Allergic Rhinitis Associated With Impaired Sleep Quality

Patients with allergic rhinitis, such as that caused by hay fever and other allergies, have more difficulty sleeping and more sleep disorders than those without allergies, according to a report in the September 18 issue of Archives of Internal Medicine, a theme issue on sleep.

Allergic rhinitis, which occurs when pollen or other allergens irritate and inflame the nasal passages, affects about 20 to 50 percent of the population, according to background information in the article. Allergies have been shown to affect quality of life and several studies have suggested that they may contribute to snoring and breathing problems during sleep, including sleep apnea, a temporary halt to breathing. However, few researchers have closely examined sleep disorders in patients with allergic rhinitis.

Damien L ger, M.D., of Assistance Publique H pitaux de Paris, and colleagues explored the association between allergic rhinitis and sleep in 591 patients (47 percent men, 53 percent women, average age 34) who had the condition for at least one year and who were being treated by an allergist or by an ear, nose and throat specialist. A control group of 502 individuals who were the same age and sex and lived in the same area, but did not have allergic rhinitis, was also assessed. In 2002, all participants reported sleep disorders and rated their sleepiness; they also provided details regarding demographics, socioeconomic status and smoking habits. For patients with allergic rhinitis, researchers recorded the type of allergies, the duration of the condition, symptoms experienced and treatments used, as well as the presence and treatment of any additional allergic disorders.

All sleep disorders and complaints – including insomnia, waking up during the night, snoring and feeling fatigued when awakening – were more common in those with allergic rhinitis, who also slept fewer hours, took longer to fall asleep and more often felt sleepy during the day. Among the 591 patients with allergic rhinitis, 41.6 percent (vs. 18.3 percent of those without allergic rhinitis) reported difficulty falling asleep, 63.2 percent said they felt they lacked adequate sleep (compared with 25.4 percent of controls) and 35.8 percent (vs. 16 percent of controls) reported insomnia. “The results show a significant impact of allergic rhinitis on all dimensions of sleep quality and, consequently, a lower quality of life as reflected by more somnolence [sleepiness]; daytime fatigue and sleepiness; and impaired memory, mood and sexuality, with a significantly increased consumption of alcohol and sedatives in cases compared with the control group,” the authors write.

The effects of allergic rhinitis on sleep became more pronounced when the condition was moderate to severe. As allergies worsened, individuals slept fewer hours at night, felt sleepy more often during the day, took longer to fall asleep and found it more necessary to take sedative drugs.

All types of physicians, including primary care physicians, pulmonologists and ear, nose and throat specialists, should question patients with allergic rhinitis about their sleep habits and difficulties, the authors conclude. “This could lead to early detection and treatment of sleep disorders in these patients,” they write. “Treating allergic rhinitis or other nasal symptoms may improve dramatically the quality of sleep. In the long term, such a strategy would have positive repercussions on a societal level; for example, the numbers of road and work accidents would be reduced. Considering the high incidence of allergic rhinitis and the high rate of associated sleep disorders, the issue is one of public health.” (Arch Intern Med. 2006;166:1744-1748)

UCLA Findings Offer Clues to SIDS, Sleep Apnea

Sleep Disorders and Sleep Apnea

Imagine raising a child who stops breathing when falling asleep – and has to be reminded to visit the bathroom after drinking a Big Gulp. That’s the dilemma faced by parents of children born with congenital central hypoventilation syndrome (CCHS). Afflicting about 250 children in the United States, the genetic disease wreaks havoc in areas of the brain that control involuntary actions such as breathing, fluid regulation and heart function.

Now an MRI study by UCLA scientists reveals that these children’s brains display stroke-like damage in regions that regulate the cardiovascular system, body temperature and urination. Published July 11 in the Journal of Comparative Neurology, the research holds important clues for unraveling the mysteries of sudden infant death syndrome (SIDS), sleep apnea and numerous other conditions.

