User:Nohoguy/Irregular sleep-wake pattern

Irregular sleep-wake pattern' ICD9 = 327.33
Classification and external resources

Irregular sleep-wake pattern is a rare form of circadian rhythm sleep disorder. It consists of a breakdown of a single consolidated sleep period into multiple naps irregularly dispersed around the 24-hour period." citation: Sufferers may have no pattern of when they are awake or asleep, may have poor quality sleep, and often may be very sleepy while they are awake. Ironically, the total amount of hours slept, could be normal for one's age. This is a serious disorder which can create social, familial, and work problems. This makes it hard for a person to maintain relationships and responsibilities, and may make a person home bound and isolated. Being home bound can make this problem worse.

Nomenclature This disorder has been referred to by multiple terms, including: Irregular sleep-wake pattern Irregular sleep-wake syndrome, Irregular Sleep Wake Rhythm, Circadian Rhythm Sleep Disorder.

Causes

It can be caused by neurological disorders such as dementia (particularly Alzheimer's Disease), brain damage, or mental retardation however, those who have this disorder do not always have neurological problems. It is thought that suffers have a weak circadian clock. The risk for this disorder increase with age, but only due to increased prevalence of co-morbid with other medical disorders.

There is a possible reciprocal relationship between bipolar disorder and sleep disorders: "During the depressed phase of the bipolar disorder, it's common to experience insomnia, characterized by difficulty falling asleep, staying asleep, or waking up too early. Bipolar depressed patients are also particularly sensitive to hypersomnia -- characterized by too much sleep, sometimes up to 18 hours per day, and daytime fatigue. What's especially problematic with bipolar patients is that sometimes deprivation of sleep for any reason -- such as caffeine consumption -- could lead to a switch into mania -- which could be a big problem."

"Irregular Sleep-Wake Schedule... This sleep disorder is yet another problem that many with Bipolar II experience and in large part results from a lack of lifestyle scheduling."

Diagnosis

File:Sleep diary.jpg

A sleep diary with nighttime in the middle and the weekend in the middle, to better notice trends

A sleep diary should be kept to aid in diagnosis and for chronicling the sleep schedule during treatment. Other ways to monitor the sleeps schedule are an actigraph or use of a CPAP machine that has a memory card. [citation?]

The following are possible warning signs: Sleeping off and on in a series of naps during the day and at night. No regular pattern of when you sleep and are awake. Hard to sleep well. Very sleepy when awake. If you add together all of the time you sleep in a 24-hour period, the total sleep time normal for your age?

During the night, it may seem like they have insomnia because they are awake for long periods of time during the night. Because of the changes in sleep/wake time, and because this is a rare disorder, initially it can seem like other Circadian rhythm sleep disorders especially Non-24-hour sleep-wake syndrome.

Initial Visit with Sleep Physician The sleep doctor may ask patients about their medical history; for example: neurological problems, prescription or non-prescription medications that you are taking, alcohol use, family history, and any other sleep problems. The doctor should do a thorough medical and neurological exam. You will be asked to complete a sleep diary to record your natural sleep and wake up times over several weeks. You may be asked to rate your sleep with the Epworth Sleepiness Scale.

Medical Testing Your doctor may suspect that a neurological condition or another medical problem is involved. In this case, you may be asked to have blood testing performed. You may also need a CT scan or an MRI. An overnight sleep study is usually not needed to detect this disorder. You may need to do a sleep study if you are at risk for other sleep disorders. The sleep study is called a polysomnogram. It charts your brain waves, heart beat, muscle activity, and breathing as you sleep. It also records how your arms and legs move. This shows if there are other sleep disorders that are causing or increasing your sleep problems. Examples include sleep apnea and periodic limb movement disorder. A sleep study is not used to make the diagnosis of irregular sleep-wake rhythm.

Management

Treatment, a set of management techniques, is specific to DSPS. It is different from treatment of insomnia, and recognizes the patients' ability to sleep well on their own schedules, while addressing the timing problem. Success, if any, may be partial; for example, a patient who normally awakens at noon may only attain a wake time of 10 or 10:30 with treatment and follow-up. Being consistent with the treatment is paramount.

