Neurology Now:
Deep, uninterrupted slumber is
important for everyone, but it's especially critical for people with neurologic
disorders. Sleep deprivation can make symptoms such as pain, stiffness, memory
loss, fatigue, and confusion worse and can provoke seizures and headaches.
Here's the rub, though: the very disorders that make sleep such a valued
commodity are often responsible for robbing you of the rest you need.
“A lot of sleep mechanisms are
based in the brain,” explains Jennifer Molano, MD, FAAN, associate professor of
neurology at the University of Cincinnati. Neurotransmitters such as serotonin
and norepinephrine control whether you're awake or asleep by signaling
different neurons in the brain to turn on and off. The “body clock” that
controls wake-sleep cycles is located in the hypothalamus. When light passes
through the optic nerve and reaches the hypothalamus, it leads to pathways that
decrease the production of melatonin, a hormone that signals your body to
sleep. “When you have a neurologic condition, those mechanisms may not work as
well,” Dr. Molano explains.
These dysfunctional
mechanisms—along with the natural effects of aging—can keep you up at night or
make you drowsy during the day. They may also cause you to sleep fitfully,
waking up several times during the night, preventing you from getting the deep,
restorative rapid eye movement sleep you need. In some cases, you may also
experience vivid dreams, nightmares, leg spasms, or other physical and
psychological effects that keep you from settling down.
“We're still trying to figure out
the function of sleep, but we know that we can't survive without it,” says Dr.
Molano. “We do understand that it helps systems stay in balance, and it
rejuvenates us for the next day.”
The most relevant and important
research reveals that during sleep the brain clears out toxins such as
amyloids, the sticky plaque proteins associated with Alzheimer's disease. “Most
of the research has been in Alzheimer's disease, but I think over time we'll
find that other neurologic conditions are affected by poor sleep and clearance
of toxins,” says Beth Malow, MD, FAAN, a professor of neurology at Vanderbilt
University in Nashville.
MAKE SLEEP A PRIORITY
The first step to getting a better
night's rest is to consider sleep a crucial part of your regimen, as important
as what you eat, how often you exercise, and even what medications you take.
“Sleep is integral to our health, and in fact, many doctors are now looking at
sleep as the fifth vital sign [in addition to heart rate, temperature, blood
pressure, and breathing rate],” says Andrew Westwood, MD, assistant professor
of neurology at Columbia University College of Physicians and Surgeons in New
York City.
RULE OUT OTHER CONDITIONS
If you're dogged by insomnia or
insufficient sleep, talk to your neurologist or a sleep specialist to rule out
any underlying primary sleep disorders, such as obstructive sleep apnea (when
you stop breathing several times during the night because of an obstruction of
airways) or restless legs syndrome (an irresistible desire to move your legs or
walk around at night), says Dr. Westwood. Both conditions are common,
especially in those with neurologic conditions such as Parkinson's disease, and
they can be treated successfully with devices such as a continuous positive airway
pressure machine for sleep apnea or medications for restless legs syndrome.
For other obstacles to sleep, such
as medication side effects and nighttime stiffness, follow these
expert-approved strategies for getting back into the sleep zone.
OBSTACLE: Medications
Even over-the-counter cold
medications and allergy pills can cause fatigue during the day or send your
heart racing in the middle of the night. Drugs used to treat neurologic
disorders can also affect sleep patterns. Medications such as anticonvulsants
for seizure disorders, cholinesterase inhibitors for dementia, or levodopa for
Parkinson's disease can cause sleepiness during the day, sleeplessness at
night, or restless interrupted sleep.
Some people also take medications
for high cholesterol or hypertension, including alpha- or beta-blockers and
angiotensin-converting-enzyme inhibitors, which are known to cause insomnia or
daytime sleepiness. And there is yet a third complication: “Many neurologic
conditions are associated with a higher rate of depression, so many patients
also take antidepressants, which can adversely affect quality of sleep,” says
Michael Thorpy, MD, director of the Montefiore Medical Center Sleep-Wake Disorders
Center in the Bronx, NY.
