Sleep Disorder Awareness
Stephen Heyman, MD, pulmonologist
STHS CENTER FOR SLEEP: BAPTIST HOSPITAL
Monday, March 9, 2009
News notes provided by webmd.com
March is SLEEP AWARENESS MONTH
Sleep Habits: More Important Than You Think
Not sleeping enough and not sleeping well is not OK. As a matter of fact, there is quite a price to pay. It may surprise you to learn that chronic sleep deprivation, for whatever reason, significantly affects your health, performance, safety, and pocketbook.
There are many causes of sleep deprivation. The stresses of daily life may intrude upon our ability to sleep well, or perhaps we trade sleep for more work or play. We may have medical or mental-health conditions that disrupt our sleep, and be well aware that we are sleep-deprived.
However, it is critically important to realize that sleep deprivation is very often due to unrecognized sleep disorders. After a typical night's sleep, you may not feel restored and refreshed and be sleepy during the day, but be totally unaware that you are sleep-deprived or have a sleep disorder. You might think, "It's just the stress of work or the kids," or you might have "always felt this way" and had no idea that you should feel differently. This lack of awareness compounds the consequences, because so many people remain undiagnosed for years.
That said, let's look at the consequences of sleep deprivation.
In the short term:
The good news for many of the disorders that cause sleep deprivation is that after risk assessment, education, and treatment, memory and cognitive deficits improve and the number of injuries decreases.
In the long term, the clinical consequences of untreated sleep disorders are large indeed. They are associated with numerous, serious medical illnesses, including:
Studies show an increased mortality risk for those reporting less than either six or seven hours per night. One study found that reduced sleep time is a greater mortality risk than smoking, high blood pressure, and heart disease. Sleep disturbance is also one of the leading predictors of institutionalization in the elderly, and severe insomnia triples the mortality risk in elderly men.
Remarkably, sleep loss may also be a contributing factor to obesity. John Winkelman, MD, PhD, medical director of the Sleep Health Center at Brigham and Women's Hospital and assistant professor of psychiatry at Harvard Medical School sums up this finding up nicely: "What most people do not realize is that better sleep habits may be instrumental to the success of any weight management plan." And Michael Thorpy, MD, director of the Sleep-Wake Disorders Center at Montefiore Medical Center in New York adds, "Any American making a resolution to lose weight ... should probably consider a parallel commitment for getting more sleep."
It is also important to realize the huge scope and prevalence of these disorders; more than 85 sleep disorders are recognized by the American Sleep Disorders Association, affecting more than 70 million Americans. Up to one-third of Americans have symptoms of insomnia; however, less than 10% of those are identified by primary-care doctors. Sleep-related breathing disorders represent a spectrum of abnormalities that range from simple snoring to sleep apnea (repeated episodes of cessation of breathing during sleep). As highly prevalent as they are, most cases remain undiagnosed and untreated.
With the wealth of information and treatment options available for sleep deprivation, much of the suffering, illness from the many related diseases, increase in accident rates, and effects on productivity, performance, concentration, and memory can be avoided. Increased awareness is the first step, for us individually and the health care community. Some researchers suggest that sleep deprivation should be recognized with the same seriousness that has been associated with the societal impact of alcohol.
Sleep: Fact or Fiction?
How much do you know about sleep disorders? Review these statements and learn which are true and which are not.
Health problems have no relation to the amount and quality of a person's sleep.
Fiction: More and more scientific studies are showing correlations between poor quality sleep and/or insufficient sleep with a variety of diseases, including hypertension, diabetes and depression. For example, insufficient sleep can impair the body's ability to use insulin, which can lead to the development of more severe diabetes. Patients with poorly controlled diabetes and sleep apnea have improvement of diabetic glucose control when treated for sleep apnea. This is also found in patients with hypertension and sleep apnea. When the sleep apnea is treated, the blood pressure also improves. In addition, too little sleep may decrease growth hormone secretion, which has been linked to obesity.
Older people need less sleep.
Fiction: The average adult needs a total sleep time of seven to nine hours per day. While sleep patterns usually change as we age, the amount of sleep we generally need does not. Older people may sleep less at night due, in part, to frequent night waking, but their need for sleep is no less than that of younger adults.
Snoring can be harmful.
