Thursday, December 21, 2006

Nocturnal leg cramps

Cortlandt Forum has a nice short article on Nocturnal leg cramps:
By Russel Kirkby, MD, and Brian Alper, MD, MSPH

Description• Involuntary nighttime painful leg muscle contraction that does not relax

ICD-9 codes• 728.85 spasm of muscle • 729.82 cramp of limb

Prevalence• 95% of people sometime in their lives • Especially common in women and elderly
Most commonly affected muscle groups• Calf • Foot

Etiology• Most commonly no cause found• Possible causes (or associated conditions) include —Fluid and electrolyte imbalance: hypocalcemia, hyponatremia, hypomagnesemia, hypokalemia, hyperkalemia, chronic diarrhea, hemodialysis —Endocrine disease: thyroid disease, diabetes mellitus, Addison’s disease — Neuromuscular disease: nerve-root compression, motor-neuron disease, mononeuropathies, polyneuropathies, dystonias —Drugs: calcium channel blockers (nifedipine), diuretics, phenothiazines, fibrates, selective estro- gen receptor modulators (raloxifene), ethanol, morphine withdrawal —Toxins: lead, strychnine, spider bites —Congenital disease: McArdle’s disease, glycogen storage disease, autosomal dominant cramping disease —Peripheral vascular disease —Iron deficiency anemia —Liver cirrhosis, chronic alcoholism, sarcoidosis —HIV myelopathy• Pathophysiology speculative, may include reduced blood flow and oxygen supply
Likely precipitating factors• Activity excessive for condition of muscle• Sleeping prone or supine with toes fully extended • Pregnancy (insufficient calcium intake)• Older age
Complications• Insomnia • Irritability • Anxiety • Depression

Clinical evaluation• History of onset and clues to underlying condition• Drug history crucial• Local exam: arterial pulses, skin, nerves—Pulses and capillary fill (rule out vascular compromise) —Assess skin changes—Sensation/vibration
Differential diagnoses• Intermittent claudication• Peripheral neuritis• Restless legs syndrome• HIV myelopathy• Physiologic cramps due to heat, exercise, excessive activity• Electrolyte abnormalities: hyponatremia, hypokalemia, hypomagnesemia• Polycythemia• Endocrine disease: diabetes, thyroid disease, parathyroid disease, adrenal disease • Muscle diseases: glycogen storage or mitochondrial

Testing (for recurrences or underlying disease)• Electrolytes • Glucose • Blood urea nitrogen, creatinine • Calcium, magnesium, phosphate • Hemoglobin, ferritin • Zinc • Liver function tests • Thyroid function tests• HIV if appropriate• Doppler studies of arteries• Electromyelography

Nonpharmacologic management• Reassurance to exclude causes that might cause patients concern, e.g., vascular disease• Major thrust is to avoid sleep disturbance• Trial of omitting possible causative medication• Other treatments to consider—Local heat —Massage —Osteopathic manipulative therapy (OMT): myofascial release, facilitated positional release

Medications to consider• Quinine sulfate 200-400 mg nightly —Beware long-term use.—Rare but serious side effects described (disseminated intravascular coagulopathy, thrombocytopenia, pancytopenia, hemolytic uremic syndrome) —Consider monitoring complete blood count or platelets.• Other drugs similar to quinine —Hydroquinine 300 mg —Quinidine sulfate 400 mg• Other drugs not similar to quinine—Verapamil 120 mg nightly—Gabapentin (Neurontin) may reduce frequency and severity of muscle cramps.—Magnesium not clearly effective• Benzodiazepines (clonazepam, diazepam) or baclofen—Not traditionally associated with nocturnal cramp therapy but helpful in other spastic muscle conditions, e.g., tetanus, status epilepticus, and back muscle spasm —Address treatment goals of avoiding sleep disturbance.• Gastrocnemius trigger point injection of 1% lidocaine• Randomized n-of-1 trials alternating drug and placebo may determine efficacy of specific drugs for individual patients.

Prevention• Stretching exercises — e.g., nightly or twice daily • 20-minute walk may enhance stretching exercises.
See for references.
Quinine is the most commonly used treatment for this poorly understood condition; however with this medication cinchonism needs to be monitored for.

Tuesday, December 19, 2006

The Challenges of Treating Restless Legs Syndrome

The following case report appears in this month's Journal of General Internal Medicine (abstract below):
Medication Tolerance and Augmentation in Restless Legs Syndrome: The Need for Drug Class Rotation
Roger Kurlan, MD, Irene Hegeman Richard, MD, Cheryl Deeley, RNP
Restless legs syndrome (RLS) is a common condition characterized by an unpleasant urge to move the legs that usually occurs at night and may interfere with sleep. The medications used most commonly to treat RLS include dopaminergic drugs (levodopa, dopamine agonists), benzodiazepines, and narcotic analgesics. We report the cases of 2 patients with RLS who illustrate the problems of tolerance (declining response over time) and augmentation (a worsening of symptoms due to ongoing treatment) that can complicate the pharmacotherapy of RLS. We discuss the optimal management of RLS and propose strategies to overcome tolerance and augmentation such as a rotational approach among agents from different classes.

Tolerance and augmentation (see abstract above for definitions) were significant problems with Sinemet, which was previously commonly used to treat RLS. Tolerance and augmentation are less of a problem with the Requip and Mirapex, two dopamine agonists FDA approved for the treatment of RLS. However augmentation and tolerance still occur with these meds, and there is little research about the best way to deal with this vexing problem. I usually treat RLS initially with Requip or Mirapex monotherapy. If tolerance or augmentation occur, I first add another RLS agent (Neurontin, benzodiazepines, or opioids) and then later switch from 1 opioid agonist to another.

Wednesday, December 06, 2006

Mississippi Sleep Criminal

The case of John L. White, a Mississippi commercial truck driver, sounds like an accident—and now a pending law suit—that didn’t have to happen.
White of Gulfport, recently collided his vehicle into a tractor-trailer, causing the death of one man and a multiple-vehicle pile up. Sadly, White is charged with involuntary manslaughter and accused of violating sleep requirements.
The National Highway Traffic Safety Administration estimates that 100,000 police-reported crashes are the direct result of driver fatigue each year. This results in an estimated 1,550 deaths, 71,000 injuries and $12.5 billion in monetary losses. What’s more, approximately 5,600 people are killed annually in crashes involving commercial trucks. While not all of these can be attributed to sleep disorders or drowsiness, research shows that commercial drivers are at risk for everything from highway hypnosis to obstructive sleep apnea (OSA).In the case of 42-year-old trucker John White, court records say he violated commercial truck driving laws requiring at least eight hours of sleep within a certain period of time on the road. According to the Kansas City Star, White was hauling a load of bananas to a Wal-Mart distribution center when he attempted to cross over US 71 and collided with a tractor-trailer. Tragically, the driver of that vehicle, Steven B. Cousineau of Wisconsin, was pronounced dead at the scene. In addition, the crash caused two other motor vehicle wrecks, but none of the other drivers reported any injuries. The news report makes no mention of White suffering from a sleep disorder and does not clearly state that he fell asleep at the wheel. The case is focused strictly on his state of sleep deprivation while on duty. A recent study by University of Pennsylvania researchers looked at why so many commercial drivers get drowsy or fall asleep at the wheel. They concluded that the two biggest culprits are chronically insufficient sleep and obstructive sleep apnea. Of the 247 commercial drivers tested by the researchers, the percentage of drivers with two or three performance impairments after less than 5 hours of sleep was 49.5%. Clearly, there is good reason for commercial drivers to abide by sleep laws intended for their own safety and the safety of others.

