What conditions can cause issues with staying asleep?

Conditions That Can Cause Issues with Staying Asleep

Multiple medical, psychiatric, and sleep-related conditions can cause difficulty maintaining sleep, including sleep apnea, restless legs syndrome, medical disorders affecting multiple body systems, psychiatric conditions, medication side effects, and primary sleep disorders. 1

Primary Sleep Disorders

Obstructive Sleep Apnea (OSA)

• Characterized by repeated episodes of upper airway obstruction during sleep
• Key symptoms: snoring, witnessed apneas, excessive daytime sleepiness
• Risk factors: obesity, large neck circumference, craniofacial abnormalities
• Diagnosis: sleep study (polysomnography) when screening tools like STOP questionnaire suggest high risk 1
• Treatment: continuous positive airway pressure (CPAP), weight loss, oral appliances

Restless Legs Syndrome (RLS)

• Characterized by uncomfortable sensations and urge to move legs, typically worse at night
• Symptoms worsen with rest, improve with movement, and interfere with sleep maintenance
• Check ferritin levels (values <45-50 ng/mL indicate treatable cause) 1
• Treatment options:
  • Dopamine agonists (ropinirole, pramipexole) 2, 3
  • Gabapentin
  • Benzodiazepines
  • Opioids in refractory cases

Periodic Limb Movement Disorder

• Repetitive limb movements during sleep causing arousals
• Often coexists with RLS
• Diagnosed through polysomnography
• Similar treatment approach to RLS

REM Sleep Behavior Disorder

• Loss of normal muscle atonia during REM sleep
• Patients physically act out dreams, potentially causing injury
• May be an early sign of neurodegenerative disease 4

Medical Conditions

Cardiovascular Disorders

• Congestive heart failure: nocturnal dyspnea, orthopnea
• Hypertension: sleep disruption and fragmentation
• Coronary artery disease: nocturnal angina 5, 6

Respiratory Disorders

• Asthma: nocturnal coughing, wheezing, dyspnea
• COPD: oxygen desaturations, coughing
• Both obstructive and restrictive lung diseases disrupt sleep quality 5

Gastrointestinal Disorders

• Gastroesophageal reflux disease (GERD): awakens patients with heartburn, coughing, choking
• Peptic ulcer disease: nocturnal pain
• Inflammatory bowel disease: pain during flares 7, 5

Endocrine Disorders

• Thyroid dysfunction:
  • Hyperthyroidism: nervousness, heat intolerance, insomnia
  • Hypothyroidism: fatigue that paradoxically disrupts sleep 7
• Diabetes: nocturnal hypoglycemia causing night sweats and arousals 7

Neurological Disorders

• Parkinson's disease: sleep fragmentation, REM behavior disorder
• Alzheimer's disease and other dementias: disrupted sleep-wake cycle
• Epilepsy: nocturnal seizures 6, 8

Pain Conditions

• Fibromyalgia: widespread pain disrupting sleep
• Arthritis: joint pain worse at night
• Chronic back pain
• Neuropathic pain syndromes 5, 8

Renal Disease

• Chronic kidney disease: insomnia, sleep apnea, restless legs syndrome
• Nocturia causing frequent awakenings 5

Infectious Diseases

• Acute viral illnesses
• HIV-related conditions
• Tuberculosis: night sweats
• Lyme disease 7, 5

Psychiatric Conditions

• Depression: early morning awakening, difficulty maintaining sleep
• Anxiety disorders: racing thoughts, worry preventing return to sleep
• Post-traumatic stress disorder: nightmares, hyperarousal
• Bipolar disorder: reduced sleep need during manic episodes 1, 6

Medication and Substance Effects

Medications That Disrupt Sleep

• Antidepressants (SSRIs, SNRIs, MAOIs)
• Stimulants (caffeine, methylphenidate, amphetamines)
• Decongestants (pseudoephedrine, phenylephrine)
• Pain medications (opioids)
• Cardiovascular drugs (beta-blockers, diuretics)
• Respiratory medications (theophylline, albuterol) 1

Substances

• Alcohol: initially sedating but causes sleep fragmentation and early awakening
• Caffeine: long half-life can affect sleep even when consumed earlier in day
• Nicotine: stimulant effects disrupt sleep maintenance 1

Circadian Rhythm Disorders

• Shift work disorder: misalignment between internal clock and work schedule
• Jet lag: temporary misalignment due to travel across time zones
• Delayed or advanced sleep phase disorders: sleep timing misaligned with desired/conventional times 1, 9

Evaluation Approach

1. Detailed sleep history including:

   • Sleep patterns (bedtime, wake time, sleep latency, awakenings)
   • Daytime symptoms (fatigue vs. sleepiness)
   • Sleep environment
   • Medication and substance use

2. Consider sleep logs or actigraphy to document sleep patterns

3. Physical examination and targeted testing based on suspected causes:

   • Thyroid function tests if thyroid dysfunction suspected
   • Ferritin levels if RLS suspected
   • Polysomnography if sleep-disordered breathing or other primary sleep disorder suspected 1, 7

Common Pitfalls in Diagnosis and Management

• Failing to distinguish fatigue from sleepiness (true sleepiness suggests sleep disorders like OSA or narcolepsy)
• Overlooking medication effects on sleep
• Not addressing underlying medical conditions
• Missing comorbid sleep disorders (multiple sleep disorders often coexist)
• Focusing only on sleep onset while ignoring sleep maintenance issues 1

Remember that chronic insomnia often involves multiple contributing factors, and addressing all relevant causes is essential for effective management of sleep maintenance problems.