The Insomnia Blog - Sleep Doctor Michael Breus, PhD

Insomnia may triple risk of heart failure

2013-05-15T09:37:40-07:00

There is an abundant—and ever-growing—body of evidence that indicates sleep plays an important role in cardiovascular health. Poor sleep is associated with a range of heart problems, including high blood pressure and increased risk of heart attack. Now, new research shows a link between insomnia and heart failure. Nearly 6 million adults in the United States suffer from heart failure, according to the Centers for Disease Control. Heart failure is directly responsible for more than 55,000 deaths every year, and is a contributing factor to hundreds of thousands more deaths in the U.S. annually.

Researchers in Norway conducted a large-scale study of the relationship between insomnia and heart failure, and found that the presence of several symptoms of insomnia is associated with a dramatically elevated risk of developing heart failure. The investigation included more than 54,000 men and women between the ages 20-89. All were participants in a large-scale public health study in Norway. At the study’s outset, none of the men and women included had known symptoms or evidence of heart failure.

Researchers collected data on participants’ sleep, including detailed information on three common symptoms of insomnia:

Difficulty falling asleep
Difficulty staying asleep
Waking feeling un-refreshed—a sign of non-restorative sleep

Researchers also gathered information on other aspects of health, including risk factors for cardiovascular disease. Participants were then monitored over a period of more than 11 years. Over that period of time, slightly more than 1,400 people developed heart failure. Researchers analyzed data to identify a possible relationship between the incidence of heart failure and insomnia symptoms, while controlling for other factors that could influence the risk of heart disease, including age, cholesterol and high blood pressure, body mass index, history of heart problems, and alcohol and tobacco use. They found that insomnia was associated with a higher risk of heart failure:

People who experienced insomnia symptoms had a higher risk of developing heart failure than those who did not experience insomnia symptoms.
The risk increased for people who had multiple symptoms of insomnia.
People who experienced all three insomnia symptoms—difficulty falling asleep, difficulty staying asleep, and non-restorative sleep—had more than triple the risk of developing heart failure than those with no insomnia symptoms. People with all three insomnia symptoms also had significantly higher risk of heart failure than those with one or two symptoms of insomnia.

The study results show a strong association between insomnia and heart failure. But they do not provide any evidence to answer the question of whether—or how—insomnia might directly cause heart failure. Additional research is necessary to determine if disrupted sleep plays a causal role in the development of heart failure.

Heart failure occurs when the heart is unable to pump blood effectively at levels that meet the body’s constant needs. This is a serious cardiovascular disease that has no cure. Other research has shown evidence of a link between sleep problems and heart failure, including studies that indicate an increased risk for heart failure among patients with obstructive sleep apnea.

There is also a great deal of evidence that sleep is critically important to heart health, and that disrupted, poor, and insufficient sleep is associated with elevated risk of cardiovascular disease:

This large-scale investigation, conducted by members of the Norwegian research team responsible for the current study, found people with insomnia at elevated risk for heart attacks. People with insomnia had a 27-45% greater risk of heart attack than those without insomnia symptoms.
This study showed people who slept fewer than 6 hours a night had a 48% higher risk of heart attack, as well as a 15% increased risk of stroke.
Sleep disordered breathing—which commonly manifests as snoring, or in obstructive sleep apnea—is associated with higher risk of heart failure, stroke, and coronary heart disease, according to this research.
Poor sleep is also linked to elevated rates of high blood pressure, an important risk factor for heart attack and heart failure.

Science is still working to get to the root of the relationship between sleep problems and cardiovascular disease. Lack of sleep has been associated with calcium build-up in the arteries, as well as with inflammation and dysfunction of the central nervous system. Definitive answers to the role that sleep plays in cardiovascular disease may well lie in these areas. But the mechanisms by which sleep may influence—or cause—diseases of the heart are not yet well understood. Still, there is little question that maintaining healthy sleep habits, and addressing sleep problems promptly with your physician, is beneficial to your overall health and to heart health in particular.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

The Sleep Doctor’s Diet Plan: Lose Weight Through Better Sleep

Everything you do, you do better with a good night’s sleep™

twitter: @thesleepdoctor

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Zolpidem-related ER visits have increased sharply

2013-05-08T09:02:14-07:00

There’s more news about complications that can arise from prescription sleep medication: Side effects from a common prescription sleep aid are sending increasing numbers of people to emergency departments.