Friday, December 01, 2006

Childhood sleep question

A reader e-mailed the following exam question regarding sleep disorders in children:

The Q with its alternatives is>as follows;All the following do not constitute>pathologic criteria for sleep except 1.hypnic jerk>2.increased somnolence 3.sleep myoclonus.are there any>different pathologic criteria for children other than>ICSD2.if so what are these criteria.Your reply would>be of immense help for my exams.

My answer was:
hypnic jerk is benign. Somnolence and myoclonus are pathologic.

If anyone has a better answer for this question, please post it in the comments.

Wednesday, November 15, 2006

New medication for restless legs syndrome

Requip now has a competitor. The National Sleep Foundation reports that Mirapex has been approved for the treatment of RLS:
The Food and Drug Administration (FDA) has approved Mirapex for the treatment of moderate-to-severe primary restless legs syndrome (RLS), a common condition in which an irresistible urge to move the legs impacts a person’s quality of life and ability to sleep. A recent analysis of NSF’s 2005 Sleep in America poll published in the journal CHEST found that 9.7% of adults reported symptoms of RLS at least a few times a week.
Mirapex is made by Boehringer-Ingelheim and since 1997 has been indicated for treatment of symptoms of Parkinson’s disease. In
clinical trials it was shown that lower doses (than used for Parkinson’s disease) improve RLS symptoms, sleep satisfaction, and quality of life. Side effects of the drug may include hallucinations, dizziness, sweating, and nausea and Boehringer-Ingelheim warns that Mirapex may cause patients to fall asleep without any warning, even while doing normal daily activities such as driving.

Monday, November 13, 2006

New ICD-9 code for restless legs syndrome

The American Academy of Sleep Medicine reports that the ICD-9 code for restless legs syndrome is being changed from 333.99 to 333.94:
The ICD-9 Coordination and Maintenance Committee recently published an addendum announcing a change in the code for restless legs syndrome. Effective October 1, 2006, the new code is 333.94. Please note it may take time for insurance companies to institute the change. For more information, visit

Sunday, November 05, 2006

Alcohol and sleep

Question: Will drinking a glass of wine at bedtime help me to get a better night’s sleep?

1 to 2 drinks of an alcoholic beverage will often help a person to fall asleep. Larger amounts of alcohol, when used on a regular basis, can interfere with the ability to fall asleep. Any amount of alcohol near bedtime can lead to awakenings later in the night, as the effect of alcohol is wearing off.
Alcoholism can lead to insomnia that may last for 2 years after alcohol use is discontinued.
Alcohol can make snoring and obstructive sleep apnea worse. Persons with untreated sleep apnea should avoid alcohol near bedtime.
Rather than treating your insomnia with alcohol, a better option is consulting with a primary care physician or sleep specialist for safer and more effective treatments.

Saturday, October 07, 2006

Bipolar Disorder and Sleep

Sleep disturbance is a well-recognized feature of acute psychiatric illness, and is included in the diagnostic criteria of many of the affective and anxiety disorders. Recent research has found that disrupted sleep and sleep complaints are common in patients with affective disorder even between mood episodes. Treatment of disrupted sleep and the maintenance of a regular sleep/wake cycle are important components of the prophylaxis of mood episodes in bipolar disorder.
Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. Even when euthymic, sleep disturbance is common. In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Clinical vignette
JW, a single 25 year-old female with bipolar type I disorder, had been relatively stable for the last three years on a regime of lithium 600 mg twice daily and Ambien (zolpidem) 10 mg at bedtime. She had not had a distinct mood episode since her last episode of bipolar mania three years ago. She obtained 7 to 8 hours of sleep at night, and was satisfied with her job as a respiratory therapist working for a durable medical equipment (DME) company.
Four weeks ago, the DME company went out of business, and JW took a job as a sleep technician working for a growing sleep disorders center. This exciting job involved working 8 pm to 6 am Tuesday through Friday. JW was only able to sleep 5-6 hours after her shift, even with the aid of Ambien. She slept about seven hours on nights she was not working.
Three days ago, on a Saturday morning, JW felt unusually energized as she was finishing her shift. She drove home and spent the next sixteen hours cleaning her house from top to bottom. JW then slept for an hour and went to a dance club. She left the dance club when it closed at 3 am and returned to her house, where she slept for two hours. She exercised extensively on Sunday and showed up at the sleep center Sunday night. She told her co-workers she was there because she was now the owner of the sleep center and she wanted to make sure they were doing their jobs right. She was talking rapidly and pacing. JW became agitated when the the other sleep technicians refused to take orders from her. The medical director was called. He, with great difficulty, was able to convince her to go to the ER. The medical director and a technician drove her to the ER, where treatment was begun for a bipolar manic episode.

Comment: JW developed a manic episode with symptoms of grandiosity, decreased need for sleep, rapid speech, and increased goal-directed activity. A change in sleep habits can precipitate a bipolar mood episode. Night work and shift work have a destabilizing influence on bipolar disorder.

Bipolar disorder is treated with mood stabilizing agents such as sodium valproate, carbamazepine, or lithium. Addition of an antidepressant may be necessary to control bipolar depression. The maintenance a stable sleep/wake cycle, as well as regularization of the circadian rhythm, are key components of a relatively new psychotherapy for bipolar disorder, Interpersonal and Social Rhythm Therapy (IP-SRT). IP-SRT is most effective for mood episode prophylaxis in the maintenance phase of bipolar, and in individuals without significant medical comorbidity or anxiety (Frank et al 2005).
The above is from a chapter I am writing for Medlink Neurol0gy entitled "Sleep disorders associated with mental disorders". It is copyrighted by Medlink Neurology.

Tuesday, October 03, 2006

Viagra worsens sleep apnea

The National Sleep Foundation reports:
Each year, millions of men in American seek treatment for erectile dysfunction (ED), a condition that is often associated with obstructive sleep apnea (OSA). Since its introduction in 1998, Viagra has become the most common form of treatment for ED. It works by enhancing the effects of nitric oxide, a compound that relaxes muscles in the penis and allows for increased blood flow, triggering an erection. Now a new study by a team of Brazilian and American researchers suggests that a single 50-mg dose of Viagra may actually worsen symptoms of obstructive sleep apnea (OSA). The study involved 14 middle-aged men with severe OSA in a double-blind crossover study. Using polysomnography, the researchers analyzed the severity of symptoms and found a significant increase following a dose of Viagra compared to placebo.
Here is the abstract for the study:
A Double-blind, Placebo-Controlled, Crossover Study of Sildenafil in Obstructive Sleep Apnea
Suely Roizenblatt, MD, PhD; Christian Guilleminault, MD, BiolD; Dalva Poyares, MD, PhD; Fátima Cintra, MD, PhD; Adriana Kauati, PhD; Sergio Tufik, MD, PhD
Arch Intern Med. 2006;166:1763-1767.
Background Sildenafil prolongs the action of cyclic guanosine monophosphate and nitric oxide by inhibiting cyclic guanosine monophosphate–specific phosphodiesterase 5. It is largely used for erectile dysfunction, a highly prevalent condition in obstructive sleep apnea. Because nitric oxide promotes upper airway congestion, muscle relaxation, and pulmonary vasodilation, the aim of this study was to establish the impact of a single 50-mg dose of sildenafil on the sleep of patients with severe obstructive sleep apnea.
Methods Fourteen middle-aged men with severe obstructive sleep apnea were consecutively selected for this double-blind, placebo-controlled, crossover study. Exclusion criteria were obesity, cardiovascular and/or respiratory disease, and conditions that interfere with sleep. All-night polysomnography was preceded by a single 50-mg dose of sildenafil or matching placebo randomly administered at bedtime, after a washout period of 1 week.
Results In comparison to placebo, a single 50-mg dose of sildenafil significantly increased the percentage of total sleep time with an arterial oxygen saturation of less than 90% (mean ± SD, 14.2% ± 9.1% vs 8.5% ± 3.2%, P<.01), without a difference in the nadir of oxygen desaturation. The mean arterial oxygen saturation also decreased (92.1% ± 1.91% vs 93.8% ± 1.3%, P = .02), and the desaturation index increased (30.3 ± 18.1 events per hour vs 18.5 ± 14.6 events per hour, P<.001). There was an increase in apnea-hypopnea index (42.4 ± 25.5 events per hour vs 34.6 ± 24.1 events per hour, P = .01), involving mostly obstructive events.
Conclusion In patients with severe obstructive sleep apnea, a single 50-mg dose of sildenafil at bedtime worsens respiratory and desaturation events.