Many people with neurologic
conditions could be taking four, five, or even more different pills during the
day, which can interact in various ways to affect sleep. Additionally, people
may even be more sensitive to the side effects of those pills because of a
neurologic condition, says Dr. Malow.
SLEEP SOLUTIONS
1. Time your doses. Always check
in with your doctor not only about the combination of medications you're taking
(don't forget to mention any over-the-counter cold medicines or supplements),
but also the timing of your doses, says Dr. Westwood. “You may be taking a pill
right before bedtime that causes drowsiness for eight hours, but then you get up
after six hours and still feel groggy during the day.” Moving some pills from
morning to night, or vice versa, or even shifting them an hour or two in either
direction may help you feel sleepy at exactly the right time.
2. Consider other drugs. If one particular
drug seems to be causing your sleep troubles, talk to your physician about
switching to another one, since drugs affect people differently. Also, if you
have been on a specific drug for several months or years, be sure to discuss
with your provider whether it's still relevant and if the benefits outweigh the
risks, including sleep disturbance, suggests Dr. Westwood.
3. Make medications work for you.
The sleep-related side effects of some medications can be used to your
advantage. Some medications for migraines, for example, cause sleepiness, so if
you have migraines and your doctor knows you have trouble sleeping, he or she
might choose the medication that can do double-duty, says Dr. Westwood.
OBSTACLE: Distracting Environments
If you live in a nursing home or
assisted living facility or have extended hospital stays, your surroundings may
be disrupting your sleep. In order for our body clocks to work properly, we
need constant environmental clues to tell us when it's morning and when it's
night, and those clues often get blurred in an institution that provides
24-hour care.
One of the biggest problems is the
lack of natural light, says Dr. Thorpy. “Being outdoors has a powerful effect
on synchronizing your body clock,” he explains. “It's crucial to get good
natural light.” Indoor light doesn't serve the same purpose, he says,
explaining that direct sunlight can measure at a brightness of 12,000 lux,
while indoor light is often 200 lux or less. In fact, a 2009 study in the
Journal of Sleep Research found that residents of nursing homes were exposed to
only about 10 minutes of light over 1,000 lux per day (people with dementia
were exposed to only about one minute a day, if at all). At night, hospitals
and nursing homes frequently leave the lights dimmed, but not fully out, notes
Dr. Thorpy, denying patients and residents the complete darkness they need to
cue their body to sleep.
In a facility, there may also be
constant activity—patients being woken up for medicines in the middle of the
night, hospital staff wheeling carts down the hall—and constant noise, such as
the humming of monitors and machines. This can throw off sleep cycles even
during a temporary stay at a hospital, and once the internal clock is out of
sync, it can be difficult to get it back. Fragmented sleep is bad for your
health and your mood. A 2015 study in Sleep found that people who were awakened
several times at night experienced much worse moods the next day than those who
had a delayed bedtime but were then allowed to progress uninterrupted through
the different stages of sleep.
Furthermore, people in
institutions tend to be more sedentary, which also affects the ability to fall
asleep, says Dr. Thorpy.
SLEEP SOLUTIONS
1. Regulate your light. Whenever
possible, open the blinds in your room during the day or sit in a visitor's
area near windows with direct sunlight. Try to get outside for a few minutes a
day, even if you're in a wheelchair and are just being wheeled around the
parking lot for some healthy sunshine. If you can't achieve total darkness in
your room at night, use an eyeshade to block out any light. If your sleep cycle
is out of sync, talk to your physician about light box therapy. The therapy
entails sitting near a box that emits anywhere from 2,500 lux to 10,000 lux of
light in the morning to help reset the internal clock. A 2009 study in the
Journal of the American Geriatric Society showed some improvement in circadian
rhythms using light box therapy with people in nursing homes.
2. Control the noise. If ambient
noise is disruptive, invest in a white noise machine to drown out other sounds,
suggests Dr. Westwood. Or purchase good quality earplugs such as the
silicon-based ones that swimmers use.
