Health.am| Table 89-4 Secondary sleep disorders due to a general medical condition | |||
| Disorder | Subjective sleep complaints | Objective sleep findings | Comments |
Neurological disorders | |||
Closed head injury | Hypersomnia (prolonged nighttime sleep, daytime sleepiness) Insomnia (reduced sleep time, increased number of awakenings) Parasomnia (sleep terrors/sleepwalking, REM sleep behavior disorder) | Hypersomnia (prolonged nighttime sleep, excessive daytime sleepiness) Insomnia with reduced sleep time, increased Stage 1 sleep, reduced Stage 3/4 sleep, reduced REM sleep Awakenings from Stage 3/4 sleep or REM coincident with abnormal behavior | Severity of sleep complaints does not necessarily relate to the degree of trauma Sleep complaints often change in acute and postacute phase (e.g., hypersomnia developing into insomnia) Sleep complaints may be chronic |
Meningitis, encephalitis | Insomnia Hypersomnia Parasomnia | No recent studies | Viral, bacterial, or fungal infections may cause sleep symptoms Focal involvement of basal forebrain and hypothalamus can cause chronic symptoms (e.g., encephalitis lethargica during the 1918 influenza epidemic) |
Epilepsy | Hypersomnia Parasomnia (nocturnal wanderings, complex automatisms) Insomnia | Electrographic seizures often occur near wake-sleep transitions Increased delta activity (especially after seizure) Polysomnographic evidence for hypersomnia, insomnia Unusual behavioral episodes during abrupt awakenings from sleep (including walking, arm movements, other automatisms) | 25%-50% of patients with epilepsy may have seizures exclusively in association with sleep Primary generalized, secondary generalized seizures are often nocturnal; absence and myoclonic seizures only rarely Seizures more likely after sleep deprivation Monitoring for frontal and temporal seizure activity is particularly important during sleep studies Audiovisual recordings (or constant observation) required for clinical correlation Sleep complaints may also be caused by anticonvulsant medications |
Stroke | Insomnia Hypersomnia | Increased wakefulness Decreased REM sleep Decreased Stage 3/4 sleep Disorganized NREM/REM cycles Sleep apnea (especially central sleep apnea, periodic breathing cessation) | Thrombotic strokes show circadian pattern of occurrence, with peak at 6:00 a.m. to 12:00 p.m. or first hour after awakening Sleep complaints may be persistent Sleep complaints may be complicated by depression Site of lesion can affect specific sleep stage changes (e.g., pontine lesions can decrease REM or cause REM atonia) |
Headache | Sleep-related migraine Cluster headaches Paroxysmal nocturnal hemicrania | Increased wakefulness Cluster headaches, paroxysmal hemicrania associated with REM sleep | Treatment may include symptomatic or prophylactic agents (β-antagonists, ergot, methylsergide) |
Dementia | Insomnia Disorganized sleep-wake schedule Excessive daytime sleepiness | Increased wakefulness Decreased REM sleep Decreased Stage 3/4 sleep Decreased sleep spindles Increased sleep apnea | Decreases in Stage 3/4 and REM sleep correlate with degree of cognitive impairment Sleep disruption is a frequent cause of institutionalization |
Parkinson's disease | Insomnia (sleep-onset difficulty, increased wakefulness) Excessive daytime sleepiness | Increased wakefulness, Stage 1 sleep Decreased REM sleep Decreased Stage 3/4 sleep Decreased sleep spindles Increased apnea, hypoventilation | Bradykinesia and lack of mobility can impair sleep quality Tremor typically decreases during sleep Sleep complaints can be complicated by depression, dementia Dopaminergic and anticholinergic drugs at high dosages can contribute to sleep complaints |
Muscle diseases (muscular dystrophies, myotonic dystrophy) | Insomnia Hypersomnia | Increased wakefulness Decreased REM sleep Sleep apnea, hypoxia | Hypoventilation may respond to CPAP or BiPAP |
General medical disorders | |||
Cardiovascular disorders (heart failure, coronary artery disease, valvular disease), cardiac arrhythmias | Insomnia Hypersomnia Orthopnea, sleep apnea | Increased wakefulness Sleep apnea (especially central sleep apnea, periodic breathing cessation) Hypoxemia Arrhythmias | Myocardial infarction has circadian rhythm with peak at 6:00 a.m. to 12:00 p.m. Angina and cardiac arrhythmias during sleep may be related to apnea Systemic and pulmonary hypertension can result from sleep apnea Cardiac medications (β-antagonists, diuretics) can also impair sleep quality Heart block, sinus bradycardia more likely during sleep; ventricular arrhythmias less likely |
Pulmonary disorders (asthma, chronic obstructive lung disease, restrictive lung diseases) | Insomnia Hypersomnia Sleep deprivation | Increased wakefulness, decreased sleep time Sleep apnea (especially obstructive apnea, hypopnea) Hypoxemia Increased airway resistance | Airflow rates vary in circadian pattern, with increased bronchoconstriction in early-morning hours (exaggerated in asthma patients) Bronchodilators at night may improve airflow and sleep in patients despite direct stimulant properties CPAP, BiPAP, or nocturnal oxygen may be helpful in individual cases |
Gastrointestinal disorders (ulcers, reflux, hepatic disorders) | Insomnia Hypersomnia | Increased wakefulness Reflux during awakenings Increased acid secretion | Positional factors, prolonged time between meals may increase reflux symptoms at night |
Renal disorders (renal failure, infections, stones) | Insomnia Hypersomnia Restless legs syndrome | Increased wakefulness, decreased sleep time Decreased REM sleep Periodic limb movements in uremia | Dialysis, transplantation may improve sleep complaints Dopaminergic agonists for restless legs syndrome Use benzodiazepines with short duration, metabolized by glucuronidation |
Rheumatological disorders (fibromyalgia, rheumatoid arthritis, degenerative joint disease) | Insomnia: increased awakenings or poor-quality sleep Hypersomnia, daytime fatigue | Increased wakefulness, Stage 1 sleep Increased alpha EEG activity during NREM sleep Daytime sleepiness | Sleep disturbance and joint or muscle pain may exacerbate each other Antidepressants may help to relieve sleep disturbances and pain |
Chronic fatigue syndrome | Insomnia: increased awakenings or poor-quality sleep Hypersomnia, daytime fatigue | Increased wakefulness, Stage 1 sleep Increased alpha EEG activity during NREM sleep Objective testing does not show increased sleepiness in most cases | Antidepressants may help to relieve sleep disturbances, depression, and fatigue in some patients |
Endocrine disorders (diabetes mellitus, hyper- or hypothyroidism, hyper- or hypocortisolemia) | Insomnia Hypersomnia | Increased wakefulness, increased Stage 3/4 sleep in hyperthyroidism Prolonged sleep, decreased Stage 3/4 sleep in hypothyroidism Increased wakefulness, decreased Stage 3/4 sleep, decreased REM latency in Cushing's disease Decreased REM sleep in diabetes | Control of blood glucose, preventing hypoglycemia can improve sleep in diabetes Polyuria, neuropathy may complicate sleep symptoms in diabetes |
Acquired immunodeficiency syndrome | Insomnia Daytime fatigue, sleepiness Nightmares | Increased wakefulness Altered temporal distribution and decreased amount of Stage 3/4 sleep Increased objective sleepiness with advancing illness | Sleep symptoms typically progress from insomnia to hypersomnia complaints Sleep symptoms may be modified by CNS infections, tumors Anti-infection drugs can exacerbate sleep symptoms |