Before starting DSPS treatment, patients are often asked to spend at least a week sleeping regularly, without napping, at the times when the patient is most comfortable. It is important for patients to start treatment well-rested.

Treatments that have been reported in the medical literature include:

AFTER REVIEWING WHICH OF THE PARAGRAPHS BELOW RELATED TO ISWR, DELETE THE PARAGRAPH JUST BELOW THIS NOTE Treatment for irregular sleep-wake rhythm is aimed at trying to increase stimulation to reset the sleep clock in the brain. The goal is to have one long sleep time at night and one long awake time during the day. Light treatment is one way to help a weakened body clock. ... Education and behavioral counseling can be helpful. Following the rules of good sleep hygiene is an important way to keep one main sleep time. Melatonin, vitamin B12, sleep aids, awake aids, and other medications may also be used. to light during the daytime, and other activities occurring at regular times each day, may help to restore the body's natural rhythm.

Because there are different systems in the body that help establish regulation, it's helpful to employ a multi-modal approach. "Each clock is differentially sensitive to zeitgebers. The SCN is very responsive to light, the clock in the liver is very sensitive to food, and clocks in muscle are sensitive to exercise.(43)." Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation Allison G. Harvey, Ph.D.

Light and dark therapy focuses on the patient's biological clock by regulating her sleep-wake cycle. Help Guide notes that when a patient has an irregular sleep-wake cycle, it can trigger manic symptoms. When a patient undergoes light and dark therapy, her exposure to light is managed by staying in a dark environment, then receiving 10 hours of artificial light each day. This therapy can also help the patient manage mood cycling and depressive symptoms."

Light therapy (phototherapy) with a full spectrum lamp or portable visor, usually 10,000 lux for 30–90 minutes at the patient's usual time of spontaneous awakening, or shortly before (but not long before), which is in accordance with the phase response curve (PRC) for light. Sunlight can also be used. Only experimentation, preferably with specialist help, will show how great an advance is possible and comfortable. For maintenance, some patients must continue the treatment indefinitely, some may reduce the daily treatment to 15 minutes, others may use the lamp, for example, just a few days a week or just every third week. Whether the treatment is successful is highly individual. Light therapy generally requires adding some extra time to the patient's morning routine. Patients with a family history of macular degeneration are advised to consult with an eye doctor. The use of exogenous melatonin administration (see below) in conjunction with light therapy is common.

Dim lights in the evening, sometimes called darkness therapy. Just as bright light upon awakening should advance one's sleep-phase, bright light in the evening and night delays it (see the PRC). One might be advised to keep lights dim the last hours before bedtime and even wear sunglasses or amber-colored goggles. Attaining an earlier sleep onset, in a dark room with eyes closed, effectively blocks a period of phase-delaying light. An understanding of this is a motivating factor in treatment.

Chronotherapy, which is intended to reset the circadian clock by manipulating bedtimes. Often, chronotherapy must be repeated every few months to maintain results. It can be one of two types. The most common consists of going to bed two or more hours later each day for several days until the desired bedtime is reached. A modified chronotherapy (Thorpy, 1988) is called controlled sleep deprivation with phase advance, SDPA. One stays awake one whole night and day, then goes to bed 90 minutes earlier than usual and maintains the new bedtime for a week. This process is repeated weekly until the desired bedtime is reached.

Melatonin taken an hour or so before usual bedtime may induce sleepiness.

File:PRC-Light+Mel.png

Phase response curves for light and for melatonin administration

Taken this late, it does not, of itself, affect circadian rhythms, but a decrease in exposure to light in the evening is helpful in establishing an earlier pattern. In accordance with its phase response curve (PRC), a very small dose of melatonin can also, or instead, be taken some hours earlier as an aid to resetting the body clock; it must then be so small as to not induce excessive sleepiness.

Side effects of melatonin may include disturbance of sleep, nightmares, daytime sleepiness and depression, though the current tendency to use lower doses has decreased such complaints. Large doses of melatonin can even be counterproductive: Lewy et al. provide support to the "idea that too much melatonin may spill over onto the wrong zone of the melatonin phase-response curve." The long-term effects of melatonin administration have not been examined. In some countries the hormone is available only by prescription or not at all. In the United States and Canada, melatonin is freely available as a dietary supplement. The prescription drug Rozerem (ramelteon) is a melatonin analogue that selectively binds to the melatonin MT₁ and MT₂ receptors and, hence, has the possibility of being effective in the treatment of DSPS.

