Medical conditions and sleep problems
Date Posted: October 1, 2007
In-Depth Report
Medical conditions and sleep problems
People who feel they sleep perfectly well may still be troubled by excessive daytime sleepiness because of a variety of underlying medical illnesses, including kidney or liver disease and respiratory disorders. A sleep disturbance may be a symptom of underlying medical illness itself or an adverse effect of therapy to treat the problem. The stress of chronic illness can also cause insomnia and daytime drowsiness. Common conditions often associated with sleep problems include heartburn, diabetes, cardiovascular disease, musculoskeletal disorders, kidney disease, mental illness, neurological disorders, respiratory problems, and thyroid disease.
Snoozing NewsAbout 10% of adults report that they use prescription sleep medications, and the number of adults ages 20 to 44 who take them doubled from 2000 to 2004. |
Heartburn
Lying down in bed often worsens heartburn, which is caused by the backup of stomach acid into the esophagus. You may be able to avoid this problem by abstaining from heavy or fatty foods — as well as coffee and alcohol — in the evening. You can also use gravity to your advantage by elevating your upper body with an under-mattress wedge or blocks placed under the bedposts. Over-the-counter and prescription drugs that suppress stomach acid secretion can also help.
Diabetes
Night sweats, a frequent need to urinate, or symptoms of hypoglycemia (low blood sugar) often rouse people with diabetes whose blood sugar levels are not well controlled. If diabetes has damaged nerves in the legs, nighttime movements or pain may also disturb sleep.
Cardiovascular disease
Patients with heart failure may awaken during the night feeling short of breath because extra body fluid accumulates around their lungs when they're lying down. Using pillows to elevate the upper body may help. These people can also be awakened just as they are falling asleep by a characteristic breathing pattern called Cheyne-Stokes respiration, a series of increasingly deep breaths followed by a brief cessation of breathing. Benzodiazepine sleep medications (see "Medications and other insomnia treatments") help some people to stay asleep despite this breathing disturbance, but others may need to use supplementary oxygen or a device that increases pressure in the upper airway and chest cavity to help them breathe and sleep more normally (see "Positive airway pressure").
Men with congestive heart failure frequently experience obstructive sleep apnea, which can disrupt sleep, cause daytime sleepiness, and worsen heart failure. In people with coronary artery disease, the natural fluctuations in circadian rhythms may trigger angina (chest pain), arrhythmia (irregular heartbeat), or even heart attack while asleep.
Musculoskeletal disorders
Arthritis pain can make it hard for people to fall asleep and to resettle when they shift positions. In addition, treatment with corticosteroids frequently causes insomnia. You may find it helpful to take aspirin or a nonsteroidal anti-inflammatory drug (NSAID) just before bedtime to relieve pain and swelling in your joints during the night.
People with fibromyalgia — a condition characterized by painful ligaments and tendons — are likely to wake in the morning still feeling fatigued and as stiff and achy as a person with arthritis. Researchers who analyzed the sleep of fibromyalgia sufferers have found that at least half have abnormal deep sleep, in which slow brain waves are mixed with waves usually associated with relaxed wakefulness, a pattern called alpha-delta sleep. In one study by researchers at Boston University School of Medicine, 62 people with fibromyalgia received treatment for six weeks with either the NSAID naproxen, the tricyclic antidepressant amitriptyline, both drugs, or a placebo. Almost half of those who took low doses of amitriptyline reported sleeping and feeling better.
Kidney disease
Kidney disease can cause waste products to build up in the blood and can result in insomnia or symptoms of restless legs syndrome. Although researchers aren't sure why, kidney dialysis or transplant does not always return sleep to normal.
Coping with frequent nighttime urinationNocturia — the need to get up frequently to urinate during the night — is a common cause of sleep loss, especially among older adults. It affects nearly two-thirds of adults ages 55 to 84 at least a few nights per week. A mild case causes a person to wake up at least twice during the night; in severe cases, a person may get up as many as five or six times. Not surprisingly, this can lead to significant sleep deprivation and daytime fatigue. Nocturia becomes more common with age. As we get older, our bodies produce less of an antidiuretic hormone that enables us to retain fluid. With lower concentrations of this hormone, we produce more urine at night. Also, the bladder tends to lose holding capacity as we age, and older people are more likely to suffer from medical problems that affect the bladder. Nocturia has numerous possible other causes, including some of the disorders mentioned in this report (heart failure, diabetes), other medical conditions (urinary tract infection, an enlarged prostate, liver failure, multiple sclerosis, sleep apnea), and medication (especially diuretics). Some cases are caused or exacerbated by excessive fluid intake after dinner, especially drinks containing alcohol or caffeine. Therapies for nocturia fall into three categories: treatments to correct medical causes, behavioral interventions, and medication. The first step is to try to identify the cause and correct it. If this is unsuccessful, try behavioral approaches such as cutting down on how much you drink in the two hours before bedtime, especially caffeine and alcohol. If the nocturia persists, your doctor may prescribe one of a growing number of medications approved to treat an overactive bladder. The most commonly used is desmopressin (DDVP, Stimate), which mimics some of the action of the antidiuretic hormone. If the problem stems from increased contractions of the bladder, relaxant agents such as tolterodine (Detrol) and oxybutynin (Ditropan) can be effective. |
Mental illness
Almost all people with anxiety disorders have trouble falling asleep and staying asleep. In turn, not being able to sleep may become a focus of some sufferers' ongoing fear and tension, causing further sleep loss.