Based on this study, physicians should be cautious in prescribing Viagra, Cialis, or Levitra in patients with known or suspected untreated severe obstructive sleep apnea.

Saturday, August 26, 2006

Mothers and Sleep

Most mothers would agree that their sleep habits are a lot different than they were before having children. Lazy weekend mornings are a thing of the past and most find fewer hours to catch some shut-eye during the week, too. Sonia Cannon, of Jackson, can relate. Erin, her 7-year-old daughter, takes up most of her time in the evenings. “During the school year, after helping Erin with homework, preparing dinner and putting her to bed, I feel like my night has just begun for relaxation,” says Cannon. “Sleep is the last thing on my mind.” Moms are not alone. According to recent studies, Americans in general are getting less sleep than ever before. Up to one-third of Americans have symptoms of insomnia; sleep apnea and restless leg syndrome are also common. Most untreated sleep disorders are associated with high blood pressure, heart attack, stroke and psychiatric problems. “Most people need seven to eight hours of sleep per night,” says Dr. Michael Rack, medical director for Somnus Sleep Clinic in Flowood. “That doesn’t change. Once we reach adulthood, our sleep needs remain the same.” Rack says that one hot topic in the news lately is the relationship between sleep and obesity. “Sleep deprivation defined as less than six hours of sleep per night, has been linked to weight gain,” adds Rack. Many moms have accepted lack of sleep as a fact of life. So how do you know if you have a real problem? Dr. Alp Baran, director of the Sleep Disorders Center at the University of Mississippi Medical Center, says that sleep disorders are more common than we think. “I tell people all the time that snoring is not normal,” he says. “If you snore, see your doctor for treatment.” Sleeping longer on weekends can be another sign of a possible problem. A mother of two teenagers and two college kids, Teresa Adams, of Madison, runs a busy household, volunteers at church and juggles graduate school every day. “I don’t get much sleep and my body is used to it now. I know it’s not a healthy lifestyle,” she says. Cannon says, “I have to make sure all of my daughter’s needs are met on a daily basis even if I’m tired from a long day at work.” Both women admit that a cup of coffee is often the only way they can jump-start the day. It can be quite a challenge to find time for those much-lauded eight hours between careers, carpool and mealtimes. Rack says set a sleep schedule and stick to it. “Going to bed and waking up at the same time every day, including weekends, is important.” Both Baran and Rack agree that avoiding caffeine and alcohol late in the day, forgoing a heavy meal or strenuous exercise before bedtime, and banishing the television from the bedroom can also help women get to sleep faster and more restfully. Rack does note, however, that exercise earlier in the day can actually contribute to a good night’s rest. Additionally, Baran reminds moms that getting kids into a good bedtime routine will help moms rest easier. Rack and Baran also suggest that married couples ask their partners what they are doing during the night — snoring, tooth grinding, etc. “Share this information with your doctor to help him/her get to the root of the problem,” Rack adds. Most sleep disorders can be easily treated with medication, counseling, behavioral therapy or a combination of treatments. So rest easy!

Friday, August 18, 2006

Thumb Ring for Sleep Apnea

I just learned that a reflexologist in Jackson MS is using "thumb rings" to treat sleep apnea. I found this add for "The Anti Snor Therapeutic ring" on the web:
From Florence Cardinal,Based on acupressure
Guide Rating -
The Anti Snor Therapeutic ring uses the concepts of acupressure to improve sleep. It's designed to reduce snoring, sinus problems and restless sleep.
Acupuncture/acupressureAcupuncture has been around for hundreds of years. Acupuncture without needles is called acupressure. Both work on the many meridians that run throughout the body carrying energy. The use of acupuncture or acupressure is said to clear stoppages of this energy.
The Anti Snor Therapeutic ring uses the concepts of acupressure to improve sleep. It's designed to reduce snoring, sinus problems and restless sleep. This is accomplished by wearing a ring that's crafted with tiny silver balls that apply light pressure to the base of the little finger of the left hand.

How the ring worksThis pressure stimulates acupressure points which, in turn, stimulate the meridian that leads to the small intestine, through the body to the heart. This meridian continues up the arm the face, jaw and head.
Stimulating this meridian frees the energy in the small intestine and heart meridians, and has a calming effect on the entire body. The It's excellent those suffering from stress induced insomnia

I don't think that it works.

Monday, August 14, 2006

CPAP use by Children

SAN JUAN, P.R. — Continuous positive airway pressure can be effective for obstructive sleep apnea in children, but parents must be persistent to ensure children's acceptance of the treatment, Dr. Ann C. Halbower said at a meeting sponsored by the American College of Chest Physicians.
Obstructive sleep apnea (OSA) is present in 2%–3% of children, and peaks at 3–6 years of age—which is also the peak age for adenotonsillar hypertrophy. The presentation depends on the age of the child: In the infant, it might present as sudden infant death syndrome (SIDS). Toddlers with OSA will have hyperactivity, school-age children will have failure to thrive and poor school performance, and adolescents may present with obesity and excessive daytime sleepiness.
Adenotonsillectomy is the first-line therapy for children with OSA. When that is not successful, continuous positive airway pressure (CPAP) can promote more ordered breathing during sleep and relieve OSA.
CPAP can be problematic in children, however. “It's very hard to take. Little kids don't like it, but there are things parents and physicians can do to help make CPAP more palatable,” said Dr. Halbower, who serves as medical director of the pediatric sleep disorders program at Johns Hopkins University, Baltimore. Dr. Halbower recommended introducing the device slowly to minimize the fear factor. Put on the mask while the child is awake and doing an activity that is fun and pleasurable, she said.
The worst thing you can do is put the mask on while the child is asleep. “If they wake up and find themselves wearing the mask, they'll panic,” Dr. Halbower said
Another trick that can be used to make CPAP part of the child's normal bedtime routine, along with brushing the teeth and a bedtime story. Other children who use CPAP are wonderful ambassadors for the device and can help relieve anxiety with a show-and-tell. Videos are good for this as well.
Despite these efforts, some children will do everything to resist attempts to put on the mask. Many parents will remove the mask in response to their child's distress.
That is a big mistake, Dr. Halbower said, because it just strengthens the child's escape and avoidance behavior. Eventually, the parent gives up.
Behavioral training can help parents block or prevent their child's avoidance behavior by using brief verbal prompting, redirection to a specific task, and if necessary, physically blocking escape while gently guiding the child to remain in the situation.
The child's attempt to remove the mask must be physically interrupted and the mask replaced immediately every time the child removes it. She said these behavioral techniques are used in her clinic under the guidance of Keith Slifer, Ph.D., a behavioral psychologist. [The techniques] “have proved very successful,” Dr. Halbower said.
Parents should also plan for safety in children who cannot remove the mask during emergencies, Dr. Halbower cautioned.
Use a nasal mask instead of a full-face mask, or have an emergency pull string that can disengage the mask to prevent aspiration or asphyxiation if the child vomits.
It is important for parents to establish a consistent bedtime routine that lasts about 30 minutes, Dr. Halbower explained. Such a routine includes soothing activities, and it always ends with the child putting on the CPAP mask, lying down, and going to sleep.
“Persistence and patience are key,” she said.

