Sleep Problems You Shouldn’t Ignore

Written By Shaw Kuster

This is the final post in our series on sleep. We will focus on medical causes for interrupted or disordered sleep and signs that you may need to seek medical care.

This post will cover:

  • Obstructive sleep apnea (and the lesser known central sleep apnea)

  • Restless Leg Syndrome 

  • Narcolepsy

  • REM Sleep Behavior Disorder

Obstructive Sleep Apnea (OSA)

OSA is an extremely common sleep condition where a narrowed or collapsed upper airway prevents you from being able to breathe in during sleep. Around 1 in 3 adults have some form of OSA, and about 13-14% have moderate to severe OSA which should be treated. 

When your body tries to breathe in, but can’t, this leads to apneas, or period of time where you do not breathe. This in turn can cause oxygen levels in your blood to drop, which sends a signal to your brain saying, “We need to breathe!”. If you still can’t get air in, that signal pings again: “We really need some oxygen here!”. This can cause you to startle awake multiple times a night as your brain tries to keep you alive. Mild apneas can cause small dips in blood oxygen and you might not completely wake up before you get a breath in, but can lead to multiple micro-awakenings throughout the night and keep your body in light sleep. Over time this leads to sleep deprivation symptoms and symptoms of oxygen deprivation. Untreated OSA may increase cortisol levels and increases the risk of high blood pressure resistant to treatment, heart attack, stroke, and dementia. People with untreated OSA are also at higher risk for car accidents if they fall asleep while driving.  

A brain that is chronically starved for oxygen functions in a less than ideal manner. 

Men over 50 who are overweight/obese are more likely to develop OSA, but this doesn’t mean that it can’t also happen to normal weight women.

OSA symptoms include:

  • High blood pressure that doesn’t respond to multiple medications

  • Waking up with headaches

  • Loud snoring or waking up gasping for air

  • A bed partner who has noticed you stop breathing during sleep

  • Daytime sleepiness

  • Frequent nighttime urination (although this can also be due to other conditions like enlarged prostate in men or diabetes)

A simple tool to assess your risk for OSA can be found here - STOP-BANG

If you are high risk for having OSA and especially if you have any symptoms please talk with a doctor about getting tested. OSA is diagnosed by wearing a monitor during sleep either at home or in a sleep lab. If you do have OSA then there are multiple treatment options, the most common of which is a CPAP (continuous positive airway pressure) mask during sleep. There are multiple versions, some which cover just your nose, some which cover both nose and mouth. Many people are not particularly excited to wear a mask that blows air down your throat all night, and it can admittedly take some getting used to, but finding a treatment that works for you if you have OSA is incredibly important to get your body the sleep it needs to function optimally.

A brief caveat that I would also like to mention here. There is another type of sleep apnea, called Central Sleep Apnea (CSA). Rather than decreased airflow during sleep caused by the airway being blocked, CSA happens when your brain forgets to tell your body to breathe while you are sleeping. Most commonly this is temporary and related to rapid ascent to altitudes over 8200 ft. However, even moderate altitude, such as that along parts of the Front Range of Colorado, can be enough to unmask CSA in susceptible individuals. So if you live at moderate altitude (generally 6,500 - 8,200 ft) and have OSA but routine treatment like CPAP is not working for you, you should talk to your doctor about the possibility of Central Sleep Apnea, since the treatment is often different.

Restless Leg Syndrome (RLS)

Another acronym. We love them in medicine. 

RLS is a condition where someone experiences leg discomfort that comes on at rest, usually in the evenings, and is at least partially relieved by movement. Briefly - your legs feel restless. It can make falling asleep difficult and for that reason I include it here.

It is more common in women and is caused by a combination of genetic predisposition and environmental factors, the most important of which is an iron deficiency in the brain (which can occur even if you aren’t anemic). This is because iron is necessary for the brain to make dopamine. 

Low brain iron -> low dopamine -> nervous system dysregulation -> restless legs

Once someone is diagnosed with RLS a ferritin level should be checked. Ferritin is your body’s iron storage protein. In people with RLS, the ideal ferritin level is >100 and the first line treatment is iron supplementation if your ferritin is lower than that. This can often resolve symptoms on its own without prescription medications. 

Narcolepsy

Most people are at least tangentially familiar with narcolepsy, though many of it’s symptoms are misunderstood. Narcolepsy is a sleep disorder caused by the loss of nerve cells in a particular part of the brain that produce a protein called orexin. Simply put, orexin is responsible for keeping you awake. Narcolepsy is thought to be at least partially an autoimmune disorder and usually shows up in adolescence. 

The most common symptoms are:

  • Daytime sleepiness

  • Cataplexy - muscle weakness triggered by strong emotions (Cute in goats, not so cute when it happens to you. I was going to link to a video here but I watched a few and just felt bad for the goats, so maybe not so cute after all…)

  • Sleep paralysis - inability to move upon waking

  • Vivid hallucinations in that in between period as you fall asleep or wake up

  • Frequent nighttime awakenings

REM Sleep Behavior Disorder

REM sleep usually takes place in the second half of the night. It is when you dream and typically your body is paralyzed during REM sleep, except for your eye muscles, which is why it is called rapid eye movement sleep.

REM Sleep Behavior Disorder (unfortunately REMSBD is not an accepted acronym here…but RBD is!) occurs when there is a dysfunction in the part of the brainstem that is responsible for muscle paralyses during REM sleep. As a consequence, the body is not paralyzed and you end up acting out your dreams. This can lead to unintentional injury of a sleep partner. RBD is associated with some antidepressant medications, narcolepsy, brainstem damage, and alcohol withdrawal. However, between 70-90% of people with RBD without a clear cause eventually develop a degenerative neurological condition such as Parkinson’s Disease or certain types of dementia, and RBD can often be the first symptom of these diseases. For this reason, RBD should not be overlooked or ignored.

This is the last post in our sleep series. To read more about healthy sleep check out the other posts in the series: Artificial Light at Night and Why You Can’t Sleep and A Better Night’s Sleep. 

Coming up soon I’m excited to get into postpartum/fourth trimester issues and to do some education on Direct Primary Care. 

Shaw Kuster
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A Better Night’s Sleep