Rheumatoid Arthritis and Sleep
Are your RA symptoms affecting your sleep, or is your trouble sleeping making your symptoms worse? The answer may be both.
If rheumatoid arthritis has you tossing and turning at night, you’re not alone. While the exact percentage of RA patients who experience sleep problems is hard to nail down, more than 80 percent of people with RA report fatigue as part of their symptoms, says Irene Blanco, MD, rheumatologist at Montefiore Medical Center in New York.
Rochelle Rosian, MD, a Cleveland Clinic rheumatologist, says that nearly all of her RA patients have sleep difficulties at least one night a week, whether from the pain and discomfort of RA or other factors. “I’ll usually ask if they’re having more difficulty falling asleep or staying asleep,” says Dr. Rosian. “If they can’t get to sleep, they may need to take their pain medication closer to bedtime, “so that their pain is not at its loudest when they go to lie down.” If they’re waking up in the middle of the night, taking an over-the-counter pain reliever at bedtime may help.
Why Sleep Matters
Sleep problems can increase levels of stress hormones and aggravate flares, Dr. Rosian says. And even if you’re not flaring, you may not manage your pain as well. “When you sleep, you make all those brain chemicals that you need to feel better. If you’re not rested you don’t have all of these good hormones, so it may be more difficult to handle your pain.”
Besides increased flares, RA patients with sleep disruptions tend to have more trouble with depression, pain severity and performing normal daily functions than RA patients who didn’t have sleep problems. In a 2011 University of Pittsburgh study , 61 percent of the randomly selected RA patients in the study were deemed poor sleepers and experienced these issues. Also, in the deepest stages of sleep, the body releases growth hormones to repair tiny muscle tears that occur during the course of the day. People with RA who sleep fitfully may not get enough growth hormone to make needed repairs.
Who’s Losing Sleep and Why?
Jeffrey Fong, MD, a rheumatologist with Kaiser Permanente in Northern California, sees two categories of RA patients with sleep problems: those with a new diagnosis who are still adjusting their medication, and those who have lived with RA long enough that their pain is under control.
With new patients, “what’s usually going to help them the most is getting enough pain relief,” says Dr. Fong. “We can easily do something about that in a specific way.” Anxiety about a new diagnosis – from worrying about the side effects of their new medications to how they’re going to function at work or at home – may also be affecting sleep.
“At the beginning, people tend to need more attention and help with these factors, and as time goes on they get better at managing their disease and its effects,” he says. “If I can help them identify those things so they can deal with them in very specific ways – like job modifications and things they can tell their family – it can help them get control of the situation.”
Some common RA medications may also contribute to sleeplessness. One is the steroid prednisone, which can cause insomnia, agitation or depression. Taking it earlier in the day is best, says Dr. Rosian. Another is hydroxychloroquine (Plaquenil). “It’s a mild arthritis medicine,” says Dr. Fong, “so I’m usually not giving it to people who are really ill, but sometimes it causes people to get kind of jumpy, nervous and twitchy.”
Patients whose RA is under control, says Dr. Fong, may have other issues like a sleep disorder unrelated to the RA, stress-inducing changes in work or relationships, or chronic depression or anxiety that’s gone untreated. Sometimes, small modifications like cutting out caffeine in the evening, “lights out” on screen time an hour before bedtime, or “realizing what’s upsetting them so they can deal with it” can improve sleep. In other cases, learning relaxation techniques with a therapist or talking with a psychiatrist or psychologist about underlying problems may help.
Suneel S. Valla, MD, a sleep specialist at St. Luke’s Hospital in Bethlehem, Pa., says sleep fragmentation – not getting good quality sleep – occurs in more than half of patients with RA that she treats. Of this group, 25 to 40 percent of patients report sleep disturbances related to RA, Dr. Valla says. The rest may have a sleep disorder in addition to RA, such as sleep apnea or restless legs syndrome.
Dr. Valla says that when diagnosing sleep problems in RA patients, he distinguishes tiredness from drowsiness. “Tiredness is usually physical tiredness – feeling drained and not able to do much,” he says. “Drowsiness is trouble staying awake during the day.
“If you’re falling asleep when you don’t want to or taking unplanned naps, that would be a clue to a primary sleep disorder.”
Doctors who suspect a sleep disorder may prescribe a sleep study that looks at weight, neck size, anatomy and other medical problems such as hypertension that may affect sleep patterns.
Sleep and Pain Processing
Recent research suggests new complexities in the relationship between sleep problems and rheumatoid arthritis. In a 2013 study, Yvonne C. Lee, MD, Brigham and Women’s Hospital, and colleagues, looked at why RA patients had a low pain threshold even when their inflammation was under control. They found that subjects with sleep problems experienced higher pain sensitivity, suggesting that lack of sleep may interfere with the way the central nervous system processes pain.
Studies in the general population “show that if you disrupt sleep, pain sensitivity and markers of inflammation increase,” she says. That research needs to be replicated in patients with RA, who have more sleep disruptions than the general population, Dr. Lee says.
Catch Some Zzzs
Tips for good sleep include:
- Eliminate caffeine.
- Avoid naps.
- Don’t drink alcohol.
- Don’t eat a large meal near bedtime.
- Try to go to bed and get up at the same times every day.
- Reserve your bedroom for sleep – no TV, piles of laundry to sort or even books. If you can’t sleep, get up after 20 minutes.
- Go into another room and read or listen to music until you’re sleepy.
- Avoid bright lights and electronic screens before bedtime.