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Sleep Disorders

Learn all about sleep disorders and how they can effect your health and well being.

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Obstructive Sleep Apnea

What is Obstructive Sleep Apnea (OSA)?

Obstructive Sleep Apnea is when a person stops breathing repeatedly during sleep. Breathing stops because the airway collapses and prevents air from getting into the lungs. Sleep patterns are disrupted, resulting in excessive sleepiness or fatigue during the day.

What causes the airway to collapse during sleep?

Extra tissue in the back of the airway such as large tonsils.

Decrease in the tone of the muscles holding the airway open.

The tongue falling back and closing off the airway

How many people have Obstructive Sleep Apnea?

4 in 100 middle-aged men and 2 in 100 middle-aged women have Obstructive Sleep Apnea. Most OSA sufferers remain undiagnosed and untreated. Obstructive Sleep Apnea is as common as adult asthma.

What happens if Obstructive Sleep Apnea is not treated?

Possible increased risk for:

  • High blood pressure
  • Heart disease and heart attack
  • Stroke
  • Fatigue-related motor related and work accidents
  • Decreased quality of life

What are the signs and symptoms of Obstructive Sleep Apnea?

If you or someone you know snores regularly and has one or more of the following symptoms, it may be Obstructive Sleep Apnea:Snoring, interrupted by pauses in breathing

  • Gasping or choking during sleep
  • Restless Sleep
  • Excessive sleepiness or fatigue during the day
  • Poor judgment or concentration
  • Irritability
  • Memory loss
  • High blood pressure
  • Depression
  • Obesity
  • Large neck size (>17″ in men; >16″ in women)
  • Crowded airway
  • Morning headache
  • Sexual dysfunction
  • Frequent urination at night

What should you do if you suspect you may have Obstructive Sleep Apnea?

See your doctor; evaluation by a doctor specializing in sleep disorders is recommended. Have a sleep study done; a sleep study can provide the doctor with information about how you sleep and breathe. This information will help the doctor to determine your diagnosis and treatment options.

What is the treatment for Obstructive Sleep Apnea?

The most common treatment for Obstructive Sleep Apnea is CPAP (Continuous Positive Airway Pressure), pronounced “see-PAP.”

Other less common treatments include surgery and oral appliances, which may be effective in certain individuals. Any treatments should include weight loss if needed, exercise, and avoidance of alcohol, sedatives, and hypnotics.

— Dee S., Lafayette, L.A.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

obstructive apnea

Obstructive sleep apnea occurs when the muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax. When these muscles relax, your airway is narrowed or closed, and breathing is momentarily cut off.

Primary Snoring

Also known as simple snoring is characterized by loud upper airway breathing sounds in sleep without episodes of apnea (cessation of breath).

How is snoring created?

Snoring is a noise produced when an individual breathes (usually produced when breathing in) during sleep which in turn causes vibration of the soft palate and uvula (that thing that hangs down in the back of the throat). The word “apnea” means the absence of breathing.

All snorers have incomplete obstruction (a block) of the upper airway. Many habitual snorers have complete episodes of upper airway obstruction where the airway is completely blocked for a period of time, usually 10 seconds or longer. This type of snoring is associated with obstructive sleep apnea.

How Does Primary Snoring Differ from Snoring that Indicates Obstructive Sleep Apnea?

A complaint of snoring by an observer w/o witnessed gasping No evidence of insomnia or excessive sleepiness due to snoring No dryness of the mouth upon awakening

Also, a polysomnogram (sleep study) will show: Snoring but…

No associated abrupt arousals, arterial oxygen desaturation (lowered amount of oxygen in the blood) or cardiac disturbances Normal sleep pattern/histogram Normal respiratory pattern during sleep No signs of another sleep disorder

What can be done about snoring?

First of all, it is necessary to rule out obstructive sleep apnea or other sleep disorders. Behavioural and lifestyle changes may be suggested. Losing weight, sleeping on your side, refraining from alcohol and sedatives are recommended.

Additional options may include:

O

There are mouth/oral devices (that help keep the airway open) on the market that may help to reduce snoring in several different ways.

Some devices: Bring the jaw forward or, Elevate the soft palate or, Retain the tongue (from falling back in the airway and thus decreasing snoring) or, All of the above.

Oral/Nasal Surgery:

There is also surgery. There is uvulopalatopharyngoplasty (UPPP) or Laser-Assisted Uvulopalatoplasty (LAUP) which involves removing excess tissue from the throat. The newest surgery, approved by the FDA in July 1997 for treating snoring is called somnoplasty and uses radio frequency waves to remove excess tissue. Recent studies demonstrate that these procedures are effective in the treatment of primary snoring, and in select cases for the treatment of obstructive sleep apnea (OSA). Particularly, UPPP is effective in treating children and adolescents with OSA secondary to enlarged tonsils.

What are the signs and symptoms of Obstructive Sleep Apnea?

If you or someone you know snores regularly and has one or more of the following symptoms, it may be Obstructive Sleep Apnea:Snoring, interrupted by pauses in breathing

  • Gasping or choking during sleep
  • Restless Sleep
  • Excessive sleepiness or fatigue during the day
  • Poor judgment or concentration
  • Irritability
  • Memory loss
  • High blood pressure
  • Depression
  • Obesity
  • Large neck size (>17″ in men; >16″ in women)
  • Crowded airway
  • Morning headache
  • Sexual dysfunction
  • Frequent urination at night

What should you do if you suspect you may have Obstructive Sleep Apnea?

See your doctor; evaluation by a doctor specializing in sleep disorders is recommended. Have a sleep study done; a sleep study can provide the doctor with information about how you sleep and breathe. This information will help the doctor to determine your diagnosis and treatment options.

What is the treatment for Obstructive Sleep Apnea?

The most common treatment for Obstructive Sleep Apnea is CPAP (Continuous Positive Airway Pressure), pronounced “see-PAP.” Other less common treatments include surgery and oral appliances, which may be effective in certain individuals. Any treatments should include weight loss if needed, exercise, and avoidance of alcohol, sedatives, and hypnotics.

— Dee S., Lafayette, L.A.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Insomnia

Trouble falling asleep or staying asleep, commonly termed insomnia, plagues one in three American adults. If you have ever suffered from insomnia, you know how it can disturb your waking, as well as your sleeping, hours. It can make you feel sleepy during the day or have trouble focusing on tasks.

Looking at both the day and the night effects of insomnia can help you and your healthcare professional understand the causes and treat the disorder. More research into psychological, lifestyle, environmental and physical/psychiatric factors behind sleep disorders is making it possible for healthcare professionals to help most troubled sleepers.

What are Some Types of Insomnia?

Insomnia can occur in people of all ages, usually just for a night or two, but sometimes for weeks, months, or even years. Insomnia is most common among women and older adults.

Transcient Insomnia:

Transcient insomnia is the inability to sleep well over a period of a few nights, but lasts less than four weeks. This type of insomnia is usually brought on by excitement or stress. Children, for example, may toss and turn just before school starts in the fall, or before an important exam or sports event. Adults often sleep poorly before an important business meeting or after an argument with a family member or close friend. People are more likely to have trouble sleeping when they are away from home, especially if try have traveled across time zones. Working out too close to bedtime (within four hours) or being sick can also cause this type of insomnia.

Short-term Insomnia:

Periods of ongoing stress at work or at home can result in four weeks to six months of poor sleep. When the stressful situation eases up, or when the sleeper adjusts to it, sleep will usually return to normal.

Chronic Insomnia:

More than 20 million Americans complain of chronic insomnia — poor sleep every night or most nights for more than six months. While most insomniacs worry about their sleep, it’s wrong to blame all troubled sleep on worrying. According to a nationwide study by the Associated of Sleep Disorders Centers, physical ailments — such as disorders of breathing or muscle activity — are often mistaken for insomnia and may account for a large number of sleep-diagnosed cases of insomnia.

What Causes Insomnia?

Insomnia is a symptom of another problem, much like a fever or a stomachache. It can be caused by any of a number of factors.

Psychological Factors

Vulnerability to Insomnia: Some people seem more likely than others to experience insomnia during times of stress, just as some people might tend to have headaches or easily get upset stomachs. Knowing that you may experience insomnia and that it will not last long can be helpful in dealing with what happens.

Persistent Stress: Relationship problems, a chronically ill child, or an unrewarding career may contribute to sleep problems. If you suffer from these types of stress you should seek counseling to gain a new outlook on your troubles and to gain more control in your life.

Learned Insomnia (also known as primary insomnia): If you sleep poorly during times of stress, you may worry about not being able to function well during the day. You may decide to try harder to sleep at night but, unfortunately, this determined effort can make you more alert and set off a new round of worried thoughts, causing sleep loss. Activities in and around the bedroom — changing into your nightclothes, turning off the lights, and pulling up the blankets — can also encourage wakefulness. Some people who have trouble sleeping in their own beds may fall asleep quickly when they don’t intend to — while reading the newspaper, watching TV, or driving. Even a few nights of poor sleep during a month can be all it takes to produce a cycle of poor sleep and increase your worry about it. Treatment for learned insomnia aims to improve sleep habits and reduce unnecessary worry.

Lifestyle

Use of Stimulants: Caffeine near bedtime, even when it doesn’t interfere with your falling asleep, can trigger awakenings later in the night. Nicotine is also a stimulant, and smokers mat take longer to fall asleep than non-smokers. You should also be aware that the ingredients in many common drugs (including nonprescription drugs for weight loss, asthma, and colds) could disrupt your sleep.

Use of Alcohol: You may think that have a glass of wine will help you sleep. But alcohol, while it may help you fall asleep quickly, is likely to make your sleep more broken throughout the night.

Erratic Hours: If you do shift work (work non-traditional hours, such as nights or rotating shifts), or maintain late hours on weekends than during the week, you are more likely to experience sleep problems. Maintaining regular hours can help program your body to sleep at certain times and to stay awake at others. Establishing a routine is important.

Inactive Behavior: You may think that a quiet lifestyle would be healthy, but people whose lifestyles are very quiet or restricted may find it difficult to sleep at night because of their inactivity during the day.

Misuse or Overuse of Sleeping Pills: If you use sleeping pills every night, they will stop helping you after a few weeks. If you stop using them suddenly, however, your sleep may be temporarily worse. This problem can be reduced by cutting back gradually on the use of sleeping pills. Your healthcare professional should oversee this process. Studies have recently found that after gradual withdrawal of sleep medication, a person’s sleep is no worse than when the individual was taking sleeping pills.

Environmental Factors

Noise: Passing traffic, airplanes, television and other noises can disturb your sleep even when they don’t cause you to wake up.

Light: Light comes through your eyelids even when your eyes are closed.

These factors should be considered even though you thought you slept soundly all night.

Physical/Psychiatric Illness

Other sleep disorders and physical illnesses may occur during sleep, disrupt sleep, and produce symptoms that can easily be mistaken for insomnia. These other disorders require medical attention and common treatments for insomnia will not help them.

Psychiatric Problems: Insomnia — especially with awakenings earlier than desired — is one of the most common symptoms of depression. If you suffer from a psychiatric disorder you may sleep poorly. Treatment of the underlying disorder, often including both medication and psychotherapy, can help improve your sleep.

