Managing Sleep Problems in RA

In these fast-paced, overworked, and TV- and Internet-addicted times, it probably comes as no surprise that a majority of Americans don’t get enough sleep. But you may not realize that staying up late isn’t the only problem. Many people also experience sleep disturbances such as snoring, waking in the night, or waking up too early.

Rheumatoid arthritis and sleep problems

In its 2011 “Sleep in America” poll, the National Sleep Foundation found that 60% of Americans reported such sleep problems every night or almost every night. For people with rheumatoid arthritis (RA), however, sleep problems are even more common and more severe than in the general population. Why so many people with RA find good sleep so tough to come by is a complex question. Researchers see sleep disturbance and sleep loss in people with RA as part of a set of common RA symptoms and complications, including pain, depression, and fatigue. The good news is that treating sleep problems can help relieve these symptoms. This article looks at the connection between rheumatoid arthritis and sleep problems and offers some simple suggestions for getting a good night’s sleep.

High rates of sleep problems with rheumatoid arthritis

According to Yvonne Lee, MD, Instructor in Medicine in the Department of Rheumatology at Brigham and Women’s Hospital in Boston, sleep disturbances are both more prevalent and more severe in people with RA. She notes that some studies have put the rate of sleep disturbances in people with RA as high as 50% or 75%. Researchers from the National Data Bank for Rheumatic Diseases at the University of Kansas School of Medicine evaluated 8,676 people with RA and compared them with a group of 1,364 people without inflammatory arthritis or fibromyalgia. They found that people with RA are more likely to have sleep disturbances, and that between 25% and 42% of this increase can be attributed to RA disease activity and the associated pain and mood changes.

What exactly is a “sleep disturbance”?

Although the term can be defined in several ways, a sleep disturbance is essentially a lapse in normal sleep. A sleep disorder, on the other hand, usually involves a pattern of sleep disturbances and requires medical attention. (The two most common sleep disorders, insomnia and sleep apnea, are discussed in Insomnia and Sleep Apnea) Just because you occasionally have a sleep disturbance does not mean that you have a sleep disorder. Most people have an occasional night or two of restlessness brought on by everyday concerns.

When determining whether your sleep disturbances indicate a larger problem, “frequency is important,” says Steven Hugenberg, MD, Associate Professor of Clinical Medicine and a rheumatologist at the Indiana University School of Medicine in Indianapolis. “If it occurs more than three days in a row or more than five days a month, it may be significant. If a person feels like lack of sleep is causing them problems in their life, it might be time to see a doctor.”

Health effects of sleep loss

Lack of sleep has been linked to many mental and physical problems. Some we experience whenever we are tired: short-term memory loss, poor performance on new or complex tasks, a decrease in attention span, and delayed response times.

But lack of proper sleep has also been found to raise the risk for high blood pressure and an elevated heart rate, impaired glucose tolerance (an early indicator of diabetes), and increased appetite (which can cause weight gain). Of special interest to people with RA, researchers have found a correlation between lack of sleep and higher blood levels of C-reactive protein, a marker of inflammation that is frequently elevated in people with RA.

Possible causes of sleep disturbances

The reasons for the connection between sleep disturbances and RA are not yet well established, and there are likely many causes. According to Dr. Lee, sleep disturbances in people with RA “may be related to their disease or other factors, such as pain and depression.” Still, she adds, “Most studies have only looked at sleep disturbances at one point in time, so it is difficult to determine cause–effect relationships. It is only recently that we have begun to delve more deeply into these relationships.”

As Dr. Lee notes, pain is obviously a major factor. People with chronic pain from any source have been shown to have trouble getting a full night’s sleep. Grant Louie, MD, and colleagues from the National Institute of Arthritis and Musculoskeletal and Skin Diseases found that sleep disturbances were more common in people with all types of arthritis.

Depression is clearly involved as well. Depression has been linked to sleep disturbances in the general population, and depressive symptoms have consistently been found to be more prevalent in people with RA. There is also evidence that when pain and depression are combined, they may further increase the risk for sleep loss. Dr. Louie’s study found that adults with arthritis who were also depressed and anxious were at the highest risk for sleep problems.