Adenotonsellectomy usually cures childhood obstructive sleep apnea. However, many obese children with OSA will end up needing CPAP.

Thursday, August 10, 2006

Traveling with CPAP

... tips to help CPAP users increase compliance while traveling:
Inform the airline about using CPAP therapy while onboard. Many airlines have strict policies regarding using CPAP therapy while in flight, but by calling beforehand, CPAP users can minimize the hassle that is sometimes involved with using a CPAP device while flying.
Use a battery-powered CPAP device
Bring an extension cord. Travel with extra filters.
Pack distilled water for humidifiers. Keeping a small bottle of distilled water in a container is an easy way for CPAP users to carry along the water needed for humidifiers, Larkin said.
From Sleep Review Magazine . I tried to find a picture of someone wearing CPAP on an airplane to illustrate this post, but apparently there is no picture like this on the internet.

Thursday, August 03, 2006

Valerian for Insomnia

Valerian is a medicinal herb that may be useful in the treatment of insomnia. It is thought to increase the level of GABA in the synaptic cleft.
The National Sleep Foundation reports:
Herbal remedies are used around the world for a variety of ailments, including sleep disorders. For many years, sleep researchers have studied herbal compounds such as valerian in hopes of finding new treatments for insomnia and other sleep problems. Sold in the United States as a dietary supplement and loosely regulated by the FDA as a food substance, valerian is available in the form of a tea, tincture, capsule, or tablet. People try valerian as a natural sedative for nervousness and insomnia. With so many Americans suffering from insomnia - 54% report symptoms at least a few nights a week or more, according to the National Sleep Foundation’s 2005 Sleep in America poll – it’s no wonder that insomnia sufferers would seek out remedies.
But does valerian really work? The latest word comes from the Office of Dietary Supplements (ODS) at the National Institutes of Health (NIH) in their recently updated and thorough fact sheet on valerian for the treatment of insomnia. It states that while evidence from some clinical studies suggests that valerian may be useful for insomnia, others do not. Also, in its State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults, NIH found that only non-benzodiazepine medications and cognitive behavioral therapy (CBT) have evidence for safety and efficacy to support their use for the treatment of insomnia. This report also found that insomnia often occurs in association with other disorders, in which case, seeking medical treatment would be recommended over the use of self-treatments such as valerian.
NIH also warns, "Like drugs, herbal or botanical preparations have chemical and biological activity. They may have side effects. They may interact with certain medications. These interactions can cause problems and can even be dangerous. Before taking an herb or a botanical, consult a doctor or other health care provider-especially if you have a disease or medical condition, take any medications, are pregnant or nursing, or are planning to have an operation. Before treating a child with an herb or a botanical, consult with a doctor or other health care provider."

Here is the NIH fact sheet on valerian.

Monday, July 24, 2006

Sleep is Underrated

Katie Couric, the former "Today" co-host and future "CBS Evening News" anchor stated in an interview: “I took the entire month of June off,” said Ms. Couric. “I found that sleep is very underrated and it was a great time for me to relax and spend quality time with my children.”

Thursday, June 29, 2006

Rich people get more sleep

In a study of sleep characteristics in 669 adults in Chicago who were compared by sex and race, investigators found that blacks got less sleep than whites, while men got less sleep than women.
Furthermore, the wealthier you are, the more sleep you're likely to get, Dr. Diane S. Lauderdale of the University of Chicago and her colleagues found.
"There was an expectation that people with very demanding jobs in terms of high status, high income, would be getting less sleep, and that was not true," Lauderdale told Reuters Health in an interview. The findings could help explain why blacks suffer from more health problems than whites, she added.

Monday, June 12, 2006

Short Naps are Better

Thinking about taking a nap, but not sure how much napping will help you wake up refreshed? A new study finds that ten minutes may be the magic number when it comes to napping. The study of 24 healthy, young adults who were good sleepers and not regular nappers investigated what would be most effective after a night of five hours of sleep – no nap, a five minute, ten minute, twenty minute or thirty minute nap. Participants took afternoon naps at 3 p.m., and their performance post-nap was measured for three hours. Benefits of the five-minute nap were similar to taking no nap, while twenty and thirty-minute naps offered improvements up to an hour and a half after the nap, though immediately following these naps there was a period of reduced performance, sleep inertia and sleepiness. In the end, the ten-minute nap yielded the most benefits with the least side effects. This nap triggered improvements in cognitive function, sleepiness, fatigue, vigor, etc., and the effects lasted for up to 155 minutes. Researchers believe further investigation is needed to understand what processes occur in the first ten minutes of sleep and how they may provide benefit.
From the National Sleep Foundation. Here is the actual abstract:

A Brief Afternoon Nap Following Nocturnal Sleep Restriction: Which Nap Duration is Most Recuperative?
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Amber Brooks, PhD; Leon Lack, PhD
School of Psychology, Flinders University, Adelaide, SA, Australia

Study Objectives: The purposes of this study were to compare the benefits of different length naps relative to no nap and to analyze the electroencephalographic elements that may account for the benefits. Design: A repeated-measures design included 5 experimental conditions: a no-nap control and naps of precisely 5, 10, 20, and 30 minutes of sleep. Setting: Nocturnal sleep restricted to about 5 hours in participants’ homes was followed by afternoon naps at 3:00 PM and 3 hours of postnap testing conducted in a controlled laboratory environment. Participants: Twenty-four healthy, young adults who were good sleepers and not regular nappers. Measurements and Results: The 5-minute nap produced few benefits in comparison with the no-nap control. The 10-minute nap produced immediate improvements in all outcome measures (including sleep latency, subjective sleepiness, fatigue, vigor, and cognitive performance), with some of these benefits maintained for as long as 155 minutes. The 20- minute nap was associated with improvements emerging 35 minutes after napping and lasting up to 125 minutes after napping. The 30-minute nap produced a period of impaired alertness and performance immediately after napping, indicative of sleep inertia, followed by improvements lasting up to 155 minutes after the nap. Conclusions: These findings suggest that the 10-minute nap was overall the most effective afternoon nap duration of the nap lengths examined in this study. The implications from these results also suggest a need to consider a process occurring in the first 10 minutes of sleep that may account for the benefits associated with brief naps.

Thursday, June 08, 2006

Dear Abby says to go see a Sleep Specialist

DEAR ABBY: I am a 37-year-old married woman with a problem. My mother committed suicide when I was 18, and I have never dealt with my loss. The day after she died, my father bagged up all of her possessions and gave them to charity. I tried talking to him about her, but he told me she was "gone" and I had to move on. I guess I have just put my pain on the back burner all these years.
For the last five years or so, I have been sleepwalking and having horrible nightmares about my mother's death. My husband tells me I carry on conversations with him, but that I am not really "there." I also take baths when I'm technically asleep. On one occasion, I woke up behind the wheel of my truck in my garage. I don't know if I went out driving or not, but the thought terrifies me.
I am afraid I will hurt myself, or possibly others, in my zombie-like state. Any advice you can give me would be greatly appreciated. -- OUT OF IT IN LAS VEGAS
DEAR OUT OF IT: Please accept my deepest sympathy for the tragic loss of your mother. The first thing you must do is ensure that your husband has the keys to your truck at bedtime.
Then, contact your physician and ask for a referral to a sleep disorder specialist for an evaluation. Some people experience the symptoms you have described as a side effect from certain sleep-aid medications. However, if you are not taking anything, you may have a treatable sleep disorder.
After that, ask your doctor to refer you to a licensed psychotherapist who can help you deal with the emotions you have kept buried all these years since your mother's death. Once your feelings are out in the open, you will be able to deal with them -- and discussing them with a professional will help you more quickly through the process.

