Irregular sleep-wake rhythm disorder

Lynn Kataria MD (Dr. Kataria of the Washington DC Veterans Affairs Medical Center has no relevant financial relationships to disclose.)
Bradley V Vaughn MD (Dr. Vaughn of UNC Hospital Chapel Hill and University of North Carolina School of Medicine received research support from Axavant.)
Antonio Culebras MD, editor. (Dr. Culebras of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
Originally released November 22, 1993; last updated January 16, 2017; expires January 16, 2020

This article includes discussion of irregular sleep-wake rhythm disorder, circadian rhythm sleep disorder, irregular sleep-wake type, disorganized sleep-wake rhythm, irregular sleep-wake schedule, and irregular sleep-wake disorder. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Irregular sleep-wake rhythm disorder (ISWRD) is characterized by the absence of circadian synchronization with an individual's sleep-wake cycle. Irregular sleep-wake rhythm disorder is typically seen in children with neurodevelopmental disorders and patients with neurodegenerative disorders, such as Alzheimer dementia, or institutionalized elderly patients; however, it has also been observed in patients with traumatic brain injury. Increased exposure to circadian zeitgebers, such as bright light and structured activities, may minimize the disturbance. Pharmacologic therapy with melatonin was generally ineffective in randomized control trials despite encouraging results in small open-label studies. This review enables basic understanding of the circadian clock biology and its interactions with the sleep-wake cycle.

Key points

 

• Individuals with irregular sleep-wake rhythm disorder lack a clearly defined sleep period but demonstrate at least 3 irregular sleep bouts, which present as fragmented sleep at night and multiple naps during the day.

 

• Irregular sleep-wake rhythm disorder is commonly seen in elderly institutionalized patients and in those with neurodegenerative or neurodevelopmental disorders.

 

• Loss of neurons in the suprachiasmatic nuclei (SCN), age-related changes in melatonin/pineal secretions, and decreased exposure to zeitgebers may contribute to the presence of irregular sleep-wake rhythm disorder.

 

• Other medical, neurologic, or psychiatric disorders and medication side-effects may contribute to the sleep-wake cycle disruption.

 

Multimodal therapy that includes combination of timed light-melatonin treatment and nonpharmacological interventions like scheduled contacts, physical activity, and enriched environment may improve the sleep-wake pattern.

Historical note and terminology

The current formal name established in the 3rd edition of the International Classification of Sleep Disorders is irregular sleep-wake rhythm disorder (American Academy of Sleep Medicine 2014). However, irregular sleep-wake disorder was recognized as an issue involving the circadian pattern for decades prior to the classification (Kales 1969).

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