Breathing Disorders: Certain disorders can cause repeated pauses in breathing during sleep. This can wake a sleeper dozens or even hundreds of times a night. Pauses can be as short as 10 seconds and may no be remembered in the morning. They are sufficient, however, to produce restless sleep. Severely disrupted breathing during sleep (sleep apnea) may affect people who breathe normally while they are awake. Breathing-related sleep problems are most common in men, overweight people, and older adults.

Severe cases of sleep apnea often benefit from a treatment known as positive airway pressure (PAP). This treatment keeps the breathing passages open with a steady stream of air flowing through a mask worn over the nose and mouth during sleep.

Period Leg Movements: Brief muscle contractions can cause leg jerks that last a second or two and occur roughly every 30 seconds (often for an hour or longer) several times a night. These movements can cause hundreds of brief interruptions of sleep each night, resulting in restless sleep. Periodic limb movements become more frequent and sever are we grow older. Treatment can include medication, evening exercise, a warm bath, or a combination of these. Iron replacement may be helpful if you have an iron deficiency, especially if you also experience restless legs.

Waking Brain Activity that Persists During Sleep: Sleep monitoring during the night has shown that some people who complain of light or less restful sleep fail to sink fully into sleep.

Gastro Esophageal Reflux: Back up of stomach contents into the esophagus can awaken a person several times a night. This is commonly known as heartburn because of the pain or tightness it produces in the mid-chest area. When reflux occurs during the day, a few swallows and an upright position will usually clear the irritating materials from the esophagus. During sleep, less frequent swallowing and a lying-down position causes more reflux, making the sleeper wake up coughing and choking. If you experience this problem, try elevating your head, or raise the head of the bed (head-board) on 6- to 8-inch blocks. Medications can also provide relief.

What is Secondary Insomnia?

When insomnia is caused by a psychiatric disorder (most often depression) or a medical disorder (most often chronic pain) it is termed secondary insomnia. Secondary insomnia may be relieved by successful treatment of the primary psychiatric/medical disorder. Or direct treatment of the secondary insomnia with behavioral methods (described below may be successful and may provide some relief for the “primary” disorder.

When Should I Seek Help?

If you sleep has been disturbed for more than a month and interferes with the way you feel or function during the day, see your healthcare professional, or ask for a referral to a sleep disorders specialist. Your medical history, a physical exam, and some blood tests may help identify certain causes. Your bed partner and other household members may have useful information about your sleep, such as whether you snore loudly or sleep restlessly. Your healthcare professional will also need to know whether insomnia makes you sleepy or depressed or affects your life in other ways.

Sometimes insomnia can be helped through education and information. Some people naturally sleep less than others, and merely need to give up the idea that everyone needs eight hours. Counseling can help people whose insomnia stems from poor sleep habits. In other cases, medication or evaluation at a sleep disorders center may be recommended.

If you are advised to get an evaluation at a sleep disorders center, you may be asked to keep a sleep diary showing sleeping and waking patterns for a week or two. If you attend a sleep center, you can expect thorough physical and psychological examinations.

Can Sleeping Pills Help?

Sleeping pills offer sounder sleep and can improve alertness the following day, but this relief is only temporary. Sleeping pills are not a cure for insomnia. Sometimes sleeping pills can be dangerous when treating insomnia symptoms that may arise from another disorder, such as that resulting from breathing disorders. Insomnia needs to be properly diagnosed and treatment options discussed with a healthcare professional before treatment with medications is undertaken.

There are many classes of sleeping pills, including over-the-counter medications that are mainly sedative antihistamines. Different types of medications vary with respect to their advantages and disadvantages. For example, some are ‘short-acting’ and works best for trouble at first falling asleep. Others are ‘long-acting’ and work best for maintaining sleep in the middle of the night. Consult your physician to find out which kind of sleep medication is best for you. Sleeping Pills May Help with the Following Conditions: Jet Lag: Change of several hours in sleep and wake times can trigger both insomnia and daytime sleepiness. For one to three nights, while the body adjusts to time zone changes, taking a sleeping pill may improve sleep and minimize daytime fatigue.

Shift Work Schedule Changes that Affect Sleep Time: Shift workers sometimes find sleeping pills make it easier to fall asleep and stay asleep for one to three nights during a shift change. This may prevent chronic “occupational jet lag.”

Acute Stress: Sleeping pills may prevent persistent sleep problems by helping people prone to insomnia through stressful times, such as a death in the family or the start of a new job.

Predictable Stress: People who always toss and turn the night before a monthly sales meeting or before giving a speech may rest better if they take a sleeping pill at such times.

Chronic Insomnia: Having sleeping pills on hand can help ease poor sleepers through periodic flare-ups and reduce the worry that goes along with sleeplessness. It is important to know that sleeping pills work best when they are used for short periods, usually less than three weeks.

What are Some Behavioral Treatments?

There are four suggested behavioral treatments that have been well-tested with insomnia. These are usually given by sleep specialists.

Sleep restriction: aims to shrink the margin between bedtime and morning awake time so that the sleep period follows your own biological sleep need. Insomniacs may stay in bed hoping this will produce more sleep time. Instead, excess time in bed spreads sleep over a longer period, breaks up sleep, and increases frustration.

Stimulus control: Seeks to set up the bedroom as an inviting setting for sleep. For some, the bedroom becomes a place things such as paper work and worrying take place. These activities and thoughts are at odds with sleep. At bedtime, these associations encourage wakefulness. Stimulus control procedures remove non sleep-related activities, including awake time in bed, from the bedroom. This is done in order to improve the chances of falling asleep quickly.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Narcolepsy

What is Narcolepsy?

Narcolepsy can be defined as excessive drowsiness during the day with a tendency to sleep at inappropriate times. The sleep episodes of narcolepsy are sometimes brought on by highly stressful situations and are not completely relieved by any amount of sleep.

Although narcolepsy is a fairly uncommon condition, its impact on a person’s life can be serious and — if not recognized and appropriately managed — disabling. Recent advances in medicine, technology and pharmacology (the study of the effects of drugs) are helping health care providers to recognize and treat this condition. A cure for narcolepsy has not yet been found, but most people with this disorder can lead nearly normal lives if the condition is properly treated.

What are the Symptoms of Narcolepsy?

The four most common symptoms of narcolepsy are excessive daytime sleepiness, cataplexy (sudden loss of strength in the muscles), sleep paralysis, and hypnagogic hallucinations (hallucinations that occur just before falling asleep, during naps and/or on waking up). In most cases, excessive daytime sleepiness is the most bothersome symptom. The symptoms of narcolepsy can appear all at once or can develop gradually over many years.

Excessive Daytime Sleepiness (EDS):

EDS is usually the first symptom of narcolepsy. People with narcolepsy often report feeling easily tired and sleepy all the time. They tend to fall asleep not only in situations in which many people normally feel sleepy (after meals or during a dull lecture), but also when most people would remain awake (while watching a movie, writing a letter, or driving). People with narcolepsy may become drowsy or feel foggy at very unusual times or when drowsiness is dangerous.

Cataplexy:

Attacks of cataplexy — sudden, brief losses of muscle control — are sometimes the first symptom of narcolepsy, but more often develop months or years after the onset of sleepiness. Cataplexy can be mild — such as a brief feeling of weakness in the knees — or it may cause a complete physical collapse, resulting in a fall. A person having such an attack is fully awake and knows what is happening. Cataplexy is usually triggered by strong emotion, such as laughter, anger or surprise. In some individuals, attacks can be caused by simply remembering or anticipating an emotional or anxiety-producing situation.

Sleep Paralysis:

Sleep paralysis is a brief loss of muscle control that occurs when a person is falling asleep or waking up. The person may be somewhat aware of the surroundings, but is unable to move or speak. Sleep paralysis, unlike cataplexy. Usually disappears when the person is touched.

Hypnagogic Hallucinations:

Hypnagogic hallucinations are vivid dreamlike experiences that occur when a person is drowsy. The hallucinations may involve disturbing images or sounds, such as strange animals or prowlers. These can be frightening because the person is partly awake but has control over the events. The dreams can also be upsetting if they are mistaken for the hallucinations or the delusions of mental illness.

Other Symptoms of Narcolepsy

Automatic Behaviors:

Automatic behaviors are routine tasks performed by a person who is not consciously controlling the activity. Sometimes a person may actually fall asleep and continue an activity, but not remember it after waking up. Automatic behaviors cam be dangerous if a person is involved in a potentially hazardous activity, such as driving or cooking.

Disturbed Nighttime Sleep:

This symptom often occurs in people with narcolepsy. A person who has trouble staying awake during the day may also have trouble staying asleep at night. The problem of daytime sleepiness is made worse by the many nighttime awakenings.

Other symptoms reported by people with narcolepsy include double vision, an inability to concentrate, and memory loss. Children with this disorder are often unable to keep up with their friends or schoolwork, and adults may be unable to fulfill normal obligations relating to work or family. Some people with narcolepsy also complain of headaches, dizziness snoring, sexual problems, and weight gain even though these symptoms are not caused by the disorder.

What Causes Narcolepsy?

Although the exact cause is not known, narcolepsy appears to be a disorder of the part of the central nervous system that controls sleep and wakefulness. Cataplexy and sleep paralysis are similar to the loss of muscle tone that accompanies normal dreaming in a stage of sleep called REM. In people with narcolepsy, however, these events (the lack of muscle tone and the dream experiences) occur at inappropriate times.

Narcolepsy is not caused by psychiatric or psychological problems. Narcolepsy sometimes runs in families, but many people with narcolepsy do not have relatives who are affected. Some researchers have suggested that certain genes, combined with other factors in a person’s life, may cause the disorder.

How is Narcolepsy Diagnosed?

The first step in the diagnosis of this disorder should be an evaluation by a sleep specialist.

At a sleep disorders center, the specialist will thoroughly review the person’s medical history and perform a complete physical examination. If the specialist suspects narcolepsy, the patient may be asked to undergo testing at the sleep center. Two tests, a polysomnograph and a multiple sleep latency test (MSLT), are commonly performed to confirm the diagnosis of narcolepsy and determine its severity.

During a polysomnograph, the patient is asked spend the night at the sleep center in a comfortable and private room. Small electrodes are attracted to the skin with a jellylike substance. The electrodes record brain waves, muscle activity, heart rate, and eye movements. The procedure is painless and the patient is asked to sleep as normally as possible. This test helps determine whether the patient has other disorders that may be contributing to the symptoms.

The MSLT is conducted the following day. With the electrodes still in place, the patient is asked to take four or five 20-minute naps at two-hour intervals. The MLST will monitor the patient’s sleep patterns, since people with narcolepsy tend to have different sleep patterns than people without the disorder with narcolepsy, REM (dreaming) sleep often begins soon after the patient falls asleep. Consequently, these two tests – together with the patient’s symptoms – help the sleep specialist determine whether the symptoms are caused by narcolepsy or by another disorder that shares some of its features.

How is Narcolepsy Treated?

