Crucial Link: Sleep Disorders and Fatigue in Multiple Sclerosis

Crucial Link: Sleep Disorders and Fatigue in Multiple Sclerosis

06/10/2023
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Crucial Link: Sleep Disorders and Fatigue in Multiple Sclerosis

Delve into this enlightening blog by guest author Nuria Vidal Fernandez, RN, MsC Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Her work has been shaped by her involvement in the MS Nurse PRO program and Birmingham City University Flexible Work-based Learning Module

The impact of insomnia or other sleep disorders on people with MS makes it increasingly important to diagnose and treat this symptom early, as having a sleep disorder is associated with an increased risk of fatigue. Insomnia is defined as persistent difficulty in the initiation, duration, consolidation or quality of sleep, which has functional repercussions on the person with MS.

Symptoms related to MS

Multiple sclerosis (MS) affects the central nervous system, causing diverse disruptions in physical, cognitive, emotional, and social aspects. Notably, it predominantly impacts women, with a prevalence of 2.6 women for every man. Globally, approximately 2.3 million individuals grapple with this condition.

For those familiar with MS, the variability of symptoms is well recognized. Factors such as a person's unique circumstances and the location of affected areas in the nervous system dictate symptom specifics and progression. This includes distinctions between relapsing-remitting MS and the progressive forms. Encouragingly, a range of treatments is available to address individual symptoms effectively, a fact well-appreciated by MS nurses.

MS symptoms, stemming from nervous system damage, manifest progressively. Early signs may subtly emerge but intensify over time. These encompass muscle spasms, stiffness, memory/concentration difficulties, sexual/urinary issues, depression due to diagnosis, and pervasive fatigue—exhaustion impacting physical and mental capacities, often exacerbated in the late afternoon.

Sleep problems and fatigue

For nurses caring for individuals with MS, understanding the pervasive impact of sleep issues and fatigue is crucial. These challenges significantly influence daily life, warranting a strategic approach for effective management.

Sleep disturbances and fatigue are prevalent in those with multiple sclerosis, profoundly affecting their well-being. These challenges can affect the daily lives of people living with MS. However, there are strategies and treatments available to help manage them.

Having trouble sleeping or dealing with other sleep problems can have a significant impact on individuals with MS. It's crucial to identify and address these issues early on, as sleep disorders are linked to a higher risk of experiencing fatigue. Insomnia, which means ongoing difficulty with falling asleep, staying asleep, maintaining sleep quality, or having restful sleep, can really affect how you function during the day.

Sleep problems are closely connected to fatigue, which is one of the most challenging symptoms of MS. In fact, fatigue is often seen as the main cause of reduced quality of life in people with MS. It's estimated that between 75% and 95% of people with MS experience fatigue, and many find it to be one of the most significant factors affecting their quality of life. Feeling tired and exhausted can really interfere with your daily activities, affecting your mood, your sense of independence, and how well you function mentally, socially, and at work. It's a complex symptom that can lead to a lack of motivation, less desire to engage with the world around you, and even impact your relationships.

Throughout the day, sleep-related symptoms manifest in diverse ways—irritability, low mood, cognitive challenges, and overall malaise. Intriguingly, sleep problems are more prevalent among those with MS than in the general population, often overlooked during medical evaluations.

Several factors contribute to disrupted sleep patterns in MS patients. These include not getting enough of essential nutrients like vitamin D, the effects of MS medications (such as therapies to modify the disease, corticosteroids, and stimulants to combat fatigue), taking more naps during the day because of fatigue, reduced physical activity due to both fatigue and MS-related disability, and emotional changes like stress, anxiety, or depression. These factors might also impact other MS symptoms like restless legs, pain, issues with urination or digestion, and difficulty regulating body temperature.

Detecting and treating sleep disorders

The impact of insomnia or other sleep disorders on individuals with MS underscores the growing importance of identifying and addressing these issues early on. Detecting and treating sleep disorders promptly is crucial because having a sleep disorder is linked to an increased risk of experiencing fatigue. Insomnia, characterised by ongoing challenges with falling asleep, staying asleep, maintaining sleep quality, or the overall sleep experience, can significantly affect a person's daily functioning.

Throughout the day, common symptoms stemming from sleep difficulties encompass irritability, low mood, cognitive impairments, fatigue, and a general sense of discomfort. Notably, sleep problems are more prevalent among individuals with MS compared to the general population, and they are often overlooked in clinical assessments. Multiple factors influence sleep in MS, such as deficiencies in essential nutrients like vitamin D, side effects of MS medications (including disease-modifying therapies, corticosteroids, and fatigue-reducing stimulants), increased daytime napping due to fatigue, reduced physical activity resulting from MS-related fatigue and disability, and emotional changes like stress, anxiety, or depression. These factors can also impact other MS symptoms such as restless legs, pain, urinary or intestinal issues, and temperature regulation.

