REM sleep disorder doubles risk of mild cognitive impairment, Parkinson's

People with symptoms suggesting rapid eye movement sleep behavior disorder, or RBD, have twice the risk of developing mild cognitive impairment (MCI) or Parkinson's disease within four years of diagnosis with the sleep problem, compared with people without the disorder, a Mayo Clinic study has found. The researchers published their findings recently in the Annals of Neurology.

16 march 2012--One of the hallmarks of rapid eye movement (REM) sleep is a state of paralysis. In contrast, people with rapid eye movement sleep behavior disorder, appear to act out their dreams when they are in REM sleep. Researchers used the Mayo Sleep Questionnaire to diagnose probable RBD in people who were otherwise neurologically normal. Approximately 34 percent of people diagnosed with probable RBD developed MCI or Parkinson's disease within four years of entering the study, a rate 2.2 times greater than those with normal rapid eye movement sleep.

"Understanding that certain patients are at greater risk for MCI or Parkinson's disease will allow for early intervention, which is vital in the case of such disorders that destroy brain cells. Although we are still searching for effective treatments, our best chance of success is to identify and treat these disorders early, before cell death," says co-author Brad Boeve, M.D., a Mayo Clinic neurologist.

Previous studies of Mayo Clinic patients have shown that an estimated 45 percent of people who suffer from RBD will develop a neurodegenerative syndrome such as mild cognitive impairment or Parkinson's disease within five years of diagnosis.

"This study is the first to quantify the risk associated with probable RBD in average people, not clinical patients, and it shows that we can predict the onset of some neurodegenerative disorders simply by asking a few critical questions," says lead author Brendon P. Boot, M.D., a behavioral neurologist. Dr. Boot was at Mayo Clinic when the study was conducted. He is now at Harvard University.

MCI is an intermediate stage between the expected cognitive decline of normal aging and the more pronounced decline of dementia. It involves problems with memory, language, thinking and judgment that are greater than typical age-related changes.

An estimated 500,000 Americans suffer from Parkinson's disease, which is characterized by tremor or shakiness, stiffness of the limbs and trunk, slowness of movement, and impaired balance and coordination.

Provided by Mayo Clinic

Sleep disorders tied to mortality risk

NEW YORK, 14 june 2009-- Poor quality sleep - whether from insomnia, sleep fragmentation, or nightmares - is associated with increased risk of death, according to several presentations this week in Seattle at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies.

One study, conducted at Penn State College of Medicine in Hershey, Pennsylvania, suggests that insomnia may be as hazardous as obstructive sleep apnea.

"Insomnia with objective short sleep duration is associated with an activation of the stress system, i.e., higher secretion of cortisol and increased risk of high blood pressure," said lead author Dr. Alexandros Vgontzas. He and his associates examined the effects of insomnia that persisted for at least 1 year and objective short sleep duration on mortality.

The subjects included 1741 randomly selected men and women. During 14 years of follow-up among men, the mortality rate was 19.6 percent. Among women, who were followed for 10 years, the mortality was 10.3 percent.

Compared with men who had normal sleep patterns and sleep durations of at least 6 hours, men with insomnia and a shorter duration of sleep had mortality risks that were up to 5-times greater. While mortality risk was also increased among women with similar characteristics, the association was not statistically significant.

"The longer follow-up of men may explain why we did not have the same finding in women," Vgontzas. "Another possibility is that men are more vulnerable physically to this type of insomnia, i.e., insomnia associated with objective short sleep duration."

Because "insomnia with objective sleep duration (of less than 6 hours) has significant medical consequences similar to sleep apnea, this type of insomnia should become a medical priority in terms of its detection and treatment," he said. "At this point there are no studies that have assessed which type of treatment -- medication vs. psychotherapy vs. a combination of the two -- is more effective," he added.

Another study assessed sleep duration using actigraphy, a small instrument worn on the wrist that measures body movement and detects patterns based on activity used to evaluate sleep-wake cycles. The investigators found that sleeping less than 5 hours per night increased the risk of death among elderly women, but not among elderly men.

Dr. K. L. Stone at California Pacific Medical Center in San Francisco and co-investigators monitored 3052 women (average age of 83.6 years) and 3055 men (average age 76.4 years) for at least three 24-hour periods.

Compared with women who slept at least 8 hours nightly, women who slept fewer than 5 hours had a significantly higher risk of death over 4.2 years of follow-up. Men who got fewer than 5 hours of sleep per night also had an increased mortality risk, but this was not statistically significant, which, again may be related to study conditions.