3. Increase your activity. Even if
walking isn't possible, find out if you can participate in a seated exercise
class. If you're in a facility that has a pool, ask about water exercise. If
you're in a hospital, see if you can take regular walks around the hallways.
OBSTACLE: Circadian Clock Changes
As you age, your circadian rhythm
undergoes natural changes—this is why a teenage grandchild may sleep easily
until noon, while your eyes pop open at 5:30 am. But for people with neurologic
conditions such as Alzheimer's disease, the internal clock can become
completely unplugged. “The circadian rhythm is controlled by a pair of small
structures in the brain called the suprachiasmatic nucleus, which is in the
hypothalamus,” explains Dr. Molano. “In studies of people with Alzheimer's
disease, we can see disease-related changes in that part of the brain, which
can be associated with an irregular sleep-wake cycle.” In fact, there is
evidence that sleep disturbance goes both ways: amyloid plaques, hallmarks of
Alzheimer's disease, affect the brain, altering sleep cycles; and lack of sleep
promotes the creation and spread of the plaques.
This disruption in the sleep
center of the brain can cause patients to confuse night for day, wake up
several times, or just wake up once in the night—but then get dressed and try
to leave the house. In fact, according to the National Sleep Foundation, people
in later stages of Alzheimer's disease rarely sleep for long periods of time.
Instead, they doze on and off throughout the day and night.
SLEEP SOLUTIONS
1. Reset the inner clock. Maintain
a consistent and active schedule during the day, and follow healthy sleep
habits (see “8 Top Sleep Habits”). “Keeping a consistent waking time is even
more important than a consistent bedtime for setting the internal clock,” says
Susan McCurry, PhD, a research professor and sleep expert at the University of
Washington in Seattle. Using light box therapy in the late afternoon or early
evening may also push the bedtime later for a person with Alzheimer's disease
who has been going to sleep and waking very early, says Helene A. Emsellem, MD,
director of the Center for Sleep & Wake Disorders in Chevy Chase, MD.
2. Talk to your doctor about
sleeping pills. In cases where a sleep disturbance affects the whole household,
a physician may prescribe a trial of tricyclic antidepressants,
benzodiazepines, antipsychotics, or sleeping pills. Sleeping pills should be
prescribed cautiously, though, warns Dr. Emsellem. Patients with neurologic
disease may be more sensitive to the effects of sleeping pills and may require
lower doses, she explains. And some patients may not tolerate them at all.
Also, for people who have trouble sleeping for a long period of time, sleeping
pills can lead to more grogginess and impaired judgment the following day.
OBSTACLE: Nighttime stiffness and
pain
For conditions such as Parkinson's
disease, muscular dystrophy, and multiple sclerosis, pain and stiffness can make
it impossible to get comfortable enough to fall asleep—and when you do, you may
wake up when you feel a cramp, pang of pain, or a sudden movement. “Being able
to change position is an important part of getting quality sleep,” says Dr.
Thorpy. “Plus, pain is often worse at night, because there are fewer
environmental stimuli coming in to distract from your pain.” Sleep deprivation
then sets in motion a vicious cycle, he explains: If you don't get enough
sleep, your tolerance for pain goes down, so more pain equals less sleep equals
more pain.
A 2015 survey by the National
Sleep Foundation found that one in four people who had chronic pain reported
very poor sleep quality. People in pain also reported the biggest sleep
deficit—that is, the difference between the amount of sleep they say they need
and the amount they actually get. While people without pain reported no sleep
deficit, those with chronic pain lost an average of 42 minutes per night. For
39 percent of people with chronic pain, the anxiety about how sleep deprivation
was affecting their health was another reason they lay awake at night. People
in pain were disturbed by environmental factors such as noise, light, and
temperature at a higher rate than people who did not report or experience pain.
1. Treat the pain. “With
conditions such as Parkinson's disease, we're often so focused on maximizing
motor performance during the day that we don't think about how the need for
those medications is affecting the patient at night,” says Dr. Emsellem. “It's
important for the patient to tell the doctor if he or she is feeling restless
at night. Often an extra dose of medication for pain or Parkinson's at bedtime
can be very helpful.”