Although narcolepsy cannot yet be cured, its symptoms can usually be controlled or improved so that sufferers experience symptoms less frequently and lead fairly normal lives. Because the array of symptoms is different in each person, the patient and sleep specialist must work together to plan a course of treatment. A treatment plan can have several important parts: medication, behavior treatment, and management of the patient’s environment.

Medication:

Over-the-counter medications containing caffeine usually do not work well in narcolepsy. However, prescription medications are available and can be effective in controlling excessive daytime sleepiness, cataplexy, hallucinations, and sleep disruptions. The patient and healthcare provider must work together to find the best balance between control of the symptoms and unwanted side affects of a drug.

Behavior Treatment:

Treatment for narcolepsy often requires not only medication, but also adjustments in lifestyle. The following suggestions can bring substantial improvement for some narcoleptics.

  • Follow a regular sleep/wake schedule. Go to bed and get up approximately the same time each day.
  • Take short naps once of twice each day, as needed.
  • Be cautious during activities that can be dangerous, such as driving or cooking, try to plan your schedule so that you will be alert at these times.
  • Carefully follow the healthcare provider’s instructions regarding medications. Immediately inform him or her of any changes or problems with medications.

Management of the Environment:

Narcolepsy can be difficult to mange if the patient’s family, acquaintances, and co-workers do not understand the disorder. Daytime sleepiness may be mistaken for laziness, depression, or lack of ability. The signs of cataplexy and dreaming during wakefulness may be mistakenly seen as a psychiatric problem.

People with narcolepsy, together with their doctors and counselors, can do the following: educate family members. A spouse or family members who have felt neglected of take advantage of can be reassured once they understand that the person’s behavior is not willful or crazy. The support of family is an important step in learning to cope with this disorder.

Let friends know about the disorder. Making certain accommodations at work can help a narcolepsy sufferer continue to be productive employee.

Find a narcolepsy support group. Knowing that other individuals share this disorder can help.

If narcolepsy interferes with the ability to work, look into financial benefits that may be available.

If the person suffering from narcolepsy is a child, make sure his or her teachers know about the disorder. Small adjustments in the classroom can make a tremendous difference in terms of the child’s self-esteem and ability to obtain a good education.

— Dee S., Lafayette, L.A.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Restless Legs Syndrome

What is Restless Legs Syndrome?

Restless Legs Syndrome is a movement disorder. It involves an intense urge to move your legs at bedtime. RLS symptoms vary from person to person. These symptoms can be hard to describe. Many people say their legs feel “creepy” or “crawly.” This is quite different from the pain of a muscle cramp. The uncomfortable sensations of RLS appear most often in the calves of the legs. They are usually worse when sitting or lying still. You can find temporary relief by stretching or moving the legs. Some people also have symptoms in the arms and other parts of the body.

Some people with RLS have symptoms only at certain times. Others have them on a regular basis. Nightly symptoms can create a constant need to stretch or move the legs. This may prevent you from falling asleep or staying asleep. As a result, people with RLS often have poor sleep quality. They may be very tired during the day. They also may be unable to perform well at work or take part in social activities.

Sleepiness is only one daytime problem that RLS causes. RLS symptoms also can make it hard to travel by car or airplane during the day. This is because it is hard to sit still for long periods of time. RLS also may interfere with your ability to stay seated at movies, concerts, and in business meetings. The sleep loss and disturbance of daytime activities can even lead to anxiety and depression.

Most people with RLS also have periodic limb movements (PLMs). These movements tend to consist of an extension of the big toe. This occurs together with an upward bending of the ankle, knee, or hip. The movements are sometimes described as jerks or kicks. PLMs occur at regular intervals. They usually happen every 20 to 40 seconds. They also tend to occur in clusters in the first half of the night. PLMs usually occur in the legs but may also affect the arms. PLMs occur most often when you are asleep. You are unaware of them and you have no control of them. On rare occasions you may notice the PLMs while you are still awake. In contrast, RLS may cause movements when you are awake. They are a voluntary response to uncomfortable feelings in your legs.

Like RLS, PLMs may contribute to poor sleep quality. These leg movements often cause you to briefly wake up from your sleep. These brief awakenings are called “microarousals.” They can cause your sleep to feel unrefreshing or disturbed. You also may find yourself falling asleep easily during the day. This can occur while you are reading, watching TV, working or driving. PLMs also may disturb the sleep of your bed partner. He or she may complain of being kicked or bumped during the night. Your leg movements may also twist or pull the covers off bed.

RLS often appears in otherwise healthy people. It can occur at any age in both men and women. Between five and 15 of every 100 people have the discomfort of RLS at some time in their lives. It may come and go over the years without any obvious cause. It occurs more often in women and in older people. Recent reports show that it can affect children. RLS in children may be called “growing pains” by mistake. Children with RLS also may be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD). RLS causes them to be restless and inattentive. RLS also can be severe during pregnancy, especially during the last six months. Studies show that more than 80% of people with RLS also have PLMs. But the majority of people with PLMs do not have RLS.

What Causes RLS?

RLS may be hard to describe, but it is not a psychological or emotional condition. Researches are unsure of its exact cause. Current studies are focused on a brain chemical known as dopamine. Medications that increase dopamine in the brain have been effective at relieving RLS symptoms.

Some people have medical conditions that seem to increase the chance of developing RLS. These conditions include the following:

  • Low blood iron levels
  • Poor blood circulation in the legs
  • Nerve problems in the spine or legs
  • Muscle disorders
  • Kidney disorders
  • Alcoholism
  • Certain vitamin or mineral deficiencies

RLS may also be inherited from a parent. If you have this form of RLS there is a good chance other members of the family are affected. About 50% of people with RLS who don’t have one of the medical conditions listed above have a family member with similar symptoms. This strongly suggests a “hereditary” cause for this disorder in some people. For unknown reasons, hereditary cases of RLS tend to be more sever and harder to treat.

No matter what the cause, some medications may trigger RLS. These include over-the-counter allergy and cold medications. Caffeine, alcohol, and tobacco use may make the condition worse.

How is RLS Diagnosed?

You may need to see a sleep specialist or neurologist who has expertise with RLS. There is currently no blood test or x-ray that detects RLS. Your doctor will base a diagnosis on a complete medical history and physical exam. Additional tests may help determine if your complaints are related to another medical condition. These tests might include blood work, x-rays or an overnight sleep study. Most of the time RLS symptoms are so unique that the diagnosis will be obvious.

Having all of these symptoms clearly indicates that you have RLS:

  1. You have an intense urge to move your legs.
  2. You have unpleasant sensations in your legs that you might describe with these words: creeping, crawling, pulling, tingling, or electric feelings.
  3. Symptoms are worse when resting or inactive, especially when sitting or lying down.
  4. Moving your legs relieves the symptoms.
  5. Symptoms are worse in the evening or at bedtime.

How is RLS Treated?

The first step in treating RLS is to see if you have any other conditions that are related to the problem. Other conditions that might be related to RLS include the following:

  • Iron deficiency anemia
  • Diabetes
  • Arthritis
  • The use of medications

Detecting and treating these conditions may sometimes relieve the symptoms of RLS. For many people with RLS, their symptoms continue even after they receive treatment for other conditions. Other people may have inherited a form of RLS that is not caused by any other disorder.

Home remedies are enough to help some people with mild or occasional RLS. These remedies include:

  • Hot baths
  • Leg Massage
  • Applied Heat
  • Ice Packs
  • Aspirin or other pain relievers
  • Regular exercise
  • The elimination of caffeine

Some people also find that staying mentally active in the evening relieves their symptoms. They might do crossword puzzles or play a board game.

When symptoms are severe or home remedies are ineffective, you can take prescription medications to treat RLS. Some people respond better to certain medications than to others, so your doctor may have you try several drugs over a period of time. Several factors will affect the success you have with any of these drugs. The severity of your condition will be important. Other medical problems that you have will also be a factor. Other medications that you take will have an impact on your treatment success. All medications have potential side-effects. A doctor needs to carefully monitor your treatment for RLS.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Circadian Rhythms

What Are Circadian Rhythms?

Circadian rhythms influence our body temperature, sleep and wakefulness, and various hormonal changes. Sunlight and other time cues help to set our circadian cycles so they are constant from day to day. For most people the length of a complete cycle is very close to 24 hours.

Circadian rhythms are coordinated by small nuclei (centers) at the base of the brain, the suprachiasmatic nuclei (SCN). The SCN is connected to other parts of the brain and helps control the body’s temperature, hormone release, and many other functions. A pathway runs from our eyes to the SCN, and light seems to play the largest role in setting our circadian clocks. Interestingly, blind people often report problems with circadian rhythms, since it is difficult for them to get the time cues needed to set their circadian clocks. Other factors that may affect the SCN and the setting of the circadian clock include exercise, hormones, and medications.

In healthy people, the various circadian rhythms are “in tune” like the many instruments of an orchestra. Body temperature, for example, starts to rise during the last hours of sleep, just before waking up. This seems to promote a feeling of alertness in the morning. In the evening, body temperature decreases in preparation for sleep. A drop in temperature also occurs in most people between 2:00 and 4:00 p.m., which may explain why many people feel sleepy in the early afternoon. Although it has not been proven that changes in our body temperature determine our sleep habits, there does appear to be a relationship between the two.

What Causes Circadian Rhythm Disorders?

To a large extent, an individual’s circadian system seems to be determined by genetics. Age-related changes in the circadian system also appear to affect the natural rhythm and ability to respond to time cues. These factors can lead to a conflict between the body’s sleep signals and the demands of society. We are just beginning to understand how the circadian system functions, and to address problems and treatments related to the circadian system.

Sleep laboratory results show that sleep generally consists of a normal progression of stages and tends to occur in a single eight-hour block. Unfortunately, work, school, and social commitments may not coincide with a person’s natural circadian cycle. Or, if a person’s circadian rhythms changed significantly, it may become difficult to cope with society’s regular demands. Numerous circumstances or factors can cause the “circadian orchestra” to fall out of sync. The next section lists some that may be responsible.

Circadian Rhythm Disorders

Jet Lag:

The most widely experienced circadian problem is jet lag, which occurs when a person travels across several time zones. A typical flight from the United States to Europe, for example, often produces jet lag symptoms that can last for a week or longer. These include insomnia, daytime sleepiness, indigestion, irritability, and poor concentration. Some people require up to a week to adjust to new time cues; some adapt more quickly, depending on the number of time zones involved. Most of us experience a mild form of “Jet lag” twice a year during the switch to and from daylight-saving time.

Shift Work:

Shift workers are employees who work nontraditional hours, such as night shifts or rotating shifts. These workers often face problems similar to jet lag without ever leaving home.

People who work the night shift have to adjust to an unnatural schedule of working while others are sleeping and sleeping while others are awake. In addition, they may not get as much sleep during the day as daytime workers get at night. Their sleep is often fragmented during the daytime because the brain is active and programmed to be awake. People who work rotating shifts often find it difficult to get enough sleep, since their work schedules change frequently.

Delayed sleep phase syndrome (DSPS):

Some people find that they are not able to fall asleep until 2:00 or 3:00 am. and then have trouble waking up in time for work or school. Few lifestyles allow for this kind of sleep/wake schedule. This problem-which is more common in young adults than in other age groups-can interfere with employment and school, and can lead to psychological stress.

