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Circadian Rhythm Sleep Disorders

By Karl Doghramji, MD, Jefferson Sleep Disorders Center, Thomas Jefferson University

Circadian rhythm sleep disorders occur when people’s internal sleep-wake schedule (clock) does not align with the earth’s cycle of darkness (night) and light (day).

  • Jet lag and shift work commonly disturb the usual rhythms of sleep and waking.

  • People cannot awaken or go to sleep when they need or want to.

  • Doctors base the diagnosis on symptoms, sometimes using information from a sleep log and sleep laboratory testing.

  • Good sleep habits and exposure to bright light can help people readjust their sleep-wake cycle.

Circadian means around (circa) the day (dies). Circadian rhythms are the regular changes in mental and physical states that occur in about a 24-hour period—a person’s internal clock. These rhythms are controlled by an area of the brain that is influenced by light (called the circadian pacemaker). After entering the eye, light stimulates cells in the back of the eye (retina) to send nerve impulses to this area. These impulses signal the brain to stop producing melatonin, a sleep-promoting hormone.

Normally, people vary in their sleep and wake times. Some (morning people or larks) prefer to go to sleep and wake early. Others (night people or owls) prefer to go to sleep and wake late. Such variations are not considered a disorder as long as people can do the following:

  • Wake up when they need to do something in the morning and fall asleep the night before in time to get enough sleep before having to get up

  • Sleep and wake up at the same time every day, if they want to

  • Adjust to new sleep and wake times within a few days after they start a new routine

People with a circadian rhythm sleep disorder fall asleep at inappropriate times and then cannot go to sleep or wake up when they need or want to. Their sleep-wake cycle is disrupted.

Causes

Causes of circadian rhythm sleep disorders may be internal or external.

Internal causes include the following:

  • Damage to the brain (for example, due to brain infection (encephalitis), stroke, head injury, or Alzheimer disease)

  • Insensitivity to the cycle of night and day

External causes include the following:

  • Jet lag (especially when traveling from west to east)

  • Working irregular shifts on a regular basis

  • Frequently going to bed and getting up at different times

  • Being confined to bed for a long time

  • Blindness or not being exposed to sunlight for long periods of time

  • Taking certain drugs

Sleep-wake reversals are common among people who are hospitalized because they are often awakened during the night and because their eyes are not exposed to sunlight long enough during the day.

There are several types of circadian rhythm disorders.

Jet lag disorder is caused by rapid travel across more than two time zones.

Shift work disorder varies in severity depending on

  • How often shifts change

  • How much they change

  • Whether they make sleep and wake times earlier or later

  • How many consecutive nights are worked

  • How long the shift lasts

Always working night or evening shifts and keeping the same bed times on days off is preferable. However, even then, daytime noise and light may interfere with sleep. Also, workers often shorten their sleep time and sleep at different times on days off to participate in social or family events.

Delayed sleep phase disorder occurs when people consistently go to sleep and awaken late (for example, go to sleep at 3 am and wake up at 10 am or as late as 1 pm). This syndrome is more common among adolescents and young adults. People with this syndrome cannot fall asleep earlier even if they try.

Advanced sleep phase disorder occurs when people consistently fall asleep and awaken early and cannot change this pattern. It is more common among older people. People with this syndrome cannot stay awake until later times even if they try.

Non–24-hour sleep-wake syndrome occurs when the sleep-wake cycle changes every day. The length of the sleep-wake cycle remains the same, but it is more than 24 hours. Thus, sleep and wake times are delayed by 1 to 2 hours each day. This syndrome is much less common and tends to occur in blind people.

Symptoms

Because people cannot sleep when they need to, they may be sleepy during the day and have difficulty concentrating, thinking clearly, and doing their usual activities. They may misuse alcohol, sleep aids, and stimulants in an effort to sleep or stay awake.

Symptoms of circadian rhythm sleep disorders may be worse when people change their sleep schedule frequently, as when they frequently travel across several time zones or change their shift at work. Symptoms are also worse if the change makes wake and sleep times earlier (advances the sleep cycle) because delaying sleep is easier than going to sleep earlier. The sleep cycle is advanced when people fly east or when shifts change from days to nights to evenings.

If the cause is external, the timing of other circadian body rhythms, including temperature and hormone secretion, is affected. Thus, people may feel generally unwell, irritable, nauseated, and depressed, as well as sleepy. The risk of heart and metabolic disorders may also be increased.

If the cause of the disruption can be corrected, symptoms resolve over several days as rhythms readjust. In older people, resolution may take a few weeks or months.

Diagnosis

  • A doctor's evaluation

Doctors suspect the diagnosis based on symptoms. People are usually asked to keep a sleep log and to record their sleep and wake times for a week or two. Testing in a sleep laboratory is rarely needed.

Treatment

  • Changes in behavior

  • Sleep aids and drugs to stimulate the brain

Developing good sleep habits can help.

