Relationship between nocturnal urinary frequency and sleep disturbances in aged men

Abstract The relationship between nocturnal urinary frequency and sleep disturbances is investigated in aged men in 12 rural towns in Kyoto and Shiga Prefectures. The subjects were 178 men who did not have diseases or symptoms that were likely to affect urinary condition or sleep. There were no significant differences in sleep disturbances, except sleep maintenance, between the normal group (nocturnal urinary frequency below twice per night) and the abnormal group (nocturnal urinary frequency twice or more per night). In healthy aged men, nocturnal urinary frequency only caused disturbance in sleep maintenance, but did not cause any other sleep disturbance.     

The effect of nocturnal physiological sleep on various movement disorders

Thirty-one subjects affected by different movement disorders underwent polygraphic and videotape monitoring during nocturnal sleep, to assess movement patterns during the night. It was possible to distinguish two categories of disorders according to their pattern of movements. In the largest group (Meige's syndrome, blepharospasm, amyotrophic choreoacanthocytosis, Tourette syndrome, tonic foot, hemiballism) abnormal movements were still present during sleep, but decreased in frequency and amplitude in all stages. The second group presented three syndromes (nocturnal paroxysmal dystonia, nocturnal myoclonus, restless legs syndrome), in which light non-rapid-eye-movement sleep induced a strong activation of abnormal movements, whereas rapid-eye-movement sleep suppressed them.     

Nocturia, nocturnal polyuria, and sleep quality in the elderly

Nocturia is a common symptom in the elderly, which profoundly influences general health and quality of life. One consequence of nocturia is sleep deterioration, with increased daytime sleepiness and loss of energy and activity. Accidents, e.g., fall injuries, are increased both at night and in the daytime in elderly persons with nocturia. Nocturia is caused by nocturnal polyuria, a reduced bladder capacity, or a combination of the two. Nocturnal polyuria can be caused by numerous diseases, such as diabetes insipidus, diabetes mellitus, congestive heart failure, and sleep apnoea. In the nocturnal polyuria syndrome (NPS), the 24-h diuresis is normal or only slightly increased, while there is a shift in diuresis from daytime to night. NPS is caused by a disturbance of the vasopressin system, with a lack of nocturnal increase in plasma vasopressin or, in some cases, no detectable levels of the hormone at any time of the 24-h period. The calculated prevalence of NPS is about 3% in an elderly population, with no gender difference. In NPS, there are serious sleep disturbances, partly due to the need to get up for micturition, but there is also increased difficulty in falling asleep after nocturnal awakenings and increased sleepiness in the morning. The treatment of NPS may include avoidance of excessive fluid intake, use of diuretics medication in the afternoon rather than the morning, and desmopressin orally at bedtime.     

Sleep-wake complaints in Parkinson's disease

We analyzed the questionnaires concerning sleep-wake complaints in 1,575 Parkinsonian patients and 2,509 controls of 945 office workers and 1564 seniors living at home. The questionnaire included 20 contents. The Parkinsonian patients complained of sleep-wake disturbances more frequently than the controls in initiation disturbance, frequent awakenings in night, early morning awakening, day time sleepiness, usage of sleep pills, parasomnias, restless legs symptoms, nocturnal myoclonus, snoring, apnea episodes and dyspnea in night (chi-square method). The incidences of restless legs symptoms and nocturnal myoclonus increased significantly with worsening of physical symptoms in the Parkinsonian patients (p less than 0.01).     