The effects of fatigue

One symptom that seems to be related to all this lost sleep is fatigue, a hallmark of RA. Fatigue is not just occasional tiredness; it is overwhelming tiredness that affects your ability to carry out your daily tasks. As many as 4 in 10 people with RA may have severe fatigue. In one study, pain severity, problems in functioning, depressed mood, worrying, helplessness, and nonrestorative sleep were all worse in people with more fatigue.

A 2010 study from New Zealand used a widely accepted fatigue assessment scale to study 103 people with RA and a similarly sized group with osteoarthritis (OA). They found that fatigue was common in both groups. However, they found that levels of pain, disease activity, or amount of damage to bones had no bearing on fatigue. Only depression and anxiety increased fatigue.

It isn’t fully understood why people with RA have so much fatigue, but sleep disturbances are thought to play a role. Research has found that poor sleep quality is part of a constellation of mutually reinforcing symptoms that affect people with RA. A 2011 study published in the Journal of Clinical Sleep Medicine looked at 162 people with RA. Sixty-one percent were poor sleepers, and one in three said that pain interfered with sleep three or more times a week. The poor sleepers had higher levels of pain, depression, fatigue, and functional disability than those with RA who did not have sleep problems.

How to get restful sleep

Now you know that RA may cause you trouble sleeping, and that the resulting fatigue can make many of the effects of RA worse. If you find yourself sleeping fitfully, the next question is, what can you do to help yourself get back into a pattern of restful sleep? You should first look at your sleep habits, or what is called “sleep hygiene.” Practicing good sleep hygiene requires that you follow a few simple rules concerning your bedtime activities and your sleep environment. Some of the more important rules are the following:

  • Try to go to bed at the same time every day.
  • Get up at the same time every day, regardless of when you fell asleep.
  • Get regular exercise, preferably in the morning, but avoid strenuous exercise just before sleep.
  • Expose yourself to the outdoors or bright lights during the day, especially late in the afternoon.
  • Make your bedroom a comfortable environment. Regulate the temperature, keep noise to a minimum, and darken the room.
  • Avoid stimulating activities before bed. These may include exercising, using the computer, or watching violent or suspenseful TV programs.
  • Avoid caffeine within six hours of bedtime and alcohol and smoking within two hours of bedtime, and don’t go to bed too hungry or too full.
  • Use the bed only for sleeping and sex. Don’t watch TV, read, or do work in bed. It helps to take the TV out of the bedroom.
  • Don’t stay in bed if you are not sleepy. If you cannot get to sleep within 30 minutes of going to bed, go to another room to read, watch (nonstimulating) TV, or do something else until you become drowsy.
  • Establish a regular bedtime routine. This can include a warm bath or shower, aromatherapy, listening to soothing music, muscle relaxation techniques, or simply imagining you are in a relaxing place.
  • For many people, “don’t nap” is good advice — napping can disrupt the sleep–wake cycle. People with RA, however, often find that to combat fatigue they need as many as 10 hours of sleep a day, and naps are therefore important for getting enough sleep. Talk with your doctor about whether napping makes sense for you.

Following these guidelines can have a very positive effect because, according to Dr. Hugenberg, “most people don’t have a clue as to what is good and what is bad sleep hygiene. Almost all of us in the United States have a TV in the bedroom, and a lot of us drink caffeinated drinks way too late in the day.”

What to take note of before visiting a doctor for sleep disturbances

If you try the sleep hygiene tips above and still are not getting enough sleep, a visit to your rheumatologist or primary-care doctor may be in order.

One of the first things the doctor will do is to assess your RA symptoms. Are you having an increase in pain, and if so, in which joint(s)? Do you have any new areas of pain? Have you been taking your RA medicines as prescribed? Depending on the answers, your doctor may order studies to see how active your RA is. Periods of high RA activity are known as flares. Because people with RA are more likely to have sleep disturbances during a flare, treating a flare can improve your quality of sleep. If the flare is caused by your not taking your medicines, taking them again as prescribed may relieve the flare and let you sleep more easily.

