For Medical Specialists

Sleep Medicine: The Internal Medicine Of The Night

A Sampling Of The Many Implications Of Sleep And Its Disorders For Medical Specialists:
Allergists:

  • Allergic rhinitis has been linked to increased daytime sleepiness even without indications of sleep-related breathing disorders.
  • Allergic rhinitis has been associated with increased difficulty falling asleep and maintaining sleep.
  • Allergic rhinitis can increase arousals with secondary bruxism and aggravation of TM joint complaints.
  • Allergic rhinitis aggravates sleep apnea and can render use of positive airway pressure more difficult.

Bariatric Surgeons:

  • While the prevalence of sleep apnea is extremely high in patients undergoing bariatric surgery, many of these patients lack any history of sleepiness or significant snoring, even if their sleep apnea is severe.

Cardiologists:

Sleep apnea has been associated with:

  • Accelerated coronary atherogenesis.
  • Precipitation of myocardial infarction.
  • Malignant cardiac dysrhythmias.
  • Systemic hypertension.
  • Pulmonary hypertension.
  • Left and right ventricular failure.

Sleep deprivation and shift work have been associated with an increased risk of myocardial infarction.

An estimated 50% of congestive heart failure patients and many patients with atrial fibrillation have central or mixed sleep apneas, often with a Cheyne Stokes breathing pattern. Failure to control the sleep-related breathing problems can lessen the effectiveness of treatments for heart failure and result in accelerated deterioration of heart function.

Dermatologists:

  • Trichotillomania has been reported to occur during sleep.
  • A patient’s sleeping position and usual duration of sleep has been found to affect the risk and distribution of facial wrinkles.
  • Sleep disturbances are a common complication of atopic eczema.
  • Pathological excoriation patients have an increased incidence of poor sleep.

Endocrinologists:

  • Sleep deprivation has adverse effects on endocrine function, glucose tolerance and body weight, and the prevalence of diabetes is increased in sleep apnea patients.
  • Sleep apnea may worsen insulin resistance in women with polycystic ovary syndrome.
  • Sleep apnea has been associated with low testosterone levels.
  • Sleep apnea can be worsened by testosterone administration even in testosterone-deficient individuals.
  • Sleep apnea is increased in prevalence in patients with acromegaly, Cushing’s syndrome, hypothyroidism, diabetes mellitus, and polycystic ovary syndrome.

Gastroenterologists:

  • Sleep deprivation has adverse effects on endocrine function, glucose tolerance and body weight.
  • Sleep apnea may worsen insulin resistance in women with polycystic ovary syndrome.
  • Sleep apnea has been associated with chronic liver injury with steatohepatitis and elevated liver enzymes.
  • GERD worsens sleep quality.
  • GE reflux tends to worsen markedly during sleep, particularly in regard to episode durations: as a consequence of recumbent posture, greatly reduced swallowing frequency, diminished awareness of episodes and (in many patients) due to aggravation by sleep apnea.
  • Sleep apnea is associated with sleep-related GE reflux, and treatment of sleep apnea can improve GERD.

Geriatrics:

  • Reduced sleep quality and duration have been associated with increased mortality rates, ncreased suicide risk and shortened lifespans in the elderly.
  • Sleep requirements are not reduced in the elderly. Shortened nocturnal sleep is the result not of decreased need but instead, inability to maintain needed sleep.
  • Daytime sleepiness has been identified as a major predictor of reduced lifespans and increased risk of cardiovascular disease in elderly women, who also were found in another study to have a higher mortality rate from sleep apnea than elderly men.
  • Many sedative hypnotics given widely to geriatric patients worsen sleep apnea, while increasing the risk of nocturnal confusion, sleepwalking and self-injury during sleep.
  • A significant number of patients seeking evaluation for possible Alzheimer’s dementia instead suffer from reversible cognitive and memory difficulties arising from sleep apnea.
  • Treatment of sleep apnea has been found to improve cognition in some patients with Alzheimer’s dementia.
  • Violent behaviors during sleep, particularly if developing after age 60, often are a manifestation of REM Sleep Behavior Disorder which in a number of cases will be followed by development of extrapyramidal disorders, particularly Parkinson’s disease.
  • The prevalence of sleep apnea increases with age and is particularly high in seniors.
  • Sleep apnea in the elderly is often not associated with a history of loud snoring.
  • Sleep apnea has been found in several studies in approximately 60% of male stroke victims.
  • Many elderly patients experience a phase advance problem (earlier times of sleep onset and final awakening) which may respond favorably to light therapy.