Advanced sleep phase syndrome (ASPS):

This syndrome is more common among older adults, and has only recently been recognized as a significant problem. Sleepiness usually begins in the early afternoon, and sufferers often wake up too early and then aren’t able to go back to sleep.

Because ASPS usually doesn’t interfere with working hours, society is more tolerant of this problem than of DSPS. ASPS becomes a problem, however, when sleepiness interferes with plans for evening business or social commitments. As in DSPS, lack of sleep does little to remedy this problem. ASPS sufferers would continue to wake up early even if they forced themselves to stay awake until later in the evening.

Irregular Sleep/Wake Pattern:

Some people find that their sleep/wake cycles cannot adjust to a 24-hour period, however hard they try. Bedtimes may be very irregular or continue to drift later and later, resulting in a variety of problems similar to those encountered with jet lag.

What Treatments Can Help Circadian Rhythm Disorders?

Certain adjustments to the sleep schedule can help travelers and shift workers alter their circadian rhythms. For example, those working rotating shift should on the last few days of the evening shift, delay bedtimes and wake-up times by one to two hours. As the night shift begins, workers will already be well on their way to adapting to the new schedule. Travelers and shift workers should also try the following:

  • Try to allow extra time for adjustment during a trip or when switching to a new work schedule. Don’t skimp on time for resting.
  • Depending upon the new time zone, a short nap at a specific time of day can be useful in helping overcome jet lag.
  • For most other circadian rhythm disorders the following suggestions could help:
  • In some cases, an abnormal sleep cycle can be a symptom of depression or poor sleep habits. Evaluation by a professional can lead to proper treatment.
  • Bright-light therapy is being studied as a way to shift the circadian system and reset the body’s clock. Properly timed exposure to bright lights may help advance or delay the sleep cycle.

In general, evening exposure to bright light is used to treat ASPS by shifting the circadian clock to a later hour. Morning exposure to bright light is used to treat DSPS by shifting the circadian clock to an earlier hour. If you think you suffer from this disorder, seek specific advice about this from your healthcare professional.

Some researches have explored the use of supplemental melatonin, a naturally occurring substance that increases in the bloodstream during the night. Although this form of treatment is experimental, it is believed to help promote sleep onset in some situations.

As with any other sleep disorder, talk to your healthcare professional about your symptoms and the appropriate treatment options for you.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Parasomnias

The term “parasomnia” is used in reference to a wide range of disruptive sleep-related events. These behaviors and experiences generally occur during sleep, and in most cases are infrequent and mild. At times, however, they may occur often enough or become so bothersome that medical attention is indicated.

What Are Disorders of Arousal?

The most common of the parasomnias are “disorders of arousal,” which include confusional arousals, sleepwalking (somnambulism), and sleep terrors. Experts believe that the various arousal disorders are related and share some characteristics. Essentially, these occur when a person is in a mixed state, both asleep and awake, and often emerging from the deepest state of non-dreaming sleep. The sleeper is awake enough to act out complex behaviors, but is still asleep and not aware of or able to remember these activities.

Parasomnias are very common in young children, and do not usually indicate significant psychiatric or psychological problems such disorders tend to run in families, and can be more severe when a child is overly tired, has a fever, or is taking certain medications. They may occur during periods of stress, and may increase or decrease with “good” and “bad” weeks.

Confusional Arousals:

Confusional arousals are most common in infants and toddlers, but are also seen in adults. These episodes may begin with crying and thrashing around in bed. The sleep appears to be awake, and seems to be confused and upset, but resists attempts to comfort or console. It is difficult to awaken a person in the grips of a parasomnia episode. The confusional arousal can last up to half an hour, and usually ends when the agitation subsides and the sleeper awakens briefly, wanting to return to sleep.

Sleepwalking:

This disorder is commonly seen in older children, and can range from simply getting out of bed and walking around the bedroom to prolonged and complex actions, such as going to another part of the house or even outdoors. A sleepwalker will sometimes speak, but is unlikely to be clearly understood. Sometimes complicated behaviors take place during a sleepwalking episode (such as rearranging furniture), but these activities are usually not purposeful. While injures during sleepwalking are uncommon, sleepwalkers may put themselves in harm’s way — such as walking outside in bedclothes during the winter. Simple precautions enhance safety.In most cases, no treatment is necessary. The sleepwalker can family can be assured that these events rarely indicated any serious underlying medical or psychiatric problem. In children, the number of events tends to decrease with age, although they can occasionally persist into adulthood or even originate during the adult years.

Sleep-related Eating:

A rare variation of sleepwalking is “sleep-related eating.” This disorder manifests itself as recurrent episodes of eating during sleep, without conscious awareness. Sleep-related eating can occur often enough to result in significant weight gain. Although it can affect both sexes and all ages, it is most common in young women.

Sleep Terrors:

These are the most extreme and dramatic of the arousal disorders, and the most distressing to witness. A sleep terror episode often begins with a “blood-curdling” scream or shout, and can produce signs that suggest extreme terror, such as dilated pupils, rapid breathing, racing heart, sweating, and extreme agitation. During a sleep terror episode, the victim may bolt out of bed and run around the room or house. In the course of the frenzied event, sleepers can hurt themselves or others.
As disturbing and frightening as these episodes are to an observer, the sleeper usually has no conscious awareness of the event, and generally does not remember it upon awakening.
Unlike typical nightmares or bad dreams, sleep terror episodes are not usually associated with vivid dream images and are recalled after awakening.

How Are Arousal Disorders Evaluated?

In typical childhood occurrences of arousal disorders, medical evaluation is unlikely to be needed. You should, however, contact a healthcare professional if a child’s disturbed sleep causes:
1. Potentially dangerous behavior, such as that which is violent or could cause injury; 2. Extreme disturbance of other household members;
3. Excessive sleepiness during the day. In these cases, formal evaluation at a sleep center is warranted.
Because disorders of arousal are relatively uncommon after childhood, adults suffering from these disorders can be triggered by other conditions, such as sleep apnea, heartburn, or periodic limb movements during sleep. A sleep specialist should evaluate the patient’s behaviors and medical history.

Are There Treatments for Arousal Disorders?

Clearing of obstructions, securing windows, sleeping on the ground floor, and installing locks or alarms on windows and doors can add a degree of security for the individual and the family.

In cases severe enough that the sleep disorders leads to injury or involves violence, excessive eating, or disturbance to others, treatment may be warranted. Therapy can include medical intervention with prescription drugs, or behavior modification through hypnosis or relaxation/mental imagery.

What Are Some Other Parasomnias?

While the great majority of sleep-related complex behaviors and experiences are due to disorders of arousal, simple precautions should be taken to ensure safety for people with arousal disorders. Clearing the bedroom several other conditions can be frightening or disturbing to those who experience them.

Hypnagogic Hallucinations and Sleep Paralysis:

Hypnagogic hallucinations are episodes of dreaming while awake, usually just before falling asleep. These dreams can be frightening because the setting reflects reality (for example, the bedroom), and the content of the dream is often threatening.

Sleep paralysis is the experience of waking up — usually following a dream — with a feeling that the muscles of the body (except those used to breath and move the eyes) are paralyzed. Hypnagogic hallucinations and sleep paralysis may occur together. They are common in people with narcolepsy, but can also affect others, particularly individuals who are sleep-deprived. While they can be terrifying, these events are not physically harmful.

Nocturnal Seizures:

These seizures, which occur only during sleep, can cause the victim to cry, scream, walk or run about, curse, or fall out of bed. Like other seizures they are usually treated with medication.

Rapid Eye Movement (REM) Sleep Behavior Disorder:

All body muscles — except those used in breathing — are normally paralyzed during REM sleep. In some people commonly older men, this paralysis is incomplete or absent, allowing dreams to be: acted out.” Such dream-related behavior can be violent and can result in injury to the victim or bed partner. In contrast to those who experience sleep terrors, the victim will recall vivid dreams. REM sleep behavior disorder can be controlled with medication.

Sleep Starts:

Most people experienced the common “motor” sleep start — a sudden, often violent jerk of the entire body upon falling asleep. Other forms of sleep starts can occur just as sleep begins. A “visual” sleep start is a sensation of blinding light coming from the inside the eyes or head. An “auditory” sleep start is a loud snapping noise that seems to come from inside the head. Such occurrences, while they can be frightening, are harmless.

Teeth grinding (bruxism):

Grinding of teeth during sleep is a very common occurrence, and little evidence suggests that teeth grinding is associated with any significant medical or psychological problems. In severe cases, mouth devices can help reduce the risk of dental injury.

Rhythmic-movement Disorder:

This condition, seen most frequently in young children, can also occur in adults. It takes the form of recurrent head banging, head rolling and body rocking. The individual may also moan or hum. These activities can occur just before sleep begins, or during sleep. Medical or psychological problems are unlikely to be associated with rhythmic movement disorder. Behavioral treatments may be effective in severe cases.

Sleep Talking (somniloquy):

Sleep talking is a normal phenomenon and is of no medical or psychological importance.

When Do I Ask a Healthcare Professional’s Help?

Since most of these sleep-related behaviors are due to disorders of arousal — which are not medically significant — medical evaluation and treatment is often not necessary. Medical attention should be considered however, if the parasomnia behaviors: 1) are violet or may cause injury; 2) are disturbing to other household members; or 3) result in excessive daytime sleepiness.

Where Do I Seek Assistance?

Minor sleep problems can be handled by a primary care professional, often with a telephone consultation with a sleep medicine specialist experience with these conditions. Due to the complex nature of some parasomnias, however, proper diagnosis requires expert clinical evaluation and sleep laboratory monitoring of many body functions during sleep. A sleep specialist should direct these evaluations with experience in such cases.

In most cases of bothersome parasomnias, a specific cause can be identified and effectively treated.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Depression & Sleep Apnea

For years, Mary had felt exhausted. She suffered from poor sleep and was a loud snorer. As she aged from her 20s to her 30s her athletic figure began to disappear because she lacked the motivation to exercise. Mary put on 55 lbs in 10 years, and she no longer had the energy for an active life. She was constantly drinking caffeine to stay awake, but even that stopped working. Mary also suffered from hyperhidrosis (constant sweating). In addition to her declining health, her family life began to suffer. Her husband and 3 year-old felt neglected because all she wanted to do was sleep. Mary became so withdrawn from life that she became depressed and assumed all of her symptoms

Common signs and symptoms of sleep apnea include:

  • Excessive daytime sleepiness
  • Loud, disruptive snoring
  • Irregular breathing during sleep (eg: gasping, long pauses, shallow breathing ñ a spouse or partner may notice these)
  • Restless sleep
  • Difficulty concentrating
  • Depression or irritability
  • Morning headaches
  • High blood pressure

Many people are not even aware that they have sleep apnea. Often, a bed partner is the first to witness their symptoms.

Mary was put on the standard dosage (20 mg) of several different types of anti-depressants, including Prozac© and Celexa©. Mary felt slightly better, but felt she was looking through “smoke and mirrors” and her symptoms had not disappeared.

