Sleep Disorders

Restless Legs Syndrome (RLS) is not associated with emotional or psychological disorders and can affect otherwise healthy individuals. As the name suggests it mostly affects the legs; however in some individuals it can also affect the arms. Some people describe the sensation of something "crawling" under their skin causing an uncontrollable urge to move their legs. In more severe instances, RLS can be extremely painful and can often be the cause of insomnia.

Periodic Limb Movement Disorder (PLMD), also known as nocturnal myoclonus, affects the limbs as well as a person's ability to sleep at night and may impact on daytime functioning. Unlike RLS where a person is awake and has voluntary movements to prevent the uncomfortable feelings in the limbs, PLMD occurs mostly when a person is asleep and movements of the limbs are involuntary (that is, not consciously controlled). As the name suggests, the movements occur at regular (periodic) intervals and are sometimes referred to as jerks or kicks.

Most people with RLS have periodic limb movements; however people with PLMD may not necessarily have RLS. Some people may not be aware of any night time disturbances; however these actions occurring at regular intervals will disturb a person's sleep at every movement, causing excessive daytime sleepiness.

What are the symptoms of restless legs?

This condition is common and can affect men and women of all ages. Some of the symptoms may include:

• Being excessively sleepy during the day
• Restless sleep
• Painful leg calves
• Inability to sit still
• Depression and/or anxiety

Who develops Restless Legs?

Although we don't know the actual cause of RLS or PLMD, there are some related conditions and hereditary signs to consider. Studies have shown that approximately 30% of RLS cases have a hereditary link. These cases are more likely to be severe and are harder to treat. The causes for the other 70% of RLS cases are not yet known, however a number of situations seem to produce RLS and PLMD symptoms. These include:

• Iron deficiency anaemia
• Poor blood circulation in the legs
• Nerve problems
• Muscle disorders
• Kidney disorders
• Alcoholism
• Vitamin and mineral deficiencies
• Certain medications
• Caffeine
• Smoking
• Extreme temperatures

How is RLS and PLMD diagnosed?

RLS and PLMD can be diagnosed during an overnight stay in a sleep investigation unit. A follow up appointment is then made with a Sleep Physician (Specialist) for discussion of treatment options.

How is RLS and PLMD treated?

Firstly it is important to determine if any other related health conditions are the primary cause of RLS or PLMD. Sometimes proper diagnosis and treatment of these conditions (including iron deficiency, arthritis or diabetes) may relieve the symptoms altogether.

For Restless Legs Syndrome: some home remedies have found to be effective and include:

• A hot bath
• Leg massage
• Applied heat
• Ice packs
• Aspirin or other pain relievers
• Regular exercise
• Avoiding caffeine

When home remedies are ineffective, RLS can be treated with prescription medications. Most often medications will be trialled over a period of time as one drug may help one RLS sufferer and not another. Like most medication, the effectiveness of the drug will depend on the severity of your condition, any other medications you are taking and any other health conditions you may have.

For Periodic Limb Movement Disorder: many people do not require treatment as their limb movements do not cause sufficient sleep disturbances. For sufferers of restless sleep and daytime sleepiness, prescription medication is available and can be prescribed by your Sleep Physician during consultation after your sleep study.

Further Reading 

Yee B & Killick R, Restless Legs Syndrome. Aust. Family Physician. 2009 May; 38(5): 296-300.

Insomnia is a sleep disorder that is represented by a difficulty with falling asleep or staying asleep and can either be primary or secondary. Primary insomnia is classed as a sleep disorder not directly associated with any other condition. Secondary insomnia is associated with a health condition (like asthma, depression, arthritis, cancer or heartburn), pain, medication, or substances (like alcohol or caffeine).

Insomnia can be either short-term (acute insomnia) or can last a long time (chronic insomnia). Often Insomnia will occur for a few weeks to a few months and then will not reoccur for a period of time, sometimes from several months to years. Acute insomnia can last from one night to a few weeks where as chronic insomnia can last at least three nights a week for a month or longer.

What are the symptoms of Insomnia?

People with insomnia have one or more of the following symptoms:

• Difficulty falling asleep
• Waking up often during the night and having trouble going back to sleep
• Waking up too early in the morning
• Feeling tired upon waking
• Sleepiness during the day
• General tiredness
• Irritability
• Problems with concentration or memory

What are the causes of Insomnia?

Causes of both acute and chronic insomnia can include:

• Stress
• Illness
• Emotional or physical discomfort
• Environmental factors like noise, light, or extreme temperatures (hot or cold)
• Medications
• Shift work
• Depression
• Anxiety
• Chronic stress
• Pain or discomfort at night

How is Insomnia diagnosed?

Insomnia is diagnosed during an overnight stay in a sleep investigation unit. You may be asked to keep a sleep diary for a week or two prior to your overnight stay to keep track of your sleeping patterns and how you feel during the day.

How is Insomnia treated?

