FitSugar

Trouble Waking Up? Try Sleeptracker Pro

FitSugar — Fri, 03 Oct 2008 13:00:00 -0700

Some of you may have a difficult time falling or staying asleep, but others are the opposite. You hit snoozeland as soon as your head hits the pillow and you could end up sleeping until lunch. If that's the case, you probably have a really tough time waking up, and this little device called the Sleeptracker Pro ($179) may interest you. Just as its name states, it tracks the series of sleep cycles your body experiences throughout the night. Most people will go through four to five full rounds of these 90 to 110 minute cycles, which are comprised of five stages. In Stages 1 and 2, you're lightly sleeping, and Stages 3 and 4, known as Delta Sleep, are when you're in the heaviest sleep. This is when your body has the chance to rebuild itself. Stage 5 is known as REM sleep is when we dream.

As your body undergoes these cycles, the Sleeptracker Pro's sensors can figure out what points during the night you are "almost awake." You set the alarm for a certain window of time, say 6:15 to 6:30 a.m., and the watch gently wakes you at the most optimal moment when you're most alert. This device may be great if you tend to be coma-like each morning. The only downside is that wearing a bulky wrist watch like this may be annoying and it'll keep you up all night. If you're a deep sleeper though, you probably won't even notice it. What do you think of the Sleeptacker Pro? Is this a helpful gadget or a waste of money?

Apparently Dr. Phil is a huge fan. To hear what he had to say read more.

Can't Fall Asleep? Try These Tips

FitSugar — Thu, 16 Jul 2009 13:30:23 -0700

It's so frustrating to be lying in bed, knowing you need your beauty rest and you can't for the life of you fall asleep. So the next time you find yourself tossing and turning, try these helpful tips from fellow FitSugar readers.

"In desperate times, I do the relaxation technique I learned in yoga when you breath and focus on relaxing each little part of your body. I start with my forehead and work down. By the time I reach my hips I'm usually out." - jadfair
"Sometimes it helps me to listen to audiobooks, especially those that I've already read/heard before. It helps me block out all of the swirling end of the day thoughts and just go to sleep." - tlsgirl
Fitsugar reader laellavita says, "If I don't work out, I just feel too restless to sleep. My workout is never at night, but expelling all that energy in one hour always makes me sleep better than a whole stressful day ever does."

For other tips on getting some shuteye, read more.

"I read every night before bed, and I drink a mug of Yogi's Bedtime tea. If I still have trouble, I either start counting backwards from 500, or I've recently discovered an even happier and more peaceful method - making a mental gratitude list based on things that happened that day. I'm usually asleep by the time I reach the third one because it's so pleasant and relaxing." - scorpstar77
Kimpossible suggests listening to "soothing music such as Enya or Enigma." She also says, "If something is really strong on my mind then I write in my journal and get the thoughts out so I can clear my head in order to get to sleep."
"I try to make sure the bedroom is dark. And I tend to get too hot when I sleep, so I try to make sure my fan is on." - Spectra
"I suffered from really bad sleeplessness until I went to my doctor and she told me about 'sleep hygiene.' I got rid of the TV, the books, the alarm clock with the light up numbers, etc. - anything that could potentially keep me awake. Now I just use the bed for sleep and . . . I also take a bath, drink some tea, and turn the computer off about one and a half hours before bedtime." - cjstraus
"Lavender linen spray works for me." - sharshar
Leila07 says, "Reading a book has always worked for me. In college I used to read my history books. I would only have to read a paragraph and then I would be out! Oh and limiting my caffeine intake after lunchtime."
"I wake up at 5 a.m. everyday, it makes going to bed a whole lot easier at night." - kclulu

Insomnia

FitSugar — Wed, 08 Oct 2008 17:35:00 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Sedative Hypnotic Drug Warnings

In March 2007, the FDA ordered stronger warning labels on sedative hypnotic drugs. These medications include benzodiazepine and non-benzodiazepine drugs, such as zolpidem (Ambien), eszopiclone (Lunesta), ramelteon (Rozerem), and triazolam (Halcion). The FDA warned that these drugs may be associated with:

Severe allergic reactions (anaphylaxis) and severe facial swelling (angioedema), which can occur even the first time a drug is taken
Complex sleep-related behaviors, such as sleep driving, making phone calls, and preparing and eating food while asleep

Patients who take sleeping pills should be sure to follow the directions. These include not combining sleeping pills with alcohol or other drugs and not taking more than the prescribed dose. All patients prescribed sedative hypnotic drugs should receive a patient medication guide that describes the potential risks, and precautions to reduce these risks.

Behavioral and Psychological Therapies

Behavioral and psychological treatments, such as cognitive behavioral therapy and relaxation techniques, are effective approaches for insomnia and can produce long-lasting benefits, according to a 2006 study in Sleep.
Behavioral interventions help over 80% of children who try them, indicates another 2006 Sleep study.

Complementary and Alternative Medicine

More than 1.6 million adults use complementary and alternative medicine to treat their insomnia, according to results of a national survey published in the Archives of Internal Medicine. About half of patients who tried herbal medicine or relaxation techniques found that these approaches helped improve their sleep.
In 2006, the American Academy of Sleep Medicine issued a position statement advising that there is only limited scientific evidence that herbal remedies are effective sleep aids.

Insomnia and Mood Disorders

Chronic insomnia can increase the risk of developing depression and anxiety, according to a 2007 study in Sleep. Research also indicates that insomnia and daytime sleepiness can cause and worsen depression and anxiety in children as well as adults.

Introduction

Insomnia comes from the Latin words for “no sleep.” Insomnia is characterized by:

Difficulty falling asleep
Difficulty staying asleep
Waking up too early in the morning

Some experts believe that poor quality (“non-restorative”) sleep is also related to insomnia. Insomnia can cause daytime fatigue, irritability, and impaired performance. About 60 million Americans each year suffer from insomnia.

Insomnia may be primary or secondary:

Primary insomnia means that the inability to sleep is not caused by other health problems.
Secondary insomnia is due to other health conditions that interfere with sleep. Some experts prefer the term “co-morbid insomnia.”

Insomnia, usually temporary, is often categorized by how long it lasts:

Transient insomnia lasts for a few days.
Short-term insomnia lasts for no more than 3 weeks.
Chronic insomnia occurs at least 3 nights per week for 1 month or longer.

Insomnia may also be defined in terms of inability to sleep at conventional times. The following examples are referred to as circadian rhythm disorders:

Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term for a circadian clock that runs late but reliably. People who have this condition (usually adolescents) fall asleep very late at night or in early morning hours, but then sleep normally.
Advanced Sleep-Phase Syndrome. This syndrome tends to develop in older people. It produces excessive sleepiness in the morning and undesired awakening early (3 - 5 a.m.) in the morning.

In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. (Infants may sleep as many as 16 hours a day.)

The daily cycle of life, which includes sleeping and waking, is called a circadian (meaning "about a day") rhythm, commonly referred to as the biologic clock. Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (If confined to windowless apartments, with no clocks or other time cues, sleeping and waking as their bodies dictate, humans typically live on slightly longer than 24-hour cycles.) It usually takes the following daily patterns:

Humans are designed for daytime activity and nighttime rest.
Additionally, there is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms intermesh with other factors that may interfere or change individual patterns:

The fraction-of-a-second-firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus (SCN).
This nerve cluster takes its name from its location, which is just above (supra) the optic chiasm, which is a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland (named so because it resembles a pine-cone) to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.

The REM/NREM Cycle. The cycle between quiet (nonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of nonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the nonREM/REM cycle repeats.
With each cycle, nonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Causes of Short-Term or Transient Insomnia

A reaction to change or stress is one of the most common causes of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder.

The trigger could be a major or traumatic event such as:

An acute illness
Injury or surgery
The loss of a loved one
Job loss

Temporary insomnia could also develop after a relatively minor event, including:

Extremes in weather
An exam
Traveling
Trouble at work

In most cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes used to the new situation. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary and some people may not experience insomnia at all, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.

Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This insomnia is usually temporary.

During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.)
During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns.
Menopause. Insomnia can be a major problem in the first phases of menopause, when hormones are fluctuating intensely. Insomnia during this period may be due to different factors that occur. In some women, hot flashes, sweating, and a sense of anxiety can awaken women suddenly and frequently at night. Insomnia may also be caused by psychologic distress provoked by this life passage. In many cases, insomnia is temporary. However, a 2006 study found that hot flashes in perimenopausal and postmenopausal women are strongly associated with chronic insomnia (sleep problems lasting more than 1 month). Treating hot flashes may help resolve chronic insomnia.

Air travel across time zones often causes insomnia. After long plane trips, 1 day of adjustment is usually needed for each time zone crossed. Traveling west to earlier times seems to be less traumatic than going east to a later time because it is easier to lengthen a circadian phase than to shorten it.

In one study, 20% of adults reported that light, noise, and uncomfortable temperatures caused their sleeplessness. Depending on the time of day, too much or too little light can disrupt sleep.

Excessive Light at Night. A person's biologic circadian clock is triggered by sunlight, and very bright artificial light maintains wakefulness. One study indicated that even dim artificial light might disrupt sleep.
Insufficient Light During the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances. One study suggested that when a person is exposed to bright daylight, melatonin levels increase in response to darkness at night, which aids sleep.

Caffeine. Caffeine is a stimulant, which can interfere with falling asleep.

Nicotine. Nicotine is also a stimulant, but quitting smoking itself can lead to transient insomnia. In fact, it has been suggested that if sleeping could be improved during withdrawal from smoking, perhaps it would be easier to quit smoking.

Partner's Sleep Habits. In one survey, 17% of women and 5% of men reported that their partner's sleep habits impaired their own sleep. Snoring can certainly be a factor in a partner's insomnia.

Medications. Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine. People who suspect their medications are causing them to lose sleep should check with their doctors or pharmacists.

Causes of Chronic Insomnia

Sleep problems seem to run in families. About 35% of people with insomnia have a family history of insomnia, with the mother being the most commonly affected family member. Still, because so many factors are involved in insomnia, a genetic component is difficult to define.

Abnormal levels of certain brain chemicals have been observed in some people with chronic insomnia.

Melatonin. Low levels of melatonin, the hormone secreted by the pineal gland, have sometimes been observed in chronic insomnia.
Stress Hormones. Some studies have reported persistently high levels of stress hormones, particularly cortisol, in people with chronic insomnia, particularly insomnia related to aging and psychiatric disorders. High levels of cortisol reduce REM sleep. However, a 2003 study of people with chronic insomnia reported that cortisol levels were high only when their sleep was of poor quality. When they slept well, levels were lower. This study and other research suggests that high levels of stress hormones are caused by poor sleep, rather than being the cause.
Growth Hormone. Normal aging is associated with a blunting of regular, cyclical surges of growth hormone, which may affect sleep as one gets older. This hormone, which is normally secreted in the late night, is associated not only with growth but with deep, slow-wave sleep. (Older people generally have less slow-wave sleep.)

Chronic insomnia occurs in people who have persistently high levels of stress hormones and a shift in the levels of certain immune factors. Studies indicate that people with chronic insomnia have higher levels of interleukin-6 and tumor necrosis factor during the day, but lower levels at night. These immune factors, called cytokines, cause symptoms of fatigue. Levels are usually higher at night in people with healthy sleep. The implications of these immune changes in people with insomnia are not known.

Many cases of chronic insomnia cases have a psychologic or psychiatric basis. The disorders that most often cause insomnia are:

Anxiety.
Depression. Sleep abnormalities are an integral part of depressive disorders, with more than 90% of depressed patients experiencing insomnia.
Bipolar disorder.

Insomnia may also cause emotional problems. It is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source.

In many cases, it is unclear if chronic insomnia is a symptom of some physical or psychological condition or if it is a primary disorder of its own. In most instances, a mix of psychological and physical conditions causes the insomnia.

Psychophysiologic insomnia occurs when:

An episode of transient insomnia disrupts the person's circadian rhythm.
The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges.
Over time, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over the inability to sleep, the consequences of sleep loss, and the lack of mental control. All attempts to sleep fail.
Eventually excessive worry about sleep loss becomes persistent and provides an automatic nightly trigger for anxiety and arousal. Unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia becomes a self-fulfilling prophecy that can persist indefinitely.

Sometimes anxiety and the inability to sleep dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready.

In one survey, 22% of adults reported that health conditions, pain, or discomfort impaired their sleep. These conditions can include:

Nightly Leg Problems. Leg disorders that occur at night, such as restless legs syndrome or leg cramps, are of special note. They are very common and an important cause of insomnia, particularly in older people.

Medical Problems. Among the many medical problems that can cause chronic insomnia are allergies, arthritis, cancer, fibromyalgia, heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, emphysema, rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention deficit hyperactivity disorder.

Medications. Among the many medications that can cause insomnia are antidepressants (fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists.

An estimated 10 -15% of chronic insomnia cases result from substance abuse, especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner, for most people, pose little danger of alcoholism and may help reduce stress and initiate sleep. Excess alcohol or alcohol used to promote sleep, however, tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery.

Shift work throws off the body's circadian rhythm and may lead to chronic insomnia.

Risk Factors

Studies estimate that between 25 - 33% of adults experience some insomnia each year. In spite of this widespread problem, however, studies suggest that only about 30% of American adults who visit their doctor ever discuss sleep problems. And, doctors seem rarely to ask patients about their sleep habits or problems.

A 2003 study suggested that there were seven significant factors that predicted high risk for insomnia:

Being older
Having conflicts with relatives
Being overworked on the job
Being overworked at home
Having a sick relative
Having low social status
Having a psychiatric or psychologic problem

Stressful events do not cause insomnia in everyone. However, negative thoughts and attitudes toward events can be significant factors in insomnia. In one study, for example, the number of stressful events did not differ between good and poor sleepers. Those with insomnia, however, tended to experience these stressful events more intensively than the healthy sleepers.

In another study, patients with insomnia and good sleepers were asked to record their pre-sleep images using a handheld counter. People with insomnia not only reported fewer images, but their images also tended to be more unpleasant than those of good sleepers. More of the images in people with insomnia were related to intimate relationships and to sleep itself. The images of sleepers were more likely to be random and disconnected.

Studies report that the strongest risk factors for insomnia are psychiatric problems (particularly depression) and physical complaints (such as headaches and chronic pain) that have no identifiable cause (called somatic symptoms). About 90% of people with depression have insomnia. A study presented at the 2005 Associated Professional Sleep Societies meeting indicated that insomnia may contribute to, and prolong, depression. Researchers analyzed data from over 1,800 adults age 65 years and older. Compared with depressed patients who did not have sleep problems, depressed patients with insomnia were 11 times more likely to remain depressed after 6 months and 17 times more likely to still be depressed after a year. The researchers suggested that treating insomnia may help patients recover from depression more quickly.

Overall, insomnia is more common in women than men, although men are not immune from insomnia. Sleep efficiency deteriorates equally in men and women as they get older.

Men. One major study suggested that as men age from 16 - 50, they lose about 80% of their deep sleep. During that period, light sleep increases and REM sleep remains unchanged. (The study did not use women as subjects, and there is some evidence to suggest they are not as affected.) After age 44, REM and total sleep diminish and awakenings increase.

Women. It is not clear why women suffer more from insomnia than men. Some theories include:

In women, a number of hormonal events can disturb sleep, including premenstrual syndrome, menstruation, pregnancy, and menopause. All these conditions are short-term, however, and in most cases the wakefulness associated with them is temporary and can be eliminated with sleep hygiene and time.
After childbirth, most women develop a high sensitivity to the sounds of their children, which causes them to wake easily. Women who have had children sleep less efficiently than women who have not had children. It is possible that many women never unlearn this sensitivity and continue to wake easily long after the children have grown.
Women are at higher risk than men are for depression and anxiety, which are known risk factors for insomnia. In fact, some researchers believe that this is a main reason for the gender differences in insomnia.

After menopause, women are susceptible to the same environmental and biologic causes of insomnia as men. In fact, older women who are not bothered by sleeplessness tend to have longer and better sleep than noninsomniac men their own age.

As people grow older, sleep patterns change. In a major 2003 survey, a third of older adults reported that they woke up frequently during the night. About a quarter of participants reported waking up too early and being unable to go back to sleep. In the same study, 33% of adults age 55 - 64 reported waking up feeling unrefreshed.

Although age itself does not appear to be a risk factor for insomnia, a number of factors may interfere with sleep as one gets older:

Elderly people are more likely to be sedentary than younger adults.
Medical conditions that cause pain or nighttime distress are common in the elderly and pose a high risk for insomnia. They include arthritis, gastrointestinal distress, frequent urination, lung disease, and heart conditions.
Neurologic diseases in the elderly, such as restless legs syndrome, Parkinson's, Alzheimer's, and other forms of dementia can cause nighttime disorientation, confused wandering, and delirium.
Older people often take a number of prescription drugs whose side effects include insomnia.
The elderly are prone to grief, depression, and anxiety, emotional factors that can cause sleeplessness. One study of healthy older adults found that psychologic factors, such as anxiety and depression, were more likely to cause insomnia than illness, medications, or living conditions.
Melatonin levels are generally lower in older people. Some research suggests, however, that elderly people have lower levels simply because they stay mostly indoors and do not receive adequate sunlight.

Lack of sleep at night can lead to excessive sleepiness during the day. A 2006 study reported the following risk factors for excessive daytime sleepiness among the elderly:

Male gender
Sleep apnea or other sleep breathing disorders
Nighttime chest wheezing
Poor sleep quality
Longer time spent in REM sleep
More than 3 episodes of nighttime pain within a week
Medications that cause sleepiness

Sleep loss among the elderly is not inevitable. While older people are more susceptible to many conditions that can cause insomnia, treatments and a healthy lifestyle, particularly regular exercises, are as useful in providing relief to the elderly as to the young. And, a number of studies have found no significant increase in insomnia in older healthy adults.

Shift workers are at considerable risk for insomnia. In a major survey, 65% of shift workers reported one or more symptoms of insomnia at least a few nights a week. Workers over age 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night-shift workers also have a high rate of sleeplessness. One study found that 53% of night-shift workers fall asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher risk for health problems in general.) A Japanese study reporting on different aspects of insomnia found that excessive computer work was associated with all forms of insomnia. People who were over-involved with their work tended to have trouble falling asleep, and they tended to awaken earlier than average.

Among the many conditions that pose a high risk for insomnia are:

Frequent travel, particularly crossing time lines
Post-traumatic stress syndrome
Brain injuries
Many chronic medical conditions ranging from seemingly minor ones, such as tinnitus (ringing in the ears) to major conditions, such as respiratory problems, heart disease, or being on dialysis

Prognosis

A 2002 study of sleeping habits in over 1 million people reported that people who slept 7 hours a night lived the longest. People who slept more than 8 hours or less than 6 hours, or who took sleeping pills, had lower survival rates.

Insomnia is not life-threatening, except in very rare cases, such as in those who have the genetic disorder called fatal familial insomnia. This rare degenerative brain disease develops in late adulthood.

Sleepiness causes as many as 200,000 automobile accidents in the U.S. and 1,500 deaths from such accidents. Studies indicate that drowsy driving is as risky as drunk driving. In a major 2003 survey, 60% of young adults reported driving while drowsy, and 20% dosed off while driving. In the study, 1% of adults who dozed off reported having an accident because of it. (One study strongly suggested that it is habitual sleepiness, however, and not just being sleepy at the time of an accident that places people at higher risk.)

Surveys show that people with severe insomnia have a quality of life that is almost as poor as those who have chronic conditions, such as heart failure. In addition to more daytime sleepiness, people with insomnia complain of more attention and memory problems compared to good sleepers.

Insomnia can also lead to irritability, mistakes at work, and poorer relationships.

Effect on Thinking and Performance. Studies suggest that insomnia makes it harder to concentrate and perform tasks.

Reduced concentration. Deep sleep deprivation impairs the brain's ability to process information.
Impaired task performance. One study reported that missing only 2 - 3 hours of sleep every night for a week significantly impaired performance and mood. An Australian study reported that 17 hours of sleep deprivation causes impaired performance levels comparable to those found in people who have blood alcohol levels indicating intoxication.
Memory problems. Whether insomnia significantly impairs learning is unclear. Some studies have reported problems in memorization, although others have found no differences in test scores between people with temporary sleep loss and those with full sleep.

Insomnia and Depression. Although stress and depression are major causes of insomnia, insomnia may also increase the activity of the hormones and pathways in the brain that can produce emotional problems. Research indicates that chronic insomnia can increase the risk of developing depression and anxiety. Some investigators are exploring the possibility of preventing psychiatric disorders by early recognition and treatment of insomnia.

Even modest alterations in waking and sleeping patterns can have significant effects on a person's mood. In both children and adults, the combination of insomnia and daytime sleepiness can produce more severe depression than either condition alone.

Effects on the Heart. Although there has been some concern that insomnia may increase the risk for heart problems, little evidence has supported any significant dangers. One study reported signs of heart and nervous system activity in people with chronic insomnia that might place such individuals at risk for coronary heart disease. If it exists, however, this increased danger is very modest compared with other risk factors for heart disease. Yet another report suggested that sleep complaints in elderly people without coronary artery disease predicted a first heart attack. Sleep disorders in such cases may have been a marker for depression, however, which is a risk factor for heart attacks in elderly people.

Effects on Weight. Lack of sleep can cause weight gain and obesity. In a 16-year study of over 68,000 women, those who slept no more than 5 hours a night were 32% more likely to gain at least 33 pounds, and those who slept 6 hours had a 12% increased risk of weight gain compared to women who slept at least 7 hours a night.

Effects on the Immune System. A 2003 study reported significant differences in immune factors among sleepers, with higher levels of certain infection-fighters observed in good sleepers than in people with chronic insomnia. The significance of these findings is still unknown, however.

Diagnosis

Diagnosing sleep disturbance and its cause is the most important step in restoring healthy sleep. However, there is little agreement, even among experts, on the best methods for effectively assessing a patient's insomnia.

A major difficulty in diagnosing this problem is its subjective nature. One study showed that there was no difference in sleep behaviors between people who said they were insomniacs and people who said they weren't. People who believe they have insomnia may have actually had frequent brief awakenings during sleep that they perceive as being continuously awake.

A number of questionnaires are available for determining whether a patient has insomnia or other sleep disorders. For example, the doctor may ask:

How would you describe your sleep problem?
How long have you had the sleep problem?
How long does it take to fall asleep?
How many times a week does it occur?
How restful is sleep?
Do you have trouble falling asleep or do you wake up too early?
What is the sleep environment like (Noisy? Not dark enough?)?
How does insomnia affect daytime functioning?
What medications do you take? (Include herbs, alcohol, and over-the-counter or prescription drugs.)
Are you taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
What stresses or emotional factors may be present?
Have you experienced any significant life changes?
Do you snore or gasp during sleep (an indication of sleep apnea)?
Do you have leg problems (cramps, twitching, crawling feelings)?
If there is a bed partner? Is this person's behavior distressing or disturbing?
Are you a shift worker?

Sleep Diary. If the patient cannot answer these questions, keeping a sleep diary is a helpful diagnostic tool. Every day for 2 weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. A bed partner can help by adding their observations of the patient's sleep behavior.

The Epworth Sleepiness Scale. The Epworth Sleepiness Scale (ESS) uses a simple questionnaire to measure excessive sleepiness during eight situations.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (e.g., a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

Multiple Sleep Latency Test. The multiple sleep latency test (MSLT) uses a machine to measure the time it takes to fall asleep while lying in a quiet room during the day:

The patient takes four or five scheduled naps 2 hours apart.
People with healthy sleep habits fall asleep in about 10 - 20 minutes.
The test can detect changes in sleepiness associated with sleep deprivation in patients with insomnia.

It has limitations, however, and does not take into consideration any situations that may affect the patients' mental state and the actual home situation. The test is used mainly after other sleep disorders have been ruled out and the doctor is uncertain whether or not insomnia is a correct diagnosis.

If unexplained insomnia persists after treatment or there is evidence of a primary sleep disorder, such as sleep apnea or narcolepsy, the doctor may recommend a sleep specialist or a sleep disorders center. Centers are accredited by the American Academy of Sleep Medicine. Patients should investigate centers carefully, to be sure that they offer full sleep studies.

Among the signs that may indicate a need for a sleep disorders center are:

Insomnia due to psychologic disorders
Sleeping problems due to substance abuse
Snoring and sudden awakening with gasping for breath (possible sleep apnea)
Severe restless legs syndrome
Persistent daytime sleepiness
Sudden episodes of falling asleep during the day (possible narcolepsy)

At most sleep disorders centers, patients undergo an in-depth analysis, usually supervised by a multidisciplinary team of consultants who can provide both physical and psychiatric evaluations.

Treatment

The American Academy of Sleep Medicine (AASM) recommends cognitive behavioral therapy (CBT) and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.

Experts agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment. A 2006 study reported that behavioral interventions can provide sustained improvement in over 80% of children with insomnia.

Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia in many cases and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia are long-lasting.

Although medications are equally effective for helping people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work in all age groups, including children and elderly patients.

Behavioral methods include:

Stimulus control
Cognitive behavioral therapy
Progressive muscle relaxation
Paradoxical intention
Biofeedback
Sleep restriction
Imagery tasks

Studies have reported that between 70 - 80% of patients who are treated with non-drug methods experience improved sleep with an average treatment duration of only 5 hours over a 4-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Proper sleep hygiene is the first step and should accompany any behavioral method. A number of behavioral approaches are available, but all have the same basic goals:

To reduce the time it takes to go to sleep to below 30 minutes
Reduce wake-up periods during the night

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

Go to bed only when ready to sleep or for sex.
If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
Maintain a regular wake-up time no matter how few hours you actually sleep.
Avoid naps.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. A 2004 study of young and middle-aged adults suggested that CBT is more effective than medication in treating chronic insomnia, and should be considered as a first-line intervention. Adding medication to CBT did not provide additional benefit. In a 2006 study of older adults, CBT worked better than zopiclone (Imovane) in managing chronic insomnia. [Zopiclone is a European sleep medication that is similar to the American drug eszopiclone (Lunesta).] Compared to zopiclone or placebo, CBT helped patients spend less time awake at night. The benefits of 6 weeks of weekly CBT sessions lasted for 6 months.

Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:

Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, then repeat with the other foot.
Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and takes it to the extreme. The first step is to make a plan to take such a paradoxical approach to insomnia.

Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective, but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In a 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first 2 months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed.

The first step is to calculate a person's sleep efficiency number:

Keep a sleep diary for 14 days. Calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours spent in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of 5 hours out of 7 hours spent in bed then the result is .714, and the sleep efficiency percentage is 71%.)
The patient's goal is to achieve sleep efficiencies of between 85 - 90%, which means only 10 - 15% of the time is spent staying awake in bed. (Sleep efficiency in older people normally falls between 75 - 85%.)

To achieve this goal, the patient takes the following actions:

Begin by going to bed 15 minutes later than usual the first week.
If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below 5 hours.
Once efficiency reaches 90% or more, begin to go to bed 15 minutes earlier each week.

Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just 8 weeks, and studies suggest that it is significantly more successful than relaxation techniques.

Imagery Tasks. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control). These images distracted them and allowed them to fall asleep faster. In support of this approach, another study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.

Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
Avoid naps, especially in the evening.
Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
Keep the bedroom relatively cool and well ventilated.
Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.)
Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
Avoid caffeine in the hours before sleep.
If one is still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.

Exercise may be one of the best ways to promote healthy sleep. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance.

The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. The use of a special box that gives off very bright fluorescent light (over 4,000 lux) for about 30 minutes each day may be helpful.

The following people might benefit from light therapy:

Shift workers. Light therapy should be maximized during hours they are at work and minimized when they need to sleep.
Frequent travelers. Light therapy may be useful for adjusting to new time zones and reducing jet lag.
Nursing home patients.
People with delayed sleep-phase syndrome. These people have a natural tendency to fall asleep very late at night or in early morning hours, but then sleep normally.

Patients should check with their doctors before using light therapy. The following people should avoid light therapy or use it only under a doctor's direction:

Anyone with eyes or skin that are highly sensitive to light
Anyone taking medications that increase the risk for photosensitivity
People with bipolar disorder

Timing of the therapy depends on the type of insomnia or sleep schedule of the individual. For example, in people who cannot get to sleep at night, light therapy in the morning and restricting bright light at night may be helpful. People who wake up early in the morning may benefit from light therapy performed in the evening, although a 2002 study reported that it had no effect in this group. Some light boxes have dawn/dusk simulators that help determine the correct brightness.

