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Some researchers believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first.
In one study, healthy volunteers reported fibromyalgia-like pain after their deep sleep had been disrupted. Other biological measures of troubled sleep, such as levels of the hormone melatonin (which helps regulate circadian rhythms and the sleep-wake cycle) appear to be normal in most people with fibromyalgia. Depressed feelings in people with fibromyalgia can be normal responses to the pain and fatigue caused by this syndrome.
Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems (auras), speech difficulty, and intense pain that is mainly on one side of the head.
Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia. The pain, emotional consequences, or sleep disturbances that come with fibromyalgia may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine. Better sleep -- some research has reported an increase in melatonin levels in experienced meditators. Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia, but trials studying so far it have not been well designed. Patients should learn to accept that relapses occur, and that over-coping and accomplishing too much too soon can often cause a relapse.
Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep in patients with insomnia. Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Insomnia is a disorder characterized by chronic sleep disturbance associated with daytime disability or distress, such as memory impairment and fatigue, that occurs despite adequate opportunity for sleep. Insomnia is a symptom-based diagnosis.3 Patients with insomnia experience one or more sleep-related complaints, including difficulty falling asleep, difficulty staying asleep, early-morning awakenings, and sleep that is nonrestorative or not adequately restorative (Slide 1). The sleep systems in patients with insomnia are relatively normal, but the individuals are hyperaroused, as reflected in catecholamines, brain metabolism, and body metabolism.
People who experience sleep difficulty often report problems with daily functioning and quality of life.
Several epidemiologic studies1-7 have used cross-sectional analysis or longitudinal data to compare people with insomnia to normal sleepers in an effort to determine the specific impairments and alterations in quality of life associated with insomnia.
At the National Institutes of Health (NIH) State-of-the-Science Consensus Conference on insomnia, held in June 2005 in Washington, DC, the Federal government addressed insomnia and its associated problems for the first time in >20 years. Sleep restriction and stimulus control are other behavioral treatments for sleep disorders.
The principles of sleep hygiene consist of largely common sense practices (Slide 3).3-5 Many patients simply do not fully understand or appreciate the various dimensions of good sleep hygiene. Likewise, increasing exposure to bright light during the day and avoiding exposure to it during the night contribute to good sleep hygiene. Patients with insomnia should engage in relaxing activities as part of their sleep preparation ritual.
Over the years, patients have used a variety of products, alone or in concert with behavioral changes and modifications, to induce sleep (Slide 4). The selective melatonin receptor agonist ramelteon is a recent addition to the sleep-agent armamentarium and is also approved by the FDA for the treatment of insomnia. Characterized by difficulty falling asleep, waking frequently after falling asleep, and being unable to go to sleep even when you are tired, insomnia is a frustrating sleep condition. A treatable condition that causes seniors to stop breathing for a short time during sleep, sleep apnea is typically diagnosed by participating in a sleep study. If your elderly loved one grinds his or her teeth, kicks, or has other aggressive movements while sleeping, he or she may have a REM sleep behavior disorder. As seniors with Parkinson’s are at an increased risk for sleep conditions, having a caregiver monitor your loved one for daytime drowsiness and other symptoms of sleep problems can help. A bed partner can help provide information based on observations of the patient's sleep behavior.
Some patients may need to consult a sleep specialist or go to a sleep disorders center in order for the problem to be diagnosed. Overnight polysomnography involves a series of tests to measure different functions during sleep.
Actigraphy is not as accurate as polysomnography because it cannot measure all the biological effects of sleep. The Epworth sleepiness scale uses a simple questionnaire to measure excessive sleepiness during eight situations. If iron stores are low, the second step is to diagnose the cause of the iron deficiency, which will help determine treatment. A test that measures a factor called serum transferrin receptor (TfR) is proving to be very sensitive in identifying iron deficiency in some patients, including the elderly with chronic diseases and possibly pregnant women. When iron deficiency anemia is diagnosed, the next step is to determine the cause of the iron deficiency itself. The following laboratory tests may be helpful in determining causes of restless legs syndrome (RLS) or identifying conditions that rule it out. In addition to other sleep-related leg disorders, many other medical conditions may have features that resemble restless legs syndrome (RLS). Cramps that awaken people during sleep are very common, but they are not part of restless legs syndrome or periodic limb movement disorder. Medical causes of muscle cramping include hypothyroidism, Addison's disease, uremia, hypoglycemia, anemia, and certain medications.
