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Sleep Disorders

Non-Restorative sleep

01/27/2006

Question:

Since 1997 I have suffered from non-restorative sleep which gradually occurred after a period of severe headaches. In 1999 I was evaluated at a sleep center in Pittsburgh, PA and the study noted "high grade sleep fragmentation " with 52 transient arousals. Each arousal ocurred at the onset of stage 3/4 sleep. My doctor noted that this was causing my unrefreshed sleep ( but not what triggered this ) and has tried a multitude of medications. To date ( now Jan, 2006 ) only two medications have been effective. Klonopin was used 1st and titrated as I quickly became tolerant to its effects although it worked immediately. After reaching 3 mg Neurontin was added and as been about 70% effective ( that is 70 out of 100 of days I will awaken feeling very refreshed ). Unfortunately, attempts to improve on this with other meds including gabitril, xyrem, ambien, tegretol, topamax, and most recently Lyrica have not been of further help. It is important to note that I fall asleep quickly 10-15 min and stay alseep 7 to 8 hours whether I take medicine or not. It is matter of quality rather than quanity. I have not other medical conditions except for hypothyroidism which is well regulated and the initial head aches resolved during a period of months back in 1997 ( negative MRI of head ) So, with all of this said I still lead a busy, active life but the effects of this non-restorative sleep disorder are very punishing on "bad" days. I feel wiped out and have no remedy to get me through the day.

I would like to know if you have any insight into my condition, what more might be done about it and if need be where I could get the best care for such a condition. Thank you for your assistance.

Answer:

Nonrestorative sleep, or feeling unrefreshed following adequate sleep time, can be a very frustrating problem. Unfortunately, it is not uncommon and can be a symptom of many different conditions. Some of these conditions are primary sleep disorders, such as sleep apnea and periodic limb movement disorder, while others are due to disorders that may result in poor sleep, such as chronic fatigue syndrome or depression. In this answer, I will address the potential sleep disorders that may be contributing to your symptoms.

Obstructive sleep apnea (OSA) is quite common in modern society, affecting up to 5% of middle aged adults in America. It is due to the recurrent complete or partial closure of the airway during sleep. When one of these breathing disturbances occurs during sleep, a brief arousal usually results in order to establish normal breathing again. As a result, individuals with OSA suffer from fragmented sleep and tend to feel unrefreshed upon awakening as well as sleepy and tired during the daytime.

The main risk factors for the development of sleep apnea include being overweight and having specific anatomic abnormalities (such as large tonsils) that may narrow the airway. Aside from unrefreshing sleep and daytime sleepiness, individuals with sleep apnea often complain of loud snoring, headaches upon awakening, a poor sense of well-being, decreased ability to concentrate and reduced alertness. Increasing research also suggests that OSA may impact other medical conditions, including blood pressure control and risk for cardiovascular disease (such as heart attacks, heart failure and stroke). Thus, it is important to diagnose and treat this condition. The diagnosis typically requires a sleep study. You mention in your question that you already had a sleep study and you were noted to frequently arouse from sleep, but you did not report on whether there was evidence of sleep apnea. Recently, advances in technology have improved the detection of even very mild sleep apnea and so repeat testing may need to be considered in your case.

Periodic limb movement disorder is another sleep condition that can fragment sleep. The primary symptom seen with this is frequent leg jerks in sleep that disrupt sleep, resulting in unrefreshing sleep and daytime sleepiness. Often times, an individual's bed partner is the first to complain about this problem. This condition also requires a sleep study to make the diagnosis and treatment is generally managed with medical therapy. Some of the medications you have been taking are commonly used to treat this condition and it is possible that periodic limb movement disorder may be part of your problem.

Aside from the conditions mentioned above, numerous other factors may influence the quality of your sleep. These can range from the environment you sleep in (i.e. too warm, too loud) to your other medical problems (i.e. heartburn or breathing problems) to medications you may taking. To determine if there is sleep-related cause for your problems, a thorough history and physical examination are needed. A referral to a Sleep Specialist by your primary care physician should be considered to help sort out whether further testing is needed. Once a history and physical examination have been performed, the Sleep Specialist will decide if further evaluation is necessary. Obtaining a copy of your old sleep study report would also be useful for the Sleep Specialist to review. If a primary sleep disorder is discovered, you should maintain hope as most of these are treatable.

To learn more about sleep, nonrestorative sleep or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you.

Good luck and here's to better sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University