Micturitional disturbance in patients with Guillain-Barré syndrome

OBJECTIVES—To examine the frequency andpathophysiology of micturitional disturbance in patients withGuillain-Barré syndrome.
METHODS—Micturitional symptoms were notedand neurological examinations made repeatedly during admission tohospital of patients with clinical and neurophysiologically definiteGuillain-Barré syndrome. Urodynamic studies consisted ofuroflowmetry, measurement of residual urine, urethral pressureprofilometry, medium fill water cystometry, and external sphincter EMG.
RESULTS—Seven of 28 (25%) patients withGuillain-Barré syndrome showed micturitional disturbance. Thesymptoms included voiding difficulty in six, urinary retention inthree, nocturnal urinary frequency in three, and urge incontinence intwo. These micturitional symptoms appeared after weakness occurred, andimproved gradually along with the neurological signs. All threepatients who showed retention became able to urinate. Urodynamicstudies were made on four symptomatic patients two of whom underwentrepeated study. Disturbed bladder sensation was noted in one patient,bladder areflexia in one, and absence of the bulbocavernosus reflex inone. Cystometry showed decreased bladder volume in two and bladderoveractivity in two, one of whom had urge urinary incontinence and theother urinary retention.
CONCLUSIONS—A quarter of the patients withGuillain-Barré syndrome tend to have micturitional disturbance. Thepatients studied had evacuation and storage disorders, as well asbladder areflexia and disturbed bladder sensation indicative ofperipheral types of parasympathetic and somatic nerve dysfunction.Decreased bladder volume with bladder overactivity but no evidence ofCNS involvement was also found, evidence that bladder overactivity alsooccurs in peripheral nerve lesions with probable pelvic nerve irritation.

     

Behavioral treatment of excessive daytime sleepiness in an elderly woman with multiple medical problems

The case is described of a 61-year-old woman who complained of excessive daytime sleepiness, periodic cataplexy, and nocturnal urinary frequency, in the context of several other medical problems. Behavioral treatment consisted of training in progressive muscle relaxation and fluid restriction to facilitate sleep maintenance, and the use of a rubber band which was snapped against the wrist to facilitate daytime arousal. Following this self-management program, improvements were noted in the following dependent measures: (1) sleep attacks at home; (2) sleep attacks while driving; (3) cataplectic episodes; (4) nocturnal awakenings, and (5) nocturnal urine output. These improvements were maintained at 6- and 12-month follow-up. The integration of medical and behavioral strategies was highlighted.     

Sleep in patients with treated Wilson's disease. A questionnaire study

Objective: To examine general sleep habits and sleep disturbances among patients with treated Wilson's disease (WD), and in comparison with an age- and sex-matched reference group (RG). Methods: Twenty-four patients with WD with a mean ( &#45 s ) age of 35.1 &#45 8.7 years and a disease duration of 17.7 &#45 5.1 years were investigated using a standardized sleep questionnaire comprising 87 questions concerning sleep habits, sleeping difficulties, demographic and lifestyle variables. The results were compared with those from a random sample of 72 individuals. Results: There was no significant difference in sleep time during the night, but WD patients had a significantly greater number of nocturnal awakenings compared with the RG. Fifty-nine per cent of the WD patients reported frequently being awake for more than 30 min during the night. Number of nocturnal awakenings was correlated to nightmares and palpitations only in the WD group. WD patients complained significantly more often than the RG over not feeling rested after sleep, taking frequent naps and fatigue during the daytime. Moreover, sleep paralysis and cataplexy occurred more often in the WD patients than in the RG. Conclusion: The sleep pattern of patients with treated WD differed from that of the reference group. The spectrum of reported symptoms by patients with treated WD suggests an altered REM sleep function. Future studies with objective methods are required to elucidate the mechanisms involved.     

A case of parasomnia at REM sleep onset

A case is reported of dyssomnia at the onset of REM sleep with thrashing, shouting, and urinary incontinence throughout the night. The attacks did not respond to, and may have been worsened by, antiepileptic drugs and diazepam, and the patient had microsleeps and brief apneas during a night of severely fragmented sleep. The case underscores the value of differentiating REM and NREM disorders in patients with atypical nocturnal attacks.     

