

• RLS affects 5 percent to 10 percent of adults.
• The prevalence of RLS in children is unknown.

Types

• Early-onset RLS starts before the age of 45 years, producing symptoms that progress gradually. The daily occurrence of symptoms usually is not present until the age of 40 to 65 years.
• Late-onset RLS advances more quickly and occurs more often. Symptoms may appear daily from the time that they begin, or they may progress rapidly over a period of about five years until they occur with regularity.
• Primary RLS occurs independently of other disorders but may be exacerbated or triggered by other factors.
• Secondary RLS is precipitated by other disorders and resolves when the other disorders are treated.

Risk groups

• Women are between 1.5 times and two times more likely than men to have RLS.
• Treatment for RLS usually is sought after the age of 40 years.
• Iron deficiency and all conditions that produce it increase the risk of RLS, with iron deficiency appearing to be a common factor for most secondary causes. Brain iron deficiency may be a primary pathology of RLS.
• Several medications may precipitate or aggravate RLS, including nonprescription allergy and cold medications that contain antihistamine (Benadryl), most antidepressants (Elavil, Prozac), and major tranquilizers (Haldol, Mellaril, Thorazine).
• More than 50 percent of people with primary RLS report a pattern of the disorder in their family. First-degree relatives of a person with RLS are three times to six times more likely to have it.
• Secondary RLS clearly has been shown to exist in pregnancy and end-stage kidney disease.

Effects

• RLS symptoms can cause severe sleep disturbances. It can hinder a person from being able to go to sleep or return to sleep after an awakening. Severe cases of RLS may be associated with sleep times of less than five hours per night. This sleep deficit is greater than that which is reported for almost any other persistent disorder. Mild cases of RLS cause less sleep disturbance, with patients typically being able to sleep much better in the early morning.
• Repeated leg movements during the night also can disturb the sleep of the bed partner.
• RLS often causes a reduction in daytime energy.
• Increased rates of depression and anxiety have been reported for people with RLS.  

Treatment

For mild cases of RLS, symptoms may improve with the implementation of a regular daytime exercise program. The use of hot baths, leg massages and heating pads also may reduce symptoms. It is important to avoid drinking alcohol in the evening. Although alcohol can decrease the time it takes to fall asleep, it leads to more awakenings during the night. This can exacerbate the awakenings that occur because of RLS.

RLS patients with low ferritin levels may see symptoms improve by increasing iron stores in the body through oral or intravenous iron treatments.

RLS often is treated with one of these types of medications:

• Dopamine agonists
  Examples: ropinirole (Requip), pramipexole (Mirapex), pergolide (Permax). These drugs are considered the first-line treatment for RLS and commonly are used to treat Parkinson disease. They affect the brain’s level of dopamine, a neurotransmitter that plays a critical role in the functioning of the central nervous system. 
   
  Other dopaminergic medications containing the ingredient levodopa (Sinemet) have been used to treat RLS, but they are less effective and have more side effects than the dopamine agonists.
• Benzodiazepines
  Example: clonazepam (Klonopin) These drugs are much less effective at reducing the symptoms of RLS, but they do improve sleep quality. Small doses of benzodiazepines may be used to counteract the stimulating effect that can result from dopamine agonists.
• Anticonvulsants
  Example: gabapentin (Neurontin) Considered less potent than the dopamine agonists, gabapentin remains an effective option in mild cases of RLS or for people who are unable to tolerate dopamine agonists. It also can be useful for RLS patients who experience painful sensations.
• Opioids
  Examples: codeine, propoxyphene (Darvon) These narcotic pain relievers are used most often for patients with severe cases of RLS that do not respond to other treatments.

Circadian Rhythm Sleep Disorders
 

Circadian rhythm sleep disorders all involve a problem in the timing of when a person sleeps and is awake. The human body has a master circadian clock in a control center of the brain known as the suprachiasmatic nucleus (SCN). This internal clock regulates the timing of such body rhythms as temperature and hormone levels. The primary circadian rhythm that this body clock controls is the sleep-wake cycle. The circadian clock functions in a cycle that lasts a little longer than 24 hours.