The number of people seeking emergency medical treatment for the adverse effects of sleep medications containing zolpidem has risen dramatically in recent years, according to a new federal report. Zolpidem is the active ingredient in several of the most commonly prescribed sleep medications, including Ambien, Ambien CR, Edluar, and Zolpimist.

The report was issued by the Substance Abuse and Mental Health Services Administration’s Drug Abuse Action Network (DAWN), which collects information about drug-related visits to emergency departments nationwide. Their analysis included all emergency-department visits that involved adverse effects of zolpidem during the years 2005-2010. During this 5-year period, visits to emergency departments involving adverse effects of zolpidem increased significantly, rising by more than 200%. Women and older adults sought emergency treatment for adverse zolpidem effects in greater numbers overall than men and younger adults. According to the report:

In 2010, there were 64,175 emergency-department visits involving zolpidem. Of these, 19,487 or 30%--specifically involved adverse reactions to the sleep medication.
In 2005, there were just 6,111 emergency-room visits involving adverse reactions to the sleep drug. During the period 2005-2010, emergency department visits involving adverse reactions to zolpidem rose almost 220%.

The analysis found women were significantly more likely to seek emergency treatment for problems with zolpidem than men:

Women accounted for 68% of emergency department visits related to adverse reactions to zolpidem in 2010. The differences between men and women fluctuated during the 5-year period, but overall women made up a greater number of the zolpidem-related emergency visits in every year but 2008.
The number of emergency-department visits made by women involving adverse effects of zolpidem increased by 274% during the years 2005-2010. Visits by men increased 144%.

Age also was a factor, with greater numbers of cases involving older adults:

Adults ages 45 and older accounted for 74% of all emergency department visits involving adverse reactions to zolpidem. As a comparison: this same age group accounted for 56% of emergency room visits involving adverse effects of any drug.
Patients ages 65 and older were the single most common age group to seek emergency treatment for adverse reactions to the sleep medication: 32% of all emergency department visits related to adverse effects of zolpidem were undertaken by people in this age group.
Patients ages 45-54 were the next largest group, accounting for 22% of all visits.

Other pharmaceutical drugs often were involved in emergency treatments related to zolpidem. Half of the emergency department visits related to adverse effects of zolpidem involved other medications as well:

Of the total visits to emergency departments related to adverse effects of zolpidem, 40% involved the sleep drug alone.
In 50% of the cases, one or more additional prescription drugs were involved.
The most common prescription drugs seen in combination with zolpidem’s adverse effects included narcotic pain relievers, anti-depressants, anti-anxiety medications and other insomnia medications.

The side effects associated with zolpidem can be disorienting, scary, and at times dangerous. These side effects include hallucinations, problems with memory, excessive daytime tiredness, sleepwalking and engaging in other behaviors such as eating and even driving while not fully awake and alert. The adverse effects of zolpidem can be exacerbated when the sleep medication is combined in the body with other common prescription drugs, including narcotic pain relievers, anti-depressants and anti-anxiety medications. Alcohol, too, can have a magnifying effect on the body’s reaction to zolpidem.

Medications containing zolpidem are prescribed to millions of Americans with sleep problems, in numbers that have been rising dramatically in recent years. The SAMHSA report does not discuss reasons for the spike in zolpidem-related emergency department visits, but it’s certainly likely that the rise in the number of prescriptions may play a significant role. For all their frequent usage, we still don’t know a great deal about the health and side effects of zolpidem medications. Stories about strange and erratic behavior associated with these sleep medications have been widely reported, but research into the effects of zolpidem is just starting to accumulate.