Night-to-night variability in sleep in cystic fibrosis

OBJECTIVES: The impact of night-to-night variability (NNV) on polysomnography (PSG) has been reported mainly in normal subjects, the elderly and patients with obstructive sleep apnea with focus on changes in the apnea/hypopnea index, rather than measures of nocturnal oxygenation. There is very limited data on NNV in patients with cystic fibrosis (CF). The goal of this study was to assess for first-night effect and reliability of PSG measurements on nocturnal oxygenation and respiratory disturbance in CF. METHODS: A prospective observational study was performed in patients with CF who consented to PSG on two consecutive nights. Paired t-tests and intra-class correlation coefficients (ICCs) were calculated for repeated measures of sleep stage time, sleep efficiency, arousal indices, measures of nocturnal oxygenation, and respiratory events in all sleep stages. RESULTS: Thirty-one patients with CF were studied, aged 27+/-8 (mean+/-1 SD) years and forced expiratory volume in 1 s (FEV(1)) of 37+/-11% of predicted. Relative to the first-night PSG, on the second PSG, we observed the following: shorter latency to rapid eye movement (REM) sleep (P<0.001), increased sleep efficiency (P<0.01), decreased wake after sleep onset (WASO) time (P<0.01), decreased percentage of non-REM time with oxyhemoglobin saturation by pulse oximetry (SpO(2))< or =90% (P<0.05), decreased number of central apneas per hour (P<0.05) and reduced respiratory rate in stage 2 sleep on night 2 (P<0.05). Despite these changes, the ICCs between night 1 and night 2 showed good repeatability/reliability for measures of nocturnal oxygenation and indices of respiratory disturbance, including the percentage of total sleep time with SpO(2)< or =90% (ICC=0.85) and apnea-hypopnea index (ICC=0.75). Likewise, the ICCs were extremely high for respiratory rate in stage 2 (ICC=0.94), slow wave sleep (ICC=0.97), and REM sleep (ICC=0.96).CONCLUSION: Although a first-night effect is seen with sleep efficiency, REM latency, and WASO, a single-night PSG in patients with CF yields reliable information on nocturnal oxygenation and respiratory disturbance.     

Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate

BACKGROUND: Sleep-related eating disorder (SRED) and nocturnal eating syndrome (NES) combine features of sleep disorders and eating disorders. Treatment of these nocturnal eating behaviors has been directed towards underlying identifiable sleep or eating disorders using dopaminergic or opioid agonists, as well as anorectic agents, at times with the addition of sedatives. METHODS: Two patients with SRED and two with NES, who had failed multiple previous trials of pharmacotherapy and psychotherapy, were treated in a naturalistic, open-label fashion with topiramate at night. Reduction in nocturnal eating was graded based on self-report. Weight was computed at the outset of, and during, topiramate treatment. RESULTS: One patient with NES had a complete elimination of nocturnal eating with topiramate, two patients (one with NES, one with SRED) had a marked response, and one patient (with SRED) had a moderate response. Mean dose was 218 mg, though three patients noted an improvement at 100 mg. Notable weight loss was observed in all patients (mean of 11.1 kg). Benefits of topiramate treatment have been maintained for a mean period of 8.5 months. CONCLUSIONS: Topiramate may be of benefit for patients with NES or SRED in reducing nocturnal eating, improving nocturnal sleep, and producing weight loss.     

Visual hallucinations as REM sleep behavior disorders in patients with Parkinson's disease.

