Diabetes - - people with diabetes often wake up with night sweats, frequent need to urinate, diarrhea or symptoms of hypoglycemia.

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1 Medical Illnesses that May Disturb Sleep More than 70% of people with medical illnesses suffer from sleep problems. Their trouble sleeping may stem from the disease itself or from the medicines used to treat the disease. 11 The following are some common medical conditions that may disturb sleep: Heart disease - - many with this disease awaken feeling short of breath and may also experience obstructive sleep apnea. Sleep apnea may increase the risk of heart attacks or death by 30%. 2 Diabetes - - people with diabetes often wake up with night sweats, frequent need to urinate, diarrhea or symptoms of hypoglycemia. Weight - - getting less sleep can contribute to weight gain. The hormones leptin and ghrelin are responsible for regulating appetite and are affected by lack of sleep. A recent University of Chicago study showed that those who slept less than eight hours a night had lower levels of leptin and higher levels of ghrelin, which leads to weight gain as well as higher body fat than those who slept at least eight hours. 15 Heartburn - - often caused by backup of stomach acid into the esophagus and can be made worse by lying down in bed. Kidney disease - can cause waste products to build up in the blood and result in insomnia or restless leg syndrome. Menopause - - Menopausal women sometimes experience difficulty falling asleep, awakening frequently during the night, and feeling unusually tired during the day. These women get less REM sleep and often experience hot flashes and awaken in a drenching sweat with their hearts pounding. Psychological Disorders - - people with anxiety disorders often have trouble falling asleep and staying asleep. Panic attacks can occur at night during stage 2 or 3 sleep. Disturbed sleep is a prominent feature of bipolar disorder. Sleep loss may bring on or worsen manic symptoms, or temporarily relieve depressive symptoms. 90% of people with serious depression experience early-waking insomnia. They spend less time in slow-wave sleep and more time in REM sleep. People with schizophrenia sleep little when they enter an acute phase of their illness while their sleep patterns may improve between their episodes. Arthritis/Fibromyalgia - - pain makes it difficult to fall asleep and resettle when changing positions. Treatments used to treat arthritis such as corticosteroids can cause insomnia. Those who suffer from fibromyalgia are likely to wake in the morning still feeling fatigued and stiff. 1

2 Neurological disorders - - Alzheimer's or dementia can cause disorientation and agitation in the evening. Many people with these conditions experience sundowning (a syndrome of recurring confusion and increased agitation in the late afternoon or early evening) and require constant supervision or they may wander. Those with epilepsy are twice as likely to suffer from insomnia, because brain wave disturbances that can cause seizures can interfere with sleep. Sleep deprivation can also trigger a seizure. Headaches that awaken people are often migraines the two types of headaches that occur frequently in the morning are cluster and migraine headaches. Respiratory problems - - nighttime asthma attacks can quickly end sleep. Many of the medications used to treat asthma are stimulants that make it difficult to go to sleep and stay asleep. Thyroid disease - - overactive thyroid can make people jumpy and unable to sleep. Night sweats that can disturb sleep are a symptom of thyroid dysfunction. Feeling cold and sleepy is a hallmark of hypothyroidism (underactivity of the thyroid gland). References: 1. American Thoracic Society. (2007). Sleep Apnea Increases Risk of Heart Attack or Death by 30%. Retrieved June 23, 3008 from 2. Shapiro, C., Devins, G.,& Hussain, M. (1993). ABC of sleep disorders. Sleep problems in patients with medical illness. British Medical Journal, 306(6891), Retrieved June 20, 2008 from: 3. WebMD Inc. (2005). The Dream Diet: Losing Weight While You Sleep. Retrieved June 27, 2008 from: 2

