Need help?

800-5315-2751 Hours: 8am-5pm PST M-Th;  8am-4pm PST Fri
Medicine Lakex


Medical comorbidity of sleep disordersDimitris Dikeos and Georgios Georgantopoulos 1st Department of Psychiatry, Athens University Purpose of review Medical School, Athens, Greece Recently published literature indicates that sleep disorders present with medical Correspondence to Dimitris G. Dikeos, MD, Associate comorbidities quite frequently. The coexistence of a sleep disorder with a medical Professor of Psychiatry, 1st Department of Psychiatry, disorder has a substantial impact for both the patient and the health system.
Eginition Hospital, Athens University Medical School,72 Vas Sofias Avenue, Athens 11528, Greece Tel: +30 2107289230; þ30 2107289324; Insomnia and hypersomnia are highly comorbid with medical conditions, such as fax: +302107289324; e-mail: chronic pain and diabetes, as well as with various cardiovascular, respiratory, Current Opinion in Psychiatry 2011, 24:346–354 gastrointestinal, urinary and neurological disorders. Restless legs syndrome andperiodic leg movement syndrome have been associated with iron deficiency, kidneydisease, diabetes, and neurological, autoimmune, cardiovascular and respiratorydisorders. Rapid eye movement behaviour disorder has been described as an earlymanifestation of serious central nervous system diseases; thus, close neurologicalmonitoring of patients referring with this complaint is indicated.
SummaryIdentification and management of any sleep disorder in medical patients is important foroptimizing the course and prognosis. Of equal importance is the search for undetectedmedical disorder in patients presenting with sleep disorders.
Keywordsexcessive daytime sleepiness, hypersomnia, insomnia, periodic leg movements insleep, rapid eye movement behaviour disorder, restless legs syndrome, sleep-relatedlimb movements Curr Opin Psychiatry 24:346–354ß 2011 Wolters Kluwer Health Lippincott Williams & Wilkins tive sleep apnoea), which falls in the field of pulmonary medicine, the remaining seven broad categories consist of Sleep disorders are increasingly met in clinical practice, insomnia; hypersomnia of central origin not due to a having major effects on well being, overall health and circadian rhythm sleep disorder; circadian rhythm sleep safety, and causing significant economic burden at both disorders; parasomnias; sleep-related movement dis- the individual and societal levels Furthermore, sleep orders; isolated symptoms, apparently normal variants, disorders are commonly associated with other major and unresolved issues; and other sleep disorders. All of medical problems such as chronic pain, cardiovascular these disorders and those in their subcategories might be disease, dementias, metabolic disorders, gastrointestinal comorbid with a multitude of medical conditions, the disorders, and so on. Thus, the approach to the patient presentation of which cannot be accomplished within the with sleep complaints should take into consideration limited space of one paper. The aim of the present review medical history, physical findings and a proper evaluation is to present and discuss the most important of these of the patient's physical health. Conversely, sleep dis- comorbidities; thus, the scope of the paper will focus on order symptoms should be sought during any evaluation medical comorbidities of insomnia, sleep-related limb of a patient with a medical condition, as co-existence of movements, that is, restless legs syndrome (RLS) and sleep problems is associated with worse quality of life, periodic leg movement syndrome (PLMS), rapid eye course and prognosis of the medical condition, and movement (REM) sleep behaviour disorder (RBD), increased use of health system facilities and hypersomnias/excessive daytime sleepiness (EDS).
In the International Classification of Sleep Disorders(ICSD-2), eight broad categories of sleep disorders are listed, along with several subcategories under each Insomnia is one of the most frequent conditions around category, as well as additional sleep-related disorders the world It is considered to be the subjective in its Appendices A and B Leaving out the category complaint of compromised sleep quantity and/or quality of sleep-related breathing disorders (including obstruc- and it can be assessed accordingly It can be either 0951-7367 ß 2011 Wolters Kluwer Health Lippincott Williams & Wilkins Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity of sleep disorders Dikeos and Georgantopoulos primary or comorbid with mental or somatic disorders in the case of somatic comorbidities, the medical con-  The comorbidity of sleep disorders and various dition may be the result of, a contributing factor to, or a medical conditions is quite frequent and its pre- separate entity from insomnia The prevalence and sence has a substantial negative impact on patient consequences of insomnia have significant implications overall status and the health system resources.
for both the patient and public health. Various studies  Chronic pain and diabetes, as well as various car- have shown that people with chronic insomnia use sig- diovascular, respiratory, gastrointestinal, urinary nificantly more medical services than those without and neurological disorders, coexist frequently with insomnia and have significantly higher risks for falls and automobile and industrial accidents, make signifi-  Iron deficiency, kidney disease and neuropathic cantly more errors at work, exhibit less productivity and conditions mainly due to diabetes, neurological or miss twice as many workdays as those without insomnia autoimmune disorders are the main factors behind restless legs syndrome and periodic leg movementsyndrome.
A multitude of medical conditions are associated with  Rapid eye movement behaviour disorder may be a insomnia: chronic pain associated or not with skeletomus- side-effect of antidepressant treatment and it is also cular disorders and/or cancer; diabetes and cardiovascular frequently an early manifestation of neurodegen- disorders; as well as various respiratory, gastrointestinal, erative disorders such as Parkinson's disease, urinary, neurological and menopausal disorders. It also dementia with Lewy bodies, Alzheimer's disease seems that presence of any chronic disease and number and multiple system atrophy, its presence preced- of hospitalizations in the previous year are significantly ing by many years the appearance of their respect- associated with insomnia .
ive characteristic symptoms.
 Hypersomnia may be comorbid with the same Insomnia in chronic pain and associated conditions medical conditions as insomnia, but its presence Among insomniac individuals, chronic pain is much more is also associated with higher general mortality.
frequent than among noninsomniac individuals (50 vs.
18%) 25–40% of patients with various chronic painconditions complained of insomnia vs. 13% of the general 10% of those without insomnia, whereas 44% of hyper- population whereas insomnia was found to be 4.3 tensive patients reported insomnia vs. 19% of individuals times more frequent among chronic pain patients in the without hypertension In the large cross-sectional Ibadan study of ageing on 2152 participants ; chronic Norwegian study, however, the prevalence of insomnia pain was mainly due to arthritis (predominantly rheuma- among hypertensive patients was greater than that of the toid), spinal pain and fibromyalgia In a large general population, but the difference was by far less cross-sectional study on 47 700 participants in Norway pronounced (15 vs. 13%, respectively) Myocardial assessing comorbidity of insomnia, mental conditions and infarction and congestive heart failure patients were more chronic pain were the only correlates of insomnia that likely than individuals with mild hypertension to suffer remained strongly significant after adjustment for other from mild insomnia [respective odds ratios (ORs) were confounders The prevalence of insomnia among 1.9 and 1.6]; for congestive heart failure, the OR for cancer patients is about double that of the general popu- severe insomnia was 2.5 Particularly for acute myo- lation, this association considered to be due to cancer cardial infarction, sleep disturbance is a frequent com- itself, various symptoms of pain and discomfort or various plaint in the initial period, but it seems to subside over a treatment complications; it has been suggested that research on the circadian timing of treatments may pro-vide results that could help reduce sleep disorders in Insomnia in conditions associated with other systems cancer patients undergoing therapy A great proportion (60%) of patients with breathingproblems complain of chronic insomnia (vs. 21% in a Insomnia in diabetes and cardiovascular disorders control sample), whereas 25% of individuals with insom- Diabetes mellitus is another condition that is associated nia report breathing problems (vs. 6% in individuals with insomnia, although this association is relatively weak without insomnia) More than half of all patients In a recent study, however, it was found that short with chronic obstructive pulmonary disease (COPD) sleep duration is a clinically significant risk factor for complain of difficulties in initiating or maintaining sleep type-2 diabetes . Impaired glucose tolerance is also and 25% present with excessive daytime sleepiness , associated with short sleep in individuals with or without and asthmatic patients were found to have an OR for diabetes . In one cross-sectional retrospective study insomnia of 1.4 compared with the general population based on a mailed questionnaire, presence of heart dis- Similarly, individuals with insomnia report a higher pro- ease was reported by 22% of individuals with insomnia vs.
portion of gastrointestinal problems vs. controls (34 vs.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity 9%) and 55% of patients with disorders of the gastroin- Health Professional follow-up study on 23 119 men after testinal tract (especially gastroesophageal reflux excluding those suffering from diabetes and arthritis.
complain of insomnia (vs. 20% of the control sample) The prevalence of Parkinson's disease was found to be . Sleep problems are also particularly common among about double among sufferers with RLS compared with end-stage renal disease (ESRD) patients undergoing nonsufferers Inversely, RLS was found to have 3% dialysis, among whom the prevalence of insomnia is prevalence among 200 Parkinson's disease patients, vs.
between about 60 and 85% female sex, 0.5% among normal controls In a controlled study, afternoon haemodialysis, other sleep disorders (RLS, the prevalence of RLS among 76 patients with amyo- obstructive sleep apnoea) and depression seem to be trophic lateral sclerosis (ALS) was found to be 25% independent predictors of insomnia among ESRD compared with 8% among 100 controls patients Self-reported insomnia and reducedsleep quality are, in addition, very frequent among Restless legs syndrome in cardiovascular disease and patients with nocturia of any cause . Various neuro- logic diseases are associated with insomnia ; 50% of In a population-based cross-sectional study examining Parkinson's disease patients have insomnia, which seems the prevalence of cardiovascular risk factors in partici- to wax and wane over time and 30–70% of trau- pants with and without RLS (N ¼ 1537), blood tests of matic brain injury (TBI) patients report insomnia symp- RLS participants showed significantly higher fasting toms Finally, in women, insomnia is associated with blood glucose level, higher prevalence of hypercholes- menopause and with the severity of the vasomotor symp- terolaemia, reduced renal function and increased preva- toms that accompany it lence of low haematocrit. Participants with RLS had ahigher BMI, larger hip circumference and were less fit. Itwas found that female sex and the high-density lipopro- Sleep-related limb movements tein (HDL)/low-density lipoprotein (LDL) cholesterol The most important sleep-related limb movements are ratio were significantly associated with RLS RLS and PLMS.
An association of RLS with obesity has been found in a General remarks on restless legs syndrome recent study on a sample of about 90 000 individuals RLS is a disorder characterized by an urge to move the assessed by mailed interviews. It was found that 6.4% extremities, frequently associated with paraesthesia or of women and 4.1% of men had RLS and the prevalence dysaesthesia; temporary relief of the urge with move- increased progressively with increasing BMI and waist ment; and onset or worsening of the symptoms at rest, circumference. This association was independent of age, inactivity or at night . RLS has a prevalence of about smoking status, anxiety score, use of antidepressants and 3–15% in the general population and it has a presence of a number of chronic diseases. A similar negative impact on physical functioning, bodily pain, association was found between obesity in early adulthood general health and vitality .
(age 18–21) and RLS prevalence in mid-life or later (age40 years and higher), suggesting that obesity is a risk Iron deficiency/kidney disease and restless legs factor for the development of RLS syndromeA well established association is that of RLS with iron RLS is strongly related to coronary artery disease (OR deficiency; it has been observed in cases of malignancies, 2.2) and any cardiovascular disease (including coronary various iron-deficiency anaemias, regular blood donors, artery disease, heart failure or stroke) findings on pregnancy and many other conditions characterized by hypertension are still controversial although low iron stores In many cases, RLS appears there seems to exist a possible relationship between even with subclinical iron deficiency (as revealed by mean blood pressure and RLS or PLMS symptoms reduced ferritin levels) while levels of haemoglobin It has been argued that the sympathetic hyperac- tivity associated with RLS/PLMS leads to heart diseaseand stroke via hypertension and/or via atherosclerotic An association of RLS with kidney disease/uraemia has plaque formation and rupture; alternatively, comorbid- been found, which is usually inverted after kidney trans- ities associated with RLS/PLMS, such as renal failure, plantation; iron deficiency might be a contributing factor diabetes, iron deficiency and insomnia, may predispose to to this association, but it does not seem to be the only one heart disease and stroke In a controlled study on 124 diabetes mellitus patients vs.
Restless legs syndrome in neurological disorders 87 controls with other endocrine disorders, the preva- The comorbidity of RLS with Parkinson's disease was lence of RLS was higher among the diabetes mellitus examined in a large cohort of men participating in the group by a factor of about 3 (17.7 vs. 5.5) In another Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity of sleep disorders Dikeos and Georgantopoulos study on 121 type 2 diabetes patients, for whom it was not . The prevalence of PLMS in the general population mentioned whether they suffered from polyneuropathy is estimated to be 4–11% or not, it was found that 45% of them were suffering fromsecondary RLS This association was found also in Periodic leg movement syndrome in other sleep prediabetic patients with normal fasting glucose and abnormal glucose tolerance test other studies PLMS is a frequent finding in various sleep disorders have suggested that RLS in diabetes mellitus is a result such as obstructive sleep apnoea syndrome (OSAS), of diabetic polyneuropathy and that it may narcolepsy and RBD; the prevalence of PLMS in OSAS respond better to neuropathic pain medications rather is 24%, decreasing with continuous positive airway pres- than dopaminergic drugs Polyneuropathy, however, sure (C-PAP) treatment, whereas up to 70% of RBD does not seem to fully explain the presence of RLS in patients have a PLMI of 10 or higher diabetes mellitus patients Presence of RLSamong diabetic patients has a significant impact on Periodic leg movement syndrome in medical conditions patients' quality of sleep PLMs are also a frequent finding in RLS and bothconditions share common somatic comorbidities. Similar Restless legs syndrome in other disorders to RLS, PLMS is found to be more frequent among RLS has also been found to be associated with a variety individuals with uraemia (20–45%) and/or ESRD, of rheumatological and immunological conditions, show- Parkinson's disease (in which the PLMI has been ing a prevalence of 20–30% (two to six times that reported up to 68), iron deficiency, severe congestive of the general population) among patients with rheuma- heart failure (52 vs. 11% in controls), juvenile fibromyal- toid arthritis, various other arthropathies, fibromyalgia, gia (38%), scleroderma (48%) and hypertension (mean Sjogren's syndrome and scleroderma Neuropathy prevalence 18%, associated with severity); PLMS' fre- due to rheumatoid arthritis is being suggested as an quency is furthermore elevated in syringomyelia (61%), explanation for the increased prevalence of RLS in this spinal cord injury (mean PLMI 35) and Gille de la condition based on neurophysiological findings but Tourette syndrome (mean PLMI 19, PLMS found in also subclinical iron deficiency due to chronic use of five out of seven patients examined) Finally nonsteroidal anti-inflammatory agents, as well as dopa- PLMs (and, to some extent, RLS symptoms) increase mine transmission abnormalities due to chronic pain, has with various psychoactive drugs, especially antidepress- ants [mainly selective serotonin reuptake inhibitors(SSRIs) and venlafaxine] and lithium Finally, a strong association between respiratory symp-toms, asthma, COPD and RLS was described in a studyon a well defined population (N ¼ 1937) from two Rapid eye movement behaviour disorder countries The relationship between RLS and RBD is a condition characterized by loss of muscular COPD has also been described before but the atonia and the appearance of motor behaviours (usually pathogenesis is unknown.
violent) during REM sleep (i.e. when dreaming) Theabnormal motor and vocal behaviours during REM sleep General remarks on periodic leg movement syndrome have different degrees of severity across different nights PLMS is a condition characterized by periodic episodes and through a single night, ranging from mild limb of repetitive and highly stereotyped limb movements jerking to jumping out of bed. Typical behaviours that occur during sleep and in wakefulness (particularly include punching, kicking, beating, biting, sitting on during rest). The movements usually occur in the legs the bed, jumping out of bed, whispering, talking, shout- and consist of extension of the big toe in combination ing, swearing, crying, laughing and singing. Patients and with partial flexion of the ankle, knee and sometimes hip.
their bed partners may suffer lacerations, contusions and They may also occur in the upper limbs and can be fractures. Nonviolent behaviours (e.g. gesturing, elabo- unilateral or bilateral rated pseudo-purposeful behaviours, whistling) mayoccasionally coexist with the typical violent behaviour The criteria for the syndrome are polysomnographic and Recalled dreams commonly have a negative first require identification of a PLM . The mean emotional content and include being attacked, robbed number of PLMs per hour of total sleep time is the or chased by people, frightened or attacked by animals PLM index (PLMI). A PLMI of more than 5 is con- and falling off a cliff sidered pathological, although it has also been suggestedthat the cut-off should be put at 10 PLMS is RBD usually develops after the age of 50 and its preva- considered mild for a PLMI up to 25, moderate for lence is estimated to be less than 1% of the general 25–50 and severe for an index 50 or higher or if there population For the diagnosis, the clinical descrip- are more than 25 PLMs per hour associated with arousal tion is needed, corroborated usually by the bed partner; Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity all-night polysomnography with infrared video monitor- and regional blood flow The conclusions of these ing is performed, mainly for differential diagnosis studies as well as of older similar ones (reviewed in ) RBD is considered to be either idiopathic or secondary are still inconclusive, and, as there are not many publi- to neurological conditions such as Parkinson's disease, cations that have followed those patients with RBD who dementia with Lewy bodies (DLB), multiple system did not develop a neurodegenerative disorder, the matter atrophy (MSA), narcolepsy, and so on is still unresolved Rapid eye movement sleep behaviour disorder inneurological disorders Hypersomnias and Excessive Daytime Compared with the population prevalence of 1%, RBD is found in 15–60% of Parkinson's disease patients (parti- All hypersomnias are characterized by the presence of cularly those having the akinetic/rigid manifestation of EDS, one of the most commonly reported symptoms the disease in 50–83% of patients with DLB and in concerning sleep. The diminished alertness, attention 90–100% of patients with MSA . As all three of the and concentration that accompany EDS increase signifi- above are synucleinopathies, it is considered that alpha cantly the risk of occupational and motor vehicle acci- synuclein pathology is a causative factor of RBD, at least dents Validated questionnaires as the Epworth in the majority of cases. On the other hand, RBD preva- Sleepiness Scale (ESS) and the Stanford Sleepiness Scale lence is also found to be high in narcolepsy and elevated (SSS) are used in order to assess EDS, whereas laboratory (though to a lesser degree) in other neurological disorders evaluation of sleep by methods such as all-night Poly- such as spinocerebellar ataxias, Huntington's disease, somnography (PSG), Multiple Sleep Latency Test ALS, Guillain-Barre´, multiple sclerosis, epilepsy, autism, (MSLT) or Maintenance of Wakefulness Test (MWT) Tourette syndrome, Alzheimer's disease, inflammatory is used to objectively evaluate reduced alertness and encephalitis, stroke, TBI, brain stem tumours and so on, excessive sleepiness, and to assist in the identification which are unrelated to synuclein disturbance of their cause(s) RBD can also be triggered by the administration ofcertain drugs, especially antidepressants belonging to EDS can be a result of a number of intrinsic or extrinsic the serotonin-uptake inhibitors conditions It can be due to one of the primaryhypersomnias [narcolepsy, idiopathic hypersomnia and Rapid eye movement sleep behaviour disorder as a recurrent hypersomnia (Kleine–Levin syndrome)]; insuf- precursor of neurodegenerative disorders ficient sleep time due to lifestyle and sleep habits, shift Clinically, the most important aspect is that the appear- work, circadian rhythm disorders or other conditions ance of RBD, in the absence of an apparent neurological characterized by reduced night-sleep (such as fragmen- condition or administration of drugs that may account for ted sleep, sleep apnoea, RLS or PLMS); and secondary to its presence, seems to be a preclinical marker for the psychiatric disorders, medications (benzodiazepines, development of a neurodegenerative disease, usually antidepressants, antipsychotics, antihistamines, opioids, Parkinson's disease or DLB In a recent follow- beta-blockers, etc.) and certain medical conditions up study of 93 patients who had been diagnosed with idiopathic RBD and were examined for a period up to12 years (mean 5.2 years), it was estimated that the risk for the development of a neurodegenerative disease Narcolepsy is the main idiopathic condition causing (Parkinson's disease, DLB, Alzheimer's disease and EDS. It can be primary (associated with the HLA MSA) was 17.7% in 5 years, 40.6% in 10 years and DQB10602 allele) or secondary resulting from neuro- 52.4% in 12 years Cumulative incidence of neuro- logical disorders and other conditions affecting the cen- degenerative disorders in various longitudinal studies tral nervous system (CNS), such as brain tumours (especi- following patients with RBD was 16–65% for Parkinson's ally diencephalic and midbrain ones), stroke, multiple disease, 8–15% for DLB, 4% for Alzheimer's disease and sclerosis, cerebral trauma or encephalitis Furthermore, the risk of narcolepsy in the presence ofa history of streptococcal throat infection before the age In recent years, several studies have been conducted in of 21 years was estimated to be 5.4 times higher, the attempt to identify indices of the probability of suggesting that rheumatic fever might induce narcolepsy, transition of RBD to a neurodegenerative disorder; auto- probably in a similar manner as it does Syndenham's nomic dysfunction due to adrenergic neuron dysfunction chorea The risk for narcolepsy was also found to is assessed by iodine-131-meta-iodobenzylguanidine be increased (OR ¼ 5.1) for individuals who had lived (I-MIBG) cardiac scintigraphy or R-R variability with two or more household smokers (a factor known to , and midbrain structures are assessed by sonography aggravate strep-throat infections) before age 21; the find- MRI diffusion tensor imaging (DTI) ing was more pronounced among genetically susceptible Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity of sleep disorders Dikeos and Georgantopoulos individuals bearing the HLA narcolepsy-associated hap- from hypersomnolence; concomitant presence of dia- betes, cardiovascular disease or depression is associatedwith persistence of daytime sleepiness even after the Hypersomnia in other neurological disorders successful treatment of sleep apnoeas by C-PAP In EDS seems to be quite prominent among Parkinson's a study evaluating the sleep/wake cycle of individuals disease patients, with a frequency ranging from 8% to with asthma, it was concluded that asthma, as a chronic more than 50% in various studies . Consider- inflammatory disease, can affect daytime wakefulness ing the association of EDS with Parkinson's disease, it has furthermore, data on 470 asthmatic patients indi- been suggested that the reason behind the EDS might be cated that women were much more likely to exhibit EDS the neurodegenerative mechanism itself (including dopa- than men EDS in renal dialysis patients has been mine pathways and other neurochemical components of shown to be correlated with higher blood urea nitrogen the ascending reticular activation system) and/or the (BUN), high frequency of PLM and sleep apnoea various drugs used . Indeed, a multicentre control Other medical disorders associated with EDS study on Japanese patients provided data suggesting that are rheumatological, respiratory, cardiovascular, urinary sleepiness in Parkinson's disease is dependent on the (such as lower urinary tract symptoms or any other disease itself and on the dopaminergic treatment rather disorders associated with nocturia), malignancy and gen- than nocturnal disturbances EDS, in addition, was found to be a predictor for the development of Parkin-son's disease in a large cohort of more than 3000 older In a study examining the relationship of EDS with men followed for 7 years In another study among common medical disorders in an unselected com- munity-based sample, the authors assessed responses examined in the sleep laboratory by MSLT, 57% had of 2612 individuals (aged 18–65) after excluding shift an ESS score greater than 10 and 37% had a mean sleep workers and those with suspected sleep disordered latency of less than 5 min during the MSLT; none of breathing or narcolepsy. Participants across a range of these patients exhibited a sleep onset REM episode, medical disorders were evaluated using the ESS and indicating that their hypersomnia was not due to comor- patient reports of nocturnal sleep. Individuals with ulcers [OR ¼ 2.21, 95% confidence interval (CI) ¼ 1.35–3.61]and migraine (OR ¼ 1.36, 95% CI ¼ 1.08–1.72) were In addition to Parkinson's disease, neurological diseases shown to have independently and clinically significantly that are frequently found among patients with EDS higher levels of EDS relative to other common medical (dementias, Huntington's disease, progressive supranuc-lear palsy, multiple sclerosis, spinocerebellar ataxia), Relationship of hypersomnia with general morbidity and stroke, epilepsy, structural brain lesions (TBI or brain tumours, especially diencephalic, midbrain, hypothala- Finally, a relationship seems to exist between EDS and mic, pituitary), infections of the CNS (especially African general morbidity and mortality. In the National Health trypanosomiasis and encephalitis lethargica) and neuro- Interview Survey 2005, a cross-sectional study of 30 397 muscular diseases (including myasthenia gravis, poly- participants, it was demonstrated that there is a positive neuropathies, poliomyelitis, etc.) association between daily sleep being longer than 9 h andcardiovascular disease, compared with sleep duration of Hypersomnia in other medical disorders 7 h per day (OR ¼ 1.57, 95% CI ¼ 1.31–1.89) Regarding the comorbidity of EDS with nonneurological Similarly, in a cohort study on 98 634 participants in medical disorders, in a study of consecutively recruited Japan (the Japan Collaborative Cohort study), it was adult type 2 diabetic patients, the proportion of diabetic concluded that long sleep duration (>10 h) was associated patients with elevated ESSs (> or ¼12) was higher than with 1.5 to two-fold increase of mortality from stroke, that of the controls (15.5 vs. 2.1%, P ¼ 0.02) A total cardiovascular disease and other causes of death secondary analysis on individuals drawn from the except cancer, suggesting that, although mechanisms are National Sleep Foundation's Sleep and Aging poll indi- not clear, long sleep duration may be an early symptom of cated that sleep disturbances affect not only sleep quality various disorders with high mortality rates but also daytime function in older adults with diabetesin another study, although the association betweenglycated haemoglobin (HbA1c) values and ESS score has been found to be significant, the causality of the effect The sleep disorders whose comorbidities are reviewed in was considered to be uncertain, as hypersomnolence in the present paper are insomnia, the sleep-related limb diabetic patients may be mediated by RLS, nocturia or movements RLS and PLMS, RBD and hypersomnia.
snoring/OSAS . OSAS patients suffer frequently Medical comorbidities are quite frequent among all these Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity conditions. Sleep disorders may be either the result of the American Academy of Sleep Medicine. International classification of sleepdisorders. 2nd ed. Diagnostic and coding manual. Westchester: American discomfort caused by a medical condition, a symptom Academy of Sleep Medicine; 2005.
caused by mechanisms related to the medical condition Soldatos CR, Allaert FA, Ohta T, Dikeos DG. How do individuals sleep (such as the dopaminergic dysregulation of neurodegen- around the world? Results from a single-day survey in ten countries. SleepMed 2005; 6:5–13.
erative disorders, which may be the causative factor of Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin RBD, or the production of cytokines in rheumatologic Sleep Med 2007; 3 (5 Suppl):S7 –S10.
disorders, which may cause a variety of sleep problems), Sivertsen B, Krokstad S, Øverland S, Mykletun A. The epidemiology of a contributing factor to it, or even a separate nosological insomnia: associations with physical and mental health. The HUNT-2 study.
J Psychosom Res 2009; 67:109–116.
Soldatos CR, Dikeos DG, Paparrigopoulos T. Athens Insomnia Scale:validation of an instrument based on ICD-10 criteria. J Psychosom Res Of all these sleep disorders, insomnia and hypersomnia 2000; 48:555–560.
have the highest number of comorbid medical conditions, Roth T. Comorbid insomnia: current directions and future challenges. Am JManag Care 2009; 15 (Suppl):S6 –S13.
followed by RLS/PLMS and RBD. The impact of the Novak M, Mucsi I, Shapiro CM, et al. Increased utilization of health services by coexistence of sleep problems with a medical disorder is insomniacs: an epidemiological perspective. J Psychosom Res 2004; substantial: presence of any sleep disorder has an impact on the quality of life of the patients, the use of health system Leger D, Guilleminault C, Bader G, et al. Medical and socio-professionalimpact of insomnia. Sleep 2002; 25:625–629.
resources by them, their overall health outcome, the loss of Sagberg F. Driver health and crash involvement: a case-control study. Accid productivity and the probability of their involvement in Anal Prev 2006; 38:28–34.
domestic, industrial or traffic accidents. In addition, recog- Taylor DJ, Mallory LJ, Lichstein KL, et al. Comorbidity of chronic insomnia with nizing certain sleep disorders such as RLS/PLMS not only medical problems. Sleep 2007; 30:213–218.
reduces suffering and the above-mentioned potential con- Parish JM. Sleep-related problems in common medical conditions. Chest2009; 135:563–572.
sequences, but it may also reveal conditions (such as Paparrigopoulos T, Tzavara C, Theleritis C, et al. Insomnia and its correlates normal haemoglobin iron deficiency) that might otherwise in a representative sample of the Greek population. BMC Public Health2010; 10:531.
go undetected. Although RBD presents with fewer comor- Gureje O, Kola L, Ademola A, Olley BO. Profile, comorbidity and impact of bid medical conditions compared with the rest of the sleep insomnia in the Ibadan study of ageing. Int J Geriatr Psychiatry 2009; disorders, it seems to be a disorder that in many cases is the earliest manifestation of a serious neurological disease, and Ancoli-Israel S. The impact and prevalence of chronic insomnia and othersleep disturbances associated with chronic illness. Am J Manag Care 2006; the detection of its presence must alert the attending 12 (8 suppl):S221 –S229.
physician to closely monitor the patient for a number of Lee K, Cho M, Miaskowski C, Dodd M. Impaired sleep and rhythms in years. In the meantime, therapeutic interventions should persons with cancer. Sleep Med Rev 2004; 8:199–212.
target the symptoms of RBD and preventive measures Liu L, Ancoli-Israel S. Sleep disturbances in cancer. Psychiatr Ann 2008;38:627–634.
taken for the protection of the patient and his/her partner Skomro RP, Ludwig S, Salamon E, Kryger MH. Sleep complaints and restless from possible accidents during sleep. Finally, hypersom- legs syndrome in adult type 2 diabetics. Sleep Med 2001; 2:417–422.
nia, apart from the high risk of accidents that it is associated Vgontzas AN, Liao D, Pejovic S, et al. Insomnia with objective short sleep with, is also a condition that has been associated with duration is associated with type 2 diabetes: a population-based study.
Diabetes Care 2009; 32:1980–1985.
higher general morbidity and mortality, and its presence Gottlieb DJ, Punjabi NM, Newman AB, et al. Association of sleep time with should be taken as a sign to follow patients more carefully diabetes mellitus and impaired glucose tolerance. Arch Intern Med 2005; and treat them more intensively.
165:863 –867.
Katz DA, McHorney CA. Clinical correlates of insomnia in patients withchronic illness. Arch Intern Med 1998; 158:1099–1107.
In conclusion, recognition and management of sleep Schiza SE, Simantirakis E, Bouloukaki I, et al. Sleep patterns in patients with disorders in any medical patient is quite important; acute coronary syndromes. Sleep Med 2010; 11:149–153.
furthermore, the search for undetected medical con- George CFP, Bayliff CD. Management of insomnia in patients with chronic ditions in patients presenting with sleep disorders might obstructive pulmonary disease. Drugs 2003; 63:379–387.
also reveal an underlying medical disorder that has not Shaheen NJ, Madanick RD, Alattar M, et al. Gastroesophageal reflux diseaseas an etiology of sleep disturbance in subjects with insomnia and minimal yet been manifested.
reflux symptoms: a pilot study of prevalence and response to therapy. Dig DisSci 2007; 53:1493–1499.
Kosmadakis GC, Medcalf JF. Sleep disorders in dialysis patients. Int J Artif References and recommended reading Organs 2008; 31:919–927.
Papers of particular interest, published within the annual period of review, have Paparrigopoulos T, Theleritis C, Tzavara C, Papadaki A. Sleep disturbance in been highlighted as: haemodialysis patients is closely related to depression. Gen Hosp Psychiatry of special interest 2009; 31:175–177.
of outstanding interest Al-Jahdali HH, Khogeer HA, Al-Qadhi WA, et al. Insomnia in chronic renal Additional references related to this topic can also be found in the Current patients on dialysis in Saudi Arabia. J Circadian Rhythms 2010; 8:7.
World Literature section in this issue (pp. 363–364).
Cengic´ B, Resic´ H, Spasovski G, et al. Quality of sleep in patients undergoing Skaer TL, Sclar DA. Economic implications of sleep disorders. Pharmaco- hemodialysis. Int Urol Nephrol 2010. [Epub ahead of print] economics 2010; 28:1015–1023.
Two hundred haemodialysis patients assessed with questionnaires on their sleepproblems.
Foley KA, Sarsour K, Kalsekar A, Walsh JK. Subtypes of sleep disturbance:associations among symptoms, comorbidities, treatment, and medical costs.
Bliwise DL, Foley DJ, Vitiello MV, et al. Nocturia and disturbed sleep in the Behav Sleep Med 2010; 8:90 –104.
elderly. Sleep Med 2009; 10:540–548.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity of sleep disorders Dikeos and Georgantopoulos Zoccolella S, Savarese M, Lamberti P, et al. Sleep disorders and the natural Gemignani F, Brindani F, Vitetta F, et al. Restless legs syndrome in diabetic history of Parkinson's disease: the contribution of epidemiological studies.
neuropathy: a frequent manifestation of small fiber neuropathy. J Peripher Sleep Med Rev 2011; 15:41–50.
Nerv Syst 2007; 12:50–53.
A very well written recent comprehensive critical review of epidemiological studies Hening WA, Caivano CK. Restless legs syndrome: a common disorder in (based mainly on those with a longitudinal design) of sleep disorders in Parkinson's patients with rheumatologic conditions. Semin Arthritis Rheum 2008; Ouellet MC, Savard J, Morin CM. Insomnia following traumatic brain injury: a Taylor-Gjevre RM, Gjevre JA, Skomro R, Nair B. Restless legs syndrome in a review. Neurorehabil Neural Repair 2004; 18:187–198.
rheumatoid arthritis patient cohort. J Clin Rheumatol 2009; 15:12–15.
Ohayon MM. Severe hot flashes are associated with chronic insomnia. Arch Salih AM, Gray RE, Mills KR, Webley M. A clinical, serological and neuro- Intern Med 2006; 166:1262 –1268.
physiological study of restless legs syndrome in rheumatoid arthritis. Br J Zervas IM, Lambrinoudaki I, Spyropoulou AC, et al. Additive effect of Rheumatol 1994; 33:60–63.
depressed mood and vasomotor symptoms on postmenopausal insomnia.
Kaplan Y, Inonu H, Yilmaz A, Ocal S. Restless legs syndrome in patients with Menopause 2009; 16:837–842.
chronic obstructive pulmonary disease. Can J Neurol Sci 2008; 35:352– Allen RP, Picchietti D, Hening WA, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless Lo Coco D, Mattaliano A, Lo Coco A, Randisi B. Increased frequency of legs syndrome diagnosis and epidemiology workshop at the Institutes of restless legs syndrome in chronic obstructive pulmonary disease patients.
Health. Sleep Med 2003; 4:101–119.
Sleep Med 2009; 10:572–576.
Allen RP, Walters AS, Montplaisir J, et al. Restless legs syndrome prevalence Pollmacher T, Schulz H. Periodic leg movements (PLM): their relationship to and impact: REST general population study. Arch Intern Med 2005; sleep stages. Sleep 1993; 16:572–577.
American Sleep Disorders Association. Periodic limb movement disorder Ulfberg J, Bjorvatn B, Leissner L, et al., Nordic RLS Study Group. Comor- and restless legs syndrome. The International Classification of Sleep Dis- bidity in restless legs syndrome among a sample of Swedish adults. Sleep orders Diagnostic, Coding Manual, Revised. Lawrence: Allen Press; 1997.
Med 2007; 8:768–772.
pp. 65–68.
Ekbom K, Ulfberg J. Restless legs syndrome. J Intern Med 2009; 266:419 – Hornyak M, Feige B, Riemann D, Voderholzer U. Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance Gao X, Schwarzschild MA, Wang H, Ascherio A. Obesity and restless legs and treatment. Sleep Med Rev 2006; 10:169–177.
syndrome in men and women. Neurology 2009; 72:1255–1261.
Ohayon MM, Caulet M, Priest RG. Violent behavior during sleep. J Clin Benediktsdottir B, Janson C, Lindberg E, et al. Prevalence of restless legs Psychiatry 1997; 20:340–348.
syndrome among adults in Iceland and Sweden: lung function, comorbidity, Nielsen TA. Disturbed dreaming in medical conditions. In: Kryger MH, Roth T, ferritin, biomarkers and quality of life. Sleep Med 2010; 11:1043–1048.
Dement WC, editors. Principles and practice of sleep medicine. 4th ed.
Epidemiological study on representative population samples from Iceland and Philadelphia: Elsevier Saunders; 2005. pp. 936–945.
Sweden, including about 2000 individuals who were clinically interviewed andsubmitted to laboratory blood tests for inflammation markers and ferritin.
Paparrigopoulos TJ. REM sleep behaviour disorder: clinical profiles andpathophysiology. Int Rev Psychiatry 2005; 17:293–300.
Kushida C, Martin M, Nikam P, et al. Burden of restless legs syndrome onhealth-related quality of life. Qual Life Res 2007; 16:617–624.
Iranzo A, Santamaria J, Tolosa E. The clinical and pathophysiological rele-vance of REM sleep behavior disorder in neurodegenerative diseases. Sleep Rijsman RM, de Weerd AW. Secondary periodic limb movement disorder Med Rev 2009; 13:385–401.
and restless legs syndrome. Sleep Med Rev 1999; 3:147–158.
Gagnon JF, Postuma RB, Mazza S, et al. Rapid-eye-movement sleep beha- Gao X, Schwarzschild MA, O'Reilly EJ, et al. Restless legs syndrome and viour disorder and neurodegenerative diseases. Lancet Neurol 2006; Parkinson's disease in men. Mov Disord 2010; 25:2654 –2657.
Study assessing the relationship of RLS with Parkinson's disease on 23 119participants of the Health Professional Follow-up Study; it was based on mailed Bliwise DL, Trotti LM, Greer SA, et al. Phasic muscle activity in sleep and questionnaires and diagnosis of Parkinson's disease was confirmed by review of clinical features of Parkinson disease. Ann Neurol 2010; 68:353–359.
medical records.
Zambelis T, Paparrigopoulos T, Soldatos CR. REM sleep behaviour disorder Loo HV, Tan EK. Case-control study of restless legs syndrome and quality of associated with a neurinoma of the left pontocerebellar angle. J Neurol sleep in Parkinson's disease. J Neurol Sci 2008; 266:145 –149.
Neurosurg Psychiatry 2002; 72:821–822.
Lo Coco D, Piccoli F, La Bella V. Restless legs syndrome in patients with Bodkin CL, Schenck CH. Rapid eye movement sleep behavior disorder in amyotrophic lateral sclerosis. Mov Disord 2010; 25:2658–2661.
women: relevance to general and specialty medical practice. J WomensHealth (Larchmt) 2009; 18:1955 –1963.
Schlesinger I, Erikh I, Avizohar O, et al. Cardiovascular risk factors in restlesslegs syndrome. Mov Disord 2009; 24:1587–1592.
Mahowald MW, Schenck CH. REM sleep parasomnias. In: Kryger MH, RothT, Dement WC, editors. Principles and practice of sleep medicine. 4th ed.
Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb Philadelphia: Elsevier Saunders; 2005. pp. 897–916.
movement disorder in the general population. J Psychosom Res 2002;53:547–554.
Postuma RB, Gagnon JF, Vendette M, et al. Quantifying the risk of neuro-degenerative disease in idiopathic REM sleep behavior disorder. Neurology Winkelman JW, Finn L, Young T. Prevalence and correlates of restless legs 2009; 72:1296 –1300.
syndrome symptoms in the Wisconsin Sleep Cohort. Sleep Med 2006;7:545–552.
Miyamoto M, Suzuki K, Nishibayashi M, et al. 123I-MIBG cardiac scintigraphyprovides clues to the underlying neurodegenerative disorder in idiopathic Winkelman JW, Shahar E, Sharief I, Gottlieb DJ. Associations of restless legs REM sleep behavior disorder. Sleep 2008; 31:717–723.
syndrome and cardiovascular disease in the Sleep Heart Health Study.
Neurology 2008; 70:35–42.
Postuma RB, Lanfranchi PA, Blais H, et al. Cardiac autonomic dysfunction inidiopathic REM sleep behavior disorder. Mov Disord 2010; 25:2304 –2310.
Walters AS, Rye DB. Review of the relationship of restless legs syndromeand periodic limb movements in sleep to hypertension, heart disease, and Stockner H, Iranzo A, Seppi K, et al., SINBAR (Sleep Innsbruck Barcelona) stroke. Sleep 2009; 32:589–597.
Group. Midbrain hyperechogenicity in idiopathic REM sleep behavior dis-order. Mov Disord 2009; 24:1906–1909.
Merlino G, Fratticci L, Valente M, et al. Association of restless legs syndromein type 2 diabetes: a case-control study. Sleep 2007; 30:866–871.
Iwanami M, Miyamoto T, Miyamoto M, et al. Relevance of substantia nigrahyperechogenicity and reduced odor identification in idiopathic REM sleep Cuellar NG, Ratcliffe SJ. Restless legs syndrome in type 2 diabetes: behavior disorder. Sleep Med 2010; 11:361–365.
implications to diabetes educators. Diabetes Educ 2008; 34:218–234.
Ellmore TM, Hood AJ, Castriotta RJ, et al. Reduced volume of the putamen in Bosco D, Plastino M, Fava A, et al. Role of the Oral Glucose Tolerance Test REM sleep behavior disorder patients. Parkinsonism Relat Disord 2010; (OGTT) in the idiopathic restless legs syndrome. J Neurol Sci 2009; Scherfler C, Frauscher B, Schocke M, et al., for the SINBAR (Sleep Polydefkis M, Allen RP, Hauer P, et al. Subclinical sensory neuropathy in late Innsbruck Barcelona) Group. White and gray matter abnormalities in idio- onset restless legs syndrome. Neurology 2000; 55:1115 –1121.
pathic rapid eye movement sleep behavior disorder: a diffusion-tensor Lopes LA, Lins Cde M, Adeodato VG, et al. Restless legs syndrome and imaging and voxel-based morphometry study. Ann Neurol 2011; 69:400– quality of sleep in type 2 diabetes. Diabetes Care 2005; 28:2633 –2636.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical comorbidity Hanyu H, Inoue Y, Sakurai H, et al. Regional cerebral blood flow changes in van der Klaauw AA, Dekkers OM, Pereira AM, et al. Increased daytime patients with idiopathic REM sleep behavior disorder. Eur J Neurol 2010.
somnolence despite normal sleep patterns in patients treated for nonfunc- [Epub ahead of print] tioning pituitary macroadenoma. J Clin Endocrinol Metab 2007; 92:3898–3903.
Focke NK, Trenkwalder C. Idiopathic REM sleep behavior disorderand Parkinson's disease: two sides of one coin? Sleep 2010; 33:731– 100 Castriotta RJ, Atanasov S, Wilde MC, et al. Treatment of sleep disorders after traumatic brain injury. J Clin Sleep Med 2009; 5:137–144.
Lindberg E, Carter N, Gislason T, Janson C. Role of snoring and daytime 101 Dang D, Cunnington D. Excessive daytime somnolence in spinocerebellar sleepiness in occupational accidents. Am J Respir Crit Care Med 2001; ataxia type 1. J Neurol Sci 2010; 290:146 –147.
102 Chasens ER, Sereika SM, Burke LE. Daytime sleepiness and functional Dembe AE, Erickson JB, Delbos RG, Banks SM. The impact of overtime and outcomes in older adults with diabetes. Diabetes Educ 2009; 35:455–464.
long work hours on occupational injuries and illnesses: new evidence from 103 Cuellar NG, Ratcliffe SJ. A comparison of glycemic control, sleep, fatigue, the United States. Occup Environ Med 2005; 62:588–597.
and depression in type 2 diabetes with and without restless legs syndrome. J Shneerson JM. Sleep medicine: a guide to sleep and its disorders. 2nd edn Clin Sleep Med 2008; 4:50–56.
(Chapter 6: Excessive Daytime Sleepiness). Oxford, UK: Blackwell Publish- 104 Koutsourelakis I, Perraki E, Economou NT, et al. Predictors of residual ing Ltd; 2005:; pp. 125–160.
sleepiness in adequately treated obstructive sleep apnoea patients. Eur McWhirter D, Bae C, Budur K. The assessment, diagnosis, and treatment of Respir J 2009; 34:687–693.
excessive sleepiness: practical considerations for the psychiatrist. Psychiatry 105 Krouse HJ, Yarandi H, McIntosh J, et al. Assessing sleep quality and daytime (Edgmont) 2007; 4:26–35.
wakefulness in asthma using wrist actigraphy. J Asthma 2008; 45:389–395.
Boulos MI, Murray BJ. Current evaluation and management of excessive 106 Sundberg R, Tore´n K, Franklin KA, et al. Asthma in men and women: daytime sleepiness. Can J Neurol Sci 2010; 37:167–176.
treatment adherence, anxiety, and quality of sleep. Respir Med 2010; Comprehensive review of the clinical features, assessment, cause, comorbidity 104:337 –344.
and management of EDS.
107 Pierratos A, Patrick J, Hanly PJ. Sleep disorders over the full range of chronic Chokroverty S. Overview of sleep & sleep disorders. Indian J Med Res 2010; kidney disease. Blood Purif 2011; 31:146–150.
131:126 –140.
108 Hanly PJ, Gabor JY, Chan C, Pierratos A. Day time sleepiness in patients with Peacock J, Benca RM. Narcolepsy: clinical features, co-morbidities & treat- CRF: impact of nocturnal hemodialysis. Am J Kidney Dis 2003; 41:403–410.
ment. Indian J Med Res 2010; 131:338 –349.
Recent extensive review of narcolepsy.
109 Parker KP, Bliwise DL, Bailey JL, Rye DB. Day time sleepiness in stable hemodialysis patients. Am J Kidney Dis 2003; 41:394–402.
Watson NF, Doherty MJ, Zunt JR. Secondary narcolepsy following neuro-cysticercosis infection. J Clin Sleep Med 2005; 1:41 –42.
110 Abad VC, Sarinas PS, Guilleminault C. Sleep and rheumatologic disorders.
Sleep Med Rev 2008; 12:211–228.
Longstreth WT Jr, Ton TGN, Koepsell T, et al. Prevalence of narcolepsy inKing County, Washington, USA. Sleep Med 2009; 10:422–426.
111 Ferentinos P, Kontaxakis V, Havaki-Kontaxaki B, et al. Sleep disturbances in relation to fatigue in major depression. J Psychosom Res 2009; 66:37–42.
Ton TGN, Longstreth WT Jr, Koepsell T. Active and passive smoking and riskof narcolepsy in people with HLA DQB10602: a population-based case- 112 Taylor-Gjevre RM, Gjevre JA, Nair B, et al. Hypersomnolence and sleep control study. Neuroepidemiology 2008; 32:114–121.
disorders in a rheumatic disease patient population. J Clin Rheumatol 2010;16:255–261.
Gjerstad MD, Aarsland D, Larsen JP. Development of daytime somnolenceover time in Parkinson's disease. Neurology 2002; 58:1544 –1546.
113 Yoo SS, Shim BS, Lee DH, et al. Correlation between nocturia and sleep: a questionnaire based analysis. Korean J Urol 2010; 51:757–762.
Poryazova R, Benninger D, Waldvogel D, Bassetti CL. Excessive daytimesleepiness in Parkinson's disease: characteristics and determinants. Eur 114 Stroe AF, Roth T, Jefferson C, et al. Comparative levels of excessive daytime Neurol 2010; 63:129–135.
sleepiness in common medical disorders. Sleep Med 2010; 11:890–896.
In a study designed to exclude possible confounders, the authors assessed the Brotini S, Gigli GL. Epidemiology and clinical features of sleep disorders in relationship of EDS with medical disorders in a sample of 2 612 adults of the extrapyramidal disease. Sleep Med 2004; 5:169–179.
general population.
Suzuki K, Miyamoto T, Miyamoto M, et al. Excessive daytime sleepiness and 115 Sabanayagam C, Shankar A. Sleep duration and cardiovascular disease: sleep episodes in Japanese patients with Parkinson's disease. J Neurol Sci results from the National Health Interview Survey. Sleep 2010; 33:1037– 2008; 271:47–52.
Abbott RD, Ross GW, White LR, et al. Excessive daytime sleepiness and A cross-sectional study of 30 397 adults of the National Health Interview Survey subsequent development of Parkinson disease. Neurology 2005; 65:1442 – whose sleep duration was categorized as < or ¼ 5, 6, 7, 8, and > or ¼ 9 h; the presence of any cardiovascular disorder was examined vs. the duration of sleep.
Baumann CR, Werth E, Stocker R, et al. Sleep-wake disturbances 6 months 116 Ikehara S, Iso H, Date C, et al., JACC Study Group. Association of sleep after traumatic brain injury: a prospective study. Brain 2007; 130:1873 – duration with mortality from cardiovascular disease and other causes for Japanese men and women: the JACC study. Sleep 2009; 32:295–301.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


Nmh report 2015 final version.indd

NMH Annual Report 2015 UCD School of Medicine and Royal College of Surgeons in UCD runs an extensive research and teaching programme at The Forty-four undergraduates from the Royal College of Surgeons National Maternity Hospital. Undergraduate students attend attended The National Maternity Hospital for their seven weeks the hospital in four iterations for a period of six weeks during

B1245 pink 7

AUTUMN 2006 PinK Conference 2007 2-3 February Cranage Hall Conference Centre,Holmes Chapel, Cheshire Registration will be at 12noonon Friday 2 February and theconference will close at Prescribing – The Benefits as 12.30pm on Saturday 3 a Specialist Parkinson's Nurse All delegates will be offered asingle room and there will beno surcharges for