To clarify whether visual hallucinations in patients with Parkinson's disease (PD) are related to rapid eye movement (REM) sleep, nocturnal polysomnographic variables were compared between a group with hallucinations (hallucinators, n = 14) and a group without hallucinations (nonhallucinators, n = 8). A multiple sleep latency test (MSLT) was performed on 3 hallucinators, and the content of dreams during daytime REM sleep was investigated. The efficacy of clonazepam, a standard treatment choice for REM sleep behavior disorders, was investigated in 8 hallucinators. Nocturnal polysomnograms of the hallucinators showed a higher amount of stage 1-REM sleep with tonic electromyogram (stage 1-REM) than the nonhallucinators, and the reported occurrences of nocturnal hallucinations corresponded with the periods of stage REM or stage 1-REM in most hallucinators. The frequency of sleep onset REM periods (SOREMP) on the MSLT were pathologically high in the hallucinators, and the content of the dreams during the MSLT period was quite similar to their hallucinations. During clonazepam treatment, the frequency of hallucinatory symptoms decreased in 5 of 8 hallucinators. These results indicate that visual hallucinations in PD are likely to be related to a REM sleep disorder manifested as the appearance of both stage 1-REM during the night and SOREMP in the daytime.     

The electroencephalographic sleep pattern in schizophrenic patients treated with clozapine or classical antipsychotic drugs

The effects of antipsychotic agents on sleep were tested by examining the nocturnal electroencephalographic recordings of 14 drug-naïve schizophrenic patients and comparing these with recordings from 12 patients treated with clozapine and 10 treated with classical neuroleptics (haloperidol: n=7; flupentixol: n=3). In both of the treated groups, sleep continuity measures and rapid eye movement (REM) density were significantly higher than in the drug-naïve group. Clozapine-treated patients showed significantly more stage two sleep, more stable non-REM sleep (stages two, three and four) and less stage one than patients treated with haloperidol or flupentixol. Clozapine had no effect on the amount of REM sleep. Although mean REM latency was almost twice as long in the clozapine compared with the other two groups, this difference was not statistically significant. The present study suggests considerable differences between the influence of typical and atypical antipsychotic agents on sleep. However, the results of this cross-sectional study should be confirmed using a longitudinal intraindividual approach.     

Preliminary observations on the effects of sleep time in a sleep restriction paradigm

OBJECTIVE: To evaluate of the effect of 7 days of sleep restriction--with sleep placed at the beginning of night or early morning hours - on sleep variables, maintenance of wakefulness test, and serum leptin. METHODS: After screening young adults with questionnaires and actigraphy for 1 week, eight young adult males were recruited to participate in a sleep restriction study. The subjects were studied for baseline data for 2.5 days, with 8.5 h per night in bed, and then over 7 days of sleep restriction to 4 h per night with a 22:30 h bedtime for half the group and a 02:15 h bedtime for the other half. At the end of study, after one night of ad libitum sleep, subjects again had 2 days of 8.5 h in bed. Wakefulness was continuously verified and tests, including Maintenance of Wakefulness (MWT), were performed during the scheduled wake time. Blood was drawn six times throughout the 24 h of the 7th day of sleep restriction and after 2 days of the post-restriction schedule. RESULTS: There was individual variability in response to sleep restriction, but independent of group distribution, MWT was significantly affected by sleep restriction, with the early morning sleep group having less decrease in MWT score. Sleep efficiency was also better in this group, which also had shorter sleep latency. Independent of group distribution there was a greater increase in the percentage of slow wave sleep than rapid eye movement sleep, despite a clear internal variability and variability between subjects. Peak serum leptin was significantly decreased with 7 days of sleep restriction for all subjects. CONCLUSION: Sleep restriction to 4 h affected all subjects, but there were individual and group differences in MWT and sleep data. In this group of young adult males (mean age 19 years), there was a better overall adaptation to the early morning sleep, perhaps related to the general tendency in most adolescents to present some phase-delay during late teen-aged years.     

Nocturnal sweating and temperature in depression.