Medications

According to a major 2003 survey, about 20% of American older adults use some form of sleep aid, including prescription or over-the-counter drugs or alcohol. Furthermore, 15% use such aids every night.

However, while behavioral or psychologic techniques can actually cure insomnia, prolonged use of sleeping pills can only result in dependency.

In general, the following precautions are important:

Start with non-prescription medication.
Drugs used specifically for improving sleeping are called sedative hypnotics. These drugs include benzodiazepines and non-benzodiazepines. Until recently benzodiazepines were most commonly prescribed, but newer non-benzodiazepines may be better tolerated and have less risk of dependency. These medicines, however, may be associated with potentially severe allergic reactions, such as anaphylaxis and facial swelling (angioedema). These medicines may also cause hazardous behaviors, such as driving, making phone calls, or eating while asleep. If you need to take one of these prescription drugs, start with as low a dose as possible.
For adults over age 60 years, studies suggest that the risks of sedative hypnotics may far outweigh their benefits.
As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than 2 - 4 days a week.
If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.
Medication should be withdrawn gradually, and the patient should be aware of the possibility of rebound insomnia after stopping medication.
Alcohol intensifies the side effects of all sleeping medication and should be avoided.
If chronic insomnia is a companion to depression or anxiety, treating these problems first may be the best approach.

Brands with Antihistamines. Many over-the-counter sleeping medications use antihistamines, which cause drowsiness. Diphenhydramine is the most common antihistamine used non-prescription sleep aids. Some drugs contain diphenhydramine alone (Nytol, Sleep-Eez, Sominex), while others contain combinations of diphenhydramine with pain relievers (Anacin P.M., Excedrin P.M., Tylenol P.M.). Doxylamine (Unison) is another antihistamine used in sleep medications. Certain antihistamines indicated only for allergies, such as chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), or hydroxyzine (Atarax or Vistaril) may also be used as mild sleep-inducers.

Unfortunately, most of these drugs leave patients feeling drowsy the next day and may not be very effective in providing restful sleep. Side effects include:

Daytime sleepiness
Dizziness
Drunken movements
Blurred vision
Dry mouth and throat

In general, these drugs should be avoided by people with angina, heart arrhythmias, glaucoma, or problems urinating. They should not be used at the same time as medications that prevent nausea or motion sickness. Some non-prescription sleeping aids, such as those containing doxylamine, should also be avoided by patients with chronic lung disease.

Common Pain Relievers. When sleeplessness is caused by minor pain, simply taking acetaminophen (Tylenol) or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin), can be very helpful without causing any daytime sleepiness. The extra "P.M." antihistamine found in combination products is simply an extra, needless chemical in these situations.

Benzodiazepines, also referred to as benzodiazepine receptor agonists (BzRAs), were once the most commonly prescribed sedative hypnotics. Originally developed in the 1960s to treat anxiety, these drugs nonselectively target receptor sites in the brain that modulate the effects of the neurotransmitter gamma-aminobutyric acid (GABA).

Brands. Commonly prescribed benzodiazepines:

Long-acting benzodiazepines include flurazepam (Dalmane) and clonazepam (Klonopin), quazepam (Doral).
Medium- to short-acting benzodiazepines include triazolam (Halcion), lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), oxazepam (Serax), prazepam (Centrax), estazolam (ProSom), and flunitrazepam (Rohypnol). Short-acting benzodiazepines may be useful for air travelers who want to reduce the effects of jet lag.

Side Effects. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. They should not take long-acting forms.

Side effects may differ depending on whether the benzodiazepine is long- or shorting acting. They include:

Severe allergic reactions, including facial swelling, can occur even with the first use of a benzodiazepine drug.
Respiratory problems may occur with overuse or in people with pre-existing respiratory illness
The drugs may increase depression, a common co-condition in many people with insomnia.
Respiratory depression may occur with overuse or with people with pre-existing respiratory illness.
Long-acting drugs have a very high rate of residual daytime drowsiness compared to other types of sleeping pills. 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.
Memory loss (so-called traveler's amnesia), sleepwalking, sleep driving, eating while asleep and other odd mood states may occur. These effects are enhanced by alcohol.
Incontinence. In one study, 33% of patients experienced incontinence at least twice a week. The risk is highest in the elderly and with older, long-acting drugs.
Because these drugs cross the placenta and enter breast milk, pregnant women or nursing mothers should not use them. Benzodiazepine use in the first trimester of pregnancy may be associated with the development of cleft lip in newborns.
In rare cases, overdoses have been fatal.

Interactions. Benzodiazepines are potentially dangerous when combined with alcohol. Some medications, like the ulcer medication cimetidine, can slow the metabolism of the benzodiazepine.

Withdrawal Symptoms. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1 - 3 weeks after stopping the drug and may include:

Gastrointestinal distress
Sweating
Disturbed heart rhythm
In severe cases, patients might hallucinate or experience seizures, even a week or more after the drug has been stopped.

Rebound Insomnia. Rebound insomnia, which often occurs after withdrawal, typically includes 1 - 2 nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases, patients may experience the return of the original severe insomnia. The chances for rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.

Newer short-acting non-benzodiazepines can induce sleep with fewer side effects than the benzodiazepines. Both benzodiazepine and non-benzodiazepine sedative hypnotics act on GABA-A receptor sites in the brain, but non-benzodiazepines are more specific in the subunits they target. Developed in the late 1980s, these drugs are increasingly prescribed and are becoming the hypnotics of choice for many doctors.

Brands and Benefits. Non-benzodiazepine hypnotics currently approved in the United States are zolpidem (Ambien, Ambien CR), zaleplon (Sonata), eszopiclone (Lunesta), and ramelteon (Rozerem).

Zolpidem (Ambien, generic) is one of the most commonly prescribed drugs for insomnia. It lasts longer than zaleplon. Patients should not take it unless they plan on getting at least 7 - 8 hours of sleep. The recommended dose is 10 mg/day for adults, although elderly patients may be prescribed half that dose. A 2002 study suggested that the drug might be used on an as-needed basis, with up to 5 tablets taken a week. After 3 weeks, two-thirds of the patients taking zolpidem this way were able to reduce their tablet intake by more than 25% without losing improvements in sleep. Ambien CR, an extended-release form, received approval from the Food and Drug Administration (FDA) in late 2005. It is the first extended-release prescription medicine for insomnia. The medicine is delivered in two steps. The first layer dissolves quickly, allowing the patient to fall asleep. The second layer helps the patient stay asleep.
Zaleplon (Sonata) is the shortest-acting hypnotic available. Because it is rapidly eliminated from the body it may be best for people who have difficulty falling asleep, not those who wake up often throughout the night. The drug takes effect within 30 minutes and may be taken at bedtime or later as long as the patient can sleep for at least 4 hours. The recommended dose is 5 - 10 mg/day. The drug is usually taken for 7 - 10 days.
Eszopiclone (Lunesta) is a newer, non-benzodiazepine hypnotic approved by the FDA in 2004. It may help improve both sleep maintenance and daytime alertness. Eszopiclone is related to zopiclone (Imovane), which has been used for many years in Europe. Unlike other sleep medications, eszopiclone can be taken on a long-term basis. In clinical trials, patients used eszopiclone for up to 6 months. Recommended doses are 2 - 3 mg/day for adults and 2 mg/day for elderly patients. Patients whose main problem is falling asleep may need only 1 mg/day.
Ramelteon (Rozerem) was approved by the FDA in 2005. Ramelteon is a novel non-benzodiazepine hypnotic. Unlike most sleep drugs, which target the gamma-aminobutyric acid (GABA) receptors, ramelteon targets the MT1 and MT2 receptors. Ramelteon does not cause dependence and is the first sleep drug not designated as a controlled substance.

These drugs can be particularly helpful for preventing jet lag (but zolpidem should not be used on flights less than 7 - 8 hours). They also may be helpful for people who also have accompanying mood disorders, such as depression or post-traumatic stress disorder. Because they are short-acting, zaleplon and zolpidem may pose fewer risks for falls and memory loss in elderly patients. In general, these drugs are recommended for short-term use (7 - 10 days) and treatment should not exceed 4 weeks. No studies have yet confirmed safety for longer-term use.

Side Effects. All of these drugs have fewer morning side effects than the benzodiazepines, including morning sedation and memory loss (although they can occur to some degree). Zolpidem’s (Ambien) record of adverse effects is similar to that of triazolam (Halcion), the short-acting benzodiazepine. Zaleplon (Sonata) and Ramelteon (Rozerem) appear to have less severe morning side effects. When patients first start taking any of these drugs, they should use caution during morning activities until they are sure how the drug affects them.

General side effects are mild but may include:

Drowsiness
Dizziness
Fatigue
Headache
Unpleasant taste
Diarrhea

Rarer side effects may include sleepwalking and hallucinations. In 2006, reports emerged of zolpidem (Ambien) causing sleepwalking and, even more bizarrely, sleep-driving. Most of these cases likely were due to patients using zolpidem along with alcohol or other drugs or taking more than the recommended dose. However, in March 2007, the FDA ordered stronger warning labels for zolpidem and all other non-benzodiazepine drugs. The new labels warn that that these drugs can cause sleep-related behavior, including sleep-driving, making phone calls, and preparing and eating food while asleep. In addition, severe allergic reactions (anaphylaxis) and facial swelling (angioedema) can occur even the first time one of these drugs is taken.

Anyone who receives a prescription for these medicines will also get a patient medication guide explaining the risks of the drugs and the precautions to take. Talk to your doctor if you have any questions concerning these drugs or their potential side effects.

Patients should carefully read the information labels for all drugs and follow the directions. Some sleeping pills take 30 - 60 minutes to take effect, while others (such as zolpidem) are fast-acting. For zolpidem, patients should:

Take zolpidem immediately before going to sleep
Take zolpidem only when able to get a full night’s sleep (7 – 8 hours)
Not drink alcohol the same evening
Not take more than the prescribed dose
Use caution in the morning when getting out of bed, driving, or operating heavy machinery

Interactions. As with any hypnotics, alcohol increases the sedative effects of these drugs. These hypnotics also interact with other drugs, including rifampin, ketoconazole, erythromycin, and cimetidine. They may also interfere or be interfered by other drugs. Patients should report all medications to their doctors.

Dependency, Withdrawal Symptoms, and Rebound Insomnia. The risk for rebound insomnia, dependence, and tolerance is lower with non-benzodiazepine hypnotics than with benzodiazepine drugs. These drugs are still subject to abuse. In any case, no hypnotic should be taken for more than 7 - 10 days or at higher than the recommended dose without a doctor's approval.

Antidepressants are sometimes used to treat insomnia that may be caused by depression (secondary insomnia). In addition, some antidepressants with sedating properties are prescribed for the treatment of primary insomnia. For example, trazodone has been frequently prescribed in low doses as a hypnotic to help induce sleep. However, there are few studies that address its safety and efficacy as a drug for treating insomnia in non-depressed patients. Several studies have warned against trazodone's use in elderly patients, due to its risk for side effects (daytime sleepiness, dizziness, priapism) and drug interactions. In fact, all hypnotics can have serious side effects in the elderly, and all must be used with caution.

Chloral Hydrate. Chloral hydrate has been in use since 1832. It has significant adverse effects, however, and most experts believe it no longer has a role in the treatment of insomnia. In any case, it does not appear to be effective in the elderly. Chloral hydrate poses a risk for addiction, and it can be fatal in overdose. It also has cancer-causing properties. Side effects include irritation of the skin, mucous membranes, and stomach. People with stomach, heart, kidney, or liver disorders should not take this drug at all. If a child is given it (usually for minor surgery), that child should never be given chloral hydrate again in their lifetime.

Barbiturates. Barbiturates (Seconal, Nembutal) were the standard sleeping medications before the introduction of benzodiazepines. Overdose is dangerous and frequent; addiction and abuse are common. These drugs should rarely or never be prescribed for insomnia.

Indiplon. The FDA is reviewing indiplon, a new non-benzodiazepine hypnotic.

According to results from a national survey published in 2006 in the Archives of Internal Medicine, more than 1.6 million Americans use complementary and alternative therapies to treat insomnia. Many people choose herbal and dietary supplement remedies. Some, such as chamomile tea or lemon balm, are generally harmless for most people. Others have more serious side effects and interactions. [See Box.] According to a 2007 study, valerian and melatonin are among the most popular alternative remedies for insomnia.

Although about half of people who use herbal medicine report that these products help their sleep, experts are not sure whether these remedies really work or whether a placebo effect is the main reason for the improvement. The American Academy of Sleep Medicine (AASM) states that there is only limited scientific evidence to show that herbal and dietary supplements are effective sleep aids. The AASM recommends that these products should be taken only if approved by a doctor. Be sure to talk to your doctor if you are considering taking any herbal or dietary supplement. Some of these products can interact with prescription medications.

Melatonin is the most studied natural remedy for insomnia. A 2005 analysis of 17 melatonin studies found that melatonin significantly reduced the time to fall asleep (sleep onset) and the time spent asleep (sleep duration). However, there are no consistent standards on melatonin doses. Some research suggests that 0.3 mg may be the most effective dosage in many people with insomnia. However, higher doses may keep some people awake.

Although melatonin may not have many benefits for most people with chronic insomnia, studies suggest that it may help the following individuals:

Elderly people. It may help certain older people with insomnia, such as those with evidence of low melatonin levels and those dependent on prescription sleeping medications. It is not clear, however, how significant the benefits are.
People without sight. A 2000 study reported that melatonin can help people without sight retrain their circadian cycle so that they can sleep at regular hours. The best dosages and timing, however, need to be clarified.
Travelers suffering jet lag. Some studies have reported that melatonin may help prevent jet lag in some travelers.
Those in withdrawal from prescription sleep medication. Melatonin may help people who are dependent on sleeping medications withdraw from these drugs and maintain good quality sleep.
People with delayed sleep syndrome. It might be somewhat helpful for people who fall asleep very late at night or in early morning hours but then sleep normally.
Children. Melatonin may help some children with chronic insomnia. In one small study, or example, melatonin was specifically helpful for children with Asperger syndrome, who are at risk for sleep disturbances. More research is warranted, however. At this time, no one should give their child melatonin without a doctor's recommendation.

Melatonin is a powerful hormone that can have major effects on all parts of the body. Doses of melatonin over 0.3 mg can disrupt the circadian system in the brain. Long-term consequences are unknown. High doses have been associated with the following adverse events:

Mental impairment
Severe headaches
Nightmares

Interactions with other drugs are not completely known. Melatonin is classified as a dietary supplement and not as a drug, so its quality is not regulated in the U.S.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.

The following are special concerns for people taking natural remedies for insomnia:

Chamomile. Many people drink chamomile tea for its sedative properties. Although it is generally safe, it may cause allergic reactions in people who have plant or pollen allergies.

Valerian root. Valerian is an herb that has sedative qualities and has been helpful in people with insomnia. One study reported that it was also useful for helping patients withdraw from benzodiazepines -- the standard prescription sleeping pills. In another study, 83% of patients rated the effects of valerian on sleep as being very good. In the same study, valerian was as effective as oxazepam, a standard prescription sleeping medication. Valerian's side effects may include vivid dreams. High doses of valerian can cause blurred vision, excitability, and changes in heart rhythm. Valerian's effects can be dangerously increased if it is used with standard sedatives.

Chinese Herbal Remedies. Studies suggest that up to 30% of herbal patent remedies imported from China are laced with potent pharmaceuticals such as phenacetin and steroids. They may also contain toxic metals. The herbal remedy Sleeping Buddha was recalled in 1998 because it contained a benzodiazepine, the major ingredient in many prescription sleeping pills, and also appeared to increase the risk for birth defects in pregnant women. Reports of a few cases of acute hepatitis have occurred from Jin Bu Huan, a Chinese herbal remedy sold as treatment for pain and insomnia.

Kava. Kava has been used to relieve anxiety and improve sleep. It is not considered safe. There have been reports of liver failure and death from this herb, with highest risk in those with liver disease. Other side effects include itchy, scaly skin, muscle weakness, and problems with coordination. It also interacts dangerously with certain medications, including alprazolam, an anti-anxiety drug. Kava also increases the strength of certain other drugs, including other sleep medications, alcohol, and antidepressants.

Tryptophan and 5-L-5-hydroxytryptophan (HTP). Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is known to promote well-being and has been associated with healthy sleep. L-tryptophan was marked for insomnia and other disorders but was withdrawn from the market after contaminated batches caused a rare and even fatal disorder called eosinophilia myalgia syndrome. 5-HTP, a byproduct of tryptophan, is still available as a supplement. There have been reports that some brands contain a substance called Peak X, which may be harmful. There is little evidence that 5-HTP relieves insomnia.

Resources

www.aasmnet.org -- American Academy of Sleep Medicine
www.nhlbi.nih.gov/about/ncsdr -- National Center for Sleep Disorders Research
www.sleepfoundation.org -- National Sleep Foundation
www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
www.wfsrs.org -- World Federation of Sleep Research Societies
www.clinicaltrials.gov -- Find clinical trials

References

Bliwise DL, Ansari FP. Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. Sleep. 2007 July 1;30(7):881-884.

Liu X, Buysse DJ, Gentzler AL, Kiss E, Mayer L, Kapornai K, et al. Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression. Sleep. 2007 Jan 1;30(1):83-90.

Mindell JA, Emslie G, Blumer J, Genel M, Glaze D, Ivanenko A, et al. Pharmacologic management of insomnia in children and adolescents: consensus statement. Pediatrics. 2006 Jun;117(6):e1223-32.

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A; American Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006 Oct 1;29(10):1263-76.

Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006 Nov 1;29(11):1398-414.

Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007 July 1;30(7):873-880.

Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleeping, and complementary and alternative medicine: Analysis of the 2002 National Health Interview Survey data. Arch Intern Med. 2006 Sep 18;166(16):1775-82.

Review Date:
7/18/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

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adam.com

Narcolepsy

FitSugar — Wed, 08 Oct 2008 17:35:12 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Prognosis
Diagnosis
Treatment
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Neuroimaging Techniques May Help Diagnose Narcolepsy

Neuroimaging techniques, such as CT and MRI scanning, have allowed researchers to characterize brain function throughout the sleep-wake cycle in the normal human brain. At the present time, few research studies have evaluated the brains of people with sleep disorders using these neuroimaging techniques. More studies involving people with sleep disorders, such as narcolepsy, will be required to gather data to help researchers diagnose, classify, treat, and monitor sleep disorders more effectively. Typically, narcolepsy is not diagnosed for up to 15 years after symptoms begin.

Health-Related Quality of Life May Be Lower for Narcolepsy Patients

Researchers in Germany evaluated 75 narcolepsy patients via a telephone interview and questionnaire to determine their health-related quality of life. Patients with narcolepsy scored lower than the general German population in all eight categories, especially for “physical role, vitality, and general health perception.” Except for irresistible sleep episodes, other symptoms of narcolepsy had only a minor impact on their perceived quality of life; factors such as employment status, living with a partner, excessive daytime sleepiness, and professional advancement had a strong influence on their quality of life.

The researchers concluded that health care providers should consider such factors that affect quality of life of narcolepsy patients when formulating guidelines for treatment.

Introduction

The word narcolepsy comes from two Greek words roughly translated as "seized by numbness." The two primary symptoms in narcolepsy reflect this phrase:

Excessive daytime sleepiness, with frequent daily sleep attacks or a need to take several naps during the day.
Temporary and sudden muscle weakness (called cataplexy), usually brought on by strong emotions.

Some, but not all, patients experience other symptoms:

Microsleep episodes, in which the patient behaves automatically but without conscious awareness
A sense of paralysis that occurs between wakefulness and sleep (called atonia)
Dreamlike states between waking and sleeping (called hypnagogic hallucinations)
Periodic leg movements during sleep (periodic limb movement disorder)

Rapid eye movement (REM) sleep is abnormal in narcolepsy. In fact, narcolepsy is sometimes defined as the loss of boundaries between wakefulness, nonREM sleep, and REM sleep. REM sleep is the active, dreaming phase of sleep.

Excessive Sleepiness. All people with narcolepsy experience excessive sleepiness during the day with episodes of falling asleep rapidly and inappropriately, even when fully involved in an activity. These events may be characterized by the following behaviors:

Patients often have periods of drowsiness every 3 or 4 hours that usually end in short naps.
Patients may sleep for a few minutes, particularly if they are in an awkward position or for a few hours if they are lying down.
Patients often underestimate the duration of their drowsy periods and may not recall clearly their behavior during that time.

Cataplexy. Cataplexy is an abrupt loss of muscle tone or strength that results in an inability to move and always occurs during wakefulness. It occurs in about two-thirds of narcolepsy patients and may be triggered by the following events:

Sudden emotion, usually anger or laughter (the most common trigger)
Following a heavy meal
During periods of stress

Muscle reflexes are completely absent during a cataplectic attack. Cataplectic attacks can be very minimal and appear as passing weakness or affecting only the eyelids and face. They may, on the other hand, be so severe that they weaken the whole body. In the most severe form of cataplexy, attacks can recur repeatedly for hours or days. Abrupt withdrawal from certain drugs used to treat narcolepsy, notably clomipramine, can trigger this uncommon but troublesome occurrence.

Cataplexy may have the following characteristics:

Most attacks last less than 30 seconds and can be missed by even skilled observers. However, in severe cases, a person may fall and remain paralyzed for as long as several minutes.
Typically the patient's head will suddenly fall forward, the jaw becomes slack, and the knees will buckle.
Speech may become suddenly loud or broken and stutter-like.

Atonia. Atonia is a sense of paralysis that occurs between wakefulness and sleep, usually upon waking or sometimes at the onset of sleep. The person is conscious but cannot speak, move (cannot even open the eyes), or breathe deeply. Atonia rarely lasts beyond 20 minutes, but when it first occurs, this experience can be terrifying, particularly if the patient also develops hallucinations.

Hypnagogic Hallucinations. Hypnagogic hallucinations are dreams that intrude on wakefulness, which can cause visual, auditory, or touchable sensations. They occur between waking and sleeping, usually at the onset of sleep, and can also occur about 30 seconds after a cataplectic attack.

Visual hallucinations have been described as a "film running through the head" or as a waking dream with strong emotional content. Images can be intrusive. More commonly they may involve seeing colored forms that shift in size and shape.
Auditory hallucinations may include random sounds or elaborate melodies.
A person may also hallucinate feelings of rubbing or light touches, even levitation.

Such symptoms may also appear in other sleep disorders and are probably related to extreme sleepiness. In general, cataplexy must also be present for a clear diagnosis of narcolepsy. Some experts believe, however, that some patients with narcolepsy may experience hypnagogic hallucinations and daytime sleepiness and not cataplexy.

Microsleep and Automatic Behavior. In some cases, patients have so-called microsleep episodes, in which they behave automatically without conscious awareness. Such automatic behavior may not be recognized as part of a disorder by either patients or the people around them. Some examples include:

People with narcolepsy can be driving or walking competently but end up in a location different from the intended one.
A narcolepsy patient can be carrying on a conversation and jump from one unrelated topic to another or just trail off and stop talking altogether.
The patient may suddenly perform bizarre actions, such as putting socks in the refrigerator.
Patients may experience severe forgetfulness.
Their movements may suddenly become slow or clumsy.
In some cases, their behavior may resemble some forms of epileptic seizures.

Disturbed Sleep. Nighttime sleep is often disturbed in narcolepsy, but it is usually mild to moderate and does not account for the daytime sleepiness experienced by people with narcolepsy.

Periodic Limb Movement Disorder. Many patients with narcolepsy experience periodic limb movement disorder, also called PLMD (formerly known as nocturnal myoclonus). In PLMD, the leg muscles involuntarily contract every 20 - 40 seconds during sleep, occasionally arousing the patient. The patient is usually unaware of the cause of the interruption.

The daily cycle of life, which includes sleeping and waking, is called a circadian (meaning "about a day") rhythm, commonly referred to as the biologic clock. Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is about 24 hours. (If confined to windowless apartments, with no clocks or other time cues, sleeping and waking as their bodies dictate, humans typically live on slightly longer than 24-hour cycles.) It usually takes the following daily patterns:

Humans are designed for daytime activity and nighttime rest.
Additionally, there is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms intermesh with other factors that may interfere or change individual patterns:

The fraction-of-a-second-firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the suprachiasmatic nucleus (SCN).

The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals. Malfunction of this area of the brain may give rise to cluster headaches.

This nerve cluster takes its name from its location, which is just above (supra) the optic chiasm, a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland (named so because it resembles a pinecone) to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness, the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

Click the icon to see an image of sleep patterns.

The REM/NonREM Cycle. The cycle between quiet (nonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of nonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the nonREM/REM cycle repeats.
With each cycle, nonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Causes

Narcolepsy is a neurological sleep disorder. It is not caused by mental illness or psychological problems. It is most likely the end result of a number of genetic abnormalities that affect specific biologic factors in the brain, coupled with an environmental trigger such as a virus.

Researchers are attempting to come up with a unifying theory involving genetic factors, autoimmunity, and deficiencies in hypocretin, a brain peptide that is important in regulating sleep. Most of the research conducted on narcolepsy uses dogs that have genetic factors that cause narcolepsy, but such studies are helping researchers find the biologic bases to this strange and distressing condition.

Hypocretin. Hypocretin (also called orexin) is a peptide that modulates activity in the hypothalamus (the region in the brain associated with sleep, well-being, and appetite). Hypocretin specifically has properties that promote wakefulness and inhibits REM sleep. Hypocretin may also have other actions that affect feeding behavior and increase activity in the autonomic (sympathetic) nervous system and systems that regulate motor control. Deficiencies in this peptide have been observed in most patients with narcolepsy who also have cataplexy. Deficiencies might set off the following chemical responses that may produce sleep attacks:

Lower levels of histamine, a chemical that promotes wakefulness
Low levels of epinephrine (commonly known as adrenaline), a hormone important in alertness and arousal
Increase in acetylcholine, which affects REM sleep
Changes in the enzyme monoamine oxidase, which is believed to be important in preventing arousal
Changes in dopamine, an important neurotransmitter (chemical messenger in the brain) that helps regulate sleep
Lower levels of leptin, a hormone associated with obesity when levels decline (people with narcolepsy tend to be overweight)
Higher-than-normal secretion of growth-hormone during the day, which may play a role in sudden falling-asleep episodes

Narcolepsy has a genetic component and tends to run in families. Experts estimate that around 8 - 10% of people with narcolepsy have a close relative who has the disorder. A 2006 study reported that the risk for narcolepsy among male first-degree relatives (parents or sibling) was 105 times higher than the general population; the risk for female first-degree relatives was 54 times higher. Other studies suggest that people who have a first-degree relative with narcolepsy are 20 - 40 times more likely to have narcolepsy than other people.

However, most experts agree that genetics are not the only factor involved in narcolepsy. Narcolepsy most likely involves a combination of genetics and one or more environmental triggers such as infection, trauma, hormonal changes, immune system problems or stress. Researchers are looking for specific genetic mutations that may make individuals susceptible to this disorder.

It has been theorized that narcolepsy may be an autoimmune disease, in which the immune system may be tricked into perceiving its own proteins to be antigens. (Antigens are foreign substances targeted for attack by immune factors in the body.)

An antigen is a substance that can provoke an immune response.

Important autoimmune diseases include multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and type 1 diabetes. In such diseases, the immune system overproduces potent factors called cytokines, which cause inflammation and injury in the susceptible cells and tissues affected by the disease. Most autoimmune diseases also tend to afflict those with particular genetically determined molecules of the immune system called human leukocyte antigens (HLAs).

Experts suggest that an immune attack in narcolepsy may occur against cells containing the brain peptide hypocretin (orexin), resulting in deficiencies that are now believed to be major components of the narcolepsy process. HLAs, particularly a subgroup known as (HLA)DQB1-0602, have been strongly associated with narcolepsy and low levels of hypocretin. Narcolepsy patients who carry this HLA group tend to have a specific syndrome of symptoms that include cataplexy and periodic limb movement disorder. However, 20 - 40% of people without narcolepsy carry these HLA types.