In January of this year, the Food and Drug Administration issued a safety alert including changes to its regulations regarding zolpidem. The FDA announced it would require drug makers to cut in half the recommended dosages for women taking zolpidem, and suggested that the recommended dosage for men be lowered as well. The alert also urged medical professionals to warn all patients taking zolpidem about early-in-the-day drowsiness and impairment. The FDA’s action came about as a result of research indicating that patients—especially women—who take zolpidem at night may have concentrations of the medication in their bloodstream high enough to cause impairment in the morning for activities such as driving. The research showed that women’s bodies take significantly longer to metabolize the drug, leaving them particularly vulnerable to excessive drowsiness and impairment in the morning.

Research also has shown that older adults are at greater risk for adverse effects from sleep medications, including those containing zolpidem. The elevated numbers of both women and older adults seeking emergency treatment for problems with zolpidem appears to align with other research suggesting these groups are at elevated risk for complications from these medications. We must continue to learn more about the short-term and long-term effects of zolpidem and other sleep medications on patient safety and health.

Sleep medications containing zolpidem can be an effective short-term treatment for disordered sleep. But these medications must be prescribed with care and caution by doctors, and used correctly by patients. Prescription sleep medications such as those with zolpidem are not intended for long-term use. For most patients with sleep problems, the best long-term prescription for healthy sleep isn’t found in a pill bottle. It’s found in the fundamentals of strong daily sleep habits, and a lifestyle that promotes good sleep hygiene.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

The Sleep Doctor’s Diet Plan: Lose Weight Through Better Sleep

Everything you do, you do better with a good night’s sleep™

twitter: @thesleepdoctor

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ADHD or sleep disorder: are we getting it wrong?

2013-05-01T08:08:17-07:00

Millions of children and adults struggle with symptoms of Attention Deficit Hyperactivity Disorder (A.D.H.D.), a condition marked by problems with concentration, impulse control, organization, and memory. It can be a frustrating and difficult condition, stigmatizing and often isolating for those who suffer from it.

But what if some of those who’ve been diagnosed with A.D.H.D. are, in fact, suffering from another disorder altogether—a sleep disorder? That’s the provocative and important question posed in this commentary by a practicing psychiatrist with extensive experience treating patients with A.D.H.D. Dr. Vatsal Thakkar, who is also a clinical assistant professor of psychiatry at NYU Langone Medical Center, makes a powerful argument for the need to consider sleep problems as a possible cause when evaluating patients for A.D.H.D.

As Dr. Thakkar points out, many of the symptoms of A.D.H.D. are very often similar to symptoms of insufficient and disordered sleep, for both children and adults. In children, the symptoms of A.D.H.D. and sleep deprivation can be indistinguishable. A diagnosis of A.D.H.D. in children frequently comes about after a child exhibits some or all of behavioral symptoms such as these:

Lack of focus: difficulty paying attention, problems listening, forgetfulness, disorganization

Agitated, excitable, impulsive behavior: excessive talking, inability to sit still, difficulty playing quietly, tendency to interrupt, difficulty sharing or waiting for one’s turn

These behaviors associated with A.D.H.D. interfere with a child’s social and intellectual development, causing problems with relationships with peers and adults, at school and at home. But what if A.D.H.D. isn’t always the underlying cause of these symptoms? Signs of poor quality and insufficient sleep in children can look remarkably like symptoms of A.D.H.D., as a number of recent studies show. There’s particularly strong evidence that children with sleep-disordered breathing exhibit many of the same symptoms—and suffer many of the same behavioral problems—as children who’ve been diagnosed with A.D.H.D.

Sleep-disordered breathing in children has been an area of growing interest among sleep scientists—with good reason. I’ve written about the dangers of sleep-disordered breathing in children, which is linked to a range of developmental and behavioral problems—problems that often mirror those associated with A.D.H.D:

This study found that children with obstructive sleep apnea had higher rates of behavioral problems including difficulty paying attention, hyperactivity, communication problems, and aggressiveness. These children were also more likely to have learning difficulties and low academic performance than those without sleep-disordered breathing.

