Sleep disorders in patients with multiple sclerosis

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Introduction. Multiple sclerosis (MS) is a chronic demyelinating disease characterized by signs of a multi-focal lesion of the nervous system, occurring with exacerbations and remissions, or progressive [1]. MS is one of the most common causes of neurological disability in young people. Worldwide, more than 2 million people suffer from this disease. The prevalence of MS is increasing due to the active introduction of neuroimaging diagnostic methods, an increase in the life expectancy of patients, due to improved methods of treatment, rehabilitation, social assistance, as well as a real increase in the primary morbidity rate[2]. With multiple sclerosis, so-called "minor" symptoms often occur: asthenia, general weakness, depression, anxiety disorders, sleep disorders, which can lead to the progression of disability. According to the results of some studies, from 22% to 50% of MS patients suffer from insomnia, 38% have obstructive sleep apnea syndrome, 37% have restless legs syndrome, and up to 30% of patients complain of daytime sleepiness [3]. Existing sleep disorders can become predisposing factors for the development of a number of mental and somatic diseases [4]. However, sleep disorders and other "minor" symptoms tend to remain undiagnosed. But recent studies have proven the role of sleep as a kind of antioxidant that counteracts oxidative stress, which underlies neuroinflammation and neurodegeneration [5]. Failure to recognize sleep disorders in patients with multiple sclerosis can lead to a deterioration in their general condition and significantly reduce their quality of life. The purpose of the work: to identify and study the most common sleep disorders in patients with multiple sclerosis, as well as to trace their relationship with other "minor symptoms" such as asthenia, emotional disorders. Materials and methods of research. The present study is a cross-sectional (cross-sectional) observational study. All participants were examined during one visit, during which data on sleep status and psychological health were collected. The study included 30 patients who were undergoing inpatient treatment in the neurological department of the Higher School of Medicine "VOKB No. 1". Inclusion criteria: the diagnosis of multiple sclerosis, confirmed in accordance with the criteria of McDonald (2017); the ability to independently fill out questionnaires. Patients with other neurological or psychiatric disorders that may affect sleep quality, as well as patients with chronic somatic diseases in the decompensation stage, were excluded. Data on the presence of concomitant diseases were collected, life history was collected, complaints were assessed, and objective and neurological status was studied to determine the severity of neurological deficits in EDSS scores. The neuropsychological profile was determined using the following scales: the Pittsburgh Sleep Quality Index (PSQI) Questionnaire, the STOP-BANG scale for calculating the risk of obstructive sleep apnea syndrome, the Epworth Sleepiness Scale, and the Hospital Anxiety and Depression Scale (HADS). The results of the study. In the course of our work, we observed 30 patients with multiple sclerosis: 19 women and 11 men, aged from 23 to 66 years. The duration of clinical manifestations of the disease ranged from 1 year to 30 years. The EDSS score ranged from 2 to 6.5. The study group included patients with various types of MS: 16 people (53%) in remission, 11 (37%) in secondary progression, and 3 (10%) in primary progression. In the course of our work, only 5 patients found the quality of their sleep satisfactory, and the remaining 25 people complained of sleep problems. Table 2 shows the most common of them.

Table 2

	< 1 time per week	1-2 times a week	3 and > once a week	Total patients with a complaint	Total patients without complaint	% of the total number of patients studied
Couldn't sleep for 30 minutes	5	4	13	22	8	73
We had to use the bathroom	4	4	20	28	2	93
We felt that it was cold	0	9	6	15	15	50
Felt like it was hot	5	7	6	18	12	60
Had bad dreams	6	4	2	12	18	40
Experienced pain	3	6	6	15	15	50
Coughed and snored loudly	2	2	1	5	25	17