2. Talk to others. Join online
support groups for people with your condition, and share tips, suggests Dr.
Molano. “Many people have found creative ways to deal with pain during
sleeping,” she says. “For example, when my father-in-law was diagnosed with
Parkinson's disease, someone suggested he wear silk pajamas, which make it
easier to move around in bed. He found that very helpful.”
3. Make your bed comfortable. Buy
an inexpensive mattress topper to make the bed softer and more comfortable,
especially if you've lost a lot of weight because of your condition, says Dr.
Emsellem. Fitted satin sheets and/or bed rails can make it easier to move
around in bed.
4. Prime your muscles. Take a warm
bath before bed to relax muscles and keep them from cramping during sleep.
OBSTACLE: Depression
Neurologic illness and depression
often go hand in hand: As many as 40 to 45 percent of people with Parkinson's
disease or multiple sclerosis experience depression, and up to 34 percent of
people recovering from stroke report depression in the first two years,
according to a 2005 study in the Journal of Neurology, Neurosurgery and
Psychiatry. People who are depressed often have difficulty falling asleep or
staying asleep, or they experience unrefreshing sleep or daytime sleepiness.
It's also very common for people with depression to wake up early and then be
unable to get back to sleep, according to the National Institute of
Neurological Disorders and Stroke. “It's not just that you're waking up
worrying about things,” Dr. Malow explains. “It's biological—when you're
depressed, your brain is wired to wake up early.”
And of course, feeling exhausted all
the time can add to your sense of hopelessness and helplessness. (According to
the Sleep Foundation, people with insomnia have 10 times the risk of
depression.) All these factors feed off each other: Your disease causes sleep
problems, the lack of sleep then increases your risk of depression; then it
turns back on itself, with the depression keeping you awake, worsening your
symptoms.
Furthermore, many antidepressants
such as selective serotonin reuptake inhibitors (SSRIs) are stimulating and can
interfere with sleep.
SLEEP SOLUTIONS
1. Monitor your medications.
Antidepressants can be very effective. A 2011 review in the Journal of
Neurology, Neurosurgery and Psychiatry found that in patients with post-stroke
depression, Parkinson's disease, multiple sclerosis, brain injury, and
epilepsy, antidepressants led to remission of depression symptoms at twice the
rate of those using a placebo. But many antidepressants, such as SSRIs, can affect
not only the quality of sleep but may also exacerbate symptoms of restless legs
syndrome, says Dr. Thorpy. Tricyclic antidepressants, which tend to be more
sedating, may be preferable for those with sleep problems, says Dr. Malow.
2. Complement with nondrug
therapies. In addition to working carefully with your doctor to find the best
drug, and the right dosage and timing of that drug, to lift your mood without
disturbing sleep, consider joining an online or in-person support group or
talking to a cognitive behavioral therapist who specializes in treating people
with chronic illness.
OBSTACLE: Daytime Sleepiness
Some neurologic conditions, such
as Parkinson's disease, can trigger sleepiness during the day. A 2003 study in
Movement Disorders found excessive daytime sleepiness in 76 percent of
Parkinson's patients. Nodding off during the day can wreak havoc on your
ability to sleep well at night. “Sleeping during the day weakens the signal for
you to fall asleep at night,” says Dr. Molano.
But don't confuse fatigue with
sleep, cautions Dr. Westwood. “Fatigue is when you feel physically or mentally
exhausted, like you just can't do anything anymore, but you're not falling
asleep during the day,” he explains. Daytime sleepiness, however, is when you
nod off every time you sit in the passenger seat of a car or in front of the
television. While fatigue is a side effect of many neurologic diseases and may
get in the way of daily life, it is not necessarily a sleep-related problem, he
says.
SLEEP SOLUTIONS
1. Build up your sleep drive. Stay
as active as possible in the afternoon, says Dr. Malow. Don't take naps later
than 1 or 2 pm and limit them to a half hour if possible.
