Heartburn - Medical Conditions And Sleep Problems: Sleep Disorders

Content provided by the Faculty of the Harvard Medical School

Heartburn

Heartburn

Lying down in bed often worsens heartburn, which is caused by the backup of stomach acid into the esophagus. You may be able to avoid this problem by abstaining from heavy or fatty foods — as well as coffee and alcohol — in the evening. You can also use gravity to your advantage by elevating your upper body with the use of an under-mattress wedge or by placing blocks under the bedposts. There are also some over-the-counter and prescription drugs that suppress stomach acid secretion.

Diabetes

Night sweats, a frequent need to urinate, or symptoms of hypoglycemia often rouse diabetics whose blood sugar levels are not well controlled. If diabetes has damaged nerves in the legs, nighttime movements or pain may also disturb sleep.

Cardiovascular disease

Patients with congestive heart failure may awaken during the night feeling short of breath because when they're lying down, extra body fluid accumulates around their lungs. Using pillows to elevate the upper body may help. These people can also be awakened just as they are falling asleep by a characteristic breathing pattern called Cheyne-Stokes respiration, a series of increasingly deep breaths followed by a brief cessation of breathing. Benzodiazepine sleep medications (see "Medications for treating insomnia") help some people to stay asleep despite this breathing disturbance, but others may need to use supplementary oxygen or a device that increases pressure in the upper airway and chest cavity to help them breathe and sleep more normally (see "Continuous positive airway pressure (CPAP)").

A recent study found that men with congestive heart failure frequently experience obstructive sleep apnea (see "Sleep apnea"), which can disrupt sleep, cause daytime sleepiness, and worsen heart failure. In people with coronary artery disease, the natural fluctuations in circadian rhythms may trigger angina (chest pain), arrhythmia (irregular heartbeat), or even heart attack while asleep.

Musculoskeletal disorders

Arthritis pain can make it hard for people to fall asleep and to resettle when they shift positions. In addition, treatment with corticosteroids frequently causes insomnia. You may find it helpful to take aspirin or a nonsteroidal anti-inflammatory drug (NSAID) just before bedtime to relieve pain and swelling in your joints during the night.

People with fibromyalgia — a condition characterized by painful ligaments and tendons — are likely to wake in the morning still feeling fatigued and as stiff and achy as a person with arthritis. Researchers who analyzed the sleep of fibromyalgia sufferers have found that at least half have abnormal deep sleep in which slow brain waves are mixed with waves usually associated with relaxed wakefulness, a pattern called alpha-delta sleep. In one study conducted by researchers at Boston University School of Medicine, 62 people with fibromyalgia received treatment for six weeks with either the NSAID naproxen, the tricyclic antidepressant amitriptyline, both drugs, or a placebo. Almost half of those who took low doses of amitriptyline reported sleeping and feeling better.

Eating disorders

People who have anorexia, an eating disorder characterized by malnutrition and excessive weight loss, get more Stage 1 sleep and less slow-wave sleep than those who maintain a healthy weight. Some people with bulimia, an eating disorder characterized by compulsive overeating and then purging (usually by inducing vomiting or using laxatives), awaken frequently during the night to eat. (For information on food-related sleep disorders, see "Nocturnal eating disorders.")

Kidney disease

Kidney disease can cause waste products to build up in the blood and can result in insomnia or symptoms of restless legs syndrome (see "Restless legs syndrome"). Although researchers aren't sure why, kidney dialysis or transplant does not always return sleep to normal.

Mental illness

Almost all people with anxiety disorders have trouble falling asleep and staying asleep. In turn, not being able to sleep may become a focus of some sufferers' ongoing fear and tension, causing further sleep loss.

General anxiety. Severe anxiety, formally known as "generalized anxiety disorder," is a mental illness that causes a person to have persistent, nagging feelings of worry, apprehension, or uneasiness. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person's everyday life. People with the disorder typically experience excessive, persistent worry every day or almost every day for a period of six months or more. Common symptoms include trouble falling asleep, trouble staying asleep, and not feeling rested after sleep.

Phobias and panic attacks. Phobias, which are intense fears related to a specific object or situation, rarely cause sleep problems unless the phobia is itself sleep-related (such as fear of nightmares or of the bedroom). Panic attacks, on the other hand, often strike at night. In fact, the timing of nocturnal attacks helped convince psychiatrists that these episodes are biologically based. Sleep-related panic attacks do not occur during dreaming, but rather in Stage 2 and Stage 3 sleep, which are free of psychological triggers. In many phobias and panic disorders, recognizing and treating the underlying problem — often with an anti-anxiety medication — may solve the sleep disturbance.

Depression. Because waking up too early in the morning is a hallmark of depression, a physician evaluating a person with insomnia will consider depression as a possible cause. Almost 90% of people with serious depression experience early-waking insomnia; some depressed people have difficulty falling asleep or get fitful sleep throughout the whole night. In chronic low-grade depression, insomnia or sleepiness may be the most prominent symptom. Laboratory studies have shown that people who are depressed spend less time in slow-wave sleep and may enter REM sleep more quickly at the beginning of the night.

Bipolar disorder. Disturbed sleep is a prominent feature of bipolar disorder (manic-depressive illness). Sleep loss may exacerbate or induce manic symptoms or temporarily alleviate depression. During a manic episode, an individual may not sleep at all for several days. Such occurrences are often followed by a "crash" during which the person spends most of the next few days in bed.

