Circadian Disorders

Circadian disorders are a group of sleep disorders where the internal circadian clock is disrupted. Our bodies have a biological clock that can regulate sleep, body temperature, as well as alertness. Sunlight is an important regulator of our biological clock, and when people have significant alterations in their biological clock, a circadian disorder can result. These sleep disorders have a variety of unique treatments, which can include melatonin, light therapy (using a light box), blue light filters, and even chronotherapy.

Delayed Sleep Phase Syndrome

Delayed sleep phase is a common condition affecting teenagers and young adults, where patients can struggle with falling asleep in the early part of the night. Frequently, this can lead to an irregular sleep schedule where the weekend and weekday hours of restorative sleep vary significantly. As a result, this can lead to frustration and lower sleep efficiency when the body is constantly struggling to maintain a regular sleep schedule and a regular circadian rhythm.

Advanced Sleep Phase Syndrome

Advanced sleep phase is simply the opposite of delayed sleep phase. This is a condition that typically affects the elderly population. The most common patient complaint is that of unwanted early morning awakenings, which are occurring because the patient may be sleeping too early in the evening and developing a shift to earlier and earlier sleep.

Shift Work Sleep Disorder

Shift work sleep disorder is a circadian rhythm disorder that leads to a combination of nighttime insomnia and daytime sleepiness. Workers of second and third shift jobs or workers who have excessively long periods of work (such as health care providers or long-distance drivers) can develop this frustrating sleep disorder. A combination of stimulant medications to promote daytime alertness plus sedating/hypnotic medications may be useful in the short-term to increase sleep efficiency. A large 2007 study led by the IARC suggested that long-term shift work is associated with an increased incidence rate of cancer, heart disease, and menstrual irregularities.

Jet Lag or Rapid Time Zone Change Syndrome

Jet-like disorder occurs when patients travel greater than 3 time zones. In general, traveling eastward makes it harder for patients to adjust to the new sleep schedule. Traveling westward makes it easier to adjust to a new sleep schedule. In general, jet-like disorder is treated with a short-term course of hypnotic medications to achieve better sleep.

Insomnias

Insomnia is a type of sleep disorder in which a person has difficulty falling asleep or staying asleep. When a person has difficulty falling asleep, a variety of reasons are explored, which can include medication effects, stress or anxiety, or poor sleep hygiene. When a person has difficulty staying asleep, primary sleep disorders such as obstructive sleep apnea or periodic limb movements of sleep should be assessed and ruled out with a sleep study,

Chronic Insomnia

When a person has difficulty falling sleep or staying asleep more than three nights a week for three months or more, this is considered chronic insomnia. The best treatment for chronic insomnia is cognitive behavioral therapy. Patients who combine behavioral strategies with pharmacologic therapy achieve better results than those who employ pharmacologic or behavioral strategies alone..

Short-term Insomnia

When the duration of insomnia does not meet criteria for chronic insomnia, this is termed short-term insomnia. Your primary care doctor may prescribe you hypnotic medications for short-term insomnia that is related to travel, stress, pain, or variety of other medical or mental health conditions.

Parasomnias

This refers to abnormal behaviors that occur during sleep. Parasomnias include nightmares, night terrors, sleep walking, and sleep talking, head banging, wetting the bed and grinding teeth.

Sleep-related Eating Disorder

Sleep eating is defined by repeated episodes of binge eating after waking up in the middle of the night. Patients may only be partially awake during these episodes and thus can be completely unaware of these behaviors. An underlying nutritional deficiency should be considered in patients who have excessive and disruptive sleep eating behaviors.

Sleep Paralysis

Isolated (or “benign”) sleep paralysis can occur with excessive sleep deprivation, anxiety or other mental health conditions, or an untreated obstructive sleep apnea. When sleep paralysis is recurrent, central causes of sleep disturbance such as narcolepsy are suspected. When people report the occurrence of sleep paralysis with excessive sleepiness during the daytime, central disorders of hypersomnolence such as narcolepsy should be ruled out with sleep testing.

Sleepwalking (somnambulism)

Sleepwalking is common in children and is often benign and self-limiting. Sleepwalking can be associated with sleep deprivation, medication use, and obstructive sleep apnea. Population studies show that ~ 40% of children have at least 1 episode of sleepwalking. Although sleepwalking is very common, excessive sleepwalking should alert parents to the possibility of an undiagnosed obstructive sleep apnea condition.

Sleep Terrors (night terrors)

Sleep terrors can be distressing to both children and their parents. When they occur over and over and have the exact same pattern, it is important to rule out frontal lobe seizures with the help of advanced sleep testing with Video EEG and to consult a Sleep Neurologist. Whereas sleep terrors tend to resolve by school age, frontal lobe seizures will continue until the correct diagnosis is made and seizure medications are started.

Sleep-related Breathing Disorders

Sleep disordered breathing or “sleep apnea” occurs when the upper airway closes and airflow to the lung stops for at least 10 seconds. The most common form of sleep apnea is called obstructive sleep apnea with ~2-4% of children suffering from obstructive sleep apnea.

Obstructive Sleep Apnea

Population studies show that 10-20% of children have at least soft snoring. When kids have snoring and ADHD behaviors (poor attention, hyperactivity, learning difficulties), obstructive sleep apnea should be considered as a potential cause. Kids do not have the same clinical features as adults who are suspected to have sleep apnea. Many kids with sleep apnea are not obese and do not have sleepiness, thus it is critical for the physician to recognize this condition early by obtaining a polysomnogram (sleep study).

The first line treatment for children with obstructive sleep apnea is surgical removal of the tonsils and adenoids and is likely to be curative. Most kids who are diagnosed with OSA will not need CPAP after surgery is performed.

Central Sleep Apnea

Central sleep apnea is a condition that is more common at higher altitudes. ~25% of people at altitudes above 2500m develop this condition characterized by frequent pauses in breathing, insomnia, and poor sleep quality. At altitudes above 3000m, almost everyone develops this condition. Denver, by comparison sits at just above 1609m. Treatment may include supplemental low flow oxygen or the use of a breathing device such as “CPAP”.

Obesity Hypoventilation

Sleep-related Movement Disorders

Restless leg syndrome, periodic limb movements of sleep, and other rhythmic movement disorders of sleep can be primary or secondary. When a secondary sleep related movement disorder is suspected, addressing the underlying problem such as excessive caffeine intake, prescription medication side effect, or low iron state is critical. When a primary sleep-related movement disorder is suspected, referral to a sleep clinic for further evaluation is recommended.

Restless Leg Syndrome

Restless leg syndrome (RLS) is a condition in which one experiences an uncontrollable urge to move the legs, usually described as “creepy crawly or worm-like sensation deep within the legs”. It typically happens in the evening when you're sitting or lying down and can lead to significant sleep disruption. Restless legs frequently run in families. The symptoms of restless legs are very difficult to elicit from children. The best description seems to be “growing pains” in the legs that occur exclusively in the nighttime period.

Periodic Limb Movements of Sleep

Periodic limb movement disorder is diagnosis that requires both clinical history of excessive leg jerks and sleep testing demonstrating PLMI (periodic limb movement index) > 5/hr. This disorder is uncommon in children but can be much more frequent in the elderly. Periodic limb movements should be distinguished from hypnic jerks, which are isolated leg jerks occur in more than half of the population and is a benign finding.