An important research report, published in 2004 in The Lancet, provided the first concrete evidence that autoimmunity may play a role in narcolepsy. The study’s research team seem to have identified an autoantibody associated with narcolepsy. The researchers injected mice with antibodies taken from patients with narcolepsy. All patients carried the (HLA)DQB1-0602 genotype. Mice were also injected with antibodies from healthy patients. Only the antibodies from patients with narcolepsy produced narcolepsy-type neuromuscular responses.

The results suggested that the antibodies triggered an autoimmune response that affected the hypocretin system. Scientists hope that this autoantibody may prove to be a diagnostic biomarker and that a blood test can eventually be developed to accurately diagnose narcolepsy. In addition to new diagnostic tests, this research may pave the way for immunomodulatory drugs that could prevent hypocretin depletion. However, other research has yet to conclusively establish a link between narcolepsy and autoimmunity.

Risk Factors

Narcolepsy affects around 1 in 2,000 people. Experts estimate that around 135,000 - 200,000 Americans have narcolepsy, but the number may be higher. Only about 25% of people who have narcolepsy are actually diagnosed with the disorder. Patients are often mistakenly diagnosed with other conditions, such as psychiatric or emotional problems. Many patients wait decades before receiving a proper diagnosis.

Genetic factors may influence narcolepsy's prevalence in different populations. For example, studies have found much higher rates among Japanese and much lower rates among people in Israel. A 2002 study suggested, however, that the disease is very consistent among all ethnic groups and does not vary in severity or symptoms.

Narcolepsy symptoms usually first appear in adolescence or young adulthood. However, narcolepsy can begin at any age. Growing evidence suggests that the disorder may emerge in early childhood in many patients. People who develop it at a young age often have a family history of the disease and a severe condition, suggesting that genetic factors are important in this group. A 2006 study found that children with frequent headaches are more likely to develop narcolepsy and excessive daytime sleepiness than other children. The researchers recommended that pediatricians ask about narcolepsy symptoms when treating children with chronic headaches.

Prognosis

Narcolepsy is a life-long problem, but it is not progressive. Symptoms may even lessen over time, but they never completely disappear. In a 2001 study comparing older adults (over 65 years old) and younger adults, the older group had less cataplexy, although there was no difference in excessive daytime sleepiness. In fact, another study suggested that sleep disturbances at night often worsen as a person ages.

Perhaps the most serious consequence of narcolepsy is the high risk for accidents. Almost 75% of patients with narcolepsy reported falling asleep while driving in one survey, and 56% reported near accidents. Other common narcolepsy-related accidents include burns from touching hot objects, cuts from sharp objects, and breaking things.

Some, but not all, studies report that people with narcolepsy have problems with memory and attention. Some research suggests that problems may be due to the abnormalities in the brain that cause the narcolepsy itself. Problems in thinking, however, are more likely to be due to tiredness and episodes of sleepiness. One study found that patients with narcolepsy had trouble with short-term memory, although if given time to repeat memory tasks their response became normal.

The patient suffers emotional and social difficulties from the uncontrollable sleep episodes and cataplexy. Studies have reported rates of depression in people with narcolepsy ranging from 30 - 57%. (In the general population, prevalence of depression is 8%.) Studies have shown severe emotional and social dysfunction in all areas, including work, relationships, and leisure activities. One study reported that 25% of men with narcolepsy suffered sexual problems. Some experts believe that the psychological and social effects are more serious than those caused by epilepsy (for which narcolepsy can be mistaken).

Headaches. Studies report a very high incidence of headaches in general, and migraines in particular. In one study, 81% of narcolepsy patients had headaches, with 57% of them reporting migraines. In another study, migraines were reported in 44% of women and 28% of men with narcolepsy. Narcolepsy developed more than a decade before the migraines did, suggesting some common disease pathway in both disorders.

Obesity. Evidence suggests that people with narcolepsy are at high risk for obesity compared to the general population. This could be a consequence of low activity level, but research also indicates that deficiencies in the brain peptide hypocretin may play a role in both narcolepsy and eating behaviors, which could increase the risk for obesity.

Diagnosis

Although narcolepsy is a physical disorder, doctors are still very likely to misdiagnose patients as having psychological problems. For most patients, narcolepsy is not diagnosed for up to 10 - 15 years after their symptoms first began. To determine specific sleep disorders, the doctor will take a medical and family history and should be told of any medications being taken. The symptoms of narcolepsy are sometimes undeniable if the patient reports all of the major symptoms:

Excessive daytime sleepiness with a tendency for frequent naps. (These frequent naps should occur every day for at least 6 months to serve as a diagnosis of narcolepsy.) Narcolepsy is usually diagnosed in adolescence and young adulthood when falling asleep suddenly in school brings the problem to attention.
Cataplexy (abrupt loss of muscle tone or weakness that causes a person to stop all motor activity).
Hypnagogic hallucinations (vivid visual or auditory phenomena) experienced at the onset of sleep.
Sleep paralysis (an inability to move on first awakening).

Diagnosis based only on symptoms, however, is often problematic for various reasons:

Patients often seek medical help for single symptoms (sleep paralysis or hypnagogic hallucinations) that might be associated with other disorders, particularly epilepsy.
Symptoms are sometimes not dramatically apparent for years, even to the patient or a skilled observer. In one study, the average number of years between onset of symptoms and diagnosis was 14. Another study conducted in a sleep clinic reported that more than half of patients were diagnosed when they were over 40 and had not realized they had narcolepsy until they experienced a bout of cataplexy.

In some cases, the patient may need to consult a sleep specialist or go to an accredited sleep disorders center for accurate diagnosis of a sleep disorder. Patients should carefully investigate centers to make sure that they offer full sleep studies. Patients who visit a sleep center undergo an in-depth analysis, usually supervised by a multidisciplinary team of consultants who can provide both physical and psychiatric evaluations.

A doctor may administer certain questionnaires on sleeping habits.

The Epworth Sleepiness Scale. The Epworth Sleepiness Scale (ESS) uses a simple questionnaire to measure excessive sleepiness. It is proving to be a very accurate measure for assessing narcolepsy.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading	(Indicate a score of 0 to 3)
Watching TV	(Indicate a score of 0 to 3)
Sitting inactive in a public place (a theater or a meeting)	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit	(Indicate a score of 0 to 3)
Sitting and talking to someone	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average 9-15: Very sleepy and should seek medical advice Over 16: Dangerously sleepy

Multiple Sleep Latency Test. The multiple sleep latency test (MSLT) uses a machine that measures the time it takes to fall asleep lying in a quiet room during the day. The patient takes 4 or 5 scheduled naps 2 hours apart. People with healthy sleep habits fall asleep in about 10 - 20 minutes. In patients with narcolepsy, polysomnography plus MSLT will show a much shorter duration of time (less than 8 minutes) from wakefulness into sleep. At least 2 of the naps are REM-onset (the active sleep phase associated dreaming). The test has limitations, however, and is most useful for measuring the severity of the problem. The Epworth Sleepiness Scale may be more accurate in differentiating narcolepsy from normal daytime sleepiness.

An overnight sleep study, called polysomnography, can be a valuable means for determining the basic cause of sleepiness. The patient arrives at the sleep center about 2 hours before bedtime without having made any changes in daily habits. The patient will be monitored by a variety of devices while sleeping:

Electroencephalogram, or EEG (monitors the electrical activity of the brain)
Electrocardiogram or ECG (monitors the heart)
Electromyogram (monitors the movements of muscles)
Electrooculogram (monitors eye movements)

These instruments record activity as the patient passes, or fails to pass, through the various sleep stages. One study using polysomnography reported that both healthy patients and those with narcolepsy perform equally during the first 5 - 10 minutes of the test, but after that, patients with narcolepsy show evidence of drowsiness and even indications of sleep. In general, however, polysomnography is most useful for ruling out other disorders, such as sleep apnea, in people with narcolepsy.

Testing the patient's spinal fluid to detect deficiencies in hypocretin may be a useful method for diagnosing narcolepsy. Low levels may indicate narcolepsy. (Low levels, however, can also occur with brain injury or Guillain-Barre syndrome.) Some researchers believe that measuring hypocretin levels may identify people with early or mild symptoms of narcolepsy (such as cataplexy without altered consciousness). This would help avoid inaccurate diagnoses such as epilepsy or psychosis, which require potent drugs that have significant side effects and are not helpful for patients with narcolepsy.

Transcranial Magnetic Stimulation. An investigative test uses an instrument that magnetically stimulates part of the brain to produce cataplexy. In one study of patients with narcolepsy, such stimulation caused loss of muscle tone in certain areas when patients were off their medication, but had no effect when they were in treatment.

Ruling out Psychologic Disorders. In one study, 40% of patients who actually had narcolepsy had been diagnosed incorrectly with some psychological or psychiatric problem. Certainly, patients with narcolepsy have emotional difficulties because of the condition, and it is often difficult, particularly for a nonspecialist, to detect the physical problem. Even worse, hypnagogic hallucinations may result in diagnoses of schizophrenia or bipolar disorder, which are treated with potent antipsychotic drugs that have severe side effects and are useless for narcolepsy.

Ruling out Epilepsy. Narcolepsy can easily be mistaken for epilepsy, a group of disorders that cause seizures. Case studies have reported a misdiagnosis of epilepsy in patients who were actually experiencing cataplexy and sleep paralysis.

Other Causes of Persistent Fatigue. A number of conditions can cause persistent fatigue and should be ruled out:

Obstructive sleep apnea. This is a major sleep disorder that causes fatigue and afternoon sleepiness and must be ruled out before a diagnosis of narcolepsy can be established. (A person may also suffer sleep apnea and narcolepsy at the same time.)
Chronic fatigue syndrome
Head trauma
Infectious mononucleosis

Swollen lymph nodes, sore throat, fatigue and headache are some of the symptoms of mononucleosis, which is caused by the Epstein-Barr virus. It is generally self-limiting, and most patients can recover in 4 - 6 weeks without medications.

Guillain-Barre syndrome
Hepatitis
Atypical pneumonia, particularly those involving echoviruses

Other Causes of Sleep Paralysis. Sleep paralysis may be triggered by certain conditions, such as:

Irregular sleep habits
Sleep deprivation
Shift work
Jet lag
Psychologic stress

These conditions may also worsen sleep paralysis in narcolepsy. Narcolepsy sleep paralysis usually occurs at the onset of sleep and is chronic.

Neuroimaging techniques have allowed researchers to confirm sleep physiological theories in humans and to discover new information about the neurobiological aspects of sleep, dreams, and memory. While few neuroimaging studies have focused on patients with sleep disorders such as narcolepsy, future studies will allow neuroimaging to play a role in diagnosing, classifying, treating, and monitoring sleep disorders in humans.

Treatment

Lifestyle treatment of narcolepsy includes taking three or more scheduled sleep-times throughout the day. One study suggested that the best approach is a combination of scheduled nighttime sleep and two 15-minute naps (for example one before lunch and another before dinner). Patients should also avoid heavy meals and alcohol, which can interfere with sleep.

People with mild narcolepsy symptoms that do not require medication may be able to maintain alertness with sleep scheduling. In a 2001 study, scheduled sleep periods were also helpful for patients who were extremely sleepy in spite of medications. The benefits of scheduled naps, however, are not clear for patients whose condition responds to medication. In the same study, patients who took stimulants and were able to maintain alertness or were only moderately sleepy derived no additional benefit from the naps.

Medications for narcolepsy target the major symptoms of sleepiness and cataplexy. Stimulant drugs are used to manage excessive daytime sleepiness while antidepressants and other compounds address cataplectic symptoms. The FDA has approved two drugs specifically for the treatment of narcolepsy. They are now the first-line treatments:

Modafinil (Provigil): For excessive daytime sleepiness
Sodium oxybate (Xyrem): For cataplexy

Modafinil. Modafinil (Provigil) is a drug used to treat the excessive sleepiness associated with narcolepsy and other sleep disorders. (Modafinil does not treat cataplexy.) The FDA approved modafinil in 1998. Since that time, it has largely replaced methylphenidate (Ritalin) and other stimulants for treatment of narcolepsy sleepiness. Patients who switch to modafinil from stimulants such as methylphenidate experience few problems if they gradually taper off the stimulant dose.

Modafinil helps patients with narcolepsy stay awake during the day. In one study, patients who had not yet taken modafinil were able to stay awake only an average of 6 out of 20 minutes. After taking the medication, awake time increased to 12 - 14 of every 20 minutes, and some patients had normal wake times. In another study, modafinil increased the ability to stay awake by 50% and reduced the number of involuntary sleep episodes by about 25%.

Some of its additional benefits include what it does not do:

Modafinil does not appear to affect natural hormones important in sleep, including cortisol (the major stress hormone), melatonin, and growth hormone. Therefore, studies suggest that it does not interfere with voluntary naps during the day or with the quantity or quality of nighttime sleep.
It does not cause anxiety to the degree that the standard stimulants do.
It does not cause a rebound effect as stimulants do. In other words, people who take modafinil do not usually "crash" when the drug wears off.
It has less potential for abuse than stimulant drugs. In one trial, no patients developed dependence on the drug after 9 weeks of daily use. However, modafinil can still be habit-forming. Patients may need to gradually lower the dose before stopping treatment.

Side effects may include:

Headache (the most commonly reported side effect)
Nausea
Diarrhea
Dry mouth
Nasal and throat congestion
Nervousness and anxiety
Dizziness
Back pain
Difficulty sleeping
Decreases the effects of hormonal methods of birth control, including the pill. (Women of childbearing age who take modafinil should switch to another form of birth control.)

A new drug, armodafinil (NuVigil), which is related to modafinil, is being investigated for treatment of narcolepsy-associated excessive sleepiness. In clinical trials comparing it with placebo, armodafinil improved wakefulness, memory, attention, and fatigue in patients with narcolepsy.

Stimulants. Medications that act as stimulants are standard treatments for narcolepsy. They include:

Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine)
Methamphetamine (Desoxyn)

Methylphenidate and dextroamphetamine last for 2 - 5 hours and are the standard drugs for excessive daytime sleepiness. These drugs are useful for people who can manage wakefulness with a night's sleep and scheduled naps. They can improve mood, mental acuity, and other aspects of mental functioning. An older drug, pemoline (Cylert), is now prescribed less frequently due to its risks for liver damage.

Stimulants can have unpleasant side effects, including:

Weight loss
Dizziness
Nausea
Changes in blood pressure and rapid heartbeat
Headache

There are some differences between these drugs:

Methylphenidate, which is the standard drug for treating attention deficit hyperactivity disorder, is safer than dextroamphetamine. Small studies suggest that high doses may help avert cataplexy, although more research is needed to confirm this effect. Psychosis from overdose is very rare. Psychologic dependence can occur, but abuse has not been reported in children who have taken it for years.
Dextroamphetamine has more severe side effects than methylphenidate. These include mood changes and jerky muscle movements. Prolonged use may cause serious depression. Overdose, which can occur at doses of only 100 to 500 mg, can cause psychosis and even death. This drug should not be used during pregnancy. There is also a risk for addiction and abuse.

Stimulants should be avoided or only taken under a doctor's guidance in people with heart disease, hyperthyroidism, glaucoma, anxiety disorder, and high blood pressure.

These drugs become ineffective if used continuously, and patients are advised to take a drug holiday one day a week or to withdraw gradually and resume treatment at a lower dose. Patients should not engage in activities that require being awake (such as driving) during withdrawal.

Sodium oxybate (Xyrem). Sodium oxybate (Xyrem), also referred to as gamma hydroxybutyrate (GHB), helps reduce the frequency of cataplexy attacks and improve daytime sleepiness. It takes about 4 weeks for significant benefits, which reach their peak at about 8 weeks. Food intake can affect it, so patients are advised to take it at a regular time after the evening meal.

In 2002, the FDA approved Xyrem for treatment of cataplexy associated with narcolepsy. However, the FDA placed tight restrictions on its use. Although the drug appears to be effective and safe when used for narcolepsy, it has a history of illegal and "date-rape" use, with street names such as "Grievous Bodily Harm" or "Liquid Ecstasy." (The last term is not to be confused with "Ecstasy," another street drug with different effects.) In high doses, it can cause dependence over time. In addition, very serious side effects -- including seizures, coma, respiratory arrest, and death -- have been reported in people who abused it. Trials of Xyrem, however, have not reported these effects with the doses used in treatment for cataplexy. Patients still report side effects, although they tend to be mild. They include nausea, headache, dizziness, urine leakage, and sleepwalking.

Monoamine Oxidase Inhibitors (MAOIs). Selegiline (Eldepryl, Movergan), also known as deprenyl, is an MAOI that blocks monoamine oxidase B, an enzyme that degrades dopamine and may play a role in narcolepsy.

Adverse Effects. Selegiline has significant side effects:

It interacts with nearly every antidepressant. Patients suffering from depression should discuss all treatment options with their doctor.
People taking any monoamine oxidase inhibitor are at risk for high blood pressure if they consume tyramine-containing foods or beverages, including aged cheeses, most red wines, vermouth, dried meats and fish, canned figs, fava beans, and concentrated yeast products.

Antidepressants. Antidepressant drugs are not approved for treatment of cataplexy, but they are commonly used to manage this condition. Unfortunately, there have been few studies conducted on antidepressant treatment of cataplexy, and there are little data on which type of antidepressant work bests. A 2005 review of antidepressants for narcolepsy noted the lack of good quality evidence to support their use and urged for more clinical trials.

Antidepressants used for cataplexy and management of REM symptoms include:

Tricyclic antidepressants: Protriptyline (Vivactil), clomipramine (Anafranil), imipramine (Janimine, Tofranil), and desipramine (Norpramin, Pertofran)
Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)
Newer antidepressants: Venlafaxine (Effexor)

Tricyclics were the first antidepressants used for cataplexy; they were also one of the first treatments for cataplexy. They can be helpful for some patients but have many unpleasant side effects, including dry mouth, constipation, and weight gain. Tricyclics can also lower blood pressure and cause disturbances in heart rhythm.

SSRIs have fewer side effects than tricyclics but may not work as well for cataplexy control. The most common side effects include nausea, drowsiness or insomnia, headache, weight gain, and sexual dysfunction.

Venlafaxine (Effexor) is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) that has shown promising results for treatment of cataplexy. Some patients with narcolepsy, and their doctors, report that venlafaxine seems to work best of all the antidepressants. [See In-Depth Report #8: Depression.]

Resources

www.aasmnet.org -- American Academy of Sleep Medicine
www.sleepfoundation.org -- National Sleep Foundation
www.narcolepsynetwork.org -- Narcolepsy Network
www.wfsrs.org -- World Federation of Sleep Research Societies
www.med.stanford.edu/school/psychiatry/narcolepsy -- Stanford Center For Narcolepsy
www.nhlbi.nih.gov/sleep -- National Center on Sleep Disorders Research
www.ninds.nih.gov -- National Institute on Neurological Disorders and Stroke

References

Dang-Vu TT, Desseilles M, Petit D, Mazza S, Montplaisir J, Maquet P. Neuroimaging in sleep medicine. Sleep Med. 2007;8:349-372.

Dodel R, Peter H, Spottke A, et al. Health-related quality of life in patients with narcolepsy. Sleep Med. 2007; May 17; [Epub ahead of print].

Harsh JR, Hayduk R, Rosenberg R, Wesnes KA, Walsh JK, Arora S, et al. The efficacy and safety of armodafinil as treatment for adults with excessive sleepiness associated with narcolepsy. Curr Med Res Opin. 2006;22(4):761-774.

Jeong JH, Hong SC, Shin YK, Han JH, Lee SP. HLA-DQB1 allele and hypocretin in Korean narcoleptics with cataplexy. J Korean Med Sci. 2007;22:127-131.

Lemon MD, Strain JD, Farver DK. Sodium oxybate for cataplexy. Ann Pharmacother. 2006;40(3):433-440.

Luc ME, Gupta A, Birnberg JM, Reddick D, Kohrman MH. Characterization of symptoms of sleep disorders in children with headache. Pediatr Neurol. 2006;34(1):7-12.

Martinez-Rodriguez JE, Sabater L, Graus F, Iranzo A, Santamaria J. Evaluation of hypothalamic-specific autoimmunity in patients with narcolepsy. Sleep. 2007;30:27-28.

Ohayon MM, Ferini-Strambi L, Plazzi G, Smirne S, Castronovo V. Frequency of narcolepsy symptoms and other sleep disorders in narcoleptic patients and their first-degree relatives. J Sleep Res. 2005;14(4):437-445.

Thorpy MJ. Cataplexy associated with narcolepsy: epidemiology, pathophysiology and management. CNS Drugs. 2006;20(1):43-50.

Vignatelli L, D'Alessandro R, Candelise L. Antidepressant drugs for narcolepsy. Cochrane Database Syst Rev. 2005;(3):CD003724.

Xyrem International Study Group. Further evidence supporting the use of sodium oxybate for the treatment of cataplexy: a double-blind, placebo-controlled study in 228 patients. Sleep Med. 2005 Sep;6(5):415-421.

Review Date:
8/3/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Sleep apnea

FitSugar — Wed, 08 Oct 2008 17:35:30 -0700

In This Report

Highlights
Introduction
Symptoms
Causes
Risk Factors
Prognosis
Diagnosis
Lifestyle Changes
Treatment
Dental Devices
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Sleep Apnea and Heart Attack

Obstructive sleep apnea can increase the risk of heart attack by as much as 30% over the course of 5 years, suggests a study presented at the 2007 American Thoracic Society International Conference. Researchers noted that the risk of developing or dying from heart disease rises with increasing sleep apnea severity.

Sleep Apnea and Diabetes

Obstructive sleep apnea may increase the risk of developing type 2 diabetes, indicates research presented at the American Thoracic Society conference. Patients who had severe obstructive sleep apnea had more than 2.5 times the risk of developing diabetes as those who did not suffer from nighttime breathing problems.
Sleep apnea may also increase the risk for women developing diabetes during pregnancy (gestational diabetes). Pregnancy-associated high blood pressure is also linked with sleep apnea.

Sleep Apnea and Depression

As sleep apnea worsens, the odds for developing depression increase, indicates a 2006 study in the Archives of Internal Medicine.

Continuous Positive Airway Pressure (CPAP)

CPAP is the best treatment for severe sleep apnea. However, according to a 2007 study in Sleep, most patients need to use it for a full night’s duration to achieve optimal benefits. The researchers noted that many patients experience some improvement in daytime sleepiness after 4 - 6 nightly hours of CPAP use, but that the best improvements in quality of life occur mostly after 7.5 hours of CPAP use each night.

Risk Factors for Sleep Apnea Surgery

According to a 2006 study in the Archives of Otolaryngology - Head & Neck Surgery, the risks for complications following uvulopalatopharyngoplasty (UPPP) increase with:

Severity of sleep apnea
Being overweight (higher body mass index)
Having other medical conditions in addition to sleep apnea
Undergoing other surgical procedures at the same time as UPPP

Introduction

Sleep apnea is a disorder in which a person stops breathing during the night, perhaps hundreds of times, usually for periods of 10 seconds or longer and sometimes for as long as a minute. These gaps in breathing are called apneas. The word apnea means absence of breath.

Sleep apnea is usually accompanied by snoring. People might not even know they have the condition. It inevitably causes daytime sleepiness.

Sleep apnea is grouped into three categories:

Obstructive
Central
Mixed

There is also another, less severe form of obstructed breathing, called upper airway resistance syndrome (UARS).

Obstructive sleep apnea (OSA) is the most common form of apnea. It occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air. In general, OSA occurs as follows:

On its way to the lungs, air passes through the nose, mouth, and throat (the upper airway).
Under normal conditions, the back of the throat is soft and tends to collapse inward as a person breathes.
Dilator (widening) muscles work against this collapse to keep the airway open. Interference or abnormalities in this process cause air turbulence.
If the tissues at the back of the throat collapse and become momentarily blocked, apnea occurs. Breath is temporarily stopped. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath.
In some cases, the interference is incomplete (called obstructive hypopnea) and causes continuous but slow and shallow breathing. In response, the throat vibrates and makes the sound of snoring. Snoring can occur whether a person breathes through the mouth or the nose. (Snoring also occurs without sleep apnea.)
Apnea decreases the amount of oxygen in the blood, and eventually this lack of oxygen triggers the lungs to suck in air.
At this point, the patient may make a gasping or snorting sound but does not usually fully wake up.

Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness.

Central sleep apnea is much less common. It is caused by some problem in the central nervous system, most likely a failure of the brain to signal the airway muscles to breathe. In such cases, oxygen levels drop abruptly and usually the sleeper wakes with a start. Often people with central sleep apnea recall waking up. They generally experience less sleepiness during the day than people with obstructive sleep apnea. Heart disease, and in particular heart failure, is the most common cause of central sleep apnea.

Mixed apnea is the term used when the two apneas occur together.

Upper airway resistance syndrome (UARS) is a condition in which patients snore, wake frequently during the night, and have excessive daytime sleepiness. However, UARS patients do not have the breathing abnormalities that characterize sleep apnea and they do not show a reduction in blood oxygen levels. Unlike apnea, UARS is more likely to occur in women than in men. Treatments are similar to those of sleep apnea. It is not known if UARS has any serious health complications.

The daily cycle of sleeping and waking is called the circadian rhythm. It's commonly referred to as the biologic clock. Circadian means "about a day." Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (People who are confined to windowless homes, with no clocks or other time cues, sleep and wake on a slightly longer cycle.) The 24-hour circadian rhythm typically adheres to the following factors:

Humans are designed for daytime activity and nighttime rest.
There is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms mix with other factors that may interfere or change individual patterns:

The firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The Response in the Brain to Light Signals

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus or SCN.
This nerve cluster takes its name from its location. It sits just above (supra) the optic chiasm, a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep Cycles

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

The REM/NREM Cycle. The cycle between quiet (NonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of NonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the NonREM/REM cycle repeats.
With each cycle, NonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Symptoms

People with sleep apnea usually do not remember waking during the night.

Symptoms may include:

Excessive daytime sleepiness
Morning headaches
Irritability and impaired mental or emotional functioning
Snoring (bed partners may report very loud and interrupted snoring)
Heartburn (acid back-up that causes heartburn may be responsible for some cases of sleep apnea)

Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:

Longer total sleep time than normal in some children, especially obese children or those with severe apnea.
Snoring. (An estimated 3 - 12% of all children snore. However, not all of them have sleep apnea.)
More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep.
Behavioral difficulties without any obvious cause, such as hyperactivity and inattention. (Some patients may even be misdiagnosed with attention-deficit hyperactivity disorder.)
Irritability
Bed-wetting
Morning headaches
Failure to grow and gain weight

Causes

Any structural abnormality in the face, skull, or airways that causes some obstruction or collapse in the upper airways and reduces air pressure can produce sleep apnea syndrome. Abnormalities in tissues that lie between the back of the mouth and the esophagus (food pipe) are one of the most common structural causes of sleep apnea. Enlarged soft palates (the base of the tongue and surrounding throat walls) are also associated with many cases of sleep apnea.

Researchers have identified several physiologic abnormalities that may play a role in causing sleep apnea or in making it worse. These include an inability to regulate levels of carbon dioxide, impaired brain and nervous system responsiveness to various chemical messengers, and poor reflexes or muscle tone in the upper airways. The underlying reasons for these disturbances and their connection to apnea require further study.

Obesity is strongly associated with sleep apnea and is a cause of it in some cases. Imaging scans have shown fatty cells clogging the throat tissue, which indicates that they narrow the airways. In one study, the more obese a person with sleep apnea was, the higher the pressure on the airway and therefore the greater the obstruction of the airway. (Obstructive sleep apnea may also contribute to obesity itself, however, since a sleepy person tends to be sedentary.)

Snoring. Chronic snoring itself may actually be a cause of sleep apnea. Over time, the vibrations and the increased pressure against the upper airways as snoring people inhale may cause the soft palate to lengthen. This stretched palate is more prone to collapse and obstruction.

It should be stressed that snoring is very common. Snoring occurs in about a third of the population, while apnea, according to one study, occurs in only 6%. Snoring, then, does not always cause apnea, nor is it always a sign of the respiratory disorder. Furthermore, while snoring is also associated with daytime sleepiness regardless of whether apneas are present, snoring alone does not appear to pose any major health risks.

Mouth Breathing. Some evidence suggests that a tendency to breathe through the mouth (rather than the nose) during childhood can actually produce structural changes in the face (longer face, narrow jaw, receding chin). Such facial characteristics may eventually put people at risk for sleep apnea.

Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes are the following:

Facial or skull abnormalities in infants.
Overgrown tonsils, adenoids, or both in small children. (Removal of tonsils or adenoids can free the airways and solve the problem.)
Premature infants also commonly have a form of apnea that may be related to lung or nervous system problems.

Risk Factors

Gender. More men than women appear to have sleep apnea. In the U.S., about 4% of men and 2% of women age 30 - 60 meet the criteria for obstructive sleep apnea. Such people have at lease five episodes of apnea or hypopnea (shallow nighttime breathing) for each hour of sleep plus excessive daytime sleepiness. A much higher percentage has just one of these two conditions.

Sleep apnea actually may be underdiagnosed in women, particularly older women. In general, older women have the same incidence of sleep apnea as men their own age. It is not clear why apnea occurs more often in men than women before menopause and why prevalence equalizes after menopause. Men tend to have larger necks and to weigh more than women and women tend to gain weight and develop larger necks after menopause. However, studies have not found that these physical factors fully explain the differences in risk by gender in young adults or the increase in sleep apnea in postmenopausal women.

Age. Sleep apnea is most common and its symptoms are worse in middle-aged adults age 40 - 60 years old. Nevertheless, it affects people of all ages.

Ethnicity. African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.

Obesity, especially having fat around the abdomen (the so-called apple shape), is a particular risk factor for sleep apnea, even in adolescents and children. However, many people with sleep-related breathing disorders, particularly women and small children, are not obese. Also, not all people who are obese have sleep apnea. Specific anatomical and physiological properties in the airways are more likely to be present in obese individuals with apnea.

Having a Larger Neck. Having a large neck is a risk factor for sleep apnea. In fact, larger necks in men may be the primary reason for their higher risk for sleep apnea compared to women. A neck measurement of 17 inches or greater in men or at least 16 inches in women is one indicator that may suggest the condition. Postmenopausal women are more likely than younger women to have sleep apnea, in part because they tend to be heavier and have larger necks.

Specific Facial and Skull Characteristics. Structural abnormalities in the face and skull may be responsible for many cases of sleep apnea. These are likely to be the cause in many non-obese people with early-onset sleep apnea, particularly if they also have a family history of the problem.

Specific physical characteristics that may increase the risk for sleep apnea in both adults and children include:

A long lower part of the face
Brachycephaly, a birth defect in which the head tends to be shorter and wider than average
A narrow upper jaw
A receding chin
An overbite
A larger tongue

Characteristics in the Soft Palate. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:

The soft palate is stiffer, larger than normal, or both. An enlarged soft palate may be a significant risk factor for sleep apnea.
The soft palate and the walls of the throat around it collapse easily.

Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.

Alcohol. Alcohol use has been associated with apnea, although studies are mixed. A major survey reported that 53% of people who use alcohol to help fall sleep experience symptoms of sleep apnea. Another study found no relationship.

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.

Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. In one study, almost half of apnea patients had symptoms of GERD. Some experts suggest that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Or, apnea itself may cause pressure changes that trigger GERD. Some evidence suggests that treating sleep apnea with continuous positive airway pressure (CPAP) may reduce GERD symptoms by nearly 50%. However, obesity is common in both conditions. More research is needed to clarify the association.

Polycystic Ovary Syndrome (PCOS). In a 2000 study, women with PCOS were 30 times more likely than other premenopausal women to have obstructive sleep apnea and excessive daytime sleepiness. Women with PCOS produce high amounts of male hormones, particularly testosterone, which can cause obesity, facial hair, and acne. About half of PCOS patients also have diabetes. Obesity and diabetes are both associated with sleep apnea and may be the common factors.

Chronic Problems in the Upper Airways. A 2001 Swedish study found that people with respiratory tract disorders, including asthma, chronic bronchitis, or seasonal allergies, reported symptoms of sleep apnea more often than those without any of these ailments.

Hypothyroidism. In rare cases, hypothyroidism (low thyroid) has been reported as a possible cause of sleep apnea. In such cases, treating the thyroid condition improves the sleep apnea.

Prognosis

Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Researchers are intensively investigating why a problem in the upper airways is associated with serious conditions of the heart and circulatory system. Here are some of their findings:

Major known risk factors for hypertension and heart disease (obesity, smoking, and alcohol abuse) are associated with sleep apnea. These factors, however, do not explain all cases of higher heart-related risks in people with sleep apnea. For example, among overweight people, those who have sleep apneas have a greater risk of heart problems than those without them.
When breathing stops during episodes of apnea, carbon dioxide levels in the blood increase and oxygen levels drop. This effect may trigger a cascade of physical and chemical events that can then increase risk for heart problems.
Apnea also causes decreased levels of the gas nitric oxide (NO), a potent substance that causes blood vessels to be elastic and expand. NO plays a crucial role in blood pressure control and heart health.
Apnea may also increase levels of a substance called angiotensin-converting enzyme (ACE), which is known to play a role in high blood pressure and congestive heart failure.
Researchers have reported high levels of certain immune factors called tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6) in people with sleep apnea, particularly those who are obese. High levels of TNF-alpha and IL-6 produce a damaging inflammatory response, which can harm cells in the body, including those in the arteries. Elevated TNF-alpha may be associated with fatigue, shortness of breath, and a diminished heart-pumping action.

At this time, however, evidence of a clear causal relationship with any of these health problems is still weak. Some studies have found no significant independent risk for heart disease from obstructive sleep apnea. The following are some discussions on the possible effects of apnea on specific health problems.

High Blood Pressure. A number of studies have found a strong association between sleep apnea and high blood pressure (hypertension). (In the past, the link between sleep apnea and hypertension was thought to be due to obesity, a risk factor for both conditions, but more recent studies contradict that theory.) A 2000 study followed patients for 4 years; the more nightly apnea episodes they had in the first year, the more likely they were to develop hypertension by the fourth year. A weak, but still higher-than-normal, association with high blood pressure has also been observed in those who snore, wake frequently during the night, or have mild sleep apnea.

A 2004 data analysis of over 200,000 patient records revealed that people who took both antidepressants and antihypertensives were 18 times more likely to be diagnosed with obstructive sleep apnea than those who did not take the medications. The probability was highest among adults age 20 - 39 years. These drugs do not cause sleep apnea, but antidepressants may be prescribed to treat hypertensive patients’ complaints of fatigue even if sleep apnea is the real cause. The researchers recommended that patients being treated for high blood pressure, depression, and fatigue should also be evaluated for sleep apnea.

One way that apnea may directly affect blood pressure, regardless of other risk factors:

Blood pressure fluctuates widely and suddenly in response to episodes of apnea and hypopnea (shallow nighttime breathing).
Such fluctuations are possibly due to a sudden surge in the sympathetic nervous system, which controls involuntary muscle responses, importantly those in the blood vessels and heart, and may also play a role in sleep apnea.
These fluctuations lead to transient constriction of blood vessels that, over time, could possibly lead to sustained hypertension and heart damage.
Effective treatment of sleep apnea with continuous positive airway pressure (CPAP) may reduce blood pressure. Sleep apneas must be significantly reduced, however, to have any effect on blood pressure. Even a 50% reduction in apneas has no effect.

Coronary Artery Disease and Heart Attack. Sleep apnea has been associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. In a 2001 study, researchers observed that the more episodes of apnea and hypopnea a patient had, the higher the risk for a heart attack.

Many of the factors associated with stroke and sleep apnea (a risk for blood clots and narrowing of the arteries) may also increase the risk for heart attacks. Research presented at the 2007 American Thoracic Society conference suggested that severe obstructive sleep apnea can increase the risk of dying from a heart attack by as much as 30% over a 4 - 5 year period. Obstructive sleep apnea, however, may have other effects that increase the risk for heart problems:

Some evidence suggests that obstructive apneas cause an increase in stiffness and inflammation in the arteries, which is now proving to be an important aspect of heart disease, particularly in older adults.
A 2002 study reported that the white blood cells of patients with apnea have an increased number of proteins called adhesion molecules on their surface that may bind to the lining of blood vessels and cause inflammation. Increasingly, scientists believe that inflammation plays an important role in the development of coronary artery disease, heart attacks, and many other major ailments.

Stroke. Sleep apnea doubles the risk for stroke. The worse the sleep apnea, the greater the risk; moderate-to-severe obstructive sleep apnea can triple the risk of stroke. Sleep apnea is also associated with high blood pressure, a known risk factor for stroke. However, people who have sleep apnea, but not high blood pressure, are also still at increased risk for stroke. Sleep apnea in stroke patients is also associated with a higher risk for worse symptoms after a stroke, including delirium, depression, poor response to speech, and difficulty conducting daily chores.

A 2000 study observed that blood becomes more viscous (stickier) in the morning in people with obstructive sleep apnea compared to people without the sleep disorder. Such "sticky" blood is more apt to form clots that can lead to strokes. To support this, another 2000 study reported that stroke victims with sleep apnea tended to have higher levels of the blood protein fibrinogen than stroke victims without sleep apnea. Fibrinogen is a factor in blood that causes it to clot. Higher levels of fibrinogen have been linked to both strokes and heart attacks.
A 1998 study reported that the carotid artery, the major artery to the brain, is in far greater danger of becoming sclerotic (hardened and narrower) in people with obstructive sleep apnea than in the average person. People with both diabetes and sleep apnea are at particularly high risk for this effect.

Heart Failure. Studies suggest that 11 - 37% of patients with heart failure also have sleep apnea. Both central and obstructive sleep apnea are linked with heart failure. The evidence for the association between heart failure and sleep apnea includes:

High blood pressure, which is associated with sleep apnea, is a major cause of later heart failure.
Sleep apnea reduces oxygen levels and causes abnormal changes in blood pressure and heart rate that add to the burden of the failing heart.
Obstructive sleep apnea can affect breathing functions that are particularly harmful for patients with existing congestive heart failure.
Sleep apnea is associated with poorer survival in patients with heart failure. Some studies have suggested that treating sleep apnea with CPAP may improve heart function in these patients. However, a 2005 New England Journal of Medicine study found that CPAP did not improve survival in patients with heart failure and central sleep apnea

Atrial Fibrillation. Sleep apnea is more common in people with atrial fibrillation (irregular heartbeat) than in patients with other heart conditions. In a 2005 study published in Circulation, 49% of patients with atrial fibrillation were at risk for developing apnea, compared with 32% of general cardiology patients. An earlier study indicated that patients with untreated obstructive sleep apnea may be at increased risk for recurrence of atrial fibrillation. Patients with atrial fibrillation who received CPAP treatment had a lower risk for recurrence.

Metabolic Syndrome. The metabolic syndrome (also called Syndrome X) is a cluster of abnormalities that cause insulin resistance. Some of these factors, including hypertension and obesity, are also associated with sleep apnea. A 2004 study found that metabolic syndrome was nine times more common among patients with obstructive sleep apnea, independent of obesity.

Diabetes. Severe obstructive sleep apnea may more than double the risk of developing type 2 diabetes. Sleep apnea also increases the risk for diabetes during pregnancy (gestational diabetes).

When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain. Some studies indicate that sleep apnea disrupts rapid eye movement (REM) sleep, which, in turn, increases the risk for obesity. Research indicates that animals deprived of REM sleep tend to eat more. People with apnea may also become too tired to exercise and so put on weight.

Sleep apnea is associated with a higher incidence of many medical conditions, other than heart and circulation. The links between apneas and the conditions are unclear.

Pulmonary hypertension.
Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
Kidney failure.
Peripheral nerve damage (tingling, pain, or numbness in the hands and feet).
Liver damage in obese individuals with sleep apnea. Recent research suggests that severe apnea may increase the risk of liver disease regardless of weight.
Seizures, epilepsy, and other nerve disorders. Sleep apnea appears to pose a particularly risk for nocturnal epilepsy, a condition in which seizures occur during sleep.
Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder has cured the headache, even the very severe and disabling form known as a cluster headache.
High-risk pregnancies. Sleep apnea causes higher rates of pregnancy complications, including gestational diabetes and high blood pressure.
Eye disorders, including glaucoma, conjunctivitis, dry eye, and various other infections and irritations. Findings presented at the 2003 annual meeting of the American Academy of Ophthalmology suggested that patients with sleep apnea may be at increased risk for glaucoma and should be tested for this eye disease. A vision-damaging condition called intracranial hypertension has also been observed in some patients with sleep apnea.

Studies report an association between severe apnea and psychological problems. In one study, 32% of patients had symptoms of depression. According to a 2006 study, the risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder. Certainly, daytime sleepiness interferes with mental alertness and quality of life.

Because sleep apnea so often includes noisy snoring, the condition can also adversely affect the sleep quality of a patient's bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system. Most often, sleep apnea in children is caused by overgrown tonsils or adenoid. Their removal often completely solves all of these problems, including resolution of sleep apnea and restoring weight gain and normal growth hormone levels.

Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Snoring, rather than sleepiness, is a stronger risk factor for hyperactivity in many of these children, especially boys under 8 years old. (Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.)

Some researchers believe that sleepiness associated with sleep apnea is the greatest risk factor for car accidents. As many as 200,000 automobile accidents in the U.S. and 1,500 deaths from such accidents are caused by sleepiness. Studies continue to report that drowsy driving is as risky as drunk driving. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents.

Diagnosis

Not all people with suspected sleep apnea require medical tests. Expensive diagnostic efforts are probably not required for individuals who have no other health risk factors and whose suspected apnea does not affect their quality of life or safety on the road.

Doctors, however, should order diagnostic sleep studies if:

The patient has a serious medical condition that might be worsened or caused by sleep apnea. Such conditions include heart disease, high blood pressure, heart failure, diabetes, chronic headaches, epilepsy, obstructive lung disease, or severe acid reflux (GERD).
A child who shows signs of sleep apnea also has attention deficit problems or fails to thrive.
The sleep apnea is severe enough to impair quality of life, increase the risk for accidents, or both.

In some cases of an uncertain diagnosis, high-risk patients may need to consult a sleep specialist or go to a sleep disorders center. At most centers, patients undergo an in-depth analysis, usually supervised by a multi-disciplinary team of consultants who can provide both physical and psychiatric evaluations. Centers should be accredited by the American Academy of Sleep Medicine.

To help determine the presence of sleep apnea, the doctor will ask the following questions:

Is the patient taking any medications?
How many periods of sleepiness are there each day and when do they occur? (Patients with apnea often do not describe this symptom as feeling "sleepy." They are more apt to describe this feeling as "lack of energy" or "feeling tired all day.")
How restful is sleep?
Do headaches occur regularly in the morning?
Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
Does the patient have any problems with mental or emotional functioning?
Does the patient suffer from heartburn?
What is the normal sleeping position (back, side, or stomach)?
If there is a sleeping partner, does he or she complain about the patient's snoring or gasping for breath? (Many times it is useful to interview the bed partner.)

Keeping a Record of Sleep. To help answer these questions, the patient may need to keep a sleep diary. Every day for 2 weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. Recording sleep behavior using an extended-play audio or videotape can be very helpful in diagnosing sleep apnea.

To diagnose sleep apnea, the doctor will check for physical indications of sleep apnea, including:

Abnormalities in the soft palate or upper airways, including enlarged tonsils
Upper body obesity
A wide neck measurement

Some evidence suggests that doctors may accurately identify nearly all cases of suspected sleep apnea using physical criteria, including taking measurements of body mass (the indication of obesity), neck circumference, and four areas inside the mouth.

If sleep apnea is not obvious after a physical examination and history, the doctor will need to rule out any other problems. These include sleep disorders, (such as narcolepsy, insomnia, or restless legs disorder), or any medical or psychologic conditions (chronic fatigue syndrome, depression) that may be causing daytime sleepiness.

Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography involves many measurements and is typically performed at a sleep center.

The patient arrives about 2 hours before bedtime without having made any changes in daily habits. Polysomnography electronically monitors the patient as he or she passes, or fails to pass, through the various sleep stages. Polysomnography tracks:

Brain waves
Body movements
Breathing
Heart rate
Eye movements

Changes in breathing and blood oxygen levels are also recorded. In patients with suspected sleep apnea, the sleep expert will track instances of apnea and hypopnea that last longer than 10 seconds. In general, if there are more than five episodes per hour, apnea is significant and if there are more than 15, the condition is serious.

Overnight polysomnography has been the gold standard for diagnosing obstructive sleep apnea in both adults and children. It is very labor-intensive and expensive, however, and also misses snoring-induced arousals. It is not always covered by health insurance, and some centers have waiting lists that are months long.

A number of portable devices are available, or are being developed, so that patients have the convenience of being monitored at home. Experts hope that such monitors eventually will replace the need for overnight sleep clinics or the need for attended monitoring at home. Limited evidence exists, however, on the accuracy of many portable monitors. Patients with serious medical conditions, including heart failure or a history of stroke or respiratory failure, should not use home tests.

The following are descriptions of some home monitoring techniques.

Home Oximetry. Pulse oximetry is a procedure that determines if oxygen levels in the blood are low. This is called hypoxia. Normal levels during the night would generally rule out sleep apnea. With this procedure, a device called a pulse oximeter is attached to the patient's finger. The oximeter transmits red and infrared light through the capillaries in the finger. Hemoglobin, a molecule in the blood that carries oxygen, absorbs part of these light waves. The ratio of the two light beams provides the measurement of oxygen. The test is not always accurate, however. A combination with polysomnography, especially heart rate measurements, may be best for diagnosing sleep apnea.

Home oximetry monitors are available to rule out sleep apnea, but their accuracy is unclear. A 2003 study indicated that home oximetry alone was not very helpful in discriminating between patients with or without sleep apnea. Home oximetry however, may be helpful in identifying patients with unsuspected and seriously low oxygen levels.

Unattended Monitoring with Auto-CPAP. This method is a recent and simple method for detecting impaired breathing. It uses an auto-CPAP machine, which is programmed to apply pressure through the airways via a tube that attaches to a mask that fits the nose. A monitor is attached that digitizes and records on a computer all the information on any apnea episodes during sleep.

Nasal Pressure Recording. One promising technique uses a very simple prong device that attaches to the nostrils. A monitor records the airflow through the mouth and nose.

Peripheral Arterial Tonometry. An investigative technique called peripheral arterial tonometry measures changes in blood flow in the arteries of the fingertips during sleep. Such measurements are proving to be accurate in detecting sleep apnea in 80% of cases.

The Epworth Sleepiness Scale uses a simple questionnaire to measure excessive sleepiness during eight situations.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

Lifestyle Changes

Sleeping on the back causes sleep apnea in about half of all people with mild sleep apnea. Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring in people who lay on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (Indeed, astronauts show a marked reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children.

As a first step in dealing with sleep apnea, the patient should simply try rolling over onto the side. Patients who sleep on their backs and have 50 - 80 apneas per hour can sometimes nearly eliminate them when they shift to one side or the other. (Changing positions is less effective the more overweight a person is, but it still helps.)

Here are some suggestions that might help a person maintain a low-risk sleeping position:

Sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it.
A special pillow that helps to stretch the neck may reduce snoring and improve sleep for people with mild sleep apnea.
Sleeping in an upright position may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.

Over-the-counter nasal strips, such as the Breathe Right strip or other devices that open the nostrils, are inexpensive and useful to prevent snoring. They may significantly improve early-stage sleep in people with sleep disorders associated with nasal obstruction and help reduce morning tiredness. They are not intended as treatments for sleep apnea, however.

All patients with obstructive sleep apnea who are overweight should attempt a weight-reducing program. Weight loss certainly reduces snoring in many people, sometimes stopping it completely. It also improves sleep and significantly reduces daytime sleepiness. A 2000 study suggested that people who lost 10% of body weight experienced an average 26% reduction in risk for developing sleep apnea in the first place. (Gaining 10% of their body weight, on the other hand, increased the odds of sleep apnea 6-fold.)

Smokers should quit, since smoking worsens apnea
Alcohol should be avoided within 4 hours of sleep

Treatment

Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.

At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of such devices available.

The best treatment for severe obstructive and mixed sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children. CPAP is not recommended for patients with mild apnea. Patients with apnea but no daytime sleepiness report little or no benefit from this treatment.

CPAP works in the following way:

The device itself is a machine weighing about 5 pounds that fits on a bedside table.
A mask containing a tube connects to the device and fits over just the nose.
The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep.

Effects on Sleep and Wakefulness. A major 2003 analysis confirmed the benefits of CPAP on both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:

Restoration of normal sleep patterns.
Greater alertness and less daytime sleepiness.
Less anxiety and depression and better mood.
Improvements in work productivity.
Better concentration and memory. Some adults with symptoms of attention deficit hyperactivity disorder have improved after CPAP treatments for apnea. In two studies, however, equal improvements were also observed in people on sham CPAP, suggesting that the actual cognitive benefits from CPAP may be modest.
Patients' bed partners also report improvement in their own sleep when their mates use CPAP, even though objective sleep tests showed no real difference in the partners' sleep quality.

If patients do not experience less sleepiness after a period of time and are still complying with the regimen, then the airflow pressure may not be high enough. Patients may require retesting. Many patients report feeling more alert after CPAP treatments even if objective laboratory tests fail to show significant differences in the number of apneas and wake-up periods.

Protection from Accidents. Studies suggest that treatment with CPAP can reduce the risk for accidents. In a 2001 study, untreated patients had a risk for automobile accidents that was three times the risk in the general population. When these patients were treated, their risk fell to normal.

Effects on the Heart and Circulation. Evidence is mixed on whether CPAP treatment may reduce serious heart conditions. Early studies suggested that CPAP could improve heart function, lower blood pressure, and prevent new cardiac events (such as heart attacks) in patients with congestive heart failure and coronary artery disease. However, a 2005 study in the New England Journal of Medicine found that, while CPAP helped improve some heart disease symptoms, it did not affect overall survival in patients with heart failure and central sleep apnea. (Patients with heart failure often have central sleep apnea.)

It is also unclear whether CPAP improves blood pressure. A 2006 study of patients with high blood pressure and sleep apnea indicated that short-term (4 weeks) CPAP treatment has no significant effect on lowering blood pressure. (It is possible that longer-term treatment may be helpful.) Other studies have found blood pressure benefits from short-term CPAP treatment. Treatment for sleep apneas must be very effective, however, to have any benefits on blood pressure. Even a 50% reduction in apneas has no effect.

Effects on Other Medical Conditions. Some studies suggest other benefits with the use of CPAP:

Fewer morning headaches
Reduction in abdominal fat (abdominal fat has been related to a higher risk for diabetes and heart disease)
Lower blood sugar levels in patients with type 2 diabetes
Improved thinking and concentration in people with impaired mental function from sleep apnea
Modest lung improvement in patients with both apnea and chronic obstructive lung disease (such as emphysema)

CPAP works well for both adults and children, but many patients have problems getting used to the device. Unfortunately, CPAP devices are often cumbersome, which can lead to patients becoming discouraged and stopping treatment. All patients should be warned that the first few nights of CPAP therapy are unnerving. The device often produces anxiety, primarily because of the mask. Starting out with low pressure to get used to the mask may help. Patients may actually experience less sleep or sleep of a different quality in the beginning of treatment.

Nearly all patients complain about at least one side effect. Nearly half of complaints are related to the mask. Many of these problems can be reduced with a well-chosen mask that is comfortable and reduces leakage as much as possible. Common complaints include:

Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal salt water sprays, or humidifiers may prevent these side effects. Heated humidification devices are also now available for CPAP users.
Excessive application of pressure making exhalation difficult.
A feeling of claustrophobia is a major factor in noncompliance. This can be improved by a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
Up to 30% of patients experience irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this effect.
Eye irritation or conjunctivitis.
Upper respiratory infections. It is very important to keep the unit clean.
Patients may also experience temporary chest muscle discomfort, which is caused by an increase in lung volume.
Severe side effects are very rare but may include heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull.
In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Patients can be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.

Although studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment, recent information suggests that it is improving, probably due to better technologies and better education. Patient education and support groups, a dedicated nurse to ensure close follow-up of patients (particularly in the first 2 weeks of therapy), and ready access to doctors to make adjustments as needed have all been shown to greatly improve compliance. (However, sleeping pills do not appear to help patients adapt to the device.) Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.

Because many patients find CPAP uncomfortable and difficult, they tend not to use it for the duration of the entire night. A 2007 study indicated that while some patients’ daytime sleepiness may improve after 4 - 6 hours of CPAP use each night, maximum benefits in quality of life require at least 7.5 hours of nightly CPAP use. It appears that longer nightly duration of CPAP use is best for achieving normal daytime functioning.

Bilevel Positive Airway Pressure. Bilevel positive airway pressure (BPAP) systems may be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. These machines are more expensive than the CPAP and may not be covered by insurance.

Automatic Titrating (Auto)-CPAP Pressure Devices. Even more sophisticated systems, called auto-CPAP devices, are available. These devices automatically customize air pressure for the individual patient. They usually use one of three methods:

Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
Pressure is low when there are no problems but is raised gradually when they are detected.
Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.

Brands include AutoAdjust, Virtuoso, and AutoSet. These devices are more expensive than those that provide continuous airflow. A 2003 study indicated that they may improve compliance, particularly in patients who require high CPAP use. They may be especially helpful for patients who require varying levels of pressure due to other conditions, such as seasonal allergies. They may also be useful as home diagnostic tools for sleep apnea. Auto-CPAP devices are not recommended for all patients, particularly those with heart failure or serious lung disease.

In general, drugs have not been very beneficial except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. The following may be helpful for certain patients:

Modafinil (Provigil), which is also used to treat narcolepsy, was approved by the FDA in 2004 as the first drug to treat the sleepiness associated with obstructive sleep apnea. However, Provigil is meant to be used in combination with -- not as a substitute for -- standard apnea treatments such as CPAP. Sleep experts stress that patients who take Provigil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying health risks associated with sleep apnea.
Thyroid hormone may help sleep apnea in those with low thyroid (hypothyroidism).
Theophylline, a drug commonly used for asthma management, has shown promise in treating central sleep apnea in patients with heart failure.
Omeprazole (Prilosec), a drug used for patients with severe heartburn, may help patients with both sleep apnea and gastroesophageal reflux disorder (GERD).

Note on Sedatives. Sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.

Dental Devices

Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with severe sleep apnea whenever possible.)

Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:

Mandibular advancement device (MAD). This is the most widely used dental device for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

MAD and similar devices seem to offer the following benefits:

Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
Improvement in sleep in many patients.
Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
Higher compliance rates than with CPAP.

According to a 2006 review, dental devices help control sleep apnea in 52% of treated patients. A 2002 report indicated that long-term use of a dental device achieved an 81% success rate in apnea improvement, which was significantly higher than the 53% success rate noted for uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There were also few complications with the dental device.

Dental devices, including MAD, are not as effective as CPAP therapy. The cost of these devices tends to be high. Side effects associated with dental devices include:

Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients stop using dental devices. Devices made of softer materials may produce fewer side effects.
Permanent changes in the position of the teeth or jaw have occurred in some cases of long-term use. Patients should have regular visits with a health professional to check the devices and make adjustments.
In a small percentage of patients, the treatment may worsen apnea. Patients should be monitored with polysomnography (sleep lab evaluation) before and after therapy and when apnea symptoms worsen or recur.

An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.

Surgery

Surgery is sometimes recommended, usually by throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.

The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.

The Goal of Surgery. The goal of UPPP is threefold:

Increase the width of the airway at the throat's opening
Block some of the muscle action in order to improve the ability of the airway to remain open
Improve the movement and closure of the soft palate

Success Rates. Success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate, which may or may not involve the tonsils. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior. In one study, sleeping on the side (rather than the back) after surgery significantly boosted success rates.

Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. It is recommended only for select patients with severe obstructive sleep apnea. The procedure also has a number of potentially serious complications. In fact, in one study, 42% of patients had complaints about the procedure. Some complications include:

Infection. In one study, this complication was so common that 40% of patients needed another operation because of it. Preventive antibiotics administered an hour before surgery can help reduce this risk.
Impaired function in the soft palate and muscles of the throat.
Mucus in the throat.
Changes in voice frequency.
Swallowing problems.
Regurgitation of fluids through the nose or mouth.
Impaired sense of smell.
Failure and recurrence of apnea. In such cases, CPAP is often less effective afterward, although one study found that oral appliances (plastic mouth retainer-like devices) may still help.

Experts estimate that in general about 1.6% of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeons. However, a patient’s health status may also affect outcomes. According to a 2006 study, patients are more likely to experience complications if they have severe sleep apnea, are overweight, have other medical problems, or undergo other surgical procedures at the same time as UPPP.