TreatmentTreatment for complaints of sleeplessness and restless legs syndrome focus on efforts to improve sleep and eliminate possible causes of RLS. BackgroundFibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue.
Patients with the condition have a higher-than-average rate of a sleep disorder called periodic limb movement disorder (PLMD). Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. Fibromyalgia patients have been found to have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback.
It is not clear whether these conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have no relationship at all with it.
It is severe, is not caused by excessive work or exercise, and is not relieved by rest or sleep. Multiple chemical sensitivity (MCS) is a term that describes conditions in which certain chemicals cause symptoms similar to CFS or fibromyalgia.
It is often thought to result from "wear and tear" on a joint, although there are other causes, such as congenital defects, trauma, and metabolic disorders. Research is indicating it may improve sleep quality, fatigue symptoms, and fibromyalgia pain. Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, because the pain is not caused by muscle or joint inflammation. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects. Roth is director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit, and clinical professor of psychiatry at the University of Michigan School of Medicine in Ann Arbor. Krystal is director of the Sleep Research and Insomnia Program at Duke University School of Medicine in North Carolina. On the other hand, it is very clear that shift work contributes to insomnia by causing changes in circadian rhythm. It is important for clinicians to understand that while insomnia interacts with other medical disorders, it is not necessarily caused by them. It is now known that sleep loss and sleep fragmentation causes pain and increased inflammatory response.
Hyperarousal overrides these normal sleep systems and causes insomnia, which then interacts with the comorbid medical and psychiatric disorders. Compared to normal sleepers, people who meet insomnia criteria have impaired quality of life. The role of CBT in insomnia is to challenge the dysfunctional beliefs and misconceptions about sleep held by a person with insomnia (Slide 2).2 One of the cornerstones of CBT for insomnia is to stop the patient from focusing too much on the time.
Sleep restriction centers on the belief that sleep continuity improves by limiting the time spent in bed.
They should begin these activities early in the evening so that they are set for sleep at bedtime. Even the intermediate-acting agents, such as estazolam and temazepam, have half-lives long enough to cause risk of residual sedation. National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute, National Institutes of Health. Lieberman: There have been no solid studies to indicate that primary sleep disorders can be treated by treating depression.

Clinicians may look very hard for an underlying psychiatric disorder or for an associated medical problem—even an acute stressor.
Many of these shift workers have dysfunctional sleeping patterns, such as napping during the daytime and adopting a normal sleep-wake cycle on weekends.
Krystal: For some people, you can institute these behavioral changes right away, but their sleep does not improve for several weeks. If you have an elderly loved one with Parkinson’s disease, he or she may be experiencing some of the invisible Parkinson’s symptoms, including difficulty sleeping. If your elderly loved one is suffering from insomnia, eliminating caffeine and alcohol from the diet may help. These attacks can occur very suddenly, causing your loved one to fall asleep while standing, eating, or driving. Family members or your loved one’s Scottsdale Parkinson’s caregiver may begin to pick up on symptoms of sleep apnea if your loved one snores loudly or experiences daytime drowsiness, even after sleeping through the night. The first step in diagnosis is usually to gather information on a person's sleep and personal history.
The device monitors or sleep quality in people suspected of having RLS, PLMD, insomnia, sleep apnea, and other sleep-related conditions.
It is more accurate than a sleep log, however, and very helpful for recording long periods of sleep. Nocturnal leg cramps can be very painful and may cause the person jump out of bed in the middle of the night. This prevents the toes and feet from pointing, which causes calf muscles to contract and cramp. Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep, which may occasionally wake them up.
Patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP), which may produce serious sleep problems and have been strongly linked to symptom severity. Since there has been no clear cause-and-effect relationship established, it may be that fibromyalgia is a result of the effects of pain and stress on the central nervous system, which lead to changes in brain circuitry, rather than a brain disorder itself. Serotonin plays important roles in creating feelings of well-being, adjusting pain levels, and promoting deep sleep. The HAP axis controls important functions, including sleep, stress response, and depression.
