Category: Sleep Disorders News

Before we get into sleepwalking itself, let’s briefly go over parasomnias. This category of sleep disorders is characterized by abnormal movements, perception, and behavior while falling asleep and during and between any stages of sleep. Most parasomnias function as a combination of sleeping and wakefulness.  Sleepwalking (or somnambulism) itself is a disorder that belongs to the parasomnia category. It makes the affected person get out of bed and start walking during their sleep or perform other waking actions. It’s also fairly common, with an estimated 3.6% of US adults having reported sleepwalking symptoms more than once per week.

The main threat of sleepwalking is the vastly increased risk of the person colliding with something or falling over, which can injure them. They can also cause damage to their surroundings, including other people (although this happens very rarely). Because of this, it is important to learn how to deal with a sleepwalker in a safe and controlled manner. There’s a myth circulating that claims that if you wake a sleepwalker while they’re moving around, it’s physically harmful to them. In general, there’s a lack of understanding of how sleepwalking works among the general public. That’s where this article comes in. We’ve made it our task to explain enough about sleepwalking that you can help your loved ones stay safe while they’re dealing with this disorder. We will look at causes, present prevention tips, and advice on how to properly wake a sleepwalker. Let’s get right into it.

What Causes Sleepwalking?

Unfortunately, we can only hypothesize about all the potential causes for sleepwalking. There is little to no evidence supporting most of these claims, but we have somewhat safe assumptions we can work with. We will briefly cover these so you can think about whether they apply to you or your loved one. The nature and symptoms of sleepwalking vary from person to person, so everyone can have their own cause and quirks.

Sleep deprivation is one of the most common causes of sleepwalking if the consensus is to be believed. Originally, it was thought that sleepwalkers couldn’t stay in slow-wave sleep for a standard amount of time, but recent studies show that they actually spend more time in slow-wave sleep than they ought to. As a result of this, increased slow-wave sleep has been considered a potential cause for sleepwalking. In some instances, a separate cause called excessive tiredness has been connected to sleep deprivation, and it certainly makes sense.

Additionally, sleepwalking may have a genetic component to it. If both parents have sleepwalked, their child has around a 60% chance to sleepwalk themselves. If only one parent has dealt with this issue, that chance drops to roughly 45%. This doesn’t mean that the child will exhibit the same sleepwalk pattern as either parent, as other factors can (and will) affect this. In general, children and adolescents are much more prone to sleepwalking than adults, and sleepwalking can subside entirely as the person grows older.

Conditions such as Parkinson’s Disease are widely considered a cause of sleepwalking, even in patients who aren’t otherwise predisposed to it and have no sleepwalking history. Children with restless legs syndrome have a greater chance of also suffering from sleepwalking, as well.

How Do We Diagnose Sleepwalking?

If the causes are unclear and vague, then how do we diagnose sleepwalking? Well, the most accurate (or the only accurate) method we have is polysomnography. This is a multi-parametric sleep study that takes place over the course of a night in a specialist sleep lab. The diagnostic devices they use measure all your relevant bodily functions while you sleep, such as skeletal muscle movement, brain activity, eye movement or heart rhythm. While polysomnography is quite accurate and helpful, it is expensive and demands a lot of time from the patient.

The American Academy of Sleep Medicine (AASM) developed and published the International Classification of Sleep Disorders (ICSD). It was made in association with sleep research associations in Latin America, Europe, and Japan. It is a diagnostic resource used by clinicians and sleep researchers, particularly in the field of sleep medicine development. Along with two other resources we will mention, it is one of the most common pieces of referential and diagnostic material used by doctors everywhere. The most recent version, called ICSD-3, was released in 2014.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is designed to provide a common language and standardized criteria for classifying mental disorders. It’s not used only by clinicians and researchers, but rather a whole host of health-related organizations, such as health insurance agencies, the legal system, and drug regulation agencies. As of May 18, 2013, the DSM is in its 5th edition, also known as DSM-5. The idea for this manual came from how census collecting systems operated, as well as a United States Army manual.

The final widely used diagnostic tool is the International Statistical Classification of Diseases and Related Health Problems, often shortened to ICD (don’t confuse this with the ICSD, although their purpose is largely the same). The ICD is managed and maintained by the World Health Organization (WHO), the primary health authority in the United Nations. The ICD provides a standardized code for disease classification, but it doesn’t stop there. Every variation and combination of symptoms, backgrounds, anomalies and external factors can be classified thoroughly using this code. The most recent version, ICD-11, comes with ontological and terminological elements to be used in the area of digital health.

Another diagnostic method is a simple report, often submitted by the patient themselves, their parent (in case the sleepwalker is a child or adolescent), or partner. If you plan on submitting a report, however, be sure you’re aware of the sleepwalker’s behavior when they’re sleepwalking. The more detail you can provide, the easier it is to receive good advice. Sleepwalkers can exhibit a wide range of different behaviors, which includes (but is not limited to):

• Playing with the bedsheets, pillows and nearby objects
• Talking in their sleep prior to other behaviors
• Getting out of bed and walking around the house
• Going to the bathroom in inappropriate places (a lot of sleepwalkers will choose rooms where the light is still on; keeping the light on in the bathroom can help minimize the inconvenience)
•  Becoming agitated and even violent (incredibly rare)
•  Attempting to have sex with their sleeping partner

They may also initially look awake, as their eyes can be open, but they won’t be nearly as responsive to their surroundings as a waking person.

How Do You Properly Wake Up a Sleepwalker?

The main risks of sleepwalking often revolve around injury. Not only can a sleepwalker put themselves in danger due to how limited their perception is of the surrounding area, but they can also potentially harm others – for example, a sleepwalker can get into and start driving a car, seriously endangering themselves and anyone in their way. It’s not always unsafe to wake a sleepwalker, but you have to be aware of the situation. Here are some general guidelines we can recommend:

–          If possible, try to avoid touching the sleepwalker. Anything more than a gentle touch can startle them, which can cause them to lash out and hurt the person trying to help. If you feel like you must wake the sleepwalker, first try loud, sharp noises. Be sure you’re at a safe distance when you attempt this, of course – that loud sound can startle them just as much as trying to shake them awake.

–          If the sleepwalker is headed in a direction where they’re putting themselves at risk (such as a stairwell, the front door or front yard, or any room with plenty of sharp furniture edges), you often have to make direct contact with them. As gently as possible, turn the sleepwalker, so they start moving in the direction of their bedroom.

–          Once they’re headed in the right direction (which is always towards their bed or another soft piece of furniture they can continue to sleep on), stay close to them and monitor their movement. You’re basically there as an extra pair of eyes, to prevent them from wandering into a corner or another risky obstacle. If they decide to “go to the bathroom” in the middle of this journey, don’t panic and fetch cleaning supplies without trying to make them stop. The good news is that most sleepwalkers tend to return to bed as soon as this happens.

–          If you manage to wake them up, remember that they will be disoriented. Most people take anywhere from five to thirty minutes to regain their senses completely. Waking up in the middle of your home is a confusing, sometimes scary situation. Be there for them and help calm them down by slowly and softly explaining what happened. Offer them some water and rub some of it on their face to help them recover from possible dizziness.

Sleepwalking Prevention Tips

There’s no single guaranteed method of stopping a person from sleepwalking. However, there are measures you can take that reduce the risks associated with sleepwalking, and that occasionally automatically wake the person, or you – so you can help them using the advice listed above. Some of these measures cost no money, and you should try them first.

–          Spend an hour before bedtime winding down. Any sort of heavy stimulus can cause sleepwalking in people with the predisposition for it. Make sure that the potential sleepwalker only engages in low-energy and relaxing activities for the whole hour before they go to sleep. Some options include a soothing bath, reading a book or planning tomorrow’s shopping. Some people enjoy listening to classical music or other relaxing tunes to unwind.

–          Plan out your sleeping schedule. Sleep deprivation is often associated with sleepwalking, and every person can actively improve their sleep schedule by organizing their time a bit better. Try to fall asleep and wake up at the same time every day, including weekends and other days off work. Keep track of your sleeping habits. Avoid substances like alcohol and caffeine before bed. Additionally, check any prescription medication you take for side-effects. If they include sleeping problems, you may want to request alternate medicine options.

–          Consult your doctor if you’re worried. Sleepwalking more than once per week is considered serious enough to warrant an investigation, and if you notice bruises and cuts that you don’t remember receiving (if you have pets, playtime with them can give you the odd scratch here and there), don’t hesitate to consult your physician. Ask your partner to keep a watchful eye on your behavior for a night or two, if they have the time to do so.

