Beyond apnoea - insomnia, circadian and restless legs

The UK private sleep market is dominated by apnoea. Most advertised services are primarily about CPAP supply. Obstructive sleep apnoea is important and we treat it actively, but it is only one of four major categories of sleep disorder that we see in clinic. This article describes the other three and why they deserve proper assessment instead of a generic "try some sleeping tablets".

Chronic insomnia

Defined as difficulty falling asleep, difficulty staying asleep, or early morning waking with inability to return to sleep, for three or more nights per week, for three months or more, with resulting daytime consequences. Prevalence in UK adults is roughly 10 percent, rising with age.

The biological mechanism is hyperarousal. A sustained state of physiological activation (elevated heart rate, elevated sympathetic tone, elevated cortisol at night, fragmented sleep architecture) that is both cause and consequence of poor sleep. Worry about sleep becomes a driver of poor sleep; the loop reinforces.

Chronic insomnia has its own health consequences: increased cardiovascular risk, depression, impaired cognitive function, reduced quality of life. It is not "just a symptom" of depression or anxiety (though it often coexists).

First-line treatment is cognitive behavioural therapy for insomnia (CBT-I). Not medication. CBT-I is a structured 6 to 8 session programme covering sleep restriction (paradoxically compressing time in bed to consolidate sleep), stimulus control (breaking the bed-wakefulness association), cognitive restructuring (reducing worry about sleep), and sleep hygiene. Effectiveness is better than medication long-term, with no side effects and no tolerance.

Where medication fits. Short course Z-drugs or sedating antidepressants for acute exacerbations. Melatonin (prolonged release, Circadin) in older adults. Not routine long-term use. Benzodiazepines are rarely appropriate.

What we do differently. Our ongoing care programme includes CBT-I as structured 12-week behavioural work, not just a leaflet. The Full Sleep Reset Programme (£895) is built around a full CBT-I protocol with clinician support. Most patients who complete it see durable remission.

Circadian rhythm sleep-wake disorders

The body's 24-hour rhythm (circadian) is largely independent of sleep per se but profoundly affects it. When circadian timing and sleep schedule misalign, the result is insomnia or unrefreshing sleep even when duration is adequate.

Delayed sleep-wake phase disorder. Body clock runs late. Patient cannot fall asleep before 2 to 3 am, wakes late, feels tired if forced to wake early. Common in adolescents and young adults. Under-recognised in adults who just think they are "bad sleepers".

Advanced sleep-wake phase disorder. Body clock runs early. Patient falls asleep at 7 pm, wakes at 3 am. More common in older adults.

Shift work disorder. Sleep-wake mismatch imposed by work schedule. Health consequences include cardiovascular and metabolic disease risk; the degree is dose-dependent on years of shift work.

Jet lag. Transient circadian misalignment after travel. Not a disorder per se but can trigger longer-lasting rhythm problems.

Irregular sleep-wake rhythm. Sleep fragmented across 24 hours without clear cycle. Often associated with dementia, severe brain injury, or severe developmental disorders.

Treatment. Timed bright light in the morning (for delayed phase) or evening (for advanced phase). Timed melatonin in low dose (0.3 to 1mg, not the 5 to 10mg over-the-counter high doses). Behavioural scheduling. Sometimes dark glasses in the evening for delayed phase.

What we do differently. Circadian assessment is part of our routine history. We prescribe timed low-dose melatonin where indicated rather than random doses taken whenever. We write structured light and schedule plans.

Restless legs syndrome

Irresistible urge to move the legs, usually accompanied by unpleasant sensations, worse at rest in the evening, relieved by movement. Disrupts sleep onset and middle-of-night sleep. Often undiagnosed.

UK prevalence is roughly 5 to 10 percent of adults with a smaller proportion having clinically significant symptoms.

Primary causes. Often genetic; runs in families. Associated with pregnancy (transient), end-stage renal disease, peripheral neuropathy, iron deficiency (even without anaemia).

Diagnosis. Clinical. Four essential criteria: urge to move worse at rest, worse in evening, relieved by movement, not explained by another condition. Ferritin level should always be checked (iron deficiency is a reversible cause).

Treatment. Iron replacement if ferritin is below 75 to 100 (target higher than for general anaemia prevention). Medication if symptoms are disruptive: dopamine agonists (pramipexole, ropinirole) first-line historically, though augmentation (worsening over time) is now recognised; alpha-2-delta ligands (gabapentin enacarbil, pregabalin) increasingly preferred. Opioids in severe refractory cases.

Periodic limb movements. A related but distinct phenomenon. Rhythmic leg movements during sleep, often asymptomatic but can fragment sleep. Often identified on sleep studies as a surprise finding.

What we do differently. Iron studies (ferritin, transferrin saturation) are part of every sleep workup. Treatment started evidence-based rather than by default prescription of pramipexole.

Parasomnias

Unwanted behaviours during sleep. Different categories by sleep stage.

Non-REM parasomnias. Sleepwalking, night terrors, confusional arousals. Usually emerge in childhood and fade; can resurface under stress in adults. Not usually dangerous but can be disruptive. Safety measures matter (locked windows, stair gates, partner awareness).

REM parasomnias. REM-behaviour disorder (RBD) is acting out dreams; associated with synucleinopathy risk (Parkinson's, Lewy body dementia), so often warrants neurology assessment. Nightmares are not themselves a disorder but can be treatment-target if frequent.

What we do differently. Proper history, structured screening. REM-behaviour disorder gets neurology referral; we do not try to manage it in isolation.

Sleep-related movement disorders beyond RLS

Bruxism (tooth grinding) often reflects apnoea or anxiety and sometimes needs a mouth guard and an apnoea assessment. Periodic limb movements of sleep have already been covered above.

Narcolepsy

Rare but important. Excessive daytime sleepiness, cataplexy (sudden muscle weakness with emotion), sleep paralysis, hallucinations. Young onset (usually teens to twenties). Needs specialist neurology input with a multiple sleep latency test. We screen for it and refer onward.

Hypersomnia

Excessive daytime sleepiness not explained by apnoea, short sleep, or circadian disorder. Requires specialist workup. We refer onward.

What a good sleep service does

At LoveMyLife, the assessment covers all the above at baseline, not just apnoea. We use a structured sleep history, apnoea screening (STOP-BANG, Epworth), insomnia screening (ISI), circadian-type questionnaire (MCTQ or simple timing history), and RLS screening (four essential criteria). We do iron studies as standard. We do a WatchPAT One study where indicated.

Most of our patients have one of these four problems rather than apnoea. Many have more than one.

The honest bottom line

Treating sleep well means diagnosing what is actually wrong rather than defaulting to what is easy to sell. CBT-I for insomnia, timed light and melatonin for circadian disorders, iron and dopamine management for RLS, and CPAP or alternatives for apnoea. Different problems, different fixes.

Ready to start?

If this article has made you think our assessment might help, the next step is a short consultation with one of our sleep-medicine doctors.

Begin your consultation at this link. Online with a WatchPAT One home study, or in person at Westfield London.