medications that interfere with sleep

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Medications that Interfere with Sleep:An Overview

3 Contact Hours


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Medications that Interfere with SleepAn Overview

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Care has been taken to confirm the accuracy of information presented in thiscourse. The authors, editors, and the publisher, however, cannot accept anyresponsibility for errors or omissions or for the consequences from applicationof the information in this course and make no warranty, expressed or implied,with respect to its contents.

The authors and the publisher have exerted every effort to ensure that drugselections and dosages set forth in this course are in accord with currentrecommendations and practice at time of publication. However, in view ofongoing research, changes in government regulations, and the constant flow of

information relating to drug therapy and drug reactions, the reader is urged tocheck the package inserts of all drugs for any change in indications of dosageand for added warnings and precautions. This is particularly when therecommended agent is a new and/or infrequently employed drug.

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Table of Contents

INTRODUCTION ................................................................................................... 7

MEDICATIONS THAT CAUSE INSOMNIA...................................................... 7

ANTIDEPRESSANTS AND SLEEP ............................................................................... 7

ANTIHISTAMINES,DECONGESTANTS AND SLEEP .................................................... 8THEOPHYLLINE....................................................................................................... 8WEIGHT LOSS MEDICATION AND SLEEP ................................................................. 8SLEEPING PILLS AND INSOMNIA.............................................................................. 8

MEDICATIONS CAN DISRUPT YOUR SLEEP ................................................ 9

MEDICATION EFFECTS ON SLEEP............................................................... 11

COMMON POSSIBLE SIDE EFFECTS ............................................................. 14

SLEEP AIDS IN MY PRACTICE ......................................................................... 14

ASSOCIATIONS BETWEEN THE USE OF COMMON MEDICATIONSAND SLEEP ARCHITECTURE IN PATIENTS WITH UNTREATED

OBSTRUCTIVE SLEEPAAPNEA....................................................................... 15

ABSTRACT ............................................................................................................ 15

EFFECTS OF PARKINSONIAN MEDICATION ON SLEEP ........................ 16

METHYLPHENIDATE VS. ATOMOXETINE ADHD MEDICATIONS:

EFFECTS ON SLEEP ........................................................................................... 17

MEDICATIONS AND THEIR EFFECT ON SLEEP ARCHITECTURE ..... 21

WHATPROBINGDEEPHASEVERSOLVEDTHEMYSTERYOFSLEEP?

............................................................................................................................. 21

PAINISTHEROOTOFKNOWLEDGE......................................................... 22PEOPLEWHOSAYTHEYSLEEPLIKEABABYUSUALLYDONTHAVE

ONE.................................................................................................................... 23PEOPLEWHOSNOREALWAYSFALLASLEEPFIRST............................. 23THEBIG3CHALLENGESOFMODERNLIFE........................................... 24HESLEEPSWELLWHOISNOTCONSCIOUSTHATHESLEEPSILL..... 25SLEEPISTHEGOLDENCHAINTHATTIESOURHEALTHANDBODIES

TOGETHER ....................................................................................................... 25REFERENCES ......................................................................................................... 26

RITALIN HELPS....BUT WHAT ABOUT THE SIDE EFFECTS?................. 27

WHEN YOUR MEDICATION CAUSES SLEEP PROBLEMS ....................... 30

INSOMNIA............................................................................................................. 31

WHAT IS INSOMNIA? ............................................................................................ 31TYPES OF INSOMNIA ............................................................................................. 31OVERVIEW............................................................................................................ 31OUTLOOK ............................................................................................................. 32LIFESTYLE CHANGES ............................................................................................ 32


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COGNITIVE-BEHAVIORAL THERAPY......................................................................33MEDICINES ............................................................................................................33

EXAMINATION .....................................................................................................35


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Medications that Interfere with SleepAn Overview#300104 3 CEUs

Learning Objectives

Identify the medications which can cause insomnia. Identify the various side effects that medications that impact

sleep.

Identify ways to minimize the negative impact medications canhave on sleep.

Introduction

Though medication and prescription drugs are designed to help withspecific problems, they can often have negative side effects. Medicine candisrupt the normal balance of the body and lead to a disruption in sleep

or insomnia. Even sleeping pills can have a negative impact on restfulsleep.

Medications that Cause Insomnia

Many people have no idea that medication can alter and interfere withsleeping patterns. Those taking medicine for a particular purpose mayattribute the sleep issues to the ailment, not the cure. However, manymedicines can cause sleep problems. Here is a short list of somemedicine types that can adversely affect sleep:

antidepressants antihistamines decongestants sleeping pills Theophylline weight loss medication.

Antidepressants and SleepWhile some antidepressants, such as Prozac, are thought to help

encourage better sleep, some have been linked to causing sleep problems.Some research has indicated that antidepressants can cause the onset ofREM sleep disorder, which causes people to physically act out theirdreams while fully asleep.


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Researchers seem to agree that for better or worse, antidepressantsdefinitely have an affect on sleep. Be sure to discuss this with yourphysician prior to beginning any course of medication, or if you thinkyour current medicine may be affecting how you sleep.

Antihistamines, Decongestants and SleepAntihistamines and decongestants tend to have opposite effects onalertness. Antihistamines can cause a person to become drowsy, whiledecongestants can cause alertness and excitability.

Taking an antihistamine during the day can cause sleepiness thatinterferes with later sleep. Decongestants, on the other hand, taken tooclose to bedtime can make it hard to fall asleep. If you are taking an over-the-counter remedy, be sure to read the possible side effects, and feel freeto walk up to the pharmacist and ask his or her opinion on the subject.

TheophyllineTheophylline and other asthma and related medications have beenstudied recently in regard to their possible effect on sleep. While themedications help clear airways during waking hours, it seems to haveother effects when the person is sleeping, including reducing time asleepand soundness of sleep. It is unclear whether this has a perceptible effecton waking function. However, if you are on asthma meds and notice achange in your sleep behavior, be sure to bring it up with your physician.

Weight Loss Medication and SleepWeight loss medication often contains some type of diuretic and/or

stimulant (such as caffeine) to rev the body up and increase metabolism.Diuretics can cause people to awaken during the night to go to thebathroom, while stimulants can overexcite the mind and make it difficultto fall asleep.

Sleeping Pills and InsomniaIronically enough, sleep medications can often exacerbate the exactproblem they are designed to help. Many sleep medicines override thebodys natural sleep mechanisms, making the body forget how to lullitself to sleep without assistance. This means that most sleeping pillsshould only be used for short durations as they have limited efficacy.


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Medications can disrupt your sleepAugust 11, 2008 10:56 AM EDTbyJulie K. Silver, M.D., Harvard Medical School

When Ive had insomnia in the past, I usually know what is causing it, beit a particularly stressful week or a time change due to cross-countryflight. But sometimes the cause of sleep troubles isnt so easy to pinpoint.According to the Special Health Report titled Improving Sleep: A guide to agood nights rest, you may need to look in your medicine cabinet to find thecause of your sleep woes. Heres what the report has to say on thesubject:

Often, medication rather than illness is the culprit behind sleep problems.A number of drugs steal sleep, while others may cause unwanteddrowsiness. Your doctor may be able to suggest alternatives that do notdisrupt sleep.

Antidepressants.The selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine(Prozac), sertraline (Zoloft), and paroxetine (Paxil) disrupt sleep orproduce daytime fatigue in about 10% to 20% of those who take them.

Anti-arrhythmics.These drugs, used to treat heart rhythm problems, may cause daytimefatigue and nighttime sleep difficulties. Such medications includeprocainamide (Procanbid), quinidine (Cardioquin, others), anddisopyramide (Norpace).