–          Try to get rid of or hide sharp edges and other potentially dangerous obstacles. While you can’t always notice when someone starts sleepwalking, you can take preventative measures to reduce the risk of injury. Keep the light on in the bathroom in case they often try to relieve themselves during their sleepwalks. You can never make your house 100% risk-proof, but anything that helps is worth doing.

–          Install a door alarm or bell that rings every time the sleepwalker’s bedroom door is opened or closed. This way, you can wake them up before they get too far, and it’s a helpful system to alert you just in case you need to intervene manually. The closer they are to the bedroom while sleepwalking, the easier it is to redirect them back to bed. This method costs money, but preventing injuries and helping the sleepwalker rest properly is worth any sum of money. Not that it’s terribly expensive, either, especially if you opt for bells (like the ones you see attached to shop doors).

REM sleep behavior disorder (RBD) is a rare sleep condition that affects less than 1% of people. But a new study from the Oregon Health and Sciences University shows that the disease is much more prevalent in veterans.

Typically, the REM phase is when most of our dreaming occurs, and during that time, our muscles are paralyzed so that we don’t act out our dreams. This is called muscle atonia, and it is often missing in people who have RBD, which results in nocturnal movements during REM sleep. As a result, a person can injure themselves or their partners during sleep.

According to the new findings published in the journal SLEEP, military veterans with traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD) are much more likely to suffer from RBD.

Researchers kept 394 veterans for an overnight sleep study at the VA Portland Health Care System to analyze their sleep performance. Muscle activity was closely monitored to diagnose RBD.

Even though the condition affects less than 1% of the general population, the number goes to 9% among veterans. And when we look at individuals with PTSD, the number jumps to 21%.

These results are troubling because RBD is often connected with other neurodegenerative conditions such as Parkinson’s disease. Both conditions affect similar brain regions, and many people with RBD develop Parkinson’s disease later on.

And although researchers do not know whether veterans with PTSD will develop Parkinson’s disease, it is essential to find an answer to this question, and possibly slow down neurodegeneration and development of the disease.

The exact mechanism behind the role of PTSD in developing RBD is not known, but scientists suspect it has to do with chronic stress. The concussions the veterans might have been exposed to could accelerate neurodegenerative processes.

The team will continue to keep track of each participant with RBD to look for the early signs of Parkinson’s disease. Unfortunately, there is no cure for this condition, but there are some treatment options that aim to ease symptoms.

That means that when a person is diagnosed with Parkinson’s disease, it is usually too late to reverse the symptoms, which is why it is vital to look for early signs of neurodegeneration, and RBD seems to fit the description. That could allow doctors to intervene early, slow down the degradation of neurons, and possibly prevent the disease from developing.

Experts all agree on one thing: lack of sleep is bad for your health. From short-term consequences like irritability, fatigue, and performance impairment, to serious health hazards if sleep deprivation becomes chronic.

However, a night or two of poor sleep shouldn’t have long term consequences. The following day may be harder to manage, but once the regular sleep schedule is back, everything turns normal. We’ve all been there, whether we had to pull an all-nighter, experienced jet lag, or were stressed or excited so much that we couldn’t sleep.

But, a new study from Uppsala University published in the medical journal Neurology hints that even a single night could have serious consequences, like an increase in a common biomarker of Alzheimer’s disease.

Participants were 15 healthy young male adults with an average age of 22 years and a healthy BMI index. They all stayed in a lab, had the same activity and meal patterns, and they also experienced two types of interventions at random. They either had a night of normal sleep, or they had to stay up and experience sleep deprivation. To stay awake, they were permitted to watch movies, play board games, and they were engaged in a conversation with experiment leaders to ensure wakefulness.

After each night, researchers took their blood samples and tasted it for several different markers of central nervous system health. Researchers looked at beta-amyloid, tau proteins, as well as levels of other factors that are commonly linked with neurological disorders.

This preliminary study found that acute sleep loss led to a 17.2% increase in tau protein blood levels. This molecule is located in the neurons of patients with Alzheimer’s disease, and it can start to accumulate decades before the symptoms appear. That is why finding the cause behind this increase in tau protein levels could help manage Alzheimer’s.

There were no changes in other biomarkers of cognitive health.

And while researchers state that the increase of tau blood level is not a good thing, it doesn’t have to be necessarily bad. Higher activity of neurons during wakefulness could lead to a higher synthesis of this protein, and it’s higher blood levels could simply reflect the overall increase. More tau in blood could be a direct consequence of the brain trying to clear itself.

A few limitations, like small sample size, were reported. Also, the subjects were all young, healthy males, and the results could be different in other groups. It is particularly interesting to see how things would play out in older individuals since they have an increased risk of dementia and different lifestyle habits.

However, the study could provide a valuable inside into an early onset of dementia and Alzheimer’s disease. It could help us understand how sleep impacts these conditions and possibly set new guidelines for lowering the risk of developing them.

Obstructive sleep apnea (OSA) is a serious sleep-related breathing disorder that affects more than 22 million Americans. Patients with this condition report multiple cessations of breathing during the night, which can severely impact sleep quality. The most common symptom is snoring, and people with sleep apnea also experience daytime fatigue frequently. The condition is not to go lightly about since it can lead to increased blood pressure, heart problems, and stroke.

It has been known that obesity is one of the main risk factors for developing sleep apnea, and when you consider that more than 70% of adults in the US are overweight, the situation is alarming. Standard treatment options for sleep apnea include continuous positive air pressure (CPAP) treatment and weight loss. However, CPAP is not always effective, and weight loss only seems to work in some instances.

That is why scientists from the University of Pennsylvania’s School of Medicine looked into the mechanisms in which weight loss improved sleep apnea symptoms.

Their 2019 study used magnetic resonance imaging of upper airways to measure the effects of weight loss on OSA symptoms. They found out that weight loss leads to reduced tongue fat, which was the strongest impact on decreasing the severity of OSA.

The findings were published in the American Journal of Respiratory and Critical Care Medicine, and their results could have a significant impact on future treatment of sleep apnea. Since we now know what the primary reason for airway obstruction is, we can find ways to target it and lose tongue fat more efficiently.

One of the co-authors MD Richard Shwab led a previous study where he compared obese people with and without OSA. He already determined that patients who had OSA also had significantly larger tongues. The next logical step would be to assess how reducing tongue fat would affect OSA symptoms, which is precisely what this new study does.

The study included 67 obese participants with mild to severe sleep apnea. During a six month intervention, participants underwent diet adjustment or weight loss surgery which resulted in a 10% bodyweight reduction on average. Sleep study after the weight loss intervention showed that patients’ sleep apnea score improved by 31%.

And with MRI scans, researchers were able to locate the exact upper airway changes that led to this decrease of OSA symptoms. Tongue fat loss was the number one predictor of improvement, but also loss of soft tissue, reduced jaw muscles, as well as decreased muscle size on the sides of the airway all improved sleep apnea.

These findings could help us create an effective way of reducing tongue fat either through surgical procedures or possibly special diets that target fat loss in this area. These interventions are yet to be tested.

Shwab’s team is also interested in whether people who aren’t overweight but have fatty tongues could be predisposed to developing OSA. They think that because they have an average body mass index, they are less likely to get the right diagnosis, which poses a threat to their health. Their future research should shed some more light on this issue and help us get the most effective sleep apnea treatment.

Sleep-related breathing disorders involve pauses in breathing or difficulties breathing during the night. If they are untreated, they can cause many serious problems, among which are heart attack, stroke, high blood pressure, and low blood oxygen.

Among the symptoms of sleep-related breathing disorders are weight gain, extreme daytime fatigue, tooth decay, and gum disease. People with these disorders often feel exhausted, and they are not aware of their problems with wheezing, snoring or breathing interruptions during the night. They usually find out about their problems when a partner tells them they snore or when they’re evaluated by a doctor or healthcare professional. They can occur at any age, in both men and women. Certain issues like sinus problems, wheezing, or obesity can increase the risk of having a sleep-related breathing disorder.

Sleep-related breathing disorders can be a subset of a broader group of disorders, including insomnia (difficulty sleeping), restless leg syndrome, parasomnias (including sleep terrors and sleepwalking), and hypersomnias such as narcolepsy (inappropriately falling asleep).

Types

As we mentioned, sleep-related breathing disorders are defined by difficulty breathing during sleep. They involve a range of breathing anomalies from chronic or habitual snoring to upper airway resistance syndrome (UARS), central sleep apnea, obstructive sleep apnea (OSA), and even obesity hypoventilation syndrome (OHS).