Based on data from the Sleep Heart Health Study, researchers led by Dr. Alison M. Laffan, formerly at Johns Hopkins University, Baltimore, and now at California Pacific Medical Center, have identified sleep fragmentation as another risk factor.

Included were 5614 subjects who underwent overnight polysomnography, in which brain wave activity is observed overnight during various phases of sleep, and were then followed for 8 years. The authors defined sleep fragmentation using an index of the number of sleep stage transitions per hour of sleep.

When transition types were considered individually, going from being awake to non-REM sleep and from non-REM sleep to being awake were tied to significantly higher mortality. "Other transition types decreased the odds of death; however, the decrease was observed only when the number of transitions was (less than) 1 per hour of sleep," the researchers found.

Findings from a fourth study indicate that, among severely depressed individuals, nightmares -- but not insomnia -- were associated with elevated suicidal symptoms.

Principal investigator Dr. Rebecca Bernert, at Florida State University, and colleagues studied 82 adults who sought emergency psychiatric evaluation and completed symptom questionnaires.

The investigators found that only scores for disturbing dreams and nightmares were independent predictors of suicidal thinking.

Thus, the researchers conclude, "a more thorough assessment of sleep in acutely ill patients is warranted and may provide an important opportunity for intervention."

Sleep disorder may be early sign of dementia or Parkinson's disease

ST. PAUL, Minn., 25 dec 2008– People with a sleep disorder that causes them to kick or cry out during their sleep may be at greater risk of developing dementia or Parkinson's disease, according to a study published in the December 24, 2008, online issue of Neurology®, the medical journal of the American Academy of Neurology.

The sleep disorder is called REM sleep behavior disorder. People with the disorder do not have the normal lack of muscle tone that occurs during REM sleep, often known as the dream stage of sleep. Instead, they have excessive muscle activity such as punching, kicking, or crying out, essentially acting out their dreams.

The study involved 93 people with this type of sleep disorder who had no signs of a neurodegenerative disease, such as dementia or Parkinson's disease. The participants were followed for an average of five years. During that time, 26 of the people developed a neurodegenerative disease. Fourteen developed Parkinson's disease, 11 developed dementia and were diagnosed with either Alzheimer's disease or Lewy body dementia. One person developed multiple system atrophy, a rare disorder that affects movement, blood pressure and other body functions.

The estimated five-year risk of developing a neurodegenerative disease was 18 percent, with the 10-year risk at 41 percent and the 12-year risk at 52 percent.

"These results are obviously of great interest to people who have this sleep disorder and their physicians and families," said study author Ronald B. Postuma, MD of McGill University in Montreal, Canada, who carried out the studies at the sleep disorders center at the Sacre Coeur hospital, University of Montreal. Postuma is also a member of the American Academy of Neurology. "The results may help us better understand how these neurodegenerative diseases develop. They also suggest that there may be an opportunity for protecting against the progression to disease, perhaps even preventing it before the symptoms can appear."

Postuma noted that the study involved only people with no known cause for the REM sleep behavior disorder. The disorder can also be caused by narcolepsy or rare brainstem abnormalities. REM sleep disorder from these causes does not necessarily carry the risk of developing a neurodegenerative disease, he said.

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The study was supported by grants from the Canadian Institutes of Health Research and the FRSQ (Fonds de la recherché en santé du Quebec) in Montreal, Canada.

Elderly More Likely to Battle Sleep Disorders

28 april 2008-- Many older adults don't get enough sleep, which can increase the risk of serious health problems such as obesity, cardiovascular disease and diabetes, says the American Academy of Sleep Medicine.
While sleep patterns do change as people age, disturbed sleep and waking up tired every day aren't a normal part of aging.
"As we get older, the amount of nightly sleep that we need remains the same as that of what we needed when we were younger. However the ability to get the sleep that we need does change. Older people have a hard time getting the sleep they need because of the interference of medical illness, the medications they take for those illnesses, and changes in their biological clock," Sonia Ancoli-Israel, a professor of psychiatry at the University of California, San Diego, School of Medicine and director of the sleep disorders clinic at the Veterans Affairs San Diego Healthcare System, said in a prepared statement.
Ancoli-Israel, who is also co-director of the Laboratory for Sleep and Chronobiology at the UCSD General Clinic Research Center, cited a number of common sleep disorders in the elderly:Insomnia affects almost half of adults aged 60 and older. Obstructive sleep apnea (OSA) affects almost 40 percent of adults, and is more common among older adults. OSA can increase the risk of high blood pressure, heart disease, stroke and cognitive problems. Restless legs syndrome, which affects more than 20 percent of people aged 80 and older, includes uncomfortable feelings in the legs, such as tingling, or pins and needles. Periodic limb movements cause people to jerk and kick their legs every 20 to 40 seconds during sleep. One study found that about 40 percent of older adults have a least a mild form of this condition.
Older adults who don't get enough sleep are more likely to feel depressed, have attention and memory problems, excessive daytime sleepiness, more nighttime falls, and to use more over-the-counter or prescription sleep medications.
In order to get a better night's sleep, older adults should:Establish a routine sleep schedule. Avoid using the bed for activities other than sleep or intimacy. Avoid substances that disturb sleep, such as caffeine and alcohol. Avoid napping during the day. If you have to nap, limit it to less than one hour and do it no later than 3 p.m. Develop pre-sleep rituals that help you relax, such as a warm bath, a light snack or a few minutes of reading. Leave worries behind. Bedtime is a time to relax, not replay the stresses of the day. Keep your bedroom dark, quiet and a little cool. If you can't fall asleep, leave the bedroom and do a quiet activity. Go back to bed only when you're tired.