Sedating antihistamines.These medications, commonly taken to relieve cold or allergy symptoms,also cause drowsiness in most people. They are also the active ingredientsin most over-the-counter sleep aids and motion sickness pills (seeAntihistamines). To find out if a medication might cause unwelcomedrowsiness, check with a pharmacist. If you are taking a sedatingantihistamine and are bothered by drowsiness, your physician mayrecommend a non-sedating alternative that does not readily enter thebrain and affect wakefulness and sleep.

Beta blockers.Beta blockers are used to treat high blood pressure, arrhythmias, andangina. These drugs can promote insomnia, awakenings in the night, andnightmares.

Medications containing caffeine.Caffeine, found in some over-the-counter painkillers and appetite


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suppressants, stimulates the nervous system and can induce insomnia.Caffeine makes people feel alert by blocking the action of adenosine, asubstance that promotes drowsiness. Caffeines direct effects graduallydiminish but may linger for six or seven hours or even longer in somepeople.

Medications containing alcohol.Cough medicines often contain alcohol, which can suppress REM sleepand break up nighttime sleep.

Clonidine.This medication, which acts on nerve cells that respond to theneurotransmitter norepinephrine, is used to treat hypertension andoccasionally to curb nicotine craving in people who are quitting smoking.The drug can cause daytime drowsiness and fatigue; it also may interferewith REM sleep. Some people report no problems with clonidine, butothers note restlessness, early morning awakening, and nightmares.

Corticosteroids.Corticosteroids such as prednisone, used to suppress inflammation andasthma, often cause daytime jitters and nighttime insomnia.

Diuretics.Diuretics, which rid the body of excess sodium and water, can interferewith sleep by inducing urination throughout the night. Potassiumdeficiency, a common side effect of some diuretics, can cause painfulnocturnal cramping of calf muscles during sleep.

Nicotine patches.Patches used to curb smoking deliver small doses of nicotine into thebloodstream around the clock. People who use them often sufferinsomnia or experience disturbing dreams.

Sympathomimetic stimulants.Sympathomimetic stimulants such as dextroamphetamine(Dexedrine), methamphetamine (Desoxyn), and methylphenidate(Ritalin) are powerful central nervous system stimulants that enhancethe effect of brain chemicals involved in wakefulness. People taking theseagents have difficulty falling asleep; once asleep, they spend less time in

REM sleep and non-REM deep sleep. When the drug is discontinued,extreme sleepiness and a craving for REM sleep may follow.

Theophylline.This respiratory stimulant, used to treat asthma, is chemically related tocaffeine. Many people who use it require doses that are high enough todisrupt sleep.


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Thyroid hormone.Thyroid hormone taken to counteract the effects of an underactive glandmay cause sleeping difficulties at higher doses.

Medication Effects on Sleep

Each person spends one third of his or her life asleep. It is not surprisingthat such a complex and pervasive cognitive state should be affected bydrugs in many different ways. A philosophy that remains cogent for theCNS is that new research almost always shows this system to be morecomplex than previously thought. Only a few years ago, if patientscomplained of difficulty sleeping, they were given pills, often dangerousand addictive pills, to induce sleep no matter what the basis of thecomplaint might be. Sleeping pills may be safer now, and theunderstanding of the sleep state itself has increased rapidly. Diagnosesare still diffuse, however, and treatments are often poorly directed.

Depression is the offspring of the phlegmatic disposition and themelancholia of another era. Clinically, diagnosis is based on a globalassessment of symptoms. It is likely that a diagnosis of depression mayinclude a spectrum of underlying diseases that cannot now be clinicallydifferentiated. Medications have multiple effects on sleep and have manyside effects. Progress has, however, been made beyond mothers littlepills. Insomnia is no longer a diagnosis but a complaint to be addressed--a symptom of 1 of 60 potential sleep disorders. Each of these disordershas specific and appropriate treatments.

Bipolar Medication Spotlight: Sleep AidsBY CANDIDA FINK MDNOVEMBER 6, 2009

With this post, we continue our biweekly series on medications used totreat bipolar disorder and related symptoms. This week, we focus thespotlight on medications that can help you sleep.

Before we crack open the medicine cabinet, Id like to say a few wordsabout bipolar disorder and sleep. Sleep is a biggie. Too much couldtrigger or be symptomatic of depression. Too little could trigger or besymptomatic of a manic episode. At least one study shows that changesin sleep patterns can be an early predictor of a manic episode. Sleep playsa major role in mood disorders and recovery, so if youre having troublesleeping, you and your doctor need to do something about it.


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That something could consist of many strategies, ranging from verysimple (such as going to bed the same time every night) to more involved medication, avoiding caffeine and other stimulants, maintaining a strictsleep schedule, and convincing other family members to stop bangingaround in the kitchen till two in the morning. In stubborn cases, you may

benefit from a sleep study to identify factors that may be contributing tothe sleep disturbances.

Assuming your doctor and you decide that sleep medication is necessary,your doctor may prescribe one or both of the following:

A mood stabilizer, atypical antipsychotic, anxiolytic (anti-anxietyagent), or other medication thats not primarily used for sleep butwill hopefully help your sleep if it treats underlying mood oranxiety symptoms. Occasionally these medications are used justfor the sedating side effects for sleep, but this is not so common.

A bona-fide sleeping pill (sedative), which brings us to the mainpoint of this post.

A little-known fact is that the active ingredient in many over-the-countersleeping pills is diphenhydramine the generic form of Benadryl!

Prescription SedativesSeveral effective sleeping pills are available, which vary in terms of safety,side effects, and other considerations. The following list provides a quickrundown of some of the more common prescription sleep medicationscurrently in use:

Ambien (zolpidem): Ambien is available in two forms Ambien (and its generic), which help you fall asleep, and AmbienCR (no generic), approved to help you fall asleep fast and stayasleep. Ambien may not be safe for those who have a history ofdepression, liver or kidney disease, or respiratory conditions.Ambien may lose its effectiveness if taken longer than two weeks,while Ambien CR can be taken for a longer period of time.Ambien can trigger unusual side effects such as sleep walking,sleep eating, and even sleep driving. Ambien should not be mixedwith alcohol the combination increases the risk of these typesof side effects. For more about Ambien CR, visithttp://www.ambiencr.com/.

Lunesta (eszopiclone): Lunesta is approved to help you get tosleep and stay asleep, so you wake up feeling rested. It has a low-risk for developing a dependency, so you can use it short- orlong-term, and rebound insomnia (increasing severity of insomniaafter stopping the medication) is rare. Lunesta may not be safefor those who have a history of depression, mental illness, orsuicidal thoughts; a history of substance abuse or addiction; liver


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disease; or are pregnant, planning to become pregnant, or breastfeeding. Lunesta should not be combined with alcohol. Foradditional information, visit http://www.lunesta.com/.

Sonata (zaleplon): Sonata is approved to help you get to sleep.Its particular niche is that it is short acting, so is less likely to

produce a hangover effect in the morning. It is so short actingthat you can take it a second time if you awaken in the middle ofnight. Sonata can be habit forming and may not be safe for thosewho have a history of depression, mental illness, or suicidalthoughts; a history of substance abuse or addiction; severe liverimpairment; or are pregnant, planning to become pregnant, orbreast feeding. Sonata should not be combined with alcohol.