Snoring

Snoring happens during sleep when air flow from your breathing forces tissues in your throat to vibrate. About fifty percent of people will snore at some period of life. Even though snoring is more common in men, many women also have this problem. About forty percent of men and twenty percent of women have habitual snoring. Research suggests that it runs in family and becomes more frequent as you get older, but men have a lesser chance of snoring after the age of 70. Snoring can also happen because the throat muscles are relaxed due to the consumption of alcohol or other depressants, or from congestion that you get from cold or allergies.

Snoring can be a nuisance for your partner because it can create a loud or harsh sound during your sleep, and it can cause difficulties for you as well. Light snoring will not disrupt your sleep, but heavy snoring might. Heavy snoring can be linked to other sleep disorders like obstructive sleep apnea or increase your risk of having a stroke, heart disease, or diabetes due to sleep deprivation. It can also cause a sore or irritated throat or a dry mouth in the morning.

Sleep Apnea

Sleep apnea is a disorder that includes a temporary loss of breath during the night, and it happens when airway gets complete or partial obstructions. These obstructions can stop your breathing for short periods, and cause shallow breathing and temporary breath loss repeatedly during the night. When you have an episode of sleep apnea, your body increases the adrenaline levels to try and stop this issue, which causes constant interruption, minimizes the quality of sleep, and increases your blood pressure.

If you have sleep apnea, you can be chronically sleep-deprived, have an increased risk of severe health issues including liver problems, weight gain, diabetes, and heart disease, and show symptoms of slow reflexes, irritability, daytime sleepiness, poor concentration, depression, and moodiness. For developing sleep apnea, many factors depend on your anatomy, but some were caused by certain injuries to the nose and nasal passageways. You can feel fatigued during the day while having difficulties concentrating and falling asleep.

Obstructive Sleep Apnea

Obstructive sleep apnea is the most common type of sleep apnea. It occurs when your airway is blocked, causing you to stop breathing for a brief period, have loud snoring, or even wake you up from sleep. The airway is repeatedly blocked, which limits the amount of air that will reach your lungs.

Obstructive sleep apnea is a serious condition that occurs when a person stops breathing during sleep due to obstruction in the airway. It causes loud and frequent snoring, deprives our brain of oxygen, and wakes us up several times a night. Such condition causes daytime sleepiness or fatigue, followed by a number of other health problems, starting from insomnia, loss of concentration, morning headaches, memory losses and so on. Also, sleep apnea in children is different from obstructive sleep apnea in adults, and there are lots of variations of this disorder. Although slim people can suffer from sleep apnea as well, excess body weight is a major risk factor this condition (it increases with higher body mass index (BMI) of 25 or more).

Central Sleep Apnea

One of the variations as mentioned above is central sleep apnea, which is not caused by a blockage of the airway, but rather by some brain or heart problems. It means your body decreases or stops the effort of breathing during sleep in an off-and-on cycle because the heart and brain fail to interact in monitoring the air flow. This causes problems such as frequent waking up, difficulty falling asleep again, and as a consequence, daytime sleepiness. People become tired, they are not capable of restoring their concentration even after daytime naps, so the quality of life is significantly reduced.

Child Sleep Apnea

The percentage of children having obstructive sleep apnea which needs to be treated is about two, and it mostly occurs before they start school, because their tonsils are too large, due to which they may also have troubles with swallowing (dysphagia). It appears to occur at the same rate in young boys and girls, but it is more likely to occur in a child who has a family member with OSA. The cause for child sleep apnea may also be immature brainstem or some other medical condition.

When they fall asleep, the muscles relax and, the soft tissue blocks the airway, causing partial reductions in breathing, called hypopneas. But these can also induce complete breathing pauses, called apneas, usually occurring during the sleeping stage known as rapid eye movement (REM). Reduced levels of oxygen in the blood which result from apneas are called hypoxemia and are common in children because of their smaller lungs and lesser oxygen reserves.  Their shallow breaths cause an increased level of carbon dioxide in the blood, which is called hypercapnia.

While snoring, younger children can show unusual chest and abdomen movement, causing their rib cage to move inward as they inhale, which is not normal for healthy children. If untreated, it can lead to serious problems, such as funnel chest or depression in the chest wall. Children suffering from OSA also tend to sleep in the sitting position, they may sweat during sleep and have headaches in the morning, and experience bedwetting. During the day, they may breathe through the mouth, thus being more susceptible to respiratory infections. The problem with children is establishing the right diagnosis on time, because otherwise, they may have a slower growth rate and higher blood pressure.

Furthermore, problems in behavior may occur, such as aggressiveness, hyperactivity disorder, development delays and similar. But, even healthy children can have brief central apnea, due to some instability in breathing, and such pauses could be isolated events, occurring after sighs or moves. In such cases, they last less than 20 seconds. However, if they have prolonged breathing pauses lasting more than 20 seconds, they may need to be checked for OSA.

Infant sleep apnea

The apneas for infants can be central, obstructive or mixed. Central apneas happen when the body minimizes or stops its effort to breathe. Obstructive apneas happen when the soft tissue in the back of the throat collapses, causing it to block the airway during sleep. Mixed apneas are essentially a central apnea that is followed by an obstructive apnea.

Sleep-Related Groaning

Catathrenia or sleep-related groaning happens when you create a prolonged sound while sleeping. This sound is quite loud, and it resembles groaning, which is where the name came from. During this episode, the breathing becomes very slow with deep breaths that end in a loud exhale that can last up to 40 seconds. The groans can end with a loud grunt, and they often repeat in groups from a couple of minutes to an hour. The condition is very rare but more frequent in men. The cause is still not known because it is not related to any breathing problems, mental disorders, or abnormal brain activity.

Diagnosis

Most sleep-related breathing disorders can be diagnosed the same way as any sleep disorder – with polysomnography, which is an overnight sleep study in a sleep lab or at home. The sleep study will determine if you have any breathing changes during sleep.

Treatment

The usual treatment for sleep-related breathing disorders requires major lifestyle changes. The first is behavior modification aimed towards improving sleep hygiene. You also need to avoid supine positioning during sleep, sedative medications, and ethanol.

There is a vast number of sleeping disorders out there. After reading about their causes and contributing factors, it’s not fully unreasonable to start thinking that almost every habit humans have can directly lead to an inability to get proper rest. Because the restorative processes during sleep are in charge of maintaining our immune system, the prospect of not getting enough rest (when we otherwise could be) is worrying. It doesn’t end there, either. Most sleep disorders don’t have real cures, and the patient is instead given long-term therapy options to deal with the symptoms and maybe get some proper rest. Some prescription medication comes with side-effects that sound just as bad as the sleep disorder it’s supposed to cure – or it can cause other sleep disorders or more fatigue.

What could be scarier than all of those things? Well, what if we told you that there’s a breathing condition that can damage your liver, brain or other organs within minutes of symptoms appearing – possibly in your sleep? Hypoxemia and its sleep-related counterpart are some of the most threatening breathing-related conditions you can encounter, and it’s important to call 911 the moment you experience their symptoms. In this article, we will go over what makes hypoxemia so threatening, as well as how it can be diagnosed and treated.

An Overview of Hypoxemia

Hypoxemia is a breathing-related condition characterized by a low amount of oxygen in the blood. As soon as the percentage of oxygen drops to 90%, it is considered quite harmful to your body. Reaching 80% means you have a severe case of hypoxemia, where the symptoms are at their worst. 92-98% is what’s considered a “normal amount of oxygen in the blood.” If you have less than the necessary amount of oxygen in your blood, it means your body cannot distribute the correct amount to each bodily organ and various tissues. As a result, parts of your body stop functioning properly, which can lead to disastrous consequences after mere minutes – such as liver damage, brain damage or cardiovascular problems. Being able to recognize the symptoms of hypoxemia quickly is incredibly important, especially if you’re already aware of a chronic breathing problem in your life. Illnesses such as asthma or sleep disorders like obstructive sleep apnea are some of the most common causes of hypoxemia, so be alert if you’re facing conditions like these. Here’s the list of symptoms:

–          Noticeable changes in the person’s skin color, usually towards blue or cherry red

–          Intense coughing

–          Confusion and disorientation

–          Fast, shallow breathing, usually through the mouth

–          Increased heart rate

–          Intense sweating

–          Wheezing and similar breathing abnormalities

–          Slow heart rate

–          Mouth breathing and excessive drooling are a big telltale sign of hypoxemia in children

–          Problems forming coherent sentences and frequent pauses for breath while speaking

All of these are clear indicators of respiratory distress and hypoxemia and should be responded to as early as possible. Severe hypoxemia can easily lead to coma or even death, so there’s never any time to spare.