Gynecologists:

  • The prevalence of sleep apnea increases rapidly after menopause, a trend that is likely to be increased by avoidance of hormone replacement therapy.
  • Sleep-related breathing disorders are far more common in women that originally thought, and frequently take the form of upper airway resistance syndrome which is frequently found in individuals of normal body weight who do not snore excessively.
  • Some studies have found sleep-related breathing abnormalities in the majority of patients suffering from fibromyalgia: a condition more common in women.
  • Women have been reported to be twice as likely to have difficulties falling asleep and maintaining sleep than are men.
  • Insomnia complaints are particularly common pre-menstrually.
  • Some women develop sleep apnea during pregnancies, necessitating a careful history.

Hematologists:

  • Sleep apnea has been associated with thalassemia as a consequence of nasal obstruction arising from extramedullary hematopoiesis.
  • Lymphomas involving the upper airway can lead to sleep apnea.
  • Polycythemia has been identified in some patients with severe sleep apnea.
  • Iron deficiency is a major aggravating factor in restless legs syndrome.
  • Treatment of anemia has been found to improve sleep apnea in congestive heart failure patients.
  • Sleep disturbances have been cited as one of seven key factors responsible for fatigue in cancer patients.

Nephrolologists:

  • Studies have shown sleep apnea syndrome in 44%, insomnia in 41% and periodic limb movement syndrome in 34% of patients with kidney failure on maintenance dialysis.
  • Renal transplantation has been reported to eliminate sleep apnea in patients with kidney failure.
  • Acoustic reflectance studies found pharyngeal narrowing in kidney failure patients: a possible factor in the pathogenesis of sleep apnea.
  • Restless legs syndrome is strongly associated with renal failure.
  • Sleep apnea was reported to be the cause of nocturia in 40% of men seeking help for that complaint: a phenomenon mediated by increased release of atrial natiuretic peptide.
  • Hypertension is a recognized complication of sleep apnea.
  • Reports have recommended assessment for sleep apnea in patients with kidney disease who are hypertensive.
  • Sleep apnea has been associated with microalbuminuria, and hypertensive sleep apnea patients have an increased prevalence of renal function abnormalities.

Neurologists:

  • Sleep related seizures can result from the tendency (in many patients) for seizures to occur primarily during sleep, seizure precipitation by sleep-related cardiac dysrhythmias or breathing disorders, or a combination of both.
  • CPAP has been reported to improve control of seizures.
  • -Partial complex seizure activity in some patients will be misinterpreted as excessive sleepiness.
  • A significant number of patients seeking evaluation for possible Alzheimer’s dementia instead suffer from reversible cognitive and memory difficulties arising from sleep apnea.
  • Treatment of sleep apnea has been found to improve cognition in some patients with Alzheimer’s dementia.
  • Violent behaviors during sleep, particularly if developing after age 60, often are a manifestation of REM Sleep Behavior Disorder which in a number of cases will be followed by development of extrapyramidal disorders, particularly Parkinson’s disease and dementia with Lewy bodies.
  • Sleep apnea has been found in several studies in approximately 60% of male stroke victims.
  • Sleep apnea has been associated with a large number of neurologic disorders including myotonic dystrophy and other muscular dystrophies, syringobulbia, syringomyelia, Arnold Chiari, poliomyelitis and post-polio syndrome, myopathies from various causes, spinocerebellar degeneration, amyotrophic lateral sclerosis, spinal muscular atrophy, Shy Drager syndrome, Parkinson’s disease, hypothalamic disorders, acromegaly, and Charcot Marie Tooth.
  • Cervical spine disease with brainstem compression can lead to sleep apnea.
  • Excessive sleepiness of central origin has been reported in a wide variety of conditions including narcolepsy (both idiopathic and secondary to inflammatory and structural brain disorders), idiopathic hypersomnia, recurrent hypersomnia (Klein Levin syndrome and menstrual-linked hypersomnia), Parkinson’s disease and other degenerative conditions, encephalitis and other inflammatory disorders, multiple sclerosis, stroke, space occupying lesions and genetic disorders such as myotonic dystrophy, Prader-Willi syndrome, Niemann-Pick type C and fragile X syndrome.
  • Headaches from sleep are frequently a manifestation of sleep apnea . They can result from repetitive fluctuations in intrathroacic pressure during struggling to overcome upper airway obstruction.
  • Peripheral neuropathies can be associated with restless legs syndrome and periodic limb movement syndrome.

Ophthalmologists:

An association has been reported between sleep apnea and:

  • Glaucoma and optic nerve perfusion deficits.
  • Papilledema.
  • Pseudotumor cerebri.
  • Floppy eyelid syndrome.
  • Precipitation of visual loss in non-arteritic AION patients, felt to be mediated by sleep-related hypotension.
  • Optic nerve disease has been linked to increased napping and sleep-wake cycle abnormalities.
  • Aqueous humor flow decreases during sleep.
  • Visually impaired seniors have been found to have a higher prevalence of sleep complaints.

Otolaryngologists:

  • Narrowing of the upper airway at any level and from any cause can increase the likelihood of obstructive sleep apnea.
  • Otolaryngologic surgical procedures appear of frequent benefit in pediatric sleep apnea.
  • Tinnitus has been associated with chronic insomnia.
  • Vertigo upon awakening and during sleep onset has been associated with sleep-related seizures, sleep apnea and migraine.

Pain Management:

  • Some studies have found sleep-related breathing abnormalities in the majority of patients suffering from fibromyalgia.
  • Sodium oxybate (Xyrem®), an agent that increases deep non-REM sleep, has been reported to improve fibromyalgia.
  • Sleep apnea is worsened by a number of drugs commonly utilized in pain management, including those administered epidurally.
  • TM joint syndrome is aggravated by bruxism which in turn can be worsened by a wide variety of disorders that cause repeated arousals from sleep.

Pediatricians:

  • Many children with symptoms suggesting attention deficit disorder suffer from underlying sleep disorders such as sleep apnea and narcolepsy.
  • Children who are excessively sleepy often present with inability to concentrate and with behavior problems, rather than perceived sleepiness.
  • Children with sleep-related breathing disorders often suffer from upper airway resistance syndrome (UARS) which can be readily missed by conventional sleep monitoring techniques. UARS frequently afflicts non-obese patients and in many cases is not associated with significant snoring.
  • Secondary enuresis (recurrent bedwetting) is a common manifestation of sleep apnea.
  • Adolescents are unusually prone to sleep phase delay problems: their frequent tendency to go to bed late and to “sleep in” late appears biologically driven.
  • Restless legs syndrome commonly occurs in pediatric patients as a manifestation of low or margin body iron stores.
  • Chronic short sleep durations greatly increase the risk of childhood obesity.
  • Sleepiness and/or sleep apnea can be associated with genetic disorders such as Down syndrome, myotonic dystrophy, Prader-Willi syndrome, Niemann-Pick type C and fragile X syndrome.