Rozerem (ramelteon): Rozerem works differently from othersleep medications and is designed to work in conjunction withyour bodys internal clock. Its non-habit-forming, wont makeyou feel groggy the next day, and is safe to use with manyprescribed medications. (Its not a controlled substance like mostother prescription sleep medications.) Although Rozerem isgenerally considered safer and gentler than other prescriptionsleep medications, it may not be safe for those who have a historyof kidney or respiratory problems, sleep apnea, or depression, orare pregnant or breast feeding. It may interact with alcohol, andhigh-fat meals may slow absorption of the drug. For more aboutRozerem, visit http://www.rozerem.com.

Some older sleep aids include Restoril(temazepam), Halcion(triazolam), and ProSomorEurodin(estazolam). These are not usedfrequently anymore and have a history of being addicting and

causing a number of side effects. Halcion has been withdrawnform the market in several countries. If your doctor recommendsone of these medications, question the reasoning for using anolder drug.

Atypical Sleep AidsSome medications that are not bona fide sedatives are often used for thispurpose. Following are a few of the more common and effectivemedications in this group:

Trazodone: This is an old fashioned antidepressant, rarely usedfor depression anymore, but, because it is so sedating, hasbecome popular as a non-habit-forming sleep aid. Its use islimited to women for the most part though, because of a risk inpriapism for men an erection that will not go away. This seemslike it might be fun but it is actually a medical emergency.


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Remeron: Another antidepressant used for sleep because it is sosedating, Remeron is pretty effective, but causes weight gain.

Clonidine: This medication was primarily used for high bloodpressure, but is quite sedating, is often used in children withADHD, and is a good sleep aid thats not habit forming. It can

sometimes cause a drop in blood pressure or rebound high bloodpressure. In high doses, it can cause liver problems.

What about melatonin?Melatonin is a natural hormone, released by the brain when it gets dark.It is available over the counter. It is an effective sleep aid and is wellstudied even in children. The safety profile is quite good. Doses rangefrom 1-5 mg per night, and it comes in pills and spray forms.

Common Possible Side Effects

All medications have side effects. Prior to taking any prescription orover-the-counter sleep aid, consult your doctor let her know all themedications you are currently taking, including over-the-countermedications and all natural or herbal remedies. In addition, be awarethat any sleep aid can cause drowsiness, so avoid driving or operatingmachinery while taking these medications, especially when you first starttaking them and are unsure of the effect they may have on you.

Additional side effects may include the following:

Dizziness

Allergic reaction, possibly severe Facial swelling Headache Prolonged drowsiness (especially the sleep aids designed to help

you stay asleep)

Sleep behaviors, such as sleep-driving and sleep-eating or acombination of the two, like if you sleep drive to McDonalds

Sleep Aids in My Practice

I recommend or provide sleep aids frequently, because sleep problemsare so commonly associated with mood disorders and other psychiatricconditions. I encourage people to practice good sleep hygiene as aprimary intervention:

Regular bed time and wake up times No stimulants after 12 noon


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No vigorous exercise in the evening Turn off screens and phones and work one hour before bedtime Try to keep the bed for only sleeping and sex no work or other

activities

No TV in the bedroom its bad for sleepIf we do need to use a sleep aid, I will often start with melatonin beforeproceeding to prescription interventions. We try hard to use medicationsfor brief periods of time. Getting enough sleep is important in recoveryfrom mood disorders, so treating aggressively is important.

If you have bipolar and accompanying sleep-related issues, please shareyour experiences and insights and any helpful suggestions. This goes foryou doctors and therapists out there, too!

Associations Between the Use of Common Medicationsand Sleep Architecture in Patients with Untreated

Obstructive SleepAapneaSmith, Simon S. and Dingwall, Kylie and Jorgensen, Greg and Douglas, James(2006) Journal of Clinical Sleep Medicine,

AbstractSTUDY OBJECTIVES:Obstructive sleep apnea (OSA) is often associated with other disorders,which are usually treated with medications. Little is known about theextent to which medications are used in the OSA population or the

effects of common prescription medications on the sleep architecture ofpatients with OSA. The aim of this study was to describe the frequencyof use of medications by patients with untreated OSA and to examine thepotential associations between specific, frequently used medication typesand indexes of sleep architecture assessed through laboratory-basedpolysomnography. DESIGN: This study used a retrospective design withanalyses of archival clinical data. SETTING: Tertiary public sleepdisorders center in Brisbane, Australia. Patients or Participants:Consecutive patients with a clinical diagnosis of OSA (N = 1779).

INTERVENTIONS:None.

MEASUREMENTS AND RESULTS:Of the patients with OSA, 77.1% were taking at least 1 medication;12.4% were taking beta-adrenergic receptor-blocking agents and 20.8%were taking antidepressant or anxiolytic medications. Analyses of


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covariance demonstrated reliable effects of medication use on sleeparchitecture, after accounting for age, sex, and body mass index variables.Both tricyclic and selective serotonin reuptake inhibitor antidepressant oranxiolytic medications were associated with a lower percentage of rapideye movement sleep and lower sleep-efficiency values in patients with

OSA, compared with those not taking any medications. The use of beta-adrenergic receptor-blocking agents and aspirin had no consistentassociations with the indexes of sleep architecture.

CONCLUSIONS:Medication use was high within this sample of patients with OSA. Somecommon medications may be associated with differences in objectivesleep quality in a large proportion of patients with OSA. The potentialeffects of classes of common medication on both the presentation andtreatment of OSA need to be further assessed.

Effects of Parkinsonian Medication on SleepD. Schfer1and W. Greulich1

Institut fr Schlafphysiologie, Klinik fr Neurologie, Klinik Ambrock,Ambrocker Weg 60, 58091 Hagen, Germany, DE

SummaryPatients suffering from Parkinsons disease (PD) often report about sleepdisorders and excessive daytime sleepiness. To some extent, motordisabilities or neural degeneration of sleep modulating structures may beresponsible for these effects. Depressive disorders also contribute to theoccurrence of insomnia and daytime sleepiness. Nevertheless,

dopaminergic, anticholinergic, and other drugs used in PD have a greatimpact on sleep/wakefulness mechanisms. They may indirectly improveor worsen sleep by changing motor symptoms such as akinesia,hyperkinesia, or tremor. Although their is only little information on thecomplex regulation of vigilance, it is well known that monoaminergic andcholinergic drugs could influence it directly. Data from animalexperiments and clinical experiences led to the hypothesis of a biphasicinfluence on sleep by dopaminergic substances: small doses of L-Dopa e.g. appear to improve sleep whilst higher doses led to insomnia. Differentdopaminergic receptor types or changes in receptor sensitivity mayexplain these phenomena. Dopaminergic and anticholinergic drugssuppress REM sleep. Recently, initial data on sleep attacks afterpramipexole or ropinirole treatment were published. Our preliminaryresults using 24 h polygraphic recordings showed excessive daytimesleepiness in patients taking ropinirole and L-Dopa which disappearedwhen changed to ropinirole monotherapy. Sleepiness did never appear asan irresistible attack. Current hypotheses on this topic are reviewed.


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Methylphenidate vs. Atomoxetine ADHD Medications:Effects on Sleep

Stimulants are often the primary source of medication for ADHD andrelated disorders. Medications such as methylphenidate (Ritalin,

Concerta, Daytrana),Adderall,Vyvanse and the like are often the firstline of defense and choice of prescription for ADHD for manypracticing physicians. However, certain drawbacks exist to thesemedications. Perhaps the three most common concerns arecardiovascular effects, stimulant induced sleep difficulties, and appetitesuppression and resulting weight loss.

As a result, some parents and prescribing physicians choose a non-stimulant form of medication for treating ADHD such asAtomoxetine (Strattera ). While some of the negative side effects mentioned above areless common for these non-stimulant options, the overall efficacy of

reducing core ADHD symptoms is often less extensive than for thestimulant counterparts.