What is sleep apnea?

Sleep apnea is a general term for breathing problems that occur during sleep. People with sleep apnea stop breathing throughout the night up to 100 times per hour.

Sleep apnea affects approximately 20 million adults, and has serious negative health effects when present with other conditions.

Sleep apnea may cause symptoms of depression. Unfortunately, many physicians may be unaware of the connection between sleep apnea and depression and may lead to a misdiagnosis of depression instead of sleep apnea. If you suffer from heart failure, high blood pressure or diabetes, treating your sleep apnea may improve all of these conditions in addition to making you feel better.

The good news is that sleep apnea can be treated easily!

Finally, Mary had a good nightís sleep. She slept upright on an airplane ride to Brazil, and didnít even snore that night. (Sleep apnea worsens when patients sleep on their back.) This helped Mary realize that her symptoms were due to a lack of sleep and not depression. Mary finally consulted a doctor who specialized in sleep disorders and had an overnight study to diagnose her sleep apnea.

Mary was prescribed a continuous positive airway pressure (CPAP) machine for her condition. After starting therapy, her quality of life improved immediately. Mary felt amazing after her first night on therapy. Her sleep apnea had completely disappeared. In addition, after one week of therapy Mary felt so much better that she began withdrawing from her depression medication. For the last three years since Mary has been on CPAP, her life has changed drastically. She has ceased taking depression medication and no longer feels depressed. She has renewed energy and eliminated most of the caffeine consumption from her diet. She has also 20 lbs because she now has the energy to exercise.

What IS CPAP therapy?

CPAP is the most widely accepted treatment for sleep apnea. A bedside device gently delivers pressurized air through a nasal mask or pillows system. This pressure acts like an “air splint” to keep the upper airway open and help prevent apneas. CPAP treatment does not involve drugs or surgery and helps hundreds of thousands of people worldwide enjoy healthier sleep and a healthier life. Many patients experience the benefits quickly-often after the first night of use. There is no cure for sleep apnea at this time.

Mary no longer feels tired or takes depression medication. Her home life has improved and her husband is thrilled she has the energy to go out to dinner and play with her children.

— Dee S., Lafayette, L.A.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Diabetes & Sleep Apnea

Harold was finally diagnosed with sleep apnea.

For years, Harold’s wife and children joked about his loud snoring that filled every room in the house at night. The family “joke” became serious when Harold’s wife started to notice long pauses in his breathing when he slept. Harold began to notice that he lacked energy nearly every day. As an advertising executive, he worked on commercial sets and would often fall asleep during his lunch break. He was no longer able to do activities he once enjoyed, like playing with his dogs. In addition, Harold found that his diabetes was affected. He became frustrated every morning when he measured his blood glucose levels and found they were unpredictably high, requiring him to take insulin injections.

Common signs and symptoms of sleep apnea include:

  • Excessive daytime sleepiness
  • Loud, disruptive snoring
  • Irregular breathing during sleep (eg: gasping, long pauses, shallow breathing ñ a spouse or partner may notice these)
  • Restless sleep
  • Difficulty concentrating
  • Depression or irritability
  • Morning headaches
  • High blood pressure

Many people are not even aware that they have sleep apnea. Often, a bed partner is the first to witness their symptoms.

Mary was put on the standard dosage (20 mg) of several different types of anti-depressants, including Prozac© and Celexa©. Mary felt slightly better, but felt she was looking through “smoke and mirrors” and her symptoms had not disappeared.

What is sleep apnea?

Sleep apnea is a general term for breathing problems that occur during sleep. People with sleep apnea stop breathing throughout the night up to 100 times per hour.

Sleep apnea affects approximately 20 million adults, and has serious negative health effects when present with other conditions.

Sleep apnea may cause symptoms of depression. Unfortunately, many physicians may be unaware of the connection between sleep apnea and depression and may lead to a misdiagnosis of depression instead of sleep apnea. If you suffer from heart failure, high blood pressure or diabetes, treating your sleep apnea may improve all of these conditions in addition to making you feel better.

The good news is that sleep apnea can be treated easily!

Finally, Mary had a good night’s sleep. She slept upright on an airplane ride to Brazil, and didn’t even snore that night. (Sleep apnea worsens when patients sleep on their back.) This helped Mary realize that her symptoms were due to a lack of sleep and not depression. Mary finally consulted a doctor who specialized in sleep disorders and had an overnight study to diagnose her sleep apnea.

Mary was prescribed a continuous positive airway pressure (CPAP) machine for her condition. After starting therapy, her quality of life improved immediately. Mary felt amazing after her first night on therapy. Her sleep apnea had completely disappeared. In addition, after one week of therapy Mary felt so much better that she began withdrawing from her depression medication. For the last three years since Mary has been on CPAP, her life has changed drastically. She has ceased taking depression medication and no longer feels depressed. She has renewed energy and eliminated most of the caffeine consumption from her diet. She has also 20 lbs because she now has the energy to exercise.

What IS CPAP therapy?

CPAP is the most widely accepted treatment for sleep apnea. A bedside device gently delivers pressurized air through a nasal mask or pillows system. This pressure acts like an “air splint” to keep the upper airway open and help prevent apneas. CPAP treatment does not involve drugs or surgery and helps hundreds of thousands of people worldwide enjoy healthier sleep and a healthier life. Many patients experience the benefits quickly-often after the first night of use. There is no cure for sleep apnea at this time.

Mary no longer feels tired or takes depression medication. Her home life has improved and her husband is thrilled she has the energy to go out to dinner and play with her children.

— Dee S., Lafayette, L.A.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Heart Disease & Sleep Apnea

Sleep and the Heart

There are two distinct types of sleep: rapid-eye-movement (REM) sleep (when most dreaming occurs), and non-REM sleep. Typically, when you fall asleep you begin in non-REM sleep and spend about 80% of the night in this type of sleep. During non-REM sleep your heart rate, breathing and blood pressure all drop to levels below those occurring while you’re awake. During REM sleep-approximately 20% of your time asleep-both your blood pressure and heart rate can fluctuate. Any time you wake up from sleep (even briefly), your heart rate and blood pressure climb, and your heart must work harder. When you wake up in the morning, your blood pressure and heart rate both go up and then stay at a higher level throughout the day.

Sleep and Heart Disease

Although all aspects of the relationship are not clear, there is definitely a direct connection among sleep, sleep disorders, and heart disease. Medical professionals have already identified an increased risk of sudden cardiac death in the first several hours after awakening, perhaps due to the increased work demand on the heart that occurs with awakening. Various studies also have clearly linked sleep-related breathing disorders with increases rates of high blood pressure and increased risk of heart disease and stroke. In fact, treating certain sleep-related breathing disorders may actually decrease a person’s chances of developing certain cardiovascular diseases.

Hypertension (High blood pressure)

Several studies have shown a link between hypertension and the presence of a disorder of abnormal breathing during sleep called obstructive sleep apnea (OSA). Not only is hypertension common in those with OSA, but evidence suggests that OSA can lead directly to the development of hypertension. People with OSA have repeated interruptions in breathing during sleep, caused by the main breathing passage in the back of the throat closing or becoming too narrow. Every time this passage is blocked, breathing stops and oxygen is used up. After awhile (usually 10-20 seconds, although up to one minute is not unusual) the breathing difficulty causes a brief awakening, often so short that the person is unaware of any interruption in sleep. The awakening relieves the blockage in the breathing passage and normal breathing resumes, at least until the person falls back asleep, when the entire process can repeat (often hundreds of times per night). The drop in oxygen level from not breathing, and the increase in heart rate and blood pressure caused by waking up, puts stress on the heart. These nightly increases in blood pressure eventually lead to permanent increases in blood pressure, even during the day.

It is important to treat hypertension since it is a known risk factor for the development of other forms of cardiovascular disease such as heart attack, heart failure, and stroke. But treating hypertension may not be enough if the key reason for a person’s high blood pressure is an unrecognized sleep disorder like OSA. Hypertension medications, for instance, may not work well if OSA remains untreated. Many people who have difficult cases of hypertension are later found to have untreated OSA and treatment of the OSA can improve hypertension. For this reason, it is important for your healthcare professional to investigate all the possible causes of your hypertension, including sleep disorders like OSA.

Coronary Heart Disease

There is a direct association between sleep-related breathing disorders and cardiovascular disease. People with OSA, for example, have been shown to have higher rates of coronary artery disease (CAD). There are several reasons why this may occur:

1. OSA increases the risk for hypertension, which is a known cause of CAD 2. The events occurring during OSA can put excessive stress on the heart and worsen existing disease.

In people with CAD, the flow of blood, which carries oxygen to the heart, is limited (due to narrowed arteries). So, if they experience OSA, their blood oxygen levels drop and their heart rate and blood pressure rise, increasing the work required of their heart. As a result, the amount of oxygen supplied to their heart decreases just as their heart is demanding more oxygen. Several research studies have shown changes indicated ischemia, or lack of blood flow, on electrocardiogram during apneas in people with CAD. In people who have had heart attacks, OSA is more likely to occur and may negatively affect their recovery. Studies have shown that the presence of OSA increases the risk of death from CAD. However, if recognized, treatment of OSA reduces death due to CAD.

Congestive Heart Failure

Congestive Heart Failure occurs when the heart is damaged so much that it is unable to pump blood effectively. Disorders of sleep and breathing can both cause heart failure and develop as a result of heart failure. Studies have shown that OSA is a significant risk factor for the development of congestive heart failure. In addition, people who have heart failure from another condition, such as coronary artery disease or hypertension, risk worsening their congestive heart failure if they develop OSA. The heart muscle, already in a weakened state, is unable to handle the additional stress caused by the OSA. However, treating OSA can improve heart function in patients with congestive heart failure.

In CSA there are repetitive episodes of interruptions in breathing during sleep, just like in OSA. However, in CSA the breathing passage remains open but the person stops making efforts to breathe. Frequent awakenings and drops in the level of oxygen in the blood also occur in CSA. The awakenings increase heart rate and blood pressure, which can worsen heart failure, in turn leading to more CSA and causing a vicious cycle that decreases heart function. The first approach to treating CAS is to prevent it by treating the heart failure as thoroughly as possible. If CSA is still present, treatments are available to correct the CSA. Treatment of CSA can improve heart function as well as improve sleep quality.

Stroke

During a stroke the brain is damaged when the supply of blood and oxygen is reduced or cut off. Hypertension is the most common cause of stroke, and, as stated above, OSA can lead to the development of hypertension. In addition, OSA May cause strokes directly since blood flow to the brain is reduced and the level of oxygen drops during apneas.

Abnormal breathing patterns during sleep, especially OSA are also more common immediately following a stroke. And, other effects of OSA, such as excessive sleepiness from disrupted sleep and impaired thinking, may hamper a person’s recovery from a stroke.