General anxiety. Severe anxiety, formally known as generalized anxiety disorder, is a mental illness characterized by persistent, nagging feelings of worry, apprehension, or uneasiness. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person's everyday life. People with the disorder typically experience excessive, persistent worry every day or almost every day for a period of six months or more. Common symptoms include trouble falling asleep, trouble staying asleep, and not feeling rested after sleep.
Phobias and panic attacks. Phobias, which are intense fears related to a specific object or situation, rarely cause sleep problems unless the phobia is itself sleep-related (such as fear of nightmares or of the bedroom). Panic attacks, on the other hand, often strike at night. In fact, the timing of nocturnal attacks helped convince psychiatrists that these episodes are biologically based. Sleep-related panic attacks do not occur during dreaming, but rather in Stage N2 and Stage N3 sleep, which are free of psychological triggers. In many phobias and panic disorders, recognizing and treating the underlying problem — often with an anti-anxiety medication — may solve the sleep disturbance.
Depression. Because almost 90% of people with serious depression experience insomnia, a physician evaluating a person with insomnia will consider depression as a possible cause. Waking up too early in the morning is a hallmark of depression, and some depressed people have difficulty falling asleep or get fitful sleep throughout the whole night. In chronic, low-grade depression, insomnia or sleepiness may be the most prominent symptom. Laboratory studies have shown that people who are depressed spend less time in slow-wave sleep and may enter REM sleep more quickly at the beginning of the night.
Bipolar disorder. Disturbed sleep is a prominent feature of bipolar disorder (manic-depressive illness). Sleep loss may exacerbate or induce manic symptoms or temporarily alleviate depression. During a manic episode, a person may not sleep at all for several days. Such occurrences are often followed by a "crash" during which the person spends most of the next few days in bed.
Schizophrenia. Some people with schizophrenia sleep very little when they enter an acute phase of their illness. Between episodes, their sleep patterns are likely to improve, although many schizophrenics rarely obtain a normal amount of deep sleep.
Other neurological disorders
Certain brain and nerve disorders can contribute to sleeplessness.
Dementia. Alzheimer's disease and other forms of dementia may disrupt sleep regulation and other brain functions. Wandering, disorientation, and agitation during the evening and night, a phenomenon known as "sundowning," can require constant supervision and place great stress on caregivers. In such cases, small doses of antipsychotic medications such as haloperidol (Haldol) and thioridazine (Mellaril) are more helpful than benzodiazepine drugs.
Epilepsy. People with epilepsy are twice as likely as others to suffer from insomnia. Brain-wave disturbances that cause seizures can also cause deficits in slow-wave sleep or REM sleep. Antiseizure drugs can cause similar changes at first, but tend to correct these sleep disturbances when used for a long time. About one in four people with epilepsy has seizures that occur mainly at night, causing disturbed sleep and daytime sleepiness. Sleep deprivation can also trigger a seizure, a phenomenon noted in college infirmaries during exam periods, as some students suffer their first seizures after staying up late to study.
Headaches, strokes, and tumors. People who are prone to headaches should try to avoid sleep deprivation, as lack of sleep can promote headaches. Both cluster headaches and migraines may be related to changes in the size of blood vessels leading to the cortex of the brain; pain occurs when the walls of the blood vessels dilate. Researchers theorize that as the body catches up on missed sleep, it spends more time in delta sleep, when vessels are most constricted, making the transition to REM sleep more dramatic and likely to induce a headache. Headaches that awaken people are often migraines, but some migraines can be relieved by sleep.
Sleepiness coupled with dizziness, weakness, headache, or vision problems may signal a serious problem such as a brain tumor or stroke, which requires immediate medical attention.