Insomnia often can be prevented or cured by practicing good sleep habits (sleep hygiene). Sleeping pills may be prescribed for a limited time by a Sleep Physician (Specialist) if your insomnia is causing day time sleepiness and inability to function properly at work. Rapid onset, short-acting medications can help you avoid effects such as drowsiness the following day. Long term use of any sleeping medication should be avoided and if symptoms persist see your Sleep Physician for further treatment.

Some suggestions for a good night sleep are:

• Try to go to sleep at the same time each night and get up at the same time each morning
• Try not to take naps during the day. If daytime sleepiness becomes overwhelming, limit nap time to a single nap of less than one hour, no later than 3 pm
• Try going to bed only when you are drowsy
• Avoid caffeine within four to six hours of bedtime
• Avoid the use of nicotine close to bedtime or during the night
• Avoid alcohol within four to six hours of bedtime
• Obtain regular exercise, however avoid strenuous exercise four to six hours before bed time
• Avoid eating a heavy meal late in the day
• Minimise light, noise and extreme temperatures in the bedroom
• Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath
• Avoid using your bed for anything other than sleep or sex
• Try making a to-do list before you go to bed. This will prevent "Worry Time"
• Avoid clock watching

If you are unable to fall asleep or stay asleep, leave your bedroom and engage in a quiet activity elsewhere. Do not permit yourself to fall asleep outside the bedroom. Return to bed when – and only when – you are sleepy. Repeat this process as often as necessary throughout the night.

Central Sleep Apnoea (CSA)

Central Sleep Apnoea differs from Obstructive Sleep Apnoea because it occurs when the brain does not send or receive a signal to the muscles of the chest that control breathing of the lungs; and not due to an airway obstruction like OSA. 

In a normal individual, the brain and heart interact to monitor and change the amount of air that we breathe. When a person has central sleep apnoea (CSA), the brain ceases respiratory drive so that no signal is given to initiate or continue breathing.

In adults there are 5 known categories of Central Sleep Apnoea:

1. Primary Central Sleep Apnoea - Cause is not known. The breathing pattern consists of the repetitive absence of breathing effort and air flow.
2. Cheyne-Stokes Breathing Pattern - Causes include heart failure, stroke and possibly kidney failure. The breathing pattern consists of a rhythmic increase and decrease of the breathing effort and volume of air flow. Breathing follows a 'crescendo-decrescendo' pattern.
3. Medical Condition - caused by medical conditions, but without the typical Cheyne-Stokes breathing pattern. It is caused by a wide range of rare conditions as well as heart and kidney conditions. It may also result from a problem in the base of the brain where breathing is controlled.
4. High-Altitude Periodic Breathing - Caused by sleeping at altitudes higher than approximately 15,000 feet. The breathing pattern is similar to the Cheyne-Stokes Breathing Pattern. The difference is that there is no history of heart failure, stroke or kidney failure. The cycle time is usually shorter.
5. Due to Drug or Substance Use - Caused by the use of various drugs; mainly pain medicines in the opioid category, sleeping pills, sedatives and tranquilizers. Breathing may stop completely or increase and decrease in a regular pattern. Breathing can also be quite irregular. It can even have elements of obstruction such as the breathing that is seen in OSA.

Many people with CSA have daytime sleepiness and find they are still tired even after a nap. It is possible for someone to stop breathing hundreds of times in one night making them feel very tired the next day. Because this condition is very serious, a Sleep specialist can determine a treatment plan after the results are collected and the cause of CSA is determined.

Narcolepsy is a sleep disorder characterised by sleep attacks as well as a constant feeling of tiredness that is not relieved with sufficient sleep. People suffering from narcolepsy have a tendency to fall asleep at inappropriate times and if the disorder is not treated correctly it can affect the quality of a person's life. Symptoms may mimic those of other sleep disorders, so more than one sleep investigation may be necessary to correctly diagnose this disorder.

What are the symptoms of Narcolepsy?

There are four common symptoms of narcolepsy, these are:

• Excessive daytime sleepiness
• Cataplexy (sudden loss of strength and tone in the muscles)
• Sleep Paralysis
• Hypnagogic &/or Hypnopompic hallucinations (hallucinations occurring just before falling asleep and/or on waking)

Excessive daytime sleepiness is most common, and therefore the reason for further sleep investigation before correct diagnosis can be made.

What are the causes of Narcolepsy?

Latest research has focussed on the possible deficiency of a neurohormone which may control sleep and wakefulness as the cause of narcolepsy. Cataplexy (a sudden loss of voluntary muscle tone) and sleep paralysis are similar to the loss of muscle tone that is associated with normal REM (dreaming) sleep. In people with narcolepsy however, these events occur at inappropriate times.
Narcolepsy can be hereditary, but many people with narcolepsy do not have a family history.

How is Narcolepsy diagnosed?