Schizophrenia. Some people with schizophrenia sleep very little when they enter an acute phase of their illness. Between episodes, their sleep patterns are likely to improve, although many schizophrenics rarely obtain a normal amount of deep sleep.

Other neurological disorders

Certain brain and nerve disorders can contribute to sleeplessness.

Dementia. Alzheimer's disease and other forms of dementia may disrupt sleep regulation and other brain functions. Wandering, disorientation, and agitation during the evening and night, a phenomenon known as "sundowning," can require constant supervision and place great stress on caregivers. In such cases, small doses of antipsychotic medications such as haloperidol (Haldol) and thioridazine (Mellaril) are more helpful than benzodiazepine drugs.

Epilepsy. People with epilepsy are twice as likely as others to suffer from insomnia. Brain wave disturbances that cause seizures can also interfere with sleep, causing deficits in slow-wave or REM sleep. Antiseizure drugs can cause similar changes at first, but tend to correct these sleep disturbances when used for a long time. About one in four people with epilepsy have seizures that occur mainly at night, causing disturbed sleep and daytime sleepiness. Sleep deprivation can also trigger a seizure, a phenomenon noted in college infirmaries during exam periods. Each semester, a few students suffer their first seizures after staying up late to study.

Headaches, strokes, and tumors. Two types of headaches — cluster headaches and migraines — may be related to changes in the size of blood vessels leading to the cortex of the brain. Pain occurs when the walls of the blood vessels dilate. People who are prone to headaches should try to avoid sleep deprivation, as lack of sleep can promote headaches. Researchers theorize that as the body catches up on missed sleep, it spends more time in delta sleep, when vessels are most constricted, making the transition to REM sleep more dramatic and likely to induce a headache. Headaches that awaken people are often migraines. But some migraines can be relieved by sleep.

Sleepiness coupled with dizziness, weakness, headache, or vision problems may signal a serious problem such as a brain tumor or stroke, which requires immediate medical attention.

Parkinson's disease. Almost all people with Parkinson's disease have insomnia and may have substantial daytime sleepiness. Treatment with sleeping pills may be difficult because some drugs can worsen Parkinson's symptoms. Some patients who are treated with levodopa, the mainstay of Parkinson's treatment, develop severe nightmares; others experience disruption of REM sleep. However, the use of levodopa at night is important to maintain the mobility needed to change positions in bed. A bedrail or an overhead bar (known as a trapeze) may make it easier for people with Parkinson's to move about and, therefore, lead to better sleep.

Respiratory problems

Circadian-related changes constrict the airway during the overnight hours, raising the potential for nocturnal asthma attacks that rouse the sleeper abruptly. Breathing difficulties or fear of having an attack may make it more difficult to fall asleep, as can the use of steroids, theophylline, or other stimulant medications. One study found that nearly 75% of people with asthma experienced frequent awakenings every week. People who have emphysema or bronchitis may also find it difficult to go to sleep and stay asleep because of excess sputum production, shortness of breath, and coughing.

Thyroid disease

An overactive thyroid can make it difficult to sleep, and night sweats that disturb sleep are a symptom of thyroid dysfunction. Feeling cold and sleepy is a hallmark of hypothyroidism, underactivity of the thyroid gland. Because thyroid function affects every organ and system in the body, the symptoms can be wide-ranging and sometimes difficult to decipher. Luckily, checking thyroid function requires only a simple blood test, so if you notice a variety of unexplained symptoms, ask your doctor for a thyroid test.

Medications that affect sleep

Often, medication rather than illness is the culprit behind sleep problems. A number of drugs are common sleep robbers, while others may cause unwanted drowsiness. Sometimes your doctor may be able to suggest alternatives that do not disrupt sleep.

Review your medications with your doctor.

Antidepressants. The selective serotonin reuptake inhibitors — such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) — disrupt sleep or produce daytime fatigue in about 15% of those who take them. These medications are increasingly used to treat some of the symptoms of narcolepsy (see "Narcolepsy"), a condition marked by powerful daytime drowsiness and sleep attacks, and a variety of sleep problems, whether or not the person is depressed.

Anti-arrhythmics. These drugs, used to treat heart rhythm problems, may cause daytime fatigue and sleep difficulties at night. Such medications include procainamide, quinidine, and disopyramide.

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

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

Medications containing caffeine. Caffeine, which is in some over-the-counter painkillers and appetite suppressants, is a nervous system stimulant that can induce insomnia. Caffeine makes people feel alert by blocking the action of adenosine, a substance that promotes drowsiness. Caffeine's effects gradually diminish but nonetheless may linger for six or seven hours.

Medications containing alcohol. Cough medicines often contain alcohol, which can suppress REM sleep.

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

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

Diuretics. Diuretics, which are taken to rid the body of excess sodium and water, can interfere with sleep by inducing urination throughout the night. Potassium deficiency, a common side effect of some diuretics, can cause painful nocturnal cramping of calf muscles during sleep.

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

Sympathomimetic stimulants. Sympathomimetic stimulants — such as dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), methylphenidate (Ritalin), and pemoline (Cylert) — are powerful central nervous system stimulants that enhance the effect of brain chemicals involved in wakefulness. People taking these agents 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 to caffeine. Many people who use it require doses that are high enough to disrupt sleep.

Thyroid hormones. Thyroid hormones taken to counteract the effects of an underactive gland may cause sleeping difficulties at higher doses.

Last updated:	January 23, 2007