Sleep is significantly disturbed for various reasons in chronic illnesses. Treating the sleep disturbance concomitantly with the underlying illness may lead to improved quality of life. Sleep, depression and pain are interdependent symptoms. Hrayr Attarian, MD discusses sleep in chronic illnesses with a focus on scleroderma.

1. Sleep in chronic illnesses with a
focus on Scleroderma.
Hrayr Attarian, M.D.

2. The Evidence.
• What do we know about sleep in scleroderma
or systemic sclerosis?
• Not much.
• A medical literature database search resulted
in 8 articles from 1965 till today.
• The following is a summary.

3. What do sleep studies show?
• In 2002 A group of 27 people with systemic
sclerosis were studies with polysomnography
or sleep study.
• Overall sleep was fragmented in all 27.
• The main correlates of poor sleep were
eosaphageal motility issues, the presence of
restless legs syndrome and shortness of
breath.

4. How about pain?
• In 2011 correlates for sleep disturbances were
looked at in a group of 70 scleroderma
patients.
• Pain was the most important correlate to
disturbed sleep followed by marital status.
• Another group compared 180 scleroderma
patients to others with chronic illness in a
large database of sleep complaints in people
with chronic illnesses.

5. Results
Average sleep per night
Snoring
Sleep disturbance
Sleep adequacy
Awakening
short of breath
Daytime sleepiness Sleep quality

6. How about other factors?
• In addition to GI disturbances, shortness of
breath and pain depression and itching have
been recently shown to have a strong
association with sleep disturbances in
scleroderma.
• Poor sleep quality, as in many illnesses,
correlated with poor quality of life.

7. Other Chronic Illnesses
• A model of sleep disturbances in chronic
illness is Rheumatoid Arthritis.
• Most of the factors that are associated with
poor sleep in Rheumatoid Arthritis can be
generalized to other chronic illnesses such as
Diabetes Mellitus and Congestive Heart
Failure.

8. Sleep Apnea and Related Conditions
• Sleep apnea and related breathing conditions
play a big role in disturbing sleep in chronic
conditions.
• In rheumatoid arthritis for instance occurs
with a frequency of 2 to 3 times more and is
not always associated with weight.
• Treating the sleep apnea significantly
improves sleep complaints.

9. Pain.
• Pain interferes with sleep in almost all chronic
illnesses but particularly rheumatologic ones.
• Pain disrupts sleep and poor sleep increases
pain.
• Treating pain is easier said than done as some
of the effective and potent meds can cause
sleep disturbances, worsen sleep apnea and
lead to dependence.

10. Depression.
• The taboo subject!
• Depression is part and parcel of all chronic
medical conditions.
• It has a similar negative relationship with
sleep as pain does.
• Depression is easily treated but effective
therapies are either expensive and not readily
available (Cognitive Behavioral therapy) or can
disrupt sleep such as antidepressants.

11. Other Common Sleep Disorders
Key RLS diagnostic criteria Supportive features
 Urge to move the legs - usually
accompanied or caused by
uncomfortable leg sensations
 Sleep disturbances
 Involuntary leg movements
 Positive family history for
RLS
 Temporary relief with movement -
partial or total relief from
discomfort by walking or
stretching
 Onset or worsening of symptoms
at rest or inactivity, such as when
lying or sitting
 Worsening or onset of symptoms
in the evening or at night

12. Other Common Sleep Disorders
• Excessive daytime sleepiness or insomnia due
to chronic increase in inflammatory
hormones.
Sleep Inducing
Sleep Disrupting

13. Solution.
• Comprehensive approach to patients.
• Multidisciplinary clinics if necessary.
• Kill two birds with one stone.
– Meds that treat both depression and pain
– Or RLS and pain.
– Improving sleep and pain
• Treat conditions simultaneously
• Pay attention to medication side effects.

14. Conclusion
• Sleep is significantly disturbed for various
reasons in chronic illnesses.
• Treating the sleep disturbance concomitantly
with the underlying illness may lead to
improved quality of life.
• Sleep, depression and pain are
interdependent symptoms