Diagnosing Hypoxemia

The earlier you can discover your susceptibility to hypoxemia (or identify its symptoms), the safer you are. Luckily, there are multiple reliable methods of diagnosing this condition, which lets treatment begin as soon as possible. We will go over each of these diagnostic methods, so you have a rough idea of what to expect when you make an appointment with your doctor. None of these methods are very painful, and the analysis typically doesn’t take too long. Here’s the list:

–          Listening to your heart and lungs is most likely going to be the first step the doctor takes. If they detect any abnormalities in how your lungs or heart operate, it is considered an indicator of breathing problems (and consequently, hypoxemia). Even if they don’t immediately hear it, almost every doctor will continue the diagnostic process because of how threatening hypoxemia is. There are no preliminary screenings here.

–          The second thing they often check is color changes on certain parts of your body, such as your lips, fingernails or skin in general. If they discover any bluish parts or cherry-red skin patches, it’s a clear sign that something is wrong with your oxygen levels.

–          An arterial blood gas test is one of, if not the most reliable method of identifying a lack of oxygen quickly. As with all blood tests, this is done using a needle, which is still pretty low on the discomfort scale (and if you have hypoxemia, it’s the last of your worries).

–          Pulse oximetry is a completely non-invasive method of checking your blood oxygen levels. It is performed using an oximeter, which is typically attached to your fingertip and used to inspect the peripheral oxygen saturation. While this method doesn’t directly analyze blood in your arteries, the results of pulse oximetry will match those of arterial blood gas tests done on the same patient in almost 100% of cases. For this reason, it’s used as a quick and reliable diagnostic method for hypoxemia.

–          Several breathing tests can help paint a clearer picture of the patient’s blood oxygen levels. Most of them involve blowing into some device (or a tube connected to the said device) and getting a reading. While not as prevalent as pulse oximetry or arterial blood gas tests, these methods find their niche thanks to their accessibility and overall reliability.

Once it’s established that you are dealing with hypoxemia, it’s time to begin treatment. It should go without saying, but follow every single instruction you’re given to the letter.

How Hypoxemia Treatment Works

Treatment is the make-or-break point in dealing with hypoxemia. The safest approach is to call 911 immediately and get taken to a hospital where health care providers will conduct oxygen therapy. Failure to administer this treatment as soon as possible can result in serious health complications for the patient. Even though all the relevant medication requires a prescription, exceptions are always made in case of severe emergencies. Hypoxemia is threatening enough to be considered an emergency. Almost every hospital has a protocol that allows for emergency oxygen therapy. Be aware that hypoxemia primarily occurs as a result of other health conditions, such as asthma, obstructive sleep apnea, heart failure, shock, myocardial infarction, etc. It’s equally as important to treat these underlying problems because ignoring them makes it much harder to get rid of hypoxemia.

Oxygen therapy may at first seem simple – the primary goal is to administer enough oxygen to hit the target saturation of 88-98%, depending on the patient’s age, medical history and other situational factors that may create special requirements. However, health care providers have to follow a list of guidelines that help them provide optimal therapy for any given patient. These guidelines may include one or more of the following steps:

–          Raising the patient’s back into a 45-degree position helps them breathe easier. The chest expands more naturally; the diaphragm moves more easily; the inhalation is much stronger and takes less effort. Patients with COPD (Chronic Obstructive Pulmonary Disease) may prefer to sit with their backs against a chair instead.

–          One of the best things to teach a patient is how to practice “controlled coughing” and various deep breathing exercises. These are all done to help clear the airway of any unwanted secretions and substances, which automatically increases the effectiveness of oxygen therapy. Patients who can’t quite muster up a strong cough can instead resort to “huffing,” where they make an intense exhalation. This technique often enables more reliable coughing later on.

–          Regular equipment inspections are mandatory. Make sure the airflow is set to the correct rate, and that any source of oxygen you’re using has enough to sustain the patient. Sometimes problems can arise if the hose connected to their facemask or nasal prongs gets twisted or bent in a way that slows down or stops the flow of oxygen.

–          Pain relief is of crucial importance. While the obvious reason is the comfort level of the patient and their responsiveness, there’s also another thing to consider. Pain increases our body’s metabolic demands, which also includes the demand for oxygen.

–          People with COPD or similar conditions tend to experience a lot of stress and anxiety. These two go hand-in-hand and are almost always overlooked or underestimated in terms of threat level. Make sure your patient receives stress relief through breathing retraining, relaxation techniques, counseling or even medication that alleviates stress and anxiety.

Sleep-Related Hypoxemia

The term “sleep-related hypoxemia” refers to hypoxemia that manifests itself as a result of sleep-related breathing disorders or during sleep in general. While most of the symptoms are the same, it’s important to keep track of where the patient tends to fall asleep. For example, sleeping during high-altitude travel or in areas full of smoke is a risky prospect, as it can lead to hypoxemia – sometimes in locations where you can’t quickly get medical help.

Diagnosis is performed in much the same way as with “normal” hypoxemia. The main unique thing here is that a formal sleep study is almost always conducted on top of everything else (such as arterial blood gas tests or pulse oximetry). If you’re dealing with sleep-related hypoxemia, make sure you maintain a sleep journal that can help any medical expert quickly deduce where the problems lie. Sleep-related hypoxemia is almost always treated through emergency oxygen therapy coupled with treatment options for underlying breathing problems, like obstructive sleep apnea, COPD and similar conditions. A diagnostic method called a “home sleep study” is used to monitor the patient’s blood oxygen levels while they’re asleep – typically through the use of an oximeter attached to their fingertip or a smart device that tracks biological functions, usually in the form of a watch. Consider this a part of sleep tracking. Home sleep studies are much less expensive and offer convenience to both the patient and their physician.

It is estimated that over 4.4% of adults in America get diagnosed with bipolar disorder at some point in their life, which is a higher incidence rate than one might initially assume. The symptoms of this disorder are more extreme and wide-ranging than those in ADHD, causing even bigger oscillations in moods and higher incidence rates of substance abuse and problematic behavior. Despite this, bipolar disorder is often difficult to diagnose, passing under the radar because people dismiss the symptoms or attribute them to another condition. There are a few possible reasons for this. One might be that the manic episodes, unless severe and involving psychosis, usually feel good while they last, so people might not think to report them as a sign of something being wrong.

On the other hand, the depressive episodes in bipolar people might simply be mistaken for clinical depression. Finally, sleep deprivation is known to cause many of the symptoms related to bipolar disorder, like irritability, hyperactivity, mood swings and even depression, to name a few. Sleep disorders cover a vast array of symptoms on their own.

In reality, disturbed sleep is a core symptom of bipolar disorder. It is no surprise, seeing as how mania and depression both negatively affect it. Sleep disorders often go hand in hand with bipolar disorder, and make its symptoms even worse  – but more about that later. First, let’s cover some ground on this specific disorder.

What is a Bipolar Disorder?

Bipolar disorder, also known as manic-depression illness, is a mental health disorder consisting of extended periods of extreme peaks (mania) and ebbs (depression) in a person’s mood and energy levels, with normal periods in-between. Contrary to popular opinion, this doesn’t refer to being emotional or having mood swings during a single day. People with bipolar disorder experience several days of long highs, known as manias, and several days of long depressive episodes. These can happen in a few different ways, don’t necessarily follow one another and can have a neutral state in between.

Bipolar disorder occurs in one’s adolescent or early adult years, often causing poor performance at school, work, and severely disrupting virtually all other aspects in one’s life (and the lives of those around them). Even so, many people suffer it needlessly for years without the appropriate diagnosis and treatment.

The cause of bipolar disorder is unknown. It has been shown to have a familial tendency, but the exact link hasn’t been discovered. The current consensus among psychiatrists is that a traumatic event triggers bipolar disorder to occur in a genetically predisposed individual.

Although bipolar disorder cannot be cured, it can be treated. With enough support and a good therapy plan, people with bipolar disorder can live fulfilling lives, have good careers and cultivate relationships.

Symptoms

Bipolar disorder symptoms are split into two categories: mania and depression symptoms.