Tuesday, June 06, 2006

The difference between CPAP, BiPAP, and auto-CPAP

A reader asks "I've been on a CPAP for years, but my sleep specialist is putting me on an AutoPAP. In the meantime, my DME has me on a loaner BiPAP and I feel a lot better even after one night's sleep.Also, does the difference in machines do anything in reducing long term complications"

CPAP, continuous positive airway pressure, delivers a single continuous level of pressure. CPAP is usually effective in treating obstructive sleep apnea. BiPAP delivers a higher pressure while breathing in, and a lower pressure while breathing out. BiPAP can be used to treat obstructive sleep apnea and is sometimes effective in treating central sleep apnea. I t can also be used to assist ventilation in various pulmonary and neurological disorders. Auto-CPAP can be used in 2 different manners: 1) to vary pressure during sleep for a person who has varying pressure requirements (for example, needing a higher pressure during REM sleep) and 2) can be used on a temporary basis to do a CPAP titration. In cases in which patients have had a CPAP titration in the sleep lab but I'm still not quite sure of the exact optimal pressure, I sometimes send them home with an auto-CPAP machine for a few nights. The machine generates a computerized printout that helps me pick the right pressure.
In OSA, the differences in the machines make no difference in reducing complications as long as the patient is compliant with treatment and receiving an effective pressure(s).

Sunday, June 04, 2006

Measuring Sleepiness in Children

Clinical Psychiatry News has a good article about the use of the Multiple Sleep Latency Test in pediatric patients:
Although a simple clinical evaluation can provide a fairly good indication as to whether the child has daytime sleepiness, it's often difficult to estimate how severe the problem is. “The multiple sleep latency test (MSLT) can help answer that question in an objective way that's been standardized and well validated,” said Dr. Hoban of the sleep disorders center at the University of Michigan, Ann Arbor.
Unlike certain questionnaire-based assessments, the MSLT has been validated in children, and provides reliable results as long as the child is at least 6 or 7 years old. However, the test is expensive and time consuming to perform and must be conducted in a sleep lab. The MSLT may be useful when a child has excessive daytime sleepiness but the clinical history, examination, and polysomnography reveal no specific cause. Dr. Hoban recommended judicious use of the MSLT in evaluations of sleep-disordered breathing, circadian rhythm disorders, narcolepsy, and other disorders of excessive sleepiness.
Developed initially at Stanford (Calif.) University in the 1970s, the MSLT has a simple premise: People who are sleepy will fall asleep faster than those who are not.
After a night of polysomnography to screen for some sleep disrupters and to ensure that the patient has had a good night's sleep, the child is given four or five chances to nap in a dark, quiet environment, with each nap separated by about 2 hours. If the child fails to fall asleep (as measured by EEG tracings) within 20 minutes, the nap opportunity ends. Otherwise the child is allowed to sleep for 15 minutes following the first epoch of sleep.
In addition to the latency of sleep, the MSLT records the presence of sleep-onset REM periods (SOREMPs). The presence of SOREMPs correlates strongly with the presence of narcolepsy. Narcoleptic patients also typically have a sleep latency of 5 minutes or less.

The article goes on to give normative data for interpreting the MSLT in pediatric patients:
Normal adults have a sleep latency of about 15 minutes, but normal latencies in children can be much longer. Detailed studies have correlated mean sleep latencies with Tanner stage. Children in Tanner stage 1 take an average of 19 minutes to fall asleep, whereas those in stage 5 take about 16.6 minutes; older adolescents take a mean 15.7 minutes to fall asleep.
“The net result of this is that in preadolescent children you can have a sleep latency of 14 or 15 minutes that would be considered solidly normal by adult standards but substantially abnormal for a child,” Dr. Hoban said.

For moreinformation about the use of the MSLT in the diagnosis of narcolepsy, see here.

Tuesday, May 09, 2006

Nocturia and Obstructive Sleep Apnea

From the National Sleep Foundation:
Who would have thought that sleep apnea might be responsible for frequent trips to the toilet at night, but a recent study of 97 individuals (75 men and 22 women), found that individuals with sleep apnea who also experienced nocturia (frequent urination at night) benefited from continuous positive airway pressure (CPAP) treatment. Researchers at the Institute of Urology in Tel Aviv, Israel found that individuals awoke to urinate 2.5 times on average per night before treatment, and after being treated with CPAP, the majority of participants only awoke 0.7 times per night on average. Of the 97 participants, 73 reported improvement in nocturia. The results indicate that CPAP treatment for obstructive sleep apnea (OSA) may also have positive effects on nighttime urination.
Nocturia is a common symptom of sleep apnea. This has been well know to sleep specialists. This study demonstrates that CPAP is an effective treatment for this OSA symptom. One of these days I'll get around to posting an explanation of how osa causes nocturia.

Friday, April 21, 2006

Vice President Cheney

Vice President Dick Cheney appears to nod off during a news briefing by President Bush and Chinese President Hu Jintao in Hu's first Oval Office visit. (Tim Sloan/AFP/Getty Images)

I don't think he's sleeping, the Vice President was just pondering matters of national security with his eyes closed.

Sunday, April 16, 2006

Insomnia can lead to desperation

Drudge links to this story about a man who backed out of re-enacting the Crucifixion.
The man was considering re-enacting the Crucifixion as part of a spiritual journey to regain his faith.
What led to his loss of faith?
“His insomnia was a major problem. He used to lie in bed all night praying for God to let him sleep and He never answered so he began to think there was no God.”

Monday, March 27, 2006

Sleep Chat

A reader posted this comment about a live web chat about sleep: Thought you all might like to know the WebMD sleep expert, Dr. Michael Breus, is going be hosting a live web chat on Saturday night (April 1) for two hours beginning at 11:30pm EST. He's going to answer sleep-related questions in a chat room on Apparently, this all part of Carpenter CO. National Sleep Better Night.

Wednesday, March 22, 2006

Update on the Relationship between Sleep and Metabolism

The Relationship between Sleep and Metabolism

Karine Spiegel, PhD, and colleagues published an article in the December 7, 2004 issue of the Annuals of Internal Medicine that suggests that sleep restriction can lead to weight gain. They found that sleep restriction (4 hrs /night) leads to decreased levels of the hormone Leptin and increased levels of Ghrelin, another hormone. The alteration of the levels of these appetite and energy regulating hormones was associated with increased hunger and appetite in the study. This study adds to the evidence linking insufficient sleep to obesity.

More recently, Dr. Henry Klar Yaggi and colleagues reported on a 15-year study that examined the association between sleep duration and the risk of developing type 2 diabetes mellitus. The prospective observational Massachusetts Male Aging Study found that men reporting short sleep duration (6 or less hours per night) and men reporting long sleep duration (more than 8 hours per night) were at significantly increased risk for developing diabetes compared to those getting 7-8 hours of sleep.

Insufficient nocturnal sleep can be caused by either a sleep disorder or voluntary sleep deprivation. Excessive sleep is usually caused by an underlying sleep disorder. Abnormal nocturnal sleep durations have been linked with obesity, impaired glucose tolerance, and diabetes mellitus.

