September 29, 2008
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Nancy Foldvary-Schaefer, DO
Dr. Nancy Foldvary-Schaefer, DO, is Director of the Sleep Disorders Center and Fellowship Program at Cleveland Clinic. She is Associate Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and staff in the Department of Neurology with a Joint Appointment in the Women’s Health Center at Cleveland Clinic.
Certified by the American Board of Neurology and Psychiatry in Neurology and Clinical Neurophysiology, the American Board of Clinical Neurophysiology and the American Board of Sleep Medicine, she has treated patients with sleep disorders and epilepsy at Cleveland Clinic since 1995.
During the next hour, Dr. Foldvary-Schaefer will answer your questions about sleep disorders including sleep apnea, restless legs syndrome and insomnia. Before we begin taking questions, Dr. Foldvary-Schaefer will address some of the most common concerns about sleep.
Types of Sleep Disorders
Cleveland_Clinic_Host: Millions of Americans, from infants to the elderly could be affected by sleep problems and most likely they don’t know it. How does someone know if they are not getting enough sleep?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: There are a variety of signs and symptoms of sleep deprivation. Some of the easiest to recognize include:
- Falling asleep or yawning during the day.
- Feeling restless and irritable with others.
- Having to check work repeatedly - making errors in school or work.
- Difficulty concentrating or staying on task.
- Reduced short-term memory.
- Decreased ability to learn.
Cleveland_Clinic_Host: As a person ages, is it just normal to need more sleep? When should we be concerned about an older relative?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Advancing age typically leads to changes in sleep patterns that cause older individuals to feel less satisfied with sleep, but are not necessarily indicative of a sleep disorder. These include more night awakenings and less sleep time overall. If such changes are accompanied by daytime sleepiness or fatigue, snoring or breathing pauses in sleep, restless leg symptoms or other usual night time behaviors, contact your doctor. Sleep disorders do tend to increase with age.
Obstructive Sleep Apnea
Cleveland_Clinic__Host: There are six main categories of sleep disorders. To begin with let's talk about them to help those chatting with us understand what they may be experiencing. What is Obstructive Sleep Apnea (OSA)?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Obstructive sleep apnea is characterized by repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep. Often the disorder's first signs are snoring, gasping for breath during sleep and excessive daytime sleepiness.
OSA is a very common disorder which probably affects 25% of men, 10% of women. It is estimated that nearly 90% of people affected are not diagnosed - meaning that the problem is a grossly under-recognized condition interfering with many other medical disorders. For example, OSA can cause or worsen high blood pressure, obesity (causing people to have difficulty losing weight) and even be associated with cardiac arrhythmias such as atrial fibrillation.
Cleveland_Clinic__Host: Is narcolepsy the same thing as daytime sleepiness?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Not exactly .The hallmark of narcolepsy is excessive daytime sleepiness which is characterized by repeated episodes of naps or lapses into sleep during wakefulness.
Narcolepsy is one of several sleep disorders that presents with significant daytime sleepiness often interfering with daytime activities. The majority of people with daytime sleepiness have other explanations for their symptom - including sleep deprivation and sleep apnea.
Narcolepsy causes daytime sleepiness as a result of an abnormal secretion of a peptide in the brain which causes people to experience difficulty staying awake as well as disrupted nocturnal sleep.
People with narcolepsy typically have other problems related to the abrupt appearance of REM sleep (the state in which we dream) intruding into wakefulness.
Cleveland_Clinic__Host: What about insomnia? I read in your book a reference to Psychophysiological insomnia.
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Psychophysiological insomnia occurs when a patient responds to stress or other environmental conditions with tension. The individual learns sleep-preventing associations, which result in difficulty falling and staying asleep.
Insomnia is probably the most common sleep complaint in adults. Insomnia can result from medical and psychiatric disorders as well as psychosocial stressors (job change, divorce). In other cases, insomnia appears to be genetic and people may develop it without any associated conditions.
