Whether someone cannot sleep due to insomnia or has loud snoring or multiple other problems linked to sleep disorders, it may be time to schedule an appointment. Let’s explore 15 symptoms and conditions that may be linked to sleep and that may benefit from evaluation, testing, and treatment.
Generally, it is understood that if it takes more than 20 to 30 minutes to fall asleep, or to get back to sleep after waking in the night, this is problematic. It may also be associated with early morning awakenings. People with insomnia have other symptoms as well, including:
FatigueDecreased energyPoor concentrationMood problems (anxiety or depression)Headache or pain complaintsMalaise (feeling unwell)Dyspepsia (upset stomach)
If it occurs at least three times per week and lasts for at least three months, it is called chronic insomnia.
According to the American College of Physicians, chronic insomnia should be treated first with cognitive behavioral therapy for insomnia (CBTI). In some cases, sleeping pills have a limited role, but they may have long-term side effects that are best avoided.
It is also likely in the context of sleep deprivation. Most adults need seven to nine hours of sleep nightly to feel rested with a regular sleep-wake schedule. For those who sleep less than their sleep need, sleepiness inevitably results.
This excessive sleepiness may be noted when sedentary, such as while reading, watching TV, riding in the car, or sitting in a meeting. It may be identified with a subjective questionnaire like the Epworth sleepiness scale.
To objectively understand its severity and cause, a diagnostic polysomnogram and multiple sleep latency test (MSLT) may be recommended.
Beyond treating an underlying sleep disorder and ensuring adequate hours of rest, stimulant medication may be necessary.
Due to the potential for long-term health consequences, it is important to know if sleep apnea is present. A home sleep apnea test or diagnostic polysomnogram may be recommended.
Fortunately, snoring can be resolved with proper treatment. Treatments will depend on the underlying contributions and the presence or absence of associated sleep apnea.
These may include over-the-counter interventions (such as nasal strips, saline spray, allergy treatment, positional therapy, etc.), surgery, or even options to address both snoring and sleep apnea such as an oral appliance or continuous positive airway pressure (CPAP).
It can also occur after surgical removal of the ovaries (often as part of a procedure called total hysterectomy and bilateral oophorectomy). Treatment for certain cancers may also lead to the onset of menopause.
Sleep often worsens, with increased insomnia, night sweats, teeth grinding, and other symptoms. These symptoms may be due to the increased risk of sleep apnea in menopause.
Prior to menopause, the risk of sleep apnea in women is approximately 1 in 200. At perimenopause the prevalence increases to 1 in 20, and by the age of 65 it is estimated that 1 in 4 women have sleep apnea. The symptoms in women may differ from men, and there is often a delay in identification and treatment of the condition.
RLS may affect 1 in 10 people. It can be exacerbated by an iron deficiency (with a serum ferritin level less than 70) or due to another coexisting medical condition. This discomfort may make it hard to fall asleep.
It can also disrupt sleep at night—of the affected individual or their bed partner—as it overlaps with periodic limb movements of sleep (PLMS), a finding noted on a diagnostic polysomnogram.
Treatment may include iron replacement (if deficient) as well as prescription medications, including ropinirole (Requip), pramipexole (Mirapex), and others.
Children are prone to sleepwalking (somnambulism) and sleep terrors, and these episodes sometimes persist into adulthood. If it can be done while awake, it may be done while asleep, with behaviors that may include eating, cooking, driving, sex, and even crimes.
It is also possible to act out dreams in a condition called REM sleep behavior disorder (RBD). Hitting, kicking, and grabbing commonly occur in RBD, often associated with a dream that has a defensive element. Injuries may occur as sleepers leap from bed, hit their bed partner in the face, or crash into the bedside lamp or nightstand.
Due to the risk of injury, certain safety precautions must be taken. In addition, it is important to rule out the contribution of an underlying sleep disorder that leads to sleep fragmentation. This is most commonly sleep apnea, but narcolepsy is another possible contributor.
Treatment may require addressing the underlying disorder or the use of high-dose melatonin or prescription medications such as clonazepam.
