Sleep Disorders

Overview

What Is It?

There are more than 70 sleep disorders. Common ones include insomnia, narcolepsy, sleep apnea, restless legs syndrome and circadian rhythm disorder.

Like eating healthily and exercising, getting enough restful sleep is critical to good health. Sleep allows your body to rest and restore energy, while at the same time carrying out important physiological and psychological functions that affect your physical and mental health.

Healthy sleep can be defined as the amount and quality of sleep that allows one to maintain optimal alertness while awake. Most adults need about eight hours of sleep each night, although sleep requirements vary somewhat among individuals. Children and adolescents typically need more than eight hours of sleep, but after age four, most children require little-to-no daytime sleep.

Many people don't get the ideal amount of sleep they need and become chronically sleep deprived. For those who suffer from sleep disorders such as narcolepsy and other illnesses, daytime sleepiness occurs even if the amount of nighttime sleep is adequate.

Research finds that sleep loss accumulates over time leading to a "sleep debt." Insufficient restful sleep can lead to mental and physical health problems, low energy and memory lapses.

Normal sleep patterns can be disrupted by many factors, including:

• stress
• family demands or an overly busy schedule
• hormonal influences and changes in core body temperature (for example, during ovulation or menstruation or the hot flashes and night sweats characteristic of menopause)
• dieting, which can lower a woman's body temperature
• pregnancy, which can result in body aches, nausea, leg cramps, fetal movements and heartburn
• intrinsic sleep disorders such as sleep apnea and restless legs syndrome
• depression, anxiety and worry
• sleepiness and fatigue

In 2007, the National Sleep Foundation (NSF) conducted a national poll of 1,003 American women aged 18 to 64 to better understand the sleep habits of women, investigate how women's sleep is affected by different reproductive stages, examine how women's multiple roles affect their sleep and look at how women experience different sleep problems. Of the women polled, 46 percent reported having sleep problems every night or almost every night during the past month, and 21 percent reported having trouble sleeping a few nights a week.

For many women, feeling tired is simply the result of hectic and demanding lifestyles that make it difficult to get a full night's sleep. However, this tiredness can be a symptom of an underlying medical condition. What's more, sleepiness and fatigue are two distinct problems that may have different causes.

Sleepiness during the day, or excessive daytime sleepiness (EDS), is defined as an inability to stay awake, especially in situations when wakefulness is important. These include at work, while caring for children and while behind the wheel of a car.
Fatigue, on the other hand, is a state of overwhelming, sustained exhaustion and a reduced capacity for physical and mental work that rest doesn't improve. Fatigue can be a symptom of an underlying medical or psychiatric disorder. Many medical and psychiatric conditions can be associated with fatigue, including heart disease, pregnancy, diabetes and anxiety. So you need a thorough medical and psychiatric examination to determine the cause.

Fatigue is a common symptom of depression, as is a change in sleeping patterns—either sleeping too much or too little. It's estimated that up to one in five women will experience depression at some point in her lifetime. And according to the National Institute of Mental Health, fatigue or decreased energy is one of the main symptoms of depression.

In general, EDS can be a symptom of a sleep disorder or insufficient sleep, while fatigue can occur even after a full night's sleep and is more likely to be associated with an underlying medical condition or an underlying psychiatric condition such as depression.

While the medical community distinguishes between sleepiness and fatigue, both conditions negatively affect a woman's quality of life, performance, safety and productivity.

Sleep Disorders

There are more than 70 sleep disorders. Five of the most common disorders are:

1. Insomnia, the most common sleep disorder, is defined as difficulty falling asleep or difficulty maintaining sleep every night or most nights, despite an adequate opportunity to sleep. Other symptoms of insomnia include waking too early in the morning and being unable to fall back to sleep and experiencing an unrefreshing night's sleep. As a result of a poor night's sleep, you typically feel tired and irritable the next day and have trouble concentrating on everyday tasks. Insomnia also can be a symptom of other physical and mental conditions, such as depression, or even of another sleep disorder, such as sleep apnea.
   
   Insomnia can last one night or up to several weeks. In some people, it can be a chronic condition lasting for months or years.
   
   Transient insomnia lasts for a short time and is described as "intermittent" when it occasionally recurs.
   
   Chronic insomnia occurs most nights and lasts one month or more. According to the National Sleep Foundation (NSF), 48 percent of Americans experience insomnia occasionally, and 22 percent experience insomnia every night or almost every night. According to the National Sleep Foundation's 2007 Sleep in American Poll, 39 percent of women said they had a good night's sleep every night or almost every night; 32 percent reported a good night's sleep a few nights a week; 14 percent said they only sleep well a few nights a month; 11 percent reported rarely getting a good night's sleep; and 4 percent reported never getting a good night of sleep.
2. Narcolepsy is a condition characterized by sudden sleep attacks during the day. Individuals with narcolepsy may fall asleep at inappropriate times and without warning several times a day. The NSF reports that the frequency of narcolepsy in North American is uncertain. When the NSF conducted a study to try to find the frequency of narcolepsy, they found that the condition isn't that uncommon in the United States. For every one million people, about 550 will have narcolepsy, and about 14 will be diagnosed with narcolepsy in a given year. Along with sleep apnea, restless legs syndrome and insomnia, narcolepsy is one of the more commonly diagnosed sleep disorders in people seeking treatment in sleep clinics. Often mistaken for depression, epilepsy or the side effects of medications, narcolepsy can occur in men or women at any age although its symptoms are typically first noticed in adolescence and young adulthood. There is some evidence that narcolepsy may run in families; up to 10 percent of people with narcolepsy report having a close relative with the same symptoms.
   
