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How Common Medical Conditions and Their Treatment Can Affect Your Sleep

To sleep well through the night, without interruption and for a sufficient amount of time, is to feel awake and healthy the following day. As a general internist, I care for patients with a wide range of complex problems, from hypertension to heart disease to diabetes, yet simple problems with sleeping are very common complaints I encounter in practice. Nearly one in seven Americans has sleep-related complaints. Part of my job is to determine which complaints reflect simple insomnia, and which complaints might reflect a more serious medical problem.

Insomnia Although the term insomnia is used to describe a multitude of sleep disturbances, most people complain of one of a few specific problems with their sleep patterns: poor sleep quality, difficulty in initiating sleep, nighttime arousals, or insufficient quantity of sleep. Difficulty in initiating sleep is most often a problem with what doctors refer to as "sleep hygiene" - the activities that precede and surround the act of going to sleep. Daytime napping, drinking alcohol or caffeine-containing beverages in the evening, or routinely using one’s bed for awake activities like reading or watching TV can make falling asleep or staying asleep difficult.

Please see our "Sleep Hygiene" article for a full discussion of this topic.

Gastroesophageal reflux, or common "heartburn", can also result in frequent nighttime awakenings and disrupted sleep. Acid from the stomach flows backward into the esophagus, or food pipe, causing irritation of its sensitive lining and a burning sensation in the chest or throat. This reflux of acid can occur as a result of a relaxation of the muscles in the esophagus during sleep which normally serve to keep acidic juices in the stomach, made worse by the simple act of lying flat. Acid reflux can interfere with sleep in more subtle ways, as well, without causing one to fully wake. An acidic or bitter taste in the mouth in the morning is sometimes the only sign that irritating stomach acid is disturbing a night’s sleep.

Effective treatments exist for managing enlargement of the prostate and acid reflux, and it is unusual for these conditions to lead to serious complications. Nighttime awakenings in a different context, however, can be a sign of much more serious problems. Heart failure results from a weakness of the heart muscle that can occur following a heart attack or as a consequence of longstanding high blood pressure. The first symptom in many people is shortness of breath that develops suddenly during sleep. Typically, people with early or mild heart failure will feel well during the day and breathe without difficulty upon lying down for the night, only to wake up abruptly an hour or so later in a panic with terrible shortness of breath. They feel an overwhelming need to sit up or stand up, and falling asleep again can be extremely difficult. Another related symptom that may suggest heart failure is the inability to lie flat without feeling short of breath, or the need for multiple pillows in order to fall asleep, even to the point of only being able to sleep sitting upright in bed.

Asthma, too, can present with symptoms that occur predominantly at night. For many asthmatics, breathing during the day is not a problem, but symptoms flare during sleep. Breathing difficulties can be mild and affect the quality of sleep without causing a full arousal from sleep, or severe, resulting in a full-blown mid-sleep asthma attack.

Obstructive sleep apnea is another disorder that manifests early on with sleep-related complaints. The problems in sleep apnea result from abnormal breathing during sleep, a consequence of relaxation and collapse of the muscles in the back of the throat that leads to obstruction of the breathing passages. Sleep apneics will literally stop breathing for brief periods of 10 to 20 seconds or more, often hundreds of times a night. The level of oxygen in the blood falls to dangerously low levels during each breathless period. The oxygen-starved brain responds by waking up to take a breath. As sleep returns, this cycle repeats over and over throughout the night.

Although this pattern results in badly fragmented sleep, sufferers of sleep apnea are usually completely unaware that they are waking many times a night. Early on the symptoms are quite subtle: daytime drowsiness, early morning headache, and impaired concentration. Bed partners are often the first to notice breathing problems during the night. Other clues like obesity or heavy snoring may help your doctor identify a possible problem, but a diagnosis of obstructive sleep apnea can be difficult to make. Despite the subtle symptoms, the consequences of longstanding sleep apnea can be devastating. High blood pressure, permanent lung disease, and heart failure can occur if the condition goes undiagnosed.

Please see our "Sleep Apnea" article for a full discussion of this topic.

Insomnia from medications

Many of the medications used to treat common medical conditions can cause significant disturbances in sleep patterns as well, often causing more troubling symptoms than the disease they’re intended to treat. Drugs can disturb sleep in a variety of ways, some delaying the onset of sleep, some disrupting the continuity of sleep, and some reducing the duration of a night’s sleep. Many of the medications used to treat asthma, for example, including the inhalers and oral drugs like steroids and theophylline, can act as stimulants and delay the onset of sleep or detract from the quality of sleep.

Although depression alone can cause disruptions in normal sleep patterns, many of the medications used to treat depression have sleep-disturbing side effects. Many of the newest antidepressants have a strong, stimulant effect. Prozacâ , Paxilâ , Zoloftâ and other medications in the class of the now widely-used SSRI’s, or serotonin-reuptake inhibitors, can cause insomnia and disturbance of normal sleep patterns. In some cases these side effects are minimal, and the sleep disturbances that result from the depression itself improve significantly with these drugs.

Many of the medicines used to treat high blood pressure and heart problems can also affect the quality of sleep. One commonly used class, known as the beta-blockers, can cause insomnia, nighttime awakenings, and increased daytime sleepiness. Vivid, disturbing nightmares are also occasionally experienced by people taking these drugs. Other cardiac medications cause increased production of urine, and when dosed in the evening can result in frequent nighttime arousal to use the bathroom, disrupting sleep significantly.

It is important to remember that over-the-counter medications can cause sleep-related problems as well. Nasal decongestants commonly contain ephedrine or pseudoephedrine, compounds similar to amphetamines with similar stimulant effects. Some over-the-counter headache remedies, like Excedrinâ , contain caffeine and can thus cause insomnia when taken in the evening or before going to bed.

These sleep-related side effects can occur at normal doses and at any time; even medications that have been taken for years without problems can be the cause of new sleep disturbances. The most important first step is to discuss your sleep problems with your doctor, before stopping any medication. In certain circumstances it can be dangerous to stop medications suddenly. In others, the benefits of the drug may outweigh the problems related to the side effects, depending on the specific drug, the disease, and the degree of the sleep disruption. Beta-blockers, for example, have a proven and powerful effect in preventing second heart attacks, so you and your doctor together may decide that some degree of insomnia is a tolerable thing. In many instances, however, options are available for alternative drugs with similar benefits and different side effects.

Any problems with sleeping should be reported to your doctor. He or she should be able to help sort out which sleep complaints suggest serious medical problems and which can be treated with improvements in sleep hygiene or brief trials of sleeping aids.

People spend nearly a third of their day sleeping, or trying to, and yet many doctors neglect to ask about sleep quality and sleep quantity when talking to their patients. One of the most important lessons I’ve learned in my career came not from medical school or residency training, but from one of my patients. Helen was 70 years old and had hypertension, heart failure, and diabetes. She was on 6 different medications to control these problems and to allow her to do her daily activities without chest pain or shortness of breath. I saw her every 3 or 4 weeks in my office to check her blood pressure and her blood sugar, constantly worried about keeping her "well". What Helen wanted was to be able to get a good night’s sleep, but suffered with both difficulty falling asleep and frequent arousals to urinate. She never mentioned her problems, and I never asked. She assumed that sleeping poorly was the burden that she had to bear in living with these medical problems. When she finally "confessed" that she was having problems, I was able to adjust her medications to improve her nights significantly. She and I both sleep better.