It is important for physicians to counsel their overweight and obese patients to allow for 8 hours of sleep per night. Since obstructive sleep apnea is both a cause and consequence of obesity, practitioners should screen their obese patients for this common disorder. Useful symptoms to ask about include snoring, prolonged sleep duration, frequent nocturnal awakenings, and excessive daytime sleepiness.

Ambien and Sleepwalking

The American College of Physicians reports:
Widely prescribed sleep aid prompts complaints of sleepwalking
A widely used sleep aid has sparked concerns about sleepwalking and other unusual behaviors among people prescribed the drug.
Cases of sleepwalking related to use of zolpidem tartrate (Sanofi-Aventis’s Ambien) have been reported in medical journals and by sleep experts, said the March 14 Washington Post. Some patients also have reported evidence of nocturnal eating after taking the drug, the article said, and of having no memory of those incidents when they awake.
The drug, which accounted for more than 24 million prescriptions in 2004, has prompted more sleepwalking reports to the FDA than all other sleep medications combined, said the Washington Post. In addition, five cases were reported in a 2002 edition of the journal Sleep Medicine while researchers at the Minnesota Regional Sleep Disorders Center reported 19 cases at a medical conference last year.
The drug’s label acknowledges somnambulism as a rare but potential side effect, along with other potential central nervous system effects, that have been reported in fewer than one in 1,000 patients, said the article. Zolpidem tartrate is among a group of newer sleep aids that are considered safer and less addictive than older drugs, the Washington Post reported, adding that the FDA did not raise questions about the side effects before approving the drug in 1993.
The FDA adverse event report databases show that 207 somnambulism reports were made between 1997 and June 2005, said the Washington Post. Most physicians reporting the episodes listed the cause as unknown but 48 linked them to zolpidem tartrate. By comparison, there were 18 reports filed about benzodiazepines, an older class of sleep aids that includes six drugs.
The Washington Post is

Monday, March 20, 2006

More Psychiatrists are going into Sleep Medicine

Psychiatric News reports that psychiatrists are becoming increasingly attracted to a career in sleep medicine:
A woman hospitalized for treatment of her mood disorder snored so loudly that other patients complained. A sleep study showed she had severe obstructive sleep apnea.
After using a continuous positive airway pressure (CPAP) device that delivers air via a mask worn in sleep, she felt more focused and alert. "Her mood improved, and we were able to make greater inroads into her psychiatric problems," related William Clemons, M.D., then a resident in psychiatry at West Virginia University in Morgantown.
The contribution of a previously unrecognized sleep disorder to the woman's psychiatric illness proved a signal event for Clemons. He pursued a sleep-medicine fellowship at the University of Michigan, completing the one-year program in 2004. He now practices sleep medicine at the Baptist Sleep Institute in Knoxville, Tenn.

"We are seeing an explosion of interest in sleep medicine as a career option for psychiatrists," said Michael Sateia, M.D., a professor of psychiatry and chief of sleep medicine at Dartmouth Medical School. This interest is reflected in the American Board of Medical Specialties' (ABMS) approval last year of sleep medicine as a subspecialty for physicians practicing psychiatry, neurology, internal medicine, and pediatrics, he noted. ABMS recently added otolaryngology to the list.
Starting in 2007, the American Board of Internal Medicine will administer the sleep-medicine board exam, with certification conferred by boards overseeing the specialties listed above. The exam formerly was given by the American Board of Sleep Medicine.
"The new exam acknowledges that sleep medicine involves a sufficient body of knowledge and skill sets to qualify as an independent medical subspecialty," said Lawrence Epstein, M.D., president of the American Academy of Sleep Medicine (AASM) and regional medical director for Sleep HealthCenters in Boston.
The Accreditation Council for Graduate Medical Education (ACGME) has approved 24 sleep-medicine fellowships nationwide. ACGME recognition means that funding for fellowships is available from the Centers for Medicare and Medicaid Services. Fellowships typically provide an annual stipend of about $60,000.

Allen Richert, M.D., the psychiatry residency training director at the University of Mississippi Medical Center, thinks sleep medicine education belongs in the psychiatry residency.
"Sleep disorders and sleep deprivation contribute to depressed mood, irritability, attention deficits, and sleepiness," he said. "Psychiatrists need experience with hypnotic medications and cognitive behavioral therapy for insomnia."
Patients with sleep disorders benefit from a psychiatric perspective, he added. "Psychiatrists understand how patients' emotions drive behavior."

Psychiatrists interested in sleep medicine should contact their local sleep disorders centers, suggested Daniel Buysse, M.D., a professor of psychiatry at the University of Pittsburgh School of Medicine. "Many centers are looking for more input from psychiatrists to help them manage patients with sleep disorders and psychiatric comorbidity."

Friday, March 03, 2006

Practice Parameters for BiPAP and CPAP

The American Academy of Sleep Medicine has issued "Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients With Sleep-Related Breathing Disorders"; here is the abstract:
Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization.8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.
Recommendation number 7 is significant. This should help patients get insurance reimbursement for having heated humidifiers added to their CPAP machines.

Thursday, March 02, 2006

Sleep Searches

One of my brothers-in-law (David) sent me the following link to the Yahoo Buzz Index:

Concerned by the results of a new poll showing Americans aren't getting the shuteye they should, we decided to get under the covers of sleep searches. We snuggled up close to our top 10 sleep queries...
Sleep Apnea
Sleep Number Bed
Sleep Disorders
Sleep Deprivation
Sleeping Pills
Sleep Paralysis
Sleeper Sofas
Sleep Aids
Sleepwalking Is eight hours of comfortable rest just a dream, or are you spending your sleepy time in a deep REM state? The thought of a nice long snooze got us daydreaming about the top 10 dream searches. Picture, if you will...
Dream Dictionary
Dream Interpretation
Meaning of Dreams
Dream Analysis
Dream Moods
Dream Symbols
Lucid Dreaming
Dream Journal
What Do Dreams Mean
Dream Poems