“For a breathing researcher, this syndrome represents a rare opportunity from Mother Nature,” said Ronald Harper, principal investigator and professor of neurobiology at the David Geffen School of Medicine at UCLA. “By using CCHS as a model to study how the brain controls breathing, we hope not only to help children born with the disease, but also provide insights into SIDS and sleep apnea.

“These children’s brains don’t respond to the same cues as the rest of us, which prevents a host of involuntary mechanisms from kicking in,” he added. “Younger children have to be reminded to breathe and to go to the bathroom. They will plop down to relax in front of the TV or a video game, start turning blue and not realize they are passing out.”

Some children show disruption of the sympathetic nervous system, which regulates cardiovascular function. They have disturbed heart rates and blood pressure, often profusely sweat or shiver, especially at night, and sometimes faint during strenuous bowel movements. A mild fever can worsen breathing problems and quickly grow life-threatening. The pupil of one eye may constrict, while the other remains dilated.

Harper and his colleagues performed MRI brain scans on 12 children with CCHS and compared their scans to those of 28 healthy children matched by age and gender.

“We were startled to see severe tissue injury in multiple regions of the brains of children with CCHS,” said Dr. Rajesh Kumar, first author and UCLA neurobiology researcher. “This damage prevents different parts of the brain from communicating with each other and blocks the nervous system from responding to involuntary reflexes.”

Located primarily on the right side of the brain, the damage proved extensive. Tissue loss centered in the brain’s emotion areas, which may explain the children’s lack of fear to the feeling of suffocation. Damage also appeared in the anterior cingulate, which helps regulate cardiovascular function, blood pressure, heart rate and pain. This region also is involved in recognizing the urge to urinate.

The basal forebrain showed damage, as well. This area contains sensors for carbon dioxide, regulates thirst and body temperature, and plays a role in maintaining sleep.

“Now that we know where the damage exists, scientists can focus on new strategies to help the brain compensate for the injury,” Harper said. “For example, we may be able to inject injured areas with nerve growth factors to stimulate the regrowth of lost nerve fibers and recover some functions.”

At least 70 percent of CCHS children tested possess a mutation of PHOX2B, a gene related to brain structures that control blood vessel diameter. Harper hypothesizes that the mutated gene prevents normal development of these regions, resulting in narrowing of the blood vessels and inadequate blood flow to the brain sites that control breathing.

“We think that insufficient blood flow starves cells of oxygen in the brain structures that regulate breathing,” Harper said. “The breathing disorder results from the brain’s inability to develop completely.”

Parents of children with CCHS are desperate to call attention to the need for research of the mysterious syndrome. The condition forces most young patients to undergo a tracheotomy, an opening in the windpipe, which enables parents to connect children quickly to ventilators at bedtime. A family vacation requires lugging the ventilator on planes and to hotel rooms.

A few years ago, ventilators weren’t available, and CCHS children died young. Now ventilators are enabling these children to live past adolescence, when they often unwittingly kill themselves by falling asleep after drinking alcohol. With proper care, CCHS children are now living into their 30s, marrying and having children of their own.

The National Institute of Child Health and Development funded the research. Harper and Kumar’s coauthors include Paul Macey and Jeffry Alger of the David Geffen School of Medicine at UCLA, Mary Woo of the UCLA School of Nursing and Thomas Keens of Children’s Hospital Los Angeles.

AASM On Sleep Medications And Insomnia Treatment

Insomnia and Sleep Medications

Insomnia occurs when people have trouble falling asleep or staying asleep, and it is a common sleep compliant. While a brief case of insomnia can arise due to temporary stress, excitement or other emotion, more than 20 million Americans report having a chronic form of insomnia that keeps them from sleeping well nearly every night. As a result, the insomnia, which is a serious and often debilitating condition, can lead to severe daytime fatigue, poor performance at school and work, physical symptoms such as headaches, and in some cases depression.