OBJECTIVE: Patients with depression may have altered thermoregulation, such as high nocturnal core temperatures, decreased daytime sweating and subjective complaints of nocturnal sweating. We sought to compare nocturnal sweating in depressed patients and non-depressed controls, and to assess the impact of REM sleep on sweat rates. METHOD: Nocturnal sweat rate, nocturnal temperature and REM sleep were measured during the night in 9 controls and 8 depressed subjects; 7 depressed patients were assessed during recovery. RESULTS: The nocturnal temperature was significantly higher in depressed patients compared to controls, and decreased significantly with recovery. The nocturnal sweat rates of depressed patients did not differ significantly from those of controls, but decreased significantly with recovery. Analyses of sweat rates before, during and after REM sleep indicated a trend for the entire sample to show a decrease in sweat rates during REM. CONCLUSION: The nocturnal sweating rates in the depressed patients suggest that impaired sweating is not the cause of the high nocturnal temperature commonly found in depressed patients.     

Effects of pergolide on nocturia in Parkinson's disease: three female cases selected from over 400 patients

We started the subject screening from over 400 patients with Parkinson's disease using strict selection criteria to identify the patients with nocturia who would allow accurate and efficient evaluation of the pergolide effects. The subjects were confined to female patients to exclude patients with potential prostate hypertrophy. The patients treated with bromocriptine at 7.5-15 mg/day adjunctive to l-dopa were selected to replace bromocriptine with pergolide of the equivalent dosage approved in Japan. The nocturia was defined as having more than two episodes of urination during sleep per night on average. The subjects received the urinary sediment test before and during the study for screening urinary tract infection and the study was discontinued when urinary tract infection was found. As a result, we identified total 11 patients with nocturia and three of those completed the 12-week study of switching dopamine agonist from bromocriptine to pergolide. We observed a decrease in nocturia frequency in all three patients, a decrease in irritative urinary symptoms in two and an improvement of sleep QOL in two. The effect of pergolide on nocturia was independent of improvement of parkinsonian symptoms, suggesting a distinct mechanism from that of anti-parkinsonian effects. Our study also suggests that switching from bromocriptine to pergolide improves nocturia, thereby improving sleep status of patients with Parkinson's disease.     

REM sleep,naps, and depression

Continued interest in rapid eye movement (REM) sleep abnormalities in depression stimulated comparative studies on daytime naps versus nighttime sleep. In a group of 15 depressed patients, REM latencies in morning and afternoon naps were similar to the shortened REM onset at night. Although REM latency did not vary across the three times, the propensity for REM sleep appeared to be greater in the morning nap than in the afternoon nap and the early portion of nocturnal sleep. Finally, the data suggest that responders to tricyclic treatment tend to be poor sleepers during daytime naps.     

Effects of acute morning and evening exercise on subjective and objective sleep quality in older individuals with insomnia

ObjectivesThe aims of this study were to compare the effects of acute morning or evening exercise on nocturnal sleep in individuals with two subjective insomnia symptoms: difficulty in initiating sleep (DIS), and early morning awakening (EMA), separately for the first vs the second halves of the night.MethodsOlder individuals (55–65 years old) with DIS (N = 15) or EMA (N = 15) and age- and sex-matched controls (N = 13) participated in this non-randomized crossover study. Participants were assigned to two exercise conditions (morning exercise and evening exercise) in counterbalanced order following the baseline condition with a two-week interval between conditions. A single session of aerobic step exercise was performed during each exercise condition. Nocturnal polysomnography was carried out to evaluate objective sleep quality. Patient global impression of change scale scores for nocturnal sleep were obtained to subjectively evaluate the different groups.ResultsAcute physical exercise did not improve subjective sleep quality. Morning exercise decreased the number of stage shifts over the whole night. The arousal index and the number of stage shifts were decreased especially during the second half of the night in all groups. Furthermore, morning exercise decreased the number of wake stages during the second half of the night in the DIS group, but not in the EMA group.ConclusionsAcute morning exercise can improve nocturnal sleep quality in individuals with difficulty initiating sleep, especially during the later part of the night.     