In this post, we will investigate one of the problem areas of stimulantmedication by examining a handful of studies comparing and contrastingthe different effects of methylphenidate and atomoxetine on sleeppatterns in ADHD individuals. Sleep patterns are often analyzed viareports (either the patients themselves, or parents if the patient is a child),actigraphy (less invasive) or polysomnography (more details andquantitative data).

MethylphenidateAdult ADHD studies on methylphenidate and sleep quality:While sleep difficulties are clearly evident in several studies, numerousothers have actually shown overall positive effects of methylphenidate onsleep performance. For example, a study by Boonstra and colleagues onsleep activity patterns in adult ADHD showed that methylphenidateadministration resulted in a delayed period of sleep onset. However, oncesubjects did fall asleep, the frequency of nighttime awakenings decreasedsignificantly for the methylphenidate group (keep in mind that all ofthese individuals had ADHD), and that the overall duration of sleep forthe night was less for the methylphenidate participants. These positive

results were echoed in a study by Sobanski and coworkers, which foundthat methylphenidate administration improved efficiency and restorativequality in adults with ADHD compared to non-medicated individualswith the disorder. In other words, it appears that althoughmethylphenidate can delay the onset of sleep, it appears to offer a


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positive effect in promoting a deeper pattern of less-interrupted sleep inADHD adults.

ADHD, Methylphenidate and Sleep Quality in Children:One of the difficulties in assessing the effects of ADHD medications on

sleep deficits in children is that it relies heavily on parental reports andobservations. Unfortunately, the overall accuracy of these parental (aswell as teacher ratings) has been called in to question by several recentfindings. More info on this is given at the bottom of the post.

Another key issue, is the relative lack of long-term controlled studies onmethylphenidate in children due to a myriad of safety and practicalityissues. As a result, obtaining clear-cut and accurate information onADHD stimulant medications and sleep disorders in children is moretenuous than in the adult model, even though the overall number ofstudies on ADHD medication effectiveness is much higher in children.In other words, sleep disorders still hold a relatively remote corner

amongst the sea of information on pediatric ADHD.

Nevertheless, several studies on the matter have been done in the pastfew years. I will highlight some of them below:

An investigation by OBrien and coworkers found a significant increasein sleep disturbances for ADHD children regardless of medication status.These findings suggest a neutral effect of stimulant medications such asmethylphenidate for children with ADHD, but cite an often-overlookedcharacteristic: ADHD children typically exhibit more sleep difficultiesthan non-ADHD children. Therefore, some of the bad rap attributed to

ADHD stimulant medications such as methylphenidate for inducingsleep disorders may simply be due to the nature of the individuals ADHD andnot to the medication. This is an important observation to keep in mind,especially when investigating sleep medication studies.

There is even some evidence that the assertion of methylphenidateadministration later in the day (afternoon) may negatively impact sleepperformance is less pronounced than popularly believed. Manyphysicians fear that a third daily dose of methylphenidate may cause sleepdifficulties and omit the afternoon dosage. However, a study by Kentindicates that this may not be the case. Of course this is just one study,

and should be regarded as such, but this may at least open the possibilitythat a number of these afternoon medication/sleep impairment fears maybe less grounded than previously believed. Nevertheless, sleepdisturbances are still a concern with ADHD medications such asmethylphenidate, but, according to recent findings, the effects arerelatively small.


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Do genetics play a role on sleep disorders and the ADHDmedication response?This is an intriguing question which needs to be investigated further. Wehave had several previous discussions on the COMTgene and its effectson ADHD. Now it appears that sleep disorders and potential medication

response may actually be impacted by an individual variation in thishotbed region of the human genome. A study done by Gruber andcoworkers suggests that ADHD children with theVal form of theCOMT gene may be more prone to sleep difficulties while onmethylphenidate compared to the Met form of the COMTgene (if youare unfamilar with this Val, Met and COMT terminology, a goodexplanation of these terms and how they relate to ADHD and ADHDmedications can be found here ).

ADHD, Sleep Quality and Strattera (Atomoxetine) in children:In contrast to methylphenidate, which seems to delay the onset of sleep,individuals on atomoxetine have a much smaller delay in sleep onset.

These differences were highlighted in an article by Sangal and coworkerstitledEffects of Atomoxetine and methylphenidate on sleep in children with ADHD.Other advantages of atomoxetine over methylphenidate include lessirritability, less difficulty getting ready for bed, less difficulty waking up inthe morning, and less of an appetite suppression. However, the postiveeffects of fewer nighttime awakenings seen in methylphenidate were notobserved in atomoxetine.

Methylphenidate vs. Atomoxetine: Comparative Effects on SleepHere are some of the highlights obtained from the Sangal study. Anumber of parameters and categories were investigated, but I have only

included ones which were either statistically significant or ones which Ipersonally found to be noteworthy:

Factor NoMeds

Atom MPH Method

Sleep onset (minutes) 19 19 36 Polysom Time to REM (minutes) 173 209 170 Polysom% of Sleep time in REM 19 18 21 Polysom# of awakenings 12 8 5 PolysomTime to fall back asleep(minutes)

18 15 7 Polysom

Sleep onset (minutes) 30 42 69 Actigraphy Total sleep time (minutes) 519 504 483 Actigraphy# of sleep interruptions 32 30 27 ActigraphyTotal interrupted sleep time(minutes)

61 62 55 Actigraphy


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A comparison of differences between Atomoxetine (Atom) andMethylphenidate (MPH), as well as the effects of both medicationscompared to unmedicated ADHD individuals are shown above.Quantitative measurements were performed using bothpolysomnography (polysom) and actigraphy. Some key trends of note:

A delayed onset of sleep was seen in Methylphenidate.

However, REM sleep (an important factor in overall sleepquality) was reached faster with Methylphenidate and slower withAtomoxetine.

Additionally, a slight increase in the percentage of sleep timespent in REM was seen with methylphenidate treatment.

Fewer sleep disruptions (partial or full, as in awakenings) wereseen with both medications, but the effects were even greater inthe methylphenidate group.

When a child did awaken during the sleep cycle, the childrenmedicated with methylphenidate were able to fall back asleep

much faster. Note this contrast to the increased time to fall asleepinitially for the methylphenidate group.

Overall, it appears that while methylphenidate does slow the onset ofsleep initially at a significant level, it appears that once a child does fallasleep, the overall sleep quality is actually improved if the child ismedicated with methylphenidate. This data runs against the grain as far asprescription medications for ADHD are concerned, in whichnonstimulants such as Strattera (Atomoxetine) are often given in favor ofstimulants such as methylphenidate if sleep disorders are a concern. Thisis likely due to the most obvious parameter (initial difficulty falling

asleep), which favors Strattera, while the other parameters, which favormethylphenidate and are more numerous, are less intrinsically obvious.

Why the pronounced difference between the two ADHDmedications?While there is still a fair amount of debate surrounding the exact cause ofdifferent impacts of these ADHD medications on sleep, the differentbiological targets and modes of action may offer some clues. Forexample, while methylphenidate primarily targets the neuro-signalingagent dopamine in brain regions such as the striatum and nucleusaccumbens, Strattera (atomoxetine) instead targets anotherneurotransmitter called norepinephrine.