Tuesday, February 28, 2006

Somnus Sleep Clinic in the News

An article in the Clarion-Ledger newspaper features Somnus Sleep Clinic:
The lesson: Listen to your spouse.
For 23 years, John Kirk snored and Linda Kirk endured.
It got so bad about 10 years ago, John hardly slept - and often, neither did Linda.
John was tired all the time, went to bed early, skipped outings, stopped exercising and made sure to do important tasks in the morning, because he was so wiped out later in the day.
He'd often stop breathing for long periods while sleeping, awake gasping for air, and remember none of it in the morning.
But still, his wife's suggestions notwithstanding, he did not seek medical advice.
He wishes he had.
Like most other sleep disorders, sleep apnea isn't all that hard to deal with once you know you have it.
"My sense is there are an awful lot of people out there doing like I did for one reason or another, your ego, whatever," said Kirk, 55, an IT manager from Brandon.
That's almost certainly true, said Dr. Michael Rack, a specialist in sleep disorders.
"Sleep disorders are very common," said Rack, who left the sleep disorder clinic at the University of Mississippi Medical Center last year to help open Somnus Sleep Clinic in Flowood.
Rack said an estimated 2 to 4 percent of the population suffers from sleep apnea, as many as 10 percent from what's called restless leg syndrome, and an untold number from various forms of insomnia.
But apnea - when you stop breathing for extended periods during sleep - is "the bread and butter of sleep medicine," he said.
That's because it's so serious. Sleep apnea deprives your brain of oxygen. There's some evidence it also can lead to high blood pressure, weight gain, heart trouble and loss of brain power.
Which is why Kirk thinks he used to forget things, like what restaurant he and Linda were going to for dinner.
What pushed him over the edge was when Linda told him a while back that she counted how long he'd stopped breathing while he was asleep. It was 30 seconds.
Unbeknownst to either of them, he was doing that all the time.
The National Institutes of Health points out sleep apnea can lead to heart disease, heart failure or stroke.
Linda looked for help and found Somnus, a sleep clinic with a homey atmosphere. John was reluctant to go to a sleep clinic because he was intimidated by what he figured would be a clinical, hospital-like atmosphere.
Clinic technicians hooked John up to a dozen electrodes and watched him sleep for about four hours in what's called a sleep study.
What they found was amazing: He wasn't breathing for 10 to 20 seconds every couple of minutes. That's considered a moderate case of sleep apnea.
After four hours of sleep, they woke him, hooked him up to a machine that helps people with sleep apnea breathe, and he slept like a baby for the rest of the night.
"For the first time in 20 years, he slept for five hours straight," said Linda.
The machine is called a CPAP, which stands for continuous positive airway pressure. It's basically a mask that gently blows air into your mouth.
(in most cases, it's the nose)
That usually fixes the problem, Rack said.
A dentist can provide a device that's placed in the mouth and keeps the airway open.
In more severe cases, surgery to open an obstructive airway is sometimes necessary.
But the CPAP fixed Kirk's problem, he said.
It was a little weird, at first, sleeping with a mask on, he said, but it changed his life so much he'd go to bed wearing a Darth Vader mask and hugging an oxygen tank if he had to.
Since undergoing the sleep study three weeks ago, he said, he's been sleeping all night, every night. He's dreaming again, something he hadn't done in a long time because he wasn't sleeping deeply enough.
He's no longer snoring, isn't tired at work, and has some of his old personality coming back, Linda said.
In short, he's learned to listen to his wife.
"I can't overemphasize enough the importance of listening to your spouse," he said. "They're the people who suffer when you're snoring. They're the people who monitor you and worry.
"Without her," he said, "I would never have come in."

Saturday, February 18, 2006

Sleeping Pill Wars

An editorial in the New York Times talks about the high use of sleeping pills in American society:
Americans are popping sleeping pills at a rapid rate, thanks to heavy marketing by the drug companies and a belief that a new generation of sleeping pills is safer than its predecessors. The upsurge is raising justifiable concerns that the pills will be overused by people who don't really need them or that doctors may reflexively prescribe pills while ignoring underlying conditions that may be responsible for sleeplessness.
As Stephanie Saul reported in The Times recently, some 42 million sleeping pill prescriptions were filled last year, up nearly 60 percent from 2000. More and more people are turning to a new generation of sleep aids called "Z" drugs. The best seller is currently Ambien, but over the past year it has been vigorously challenged by a newcomer, Lunesta, prompting a huge advertising and marketing battle.
Decades ago barbiturates were the drugs of choice for insomnia, but they are addictive and carry a high risk of death by overdose. In the 1970's they were largely displaced by benzodiazepines, drugs that include Dalmane and Halcion, which are less prone to overdose but have their own unpleasant side effects, including next-day drowsiness, dependence and withdrawal symptoms. The Z pills were developed to overcome such side effects.
But any implication that they are a huge breakthrough must be viewed skeptically. Roughly speaking, the recommended starting doses of two brand-name Z pills seem to cut only 15 minutes or so from the time needed to fall asleep after taking a placebo, while extending the duration of sleep by a half-hour or less. Most are classified as controlled substances because they can be abused and can cause dependence. Recent evaluations have reported finding no evidence that Z drugs are much different from their predecessors in terms of effectiveness and short-term adverse events.
Most experts believe that people should try a range of tricks, like minimizing the habits that interfere with sleep, before turning to pills. Some experts say psychotherapy, where available, has more lasting effects than sleeping pills. Insomniacs need to weigh whether sleeplessness is worse than the pills designed to ameliorate it.

I haven't heard the term "Z pill" used before. The Z pills include Lunesta, Ambien (and now Ambien CR), and Sonata. The Z pills bind to a subtype of the benzodiazepine receptor, and are more selective than the benzos such as valium and xanax. The Z pills have fewer side effects than the benzos: they are less addictive, and cause fewer memory problems.
The article mentions psychotherapy for insomnia. This is not commonly available. Here is a list of the less than 100 doctors and psychologists in the country who are certified in behavioral sleep medicine.

Friday, February 17, 2006

I'd love to do a sleep study on this guy

The Drudge Report links to this story about a Vietnamese man who hasn't slept since 1973:
You’d think going without sleep for that long may have its drawbacks, but not for the man in central Quang Nam province who has never been ill after decades of insomnia.
His inability to sleep has not only made him famous, but also represents a “miraculous” phenomenon worthy of scientific study.
Sixty-four-year-old Thai Ngoc, known as Hai Ngoc, said he could not sleep at night after getting a fever in 1973, and has counted infinite numbers of sheep during more than 11,700 consecutive sleepless nights.
“I don’t know whether the insomnia has impacted my health or not. But I’m still healthy and can farm normally like others,” Ngoc said.

Insomnia frequently occurs after brain injury (usually by trauma, but fever and infectious disease can also cause brain injury). However, I am not aware of any medically-documented cases of total insomnia. I do not believe this story, he must drift off into sleep at some point during the 24-hour day.
A recent movie dealt with this topic.

Thursday, February 16, 2006

Sleep Education

The American Academy of Sleep Medicine now has a Sleep Education site aimed at patients with sleep disorders.

Saturday, February 11, 2006

Oral Appliances for Sleep Apnea

The National Sleep Foundation reports on the new American Academy of Sleep Medicine Practice Parameter for the use of oral appliances for the treatment of obstructive sleep apnea:
An oral appliance for sleep disordered breathing is a device that a dentist fits on the teeth or mouth to reduce snoring and to treat sleep apnea. Given how creative dentists are hundreds of such devices have been developed. Now the American Academy of Sleep Medicine (AASM) has updated its practice parameter recommendations for use of such devices. AASM’s experts find that the devices can be effective to treat snoring and mild to moderate sleep apnea, but they also caution that there is much more evidence – and better evidence – that continuous positive air pressure (CPAP) should be the first form of therapy for obstructive sleep apnea. They also caution that patients fitted with oral devices should be thoroughly evaluated before and after a device is fitted to determine whether it is not only reducing snoring and improving sleep as perceived by the patient, but also maintaining blood oxygen at the appropriate levels. But according to one practitioner of dental sleep medicine, it is very important to find a specialist who is familiar with the many available types of devices. He said that too many dentists fitting patients with oral appliances are familiar with only one type and this is an area where "one type does not fit all."
The major changes compared to the old 1995 practice parameters are:
1) a follow-up sleep study to ensure resolution of OSA is now recommended even for mild cases of OSA
2) the new parameters specify that dentists should be fitting these devices. There are some oral appliances out there that can be fitted by physicians without dental training. I was planning on using one of these in my sleep practice, but will now reconsider this.

Monday, January 23, 2006

Grand Rounds

Grand Rounds are now up at Kevin, MD.

Thursday, January 19, 2006

Watching television in bed

Watching television in bed can contribute to insomnia. This study found another adverse effect of having a television in the bedroom:
A study by an Italian sexologist has found that couples who have a TV set in their bedroom have sex half as often as those who don't.
"If there's no television in the bedroom, the frequency (of sexual intercourse) doubles," said Serenella Salomoni whose team of psychologists questioned 523 Italian couples to see what effect television had on their sex lives.

