Sleep disorders are quite common in people who endure multiple sclerosis (MS) and is generally not considered by many physicians to be within the same categorizations or priorities as other symptoms associated with MS. Quality sleep, however, is extremely important when it comes to multiple sclerosis management.
Poor sleep quality can result in myriads of additional quality of life issues including both physical and psychological matters. Fatigue, pain, situational awareness, headaches, drowsiness, loss of appetite, weight loss and even respiratory events are but a few of the more physical manifestations. Cognition, depression, anxiety, irritability, anger, rapid mood swings, isolation are but a few of the psychological manifestations. All of these factors and more can result in severe consequences towards quality of life, job performance, family, friends and personal well-being. Sleep disorders need be a primary concern if you are an MS patient or caregiver to an MS patient. Not addressing sleep disorders can ONLY result in poor long-term outcomes in respect to multiple sclerosis. They can readily exacerbate other symptoms resulting in a complex cascade that can be very difficult to recover from.
Sleep disorders exist in many diseases and among the healthy population as we all are aware. When you add into the sleep disorder mix the complexities of other symptoms of MS it becomes very apparent that the myriads of issues that can result from sleep disorders are far more paramount to have addressed than that of the healthy global population.
Multiple sclerosis (MS) is a chronic autoimmune disorder affecting movement, sensations, bodily functions and more. It is caused by destruction of the myelin insulation covering nerve fibers (neurons) in the central nervous system (brain and spinal cord). When the myelin is destroyed, nerve messages are sent more slowly and less efficiently. Patches of scar tissue, called plaques or lesions form over the affected areas, further disrupting nerve communication. Symptoms of MS occur when the brain and spinal cord nerves no longer communicate properly with other parts of the body. MS causes a wide variety of symptoms and can affect vision,balance,strength,sensation, coordination,and bodily functions. MS rates are higher in the United States, Canada, and Northern Europe than in other parts of the world. Over 2.4 million people suffer from multiple sclerosis globally.
The Sleep Cycle
There are 5 stages of sleep. The stages relate to the slow progression of sleep all ending at the REM sleep (rapid eye movement). Stage 1 is the initial stage of relaxation lasting 5 to 10 minutes. Stage 2 lasts around 20 minutes as every body function starts to slow including brain function. Stage 3 is the in between stage of light sleep and very deep sleep. It is during this time we recharge and restore our main batteries and heal any damage. Stage 4 or Delta sleep: the brain continues to slow and produce delta waves (Delta activity stimulates the release of several hormones) this stage can last up to 30 min on average. Finally, after approximately 90 minutes the mind is ready to enter REM sleep, the final stage. It is during this stage we dream, our minds become active again but our bodies are paralyzed. The whole process takes us into REM sleep our ultimate goal for sleeping. Babies spend approximately 50% of their sleep time in REM, whereas adults tend to stay 20% in REM sleep. We do not stay in REM sleep all though we come in and out like the ebbing tides of the oceans.
In 2014 a large study of sleep disorders in MS took place in California in the United States of America over 2300 patients were surveyed with findings that over 70% of the participants had a sleeping disorder and of these less than 12% had the disorder being addressed.
Most of the participants – nearly 52 percent – said it took them more than one half hour to fall asleep at night, and nearly 11 percent reported taking a medication to fall asleep. Close to 38 percent of participants screened positive for obstructive sleep apnea. Nearly 32 percent had moderate to severe insomnia and nearly 37 percent had restless legs syndrome.
However, most of the participants had not been diagnosed with a sleep disorder by a physician. While nearly 38 percent reported having obstructive sleep apnea, only a little more than 4 percent reported being diagnosed by a physician with the condition. Similar statistics were seen for other sleep disorders.
“Sleep disorder frequency, sleep patterns and complaints of excessive daytime sleepiness suggest that sleep problems may be a hidden epidemic in the MS population, separate from MS fatigue,” said Steven Brass, associate clinical professor and director of the Neurology Sleep Clinical Program the UC Davis Sleep Medicine Laboratory in a university recent news release.