Changes in Behavior to Improve Sleep

What to Do

How to Do It

Follow a regular sleep-wake schedule

People should go to bed at the same time each night and, more importantly, get up at the same time each morning, even on weekends and vacations. People should not spend too much time in bed.

Follow a regular routine before bedtime

A regular pattern of activities—such as listening to soft music, brushing the teeth, washing the face, and setting the alarm clock—can set the mood for sleep. This routine should be followed every night, at home or away. As part of this routine, people should avoid bright lights before bedtime.

Make the environment conducive to sleep

The bedroom should be kept dark, quiet, and not too warm or too cold. Loud noises can disturb sleep even when people are not awakened by them. Wearing ear plugs, using a white-noise machine or a fan, or installing heavy curtains in the bedroom (to block out outside noises and light) can help. Wearing a mask over the eyes can help people who must sleep during daylight in a room that cannot be completely darkened. If people wake up during the night, they should avoid bright lights.

Use pillows

Pillows between the knees or under the waist can make some people more comfortable. For people with back problems, lying on the side with a large pillow between the knees or lying on the back with a large pillow under the knees may help.

Use the bed primarily for sleeping

The bed should be used for sleep and sex. It should not be used for eating, reading, watching television, paying bills, or other activities associated with being awake.

Get up

When people are unable to fall asleep within 20 minutes, getting up and doing something else in another room and coming back to bed when sleepy may be more effective than lying in bed and trying harder and harder to fall asleep.

Exercise regularly

Exercise can help people fall asleep naturally. However, exercise within 5 hours of bedtime can stimulate the heart and brain and keep people awake.

Relax

Stress and worry interfere with sleep. People who are not sleepy at bedtime can relax by reading or taking a warm bath. Relaxation techniques, such as visual imagery, progressive muscle relaxation, and breathing exercises, can be used. People can aim to leave their problems at the bedroom door. Scheduling a worry time during the day to think about concerns can diminish the need to worry at bedtime.

Avoid stimulating activity before bedtime

Watching exciting television shows, playing thrilling computer games, or dealing with complicated work-related matters during the hour or so before bedtime can make sleeping difficult.

Avoid substances that interfere with sleep

Food and beverages that contain alcohol or caffeine (such as coffee, tea, cola drinks, and chocolate) can interfere with sleep, as can appetite suppressants, diuretics, and nicotine (in cigarettes and nicotine patches). Caffeinated substances should not be consumed within 12 hours of bedtime. Drinking a large amount of alcohol in the evening causes early morning awakenings. Quitting smoking may help.

Eat a light snack

Hunger can interfere with going to sleep. Occasionally, eating a light snack, especially if warm, can help, unless a person has gastroesophageal reflux. However, people should aim to stop eating at least a few hours before bedtime and not eat any meals, especially heavy meals, near bedtime. Heavy meals may cause heartburn, which can interfere with sleep.

Eliminate behaviors that provoke anxiety

People can turn the clock away so that time is not a focus. They should not watch the clock while they are in bed.

Spend time in bright light during the day

Exposure to light during the day can help people readjust their sleep-wake schedule to be in sync with the earth’s cycle of light and dark.

Avoid daytime naps, except for shift workers and people with narcolepsy

Daytime naps may interfere with sleeping at night in people with insomnia. However, naps reduce the need for drugs in people with narcolepsy and improve performance in shift workers. If needed, naps should be taken at the same time each day and limited to 30 minutes.

Exposure of the eyes to bright light at appropriate times may be the most helpful strategy. Such exposure helps reset the internal clock. For example, travelers should spend time in sunlight, particularly in the morning, after they reach their destination (see Problems in Transit : Sleep Disturbance). Shift workers should spend time in bright light (sunlight or artificial light) at times when they should be awake. Wearing sunglasses on the way home from work reduces exposure to bright light before bedtime and may help shift workers fall asleep more easily after arriving home. While shift workers are asleep, they should make the bedroom as dark and quiet as possible. Sleep masks and white-noise devices can be used. Exposure to bright light in the morning may help people with delayed sleep disorder. Bright light in the evening may help people with advanced sleep disorder.

Another strategy is to gradually shift the sleep-wake schedule to the one that is desired. Travelers may benefit from gradually shifting their schedule to approximate that of their destination, beginning well ahead of travel time.

Drugs

If symptoms persist, sleep aids with effects that last only a short time (short-acting drugs) may help people with insomnia sleep better, and drugs that stimulate the brain (such as modafinil) may help people feel more alert during the day, or, for people with shift work disorder, during their awake time. However, these drugs do not adjust the body rhythms any faster.

Melatonin may help minimize the effects of jet lag and problems related to working shifts. However, its use is controversial. Melatonin appears to be safe for short-term use (up to a few weeks), but the effects of using it for a long time are unknown.

Tasimelteon acts like melatonin. It can help people who are totally blind and have non–24-hour sleep-wake syndrome by increasing nighttime sleep time and decreasing daytime sleep time. This drug is taken by mouth before bedtime at the same time every night. The most common side effects are headaches and abnormal dreams or nightmares.

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