3 Sleep Disorders Sleep difficulties may be a sign of a more serious problem. The following is a description of some of the major sleep disorders. If you or someone you know is experiencing any of the following it may be helpful to talk about it with a doctor. Insomnia People with insomnia may have difficulty falling asleep, wake up during the night, have fitful sleep, wake too early and/or experience daytime drowsiness. There are four common forms of insomnia 4 : Transient - -The cause of transient (short-term insomnia) is obvious to the sufferer stress, a death, job loss, etc. It lasts from one night to a few weeks Intermittent - - Intermittent insomnia only happens from time to time and is short term Chronic insomnia - - Chronic insomnia lasts three nights a week for a month or more Learned insomnia - - People learn to associate the bedroom with wakefulness. As insomnia worsens, lack of sleep causes anxiety and stress which then becomes a vicious cycle. Treatments include spending less time in bed and use of relaxation techniques or reconditioning. Reconditioning uses four basic rules: Use bed only for sleep (don t read or watch television in bed). Go to bed only when sleepy. If unable to sleep, get up and move to another room. Stay up until you are sleepy, and then return to bed. If you don t fall asleep right away (within minutes), then repeat. Get up at the same time every day and do not nap during the day. Most sleep experts now advise against using any sleep medication as it can cause rebound insomnia (insomnia after medicine wears off). If any medication is prescribed it is most likely antidepressants with a sedative effect, prescribed to improve both sleep and mood. Breathing Disorders in Sleep It s important to remember that everyone who snores doesn t have a sleeping disorder, and everyone with a sleeping disorder doesn t snore. Snoring when person inhales, air rushes past the upper throat and down the windpipe. Snoring occurs when dangling or loose tissue in the area vibrates during breathing. One in four adults snore regularly most often the cause is poor muscle tone or excess fat in the neck area. Some treatments recommended are: air strips over the nose sewing a tennis ball onto the back of the sleep garment (to prevent sleeping on your back) sleeping with head elevated Losing weight can often help lessen the problem considerably. A humidifier or medication may help reduce swelling if nasal tissues are the problem. 3

4 Sleep apnea - is a serious disorder in which breathing stops during sleep. These episodes usually last 10 seconds or longer and occur many times throughout the night. It is estimated that at least million American adults have sleep apnea, making it as common as asthma. 1 It is most common among the overweight, and occurs more often in men than women. Sleep apnea can be fatal if untreated. It also may put people at greater risk for strokes and heart attacks. Usually lifestyle changes are helpful in the treatment of apnea: Weight loss Increasing muscle tone Avoiding alcohol and other sedative medications Quitting smoking Some people will need to sleep with a ventilation mask that keeps the airway open this device delivers pressurized air through a mask. Drugs and surgery are also options for some people. Movement Disorders in Sleep These are uncontrollable movements during sleep: Restless leg syndrome - is a neurological disorder whose symptoms are a pulling, aching or crawling sensation under the skin of the calves. It can be temporarily relieved by moving the legs. Because symptoms are worse while sitting still, people often want to get in and out of bed many times during the night. There is a strong genetic component to this disorder at least 50% who have this disorder also have a parent with the same disorder. Relaxation techniques, regular sleep habits and exercises for the legs during the day can help. If behavioral changes don t work, some medicines are available. Periodic limb movement disorder - While restless leg syndrome can happen at any time during the day or night, periodic limb movement happens exclusively during the night. The leg muscles involuntarily contract at regular intervals, causing jerking movements and waking the person at least partially from sleep. Up to half of elderly people experience these leg movements during sleep. Some treatments involve using anti-parkinson s drugs or Valium. Narcolepsy A disorder of sleep/wake regulation in which a person suddenly falls asleep for five or ten minutes (or more) when relaxing or even carrying on a conversation. Some other symptoms are: Cataplexy - a complete and sudden momentary loss of muscle tone Sleep paralysis - inability to move that occurs during the transition between wakefulness and sleep Hypnagogic hallucinations a person has vivid and often frightening images appear that are difficult to distinguish from reality Disturbed nighttime sleep - awakenings during the night Automatic behavior - person performs many routine tasks without being fully aware of what they are doing. One man washed and dried the dishes and then stacked them in the refrigerator. 4