As with CFS and fibromyalgia, some experts are uncertain whether MCS is a medical problem or psychologically based condition. While some studies have reported pain relief and improved sleep with osteopathic manipulation, larger controlled studies are needed to clearly identify whether manipulation is an effective treatment. One study found that three different doses of pregabalin -- 300 mg, 450 mg, and 600 mg -- were all effective at improving pain and sleep, and all were well tolerated by patients. The most common side effects with this medication are nausea, dry mouth, constipation, decreased appetite, sleepiness, increased sweating, and agitation. Milnacipran appears to improve fibromyalgia pain and other symptoms, including fatigue, poor sleep, and depression. European studies suggest that it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Any one of these latter symptoms must be present with the sleep-related complaint, and must occur despite adequate opportunity for sleep. Derivation of Research Diagnostic Criteria for Insomnia: Report of an American Academy of Sleep Medicine Workgroup.
Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. One important question is whether insomnia causes alterations in physiology or behavior that might lead to longer-term adverse consequence. The incidence of hypertension increased in those who had difficulty initiating sleep or staying asleep compared with those who did not meet have insomnia. Another problem is that studies of daytime function, quality of life, and associated psychiatric and medical conditions have widely variable measures and methodologies.
Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults.
Sleep complaints predict coronary artery disease mortality in males: a 12-year follow-up study of a middle-aged Swedish population.
Nightly treatment of primary insomnia with eszopiclone for six months: Effect on sleep, quality of life and work limitations.
Patients should not try to catch up on sleep during the weekends, but rather set their own internal clock to consistently go to bed at a certain time and wake up at a certain time.
Exposure to a 150-watt light bulb during a nighttime lavatory visit can cause difficulty sleeping in very susceptible patients.
A warm bath and socks are just two ways that patients can reduce core body temperature to predispose themselves to sleep. As a general rule of thumb, what we have tried to do in our practice is ensure that the patient understands what good sleep hygiene is.
There are some patients who are so afraid that they are not going to be able to sleep that they keep themselves awake. To help ensure you’re able to recognize when Parkinson’s is affecting your loved one’s sleep, Home Care Assistance in Scottsdale discusses four sleep conditions caused by PD.
Often, setting a consistent sleep schedule and promoting sleep hygiene can also help promote healthy and deep sleep. After diagnosis, physicians frequently recommend non-prescription treatments for sleep apnea, including the use of CPAP machine while sleeping. Sleep apnea is a condition in which breathing stops for short periods many times during the night. The patient should record all sleep-related information, including responses to the questions listed above described on a daily basis. Tests to check for an underlying cause of iron deficiency, such as gastrointestinal (digestive tract) bleeding, are particularly important in men, postmenopausal women, and children.
Several conditions can cause these disorders; diabetes is a very common cause of painful peripheral neuropathies. Peripheral neuropathy, a complication of diabetes, can cause cramp-like pain, numbness, or tingling in the legs. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may trigger the disorder, but no one trigger has proven to be a cause of primary fibromyalgia. Health care providers should consider medications as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Those with a significant life crisis, or who are on disability, have a poorer outcome, as determined by improvements in the patients' ability to work, their own feelings about their condition, pain sensation, and levels of disturbed sleep, fatigue, and depression. Do not meditate before going to bed, because it causes some people to wake up in the middle of the night, alert and unable to return to sleep. There have also been reports of problems with the electrical system of the heart in people taking this drug. Finally, the sleep difficulty must occur at least three times per week for at least 1 month.
The night after a tornado, for example, a town population may have a sleep disturbance prevalence as high as 70% to 80%.
Nofzinger and colleagues8 demonstrated increased brain metabolism in the arousal centers in the brain, indicating that insomnia does not result from broken sleep systems but from over-engaged arousal systems (Slide 7).
After that interval, there was a much greater incidence of major depression, anxiety, and alcohol and drug dependence problems in those who had insomnia.
There was a ~40% incidence of hypertension in those with sleep problems (initiating or maintaining sleep) versus a 31% incidence in normal sleepers. These studies show that reported sleepiness, number of naps, and time spent napping all decreased following treatment, while ability to carry out professional activity increased. Usually, hypnotics should be prescribed only if good sleep hygiene principles and cognitive interventions are not sufficient to allow patients to get a good night’s sleep. People without any insomnia at all were asked whether they have difficulty sleeping when they experience stress. Though primary care clinicians may seize upon the potential to use one medication to treat two different problems, the efficacy of using a solitary agent to treat these separate conditions has not been demonstrated. First, if you get them to sleep 8 hours during the day, which is itself an incredible challenge, they still will have difficulty staying awake at work and driving home because they are trying perform these activities in a downside of the circadian rhythm. We use the cognitive interventions first, and then we use pharmacotherapeutic agents for awakening or increased alertness, and to help with sleep. However, before one decides that a patient has insomnia, one should make sure that the patient has adequate opportunity to sleep.