The vast majority of these sleep disorders are potentially undiagnosed and untreated,” he said. “This work suggests that patients with MS may have sleep disorders requiring independent diagnosis and management.”
Women appear statistically to have more problems with sleep than men diagnosed with MS. The varieties of studies performed over years of time show that MS patients often take longer to fall asleep and also wake earlier that they may desire known as early insomnia, wake during the night (middle insomnia) and symptoms also may play significant roles in affecting quality of sleep.
The most common sleep disorders seen in patients with MS include insomnia, nocturnal movement disorders such as restless leg syndrome, sleep-disordered breathing such as sleep apnea, narcolepsy, and rapid eye movement sleep behavior disorder.
Factors that influence the quality of sleep in the multiple sclerosis patient population include pain, nocturia (frequent trips to the bathroom), depression, medication effects, location of lesions, and disease severity.
Types of Sleep Disorders
People who have insomnia have trouble falling asleep, staying asleep, or both. As a result, they may get too little sleep or have poor-quality sleep. They may not feel refreshed when they wake up. Insomnia is quite common in people enduring multiple sclerosis. If insomnia occurs frequently then it needs to be addressed. Problems falling asleep, waking too early or in the middle of the night may all be forms of insomnia.
Insomnia can be acute (short-term) or chronic (ongoing). Acute insomnia is common and often is brought on by situations such as stress at work, family pressures, or a traumatic event. Acute insomnia lasts for days or weeks. Chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary, which means they are the symptom or side effect of some other problem. Medical conditions, medications, sleep disorders, and substances can cause secondary insomnia. In contrast, primary insomnia isn’t due to medical problems, medicines, or other substances. It is its own distinct disorder, and its cause isn’t well understood. Many life changes can trigger primary insomnia, including long-lasting stress and emotional upset.
Insomnia can cause daytime sleepiness and a lack of energy. It also can make you feel anxious, depressed, or irritable. You may have trouble focusing on tasks, paying attention, learning, and remembering. Insomnia also can cause other serious problems. For example, you may feel drowsy while driving, which could lead to an accident.
Sleep apnea is a common disorder in which a person has one or more pauses in breathing or shallow breaths while sleeping. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound. Sleep apnea usually is a chronic ongoing condition that disrupts sleep. When breathing pauses or becomes shallow, a person often will move out of deep sleep and into light sleep. As a result, the quality of sleep is poor and the effects of poor sleep manifest during the day.
There are three common types of sleep apnea:
- Obstructive sleep apnea, the more common form that occurs when throat muscles relax. In this condition, the airway collapses or becomes blocked during sleep. This causes shallow breathing or breathing pauses.
- Central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing. As a result, you’ll make no effort to breathe for brief periods. Central sleep apnea can affect anyone. However, it’s more common in people who have certain medical conditions or use certain medicines. Central sleep apnea can occur with obstructive sleep apnea or alone. Snoring typically doesn’t happen with central sleep apnea.
- Complex sleep apnea syndrome, also known as treatment-emergent central sleep apnea, occurs when someone has both obstructive sleep apnea and central sleep apnea.
Sleep apnea often goes undiagnosed. Doctors usually can’t detect the condition during routine office visits. Also, no blood test can help diagnose the condition. Most people who have sleep apnea don’t know they have it because it only occurs during sleep. A family member or bed partner might be the first to notice signs of sleep apnea.
Untreated sleep apnea can:
- Increase the risk of high blood pressure, heart attack, stroke, obesity, and diabetes.
- Increase the risk of, or worsen, heart failure.
- Make arrhythmias, or irregular heartbeats, more likely.
Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes, mouthpieces, surgery, and breathing devices can successfully treat sleep apnea in many people.
