To complicate matters, fatigue can be a symptom of insomnia. This is of particular importance for people with MS because fatigue affects the great majority of people with MS. Precisely because of its high prevalence among people with MS, fatigue as a symptom of some other problem can easily be missed. Fatigue can be related to psychiatric problems, such as depression; or, fatigue can also be related to medical problems such as hypothyroidism, or anemia. And certainly, those with fatigue should consider whether they have insomnia.
INSOMNIA AS A SYMPTOM
Because of this complexity, insomnia cannot be treated without consideration of many factors, and people with MS who experience insomnia should consider many possible causes. In addition to depression and other mental health problems, there are at least three other common causes of insomnia among people with MS: pain, urinary problems, and spasticity. Indeed, many people with MS have all three of these symptoms.
A fourth common reason for sleep disturbances among people with MS is related to the medications used in MS. For example, a class of medications knows as SSRIs (including Zoloft, Prozac and Paxil), while possibly helpful for depressive symptoms, may worsen sleep. Stimulants and wake-promoting agents (including Provigil and Adderall), which are commonly used for fatigue management, may interfere with sleep initiation, especially if taken during the late afternoon or early evening hours. An older class of MS disease modifying medication, β interferon (Avonex, Betaseron, Rebif, Extavia), may also interfere with sleep. This is only a partial list of medications that may interfere with sleep. And non-prescription drugs, such as such as caffeine, nicotine, and alcohol can certainly interfere with sleep. Alcohol is a particularly sneaky culprit because it can actually sometimes improve sleep initiation; even so it is clearly detrimental to sleep quality and the ability to stay asleep.
Insomnia may be a symptom of medical problems apart from MS, such as heartburn, diabetes, cardiovascular disease, musculoskeletal disorders, kidney disease, respiratory problems, and thyroid disease. All of these and more need to be considered depending on the circumstances.
INSOMNIA AS A MALADY (PRIMARY SLEEP DISORDERS)
Sometimes managing the above problems may be enough. But in other cases, primary sleep problems may need to be considered. For example, people with MS seem to be at an increased risk for sleep apnea. Other risk factors include obesity, snoring, pauses in breathing witnessed by a bed partner, gasping or choking upon awakening, non-restorative sleep, fatigue, cognitive disturbances, and nighttime awakenings. People with insomnia and one or more of these symptoms may need to be referred to a sleep specialist, a sleep study, or both.
Restless leg syndrome (RLS) is another primary sleep problem that is much more common among people with MS than it is in the population generally. RLS is dened as a restlessness or uncomfortable sensation of the lower extremities that is exacerbated by rest and inactivity, has a tendency to occur in the evening or before bedtime, and is relieved with movement. A question that is sometimes used in the clinic to identify RLS is: When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? For those who answer yes, referral to a sleep expert may also be useful.
TREATMENT: THE GOOD NEWS
The good news is that each of the common problems described above is potentially treatable or manageable, potentially improving sleep. Improved sleep, in turn, can improve the overall quality of life, symptoms in mood disorders, decrease symptoms of excessive daytime sleepiness, and decrease cardiovascular problems.
Clearly, based on the above brief review of sleep problems, you should not diagnose or treat sleep problems on your own, especially if the problem is of sudden onset or severe.
Meanwhile, for people with mild sleeping diffculties, there is good news. There are simple, inexpensive, and safe behavioral tips that are likely to help. Those following these steps are sometimes said to have good “sleep hygiene.”
GOOD SLEEP HYGIENE
- Go to sleep and wake up at the same time each day — Good sleep begins with having good routine sleep times. Certainly, this is not always possible, but to the extent that it is possible, trying going to bed the same time every night and, even more importantly, waking up at the same time every day.
- Create a comfortable sleep environment — Make sure that your sleeping environment will promote sleep. Most people can’t fall asleep with loud music blaring and bright lights blinking!
- Temperature — For most people, cool is better than hot. Try cracking or opening your window. Warm feet are important for falling asleep; otherwise cooler is better.
- Light — Keep your bedroom as dark as possible. You might even consider wearing an eye mask. Remember to look for nonobvious sources of light – hide the blinking electric toothbrush; turn the LED alarm clock around so you can’t see it.
