Q. Should patients with sleep disorders receive melatonin?

A. Routine use of melatonin is not currently recommended. Melatonin’s purity, dosages, and additives are unregulated by the FDA. A hormone secreted by the pineal gland, melatonin is thought to have hypnotic and circadian properties when administered at different dosages and at different circadian times. Ongoing experiments suggest that melatonin may cause infertility in both sexes; testicular atrophy; and even arterial vasoconstriction, such as coronary and cerebral vasospasm. Blood levels may increase disproportionately with oral dosing. Melatonin has not undergone standard testing for side effects, toxicology, or other scientific drug standards, and many patients are self-medicating with supraphysiologic doses.

Q. What is RLS?

A. Restless legs syndrome, also known as “Ekbom syndrome,” is an unexplainable dysesthesia of creepy, crawling, pulling leg sensations, associated with the irresistible urge to move one’s legs. Typically, symptoms begin at bedtime and interfere with sleep, but in the more severe cases, symptoms may occur in any confined location, such as a car or plane. The syndrome may affect five percent of the population.

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Symptoms follow an unpredictable course over time, with periods of remission regardless of treatment and periods of exacerbation lasting weeks or months. Typically, patients walk for relief, or they may rub or squeeze the legs. The cause is unknown, although the syndrome may be seen in association with such conditions as anemia due to deficiencies of iron or folic acid, neuropathies, diabetes, renal disease and uremia, chronic alcoholism, and pregnancy. Familial RLS is more severe. Fatigue, certain foods, extreme temperatures, nicotine/smoking, caffeine, alcohol, certain medications (including nearly all antidepressants), and confined position increase restless legs symptoms. Most patients with the syndrome also have a sleep disorder called “periodic limb movement disorder,” or “nocturnal myoclonus.”

Q. How should patients with RLS be managed?

A. Patients should be interviewed to obtain a complete history and should undergo medical and neurologic exams, as well as baseline blood testing for associated conditions, such as anemia. The clinician must differentiate between restless legs and nocturnal myoclonus, obtaining additional history from the bed partner. The syndrome should also be differentiated from other movement disorders that occur during sleep, such as REM behavior disorder (RBD), when patients act out violent dreams during REM-stage sleep. Unclear histories or more severe symptoms, including resultant daytime sleepiness, warrant nocturnal polysomnography or referral to a neurologist or sleep specialist.

Therapy for milder cases of RLS includes treatment of underlying medical conditions, such as anemia, and conservative measures, such as avoidance of fatigue, caffeine, alcohol, antidepressants, extreme temperatures, or other known offending situations. Medical options are indicated when RLS is causing daytime sleepiness or when symptoms are severe; treatment includes bedtime medications, such as Sinemet (carbidopa-
levodopa), Klonopin (clonazepam), Permax (pergolide), or Neurontin (gabapentin). Patients and clinicians can learn more about RLS through the Restless Legs Syndrome Foundation, Inc., 819 Second Street SW, Rochester, MN 55902; phone: (877) 463-6757; E-mail:[email protected]; Web site: www.rls.org.

Q. Is sleepwalking ever considered normal in adults?

A. Persistent sleepwalking in adults is not normal but is one of several disorders of arousal, or parasomnias, that occur during partial arousals, especially from delta or deep sleep (stages 3 and 4 sleep). Other parasomnias include night terrors and confusional arousals. There is usually a family history of parasomnias or enuresis and a higher incidence of psychopathology in sleepwalkers than in the general population, although there is no known causal relationship. Sleepwalking can result in potentially dangerous injuries to the sleepwalker and to other family members. A thorough history of injuries must be obtained.

Sleepwalking is unlikely to have late-life onset; a very careful history, physical exam, and workup must be obtained to rule out more likely etiologies of nocturnal movements, such as RBD, partial seizure disorder, or nocturnal wandering with dementia. The classic sleepwalker may sit up in bed or walk around performing only simple, uncomplicated behaviors. Episodes usually take place during the first part of the night, when delta
sleep more commonly occurs. Usually, sleepwalkers are amnesic to the episode and may appear confused or disoriented if awakened.

On the other hand, patients with RBD are typically middle-aged or older males who leap out of bed,  punch their bed partner, or curse in the latter portion of the night. Such patients are easily oriented upon awakening. The onset of RBD may precede that of Parkinson’s disease by many years.

Q. What approach should be taken when treatingsleepwalking patients?

A. Sleepwalkers do not display seizurelike symptoms or focal neurologic symptoms; the presence of these should alert the clinician to contact a neurologist promptly. However, sleepwalking cannot be differentiated from seizures or RBD by history alone. It may also be difficult to differentiate sleepwalking from malingering, dissociative states, or other psychiatric disorders. In general, though, patients with psychiatric disorders usually display more complex, complicated, or purposeful behaviors of longer duration than do sleepwalkers.