People suffering from insomnia need to know that there are effective insomnia treatments and their sleep can improve. The American Academy of Sleep Medicine recommends that people who experience insomnia see a sleep medicine specialist or primary care physician for proper diagnosis and to discuss treatment options before treatment with medications is undertaken. This evaluation should also look for specific causes of insomnia such as restless legs syndrome or depression.

Sleep medications are often used for the short-term treatment of insomnia and, on occasion, for more chronic insomnia. Medications that currently are available by prescription are known to improve sleep by reducing the amount of time it takes to fall asleep, increasing sleep duration and/or reducing the number of awakenings during sleep. While modern hypnotics are considered safe, individuals should be aware that, like all medications, side effects may occur in a minority of patients. These side effects can include sleep walking, sleep eating and other complex sleep behaviors as well as difficulty with memory.

RECOMMENDATIONS FOR PATIENTS

Behavioral therapies and medications have been shown to be effective therapies for insomnia. Behavioral therapies use nonpharmacologic methods to improve sleep and are effective and long lasting. Sleep medications are effective and safe treatments for insomnia when used properly and judiciously by a patient who is under the supervision of a sleep medicine or primary care physician.

The American Academy of Sleep Medicine offers the following recommendations for individuals who use sleep medications:

 

  • Read carefully the package insert and all information provided by your physician and pharmacist for your sleep medication. This information will help guide you in the safe use of the medication. 

 

  • Especially read the package insert and all information to learn the side effects of the medication. 

 

  • Adhere strictly to the indicated use of your sleep medication. Do not take it for purposes other than to sleep. 

 

  • Follow the prescription carefully and do not take more than the dosage your doctor prescribes. 

 

  • Allow time for a full night of sleep when using sleep medication to avoid morning or daytime drowsiness. 

 

  • Avoid combining sleep medication with alcohol. 

 

  • Ask your doctor any questions you have about the intended use, dosage and side effects. Communication with your physician will help ensure safe use of the medication. 

 

  • Inform your doctor right away of any problems you have while taking a sleep medication. 

 

  • Make your doctor aware of any other medications, prescriptions or over-the-counter, that you use. Mixing medications may cause adverse effects. 

 

  • Make your doctor aware of other medical conditions, including other sleep disorders, you may have. Sleep medications can be dangerous when treating sleep disruption that may arise from another disorder. 

 

RECOMMENDATIONS FOR PHYSICIANS

The American Academy of Sleep Medicine is committed to educating sleep medicine and primary care physicians about treatment options for insomnia. Behavioral therapies and medications have been shown to be effective therapies for insomnia. The American Academy of Sleep Medicine offers the following recommendations for primary care physicians who see patients with insomnia:

 

  • Read the practice guidelines for chronic insomnia created by the American Academy of Sleep Medicine.

 

  • Become intimately familiar with sleep medications you prescribe, including the indications for use and side effects.

 

 

  • Educate your patients about the sleep medicine you are prescribing to them, including the indications for use, dosage and side effects. Ensure your patients fully understand the intended use and potential effects.

Insomnia contributed to Michael Jackson’s death

Michael Jackson had an extreme case of insomnia. As a result of this, he was on several medications to help him sleep. He was treated by many doctors and a nurse practitioner. The preliminary findings from the coroner indicate that Jackson had lethal amounts of the drug propofol in his system at the time of death. He also had other drugs in his system as well. According to the doctor that was treating him, these were for insomnia.

Dr. Conrad Murray was the doctor in attendance that night. He was trying to alleviate Jackson’s insomnia. He told detectives what occurred that night before the propofol was administered. First he gave 10 mg of Valium at 1:30 am, followed by an injection of 2 mg of Ativan at 2 am. At 3 am, Murray gave Jackson 2 mg of Versed, which is a sedative. Valium and Ativan are antianxiety medications, but are often given for insomnia as they are more gentle than some sleeping medications.

At 7:30 am, Murray gave Jackson more Versed, and finally gave him propofol at 10:40 am. After 10 minutes, Michael Jackson was asleep and so the doctor left his side to go to the restroom for just a moment. When he came back, Jackson was no longer breathing.

