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Dr. Hans Hamburger

According to the latest International Classification of Sleep Disorders, there are roughly six different groups of sleep disturbances. All syndromes need a different approach for diagnosis and treatment. Hereunder a very brief description of the multiple options for treatment is given with and without use of medication. For all diagnosis groups definitions are given elsewhere (ICSD3). Diagnosis and treatment can be found in different handbooks (see below).

TREATMENT OF SLEEP DISTURBANCES AND MEDICATION

Introduction

According to the latest International Classification of Sleep Disorders, there are roughly six different groups of sleep disturbances:

1. Insomnia
2. Sleep Related Breathing Disorders
3. Central Disorders of Hypersomnolence
4. Circadian Rhythm Sleep-Wake Disorders
5. Parasomnia
6. Sleep related Movement Disorders

All above mentioned syndromes need a different approach for diagnosis and treatment. Hereunder a very brief description of the multiple options for treatment is given with and without use of medication. For all diagnosis groups definitions are given elsewhere (ICSD3). Diagnosis and treatment can be found in different handbooks (see below)

1. Insomnia’s are considered to be chronic when it is present

more than 3 days per week for more than 3 months. Other medical conditions should be excluded. Insomnia’s are the most common complaint in a Sleep Centre. 22% of the insomnia’s are caused by another sleep disturbance and should be treated accordingly.

Insomnia’s are treated mainly using Cognitive Behavioural Therapy, a combination of multiple techniques to help the patient coping with this disorder. Insomnia’s are however too often treated by most doctors with benzodiazepines. These drugs have many side effects causing drowsiness, falls and traffic accidents. In some cases low-dose anti-depressants can be used (amitriptyline, trazodone or mirtazapine). Often insomnia’s are caused by medication for other diseases. The best treatment option is then to lower the dose of these drugs or changing them to less harmful medication. Well known is the tendency of beta-blockers to cause insomnia and dreams or nightmares from which patient have frequent awakenings.

2. Sleep Breathing Disorders are most often caused by Obstructive Sleep Apnea syndrome and less often by Central Sleep Apnea.

These disorders are treated using MRA (Mandibular Repositioning Devices) or CPAP (Continuous Positive Airway Pressure). In some cases Central Sleep Apnea will be treated with pure Oxygen during the night, in rare cases with drugs like acetazolamide.

3. Central Disorders of Hypersomnolence

This group contains Narcolepsy type 1 and 2, idiopathic hypersomnolence and Kline-Levin Syndrome. All these syndromes can be treated with drugs, depending on the diagnosis and complaints of the patients. Medication to induce better sleep and drugs to reduce cataplexy can be given. The best drug to enhance sleep is sodium oxybate, this substance can also reduce cataplexy after a treatment period of more than 3 month. Some tricyclic antidepressants (clomipramine) also reduce cataplexy. To minimise hypersomnolence medication that increase vigilance are often applied. In this group of stimulants the most common medications are methylphenidate and modafinil

4. Circadian Rhythm Sleep-Wake Disorders

Circadian Rhythm Disorders are generally treated with light therapy. For Delayed Sleep Phase Disorder (night owls) that means less or no light in the night and bright light therapy in the morning. For Advanced Sleep Phase Disorder (early birds) one can use bright light in the evening and night to shift sleep to a later moment in the evening. In some cases in the beginning of the treatment the use of low dose melatonin is used. For DSPD this drug should be given 2-3 hours before sleep time. Other medication is never indicated.

5. Parasomnia

Parasomnia can occurs in different sleep stages: Wake to Sleep onset, in deep sleep, in all sleep stages and in REM slap. The parasomnia attacks should first be differentiated from epilepsy during sleep. Furthermore the treatment is depending on the sleep phase in which they occur. Most parasomnia occur during early and late childhood. Some stay during adolescence and in adults. REMsleep parasomnia mainly occur in the elderly. In general parasomnia in NonREM sleep are elicited by sleep deprivation, alcohol and party drugs. Stress factors can increase parasomnia attacks. In rare cases, especially when violent attacks occur, medication can be used. REMsleep behaviour disorder (RBD) is the first sign of a disease in the elderly (alpha-synucleopathy). The diagnosis can only be made after video-polysomnography. This syndrome can be treated using melatonin or low dose clonazepam.

6. Sleep related Movement Disorders

This is a large group of disorders amongst others RLS (Restless Legs Syndrome), Periodic Limb movement disorder, Leg Cramps, Sleep Bruxism, Rhythmic Movement Disorder, Myoclonus at Sleep onset etc. RLS and PLMD occur mainly in elderly, othes such as RMD occur mainly in children. Primary part of the treatment is to find and reduce or abolish factors that elicit the movement disorder. In RLS alcohol, nicotine and medication like SSRI’s  use are causal factors that should be stopped before medication shall be given. Also other diseases should be recognized and treated. Known causal factors are low ferritin and iron thatv should be treated first.

Medication is initiated only when sleep is disturbed causing problems in daytime functioning. For RLS medication that is often used are alfa 2 delta ligands (gabapentin, pregabalin) and DOPA agonists (pramipexole, ropinerole, rotigotine). The medication that was described in the 17th century by Willis is an opiate. These drugs are rarely used at present in cases of augmentation, when the above drugs do not work anymore.
Most sleep disorders can adequately be treated. Good sleep drink, food and exercise are the basis of health. Bad sleep is often caused by bad sleep hygiene and behavioural problems. The multitude of sleep disorders makes it necessary to treat the patient in a multi-disciplinary group of specialists, somnologists in accredited sleep centres.

Literature:

  • Leerboek Slaap en Slaapstoornissen (2013) eds Verbraekekn, Buysse, Hamburger, van Kasteel & van Steenwijk, ACCO in boekvorm of als e-book verkrijgbaar
  • International Classification of Sleep Disorders nr 3: (2014) American Academy of Sleep Medicine
  • Principles and practice of Sleep Medicine 5the ed (2012) Kryger, Roth & Dement American Academy of Sleep Medicine (Elsevier)
  • Sleep Medicine Textbook (2014) Bassetti, Dogas, Peigneux European Sleep Research Society (ESRS)
     

Contact

Hans L. Hamburger MD, PhD, neurologist, somnologist

Amsterdam Sleep Centre
Slotervaartziekenhuis Amsterdam, Boerhaave Medical Centre, Amsterdam and MC Zuiderzee Lelystad

Hans.Hamburger@SLZ.nl