   Recent research finds that people with narcolepsy lack a chemical in the brain known as hypocretin. This substance normally stimulates arousal and helps regulate sleep.
   
   Other symptoms that may appear alone or in combination months or years after the daytime sleep attacks begin include:
   • Cataplexy. These sudden episodes of loss of muscle function can range from slight weakness (such as limpness at the neck or knees, sagging facial muscles or an inability to speak clearly) to complete body collapse. Attacks are typically triggered by sudden emotional reactions such as laughter, anger or fear, and may last from a few seconds to several minutes. Cataplexy is seen almost exclusively in patients with narcolepsy.
   • Sleep paralysis. These episodes, which may last for a few seconds to a few minutes, are characterized by a temporary inability to talk or move when falling asleep or waking up. Sleep paralysis may also occasionally occur in people with no sleep-related disorder.
   • Hypnagogic hallucinations. These vivid, often frightening, dream-like experiences occur while dozing or falling asleep. Like sleep paralysis, they are common in people with narcolepsy but can also occur in those with no identified sleep disorder.
     
     The development, severity and order of appearance of narcoleptic symptoms vary, and not all people with the disorder experience all four symptoms. While excessive daytime sleepiness generally persists throughout life, sleep paralysis and hypnagogic hallucinations may not. The symptoms of narcolepsy, especially the excessive daytime sleepiness and cataplexy, may cause serious disruptions to personal and professional life and severely limit activities.
3. Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally appreciated. It is characterized by repetitive, brief interruptions of airflow during sleep.
   
   Obstructive sleep apnea, the most common form of apnea, occurs when airflow is blocked, often due to narrowing of the airway by excess tissue (typically as a result of obesity), enlarged tonsils or a large uvula (the small fleshy pendulum of tissue that hangs from the soft palate at the back part of the roof of the mouth).
   
   If air cannot easily flow into or out of the nose or mouth, it's more difficult to breathe. The increased effort of breathing causes a suction force in the upper part of the airway that causes it to collapse further. This can result in heavy snoring or a pause in airflow, low levels of oxygen and increased levels of carbon dioxide in the blood, which, in turn, may wake a person from sleep or cause an arousal—a brief disturbance in sleep that does not last long enough to be considered an awakening but which can contribute to sleep disruption. With each abrupt change from deep sleep to light sleep, a signal goes from the brain to the upper airway muscles to open the airway; normal breathing resumes, often with a loud snort or gasp.
   
   Frequent arousals, although necessary for breathing to restart, prevent restorative, deep sleep. Drinking alcohol or taking sleeping pills increases the frequency and duration of breathing pauses by sedating the brain and preventing the arousal.
   
   Sleep apnea occurs in all age groups and both sexes but is more common in men. However, it may be underdiagnosed in women. According to the NSF, more than 18 million people in the United States suffer from sleep apnea. Men are more likely to develop sleep apnea than women, and the condition is more common in people over age 40.
   
   Although not everyone who snores has this condition, if you snore loudly and are also overweight, have high blood pressure or have some physical abnormality in the nose, throat or other part of the upper airway and are excessively sleepy, you may have sleep apnea. This sleep disorder also seems to run in some families, suggesting a possible genetic predisposition.
4. Restless legs syndrome (RLS) is a sleep disorder characterized by unpleasant sensations in the legs or arms, often described as creeping, crawling, tingling, pulling or painful burning. These symptoms occur when lying down or sitting for prolonged periods. RLS symptoms tend to follow a set daily cycle, with worse symptoms at night.
   
   The sensations usually occur in the legs but can also occur in the arms, genital region, face and torso. One or both legs may be affected; for some, the sensations also are felt in the arms. RLS produces an irresistible urge to move your legs when the sensations occur, making sleep almost impossible. If you have RLS, you probably sleep best toward the end of the night or during the morning hours. Symptoms may improve, then worsen and improve again, over the years.
   
   Many people with RLS also have a related sleep disorder called periodic limb movement disorder (PLMD). This disorder is characterized by involuntary jerking or bending leg movements that typically occur every 20 to 40 seconds during sleep. Some people experience hundreds of such movements a night. They may wake up, sleep fitfully or disturb their partner's sleep. The National Sleep Foundation's 2005 Sleep in America Poll found that 15 percent of adults reported symptoms of RLS a few nights a week and 86 percent of them said their condition kept them from sleeping. Symptoms can begin at any time but are usually more common and more severe among older people. Children with RLS are sometimes thought to have "growing pains" or may be labeled hyperactive because they have trouble sitting still in school.
5. Circadian rhythm disorder refers to a group of conditions in which the body's natural psychological and biological rhythms are disrupted. They are very common; shift workers who work nontraditional hours are particularly vulnerable to this condition. According to the Bureau of Labor Statistics, about 15 percent of Americans are shift workers.
   
   Other people at risk for circadian rhythm disorders are frequent travelers who experience jet lag, those with irregular sleep patterns, teenagers and people with a genetic predisposition for this condition.