Mania symptoms can last over three months if not timely treated. They include:

•         Extreme, euphoric feelings. In a manic episode, this extreme high is unphased by one’s sad experiences or even tragic news
•         Extreme restlessness. Extreme amounts of energy, inability to slow down or sit calmly
•         Racing thoughts and inability to speak at a normal pace
•         Diminished need for sleep. Going days on end with minimum to no sleep without feeling exhausted or even slightly tired, frequently resulting in insomnia
•         Feeling very excited
•         Extreme self-confidence. Feeling “on top of the world” with unrealistic assurance in own abilities; planning ambitious, overly-optimistic projects and feeling all-powerful
•         High irritability and sometimes aggression
•         Being easily distracted, poor focus
•         Poor judgment. Acting impulsive and noticeably out of character
•         Substance abuse and increased sexual activity
•         Psychosis

A manic episode is characterized by at least three of these symptoms (frequently including psychosis) happening at the same time and lasting for at least a week. During this time, behavior patterns are not only noticeably out of character, but functioning in usual environments like home or work is almost impossible. The symptoms are so severe that the person might get hospitalized to prevent serious self-harming or harming others around them.

When at least three of the listed symptoms occur together for a minimum of four days, but without the presence of psychosis, the episode is called hypomania. This term signifies a less severe and shorter lasting episode, with some noticeable impairment of the usual functioning but not to the extent as with mania. Hospitalization isn’t required as the person experiencing hypomania isn’t nearly as dangerous for self or others as one often is in a manic episode.

After a manic or hypomanic episode, one often feels ashamed of how they behaved and remembers little to none of what happened during the episode. These people may suddenly feel the burden of the responsibilities they signed up for, or promises they made during the manic episode that now don’t seem realistic or achievable.

Depression symptoms:

•         Persistent hopelessness or guilt
•         Anxious or even suicidal thoughts
•         Changes in meal patterns – eating less or more than usual, fluctuating weight
•         Reduced energy, lethargia
•         Daytime sleepiness and fatigue
•         Changed sleep pattern – hypersomnia or insomnia
•         Poor memory, inability to concentrate or finish simple tasks
•         Restlessness

A depressive episode might occur right after a manic episode, due to the sobering effect of the mania ending and the realization of how one behaved. Many people find depressive episodes more difficult to handle than manic or hypomanic episodes. It is probably because of the contrast between them; after a week-long period of euphoria, depression can seem that much more miserable. Depressive episodes can also occur after a neutral period.

A mixed episode is a term referring to an episode that features symptoms from both mania and depression lists and often carries a heightened suicide risk.

Types of bipolar disorder

Based on how frequently the episodes occur, and the nature of their symptoms, bipolar disorder is often split into four main types:

1. Bipolar I disorder. To be diagnosed with this type of disorder, one has to have experienced at least a single manic episode. Although frequently accompanied by hypomanic and depressive episodes, a person diagnosed with bipolar I disorder may only ever experience manic episodes.
2. Bipolar II disorder. This type of bipolar disorder describes a person who had at least one major episode of depression, and one of hypomania. People with this diagnosis often experience longer depressive episodes compared to people diagnosed with bipolar I disorder.
3. Cyclothymic disorder. Much like the one before, this disorder includes depressive and hypomanic episodes, but to fall into this category, they have to occur on a fairly regular basis. The symptoms in these episodes are less severe than with the first two types of bipolar disorder, but their sheer frequency poses a problem in a person’s life.
4. Rapid cycling refers to a disorder where one experiences at least four, and often more episodes of either mania, hypomania or depression within the time frame of a year.

Treating Bipolar Disorders

The treatment plan is not the same for everyone, as everybody has their own set of bipolar disorder symptoms, along with other contributing factors like one’s immediate surroundings, daily schedule, stress levels, etc.

For all bipolar disorders, a few types of treatments have been shown to help:

Medication, most commonly used being lithium, mood stabilizers, and antipsychotics.

Behavioral therapy, including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT) and some others.

Support and self-care groups entered alone or with family and friends. These help to create a sense of community and relieve the feeling of isolation and otherness.

How bipolar disorder affects sleep

After learning more about the types of episodes that occur in people with bipolar disorder, it’s no surprise that sleep issues would follow these. During manic episodes, a person can go a few days with barely any or no sleep while being overly active and spending more energy than their body can handle. After the episode is done, this debt catches up, resulting in major fatigue and a disrupted sleep pattern. Depressive episodes, on the other hand, come with sleep issues generally linked to clinical depression, like insomnia, hypersomnias and excessive daytime sleepiness.

Vice versa applies as well – sleep deprivation and other sleep-related difficulties make bipolar disorder symptoms during an episode even worse; if happening outside of an episode, they may even trigger one. Sleep issues that progressively get more annoying can also signal the beginning of the next episode.

Sleep issues linked to bipolar disorder include insomnia, hypersomnia, sleep apnea, decreased need to sleep, fatigue, and delayed sleep-wake phase disorder.

Insomnia

Insomnia is a sleep disorder characterized by difficulties with either sleep onset or its maintenance over the course of the night. People who have this disorder might take over an hour to fall asleep, even though they physically feel tired. Some people only struggle with one of the two symptoms of insomnia, managing to fall asleep but waking up frequently or taking long to onset sleep but then staying asleep until morning. In any case, people who experience this disorder suffer excessive daytime sleepiness and poor sleep quality. Studies have shown that almost all people with bipolar disorder experience insomnia in depressive episodes.

Hypersomnia

The over-sleeping disorder affects over 78% of people with bipolar disorder according to recent studies. For comparison, out of the unipolar population, only about 4% are affected by this disorder. As with insomnia, long sleep hypersomnia issues usually happen during a depressive episode or signal the beginning of one. However, excessive daytime sleepiness (wishing to sleep more) may signal the proximity of a manic episode instead.

Decreased Sleep Needs

At first glance, this issue looks similar to insomnia, but in reality, they are easily distinguished by a simple difference. People who have insomnia can’t fall or stay asleep despite their physical tiredness. They want to sleep; it is just that they achieve this goal with difficulties. On the other hand, people who experience decreased need to sleep don’t physically feel tired because the mania powers them, so to speak. Although the sleep deprivation takes a toll on their body, they only feel tired after the manic episode is over, and the sleep debt swamps them. An estimated 99% of people with bipolar disorder experience decreased need to sleep during a manic episode.

Sleep Apnea

This form of sleep-disordered breathing describes a sudden airway blockage that happens when one’s asleep, often occurring in people with obesity. It is also frequent among the people with bipolar I disorder. The suggested treatment for severe cases of apnea involves CPAP therapy, a mask worn during sleep to help keep the airways open. However, in some cases, this method might trigger the symptoms of mania and may not be appropriate for people with bipolar disorder.

Fatigue

The least surprising, often constant sleep-related issue universally experienced by people with all types of bipolar disorder, fatigue occurs as a result of big fluctuations in moods and energy between manic and depressive episodes. After the sleep deprivation typical for periods of mania, the person is physically and emotionally exhausted, making it easy to fall straight into depression.

Delayed Sleep-Wake Phase Disorder (DSPD)

This circadian rhythm disorder isn’t rarely provoked by extreme sleep pattern changes in people with more severe types of bipolar disorder. People who have this disorder have a later bedtime than average, meaning they naturally fall asleep but also wake up later. It causes a lot of difficulties to accommodate school and work schedules. In attempts to do that, people with DSPD often try to forcefully wake up earlier than they normally would, resulting in daytime sleepiness and fatigue.

Treatment Options

While sleep issues frequently comorbid bipolar disorders, treating both is possible and methods vary between different problem combinations. We listed some common methods below to give you a general idea of how a treatment procedure might go.

Cognitive behavioral therapy is an overall helpful treatment method, used for a vast scale of different sleep disorders. The method is simple and pill-free; works by setting up a set of steps to help form a base of a healthy relationship with sleep.

Light therapy used strategically can help solve different types of sleep problems by boosting the body’s circadian rhythm and alerting you to stay awake until the desired bedtime. Unless otherwise specified, this method is used only in the morning or early afternoon.

Melatonin supplement is commonly used to complement light therapy. This supplement is a form of a hormone that is produced in our brains shortly before and during sleep and has a role in inducing this process. Melatonin is supplemented in a prescribed dose before going to bed and has virtually no health risks unless taken in large doses.

Some drugs like benzodiazepines are used to treat bipolar disorder but also insomnia. If you are taking this or any other drug for bipolar or sleep disorder, talk to your doctor about side-effects and risks. Unless carefully instructed by a specialist, don’t combine any two medications; otherwise, you will needlessly put yourself at great risk.