Restless Leg Syndrome
Cleveland_Clinic__Host: We see many advertisements about Restless Leg Syndrome (RLS). Can you explain what this is?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: RLS is characterized by a strong, often irresistible urge to move the legs. This may be accompanied by sensations such as tingling, numbness or even pain. Symptoms usually begin in the evening and are relieved by moving, stretching or rubbing the legs.
It affects about 15% of adults, more often Caucasian patients. RLS can occur in people of any age, even children, but most often presents in mid-life and increases as we get older.
RLS is considered ‘primary’ when there is no known associated disorder, in which case we believe it is inherited. Or it may be considered ‘secondary’ in the presence of a known associated medical problem or medication.
Examples of medical problems that can trigger or exacerbate RLS include iron deficiency anemia, kidney failure, pregnancy and some anti-depressant medications.
RLS occurs primarily at night but as it progresses can appear during the day. In advanced cases it can also appear in the upper extremities. It often appears when the person is sedentary - for instance when in an airplane or a movie theatre.
REM Behavior Disorder
Cleveland_Clinic__Host: The last two categories are something that may or may not be familiar to many people. What is REM (Rapid Eye Movement) Behavior Disorder (RBD)?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: REM Behavior Disorder occurs when the physical paralysis of REM sleep is incomplete or absent. This condition allows individuals to actually act out their dreams.
RBD is one of many parasomnias (disorders presenting with unusual behavior in sleep.) Other parasomnias include sleepwalking, sleep talking, sleep terrors.
RBD is a very specific parasomnia that occurs during REM sleep, generally affecting men age 60 and older. Because they are not paralyzed in REM as we normally are - these individuals can act out frightening dreams that can lead to injury both to themselves and their bed partners. In many cases, it is associated with neurological disorders such as Parkinson's disease.
Delayed Sleep-Phase Syndrome
Cleveland_Clinic__Host: And the last category of sleep disorders - can you elaborate on Delayed Sleep-Phase Syndrome (DSPS)?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Let's first talk about Circadian rhythm sleep disorders. These occur when the normal sleep-wake rhythms are disturbed like when your natural sleep-wake cycles do not conform to society's norm. This can be due to alterations in the internal body clock - or misalignment between the body's internal rhythms and environmental factors.
Delayed sleep-phase syndrome is a circadian rhythm disorder that is most commonly seen in teens and young adults whose night owl tendencies delay sleep onset. Early wake times result in sleep deprivation, daytime sleepiness, and impaired work or school performance.
Cleveland_Clinic_Host: How bad should a sleep problem get before someone sees a doctor?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Some sleep problems are directly linked with a life- altering or stressful event, such as a job change or death of a loved one. Many such cases resolve on their own in weeks to months. Contact your doctor when sleep complaints are severe and/or longer than a few months in duration. In many of these cases, the sleep evaluation suggests that the disorder was actually present for much longer, sometimes many years longer, than the patient actually recognized.
Untreated sleep disorders are associated with a variety of problems including work and school underachievement, driving accidents, depression and interpersonal conflicts and exacerbation of underlying medical problems such as hypertension, cardiovascular disease, diabetes and obesity.
The short answer is - if the sleep problem is lasting longer than 3 months or interfering with daytime functioning of any duration it should be investigated.
Cleveland_Clinic_Host: Can certain medications cause sleep disorders?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Yes. Many commonly used prescription and over - the - counter (OTC) medications can cause drowsiness and some can cause insomnia, exacerbate restless legs syndrome or cause other sleep-related problems including sleepwalking and other unusual night time behaviors. These symptoms are generally reversible once the problematic drug is discontinued. Herbal remedies can also affect sleep and wakefulness.
sleepless_in_stlouis: My husband goes to bed between midnight and 1am. He falls asleep reading with the light on, glasses on, sometimes the TV is still on. I usually wake up and put everything away. And then between 3-5am he wakes up and reads again in bed. This cycle has been for almost one year now. I am sure a lot of it is stress-related and thinking about work in the middle of the night. He gets plenty of exercise and is otherwise healthy. Should he try a sleep aid to get over the hump, see a therapist or what? Do you have any suggestions?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: I would recommend that he consult a physician, perhaps a sleep specialist, to determine the type of treatment best suited. A specialist will interview your husband about his sleep patterns and habits. Is he having difficulty falling asleep, staying asleep, ruminating about daytime events or is there a physical sensation preventing him from falling asleep and staying asleep? All of these questions and more will need to be answered in order to determine the best course of action.