Diagnosis

As a first step in gauging the severity of your sleepiness and fatigue symptoms, consider answering the questions on the Epworth Sleepiness Scale (available online at https://www.healthywomen.org/content/article/epworth-sleepiness-scale-ess) and the Fatigue Severity Scale (available online at https://www.healthywomen.org/content/article/fatigue-severity-scale-fss). These are self-administered tests designed to measure your general level of daytime sleepiness and fatigue. They are useful screening tools but shouldn't be used to diagnose a condition.

If you have a sleep-related problem, a diagnosis may be as simple as talking to your primary health care professional about the amount of sleep you're getting and taking simple steps, such as going to bed earlier and avoiding caffeine and alcohol, to sleep longer and better each night.

However, if you experience long-term sleep and fatigue issues that don't improve with lifestyle changes, you should probably see a board-certified sleep specialist. Board certification indicates that a physician has had specialized training and passed a rigorous examination in sleep medicine offered by a member board of the American Board of Medical Specialties. Sleep medicine is a multidisciplinary specialty, and practitioners typically have backgrounds in one of the following specialties as well: internal medicine; neurology; psychiatry; ear, nose and throat; or pediatrics.

You may need to stay overnight in a sleep disorders center to have your sleep monitored. You can find a list of accredited sleep disorder centers and laboratories from the American Academy of Sleep Medicine at www.sleepcenters.org.

The following outlines the typical diagnostic procedures for the most common sleep disorders:

Insomnia

The key to accurately diagnosing insomnia is talking with your health care professional about your overall health. If you experience chronic insomnia, one or more of the following conditions may be the cause:

• medical, emotional and psychological problems
• depression, anxiety and emotional crises, such as a death, illness, divorce or other stressful events.
• physical conditions such as arthritis, kidney disease, heart failure, heartburn, asthma, Parkinson's disease and hyperthyroidism
• circadian rhythm disruptions such as shift work
• prescription or nonprescription medications
• stimulants such as caffeine and nicotine
• alcohol and other drugs
• other specific sleep disorders such as restless legs syndrome or sleep apnea

Intermittent and transient insomnia (insomnia that lasts only for a few nights and returns from time to time) can result from:

• temporary changes in the surrounding environment
• stress
• extreme temperatures
• circadian rhythm disruptions such as jet lag
• side effects from medication taken on a short-term basis

If you're suffering from insomnia, your health care professional may need a sleep history as well as a medical history. The sleep history comes from a sleep diary you complete at home or via an interview with a health care professional about the quantity and quality of your sleep.

Your bed partner may participate in the evaluation to provide insight into snoring, movements or other symptoms you might not be aware of.

Your health care professional may also recommend specialized sleep studies to diagnose or rule out another primary sleep disorder.

Narcolepsy

It's not unusual for people suffering from narcolepsy to visit a variety of health care professionals for years before they receive an accurate diagnosis. To get an accurate diagnosis, you should be seen in an accredited sleep center by a sleep specialist. The following tests are used to diagnose narcolepsy:

• The nocturnal polysomnogram ("sleep study"). This test involves continuous recording of brain waves and several nerve and muscle functions during nighttime sleep. It also includes monitoring your breathing pattern and oxygen levels while you sleep. When tested, people with narcolepsy fall asleep rapidly, enter REM (rapid eye movement) sleep early and may wake often during the night. The polysomnogram also helps detect other possible sleep disorders such as sleep apnea that could cause daytime sleepiness.
• The Multiple Sleep Latency Test (MSLT). This test measures the degree of daytime sleepiness and detects when REM sleep occurs. During this test, you're given a chance to sleep every two hours during normal wake times. A sleep specialist observes how long it takes you to fall asleep. People with narcolepsy fall asleep rapidly and enter REM sleep very early in their sleep cycle.

Sleep Apnea

If you suffer from sleep apnea, you may have as many as 100 or more involuntary interruptions in airflow, or "apneic events," each night. It's important that you get a diagnosis and treatment as soon as possible because the condition is associated with heart rhythm problems, high blood pressure (experienced by an estimated 50 percent of sleep apnea patients) and a higher risk of heart attack and stroke. Other possible consequences of sleep apnea include depression, irritability, sexual dysfunction, nocturia (the need to urinate several times a night), learning and memory difficulties and falling asleep while at work, on the phone or driving. Recent studies also suggest that sleep apnea may negatively affect blood sugar control in people with diabetes.

Sleep partners often are the first to suspect that something is wrong, usually because of their partner's heavy snoring and apparent struggle to breathe. If you suffer from sleep apnea, you may not realize you aren't sleeping normally and may not believe it when someone tells you. For proper diagnosis, consult a health care professional with special training in sleep disorders.

A nocturnal polysomnogram is the standard test to diagnose sleep apnea.