Narcolepsy is diagnosed during an overnight stay in a sleep investigation unit followed by a daytime Multiple Sleep Latency Test (MSLT), also conducted in the sleep investigation unit. You may be asked to keep a sleep diary for a week or two prior to your overnight stay to keep track of your sleeping patterns and how you feel during the day. An MSLT as mentioned is a daytime test which involves four or five 20 minute naps at two-hour intervals. This test monitors your sleep patterns, and will show an increase in certain sleep stages (mainly REM sleep) in narcoleptic patients. Most often your Sleep Physician (Specialist) will compare your night study and your day study, along with your symptoms to correctly diagnose your condition.

How is Narcolepsy treated?

Unfortunately there is no cure for narcolepsy, however medications, behaviour treatment and management of your environment can all help control and improve sufferers experiencing symptoms less frequently.

Medication: Prescription medications are available and can be effective in controlling excessive daytime sleepiness, cataplexy, hallucinations and sleep disturbances.

Behaviour Treatment: The following is a guideline for all sleep disorders and recommended for good sleep hygiene:

• Try to go to sleep at the same time each night and get up at the same time each morning
• Try not to take naps during the day
• Try going to bed only when you are drowsy
• Avoid caffeine within six hours of bedtime
• Avoid the use of nicotine close to bedtime or during the night
• Avoid alcohol within six hours of bedtime
• Obtain regular exercise, however avoid strenuous exercise four hours before bed time
• Avoid eating a heavy meal late in the day
• Minimise light, noise and extreme temperatures in the bedroom
• Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath
• Avoid using your bed for anything other than sleep or sex
• Try making a to-do list before you go to bed. This will prevent "Worry Time"
• Avoid clock watching
• If you are unable to fall asleep or stay asleep, leave your bedroom and engage in a quiet activity elsewhere. Do not permit yourself to fall asleep outside the bedroom. Return to bed when - and only when - you are sleepy. Repeat this process as often as necessary throughout the night.

Management of the environment: Educate family members on your disorder. Let friends know about your disorder so they can understand the symptoms. Educate your employer about the disorder to help you continue to be a productive employee and find a narcolepsy support group to discuss with others how they manage their sleep disorder.

Sleep terrors are also called night terrors and is another kind of parasomnia. A typical episode may include a person sitting up in bed and screaming or shouting and can include kicking and thrashing. Those experiencing sleep terrors may have open eyes, may sweat and breathe heavily. During an episode, individuals usually do not respond to voice, they can be hard to wake and once woken they will be very confused and may not know where they are or what is going on.

Sleep Terrors most often occur during the slow-wave cycle of sleep, usually within the first third of the night. Episodes in adults can occur at any time in the sleep cycle and adults are more likely to recall a dream that was a part of the event.

Episodes of sleep terrors and sleepwalking share many of the same causes and these can include:

Sleep talking occurs when you talk out loud during sleep and can occur by itself or may also be a feature of another sleep disorder, such as REM sleep behaviour disorder (RBD), Sleepwalking, Sleep terrors or Sleep related eating disorder (SRED)

Sleep talking may occur in any stage of sleep and is still unknown if the talking is closely linked to dreaming. Sleep talking related to RBD or sleep terrors is much more dramatic. As a part of RBD, talking may be loud, emotional, and profane. Talking during sleep terrors tends to involve intense fear with screaming and shouting.

Sleep talking is very common and is reported in more than half of young children. A small percentage of adults are reported to talk in their sleep and occurs at the same rate in both men and women. In some cases it appears to run in families.

Sleepwalking is also called somnambulism and is yet another type of parasomnia. Sleepwalking occurs when you can get out of bed and walk around even though you are still asleep However, most individuals may experience sitting up in bed and look around. Some may talk or shout as they are walking. A person's eyes are usually open and have a confused, "glassy" look to them. A person may initiate unusual behaviours, many of which should occur while awake.

It can be very hard to wake a sleepwalker up and when they are woken, they are often confused. Many have no memory of the sleep walking event and less often, they will have a very clear memory of all that happened.

Sleepwalking most often occurs during the slow-wave cycle of sleep, and this particular stage of sleep will predominantly occur within the first third of the night. Every now and then, it can occur during a daytime nap.  Episodes occur rarely, and can even happen multiple times a night for a few nights in a row.

Sleep paralysis is classed as a parasomnia, which is an undesired event that occurs with sleep. Sleep paralysis causes inability to move your body either when falling asleep (hypnagogic) or when waking up from sleep (hypnopompic).

It is normal for the brain to decrease muscle tone (atonia) as you sleep, however sleep paralysis seems to transpire when atonia occurs while awake. An episode of paralysis may cause inability to speak or move your arms, legs, body or head; however you are still able to breathe normally.

People who have experienced sleep paralysis are fully aware during the event. It usually ends on its own, by someone touching or speaking to you, or by making an intense effort to move. 

Because sleep paralysis can be very scary when you are unable to move, it may cause anxiety. It tends to first appear in the teen years and then most often occurs during the ages of 20s and 30s. It may continue into your later years; however there is no serious medical risk associated with sleep paralysis.