Sleep in chronic illnesses with a focus on Scleroderma.

Hrayr Attarian, M.D.

The Evidence.

• What do we know about sleep in scleroderma or systemic sclerosis?

• Not much.• A medical literature database search resulted

in 8 articles from 1965 till today.• The following is a summary.

What do sleep studies show?

• In 2002 A group of 27 people with systemic sclerosis were studies with polysomnography or sleep study.

• Overall sleep was fragmented in all 27.• The main correlates of poor sleep were

eosaphageal motility issues, the presence of restless legs syndrome and shortness of breath.

How about pain?

• In 2011 correlates for sleep disturbances were looked at in a group of 70 scleroderma patients.

• Pain was the most important correlate to disturbed sleep followed by marital status.

• Another group compared 180 scleroderma patients to others with chronic illness in a large database of sleep complaints in people with chronic illnesses.

Results

Average sleep per night

Snoring

Sleep disturbance

Awakening short of breath

Sleep adequacy

Daytime sleepiness Sleep quality

How about other factors?

• In addition to GI disturbances, shortness of breath and pain depression and itching have been recently shown to have a strong association with sleep disturbances in scleroderma.

• Poor sleep quality, as in many illnesses, correlated with poor quality of life.

Other Chronic Illnesses

• A model of sleep disturbances in chronic illness is Rheumatoid Arthritis.

• Most of the factors that are associated with poor sleep in Rheumatoid Arthritis can be generalized to other chronic illnesses such as Diabetes Mellitus and Congestive Heart Failure.

Sleep Apnea and Related Conditions

• Sleep apnea and related breathing conditions play a big role in disturbing sleep in chronic conditions.

• In rheumatoid arthritis for instance occurs with a frequency of 2 to 3 times more and is not always associated with weight.

• Treating the sleep apnea significantly improves sleep complaints.

Pain.

• Pain interferes with sleep in almost all chronic illnesses but particularly rheumatologic ones.

• Pain disrupts sleep and poor sleep increases pain.

• Treating pain is easier said than done as some of the effective and potent meds can cause sleep disturbances, worsen sleep apnea and lead to dependence.

Depression.

• The taboo subject!• Depression is part and parcel of all chronic

medical conditions.• It has a similar negative relationship with

sleep as pain does.• Depression is easily treated but effective

therapies are either expensive and not readily available (Cognitive Behavioral therapy) or can disrupt sleep such as antidepressants.

Other Common Sleep DisordersKey RLS diagnostic criteria Supportive features

Urge to move the legs - usually accompanied or caused by uncomfortable leg sensations

Sleep disturbances

Involuntary leg movements

Positive family history for RLS

Temporary relief with movement - partial or total relief from discomfort by walking or stretching

Onset or worsening of symptoms at rest or inactivity, such as when lying or sitting

Worsening or onset of symptoms in the evening or at night

Other Common Sleep Disorders

• Excessive daytime sleepiness or insomnia due to chronic increase in inflammatory hormones.

Sleep Inducing

Sleep Disrupting

Solution.

• Comprehensive approach to patients.• Multidisciplinary clinics if necessary.• Kill two birds with one stone.

– Meds that treat both depression and pain– Or RLS and pain.– Improving sleep and pain

• Treat conditions simultaneously• Pay attention to medication side effects.

Conclusion

• Sleep is significantly disturbed for various reasons in chronic illnesses.

• Treating the sleep disturbance concomitantly with the underlying illness may lead to improved quality of life.

• Sleep, depression and pain are interdependent symptoms