A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates from LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.

More than 50% of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.

The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. It helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate. The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia. Studies indicate it works as well as UPPP, with less pain and quicker recovery time.

Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:

The surgeon makes an opening through the neck into the windpipe and inserts a tube.
It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.

Today, this operation is performed rarely, usually only if sleep apnea is life-threatening.

A technique called radiofrequency ablation uses radiofrequency energy to shrink tissues in the upper airways:

The radio waves heat, stiffen, and shrink a small amount of tissue at the base of the tongue.
The therapy takes about 20 minutes and can be done in a doctor's office.
It typically requires 10 treatments within five or six sessions. (A newer form requires fewer treatment sessions, and it appears to be effective.)
It is far less invasive than standard surgery and results in far less pain and fewer complications. Discomfort can be controlled with simple pain relievers.

Studies reporting significant improvement in reduced snoring and less daytime sleepiness for some patients although, as with other surgeries, the benefits may be short term in the majority of patients. It may be helpful for mild obstructive sleep apnea.

Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. They include:

Tongue advancement, in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
Genioplasty, which is plastic surgery on the chin.
Hyoid surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
Maxillary or maxillomandibular advancement (MMA), which moves the upper (maxilla) or lower (mandible) jawbone forward. A survey of patients who had MMA found that the surgery changed their facial appearance, but most people thought it was a change for the better.
Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.

Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea. It cures the condition in 75 - 100% of cases. Two studies, published in 2005, suggested that adenotonsillectomy can significantly improve quality of life for children with obstructive sleep apnea.

Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:

Age under 3 years old
Severe sleep apnea
Heart complications
Failure to thrive
Obesity
Prematurity
Recent lung infections
Certain facial structures
Neuromuscular disease

The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.

Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.

Resources

www.sleepapnea.org -- American Sleep Apnea Association
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.aasmnet.org -- American Academy of Sleep Medicine
www.sleepfoundation.org -- National Sleep Foundation
www.nhlbi.nih.gov/about/ncsdr -- National Center on Sleep Disorders Research
www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
www.wfsrs.org -- World Federation of Sleep Research Societies

References

Bradshaw DA, Ruff GA, Murphy DP. An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea. Chest. 2006 Nov;130(5):1369-76.

Kezirian EJ, Weaver EM, Yueh B, Khuri SF, Daley J, Henderson WG. Risk factors for serious complication after uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 2006 Oct;132(10):1091-8.

Peppard PE, Szklo-Coxe M, Hla KM, Young T. Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med. 2006 Sep 18;166(16):1709-15.

Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007 Jun 1;30(6):711-9.

Review Date:
7/18/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Sleeping difficulty

admin — Thu, 04 Sep 2008 19:07:21 -0700

Overview

Definition
Alternative Names
Considerations
Common Causes
Home Care
Call your health care provider if
What to expect at your health care provider's office

Illustrations

Depression and insomnia

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Sleeping difficulty, called insomnia, can involve difficulty falling asleep when you first go to bed at night, waking up too early in the morning, and waking up often during the night.

Alternative Names

Insomnia; Inability to sleep; Dyssomnia; Sleeplessness; Wakefulness

Considerations

Everyone has an occasional sleepless night, and this is not a problem for most people. However, as many as 25% of Americans report occasional sleeping problems, and insomnia is a chronic problem for about 10% of people.

The lack of restful sleep can affect your ability to carry out daily responsibilities because you are too tired or have trouble concentrating. All types of insomnia can lead to daytime drowsiness, poor concentration, and the inability to feel refreshed and rested in the morning.

Most adults do best with about 8 hours of sleep each night until age 60, after which 6 hours may be enough. Even though the elderly need less sleep, almost one half of people over 60 experience some degree of insomnia.

The best measure of the amount of sleep needed is how you feel. If you awaken feeling refreshed, you are getting enough sleep. For some people, this may take only 4 hours. Others can need up to 10 hours to feel rested.

Using long-acting or high-dose sedatives as a "cure" for insomnia can make the problem worse, not better, over time. Antihistamines (the main ingredient in over-the-counter sleeping pills) can lead to similar difficulties. Using antihistamines over time may also affect your memory.

Strong, prescription sedatives do not produce a natural, restful sleep. In addition, you can become dependent on or tolerant of these drugs. In this case, the same dose of the drug no longer produces sleep, which may lead you to try a higher dose. Higher doses worsen the chance of dependence, tolerance, and side effects. Stopping these medications can cause a rebound insomnia and withdrawal.

A life-threatening disease is rarely the cause of problems with sleep. For many people, poor sleep habits are the cause. However, because insomnia is a key symptom of depression, you should be checked for depression if you are having trouble sleeping.

Insomnia may cause:

Dark circles under the eyes
Disorientation
Fatigue
Irritability
Posture changes
Reduced energy level

It may help to see a psychiatrist, doctor, or another mental health provider to evaluate psychiatric disorders that can lead to insomnia. If you are depressed, antidepressants can help both the sleeping problem and the depression. These medications do not carry the same concerns about tolerance and dependence as sedatives.

Counseling may help with nightmares and dreams that interfere with sleep.

Common Causes

Sleeplessness in adults may be due to:

Aging
Alcoholism or abruptly stopping alcohol after long-term use
Anxiety
Bed or bedroom that does not promote sleep
Depression or major depression
Diseases, such as an enlarged prostate, cystitis, COPD, arthritis, heartburn, and heart or lung problems
Exhilaration or excitement
Grief
Illicit street drugs, such as amphetamines and cocaine
Jet lag
Lack of exposure to bright light or sunlight
Medications, such as too much thyroid medicine, ephedrine, phenylpropanolamine, theophylline derivatives, and others
Overactive thyroid
Restless leg syndrome
Shift work
Sleeping too much during the day
Stimulants taken in the evening, including nicotine, alcohol, caffeine, or food
Stress and worrying
Suddenly stopping a medication (such as sleeping pills or sedatives)
Too much stimulation at bedtime
Wake-sleep pattern disturbances

IN INFANTS

Most newborn babies wake several times during the night, but by the age of 6 months they usually sleep through the night. At age 1, babies will sleep an average of 16 out of every 24 hours. Two to three hours of this sleep will be during the day.

Sleeplessness in infants may be due to:

Desire for attention from parents
Fever or other illness
Hunger
Indigestion
Infantile colic or other digestive problems
Teething

Home Care

Try changing your nighttime sleeping habits and other behavior before taking drugs for insomnia. For example:

Avoid emotional upset or stressful situations before bedtime.
Avoid using alcohol in the evening. Avoid caffeine for at least 8 hours before bedtime. Give up smoking, because nicotine is a stimulant.
Eat a light snack before bedtime. Foods such as warm milk or turkey contain a natural sleep inducer called L-tryptophan.
Establish a regular bedtime, but don't go to bed if you feel wide awake.
Exercise regularly, but not in the last 2 hours before going to bed. Exercise, especially aerobic exercise, has been shown to make people fall asleep faster and get deeper and more restful sleep. Sex can be a natural sleep inducer for some people.
Relax by reading, taking a bath, or listening to soothing music before going to bed.
Take your TV or computer out of your bedroom. Otherwise, your brain becomes used to the stimulation and starts to expect it when you are there. This makes it harder for you to fall asleep.
Use the bedroom for bedroom activities only. Once in bed, use creative imagery and relaxation techniques to keep your mind off unrestful thoughts. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom.

IN INFANTS AND CHILDREN

Avoid going in to your child's room throughout the night. Otherwise, the child may depend on the attention and become sleepless if you don't offer it.
Avoid sending your child to bed as punishment, which can make the child afraid and lead to poor sleep.
For children who have trouble falling asleep, try to make sure that the child is not disturbed by noise. Leaving a radio playing soft music may help cover up disturbing noises.
Never give a child sleeping medicine without asking the doctor first. It's usually not a good idea to treat the problem with drugs.

MEDICATION

Avoid all sedatives, including benzodiazepines, during pregnancy.
Over-the-counter sleep medicines can have side effects, including a "hangover" effect the next morning. If these fail, you may want to ask your health care provider to recommend other options.
Use medication as a last resort.

Call your health care provider if

Call your health provider if:

Your sleeping problem becomes persistent and unbearable, despite home treatment
Your sleeping problem occurs more than 3 nights per week for more than 1 month
You have other worrisome symptoms, such as chest pain or shortness of breath

What to expect at your health care provider's office

Your health care provider will do a physical examination. To help better understand your sleeping problems, he or she may ask the following:

Do you have difficulty falling asleep or staying asleep (insomnia)?
Do you wake up not feeling rested?
How often do you wake up at night?
How long have you had the problem?
Have you taken any over-the-counter sleeping products?
What medications do you take?
Do you take any herbal supplements or alternative remedies?
Do you drink much coffee or alcohol? Have you recently cut down on your coffee or alcohol?
Do you have any excessive stress or anxiety?
How much do you normally sleep? What hours?
What do you do during the few hours before you go to bed?
Does your sleep schedule change often? (shift work)
Do you fall asleep at the wrong times or places?
Does your sleep schedule change a lot on weekends?
Do you worry too much about sleep?
Do you have breath-holding spells, or do you snore?
Do you have any aches or pains that prevent you from sleeping?

In some cases, the health care provider may recommend the following tests:

Psychological tests
Sleep log record
Thyroid tests (TSH, T3, T4)

In some rare cases, your health care provider may want you to see a sleep medicine specialist who will perform a sleep study (polysomnography)

MEDICATIONS

Most people don't need medication. Your health care provider can talk to you about using prescribed medications if everything else has failed.

Some antidepressants such as Elavil (amitriptyline) can be used at bedtime because they make you drowsy. They require a prescription. If insomnia is caused by depression, treating the depression with the right medications or therapy should solve the problem.

Benzodiazepines such as Valium (diazepam) or Ativan (lorazepam) are anti-anxiety medications that can also help people sleep. They must be used with caution because they can be addictive. They also require a prescription.

Newer sleep medicines help reduce the time it takes you to fall asleep. They are less likely to be addictive than benzodiazepines. Two examples are the prescription medicines Ambien (zolpidem) and Sonata (zaleplon).

WARNING: The FDA has asked manufacturers of sedative-hypnotic sleep medicines to put stronger warning labels on their products so that consumers are more aware of the potential risks. Possible risks while taking such medicines include severe allergic reactions and dangerous sleep-related behaviors, including sleep-driving.

Review Date: 2/6/2008

Reviewed By: Christos Ballas, M.D., Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed byDavid Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Source Doc: 1_003210

Gastroesophageal reflux disease and heartburn

FitSugar — Wed, 08 Oct 2008 17:35:29 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Symptoms
Complications
Barrett's Esophagus
Diagnosis
Treatment
Prevention
Medications
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

New Research

Obesity and GERD. Increased weight in women is linked to more frequent GERD symptoms, according to the Nurses' Health Study, which included 10,545 female participants. Overweight and obese women were two to three times more likely to have frequent symptoms than women of normal weight. GERD symptoms decreased nearly 40% in women whose body mass index (BMI) dropped by more than 3.5, compared to women whose BMI remained the same.
Proton-Pump Inhibitors and Bone Fracture. Long-term use of PPIs may increase the risk of hip fractures in older adults, according to a study in the Journal of the American Medical Association. People taking high doses of PPIs for more than a year were 2.6 times as likely to fracture a hip as those who were not taking the drug. The authors suggested that the stomach acids blocked by PPIs may be needed to absorb calcium, or the drugs may interfere with the body's natural process of breaking down and rebuilding bones.
PPIs and H2 Blockers in Children. Otherwise healthy children who take PPI inhibitors or H2 blockers may be at increased risk for intestinal and respiratory infections, according to a study of 186 children with GERD. The rate of gastroenteritis and community-acquired pneumonia significantly increased in children who were taking these medications when researchers compared the 4 months before and after enrollment in the study.

New Approval

Proton-Pump Inhibitor Approved for Adolescents. Esomeprazole (Nexium) delayed-release capsules have been approved for use in children ages 12 - 17 for the short-term treatment of GERD. Research shows that this medication reduces heartburn symptoms in adolescents.

Introduction

Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach move backward into the esophagus (an action called reflux). Reflux occurs if the muscular actions in the esophagus or other protective mechanisms fail.

Click the icon to see an animation about heartburn.

The hallmark symptoms of GERD are:

Heartburn: a burning sensation in the chest and throat.
Regurgitation: a sensation of acid backed up in the esophagus.

Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful.

Heartburn is a condition in which the acidic stomach contents back up into the esophagus, causing pain in the chest area. This reflux usually occurs because the sphincter muscle between the esophagus and stomach is weakened. Standing or sitting after a meal can help reduce the reflux that causes heartburn. Continuous irritation of the esophagus lining as in gastroesophageal reflux disease is a risk factor for the development of adenocarcinoma.

The esophagus, commonly called the food pipe, is a narrow muscular tube about nine-and-a-half inches long. It begins below the tongue and ends at the stomach. The esophagus is narrowest at the top and bottom; it also narrows slightly in the middle. The esophagus consists of three basic layers:

An outer layer of fibrous tissue.
A middle layer containing smoother muscle.
An inner membrane, which contains numerous tiny glands.

Click the icon to see an image of the esophagus.

When a person swallows food, the esophagus moves it into the stomach through the action of peristalsis, wave-like muscle contractions. In the stomach, the starch, fat, and protein in food are broken down by acid and various enzymes, notably hydrochloric acid and pepsin. The lining of the stomach has a thin layer of mucous that protects it from these fluids.

If acid and enzymes back up into the esophagus, however, its lining offers only a weak defense. The esophagus is protected using specific muscles and other factors.

The most important structure protecting the esophagus may be the lower esophageal sphincter (LES). The LES is a band of muscle around the bottom of the esophagus where it meets the stomach.

The LES opens after a person swallows to let food enter the stomach and then immediately closes to prevent regurgitation of the stomach contents, including gastric acid.
The LES maintains this pressure barrier until food is swallowed again.

Click the icon to see an image of the stomach.

If the pressure barrier is not sufficient to prevent regurgitation and acid backs-up (reflux), then peristaltic action of the esophagus serves as an additional defense mechanism and pushes the contents back down into the stomach.

Esophagitis. In most people, GERD symptoms are short-lived and occur infrequently. In about 20% of cases, however, the condition becomes chronic. When the acid causes irritation or inflammation, the condition is called esophagitis. If the damage becomes extensive and injures the esophagus, the disorder is known as erosive esophagitis.

Non-Erosive Esophageal Reflux Disease. Symptoms of gastroesophageal reflux disease can occur without any signs of inflammation or injury to the esophagus. This condition is also referred to as non-erosive esophageal reflux disease (NERD). NERD rarely progresses to full-blown GERD. Patients with NERD have no signs of inflammation or erosion in the esophagus, but they experience certain symptoms of GERD, such as burning sensations behind the breastbone for at least 3 months. Researchers suggest that nerves lying near the surface of the lining become exposed to acid that has penetrated the layers. The nerves then trigger prolonged and painful symptoms in response.

Barrett's Esophagus. A small percentage of patients with GERD may eventually develop Barrett's esophagus, a serious complication of GERD that results in precancerous changes in the tissue lining the esophagus.

Eosinophilic Esophagitis. This is a distinct disorder characterized by difficult or painful swallowing. It can occur along with GERD. The lining of the esophagus develops furrows and rings. This condition can be treated with swallowed fluticasone propionate, the active ingredient in some asthma medications.

Causes

Anyone who eats a large amount of acidic foods can have mild and temporary heartburn. This is especially true when lifting, bending over, or taking a nap after eating a large meal high in fatty, acidic foods. Persistent GERD, however, may be due to various conditions, including abnormal biologic or structural factors.

The band of muscle tissue called the LES is responsible for closing and opening the lower end of the esophagus and is essential for maintaining a pressure barrier against contents from the stomach. It is a complex area of smooth muscles and various hormones. If it weakens and loses tone, the LES cannot close up completely after food empties into the stomach. In such cases, acid from the stomach backs up into the esophagus. Dietary substances, drugs, and nervous system factors can weaken the LES and impair its function.

A study showed that more than half of GERD patients had abnormal nerve or muscle function in the stomach. These abnormalities cause impaired motility, which is the inability of muscles to act spontaneously. The stomach muscles do not contract normally, which causes delays in stomach emptying, increasing the risk for acid back-up.

Some studies suggest that most people with atypical GERD symptoms (such as hoarseness, chronic cough, or the feeling of having a lump in the throat) may have specific abnormalities in the esophagus. (In one study, such abnormalities appeared in 73% of patients who had atypical symptoms.)

Motility Abnormalities. Problems in spontaneous muscle action (peristalsis) in the esophagus commonly occur in GERD, although it is not clear if such occurrences are a cause or result of long-term effects of GERD.

Adult-Ringed Esophagus. This condition is characterized by an esophagus with multiple rings and persistent trouble with swallowing (including getting food stuck in the esophagus). It occurs mostly in men.

The hiatus is a small hole in the diaphragm through which the esophagus passes into the stomach. It normally fits very snugly, but it may weaken and enlarge. When this happens, part of the stomach muscles may protrude into it, producing a condition called hiatal hernia. It is very common, occurring in over half of people over 60 years old, and is rarely serious. Until recent years, it was believed that most cases of persistent heartburn were caused by a hiatal hernia. Hiatal hernia may impair LES muscle function. Studies have failed to confirm evidence, however, that it is a common cause of GERD, although its presence may increase GERD symptoms in patients with both conditions.

A hiatal hernia occurs when part of the stomach protrudes up into the chest through the sheet of muscle called the diaphragm. This may result from a weakening of the surrounding tissues and may be aggravated by obesity or smoking.

Studies indicate that 31 - 43% of reflux may be hereditary. An inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in the stomach or esophagus. Genetic factors may play an especially strong role in susceptibility to Barrett's esophagus, a precancerous condition caused by very severe GERD.

At least half of people with asthma also have GERD. Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux. Certain asthma drugs that dilate the airways may relax the LES and contribute to GERD. On the other hand, GERD has been associated with a number of other upper respiratory problems and may be a cause of asthma, rather than a result.

Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus. Other disorders that may affect areas that can contribute to GERD include diabetes, any gastrointestinal disorder, peptic ulcers, lymphomas, and cancer.

Click the icon to see an image of inflammatory bowel disease.

Helicobacter Pylori, also called H. pylori, is a bacterium found in the mucous membranes and is now known to be a major cause of peptic ulcers. Antibiotics used to eradicate H. pylori are now accepted treatment for curing ulcers. Of some concern, however, are studies indicating that H. Pylori may actually protect against GERD by reducing stomach acid. Furthermore, curing ulcers by eliminating the bacteria might actually trigger GERD in some people. Studies are mixed, however, on whether patients with cured H. Pylori infections are at risk for GERD. An analysis of 8 studies reported no higher risk for GERD after antibiotic treatments, nor was GERD any worse in patients who already had it. Seven of the 8 studies, however, were conducted only 2 months after antibiotic treatment. Longer follow-up studies are needed to determine long-term consequences, if any.

In any case, the bacteria should be eradicated in infected patients with existing GERD who are taking ongoing acid suppressing agents. There is some evidence that the combination of H. pylori and chronic acid suppression in these patients can lead to atrophic gastritis, a precancerous condition in the stomach.

In some cases, the esophagus appears normal, but GERD symptoms are present. This may indicate an over-reaction of the immune system to irritants that are introduced into the esophagus. In such cases, the immune system reacts with an exaggerated (or hyper-reactive) response, triggering the release of certain factors that end up causing inflammation and possibly injury. (This event is similar to the asthmatic response in the airways.)

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs), common causes of peptic ulcers, may also cause GERD and increase severity in people who already have GERD. In a 3-year study of 25,000 people, NSAID users were twice as likely to have GERD symptoms as non-users. Symptoms did not become evident until after about 6 months of regular use. There are dozens of NSAIDs, including over-the-counter aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve), as well as prescription anti-inflammatory medicines. A person with GERD who takes the occasional aspirin or other NSAID will not necessarily experience adverse effects. This is especially true if there are no risk factors or indications of ulcers. Acetaminophen (Tylenol), which is NOT an NSAID, is a good alternative for those who want to relieve mild pain. It does not, however, relieve inflammation.

Other Drugs. Many other drugs can cause GERD, including but not limited to the following: calcium channel blockers (used to treat high blood pressure and angina), anticholinergics (used in drugs that treat urinary tract disorders, allergies, and glaucoma), beta adrenergic agonists (used for asthma and obstructive lung diseases), dopamine (used in Parkinson's disease), bisphosphonates (used to treat osteoporosis), sedatives, antibiotics, potassium, or iron pills.

Weakened peristaltic movement in the esophagus may contribute to GERD. If the mucous membrane is impaired, even a normal amount of acid can harm the esophagus. Pressure on the abdomen caused by obesity and also wearing tight clothing can contribute to acid backing up into the esophagus.

Click the icon to see an image of peristalsis.

Risk Factors

GERD occurs monthly in about half of American adults. People of all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people.

Eating Pattern. Anyone who eats a heavy meal and subsequently lies on the back or bends over from the waist is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for heartburn.

Pregnancy. Pregnant women are particularly vulnerable to heartburn in their third trimester as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even antacids.

Obesity. A number of studies suggest that obesity contributes to GERD and may increase the risk for erosive esophagitis in GERD patients. The Nurses' Health Study found that being overweight or obese significantly increased GERD symptoms in women. The higher a woman's body mass index (BMI), the study found, the more frequent were her symptoms. Women who lost weight in the study saw a decrease in their symptoms. Research suggests that the prevalence of GERD symptoms among obese patients has been underreported. Other researchers have reported that increased BMI is associated with a higher risk for cancer of the esophagus (esophageal adenocarcinoma).

Respiratory Diseases. People with asthma are at very high risk for GERD. One study indicated that patients with chronic obstructive pulmonary diseases (e.g., emphysema or chronic bronchitis) were more likely to have GERD.

Chronic obstructive pulmonary disease (COPD) refers to chronic lung disorders that result in blocked air flow in the lungs. The two main COPD disorders are emphysema and chronic bronchitis, the most common causes of respiratory failure. Emphysema occurs when the walls between the lung's air sacs become weakened and the sacs get enlarged and filled with too much air. Damage from COPD is usually permanent and irreversible.

Smoking. Increasing evidence indicates that smoking raises the risk for GERD. Studies suggest that smoking reduces LES muscle function, increases acid secretion, impairs muscle reflexes in the throat, and damages protective mucous membranes. Smoking reduces salivation, which helps neutralize acid. Whether it is the smoke, nicotine, or both that triggers GERD is unknown. Some people who use nicotine patches to quit smoking, for example, experience heartburn, but it is not clear if it's the nicotine or stress that produces acid back-up.

Alcohol Use. Alcohol has mixed effects on GERD. It relaxes the LES muscles and, in high amounts, may irritate the mucous membrane of the esophagus. All alcoholic beverages increase stomach acid levels. A combination of heavy alcohol use and smoking increases the risk for esophageal cancer. (Small amounts of alcohol, however, may actually protect the mucosal layer.)

In general, overweight Caucasian males over 40 are at highest risk for complications, notably Barrett's esophagus. Others at high risk for severe symptoms, inflammation, or both include:

People who use nonsteroidal anti-inflammatory drugs (NSAIDs). Studies suggest that certain NSAID users are at higher risk for GERD, including older adults, women, alcohol and tobacco users, and patients with asthma, hiatal hernia, or obesity. One study reported that NSAIDs put people at risk for ulcers but not for erosive esophagitis or strictures. Interestingly, NSAIDs are being studied for protection against Barrett's esophagus.
People with hiatal hernia

GERD is very common in children of all ages, but it is usually mild. Heartburn has been reported in 1.8% of 3-year-olds and in 5.2% of young people 10 - 17 years old. Children with the following conditions are at higher risk for severe GERD:

Neurologic impairments
Food allergies
Scoliosis
Cyclic vomiting
Cystic fibrosis
Problems in the lungs, ear, nose, or throat
Any medical condition affecting the digestive tract

Symptoms in Children. A physician should examine any child who has the following symptoms as soon as possible, because they may indicate complications such as anemia, failure to gain weight, or respiratory problems. Symptoms of severe GERD in infants and small children may include:

Chronic coughing
Frequent infections
Wheezing
Gasping or frequent cessation in breathing while asleep (called sleep apnea). However, one study found no association between GERD and apneas in premature infants.
Frequent vomiting in infants. About half of all infants up to 3 months old regurgitate milk at least once a day. Some simply spit up; others vomit large amounts after feedings. Vomiting in infants and older children is rarely a sign of GERD. In infants it usually resolves by age one. Severe vomiting -- particularly if it is bilious (green colored) -- always requires a doctor's visit, since it could be a symptom of severe obstruction.
Having to burp babies very frequently during and after feeding.

Babies and children may experience these symptoms without having GERD. An Australian study suggested that many infants who have normal irritability may be treated inappropriately for reflux disorders.

Feeding Problems. Feeding problems may be more severe than previously thought in children with GERD. In one study, children who had GERD and problems swallowing tended to refuse food and were late in eating solids. They also cried more and reacted more negatively in general than non-GERD babies. Such behaviors negatively affected the mothers as well. These findings were supported in an earlier study which reported that children at 1 year who had GERD in infancy were no longer spitting up, but still tended to have negative dining experiences ("too slow," "upsetting"). However, these children were at no greater risk for respiratory illnesses than other 1-year-old children.

Associations with Asthma and Infections in the Upper Airways. In addition to asthma, GERD is associated with other upper airway problems, including ear infections and sinusitis. Some experts argue that the association with common childhood infections and asthma is unfounded, since GERD is normal in most children.

Dental Erosion. GERD can cause irreversible loss of tooth enamel. Based on a 2002 study, some experts suggest checking for GERD in children with dental erosions. In the study, no child without GERD experienced loss of tooth enamel.

Rare Complications in Infants. Although GERD is very common, the following complications are very rare and only occur in certain cases:

Failure to thrive
Feeding problems and severe vomiting may cause anemia
Acid back-up may be inhaled into the airways and cause pneumonia

The infant's life may be in danger if acid reflux causes spasms in the larynx severe enough to block the airways. In fact, some experts believe this action may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.

Managing GERD in Infancy. Here are some hints on managing GERD in infants:

During and after feeding, infants should be positioned vertically and burped frequently.
If a baby with GERD is fed formula, the mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
Parents of infants with GERD should discuss the baby's sleeping position with their pediatrician. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome (SIDS). For babies with GERD, however, lying on the back may obstruct the airways. In one study, infants with gastroesophageal reflux who spent prolonged periods of time in infant seats, including car seats, had more reflux than those who spent waking time on their stomachs. If the physician recommends that babies with GERD sleep on their stomachs, parents should be sure that their infant's mattress is very firm, possibly tilted up at the head, and that there are no pillows. The baby's head should be turned so that the mouth and nose are completely unobstructed.
Because food allergies may trigger GERD in children, parents may want to discuss a dietary plan with their physician that starts the child on formulas using non-allergenic proteins, and then incrementally adds other foods until symptoms are triggered.

Managing GERD in Children. The same drugs used in adults may be tried in children with chronic GERD. While some drugs are available over the counter, they should not be given to children without physician supervision.

Milder medications, such as antacids, are used first.
H2 blockers may be tried next. They are available over the counter and include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). The FDA has issued a warning on Pepcid AC for adults with kidney problems.
Proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) and lansoprazole (Prevacid), are even more powerful agents that suppress the production of stomach acid. Delayed-release esomeprazole (Nexium) capsules have been approved for use in children ages 12 - 17 for the short-term treatment of GERD. One study found that esomeprazole (Nexium) in either a 20 or 40 mg dose once a day significantly reduced heartburn symptoms in adolescents. PPIs appear to be safe and effective even for children as young as 1 year old who fail the less intensive therapies. However, a 2006 study found that otherwise healthy children who were treated with H2 blockers and PPIs had an increased risk of developing respiratory and intestinal infections.

