Clinic speak: sleep problems

Sleep, Where art thee? Sleep cycle disorders in MS. #MSBlog #MSResearch #ClinicSpeak

'O Sleep, O Gentle Sleep, Natures Soft Nurse, How Have I Frighted Thee, That Thou No More Wilt Weigh my Eye-Lids Down And Steep My Senses In Forgetfulness?' – William Shakespeare

"Do you suffer from sleep cycle reversal or an altered sleep cycle? In other words your sleep pattern is not synchronized with the normal day-night or light-dark cycle. You tend to sleep during the day and not at night. Some normal people are like this; for example Mouse Doctor tends to be a night owl and goes to sleep very late (2 or 3 am), but then gets up later. I am probably the opposite."

"The area that controls the sleep cycle or circadian rhythm is the hypothalamus, which is located at the base of the brain. MS affects the hypothalamus. At post-mortem MS lesions are seen in the hypothalamus and there is a loss of neurons and axons as a result of this damage. Therefore it is not surprising that MS causes sleep disorders. It is not uncommon for MSers to complain about a reversal of their sleep-wake cycle or a shift in its timings. Sometimes the shift is dictated by poor sleep hygiene; if you feel tired during the day you take a nap and sleep for several hours. Hence when it comes to bedtime you are not tired and you only fall asleep in the early hours of the morning. When you wake you feel tired and unrefreshed and the cycle then repeats itself and becomes the new norm. It can be difficult to break the cycle without medication; but we have several drugs that we can prescribe for a short period of time to get things back in sync. I tend to use a low dose of one of the sedating tricyclic antidepressants for this problem, for example 10-50mg of amitriptyline. I don't use classic sedative such as benzodiazepines, because of tolerance to their sedative effects that comes on very quickly."

"This study below documents how common circadian sleep disorder is in MSers and shows you how closely linked it is to fatigue."

"If you suffer from fatigue the first question you need to ask yourself is are you getting enough, good quality, sleep? Are you waking feeling refreshed? Things that you can address are poor sleep hygiene, i.e. trying not to nap too often and too long in the day. If you are taking sedating medication you may need to change these are alter the way you take them. Do you have symptoms that are keeping you up at night? Bladder problems (nocturia), spasms, pain, cramps, restless legs, difficulty rolling over in bed, general discomfort, etc.? You may have obstructive sleep apnoea; I have discussed the latter before and it is not uncommon in MS. A clue to this is snoring (ask your partner) and waking up with a mild headache, or sore throat from trauma to the uvula (little tongue at the back of the throat); when you snore the uvula gets traumatised. If you don't have a partner you can download one of the sleep apps for your smart phone that can detect snoring. Failing this you may have to be investigated in an overnight sleep laboratory."

"If you have problems getting or staying asleep at night this may be relate to anxiety or depression. Are you worried about something? The future? Are you having too many stimulants in the day; caffeine or energy drinks? Are you drinking too much alcohol? Paradoxically alcohol results in poor sleep as it affects the different stages of sleep so that you don't get enough restorative or refreshing deep wave sleep."

"If you missed it a few weeks ago I suggest you look at the results of the survey we did on sleep. It is based on a simple a screening questionnaire that you can download and score yourself (see below). If your scores suggest a sleep problem and you don't feel right go and see your neurologist or MS nurse for advice to get to the bottom of your sleep problems. Sort these out and you may find your daytime energy levels improve and your mood improves - try it!"

"One thing I have not discussed here is exercise. Aerobic exercise several times of week improves sleep. If you don't believe it try it. If you can't exercise due to disability ask your physiotherapist, or arrange to see a physiotherapist,to devise a bespoke exercise programme for you. You will be pleasantly surprised at the benefits of exercise."


Najafi et al. Circadian rhythm sleep disorders in patients with multiple sclerosis and its association with fatigue: A case-control study. J Res Med Sci. 2013 Mar;18(Suppl 1):S71-3.

BACKGROUNDCircadian rhythm sleep disorders are a presentation of sleep disorders in MSers. This study aimed to compare this problem in MSers with healthy people and to determine its association with chronic fatigue in MSers.

MATERIALS AND METHODS: A case-control study was performed on 120 MSers and 60 healthy subjects matched for age and sex, in 2009 in MS Clinic Alzahra Hospital. Sleep quality, rhythm and fatigue severity were assessed using PSQI (Pittsburgh sleep quality index) and FSS (Fatigue severity Scale) questionnaires, respectively. Its reliability and validity has been confirmed in several studies (Cronbach's alpha = 0.83). This index has seven sections including subjects assessment of his/her sleep, sleep duration, efficacy of routine sleep, sleep disorders, use of hypnotic medication, and dysfunction in daily activities.

RESULTS: Circadian rhythm sleep disorder was more frequent in MSers relative to healthy subjects (P: 0.002). It was higher in MSers with severe fatigue relative to MSers with mild fatigue (P: 0.05). Fatigue severity was 49.9 ± 8.2 and 22.5 ± 7.4 in the first and second group, respectively. PSQI index was 7.9 ± 4.5 in MSers with severe fatigue and 5.9 ± 4.5 in patients with mild fatigue and 4.5 ± 2.4 in the control group (P: 0.0001).

CONCLUSION: Circadian rhythm sleep disorders are more frequent in MSers and those with fatigue. Recognition and management of circadian rhythm sleep disorders in MSers, especially those with fatigue may be helpful in improving care of these patients.

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