Sleeping pills may be effective for insomnia in the short run. But these drugs are associated with side effects. A better long term approach to treating insomnia is to use behavioral strategies which teach people how to sleep normally.
Cranky: If you feel you are suffering from insomnia, should you seek help and get a sleeping pill prescribed? I am afraid of becoming dependent on the medication.
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Millions of Americans are asking the same question. While sleeping pills can help a person fall asleep more quickly, most patients with chronic insomnia would better be served by learning healthy strategies for getting a restful sleep. It is true that some of the newer medications advertised on TV are not addictive as was the case with drugs of the past. But still some people get psychologically addicted to medicine and find themselves shopping between one drug and another. I generally prescribe sleeping pills for short term use only.
For an occasional sleepless night - chamomile tea, a warm glass of milk, a soothing bath or valerian are effective.
But for the person experiencing insomnia every night that interferes with daytime functioning, the best approach is to talk to your doctor.
cattricks: How do I know that what I have is really a sleep disorder? Do some disorders require sleep testing for diagnosis – and others not?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Yes. Some disorders are diagnosed by history – the patient interview alone - which is the case in most people with insomnia and RLS. Others require laboratory testing - either an overnight sleep study called a polysomnogram and/or daytime testing. Daytime testing is used to diagnose narcolepsy.
lovescoffee: What is a sleep history? Does it involve keeping a sleep diary?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: A sleep history generally consists of a series of questions that a physician will ask a patient about their sleep habits and patterns. A sleep diary or log is something that a person keeps for a period of time and can be a nice complement to the sleep history. The sleep history can go very far in determining the type of sleep disorder the patient may have.
lovescoffee: What does a sleep study -sleep testing in the lab involve? What is the experience like?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: First - visit the web site to Cleveland Clinic Sleep Center to take a tour, learn more about sleep testing and how to prepare for your sleep study.
The test is an all night recording lasting generally 8 hours. Sensors are placed on the head, chin, legs, under the nose, by the mouth, and around the chest and abdomen to measure brain wave activity, body movements and breathing patterns in sleep.
The test is performed in a private room. A technologist is present to monitor the recording and make observations about sleep patterns throughout the night.
Sleep in the laboratory is definitely not the same as a home environment; however the vast majority of people can sleep adequately in the laboratory in order for the study to make a diagnosis.
sleepyalot: I have Hypersomnia throughout the day. I have problems in quieter situations, such as working on the computer, in meetings, watching TV, etc., where I am not too active. I don't necessarily fall asleep, but it's close. I have to fight to stay awake. And when it hits, it’s like a curtain coming down. One minute I am fine, the next I am not. Luckily, this doesn't occur when I am driving. What can I do to help this and what exactly causes it?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: There can be many different causes of daytime sleepiness, or hypersomnia. The treatment depends on the underlying cause. By far the most common cause of daytime sleepiness is inadequate sleep at night. If there is any possibility that you are not getting enough sleep - the treatment is to extend your sleep time by one hour and see if this helps. If it does not help, you should be seen by a sleep expert. A sleep study would be indicated and laboratory testing should be tailored to your sleep history.
Aging and Sleep
VirginiaM: Would you address aging and sleep? I am in my 80’s – finding it difficult to get more than a couple of hours of sleep at night. I wake up around 4 am, and then I need a nap at 8am and again in the afternoon. I would love to get 8 hours of sleep again. I am tired of waking up when nothing good is on the television to watch. Thank you.
Speaker_-_Dr__Nancy_Foldvary-Schaefer: This is a textbook example of the normal aging process as it relates to sleep. With aging - normal older people do not require as much sleep as they did at one time. There is a shift in the circadian rhythm which causes the individual to fall asleep earlier in the evening, wake up early morning hours. Sometimes increasing light exposure in the evening helps the individual to fall asleep later in the evening and thus wake up later in the morning hours.