It appears that the different neurochemical targets and specific brainregions impacted by the two medications are responsible for thedifferences. For example, we have previously mentioned in another poston gene variations and attention control that the cingulate region of thebrain, which essentially acts as the brains gear shifter, has a high density


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of receptors for dopamine, the very chemical that methylphenidatetargets. It is possible that changes in dopamine levels frommethylphenidate may indirectly impact the gear shifting ability of thekey brain region of the cingulate. We have previously discussed that anoveractive cingulate region can lead to difficulties changing focus or

transitioning between topics or activities, while an underactive cingulatecan lead to difficulty maintaining focus on a particular thought or state.

Putting this into context of our sleep and ADHD medication discussion,it is also worth noting that the Sangal paper mentioned that children whotook the methylphenidate had a more difficult time getting up in themorning and settling down into a pre-bedtime routine than the Stratteragroup. In other words, it seems like the methylphenidate group hadtrouble with transitions. As a result, this blogger hypothesizes that thetransitions may be caused, at least in part, by the increased activity of thecingulate region of the brain and its high density of dopamine targets,which see increased activities driven by a boost in free dopamine levels

from the methylphenidate. In other words, I suggest the possibility thatmethylphenidate induces a state of the cingulate gear shifter becomingoveractive and getting stuck in one routine (either the waking or sleepingstate) and having trouble moving to another (getting out of bed or fallingasleep). Further supporting this hypothesis is the data from the tableabove showing that the methylphenidate treatment group appears to bemore inert (i.e. fewer sleep interruptions, and a quicker return to aprevious sleeping state).

MEDICATIONS AND THEIR EFFECT ON SLEEP

ARCHITECTUREThomas Bailey AldrichSimone WeilMarianne J Davey MSc, Director, British Snoring & Sleep Apnoea Association

WHAT PROBING DEEP HAS EVER SOLVED THEMYSTERY OF SLEEP?Sleep patterns vary from one individual to another, some need only 4-5hours and others may need 10-12, but in general, adults sleep for about7-8 hours per night. It is estimated that we spend around one third of our

lives asleep and our day-to-day well-being is often measured by ourperceived sleep quality. Approximately 35% of the population suffersfrom insomnia but only about 5% of them consultant their GP(12,16).

Sleep is divided into two distinct states Rapid Eye Movement (REM)sleep and non-REM which is further divided into 4 stages: Stage 1


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(drowsiness), Stage 2 (light sleep), and Stages Nr-3 (deep sleep). Deepsleep is often referred to as slow-wave sleep (SWS).

These stages of sleep alternate in 70 - 90 minute cycles and in an averagenight, sleep will move through 4 to 5 cycles.

However, many individuals rarely obtain a good nights sleep. Sleepdisturbances can be classified according their duration as either transient(


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SWS). However, Genco in his study, treated healthy subjects with 400mgibuprofen TID for 3 days, and reported no interference in sleep patterns.

Adjuvant analgesics comprise those drugs that have a primary indicationother than pain but are also known to be analgesic in some

circumstances. These analgesics usually include antidepressants andanticonvulsants. Although antidepressants suppress REM sleep, inducemore restless sleep, and sometimes worsen insomnia, according to Lamthey objectively and subjectively improve quality of sleep in depressedindividuals.

PEOPLE WHO SAY THEY SLEEP LIKE A BABY USUALLYDONT HAVE ONEBenzodiazepines, are among the most commonly prescribed hypnotics.As well as affecting sleep architecture they can have an adverse effect onbreathing during sleep. These medications are mild respiratorydepressants and can increase the apnoea/hypopnoea index and decreaseoxygen saturation. Browns study found the mean number of apneasincreased from 5/hr on a control night to10/hr on the drug night withoxygen desaturation. This effect is more pronounced in those individualswho suffer from sleep disordered breathing (SDB).

Antidepressants are prescribed for mood disorders but they aresometimes prescribed for use as hypnotics. In polysomnography (PSG)studies antidepressants were found to suppress REM sleep, increaseawakenings and arousals and reduce total sleep time (TST). There is alsothe tendency to exacerbate periodic limb movements during sleep and

restless leg syndrome. Symptoms of sleep abnormalities have beenreported to occur in around 60-80% of depressed patients but there havebeen mixed reports on the use of antidepressants. In one study,improvements in both SL and TST were demonstrated. However, inWilsons study, only an increase in REM onset latency was reported.

PEOPLE WHO SNORE ALWAYS FALL ASLEEP FIRSTThe use of medications for the treatment of sleep disordered breathing istheoretically attractive.

Compared with current treatments (Mandibular Advancement Therapy,CPAP), compliance would improve dramatically if patients simply had totake a daily pill. The use of ventilatory drive stimulants, central nervoussystem stimulants, antidepressants, serotonin reuptake inhibitors orantagonists, antihypertensive agents and even sedative hypnotics agentshave been studied but no data has demonstrated that pharmacologic


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agents improve upper airway muscle activity. Indeed studies have shownthat sedatives have a deleterious effect on respiration during sleep,reduced genioglossal muscle tone with consequent worsening ofObstructive Sleep Apnea (OSA), increased apneas and increase inseverity of nocturnal oxygen desaturation. Lu in his study, found some of

the physicians (who did not usually treat patients with sleep disorders)prescribed sedatives to patients with undiagnosed OSA who presentedwith sleep related symptoms. Of the 50 physicians in the study, only onethird of them screened their patients for OSA prior to prescribingsedatives.

THE BIG 3 CHALLENGES OF MODERN LIFECaffeine is without question the most commonly used stimulant world-wide, with an estimated mean consumption of 210-238 mg per personper day. PSG studies demonstrate the most prominent effects of caffeineto be prolonged SL, reduced sleep efficiency, reduced SWS and increasedawakenings during sleep.

Alcohol is the second most commonly used psychoactive substance usedworld-wide. An estimated 13% of people use alcohol as an aid to sleep. Itis similar to sedative hypnotics and has significant effects on sleep. Onestudy reported alcohol users to suffer decreased SL, suppressed REMsleep (dose-dependent) and increased excessive daytime sleepiness,significantly more than nonusers. The authors concluded that continueduse of alcohol as a sleep aid exacerbates these disturbances. The effect ofalcohol in alcoholics is different. SL and TST is decreased and their sleepis composed primarily of non-REM sleep. Even after more than two

years of abstinence, recovering alcoholics show abnormal sleep patterns.Alcohol decreases muscle tone, particularly in the upper airway and leadsto the development or worsening of snoring and OSA. It decreases thearousal response so that obstructive events become longer in duration.

Nicotine affects sleep both during use and on withdrawal. PSG studiesshow that compared to nonsmokers, current smokers experienceincreased SL, less TST and lower sleep efficiency.

Additionally, a drop in nicotine levels in the brain during sleep causesnicotine craving. This state of withdrawal modifies sleep continuity and

subjective results showed smokers experience more difficulties withmorning wakefulness and EDS than non-smokers. Cessation of smokingcan reverse these conditions.


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HE SLEEPS WELL WHO IS NOT CONSCIOUS THATHE SLEEPS ILLInsomnia (specifically increased SL) is a common complaint of personsusing illicit drugs, although withdrawal from the drug itself can alsoinduce a variety of sleep problems. Increased TST and REM sleep occur

during initial abstinence followed by persistent insomnia and REMdisturbance for several weeks after. For some, sleep disturbance is sosevere it can inhibit treatment success with consequent relapse toaddiction.

In asthma and allergic rhinitis inflammation increases at night oftenleading to disturbed sleep. The use of antihistamines and decongestants iscommon but the side effects of these medications can cause insomniaand subsequent daytime fatigue.

