Advanced sleep phase syndrome (ASPS)

What is advanced sleep phase syndrome?

Advanced sleep phase syndrome is a disorder in which the major sleep episode is advanced in relation to the desired clock-time, that results in symptoms of compelling evening sleepiness, an early sleep onset, and an awakening that is earlier than desired.

What are the symptoms?

• Inability to stay awake until the desired bedtime or inability to remain asleep until the desired time of awakening
• There is a phase advance of the major sleep episode in relation to the desired time for sleep
• Symptoms are present for at least 3 months
• When not required to remain awake until the later bedtime, patients will:

1. Have a habitual sleep period that is of normal quality and duration, with a sleep onset earlier than desired
2. Awaken spontaneously earlier than desired
3. Maintain stable entrainment to a 24-hour sleep-wake pattern

There is a chronic inability to stay awake in the evening or sleep later into the morning hours.

The major complaint may concern either the inability to stay awake in the evening, or early morning awakening insomnia, or both.

Unlike other sleep maintenance disorders, the early morning awakening occurs after a normal amount of undisturbed sleep.

Unlike other causes of excessive sleepiness, daytime school or work activities are not affected by sleepiness. However, the evening activities are cut short by the need to retire much earlier than the social norm.

Typical sleep onset times are between 6 and 8 p.m., and no later than 9 p.m., and wake times between 1 and 3 a.m., and no later than 5 a.m. These sleep-onset and wake times occur despite the patient's best efforts to delay sleep to later hours.

How does this affect a person?

There can be negative personal or social consequences that are due to leaving activities in the early to mid-evening hours in order to go to sleep.

Attempts to delay sleep onset to a time later than usual may result in embarrassment due to falling asleep during social gatherings, or more seriously from drowsiness or falling asleep while driving in the evening.

Individuals with advanced sleep phase syndrome who attempt to work evening or night shifts would have difficulty staying awake during the evening and early morning hours.

If chronically forced to stay up later for social or vocational reasons, the early awakening aspect of the syndrome could lead to chronic sleep deprivation and daytime sleepiness or napping.

Who gets advanced sleep phase syndrome?

It is more likely to appear in the elderly.

How is it treated?

Advanced sleep phase syndrome is treated with chronotherapy or bright light therapy. Chronotherapy would involve a systematic advancement of bedtime until the desired bedtime is achieved. Bright light therapy would involve inducing a phase delay and the light exposure must be in the early evening. There is not a lot of data about the effectiveness of light therapy for ASPS.

 

REM Sleep Behavior Disorder

What is REM Sleep Behavior Disorder?

People with REM Sleep Behavior Disorder (RBD) tend to speak, shout and move vigorously or violently during REM sleep. These episodes of abnormal movements may result in injury to the patient or a bed partner. If the patient awakens during these episodes, the patient will report the dream with the violent events that correspond with the observed movements.

All muscles are paralyzed during REM sleep, except those that mediate breathing and movement of the eyes, fingers and toes. Electrical activity and oxygen consumption of the brain continues to the same degree as during wakefulness.

The diagnosis of RBD is sometimes very apparent based on the patient's history. Other cases, it is difficult to distinguish the symptoms from those of sleepwalking, sleep talking, seizures or sleep terrors. It is helpful to do an overnight sleep recording, known as a polysomnogram (PSG). The Polysomnogram may record an episode of REM sleep behavior disorder by recording one or more awakenings directly from Stage REM sleep.

 

What are the symptoms?

The main symptom of REM sleep behavior disorder is dream-enacting behaviors, sometimes violent, causing self-injury or injury to the bed partner. The dream-enacting behaviors are usually non-directed and may include punching, kicking, leaping, or jumping from bed while still asleep. The person may be awakened or may wake spontaneously during the attack and vividly recall the dream that corresponds to the physical activity.

 

What Causes REM Sleep Behavior Disorder?

That this time the cause of REM Sleep Behavior Disorder is unknown, although the disorder may be associated with other degenerative neurological conditions such as Parkinson disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. It is estimated that 55% of persons with the disorder, the cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine, sertraline, or paroxetine) or other types of antidepressants (mirtazapine).

 

How is it treated?

Medication can help to treat REM Sleep Behavior Disorder such as Clonazepam (Klonopin). Clonazepam helps to relieve symptoms in nearly 90% of patients with little evidence of tolerance or abuse. There is normally a response to the medication during the first week, often on the first night. The initial dose is 0.5 mg at bedtime, with some persons requiring a rapid increase to 1 mg. After continued use over the years, symptoms may resurface.

Several other medications, such as tricyclic antidepressants, may be effective for REM Sleep Behavior Disorder.. Though, tricyclics are also known to increase REM Sleep Behavior Disorder in some patients.

Persons with REM sleep behavior disorder have a risk of injuring themselves and their sleep partners, safety of the sleeping environment is very important. Take the following precautions to make the environment safe:

• Remove potentially dangerous objects from the bedroom.
• Clear the floor of furniture and objects that could injure the person if he or she fell from bed.
• Place the mattress on the floor, or place a cushion around the bed.
• Have the person sleep in a bedroom on the ground floor if possible, especially for people who leave the bed during an episode.
• The bedmate should sleep in another bed until the symptoms resolve.
• A bed with padded bedrails can be considered.

Used with permission from Nationwide Respiratory a division of VGM, Inc.