If you find yourself less than satisfied with treatment results or think there might be some better therapy method to try, discuss it with your doctor before taking any action or giving up altogether. Lastly, don’t forget that any method of treatment alone won’t work unless you do your best to cultivate healthy sleep hygiene. Diet, exercise, and stress levels are just some external factors that play a role in how well you sleep. Whether this role will be positive or negative is up to you.

Our body needs a constant flow of oxygen coming in so that cells can produce energy. Oxygen is delivered to cells via blood flow, and metabolic reactions that produce energy also create some waste in the process. Carbon dioxide is one of the waste molecules, and our bodies need to get rid of it as much as they need oxygen. If the blood level of carbon dioxide is high, it can lead to headaches, drowsiness, coma, and even death.

We inhale through our nose and mouth, and then air passes through the main windpipe called trachea, and continue through two bronchi to each lung. Air goes through smaller and smaller pipes until it reaches small sacks of air called alveoli. This structure of tubes in our lungs is often called a tracheobronchial tree because it is remarkably similar to the branching pattern of trees. Alveoli are surrounded by a fine network of tiny blood tubes called capillaries. This is where the exchange of gasses happen; oxygen enters blood where it is taken by red blood cells (erythrocytes) and later delivered further in the body. Erythrocytes also carry carbon dioxide to alveoli, where it is released, and then let out during the next expiration. Any breathing dysfunction can compromise this, and leave your body in a suboptimal state.

Hypoventilation during sleep is one of the sleep-related breathing disorders, and it involves slow or shallow breathing, known as respiratory depression. Usually, there is some problem in the communication between the brain, neurons, and the muscles, and it results in inappropriate breathing regulation. That can lead to a lack of oxygen and build up of carbon dioxide, which can even have fatal consequences.

Symptoms of Hypoventilation

This type of breathing disorder can occur in anyone, even babies and young children. The exact prevalence of this respiratory problem is not known, but it is not considered to be a common disorder. Because many different underlying conditions can be to blame for nocturnal hypoventilation, the symptoms vary between individuals. The most frequent ones include excessive daytime sleepiness, fragmentation of sleep, insomnia, morning headaches, stomach problems, difficulty breathing, faintness, mood changes, lack of focus, impaired memory, and reduced exercise capacity.

A lot of people don’t experience, or the symptoms are very mild in the beginning, so they don’t realize that they have a progressing condition. Chronic hypoventilation can lead to serious health problems such as respiratory and heart failure, and blood and brain disorders. Keep in mind that most of these signs also occur in other sleep-related disorders, so you need to check with a medical professional if you are experiencing any of them.

Causes of Hypoventilation

Many factors can lead to sleep hypoventilation syndrome. The autonomic nervous system that is in charge of involuntary movements like breathing may not work correctly, and it can lead to hypoventilation problem. Usage of specific medications such as opiates and benzodiazepines could also lead to this condition.

Obstructions of the airflow often caused by a medical condition such as emphysema, bronchitis and cystic fibrosis for the lower, and obstructive sleep apnea for the upper airway, are also risk factors. Nocturnal hypoventilation can also be due to a physical disorder such as an abnormally shaped chest wall, that is not letting lungs to move. People with muscular dystrophy are also more likely to suffer from this condition.

People with diseases of lung tissue are also more prone to hypoventilation. Smoking is a significant risk factor that causes inflammation and obstruction of the lower airway. Environmental factors, such as breathing in pollutants, chemicals, and other dangerous molecules can lead to damaging of the lungs and can cause a lack of respiration.

Neurological disorders where the brain’s control is impaired also leads to lack of respiration. Congenital central ventilation syndrome and central sleep apnea are good examples of that. Other medical conditions that could cause it are asthma and other pulmonary disorders, obesity, and hypothyroidism.

Different Types of Sleep-Related Hypoventilation Disorder

Within the term sleep-related hypoventilation, there are a few distinct disorders, that all have one thing in common, lack of gas exchange happening during sleep. Whether it is the cause of shallow or slow breathing, or a lung, brain or blood disorder, the body lacks oxygen and has excess carbon dioxide.

Hypoventilation can be caused by the excess weight that a person is carrying, and it is called obesity hypoventilation syndrome. Obesity is linked with many health problems, and all of the professionals agree that the goal for everybody would be to reach a healthy weight, as it greatly improves health, happiness, longevity and overall quality of life. Extra fat can block the airways, thus providing obstructions, and preventing the proper ventilation of the lungs.

Congenital hypoventilation syndrome appears in infants, and it is characterized by the abnormally slow and shallow breathing. Infants with this syndrome can appear bluish after or during sleep, and this condition is known as cyanosis (derived from the Greek kyanos meaning dark blue). Babies with this syndrome need an artificial diaphragm pacemaker to stimulate normal breathing patterns, and might also need mechanical ventilation. In most cases, that is only required during the night, but in more severe cases, they need this assistance all day long.

Central hypoventilation with hypothalamic dysfunction looks similar to congenital hypoventilation, but it appears later in childhood. Symptoms of this disorder are accompanied by signs of hypothyroidism, that include fatigue, feeling cold, and slow metabolism.

In some rare cases, the cause of the hypoventilation can be unknown, as everything looks normal upon observation. This condition is called primary alveolar hypoventilation.

Diagnosis and Treatment

A series of tests are done to determine if the patient is suffering from the sleep-related hypoventilation. Firstly, doctors will determine if the lungs are working correctly, then they’ll asses the respiratory muscle strength. Daytime oxygen and capillary gas tests are done to determine the quantity of oxygen and carbon dioxide in the blood during the day. All those tests can tell doctors if there is anything wrong with your respiration.

Additionally, they’ll need to do an overnight sleep study, called polysomnography. You’d have to stay in a sleep facility, where they hook you up to a bunch of electrodes and different machines that measure your brain waves, respiration, heart rate, oxygen blood levels, limbs, and chest movement, as well as any snoring or other sounds you might produce during sleep. The information gained from this study is essential, and it helps doctors to see what is exactly the cause of your nocturnal hypoventilation, and to treat it properly.

Treatment of sleep-related hypoventilation depends on the case, and it usually involves treating any underlying condition that might be the cause of it. For instance, for obese individuals, weight loss will be advised. For people with hypothyroidism, the regulation of hormone levels will be needed, while for people with a narrowed airway, respiratory stimulants might be prescribed. These substances help to correct the closed pipes that might be the consequences of drug or alcohol abuse.

For some other conditions, you might be prescribed oxygen or continuous positive airway pressure (CPAP) therapy. CPAP is mostly used as a treatment of sleep apnea, but it can be beneficial to other conditions as well. You usually put a mask over your nose or mouth, that is connected with a machine that sits next to your bed. The device is continuously pumping pressurized air so that you get the amount you need. There are different types of masks, and settings, so you can get the ones that suit you best, and you’d also need to follow your doctor’s instructions with the amount of air that is delivered to you.

Some people have problems with CPAP therapy as they have trouble breathing out with air continuously coming in. That’s why decide for a bilevel positive airway pressure (BiPAP) therapy. The principle behind this is similar to CPAP; it is just that there are two different pressures when you try to inhale and exhale. During inspiration, the pressure is stronger, filling you with the needed air, while it is weaker during expiration so that you don’t have any trouble doing it. These machines can also be programmed to take automatically take a breath if you haven’t inhaled for a certain amount of time, thus additionally preventing hypoventilation.

Around 50% of people around the world experience a form of sleep issues at some point in their lives. While all of them carry certain levels of discomfort, some of them are very dangerous and seriously compromise the health of an individual, and others are merely changes to a person’s sleep pattern. The most common problems include teeth grinding (bruxism), insomnia, certain parasomnias and catathrenia (producing a groan-like sound while exhaling during sleep, as opposed to snoring). Some of these target very specific parts of the population, some are more equally prevalent in all groups, and some are so rare they are barely known outside of the sleep community. It is the case with the family of circadian rhythm disorders, although with the exception of the delayed sleep-wake phase disorder, which rates much higher on the common sleep disorder list.

What each one out of this family has in common, as the name suggests, is some form of abnormality of the circadian rhythm. A normal human circadian rhythm is a process that oscillates and re-occurs every 24 hours, regulated by the circadian clock. These rhythms control our core body temperature, hormone secretion, alertness levels, and regulate the sleep pattern in response to our exposure to light. The purpose of this is to make sure we do the right things at the right times: we fall asleep when it’s dark outside and wake up in the morning.

Abnormalities of this rhythm have a few variations: our sleep onset can be delayed or advanced; our sleep nonrestorative, stuck by jet-lag or shift-jobs, scattered throughout the day, or sometimes “run free” of the standard 24-hour rhythm. The last two disorders are often grouped into a subcategory called the “sleep-wake rhythm disorders.”