The doctor will also ask about the nature of your sleep. Among the questions he or she may ask are the following:

  • Do you have trouble falling asleep?
  • How often do you wake during the night, and is there any reason (for example, do you have to go to the bathroom)?
  • If you wake up during the night, do you have trouble falling back to sleep?
  • Do either you or your bedmate snore?
  • How many pillows do you use?

Don’t be surprised if the doctor wants you to ask your bedmate the same questions. He or she often has information about your snoring or sleep habits that you might not know or don’t think to mention.

Next, the doctor will review the medicines or supplements you are taking. Make sure you let your doctor know about everything you are taking, including herbal supplements and vitamins. You may think these are natural and thus harmless, but that may not be the case. Some medicines or supplements have sleep loss as a known side effect. Others may cause a problem with sleep only when you take them with other drugs. Fatigue, especially in the morning, is a possible side effect of many medicines used to treat arthritis, including methotrexate (brand names Rheumatrex and Trexall).

Dr. Hugenberg notes that the reason for sleep disturbances is often a well-known side effect of a drug. “Lots of times when I have asked [my patients] if they get up in the middle of the night, I find out that they are on a diuretic or other medication that makes you urinate often,” he says. “There may be another condition completely independent of the RA that is causing the problems.”

You may also be given a short screening test for depression and anxiety if your doctor suspects you are struggling with these problems. Depending on the outcome, your doctor may request that you have a more thorough workup. Depression can be treated through medicines or psychotherapy — and treating depression can help to ease RA symptoms.

Finally, your doctor will perform a complete physical examination. There are scores of illnesses that can disturb sleep, including thyroid disorders and heart conditions. After you consult with your doctor, the cause or causes of your sleep loss should be clearer. But as Dr. Hugenberg warns, “It takes a lot of digging to find out what is happening with a person that might interfere with sleep.”

If your doctor cannot identify what is causing you to lose sleep, he or she may refer you to a sleep specialist. Sleep specialists are doctors who are experts in finding and treating causes of sleep loss, such as sleep apnea (see the Insomnia and Sleep Apnea for more about this condition).

Treating sleep problems

If your sleep problems are interfering with your everyday life, your doctor may prescribe a sleep medicine temporarily. Sleep medicines come in several varieties. The most common for short-term insomnia are the benzodiazepines, which include lorazepam (Ativan), temazepam (Restoril), and triazolam (Halcion), and the nonbenzodiazepines, which include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien). Tricyclic antidepressants, such as amitriptyline, are also sometimes used to help people sleep.

Dr. Hugenberg says that he tries to avoid sleep medicines when possible, and that he especially stays away from the benzodiazepines. People can build up a tolerance to their effects, requiring the dose to be increased for the drug to remain effective. People can also become physically dependent on sleep medicines, making it difficult to stop taking them. Even newer drugs such as Lunesta and Ambien, while effective in the short term, have potentially serious side effects when used in the long term. Dr. Lee notes that although prescription sleep aids are well studied in the general population, there is little research on how well they work for people with RA.

Although it is important to recognize that pain can affect sleep and helping to control pain may be beneficial, opioids such as hydrocodone (Vicodin), sometimes used to treat severe arthritis pain, should not be used to help start or maintain sleep. Opioids can make you drowsy, but they do not result in good quality sleep, and they have the same risks of tolerance and dependence as benzodiazepines and other sleep medicines. Over-the-counter medicines such as, diphenhydramine (Benadryl), have drowsiness as a side effect. They can usually be safely used for the occasional sleepless night, but they will not be effective for long-term use.

Your doctor is best equipped to help you find a drug that can effectively treat your sleep disturbances. It’s a serious problem for people with RA, but by practicing good sleep hygiene and working with your doctor, you can sleep better and feel better.

Kurt Ullman has been a medical writer for more than 25 years. He is based in Indiana.

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