Sleep Issues

 
Frequent Nighttime Urination

The need to urinate during the night, referred to as nocturia, is likely the most common culprit in sleep interruption for people with MS. Bladder problems are common in MS, and many people need to use the bathroom multiple times each night. Most people are able to regain sleep after getting up once, but it becomes increasingly difficult to sleep soundly when sleep is interrupted many times per night due to the need to urinate.

Fortunately, a number of solutions are available for urinary frequency in MS. Consulting with a urologist (a physician who specializes in urinary difficulties) is an important first step. If you are having nocturia and/or the frequent or urgent need to urinate during the day, ask your neurologist to refer you to a urologist experienced with patients who have MS, and who has experience treating the symptoms of a neurogenic bladder.

Strategies to Help: Some people with the frequent and urgent need to urinate restrict their liquid intake, but this is not a healthy practice and can lead to other problems. Drink normally during the day, but have your last drink about three hours before going to bed. Drinks with caffeine stimulate the bladder, so reduce your caffeine intake, or drink caffeinated beverages only in the morning. Alcoholic beverages often cause nighttime urination, so do not drink alcoholic beverages late at night. You will find more information on caffeine and alcohol to follow.

Certain medications may help. Detrol^® (tolterodine), Ditropan^® (oxybutynin), Enablex^® (darifenacin), Flomax^® (tamsulosin), Myrbetriq^® (mirabegron), and Botox^® (botulinum toxin injections) may each be prescribed for certain bladder problems.

 
Depression
Depression can often interfere with one’s ability to sleep and is one of the main symptoms of depression. “Early morning awakening” is a common sleep problem in people who are depressed. People with this problem are able to fall asleep, but they wake up in the early morning hours and are unable to get back to sleep. Knowing the other symptoms of depression can help you to determine if depression is interfering with your sleep.

Common signs of depression include:

• Feeling low or down
• Poor appetite or overeating
• Low energy
• Low self-esteem
• Difficulty with attention and concentration
• Feeling hopeless

Strategies to Help: The best treatment for depression in MS is the combination of counseling and medication. If you think you might be depressed, speak with your neurologist or primary-care doctor, or seek treatment from a mental-health provider. Exercise also helps depression, but is not a replacement for professional help.

Common medications for depression in people with MS include the SSRIs (selective serotonin reuptake inhibitors), including Prozac^® (fluoxetine), Zoloft^® (sertraline), Paxil^® (paroxetine), Celexa^® (citalopram), and Lexapro^® (escitalopram). The NDRI antidepressant (norepinephrine-dopamine reuptake Inhibitor) Wellbutrin^® (bupropion), is also commonly used to treat depression in MS.

Additional medications for depression are SRNIs (selective serotonin and norepinephrine reuptake inhibitors), which include Cymbalta^® (duloxetine hydrochloride), Serzone^® (nefazodone), and Remeron^® (mirtazapine). Tricyclic antidepressants are yet another group of antidepressants, and these include Elavil^® (amitriptyline), Pamelor^® (nortriptyline), and Tofranil^® (imipramine). However, please note that new treatments for depression continue to be studied, approved, and added to this list.

 
Spasticity

Spasticity is a common symptom of MS, which is characterized by muscles becoming tight and sometimes even rigid. Spasticity can be very uncomfortable or even painful, and limb movements may be associated with spasticity as well. Pain from spasticity can interfere with sleep.

Strategies to Help: Medications for spasticity include baclofen (also available as Lioresal^®), Flexeril^® (cyclobenzaprine), Zanaflex^® (tizanidine), and Botox^® injections for severe spasticity. Exercise and stretching can help to reduce spasticity, and a consultation with a physical therapist is recommended. If you or your partner notice that you are having a lot of limb movements and/or discomfort at night, consult your neurologist.

 
Sleeping Position

The human body was not designed to sleep in one position all night. Our skin and tissue experience a great deal of pressure from the weight of our bodies when we are asleep. We therefore must move and change position multiple times during the night. When we change position, we wake up briefly, but if we are good sleepers we fall right back to sleep and don’t even remember waking up.

Some people with mobility problems due to MS have more difficulty moving around in bed at night. The pain and discomfort coming from the skin and tissues that are in contact with the bed can keep a person awake.