Patients with Alzheimers disease (AD) commonly have poor sleep and ahigh incidence of SDB. Sleep disturbance in AD may be multifactorialand involve SDB and disrupted chronobiology often characterized byexcessive daytime napping. In a study by Cooke(4), PSG resultsdemonstrated that AD patients with SDB spent less of the night in REMsleep than those with no SDB, but there were no differences in othersleep stages. In a further study by Cooke, it was found thatAcetylcholinesterase Inhibitors (AChEls) used in AD, changed sleeparchitecture significantly.

There were changes to stages 1 & 2 sleep, but no changes to REM orSWS. A better understanding of the cause-and-effect relationship ofAChEls is needed to further understand their effects on sleep

architecture. Meanwhile treating these patients SDB may improve theirdaytime functioning.

SLEEP IS THE GOLDEN CHAIN THAT TIES OURHEALTH AND BODIES TOGETHERAlthough the effects of a drug are known, some medications may actdifferently in individuals who are more susceptible to sleep relatedproblems. Screening patients for substance use/abuse, SDB and self-medication with OTCs will provide useful information when patientspresent with sleeping difficulties. The Epworth Sleepiness Scale (ESS) is

a simple and efficient test to determine the degree of daytime sleepiness.Patients with a high ESS and a BMI >25 are at risk of sleep disorderedbreathing.


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References

1. Bliwise DL (2004) Sleep disorders in Alzheimers disease and other dementias. ClinCornerstone 6 Suppl 1A S16-28

2. British Snoring & Sleep Apnoea Association (2007) Patient Information.www.britishsnoring.co.uk

3. Brown D (2006) The effects of medication on sleep. Respiratory Care Clinics ofNorth America 12 81-99

4. Cooke JR et al (2006) Acetylcholinesterase inhibitors and sleep architecture inpatients with Alzheimers disease. Drugs & Aging 23 (6) 504-511

5. Cooke JR et al (2006) The effect of sleep disordered breathing on stages of sleep inpatients with Alzheimers disease. Behav Sleep Med 4 (4) 219-27

6. DeMartinis NA & Winokur A (2007) Effects of psychiatric medications on sleepand sleep disorders. CNS & Neurological Dirsorders 6 17-29

7. Drapeau C et al (2006) Challenging sleep in aging: the effects of 200mg cafeineduring the evening in young and middle-aged moderate caffeine consumers. Journalof Sleep Research 15 133-41

8. Gengo F (2006) Effects of Ibuprofen on sleep quality as measured usingpolysomnography and subjective measures in healthy adults. Clinical Therapeutics28 (11) 1820-1826

9. Hudgel DW & Sitthep T (1998) Pharmacologic treatment of sleep disorderedbreathing. American Journal of Respiratory Care & Critical Care Medicine 158 (3)691-699.

10. Johnson EO et al (1998) Epidemiology of alcohol and medication as aids to sleepin early adulthood. Sleep 21 (2) 178-186

11. Kosinski M et al (2007) Pain relief and pain related sleep disturbance with extendedrelease Tramadol in patients with osteoarthritis. Current Medical Research &Opinions 23 (7) 1615-1626

12. Lam R (2006) Sleep disturbances and depression: a challenge for antidepressants.Int Clin Psychopharmacol 21 (suppl 1) S25-S2913. Lu B et al (2005) Sedating medications and undiagnosed OSA: Physician

determinants and patient consequences. J Clin Sleep Med 1 (4) 367-371

14. Onen H et al (2005) How pain and analgesics disturb sleep. Clin J Pain 21 (5) 422-431

15. Teplin D et al (2006) Screening for substance use patterns among patients referredfor a variety of sleep complaints. The American Journal of Drug and AlcoholAbuse 32 111-120

16. Verster J et al (2004) Residual effects of sleep medication on driving ability. SleepMedicine Reviews 8 309-325

17. Wilson S et al (2002) Effects of 5 weeks of administration of fluoxetine anddothiepin in normal volunteers on sleep, daytime sedation, psychomotorperformance and mood. Journal of Psychopharmacology 16 (4) 321-331

18. Woods L & Craig T (2006) The importance of rhinitis on sleep, daytimesomnolence, productivity and fatigue. Curr Opin Med 12 390-396


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19. Zhang L et al (2006) Cigarette smoking and nocturnal sleep architecture. Am JEpidemiol 164 529-537

Ritalin Helps....but what about the side effects?Carol E. Watkins, M.D.

Glenn Brynes, Ph.D., M.D.

The stimulants are often used to treat AD/HD and other conditions.The most common stimulants are methylphenidate (Ritalin, Concerta,Metadate-ER) and amphetamine (Dexedrine, Dexedrine Spansules,Adderall and Adderall XR.) We have been using these medications foryears. Despite some dramatic media reports, the stimulants have a fairlygood safety record.

When a medication gives you a symptom that you did not want, we callthat symptom a side effect. Many individuals take stimulants with fewside effects. Others experience mild problems. Some are simply unable totolerate stimulants. Often we can treat annoying side effects so theindividual can continue to take the stimulant. Too many people stop theirmedication instead of working with their physician to find a way todecrease side effects. On the other hand, stimulants can have thepotential for real side effects. This is why it is a good idea to keep in closecontact with your doctor, especially during the early stages of treatment.

Often we can treat side effects so you can continue to take yourmedication. Instead of stopping your medication, work with yourphysician to find a way to reduce side effects.

Reduced appetite: This effect may be worse in the very young. It mayimprove after several weeks or months. If it continues to be problematic,one may reduce the dose; or time a short-acting stimulant to wear offbefore mealtimes. Some people find that methylphenidate compoundshave slightly less appetite suppression than amphetamine compounds. Insome cases we resign ourselves to a eating a large breakfast and supperfollowed by a very small lunch. A late evening snack can also help. Somenon-stimulant AD/HD medications do not cause the same degree ofappetite suppression.

Rebound: Some people who take short acting methylphenidate or

amphetamine experience irritability or depression for an hour as thestimulant wears off. Sometimes this is worse than the individualsbehavior before the medication was started. One can avoid rebound byspacing the doses closer together, giving a smaller dose after the finallarger dose, or by switching to a longer acting stimulant. Recently severalnew long-acting stimulant preparations have been released. Although the


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long-acting compounds often have less rebound, it may still occur insusceptible individuals. Sometimes, we add a tiny dose of short-actingstimulant when the longer-acting stimulant wears off.

Headache: If this does not improve with time, we may reduce the dose

or switch to another stimulant. Sometimes caffeine restrictionhelps. However, if an individual with a heavy caffeine habit suddenlystops the caffeine he may get a caffeine withdrawal headache. If thecaffeine cessation happens at the same time as the start of the stimulant,the caffeine withdrawal headache may be mistaken for a stimulant sideeffect.

Jittery feeling: Eliminate caffeine or other stimulant-type medications. Asmall dose of a beta-blocker (a type of blood pressure medication) canblock tremor or jitters. Make sure that the individual is eating regularmeals.

Gastrointestinal upset: Take the medication with meals or eat smaller,more frequent meals.

Sleep difficulty: It is a good idea to take a sleep history before startinga stimulant medication. Sometimes the sleep problem is due to theAD/HD, not the medication. If the sleep problem is truly due tomedication effect, we have several options. Sleep difficulty is morecommon when one is using a long-acting stimulant or if one is giving ashort-acting stimulant in the evening. Now that there are more long-acting stimulants on the market, one can often eliminate this problem byusing one of the more intermediate-length stimulants. Clonidine or

guanfacine may help decrease agitation and may also facilitate sleep. Wealso counsel the individual on establishing good sleep habits.