Parkinson's disease. Almost all people with Parkinson's disease have insomnia. Just getting in and out of bed can be a struggle, and the disease often disrupts sleep. Some arousals are from the tremors and movements caused by the disorder, and others seem to result from the disorder itself. As a result, daytime sleepiness is common. Treatment with sleeping pills may be difficult because some drugs can worsen Parkinson's symptoms. Some patients who take drugs that include levodopa, the mainstay of Parkinson's treatment, develop severe nightmares; others experience disruption of REM sleep. However, the use of these medications at night is important to maintain the mobility needed to change positions in bed. A bed rail or an overhead bar (known as a trapeze) may make it easier for people with Parkinson's to move about and, therefore, lead to better sleep.
Respiratory problems
Circadian-related changes constrict the airway during the overnight hours, raising the potential for nocturnal asthma attacks that rouse the sleeper abruptly. Breathing difficulties or fear of having an attack may make it more difficult to fall asleep, as can the use of steroids, theophylline, or other breathing medications that act as stimulants. One study found that nearly 75% of people with asthma experienced frequent awakenings every week. People who have emphysema or bronchitis may also have difficulty falling and staying asleep because of excess sputum production, shortness of breath, and coughing.
Thyroid disease
An overactive thyroid gland (hyperthyroidism) can cause sleep problems. The disorder overstimulates the nervous system, making it hard to fall asleep, and it may cause night sweats, leading to nighttime arousals. Feeling cold and sleepy is a hallmark of an underactive thyroid (hypothyroidism). Because thyroid function affects every organ and system in the body, the symptoms can be wide-ranging and sometimes difficult to decipher. Checking thyroid function requires only a simple blood test, so if you notice a variety of unexplained symptoms, ask your doctor for a thyroid test.
Medications that affect sleep
Often, medication rather than illness is the culprit behind sleep problems. A number of drugs steal sleep, while others may cause unwanted drowsiness. Your doctor may be able to suggest alternatives that do not disrupt sleep.
Antidepressants. The selective serotonin reuptake inhibitors (SSRIs) — such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) — disrupt sleep or produce daytime fatigue in about 10% to 20% of those who take them.
Anti-arrhythmics. These drugs, used to treat heart rhythm problems, may cause daytime fatigue and nighttime sleep difficulties. Such medications include procainamide (Procanbid), quinidine (Cardioquin, others), and disopyramide (Norpace).
Sedating antihistamines. These medications, commonly taken to relieve cold or allergy symptoms, also cause drowsiness in most people. They are also the active ingredients in most over-the-counter sleep aids and motion sickness pills (see "Antihistamines"). To find out if a medication might cause unwelcome drowsiness, check with a pharmacist. If you are taking a sedating antihistamine and are bothered by drowsiness, your physician may recommend a non-sedating alternative that does not readily enter the brain and affect wakefulness and sleep.
Beta blockers. Beta blockers are used to treat high blood pressure, arrhythmias, and angina. These drugs can promote insomnia, awakenings in the night, and nightmares.
Medications containing caffeine. Caffeine, found in some over-the-counter painkillers and appetite suppressants, stimulates the nervous system and can induce insomnia. Caffeine makes people feel alert by blocking the action of adenosine, a substance that promotes drowsiness. Caffeine's direct effects gradually diminish but may linger for six or seven hours or even longer in some people.
Medications containing alcohol. Cough medicines often contain alcohol, which can suppress REM sleep and break up nighttime sleep.
Clonidine. This medication, which acts on nerve cells that respond to the neurotransmitter norepinephrine, is used to treat hypertension and occasionally to curb nicotine craving in people who are quitting smoking. The drug can cause daytime drowsiness and fatigue; it also may interfere with REM sleep. Some people report no problems with clonidine, but others note restlessness, early morning awakening, and nightmares.
Corticosteroids. Corticosteroids such as prednisone, used to suppress inflammation and asthma, often cause daytime jitters and nighttime insomnia.
Diuretics. Diuretics, which rid the body of excess sodium and water, can interfere with sleep by inducing urination throughout the night. Potassium deficiency, a common side effect of some diuretics, can cause painful nocturnal cramping of calf muscles during sleep.
Nicotine patches. Patches used to curb smoking deliver small doses of nicotine into the bloodstream around the clock. People who use them often suffer insomnia or experience disturbing dreams.
Sympathomimetic stimulants. Sympathomimetic stimulants — such as dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and methylphenidate (Ritalin) — are powerful central nervous system stimulants that enhance the effect of brain chemicals involved in wakefulness. People taking these agents have difficulty falling asleep; once asleep, they spend less time in REM sleep and non-REM deep sleep. When the drug is discontinued, extreme sleepiness and a craving for REM sleep may follow.
Theophylline. This respiratory stimulant, used to treat asthma, is chemically related to caffeine. Many people who use it require doses that are high enough to disrupt sleep.
Thyroid hormone. Thyroid hormone taken to counteract the effects of an underactive gland may cause sleeping difficulties at higher doses.
Review Date: 2007-10-01
Harvard Medical School does not endorse products or services.
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