Restless Legs Syndrome (RLS) and Periodic Limb Movements (PLM) in Sleep

Although the cause is unknown in most cases, certain factors may be associated with RLS:

• Family history. RLS seems to run in some families with parents passing on the condition to their children
• Pregnancy. Some women experience RLS during pregnancy, especially in the last months. The symptoms usually disappear after delivery.
• Low iron levels or anemia. If you have low iron levels or anemia, you are prone to developing RLS. The symptoms may improve once the iron level or anemia is corrected. Low ferritin levels (a protein used to carry iron in the blood) have also been associated with RLS. Some studies find that supplementing with iron can improve symptoms. Don't supplement on your own, however; too much iron can be dangerous and cause damage to vital organs such as the liver and heart.
• Chronic diseases. Kidney failure and other chronic diseases such as diabetes, rheumatoid arthritis and peripheral neuropathy can lead to RLS.
• Caffeine intake. Reducing your intake of caffeine can improve symptoms.

No specific laboratory test can diagnose RLS, so it usually depends on your symptoms.

To help make a diagnosis, your health care professional may ask about all current and past medical problems, family history and medications. You may need basic laboratory tests to assess your general health and a blood test to rule out anemia. A complete physical, a neurological exam and additional diagnostic and/or serum chemistry testing may help identify other conditions that may be associated with RLS.

These other causes include kidney failure, diabetes, nerve damage and certain medications including antiseizure drugs such as phenytoin (Dilantin); antinausea drugs such as prochlorperazine (Compazine) or metoclopramide (Reglan); antipsychotic drugs such as haloperidol (Haldol); and some antidepressant medications, including widely prescribed ones such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). Some cold and allergy medications may also aggravate symptoms.

In some cases, your health care professional may suggest an overnight sleep study to determine whether you have PLM disorder or other sleep problems. Most people with RLS, however, have no identifiable cause for their RLS and do not require a sleep study.

Circadian Rhythm Disorders

Circadian rhythm disorders, like insomnia, can be categorized as either temporary (transient) or chronic. Transient circadian rhythm disruptions are typically caused by temporary disturbances to sleep patterns, such as jet lag, or altered sleep schedules due to work, social responsibilities or illness.

A common type of circadian rhythm disorder is delayed sleep-phase syndrome (DSPS). Those with DSPS have a persistent inability (more than six months) to fall asleep and wake up at normal times. They tend to go to bed very late and get up in the late morning or early afternoon. Once asleep, they have normal total sleep times and normal sleep. Another type is advanced sleep-phase syndrome (ASPS). Those with ASPS go to sleep in the early evening (between 6 and 9 p.m.) and wake up early, generally between 2 and 5 a.m. As with all sleep disorders, a thorough medical history is the first step to accurately diagnose circadian rhythm disorders. Be prepared to discuss your symptoms, including how long they last, their severity and how they affect your ability to function during the day.

Your health care professional will also want to know what, if any, medications you're taking; what you've tried to improve your sleep; and any medical or mental health conditions that could affect sleep.

Treatment

A variety of treatments exist for sleep disorders. The specifics of the sleep disorder determine which type of treatment will be recommended.

Insomnia

Transient and intermittent insomnia may not require treatment because episodes only last a few days. Some people who experience daytime sleepiness and impaired performance from transient insomnia can find relief with short-acting sleeping pills. However, over-the-counter sleep medicines, if used at all, should be used on a short-term basis and are not recommended for chronic insomnia.

Lifestyle changes (described below) and consultation with a health care professional are your best options for persistent insomnia.

These consist of:

• Identifying and treating any underlying medical or psychological problems.
• Reducing sleep-impairing activities, such as limiting caffeine consumption or managing stress.
• Modifying behavior through special behavioral techniques, such as:

• Relaxation therapy. Specific techniques to reduce or eliminate anxiety and body tension, such as yoga, meditation or guided imagery. Ideally, your mind is able to stop racing, your muscles can relax, and you can get some restful sleep. You typically have to practice these techniques for a few weeks before they're effective.
• Sleep restriction. Some people suffering from insomnia spend too much time in bed trying to sleep. They may benefit from a program that initially allows only a few hours of sleep during the night, gradually increasing sleep time until a more normal night's sleep is achieved.
• Reconditioning. Another treatment is to recondition yourself so you learn to associate the bed and bedtime with sleep. For most people, this means not using the bed or bedroom for any activities other than sleep and sex; this is also referred to as "stimulus control." As part of the reconditioning process, you should only go to bed when you're sleepy. If you're not able to fall asleep, get up, stay up until you're sleepy, and then return to bed. Throughout this process, you should avoid naps, and wake up and go to bed at the same time each day. Eventually your body and mind begin to associate the bed and bedtime with sleep.

• Using medications that aid in insomnia treatment. These include:

• Zaleplon (Sonata), eszopiclone (Lunesta) and zolpidem (Ambien) are prescription medications available for short-term treatment of insomnia that fall into a class of drugs known as non-benzodiazepines or benzodiazepine receptor agonists (benzodiazepines are an older family of medications that includes drugs such as Valium and Restoril). They have minimal next-day effects due to their rapid metabolism; however, daytime drowsiness may still occur. And in rare cases, these medications may cause unusual behaviors, such as trying to drive or prepare and eat food while asleep. They may also cause severe allergic reactions or facial swelling. If any of these reactions occur while you are taking one of these medications, contact your health care professional right away. Withdrawal symptoms, such as nausea and rebound insomnia, may occur if you abruptly stop taking these medications. These drugs seem to have better safety profiles than benzodiazepines, so health care professionals are more likely to prescribe them than benzodiazepines.
• Ramelteon (Rozerem) is a prescription drug that works differently from the other hypnotic medications used to treat insomnia. Its actions are similar to those of melatonin, although it is more potent than melatonin. It is best for people who have trouble falling asleep, and it is less likely than other sleep aids to cause daytime sleepiness or to be habit-forming. Side effects include headache, sleepiness and sore throat.
• Hypnotic medications. Prescription drugs that promote sleep are called hypnotics. One group of hypnotics is the benzodiazepines. Medications in this group include: lorazepam (Ativan), quazepam (Doral), triazolam (Halcion), flurazepam (Dalmane), estazolam (ProSom) and temazepam (Restoril). These drugs can help induce and maintain sleep, relieving nighttime and daytime symptoms. The most common side effect is residual daytime drowsiness and short-term memory impairment. While hypnotics are usually safe and effective treatments, they are no longer used as a first line of treatment; lifestyle approaches that promote restful sleep should be pursued first.
• Antidepressants. Your health care professional may prescribe sedating antidepressants such as trazodone (Desyrel), but there is little data to support their use as sleep aids in women who are not depressed. Recently, the drug doxepin (Silenor) was approved for the treatment of insomnia. At higher doses, this medication (marketed as Sinequan) acts as an antidepressant; however, it has been observed that doxepin is quite sedating, even at low doses. It is particularly effective for patients who have difficulty maintaining sleep.
• Antihistamines. Because they have sedative effects, antihistamines may be prescribed for insomnia. Diphenhydramine products (Benadryl, Nytol and Sominex) are available without a prescription. Side effects include daytime sleepiness, problems thinking, high blood pressure and dry mouth. You shouldn't use these for more than a couple of nights.

Don't drink alcohol if you're taking any sleep medications because it can intensify their effects.

Excessive Daytime Sleepiness Associated With Narcolepsy and Cataplexy

Although there is no cure for narcolepsy, individualized treatments can help reduce symptoms, although it may take weeks or months to find what works best for you.

• Lifestyle approaches, such as taking three or more short, scheduled naps throughout the day, may help control excessive daytime sleepiness (EDS) and help you stay alert. However, daytime naps can't replace nighttime sleep.
• Prescription medications, such as:

• Modafinil (Provigil) and armodafinil (Nuvigil). Armodafinil and modafinil are considered first-line drug treatments for narcolepsy. These medications help you stay awake but don't interfere with nighttime sleep. They work on the sleep/wake centers of the brain so you are less likely to feel jittery or overly stimulated as you might with caffeine or other stimulant medications. The most commonly observed side effects are headache, nausea, nervousness, anxiety and insomnia.
• Central nervous system stimulants. These include dextroamphetamine sulfate (Dexedrine) and methylphenidate hydrochloride (Ritalin). Although these drugs are usually effective in people with narcolepsy, they also produce some undesirable side effects and so must be carefully monitored. The most common side effects include headache, irritability, nervousness, insomnia, palpitations and mood changes.
• Antidepressants. Several categories are prescribed to treat cataplexy, hypnagogic hallucinations and sleep paralysis. One category includes tricyclic antidepressants, such as imipramine (Tofranil), clomipramine (Anafranil) and protriptyline (Vivactil). Other antidepressants commonly used are the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft). Venlafaxine (Effexor) has properties similar to the SSRIs and is also sometimes used to treat the symptoms of narcolepsy. Side effects from tricyclics include drowsiness, sexual dysfunction and low blood pressure. In some women, SSRIs may cause over-excitement, anxiety, insomnia, nausea and reduced sexual drive. There is some evidence that antidepressants may increase suicide risk in some people, especially in children and adolescents, according to the FDA. Discuss this risk with your health care professional, and always review medication packaging information.
• Sodium oxybate (Xyrem). Sodium oxybate helps control cataplexy in people with narcolepsy. It works to improve sleep, and in higher doses, to control daytime sleepiness. However, because it has been associated with serious side effects, such as trouble breathing during sleep and bed wetting, it's strictly regulated by the FDA.

If you have narcolepsy and other health conditions, such as high blood pressure or heart disease, make sure you talk with your doctor about any possible medication interactions.

Sleep Apnea

Medications are usually not helpful in treating sleep apnea. The most common and effective treatment is nasal continuous positive airway pressure (CPAP).

With this treatment, you wear a mask over your nose while you sleep. A machine gently blows air through your nasal passages to prevent your throat from collapsing during sleep. The device must be worn every night to be effective.

Other treatments include:

• Behavioral therapy. Behavioral changes are an important part of the treatment program, and in mild cases, behavioral therapy may be all that is needed. You should avoid using alcohol, tobacco and sleeping pills, which make the airway more likely to collapse during sleep and prolong the apneic periods. Overweight people almost invariably benefit from losing weight; even a 10 percent weight loss can significantly reduce the number of apneic events. Sometimes in mild sleep apnea, breathing pauses occur only when you sleep on your back; in this case, using pillows and other devices that help you sleep in a side position can reduce apneic events.
• Physical or mechanical therapy. In addition to CPAP, cases of mild to moderate sleep apnea can be treated using a dental appliance that repositions the lower jaw and the tongue. Possible side effects include damage to teeth, soft tissues and the jaw joint. These should be fitted by a dentist or orthodontist with experience in the use of these devices.
• Surgery. Several procedures can increase the size of the airway, but they all have risks, and the success rate for curing sleep apnea is not high. Some of the more common procedures performed include:

• Uvulopalatopharyngoplasty (UPPP). This involves removing portions of the uvula and soft palate to stop throat structures from vibrating and causing snoring. The surgeon may also remove the tonsils and adenoids at the same time.
• Removing nasal polyps. This sometimes improves, but almost never cures, sleep apnea.
• Surgically correcting structural deformities in the face and/or lower jaw.
• Tracheostomy. This is used in people with severe, life-threatening sleep apnea. In this procedure, a small hole is made in the windpipe and a tube inserted into the opening. The tube remains closed during waking hours and is only opened during sleep so air flows directly into the windpipe and lungs, bypassing any upper airway obstruction. Although this procedure is highly effective, it is an extreme measure and is not often used.
• Surgical procedures to treat obesity. Surgery can result in weight loss and, therefore, improve the severity of sleep apnea.

Restless Legs Syndrome

Some women find that activities such as taking a hot bath, massaging their legs, using a heating pad or ice pack, exercising and eliminating caffeine help relieve symptoms of restless legs syndrome (RLS). In more severe cases, medications may be prescribed.

Physicians may suggest a variety of drugs to treat RLS. Ropinirole (Requip) and pramipexole (Mirapex) are FDA-approved to treat moderate to severe RLS. These drugs are in a class of medications known as dopamine agonists and were first approved for the treatment of Parkinson's disease. Recently another dopamine agonist, rotigotine (Neupro), was approved for the treatment of RLS. Rotigotine is unique because it is worn as a transdermal patch and the medication is absorbed through the skin. Beyond these, the most commonly used medications for RLS are:

• Benzodiazepines and 'benzodiazepine receptor agonists' are central nervous system depressants that allow you to get more sleep but don't fully suppress RLS sensations or leg movements. The most commonly prescribed benzodiazepine for RLS is clonazepam (Klonopin) while eszopiclone (Lunesta), zolpidem (Ambien) and zaleplon (Sonata) are considered 'benzodiazepine receptor agonists'. The most common side effects of these medications are residual daytime drowsiness and short-term memory impairment.
• Opioid analgesics, such as the combination of oxycodone and acetaminophen (Percocet) and codeine are pain-relieving medications that can also suppress RLS and periodic limb movement disorder (PLMD). Side effects include dizziness, nausea, vomiting, constipation and the risk of addiction.
• Anticonvulsant drugs such as gabapentin (Neurontin) and gabapentin enacarbil (Horizant) may also help reduce the sensory disturbances associated with RLS. Those sensations include pulling, itching, tingling, burning or aching—sometimes described as creeping and crawling. Dizziness, fatigue and sleepiness are among the possible side effects.
• Other Parkinson's disease medications, including a combination of carbidopa and levodopa (Sinemet), reduce the uncomfortable sensations in your legs by affecting levels of the chemical dopamine in your brain. People who have RLS are not at an increased risk of developing Parkinson's disease, however.

Circadian Rhythm Disorder

The following treatments can help eliminate the symptoms of circadian rhythm disorder, a recurring disruption in the body's natural psychological and biological sleep rhythms that is common in students and those who work evening and night shifts.

• Follow the principles of sleep hygiene as much as possible, including establishing a sleep schedule in which you go to sleep and wake up at the same time every day.
• Exercise at least five days week for a minimum of 30 minutes to help relieve stress.
• Follow a healthy diet.

Some people with advanced or delayed sleep phase syndrome benefit from phototherapy, a treatment in which you are exposed to bright lights at certain times of the day to reset your circadian clock. If you have delayed sleep phase syndrome, you receive the exposure in the morning, while those with advanced sleep phase syndrome are exposed in the evening.

In addition, treatments such as melatonin (a hormone available over the counter), short-term sleep aids and wake-promoting agents may be used to get someone with circadian rhythm disorder on a desired schedule.

Prevention

Your diet, activity levels, other lifestyle habits and environment all affect how well you sleep.

There are many "sleep hygiene" steps you can take on your own to promote sound sleep. These include:

• Reduce caffeine intake and avoid it completely in the evening.
• Quit smoking.
• Eliminate alcohol within four to six hours of bedtime; although alcohol initially makes you drowsy, it disrupts sleep later in the night.
• Avoid heavy meals before bedtime that may cause heartburn; however, a light snack may promote sound sleep.
• Use your bed only for sleeping and sex. Don't watch TV, eat, pay bills or do other such tasks in bed.
• Avoid the regular use of sleeping pills.
• Exercise regularly. Exercising in the early evening, at least three hours before bed, may improve sleep.
• Go to bed and wake up at the same time every day.
• Create a comfortable sleeping environment conducive to sleep.
• Drink less fluid before sleep.
• Initiate a relaxing routine, like soaking in a hot tub before bedtime.