5 There is no cure for narcolepsy; however, doctors can prescribe stimulant medication such as Ritalin to counter the sleep attacks and drowsiness. Antidepressants and other drugs that suppress REM sleep can prevent muscle weakness, sleep paralysis, and vivid dreaming. Doctors also recommend that people with narcolepsy take 2-3 short naps a day (10-15 minutes each). Parasomnias Parasomnias occur when a person experiences the walking, talking and other bodily functions that normally don t happen during sleep. Parasomnias are most common in children, but adults who are sleep-deprived or have other sleep disorders may also experience symptoms. Certain medications may also contribute to the disorder. Nightmares - nighttime events that cause fear and anxiety. The person awakens suddenly from REM sleep and can usually remember their disturbing dream. Nightmares can be caused by illness, anxiety, stress or medications. If you re experiencing more than one nightmare per week or they prevent you from getting a good night s sleep for a period of time you may want to talk to your doctor. Sleep terrors - occur during deep sleep, usually within the first hour after going to sleep. The person appears to be awake but acts confused and cannot communicate. They usually last about 15 minutes and then the person is able to return to sleep. Sleep terrors appear to run in families and occur most often in young children. The use of alcohol and a great deal of emotional tension can cause them to appear in adults. Sleepwalking (somnambulism) - occurs during partial awakening from deep sleep the eyes are open but the senses are asleep. Sometimes sleepwalkers can carry out complex actions or they may simply pace back and forth next to the bed. This occurs frequently in children when the brain has not mastered regulation of sleep and waking. It s okay to wake a person who is sleepwalking. In fact, it may prevent injury. Sleep talking - can occur during any or all stages of sleep. The person doing the talking usually has no memory of what they said. It can be triggered by fever, emotional stress or other sleep disorders. Bedwetting - Usually occurs with children, more often with boys, but can also occur in 1% of adults usually from excessive caffeine or alcohol consumption. It can also sometimes be caused by medical conditions (including diabetes, urinary tract infection, or sleep apnea) or by psychiatric disorders. REM behavior disorder (RBD) the sleeper may twitch, shout, punch or otherwise act out their dreams. Sleepers with this condition may hurt themselves or injure their bed partners. Usually, RBD occurs in men aged 60 and older. Nocturnal eating disorder - getting out of bed and eating excessive amounts of food. These people are usually light sleepers and awaken frequently. Although not really hungry, they cannot return to bed without eating. Most people with this disorder do not overeat when fully awake. 5

6 Circadian Rhythm Sleep Disorders We all have an internal body clock that depends upon the sunlight to tell us when to be awake and active and when to sleep. This internal body clock produces signals to us called circadian rhythms. These circadian rhythms are the changing levels of hormones and neurochemicals that control our sleep, activity and mood. 3 Due to the hectic lives we lead, we often leave our homes when it s dark, work in an office without natural light during the day, and return home when it s dark in the evening. This shifts our circadian rhythms and our body may stop or incorrectly produce the sleep-regulating chemicals it needs. As a result, you may suffer mood or sleep problems. The DSM-IV-TR lists four types of circadian rhythm sleep disorder: delayed sleep phase type, jet lag type, shift work type, and unspecified type: Delayed sleep phase syndrome Most common in adolescents and young adults. This is when a person s sleep pattern is delayed by two or more hours. If allowed, these people would sleep and wake up an hour later on each successive day and would prefer a schedule where they go to bed around 1 or 2 a.m. and wake at 10 a.m. If someone with this disorder has to wake up early, they often experience daytime drowsiness and can be seen as lazy and unmotivated. They can maintain a regular sleep schedule only by relying on external cues such as alarm clocks. If this sounds like you, you may be able to gradually synchronize your schedule by going to bed and getting up at the same hours each day (even on weekends). Advanced sleep phase syndrome These people go to bed earlier and earlier and eventually cannot stay awake past early evening. This is more common in older people. Two treatments being used are exposure to bright light, which helps reset the body s clock, and carefully timed doses of melatonin. Jet lag - This occurs when air travel requires you to sleep at a time that is not in line with your body s natural sleep rhythms. People may experience headaches, stomach upsets, difficulty concentrating, and may suffer from shallow and fitful sleep. A common rule of thumb is that it takes one day to adjust for every time zone crossed. Shift work over 20% of U.S. workers are on the evening or night shift. Almost 60-70% of these workers experience sleep disturbances. 2 If you work the night shift, try to schedule breaks into your shift. Rotating shifts from day to evening to night rather than the other way around, or try to maintain the same schedule seven days a week. Consistently practicing good sleep hygiene habits will help ease the sleep disturbance. Seasonal Affective Disorder (SAD) - Abbreviated sunlight in many parts of North America can mean that many people do not get adequate exposure to sunlight. As the days get shorter, people find themselves depressed, sleepy, and drawn to high-carbohydrate foods. SAD sufferers produce too much melatonin and don t make enough serotonin. Exposure to bright light through use of light boxes may alleviate the symptoms of SAD and help people wake up in the mornings. 6

