Poor Sleep Habits
Poor sleep habits, referred to as sleep hygiene, are one of the most common problems encountered in our society. We stay up too late and get up too early. We interrupt our sleep with drugs, chemicals, work, and we over stimulate ourselves with late-night activities such as television. Click here for more information on sleep hygiene, which may provide useful tips on attaining a normal night’s sleep. Many of the tips are “common sense,” but it is surprising how many people fail to follow these.
Insomnia is the inability to sleep or inability to sleep well at night. Many different medical and mental health problems cause insomnia. Insomnia may be situational, lasting a few days to weeks, or chronic, lasting for more than 1 month. Around 9-12 percent of the American population report chronic insomnia. In severe cases, patients experience fatigue, sleepiness, difficulty concentrating and difficulty with thinking. Clearly this can impact one’s quality of life. Insomnia may be a symptom of breathing problems at night like sleep apnea, of medical illness like heart failure, a side effect of medication, or a symptom of severe anxiety or depression. While short-lasting insomnia periods are well treated with medication, chronic or long-lasting insomnia may not respond well to medications. Treating patients with chronic insomnia with sleeping pills is not an effective way to treat the problem. An evaluation by the patient’s personal physician or a sleep specialist can often help get to the root of the problem. Many patients respond well to what is called “cognitive behavioral therapy.” In this form of therapy, incorrect ideas about sleep are corrected. In addition, relaxation and behavioral techniques may be used to help patients fall asleep. This combined with treatment of any underlying disorders is often the best way to treat the insomnia.
Sleep apnea is a common and potentially devastating sleep disorder. It is the most common reason that patients are referred to sleep centers around the country. The word apnea means “not breathing.” Patients with the usual form of sleep apnea actually close off their airway at night. This airway closure occurs either behind the tongue or behind the nose. Patients continue to make efforts to breathe. After a period of time the brain, realizing it is not getting any oxygen, actually “wakes up.” The brain then tells the upper airway to open to let some air in. This is associated with loud snoring, often described as snorting and gasping. Patients may take a few breaths of air, the brain goes to sleep again and the cycle may repeat itself several hundred times a night. Patients are often not even aware that they are doing this.
Sleep apnea is common. It affects about 4% of men and about 2% of women. Sleep apnea is also dangerous. Patients with sleep apnea are at great risk for heart disease, heart attacks, strokes and high blood pressure. In addition, since the sleep is poor quality, patients are often very sleepy during the day. Sleepiness is associated with inability to concentrate, remember or think. There is also increased risk in falling asleep while at work and while doing vital tasks such as driving or using heavy machinery.
Medical treatment involves weight loss if the patient is overweight, avoidance of drugs, which increase the risk of apneas such as sleeping pills, alcohol and sedative medicines, and sometimes sleeping semi-upright. In most cases additional treatment is warranted. In some cases we use Continuous Positive Airway Pressure (CPAP for short) to treat patients. For this treatment a mask is fit over the nose or over the nose and mouth. The mask is pressurized slightly to hold the airway open and allow the patient to sleep normally. Newer technology has made the masks relatively comfortable to use. Some patients may be candidates for surgery on the upper airway. In the usual upper airway surgery the uvula and some of the surrounding soft tissue is removed to enlarge the air passage. In other cases a dental device designed to move the lower jaw down and outwards slightly may be worn at night. Very rarely a tracheostomy is indicated when sleep apnea is considered to be life-threatening. The treatment used to manage sleep apnea should be decided by the patient and his/her physician on the basis of the sleep study and other data.
Narcolepsy is a chronic sleep disorder that commonly begins during adolescence and is characterized by excessive daytime sleepiness with the occurrence of sleep attacks. Narcolepsy is rare, occurring in about 100,000 Americans. It may start in childhood but typically peaks in young adulthood.Narcolepsy can run in families, but can occur in the absence of any family history as well. There are several other characteristic symptoms that may or may not be present, including cataplexy, sleep paralysis and hypnogogic hallucinations. Cataplexy is the sudden loss of muscle tone, commonly associated with strong emotions. It may be a subtle sensation of weakness or a complete loss of strength with a fall to the ground. Sleep paralysis is a sensation of not being able to move on waking, usually for a few seconds. Hypnogogic hallucinations are very vivid and sometimes violent or bizarre sensations, almost dreamlike, that occur on waking or falling asleep.
The treatment of narcolepsy and its associated symptoms commonly requires a combination of behavioral modification and drug therapy. Many patients with narcolepsy will do well with naps scheduled at specific times during the day. Stimulant medication may be used to alleviate symptoms of daytime sleepiness. Other medications, such as certain anti-depressants, are used to treat cataplexy. Treatment for each patient must be individualized and each patient with his/her physician needs to discuss this on a case-by-case basis.
Restless Legs Syndrome and Periodic Limb Movement Disorder
Restless legs syndrome (RLS) is characterized by an intolerable, internal itching-like sensation occurring in the lower extremities that causes an almost irresistible urge to move the legs. The sensation is commonly described as a “creepy” or “crawly” sensation and is typically relieved by movement of the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours. In some patients, this problem persists into the nighttime and may prevent patients from getting a restful night’s sleep. Pregnancy and iron deficiency are associated with an increased frequency of this disease. In many patients, RLS is extremely distressing. RLS is common, affecting 5-10% of adults; this increases with age. Almost all patients with restless legs syndrome have a problem called period limb movement disorder. With this, there are leg (sometimes arm) movements occurring at regular intervals during the night. This may fragment sleep, leading to poor quality, non-refreshing sleep. Periodic limb movement disorder can also occur as an isolated problem.
In most people, restless legs syndrome and periodic limb movement disorder are relatively easily treated. Treatment commonly includes the incorporation of both aerobic and leg stretching exercises. Leg stretching or even yoga exercises can be done prior to bedtime to alleviate symptoms and may be all that is needed in mild cases. Iron replacement therapy is used if patients are iron deficient. Drugs used to treat this condition include the pramipexole (Mirapex®) and ropinirole (Requip®). Medications, such as valium-type medications, such as clonazepam (Klonopin®) or analgesic medications related to morphine can be also be used. In some cases, anti-seizure medications may be effective.
Sleepwalking, also known as somnambulism, is characterized by walking or other physical activities during sleep. Sleepwalking is common in children — up to 15 percent of children have had this problem. However, it can occur at any age. In children, it can be associated with sleep deprivation or anxiety. In adults, it is more commonly associated with other medical disorders, medication use, or anxiety or depressive disorders. Clinically, the person may simply sit up with their eyes open, appearing to be awake, or they may engage in a complex task. Episodes can last from seconds to minutes. Contrary to popular belief, it is safe to wake a sleepwalker, but they may be confused and disoriented on waking. There is no specific treatment except to avoid triggers if known, or treat anxiety or depression. If severe, short-term use of sedatives may be considered. Otherwise it is best to keep the person safe and out of harm’s way. We often advise families to make sure the windows are closed and that there is no possibility of sleepwalking leading to danger for the patient.
Sleep Disorders in Medical Illnesses
Many medical illnesses are associated with disturbances of sleep. Patients with chronic lung disease may experience low oxygen levels at night that disturb sleep. Patients with asthma may develop wheezing or shortness of breath at night, usually in the early morning hours. Patients with heart failure may develop abnormal breathing at night, which disturbs sleep much in the way that sleep apnea does. Patients with Parkinson’s or other neurological diseases may develop disturbed sleep.