Facts to Know

1. Adequate restful sleep—like a healthy diet and exercise—is critical to good health. Insufficient sleep can result in mental and physical health problems and possibly premature death.
2. Research has shown that sleep loss accumulates over time, causing sleep debt. Most people don't get the ideal amount of sleep they need and become chronically sleep deprived.
3. According to the National Sleep Foundation's 2007 Sleep in America Poll, biological and hormonal changes over a woman's lifetime affect her quality of sleep. The poll revealed that 24 percent of women of childbearing age, 40 percent of pregnant women, 55 percent of postpartum women, 25 percent of perimenopausal women and 30 percent of postmenopausal women report getting a good night's sleep only a few nights a month or less.
4. The National Sleep Foundation's 2007 Sleep in America Poll also revealed that sleep problems take a toll on many aspects of women's lives. Of the women who reported daytime sleepiness, 80 percent reported high levels of stress, 39 percent admitted they spend less time with family, 33 percent said they are too tired for sex, 27 percent admitted driving drowsy at least once a month and 20 percent reported being late for work in the past month.
5. There is a difference between sleepiness and fatigue. Sleepiness is defined as the inability to stay awake even in situations when wakefulness is required, such as at work or while driving. Fatigue is a general sense of discomfort, irritability and malaise, accompanied by the inability to focus on specific tasks, even after a full night's sleep. Both sleepiness and fatigue can greatly affect quality of life, performance, productivity and safety.
6. People complaining of fatigue may have any one of numerous medical, neurological or psychiatric disorders, such as depression, anemia, chronic fatigue syndrome or lack of sleep. Fatigue and changes in sleeping patterns can be symptoms of depression as well.
7. Insomnia, sleep apnea, restless leg syndrome and narcolepsy are the most commonly diagnosed sleep disorders in people seeking treatment in sleep clinics.
8. Insomnia is defined as difficulty falling asleep or staying asleep every night or most nights despite an adequate opportunity to sleep. Insomnia lasting from a single night to a few weeks is referred to as transient or short-term. If it lasts longer than a month, it's referred to as chronic insomnia. Insomnia has many causes, including physical and mental conditions and stress.
9. More than a third of American adults experience insomnia, and women are nearly twice as likely to suffer from insomnia as men. Hormonal influences and changes in core body temperature may contribute to shifting sleep patterns. Researchers also have found that dieting can lower a woman's body temperature, altering her sleeping pattern.
10. Sleep apnea occurs when a person temporarily experiences obstruction of the upper part of the airway while sleeping. According to the NSF, more than 18 million Americans have sleep apnea. Men are more likely than women to develop sleep apnea but women are underdiagnosed, and sleep apnea increases in prevalence in postmenopausal women. Sleep apnea may lead to hypertension, heart attack and stroke. However, it can be treated.

Questions to Ask

Review the following Questions to Ask about sleep disorders so you're prepared to discuss this important issue with your health care professional.

1. Could my excessive daytime sleepiness (EDS) or insomnia be caused by an underlying physical, emotional or psychological condition? How are EDS and insomnia treated?
2. Could my excessive daytime sleepiness or insomnia be caused by a medication I'm taking?
3. Could my fatigue be caused by an underlying physical, emotional or psychological condition? How can it be treated?
4. I don't sleep as well as I did when I was younger. Are sleep changes normal in older adults?
5. How much sleep do I really need, under normal conditions?
6. Should I take sleeping pills for my insomnia? What are their possible side effects? Am I at risk of becoming addicted to them?
7. How can I improve my sleep habits to help relieve my insomnia? What should I do if I find myself tossing in bed, unable to sleep?
8. What should I avoid eating or drinking if I want to improve my chances of getting a good night's sleep? Should I avoid napping during the day?
9. If a polysomnogram, or sleep study, is recommended for me, how should I prepare for it?
10. What is a sleep diary? How can it help you evaluate my sleep problems?
11. What details should I include in a sleep diary to help diagnose the causes and effects of my sleeping problem?
12. Are there any tests that I can do at home to determine if I'm suffering from excessive sleepiness or fatigue? If so, what are they?

Key Q&A

Lifestyle Tips

1. Medication: Not the Only Answer for Insomnia

Medications can help relieve insomnia but should not be considered a long-term solution. Try these lifestyle changes for a more long-lasting solution:

• Drink less caffeine (a stimulant) and alcohol (which causes frequent nighttime awakenings).
• Quit smoking. Nicotine is also a stimulant, and you'll sleep better and enjoy better health the sooner you can quit.
• Don't drink a lot of fluids close to bedtime.
• Avoid spicy or heavy meals close to bedtime.
• Exercise regularly (but at least three hours before bedtime). It will help you fall asleep faster and sleep more deeply.
• Find a relaxing routine at night (such as a hot bath).

2. A Nod to Naps
Contrary to popular belief, short naps during the day generally aren't bad for you and can be a good way to restore your alertness and sense of well-being. But, if you have insomnia, you may need to avoid daytime naps.

3. Less Sleep as You Age?
It's a myth that older people need less sleep. Personal sleep requirements range from less than six hours to more than eight hours each night. Sleep needs are determined individually and not by age. It is common for older people to have more fragile sleep, however, and to be more easily disturbed from sleep by light, noise and pain.

4. Snoring: No Big Deal?
Snoring is no joke, and it can be a big health deal. It may be a sign of sleep apnea—a serious, potentially life-threatening condition that is more common than is generally appreciated. Sleep apnea occurs when airflow is blocked during sleep. Because it disrupts sleep, sleep apnea may cause you to be excessively sleepy and more prone to accidents during the day. Because it may deprive you of oxygen at night, sleep apnea can aggravate hypertension or other cardiovascular problems. Talk to your health care professional about an evaluation if your bed partner tells you that you snore and struggle for breath at night. Treatment is available. If you are diagnosed with sleep apnea, avoid alcohol close to bedtime, sleeping pills and tobacco; try to lose weight if you're overweight; and use a pillow to help you sleep on your side.