Effects of Heart Disease on Sleep

As outlined above, sleep-related breathing disorders can directly cause heart disease. Yet there are effects of heart disease on sleep that, though more subtle, are also important to address. For instance, patients with congestive heart failure often report difficulty falling asleep or staying asleep because of the shortness of breath that often accompanies heart failure. This shortness of breath is often worse when he patient lies down because blood in the legs flows back into the heart and can overwhelm its’ ability to pump. Doctors call these symptoms orthopnea (shortness of breath when lying down) and paroxysmal nocturnal dyspnea (waking up from sleep short of breath). The patients who experience these symptoms may feel like they have insomnia sine their sleep is interrupted. In addition to experiencing these complications from heart disease, patients often worry about the long-term consequences of a heart attack or chronic heart disease. Such anxiety, by itself, can lead to the development of chronic insomnia. Taking into consideration all of these plus the direct relationship of numerous heart conditions with sleep-related breathing disorders, it is clear that people with heart conditions need to take special care and seek medical attention in order to ensure their ability to sleep well

Good Sleep = A Healthy Heart

Many things can be done to maintain a healthy heart: eat a nutritional diet, maintain a healthy weight, exercise regularly, get regular medical check-ups, and get adequate amounts of good quality sleep. If you have any kind of heart condition, it is especially important to watch for signs that you may have a sleep-related breathing disorder, such as OSA, which could stress your heart. People with OSA are often overweight and experience loud snoring, gasping, or choking episodes while sleeping, as well as trouble staying awake during the daytime. If you already have hypertension or cardiovascular disease (coronary artery disease, angina pectoris, stroke), talk with your healthcare professional about whether or not you may have a sleep and breathing disorder, such as OSA or CSA. It is also important that patients with congestive heart failure be monitored for CSA and other sleep disorders. In contrast to people with OSA, those with heart failure and CSA are commonly thin and may not snore at all.

If your healthcare professional thinks that you have a sleep disorder, he or she may suggest you have a diagnostic test, called a sleep study, or refer you to a sleep medicine specialist. Sleep studies are usually done in a sleep laboratory. Small sensors called electrodes are attached to your body to measure your sleep, breathing, heart rate, and oxygen level. The sleep specialist will be able to determine whether you have any abnormalities in the quality of your sleep. Your healthcare professional is then given the results and the two of you can decide on the best course of treatment. Sleep disorders are treatable, and treatment can lead to a more healthy heart.

Heart Conditions Associated with Sleep-Related Breathing Disorders

  • Hypertension
  • Coronary Artery Disease
  • Congestive Heart Failure
  • Stroke

Symptoms of Obstructive Sleep Apnea

  • Loud snoring
  • Gasping or choking episodes while sleeping
  • Witnessed episodes of stopped breathing while asleep
  • Excessive sleepiness
  • Falling asleep at inappropriate times
  • Driving or workplace accidents
  • Trouble concentrating, irritability, depression
  • Morning headaches

Symptoms of Central Sleep Apnea

  • Symptoms of congestive heart failure
  • Shortness of breath
  • Difficulty breathing while lying flat
  • Restless sleep
  • Waking up gasping or short of breath
  • Witnessed episodes of stopped breathing while sleeping
  • Unrefreshing sleep
  • Snoring may be absent

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Heart Failure & Sleep Apnea

A Case of Sleep Apnea and Heart Failure

For years Jerry had been taking medication for his heart problems. He suffered from atrial fibrillation-a constant fluttering of the heart and was diagnosed with heart failure. Jerry also suffered from poor sleep. He was constantly tired and often fell asleep while driving. However, Jerry was very reluctant to go to the doctor and seek treatment

Sleep and Heart Disease

Although all aspects of the relationship are not clear, there is definitely a direct connection among sleep, sleep disorders, and heart disease. Medical professionals have already identified an increased risk of sudden cardiac death in the first several hours after awakening, perhaps due to the increased work demand on the heart that occurs with awakening. Various studies also have clearly linked sleep-related breathing disorders with increases rates of high blood pressure and increased risk of heart disease and stroke. In fact, treating certain sleep-related breathing disorders may actually decrease a person’s chances of developing certain cardiovascular diseases.

Courtesy of American Academy of Sleep Medicine (www.aasmnet.org)

How To Sleep Well

The following are some general guidelines that help promote sleep wellness. Please speak to your healthcare provider for more information.

  1. Maintain a regular wake time, even on days off work and on weekends.
  2. Try to go to bed only when you are drowsy.
  3. If you are not drowsy and are unable to fall asleep for about 20 minutes, leave your bedroom and engage in a quiet activity elsewhere. Do not permit yourself to fall asleep outside the bedroom. Return to bed when, and only when, you are sleepy. Repeat this process as often as necessary throughout the night.
  4. Use your bedroom only for sleep, sex and times of illness.
  5. Avoid napping during the daytime. If you nap, try to do so at the same time every day for no more than one hour. Mid-afternoon (no later than 3:00pm) is best for most people.
  6. Establish relaxing pre-sleep rituals such as a warm bath, light bedtime snack, or ten minutes of reading.
  7. Exercise regularly. Confine vigorous exercise to early hours, at least six hours before bedtime, and do mild exercise at least four hours prior to bedtime.
  8. Keep a regular schedule. Regular times for meals, medications, chores, and other activities help keep the inner clock running smoothly.
  9. While a light snack before bedtime can help promote sound sleep, avoid large meals.
  10. Avoid ingestion of caffeine within six hours of bedtime.
  11. Do not drink alcohol when sleepy. Even a small dose of alcohol can have a potent effect when combined with tiredness.
  12. Avoid the use of nicotine close to bedtime or during the night.
  13. Sleeping pills should be used conservatively. Most doctors avoid prescribing sleeping pills for periods longer than three weeks.
  14. Do not drink alcohol while taking sleeping pills or other medications.

Courtesy of the American Academy of Sleep Medicine (www.aasmnet.org)

Stimulus Control

Stimulus control is a measure of behavioral management in the treatment of Insomnia. It simply means adjusting your pattern of behavior to promote a regular sleep schedule and refreshing sleep.

Stimulus Control Instructions:

  1. Go to sleep only when you feel sleepy.
  2. Do not use your bed or bedroom for anything except sleep (sexual activity is the only exception).
  3. If you have not fallen asleep within approximately 20 minutes, get up and go into another room.
  4. Engage in relaxing activities, such as non-work related light reading, and go back to bed when you feel sleepy or are ready for sleep. If you cannot fall back to sleep, repeat step 3.
  5. Set your alarm for the same time each morning.

Sleep Tips

Falling Asleep:

If you can’t get to sleep, rather than trying harder and harder to fall asleep, try getting out of bed and doing something else. Preferably, move to another room and return to bed only when sleepy. If you have trouble getting to sleep, establish a routine for an hour or so each night before bedtime, such as reading, taking a warm shower or bath, light exercise, or resting quietly. Avoid too much mental stimulation during the hour or so prior to bedtime. Read a light novel or watch a relaxing TV program; do not finish office work or discuss family finances with your spouse, for example.

Stress:

Almost everyone experiences an occasional night of lost or disturbed sleep. It is a natural, perhaps adaptive, response to acute stress.

Naps:

If you are having trouble falling asleep at night avoid naps in the early afternoon or early evening.

Getting Up:

No matter how poorly you have slept the night before, always set your alarm to arise at the same time each morning.

Exercise:

Regular exercise can be an effective aid to sleep. It releases energy and mental tensions. It is better not to exercise strenuously just before bedtime.

Noises:

Occasional loud noises from aircraft, streets, or highways disturb sleep even in people who do not awaken and who cannot remember the noise in the morning. These sleep disturbances can reduce restful sleep. People who sleep near excessive noise should try heavy curtains in their bedrooms or earplugs to protect the amount of restful sleep they get.

Hunger:

Hunger may disturb sleep. A light snack especially warm milk seems to help people get to sleep.

Food:

Various foods stimulate the body and disturb sleep. Avoid coffee, tea, and cola drinks near bedtime. Avoid late heavy meals.

Sleep Patterns:

Everyone has a unique sleeping pattern. Some adults need 10 hours a night. Other adults need only 5 hours a night. Many people function best with approximately 8 hours of sleep. Your requirement for sleep is unique. What is effective for your husband, your wife, or your friends is not what may be helpful to you. If you need only 5 hours of sleep a night, do not worry about it, or try to force longer sleeping hours. Instead, learn to use your extra waking hours for something you would like to do or get done.

Quantity and Quality:

Everyone’s sleep needs change. The amount and quality of sleep varies in the course of each person’s life. The infant may require 16 hours of sleep each day, an elderly person may sleep 3 to 4 hours at night with frequent naps during the day. Changes in the length and depth of sleep are a normal part of life. within limits the quality of our sleep is more important than quantity.

Symptoms of a Medical Problem:

Sleeping problems may signal a medical condition such as anxiety, depression, and other disorders. It is important to get a proper diagnosis and treatment of the underlying cause of a chronic sleep disturbance.

Pregnancy:

Excessive sleepiness the first 3 months of pregnancy is normal don’t worry about it. Pregnant women also tend to sleep about two more hours at night.

Sleeping Medications:

An occasional sleeping pill may be of some benefit, but chronic (nightly) use of sleeping pills may actually hinder good sleep. Natural sleep is the best sleep. Sleeping medications should be used with caution and only upon the advice of a physician. They should also be avoided by elderly patients, pregnant women, people with respiratory disease, kidney disease, or a liver impairment.

If your doctor prescribes a sleep medication, ask for clear directions and information about the particular drug you are to take. Some sleeping pills have a prolonged effect, and can impair your coordination and driving skill the following day.

Sleep medications should be used only for the short term management of a sleep complaint. Do not self medicate or increase the dosage yourself. If you feel that your medication is losing its effect, report this to your doctor.

Alcohol:

Although alcohol may help to induce sleep, the chronic use of larger quantities of alcohol causes disturbed sleep and dependency on alcohol to fall asleep.

Coping With Shift Work

More than 22 million Americans are like you-working evening, rotating, or on-call shifts and facing sleep-related problems like trouble sleeping during the day and staying alert on the job. Shift work may cause you social and family problems or even physical illness. Working a schedule different from most people’s can be challenging, but following the guidelines on this webpage may make shift work easier for you to live with-and safer too.

A main reason that shift work can be challenging to your health and lifestyle is the fact that your body is so sensitive to changes in circadian rhythms. “What are circadian rhythms?” you ask. Circadian rhythms are like “messages” that tell various body functions when to kick in. Things like temperature, alertness, sleepiness, hunger, and most hormones operate at different time during a 24-hour day. In healthy adults, sleepiness tends to occur during a specific phase of the circadian rhythm, with the strongest sleep urges between 2:00 AM and 5:00 AM. If you work at night you must fight your body’s natural rhythms by staying awake when you would normally be sleepy and by trying to sleep when you would normally be awake
Some researches believe that complete adjustment to permanent irregular shift work may take as long as three years to achieve. Others believe that a person never fully adjusts to an unusual sleep/wake schedule.
Whichever is true, shift workers tend to be continually sleep-deprived (not getting enough sleep). If you are a night shift worker who sleeps during the day, your average sleep cycle may be two to four hours shorter than that of a day worker who sleeps at night. Your day sleep is probably light, interrupted, and less likely to make you feel well rested. You may even be experiencing sleep deprivation and insomnia (inability to fall asleep).