It is better known as being a “night owl.” It affects about 10% of people, has a genetic predisposition, and often begins in adolescence. With DSPS, someone may not naturally fall asleep until 2 a.m. or later and desire to wake in the late morning or even early afternoon.
In attempting to go to bed earlier, severe sleep-onset insomnia may occur. It can be profoundly difficult to wake in the earlier morning, often causing problems with tardiness, absenteeism, and family conflict. Sleep deprivation from an abbreviated sleep period overnight may have other long-term consequences.
CBTI may be helpful, as can a regular sleep-wake schedule with 15 to 30 minutes of morning sunlight (or light box) exposure upon awakening. In some circadian disorders, low-dose melatonin may also have a role in treatment.
Assuming other concerning symptoms (vision changes, weakness or numbness on one side of the body, nausea or vomiting, etc.) are not present, several types of headaches may be suspected that may be linked to disturbed breathing in sleep.
Sleep apnea may be the primary factor driving these headaches. Oxygen levels drop and carbon dioxide levels increase repeatedly through the night. Carbon dioxide dilates blood vessels to the brain, increasing pressure and often contributing to a frontal headache that fades in the first hours of the day.
In addition, bruxism at night may be secondary to sleep apnea, with muscle tightness affecting the temporomandibular joint (TMJ) as well as the back of the head and into the neck and shoulders.
Although a guard may alleviate enamel wear and some discomfort, treatment of the underlying breathing issue may be needed to resolve the condition.
This drowsy driving may occur more often on long drives, or when driving occurs overnight. Falling asleep driving is also more likely with sleep deprivation and untreated sleep disorders like sleep apnea.
As Dr. William Dement, the father of modern sleep medicine, liked to say, “Drowsiness is red alert!” Drowsy drivers should pull off the road at the first sign of sleepiness.
For those with chronic problems staying alert behind the wheel, a sleep evaluation may be needed to ensure safety. If an accident or near miss occurs, driving should be ceased until this evaluation is complete.
During sleep, bruxism may be a self-protective activity that locks the jaw and tongue in a forward position and activates the muscles of the airway. This opens the airway to improve breathing. It may occur in response to sleep apnea during the arousal (or awakening) that terminates the episode.
Treatment of the underlying breathing issue may resolve the bruxism and provide long-term improvement to dental health.
Obstructive sleep apnea increases the acidity of the blood and strains the heart, two factors that will activate the kidneys and lead to increased nocturia. If someone is waking two to three times to urinate at night, treatment of sleep apnea may significantly reduce this, even with the other risk factors left unchanged.
If the high blood pressure is resistant to the use of medications, it is even more likely that sleep apnea underlies the problem. For example, a man with treatment-resistant hypertension who is on three blood pressure medications has a 95% chance of having sleep apnea.
CPAP can lower blood pressure, with some studies showing a drop in the systolic blood pressure by up to 10 mm Hg, especially among those with severe sleep apnea and higher compliance to therapy.
This may be due to both the drops in oxygen levels as well as the disruption to sleep continuity that may disturb the function of the glymphatic system, a network of vessels that cleanse the brain’s tissues during sleep.
Much like a cleaning crew, if this is not achieved, the debris in the form of protein plaques may lead to degeneration of the brain. This may ultimately contribute to dementia or Alzheimer’s disease.
Moreover, poor sleep has significant negative effects on mood. The difficulties sleeping that characterize insomnia are especially important. Sleep problems may lead to anxiety, depression, and irritability.
This is a bi-directional relationship, as mood can also undermine sleep. When both are present, research suggests that focusing on improving sleep is more helpful.
Fortunately, there are some effective treatments, including medications like prazosin as well as dream rehearsal therapy. If an underlying sleep disorder is suspected, testing may lead to the cause and ultimately to the resolution of the bad dreams.
Unfortunately, medical doctors don’t get a lot of education on managing sleep and many primary care physicians may be uncomfortable providing a diagnosis, testing, and treatment. If needed, ask for a referral to a board-certified sleep physician to get the care that you deserve to sleep and feel better.