Surgical fundoplication involves wrapping the upper curve of the stomach (fundus) around the esophagus. The goal of this surgical technique is to strengthen the LES. Until recently, surgery was the primary treatment for children with severe complications from GERD because older drug therapies had severe side effects, were ineffective, or had not been designed for children. However, with the introduction of proton-pump inhibitor drugs, some children may be able to avoid surgery. Surgical fundoplication can be performed laparoscopically through small incisions. In one study, of 238 children from 5 months to 16 years of age who underwent laparoscopic fundoplication, all but 9 were symptom free at least 5 years after the surgery. A 2006 study found that children who underwent antireflux surgery before age 4 were less likely to be hospitalized again, or to have reflux-related events such as pneumonia and esophagitis after the surgery.

Symptoms

Heartburn. Heartburn is the primary symptom of GERD. It is a burning sensation that radiates up from the stomach to the chest and throat. Heartburn is most likely to occur in connection with the following activities:

After a heavy meal
Bending over
Lifting
Lying down, particularly on the back

According to one study, nearly three-quarters of patients with frequent GERD symptoms experience them at night. Patients with nighttime GERD also tend to experience more severe pain than those whose symptoms occur at other times. One study found that patients with nighttime pain reported levels of severity that were similar to those reported in angina and heart failure.

The severity of heartburn does not necessarily indicate actual injury in the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may trigger few symptoms, especially in elderly people. On the other hand, people can suffer severe heartburn without the presence of damage to the esophagus.

Dyspepsia. Up to half of GERD patients have dyspepsia, a syndrome consisting of the following:

Pain and discomfort in the upper abdomen
Fullness in the stomach
Nausea after eating

People can have dyspepsia without having GERD.

Regurgitation. Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.

Many patients with GERD do not experience heartburn or regurgitation. Elderly patients with GERD often have less typical symptoms than do younger people. Instead symptoms may appear in other locations.

Chest Sensations or Pain. Patients may have the sensation that food is trapped behind the breastbone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.

Symptoms in the Throat. Less commonly, GERD may produce symptoms that occur in the throat:

Acid laryngitis. A condition that includes hoarseness, dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat.
Trouble swallowing (dysphagia). In severe cases, patients may even choke or food may become trapped in the esophagus, causing severe chest pain. This may indicate a temporary spasm that narrows the tube, or it could also be an indication of serious esophageal damage or abnormalities.
Chronic sore throat
Persistent hiccups

Coughing and Respiratory Symptoms. Asthmatic symptoms, such as coughing and wheezing, may occur. In fact, in one study, GERD alone accounted for 41.1% of cases of chronic cough in nonsmoking patients. The incidence was even higher when GERD and asthma were combined.

Chronic Nausea and Vomiting. Nausea that persists for weeks or even months and is not attributable to a common cause of stomach upset may be a symptom of acid reflux. In rare cases, vomiting can occur as often as once a day. All other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, and pancreas or gallbladder disorders.

Complications

Nearly everyone has an attack of heartburn at some point in their lives. In the vast majority of cases the condition is temporary and mild, causing only transient discomfort. If patients develop persistent gastroesophageal reflux disease with frequent relapses, however, and it remains untreated, serious complications may develop over time. They can include the following:

Erosive esophagitis (severe inflammation in the esophagus)
Severe narrowing (stricture) of the esophagus
Barrett's esophagus
Problems in other areas, including the teeth, throat, and airways leading to the lungs

Older people are at higher risk for complications from persistent GERD. The following conditions also put individuals at risk for recurrent and serious GERD:

The esophagus is very inflamed.
Initial symptoms are severe.
Symptoms persist in spite of treatments that successfully heal the esophagus.
There are severe underlying muscular abnormalities.

Erosive esophagitis develops in chronic GERD patients when acid causes enough irritation and inflammation to produce extensive injuries in the esophagus. Some studies have suggested that overweight Caucasian males with GERD are at highest risk for this condition. In anyone, however, the longer and more severe the GERD condition, the higher the risk for erosive esophagitis.

Bleeding. In one study, bleeding occurred in more than 8% of patients with erosive esophagitis (severe inflammation of the esophagus), which is associated with GERD. In very severe cases, the patient may detect dark-colored, tarry stools (indicating the presence of blood) or may vomit blood, particularly if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.

Sometimes long-term bleeding can result in iron-deficiency anemia and may even require emergency transfusions. This condition can occur without heartburn or other warning symptoms, or even obvious blood in the stools.

Barrett's Esophagus (BE) and Esophageal Cancer. In some cases, BE develops as an advanced stage of erosive esophagitis. BE results in abnormal cellular changes in the esophagus that, in turn, put a patient at risk for esophageal cancer. There are many issues involved with BE, however, including its prevalence and true severity, that are unresolved.

Of note, GERD itself poses no significant risk for esophageal cancer. One study reported an annual incidence of 6.5 cancer cases per 10,000 people with regular GERD symptoms.

If the esophagus becomes severely injured over time, narrowed regions called strictures can develop, which may impair swallowing (dysphagia). Food may even become blocked in some cases. Stretching procedures or surgery may be required to restore normal swallowing. Paradoxically, strictures may actually prevent other GERD symptoms by helping to keep acid from traveling up the esophagus.

Asthma. Asthma and GERD often occur together. Studies report that reflux disorder coincides with 32 - 80% of asthma cases. Some theories for the causal connection between GERD and asthma are as follows:

Acid leaking from the lower esophagus in GERD stimulates the vagus nerves, which run through the gastrointestinal tract. These stimulated nerves trigger the nearby airways in the lung to constrict, which causes asthma symptoms.
Acid back-up that reaches the mouth may be inhaled into the airways (aspirated). Here, the acid triggers a reaction in the airways that causes asthma symptoms.

There is some evidence that asthma causes GERD. In contrast, some evidence suggests that GERD causes asthma. Some clinical trials report that treating GERD in patients who also have asthma reduces symptoms of both conditions. Not all such patients report improved asthma symptoms with GERD treatments, and these treatments do not appear to have much effect on actual lung function. One study suggested that this approach works in asthmatic individuals who tended to be overweight and to have severe GERD in the lower part of the esophagus.

Other Respiratory and Airway Conditions. Current studies indicate an association between GERD and various upper respiratory problems that occur in the sinuses, ear and nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for chronic bronchitis, chronic sinusitis, emphysema, pulmonary fibrosis (lung scarring), and recurrent pneumonia. If a person inhales fluid from the esophagus (aspirates) into the lungs, serious pneumonia can occur. It is not yet known whether treatment of GERD would also reduce the risk for these respiratory conditions.

Dental erosion (the loss of the tooth's enamel coating) is a very common problem among GERD patients, including children. It results from the acid backing up into the mouth and eroding the enamel.

An estimated 20 - 60% of patients with GERD have atypical symptoms in the throat (hoarseness, sore throat) without any significant heartburn. A failure to diagnose and treat GERD may lead to persistent throat conditions such as chronic laryngitis, hoarseness, difficulty in speaking, sore throat, cough, constant throat clearing, and granulomas (soft, pink bumps) on the vocal cords.

GERD commonly occurs with obstructive sleep apnea, a condition in which breathing stops temporarily but repeatedly during sleep. It is not clear which condition is responsible for the other, but GERD is particularly severe when both conditions occur together. One study reported that spasms in the vocal cords caused by acid reflux may block the flow of air and cause sleep apnea in adults. On the other hand, other research suggests that the disordered breathing in sleep apnea alters pressure in the chest area and causes GERD. Both conditions may also have risk factors in common, such as sleeping on the back. Studies suggest that in such patients GERD can be markedly improved with a continuous positive airway pressure (CPAP) device, which opens the airways and is the standard treatment for severe sleep apnea.

Barrett's Esophagus

Barrett's esophagus (BE) is a serious condition in which changes occur in the cells that line the lower esophagus and cause the cells to become abnormal and precancerous. Barrett's esophagus is categorized as either long-segment or short-segment disease:

Long-segment BE occurs when abnormal cells affect 3 cm or more of the esophagus. This condition occurs in about 3 - 7% of GERD patients. It is associated with a more severe condition.
Short-segment BE affects less than 3 cm of the esophagus and is found in about 10 - 17% of GERD patients.

About 10% of patients with symptomatic GERD have BE. In some cases, BE develops as an advanced stage of erosive esophagitis. Some studies suggest that individuals at highest risk for BE are obese white males over the age of 50 with persistent GERD who drink alcohol. However, a number of studies have reported no relationship between alcohol use or being male and overweight with BE. Such studies have also reported no higher risk in smokers or relatives of BE patients. Only the persistence of symptoms suggested a higher risk. Nevertheless, not all patients with BE have either esophagitis or symptoms of GERD.

The true prevalence of BE, in fact, is not entirely clear, since studies suggest that significantly more than half of people with BE have no GERD symptoms at all. BE, then, is likely to be much more prevalent and probably less harmful than is currently believed. (BE that occurs without symptoms can only be identified in clinical trials or in autopsies, so it is difficult to determine the true extent.) Some evidence suggests that the presence of specific immune factors may be involved in determining the development of BE.

The rate of esophageal cancer has been rising steadily at about 2% a year in white men. The American Cancer Society estimates that there will be 15,560 new cases of esophageal cancer and 13,940 deaths from the disease in 2007. Esophageal cancer is also very difficult to cure. The 5-year survival rate for all stages of esophageal cancer is 17% in white patients, and 12% in African-American patients. Most cases of esophageal cancer start with BE, with less than half of the cases developing with any symptoms. Of note, only a minority of BE patients develop cancer. Some evidence suggests that acid reflux may contribute to the development of cancer in BE. Researchers have speculated that exposure to extra acid in people with Barrett's esophagus produces more of an enzyme called NOX5-S, which may put stress on cells, leading to DNA damage.

Evidence suggests that asymptomatic BE is quite common in the general population, and if true, BE would pose far less of a threat than is now believed. (GERD itself poses no significant risk for esophageal cancer. One study reported an annual incidence of 6.5 cancer cases per 10,000 people with regular GERD symptoms.)

Barrett's esophagus is diagnosed using endoscopy, a procedure that involves inserting a tube down the throat so that the physician can view the esophagus.

Monitoring High-Risk GERD Patients. Some experts recommend a one-time screening test for BE using endoscopy in high-risk patients (such as Caucasian overweight men) with chronic GERD.

Monitoring Patients with Barrett's Esophagus for Cancer. Periodic endoscopy is recommended for detecting early cancer in patients who have been diagnosed with Barrett's esophagus. In an important 2002 study, 5-year survival was 73% in BE patients whose cancer was detected with endoscopy screening and was 0% in patients who were not regularly screened.

To date, no treatments can reverse the cellular damage done after Barrett's esophagus has developed, although some procedures are showing promise.

Medications. Some evidence suggests that a combination of proton-pump inhibitors to suppress acid, coupled with anti-inflammatory COX-2 inhibitors, might be a promising approach.

Proton-Pump Inhibitors. Some experts recommend very aggressive treatments to reduce acid reflux using high-dose proton-pump inhibitors. The standard agent has been omeprazole (Prilosec). Newer oral PPIs include lansoprazole (Prevacid), esomeprazole (Nexium), and rabeprazole (Aciphex). Even when drugs relieve symptoms completely, the condition usually recurs within months after the drugs are discontinued. In chronic cases, drugs may need to be taken throughout a patient's life. These agents provide no protection against Barrett's esophagus. Still, there is some evidence that acid reflux may contribute to the development of cancer in BE, although it is not yet known if acid blockers have any protective effects against cancer in these patients.
COX-2 (cyclooxygenase-2) inhibitors reduce inflammation and pain, as do well-known agents such as aspirin and ibuprofen, but COX-2 inhibitors may pose less of a risk for peptic ulcers and bleeding. Some early evidence suggests they may be protective against cancerous changes in patients with Barrett's esophagus. However, Vioxx and Bextra have been withdrawn from the market due to their association with an increased risk of heart attack. Celebrex remains available, but must be used with caution, especially by patients with cardiovascular risk factors. Also, research is mixed on the benefits of NSAIDs for esophageal cancer. Some studies have found that they may decrease the risk of developing or dying from esophageal cancer. However, a 2007 study indicated that a small dose of Celebrex did not prevent the progression of cancer in Barrett's esophagus patients.

Peptic ulcers may lead to emergency situations. Severe abdominal pain with or without evidence of bleeding may indicate a perforation of the ulcer through the stomach or duodenum. Vomiting of a substance that resembles coffee grounds, or the presence of black tarry stools, may indicate serious bleeding.

Procedures to Remove the Mucous Lining. Various techniques or devices have been developed to remove (ablate) the mucous lining of the esophagus. The intention is to remove early cancerous or precancerous tissue and allow regrowth of new and hopefully healthy tissue in the esophagus. Such techniques include photodynamic therapy (PDT) or laser, electrical, or heat probes.

Studies on the use of these ablation techniques combined with aggressive use of proton-pump inhibitors or surgical treatments are very encouraging. Some of these techniques may eventually even offer potential cures. At this time, they can be very effective in removing harmful tissue, although the benefits do not last in all patients. In one study, an average of 5.6 years after anti-GERD surgery and laser treatment, only a third of patients showed no evidence of renewed precancerous cell growth. These procedures also have complications, such as possible problems swallowing, that patients should discuss with their physician.

Esophagectomy. Esophagectomy is the surgical removal of all or part of the esophagus. Patients with Barrett's esophagus, who are otherwise healthy, are candidates for this procedure if endoscopy shows developing cancer. After esophageal removal, in total or in part, a new conduit for foods and fluids must be established to replace the absent esophagus. Alternatives include the stomach, colon, and part of the small intestine called the jejunum. The stomach is the optimal choice.

Diagnosis

If a patient suffers from chronic heartburn, chances are good the patient also has GERD. (Occasional heartburn does not necessarily indicate the presence of GERD.) The following is the general diagnostic approach:

A physician can usually make an easy diagnosis of GERD if the patient finds relief from persistent heartburn and acid regurgitation after taking antacids for short periods.
If the diagnosis is uncertain but the physician still suspects GERD, a drug trial using a proton-pump inhibitor medication, such as omeprazole (Prilosec) identifies 80 - 90% of people with the conditions. This class of medication blocks stomach acid secretion.

Laboratory or more invasive tests, including endoscopy, may be required if the diagnosis is still uncertain, if atypical symptoms are present, if Barrett's esophagus is suspected, or if complications, such as signs of bleeding or difficulty in swallowing, are present. Some of these tests are described below.

A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and erosive esophagitis (severe inflammation). When taking this test, the patient drinks a solution containing barium, then x-rays are taken. This test can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. The test cannot reveal mild irritation.

Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium-swallow radiograph. It is also more invasive and expensive. It is widely used in GERD, including for identifying and grading severe esophagitis, for periodic monitoring of patients with Barrett's esophagus or for screening people at high risk, or when other complications are suspected. It is also now employed as part of various surgical techniques.

Endoscopy to Diagnose GERD. Endoscopy may be performed either in a hospital or in a doctor's office:

First, the patient should eat nothing for at least 6 hours before the procedure.
The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and to relax the patient.
Next, the physician places an endoscope (a thin flexible plastic tube containing a tiny camera) into the patient's mouth and down the esophagus. The procedure does not interfere with breathing. It may be slightly uncomfortable for some patients; others are able to sleep through it.
Once the endoscope is in place, the tiny camera allows the physician to see the surface of the esophagus and to search for abnormalities, including hiatal hernia and damage to the mucous lining.
The physician performs a biopsy (the removal and microscopic examination of small tissue sections). The biopsy may detect tissue injury indicative of GERD. It may also be used to detect cancer or other conditions, such as yeast (Candida albicans) or viral infections (e.g., herpes simplex and cytomegalovirus). Such infections are more likely to occur in people with impaired immune systems.
Complications from the procedure are uncommon. If they occur, complications are almost always mild and typically include minor bleeding from the biopsy site or irritation where medications were injected.

If a patient has moderate-to-severe GERD symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis. The test is not foolproof, however. A visual view misses about half of esophageal abnormalities.

Capsule Endoscopy. Capsule endoscopy was first approved for use in 2001. A new version of this pill-sized camera, renamed PillCam, was approved by the FDA in 2004. PillCam reduces the imaging time previously required by the original capsule endoscopy technique. The PillCam capsule contains tiny video cameras on both ends. After the patient swallows the capsule, a series of 2600 color pictures are transmitted to a recording device where they can be downloaded and interpreted by a doctor. A newer version of the PillCam takes 14 frames per second as opposed to the 4 frames per second of the original device. The newer PillCam is superior in visualizing the entire esophagus and in identifying GERD. The entire procedure takes 20 minutes. The capsule is naturally passed through the digestive system within 24 hours. Capsule endoscopy may provide a more attractive and less invasive alternative for patients than traditional endoscopy. However, while capsule endoscopy is useful as a screening device for diagnosing esophageal conditions such as GERD and Barrett's esophagus, traditional endoscopy is still required for gathering tissue samples or removing polyps.

The (ambulatory) pH monitor examination may be employed to determine acid back-up. It is useful when endoscopy has not detected damage to the mucous lining in the esophagus, but GERD symptoms are present. pH monitoring may be used when patients have not found relief from medicine or surgery. The traditional trans-nasal catheter diagnostic procedure involved inserting a tubular probe through the nose and down to the esophagus. The tube was left in place for 24 hours. This test was irritating to the throat, and uncomfortable and awkward for most patients.

A new method, known as the Bravo pH test, uses a small capsule-sized data transmitter that is temporarily attached to the wall of the esophagus during endoscopy. The capsule records pH levels and transmits these data to a pager-sized receiver worn by the patient. Patients can continue their usual diet and activity schedule during the 24 - 48-hour monitoring period. After a few days, the capsule detaches from the esophagus, passes through the digestive tract, and is eliminated through a bowel movement.

Manometry is a technique that measures muscular pressure. It employs a tube containing various openings, which is placed through the esophagus. As the muscular action of the esophagus exerts pressure on the tube in various locations, a computer connected to the tube measures it. It is useful for the following situations:

To determine if a GERD patient would benefit from surgery by measuring pressure exerted by the lower esophageal sphincter muscles (LES).
To detect impaired stomach motility (an inability of the muscles to contract normally), which cannot be surgically corrected with standard procedures.
To determine if impaired peristalsis or other motor abnormalities are causing chest pain in people with GERD who have these symptoms.

Blood and Stool Tests. Stool tests may show traces of blood that are not visible. Blood tests for anemia should be performed if bleeding is suspected.

Bernstein Test. For patients with chest pain in which the diagnosis is uncertain, a procedure called the Bernstein test may be useful, although it is rarely used. A tube is inserted through the patient's nasal passage. Then solutions of hydrochloric acid and saline are administered separately into the esophagus. If the acid infusion causes symptoms and the saline solution does not, then a diagnosis of GERD is established.

Because many illnesses share similar symptoms, careful analysis and consideration of the patient's history is key to an accurate diagnosis. The following are only a few of the conditions that could accompany or resemble GERD.

Dyspepsia. The most common disorder confused with GERD is dyspepsia, which is defined as pain or discomfort in the upper abdomen without heartburn. Specific symptoms may include a feeling of fullness (particularly early in the meal), bloating, and nausea. Dyspepsia can be a symptom of GERD, but does not always occur with GERD. The drug metoclopramide (Reglan) helps stomach emptying and may be helpful for this condition.

Angina and Chest Pain. About 600,000 people come to emergency rooms each year with chest pains. More than 100,000 of these people are believed to actually have GERD. Chest pain from both GERD and from severe angina can occur after a heavy meal. In general, a heart problem is probably not responsible for the pain if it is worse at night and does not occur after exercise. It should be noted that the two conditions often coexist. In fact, there is some theory that in patients with coronary artery disease, acid reflux may actually trigger angina. In such cases, experts believe that acid in the esophagus may activate nerves that temporarily impair blood flow to the heart.

Asthma. Because asthma and GERD commonly occur together, physicians must be sure that each disorder is diagnosed accurately.

Other Diseases. Many gastrointestinal diseases (e.g., inflammatory bowel disease, ulcers, intestinal cancers) can cause GERD, but they are often easily identified, since they have other symptoms and affect other areas of the intestinal tract.

Treatment

Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid present and improve any abnormalities in muscle function of the lower esophageal sphincter (LES), the esophagus, or the stomach.

Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes and over-the-counter medications and antacids.

Patients with moderate-to-severe symptoms that do not respond to lifestyle measures, or who are diagnosed at a late stage may be started on more or less potent agents depending on their complications at diagnosis. Experts argue, however, about the best way to initiate drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approaches:

Step-up. With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. These drugs include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitors, usually omeprazole (Prilosec).
Step-down. A step-down approach first uses a more potent agent, most often a proton-pump inhibitor (PPI), such as omeprazole (Prilosec). When patients have been symptom-free for 2 months or longer, they are then "stepped down" to a half-dose. If symptoms do not recur, the drug is withdrawn. If symptoms recur, the patient is put on high-dose H2 blockers. In one study using this step-down approach, 58% of patients remained symptom-free after a year, with 27% not using any medications at all. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.

Recent guidelines indicate that PPIs should be the first drug treatment, and that these drugs should be given once a day for approximately 8 weeks. Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Long-term maintenance may be necessary.

If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders. In some cases, bile, not acid, may be responsible for symptoms, so that acid-reducing or blocking agents would not be helpful. (Bile is a fluid that is present in the small intestine and gallbladder.)

Surgery may be indicated under certain circumstances:

If lifestyle changes and drug treatments have failed
In patients with other medical complications
In younger people with chronic GERD, who face a lifetime of expense and inconvenience with maintenance drug treatment

Some physicians are recommending surgery as the treatment of choice for many more patients with chronic GERD, particularly since minimally invasive surgical procedures are becoming more widely available, and since only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of acid suppression using medication is still uncertain.

Nevertheless, anti-GERD procedures have many complications and high failure rates (ranging from 30% at 5 years to 63% at 10 years) and, as with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Finally, evidence -- notably an important 2002 Swedish study -- now strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and their primary doctor.

Prevention

People with heartburn should first try lifestyle and dietary changes. In one study, 44% of patients who experienced symptoms of gastroesophageal reflux disease (GERD) reported improvement after changing their diet. Some suggestions are the following:

Avoid or reduce consumption of foods and beverages that contain caffeine, chocolate, peppermint, spearmint, and alcohol. Both caffeinated and decaffeinated coffees increase acid secretion.
Avoid all carbonated drinks, because they increase the risk for GERD.
Although physicians often advise patients with GERD to cut down on fatty foods, many studies have found no evidence that a low-fat or high-fat meal makes any difference in symptom exacerbation. One small study, however, found that the frequency of GERD symptoms increased with a high-fat compared to a low-fat diet. Better studies are needed to confirm this. In any case, as a rule, it is always wise to avoid saturated fats (which are from animal products), and cut down on all fats if one is overweight.
Choose low-fat or skim dairy products, poultry, or fish. Increasing protein may help strengthen muscles in the muscle valve.
Consume whole-grain products rich in selenium, which may have some protective role against dangerous cell changes in Barrett's esophagus.
Eat a diet rich in fruits and vegetables, although it's best to avoid acidic vegetables and fruits (e.g., oranges, lemons, grapefruit, pineapple, tomatoes).

Patients who have trouble swallowing should avoid tough meats, vegetables with skins, doughy bread, and pasta.

Nearly three-quarters of patients with frequent GERD symptoms have them at night. Patients with nighttime GERD also tend to experience severe pain. It is very important to take preventive measures before going to sleep. Some suggestions for preventing acid reflux at night are as follows:

After meals, take a walk or, at the very least, remain upright.
Avoid bedtime snacks. In general, avoid eating for at least 2 hours prior to bedtime.
When going to bed, try lying on the left side rather than on the right. The stomach is located higher than the esophagus when a person sleeps on the right side, which can put pressure on the lower esophageal sphincter (LES), increasing the risk for fluid back-up.
Sleep in a tilted position to help keep acid in the stomach at night. To do this, raise the bed at an angle using 4- to 6-inch blocks at the head of the bed and use a wedge-support to elevate the top half of the body. (Extra pillows that only raise the head actually increase the risk for reflux.)

A reflux board is prescribed for use in children who have gastroesophageal reflux. A board tilts the child upward while he is lying in bed to prevent the stomach contents from going back into the esophagus and mouth, and possibly into the lungs.

Quitting smoking is essential.
People who are overweight should try to reduce food intake and exercise to lose weight.
People with GERD should avoid tight clothing, particularly around the abdomen.
If possible, GERD patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Motrin, Advil), or naproxen (Aleve), among others. Tylenol (acetaminophen) is a good alternative pain reliever.

Although gum chewing is commonly believed to increase the risk for GERD symptoms, one study reported it might be helpful. Because saliva helps neutralize acid and contains a number of other factors that protect the esophagus, chewing gum 30 minutes after a meal has been found to help relieve heartburn and even protect against damage caused by GERD. Chewing on anything at all can help since it stimulates saliva production.

Medications

Antacids neutralize digestive acids and are the primary drugs for mild symptoms. They are best used alone for relief of occasional and unpredictable episodes of heartburn. They all work by neutralizing the acid in the stomach. They may also stimulate the defensive systems in the stomach by increasing bicarbonate and mucous secretion. Many antacids are available without a prescription and are the first drugs recommended to relieve heartburn and mild symptoms. Despite the many brands, they all rely on various combinations of three basic ingredients: magnesium, calcium, or aluminum.

Magnesium. Magnesium salts are available in the form of magnesium carbonate, magnesium trisilicate, and most commonly, magnesium hydroxide (Milk of Magnesia). The major side effect of magnesium salts is diarrhea. Magnesium salts offered in combination products with aluminum (Mylanta and Maalox) balance the side effects of diarrhea and constipation.

Calcium. Calcium carbonate (Tums, Titralac, and Alka-2) is a potent and rapid acting antacid that can cause constipation. These antacids are actually sources of calcium. There have been rare cases of hypercalcemia (elevated levels of calcium in the blood) in people taking calcium carbonate for long periods of time. This can lead to kidney failure and is very dangerous. None of the other antacids has this side effect.

Aluminum. Aluminum salts (Amphogel, Alternagel) are also available. The most common side effect of antacids containing aluminum salts is constipation. People who take large amounts of antacids that contain aluminum may also be at risk for calcium loss, which can lead to osteoporosis.

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

It is generally believed that liquid antacids work faster and are more potent than tablets, although evidence suggests that they all work equally well. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin (Cipro), propranolol (Inderal), captopril (Capoten), and H2 blockers. Interactions can be avoided by taking the drugs 1 hour before or 3 hours after taking the antacid. Long-term use of nearly any antacid increases the risk for kidney stones.

H2 blockers impede acid production by blocking or antagonizing the actions of histamine, a chemical found in the body that encourages acid secretion in the stomach. They are available over the counter and provide symptom relief in about half of GERD patients. It takes 30 - 90 minutes for them to work, but the benefits last for hours. The drugs are usually taken at bedtime. Some people may need to take them twice a day.

H2 blockers inhibit acid secretion for 6 - 24 hours and are very useful for people who need persistent acid suppression. They may also prevent heartburn episodes in people who are able to predict its occurrence. In some studies, H2 blockers improved asthmatic symptoms in people who have both conditions. A 2001 study suggested, however, that they rarely provide complete symptom relief for chronic heartburn and dyspepsia and they have done little to reduce office visits to physicians for GERD.

Brands. Four H2 blockers are currently available in the U.S.:

Famotidine (Pepcid AC). Famotidine (Pepcid AC, Pepcid Oral) is the most potent H2 blocker. The most common side effect of famotidine is headache, which occurs in 4.7% of people who take it. Famotidine is virtually free of drug interactions, but the FDA has issued a warning on its use in patients with kidney problems.
Cimetidine (Tagamet, Tagamet HB). Cimetidine (Tagamet) is the oldest H2 blocker. It has few side effects; approximately 1% of people taking it will experience mild temporary diarrhea, dizziness, rash, or headache. Cimetidine interacts with a number of commonly used medications, such as phenytoin, theophylline, and warfarin. Long-term use of excessive doses (more than 3 grams a day) may cause impotence or breast enlargement in men. These problems resolve after the drug is discontinued.
Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac injection, Zantac Syrup). Ranitidine (Zantac) interacts with very few drugs. In a recent study, ranitidine provided more pain relief and healed ulcers more quickly than cimetidine in people less than 60 years old, but there was no difference in older patients. A common side effect associated with ranitidine is headache, which occurs in about 3% of the people who take it.
Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules). Nizatidine (Axid) is nearly free of side effects and drug interactions. A controlled-release form is proving to help alleviate nighttime GERD symptoms.

