Sleep and multiple sclerosis

Antonio Culebras MD (Dr. Culebras of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
Originally released June 30, 1995; last updated October 4, 2016; expires October 4, 2019

This article includes discussion of sleep and multiple sclerosis, narcolepsy associated with multiple sclerosis, and restless legs syndrome associated with multiple sclerosis. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The author reviews sleep-related manifestations in patients with multiple sclerosis and points out the intimate relationship between this condition, fatigue, and excessive daytime sleepiness. Several cases of symptomatic narcolepsy have been described in patients with multiple sclerosis raising the question of demyelinating plaques involving hypothalamic centers. Other studies have indicated that disruption of nocturnal sleep as well as circadian rhythm disorders may underlie fatigue responsive to sleep management. Case studies have described REM sleep behavior disorder in association with acute multiple sclerosis. There is growing evidence that sleep-related respiratory disturbance is common in patients with multiple sclerosis and that in general the condition is underdiagnosed. Sleep disorders are significant contributors to fatigue in multiple sclerosis, and this notion highlights the desirability of conducting an in-depth evaluation of sleep-related manifestations, which are commonly multifactorial in patients with multiple sclerosis.

Key points

 

• Contributing comorbid factors to fatigue in multiple sclerosis are sleep disturbance, depression, medication, and deconditioning.

 

• Sleep disturbance in multiple sclerosis is commonly multifactorial and may include difficulty initiating or maintaining sleep, frequent awakenings due to leg spasms, habitual snoring, occasional sleep apnea, and nocturia.

 

• Cases of symptomatic narcolepsy have been described in multiple sclerosis raising the question of demyelinating plaques involving hypothalamic centers.

 

• Case studies have described REM sleep behavior disorder in association with acute multiple sclerosis and RLS in chronic multiple sclerosis, highlighting the desirability of conducting an in-depth evaluation of sleep-related manifestations, which includes polysomnography.

 

• Patients with multiple sclerosis have a predisposition to develop sleep apnea, and this association may be underdiagnosed.

Historical note and terminology

European reports published in the first half of the 20th century cite cases of multiple sclerosis associated with sleep attacks variously termed as narcolepsy, drowsiness, and deep sleep (Jacobsohn 1926; Guillain and Alajouanine 1928; Grigioresco 1932). In 1949 the association between multiple sclerosis and narcolepsy was mentioned in a review and case presentations of narcolepsy (Drake 1949). Subsequently, cases of narcolepsy-cataplexy and multiple sclerosis (Berg 1963) and of familial multiple sclerosis with narcolepsy-cataplexy were reported (Ekbom 1966). Based on the presence of DR2 histocompatibility antigen in 2 patients with narcolepsy and multiple sclerosis, Younger and colleagues suggested a common inheritance for both conditions (Younger et al 1991). Other authors have indicated that sleep disturbance is relatively common in multiple sclerosis, suggesting a multifactorial etiology that ranges from depression to lesion site (Leo et al 1991). A polysomnographic study of 25 patients with definite multiple sclerosis showed significantly reduced sleep efficiency and more awakenings during sleep (Ferini-Strambi et al 1994). Periodic leg movements were found in 36% of patients compared to 8% in controls. Central sleep apnea was found in 2 patients. MRI of the brain showed a greater load of lesions in cerebellum and brainstem in patients with periodic leg movements.

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