Restless Leg Syndrome:
Restless legs syndrome (RLS) is a disorder that causes a strong urge to move your legs. This urge to move often occurs with strange and unpleasant feelings in your legs. Moving your legs relieves the urge and the unpleasant feelings. People who have RLS describe the unpleasant feelings as creeping, crawling, pulling, itching, tingling, burning, aching, or electric shocks. Sometimes, these feelings also occur in the arms. The urge to move and unpleasant feelings happen when you’re resting and inactive. Thus, they tend to be worse in the evening and at night.
RLS can range from mild to severe based on:
- The strength of your symptoms and how often they occur
- How easily moving around relieves your symptoms
- How much your symptoms disturb your sleep
Falling asleep suddenly and uncontrollably during the day is known as narcolepsy. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime. These sudden sleep attacks may occur during any type of activity at any time of the day.
It is thought that an autoimmune reaction associated with MS in the brain may cause narcolepsy. Narcolepsy is more common in patients with MS than it is in the general population. Most narcolepsy occurs due to low levels of a neurotransmitter called hypocretin also called orexin (a neuropeptide that regulates arousal, wakefulness, and appetite), which is produced by the hypothalamus. The hypothalamus governs physiologic functions such as temperature regulation, thirst, hunger, sleep, mood, sex drive, and the release of other hormones within the body.
In contrast to popular perception, narcoleptics do not sleep more than the average person. They have simply have highly disturbed sleep patterns resulting in restless and inadequate sleep during the evenings, and napping or uncontrollable sleep during the day. Additional symptoms that be present in some narcoleptics include sleep paralysis, cataplexy, hypnogogic hallucinations and automatic behavior.
- Sleep paralysis is the temporary inability to act upon waking up, and can last from a few seconds to several minutes.
- Cataplexy is a form of muscle weakness triggered by strong emotions, and can result in drooping eyes or head, weakness in the knees, or a complete collapse. It is usually accompanied with blurred vision and occasionally ringing noises in the ear, though the person’s senses remain aware during the entire process, often making it a harrowing experience.
- Hypnogogic hallucinations occur just before sleep, or just prior to waking up, and can include visual, tactile and auditory sensations. The most common of these, and one that many people experience is the sensation of falling just before waking, resulting in a startled awakening that may include lingering elements of fear and muscle tension. Visual hallucinations often include apparitions of some sort, and are believed to explain some of the reported cases of ghost sightings and alien abductions. Auditory hallucinations often feature undefined sound, such as deep ringing, buzzing or static-like noise.
- Automatic behavior is a form of sleep walking, in which the person continues to perform activities despite being in a sleeping state. The person will have no recollection of their automatic behavior state, and upon waking will often find themselves surprised by where they are, or the changes in their environment. Automatic behavior affects over 40% of narcoleptic
Hypersomnia causes a person to have feelings of excessive tiredness during wake time. Unlike sleep apnea, hypersomnia is not related to problematic sleep at night. MS patients who suffer from hypersomina often take many naps during the day irrespective of how much sleep they obtain at night. The naps may occur at any time and generally are deep sleep that can be difficult to wake up from. Hypersomnia is also often associated with anxiety or irritability when waking.
People with primary hypersomnia will often sleep in excess of 10 hours, and are very difficult to wake during this time. Despite what would be considered an abundance of sleep for most people, they will still feel tired during the day, and may feel compelled to nap multiple times, even at times or in places that would not be considered socially acceptable. Like the prolonged sleep periods, these naps often provide only short periods of relief from the chronic tiredness, and another desired nap session will quickly approach.
Periodic Limb Movement Disorders:
Periodic limb movement disorder (PLMD) is a sleep disorder in which one or more of the subjects limbs will involuntarily move during sleep. The degree to which this occurs and its frequency varies. Some people with PLM’s will only experience mild symptoms such as slight twitches or ‘shudders’ (periodic limb movement syndrome (PLMS)), while others will have movements best characterized as thrashing or wailing. Those with extreme movements may find themselves waking up at their own movements, and will almost certainly disturb and arouse their partners.
