Gary Birnbaum, MD
Updated: Feb 10, 2019
Sleep Abnormalities in Multiple Sclerosis.
Sakkas GK, Giannaki CD, Karatzaferi C, Manconi M
Curr Treat Options Neurol. 2019 Jan 31;21(1):4. doi: 10.1007/s11940-019-0544-7.
a) More than half of persons with MS have poor sleep, greatly adding to fatigue, a major symptom of MS, and greatly decreasing quality of life.
b) Poor sleep also is associated with increased levels of substances that increase inflammation, possibly adding to MS-related inflammation.
c) Sleep is a complex phenomenon, with four phases of sleep. These range from drowsiness to deep sleep to rapid eye-movement sleep (REM sleep).
d) All are essential for feeling refreshed in the morning, especially REM sleep, the time that we dream.
e) Poor sleep in persons with MS can have multiple causes. These include muscle cramping and spasms, medication side effects, restless legs, anxiety, bladder and bowel urgency and frequency, breathing disorders such as sleep apnea, and poor sleep hygiene.
f) Many causes of poor sleep can be treated, such as restless legs, muscle cramping, bladder and bowel urgency, and sleep apnea.
g) Unfortunately, healthcare providers often may not address sleep behavior in persons with MS.
h) Discussing how one sleeps should be part of any MS evaluation. If appropriate, seeing a neurologist specializing in sleep disorders can be of benefit.
Sleep disorders effect more than half of persons with MS. Examples of sleep disorders are insomnia, incomplete sleep cycle with poor REM sleep, broken-up sleep with frequent waking up, restless legs (an urgent, voluntary need to move legs), periodic leg movements (involuntary leg movements) and sleep apnea (prolonged periods of not breathing with loud snoring noises). Poor sleep hygiene also can greatly effect sleep, and a recommended article reviews this essential subject.
Medications such as antihistamines, as well as alcohol, can reduce REM sleep, an essential component of the sleep cycle. Bladder and bowel urgency can be treated with medications such as ditropan, though side effects of such drugs may be significant and need to be discussed. The frequency of restless legs syndrome (RLS) is greatly increased in persons with MS. RLS must be distinguished from involuntary leg movements due to cramping or leg spasms. RLS is a voluntary, overwhelming need to move one’s legs, thus preventing sleep. Evaluation of RLS should include testing for iron deficiency. Several medications are effective in treating RLS. One such drug is gabapentin. Involuntary leg movements due to cramping spasms can be treated with drugs such as baclofen and tizanidine. Supplemental magnesium at bedtime also may help. Persons with MS also have an increased frequency of periodic leg movement disorder (PLMD), not related to cramping or spasms. Very low doses of a drug such as lorazepam may help, though again medication side effects and potential effects on sleep patterns need to be discussed.
Sleep apnea is relatively common in persons with MS. It is characterized by long episodes of not breathing (up to a minute or more), with load snoring, frequent partial awakening and thrashing of arms and legs. As a result, persons with sleep apnea awaken feeling exhausted. It usually results from blockage of airflow into the lungs. It is more common in older persons (yes, all of us sag with age), in males, in persons who are overweight with large necks and small mouths, and those with chronic nasal congestion. Smoking also increases this risk as does having alcohol before bedtime and sleeping on one’s back. Not breathing when asleep can also occur due to a condition called “central sleep apnea.” It is not related to airflow blockage, but results from an injury to the breathing center at the base of the brain (brainstem). Such an injury can occur in persons with MS. There can be serious consequences to not treating sleep apnea. Thus, if sleep apnea is suspected, a full evaluation by a neurologist specializing in sleep disorders should be considered. A test called a “polysomnogram” may be needed. It is administered in a special sleep laboratory and takes place while the person sleeps. Brain waves are measured, as is blood oxygen content (which falls when not breathing), and breathing rhythms. There are multiple ways to treat sleep apnea. These include throat surgery for persons with airway obstruction and mechanical devices that open a person’s airway and force air into the lungs. Again, an evaluation by a neurologist specializing in sleep disorders can be very valuable.
Certain substances related to inflammation, such as tumor necrosis factor-alpha (TNF-alpha) and interleukin 1beta, can affect sleep. Such substances are increased in persons with poor sleep and may add to brain inflammation already present in MS. Thus, fully addressing how persons with MS sleep, and providing best treatment, is an essential component of good MS care.
PURPOSE OF REVIEW:
This review summarizes the most well-documented sleep disorders seen in patients with multiple sclerosis (MS), with a special focus on the impact on quality of life.
Sleep abnormalities in patients with MS are a multifactorial and relatively complex issue affecting approximately 60% of the patients while the pathophysiology of these symptoms is not fully understood. Circadian rhythm disorders and increased levels of pro-inflammatory cytokines have been recognized as potential players in affecting sleep homeostasis in MS patients. Medication-related side effects such as in immunotherapy and other factors such as lesion load can contribute to the disruption of normal sleep patterns. Most frequently encountered sleep disorders are insomnia, sleep-related movement disorders, sleep-related breathing disorders, and circadian rhythm disorders affecting both adults and paediatric MS populations. Aetiology still remains unknown with treatment options focusing on behavioural cognitive therapy and lifestyle modification including improvement in sleep hygiene as well as melatonin supplementation. Given MS prevalence is still rising affecting millions of people, more personalized medicine applications should possibly form the key approach for improving patients' quality of life and quality years.