Grace: Why do you sometimes experience bad or weird dreams – even nightmares? This happens to me when I would not expect that I wouldn’t sleep well. No caffeine or alcohol keeping me up – just really exhausted when I go to sleep.
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Nightmares are common disorders, generally benign. At some level they are probably a reaction to a disturbing memory or event from the recent past. They do not necessarily occur in a logical fashion. Nevertheless - they are almost always harmless..
copley_32: I seem to have dreamless sleep. I can't remember the last dream I have had; it’s been that long ago. Can you explain this?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Not everyone remembers their dreams. Simply not remembering does not mean that you are not dreaming and achieving deep stages of sleep. If you have other sleep symptoms such as snoring or daytime sleepiness - there may be more to it.
imacontender: There are some nights where it seems I do nothing but dream. I wake up constantly, go right back to sleep, but back into another dream. I wake up feeling terrible. I don't really like taking sleeping pills because I'm afraid I won't get up on time in the morning. What can I do to help with this?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: If excessive dreaming that is disturbing and disruptive is the norm - you should be evaluated by a sleep expert. Symptoms such as these may be a sign of narcolepsy, sleep deprivation or alcohol overuse and withdrawal.
crusher: Please address snoring issues and available treatment options. Is there any product available to help reduce snoring?
Speaker_-_Dr__Nancy_Foldvary-Schaefer: Snoring is quite common and must be differentiated from sleep apnea. Sleep apnea presents with snoring and periods of breathing cessation in sleep. Typically a sleep study is needed to diagnosis sleep apnea.
For people who snore only and do not have symptoms of sleep apnea, nasal strips could be used as well as nasal sprays to reduce inflammation in the nose thus minimizing snoring. There are minimally invasive surgical procedures that are excellent to reduce snoring.
Unfortunately, there is no magic cure for snoring.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Foldvary-Schaefer is now over. Thank you again Dr. Foldvary-Schaefer, for taking the time to answer our questions today.
Speaker_-_Dr__Nancy_Foldvary-Schaefer: This has been a great venue to answer questions. Here’s to a good night’s sleep for everyone. Sweet dreams!
Cleveland_Clinic_Host: Remember, you don't need to suffer with poor quality sleep or daytime sleepiness. The first step toward a better night's sleep is a comprehensive evaluation by a Cleveland Clinic Sleep Disorders specialist. To make an appointment call 216.444.2165 or toll free 800.223.2273, ext. 42165, from 8 am to 5 pm. Learn more
Once your disorder is diagnosed, a treatment plan will be designed specifically for you. As part of your sleep disorder treatment, your sleep medicine physician may recommend a consultation with a sleep psychologist, psychiatrist, otolaryngologist (ENT specialist), dentist or a physician specializing in weight reduction.
Cleveland_Clinic_Host: If you are looking for a Sleep Center and your physician recommends testing in the sleep laboratory for your convenience and comfort, you can have your sleep study performed at any of the Cleveland Clinic Sleep Laboratories located throughout the region:
- For Adult and Pediatric Sleep Studies:
- Cleveland Clinic Sleep Disorders Center at Fairhill in Cleveland, Ohio a state-of-the-art sleep facility, including a 9-bed sleep laboratory and outpatient clinic, just one mile east of the main campus downtown.
For Adult and Pediatric (12 years and older) Sleep Studies:
- The Courtyard by Marriott hotel in Beachwood on Cleveland’s eastside
- The Courtyard by Marriott hotel in Willoughby on Cleveland’s eastside
- The Courtyard by Marriott Airport/North hotel in North Olmsted on Cleveland’s southwest side
- The Hilton Garden Inn in Twinsburg on Cleveland’s southeast side
- Marymount Sleep Disorders Center in Garfield Heights on Cleveland’s eastside
- The Holiday Inn in Elyria/Lorain on Cleveland’s westside
- View more information regarding sleep disorders
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- If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 4-3771 to speak with a Health Educator. We would be happy to help you. Tell us if you would like to be informed about future web chat events!
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