Insomnia has several different causes. Significant life stress such as job change or the death of a loved one can cause insomnia. Even good stress can be a cause. Emotional or physical discomfort make sleeping difficult. Noise, light, or extreme temperatures may cause acute insomnia. Some medications may cause insomnia, so it may be necessary to talk with your doctor or pharmacist if you are having any difficulty sleeping. Jet lag or switching from a day to night shift can also alter sleep patterns. Depression and anxiety, chronic stress and pain or discomfort at night may be a cause of chronic insomnia.

Symptoms of insomnia include sleepiness during the day, general fatigue, irritability, and problems with concentration or remembering things. There are treatments for insomnia. Michael Jackson had an addiction to several prescription drugs as a result of his insomnia. The drugs used to treat the insomnia no doubt also contributed to more insomnia. Dr. Murray stated that he was in the process of helping Jackson get off some of those medications.

If you think you have insomnia, talk with your doctor. He may have you keep a sleep diary for a week, maybe two weeks. This helps to identify your sleeping patterns. You may be prescribed a sleeping pill for a short amount of time. However, other treatment should be included with this. Some behavioral approaches may help. Relaxation exercises, sleep restriction therapy, and reconditioning have been used to treat insomnia.

Some other tricks can be used to help with insomnia. Avoid caffeine and nicotine late in the day as they can keep you from sleeping. Regular exercise helps the body to relax and thus fall asleep and stay asleep. Eating heavy meals late in the day may make sleeping difficult. Use the bed for sleeping and sex. Do not use it for anything else. Make your bedroom comfortable and cozy. Finally, if you cannot sleep, do not stay in bed. Get up and read a book or do something until you feel sleepy.

Insomnia is not treated over night. It takes time. Taking sleeping meds for a short amount of time may help, but finding ways to ease your body into sleep each night work better in the long run. Jackson became tolerant to the prescription drugs and needed higher doses and more drugs to feel the same comfort of falling asleep. Do not let this happen to you. Be careful and mindful of your health. Be proactive and be a partner with your doctor to solve your insomnia.

Sleep Experts Offer Tips for Daylight Saving Time Shift

This coming Sunday morning, a lot of brains will be thrown out of whack, as the clocks shift forward by an hour in the earliest-ever return to Daylight Saving Time (DST).

Even though the clock will say 8 a.m., it will feel like 7 a.m. to our brains and bodies � � ” and that will leave many people feeling groggy or “not quite right” for a day or more. The Monday morning commute on the day after DST starts is especially hard, and is associated with a spike in sleepy-driving crashes.

Fortunately, there’s still time to reduce the impact that this time shift will have on you, say experts from the University of Michigan Sleep Disorders Center. Starting a few days before the time shift, start heading to bed a little earlier each night � � ” even 15 minutes earlier for three days can start to make a difference. And, set your alarm clock for 15 minutes earlier, too.

Then, set your clock ahead one hour before you go to bed Saturday, and wake up at your “regular” time on Sunday morning. Don’t sleep in just because the clocks have changed! In fact, sleeping late on weekends isn’t a good idea any time of the year.

Making a gradual adjustment in this way will lessen the disjointed feeling that comes with losing or gaining an hour, whether it’s because of the twice-a-year time shift or travel to another time zone, says Todd Arnedt, Ph.D. He’s a sleep psychologist who heads the Behavioral Sleep Medicine program at the U-M Sleep Disorders Center, which offers treatment without medication for people with certain types of sleep disorders. He’s also a researcher with the U-M Depression Center’s Sleep & Chronophysiology Laboratory, which studies the relationship between sleep/wake cycles and depression.

Women are especially likely to develop insomnia or other irregular sleeping patterns. This week, two other U-M sleep experts presented at a conference in Washington, D.C. on sleep and women, sponsored by the National Sleep Foundation. Roseanne Armitage, Ph.D., director of the Sleep & Chronophysiology Lab, presented findings from her research on how women’s natural sleep rhythms differ from men� � �,, s, the role of women’s hormones in sleep patterns, and the impact these can have on brain health. Flavia Consens, M.D., associate director of the Sleep Disorders Center, spoke on narcolepsy in women, a relatively uncommon but serious problem.