Strategies to Help: If turning in bed is difficult, install rails on one side of your bed, so you can use your arms to change position. Sometimes partners arrange to turn the partner who has MS during the night. You should take care not to cause your partner to lose too much sleep with the task of turning you in bed. Speaking to your neurologist or physical therapist about this problem can be very useful.

Insomnia can occur for a number of reasons, including “over-activation,” where someone has too much on his or her mind to drift off to sleep. Specific or general worries, or an upsetting event, can often keep someone awake, and the worry of not falling asleep only worsens the problem. Naps can be helpful to re-energize people during the day, but too much napping will also contribute to nighttime insomnia.

Another issue is when a person’s biological clock and circadian rhythm, which normally promote sleepiness during the dark of evening and wakefulness during the light of day, are not working properly. These can get off balance by not staying on a schedule, or from late-night activities, including shift work.

Sensory disruptions of noise or light during the night can interrupt one’s sleep schedule as well, and taking steps to minimize these disturbances during times of sleep can be of help. Possible solutions include closing windows, installing shades or curtains that block outside light, turning down the phone, and dimming or blocking inside light. Some people sleep better with the constant sounds of “white noise,” from a room fan or a CD designed for that purpose.

Sleep apnea is a serious disorder which occurs when a person’s throat muscles relax too much and the airway is temporarily blocked. Overweight individuals are more prone to this disorder, and snoring can sometimes be a sign of the condition. While people with sleep apnea usually do not have trouble falling asleep, their breathing is affected once asleep, and the sudden inability to take a breath wakes them repeatedly throughout the night, sometimes as often as every 30 seconds.

Sleep apnea can be particularly dangerous since it affects breathing. For a proper diagnosis, a sleep study in your home or at a sleep center is often prescribed. Some overweight individuals lose weight once they are able to get adequate sleep, due to a decrease in the production of a hormone that promotes appetite.

Restless legs syndrome or RLS is a movement disorder that is not related to MS, but may occur more frequently in people with MS than in the general population. It is sometimes difficult to distinguish RLS from MS spasticity, so the actual prevalence of RLS in MS is not clear. When relaxed in a chair or bed during the evening, people with RLS feel uncomfortable and have the constant urge to move their legs.

Reducing consumption of alcohol, caffeine, and nicotine can be helpful for RLS. RLS can be a side effect of certain medications, and other medical conditions may cause RLS, so individuals who think they might have RLS should consult their neurologist.

A number of medications are used to treat RLS, including Requip^® (ropinirole) and Mirapex^® (pramipexole). Other helpful strategies include stretching, taking warm or cool baths, applying hot or cold packs to the affected area, and limb massage.

Other sleep problems can include sleepwalking, sleep terrors, and nightmares, as well as acting out physically while dreaming, waking up confused, and even overeating while asleep. Grinding teeth and/or snoring can have health implications and are disruptive to a partner’s sleep. Any underlying medical conditions that may affect sleep need to be investigated, diagnosed, and treated.

To encourage a good sleep regimen, experts recommend practicing a healthy lifestyle, which includes daily exercise, a healthy diet, limiting one’s alcohol and caffeine intake, and not smoking. Staying on a good sleep and waking schedule is important, as is preparing for sleep. For the latter, time should be allowed to finish household chores or take care of any loose ends before going to bed.

Writing down any concerns is a good way to put them aside until the next morning. Taking time to unwind and relax by reading a book, for example, can assist with falling asleep more naturally. Some individuals may find relaxation techniques, such as guided imagery, meditation, or biofeedback, to be of great help.

To encourage a good sleep regimen, experts recommend practicing a healthy lifestyle, which includes daily exercise, a healthy diet, limiting one’s alcohol and caffeine intake, and not smoking. Staying on a good sleep and waking schedule is important, as is preparing for sleep. For the latter, time should be allowed to finish household chores or take care of any loose ends before going to bed.

Writing down any concerns is a good way to put them aside until the next morning. Taking time to unwind and relax by reading a book, for example, can assist with falling asleep more naturally. Some individuals may find relaxation techniques, such as guided imagery, meditation, or biofeedback, to be of great help.

