Thursday, June 19, 2008

Lyme and sleep

Most discussions about late Lyme mention "sleep disorder" as one of the symptoms. Certainly patients can have a wide variety of psychiatric symptoms including depression, anxiety and mood swings which are typically associated with disturbances in sleep. The use of sleep medicines or hypnotics may be helpful. Good quality sleep is important.
What I am most concerned about is a disorder called sleep apnea. Sleep apnea is more common in Lyme patients in my experience. It is classically associated with obesity, snoring and fatigue. But these signs may be absent. Many Lyme patients have neurologic dysfunction of the palate and uvula which may contribute to this disorder. In addition, brain abnormalities of Lyme may be a contributing factor. Sleep apnea is mostly peripheral, due to floppiness of the soft tissues in the back of the throat; but it may also be central, due to brain dysfunction. Patients with sleep apnea have severe fatigue, a symptom commonly reported in Lyme disease. These patients also have cognitive difficulties which may be similar to those seen in Lyme. Patients with sleep apnea have been shown to have abnormal SPECT scans with decreased blood flow to the frontal lobes of the brain. This is associated with poor executive function. This creates a syndrome which mimics attention deficit disorder, a finding which is also common in Lyme patients. Patients who are chronically deprived of deep sleep called stage 4 sleep, associated with delta waves on the EEG, electroencephalograph, have been shown to develop diffuse muscle pain which resembles fibromyalgia, another common Lyme syndrome. Many researches have described fibromyalgia as a syndrome related to a sleep disorder.Obstructive sleep apnea occurs when patients enter deep sleep, stage 4 and the airway closes off. The individual is unable to exhale. This may causes a decrease in respiration (hypopnea) or complete apnea, a cessation of breathing. The person has an arousal, of which he is unaware, which puts him in a more superficial stage of sleep and allows the closed airway to open again. The condition is frequently associated with low blood oxygen levels. It puts tremendous stress on the heart and is associated with hypertension and heart failure. The fatigue is profound and may cause day time drowsiness which includes falling asleep while driving. Sleep apnea is also associated with activation of the immune system. Markers of inflammation, including cytokines are elevated in these patients.
Patients with fatigue, day time drowsiness, snoring, hypertension and possibly ADD should have sleep studies. If narcolepsy is suspected another test called a multiple sleep latency test is also necessary. A full discussion of this and other related sleep disorders is outside the scope of this Blog. But I recommend that all patients with these symptoms have sleep disorders excluded as part of their evaluation.

3 comments:

girl Mark said...

Could you elaborate just a bit about the uvula and soft palate neurological stuff? I've seen this reference here and there.

What makes me interested is that I'm trying to learn more about air hunger, and the nausea that some babesia patients get. I have these un-fun symptoms and they feel very connected- yawning/trying to take a deep breath when having an attack of air hunger would bring on gagging or nausea when this symptom was really bad. It's clearing up with therapy for babesia.

Rumor on the Lyme patient end of the internet says that air hunger has something to do with the vagus nerve, as does nausea. Is this true, and does it have anything to do with the soft palate issues you're describing?

Lyme report: Montgomery County, MD said...

The movements of the uvula and soft palate are controlled by two cranial nerves the 9th and 10th: glossopharyngeal and vagus.

If these structures are compromised it would exacerbate sleep apnea. These cranial nerves are frequently diseased due to Lyme disease. I don't think this has anything to do with air hunger. The cause of air hunger in Babesia might be an asthma like reaction. When the lungs are hyper-expanded due to air trapping, one gets the sensation of not being able to take a breath. The inspired column of air meets pressure from residual trapped air in the lungs. I would guess that Babesia triggers an inflammatory response in airways which sets up this response.

girl mark said...

Do you ever see the damage to those tissues improve in your patients with treatment? I now have that classic 'deviated' uvula issue (soft palate in back of the throat is drooping on one side too), and I'm wondering whether it's going to get back to normal with treatment.

Are there any sleep drugs that help with sleep apnea symptoms, without having to go to the CPAP and similar devices?