Famotidine is excreted primarily by the kidney. This can pose a danger to people with kidney problems. Physicians are now being advised by the U.S. Food and Drug Administration (FDA) and Health Canada to reduce the dose and increase the time between doses in patients with kidney failure. Use of the drug in those with impaired kidney function can affect the central nervous system and may result in anxiety, depression, insomnia or drowsiness, and mental disturbances.

Drug Combinations.

Over-the-counter antacids and H2 blockers: This combination may be the best approach for many people who experience heartburn after eating. Both classes of drugs are effective in relieving GERD, but have different timing. Antacids work within a few minutes but are short-acting, while H2 blockers take longer but have long-lasting benefits. Pepcid AC combined with an antacid (calcium carbonate and magnesium) is now available as Pepcid Complete.
Proton-pump inhibitors and H2 blockers: Physicians sometimes recommend a nighttime dose of an H2 blocker for people who are taking proton-pump inhibitors twice a day. This is based on the belief that adding the H2 blocker will prevent a rise in acid reflux at night. An important 2002 study, however, reported no additional benefits from the nighttime H2 blocker. Some experts recommended an H2 blocker in patients who are on proton-pump inhibitors only to prevent breakthrough symptoms, such as before a heavy meal.

Long Term Complications. In most cases, these agents have good safety profiles and few side effects. H2 blockers can interact with other drugs, although some less so than others. In all cases, however, the physician should be made aware of any other drugs a patient is taking. More research is needed. Anyone with kidney problems should use famotidine only under the direction of a physician.

Concerns and Limitations. Some experts are concerned that the use of acid-blocking drugs in people with peptic ulcers may mask ulcer symptoms and increase the risk for serious complications.

These agents provide no protection against Barrett's esophagus. In fact, of concern are reports that long-term acid suppression with these drugs may cause cancerous changes in the stomach in patients who are infected with H. pylori. Research on this question is still ongoing.

Proton-pump inhibitors (PPIs) suppress the production of stomach acid and work by inhibiting the molecule in the stomach glands that is responsible for acid secretion, which is called the gastric acid pump. According to recent guidelines, initial drug treatment should be with PPIs once daily for about 8 weeks.

The standard agent has been omeprazole (Prilosec), which is now available over the counter without a prescription. Newer prescription oral PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).

Studies report significant relief from PPIs in most patients with heartburn. PPIs are effective for healing erosive esophagitis and may also be helpful in patients with chronic laryngitis that is suspected to be caused by GERD. The newer agents provide quicker symptom relief compared to omeprazole. However, a comparison study suggested that, to date, esomeprazole (Nexium) is the only newer oral PPI to show any significant advantage over omeprazole (Prilosec). All PPIs are more effective than the H2 blockers.

In addition to relieving most common symptoms, including heartburn, proton-pump inhibitors also have the following advantages:

They are effective in relieving chest pain and laryngitis caused by GERD.
They may also reduce acid reflux that typically occurs during strenuous exercise.

Patients with impaired esophageal muscular action are still likely to experience acid breakthrough and reflux at night. Proton-pump inhibitors also may have little or no effect on regurgitation or asthmatic symptoms. Some experts believe, however, that they should be the first drugs of choice, even for patients with milder symptoms. At this time, these drugs are recommended for the following patients:

Those with moderate symptoms that do not respond to H2 blockers
Those with severe symptoms
Those who have respiratory complications
Those who have persistent nausea
Those who have esophageal injury

These agents have no affect against non-acid reflux, such as bile back-up.

Adverse Effects. Proton-pump inhibitors may pose the following concerns:

Side effects are uncommon but may include headache, diarrhea, constipation, nausea, and itching.
Proton-pump inhibitors should be avoided by pregnant women and nursing mothers, although recent studies suggest that they do not pose an increased risk of birth defects.
They may interact with certain drugs, such as anti-seizure agents (such as phenytoin), anti-anxiety drugs (such as diazepam), and blood thinners (such as warfarin).
Long-term use of high-dose PPIs may produce vitamin B12 deficiencies, but studies are needed to confirm whether there is any significant risk. High-dose PPIs used over the long-term also may increase the risk of hip fracture in older adults, according to one study.

There is some evidence that acid reflux may contribute to the higher risk of cancer in BE, but it is not yet confirmed whether acid-blockers have any protective effects against cancer in these patients. In fact, the long-term use of proton-pump inhibitors by people with H. pylori may, in theory at least, reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach). This condition is a risk factor for stomach cancer. To compound concerns, long-term use of PPIs may mask symptoms of stomach cancer and so delay a diagnosis. To date, however, there have been no reports of an increased risk of stomach cancer with the long-term use of these drugs.

Sucralfate (Carafate) protects the mucous lining in the gastrointestinal tract. It seems to work by sticking to an ulcer crater and protecting it from damage due to stomach acid and pepsin. It may be helpful for maintenance therapy in people with mild-to-moderate GERD. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.

Most drugs used for GERD have no effect on non-acid reflux, such as back-up of bile. Baclofen, known as a gamma-amino butyric acid agonist, is commonly used to reduce muscle spasms. Investigators are now showing that it can reduce both acid and non-acid reflux episodes (as much as 70% in one study) and increase LES pressure, an important factor for preventing back-up.

Surgery

The standard surgical treatment for GERD is fundoplication. The goal of this procedure is twofold:

To increase LES pressure and, therefore, prevent acid back-up (reflux)
To repair any present hiatal hernia

There are two primary approaches:

Open Nissen fundoplication (the more invasive technique)
Laparoscopic fundoplication

In general, the overall long-term benefits of these procedures are similar. Some studies report that more than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after 5 years. Fundoplication relieves GERD-induced coughs and some other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in about 14% of patients, although in such cases the problem does not appear to be very significant.)

Still, it has other significant limitations and postoperative problems. For example, the results of one 2003 survey suggested that 18% of surgical patients still required anti-GERD medications and 38% had new symptoms (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Other studies have reported similar results. Also, fundoplication does not cure GERD. Finally, evidence from a 2002 Swedish study strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus.

Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:

Esophagitis (inflamed esophagus)
Symptoms that persist or are recurrent in spite of anti-reflux drug treatment
Strictures
Failure to gain or maintain weight (children)

Fundoplication has little benefit for patients with impaired stomach motility (an inability of the muscles to move spontaneously).

The Open Nissen Fundoplication Procedure. Until recently, most fundoplication procedures for GERD have been the 360° Nissen fundoplication. This is called an open procedure because it requires wide surgical incisions.

With this procedure, the physician wraps the upper part of the stomach (fundus) completely around the esophagus to form a collar-like structure.
The collar places pressure on the LES and prevents stomach fluids from backing up into the esophagus.
Open fundoplication requires a 6- to 10-day hospital stay.

Click the icon to see an illustrated series detailing gastroesophageal reflux surgery.

Laparoscopic Fundoplication. The standard invasive fundoplication procedure has been replaced in many cases by a less invasive fundoplication procedure that uses laparoscopy. In the operation:

Tiny incisions are made in the abdomen.
Small instruments and a tiny camera are inserted into tubes, through which the surgeon can view the region.
The surgeon creates a collar using the fundus, although the area is smaller to work with.

When performed by experienced surgeons, the procedure shows results that are equal to those of standard open fundoplication, but with faster recovery time.

Overall, laparoscopic fundoplication appears to be safe and effective in people of all ages, even babies. Laparoscopy is more difficult to perform in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. It may also be less successful in relieving atypical symptoms of GERD, including cough, abnormal chest pain, and choking. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure because of unforeseen complications.

Other Variations. There are now a number of variants of fundoplication procedures. Examples include the following:

Toupet fundoplication employs only a partial wrap, as does a Thal fundoplication. Partial fundoplication procedures may be more effective in patients with poor or no esophageal motility (spontaneous muscle contraction). Those with normal motility may do better with the full-circle wrap.
Others use a very short and "floppy" Nissen full wrap.

Many surgeons report that such limited fundoplications result in earlier feeding and discharge from the hospital and a lower incidence of complications (trouble swallowing, gas bloating, gagging) than the full Nissan fundoplication. A British study, however, reported no significant differences in swallowing problems.

Postoperative Problems and Complications after Fundoplication. Postoperative problems can include a delay in intestinal functioning causing bloating, gagging, and vomiting. These side effects usually resolve in a few weeks. A 2003 study suggested, however, that 38% of patients develop such symptoms, and most occur more than a year after the procedures. If symptoms persist or if they start weeks or months after surgery, particularly if vomiting is present, then surgical complications are likely. Complications include the following:

An excessively wrapped fundus. This is fairly common and can cause difficulty swallowing (dysphagia), as well as gagging, gas, bloating, or an inability to burp. (A follow-up procedure that dilates the esophagus using an inflated balloon may help correct dysphagia, although it cannot treat other symptoms.)
Bowel obstruction
Wound infection
Injury to nearby organs
Respiratory complications, such as a collapsed lung. These are uncommon, particularly with laparoscopic fundoplication.
Muscle spasms after swallowing food. This can cause intense pain, and patients may require a liquid diet, sometimes for weeks. This is a rare complication in most patients, but it can be very high in children with neurologic abnormalities. Such children are already at very high risk for GERD.

Reasons for Treatment Failure. Long-term failure rates after fundoplication are 30% after 5 years and 63% after 10 years. Hiatal herniation is the most common reason for surgical failure and the need for a repeat fundoplication. Other common reasons for reoperation include breakdown, slippage, and excessive tightness of the wrap. Surgeon experience can lessen complication risks. Some studies have reported that repeat operations after open procedures occur in 9 - 30% of cases and 13% after laparoscopy. (Repeat surgery usually has good results.)

A number of treatments that make use of endoscopy are being used or investigated for increasing LES pressure and preventing reflux, as well as for treating severe GERD and its complications.

Transoral Flexible Endoscopic Suturing. Transoral flexible endoscopic suturing (sometimes referred to as Bard's procedure) uses a tiny device at the end of the endoscope that acts like a miniature sewing machine. It places stitches in two locations near the LES, which are then tied to tighten the valve and increase pressure. There is no incision and no need for general anesthesia.

Radiofrequency. Radiofrequency energy generated from the tip of a needle (sometimes called the Stretta procedure) heats and destroys tissue in the problem spots in the LES. Either the resulting scar tissue strengthens the muscle, or the heat kills the nerves that caused the malfunction. Patients may experience some chest or stomach pain afterwards. Few serious side effects have been reported, although there have been reports of perforation, hemorrhage, and even death. A recent study reported that 81% of patients remained symptom-free for up to 3 years following the Stretta procedure.

Implants. In 2003, the FDA approved the Enteryx procedure as a treatment option for people who have persistent symptoms of GERD and who regularly take and respond to PPIs. In 2005, however, the manufacturer of Enteryx (Boston Scientific), voluntarily removed Enteryx from clinical use due to problems related to the difficult injection technique.

Techniques to Stop Bleeding. Endoscopic ablation treatment of bleeding involves using a probe passed through the endoscopic tube, which applies electricity or heat to coagulate blood and stop the bleeding.

Dilation Procedures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce the duration of treatments.

One study also suggested that dilation may help correct swallowing problems that can occur after fundoplication. In the study dilation improved dysphagia in 67% of the surgical patients who had experienced it.

A recent advance is the development of small-caliber upper endoscopy, which does not require sedation and can be performed in the physician's office.

Resources

http://digestive.niddk.nih.gov -- National Digestive Diseases Information Clearinghouse
www.gastro.org -- American Gastroenterological Association
www.acg.gi.org -- American College of Gastroenterology
www.asge.org -- American Society for Gastrointestinal Endoscopy
www.ssat.com -- Society for Surgery of the Alimentary Tract
www.naspgn.org -- North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
www.reflux.org -- Pediatric/Adolescent Gastroesophageal Reflux Association
www.iffgd.org -- International Foundation for Functional Gastrointestinal Disorders

References

DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100(1):190-200.

Deviere J, Costamagna G, Neuhause H, Voderholzer W, Louis H, Tringali A, et al. Nonresorbable copolymer implantation for gastroesophageal reflux disease: a randomized sham-controlled multicenter trial. Gastroenterology. 2005;128(3):532-540.

Esposito C, Montupet P, van Der Zee D, Settimi A, Paye-Jaouen A, Centonze A, Bax NK. Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease. Surg Endosc. 2006 Jun;20(6):855-8. Epub 2006 May 12. Accessed June 2, 2006.

Gilger MA, Yeh C, Chiang J, Dietrich C, Brandt ML, El-Serag HB. Outcomes of surgical fundoplication in children. Clin Gastroenterol Hepatol. 2004;2(11):978-984.

Gold BD, Schelman JM, Sabesin SM, Vitat P. Updates on the management of upper gastrointestinal disorders in primary care setting:NSAID-related gastropathies and pediatric reflux disease. The Journal of Family Practice. March 2007;56(3):S1-S11.

Hirano I, Richter JE, and the Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. American Journal of Gastroenterology. 2007;102:668-685.

Kim CY, O'Rourke RW, Chang EY, Jobe BA. Unsedated small-caliber upper endoscopy: an emerging diagnostic and therapeutic technology. Surg Innov. 2006 Mar;13(1):31-9.

Koslowsky B, Jacob H, Eliakim R, Adler SN. PillCam ESO in esophageal studies: improved diagnostic yield of 14 frames per second (fps) compared with 4 fps. Endoscopy. 2006 Jan;38(1):27-30.

Remedios M, Campbell C, Jones DM, Kerlin P. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings,and response to treatment with fluticasone propionate. Gastrointest Endosc. 2006 Jan;63(1):3-12.

Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2: S1-S31.

Review Date:
5/22/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Fibromyalgia

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

In This Report

Highlights

Introduction

Causes

Risk Factors

Diagnosis

Conditions with Similar Sym...

Prognosis

Treatment

Lifestyle Changes

Behavioral Therapy

Medications

Resources

References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Causes

People with fibromyalgia have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain, researchers have found. This might explain why fibromyalgia patients are likely to experience depression, and are not very responsive to opioid painkillers.

Researchers have identified a conflict between sensory perception and nervous system processing in people with fibromyalgia. One study suggests that people with the condition might have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might enhance the perception of pain.

Treatment

New research adds to the evidence that exercise relieves some of the symptoms of fibromyalgia. Women with fibromyalgia who took part in a program that combined aerobic, strength training, and flexibility exercises had better physical and emotional function, as well as reduced symptoms. Another study found that an at-home exercise program improved upper body pain and function, especially in women who were having functional difficulties at the beginning of the study.

An anti-convulsant medication, gabapentin (Neurontin), significantly improved pain in fibromyalgia patients compared to placebo. Patients who took gabapentin also reported that they slept better and felt less tired.

The selective serotonin-reuptake inhibitor paroxetine (Paxil) significantly lowered patient scores on a fibromyalgia symptom questionnaire, and was well-tolerated, although the drug do much for their pain.

Introduction

Fibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue. Fibromyalgia is also known as fibrositis or fibromyositis.

Pain. The primary symptom of fibromyalgia is pain. The pain can be in one place or all over. The exact locations of the pain are called tender points. The pain of fibromyalgia is often is described as follows:

Tender point pain occurs in local sites, usually in the neck and shoulders. The pain then spreads out from these areas. The actual pain starts at the muscles. The joints are not affected. There are no lumps or nodes associated with these points of pain, and no signs of inflammation (swelling). People diagnosed with fibromyalgia feel pain in at least 11 of 18 specific tender points.

Widespread pain described as stiffness, burning, and aching. The pain also "radiates," or spreads, to nearby areas. Most patients report feeling some pain all the time. Many describe it as "exhausting." The pain can vary depending on the time of day, weather changes, physical activity, and the presence of stressful situations. The pain is often more intense after disturbed sleep.

Fatigue and Sleep Disturbances. Another major complaint is fatigue. Some patients report that fatigue is more unbearable than their pain. Sleep disturbances, particularly restless legs syndrome, are also very common. Fatigue and sleep disturbances are almost universal in patients with fibromyalgia. Some experts believe that if these symptoms are not present, doctors should seek a diagnosis other than fibromyalgia.

Depression and Mood. Up to a third of patients have depression. Disturbances in mood and concentration are also very common. These conditions often go undiagnosed in patients with fibromyalgia.

Other Symptoms. The following symptoms may also be present:

Digestive problems, including irritable bowel syndrome with gas, and alternating diarrhea and constipation

Dizziness

Painful menstrual periods

Tension or migraine headaches

Tingling or numbness in the hands and feet

Urinary frequency caused by bladder spasms

Symptoms in Children. In general, children with fibromyalgia most often have sleep disorders and widespread pain.

Causes

The most common type is primary fibromyalgia, in which the causes are not known. Many experts believe that fibromyalgia is not a disease, but rather a chronic pain condition brought on by several abnormal body responses to stress. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may be triggers of the disorder, but none have proven to be a cause of primary fibromyalgia.

Research published in the December 2006 issue of Current Pain and Headache Reports found that the areas in the brain that are responsible for the sensation of pain are different in fibromyalgia patients from the same areas in healthy people.

People with fibromyalgia have been found to have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain. This reduced response might explain why fibromyalgia patients are likely to havedepression, and are less responsive to opioid painkillers, researchers say.

Sleep disturbances are common in fibromyalgia. Both adult and young patients with fibromyalgia have a higher-than-average rate of a sleep disorder called periodic limb movement disorder (PLMD). PLMD used to be called nocturnal myoclonus. Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep. This may occasionally wake up the patient.

Some researchers believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between fibromyalgia and sleep.

In one study, healthy volunteers reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. A 2004 study found that patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP). Increased CAP produced serious sleep problems, which were strongly linked to symptom severity. Previous studies have also suggested that CAP may be related to PLMD.

A 2004 report found that sleep disorders that cause breathing problems are common in women with fibromyalgia.

Other biological measures of troubled sleep, however, 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.

Many abnormalities of hormonal, metabolic, and brain chemical activity have been described in studies of fibromyalgia patients. Changes appear to occur in several brain chemicals, although no regular pattern has emerged that fits most patients. Since there has been no clear cause-and-effect relationship established, this may be a result of the effects of pain and stress on the central nervous system, and not a cause of fibromyalgia.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger found in the brain, gut, and other areas of the body. Serotonin plays important roles in feelings of well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also found abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, response to stress, and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Deficiencies in the levels of stress hormones produce impaired and weaker responses to psychological or physical stresses. (Examples of physical stress include infection or exercise.)

The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals.

Click the icon to see an image of the adrenal glands.

Low Growth Hormone Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF-1) in about a third of fibromyalgia patients. IGF-1 is a hormone that is controlled by the adult growth hormone, and promotes bone and muscle growth. Low levels of growth hormone are related to impaired thinking, lack of energy, muscle weakness, and intolerance to cold. Studies suggest that changes in growth hormone likely stem from the hypothalamus in the brain. While researchers did not find a link between IGF-1 levels and fibromyalgia, a 2005 study indicated that serum growth hormone levels may be a marker of the disorder.

Abnormal Pain Perception and Substance P. Some studies have suggested that fibromyalgia may involve too much activity in the parts of the central nervous system that process pain (the nociceptive system). Brain scans of fibromyalgia patients have suggested abnormalities in pain processing centers. For example, researchers have detected up to three times the normal level of substance P in the cerebrospinal fluid of fibromyalgia patients. Substance P, a chemical messenger of the nervous system, is associated with increased pain perception.

Some fibromyalgia patients may also be oversensitive to external stimulation, and overly anxious about the sensation of pain. This increase in awareness is called generalized hypervigilance. One study compared patients with fibromyalgia or rheumatoid arthritis to those without chronic pain. Researchers then measured the different groups' responses to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant, and most aware, of such stimuli. However, one analysis of studies on fibromyalgia found no strong support for the hypervigilance theory.

A conflict between sensory perception and nervous system processing might occur in people with fibromyalgia. 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. This mismatch in sensory signals might enhance the perception of pain.

Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.

Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

They could make individuals susceptible to fibromyalgia.

They may play some role in triggering the onset of the condition.

They may perpetuate, or be responsible for, the condition.

Studies have reported a greater number of severe experiences of emotional and physical abuse in patients with fibromyalgia, compared with the general population. Most often, the abuse came from family members or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD, an anxiety disorder, is a reaction to a specific traumatic event. Symptoms of this condition, which can last for years after the traumatic event, include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. Some evidence indicates that PTSD actually results in changes in the brain, possibly from long-term over-exposure to stress hormones.

Some research found muscle abnormalities in fibromyalgia patients. These problems can be classified as the following:

Biochemical abnormalities: For example, one study reported that fibromyalgia patients had lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the level of calcium in muscle cells. Calcium is an important component in the muscles' ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells, and the muscle remains contracted.

Functional abnormalities: The pain and stress of the disease itself may harm muscle function.

Structural and blood flow abnormalities: Some researchers saw overly thickened capillaries (tiny blood vessels) in the muscles of fibromyalgia patients. The abnormal capillaries could produce lower levels of compounds essential for muscle function, as well as reduce the flow of oxygen-rich blood to the muscles.

To date, none of these abnormalities have a clearly defined relationship with fibromyalgia.

Risk Factors

About 3.7 million Americans have fibromyalgia. The condition affects 2% of Americans, including 3.4% of women and 0.5% of men.

Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors include:

Being female

Coming from a very stressful culture or environment

Having a psychological vulnerability to stress

Having had difficult experiences in childhood

Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.

The disorder usually occurs in people ages 20 - 60 years, though it can occur at any time. Some studies have noted peaks around age 35. Others note that fibromyalgia is most common in middle-aged women. In one study, cases of fibromyalgia increased with age, and reached a frequency of more than 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This type of fibromyalgia appears in adolescents, typically after age 13, with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. One study found that 1.2% of school children, all girls, met the criteria for fibromyalgia. Other studies have found an even higher frequency of fibromyalgia in children. Symptoms are similar to adult fibromyalgia, but outcomes may be better in young people.

Studies report a higher incidence of fibromyalgia among family members. It is not clear if genetic or psychological factors, or both, are involved.

One study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. Offspring who developed fibromyalgia were no more likely to have psychological disorders than those who did not.

Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain. About 10% of them had fibromyalgia.

Diagnosis

There is no obvious, objective method for diagnosing fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, which could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any person with muscle and joint pain with no identifiable cause.

In 1990, the American College of Rheumatology (ACR) set the following criteria for the classification of fibromyalgia:

A. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

Both sides of the body

Above and below the waist

Along the length of the spine

B. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:

The left or right side of the back of the neck, directly below the hairline

The left or right side of the front of the neck, above the collar bone (clavicle)

The left or right side of the chest, right below the collar bone

The left or right side of the upper back, near where the neck and shoulder join

The left or right side of the spine in the upper back between the shoulder blades (scapula)

The inside of either arm, where it bends at the elbow

The left or right side of the lower back, right below the waist

Either side of the buttocks below the hip bones

Either kneecap

Other Factors. The ACR classification provides a guideline, but doctors will also use a patient's medical history and other symptoms to reach a diagnosis. Fibromyalgia is often diagnosed when other diseases have been excluded. Long-term symptoms that may indicate fibromyalgia include:

Fatigue

Headache

Morning stiffness

Numbness or tingling in the hands and feet

Sleep disturbance

The 18 fibromyalgia tender points are located throughout the body. According to the American College of Rheumatology, a diagnosis of fibromyalgia requires widespread body pain plus localized pain in 11 of these 18 specific points.

A doctor should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might indicate disorders other than fibromyalgia. Such factors might include:

Infectious diseases

Muscle weakness

Physical injuries

Rashes

Recent weight change

Sexual, physical, or substance or alcohol abuse

Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.

Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. They must be painful when pressed, not simply tender. In addition, for a doctor to reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness, swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over time. A doctor, then, may recheck tender points that do not respond the first time, in patients who have other significant symptoms.

Detection of Other Causes of Symptoms. A health care provider will also examine nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

No blood, urine, or other laboratory tests can provide a definitive diagnosis of fibromyalgia. If such tests show abnormal results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms. They may include:

Blood count

Sedimentation rate

Tests of certain antibodies

Thyroid and liver function tests

The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific disease.

Conditions with Similar Symptoms

Between 10 - 30% of all doctor office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and widespread muscle pain. Since no laboratory test can confirm a diagnosis of fibromyalgia, doctors will usually first test for similar conditions. It should be noted that a diagnosis of many of the disorders below may not always rule out fibromyalgia, since it can accompany other common and similar conditions.

Several conditions overlap or often coexist with fibromyalgia, and have similar symptoms. It is not clear if these conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have no relationship at all with it.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome (CFS). In a 2003 study, for example, 43% of CFS patients also had a diagnosis of fibromyalgia. As with fibromyalgia, the cause of CFS is unknown. A doctor can diagnose either disorder based only on symptoms reported by the patient. The two disorders share most of the same symptoms. They are also treated almost identically. The differences are primarily the following:

Pain with tender points is the primary symptom in fibromyalgia. Some patients with CFS exhibit similar tender pressure points. However, muscle pain is less prominent in patients with CFS.

Fatigue is the dominant symptom in CFS. It is severe and not relieved by rest or sleep, and it is not the result of excessive work or exercise.

Some doctors believe that fibromyalgia is simply an extreme type of chronic fatigue syndrome. There Some physical evidence, however, indicates that the two disorders are distinct, with treatments that are specific to each.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points, and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the doctor presses on these points, the patient may experience a muscle twitch. Unlike tender points, trigger points are often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong and problematic. Certain studies report that 50 - 70% of fibromyalgia patients have a lifetime history of depression. Only 18 - 36% of fibromyalgia patients, however, also have major depression, a severe form of depression.

Some studies found that people who have both psychological disorders and fibromyalgia are more likely to seek medical help, compared with patients who simply have symptoms of fibromyalgia. If this is the case, study results may be biased, favoring a higher-than-actual association between depression and fibromyalgia.

Depression most likely does not cause fibromyalgia, but it may increase susceptibility. Depressed feelings in people with fibromyalgia can certainly be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are temporary and related to the situation a person is in. They are not considered to be a depression disorder. Unlike ordinary periods of sadness, an episode of major depression disorder can last many months.

Symptoms of major depression include the following:

Depressed mood every day

Feeling worthless or inappropriately guilty

Inability to concentrate or make decisions

Insomnia or excessive sleeping

Low energy every day

Restlessness or a sense of being slowed down

Significant weight gain or loss (of 10% or more of an individual's typical body weight)

Suicidal thoughts

If several of the above symptoms are present, and none of the physical symptoms (particularly the tender points) of fibromyalgia exist, the condition is most likely major depression.

Chronic Headache. Chronic primary headaches such as migraines are common in fibromyalgia patients. Some experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that regulate certain chemical messengers in the brain, including serotonin and epinephrine (adrenaline). Low levels of magnesium have also been noted in patients with both fibromyalgia and migraines. In fact, chronic migraine sufferers who fail to benefit from usual therapies may also have fibromyalgia.

Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems (auras), speech difficulty, and intense pain predominating on one side of the head.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term that describes conditions in which certain chemicals can cause symptoms similar to CFS or fibromyalgia in some people. Still, as with CFS and fibromyalgia, some experts are uncertain whether MCS is a medical condition or if it is psychologically based.

In one study, for example, CFS patients who believed their problem was chemically triggered were exposed to either an active chemical or a placebo (an inactive substance). Both groups reported symptoms, including those only exposed to a placebo. Because everyone is exposed to many chemicals on a daily basis, it is very difficult to determine whether chemicals are responsible for specific symptoms.

Experts have come up with criteria to help recognize MCS:

Symptoms can be produced by exposure to the chemical at levels lower than previously or usually tolerated.

Symptoms can be triggered by multiple substances that are chemically unrelated.

Symptoms involve multiple organ systems.

The condition is chronic.

The symptoms always happen with repeated exposure to a chemical. (These are often common chemicals found in popular products, such as perfumes, fabric softeners, and air fresheners.)

The symptoms improve when the chemical is removed.

Restless Legs Syndrome. About 15% of people with fibromyalgia have restless legs syndrome. Restless legs syndrome is an unsettling and poorly understood movement disorder that is sometimes described as a sense of unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Disorders Affected by the Sympathetic (also called Autonomic) Nervous System. Other conditions that commonly accompany fibromyalgia include:

Chest pain and heart palpitations

Mitral valve prolapse

Sudden drop in blood pressure

Certain stress-related disorders commonly occur with fibromyalgia, and have overlapping symptoms. In fact, some experts believe these disorders so often interact that they may all be part of one general condition.