We mostly think of habits when in the context of “bad habits,” such as smoking or chewing our nails. But habits can be either bad or good habits, and good habits can help us sleep. The term “Sleep Hygiene” relates to our habits in the bedroom, in bed, and in relation to our sleep.

Consider “Susan,” a 34-year-old woman with MS. She is tired when she gets home from work, so she heats up some food, and then gets into bed to eat dinner. She then lays out her bills on the bed to determine which ones need to be paid, and pays her bills. Then she catches up on some work for her office. Susan has developed habits that make her bed a place of work, dining, and sometimes turmoil (when she doesn’t have the money to pay her bills). Her bed is no longer a place of peace, comfort, and sleep.

“Jerry” is a 55-year-old man with MS who likes to watch TV late at night. Some days he goes to sleep at 1 am, but at other times, he goes to bed at 3 am or even later. He is almost always tired the next day, and as a result, takes a nap. His nap times can vary – sometimes they are for 15 minutes, and other times for an hour. His naps prevent him from feeling tired enough to go to bed by midnight, and he stays up late again.

Strategies to Help: Many sleep problems in MS and in the general population can be resolved by improving our sleep hygiene (or sleep habits). Below is an adaptation of the standard program to improve these types of habits:

1. Use your bed only for sleep and sex
2. Reduce stimulant use (caffeine) later in the day
3. Avoid alcohol use in the evening
4. Go to bed at the same time every night
5. Stop working, making phone calls, or participating in any stressful activity two hours before bedtime
6. Set your alarm clock for eight hours after bedtime
7. When you get into bed, think about pleasant memories from the past; try to remember more and more details
8. If you haven’t fallen asleep after 20 minutes, get out of bed
9. Once out of bed, sit in a comfortable chair in a quiet place and read something that is not stimulating; when you feel like you are ready to fall asleep, get back into bed, but repeat steps 6 and 7 as many times as needed
10. Discontinue napping during the day

With regard to alcohol, we know that drinking a small amount of an alcoholic beverage can help a person to fall asleep. What people often do not realize, however, is that alcohol has a “rebound” effect, causing people to wake up during the night. It also causes people to urinate more frequently during the night, another cause of lost sleep.

Working with a trained psychologist on your sleep hygiene program is advisable, as a program often needs to be individualized or “tweaked” for each person, and adjusted over time. When people have tried to improve their sleep hygiene and have been unable to improve their sleep, they sometimes use medication to help them sleep.

You will find many advertisements on TV for sleep aids, and they all show a person refreshed in the morning. Most people who use “sleeping pills” do not wake up refreshed; instead, they wake up feeling drowsy.

There are alternatives to sleeping pills. An older form of antidepressants (tricyclics) is sometimes used because they are sedating. These types of antidepressants are not habit forming and a person can stop at any time. Many people find the supplement melatonin to be helpful. If used occasionally, antihistamines like Benadryl^® (diphenhydramine HCI) can be taken for their sedating side-effects. But again, most sleep problems can be solved without medication.

If you are not sleeping well at night, finding solutions to your sleep problems is well worth the effort, so you can get a better quality and increased quantity of sleep. Most of us require 7½ to 9 hours of sleep, and some require more.

Without enough sleep, people typically don’t feel well throughout the day and fatigue can become a big problem. However, if you examine what is interfering with a good night’s sleep, consult your physician, and take the necessary steps to resolve your sleep issues, you should feel better and experience less fatigue during the day. As noted earlier, for recalcitrant or complex sleep disorders, a sleep specialist should be consulted.

Arnett, P., Ben-Zacharia, A., Benedict, R., Bobholz, J., Caruso, L., Chelune, G.,… Goldman Consensus, Grp. (2005). The Goldman Consensus statement on depression in multiple sclerosis. Multiple Sclerosis, 11(3), 328-337. doi: 10.1191/1352458505ms1162oa

Association, American Psychiatric. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR): American Psychiatric Association.

Lunde, HMB, Bjorvatn, B, Myhr, K-M, & Bø, L. (2013). Clinical assessment and management of sleep disorders in multiple sclerosis: a literature review. Acta Neurologica Scandinavica, 127(s196), 24-30.