The Insomnia Blog - Sleep Doctor Michael Breus, PhD

Challenging conventional wisdom about sleepwalking

2013-05-23T12:07:07-07:00

New research about sleepwalking has raised questions about several common beliefs regarding this frequently misunderstood sleep disorder. Researchers at the University of Montreal conducted a comprehensive review of more than 15 years of study on the topic of sleepwalking. Their analysis produced what may be a clearer picture of the sleep disorder, its possible mechanisms, and its risk factors. Their analysis also challenges some common beliefs about sleepwalking—beliefs that, if outdated, could interfere with diagnosis and treatment.

What are these views on sleepwalking that researchers say are not supported by data? There are three primary ones, which involve the experience of activities during sleepwalking as well as the daytime effects of the disorder. Researchers say that the cumulative data challenges these three notions:

Sleepwalkers do not remember their episodes
The actions that sleepwalkers take during episodes have no underlying motivation
Sleepwalking has no effect on daytime behavior

Researchers found, in fact, that the memory recall can vary, with some sleepwalkers retaining memories of their episodes and others not. During an episode of sleepwalking, people are in a state that researchers call “dissociated arousal,” with parts of the brain in a sleeping state and other parts of the brain in a waking state. This may help to explain why some can remember their experiences while others cannot.

Scientists also found evidence to contradict the common belief that people’s actions during sleepwalking are simply irrational, lacking any underlying motivation. The accumulated data, researchers say, suggests otherwise. It is true that episodes of sleepwalking often include strange and seemingly irrational behavior. But researchers found that sleepwalkers who were able to recall their actions during these episodes could also identify a rationale for their behavior, even in circumstances where their actions later seemed strange to them. This led researchers to conclude that sleepwalkers retain motivation for their actions during episodes.

Contrary to the view that the effects of sleepwalking are confined to nighttime episodes, this analysis found that sleepwalkers do experience daytime effects from the disorder. A high percentage of sleepwalkers—nearly 45%--reported daytime sleepiness. Sleepwalkers perform less well on vigilance tests than those without the disorder. And sleepwalkers who were allowed to nap during the day fell asleep more quickly than those who did not sleepwalk.

Other conclusions that came from this analysis aligned with recent research on sleepwalking. One has to do with genetics. The current review found that nearly 80% of sleepwalkers have a family history of the sleep disorder. Researchers identified stress and fatigue as possible causes of sleepwalking, but said that for people who have a genetic predisposition, any disruption to sleep might trigger the disorder.

This conclusion is in line with previous studies, which also found family history linked strongly to the disorder. In this study, researchers at Stanford University investigated sleepwalking and found a strong family connection, with more than 30% of the study population able to identify least one other family member with the sleep disorder. The Stanford study, reported in 2012, also found sleepwalking to be significantly more common than often is thought. Stanford researchers found as many as 3.6% of U.S. adults may experience some form of nocturnal wandering during any given year. And when sleepwalking is considered over the course of a lifetime, including childhood, as many as 30% of the population may have some experience of the disorder.

Sleepwalking is more common during childhood, a conclusion confirmed by this latest research review. Data indicates that sleepwalking is most common in children ages 6-12. Researchers link childhood prevalence of sleepwalking to brain development, and the readiness of a young brain to successfully complete the complicated neurological task of transitioning from wake to sleep. Very often, episodes of sleepwalking will diminish and disappear altogether during adolescence. But as many as 25% of adolescent sleepwalkers will continue to have episodes during adulthood, researchers say.

Sleepwalking in adulthood will also decrease with age. This is related to a diminished amount of time spent in the phases of deep sleep, also known as slow-wave sleep. Sleepwalking occurs during periods of slow-wave sleep. As we age, we naturally spend less time in slow-wave sleep, and sleepwalking tends to occur with less frequency. Researchers conducting the review point to evidence of abnormalities in the slow-wave sleep of sleepwalkers, including repeated episodes of “micro-arousals.” Further study into the slow-wave sleep of people who experience sleepwalking may shed important light on the underlying causes and triggers for the disorder.

What about the dangers of sleepwalking? The current research review indicates that sleepwalking overall is not particularly dangerous, that its episodes are brief and usually harmless to sleepwalkers and their bedmates. However, other recent research paints a very different picture, one that suggests sleepwalking poses significant risks for physical harm. Among sleepwalkers in this study, 58% experienced some kind of violent sleep-related behavior, and 17% had at least one episode that required medical treatment for either the sleepwalker or a bed partner.

We’ve got a long way to go in our understanding of the causes and behaviors of sleepwalking. I hope this latest review will spur more interest in the questions that remain unanswered by this often-overlooked sleep disorder.

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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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

Facebook: www.facebook.com/thesleepdoctor