This large-scale study of more than 11,000 children found that those with sleep-disordered breathing were significantly more likely to show signs of hyperactivity, trouble interacting with peers, and conduct issues including aggressiveness and inability to follow rules. The study examined the effects of sleep-disordered breathing on children as young as 6 months. Researchers found that very young children who experienced some form of sleep-disordered breathing were, by the age of 7, 40-100% more likely to have behavioral problems similar to those used to diagnose A.D.H.D.

Many adults being treated for A.D.H.D. have symptoms that are difficult to distinguish from the effects of poor quality and insufficient sleep. Difficulty concentrating, trouble completing tasks, problems with organization, and memory lapses are all common struggles for adults who’ve received an A.D.H.D. diagnosis. These are also some of the most common problems for adults with sleep problems. I’ve written about the challenges that lack of sleep and disrupted sleep pose to cognitive function in adults, including problems with memory, learning and focus.

Given the similarities of symptoms between A.D.H.D. and poor sleep in children and adults, it’s not hard to see how misdiagnosis is possible, even likely. That risk increases when we consider the lack of regular screening that exists for sleep problems. We’ve made great scientific strides in our understanding of sleep in recent years. But we still struggle with a lack of attention paid to sleep problems by both physicians and patients. For both children and adults, sleep problems continue to be significantly under-diagnosed. This study of members of the American Academy of Pediatrics evaluated sleep-screening practices among pediatricians. Researchers found that fewer than 1 in 5 pediatricians surveyed had received any training in sleep disorders, and fewer than 1 in 6 felt confident about their ability to offer guidance to parents about children’s sleep. The study also revealed serious knowledge gaps among pediatricians about sleep, with most unable to answer correctly questions about sleep disorders in children.

The news isn’t any better for adults. An analysis of data from the 2005-2006 National Health and Nutrition Examination Survey found that sleep disorders such as insomnia and sleep apnea remain drastically under-diagnosed. What’s more, though nearly all of the more than 2,000 adults surveyed reported at least one complaint about their sleep, fewer than 1 in 4 of them had talked with physicians about their sleep problems.

More rigorous and effective screening for sleep problems starts with better training for physicians and medical professionals who must make diagnoses every day. As patients and as parents, we also need to be attentive to symptoms of poor sleep in ourselves and in our children. And we need to take these concerns—however mild they may appear—to our physicians.

Another thing we can do? Protect our sleep, and our children’s sleep, by setting sleep-friendly limits against the nonstop, perpetually wired, always “on” culture we live in today. As Dr. Thakkar points out, the escalation of A.D.H.D. cases in the 1990s and 2000s coincided with the rise of the digital age, and the widespread use of personal technology that now pervades our daily lives. These devices—our laptops and tablets and cell phones—that enable so much convenience and connection, also threaten the quality and quantity of sleep. The nighttime exposure to light they emit interferes with the body’s release of melatonin, disrupting sleep cycles and diminishing time spent in the deepest, most restorative phases of sleep. More than ever before in history, we must work to create the darkness that is so essential to sleep. Keeping our bedrooms, and our children’s bedrooms, gadget-free sanctuaries for sleep is one important way to guard against chronic sleep deprivation.

To raise the possibility that some cases of A.D.H.D. in children and adults may actually be un-diagnosed sleep disorders does not call into question the seriousness of A.D.H.D., the difficulties it poses, and the importance of effective treatment for this very real disorder. Additional research is critical to determine whether, and how often, sleep disorders are being misdiagnosed as A.D.H.D. The goal is to make the right diagnosis—whether A.D.H.D. or sleep problems—and pursue the most effective treatment. All patients, whatever their condition, deserve no less. Pursuing the question of a link between disrupted sleep and symptoms of A.D.H.D. is a matter of public health, one that deserves prompt and sustained attention.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

The Sleep Doctor’s Diet Plan: Lose Weight Through Better Sleep

Everything you do, you do better with a good night’s sleep™

twitter: @thesleepdoctor

Facebook: www.facebook.com/thesleepdoctor