- Noise — Less noise means more sleep. You can reduce noise levels with rugs and drapes, earplugs, background “white” noise (such as a fan), or soothing music. Music without words may deepen sleep quality greater than music with words.
- Comfort — A good mattress and comfortable pillow can improve the quality of sleep.
- Function — Try not to use your bedroom for work activities, such as balancing the checkbook,studying, or scrolling through email on your phone or tablet. Make your bedroom a stress-free zone. The bedroom is for sleep only.
AVOID ALCOHOL AND CAFFEINE
Alcohol may help you get to sleep, but it will make your sleep restless and uneasy. Many people who drink experience an alcohol rebound and may wake up early in the morning. Caffeine can certainly keep you awake and most people are aware of this. The problem is that caffeine can be found in unexpected places, such as chocolate or soda. Caffeine – contained in tea, cola, and chocolate, (and, of course, in coffee) – is a stimulant and can cause problems for people trying to fall asleep. The half-life of caffeine is usually reported to be about 5 or 6 hours. For those who are sensitive to caffeine, it may be best to stop drinking coffee 10 hours before bed.
WATCH YOUR DIET
A heavy meal or spicy foods before bedtime can lead to nighttime discomfort, and uids can require disruptive trips to the bathroom. A light snack, however, can prevent hunger pangs and help you sleep better.
GET OUT OF BED IF YOU’RE NOT SLEEPING
If you don’t fall asleep within 10 to 30 minutes, get up. Get back into bed only when you feel sleepy. This tip is especially diffcult to follow in the cold winter months when that warm bed is all the more comfortable. But, this is one of the most important tips to follow. We need our minds to associate getting comfortable in bed and drifting off into deep, restorative sleep. The more time we spend in bed lying awake and frustrated, the more our mind associates getting comfortable in bed with anxiety and then we’re less likely to fall asleep.
Instead, have a comfortable spot in your home where you can do a soothing activity like reading to calm your overactive mind. Avoid the temptation to turn on the TV or computer, the light stimulation from both just stimulate our brains further though the activities may feel calming.
EXERCISE REGULARLY
Regular exercise has been shown to improve sleep. Exercising in the morning or afternoon – at least three hours before bedtime, so you won’t be too “revved up” – will help you get a deeper, more restful sleep. Exercise helps us to burn off those stress hormones that have been triggered in our bodies during the day.
STOP TOBACCO USE
Nicotine, like caffeine, is a stimulant and can cause problems for people trying to fall asleep. Also, as a stimulant, nicotine causes the sleep we do get to be less restorative.
AVOID WATCHING THE CLOCK
Set the alarm and place the clock out of sight. Constant checking can even cause insomnia. Every time we look over and notice more time has passed, we begin fretting about how sleep deprivation is going to interfere the next day.
CREATE A RELAXING BEDTIME ROUTINE
Read a good book, listen to music, practice relaxation techniques, or sip on a warm cup of Sleepytime tea.
MAKE SURE YOUR URINARY PROBLEMS ARE WELL MANAGED
Many people with MS have urinary frequency. If you are waking up frequently to go to the bathroom and not falling back asleep, it may be helpful to try to address this problem through behavioral strategies (e.g., not drinking within two hours of bedtime, using physical techniques for promoting maximum urination) or medications. Of course, if you experience this problem, you should discuss it with your health care provider.
FOR MORE INTRACTABLE SLEEP PROBLEMS: SLEEP STUDIES AND CBT
For those who have tried the simple steps above and still have trouble sleeping, it is de nitely a good idea to discuss sleep problems with your health care provider. Your health care provider may recommend a sleep study, which may identify specific, medical causes of your sleep issues.
If medical conditions have been excluded, keep in mind that even severe insomnia can sometimes be managed without medications. Cognitive behavioral therapy for insomnia (CBT-I) includes regular, often weekly, visits to a clinician, who will give you a series of sleep assessments, ask you to complete a sleep diary and work with you in sessions to help you change the way you sleep. Working with a specialist in this way, you should be able to identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep.