We published data showing that starting a sleep agent with behavioral therapy, with buy-in from the patient, can improve in sleep right away.
In some cases, sleep attacks are caused by the medications used to treat Parkinson’s, so speaking with your loved one’s physician can help your loved one have his or her medications adjusted and reduce or eliminate sleep attacks as soon as possible.
Using an extended-play audio or videotape to record sleep behavior can be very helpful in diagnosing sleep apnea. Other causes include alcoholism, rheumatoid arthritis, systemic lupus erythematosus, amyloidosis, HIV infection, kidney failure, and certain vitamin deficiencies.

Severe symptoms that occur often can cause chronic insomnia and considerable mental distress.
Food and Drug Administration (FDA) banned its sale over the counter because it reportedly caused some serious, although rare, side effects.
Fibromyalgia should be suspected in any person who has muscle and joint pain with no identifiable cause. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the organism that causes this disease. However, the 30% sleep disturbance prevalence does not account for the population suffering from insomnia. Age is the greatest risk factor for insomnia; however, the reason elderly people experience increased risk of insomnia is not due to a breakdown of their sleep systems. However, the fact that the incidence of insomnia is not 100% among patients who have three or four medical disorders indicates that medical disorders themselves are not responsible for causing insomnia. Fava and colleagues7 demonstrated that patients with comorbid insomnia and depression experience a quicker, more effective antidepressant response when treated with a sleep agent and antidepressant combination than when treated with either a sleep agent or antidepressant alone. The results demonstrated that people with insomnia differ from normal sleepers in their vitality, their emotional role, their health, and their physical role.
Similarly, stimulus control ensures that patients restrict their psychological associations with the bed to just sleep and sexual activity. A 4-watt nightlight, for example, might provide light sufficient to prevent injury without interfering with a patient’s ability to go back to sleep. Alcohol makes people sleepy, but it has a short half-life, and as it is metabolized the body produces neurotoxins that are irritants to the central nervous system. It turns out that those people who have more disturbed sleep in stressful circumstances, in age- and sex-matched controls, have an ~11-fold increased risk of developing insomnia in the future. I think both problems must be treated based on their individual symptomatologies, and one cannot be considered secondary to the other, though this was common in the past. However, comorbid insomnia is very different from secondary insomnia, in which a condition or disorder is the primary cause of insomnia.
These shift workers will have worse sleep hygiene, too, because their sleeping environment will be affected by daylight. It can also track whether PLMD occurs in both legs at the same time, and the effect it has on sleep.
For example, in rare cases manipulation of the neck has caused stroke or damage to the large blood vessels in the neck.
While these studies do not prove causality, they show strong association, which is intriguing and worthy of further inquiry. Patients should enhance their sleep environment by reducing ambient noise, keeping the room dark, and having adequate bed covers and sleep surface.
These irritants act as stimulating agents that can overwhelm the initial sense of sedation alcohol causes.
Most of the time, the cause is unknown, although it may arise from spinal injuries or herpes zoster infection. Also, sitting on a aisle during meetings or airplane travel can allow for more leg movement.Changing sleep patterns.
However, most studies are powered to determine whether therapies include sleep and are not powered to find the effects on non-sleep outcomes.
I think the more interesting question is how much of that hyperarousal is due to the insomnia, rather than the cause of insomnia. Second, the temptations not to maintain a regular sleep schedule are greater for shift workers, because, for example, they can attend their children’s t-ball games in the middle of the afternoon.
Specific characteristics of RLS include:"Pulling, searing, drawing, tingling, bubbling, or crawling" beneath the skin, usually in the calf area, causing an irresistible urge to move the legs.
Also, movement does not relieve the discomfort, and the the problem does not worsen at bedtime.Akathisia.