A review by a US government agency found little difference between melatonin and placebo for most primary and secondary sleep disorders. The one exception, where melatonin is effective, is the "circadian abnormality" DSPS.

Cannabis has been suggested as an aid to combat DSPS. However, no research has yet been done that shows cannabis works in DSPS. Sleep onset is affected by the two primary cannabinoids. THC, Δ9-Tetrahydrocannabinol, dramatically increased melatonin production in some subjects in a small study in 1986 where the authors state that "[t]hese preliminary results are difficult to interpret". An older study showed that CBD, cannabidiol, was effective in helping insomniacs sleep. Heavy cannabis use can lead to decreased levels of REM sleep and increased levels of slow-wave sleep along with reduced mental function the next morning. However, 5 mg doses of THC and CBD have been shown not to have these effects.

Modafinil (Provigil) is approved in the US for treatment of shift-work sleep disorder, which shares some characteristics with DSPS, and a number of clinicians are prescribing it for DSPS patients. Modafinil does not deal with underlying causes of DSPS, but it may improve a sleep-deprived patient's quality of life. Taking modafinil less than 12 hours before the desired sleep onset time will likely exacerbate the symptoms by delaying the sleep/wake cycle.

Vitamin B₁₂ was, in the 1990s, suggested as a remedy for DSPS/DSPD, and can still be found to be recommended by many sources. Several case reports were published. However, a review for the American Academy of Sleep Medicine in 2007 concluded that no benefit was seen from this treatment.

A strict schedule and good sleep hygiene are essential in maintaining any good effects of treatment. With treatment, some people with mild DSPS may sleep and function well with an early sleep schedule. Caffeine and other stimulant drugs to keep a person awake during the day may not be necessary, and should be avoided in the afternoon and evening, in accordance with good sleep hygiene. A chief difficulty of treating DSPS is in maintaining an earlier schedule after it has been established. Inevitable events of normal life, such as staying up late for a celebration or having to stay in bed with an illness, tend to reset the sleeping schedule to its intrinsic late times.

Some people try behaviors or medicines to correct the problem. This may only worsen the problem. In some cases, they may get into trouble if they try to fix this problem on their own by taking caffeine, stimulants, sleeping pills, amphetamines, or alcohol. However, some of these substances could be helpful, ideally under the direction of a physician.[citation?]

The following approaches are recommended by one source: 1. Spend <7-8 hours in bed
2. Add environmental cues such as light and social interactions, regular meal times, and regular sleep-wake times.
3. Morning and eve light 3000lux for 2 hours have been shown to improve nocturnal sleep in instituionalized patients and reduce agitation in demented patients.
4. Melatonin 2.5-10mg at desired sleep time.

Research

There is currently a great deal of active research on various aspects of circadian rhythm; this often occurs at major universities in conjunction with sleep research clinics at major hospitals. An example is the program with Harvard Medical School and Brigham and Young Hospital. This research includes programs that are staffed by researchers from various departments at the University, including psychiatry, neurology, chemistry, biology. Research including a wide variety of sleep disorders, are actively being researched according to Harvard Medical School and Brigham and Young Hospital. Measuring body temperature or melatonin levels may be used. Some hospitals do blood tests for Melatonin levels. Melatonin saliva tests are now available for online purchase. It can also be tested in urine.

See also

• Sleep disorder
• Circadian rhythm
• Circadian rhythm sleep disorder
• Advanced sleep phase syndrome
• Delayed sleep phase syndrome
• Non-24-hour sleep-wake syndrome

External links

Blogs and Mailings Lists

• An active email mailing list for peer support and information related to Circadian Rhythm Disorders
• An active mailing list for peer support and information related to Sleep Disorders
• American Academy of Sleep Medicine: Blog/Breaking News

Find medical professiionals

• Find a sleep disorder clinic

Associations

• American Sleep Disorders Association

Journals and Research Sites:

• Journal of Clinical Sleep Medicine
• Journal Sleep
• search on term: Irregular sleep-wake pattern/ Abstract of study with lots of information