Reviews for Primary Care - Fall 2007 - (Page 47) Insomnia and Neurological Disorders during the day and sleeplessness at night. Patients with chronic pain disorders, including fibromyalgia, report significantly more sleepiness, more fatigue, and less refreshing sleep.72,73 Thus, patients with chronic pain are a population at high risk for sleep disturbances. Adequate management of chronic pain requires treatment of the pain itself and the associated comorbid mood disorders. Sleep and Stroke Sleep and stoke interact in a number of fascinating and complex ways. Probably the most important of these interactions is the fact that patients with SDB present with cardiac arrhythmias, intellectual decline, and increased risk of stroke. Bilateral lacunar ischemic infarcts in the tegmentum of the pons and periventricular white matter damage can present as REM sleep without atonia, which leads to RBD.74,75 Secondary consequences from the stroke, such as immobilization, pain, hypoxia, and depression, can also affect sleep. In a large study of 277 stroke patients, 56.7% reported insomnia and 37.5% fulfilled the DSM-IV criteria of insomnia.76 In 38.6% of the patients, insomnia had already been present before the stroke, but in 18.1% it was a consequence of the stroke.76 On further analysis, independent correlates of insomnia were anxiety and the use of a psychotropic drug. Independent correlates of post–stroke-onset insomnia were disability after stroke (Barthel index), dementia, anxiety, and use of psychotropic drugs.76 It is therefore important not only to evaluate but also to properly treat insomnia in post-stroke patients. disturbances and insomnia.77-80 The mechanism of respiratory disturbance in this disorder may be the result of the weakness of the upper airways caused by bulbar weakness, diaphragmatic weakness (due to a phrenic nerve lesion), and intercostal muscle weakness (due to the degeneration of intercostal nerve nuclei). Degeneration of the central respiratory neurons accounts for both central and obstructive sleep apnea. Polysomnographic findings include apneas in the form of central, obstructive, and mixed events; increased awakenings; sleep fragmentation; and reduced nocturnal oxygen saturation.77,78,81-83 Noninvasive positive-pressure upper airway ventilation provides a longlasting benefit on symptoms and quality-of-life indicators for ALS patients and should be offered to all patients with symptoms of SDB or inspiratory muscle dysfunction.84 Positive-pressure therapy can also prolong tracheostomy-free survival.85 creased use of cardiac medication in tetraplegics with SDB may implicate a link between SDB and cardiovascular morbidity, one of the leading causes of death in tetraplegia. Obstructive sleep apnea appears to be more common in older patients with SCI than in the general population and is related to ventilatory dysfunction secondary to the SCI.89 Post-Polio Syndrome Besides a high predilection for sleepdisordered breathing (SDB), postpolio syndrome (PPS) often manifests itself in sleep with random myoclonus, periodic movements in sleep with muscle contractions, ballistic movements of the legs, and restless legs syndrome.90 Poliovirusinduced damage to the spinal cord and brain may be implicated as a possible cause of these abnormal movements in sleep.90 It is suggested that polysomnography be performed on PPS patients with excessive daytime sleepiness and respiratory complaints.91 Spinal Cord Diseases Patients with ALS and spinal cord injury (SCI) often present with sleep disturbances related to respiratory dysfunction. In SCI, this is particularly critical when the lesion occurs in the upper cervical spinal cord within the vicinity of the phrenic nerve nuclei.86 Patients with SCI have greater difficulty in falling asleep, describe more frequent awakenings, are more likely to be prescribed sleeping pills, sleep more hours, take more frequent and longer naps, and are more likely to snore than controls.87 In particular, spasms, pain, paresthesia, and voiding difficulties have a higher association with sleep problems.87 The incidence of SDB in SCI is high in patients with tetraplegia, especially when the patient is elderly, has an increased neck circumference, has a long duration of the disease, and is taking cardiac medications.88 The in- Huntington’s Disease Sleep disturbances are common in Huntington’s disease (HD) and consist of disturbed sleep pattern with increased sleep onset latency, reduced sleep efficiency, increased arousals and sleep fragmentation, decreased SWS, frequent nocturnal awakenings, increased density of sleep spindles, increased time spent awake, and reduced sleep efficiency.92-94 Patients who have HD have also shown higher-density sleep spindles, in contrast with findings in other neurodegenerative dementia populations.93 These abnormalities correlated in part with duration of illness, severity of clinical symptoms, and degree of atrophy of the caudate nucleus. 94 Based on actigraphy data, patients with HD demonstrated significant activity and spent more time making Amyotrophic Lateral Sclerosis The major sleep complaint in amyotrophic lateral sclerosis (ALS) is excessive daytime sleepiness, likely caused by sleep-related respiratory VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 47
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