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.

Irritable bowel syndrome

Osteoarthritis -- a common form of arthritis than can coexist with fibromyalgia. The two conditions may be confused, particularly in elderly people. Osteoarthritis, however, causes joint pain, not widespread or generalized pain.

Osteoarthritis is a chronic disease of the joint cartilage and bone. 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. Joints appear larger, are stiff and painful, and usually feel worse the more they are used throughout the day.

Temporomandibular joint disorders

Some tests may be positive for one or more of these diseases. However, if the results are uncertain or weak, or if these conditions have been treated successfully, fibromyalgia should not be ruled out if the patient still meets the criteria for it.

Multiple sclerosis. This condition may have symptoms similar to those of fibromyalgia. Magnetic resonance imaging (MRI) scans often detect patches of tissue in the brain that confirm the presence of multiple sclerosis (MS). MRI findings combined with other tests and clinical findings usually make this diagnosis fairly certain. However, some patients may have symptoms that suggest MS, but diagnostic tests cannot confirm the diagnosis. Some of these patients may have symptoms similar to those of fibromyalgia.

Click the icon to see an image of multiple sclerosis.

Sjogren syndrome. This condition, characterized by dry eyes and mouth, is sometimes mistaken for fibromyalgia.

Autoimmune diseases. Rheumatoid arthritis, systemic lupus erythrometosis, and Sjogren syndrome are usually easy to diagnose but may develop slowly and be difficult to diagnose at first. Even if a doctor determines that a patient is most likely to have fibromyalgia, the doctor should keep track of any changes in symptoms over time in case one of these other illnesses is actually present.

Lyme Disease. Lyme disease is a bacterial disease transmitted by ticks. Health care providers can usually diagnose early Lyme disease correctly, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that 15 - 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the organism that causes this disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, symptoms of dependency on, or abuse of, alcohol or drugs appear as constant fatigue. Health care providers should consider medications as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness, and generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. A higher-than-normal erythrocyte sedimentation rate (ESR) can suggest polymyalgia rheumatica. Elevated ESR, however, also occurs with other conditions. Polymyalgia rheumatica often gets better in about a year, but there is a risk of persistent disease. Worse, it is sometimes associated with a rare condition called temporal arteritis, which may cause blindness if not treated, so an accurate diagnosis of polymyalgia rheumatica is important.

Prognosis

Fibromyalgia can be mild or disabling, and the emotional toll can be substantial. About half of all patients have difficulty with routine daily activities, or are unable to perform them. An estimated 30 - 40% of patients have had to quit work or change jobs. In a 2003 study, patients with either CFS or fibromyalgia were more likely to suffer losses of jobs, possessions, and support from friends and family than were people suffering from other conditions that caused fatigue.

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.

Outlook in Adults. Some studies show that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with 25 - 35% of patients reporting improvement in pain symptoms over time. Studies suggest that regular exercise specifically improves the outlook. Those with a significant life crisis, or who were on disability, had a poorer outcome than others. Outcome was 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. Although the disease is life-long, it does not get worse and is not fatal.

Outlook in Children. Children with fibromyalgia tend to have a better outlook than adults with the disorder. Several studies reported that more than half of children with fibromyalgia recover in 2 - 3 years.

Treatment

Many patients with fibromyalgia are treated first with medication; however, the American Pain Society Fibromyalgia Panel recommends a combined approach using cognitive-behavioral therapy, education, medication, and exercise.

Fibromyalgia is a mysterious condition. Its causes are still largely unknown, as is how it inflicts damage. No strong evidence indicates that any single treatment (or combination of treatments) has any significant effect for most patients. However, in 2007 the U.S. Food and Drug Administration approved pregabalin (Lyrica) as the first drug treatment for fibromyalgia after a study showed the medicine reduced fibromyalgia pain by at least 50% in 63% of patients.

Treatment usually involves not only relieving symptoms but also changing a pateint's attitude about their disease. Treatment should also teach patients behaviors that help them cope.

Treatments usually involve trial and error:

Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.

If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the treatment. Doctors usually prescribe these drugs because they can may improve pain tolerance.

Patient education and programs that encourage coping skills are an important part of any treatment plan.

According to a 2005 study published in the Clinical Journal of Pain, a combination of non-drug therapies works just as well as drug therapy in improving pain, depression, and disability. This combination includes exercise, stress management, massage, and diet.

Patients must have realistic expectations about the long-term outlook of their condition, and their own individual abilities. It is important to understand that fibromyalgia can be managed, and patients can live a full life. The following tips may be helpful when starting a treatment program for fibromyalgia:

The goal of therapy is to relieve symptoms, not cure them.

Treatment must be tailored to each patient, and a combination approach is often needed.

Patients must begin all treatments with the attitude that these treatments are trial-and-error. There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.

Treatments are long-lasting, in some cases life-long, and patients should not be discouraged by the return of symptoms (relapses).

Enlisting family members, partners, and close friends, particularly to help with exercise and stretching programs, can be helpful.

Becoming involved with support groups of fellow patients also benefits many patients. Support groups may also benefit family members, particularly parents of children with fibromyalgia. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their child's pain.

The definition of improvement is personal. For example, some patients are pleased with only a 10% reduction in pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases well-being, and, over time, reduces fatigue and pain. Many studies have also demonstrated the exercise can improve physical and emotional function, as well as reduce symptoms, including pain.

Programs often combine aerobic, strength-training, and flexibility exercises with self-management education. Some studies have shown improvements lasting for up to 9 months after the exercise program.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity.

In general, graded exercise involves:

A very gradual program of activity, beginning with mild exercise and building in intensity over time.

Stretching exercises before exercising. A daily stretching routine can help relax tense muscles and prevent muscle soreness.

Walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water therapy are good because they don't require putting weight on the joints.

Patients who try hard exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but should not get discouraged. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.

Sleep is essential, particularly since sleep disruptions worsen pain. Many patients with fibromyalgia have trouble getting a restful and healing night's sleep. Those who are unable to sleep consistently have low improvement. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can add to sleep problems. Tips for good sleep habits include:

Avoid caffeine or alcohol 4 - 6 hours before bedtime.

Avoid drinking fluids right before bedtime so that needing to uriniate does not disturb your sleep.

Avoid exercising 6 hours before bedtime.

Avoid large meals before bedtime. A light snack, however, may help you sleep.

Avoid naps, especially in the evening or late afternoon.

Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacation.

If you are unable to fall asleep after 15 or 20 minutes, go into another room and start a quiet activity. Return to bed when you feel sleepy.

Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated.

Use the bed only for sleep and sexual relations.

[For more information see In-Depth Report #27: Insomnia.]

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits, and vegetables. Although everyone should be careful about calories from fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold-water fish. You can also purchase these oils as supplements called EPA-DHA or omega 3.

Omega-3 fatty acids are a form of polyunsaturated fat that the body gets from food. Omega-3s are known as essential fatty acids (EFAs) because they are important for good health. These healthy fatty acids can be found in certain fish, dark green leafy vegetables, and some oils. Omega-3 fatty acids have anti-inflammatory properties, which help prevent blood clots, lower cholesterol and triglyceride levels, and reduce blood pressure. Omega-3s may also reduce the risks and symptoms of diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease, ulcerative colitis, some cancers, and mental decline.

Vegetarian Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. The actual benefit of various vegetarian diets remains unproven.

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. Evidence shows that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. Several relaxation and stress-reduction techniques may be helpful in managing chronic pain:

Biofeedback

Deep breathing exercises

Hypnosis

Massage therapy

Meditation

Muscle relaxation techniques

Biofeedback. Evidence from controlled trials does not suggest that biofeedback techniques may be very helpful for fibromyalgia patients. During a biofeedback session, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people using biofeedback connect the sound with the relaxed state, and learn to achieve relaxation on their own.

Meditation. Meditation, used for many years in Eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a continued and regular basis. The practiced meditator can achieve the following physical benefits:

Reduced heart rate, blood pressure, adrenaline levels, and skin temperature while meditating.

Improved well-being.

Better sleep -- some research has reported an increase in melatonin levels in experienced meditators. Melatonin is important in regulating the sleep-wake cycle.

Less pain, possibly from reductions in levels of cortisol, a stress hormone.

An important goal for both religious and therapeutic meditation practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. Several meditation techniques are available. Some may be more useful for fibromyalgia than others.

Breath meditation. Other meditative forms involve focusing on the present moment and observing (but not examining or judging) one's thoughts. During breath meditation, one sits upright with the spine straight and the eyes closed. The subject begins to breathe regularly and continues to observe the outward exhalation of the breath. As the mind wanders, one simply notes the thoughts as a fact and returns to the breath. A variant of this technique called mindfulness meditation has been helpful for fibromyalgia patients. It involves focusing on the present moment and letting thoughts pass without the accompanying breathing exercises.

Fixed point meditation involves focusing on a stationary object, mental image (such as a candle flame), or internal sound (such as a mantra). When the mind begins to wander, the meditator gently brings concentration back to the central image or sound. This exercise promotes focus, but it is often experienced as a thinking exercise. A popular variety of this type of meditation is known as transcendental meditation, or TM.

Mini-meditation. This method involves heightening awareness of the immediate surrounding environment. One should first choose a simple routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes. Allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions, or worries, redirect it gently back.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in the early evening before dinner. Even once a day is helpful. A person should probably 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.

Hypnosis. In one small, short-term controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. In one study, patients who were given 30-minute massage sessions twice a week experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Everyone should be wary of those who promise a quick cure or urge the purchase of expensive but potentially dangerous treatments.

Although some studies have reported benefit from these treatments, there is not enough evidence to recommend them. In one analysis, evidence was weakest on the advantages of so-called manipulative ("hands-on") approaches, such as chiropractic treatments.

Acupuncture. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest that it offers some benefit, especially to those who cannot take medicines because of their side effects. A larger controlled study found that inserting needles at fibromyalgia-related pressure points was no better at relieving pain for fibromyalgia than randomly inserting needles ("sham acupuncture"). A 2006 review of five randomized, controlled trials did not find enough evidence to support the use of acupuncture for fibromyalgia.

Click the icon to see an image of acupuncture.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. 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. Osteopathic techniques may include manipulation of the spine or muscle tissue release. Note that there is always some very small risk for adverse effects from any of these techniques. For example, in rare cases manipulation of the neck has caused stroke or damage to the large blood vessels in the neck.

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves soaking in water, such as hot tubs, pools, or baths, to help relieve pain.

Herbal or Natural Remedies. Some alternative agents are being investigated for fibromyalgia:

Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia.

S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. You should consult a doctor before using any untested products or dietary supplements. You should also discuss with your doctor any potential interactions between the supplements and any medications you take.

Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the U.S. Food and Drug Administration to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even deadly side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Behavioral Therapy

Studies continue to show that fibromyalgia patients feel better when they deal with the specific conditions of their disorder and their lives. Cognitive-behavioral therapy (CBT) enhances a patient's belief in their own abilities and helps them develop methods for dealing with stressful situations. CBT, also called cognitive therapy, is a known, effective method for dealing with chronic pain from arthritic conditions. Some evidence also suggests that cognitive-behavioral therapy can help some patients with fibromyalgia.

Although the effects of CBT and other non-medication treatments for fibromyalgia do not always last over the long-term, they may help certain groups of people, particularly those with a high level of psychological stress.

CBT may be particularly useful for addressing insomnia, one of the hallmark symptoms of fibromyalgia. Patients who received CBT for insomnia woke up 50% less at night, and had fewer symptoms of insomnia and improved mood.

The Goals of CBT. The primary goals of CBT are to change any unclear or mistaken ideas and self-defeating behaviors. Using specific tasks and self-observation, patients learn to think of pain as something other than a negative factor that controls their life. Over time, the idea that they are helpless against the pain goes away and, instead, they learn that they can manage the pain.

Cognitive therapy is particularly helpful in defining and setting limits -- a behavior that is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, pushing themselves too far until they collapse. This collapse reverses the way they view themselves, and they then think of themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route. Patients learn to prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more manageable life. Patients learn to view themselves and others with a more flexible attitude.

The Procedure. Cognitive therapy usually does not last long, typically 6 - 20 one hour sessions. Patients also receive homework, which usually includes keeping a diary and trying tasks they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

Keep a Diary. Patients are usually asked to keep a diary, a key part of cognitive therapy. The diary serves as a general guide for setting limits and planning activities. Patients use the diary to track any stress factors, such as a job or a relationship that may be making the pain worse or better.

Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs. For example, "I'm not good enough to control this disease, so I'm a total failure" becomes the coping statement, "Where is the evidence that I can control this disease?"

Set Limits. Limits are designed to keep both mental and physical stress within manageable levels, so that patients do not become discouraged by getting "in over their heads." For example, tasks are broken down into incremental steps, and patients focus on one at a time.

Seek out Pleasurable Activities. Patients list a number of enjoyable low-energy activities that they can conveniently schedule.

Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.

Patients should learn to accept that relapses occur, and that over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of failure.

Research also shows that patient education can be effective in treating fibromyalgia, especially when combined with CBT, exercise, and other therapies. Educational programs can take the form of group discussions, lectures, or printed materials, although there isn't any clear evidence on which type of education works best.

Cognitive therapy may be expensive and not covered by insurance. Alternative and effective approaches that are free or less costly include strong, intelligently managed support groups or group psychotherapy. In one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results are not typical in all centers, of course. Therapeutic success varies widely depending on the skill of the therapist.

Medications

Typically the first choice in drug treatment of fibromyalgia has consisted of an antidepressant or a muscle relaxant. The goal has been to improve sleep and pain tolerance. Medications from other drug classes (such as sleeping aids and pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies. In 2007 the Food and Drug Administration approved Pregabalin (Lyrica) as the first drug for the treatment of fibromyalgia.

Pregabalin is an anti-epileptic. Also called anti-seizure drugs and anti-convulsants, these medicines affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing.

Pregabalin was previously approved in 2004 to treat nerve pain and diabetic peripheral neuropathy. A 2005 study of 529 patients with fibromyalgia reported that 450 mg per day of pregabalin reduced pain and improved sleep quality and fatigue symptoms. Study results presented in November 2006 showed pregabalin cut fibromyalgia pain by at least 50% in 63% of patients, and the effect was long-lasting. The study, lasting 6 months, was one of the longest controlled studies of pregabalin in fibromyalgia to date. The most common side effects include mild-to-moderate dizziness and sleepiness. Pregabalin can impair motor function and cause problems with concentration and attention. Patients should talk to their doctor about whether pregabalin may impair their ability to drive.

Studies have shown that another anti-convulsant, gabapentin (Neurontin), which is approved for treatment of postherpetic neuralgia, affects pain transmission pathways and may relieve pain associated with fibromyalgia when compared with placebo. Patients who took gabapentin also reported that they slept better and were less tired.

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses of tricyclic antidepressants are needed to relieve fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include:

Blurred vision

Difficulty urinating

Dizziness

Drowsiness

Dry mouth

Heart rhythm disturbances

Sexual dysfunction

Weight gain

As with all medications, tricyclics must be taken as directed. An overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin. These drugs include:

Duloxetine (Cymbalta) is gaining attention as a treatment for fibromyalgia. In a 2004 study, 207 patients with fibromyalgia were randomized to receive either 60 mg of duloxetine twice a day or placebo for 12 weeks. Duloxetine significantly improved pain and tenderness and was effective for both depressed and non-depressed patients. Duloxetine was most effective for women, but very few men were enrolled in this trial.

Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart when taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.

Milnacipran (Ixel) is under investigation and is not yet approved in the United States. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. In a 2004 study of 125 patients, milnacipran improved fibromyalgia pain and other symptoms, including fatigue, sleep, and depression.

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects, including drowsiness, dry mouth, and dizziness. A 2004 review of five randomized controlled trials found that patients who received cyclobenzaprine were three times more likely to report improvement in fibromyalgia symptoms than patients who received placebo.

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep for patients who suffer from insomnia.

Pain relief is of major concern for patients with fibromyalgia. Pain relievers for fibromyalgia include:

Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.

For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil).

Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful in relieving painful areas in other disorders. It may have some value for fibromyalgia patients.

Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot find relief with other, less potent treatments. Some patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids. The patients should be evaluated periodically for continuing pain relief, side effects, and indications of dependence.

Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia, according to one study. Pramipexole stimulates production of dopamine, a chemical messenger in the brain. Researchers compared pramipexole with a dummy pill (placebo). After 3.5 months, 36% of those who took pramipexole said they felt much better, compared to 9% of those who received a dummy pill. Overall, patients had a 50% or greater decrease in pain.

One small 2005 study conducted in Spain suggests that the atypical antipsychotic olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects.

Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies suggest that it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Much of the pain patients experience occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular exercise program. Stretching techniques may also use injections or cooling agents to inactivate the pressure points so that muscles can be more effectively stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One technique is known as "spray and stretch." This method uses the following approach:

The patient must be in a comfortable position.

The partner presses on suspected tender points and the patient reports any pain.

The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. These chemicals are not numbing medicines. They cool the blood vessels in the skin to inactivate the tender points. Numbing skin creams do not appear to be effective for this treatment.

The spray bottle is held upside-down about 12 - 18 inches from the targeted area. The patient's face should be covered if the spray is being used near the head.

The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of a numbing drug, such as lidocaine, may be used for particularly painful tender points as an aid to stretching.

The injection causes intense, but brief, pain in the trigger point. After the medication has taken effect, however, the muscle's ability to stretch is much greater.

There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.

In some cases, injections may be needed several times over 6 - 8 weeks.

Resources

www.rheumatology.org -- American College of Rheumatology

www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases

www.arthritis.org -- Arthritis Foundation

www.fmaware.org -- National Fibromyalgia Foundation

www.fmpartnership.org -- National Fibromyalgia Partnership

www.fmnetnews.com -- Fibromyalgia Network

www.aapainmanage.org -- American Academy of Pain Management

www.ampainsoc.org -- American Pain Society

www.medicalacupuncture.org -- American Association of Medical Acupuncture

www.asch.net -- American Society of Clinical Hypnosis

www.aabt.org -- Association for Advancement of Behavior Therapy

www.clinicaltrials.gov -- Find a clinical trial

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Rooks DS, Gautam S, Romeling M, Cross ML, Stratigakis D, Evans B, et al. Group exercise, education, and combination self-management in women with fibromyalgia. Arch Intern Med. 2007;167;2192-2200.

Van Koulil S, Effting M, Kraaimaat FW, van Lankveld W, van Helmond T, Cats H, et al. Cognitive-behavioural therapies and exercise programmes for patients with fibromyalgia; state of the art and future directions. Ann Rheum Dis. 2007;66:571-581.

Zheng L, Faber K. Review of the Chinese medical approach to the management of fibromyalgia. Curr Pain Headache Rep. 2005;9(5): 307-12.

Review Date:
12/17/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Modafinil (By mouth)

admin — Thu, 04 Sep 2008 19:57:01 -0700

Overview

Introduction

Brand Name(s)

When This Medicine Should Not Be Used

How to Use This Medicine

How to Store and Dispose of This Medicine

Drugs and Foods to Avoid

Warnings While Using This Medicine

Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

Modafinil (moe-DAF-i-nil)

Improves daytime wakefulness in people with uncontrollable sleepiness caused by narcolepsy or sleep apnea. Also used in people who are sleep deprived from working odd hours such as a night shift.

Brand Name(s)

Provigil

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not use this medicine if you have had an allergic reaction to modafinil or other similar medicines (such as armodafinil).

How to Use This Medicine

Tablet

Your doctor will tell you how much of this medicine to use and how often. Do not use more medicine or use it more often than your doctor tells you to.

If you use this medicine for daytime wakefulness, take it in the morning. If you use it to stay awake during shift work, take the medicine 1 hour before you begin working.

You may take this medicine with or without food.

If you have sleep apnea and use a CPAP machine at night, continue using this machine with the medicine.

This medicine may not work as well if you use it during a time when you are unusually sleepy.

This medicine comes with patient instructions. Read and follow these instructions carefully. Ask your doctor or pharmacist if you have any questions.

If a dose is missed:

If you miss a dose or forget to use your medicine, use it as soon as you can. If it is almost time for your next dose, wait until then to use the medicine and skip the missed dose. Do not use extra medicine to make up for a missed dose.

If you have missed your dose by more than half a day, skip the missed dose so you will not be kept awake during your normal sleeping hours.

How to Store and Dispose of This Medicine

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.

Ask your pharmacist, doctor, or health caregiver about the best way to dispose of any leftover medicine after you have finished your treatment. You will also need to throw away old medicine after the expiration date has passed.

Keep all medicine away from children and never share your medicine with anyone.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Make sure your doctor knows if you are also using dextroamphetamine (Adderall®, Dexedrine®), itraconazole (Sporanox®), ketoconazole (Nizoral®), methylphenidate (Ritalin®), or rifampin (Rifadin®, Rimactane®). Tell your doctor if you are using blood thinners (such as warfarin, Coumadin®), or an MAO inhibitor (such as Marplan®, Parnate®, Nardil®, Eldepryl®).

Your doctor should know if you are also using medicine for depression (such as clomipramine, desipramine, Anafranil®, Norpramin®), or medicine for seizures (such as carbamazepine, phenobarbital, Tegretol®).

Talk to your doctor if you are also using cyclosporine (Neoral®, Sandimmune®), diazepam (Valium®), phenytoin (Dilantin®), propranolol (Inderal®), or triazolam (Halcion®). Your dosages of these medicines may need to be adjusted if you use them together with modafinil.

Birth control pills, implants, shots, or an IUD may not work while you are using modafinil. To keep from getting pregnant, use another form of birth control while you are using this medicine and for one month after your last dose. Other forms of birth control include condoms, a diaphragm, or contraceptive foam or jelly.

Do not drink alcohol while you are using this medicine.

Warnings While Using This Medicine

Make sure your doctor knows if you are pregnant, planning to become pregnant, or breastfeeding, or if you have high blood pressure, kidney disease, liver disease, heart rhythm problems, heart disease, or have recently had chest pain or a heart attack. Tell your doctor if you have a history of mental illness or drug abuse.

This medicine may cause a a serious rash or a serious type of allergic reaction called anaphylaxis. Anaphylaxis can be life-threatening and requires immediate medical attention. Stop taking this medicine and call your doctor right away if you have a skin rash, itching, hives, hoarseness, trouble breathing, trouble swallowing, or any swelling of your hands, face, or mouth while you are using this medicine.

Until you know how this medicine affects you, avoid driving, using machines, or doing anything else that requires you to be alert.

This medicine is not for use with occasional sleepiness that has not been diagnosed as caused by narcolepsy, sleep apnea, or shift-work sleep disturbance.

Your doctor will need to check your progress at regular visits while you are using this medicine. Be sure to keep all appointments.

This medicine may be habit-forming. If you feel that the medicine is not working as well, do not use more than your prescribed dose. Call your doctor for instructions.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.

Blistering, peeling, red skin rash.

Chest pain.

Fast, slow, pounding, or irregular heartbeat.

Feeling unusually agitated, aggressive, confused, or excited.

Fever, chills, cough, sore throat, and body aches.

Mood or mental changes.

Numbness, tingling, or burning pain in your hands, arms, legs, or feet.

Severe nausea, vomiting, or diarrhea.

Skin rash or itching.

Tremors or shaking.

Unusual bleeding, bruising, or weakness.

Unusual thoughts or behavior.

If you notice these less serious side effects, talk with your doctor:

Anxiety, nervousness, trouble sleeping.

Back pain.

Headache, dizziness.

Nausea, diarrhea, upset stomach, loss of appetite.

Runny or stuffy nose, dry mouth.

Review Date: 8/4/2008

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 45_0906

Depression - elderly

admin — Thu, 04 Sep 2008 18:47:10 -0700

Overview

Definition

Causes, incidence, and risk factors

Symptoms

Signs and tests

Treatment

Expectations (prognosis)

Complications

Calling your health care provider

Prevention

References

Illustrations

Depression among the elderly

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Depression is a medical illness in which a person has feelings of sadness, discouragement, and a lack of self-worth.

Causes, incidence, and risk factors

Depression can be caused by the loss of a spouse or close friend, chronic pain and illness, difficulty getting around, frustration with memory loss, trouble adapting to a life change such as moving from a home to a retirement facility, or changes within the family.

Depression can also be a sign of a medical problem. It may be complicated by brain disorders that occur with age, such as Alzheimer's disease.

Depression in the elderly is a widespread problem that is often not diagnosed and frequently undertreated. Many older people will not admit to the signs and symptoms of depression, for fear that they will be seen as weak or crazy.

Symptoms

Symptoms of depression include:

Depressed or irritable mood

Feelings of worthlessness or sadness

Loss of interest or pleasure in daily activities

Temper, agitation

Change in appetite (usually a loss of appetite)

Change in weight

Unintentional weight loss (most common)

Weight gain

Trouble sleeping

Daytime sleepiness

Difficulty falling asleep (initial insomnia)

Waking up many times through the night (middle insomnia)

Waking up early in the morning (terminal insomnia)

Fatigue (tiredness or weariness)

Aches and pains

Difficulty concentrating

Memory loss

Abnormal thoughts, excessive or inappropriate guilt

Irresponsible behavior

Abnormal thoughts about death

Thoughts about suicide

Plans to commit suicide or actual suicide attempts

If you have these symptoms every day for more than 2 weeks, you likely have depression.

Depression in the elderly may be hard to detect because of several factors. Symptoms such as fatigue, appetite loss, and trouble sleeping also can be part of the aging process or a medical condition.

Signs and tests

A physical exam will help determine if a medical illness is causing the depression. A psychological evaluation and other tests may be needed.

Blood tests may be done, including:

CBC

Blood differential

Thyroid function tests

Liver or kidney function tests

Treatment

Sometimes depression can be helped by relieving loneliness through group outings, volunteer work, or having regular visitors.

Treating the underlying medical conditions or stopping certain medications can relieve the symptoms of depression.

Antidepressant drug therapy has been shown to increase quality of life in depressed elderly people. These medications are carefully monitored for side effects. Doctors usually prescribe lower doses of antidepressants for older people, and increase the dose more slowly than in younger adults.

Talking through problems (psychotherapy) with a psychologist, psychiatrist, or other therapist is also an effective treatment. In cases of moderate-to-severe depression, people may get the best results by combining psychotherapy with antidepressant medications.

Neuroleptic medications can help treat agitation in some people. Electroconvulsive therapy (ECT) can be used in people who are severely depressed if other treatments don't work.

Expectations (prognosis)

Depression can respond to medical treatment. If it is not detected, depression can lead to complications. The outcome is usually worse for people who have limited access to social services, or to family or friends who can help them stay interested in activities.

Complications

Depression can be complicated by Alzheimer's disease or other forms of dementia. It also can complicate other medical conditions in the elderly. There is a high rate of suicide among elderly people with untreated depression.

Families should pay special attention to elderly male relatives who are alone, because they are at especially high risk for suicide. In addition to finding psychiatric help for them, family members should remove anything from their homes (such as knives) that they could use to harm themselves.

Calling your health care provider

Call your health care provider if you feel worthless or hopeless, or if you cry often. Also call if you are having trouble coping with stresses in your life and want to be referred for counseling.

Go to the nearest emergency room or call your local emergency number (such as 911) if you are thinking about suicide (taking your own life).

If you are caring for an aging family member and think they might have depression, contact their health care provider. Often, older patients will not admit to the signs and symptoms of depression out of pride.

Prevention

Preventing depression depends on the factors involved. Social supports that help people deal with loss, mobility changes, and other depression triggers can be helpful. In many cases, there is no way to prevent depression.

References

Screening for Depression Recommendations and Rationale. US Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services: 3rd ed. Rockville, Md. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; May 1, 2002.

Guide to Clinical Preventive Services: Screening for Depression, Recommendations and Rationale. Rockville, Md. US Preventive Services Task Force, Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Ann Intern Med. 2002; 136(10): 760–764.

Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 2nd ed. Arlington, VA: American Psychiatric Association; 2000.

Review Date: 7/27/2007

Reviewed By: Benjamin W. Van Voorhees, MD, MPH, Assistant Professor of Medicine, Pediatrics and Psychiatry, The University of Chicago, Chicago, IL. Review provided by VeriMed Healthcare Network.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 1_001521