Circadian Rhythm Sleep Disorders Get New Guidelines

ROCHESTER, Minn., Nov. 1 -- The first comprehensive guidelines for circadian rhythm sleep disorders are out, though with few surprises for sleep medicine specialists.
Action Points
Explain to interested patients that the guidelines provide a more comprehensive approach to circadian rhythm sleep disorders than was previously available.
Consider recommendations from the American Academy of Sleep Medicine in diagnosis and treatment of circadian rhythm sleep disorders.
Nonetheless, the American Academy of Sleep Medicine recommendations may be helpful for clinicians in treating and diagnosing shift work disorder and in the use of melatonin, said Timothy I. Morgenthaler, M.D., of the Mayo Clinic here.
He and colleagues developed the practice parameters because research in the relatively new but growing field of sleep medicine has outpaced clinical developments, they wrote in the Nov. 1 issue of SLEEP.
"Many of the [existing] practice parameters had to do with diagnostic procedures, [and] some of them had to do with very specific therapeutic endeavors," Dr. Morgenthaler said, but there were no cohesive evidence-based guidelines.
The guidelines were developed from two review articles to be published in the same journal issue.
One encompassed exogenous circadian rhythm sleep disorders (shift work disorder and jet lag disorder). The other dealt with endogenous circadian rhythm sleep disorders, which included advanced sleep phase disorder, delayed sleep phase disorder, irregular sleep-wake rhythm, and the non-24-hour sleep-wake syndrome (free-running disorder).
The recommendations were divided by level of evidence into standards that were backed by high-quality randomized controlled trials or well-validated cohorts; guidelines that were supported with only cohort studies or flawed clinical trials; and options, defined by inconclusive or conflicting evidence or conflicting expert opinion.
Melatonin was recommended as indicated across the spectrum of circadian rhythm sleep disorders, except for irregular sleep-wake rhythm disorder in elderly patients with dementia or those in nursing homes. These recommendations were considered options for advanced sleep phase, free-running disorder in sighted patients, and for irregular sleep-wake rhythm patients with moderate to severe mental retardation.
For shift work sleep disorder, actigraphy was recommended for diagnosis and monitoring response to therapy, as was use of a sleep log or diary. But polysomnography, Morningness-Eveningness Questionnaires, and circadian phase markers were not recommended for routine use.
Planned sleep schedules were considered a standard therapy for shift work sleep disorder whereas use of timed light exposure and melatonin, hypnotics, and alerting agents had a lower level of evidence. Caffeine, modafinil (Provigil), and methamphetamine were suggested as options for treatment.
Overall, the standard for polysomnography use was to rule out another primary sleep disorder but not for routine diagnosis of circadian rhythm sleep disorders.
Other guidelines included:
Use of a sleep log or diary to assess patients with a suspected CRSD.
Actigraphy for diagnosis of circadian rhythm disorders aside from jet lag and for evaluating response to treatment across the board.
Morning light exposure for treatment of delayed sleep phase disorder.
Other recommendations at the option level of evidence included:
Maintaining home-based rather than destination sleep hours to combat jet lag when the duration of a trip is expected to be brief.
The combination of morning exposure to bright light and shifting the sleep one hour earlier each day for three days prior to eastward travel to lessen jet lag symptoms.
For advanced sleep phase disorder, use of prescribed sleep-wake scheduling, timed light exposure, or timed melatonin administration.
Progressive delay in scheduled sleep time (chronotherapy) for delayed sleep phase disorders.
For free-running disorder, use of sleep logs and circadian phase markers for assessment and prescribed sleep-wake scheduling as treatment for sighted patients and timed light exposure or melatonin for treatment of both blind and sighted patients.
Daytime light exposure for nursing home residents with dementia and irregular sleep-wake rhythm disorder.
All members of the AASM Standards of Practice Committee and Board of Directors completed detailed conflict of interest statements and were found to have no conflicts of interest with regard to this subject.
Primary source: SLEEPSource reference: Morgenthaler TI, et al "Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders: An American Academy of Sleep Medicine Report" Sleep 2007.