Physical Medicine Specialists:

  • Some studies have found sleep-related breathing abnormalities in the majority of patients suffering from fibromyalgia.
  • Fibromyalgia can be induced in asymptomatic individuals by selective deprivation of deep non-REM sleep.
  • Sodium oxybate (Xyrem®), an agent that increases deep non-REM sleep, has been reported to improve fibromyalgia.
  • Sleep-related breathing abnormalities can complicate a variety of conditions that cause muscular weakness, deformities of the spine and chest wall and incoordination of the upper airway.

Psychiatrists and Psychologists:

  • Depression is commonly worsened by sleep apnea and other disorders of excessive sleepiness. Treatment of these conditions has been found to yield lasting improvement in depressive symptoms.
  • Sleep-related breathing problems have been associated with mood swings, depression, irritability, impotence, dimished libido, anhedonia, paranoia, memory loss, cognitive dysfunction, deliriumand marital and job-related problems.
  • A large percentage of the available psychotropic agents can worsen sleepiness. Some will also worsen breathing during sleep.
  • Violent behaviors during sleep are typically of neurological rather than psychological origin, although stressors sometimes increase their frequency and/or severity.
  • Major depression is frequently associated with insomnia, fatigue and a shortened REM latency.
  • Persistent insomnia complaints have been associated with a three to four-fold increased risk of major depression and persistent hypersomnia complaints, with a 2.9-fold increased risk. Suicide risk has been reported to be greater in patients with insomnia (70%) and hypersomnia (50%) than controls.
  • Bipolar disorder and seasonal affective disorder have a higher prevalence of hypersomnia.
  • Sleep deprivation has been reported to precipitate and intensify mania.
  • Sixty-nine percent of patients seeking help from panic attacks have been reported to have experienced some of their panic attacks from sleep.
  • Panic attack patients who have experienced panic attacks in sleep are 2-3 times as likely as those without sleep panic attacks to have a history of depression and triggering of attacks by both sleep deprivation and relaxation.
  • Sleep apnea can be a trigger for panic attacks from sleep.
  • Seventy percent of patients with generalized anxiety disorder reported sleep disturbances in one study (rated as severe in 30%).
  • Sleep symptoms and frequent nightmares have been reported in 59-68% of patients with post-traumatic stress disorder.
  • A significant number of adults with symptoms suggesting attention deficit disorder suffer from underlying sleep disorders such as sleep apnea and narcolepsy.
  • Patients with symptoms of chronic fatigue and fibromyalgia have been found to have a significant prevalence of underlying sleep apnea and upper airway resistance syndrome.

Pulmonologists:

  • Frequent nocturnal cough and asthmatic attacks are often triggered by sleep-related gastroesophageal reflux which in turn is associated with sleep apnea in many patients. Treatment of sleep apnea can help address both these problems.
  • Patients with both chronic obstructive pulmonary disease and sleep apnea are at greater risk of pulmonary hypertension, right heart failure and carbon dioxide retention than are patients with sleep apnea only.
  • A large percentage of patients with pulmonary fibrosis have been reported to be at high risk for obstructive sleep apnea.
  • Nocturnal nasal intermittent positive pressure ventilation plus oxygen has been found to lead to more favorable survival rates and better respiratory function in kyphoscoliosis patients than nasal oxygen alone.

Rheumatologists:

  • Rheumatoid arthritis can lead to obstructive sleep apnea via temporomandibular joint destruction or atlantoaxial subluxation, with secondary narrowing of the upper airway.
  • Cervical spine disease with brainstem compression can lead to sleep apnea.
  • Some studies have found sleep-related breathing abnormalities in the majority of patients suffering from fibromyalgia.
  • Fibromyalgia can be induced in asymptomatic individuals by selective deprivation of deep non-REM sleep.
  • Sodium oxybate (Xyrem®), an agent that increases deep non-REM sleep, has been reported to improve fibromyalgia.

Urologists:

  • Sleep apnea was reported to be the cause of nocturia in 40% of men seeking help for that complaint.