Sunday, January 15, 2006

Obstructive Sleep Apnea

Childhood Sleep Disorders

Word of the Day

somnolent (SOM-nuh-luhnt) adjective1. Sleepy; drowsy; inclined to sleep.2. Tending to cause sleepiness or drowsiness.[From Latin somnolentus, from somnus, "sleep." A related word is insomnia (in-, "not" + somnus).] Use: "Meanwhile, many a somnolent local authority has been stirred into action by Davidson's blunt approach."--John Lucas. "Memorials are made of these on the eve of Remembrance Sunday." Daily Telegraph: November 7, 1998.

Alcohol and Sleep

Wednesday, January 11, 2006

Update on Requirements for the New Sleep Board Examinations

The new ABMS examination [sleep medicine board examinations], starting in 2007, will be co-sponsored by the American Board of Internal Medicine, the American Board of Psychiatry and Neurology, and the American Board of Pediatrics with the addition of the American Board of Otolaryngology pending ABMS approval. There are three pathways that qualify physicians to sit for the new examination: (1) certification by one of the primary sponsoring boards and the current American Board of Sleep Medicine (ABSM); (2) certification by one of the primary sponsoring boards and completion of training in a 1-year sleep medicine fellowship program, not overlapping with any other residency or fellowship; and (3) clinical practice experience: this clinical practice experience pathway consists of a 5-year "grandfathering" period open to physicians who are board certified in one of the sponsoring specialty boards and who can attest that he or she has the equivalent of 1 year of clinical practice experience in sleep medicine during the prior 5 years.
Starting in 2007, to sit for the new sleep board exams and become board certfied in sleep medicine, a physician must first become board certified in psychiatry, internal medicine, neurology, pediatrics, or ENT. The current requirement of the American Board of Sleep Medicine is only that a physician be board certified in any speciality prior to taking their exam. No official word yet on whether or not the Family Practice Board is planning on becoming a sponsoring board for the new sleep exams.

Tuesday, January 10, 2006

Bedwetting and Obstructive Sleep Apnea

Nocturnal enuresis (bedwetting) affects approximately 5 million school-aged children. A child must be at least five-years old before this diagnosis can be made. A child with nocturnal enuresis should be examined by a physician to rule out an organic etiology, such as a urinary tract infection. Often no specific organic cause is found. However, pediatricians frequently neglect to ask their enuretic patients about symptoms of obstructive sleep apnea, a common cause of nocturnal enuresis.

Nocturnal enuresis is present in approximately 1/3 of children with obstructive sleep apnea. Besides enuresis, other symptoms of pediatric sleep apnea include snoring, sleepiness, hyperactivity, poor school performance, and behavior problems. In a recent study of children with both nocturnal enuresis and obstructive sleep apnea, Basha and colleagues found that treatment of obstructive sleep apnea by adenotonsillectomy often cured enuresis. In their study, postoperatively 61.4% of children were free of enuresis, 22.8% had a decrease in enuresis, and 15.8% had no change in enuresis.

How does obstructive sleep apnea (OSA) cause enuresis? Proposed factors include: 1) decreased arousal response, 2) impaired urodynamics, and 3) altered secretion of hormones that regulate fluid balance.

Decreased Arousal Response – OSA may promote enuresis by decreasing the arousal response from sleep.
Impaired Urodynamics – Increased intra-abdominal pressure during obstructive respiratory events increases bladder pressure.
Altered Secretion of Hormones – OSA can affect the secretion of atrial natriuretic peptide and antidiuretic hormone.

Nocturnal enuresis is a common childhood condition. Nocturnal enuresis is frequently due to OSA, and in these cases it usually resolves or improves with treatment of OSA.


1. Sheldon SH. “Sleep-Related Enuresis”. In Principals and Practice of Pediatric Sleep Medicine.

2. Basha S, et al. Effectiveness of Adenotonsillectomy in the Resolution of Nocturnal Enuresis Secondary to Obstructive Sleep Apnea. Laryngoscope, 115:1101-03, 2005.

3. Brooks LJ and Topol HI. Enuresis in Children with Sleep Apnea. J Pediatr 2003, 142:515-8.

Sunday, January 08, 2006

Friday, January 06, 2006

night eating syndrome (NES)

People with NES overeat in the evening and even awaken from sleep to eat one to two times a night on average, according to Kelly Allison, Ph.D. They consume one-quarter or more of their daily food intake after their evening meal, said Allison, a research assistant professor of psychology in psychiatry at the University of Pennsylvania School of Medicine and director of a NES-focused cognitive-behavioral therapy (CBT) study.
People with NES typically lack appetite in the morning. Some curb their daytime food intake, knowing they will graze after dark.
Not all people with NES are obese. Some maintain normal weight via daytime food restriction or intensive exercise. These individuals typically are younger by about a decade than obese people with NES, suggesting NES may serve as a pathway to obesity.
Many people with NES keep a small refrigerator next to the bed, favoring peanut butter, popsicles, candy bars, nuts, and sometimes fruit as handy middle-of-the-night snacks. They rely on food as an aid to returning to sleep, probably a conditioned response, Allison reported.
People with NES remember what they eat in the night, unlike people with sleep-related eating disorder (SRED), a rare parasomnia [similar to sleepwalking]. Those with SRED often have only partial recall of having consumed frequently unpalatable items, such as buttered cigarettes, raw bacon, or cat food.
"We think NES represents a dysregulation of circadian patterns of food intake, but without disruption of the circadian sleep pattern," he explained. "NES is primarily an eating disorder, and only secondarily a sleep disorder." While appetite normally shuts down in sleep, NES appears to be a rare clinical example of an uncoupling of eating and the sleep/wake cycle. Its cause has not been determined.
"While people with NES who stay on sertraline continue to do well," Allison notes, "learning CBT strategies may give them a better long term prognosis."

Tuesday, January 03, 2006

Study Finds Behavioral Therapy Benefits Older Adults with Insomnia

While insomnia in older adults is often treated with pharmacological therapies, a new study finds that behavioral therapies are effective and have the benefit that they continue to work over a long period of time. The review, conducted by lead author Michael Irwin, MD of UCLA and fellow researchers examined 23 randomized, controlled clinical research trials of more than 500 participants in total. The results showed that behavioral therapies including cognitive behavioral therapy (CBT), relaxation therapy and modifications in sleep behavior offered significant benefits to insomnia sufferers. The most common complaint among older adults with insomnia, frequent nighttime awakenings, was markedly improved by behavioral therapy.
The study comes on the heels of a 2005 National Institutes of Health state-of-the-science report which indicates that CBT is an effective treatment for chronic insomnia and may yield long-term benefits for patients. Yet both the NIH report and Irwin’s study call for more scientific investigation when it comes to insomnia treatments. In fact, Irwin’s review found that only eight studies on individuals over age 55 yielded statistically significant results. Irwin and fellow researchers call for more studies of older adults using objective measures to determine how insomnia can be treated best long-term.
The study is published in the January 2006 issue of Health Psychology and is the first in a series of evidence-based health reviews to be published by the journal.

From the National Sleep Foundation

The Relationship between Sleep and Metabolism

Karine Spiegel, PhD, and colleagues published an article in the December 7, 2004 issue of the Annuals of Internal Medicine that suggests that sleep restriction can lead to weight gain. They found that sleep restriction (4 hrs /night) leads to decreased levels of the hormone Leptin and increased levels of Ghrelin, another hormone. The alteration of the levels of these appetite and energy regulating hormones was associated with increased hunger and appetite in the study. This study adds to the evidence linking insufficient sleep to obesity. Other studies have linked sleep restriction to impaired glucose tolerance and diabetes mellitus.

It is important for physicians to counsel their overweight and obese patients to allow for at least 8 hours of sleep per night. Since obstructive sleep apnea is both a cause and consequence of obesity, practitioners should screen their obese patients for this common disorder. Useful symptoms to ask about include snoring and excessive daytime sleepiness.