Sleep Deprivation Leads to Emotional Instability Even in Healthy Subjects

October 25, 2007 — New research sheds important light on the link between sleep deprivation and psychiatric illness. A study appearing in the October 22 issue of Current Biology shows that parts of the brain governing emotional responses were much more active in people who had skipped a night's sleep and were exposed to disturbing images than in a control group of individuals exposed to the same pictures.
"The study provides a new foundation of evidence on which to consider more seriously that sleep may play a significant role in regulating our emotional stability," said Mathew Walker, director of the University of California, Berkeley's Sleep and Neuroimaging Laboratory, and senior author of the study.
"This is the first set of experiments that demonstrate that even healthy people's brains mimic certain pathological psychiatric patterns when deprived of sleep."
Sleep-Deprived Brains More Reactive
Dr. Walker and his colleagues enrolled 26 healthy undergraduates aged 18 to 30 years and separated them into 2 groups with equal numbers of males and females. One group stayed awake for about 35 hours (1 day, 1 night, and the following day) while the control group stayed awake on both days but slept normally at home during the night. At the end of the second day, both groups were shown 100 images that ranged from the emotionally neutral to the highly disturbing (ie, pictures of mutilated bodies and children with tumors) while undergoing brain scanning with functional magnetic resonance imaging (fMRI).
When the researchers quantified and compared brain activity in the amygdala, the area of the brain that oversees emotional reactions, they found significant differences in the brains of the sleep-deprived group when they were exposed to the negative pictures. "Rather than the brain being dulled or suppressed in its activity when you're sleep deprived, we found that the deep emotional centers of the brain were approximately 60% more reactive when you're sleep deprived," Dr. Walker told Medscape Psychiatry.
The amygdala serves to alert the body to protect itself in times of danger, according to background information supplied by UC Berkeley. In the setting of sleep deprivation, the amygdala goes into overdrive in response to emotional images — for example, shutting down the prefrontal cortex, the area of the brain that governs logical reasoning. Instead, it activates the locus coeruleus, which releases noradrenaline to ward off imminent threats to survival, a potentially volatile mix, they note.
Chicken or Egg?
The study provides useful insights into the relationship between sleep disruption and mood and other psychiatric disorders, said Dr. Walker. Almost all psychiatric conditions have some sleep abnormalities, he explains. "In fact, it's difficult to find a psychiatric disorder, particularly ones involving emotion, that don't have some kind of sleep impairment." The issue that has remained unresolved, however, is the exact relationship between sleep and psychiatric illness: does a psychiatric disorder cause sleep impairment, or does a sleep problem cause a psychiatric disorder?
In the past, most people assumed that sleep disorders were an offshoot of psychiatric problems, but this study casts doubt on that assumption, he said. It shows that emotional reactions of healthy but sleep-deprived people are similar to those seen in psychiatric disorders. "The patterns of brain activity that you see in those healthy people who have had a lack of sleep are not dissimilar to the patterns of brain activity that you see in people suffering things like depression and [posttraumatic stress disorder]," said Dr. Walker.
Although the difference in emotional brain responses between the 2 groups in the study averaged 60%, it ranged from as low as 40% to as high as 80%. One of the next steps for researchers, Dr. Walker said, is to determine whether women are more likely to have the greater emotional brain reaction when they're sleep deprived. "That's something we will be looking into," said Dr. Walker.
Researchers already believe that there's a closer relationship between sleep disturbance and depression among women than among men. If that is the case, "it suggests that what we should find in our results is that the females should be responding more abnormality than the males, but we don't know that yet."
What About the Real World?
Another question that remains unanswered is whether the relationship between sleep deprivation and psychiatric disorders exists not just inside the controlled environment of a sleep laboratory but also "in the real world," where people may not be totally sleep deprived but may regularly get only a few hours of sleep a night. "We don't know yet whether there would be the same amplified emotional brain response if we were to put people on a 5-hour sleep schedule for a week, so they accumulate approximately the same amount of sleep deprivation, and then perform the same experiment," he said.
Another element of the real world is shift work. There is anecdotal evidence that people who work overnight shifts might be more emotionally unstable than other workers, said Dr. Walker. "In terms of their mental health, they just don't seem to be functioning very well. I think [with this study], we're starting to see some of the reasons [for this]."
The authors report no relevant financial relationships. The research was supported in part by grants from the National Institutes of Health and the American Academy of Sleep Medicine.
Current Biology 2007;17:95-97.