It is worth noting that 20 patients were forced to get up at night to use the bathroom three or more times a week, which is 93% of the total number of patients studied. Insomnia also accounted for a high percentage (73%) – 22 patients could not sleep for 30 minutes, while 6 of them could not sleep for an hour or more, which is 20% of the total. Patients also often complained of a sudden feeling of heat and cold: 15 patients felt cold (50%), 18 felt hot (60%). As for the pain experienced at night (in 50% of patients), their localization is diverse: upper and lower extremities, headaches, spine. At the same time, pain in the extremities was closely related to physical exertion and subsequent muscle spasm. In addition to the complaints listed above, there were also numbness of the extremities, seizures, tinnitus, severe headaches, nervous and emotional tension, night sweats, paresthesia in the extremities in the form of burning. Separately, the time it takes for patients to fall asleep and the number of hours of full sleep per night were analyzed. It should be noted that 37% slept less than 6 hours and 33% - about 6-7 hours. The respondents were less likely to sleep for more than 9 hours, and they showed varying degrees of daytime sleepiness. The Epworth sleepiness scale revealed only three patients with daytime sleepiness with values of 8.9 and 10 points, which correspond to mild (3%), moderate (3%), pathological drowsiness (3%), respectively. Despite frequent complaints of sleep problems, only 12 patients from the entire group took medications that help them fall asleep, and 11 of them used them three or more times a week. Among the medications taken were: 1) H1-antihistamines – diphenhydramine, Reslip/ Donormil (doxylamine); 2) anxiolytics – Elsepam (bromdihydrochlorophenylbenzodiazepine), Atarax (hydroxyzine, which also refers to H1-antihistamines); 3) neuroleptics – Seroquel (quetiapine) and chlorprotexene; 4) antidepressants – selective serotonin reuptake inhibitors (fluoxetine); 5) anxiolytic and tranquilizer – Relanium (diazepam); 6) hypnotics and adaptogen – melatonin; 7) sedatives – Validol and Corvalol. According to the frequency of use, hydroxyzine and doxylamine are in the first place – both were taken by 3 patients, the neuroleptic quetiapine, which was used by 2 people, was in the second place, the rest of the patients took drugs from different pharmacological groups. At the same time, only 5 patients went directly to a psychiatrist about existing sleep disorders and the appointment of therapy that would help normalize sleep. We also examined one of the most common dissomnia disorders, restless legs syndrome (RLS). In MS, the appearance of this syndrome is more associated with inflammatory processes in the brain, which leads to dysfunction of the dopaminergic system. At the same time, according to some studies [6], the sensory component (discomfort and unpleasant sensations in the legs) is most pronounced in MS, which may indicate the existence of a specific, predominantly sensory phenotype of restless legs syndrome in MS. Indeed, 16 respondents (53% of the respondents) described the need to move their legs, accompanied by discomfort, which usually occurred in the evening or at night, while 5 people had less than once a week, 4 had one or two times a week, and 7 people had three or more times a week.. During the data analysis, we found that 12 (75%) out of 16 patients with restless legs syndrome rate their sleep quality as poor or very poor. 10 (62%) of the respondents have less than 7 hours of sleep per night, which indicates a lack of sleep in such patients. Eight of the subjects are taking various medications that affect the normalization of sleep, which accounts for 67% of the total number of patients using medications to correct dissomnia disorders. Using the STOP-BANG scale, we found that most of the subjects had a low risk of developing obstructive sleep apnea syndrome (OSA): 37% scored 1 point and 40% scored 2 points. The result of 3 points – the average risk of developing obstructive sleep apnea - was observed in 7 (23%) patients, another person scored 6 points according to the results of the questionnaire, which corresponds to a high risk. During the analysis of the composition of the group of patients at medium and high risk, it turned out that 5 out of 8 (63%) of the subjects were over 45 years old, 63% of the patients suffered from hypertension, 63% had less than 7 hours of sleep per night, and half of the subjects showed clinically pronounced anxiety and depression according to the hospital scale. the alarm.

In the course of our study, based on the results of filling out the HADS scale, it was found that 13 patients (43% of the total number of subjects) had emotional disorders in the form of depression or anxiety of varying severity. The number of patients with subclinically expressed anxiety was 13%, with clinically expressed anxiety - 23%, with subclinically expressed depression - 23% and 3% with clinically expressed depression. At the same time, 5 people suffered from both subclinically expressed depression and clinically expressed anxiety, 1 person simultaneously had both subclinically expressed anxiety and clinically expressed depression. Using the Pittsburgh Sleep Quality Questionnaire (PSQI), the severity of dissomnia disorders in patients with emotional disorders was assessed by analyzing the number of points scored. In all patients with anxiety or depression, this score was more than 10, which indicates the presence of significant sleep disorders. In addition, restless legs syndrome was found in 19% of patients with subclinically expressed anxiety, 31% with clinically expressed anxiety, 25% with subclinically expressed depression, and 6% with clinically expressed depression. Half of the subjects with clinically expressed anxiety and a quarter with subclinically expressed depression had an average risk of developing obstructive sleep apnea syndrome. Conclusion. 1. Patients with multiple sclerosis experienced sleep problems, among which frequent night urination and difficulty falling asleep were the most common, which led to insomnia and a reduction in the duration of full sleep. Sensory impairments, such as feeling hot and cold, also had a significant impact on sleep quality. 2. The majority of MS patients had a sleep deficit, about 70% of them slept less than 7 hours, which adversely affected their general condition and could lead to disorders in the psycho-emotional sphere and disruption of general adaptation mechanisms. It is necessary to use various non-pharmacological and pharmacological methods to minimize existing sleep disorders. It is important to explain to the patient the importance of finding a safe and effective therapy that would promote healthy sleep. 3. RLS is quite common in MS patients – in our work, the incidence rate was 53%. The presence of RLS can exacerbate other dissomnia disorders, as 75% of patients with this syndrome complained of poor sleep quality, and half of them took medications to normalize sleep. Cases of obstructive sleep apnea syndrome (OSA) were less common and were often caused by other pathological or physiological factors such as age and hypertension. 4. Psychoemotional disorders, namely anxiety and depression, are common in patients with multiple sclerosis and require medication and/or psychotherapy to improve their quality of life and sleep.

About the authors

Polina Alexandrovna Shramkova

Voronezh State Medical University named after N. N. Burdenko

Author for correspondence.
Email: polinashramkova11@mail.ru
ORCID iD: 0009-0000-5687-3415

student

Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

Julia Alexandrovna Pozhidaeva

Voronezh State Medical University named after N. N. Burdenko

Email: dr.pozhidaeva@mail.ru
ORCID iD: 0009-0008-1492-4323
SPIN-code: 3673-2999

Candidate of Medical Sciences, Assistant of the Department of Neurology

Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

References

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