Because sleepwalking may be caused by physiologic arousals, a careful history for snoring, sleep apnea, or myoclonus must be obtained. Sleepwalking episodes may be exacerbated by sleep deprivation, alcohol, numerous medications, and other conditions. Bedroom safety to avoid injury is mandatory and may include such actions as moving the bed away from windows. Specific safety precautions should be reviewed for individual patients. It is also critical to rule out other diagnoses previously described. A diagnostic workup and possible referral to a clinician familiar with sleepwalking should be considered in an adult who displays frequent or dangerous sleepwalking.

Treatment for sleepwalking includes adequate total sleep time with a regular sleep schedule and avoidance of known precipitators, such as stress or alcohol, as well as careful bedroom and safety precautions. Medications, such as clonazepam, may be beneficial in more severe cases.

Q. What are circadian rhythm sleep disorders?

A. These are disorders of inappropriate timing of sleep. Examples include shift work, delayed sleep-phase syndrome, advanced sleep-phase syndrome, irregular sleep-wake pattern, non-24-hour sleep-wake disorder, and jet lag. Shift workers, those who work a regular night schedule or a series of rotating shifts, often become chronically sleep-deprived when they shift from a work schedule to a home schedule. To decrease sleep and sleepiness problems, shift workers should stay on the same schedule on days when they work as well as on days off. Shift workers should also try to use environmental cues, such as setting bright lights to come on upon awakening and avoiding exposure to light before going to bed (e.g., wearing sunglasses on the way home after the night shift).

Patients with delayed sleep-phase syndrome may describe themselves as “night owls” and may normally sleep from 3 or 5 am to noon or later. This schedule is ideal for evening shift workers but not for 8 am to 5 pm workers who often believe they have insomnia but “cannot get out of bed in the morning.” Conversely, patients with advanced sleep-phase syndrome may describe themselves as “morning larks” and sleep from 7 pm to 3 am. This schedule is ideal for a farmer, baker, or surgeon but may cause social, marital, and family-scheduling problems. Patients with non-24-hour sleep-wake syndrome chronically delay sleep and wake time for one to two hours, often with sleep and wake periods appearing to cycle in and out of phase. For example, a blind patient may chronically delay wake and sleep onset by one to two hours every day. Patients who have an irregular sleep-wake pattern have no recognizable sleep-wake schedule, often having three or four sleep periods per 24-hour day, similar to the pattern of newborns.

Q. How do circadian rhythm disturbances relate to jet lag?

A. Jet lag refers to physiologic and psychological symptoms resulting from a mismatch between an individual’s circadian rhythm and the environment. The body has many circadian rhythms that are generated or influenced by the biologic clock, the suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN, which generates 24-hour circadian rhythms, is resistant to change; it takes days or a week or more to realign with a changed environment or routine. Examples of the many circadian cycles include decreasing core body temperature with sleep (particularly REM sleep); increasing body temperature with wakefulness; release of growth hormone, melatonin, and other hormones with sleep onset; and morning release of cortisol, etc.

Q. What are the symptoms of jet lag?

A. Symptoms resulting from a lack of synchronicity between the body clock, circadian rhythms, and the environment include nocturnal awakenings related to hunger or need to void, changes in body temperature, headache, loss of appetite, bowel irregularities, malaise, fatigue, difficulty concentrating, and lack of alertness. These symptoms are due to a combination of partial sleep loss and the circadian clock’s preparing the individual inappropriately for sleep or wake physiology or behavior. The severity of symptoms is generally related to the direction of travel and the number of time zones crossed. Eastward travel shortens the day, requiring a phase advance, a more difficult adaptation for the body. Westward travel lengthens the day, requiring a phase delay, a less difficult adaptation for the body. Adjustment rates vary with age and are specific to each individual, although many travelers adjust at a rate of 1.5 hours per day going eastward and one hour per day going westward.

Q. How can travelers best cope with jet lag?

A. Awareness of the potential for circadian mismatch between physiology and environment is an important countermeasure for jet lag. Generally, it is optimal for travelers to assimilate as soon as possible to the new environment. Consider, for example, the person who arrives in London from New York at 6 am; the body “thinks” the time is midnight. A short nap that morning might be helpful, but ideally, the traveler should try to obtain light exposure that morning and delay the sleep time until early evening London time. After a lengthy sleep, this traveler would awaken on the second travel day at the normal London morning time. If the stay in London will be long, the traveler from New York could begin slowly resetting his or her internal clock days before departure, going to bed earlier and getting up earlier in New York before boarding the flight to London.

Other jet-lag countermeasures include avoiding sleep deprivation prior to departure, caffeine, alcohol, large meals, long and poorly timed napping, and social/environmental (light/dark) isolation. Short-acting sleeping pills are sometimes used adjunctively.