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Sleep Disorders

Problems after surgery

05/16/2008

Question:

My boyfriend developed RLS and complex sleep apnea. Never had any problems until after surgery. Our lives are a nightmare. He can`t relax or sleep to the point were he has become suicidal. Medication made his symptoms worse. No one Will acknowledge the cause or why he has developed sleep problems. He can`t drive or work much less function. Some advice, answers, anything!!!

Answer:

Sounds like you a have on your hands. Your boyfriend appears to have 2 separate sleep issues, restless legs syndrome and complex sleep apnea, and both should be treatable. I will address them separately.

Restless Legs Syndrome (RLS):

RLS is quite common, affecting roughly 10% of the adult population. The diagnosis of RLS rests upon the history of symptoms with 4 key elements necessary to make a diagnosis. These are: 1) an urge to move the legs, usually associated with an uncomfortable or unpleasant sensation in the legs, 2) the symptoms typically occur at rest, 3) the symptoms typically occur in the evening or at night, and 4) the symptoms are totally or partially relieved with movement, such as walking or stretching. Assuming your meet these criteria for the diagnosis, then he likely has RLS.

The cause of RLS is unknown in most cases, though a search for potential underlying contributors is always worthwhile. Conditions or factors that may be associated with the onset or worsening of RLS include iron deficiency (this can be quite mild and still affect RLS), kidney failure, pregnancy, neuropathy (disease of the nerves), deficiencies of folate, vitamin B12 or magnesium, excessive caffeine ingestion, and certain medications (such as tricyclic antidepressants and selective serotonin reuptake inhibitor antidepressants). If one of these factors is found, particularly one that may be reversible (such as iron deficiency), then addressing this as the initial treatment strategy may be effective and prevent the need for additional medications.

There are a number medications that can be used for the specific treatment of RLS, though at present only roperinole (Requip) and pramipaxole (Mirapex) are FDA approved. Roperinole and pramipaxole come from a class of drugs known as dopaminergic agonists, or drugs that mimic or help to release the chemical dopamine in the brain. Problems with this chemical are thought to be important in the underlying cause of RLS in most RLS patients. There are a other drugs in this class aside from roperinole, including pergolide (Permax) and caridopa-levodopa (Sinemet). In general, this class of agents is about 80-90% effective in controlling RLS symptoms and the medications are fairly well-tolerated. Sinemet has the problematic side-effect of increasing RLS symptoms with long term usage and therefore is not routinely used these days.

While there is less data to support their use, other non-FDA approved medications commonly used for the treatment of RLS include the antiepileptic medications gabapentin (Neurontin) and carbamazepine (Tegretol), narcotics such as oxycodone (Percocet or Roxicet) and propoxyphene (Darvocet), sedatives such as clonazepam (Klonipin), and antihypertensive medications such as clonidine (Catapres). Each of these medications has its own list of contraindications and side effects. In addition, some medications, such as the narcotics and sedatives, may create problems with tolerance (becoming adapted to the medication and needing higher and higher doses to get an effect) and addiction with long term use. Some individuals respond best to one class more than the others and often a "trial and error" approach is required to determine which medication(s) may be most effective for a given individual.

Complex Sleep Apnea:

When Sleep Physicians speak of sleep disordered breathing, they are generally referring to sleep apnea. Sleep apnea is a condition where individuals have problems with breathing in their sleep - usually due to intermittent episodes of not breathing or reduced breathing effort. Sleep apnea can generally be categorized into 2 different forms - obstructive sleep apnea and central sleep apnea. However, there is a relatively recent form of sleep apnea, called complex sleep apnea, which has been recognized and described. As obstructive sleep apnea is much more common than central sleep apnea, I will discuss that first and then follow-up with brief discussions on central apnea and complex apnea.

Obstructive sleep apnea is defined as repetitive episodes of airway narrowing or collapse during sleep. During sleep, the muscles supporting the upper airway in the back of the throat tend to relax. When individuals with a narrowed airway to start with fall asleep, this muscle relaxation may be enough to cause significant narrowing or collapse of the tissue in the back of the throat. A narrowed airway is most commonly the result of being overweight as fatty tissue tends to deposit in the tissues of the airway. Other causes of a narrowed airway may include large tonsils (a very common cause of sleep apnea in children), a large tongue, and abnormal jaw anatomy or nasal anatomy.

When the airway collapses in obstructive sleep apnea, the brain and body protect themselves by making the individual briefly awaken (most people who do this are not aware of this happening) and opening their airway to allow for normal breathing. Unfortunately, as they fall back asleep, the process of airway closure tends to repeat over and over. These recurrent awakenings fragment or break up sleep, resulting in poor sleep, a lack of feeling refreshed after sleep and daytime sleepiness. Other symptoms of obstructive sleep apnea may include morning headaches and restless sleep. Loud snoring often accompanies the sleep disordered breathing. If you are experiencing these symptoms, it is best to have a full sleep evaluation. Not only does the poor sleep affect your quality of life, but obstructive sleep apnea has now been linked to numerous other problems if it goes unrecognized and untreated for years and years. Most concerning of these conditions are high blood pressure and cardiovascular disease (for example stroke and heart disease). Obstructive sleep apnea is treatable by a number of methods and the type of treatment best suited for each individual depends on a number of factors.

Central sleep apnea is much less common than OSA. As opposed to the airway collapsing as in obstructive sleep apnea, in central sleep apnea, there is generally a lack of effort to breath during sleep. The brain fails to send the signal to breath and individuals will experience a lack of breathing for several seconds at a time before resuming normal respirations. This condition may be seen in individuals who have had strokes or who have advanced heart failure, though for some individuals, no cause is identified. Unlike OSA, those with central sleep apnea often complain of trouble sleeping and insomnia. They may feel tired and fatigued as a result. A number of treatment options are available for central sleep apnea as well and will depend upon the associated conditions and other clinical factors. Some of these treatments include CPAP or oxygen therapy. However, each of these treatments is not uniformly effective and thus therapy really needs to be tailored to each individual.

Complex sleep apnea is, in some respects, a mix of OSA and central sleep apnea. This is condition is defined based on certain characteristics of an individuals sleep during a sleep study. In complex sleep apnea, there is a diagnosis of OSA during monitored sleep. However, when placed on CPAP therapy to eliminate the obstructive events, the individual develops a central sleep apnea pattern. In other words, the CPAP is effective at keeping the airway open, but now the brain fails to send the signal to breath. As such, complex sleep apnea can only be diagnosed if you have OSA on a diagnostic sleep study and then central sleep apnea while being monitored on CPAP.

The significance of having complex sleep apnea is not entirely clear. It is not known if this represents a different type of sleep apnea or something we see on a single night sleep study that resolves over time. Some individuals with this condition can be controlled with CPAP, others with Bipap and some need the newer type of device called adaptive servo ventilation (ASV or VPAP). Oxygen is not considered a treatment for this condition as it is generally not a treatment for OSA.

Your boyfriend should seek the help of a well-trained Sleep Physician to sort out the complicated issues mentioned above. Both of these conditions are treatable, though often patience and motivation are needed to achieve success.

If you would like further information about restless legs syndrome, sleep apnea, sleep disorders or sleep itself, I recommend the American Academy of Sleep Medicine website. In addition to information about sleep medicine, the website also contains a list of accredited Sleep Centers and may help you to locate one nearest you. Another organization that may be very useful for those that suffer from RLS is the Restless Legs Syndrome Foundation. Their website has plenty of good information about RLS and is regularly updated. Good Luck!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University