Paradoxically, there are a few individuals who sleep better when they takea small dose of stimulant in the late evening. For these individuals, thestimulant helps slow racing thoughts and helps them lie still in their beds.Irritability: Sometimes irritability may be due to the AD/HD or anotherpsychiatric disorder. If the irritability is truly due to the stimulant, onemight reduce the stimulant dose, switch to a different stimulant, add anSSRI, (paroxetine, sertraline) an alpha agonist (clonidine/guanfacine) oruse another class of medications to treat the AD/HD.

Depression: This may occasionally be a delayed effect of stimulantmedication. It may be more common with the long-acting stimulants.Screening for a history of depression, and treating co-existing depressioncan minimize this. If the depression truly is related to the medication, onemay switch to another class of medications to treat the AD/HD. These


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second-line medications would include the tricyclic antidepressants,bupropion (Wellbutrin) and atomoxetine (Strattera.)

Anxiety: If an individual is anxious, the stimulants can exacerbate thesymptoms. The treatment of this side effect is similar to that of

depression. It may be best to treat a co-existing anxiety disorder beforetreating the AD/HD.

Blood glucose changes: Individuals with diabetes mellitus or borderlineglucose tolerance could potentially see a rise in blood sugar. On the otherhand, if the stimulant cuts ones appetite, one may use less insulin.Individuals with diabetes can often take stimulants but may need closermonitoring of their diabetic control.

Increased blood pressure: Stimulants may cause increases in bloodpressure or pulse. This is usually not significant at normal doses in mostpeople. However occasionally, the blood pressure effects can be

significant. Individuals on very high doses of stimulants or individuals atrisk for blood pressure problems should be monitored more closely.Some adults may opt to continue the stimulant and add a blood pressuremedication. A small open study suggested that adults who were wellcontrolled on their blood pressure medications could take amphetaminewithout significant increases in blood pressure. Individuals with bloodpressure changes need to discuss the risks and benefits with theirphysicians. (1)

Tics and stereotyped (repetitive) movements: In the past we rarelygave stimulants to individuals with tics because we believed that the

stimulant would make the tics worse. Recent data seems to indicate thatlow to moderate doses of amphetamine or methylphenidate do notexacerbate tics. If an individual has tics, or develops them while on astimulant, it should be discussed with the prescribing physician. Thepatient and physician should then carefully weigh the risks and potentialbenefits or medication treatment.

Psychosis or paranoia: These are rare side effects. They may occur inan individual who is already predisposed to a bipolar disorder or anotherpsychotic disorder. In a few cases, psychosis has occurred in individualswho have no previous history of bipolar disorder or psychosis. Psychosis

may also occur when someone takes a stimulant overdose. It is importantto screen for and treat certain other psychiatric disorders prior to startinga stimulant. If psychosis occurs while taking a stimulant, one shouldimmediately stop the medication and call the prescribing doctor.


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When Your Medication Causes Sleep Problemsby Aimee Amodio24 FEB 2009

When I was trying to clear up my clogged ear, I picked up a variety ofdecongestants to try. My family doctor suggested traditional Sudafed --made with pseudoephedrine, which can be hard to get in some areas.

The Sudafed worked, but caused a different problem: I had troublesleeping. Most nights, Id wake up every few hours -- instead of sleepingstraight through like I normally do. The doc had warned me that thedecongestant might cause problems sleeping, and suggested that I onlytake it in the mornings (instead of twice per day as indicated on thepackage). But I was in a hurry to get my ear cleared, so I took theSudafed twice daily.

Medications come with a laundry list of side effects, and sometimes the

cure seems worse than the problem! Here are some tips that might help ifyour medications are wreaking havoc with your nights.

If a prescription medication is the culprit:

DONT just stop your medication cold turkey. Your doctor gaveyou that particular medication for a reason. Stopping it without adoctors approval may do you more harm than good.

Talk to your doctor about your problem. There may be analternate version of the same medication that comes withdifferent side effects. There may be a different medication thattreats the same problem without the insomnia.

Ask about sleep aids. An over the counter or prescription sleepaid may help get you through the adjustment period for yourmedication. Just make sure your doctor or pharmacist approvesyour choice -- you dont want a medication that will interactnegatively with your prescription.

If an over the counter medication is the culprit:

Talk to your pharmacist. They may be able to suggest an alternatemedication that comes without the sleep problems.

Take a look at natural sleep aids. That warm glass of milkgrandma offered might do the trick. You might have some luck

with a warm bath before bed, or some gentle aromatherapy (likelavender or chamomile) to help you relax. Sip chamomile orvalerian tea.

Try some relaxation. Reading an old favorite book, taking a bathbefore bed, or curling up with a cup of tea might help settle yourmind and body at bedtime.


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Try taking your medicine at a different time. Maybe right beforebed isnt the best choice -- you might sleep better taking yourmedication in the afternoon or morning.

Insomnia

What Is Insomnia?Insomnia is a condition in which you have trouble falling or stayingasleep. Some people with insomnia may fall asleep easily but wake up toosoon. Other people may have the opposite problem, or they have troublewith both falling asleep and staying asleep. The end result is poor-qualitysleep that doesnt leave you feeling refreshed when you wake up.

Types of Insomnia

There are two types of insomnia. The most common type is calledsecondary insomnia. More than 8 out of 10 people with insomnia arebelieved to have secondary insomnia. Secondary means that the insomniais a symptom or a side-effect of some other problem. Some of theproblems that can cause secondary insomnia include:

Certain illnesses, such as some heart and lung diseases Pain, anxiety, and depression Medicines that delay or disrupt sleep as a side-effect Caffeine, tobacco, alcohol, and other substances that affect sleep Another sleep disorder, such as restless leg syndrome: a poor

sleep environment; or a change in sleep routine

In contrast, primary insomnia is not a side-effect of medicines or anothermedical problem. It is its own disorder, and generally persists for least 1month or longer.

OverviewInsomnia is a common health problem. It can cause excessive daytimesleepiness and a lack of energy. Long-term insomnia can cause you to feeldepressed or irritable; have trouble paying attention, learning, andremembering; and not do your best on the job or at school. Insomnia

also can limit the energy you have to spend with friends or family.Insomnia can be mild to severe depending on how often it occurs andfor how long. Chronic insomnia means having symptoms at least 3 nightsper week for more than a month. Insomnia that lasts for less time isknown as short-term or acute insomnia.


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OutlookSecondary insomnia often resolves or improves without treatment if youcan eliminate its cause. This is especially true if the problem can becorrected soon after it starts. Better sleep habits and lifestyle changesoften help relieve insomnia. You may need to see a doctor or sleep

specialist to get the best relief for insomnia that is persistent or for whichthe cause of the sleep problem is unclear.

How Is Insomnia Treated?Making lifestyle changes that make it easier to fall asleep and/or stayasleep can often relieve insomnia. For longer lasting insomnia, a type ofcounseling called cognitive-behavioral therapy can help relieve theanxiety linked to your sleep problem. Anxiety tends to prolong theinsomnia. Several medicines also can help relieve insomnia and re-establish a regular sleep schedule.

Lifestyle ChangesTo relieve insomnia, you should avoid substances that make it worse andhave good bedtime habits that make it easier to fall asleep and stayasleep. Make sure your bedroom is a comfortable temperature, dark, andquiet enough for sleep.

Avoid substances such as:

Caffeine, tobacco, and other stimulants taken too close tobedtime (effects of caffeine can take as long as 8 hours to wearoff).

Certain over-the-counter and prescription medicines that candisrupt sleep (for example, some cold and allergy medicines).

Alcohol. An alcoholic drink before bedtime may make it easierfor you to fall asleep. But alcohol triggers sleep that tends to belighter than normal and makes it more likely that you will wakeup during the night.