2. Adjust your medications. If you
take anti-Parkinson's medication, talk to your doctor about taking a dose at
bedtime to help you sleep; you may also want to discuss taking a medication
such as modafinil, which promotes wakefulness, or a long- or short-acting
traditional stimulant during the day to help alleviate sleepiness, says Dr.
Emsellem.
8 Top Sleep Habits Cited Here...
Try these expert-approved
strategies to help prime your body for sleep.
1. Stick to a regular bedtime
routine. The hour before you go to bed should be spent the same way every
night. A routine creates positive conditioning, preparing your body for sleep.
2. Get up at the same time every
morning. This helps keep your internal clock running correctly.
3. Avoid caffeine and alcohol. “A
nightcap might help you fall asleep, but alcohol is associated with multiple
awakenings later in the night,” says Jennifer Molano, MD, FAAN, associate
professor of neurology at the University of Cincinnati. If you must have a cup
of coffee or hot chocolate, be sure you finish it at least six hours before you
go to bed.
4. Get daily exercise. Even a
brief walk in the morning can help calibrate your body clock and help you sleep
better at night.
5. Make the bedroom dark and
quiet. Install shades that keep out any light, and use a white noise machine if
there is excessive noise from cars.
6. Put disruptive pets out of the
bedroom. Dogs and cats snore, shed, and move around during the night, so assess
whether it's worth letting your animal in the bed.
7. Keep the temperature cool. The
ideal room temperature for falling asleep is between 60 and 67 degrees
Fahrenheit, according to the National Sleep Foundation. Your body temperature
naturally drops in order to initiate sleep, and keeping the room cool can help
move this process along.
8. Avoid electronics before bed.
Answering emails or playing video games gets your brain buzzing. And research
from Rensselaer Polytechnic Institute shows that exposure to light from
computer tablets significantly lowers your levels of the hormone melatonin,
which, along with light, regulates circadian rhythm. If you prefer to read on a
tablet before bed, use orange-filter sunglasses to filter out the disruptive
blue light, says Helene A. Emsellem, MD, director of the Center for Sleep &
Wake Disorders in Chevy Chase, MD.
Say Good Night to Insomnia
Heed this advice to nip
sleeplessness in the bud.
Insomnia is often triggered when a
single stressful event disrupts your sleep. As you try to make up for lost
sleep, you can get into an unhealthy cycle where you start to establish bad
habits, says Michael Thorpy, MD, director of the Montefiore Medical Center
Sleep-Wake Disorders Center in the Bronx, NY. “You have to recondition yourself
quickly, because the longer insomnia goes on, the more difficult it is to
reverse.”
A 2010 review in the Journal of Clinical
Psychology found that pharmaceuticals are helpful for acute insomnia, but
psychological treatments are more effective over the long term for both primary
insomnia and insomnia that is secondary to other disorders, improving sleep up
to 80 percent of the time. These tips can help.
1. USE THE BED ONLY FOR SLEEP. No
matter how exhausted you are, stay in your bed only for the number of hours you
plan to sleep. Don't lounge in bed all morning hoping to catch up on sleep, or
stare at the ceiling when you can't sleep, advises Dr. Thorpy. When you spend
time in the bedroom not sleeping, your brain associates the space with worry
and wakefulness. The process of conditioning yourself to use the bed only for
sleep is called “stimulus control therapy,” and in the Journal of Clinical
Psychology report it was found to be the single most effective strategy. “If
you can't fall asleep after 20 minutes, get out of bed and do a quiet activity
like reading in another room before coming back to bed,” suggests Jennifer Molano,
MD, FAAN, associate professor of neurology at the University of Cincinnati.
2. COCOON YOURSELF WITH MUSIC.To
keep your brain from cycling through anxious thoughts as you try to sleep,
download your favorite soothing music—Gregorian chants, classical music, or
nature sounds—onto an MP3 player or your smartphone, says Helene A. Emsellem,
MD, director of the Center for Sleep & Wake Disorders in Chevy Chase, MD.
If you wake up at 2:30 am, for example, lie on your side, plug in one ear bud,
and let the sounds lull you back to sleep.