Not getting enough restful sleep can lead to daytime sleepiness and make certain MS symptoms worse. Quality sleep is essential for one's overall health and well-being, but sometimes it's challenging to achieve. Despite its potential impact on the disease and its management, sleep disorders in MS are often overlooked and not properly diagnosed.

Think about how you feel after a good night's sleep – full of energy, in a better mood, and ready to take on the day. On the other hand, after a night of tossing and turning, struggling to sleep, feeling restless in your legs, and getting up multiple times to use the bathroom, you can find it really hard to make it through the day. This disrupted sleep pattern is associated with more depressive symptoms, fatigue, and difficulties with cognitive function. Unfortunately, in many MS consultations, people with MS aren't asked about the quality of their sleep. As mentioned earlier, managing fatigue is closely linked to one’s sleep patterns and how well they take care of their sleep habits. Hence, as a nurse working with people with MS, it is important that you ask your patients about their sleep.

Conclusion

Feeling sleepy during the day, experiencing unusual sleep patterns, and struggling with poor sleep quality are common among people with MS. These issues often don't get the attention they need. Moreover, studies show that these sleep problems can lead to more feelings of sadness, fatigue, and difficulties with thinking.

Many people with MS have trouble sleeping due to nocturia, which means having to get up multiple times during the night to use the bathroom. Other sleep problems that are quite common in people with MS include not getting enough sleep because of drinking too much alcohol or using stimulants too often during the day. Anxiety and depression can also take a toll on sleep, and experiencing pain can make it even harder to get a good night's rest.

Insufficient sleep in MS patients worsens disability, exacerbates fatigue, and impairs cognitive function. Not sleeping well can impact how someone feels and functions the next day. And since poor sleep quality is linked to MS-related fatigue, making sure our patients have a good sleep habits is important for managing fatigue. However, the issue is that many regular MS appointments rarely talk about sleep and sleeping habits. Patients are usually expected to bring up any concerns they might have, but there might not be a lot of active help coming from the MS consultations themselves. Hence, nurses working with people living with MS are encouraged to address sleeping patters within their consultations.

To sum up, recognising and addressing sleep problems in MS is essential. Early intervention can significantly improve the quality of life for those affected, by alleviating fatigue and its associated challenges.

Sources | Further reading

  • Kotterba, S., Neusser, T., Norenberg, C., Bussfeld, P., Glaser, T., Dörner, M. and Schürks, M. (2018). Sleep quality, daytime sleepiness, fatigue, and quality of life in patients with multiple sclerosis treated with interferon beta-1b: results from a prospective observational cohort study. BMC Neurology, 18
  • Sleep (2015). Sleep. [online] National Multiple Sclerosis Society. Available at: https://www.nationalmssociety.org/Living-Well-With-MS/Diet-Exercise-Healthy-Behaviors/Sleep.
  • Forbes A, While A, Dyson L, Grocott T, Griffiths P. Impact of clinical nurse specialists in multiple sclerosis--synthesis of the evidence. J Adv Nurs. 2003 Jun;42(5):442-62. doi: 10.1046/j.1365-2648.2003.02644.x. PMID: 12752865. 
  • Observatori (2023). Fatiga y cansancio. Guía para esclerosis múltiple. [online] Fundación Esclerosis Múltiple. Available at: https://www.fem.es/es/fatiga-una-guia-para-personas-con-esclerosis-multiple/ 
  • Hughes, A.J., Dunn, K.M. and Chaffee, T. (2018). Sleep Disturbance and Cognitive Dysfunction in Multiple Sclerosis: a Systematic Review. Current Neurology and Neuroscience Reports, 18
  • Sakkas GK, Giannaki CD, Karatzaferi C, Manconi M. Sleep Abnormalities in Multiple Sclerosis. Curr Treat Options Neurol. 2019 Jan 31;21(1):4. doi: 10.1007/s11940-019-0544-7. PMID: 30701337.
  • Veauthier, C., Gaede, G., Radbruch, H., Gottschalk, S., Wernecke, K.-D. and Paul, F. (2013). Treatment of sleep disorders may improve fatigue in multiple sclerosis. Clinical Neurology and Neurosurgery, 115(9), pp.1826–1830. doi:https://doi.org/10.1016/j.clineuro.2013.05.018.
  • Fatigue: What You Should Know. (n.d.). Available at: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Fatigue-What-You-Should-Know.pdf 
  • Pelayo, Carolina, Lozano, Prudencio, Navarrete, Carlos, Molt, Fernando, & Benavides, Evelyn. (2020). Trastornos del sueño en pacientes con Esclerosis Múltiple: Fisiopatología y clínica. Revista chilena de neuro-psiquiatría, 58(3), 259-269
  • Sleepeducation (n.d.). Insomnia. [online] Sleep Education. Available at: https://sleepeducation.org/sleep-disorders/insomnia/.
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