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 www.dynamicmedical.com) references.
Quinine is the most commonly used treatment for this poorly understood condition; however with this medication cinchonism needs to be monitored for.

The Challenges of Treating Restless Legs Syndrome

The following case report appears in this month's Journal of General Internal Medicine (abstract below):
CASE REPORT
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.

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.

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.

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.

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 http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm

Alcohol and sleep

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

Answer:
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.

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).
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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.

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.

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!
http://www.print2webcorp.com/news/Jackson/MissParentingResource/20060801/p19.asp

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.

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.

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 or 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.

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.

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.”

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.

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?
Volume :

29
Issue :

06
Pages :

831-840
View PDFEmail a Friend
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.

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.

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).

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