Children and Insomnia

There is a review from Medscape about an article that's coming out in the August edition of Sleep Medicine. The authors performed a nation-wide survey of child and adolescent psychiatrists about their patients with insomnia. Apparently, upto one-third of patients receiving psychiatric care have insomnia. At least one-fourth of those with insomnia receive either prescription or over-the-counter medications for their sleeping difficulty.

However, those surveyed expressed concerns about the side effects and lack of proof that medications for insomnia work. I guess this is why only one-fourth of their patients with insomnia received medications.

It's my opinion that medications are not a good long term strategy for children and adults that struggle with insomnia. Even if these medications have few side effects and are not physically addictive, patients can still develop psychological dependence to the medication. The patients often begin to believe they must have a pill to sleep, instead of using their body's own sleep drive and circadian rhythm to help them sleep.

Treating insomnia in children is very challenging and obviously common. Parents must be educated because the work really falls on their shoulders. The child can not be expected to do it alone. When dealing with adolescents, however, they need to become willing participants in their own insomnia treatment. Non-medication treatments for insomnia often work well in both children and adolescents, and it can be rewarding to see family dynamics improve once the child is sleeping better.

Insomnia and Women

I saw an article in Current Psychiatry about insomnia across women's life stages. It was a nice review of how menstruation, pregnancy, and menopause can change sleep. I'll point out some of the highlights.

Compared to men, women have a 1.3 to 1.8-fold greater risk of developing insomnia. The reasons vary, but include hormonal changes, a greater chance of developing mood and anxiety disorders, and other factors like being single, separated, or widowed.

Sleep complaints are common in Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD).

Of course, any woman who has been pregnant will tell you how difficult it can be to sleep as the baby grows. Usually, sleep worsens as women approach the delivery date. Difficulty breathing is a common complaint, as the baby pushes up on the diaphragm, which then compresses the lungs. Obstructive sleep apnea can also become an issue during pregnancy, usually associated with weight gain. Pregnancy can also bring on Restless Legs Syndrome, possibly related to temporary iron deficiency.

Finally, post-menopausal women can have sleeping difficulties due to hot flashes at night. Also, they are at increased risk of obstructive sleep apnea as their female hormone levels diminish.

Chronic insomnia increases mortality?

I saw a review from Medscape about a poster presented at the annual SLEEP meeting in San Antonio last month. In this study, researchers analyzed patients from the Wisconsin Sleep Cohort. The patients were mailed surveys about insomnia symptoms - difficulty starting or staying asleep, for example. After adjusting for other factors that could be contributing to death (age, BMI, chronic conditions, e.g.), the researchers concluded that there was an approximately 2-fold increase risk for all-cause mortality in chronic insomnia patients.

The problem with this study is in the way the researches determined if someone has insomnia, and what type of insomnia they might have. Insomnia is difficult to diagnose off of a mailed survey. Although I did not read the poster because I did not attend this meeting, the review of the poster mentions nothing about whether the patients in this study might have had a coexistent sleep-related breathing disorder. Not all insomnia symptoms are due to primary insomnia - many times, insomnia is due to undiagnosed obstructive sleep apnea, a condition known to increase mortality if left untreated.

This study is misleading in that it implies that patients with primary chronic insomnia have an increased risk of dying. Insomnia is a serious disorder, but it is not life threatening and has not been linked to other physical diseases based on research studies where primary insomnia was diagnosed by an experienced sleep clinician.

Aliens, Darth Vader, and Hannibal Lecter

What do these three have in common? They either had a mask (Darth Vader and Hannibal) or had young that attached to a human host's face (Aliens). What does this have to do with sleep? Everything, as these are the three most common comparisons to CPAP masks.

There are dozens of masks available for CPAP, several manufactures, but only a handful of styles. In my practice, I use mainly Resmed and Fisher Paykel masks. A pillows style fits into the nostrils like thick oxygen prongs, such as Resmed's Swift FX. This mask is the least bulky and does not block the vision while being worn. Nasal masks like Resmed's Activa fit over the nose. Because most of these have a T-piece that touches the forehead, vision can be blocked somewhat while the mask is on. Full-face masks cover the nose and mouth, such as Fisher Paykel's Forma. This style tends to be the bulkiest and can be difficult to get an air-tight seal.

All masks work with the same CPAP devices, meaning no special or extra equipment is necessary if a patient wants to change mask brands or styles. Mask choice depends on multiple factors, many of which are patient preference. Working with a knowledgeable person to find the most appropriate mask can help determine whether a patient uses CPAP enough to benefit.

Not Your Parents CPAP

Many of my patients have heard of or know someone who uses CPAP. When I discuss this treatment option for obstructive sleep apnea, the most common question is if the CPAP flow generator is loud. They've heard that the fan inside the CPAP can be loud.

It is true that older models of CPAP were louder. But modern CPAP units are whisper quiet. And they have many comfort features. Most can ramp up the pressure from the lowest to the prescribed pressure over an amount of time chosen by the patient. I always prescribe a heated humidifier with CPAP to ease the dryness. The size of CPAPs has gradually decreased over time, meaning they fit easier on a nightstand or in your luggage.

My two favorite CPAPs currently are the S9 from Resmed and the System One from Respironics. Both of these offer a pressure relief feature that can make breathing out more comfortable. Plus, the data recorded from these devices gives me a wealth of information about a patient's breathing while they are asleep. I can download this data from the CPAP and go over it with the patient in my office during follow ups. Most patients appreciate this information, as they are unaware of how they might (or might not) be breathing when they sleep.

Sleep and Headaches

Although I did not go this year, I saw that the American Headache Society Annual Scientific meeting recently occurred. I received an update from Medscape about the importance of screening for sleep disorders in chronic headache sufferers. This goes along with my clinical experience treating patients with sleep disorders.

There is an association between sleep and headaches, but it's not been entirely worked out. Headaches can disrupt sleep, and sleep disorders can worsen headaches. A common referral I get is waking up with headaches, which sometimes can be from a sleep-related breathing disorder like obstructive sleep apnea. Migraine headache patients seem especially vulnerable to disorders that break up sleep.

Most headache physicians know the importance of adequate sleep in treating patients with chronic headaches. Hopefully, the recent Headache meeting will remind headache specialists to consider sleep disorders as they attempt to manage their headache patients.

The Other Sleep Apnea?

When patients ask me about sleep apnea, most often they are referring to obstructive sleep apnea, characterized by repetitive throat collapse while asleep. There is another type of sleep apnea, central sleep apnea, where a person will stop breathing, but the throat remains open.

Central sleep apnea occurs when a person breathes too slowly or not deep enough. It can occur in the setting of brain, heart, or lung diseases. In heart failure, central sleep apnea can be a problem, and not all cardiologists are aware of it.

The symptoms of central sleep apnea can be similar to those seen in obstructive sleep apnea, such as restless sleep, daytime sleepiness or extreme fatigue, and unusual breathing patterns while asleep (usually observed by a bed partner).

Although central sleep apnea gets less attention than the more common obstructive sleep apnea, both deserve to be treated since both conditions can increase mortality rates. However, the treatment for each sleep apnea type can be different, making it important to figure out the exact type of sleep apnea that is affecting the patient.