5. Sleepiness and Fatigue: Know the Difference
Sleepiness and fatigue are two distinct conditions. Sleepiness refers to the inability to stay awake even in situations in which wakefulness is required, such as at work or behind the wheel of a car. Fatigue is a state of overwhelming sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Both conditions can greatly affect your quality of life, productivity, performance and safety, and should be evaluated for underlying causes so that appropriate treatment may be prescribed.

6. Keep a Sleep Diary
A sleep diary can help you keep track of things that affect your sleep patterns. Your sleep diary can provide helpful information to your health care professional and give you a place to record questions or other things you'd like to discuss during your medical appointments. Keep your sleep diary handy—on your bedside table, for example—and fill it out for 10 days in a row. Bring your diary with you when you visit your health care professional. Download a sample sleep diary from the National Sleep Foundation.

7. Traveling, Jet Lag and Sleep
Avoid jet lag by anticipating the time change at your destination by getting up and going to bed earlier (eastbound) or later (westbound) a few days before you leave. Try to use a flight that gets you there in the early evening. Change your watch to the destination time en route. Once you've arrived, don't go to sleep until 10 p.m. local time. Walk around outside and get as much sunlight exposure as possible, because this signals your body to stay awake. Light exercise is OK, but avoid heavy exercise—as well as alcohol or caffeine—close to bedtime.

8. How to Get the Sleep You Need if You Work Shifts
On your way home from work, wear wraparound dark glasses to keep sunlight from activating a wake cycle. (Make sure you can see clearly if you're driving.) Go to sleep as soon as possible after work. Use bedtime rituals like a hot bath to prepare for sleep. Don't do anything energizing before your sleep time. Put a "do not disturb" sign on your door, and turn off the telephone ringer. Schedule home repairs for after your sleep time. Make sure friends and family understand your schedule. Wear dark shades and earplugs if necessary. Avoid caffeine, alcohol and tobacco, which can disrupt your sleep.

9. Living with Restless Legs
Approximately 80 percent of people with RLS have periodic limb movements during sleep and, overall, about 10 percent of the population experiences periodic limb movements during sleep (twitching, jerking and thrashing while sleeping). These movements can certainly disturb your bed partner and disrupt your sleep. Sufferers of restless legs syndrome feel an uncomfortable urge to move the legs. Moving offers temporary relief, and stretching or walking may help. If it's disrupting your sleep, see your health care professional.

Organizations and Support

For information and support on Sleep Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Sleep Medicine
Website: https://www.aasmnet.org
Address: One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
Phone: 708-492-0930
Email: inquiries@aasmnet.org

American Sleep Apnea Association (ASAA)
Website: https://www.sleepapnea.org
Address: 6856 Eastern Avenue, NW, Suite 203
Washington, DC 20012
Phone: 202-293-3650

National Center on Sleep Disorders Research
Website: https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
Address: National Hearth, Lung & Blood Institute/ NIH Information Center
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: ncsdr@nih.gov

National Sleep Foundation
Website: https://www.sleepfoundation.org
Address: 1522 K Street, NW, Suite 500
Washington, DC 20005
Phone: 202-347-3471
Email: nsf@sleepfoundation.org

Neurocare, Inc.
Website: https://www.neurocareinc.com
Address: Center for Sleep Diagnostics
70 Wells Avenue
Newton, MA 02459
Hotline: 1-800-432-8808

Restless Leg Syndrome Foundation
Website: https://www.rls.org
Address: 1610 14th St, NW, Suite 300
Rochester, MN 55901
Hotline: 1-877-INFO-RLS (1-877-463-6757)
Phone: 507-287-6465
Email: rlsfoundation@rls.org

Books

A Woman's Guide to Sleep Disorders
by Meir H. Kryger

A Woman's Guide to Sleep: Guaranteed Solutions for a Good Night's Rest
by Joyce Walsleben and Rita Baron-Faust

Desperately Seeking Snoozin': The Insomnia Cure from Awake to Zzzz
by John Wiedman

Don't Snore Anymore: Your Complete Guide to a Quiet Night's Sleep
by Jeffrey N. Hausfeld M.D. F.A.

Good Nights: How to Stop Sleep Deprivation, Overcome Insomnia, and Get the Sleep You Need
by Gary K. Zammit and Jane A. Zanca

Insomnia Kit: Everything You Need for a Good Night's Sleep
by Christopher Idzikowski

No More Snoring: A Proven Program to Conquer Snoring & Sleep Apnea
by Victor Hoffstein and Shirley Linde

Say Good Night to Insomnia
by Gregg D. Jacobs

Sleep Technique: Simple Secrets for a Deep, Restorative Night's Sleep
by Anthea Courtenay

Sleep Well Tonight! Sure-Fire Solutions for a Good Night's Rest
by Harriet Griffey

Spanish-language resources

Medline Plus: Sleep Disorders
Website: https://medlineplus.gov/spanish/sleepdisorders.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov