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  • Updated 07.19.2021
  • Expires For CME 07.19.2024

Drug-induced parasomnias, sleep apnea, and restless legs syndrome

Introduction

Overview

Several drugs are associated with sleep disorders. Drug-induced insomnia and daytime sleepiness as well as drowsiness are described in a companion MedLink Neurology article. This article starts with a classification of various drug-induced parasomnias and lists drugs associated with each. Some sleep disorders, such as sleepwalking, have been associated with the use of hypnotics for insomnia. Pathomechanism is described when known. This knowledge may help in the modification of drug therapy or alternative medications.

Key points

• Several sleep disorders have been reported as secondary to adverse effects of drugs.

• Various drug-induced parasomnias as well as disorders of breathing and movement may occur during sleep.

• Recognition of drug-induced sleep disorders and their distinction from primary sleep disorders and sleep disturbances that occur in neurologic diseases is important for the management of patients.

Historical note and terminology

Sleep disorders, particularly insomnia, and the use of sleep-inducing drugs have been well known throughout medical history. Similarly, sleep disturbances induced by ill-timed use of beverages such as alcohol and coffee, as well as by the desired or undesired effects of recreational drugs, are common knowledge. Drugs are also associated with parasomnias, a category of sleep behavioral disorders in which abnormal events, such as sleepwalking, occur during sleep. Drug-induced arousal disorders include confusional arousals, sleepwalking, and nightmares. Although the broad term sleep-induced sleep disorders is used frequently, this is usually based on observed association and the causality is not always proven.

In contrast to the therapy of sleep disorders, little attention was paid to the adverse effects of therapeutic drugs on sleep until the introduction of barbiturates as hypnotics. The long-term use of hypnotics as a cause of drug-induced insomnia was recognized in 1970s. Reports of sleep disturbances associated with other therapeutic drugs also started to appear in the 1970s and 1980s. Nightmares (sleep terrors) were observed with the initiation or withdrawal of tricyclic antidepressants and with the use of neuroleptic drugs (29). Although levodopa was introduced in the 1960s, reports of levodopa-induced sleep disruptions did not appear until several years later (27).

This article describes sleep disorders associated with the use of therapeutic drugs. The information is based on a review of the literature and on reports of adverse reactions received by pharmaceutical manufacturers. The causal relationship is not proven by the usual scientific criteria, but the list of drugs should be considered during investigation of patients with sleep disorders. The International Classification of Sleep Disorders ICSD-3 mentions "sleep disorders resulting from a drug or substance" under the following categories: (1) central sleep apnea; (2) sleep-related hypoventilation; (3) hypersomnia; (4) parasomnia; and (5) sleep-related movement disorders (01). “Drug or substance” can be a prescription medication, recreational drug, caffeine, alcohol, or food item or exposure to an environmental toxin. A practical classification of drug-induced sleep disorders, which reflects how they are reported in the literature, is shown in Table 1.

Table 1. Classification of Drug-Induced Breathing Disorders, Abnormal Movements, and Parasomnias

Drug-induced sleep-related breathing disorders

• snoring
• sleep apnea

Drug-induced sleep-related movement disorders

• excessive movements of limbs, restless legs syndrome
• myoclonus

Drug-induced parasomnias: sleep behavioral disorders

• rapid eye movement sleep behavior disorder
• vivid dreams and nightmares
• sleepwalking
• sleep-driving
• Sleep-using-a-stove
• sleep-eating
• sleep paralysis
• enuresis
• bruxism

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