The sleep problems you face as a shift worker can be made worse if you already have some kind of sleep disorders (such as narcolepsy or sleep apnea) and/or a schedule that does not allow for you to get enough sleep each day. If you suspect that you have a sleep problem, even if it existed before you started shift work, see your healthcare professional for advice and treatment.

How Can A Sleep Problem Affect My Life?

A main way sleep loss (whether caused by shift work or a sleep disorder) can affect your life is by lessening the quality of your job performance. Numerous laboratory and field studies that sleepiness affects a person’s normal functions: memory, mental ability, motor skills, and moods. There are many examples among night workers of serious accidents caused, at least in part, by sleepiness. Two such examples include the Three Mile Island nuclear power accident and the Exxon Valdez grounding. The cost to society of sleep-related accidents is huge.

Besides such obviously harmful effects shift work, some less noticeable problems can make life difficult for shift workers. Have you ever felt that you did not have enough time for your friends or family? That you can’t make appointments or run errands? Maybe you have experienced this feeling without realizing how many activities are planned according the schedule of the average day worker, and not with your needs in mind. As a shift worker, it can be disturbing to have so many differences between your personal schedule and the rest of the worlds. Are There Treatments for Sleep Loss Related to Shift Work? Since your work setting and tasks can vary greatly from other worker’s, whether they work shifts or not, it is necessary o explore a variety of solutions and treatments to help you overcome your sleep problems. The ideal approach for someone who works in a hospital, for example, may not be best for someone who works on an assembly line. Also, some people are more naturally to working one kind of shift than another. “Night People” may adjust to the night shift better than “morning people”. Older workers in general find it harder to work nights or rotate shifts.

Several treatments appear to help with shift workers’ problems, but the approach likely to help you best depends on your individual needs and circumstances.

Work Schedules

the best work schedule is one that allows you to sleep when you are off duty and be alert when you are on duty. Of course, the best schedule for you may depend on the above-mentioned factors as well as the job and position you holds.

Work schedules that go along with your body’s circadian rhythm by rotating clockwise (from day to evening to night) are helpful. Studies have shown that changes in the work schedule that consider circadian factors are likely to lead workers to be more productive and eel more satisfied, and to reduce accidents. Your ideal schedule should be determined by your body’s natural sleep needs, by what feels “right” and helps your overall work-time-alertness.

Breaks during work hours may also increase your alertness. There is evidence that brief rest periods in certain types of jobs reduce fatigue without reducing output; in fact, breaks may actually increase your productivity and job satisfaction. Ask your employer to work with you to determine a scheduling change that could improve your job performance and make you feel less tired.

Sleep Schedules

If you are a permanent night shift worker, you should keep a regular (day) sleep schedule seven days a week, even on your days off work. Going back to a typical day schedule during time off will only make it harder for you to sleep during the day when you return to your night shift work.

If you are someone who works rotating shifts, try to adjust your sleep schedule so that you will be able to adjust more easily to a new shift time when it happens. ON the last few days of the evening shift, for example, bedtimes and arise times should be delayed by one to two hours. Then you can begin your night shift work already well on the way to being adjusted the new schedule. Family and social responsibilities may, of course make this difficult or impossible to do. Still, following this treatment approach may really help improved your life, and indirectly help your family and social relationships.

If you are an on-call shift worker, you are probably aware that your sleep problems are somewhat different from those of night shift or rotating shift workers. Because on-call workers usually can’t predict work schedules far enough in advance to plan the right sleep/wake schedule they should try to be well rested at all times. Napping may be worth trying.

Although there is some evidence that sleeping in one longer stretch is better than sleeping in several shorter periods, those of you who can’t get all of your sleep in one stretch may increase your total number of sleep hours by napping. Napping is especially helpful when naps are taken off-shift at an appropriate point in your circadian rhythm. Then napping can help offset the sleep loss associated with poor daytime sleep.

On the other hand, brief naps taken during a work shift may only increase your alertness for the moment, since your job performance can be slowed at first as a result of sleep inertia (the body’s tendency to want to remain at rest for 15 minutes to an hour after awakening). You should seriously consider the effects of sleep inertia before you decide to use napping during the work shift (say, on a break), especially if your job requires you to wake up quickly or react immediately to different situations.

While naps are not a substitute for a regular schedule of normal sleep, they can help you reduce your sleep “Debt” and improve your alertness, at least for the time being.

Sleep Aides

Shift workers often use sleeping pills (also known as hypnotics or sedatives) to override the time of day and make themselves able to sleep. There are disadvantages to using these medications, including side effects in some people. You should avoid long-term use of medication because its effectiveness may wear off over time, and you may develop a dependence on the drug. Most important, however, is the evidence that even if daytime sleep is improved with the use of sleeping pills, there will likely be only partial improvement in alertness and performance in the night shift following a worker’s dose of such a medication. Although sleeping pills may offer relief, and may be appropriate along with other treatment, they do not address the actual cause of your sleep problems. Sleeping pills cannot reset your internal clock.

If you think sleeping pills could help you once in a while, talk with your healthcare professional. Over-the-counter sleep aids are not the best choice to help you sleep since many of them cause drowsiness for several hours after you awaken, which can be unsafe.

Some people believe that alcohol helps them sleep, but that is only because of an initially sleepy feeling they might experience as a result of drinking. Alcohol is NOT beneficial to sleep. In fact if you drink alcohol when you are already tired, and in the wrong circadian phase, the alcohol may have a rebound effect, waking you within a short period of time and making it harder for you to return to sleep.

  • Stimulants:

    Studies have shown that the occasional use of stimulants, such as caffeine, can reduce sleepiness and improve your ability to be alert on a night shift. However you should avoid caffeine within four hours of your desired bedtime since it can actually cause difficulty falling asleep

  • Melatonin:

    Our brain’s natural production of melatonin appears to affect our sleep/wake cycle. Melatonin is a chemical produced by the pineal gland in the brain at night, during sleep. Research has recently begun to explore the possibility of giving a synthetic (ma-made form of melatonin to night workers in the morning to help adjust their circadian rhythms so they can sleep during the day and be awake at night. Further research is needed to determine the effectiveness of this treatment.

  • Bright Lights Therapy:

    Some recent studies have produced early evidence that timed exposure to bright light can help adjust the sleep cycle quickly. Just as the sun helps set your body’s clock, exposure to bright light may actually shift the circadian phase, reversing your sleep/wake schedule so you are able to sleep during the day and be alert on the job at night. Bright-light boxes are available from several manufacturers. Your healthcare professional can help determine the right amount of light exposure you should get to help your sleep cycles. Along the same lines night shift workers can wear sunglasses after sunrise on the trip home in order to minimize the effect of sunlight on their body clocks.

Sleep Hygiene

The best treatment may be to follow the guidelines of good sleep hygiene, especially the need to sleep in a dark, quiet room. Proper sleep hygiene requires using the bedroom only for sleep and sexual activity (not for watching TV or balancing the checkbook), keeping the room temperature cool and comfortable, relaxing before falling asleep, and having a regular routine for preparing to sleep (brushing teeth, putting on pajamas and so on. It may also be helpful to buy dark curtains for the bedroom windows, or to wear eyeshades for sleep. You may find it helpful to use “white noise” (produced by tuning a radio to the far end of the dial, or by running a fan to block out other noises. Turning off the phone (an answering machine can be used if necessary) and disconnected the doorbell or putting up a “Do Not Disturb” sign can also help.

Workplace Conditions

Lighting levels, temperature, and job responsibilities in the workplace are among the factors likely to play a role in your alertness levels at work. Your workplace should be well lighted and call rather than warm. The setup of your workplace will determine how you can best control these factors to increase your alertness on the job. In general, you and your employer should educate yourselves about the effects of shift work in your workplace, and should encourage safety and productivity.

Other Measures

Lighting levels, temperature, and job responsibilities in the workplace are among the factors likely to play a role in your alertness levels at work. Your workplace should be well lighted and call rather than warm. The setup of your workplace will determine how you can best control these factors to increase your alertness on the job. In general, you and your employer should educate yourselves about the effects of shift work in your workplace, and should encourage safety and productivity.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Drowsy Driving

Drowsy driving. It doesn’t sound serious, does it? Yet, asleep-at-the-wheel and driving-off-the-road accidents are claiming more lives and causing more injury and property damage each year. In fact, drowsy driving is now as dangerous as drinking and driving, based on the injuries, deaths and damages it causes. Whether you actually fall asleep at the wheel, or you have delayed reactions and mistakes in your driving, you are equally at risk for serious results of drowsy driving.

What Is Drowsiness?

Your body requires three things: water, food and sleep. You can choose not to drink water until you eventually die. Your body’s need to sleep is so strong however; that you can try not to sleep, but your brain will eventually make your body sleep, no matter what you are doing at the time.

Several factors can cause drowsiness: the time of the body clock, exposure to daylight/darkness, and how long you’ve been awake. Your body’s internal clock (called circadian rhythm) signals you to be sleepy twice a day: first in the evening at bedtime, and again about 12 hours later, during the “siesta” time of the afternoon. The cycle of sunlight and darkness in a day helps set our bodies’ internal clock. In addition, the length of time we stay awake can increase our need for sleep (i.e., the longer you stay awake, the more you need sleep).

Although each person’s sleep needs and patterns vary, most adults require an average of eight hours of restful sleep each night. If you are not getting enough sleep, you build up sleep debt. Your sleep continues to grow as you “add on” more and more hours of sleep time. The longer you try to stay awake or the more nights you do not get enough sleep, the drowsier you become and the greater the effect on your mental and physical abilities.

Excessive sleepiness reduces your alertness and performance. You react more slowly and have more trouble making decisions. You also have a difficult time paying attention, and your memory and coordination are weaker. In fact, people who are drowsy sometimes don’t realize that they have these symptoms, making drowsiness that much more dangerous.

The effects of drowsiness are actually just like the effects of drinking. In many states a blood alcohol concentration (BAC) of .08 is the legal limit for alcohol. A 1997 research study found that being awake for 18 hours produced impairment equal to a BAC of 0.05. After 24 hours of being awake, it jumps to 0.10. Even if you only lose one or two hours of sleep a night, drowsiness can impair your ability to drive at a rate that is higher than the legal alcohol limit.

This fact is even more disturbing when compared with the average amount of sleep that adults get every night. Sleep studies report that adults do not get the recommended eight hours of restful sleep at night. One study found 64% get less than eight hours and 32% report they get six hours or less. Whether you are severely drowsy only once in your lifetime, or you’re sleepy all the time, the consequences can be fatal.

How Widespread is Drowsy Driving?

The U.S. National Highway Traffic Safety Administration (NHTSA) cites drowsiness as a factor in 100,000 police-reported crashes annually involving 76,000 injuries and 1,500 deaths. This represents 1%-3% of all police reported crashes and 4% of fatalities.

