Introduction:
Sleep is an essential human requirement and can be influenced by various factors, including biology, psychosocial elements, and the environment. Insufficient sleep has been connected to a decline in overall well-being and an increase in mortality rates. Among individuals with rheumatic diseases, typical subjective sleep issues include difficulty in falling or staying asleep, non-restorative sleep, and heightened daytime sleepiness or fatigue. Rheumatic disease patients are more prone to experiencing primary sleep disorders like obstructive sleep apnea (OSA) or restless legs syndrome compared to the general population. Since sleep disturbances have been associated with the activation of pro-inflammatory cytokines, assessing sleep disruptions and primary sleep disorders holds particular importance in the comprehensive care and management of rheumatic disease patients.
Why Is Sleep Important in Those With Rheumatic Diseases?
Sleep plays a crucial role in managing rheumatoid arthritis (RA) and its related symptoms. Sleep problems can lead to elevated levels of stress hormones, exacerbating flares and making it more challenging to manage pain. The production of essential brain chemicals that contribute to a sense of well-being occurs during sleep. When individuals are not well-rested, they may lack these beneficial hormones, making it more difficult to cope with pain.
In addition to increased flares, RA patients experiencing sleep disruptions often face difficulties with depression, heightened pain severity, and reduced ability to perform daily activities compared to those without sleep issues. Deep stages of sleep are vital for the release of growth hormones that aid in the repair of minor muscle tears that naturally occur throughout the day. Individuals with RA who experience fragmented sleep may not receive adequate amounts of growth hormone necessary for these reparative processes. Sleep deprivation has a significant impact on rheumatic diseases, exacerbating symptoms and affecting disease outcomes in several ways:
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Increased Pain Intensity: Sleep deprivation can intensify pain sensitivity and perception in individuals with rheumatic diseases. Lack of sufficient sleep lowers the pain threshold, making the experience of pain more severe. This can lead to heightened discomfort and reduced pain tolerance, impacting daily functioning and quality of life.
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Inflammation Aggravation: Sleep deprivation disrupts the body's immune system and promotes systemic inflammation. In rheumatic diseases characterized by inflammation, such as rheumatoid arthritis or lupus, inadequate sleep can amplify the inflammatory response, worsening disease activity and increasing the risk of flares.
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Impaired Healing and Repair: Sleep deprivation hampers the body's natural healing and repair processes. Growth hormone is secreted during deep sleep cycles, which helps with tissue repair. In rheumatic diseases, where joint damage and muscle injuries are common, sleep deprivation can impede the healing of these tissues, leading to delayed recovery and prolonged symptomatology.
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Fatigue and Reduced Energy: Sleep deprivation contributes to chronic fatigue and reduced energy levels in individuals with rheumatic diseases. This fatigue can be debilitating and significantly impact daily activities, work productivity, and overall quality of life. The persistent lack of restorative sleep impairs physical and mental functioning, making it challenging to manage the demands of the disease.
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Mood Disturbances: Sleep deprivation is closely linked to mood disturbances, including increased risk of depression and anxiety. In rheumatic diseases, which often entail psychological challenges and emotional distress, inadequate sleep can exacerbate these symptoms, leading to a negative cycle of poor mental health and disease management.
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Impaired Cognitive Function: Sleep deprivation impairs cognitive function, including attention, memory, and decision-making abilities. In individuals with rheumatic diseases, compromised sleep can impact cognitive performance, making it more difficult to manage treatment regimens, adhere to medication schedules, and engage in self-care practices effectively.
What Causes Sleep Disturbances in People With Rheumatic Diseases?
Sleep disturbances in rheumatic diseases can arise from various factors related to the conditions themselves. Some common causes:
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Pain and Discomfort: Chronic pain and discomfort are frequently a part of rheumatic diseases, which can make it difficult to fall asleep and stay asleep all night. Widespread pain, stiff muscles, and joint inflammation can interfere with sleep cycles and make it difficult to get a good night's sleep.