Fact: Snoring can be a sign of sleep apnea, a sleep disorder that is associated with other medical problems such as cardiovascular disease. Sleep apnea is characterized by episodes of reduced or no airflow throughout the night. People with sleep apnea may remember waking up frequently during the night gasping for breath.
You can "cheat" on the amount of sleep you get.
Fiction: Sleep experts say that most adults need between seven and nine hours of sleep each night for optimal health. Getting fewer hours of sleep will eventually need to be replenished with additional sleep in the next few nights. Our body does not seem to get used to less sleep than it needs.
Teens need more sleep than adults.
Fact: Teens need at least 8.5 - 9.25 hours of sleep each night, compared to an average of seven to nine hours each night for most adults. The internal biological clocks of teenagers can keep them awake later in the evening and can interfere with waking up in the morning.
Insomnia is characterized only by difficulty falling asleep.
Fiction: One or more of the following four symptoms are usually associated with insomnia:
Daytime sleepiness means a person is not getting enough sleep.
Fiction: While excessive daytime sleepiness often occurs if you don't get enough sleep, it can also occur even after a good night's sleep. Such sleepiness can be a sign of an underlying medical condition or sleep disorder such as narcolepsy or sleep apnea.
Your brain rests during sleep.
Fiction: The body rests during sleep, not the brain. The brain remains active, gets recharged, and still controls many body functions including breathing during sleep.
If you wake up in the middle of the night and can't fall back to sleep you should get out of bed and do something.
Fact: If you wake up in the night and can't fall back to sleep within about 15-20 minutes, get out of bed and do something relaxing. Do not sit in bed and watch the clock. Experts recommend going into another room to read or listen to music. Return to bed only when you feel tired.
Getting too little sleep may impact weight.
Fact: How much a person sleeps at night can impact their weight. This is because the amount of sleep a person gets can affect certain hormones, specifically the hormones leptin and ghrelin, that affect appetite. Leptin and ghrelin work in a kind of "checks and balances" system to control feelings of hunger and fullness. Ghrelin, which is produced in the gastrointestinal tract, stimulates appetite, while leptin, produced in fat cells, sends a signal to the brain when you are full. When you don't get enough sleep, it drives leptin levels down, which means you don't feel as satisfied after you eat, and increases ghrelin levels, stimulating your appetite so you want more food. The two combined can set the stage for overeating, which in turn may lead to weight gain.
How to Sleep Better
'Sleep Hygiene' Solutions for Better Sleep
From having occasional difficulty sleeping to insomnia, there is a lot you can do to get a better night's sleep, feel refreshed when you awake, and remain alert throughout the day. It's called "sleep hygiene" and refers to those practices, habits, and environmental factors that are critically important for sound sleep. And most of it is under your control.
There are four general areas important to sleep hygiene:
We all have a day-night cycle of about 24 hours called the circadian rhythm. It greatly influences when we sleep and the quantity and the quality of our sleep. The more stable and consistent our circadian rhythm is, the better our sleep. This cycle may be altered by the timing of various factors, including naps, bedtime, exercise, and especially exposure to light (from traveling across time zones to staring at that laptop in bed at night).
Aging also plays a role in sleep and sleep hygiene. After the age of 40 our sleep patterns change, and we have many more nocturnal awakenings than in our younger years. These awakenings not only directly affect the quality of our sleep, but they also interact with any other condition that may cause arousals or awakenings, like the withdrawal syndrome that occurs after drinking alcohol close to bedtime. The more awakenings we have at night, the more likely we will awaken feeling unrefreshed and unrestored.
Psychological stressors like deadlines, exams, marital conflict, and job crises may prevent us from falling asleep or wake us from sleep throughout the night. It takes time to "turn off" all the noise from the day. No way around it. If you work right up to the time you turn out the lights, or are reviewing all the day's events and planning tomorrow (sound familiar?), you simply cannot just "flip a switch" and drop off to a blissful night's sleep.
One must develop some kind of pre-sleep ritual to break the connection between all the stress and bedtime. This is perhaps even more important for children. These rituals can be as short as 10 minutes or as long as an hour. Some find relief in making a list of all the stressors of the day, along with a plan to deal with them, as it serves to end the day. Combining this with a period of relaxation, perhaps by reading something light, meditating, or taking a hot bath can also help you get better sleep. And don't look at that clock! That tick-tock will tick you off.