What are Sleep-Wake Rhythm Disorders?

The two disorders that fall under this category are irregular sleep-wake rhythm disorder and non-24-hour sleep-wake disorder. These two neurological disorders are typically the rarest forms of all circadian rhythm disorders; their prevalence is practically unknown in otherwise healthy people, without the presence of another condition. However, the incidence rate among blind individuals, the elderly and people who have Alzheimer’s is significantly higher between these disorders.

Irregular Sleep-Wake Rhythm Disorder

The main characteristic of the irregular sleep-wake rhythm disorder is its unpredictable sleep pattern, with sleep periods occurring randomly throughout the 24-hour cycle. People who have this condition sleep a few times a day for shorter periods that can last anywhere from one to four hours, but their daily sleep sums up to eight or nine hours overall. They take multiple naps over the day but usually sleep the longest at nighttime.

While this disorder doesn’t impair the length of sleep an individual gets per day, the uncontrollable, scattered manner of it results in struggles with handling daily responsibilities; shifts at work and tasks requiring attentiveness can be compromised by an unpredictable, spontaneous sleep urge in the middle of the day. It can quickly put you and the people around you in danger. Besides that, if continued over a longer timespan, irregular sleep-wake rhythm disorder can lead to sleep deprivation, risking other potential complications for your health.

The exact cause of the irregular sleep-wake rhythm disorder is unknown, but infrequent light exposure and unpredictable mealtimes are the two factors believed to contribute to its development. Since these stimuli have a direct impact on the circadian rhythm, their infrequency lessens its ability to time sleep properly. Such a situation may happen when the patient lives in a nursing home, hospital, or has some debilitating condition that deters them from going outside and getting enough sunlight on a steadier, more regular basis.

Another possible factor could be age. Our body gradually stops producing certain circadian rhythm regulating hormones as we get older, making it harder for our brains to differentiate sleep time from wake time. Aside from that, Alzheimer’s disease and dementia are believed to be related to the irregular sleep-wake rhythm disorder; it is much more prevalent in patients who have one of these neurological conditions than in otherwise healthy people. In people under the age of 60 who don’t have another medical condition, the incidence rate is estimated to be under 1%, making this sleep disorder very rare.

Symptoms include:

•         Difficulties falling asleep
•         Waking up after sleeping for only 1-4 hours, even at night
•         Excessive daytime sleepiness
•         Unpredictable but very strong sleep urge
•         Having a fragmented sleep manner, napping a few times during the day

Diagnosis and treatment

In order to diagnose irregular sleep-wake rhythm disorder, a doctor will start by taking your medical history and asking to hear your subjective impressions about the problem you came to address. A sleep diary is something you can start even before you go to your first appointment. Simply record everything you notice about your sleep pattern for a few weeks. How often you sleep, for how long, at which times of day, whether you are sleepy during daytime or not – all of these can be useful for a specialist to narrow down your symptoms much faster. Although used as a subjective overview, the information provided in a sleep log is often much more detailed and precise because it was fresh when you recorded it.

To rule out some other sleep disorders, the doctor might order polysomnography. This test is performed during the night, or during the patient’s usual sleep time; it tracks all the major bodily processes that occur during sleep, monitored by a sleep specialist. It could help determine whether or not you have the irregular sleep-wake rhythm disorder by tracking the circadian rhythm markers in the body – melatonin production and core body temperature oscillations.

The treatment of irregular sleep-wake rhythm disorder usually consists of a combination of behavioral therapy, phototherapy and melatonin supplementation.

• Behavioral changes include re-associating your bed with sleep – setting up a comfortable atmosphere in the bedroom and sticking to a planned daily bedtime and waking up schedule. Your eating pattern also needs to be regular and predictable.
• Phototherapy is a treatment using bright light in the morning or as needed until noon, to help the circadian rhythm boost your alertness level and prolong your time awake until nightfall.
• Melatonin is a hormone naturally secreted in our brains that serves a purpose in inducing sleep. Supplementing the prescribed dose of melatonin in the evening, before bedtime, helps cue your body to fall asleep and maintain it for longer than a few hours.

Non-24-Hour Sleep-Wake Disorder

The other neurological sleep-wake condition is known for causing the usually 24-hour long circadian rhythm to stretch beyond that time frame, moving the person’s sleep time later and later, seemingly at free will. This time frame gets progressively longer over time and causes fatigue and excessive sleepiness.

Non-24-hour sleep-wake disorder is caused by anomalies in the suprachiasmatic nucleus, the area of our brain that maintains the circadian clock. As mentioned above, this clock normally responds to light and synchronizes the body with external light-dark times of the day. Occasional disturbances in this cycle may happen prompted by travel, shift work, illness and so forth, usually when our light exposure changes, but then fall back in place after a bit of adjustment. However, in people with the non-24-hour sleep-wake disorder, this function is impaired, for two possible reasons:

1. The brain’s response to light in the patient with non-24-hour sleep-wake rhythm is abnormal, or there is little to no exposure to light. Melatonin levels might also be higher than average.
2. The person is blind. People with blindness can’t use light as a cue for alertness, as usually regulated by the circadian rhythm, which makes them more prone to this disorder.

The non-24-hour sleep-wake disorder is highly prevalent in blind individuals; up to 70% of them also have this disorder. The exact incidence rate of this disorder among sighted people is unknown, but those with current issues or a history of delayed sleep-wake phase disorder are prone to developing the non-24-hour sleep-wake disorder as well, pushing their already late bedtime even later. If this keeps going on for long enough, the person will get stuck, going back and forth between night owl and early bird sleep schedule, forming full circles before starting new rounds. This wheel results in excessive sleepiness and exhaustion, making any social life or work shift impossible to maintain for longer than a day.

Sleep scientists have recently begun researching the possibility of a genetic predisposition towards developing the non-24-hour sleep-wake disorder, but no significant evidence has yet linked the two.

Symptoms include:

•         Bedtime moving later and later as time goes by
•         Waking up progressively later as well
•         Difficulty onsetting sleep
•         Current issues or a history of the delayed sleep-wake phase disorder
•         Insomnia
•         Depression
•         Excessive daytime sleepiness
•         Unsatisfactory quality of sleep
•         Feeling isolated from other people

Diagnosis and treatment

As with irregular sleep-wake rhythm disorder, after questionnaires, a physical exam and a thorough medical history, your doctor might suggest using a sleep tracking tool. Actigraphy is a device worn around the wrist to record your sleep-wake cycles – this method is used when polysomnography isn’t available or necessary.

As far as the treatment goes, a combination of melatonin supplements and light therapy is frequently used for patients with the non-24-hour sleep-wake disorder. The procedure is standard – melatonin is used in the evening to help with sleep onset, and light therapy is used in the morning, to alert the body and keep it awake until bedtime. However, unlike the other circadian rhythm disorders, non-24-hour sleep-wake disorder has to be treated even after optimal results have been achieved; that is, even when the circadian rhythm gains its usual functionality back. If the treatment stops abruptly and the new, balanced sleep hygiene isn’t properly maintained, the non-24-hour sleep-wake disorder often recurs. For blind people with this disorder, carefully timed and dosed melatonin is the most effective and frequently used method of therapy. Maintaining the normal circadian rhythm is especially difficult for them as well; regular medical help is often needed.

Tips for Maintaining Healthy Sleep

In addition to virtually all methods used for treating sleep disorders, some behavioral changes are a safe bet to keep your sleep in check and make sure past issues don’t return in the future. Try to follow these guidelines:

• Don’t procrastinate sleep. Some adjustments to your schedule are fine once in a while, but no treatment or medication will eradicate issues caused by poor organization or complete neglect of your sleep. Take responsibility to avoid unnecessary complications.
• Abusing substances, doctor approved or not, is another no. Just because your sleep pills might have been prescribed at some point, using them while disregarding the doctor’s instructions will do more harm than good. Steer clear of alcohol, caffeine, antihistamines, and other drugs before sleep.
• Make sure you get out of the house during sunlight. It will help maintain the healthy circadian rhythm, plus any physical activity that you can fit into your day is worth it – exercise has been shown to boost sleep among other systems in your body, like immunity and metabolism.
• In the late afternoon and evening, try dimming the lights, especially in the bedroom. Lowering the light levels will be suggestive to the circadian rhythm, preparing you for nighttime and sleep.
• Do daytime activities away from your bed. By limiting the use of your bed to sleep-related activities, you will establish the relationship between the two in your mind. Falling asleep at night will be easier when your body is trained to expect sleep simply by being in bed.