3. GET TENSE, THEN RELAX. The
second most successful treatment, according to the study, is progressive muscle
relaxation. This exercise involves squeezing different muscles for four to
seven seconds each, then relaxing for 20 to 45 seconds. Start with hands, then
work your way through arms, shoulders, neck, face, jaw, abdomen, thighs,
buttocks, feet, and ankles, focusing on the feelings of tension and relaxation.
4. TRY COGNITIVE BEHAVIORAL
THERAPY. This type of therapy aims to change the way you think about sleep,
replacing thoughts like, “I'll never sleep again!” and “If I don't get eight
hours, I'll get sick” with more valid and helpful thoughts, explains Dr.
Emsellem. “There is very good evidence that cognitive behavioral therapy [CBT]
is not only as effective as sleep medications, but its positive effects last
much longer.” Look for a therapist specifically trained in CBT for insomnia,
but if you can't find one near you, there are several helpful online programs.
Dr. Emsellem recommends the SHUTi program at shuti.me.
5. EXERCISE DAILY. A 2010 study in
the Journal of Clinical Sleep Medicine found that people with insomnia who did
moderate-intensity exercises (running on a treadmill) had reduced levels of
anxiety, possibly because of the distraction and increased levels of serotonin,
a neurotransmitter associated with well-being, and achieved approximately one
hour of added sleep time. They also took less time to fall asleep.
6. USE PILLS JUDICIOUSLY. Because
sleeping pills can cause daytime drowsiness, confusion, and a greater risk of
falls—especially in older and cognitively impaired people—they should be used
with caution, and only for a brief period of time. “CBT can take several weeks
to work, so I often tag on a short-acting sleeping pills in the beginning so
patients can fall asleep and get positive reinforcement while they are doing
the therapy,” says Dr. Emsellem. Once the therapy is working, usually within a
month, talk to your doctor about weaning off the sleep medication.
Caregivers Need Sleep Too
Sleep-deprived? These tip will
keep you on top of your game.
About two-thirds of older adult
caregivers experience sleep disturbances, according to Susan McCurry, PhD, a
professor at the University of Washington in Seattle who has published several
studies on the topic, including a 2007 overview in Sleep Medicine Reviews. The
reasons are complex, she says. First, there's the obvious problem that if the
person they are caring for is up several times during the night, they will be
waking with them. “But even if the person you are caring for sleeps relatively
well, you might lie awake at night worrying about tomorrow or feeling anxious
about the long-term consequences of the person's condition.” And many family
caregivers are older themselves, so they may already be dealing with the sleep
problems that come with age, notes Dr. McCurry.
“If you're not getting enough
sleep, it increases the burden of care,” says Dr. McCurry. “You have a greater
risk of depression and of health problems like cardiovascular disease.” Plus,
she adds, when you haven't slept, it's natural to become more irritable and
less flexible or positive in challenging caregiver situations.
Here are solutions to common
caregiver scenarios.
If the person you're caring for
gets up at night…
In addition to instituting good
sleep habits, consider hiring someone at night (some insurance plans may cover
it). Look into adult day programs, which provide structured activities during
the day, to keep your family member up and busy so he or she might sleep better
at night. These programs also give you much needed time alone. “Some
communities are even starting to have nighttime programs for people who have
switched night for day,” says Dr. McCurry.
If you're up at night worrying…
Yoga, meditation, and talk therapy
can all be helpful for worried caregivers, says Dr. McCurry, although finding
time to pursue these activities can be tricky. If the person you care for has
quiet time during the day (napping or watching TV), use that time to join an
online support group, talk to a therapist over the phone, or sit quietly and
meditate.
“We've found in our research that
there is a huge benefit for both people with dementia and their caregivers to
increasing the number of pleasant and meaningful activities they engage in
during the day,” says Dr. McCurry. “This can be something as small as putting a
bird feeder in your yard and going outside for a few minutes each day to watch
the birds frolicking, or looking through an old photo album and playing some
favorite music.” Engagement in these types of activities improves mood or
reduces boredom and daytime napping, which in turn can improve sleep.
© 2016 American Academy of
Neurology
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