The circadian clock is “set” primarily by visual cues of light and darkness that are communicated along a pathway from the eyes to the SCN. This keeps the clock synchronized to the 24-hour day. Other time cues, know as zeitgebers, also can influence the clock’s timing. These cues include meal and exercise schedules. Circadian rhythms and their sensitivity to time cues may change as a person ages.
 

Each circadian rhythm sleep disorder involves one of these two problems:

• The timing of sleep and wakefulness is misaligned with the internal circadian clock. 
• The timing of sleep and wakefulness is misaligned with the time of day when most people sleep and are awake.

Prevalence

• The prevalence of circadian rhythm sleep disorders in the general population is unknown.

Risk groups

• DSP is more common in teens and young adults, occurring at a rate of 16 percent. 
• ASP is more common as people age, occurring in about one percent of middle-aged and older adults.
• Irregular sleep-wake rhythm may occur in nursing home residents and other people who have little exposure to time cues such as light, activity and social schedules.
• Free-running (nonentrained) type occurs in more than half of all people who are totally blind.
• Jet lag can affect anyone who travels by air, but symptoms may be more severe and may last longer in older people and when anyone travels in an eastward direction.
• Shift work disorder is most common in people who work night shifts and early-morning shifts.

Effects

These are some of the effects that can occur because of a circadian rhythm sleep disorder:

• Sleep loss
• Excessive sleepiness
• Insomnia
• Depression
• Impaired work performance
• Disrupted social schedules
• Stressed relationships

Treatments

The treatment strategy that a sleep specialist uses for a circadian rhythm sleep disorder will depend on the unique nature of that disorder and will incorporate one or more of these methods:

• Lifestyle changes
  People may cope better with certain circadian rhythm sleep disorders by doing such things as adjusting their exposure to daylight, making changes in the timing of their daily routines, and strategically scheduling naps.
• Sleep hygiene
  These instructions help patients develop healthy sleep habits and teach them to avoid making the problem worse by attempting to self-medicate with drugs or alcohol.
• Bright light therapy
  This therapy synchronizes the body clock by exposing the eyes to safe levels of intense, bright light for brief durations at strategic times of day.
• Medications
  A hypnotic may be prescribed to promote sleep or a stimulant may be used to promote wakefulness.
• Melatonin
  This hormone is produced by the brain at night and seems to play a role in maintaining the sleep-wake cycle. Taking melatonin at precise times and doses may alleviate the symptoms of some circadian rhythm sleep disorders.

Types

Other parasomnias that involve disturbing features include the following sleep disorders:

• Confusional arousals
  A person wakes in a confused state and may display disoriented behavior. Slow speech, confused thinking, blunt responses and memory impairment are common. Behavior can be agitated or even aggressive, especially after a forced awakening. Attempts to console the person may increase the agitation. Episodes in children may appear bizarre and frightening to a caregiver, with the child “staring through” the observer with a confused expression. Arousals tend to occur during the slow-wave stages of sleep during the first part of the night. Most episodes last from five to 15 minutes.
• Hallucinations
  Sleep-related hallucinations are vivid perceptual experiences that occur as a person falls asleep (hypnagogic) or wakes up (hypnopompic). The person has a realistic awareness of the presence of someone or something that really is not there. Hallucinations tend to produce feelings of fear or dread. Although primarily visual, they may involve sensations of sound, touch or movement.
• Rapid eye movement (REM) sleep behavior disorder
  REM sleep behavior disorder, or RBD, occurs when a person begins to physically act out a dream during the REM stage of sleep. These dreams tend to be unpleasant, action-filled or violent. Often the dreamer is being confronted, attacked or chased by a person or animal. Upon waking from an episode, the sleeper typically becomes rapidly alert and can describe a dream with a coherent story that corresponds with the unusual actions.
• Sleep terrors
  Sleep terrors, sometimes called night terrors, is a sleep disorder that occurs when a person sits up in bed with a loud scream or cry and a look of intense fear. Adults may jump out of bed and run, attempting to leave through a door or window. The person tends to be unresponsive and will be confused and disoriented if awakened. Attempts to console the person may prolong or intensity the episode. There usually is no memory of the episode, although adults sometimes recall fragments of a dream. It tends to occur during slow-wave sleep in the first third of the sleep period.