Public surveys, however, suggest an even higher rate of drowsy driving. In one survey, 55% of those answering said they had driven while drowsy in the past year. Over a lifetime, 23% said they had fallen asleep but had not crashed, 3% had fallen asleep and crashed, and 2% had crashed when driving while drowsy. It is not easy to pinpoint drowsy driving as a cause for an accident because there is no physical test to determine sleepiness (like the Breathalyzer for detecting alcohol levels). Traffic officials are often not trained to look for sleep-related causes and, therefore, may attribute a sleep-related accident to speeding or intoxication. Many states do not have a “fall asleep crash” code on their crash report forms, nor do they have a central database to track such causes.

There are usually no witnesses to a driver’s drowsiness prior to a crash, and drivers themselves don’t always realize they are drowsy before they doze off. In fact, drowsy drivers are often more alert after an accident or other sleep-related mistake, which can be misleading since you can’t tell how sleepy they were before the incident. When drowsiness is combined with alcohol, often the alcohol is listed as the only cause of an accident. After an accident, many drivers are also reluctant to tell police they were drowsy. With all these factors working against awareness of drowsiness as a cause of car accidents, it is no wonder that official statistics that do exist, however all show that drowsy driving accidents are increasing every year.

Drowsy drivers need to know more about good sleep habits in order to stop driving while they are sleepy. Sleep debt also needs to be recognized as a serious problem. It is currently overlooked because it is too common.

What Are The Common Characteristics in Drowsy Driving Accidents?

Time of Day:

As mentioned above, there are two times during a 24-hour period when our body clocks tell us to sleep – at night and during the “siesta” time of the afternoon. These are the two times when most people are naturally sleepy, whether they are getting enough sleep or not. Statistics show that these are also the two most common times for drowsy driving accidents. Most occur between midnight and 8:00 A.M.; the rest typically occur between 1:00 P.M. and 3:00 P.M. If you must drive during these times, make sure you are aware of the risks, and get plenty of rest before hand. Single driver: In one study, 82% of reported fall-asleep/drowsy crashes involved someone driving alone. A single driver has no one to interact with and help keep him or her alert. Another person in the vehicle usually will be able to notice when the driver is getting sleepy. In addition, someone driving by him or herself is responsible for doing all the driving, while two or three other people carpooling can rotate when the driver gets sleepy.

No attempt to avoid crash:

Because a drowsy or asleep driver may close his or her eyes for a moment, a common characteristic of drowsy driving accidents is that the driver did not seem to avoid the crash. Because of this, a high percentage of drowsy driving accidents are fatalities. A reported 4% of all motor vehicles fatalities are attributed to driver sleepiness. A sleepy driver is less able than an alert driver to take corrective action prior to a crash, which is shown by the lack of evidence of skid marks or witness accounts of seeing brake lights.

Who is Most at Risk?

Young male drivers:

In one study of fall-asleep accidents, the driver was under the age of 25 in 55% of the crashes. Seventy-five percent of those drivers were males. Sleepiness may be due to lifestyle of behavior choices, and this group is usually more likely to make choices that cause sleepiness (staying up late, working longer hours).

Shift workers, business travelers, others experiencing circadian rhythm disorders:

Shift workers (people who work overnight) are always trying to sleep when their bodies want to be awake, and to work when their bodies want to sleep. For this reason, they may suffer from body clock (circadian rhythm) disorders where their bodies are programmed for a sleep-wake schedule that differs from their bodies’ natural schedule or form what they are used to at home. Any of these circumstances can cause lack of sleep, or poor sleep quality. This can result in excessively sleepy drivers, who may have far less alertness for the task of driving.

Drivers suffering from cumulative partial sleep deprivation:

Some people suffer from cumulative partial sleep deprivation (i.e., they consistently get less than the recommended eight hours of restful sleep per night). They report a high tendency to doze off in many different situations and, therefore, are also at greater risk for drowsy driving incidents. Their sleep debt grows larger over time. As the debt becomes greater, so does their bodies’ desire to sleep. They become excessively sleepy, which affects their attention and performance in a variety of tasks, including driving.

Drivers suffering from acute sleep deprivation:

People who have acute sleep deprivation have been awake for many hours (e.g., working all day and making a trip that same night). This lack of sleep has a serious impact on their ability to pay attention and react while driving. One study showed drivers awake for 15 or more hours had four times the risk of a drowsy driving crash. If a driver had been awake for 20 more hours, the risk of crashing increased by 30 times.

Drivers suffering from untreated sleep disorders:

Drivers who have undiagnosed or untreated obstructive sleep apnea syndrome (OSAS), narcolepsy, or other sleep disorders are also at greater risk, because if left untreated, sleep disorders rarely allow the person to get enough restful sleep at night. Because of this, the most common symptom of many sleep disorders is excessive daytime sleepiness. Studies show OSAS occurs in many people and creates a two- to seven-time increase in the rate of drowsy driving crashes.

Drivers using medications with sleep-inducing side effects:

Certain over-the-counter and prescription medication may cause you to be very drowsy. Such medications have warning labels because these effects can certainly impair a driver’s attention and ability to react quickly. These medications include: sleeping pills, narcotic pain pills, some antidepressants, tranquilizers, some high blood pressure pills, cold or cough tablets/liquids, and muscle relaxants.

Drowsy drivers who have consumed alcohol:

Alcohol naturally makes you sleep, and it alone can be enough to cause a vehicle crash. However, when combined with excessive drowsiness, its effects are multiplied. Alcohol interacts with sleepiness, greatly lowering mental and physical alertness, and creating a greater amount of swerving and drifting off the road than either alcohol or drowsiness alone. In one driving simulation study, alcohol levels below the legal driving limit produced a higher number of mistakes after four hours of sleep than after eight hours of sleep. In fact, the study found that on four hours of sleep, one beer had the impact that a six-pack had on a well-rested person.

What are the Signs of Drowsy Driving?

Below, are a few of the most common signs that a driver is excessively drowsy. If you experience any or all of these signs, you may be at risk for a car accident.

  • You can’t remember driving the last few miles
  • You drift from your lane or hit the rumble strip
  • Your attention is weakened and your thoughts wander
  • You find yourself yawning frequently
  • You are unable to focus or keep your eyes open
  • You tailgate or miss traffic signs
  • You catch yourself “nodding off” and have trouble keeping your head up.

How Do We Prevent Drowsy Driving?

Behavior:

The two most effective ways to prevent drowsy driving involve behavior choices. The first is to get a good night’s sleep prior to driving. Unfortunately, most people don’t think of the effects of drowsy. However, prevention is the best measure, and for that, there is no substitute for sleep. Consistently good sleep habits are the best prevention for drowsy driving. The second way to prevent drowsy driving is to stop and sleep when you are feeling drowsy, whether you think you have any signs of drowsy driving or not. When you’re drowsy, you are not always aware of your own symptoms of drowsy driving, or you think you can deal with the problem as you continue to drive. If you feel at all tired or sleepy while driving, be safe and stop before your drowsiness is out of control. Even if you think you can handle it, try to remember that it is not easy for drowsy drivers to realize how much danger they’re in. It is also wise for all drivers to avoid alcohol and medications that impair their ability to drive. Ask your healthcare professional about any medications you take if you do knot know whether they can hinder your driving ability.

Alerting devices:

One of the most effective alerting devices to date is the roadway rumble strip, which is the pattern of grooves along both sides of a highway or freeway. The purpose of a rumble strip is to make enough noise and vibration to wake up a dozing driver if his or her vehicle starts drifting off the road. While rumble strips have been proven to reduce off-road deviations, they are definitely not a cure-all for drowsy driving since drivers are just as likely to drift into oncoming traffic, as they are to drift off the road. Some auto manufacturers have been experimenting with the use of in-vehicle devices for keeping drivers alert. These devices are used to keep drivers alert. These devices are intended to monitor driver sleepiness and some include alarms. However, there is insufficient data at this time to prove the effectiveness of such devices. Also, driver dependence on such devices does not address the issue of preventing drowsy driving by getting enough restful sleep. These devices may, in fact, give drowsy drivers a false sense of security – they may feel safer driving while sleepy, trusting these devices to keep them awake.

Shift work & Jetlag:

The best preventive measure for shift workers and their employers is education. Several programs have had success in this area. Reducing the number of times a worker’s shift changes, changing shifts forward in time rather than backward, implementing regular rest periods, offering the option of exercise periods, and using bright light can all minimize the effects of shift work on a person’s body clock. Jet-lagged travelers can adjust their sleeping times prior to their trip to help them adjust (try to use the new sleep/arise times if possible). Rest periods, exercise, and the use of bright light can also be helpful for adjusting to a different time zone.

Awareness of medical disorders:

As mentioned earlier, some drowsy drivers may actually suffer from untreated sleep disorders. The two most common are Obstructive Sleep Apnea Syndrome (OSAS) and narcolepsy. Habitual loud snoring, gasping for air while sleeping, or the stopping of breathing are the most common symptoms of OSAS. OSAS results in many awakenings during the night (even though they may not be remembered) and non-restful sleep. Narcolepsy causes someone to fall asleep rapidly in almost any situation at any time throughout the day. Both sleep disorders should be diagnosed by a sleep specialist.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

Bariatric Surgery

Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).

Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality. However, a study in Veterans Affairs (VA) patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care.

What causes the airway to collapse during sleep?

  • Extra tissue in the back of the airway such as large tonsils.
  • Decrease in the tone of the muscles holding the airway open.
  • The tongue falling back and closing off the airway

Indications

The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 plus serious coexisting medical conditions such as diabetes, hypertension, impaired glucose tolerance, hyperlipidemia, and obstructive sleep apnea.

Eating and Drinking After Bariatric Surgery

Eating Issues:

Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free gelatin desserts.

Fluid Issues:

It is very common, within the first month post-surgery, for a patient to become dehydrated. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume.

Effectiveness of Surgery

Reduced Mortality and Morbidity:

Several recent studies report decreases in mortality and severity of medical conditions after bariatric surgery. In the Swedish prospective matched controlled trial, patients with a body mass index (BMI) of 34 or more for men and 38 or more for women underwent various types of bariatric surgery and were followed for an average of 11 years. Surgery patients had a 23.7% reduction in mortality (5.0% vs. 6.3% control, adjusted hazard ratio 0.71).

A randomized, controlled trial in Australia compared laparoscopic adjustable gastric banding (“lap banding”) with non-surgical therapy in 80 moderately obese adults (BMI 30–35). At 2 years, the surgically-treated group lost more weight (21.6% of initial weight vs. 5.5%) and had statistically significant improvement in blood pressure, measures of diabetic control, cholesterol.

What should you do if you suspect you may have Obstructive Sleep Apnea?

See your doctor; evaluation by a doctor specializing in sleep disorders is recommended. Have a sleep study done; a sleep study can provide the doctor with information about how you sleep and breathe. This information will help the doctor to determine your diagnosis and treatment options.

Adverse Effects

Complications from weight loss surgery are frequent. A study of insurance claims of 2500 who had undergone bariatric surgery showed 21.9% complications during the initial hospital stay and a total of 40% risk of complications in the subsequent six months. This was more common in those over 40 and led to an increased health care expenditure. Common problems were gastric dumping syndrome in about 20% (bloating and diarrhea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%.

Increased risk of fracture has also been linked to bariatric surgery. Rapid weight loss after obesity surgery can contribute to the development of gallstones as well.

Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

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