In addition to actual physical movement of the limbs, many people with PLM will experience involuntary tightening or flexing of the muscles, which can be quite painful and disconcerting, and causes the subject to wake up at a high frequency. PLM can occur throughout the night, but in most patients occurs in batches, lasting from 30 minutes to 2 hours on average, with actual movements happening every 5 to 90 seconds during that span. Physical movements are likely to occur in both limbs, while involuntary tightening or flexing of the muscles is more likely to occur in just one limb. PLM typically occurs in the slow-wave phase of sleep just before the deep sleep of REM (rapid eye movement) sleep.
PLM is found with high frequency in those suffering with restless legs syndrome, with as many as 85% of people with RLS also having PLM. Conversely, the number of people with PLM also having RLS is quite low, owing to the fact that PLM is somewhat more common than RLS. Like RLS, PLM can occur in the legs or arms, but most often appears in the legs.
Periodic Limb Movements during Sleep:
Periodic Leg Movement during Sleep (PLMS) is characterized by involuntary movements of the legs while asleep. People who suffer from PLMS can be unaware of their limb movements, as they do not always wake from them. These movements happen during the night, at regular intervals before one enters REM sleep. Sufferers often complain of the inability to fall asleep or to remain asleep in association with PLMS. Men and women are equally affected by PLMS.
The characteristic movements associated with PLMS usually occur in the legs, but less commonly can occur in the arms as well. These rhythmic movements usually consist of involuntary extension of the big toe and then progress to an upward bending of the knee, ankle or hip. The symptomatic limb movements will usually persist over a certain interval, lasting from a few minutes up to several hours. Within these events, the leg movements will occur about 5 – 90 seconds apart and last from .5 seconds to 10 seconds. Sufferers of PLMS may also experience some of the same symptoms of RLS like burning, tingling sensations or general discomfort in their legs when they lay down to rest. Not everyone who has PLMS has RLS; however, about 80% of people who suffer from RLS also suffer from PLMS.
These movements will often occur in the first stage of your sleep cycle, before REM sleep. REM sleep is the “dream cycle” of sleep; it is also the episode in which one obtains their most restful sleep. Constant disruptions of the sleep cycle can keep one from attaining REM sleep, leaving a person unrested in the morning. During the REM sleep cycle a persons voluntary muscles are paralyzed, which keeps one from acting out their dreams. It is possible that because of this paralysis, PLMS can only occur before or after REM sleep.
Nocturia is a condition in which you wake up during the night because you have to urinate. The condition is common in MS patients and is prevalent more in patients who also urinate frequently during the day or have issues emptying their bladder completely during urination. Studies have suggested 7 in 10 people diagnosed with MS suffer from nocturia. There are other causes that can result in nocturia which should be investigated by your health care team such as diabetes.
In patients with MS awakening more than once during the night to urinate is often a signal of nocturia. Some patients awaken 5 to 6 times each night. The result of nocturia is broken sleep and other sleep disorders may cause problems returning to rest.
Stress and Depression:
Stress and depression are often both associated with obtaining quality sleep as well as resultant symptoms of poor sleep quality. Stressful and depressive thoughts often disallow us from entering into the peaceful sleep cycles. Both may keep a person from entering into sleep timely and in consistent patterns. Both conditions can make our minds race with thoughts instead of shutting down at night. Studies have suggested that memory, muscle repair, mood and even the immune system falter through these sleep disorders.
Stress and depression can make us toss and turn at night. According to the American Psychological Association 43 percent of adults say that stress causes them to lie awake at night, and more than 50 percent of adults report feeling sluggish or lazy after a night of sleep. Both depression and stress can send ones brain into overdrive and it may not just negatively affect some sleep but can completely rob a person of sleep. Studies of ongoing stress show people become more susceptible to insomnia, and each additional stressor increases the risk for the disorder by 19 percent according to research published in The Journal of Sleep.