Prevalence

• Nightmare disorder affects about two percent to eight percent of people. About 50 percent to 85 percent of adults report having at least an occasional nightmare. About 75 percent of children can remember having at least one nightmare during childhood.
• Confusional arousals occur in about 17 percent of children and three percent to four percent of adults.
• Hallucinations are common, occurring in about 30 percent to 50 percent of people.
• Less than one percent of people have RBD.
• About two percent of adults and up to six percent of children have sleep terrors.

Risk groups

• More than one parasomnia often occurs in the same person, and they can emerge in close association with other sleep disorders such as obstructive sleep apnea and periodic limb movements.
• Many parasomnias emerge and peak during the childhood years.
• Some parasomnias may be related to post-traumatic stress disorder.
• Medications such as antidepressants may be related to the occurrence of a parasomnia.
• A parasomnia may be related to narcolepsy, Parkinson disease or another neurological disorder.
• Parasomnias are common in otherwise healthy people.

Effects

• Anxiety and fear
• Embarrassment
• Sleep avoidance & deprivation
• Insomnia and daytime sleepiness
• Depression
• Physical injury

Treatments

Because parasomnias often occur in healthy people, treatment may be unnecessary. Many parasomnias that emerge in childhood begin to resolve as the child grows older. Treatment may be necessary if the parasomnia is especially disturbing to the sleeper or to others in the household, or if it produces behaviors that are potentially dangerous. A treatment program may include the following strategies:

• Sleep hygiene
  Educating the patient to avoid drugs, alcohol, and sleep deprivation, all of which may exacerbate a parasomnia
• Medications
  Using antidepressants or benzodiazepine sleeping pills to limit episodes and promote sleep
• Cognitive behavioral therapy
  Providing the patient with effective, long-term strategies to overcome fear and anxiety related to the parasomnia

Sleep Deprivation
 

Sleep deprivation occurs when an individual fails to get enough sleep. The amount of sleep that a person needs

varies from one person to another, but on average most adults need about seven to eight hours of sleep each

night to feel alert and well rested. Teens need an average of about nine hours of sleep per night, and children

need nine hours of nightly sleep or more, depending on their age.
 

Prevalence

• About one in five adults fail to get enough sleep.

Causes

• Voluntary behavior
  People who engage in voluntary, but unintentional, chronic sleep deprivation are classified as having a
  sleep disorder called behaviorally induced insufficient sleep syndrome. This is a type of hypersomnia. It involves a pattern of restricted sleep that is present almost daily for at least three months.
• Personal obligations
  Sleep deprivation can occur when personal obligations restrict sleep time. For example, a person may lose sleep while providing home care for a relative with a chronic illness.
• Work hours
  The work hours required by some occupations can produce sleep deprivation.
• Medical problems
  Sleep deprivation may be a symptom of an ongoing sleep disorder or other medical condition that disturbs sleep.

Risk groups

• Males and females of all ages
• Adolescents, among whom restricted sleep times are common
• Caregivers who look after the needs of a family member who has a chronic illness.
• People who perform shift work, who work multiple jobs, or who work in a profession that has demanding work hours.
• People who have a sleep disorder that causes insufficient sleep, such as delayed sleep phase disorder, environmental sleep disorder, psychophysiological insomnia, periodic limb movements and restless legs syndrome
• People who have a medical condition that causes insufficient sleep, such as Parkinson’s disease

Effects

The primary effect of sleep deprivation is excessive daytime sleepiness. A sleep-deprived person is likely to

fall asleep when forced to sit still in a quiet or monotonous situation, such as during a meeting or class. This

degree of severe sleepiness can be a safety hazard, causing drowsy driving and workplace injuries.

The other effects of sleep deprivation are widespread:

• Mood
  o Irritability
  o Lack of motivation
  o Anxiety
  o Symptoms of depression
• Performance
  o Lack of concentration
  o Attention deficits
  o Reduced vigilance
  o Longer reaction times
  o Distractibility
  o Lack of energy
  o Fatigue
  o Restlessness
  o Lack of coordination
  o Poor decisions
  o Increased errors
  o Forgetfulness
• Health
  Sleep deprivation has been associated with an increased risk of these medical conditions:
  o High blood pressure
  o Heart attack
  o Obesity
  o Diabetes
   Severe sleep deprivation has even been associated with an increased risk of age-specific mortality.