A polysomnographic and clinical report on sleep-related injury in 100 adult patients

In 100 consecutive adults who came to a sleep disorders center complaining of repeated nocturnal injury, polysomnographic study identified five disorders: night terrors/sleepwalking (N = 54), REM sleep behavior disorder (N = 36), dissociative disorders (N = 7), nocturnal seizures (N = 2), and sleep apnea (N = 1). Ninety-five patients sustained ecchymoses, 30 had lacerations, and nine had fractures. DSM-III axis I disorders (past or current) were found in 48.1% of the group with night terrors/sleepwalking and in 30.6% of the group with REM sleep behavior disorder; these were mainly affective disorders. In these two groups, clonazepam controlled the symptoms of 51 of the 61 patients to whom it was given.     

Repeated nocturnal sleep latencies in narcoleptic, sleepy and alert subjects.

OBJECTIVES: The purpose of this study was to assess nocturnal sleep latencies among narcoleptics. METHODS: Thirteen narcoleptics and matched sleepy and alert controls participated in this study. Subjects were awakened three times on each of two experimental nights. The latencies to sleep and rapid eye movement sleep were evaluated at the beginning of the night and following each experimental awakening. RESULTS: The alert group (AG) had a significantly longer mean nocturnal sleep latency than the narcoleptic (NG) and sleepy groups (SG). The sleep latencies at 23:00 and 01:10 h were significantly longer than the latencies at 03:10 and 05:10 h. The interaction between group and time of night demonstrated longer latencies at 23:00 and 03:10 h for the AG when compared to the SG and the NG. At 01:10 and 05:10 h all groups had comparable latencies. The number of subjects in the NG who had multiple sleep onset REM periods (SOREMPs) was significantly higher than in either the AG or the SG. CONCLUSIONS: Narcoleptics were found to have a heightened propensity to fall asleep and increased number of SOREMPs during nocturnal sleep opportunities. These characteristics are consistent with the daytime polysomnographic findings known in this patient population.     

Chronic benzodiazepine usage and withdrawal in insomnia patients

We studied the sleep of patients with insomnia during continuous and very long-term use of benzodiazepines (BZDs), and after withdrawal. A group of 25 patients (mean age 44.3+/-11.8 years) with persistent insomnia, who had been taking BZDs nightly for 6.8+/-5.4 years was selected. The control group was comprised of 18 age-matched healthy individuals. Sleep stage parameters were analyzed during Night 1 (while taking BZDs), Night 2 (first night after completing BZD withdrawal), and Night 3 (15 days after gradual BZD withdrawal). Sleep data for control subjects was monitored in parallel. Sleep EEGs of the patients were analyzed using Period Amplitude Analysis (PAA), during Nights 1 and 3 only. During BZD use, a significant reduction of Total Sleep Time (TST) and increased sleep latency were found in the insomniac group when compared to controls. We found an increase in stage 2 non-REM (NREM) sleep, and a reduction in Slow Wave Sleep (SWS) when comparing to night 3 (after withdrawal). Sleep EEGs analysis showed an increase in sigma band and decrease in delta count in stages 2, 3, 4 NREM and REM sleep in the BZD group when comparing to night 3 (after withdrawal). During the BZD withdrawal period, six out of nine subjects taking lorazepam failed withdrawal. In the remaining 19 subjects, gradual withdrawal of BZDs was associated with immediate worsening of nocturnal sleep, as indicated by sleep parameters. However, 15 days after withdrawal (Night 3), some of the sleep structure parameters of patients were not significantly different from baseline (while taking BZDs), except for a significant increase in SWS and in delta count throughout most sleep stages, and a decrease in stage 2 NREM sleep. These values were not different from those shown by control subjects. REM sleep parameters showed no significant variation across the experimental conditions. Subjective sleep quality was significantly improved on Night 3 compared with Night 1. Conclusions: Chronic intake of BZDs may be associated with poor sleep in this population. A progressive 15-day withdrawal did not avoid an immediate worsening of sleep parameters. But at the end of the protocol, SWS, delta count, and sleep quality were improved compared to those recorded during the chronic BZD intake, despite the lack of change in sleep efficiency.