How to diagnose and manage sleep disorders

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The evidence surrounding the importance of high-quality sleep is ever-increasing, with more and more health problems linked with poor sleep.

We know that many people with MS do not find they get restful, quality sleep, and that there is a high prevalence of sleep disorders within the MS population, particularly around sleep disordered breathing and sleep apnea. Other sleep disorders such as insomnia, restless leg syndrome, and circadian rhythm disorders. Side-effects caused by medications including disease-modifying therapies and those for symptom management can also impact sleep quality.

MS symptoms such as fatigue, cognitive impairment, mood and pain can all be exacerbated by poor sleep. Mental health problems like anxiety and depression can also be impacted, affecting an individual's ability to manage stress effectively which has also been linked to worsened symptoms.

This webinar, featuring Professor Matthew Walker and Prof Gavin Giovannoni, looks at how to diagnose and manage sleep disorders.

Summary

Despite a “significant number of people with MS” having sleep problems, Professor Matthew Walker sees “very few referrals”.

“Sleep disorders are definitely prevalent and underrecognized in people with multiple sclerosis,” he said.

“They are multifactorial. Both direct and indirect causes of sleep disruption result in fatigue, sleepiness, and cognitive problems, as well as increase in mortality, and may have an effect on the immune system."

“What we really need is improved recognition and treatment of sleep problems in multiple sclerosis.”

Sleep cycles

Giving delegates some background, he said people tended to need between seven-and-a-half and eight hours of sleep a night. All animals need sleep, though scientists still do not fully understand why, he added.

The two dominant stages of sleep are non-rapid eye movement (REM) sleep, which is divided into three categories, and REM sleep.

During the night, we cycle through the stages as follows:

• Stage 1 non-REM: light sleep or “dropping off”
• Stage 2 non-REM: may be important for memory consolidation
• Stage 3 non-REM: deep sleep which is recuperative and may be necessary for clearing toxins from the brain
• REM: dreaming sleep

Each cycle lasts around 90 minutes, with the REM periods getting long and the deep sleep getting shorter as the night progresses.

“By the end of the second half of the night you are not having any deep sleep at all. It tends to be light sleep and REM sleep, and this is important for a number of reasons,” said Matthew.

“We're much more easily woken during the morning, while we tend to be much more deeply asleep at night. If people have their sleep disrupted in the early part of the night, it will often disrupt deep sleep, which can have a number of effects on the way they feel during the day.”

Things that occur during deep sleep, such as sleep walking and night terrors, tend to occur in the first third of the night. By contrast, things that happen during REM sleep, like REM sleep behaviour disorder, usually occur towards the morning, Matthew explained.

“The time when things occur during the night is often a useful indicator of what the problem may be,” he added.

Sleep deprivation

Sleep deprivation and daytime sleepiness has an “incredible impact” on performance and on quality of life, said Matthew.

It can also affect memory, cognition, and mood, as well as increase in anxiety, depression, and anger, he explained.

“Sleep has a profound effect on our ability to cope with things that occur during the day… but there is also increasing evidence that sleep deprivation increases mortality,” he said.

“There is also increasing recognition that sleep is crucial for our immune response.”

Sleep and MS

Sleep problems are common in people with MS, Matthew explained. Around 30% of people with the condition have moderate to severe insomnia, compared to just 10 to 20% of the general population.

Around 40% of people with MS are at risk of obstructive sleep apnoea, and 19% experience restless leg syndrome.

Asking about excessive daytime somnolence can help teams to identify problems. It is also important to differentiate between fatigue, or a lack of physical or mental energy, and daytime somnolence, defined as wanting to fall asleep.

“They are interrelated, but they are not the same thing,” he said, adding that sleep problems had a considerable impact on people’s lives.

“If you are not addressing these problems, you may not be addressing something that could have a huge impact on quality of life.”

Mechanisms

A multitude of factors can drive sleep problems in people with MS.

Pain and urinary frequency can disrupt sleep, as can anxiety, and depression, for example. Weight gain can predispose people to obstructive sleep apnoea, and medication, particularly steroids, can affect sleep quality. It’s also worth noting that inflammation can impact how much sleep people need, Matthew said.

The physical symptoms of MS also play a role. Spinal cord disease is associated with restless leg syndrome, for instance, and REM sleep behavioural disorders can occur when someone has lesions in the brainstem.

Summary: Management of sleep disorders in people with MS

Matthew also spoke about the management of sleep disorders in MS on behalf of UCL’s Dr Sofia Eriksson, who was unable to attend the webinar.

“The main thing is taking a history about sleep, and establishing when they go to bed, what time they get up, whether they're napping during the day, and how long it takes them to get to sleep,” he said.

Other things to note include their BMI, whether they snore, and any other events they are aware of during the night, such as restless legs.

“Remember, restless leg syndrome is not just the need to move. If people do not move it becomes painful and uncomfortable, and so they are driven to move,” Matthew noted.

HCPs should also look at non-sleep issues, such as spasms, nocturia, and medications which can “have a profound effect on sleepiness”.

“Anxiety is one of the biggest drivers of insomnia and sleep disorders so asking and anxiety about depression is absolutely critical,” said Matthew.

Sleep diaries can help with this history taking. Many people have fitness trackers that monitor sleep and can provide clinicians with useful information.

Scores

Matthew’s team uses the Epworth sleepiness score, which only takes about five minutes to perform. It asks about a person’s chances of dozing in particular situations and helps clinicians decide if the patient is excessively sleepy.

“Then you need to identify why they're excessively sleepy and address that specific problem. The most common cause is insufficient sleep at night or going to bed too late and getting up too early,” said Matthew, adding that this is where the sleep diary is valuable.

The STOP BANG score can be helpful in screening for obstructive sleep apnoea, he went on. Despite not being validated in neurological conditions, it provides a useful guide for the kind of questions we should all be asking in practice, said Matthew.

Restless leg syndrome

The criteria for the diagnoses of restless leg syndrome include:

• The urge to move extremities, usually due to discomfort or pain
• Motor restlessness where movement relieves the discomfort
• Symptoms are worse at night or later in the evening

Matthew said: “The problem with periodic limb movements while asleep is that people may not be aware of them. They're often just a very short little shuddering movement of the foot or leg that might be so slight the person is not aware of it, but it's enough to disrupt and to stop people getting into deep sleep.”

As well as neurological disorders, restless leg syndrome can be related to medications, especially antidepressants, and anemia.

The RLS severity scale can help HCPs understand the impact of the disorder on people’s quality of life, said Matthew.

Management

The first step is offering advice on good sleep hygiene. That includes limiting day time naps to 15 minutes and the person giving themselves enough time to sleep at night.

Treating any underlying sleep disorders and sleep-disturbing MS symptoms is vital, as is optimising medications to reduce the risk of sleep interference.

References
Brass, S., Li, C-S., et al. The underdiagnosis of sleep disorders in patients with multiple sclerosis. (2014). https://pubmed.ncbi.nlm.nih.go...
Mancoi., M.., Ferini-Strambi, L., et al. Multicenter case-control study on restless legs syndrome in multiple sclerosis: the REMS study. (2008). https://pubmed.ncbi.nlm.nih.gov/18655317/
2012 Revised IRLSSG Diagnostic Criteria for RLS. (2012). http://irlssg.org/diagnostic-c...

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