Meanwhile, the U-M Sleep Disorders Center recently opened a new location where people who have sleep problems of any kind can stay overnight and have intensive testing to help diagnose their specific problem and guide their treatment. Located in the Med Inn building at the U-M Health System’s main campus, the nine-bed facility replaces one formerly located in the main University Hospital. It complements the center� � �,, s other nine-bed location on South State Street.

The center’s director, Ronald Chervin, M.D., M.S., notes that this week has been designated Sleep Awareness Week by the National Sleep Foundation, and encourages anyone who has been having trouble sleeping to visit the NSF’s web site, www.sleepfoundation.org, for information and tips.

The U-M team offers these tips that everyone should follow to get a good night’s sleep every night:

  • Go to bed and get up at the same time each day, even on the weekends
  • Avoid daytime naps or limit them to one brief (15-30 minutes) mid-afternoon nap
  • Avoid drinking alcohol in the evening and do not use it to help you sleep
  • Avoid caffeinated products (coffee, tea, soda, chocolate) after mid-afternoon
  • Eliminate tobacco use, especially close to bedtime and during the night
  • Exercise regularly during the day, but avoid evening exercise
  • Avoid using the bedroom for school work, business affairs, TV, exercise, or other activities
  • Keep the bedroom dark, quiet, and comfortable
  • Set aside 30 to 45 min� � utes or more to wind down at the end of the day before going to bed.
  • If insomnia becomes chronic � � ” when it occurs on most nights and lasts a month or more � � “you may want to seek medical treatment.

Some common sleep problems include:

Insomnia: People with insomnia have difficulty falling sleep, frequently wake during the night, or wake too early in the morning. This is a fairly common problem in adults; up to 1/3 of adults report periodic symptoms of insomnia and 10 to 20 percent report chronic insomnia that interferes with their daytime functioning. Interestingly, women are affected more than men, and people over 65 years of age are more likely to suffer from insomnia.

Restless Legs Syndrome: Restless legs syndrome causes an irresistible urge to move the legs often accompanied by uncomfortable sensations (e.g., creepy crawling), typically when seated for long periods of time, at night, and when trying to fall asleep. Roughly 10 percent of the population in Western countries suffers from this syndrome.

Narcolepsy: Narcolepsy affects about 0.03 percent of the population, or three in every 10,000 people. Typical features include excessive daytime sleepiness, cataplexy (loss of muscle tone in response to intense emotion, such as laughter), sleep paralysis, and sleep-onset hallucinations. Narcolepsy is debilitating, severely interfering with work productivity and social interactions.

Obstructive Sleep Apnea: This condition occurs when a person’s airway partially or completely closes repeatedly during sleep for 10 seconds or longer, resulting in brief awakenings to resume breathing.� � People with sleep apnea often snore loudly or experience choking arousals during the night. One of the most common consequences of obstructive sleep apnea is excessive daytime sleepiness. About 4 percent of adult men and 2 percent of adult women suffer from sleep apnea and admit to daytime sleepiness. More people have sleep apnea but do not admit or experience sleepiness. Interestingly, 80 percent of men and 90 percent of women who have sleep apnea do not know that they have this condition. It is more common in people who are overweight, and is associated with an increased risk for vehicle crashes, high blood pressure, stroke and heart attack.

Children are also at risk of sleep apnea: At least 1 to 3 percent of children have clear sleep apnea, while up to 10 percent of children have a milder form. Children with sleep apnea perform worse in school, and it may contribute to attention deficit hyperactivity disorder and aggressive behavior. Most children with sleep apnea are not diagnosed. U-M research has suggested that removing the tonsils of children with OSA may help both their nighttime sleep and their daytime behavior.

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