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Inflammation and Immune Dysregulation: Rheumatic diseases involve chronic inflammation and immune system dysfunction. Elevated levels of pro-inflammatory cytokines, such as interleukin-6 and tumor necrosis factor-alpha, can impact sleep by affecting the sleep-wake cycle and promoting wakefulness instead of restful sleep.
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Medications: Some medications used to manage rheumatic diseases, such as Corticosteroids or disease-modifying antirheumatic drugs (DMARDs), may have side effects that disrupt sleep. For example, Corticosteroids can cause insomnia, while DMARDs may lead to fatigue or drowsiness. One is the steroid Prednisone, which can lead to restlessness, agitation, or depression. It is best to take it earlier in the day. Another example is Hydroxychloroquine. On occasion, it can make people anxious and twitchy.
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Psychological Factors: Living with a chronic condition can result in increased stress, anxiety, and depression, all of which can negatively impact sleep. Psychological factors can contribute to difficulties falling asleep, staying asleep, and achieving deep, restorative sleep.
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Comorbidities: Rheumatic diseases often coexist with other health conditions, such as sleep apnea, restless leg syndrome, or depression, which can further disrupt sleep and exacerbate symptoms.
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Lifestyle Factors: Unhealthy sleep habits and poor sleep hygiene can worsen sleep disturbances in rheumatic diseases. Irregular sleep schedules, excessive caffeine intake, lack of physical activity, and an uncomfortable sleep environment can all contribute to sleep difficulties.
What Are the Different Diagnostic Sleep Tests?
Diagnostic sleep tests are valuable tools that provide objective evidence of sleep patterns, allowing for the identification of both normal sleep patterns and abnormal occurrences. These tests are classified into four main types: Type I, Type II, Type III, and Type IV. Among these, Type I and Type III tests are the most commonly employed methods, conducted either in a laboratory or through home-based portable monitoring.
Types of Diagnostic Sleep Tests include:
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Type I: This test involves fully attended polysomnography (PSG) conducted in a laboratory setting. It utilizes at least seven channels to monitor various parameters.
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Type II: Similar to Type I, Type II entails full unattended PSG with at least seven channels.
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Type III: This type employs limited channel devices, typically using four to seven channels for monitoring.
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Type IV: Type IV tests utilize one or two channels, often including oximetry among the parameters measured.
Polysomnography -
A typical overnight PSG study includes comprehensive measurements to assess different aspects of sleep health and architecture. Various measurements are taken during sleep tests, including electroencephalogram (EEG), electrooculogram (EOG), electromyogram (EMG), electrocardiogram (ECG), pulse oximetry, body position, nasal airflow, respiratory muscle effort, snoring, chest wall motion, and abdominal wall motion. Polysomnograms commonly evaluate various aspects, such as total sleep time, sleep latency, sleep efficiency, arousals, sleep fragmentation, periodic limb movement (PLM) frequency, sleep stage transitions, percentage of non-rapid eye movement (NREM), and rapid eye movement (REM) sleep, apnea-hypopnea index (AHI), oxygen desaturations, and respiratory disturbance index (RDI). The RDI is calculated by combining apneas, hypopneas, and respiratory effort-related arousals per hour of sleep.
Additional Sleep Tests -
Apart from polysomnography, there are other diagnostic sleep tests available.
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Actigraphy involves using wrist-worn devices to detect movement, providing data for estimating sleep or wake parameters. This test is particularly useful in assessing conditions such as periodic limb movements, circadian rhythm disorders, excessive sleepiness, and insomnia.
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Another test, the multiple sleep latency test, consists of several 20-minute naps conducted during the day following an overnight polysomnography. This test aids in diagnosing narcolepsy and identifying the causes of excessive daytime fatigue.
Conclusion:
Sleep issues have a significant impact on patients' overall health and quality of life, in addition to increasing symptom burden and disease activity. For the best disease management and better results, treating sleep issues as part of a thorough treatment plan is crucial. More research is required to better understand the underlying mechanisms and develop more focused interventions to improve sleep quality and lessen the effects of sleep disturbances in rheumatic diseases.