AANP: Sleep Debt Can Bankrupt Mind and Body, But the Account Can Be Replenished

INDIANAPOLIS, June 22 -- More than a third of U.S. adults report problems falling asleep or daytime sleepiness, and lack of sleep is linked to one in five serious motor vehicle accidents.
Sleep deprivation can affect a person's ability to function mentally and physically, Margee Krebs, M.S., WHNP, told attendees at the American Academy of Nurse Practitioners meeting here.
"Sleep is like a bank account; you need to deposit 8 hours of sleep to compensate for 16 hours of wakefulness," she said. "If you don't, you go into debt. Sleep debt is cumulative so if you lose an hour of sleep every night, by the end of the week it's like being awake for 24 hours straight. Being sleepy is an indication of a sleep debt, just like thirst is a sign you need water."
Lack of sleep has been shown to decrease alertness, impair judgment, interfere with memory, and bring about moodiness or depression, Krebs said, noting that studies have shown that as sleep deprivation builds, people make more mistakes, and are less able to realize that a mistake has been made.
As the sleep debt piles up, there are also changes in how the body works Krebs explained. Stress hormones increase and there is an increase in hunger and appetite, which can lead to weight gain.
In addition, she said, pain can be worsened, and there is evidence linking lack of sleep to inflammation markers, which, in turn, have been linked to heart disease, stroke, and some forms of cancer.
To eliminate sleep debt, Krebs has some specific suggestions:
Go to bed earlier instead of trying to sleep later.
Nap, but for no more than 15 minutes; midday is best.
Get back to a normal schedule as soon as possible.
Noting that dependence can be an issue with non-benzodiazepine hypnotic sleep aids, Krebs listed the peak activity and half-life of zolpidem (1.6 hours; 2.5-2.8 hours), eszopiclone (1 hour; 6 hours), and Zaleplon (1 hour; 6 hours).
All of them, she pointed out, are schedule IV drugs and should be used with caution in older patients and those with respiratory issues.
Addressing non-pharmaceutical sleep aids, Krebs noted a number of strategies. Among them: meditative relaxation, exercise, mental stimulation during the daytime, reducing caffeine and nicotine intake, and establishing a bedtime routine.
Key ways to stay out of sleep debt, she said are:
Get an adequate amount of sleep each night.
Establish a regular sleep schedule,
Get continuous sleep; six straight hours is better than eight interrupted ones.
"Light is the most powerful cue that the body uses to reset your internal clock," said Krebs, so she suggests keeping the bedroom dark.
If a person is having trouble getting to sleep, bright lights early in the morning may help, she said. On the other hand, if staying asleep is the concern, lights should be used in the evening.
"Most people think of insomnia as a disease,"said Krebs. "However, it is not a disease, it is a symptom. It is important to get at the root of the insomnia and then pick out the sleep strategies that best address the actual causes." Primary source: American Academy of Nurse Practitioners National Conference
Source reference: "Sleep: Why It Is Important and How to Get It "

Mild Brain Injury May Cause Chronic Sleep Trouble

And that could make rehab even tougher, researchers say
WEDNESDAY, April 4 (HealthDay News) -- People who suffer mild brain injuries may be at increased risk for sleep disorders, researchers say.
Reporting in the April 3 issue of Neurology, researchers at the University of California, San Diego, assessed 42 people who complained of insomnia after they'd had a mild traumatic brain injury. Of those 42 patients, 15 (36 percent) had a circadian rhythm sleep disorder (CRSD) -- a problem with the timing of sleep.
Of the 15 patients with CRSD, eight had a "delayed sleep phase syndrome," including problems falling asleep and waking up; and seven had irregular sleep patterns.
"The frequency of sleep disorders in this study is considerably higher than the rate of these disorders among people attending sleep clinics for insomnia, which is seven to 10 percent," study author Liat Ayalon said in a prepared statement.
The findings highlight the need for improved diagnosis and treatment of circadian rhythm sleep disorders in patients who've had a mild brain injury and complain of insomnia.
"Misdiagnosis of these patients as insomniac may lead to prescription of medications, which help people fall asleep but don't help normalize the sleep-wake cycle," Ayalon said.