7 References: 1. American Thoracic Society. (2007). Sleep Apnea Increases Risk of Heart Attack or Death by 30%. Retrieved June 23, 3008 from 2. AOL Health. (2007). Shift work. Retrieved June 26, 2008 from: 3. Talk About Sleep, Inc. (2005). What Are Circadian Rhythm Sleep Disorders? Retrieved June 26, 2008 from: 4. U.S. Department of Health and Human Services. (2006). Insomnia. Retrieved June 13, 2008 from: 7

8 Good Sleep Habits Avoid caffeine within 6 8 hours of bedtime. Avoid nicotine close to bedtime or during the night. Avoid using the bedroom for any activities other than sleep. Avoid alcoholic beverages within 2 4 hours of bedtime. It may help you fall asleep but will result in a poorer quality of sleep, and more nighttime waking. Avoid eating large meals or greasy, spicy, or gas-producing foods before bedtime. However, a light snack composed mainly of carbohydrates can help promote sound sleep. Do get regular exercise but don t do it within 2 hours of bedtime. Minimize light, noise, and extremes in temperature in the bedroom. Establish relaxing pre-sleep rituals, such as a warm bath, reading, imagery, repetitious techniques (e.g., deep breathing, counting sheep), or progressive relaxation. If you are unable to fall asleep within minutes after lights out, leave the bedroom and do a non-stimulating activity such as those above. Get up at about the same time everyday a regular rising time is even more important than a regular bedtime. In other words, don t sleep in just because you can. Go to bed only when you are sleepy again, bedtime is less important than rising time. Avoid napping late in the afternoon or evening. If you choose to nap, do so early in the afternoon and limit it to minutes or so. Choose a time during the day to think about your worries or concerns and make plans for handling them, so that you can avoid dwelling on them in bed. Sleeping pills are intended as a last resort and for short-term use only. Sleeping pills have many side effects, and can cause drowsiness into the next day. Their long-term use can actually lead to rebound insomnia. If you have been using sleeping pills for more than a few months, consult with your doctor about how to stop them. 8

9 Relaxation Exercise Let go of your worries using the following 10-step relaxation exercise: 1. Find a quiet place where you won t be disturbed. 2. Sit in a comfortable position with your arms and legs uncrossed and relax your body. 3. Close your eyes, focusing only on what is happening in the present moment. 4. Tell yourself that you re going to spend the next few minutes concentrating and relaxing. 5. Take a slow, deep breath. As you inhale, say the word RELAX to yourself. 6. As you exhale, say the word CALM to yourself. 7. Notice how the air moves in and out of your body as you continue to breathe slowly. 8. If your mind begins to wander, imagine your thoughts disappearing into the air, and then simply return your focus onto your breathing. 9. Continue this process for as long as you feel necessary. 10. When you feel relaxed, slowly open your eyes and bring your thoughts back to your present environment. This material is provided by CIGNA for informational/educational purposes only. It is not intended as medical/clinical advice. Only a healthcare provider can make a diagnosis or recommend a treatment plan. For more information about your behavioral health benefits, you can call the member services or behavioral health telephone number listed on your healthcare identification card. 9

10 Telephone Seminar Evaluation Please complete this form and fax it to , or it to Your company: Seminar date: Presenter: Company city, state: Title of seminar: Please state your agreement/disagreement with the following statement using this scale. 4 Strongly Agree 3 Agree 2 Disagree 1 Strongly Disagree 1. SEMINAR CONTENT: a. The information I received was helpful b. The seminar met the stated objectives SPEAKER EVALUATION: a. The speaker presented the information clearly b. The speaker responded well to participants c. The speaker was knowledgeable on the subject Overall I was satisfied with the seminar presentation What part(s) of the seminar did you like best, and why? 5. What part(s) of the seminar did you like least, and why? 10