Have you ever had a feeling that you should be living in a different time zone? When others are waking up early to go to work, you are feeling sleepy and ready to start snoozing and vice versa. Others keep telling you that you are such a night owl, and even though somehow you manage to function that way and feel good, you probably have a sleep-wake phase disorder.

Sleep-wake cycle refers to our daily pattern which consists of optimally recommended 16 hours of wakefulness and 8 hours of sleep during the night. Our body’s circadian rhythm controls the sleep-wake cycle. Circadian rhythm is controlled by the body’s inner clock located in the brain which controls many biological functions such as hormone release, body temperature, and sleep-wake cycle. Our biological cycles are usually synchronized with the daily cycle of light and dark, which affects our sleeping and waking time. Beside disorders of the sleep-wake phase, our body’s circadian rhythm can be disrupted due to working in shifts, jet lag, etc.

Just like with other disorders of circadian rhythm, sleep-wake phase gets disrupted when our circadian rhythm is not aligned with normal sleep routine. People who suffer from this disorder have a strong biological urge to stay up when most of the other people are sleeping and to sleep when others are already fully awake. This disorder can sometimes be mixed with insomnia, or be prescribed to someone’s laziness or late night binge-watching habits, but the reality is that it is also a type of disorder which has a strong impact on everyday life since it can be hard for those people to socialize or hold a job with that particular lifestyle.

There are two main types of this disorder, advanced and delayed sleep-wake phase syndrome, for both cases, the best thing that you can do is to go to a sleep clinic and let them perform a sleep study on you. You might be asked to write a sleep diary for a few weeks or to wear an actigraph to track your sleep. All this is needed so that the doctors can set the correct diagnose, as these disorders are often caused by others or mixed with them due to similar symptoms.

Excessive daytime sleepiness and a struggle with maintaining a sleep routine are common symptoms of both types of sleep-wake phase disorder, and we are now going to discuss both of them.

Delayed Sleep-Wake Phase Disorder

DSPD stands for delayed sleep-wake phase disorder which is also known as DSPS, delayed sleep-wake syndrome. People who have been diagnosed with this disorder usually have their sleep pattern delayed by at least two or more hours. That means that the circadian rhythm of those people is shifted to later at night and in the morning too. Their sleep is generally healthy, there are not any disruptions or issues while they are asleep, but the fact that it occurs later than normal or socially acceptable can be a problem for them once it starts hindering their job or other activities. Since they are usually a minority in society, they have to struggle to fulfill expectations and do things on time. Getting up early to go to school or work can be challenging for them, and many people with normal sleep cycle are having problems to understand that. Parents, employers and even some doctors can sometimes show the lack of understanding for this disorder, which can be an additional aggravating factor for people dealing with this it.

People with DSPD prefer going to bed late, and when they are on their own schedule without any obstacles, they can get the desired amount of quality sleep time and function as normal as everyone else. The solution to this problem is not simply going to bed earlier, because these people really cannot fall asleep earlier; it is not something that they can easily control or change on their own. People with DSPD who are trying to live as “normal” as possible and go to work etc. are usually sleep deprived, which then triggers some other complications.

Symptoms of DSPD resemble the ones of insomnia, and people’s daytime functioning is jeopardized and followed by severe fatigue and daytime sleepiness. Around 10% of people who believe to have chronic insomnia actually have DSPD. We suggest consulting a sleep specialist at a sleep clinic to set you a correct diagnose and examine your sleep habits.

When it comes to age, teenagers and adolescents are especially affected by this disorder, around 7% to 16% of them have it, and girls experience it more often than boys. It is hard to tell what can be the cause of DSPD, and there are probably some genetic predispositions to it since around 40% of people with this disorder have a family history of DSPD. DPSD should not be considered a psychological disorder, since it more of a neurological disorder, but sometimes, living with DPSD can cause stress and lead to mental diseases such as depression. Environmental conditions, (such as lack of exposure to morning sunlight), other health problems, medications, substance abuse, or other sleep disorder can trigger DSPD

Most common symptoms include:

• Troubles with falling asleep at the preferred time of night
• Being unable to wake up at desired or socially acceptable time
• Chronic fatigue and daytime sleepiness
• People who experience this stable but delayed sleep routine for more than seven days can consider their condition for a sleep-wake phase disorder.

When it comes to treatment or cure for DSPD, timed melatonin has shown great results when used in teens, and it can also be an effective solution for adults. Melatonin is a hormone naturally produced by our body which helps to regulate our sleep-wake cycle by sending signals to our body when our bedtime is approaching. Although it is widely available in the form of a supplement, sleepers should not use it on their own. They should always consult a sleep specialist for the recommended dosage and timing. In theory, another possible treatment is bright light therapy which provenly enhances and changes the circadian rhythm, but it has not been yet scientifically tested and validated as a treatment for DSPD. After waking up at a desired time in the morning, a person that undergoes light therapy should be exposed to bright light, and in the evening hours, bright light should be avoided. Light therapy in combination with cognitive behavioral therapy should be highly efficient among teens and younger adults.

Advanced Sleep-Wake Phase Disorder

Contrary to people who have DPSD and are considered night owls, people with ASPD, advanced sleep-wake phase disorder or syndrome (ASPS), are known as early birds. Their sleep cycle is also out of balance but in a different way. They usually fall asleep several hours before regular bedtime and wake up hours before everyone else.

People with ASPD are already feeling sleepy in the afternoon, and their preferable bedtime is somewhere between 6 PM and 9 PM, which means that they will wake up naturally between 2 AM and 5 AM. Just like with people with DSPD, their sleep is healthy, good quality and not disrupted. All processes of circadian rhythm occur earlier for them, the release of hormones including melatonin, body temperature curve also, and that is used for detecting this syndrome.

Unlike people with DSPD, those with ASPD have no problem with working and functioning normally during the morning hours. For them, the problem occurs during the afternoon and especially evening hours when they start struggling to stay awake and “shutting down.” Missing those few hours of sleep during the early evening will eventually result with sleep deprivation, and even when they are sleep-deprived, people with ASPD will still wake up way earlier than everyone else.

ASPD is also often mixed with insomnia or depression, people start to worry about waking up so early, they are not feeling good about themselves, and that may lead to developing a secondary form of insomnia.

For people with ASPD, it can be a bit easier to organize their life around their early bird lifestyle, since they are the ideal workers for notorious early morning shifts. They should not push themselves to stay awake in the late afternoon by drinking gallons of coffee or taking some stimulants to stay up. The same applied to morning hours; sleeping pills and alcohol should not be used as a way of “help” to prolong their sleep time.

This disorder is not so common since it affects only 1% of middle-aged people, but it is more common among seniors, regardless of their sex. ASPD also runs in families, so genetics are most likely the primary cause of it.

Main symptoms that are signals for ASPD are:

• Falling asleep in the afternoon hours
• Waking up between midnight and 5 AM
• Functioning normally as an early bird for more than a week

ASPD is a disorder with whom people can live if they can adjust to it, as it does not hinder everyday life functioning as much as DSPD. But if it is bothering you and jeopardizing your social life, consult with a doctor, preferably with a sleep specialist. They will examine your family medical history and probably perform a sleep study, for example, polysomnogram, which will follow your brain waves, heart rhythm, and breathing while you are sleeping. It will show if any other sleep disorders caused or increased the effects of ASPD, some of them might be sleep apnea or periodic limb movement disorder.

You will probably have to wear a device called actigraph on your wrist, for around one or two weeks. This device measures and records sleep activity during that time. Some other methods and tests may be included, but these are the most common ones.

When it comes to treatment, as we mentioned, sometimes it is not necessary if people are able to adjust their life to their sleep pattern. Try looking at it in a positive way – a lot of things can be done in the morning or while others are sleeping, and you will be more productive and have more time for yourself. Also, try consulting with a sleep specialist in behavioral counseling. They will provide you with some useful tips such as, for example, not making any plans for evenings, avoiding afternoon shifts or shift work in general, also avoiding caffeine during the late afternoon and not using any pills to help you stay asleep longer.

But, if you want to try ”fixing” it, bright light therapy during the evening hours can help with resetting their inner clock. The light should be brighter than regular indoor lighting, and there are specialized light boxes or portable devices that you can try out for that. You should practice bright light therapy for around two hours before the desired bedtime, at least for one week. Melatonin supplement is another option, but you will have to ask your doctor to prescribe you the optimal dosage.