Coping Strategies

The only sure way for an individual to overcome sleep deprivation is to increase nightly sleep time to satisfy his

or her biological sleep need; there is no substitute for sufficient sleep. The following strategies may provide a

short-term benefit to reduce the effects of sleep deprivation. They are not a long-term solution, however, and

they may not restore alertness and performance to non-sleep-deprived levels.

• Caffeine: Caffeine is arguably the most commonly ingested stimulant, as it is used regularly by 80
  percent of adults in the U.S in liquid, tablet or gum form. It can provide improved alertness and
  performance at doses of 75 mg to 150 mg after acute sleep restriction. Higher doses are required to
  produce a benefit after a night or more of total sleep loss. Frequent use of caffeine can lead to tolerance
  and negative withdrawal effects.
• Sleep prior to deprivation: Getting extra sleep before a period of sleep loss, known as a “prophylactic
  nap,” may decrease some of the negative performance and alertness effects.
• Naps during deprivation: During a period of sleep loss a brief nap of 30 minutes or less may boost
  alertness. It can be difficult to awaken from a longer nap, which also can produce severe grogginess, or
  “sleep inertia,” that persists after waking up.
• Caffeine and a nap: The beneficial effects of naps and caffeine may be additive; the combination of a
  nap prior to sleep deprivation with caffeine use during sleep deprivation can provide improved alertness
  over a longer period.
• Other stimulants: In certain situations in which sleep will not be possible, treatment with medications
  may become a necessity. Stimulants can reduce many of the major effects of sleep loss to some extent,
  but they may be associated with a number of side effects and potential risks, including a high abuse
  liability. Other stimulants include amphetamines, methylphenidate and modafinil. These medications
  should only be used under the supervision of a licensed physician.

Sleepwalking & Sleep Talking
 

Sleepwalking, also known as somnambulism, is a parasomnia that tends to occur during arousals from slow-wave sleep. It most often emerges in the first third or first half of the sleep period when slow-wave sleep is more common. Sleepwalking consists of a series of complex behaviors that culminate in walking around with an altered state of consciousness and impaired judgment.

Before walking the person often sits up in bed and looks about in a confused manner with eyes wide open. Sometimes the person immediately gets up and walks or even bolts from the bed running. The sleepwalker can be hard to awaken. Once he or she is awake, the person often is confused and has little recall of the event. The sleepwalking may end suddenly, sometimes in unusual or inappropriate places. In other cases the person may return to bed and continue sleeping without ever becoming alert.

Sleepwalking can involve strange, inappropriate and even violent behaviors. The person may walk out of the house or even climb out of a window. On rare occasions the sleepwalker may get in a car and drive. A sleepwalking child may walk quietly toward a light or to the parents’ bedroom. Sleepwalking can be dangerous if the child walks toward a window or goes outside.

Sleep talking is a common sleep disorder that is classified as an isolated symptom. It can arise during any stage of sleep and can occur with varying levels of comprehensibility. The sleep talker tends to be unaware of the problem, but loud and frequent talking can disturb the sleep of the bed partner. At times the content of the talking can be objectionable and offensive to others.
 

Prevalence

• Sleepwalking occurs in as many as 17 percent of children and four percent of adults.
• Sleep talking occurs in half of young children and in about five percent of adults.

Risk groups

Sleepwalking tends to be a fairly normal part of a child’s development, peaking by the age of eight to 12 years. When they were younger most children who sleepwalk had another parasomnia called confusional arousals. Sleepwalking is more common when one parent has a history of the disorder, and it is much more common if both parents were sleepwalkers.

Sleepwalking may occur in people who have other parasomnias such as sleep terrors or REM sleep behavior disorder (RBD).

Sleepwalking may occur as a rare side effect of medications such as sleeping pills.

These factors also may cause sleepwalking:

• Sleep deprivation
• Hyperthyroidism
• Migraine headaches
• Head injuries or brain swelling
• Stroke
• Obstructive sleep apnea
• Other sleep disorders
• Travel or unfamiliar surroundings
• Stress
• The premenstrual period
• Alcohol