When a person moves from being awake towards sleep changes occur in the autonomic nervous system which is governed in large part by the sympathetic and parasympathetic subsystems. Stress and depression can interrupt this process resulting in the sympathetic nervous system staying completely active or even hyperactive leaving the person wide awake.
As we all are aware stress and depression can also the result of poor quality of sleep and thus stress and depression impacting quality or sleep can result in a vicious circle.
In MS patients stress and depression along with fatigue, anxiety, cognitive matters and symptoms associated with MS create a more toxic environment for stress and depression to occur. This makes for a complex mix when addressing stress and depression in association to sleep quality.
Circadian Rhythm Disorders (Sleep Rhythms):
Circadian rhythm disorders are disruptions in a person’s circadian rhythm—a name given to the “internal body clock” that regulates the (approximately) 24-hour cycle of biological processes in animals and plants. The term circadian comes from Latin words that literally mean “around the day.”
The key feature of circadian rhythm disorders is a continuous or occasional disruption of sleep patterns. The disruption results from either a malfunction in the “internal body clock” or a mismatch between the “internal body clock” and the external environment regarding the timing and duration of sleep.
Sleep disorders are quite common in patients with multiple sclerosis (MS) and there are many mechanisms of helping mitigate and cope with these disorders. It is both important to manage sleep disorders for purposes of quality of life as well as not exacerbating conditions that exist often during wake time such as fatigue, mood disorders or physical problems such as balance or engaging in poor eating habits. Results of sleep quality filters down through our waking day from start to finish.
It is of extreme importance in MS to get the best quality of sleep possible. It is just as important as dietary, exercise and relaxation during waking hours. One third or more of each day is spent in sleep allowing our bodily systems to regenerate and have a restful state.
In examining your quality of sleep grab a piece of paper and over a week or two’s time start writing down any issues you have regarding the quality of your sleep. The time it takes for you to enter into sleep. If you have a partner have them note on paper any issues they see as you sleep such as snoring, periods of erratic breathing, tossing or turning frequently, etc. Examine your sleep patterns nightly and any periods during the day. Your goal is to identify as many factors as you can that may be impacting or are knowingly impacting your sleep.
Organize your findings and speak to your members of your health care team to get their input. With MS a good sound protocol is to first attempt to eliminate or in as far as possible mitigate waking MS symptoms. For example, spasticity has a variety of methods to help cope with it. Medicinal marijuana or cannibinoids, medications, TENS unit stimulation. Work with your health care team to mitigate MS symptoms prior to rest time. Pain management prior to sleep time for example.
Lifestyle management is important to sleep quality as well. Create a sleep schedule that you can adhere to. You may need to gradually ease into the schedule. If you normally go to bed at 1AM in the morning, shaving 10-15 minutes off that every 2-3 days towards a more reasonable time such as 11PM can be tried.
With sleep disorders such as nocturia make sure not to drink fluids for several hours before bedtime and urinate before going to sleep.
For matters of moving towards sleep once in bed consider ways to clear your mind. Short meditation, mood music or nature sounds CD’s. Reading may also bring on drowsiness. We are all different and it may take you a little time to find what works best for you.
Consider your bed, pillow(s), comfort zone in temperature, sleep position. Comfort while sleeping can greatly enhance your quality of sleep. You may wish to consider going out and trying different bed mattresses such as Tempurpedic or Sleep Number beds.
Avoid caffeine which can affect you for 5-6 hours after ingestion. Avoid alcoholic beverages and nicotine.
As you make changes attempt to keep a sleep record of results which can then be refined.
Natural homeopathic mechanisms towards quality sleep should be your first round at moving towards quality sleep.
Once you have mechanisms in place that have improved your quality of sleep if problems still exist medications and / or dietary supplements can be explored by you and your health care team to get you the best quality sleep results.