Clinicians may be trained to infer that a patient’s depression causes their insomnia. More than anything else, people on rotating or night shifts need incredible lessons on sleep environment. Therefore, patients may consider changing their sleep patterns if feasible.Avoiding caffeine, alcohol, and nicotine also improves some cases of RLS. Medications from other drug classes (such as sleeping aids and pain relievers) may also be prescribed. However, insomnia may be best treated with cognitive-behavioral therapy and instruction in good sleep hygiene, either alone or in concert with pharmacologic agents.
However, if insomnia is caused by depression, treating depression should, and does, alleviate sleep disruptions. A condition called hypotensive akathisia is caused by failure in the autonomic nervous system.
An uncommon nerve condition, meralgia paresthetica causes numbness, pain, tingling, or burning on the front and side of the thigh.
These may be the first symptoms of RLS in some people.About 4 out of 5 patients with RLS also have semi-rhythmic movements during sleep, a condition called periodic limb movement disorder (PLMD). The condition may be caused by compression of the thigh nerve as it passes through the pelvis.
So far, there is no evidence to support a cause and effect relationship between neuropathy and RLS.Abnormalities of Iron MetabolismIron deficiency, even at a level too mild to cause anemia, has been linked to RLS in some people. Anti-nausea drugs and drugs used to treat schizophrenia and other psychoses can cause akathisia.
Very clearly, use of medications can be helpful, but only after the patient’s opportunity to sleep has been maximized. Some research suggest that RLS in some people may be due to a problem with getting iron into cells that regulate dopamine in the brain. Patients with either CFS or fibromyalgia are more likely to lose jobs, possessions, and support from friends and family than are people suffering from other conditions that cause fatigue. Finally, it is most important to recognize that guaranteeing 8 hours of sleep will still not guarantee shift workers a safe drive home after a night of work.
Up to a quarter of children diagnosed with attention-deficit hyperactivity disorder (ADHD) may also have RLS, sleep apnea, and PLMD. The disorders have much in common, including poor sleep habits, twitching, and the need to get up suddenly and walk about frequently. PLMD is also very common in narcolepsy, a sleep disorder that causes people to fall asleep suddenly and uncontrollably.CausesThe main cause of RLS is unknown. Scientists are researching nervous system problems that may arise in either the spinal cord or the brain. Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.
However, iron tablets can aggravate existing digestive problems such as ulcers and ulcerative colitis.Nausea and vomiting may occur with high doses.
Switching to ferrous gluconate may help some people with severe digestive problems.Black stools are normal when taking iron tablets. Osteoarthritis is a chronic disease of the joint cartilage and bone, once thought to result from "wear and tear" on a joint, although there are other causes such as trauma, and metabolic disorders. A study found that people who walked briskly for 30 minutes, four times a week, improved minor sleep disturbances after 4 months. MedicationsThe American Academy of Sleep Medicine recommends medications for RLS or PLMD only for persons who fit strict diagnostic criteria, and who experience excessive daytime sleepiness as a result of these conditions. Tylenol and Non-Steroidal Anti-Inflammatory DrugsBefore taking stronger medications, people should try over-the-counter pain relievers, such as acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin, Rufen), naproxen (Anaprox, Naprosyn, Aleve), and ketoprofen (Orudis KT, Aktron).Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers, bleeding, and possible heart problems.
In April 2005, the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart-related problems and digestive tract bleeding.Levodopa and Other Dopaminergic DrugsDopaminergic drugs increase the availability of the chemical messenger dopamine in the brain, and are the first-line treatment for severe RLS and PLMD. These drugs significantly reduce the number of limb movements per hour, and improve the subjective quality of sleep.
Adding a drug called entacapone (Comtan) may prolong the duration of action of carbidopa-levodopa therapy, but it can cause nausea.Rebound effect, augmentation, and tolerance can reduce the value of dopaminergic drugs in the treatment of RLS.
They may be helpful for restless legs syndrome (RLS) that disrupts sleep, especially in younger patients. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly, particularly in the first week after taking them.
Shorter-acting benzodiazepines do not appear to pose as high a risk.There are reports of memory loss (so-called traveler's amnesia), sleepwalking, and odd mood states after taking triazolam (Halcion) and other short-acting benzodiazepines. Patients on long-term opiate therapy should also be monitored periodically for sleep apnea, a condition that causes breathing to stop for short periods many times during the night.

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