Good bedtime habits include:

Following a routine that helps you wind down and relax beforebed, such as reading a book, listening to soothing music, ortaking a hot bath.

Not exercising, eating heavy meals, or drinking a lot shortlybefore bedtime.

Making your bedroom sleep-friendly. Avoid bright lighting andminimize possible sleep distractions, such as a TV, computer, orpet.


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Going to sleep around the same time each night and waking uparound the same time each morning, even on weekends. Ifpossible, avoid night shifts or alternating schedules at work andother causes of irregular sleep schedules.

Cognitive-Behavioral TherapyCognitive-behavioral therapy for insomnia targets the thoughts andactions that can disrupt sleep. Besides encouraging good sleep habits, thistype of therapy may use several methods to relieve sleep anxieties,including:

Relaxation training and biofeedback at bedtime to reduce anxiety.These strategies help you better control your breathing, heartrate, muscles, and mood.

Replacing worries about not being able to fall asleep with morepositive thinking that links being in bed with being asleep. This

method also teaches you what to do if youre unable to fall asleepwithin a reasonable period.

Talking with a therapist individually or in group sessions to helpyou consider your thoughts and feelings about sleep. Thismethod may encourage you to describe thoughts racing throughyour mind in terms of how they look, feel, and sound. The goal isfor your mind to settle down and stop racing.

Limiting the time you spend in bed while awake. This methodinvolves setting a sleep schedule and, at first, limiting total time inbed to the typical short length of time youre usually asleep. Atfirst, this schedule may make you even more tired because some

of the allotted time in bed will be taken up by difficulty sleeping.The resulting fatigue (tiredness) is intended to help you get tosleep more quickly. Gradually, the length of time spent in bed isincreased until you get a full night of sleep.

For success with this type of therapy, you may need to see a therapistwho is skilled in this approach weekly over 2 to 3 months. Cognitive-behavioral therapy is as effective as prescription medicine for many typesof chronic insomnia. It also may provide better long-term relief thanmedicine alone.

MedicinesSeveral medicines cause sleepiness. Doctors sometimes prescribe sleep-inducing medicine for 1 to 2 weeks to help establish a regular sleepschedule. Insomnia medicine helps you fall asleep, but can leave somepeople feeling unrefreshed or groggy in the morning. You may also be


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groggy and should exercise caution if you must get up before getting afull nights sleep of 7 to 8 hours while taking these medicines. The Foodand Drug Administration (FDA) hasnt approved all insomnia medicinesfor continuous, long-term use. Your doctor can help you understand thebenefits and potential problems if medicines will be needed for long

periods.

Some people use natural remedies to treat their insomnia. These remediesinclude melatonin and L-tryptophan supplements and valerian teas orextracts. The FDA doesnt regulate these over-the-counter treatments.This means that their dose and purity can vary from product to product.Their safety and effectiveness is not well understood.

Medicines also are available to treat symptoms of excessive sleepiness ifyour insomnia is the result of shift work or alternating work schedules.You should discuss your situation with your doctor to determine whetherthese medicines, together with improving sleep habits, can help you

overcome insomnia.


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Examination

Select the bestanswer to each of the following items. Mark yourresponses on the Answer form.

1.

Though medication and prescription drugs are designed to help withspecific problems, they can often have negative side effects. Medicinecan disrupt the normal balance of the body and lead to a disruptionin sleep or insomnia. Even _______ can have a negative impact onrestful sleep.

a. aspirinsb. sleeping pillsc. vitaminsd. All of the above

2. However, many medicines can cause sleep problems. A short list ofsome medicine types that can adversely affect sleep includes:

a. antihistaminesb. antidepressantc. decongestantsd. All of the above

3. Some antidepressants, such as_______, are thought to helpencourage better sleep, some have been linked to causing sleepproblems. Some research has indicated that antidepressants can causethe onset of REM sleep disorder, which causes people to physicallyact out their dreams while fully asleep.

a. Zincb. Prozacc. Antihistaminesd. None of the above

4. _______and other asthma and related medications have been studiedrecently in regard to their possible effect on sleep. While themedications help clear airways during waking hours, it seems to haveother effects when the person is sleeping, including reducing timeasleep and soundness of sleep.

a. Prozacb. Corticosteroidsc. Theophyllined. None of the above


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5. Weight loss medication often contains some type of diuretic and/orstimulant (such as caffeine) to rev the body up and increasemetabolism. Diuretics can cause people to awaken during the night togo to the bathroom, while stimulants can overexcite the mind andmake it difficult_______.

a.

to fall asleepb. enter REM sleepc. dreamd. None of the above

6. Ironically enough, sleep medications can often exacerbate the exactproblem they are designed to help. Many sleep medicines overridethe body's natural sleep mechanisms, making the body "forget" howto lull itself to sleep without assistance. This means that mostsleeping pills should only be _______ as they have limited efficacy.

a. used for short durationsb. used when sleep is urgentlyc. rarely usedd. None of the above

7. These drugs, used to treat heart rhythm problems, may cause daytimefatigue and nighttime sleep difficulties. Such medications includeprocainamide (Procanbid), quinidine (Cardioquin, others), anddisopyramide (Norpace).

a. Trueb. False

8. Beta blockers are used to treat high blood pressure, arrhythmias, andangina. These drugs can promote _______.

a. insomniab. awakenings in the nightc. nightmaresd. All of the above

9. Caffeine, found in some over-the-counter painkillers and appetitesuppressants, stimulates the nervous system and can induce insomnia.Caffeine makes people feel alert by blocking the action of _______, asubstance that promotes drowsiness. Caffeines direct effectsgradually diminish but may linger for six or seven hours or even

longer in some people.a. synapsesb. adenosinec. adrenalined. None of the above


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10.Corticosteroids such as prednisone, used to suppress _______, oftencause daytime jitters and nighttime insomnia.

a. inflammationb. asthmac. None of the aboved.

All of the above

11.Patches used to curb smoking deliver small doses of nicotine into thebloodstream around the clock. People who use them often _______.

a. suffer insomniab. experience disturbing dreamsc. None of the aboved. All of the above

12.Ambien may not be safe for those who have a history of depression,liver or kidney disease, or respiratory conditions. Ambien may lose itseffectiveness if taken longer than.

a. two weeksb. four weeksc. six weeksd. None of the above

13.Sonata is approved to help you get to sleep. Its particular niche is thatit is short acting, so is less likely to produce a hangover effect in themorning. It is so short acting that you can take it a second time if youawaken in the middle of night. Sonata can be habit forming and maynot be safe for those who have a history of _______, or a history ofsubstance abuse or addiction; severe liver impairment; or are

pregnant, planning to become pregnant, or breast feeding.a. depressionb. mental illnessc. suicidal thoughtsd. All of the above

14.Clonidine: This medication was primarily used for high bloodpressure, but is quite sedating, is often used in children with ADHD,and is a good sleep aid thats not habit forming. It can sometimescause a drop in blood pressure or rebound high blood pressure. Inhigh doses, it can cause liver problems.

a.

Trueb. False


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Notes

15.All medications have side effects. Prior to taking any prescription orover-the-counter sleep aid, consult your doctor let her know all themedications you are currently taking, including over-the-countermedications and all natural or herbal remedies. In addition, beaware that any sleep aid can cause drowsiness, so avoid driving or

operating machinery while taking these medications, especially whenyou first start taking them and are unsure of the effect they may haveon you. Additional side effects may include the following _______.

a. Dizzinessb. Prolonged drowsiness (especially the sleep aids designed to

help you stay aslec. Facial swellingd. All of the above

medications that interfere with sleep

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