Social or Recreational Drugs
Social or recreational drugs like caffeine, nicotine, and alcohol may have a larger impact on your sleep than you realize. Caffeine, which can stay in your system as long as 14 hours, increases the number of times you awaken at night and decreases the total amount of sleep time. This may subsequently affect daytime anxiety and performance. The effects of nicotine are similar to those of caffeine, with a difference being that at low doses, nicotine tends to act as a sedative, while at high doses it causes arousals during sleep.
Alcohol may initially sedate you, making it easier to fall asleep; however, as it is metabolized and cleared from your system during sleep, it causes arousals that can last as long as two to three hours after it has been eliminated. These arousals disturb sleep, often causing intense dreaming, sweating, and headache. Smoking while drinking caffeine and alcohol can interact to affect your sleep dramatically. These sleep disturbances may be most apparent upon awakening, feeling unrefreshed, groggy, or hungover.
It is important to realize that not getting the proper amount of and the best quality sleep may have serious short-term and long-term consequences. Many studies have shown that sleep deprivation adversely affects performance and alertness.
Reducing sleep by as little as one and a half hours for just one night reduces daytime alertness by about one-third. Excessive daytime sleepiness impairs memory and the ability to think and process information, and carries a substantially increased risk of sustaining an occupational injury. Long-term sleep deprivation from sleep disorders like apnea have recently been implicated in high blood pressure, heart attack, and stroke.
All that said, here are some sleep hygiene tips to help you relax, fall asleep, stay asleep, and get better sleep so that you wake up refreshed and alert.
1. Avoid watching TV, eating, and discussing emotional issues in bed. The bed should be used for sleep and sex only. If not, we can associate the bed with other activities and it often becomes difficult to fall asleep.
2. Minimize noise, light, and temperature extremes during sleep with ear plugs, window blinds, or an electric blanket or air conditioner. Even the slightest nighttime noises or luminescent lights can disrupt the quality of your sleep. Try to keep your bedroom at a comfortable temperature -- not too hot (above 75 degrees) or too cold (below 54 degrees).
3. Try not to drink fluids after 8 p.m. This may reduce awakenings due to urination.
4. Avoid naps, but if you do nap, make it no more than about 25 minutes about eight hours after you awake. But if you have problems falling asleep, then no naps for you.
5. Do not expose your self to bright light if you need to get up at night. Use a small night-light instead.
6. Nicotine is a stimulant and should be avoided particularly near bedtime and upon night awakenings. Having a smoke before bed, although it may feel relaxing, is actually putting a stimulant into your bloodstream.
7. Caffeine is also a stimulant and is present in coffee (100-200 mg), soda (50-75 mg), tea (50-75 mg), and various over-the-counter medications. Caffeine should be discontinued at least four to six hours before bedtime. If you consume large amounts of caffeine and you cut your self off too quickly, beware; you may get headaches that could keep you awake.
8. Although alcohol is a depressant and may help you fall asleep, the subsequent metabolism that clears it from your body when you are sleeping causes a withdrawal syndrome. This withdrawal causes awakenings and is often associated with nightmares and sweats.
9. A light snack may be sleep-inducing, but a heavy meal too close to bedtime interferes with sleep. Stay away from protein and stick to carbohydrates or dairy products. Milk contains the amino acid L-tryptophan, which has been shown in research to help people go to sleep. So milk and cookies or crackers (without chocolate) may be useful and taste good as well.
10. Do not exercise vigorously just before bed, if you are the type of person who is aroused by exercise. If this is the case, it may be best to exercise in the morning or afternoon (preferably an aerobic workout, like running or walking).
11. Does your pet sleep with you? This, too, may cause arousals from either allergies or their movements in the bed. Thus, Fido and Kitty may be better off on the floor than on your sheets.
Good sleep hygiene can have a tremendous impact upon getting better sleep. You should wake-up feeling refreshed and alert, and you should generally not feel sleepy during the day. If this is not the case, poor sleep hygiene may be the culprit, but it is very important to consider that you may have an unrecognized sleep disorder. Many, many sleep disorders go unrecognized for years, leading to unnecessary suffering, poor quality of life, accidents, and great expense. Since it is clear how critical sound sleep is to your health and well-being, if you are not sleeping well, see your doctor or a sleep specialist.