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Sleep Disorders

How Can I Sleep at Night?

05/27/2009

Question:

I literally can no longer sleep at night. I`m a 54 year old male with diabetes and I`ve had this "insomnia" as long as I can remember, but never this bad. I also suffer from SEVERE restless legs syndrome which I didn`t know even had a name until 2002, as it was always so hard to describe. Now its spread to my left arm and abdomen. To me it`s fairly simple. I love the night time. I can`t understand why people choose to miss it. I don`t hate the daytime, I just prefer dark. This has caused me untold troubles throughout my life, but lately is worse than ever. I quit high school in 10th grade because I was sick of the "tardy" speeches. (I graduated with my GED a few years later in 4 hours with a score of 96.) I`m not an idiot. I read voraciously, which is just another part of the problem. The economy is hitting me hard like everyone else I know, but I`m honestly afraid to take a job I`m good at, because I don`t know if I can sleep anymore. I`ve taken every kind of drug imagineable (presciption and otc), in all kinds of combinations, to no avail unless you count near coma-like successful. Any help would be forever appreciated.

Answer:

Your situation sounds quite complex and you are right to seek help. Unfortunately, it’s not clear to me if your major problem is a circadian rhythm problem (i.e. you like to stay awake at night and sleep during the daytime) or a primary insomnia problem (lack of sleep, regardless of the sleep hours). On top of that, it sounds like you have significant restless legs syndrome. A detailed sleep history and examination will be needed to help sort out your problems and determine the best therapy for you. What I can do is speak briefly about the 3 major issues that you may: 1. Possible delayed sleep phase (i.e. being a night owl) 2. insomnia and 3. restless legs syndrome.

Delayed sleep phase:

Our internal body clocks play a major role in determining when we feel sleepy and when we feel awake. For most individuals, the circadian rhythms (or biorhythms that control the internal clock) are in line with the usual day-night schedule and they have no trouble sleeping at night and staying awake during the daytime. However, in some individuals, there appears to be underlying genetic influences that favor staying up late and sleeping in late into the daytime (these are the so called “night owls”). Likewise, others appear to be genetically engineered to do just the opposite; they have a tendency to go to fall asleep early in the evening and then awaken early in the morning (these are the so called “morning larks”). You may fit into the first category and have what is known as a delayed sleep phase. This will become a problem when situations arise that place the internal rhythms out of synchrony with the environment (such as in Jet Lag – see previous Netwellness answers) or when the delay in getting to sleep makes it difficult to obtain enough sleep on a nightly basis, as may occur in your situation if your internal clock is not changed to match your lifestyle demands.

Individuals with a delayed sleep phase may develop a lack of sleep that may contribute to daytime sleepiness and poor performance at school or work. Delayed sleep phase syndrome can usually be treated with behavioral modification and measures to help change the individual’s circadian rhythm cycle, which determine when an individual becomes sleepy.

The body’s circadian rhythms usually cycle over a 24 to 25 hour time period. These rhythms are reset daily to match a 24 hour day by factors such as exposure to daylight and social cues, for example when we eat our meals. The internal clock can be advanced (moved forward so you are sleepy earlier in the evening) or delayed (moved backwards so you are more awake late into the night) by changing the timing of light exposure and other social cues. However, the internal clock can only be adjusted by 1-2 hours in either direction per day with these maneuvers. When individuals try to alter their rhythms by more than this, they tend to feel poorly with fatigue, sleepiness and nausea (as seen with Jet Lag, for example). Furthermore, it often takes several days to fully adjust our circadian rhythms to a new schedule.

The most powerful tools available to shift the sleep pattern forward (or to “advance” sleep) are light exposure and melatonin. Light exposure has the strongest effect on the circadian cycle and timing of light exposure is crucial for individuals with circadian rhythm disorders. For delayed sleep phase syndrome, early day light exposure (usually between 6 and 9 AM), while avoiding bright light late in the day, can advance the sleep schedule. However, for this to be effective, enough bright light for a long enough time period is usually required (this is often accomplished with the use of a “light box” that can deliver 10,000 lux for 30 minutes or 2500 lux for 2 hours, though the optimal dose and length of exposure are not clearly known). Strictly adhering to the treatment regimen is vital to ensure success for this therapy. Melatonin, which is naturally produced by the brain in response to darkness, helps to promote sleep. For those with delayed sleep phase syndrome, use of this drug may help to advance the sleep phase. However, caution must be advised as this drug is sold as an over the counter supplement and is not FDA regulated. Therefore, there is no guarantee with regards to the purity of the product and this may place an individual at risk for unpredictable side effects. Recently, a prescription melatonin-like drug has become available (ramelteon), though this has not yet been studied in humans for use in circadian rhythm disorders. Other tools that can help to shift the sleep phase include timing of meals (avoiding late meals), pre-bedtime rituals (avoiding stimulating activities) and avoiding medications or substances (for example caffeine and nicotine) with stimulating side effects near bedtime. Daytime stimulant therapy is not typically recommended for delayed sleep phase syndrome as the above measures, when adhered to, are often quite effective. Likewise, sleeping pills such as tranquilizers tend to be less effective without some changes in the underlying circadian rhythms.

Insomnia:

Insomnia is very common in modern society with an estimated 1/3 of Americans suffering from insomnia at any one point in time. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.

Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia are extremely important to ensure appropriate treatment. Insomnia can usually be divided into two broad categories: trouble falling asleep at the start of the night (also known as sleep onset insomnia) and difficulty staying asleep during the night (also known as sleep maintenance insomnia). Some individuals may experience problems with both. Factors affecting one’s ability to fall asleep at the start of the night, as you describe, are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breath well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed). The problem of maintaining sleep, or staying asleep once you fall asleep, has other underlying causes such as; depression, substance abuse (especially alcohol use, that can result in withdraw in the middle of the night), certain medications, pain, medical conditions that cause frequent urination throughout the night, heartburn, breathing disturbances in sleep, leg jerks in sleep and circadian rhythm disturbances (when the biologic rhythms are advanced earlier in the night). Shift workers are particularly vulnerable to changes in their circadian rhythms that may create problems with insomnia. Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as “idiopathic insomnia” or insomnia for which a cause can not be found.

As you can see, insomnia is a complex problem that requires a detailed evaluation to help sort out important underlying factors that may need to be addressed. This type of evaluation often starts with your primary care physician, but may require the help of specialist in insomnia. Referral to a Sleep Specialist is necessary in some cases. A Sleep Specialist will take a detailed history and perform a physical examination. Based on this information, they will determine if further testing is needed or if a treatment strategy can be initiated.

Restless legs syndrome (RLS):

RLS is quite common, affecting roughly 10% of the adult population. The diagnosis of RLS truly rests upon the history with 4 key elements necessary to make a diagnosis. These are as follows: 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 you meet these criteria for the diagnosis, there are a number of treatment options available.

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), lack of folate or 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 some of the dopaminergic agonist agents (roperinole or Requip, and pramipaxole or Mirapex) are FDA approved. Sinemet, another dopaminergic drug, is less effective and not currently FDA approved for RLS. This class of drugs mimics or helps the release of 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. In general, this class of agents is about 80-90% effective in controlling RLS symptoms and the medications are fairly well tolerated. 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.

* Learn important new information concerning the FDA withdrawal of the medication Propoxyphene(Darvon, Darvocet)

You should consider discussing your problems with your primary care physician. Specific factors in your history may be useful in tailoring a strategy that might work best for you. Referral to a Sleep Specialist in your area may also be helpful.

If you would like further information about circadian rhythms, 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. 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