Sleep Disorders

OVERVIEW

Excessive daytime sleepiness, difficulty sleeping, and abnormal sleep behaviors are common problems that can have large impacts on a person's overall health, safety and quality of life. With accurate diagnosis, however, most sleep disorders can be effectively treated.

Sleep Disorders Treated by Dr Yacoob Omar Carrim - Sleep Medicine Specialist

Sleep-related breathing disorders

• Obstructive sleep apnea (OSA) (including upper airway resistance syndrome)
  • Pediatric sleep apnea
• Central sleep apnea (CSA)
• Snoring

Insomnia

• Insomnia

Hypersomnias

• Narcolepsy
• Idiopathic hypersomnia

Circadian rhythm disorders

• Delayed sleep phase syndrome
• Advanced sleep phase syndrome
• Jet lag
• Shift work

Parasomnias

• Arousal Disorders
• Sleepwalking
• Sleep terrors
• REM behavior disorder (RBD)
• Nightmares
• Sleep-related eating disorder

Sleep-related movement disorders

• Restless legs syndrome (RLS)
• Periodic limb movement disorder (PLMD)
• Bruxism
• Leg cramps
• Sleep starts
• Sleep talking

Insomnia - what is Insomnia and why is Insomnia important - what should we do about Insomnia

Insomnia - this remains and justifiably so - one of the top reasons persons seek medical help. This problem is at the best of times resistant to remedies.

Insomnia refers to repeatedly difficulty in falling asleep or staying asleep, waking up too early, and or feeling unrefreshed the following day.  If you have had difficulty falling asleep or had woken repeatedly at night but could function normally the next day, indicates that you have had sufficient appropriate sleep.

You do not have to sleep for eight hours or fit a social norm of sleep. You have to sleep the amount of time that is just right for you. All of us are different.

Some of us believe that we can abuse our sleep patterns by working all day and night - with a minimum of sleep and not get enough sleep. These people will soon realise that sleep is rigid and is madatory for survival. The birds, insects, animals, fish and all that is created needs to sleep - yes this includes all of us - inclusive of man and beast. Dolphins are fortunate to sleep with one brain hemisphere at a time - the other half of the brain remains awake to keep swimming.

The only being that does not have to sleep is God himself - "slumber does not seize him nor sleep" and "there is none like unto him." For us simple  mortals we will have severe problems with every system of our bodies and mind if we deprive ourselves of sleep.

There are those that are short sleepers and require less sleep than average - the function perfectly well on 5 to 6 hours of sleep.  These short sleepers are few and far between. For the average Joe we have to sleep on average 8,15 hours - a SA high school metric student requires 9 hours sleep!

Epidemiology and importance: Insomnia is known to affect 58% of western adults.

People that do not get sufficient appropriate sleep run the risk of having impaired cognition, memory, attention, and ability to plan , execute and follow up. They usually appear more irritable, more aggressive, and develop an underlying anxiety (more than depression). They perform poorly in their daily tasks - in whatever they choose to do. They have more motor vehicle accidents than average. Some suggest they have the same number of accidents as alcoholic drivers - I hope the authorities are reading this.

Definition of Insomnia
Insomnia is defined by time - there are 3 basic types:

• Transient: Insomnia that lasts for less than a few weeks
• Intermittent: Recurring transient insomnia
• Chronic Insomnia: Insomnia that occurs for most nights for more than one month

Insomnia may be classified according to when it causes trouble: Recalling the definition of insomnia we may divide sleep into sleep onset insomnia, sleep maintenance insomnia and early morning awakening.

• sleep onset insomnia, occurs when a person has trouble falling asleep in the first place
• sleep maintenance insomnia, when a person wakes up at night and cant go back to sleep and 
• early morning awakening - waking up too early in the morning. 

One may also get a combination of the above - mixed insomnias.

The time that it takes for the average South African to fall asleep differs - on average it takes people 7 minutes to fall asleep but you may require 20 to 30 minutes to fall asleep. The key question is are you able to function the next day, do you feel restored after sleep.

If you dont feel restored or you cant stand your inability to fall asleep or maintain sleep then its time to seek help from a Sleep Medicine Specialist.

How would I recognise an Insomniac? 
Apart from those with underlying medical and psychiatric problems that need a sufficient appropriate diagnosis by their medical service provider there is a spectrum of Insomniacs -
The first are those that do all the right things to get ready for sleep and feel ready for sleep but just cant fall asleep.

The next are those that have no trouble falling asleep but are parting or working all night - burning the candle on both ends thinking that sleep is for the dead - they are of the mistaken belief that sleep is like a soccer ball that can be kicked about without any implication on their long term health.

There are also those that are being kept awake by the environment - the husband snoring, the wife with the restless moving legs, the sleep talking and sleep walking bed partners, a child with night terrors.  We must never forget the nursing mothers that sacrifice their sleep for the suckling babes in the middle of the night (Breast remains best).

So who gets insomnia?
Anyone can get insomnia but these are the groups that have the highest risk of getting insomnia:

• Elderly persons - the older you are, the more likely you are to have insomnia. One third of persons greater than 65 have insomnia.
• Worriers: Those that are prone to anxiety are more likely to have insomnia.
• Women have a slightly higher incidence of insomnia
• Psychiatric disorders: those that have psychiatric disease such as anxiety, depression really do need the assistance of a registered psychiatrist.
• Physical disorders: Pain, heart disease (cardiac disease)
• Alcohol abuse and drug abuse: Alcohol induces sleep but does not allow you to have the deep stage 3 and 4 slow wave sleep required to restore the body or the REM sleep required to file the information for the day.
• Certain Jobs - the more repetitive jobs that required less mental engagement had more difficulty falling asleep - as if the brain protests compelling you to use it before it will allow you to rest. If you dont use your brain - it will not allow you to sleep.

Insomnia may be caused by changes in the environment, physical medical causes, and psychological causes.

• The changes in the environment may be a change in routine, and sudden change in the weather or poor sleeping conditions.  
• My patients that have illness be it the flu or a serious heart, lung, kidney or stomach problem have worsening insomnia. Those that suffer the most are those with chronic pain conditions. Medication given by homoeopaths and doctors may cause change in the wake sleep cycle. 
• Changes in hormones - menstruation, pregnancy, menopause and hot flushes really cause havoc in my female patients sleep.
• Caffeine and smoking: Tea, coffee, coke and dark chocolate are stimulants that keep most patients awake - patients should not consume caffeine 6 hours before bedtime.  You should have your last cigarette four hours or more before you sleep. 

I still wonder how James Bond managed to smoke, have alcohol and still look refreshed.

There are a number of psychological causes for Insomnia :

• Anxiety
• Depression
• Stress
• Worry about sleep 

SO WHAT SHOULD I DO IF I HAVE INSOMNIA?

• Don't lie there - get out of bed and do something else - if you are not sleeping you should not be in your bedroom. 
• Keep a constant schedule: remember dont change your waking time no matter what time you go to bed
• Exercise early - Do not exercise at night
• Avoid napping if you an insomniac - remember daytime napping improves performance if you are not an insomniac
• Sterilise the bedroom: the bedroom must be free of the TV, the Blackberry,the cell phone, the iPhone, Books, the alarm clock - the bedroom is only for sleep and sleeping with your partner.
• Quit smoking
• No alcohol
• No tea, coffee and chocolate
• Restrict your sleep: if you feel you only sleep 4 hours a night out of the eight hours you lie in bed than restrict your sleep to to the 4 hours that you need - this will improve your sleep efficiency. Use only the time you need to sleep.
• Reduce environmental distractions.
• Stop all over the counter supplements and medication for sleep unless prescribed - there is little evidence that using non-prescribed medication works - why waist your money and risk you health with these drugs or supplements - if they are proven not to work. If insomnia remains a problem than contact your health care provider that will direct the treatment at the underlying cause of the insomnia.

Medications of you must:

There are 3 classes of drugs that are approved for the treatment of Insomnia:

1. The Benzodiazepines - these work in an undirected manor on the brain - and may allow you to have sleepiness the next morning.
2. The non-benzodiazepines - The "Z" drugs - zolpidem and zaleplon. These act with the benzodiazepine receptor of the brain. Their advantage is the rapid absorption and lack of active metabolites, and low risk for side effects. 
3. Melatonin - this has some interesting promise when used alone or in combination with the other approved sleep drugs. Melatonin is a naturally occurring hormone that is secreted by the pineal gland and controls the day night cycle in the brain - the circadian rhythm. Melatonin does not put you to sleep, but gets your night time hormones ready for sleep and in the event that you are asleep - makes your sleep more efficient. Please ensure that the melatonin that you buy is from a regulated pharmaceutical manufacturer - that apply the highest standards of quality or you may not be getting the melatonin you paid for as I have come to see with my SA patients.
4.  Herbal remedies: Although there are very few studies proving the value of herbal treatments - Valerin and Keva are the most commonly promoted herbal remedies.  

MOST EFFECTIVE TREATMENT

Prescription medication with behavioural treatments work best in combination. Cognative Behavioural therapy  appears to be the most effective behavioural therapy. Sleep hygiene is imperative, limiting or controlling stimulus at bedtime. 

Remember Insomnia is not a way of life - you need to seek appropriate medical help from your health care provider. 

Dr Yacoob Omar Carrim

Sleep Medical Specialist 

Zuid Afrikaans Hospital

zasleep@gmail.com

http://zasleep.blogspot.com

   

Insomnia

Having sufficient restful sleep is a critical human requirement. It is vital to emotional and physical well being. Most adults sleep between 6 and 8 hours per day, without interruption. A few nights of poor sleep do no harm, but prolonged sleep disturbances can have serious consequences.

The Physiology of Sleep

People function according to a natural cycle that repeats itself about every 24 hours. This is known as the circadian rhythm, and it governs our sleep-wake cycles. As it gets dark, the cells in the retina of the eye send a message directly to a part of the brain called the hypothalamus, which then signals the pineal gland located in the hypothalamus to produce the hormone melatonin, which causes a drop in body temperature and sleepiness. At the same time there is a reduction in the chemicals responsible for arousal, like histamine, noradrenalin, and serotonin. In a normal person, this sequence brings on sleep. There are two types of sleep: rapid eye movement (REM) and nonrapid eye movement (NREM). NREM has four stages, with stage 1 being transitional sleep, stage 2 light sleep and stages 3 and 4 deep (delta) sleep. Delta sleep is the most restful kind. During NREM sleep, brain activity and body functions slow. During REM there is increased activity - body functions speed up and a person dreams. A person moves from one phase of sleep to another during the night.

What is Insomnia?

Insomnia is a sleeping problem in which there is either inadequate sleeping time, or poor quality sleep, occurring on a regular or frequent basis, often for no apparent reason. A person with insomnia may have difficulty falling asleep, may wake up too early, wake up intermittently during the night, or may wake feeling unrefreshed.

During the day a person with insomnia may suffer from general tiredness, lack of energy, difficulty concentrating, and irritability. Sleep deprivation also impairs memory, reaction time and alertness. Tired people are less productive at work, less patient with others, and less interactive in relationships. Sleep deprivation can also be dangerous for people who have to drive. When people are deprived of sleep over long periods, the body's immune system becomes depressed, lowering resistance to disease and infections.

Insomnia is very common - between 20% and 30% of adults suffer insomnia to some degree, and about 10% to 15% of people have insomnia which is chronic or severe. Insomnia is more of a problem in the elderly, and is more common in women. Sleeping pills are amongst the most prescribed medicines in the world.

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Types of Insomnia

Transient insomnia is a temporary disturbance of the normal sleep pattern. It generally lasts no more than several nights, and usually disappears on returning to a regular sleep pattern. Travel or relocation may cause it.

Short-term insomnia lasts for 2 - 3 weeks and can accompany worry or stress. It often disappears if the cause is resolved.

Chronic insomnia disrupts sleep for extended periods of time - sleeping problems occur for at least 3 nights a week for one month or more. It is a complicated disorder with potentially serious effects.

What causes Insomnia?

Insomnia is usually the result of an underlying condition. Discovering the cause is the most important step in relieving insomnia.

Lifestyle factors are common causes of insomnia, particularly transient or short term insomnia. These include factors like high stress or anxiety, an uncomfortable sleeping environment, eating a heavy meal or drinking alcohol or caffeine-containing drinks before bedtime, exercising just before bedtime and cigarette smoking.

Medical conditions may cause chronic insomnia. These include chronic illnesses like kidney disease, heart failure or asthma, painful illnesses like arthritis or cancer, and hormone imbalances like hyperthyroidism, menopause or pregnancy.

Psychiatric conditions like depression, anxiety disorders or schizophrenia may be associated with chronic insomnia.

Medications are a common cause of insomnia. Some antidepressants, high blood pressure and steroid medications can interfere with sleep. Many painkillers, decongestants and weight loss products contain caffeine and other stimulants which will keep a person awake. Reducing or stopping your regular dose of sleeping pills may also cause insomnia.

Certain sleep disorders may result in insomnia. Restless leg syndrome is a condition where a person experiences unpleasant sensations in the legs or feet, preventing sleep. Periodic limb movement disorder is where uncontrollable twitching of the legs or arms prevent refreshing sleep. Obstructive sleep apnoea is a condition in which people intermittently stop breathing for short periods during sleep, causing them to wake frequently. Circadian rhythm disorders develop due to time zone changes (jet lag), or in people who do shift work.

Psycho Physiological Insomnia is one of the commonest causes of insomnia affecting about 5% of people. It develops when a person experiences a poor night's sleep and then has increased anxiety the next night, which again prevents him from falling asleep. This "vicious cycle" is repeated night after night, leading to chronic insomnia.

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How Is Insomnia Diagnosed?

The many potential causes of insomnia mentioned above can be determined by assessing lifestyle factors, by reviewing physical or psychiatric symptoms and by performing a physical examination. Certain laboratory tests and special investigations may be necessary. A sleep diary, which provides a record of how long and when you sleep, may also be helpful. In some patients an assessment at a sleep clinic may be necessary.

Treatment of Insomnia

Chronic or severe insomnia should be discussed with a doctor to rule out any medical or psychiatric condition.

Lifestyle changes: Regular moderate exercise, a balanced diet and avoiding excessive alcohol or caffeine will improve health and sleep. Reduce tension, promoting better sleep.

Behavioural therapies may also be used to treat some patients with insomnia. Relaxation therapy uses special techniques to calm the person and relax the muscles. Sleep restriction is a program that initially permits only a few hours of sleep per night, then gradually increases the nightly sleeping time. Reconditioning teaches the person to associate a bed with sleeping (and sexual activity), not daytime naps.

Drug treatment: If insomnia is transient or short-term, and sleep hygiene (see below) or non-medical treatments are not helpful, medication may be effective to prevent psycho physiological insomnia. In chronic insomnia, it is important to diagnose any underlying medical or psychiatric condition, and treat this effectively. Prolonged use of pills, without addressing the root cause may result in dependency. Hypnotic (sleep-inducing) medications, like the benzodiazepines, should be used for a few days at a time, to try to break a pattern of sleeplessness, while addressing any underlying problem. They should be used for short periods only, as they may become addictive. Antidepressants are effective in patients in whom depression has been diagnosed. Some Antihistamines have sedative effects and may be effective in the short-term. Melatonin may help insomnia by shifting the phases of the circadian rhythms, but is still undergoing further studies.

Sleep Hygiene is a holistic approach to sleeping. Good sleep hygiene prevents or relieves insomnia, and makes sleep more restful and pleasurable.

• Establish a regular time for going to bed and waking up.
• Use the bed for sleep or sexual activity only, not for reading, TV, or work.
• Avoid naps, especially in the evening.
• Exercise before dinner - exercising close to bedtime, however, may increase alertness.
• Take a hot bath about an hour and a half before bedtime.
• Do something relaxing in the half-hour before bed like reading or a walk.
• Keep the bedroom cool and ventilated.
• Do not look at the clock. Worrying about the time and "forcing" yourself to sleep makes it more difficult to sleep.
• A light snack before bed can help sleep. A large meal may do the opposite.
• Avoid fluids just before bedtime to reduce the need to urinate.
• Avoid caffeine in the hours before sleep.
• Quitting smoking eliminates the effects of nicotine on sleep loss.
• People who can't sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until sleepy again.
• If a person with insomnia is distracted by a sleeping bed partner, a couple of nights apart may be useful.

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Tips to beneficial sleep and feeling energized day after day: While many strategies are available, it is important to experiment and discover what works for you, what works for one person may not work for another!

1. Take control of the stressors in your life.
2. Focus on what's really important in life.
3. Make time for two or three quiet moments during the day and before retiring for the night.
4. Fitness through exercising.
5. Exercise will lower anxiety and tension.
6. Heart and lung fitness, a direct result of exercise, promote healthy sleep.
7. Easy stretching should precede all exercise.
8. Exercises such as walking, dancing and aerobic work outs should be done in the late afternoon.
9. Stay alert during the day.
10. Keep yourself busy and involved during your daytime activities.
11. Involvement with other people allows you to reduce stress by focusing on issues other than your own.
12. Eat balanced meals.
13. Make this part of the total, personal health plan.
14. Strive for a balance between vegetables, protein and carbohydrates.
15. Avoid a large meal within four hours of going to bed.
16. Alcohol and bedtime do not mix.
17. The effects of alcohol are greatly magnified by sleep deprivation.
18. Sleep apnoea can be aggravated by drinking at bedtime.
19. Avoid alcohol within three hours of bedtime.
20. Develop a bedtime ritual.
21. Read for pleasure.
22. Gradually dim the lights.
23. As your mind clears and you become drowsy, turn off the light.
24. Cleanse the mind.
25. Commit your worried thoughts to an index card on the night stand.
26. Add some points about the potential solution.
27. Leave the card there in case you awaken during the night.
28. Relaxation at bedtime
29. Play mind games with yourself.
30. Mental imagery.
31. Deep breathing.
32. Time in bed: Only as long as is necessary
33. You may go to bed earlier than usual due to stress and worries.
34. Stay in bed only for the period that you usually need for sleep.
35. Sleep until you are refreshed.
36. Consult a sleep specialist if needed.
37. Always share your sleep problems with your doctor.
38. He/she may give you valuable advice or refer you to a sleep specialist.
39. Awaking with shortness of breath or chest pain requires prompt attention.
40. Your doctor must be told if you are falling asleep at inappropriate times.

Reference: Maas J.B. (1999): Power Sleep, New York: Harper Perennial p84-99

Courtesy of Medical Essentials, Health Information

Insomnia

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Insomnia
? Who:
o 30 to 50% of the population (8-18% DSM IV ? 4-11%)
o 9-15% report adverse daytime consequences
? Risk:
o Increasing age, female sex, psychiatric and medical disorders, genetic basis
o Non-restorative sleep
? PSG Definition: WASO or SL is greater than 31 minutes; 3x per week after 6 months
? Morbidity:
1. pronounced negative impact on daytime functioning and general well being
2. increased daytime fatigue,
3. poorer mood, more anxiety or stress,
4. less vigour,
5. greater coping difficulties,
6. less ability to complete tasks,
7. greater impairment of family and social functioning
? QOL: health related QOL score is similar to congestive cardiac failure and depression
o Risk for depression and cognitive decline over time (1,5 to 3 years)
? Diff diagnosis:
o Comorbidity with psychiatric disorders
? 50% have a current or past psychiatric disorder
? Insomnia precedes
? mood disorder 41% and
? anxiety disorder 18%
? primary sleep pathologies ? PLMS, RLS, SDB (also exclude infrequent parasomnias)
? Chronic pain
? Assessment:
o Rheumatologic (arthritis and fibromyalgia)
o Pulmonary ? Asthma and COPD
o Cardiac
o GIT ? reflux and peptic ulcer disease
o Neurologic ? seizure disorders
o Endocrine ? hyperthyroidism
o Menopausal status / prostate disease
? Lab
o PSA; TFT; Ferritin levels for PLMS
? Psychiatric history
o Anxiety and depression
? Medication use:
o Steriods, stimulents, anti-depressants and anti-hypertensives
? Self reporting questionnaire
? Psychological testing: Becks Depression inventory ? 1979
? Sleep Logs
? PSG ? unless clinically indicated
? Actigraphy ? with sleep log for a minimum of 3 nights (SPC ? AASM ? 2003)
Eitiology and pathophysiology of Insomnia:
3 models:
1. Physiological
2. Cognitive
3. Behavioural

1. Physiological
? HR, RR, Temp, skin conductance/resistance, peripheral blood flow or vasoconstriction
? Whole body metabolic rate ? VO2
? Heart rate variability = increase HR, increased sympathetic activity, decrease parasympathetic activity
? Caffine induced hyperarousal and insomnia
? Neuro-endocrine measures = HPA hypothalamus pituitary adrenal axis
? HPA axis:
? Urine
? u-free cortisol (proportionate to Total Wake Time)
? catacholamines (DHPG)
? DOPAC proportionate to S1 % and WASO
? Growth Hormone
? Plasma ? Increased ACTH and Cortisol levels over 24 hours


2. Cognative Model of arousal
? Rumination and worry
? predisposing personality trait;
? precipitated by life stressors -;
? perpetuating factors ? worry and remuneration about inability to sleep Maladaptation.
? Selective attention: Sleep related threats in the internal and external environment, increasing cognitive and physiological arousals
? Distorted Perception of Daytime Deficits: increased attention on the effects of poor sleep, fatigue, sleepiness and performance deficits
? Increased safety behavious ie work or tasks that are mentally or physically taxing

3. Behavioural model
? Sleep hygiene model
? Stimulus control Model
? Spielman model:
? Inhibitor to wakefulness
Behavioural therapy for primary insomnia
CBT ?
? sleep restriction ? adjust by 15 to 30 minutes per week to SE>80%.
? Stimulus control therapy
? Go to bed only when sleepy ? not just fatigued, but sleepy
? Get out of bed when unable to sleep (eg 20 minutes) go to another room and return only when sleep is imminent
? Curtail all sleep incompatible activities ? overt and covert-, no eating, TV watching, radio listening, planning or problem solving in bed
? Arise at a regular time every morning regardless of the amount of sleep the night before
? Avoid daytime napping
? Relaxation training
? Cognitive therapies
Secondary insomnia
? Latelife insomnia
? Hypnotic insomnia HDI
? Secondary insomnia SI
Pharmacological therapy:
Benzodiazepine receptor agonists BzRA works on the GABA1 ? opens the Chloride channels and facilitates GABA inhibition.
? WHY GABA1: Sedation, amnesia and some anticonvulsive - no anxilytic or myorelexation
? SAFETY: and improved daytime functioning
? SE:
? Residual effects
? Amnesic effects ? antrograde amnesia
? Discontinuation Effects
? Dependence Liability is low
? Falls cognitive effects and other considerations for older adults

Sedative Antidepressants
? Trazidone 100mg MOLIPAXIN? 100 mg - a triazolopyridine antidepressant unrelated to any of the aforementioned antidepressants. It affects the serotonin neurotransmitter system working on pre- and postsynaptic neurones (SSRI?s exert their effects on presynaptic neurones only). The main side effect is sedation. Priapism (sustained penile erection) has been reported and may result in irreversible impotence, but this is not a common side effect.
? Amitriptaline TREPILINE?-10 TABLETS

? Mitazepine Remeron - belongs to a new class of antidepressant called NaSSA?s (noradrenergic and specific serotonergic antidepressants) which are particularly useful if anxiety and insomnia are problems. Side effects include sedation and weight gain.
? SE:
? Dry mouth, headache, dizziness, and nausea
? Orthostatic hypotension, weakness and light headedness
? Abusive potential with lower margin of safety than BzRA

BzRA = caution with
? Sleep Apnoea
? Concomitant alcohol use
Pregnancy

To sleep, perchance... By Juliet Pitman

To sleep, perchance...

Sleep disorders leave one feeling exhausted and frustrated. We look at the many facets of this condition and how to treat them.

By Juliet Pitman

Narcolepsy, insomnia, sleep apnoea, restless leg syndrome. Apart from all having peculiar-sounding names, these conditions are all sleep disorders and, in a variety of different ways prevent their sufferers from feeling well-rested. If you’ve ever felt exhausted and in desperate need of sleep, imagine not being able to get to sleep, falling asleep unexpectedly or having severely disturbed sleep and you’ll have some idea of what it’s like to have a sleep disorder.

For sufferers, the road to treatment can be a long and frustrating one – but it’s a journey that starts with understanding the basics of sleep.

 

What is sleep?

The Morningside Sleep Centre in Johannesburg provides diagnosis and treatment for people with sleep and neurological disorders, and conducts research into sleep and neurological conditions. Lead by neurologist Dr Kevin Rosman, who has been Chairman of the Sleep Society of South Africa since 2002, the Centre’s literature describes sleep as “an active highly organised sequence of events and psychological conditions.”

Furthermore, sleep can be divided into two separate and distinctly different stages – non-rapid eye movement (NREM) sleep, which is further divided into four phases (1, 2, 3, 4) and rapid eye movement (REM) sleep. Your body cycles about 4 to 5 times during the night through NREM and REM sleep. The physiological differences of each stage are listed below

1. NREM Sleep: Around 75% of the time you are asleep is spent in the NREM state.

• Stage 1: this is the transitional phase just after you fall asleep during which time you can be easily awakened. It’s a short period.
• Stage 2: this phase accounts for almost half (45%) of NREM sleep and is characterized by a lack of eye movement and two kinds of brain waves called sleep spindles and K-complexes.
• Stage 3: this involves a deeper state of sleep and during this time the person will be difficult to wake. Around 12% of NREM sleep is made up of stage 3 sleep.
• Stage 4: this is very deep sleep and the final phase of NREM sleep. If you wake up during this time you may feel disorientated or very sleepy.

 

2. REM Sleep: most dreaming takes place in REM sleep, a period during which the brain blocks signals to the muscles to prevent you from being able to physically ‘act out’ your dreams. REM accounts for around 20 – 25% of your sleep.

Each of these phases is important but deep sleep possibly offers the most benefits. Studies of sleep deprived people show that the brain naturally attempts to recover deep sleep first and sleep experts know that the worst effects of sleep deprivation occur when people are deprived of deep sleep.

REM sleep is also important because it’s the period during which our brains process emotions, memories and stress. Although its function is not fully understood, it is believed to influence many things, from our ability to learn and develop new skills, to our ability to make proteins. If REM sleep is disrupted one night, your body will go through more REM the next to ‘catch up’.

 

How much is enough?

Your mother may have told you that a good night’s sleep was eight hours long, but the fact is that different people need different amounts of sleep. This may be because their body can operate on less sleep, or that they sleep more ‘effectively’ and are able to get maximum rest from less time spent sleeping. There is a misconception that older people need less sleep but this is not true; they often get less sleep but this is not because their body no longer needs as much. Children, on the other hand, definitely need more sleep than adults. If you were to look at averages, most adults need around 6 - 8 hours to function at their best. Experts suggest that the best way to determine how much sleep you naturally need.

     

When to sleep

Many things influence when we need to sleep and when we feel alert and awake. You may have heard of circadian rhythms. Dr Alison Bentley, head of the Wits Dial-a-Bed Sleep Laboratory describes what these are and how they influence sleep cycles in an article published in Science in Africa magazine: “These are our 24-hour body rhythms including changes in body temperature, plasma levels of various hormones and variables such as heart rate and blood pressure. These increase and decrease during the day and night.” She goes on to explain how simply changing the time you go to bed – for example going to bed in the morning and staying awake at night if you are a shift worker – does not mean your body will be ready to sleep or be wakeful when you want it to be. This also applies to travellers who are going to different time zones e.g. Australia which is nine hours ahead of us. “All the other rhythms need to be changed as well and that can take up to seven days to occur,” she explains.

The point is that sleep is complex, which is perhaps why sleep disorders are so difficult to understand and to treat.

 

Narcolepsy

Narcolepsy is probably one of the strangest sleep disorders. A chronic disorder caused by the brain’s inability to regulate sleep-wake cycles normally, it causes sufferers to experience urges to sleep, and in many cases to actually fall asleep, at various periods throughout the day. They typically remain asleep for a few seconds up to a few minutes, but in some cases can even be asleep for an hour or more.

In addition to falling asleep in this way during the day, people with narcolepsy can experience vivid hallucinations as well as brief periods of total paralysis during the onset of sleep or when they wake up. The cause of the disorder is unknown and at this time there no cure for it. In addition to antidepressant drug therapies, narcoleptics are treated using various behaviour strategies, such as taking short, regular naps during the day and improving the quality of sleep at night.

 

Restless legs syndrome

As its name suggests, Restless Legs Syndrome (RLS) is characterised by unpleasant sensations in the legs and an uncontrollable urge to move them when they are at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs.

RLS is most noticeable in the evening and at night, and can severely disrupt sleep. Although its precise cause is not known, it is associated with low iron levels, end-stage kidney disease in people who are on dialysis and damage to the peripheral neurosystem. Pregnant women also often report experiencing RLS and certain medications, such as anti-nausea, anti-seizure and antipsychotic drugs, as well as some cold and allergy medications, may aggravate symptoms

Again, there is no cure for RLS, but there are drugs that can help to alleviate the symptoms. They include sedatives, pain relievers, anticonvulsants and dopaminergic drugs. In addition, the Restless Legs Syndrome Foundation suggests that sufferers have their iron and vitamin levels checked, remove alcohol and caffeine from their diet, change any medication that may be the cause and identify and try to avoid habits and activities that seem to make RLS symptoms worse.

 

Obstructive sleep apnoea

Described by the Morningside Sleep Centre as “a serious, potentially life-threatening condition that is far more common than is generally understood”, Obstructive Sleep Apnoea (OSA) is characterised by brief interruptions of breathing during sleep. It owes its name to the Greek word, apnoea, meaning “without breath”. The interruptions themselves are known as apnoeas and can last for 10 or more seconds. During this time the soft tissue at the back of the throat collapses, closing the airway. Breathing stops which in turn causes the brain to react by waking the person so that the airways can open again and breathing can resume.

Although sufferers are usually unaware of the process, they can be experiencing it hundreds of times a night, which makes restful sleep impossible. The excessive tiredness (even after what the person thought was a full night’s sleep) is one of the first signs of OSA. Loud snoring, followed by a gasp and then loud snoring again, is another common symptom. Experts at the Morningside Sleep Centre say, “Although the typical OSA patient is overweight, male, and over the age of 40, sleep apnoea affects both males and females of all ages and those of ideal weight.”

 

Insomnia

At some period in their lives, most people have experienced insomnia, or the inability to fall or stay asleep. The condition is so common that it affects one third of the population each year, and around 10% of adults are regular insomniacs. It can last for days, months or even years and sufferers experience extreme fatigue, lethargy, concentration difficulties, poor memory, irritability and a depressed mood as a result.

The causes of insomnia vary widely and include psychological factors such as stress and depression, the use of stimulants such as alcohol and caffeine, keeping erratic hours and environmental factors such as too much noise or light. Many people find that once they’ve experienced a bout of insomnia, they become hyper-vigilant and are unable to fall asleep precisely because they are focusing on the fact that they won’t.

Treatment for insomnia takes many forms. If the problem is acute, your doctor may prescribe sleeping tablets, but many of these are potentially habit-forming and don’t offer a sustainable long-term solution. Natural non habit-forming over-the-counter remedies can provide relief. They include herbal remedies such as chamomile, valerian root, kava kava, lemon balm, passionflower, lavender, and St. John’s Wort. Some people have found essential aromatherapy oils to be of benefit. The ones most commonly used include lavender, jasmine, clary sage, and chamomile. Your homeopath might recommend you try Belladonna, Nux vomica, Hyoscyamus or Chamomilla, depending on your condition and the reasons underlying your insomnia. Relaxation techniques such as yoga and meditation can also be very helpful. 

Managing insomnia in shift workers

Issued by: Jenni Newman Public Relations

Some of the most significant industrial accidents in human history - the Exxon Valdez incident, the Chernobyl disaster, the Three Mile Island accident and the Challenger Space Shuttle crash - were caused by human error as a result of fatigue.

The human, environmental and financial implications of these disasters have been considerable, and have been long remembered.

What these disasters also have in common is that all have been attributed to fatigue. People working shifts will be able to relate to the excessive sleepiness than can occur either when working night shifts, or working double shifts. Jet lag presents similar feelings of excessive sleepiness. In a nutshell shift work throws out your body clock and is a well-known risk factor for insomnia.

Referred to as circadian rhythm sleep disorder, shift-work type, but more commonly known as shift-work disorder, this particular manifestation of insomnia can have serious implications: nurses, doctors, ambulance drivers - all are professions which rely on shift work, and their capacity to make life and death decisions on the spot. Sleep deprivation can lead to poor decisions being made. In fact, neurologist and sleep expert Dr Kevin Rosman says that people who have been awake for 17 hours straight function as if they have a blood alcohol level of 0.05%, the legal blood alcohol limit in South Africa. Stay awake for a further two hours, and you are functioning with the equivalent of a 0.08% blood alcohol level. “The most dangerous time to be on our roads is at 3am, as people are driving home incredibly tired after a long day at work followed by an evening out,” says Dr Rosman. “Traffic accidents in South Africa are all too common, and a huge number of these accidents are related to fatigue. When tired, people tend to respond rapidly, but the response isn't always the right one.”

Of particular concern for Dr Rosman are the long hours truck and bus drivers are expected to undertake here in South Africa. “People can fall asleep in three seconds without warning. You simply can't beat fatigue, you will succumb to it eventually. Winding down windows and putting up the music only delays the inevitable if you are suffering from extreme sleep fatigue.”

But there are ways to address the challenges inherent in shift-work disorder. The focus of most interventions is to optimise the natural sleep-wake cycle. “Shift-workers often don't have a problem falling asleep, their problem is staying asleep. They need to sleep better, and for longer, so that they wake up feeling refreshed - irrespective if it is day or night - and then to stay awake.”

First and foremost, shifts need to be properly structured, with speed of shift rotation, direction of rotation and even shift length and time playing a significant role in minimising the negative consequences of shift-work disorder. Short-acting sleeping agents such as sleeping pills can be hugely beneficial in facilitating a higher quality of sleep. People working longer shifts can benefit from a one hour nap - even a 10 minute power nap can be invigorating. Night shift workers should wear dark goggles when going home to avoid exposure to sunlight (the retinal cells of the eye will pick up the stimulus of the sun and suppress melatonin which encourages wakefulness). “Of equal importance is the understanding and compassion of family members and friends who must realise that, even though a shift worker is home during the day, it does not mean he or she can now do the shopping or look after the children. They need to sleep for their own safety, and for that of others.”

There are also people who are more suited - and less suited - to working shifts. People over 40 or who have pre-existing sleep problems, gastrointestinal disorders, need a rigid sleep schedule or conditions to sleep well, or are ‘morning' people, should generally avoid shift work. Conversely, ‘night owls' and people suffering from delayed sleep phase disorder may adapt to shift work very well.

Issued on behalf of sanofi aventis

Editorial contact
Natalie Jackson
Tel: +27 11 772 1061
Cell: +27 82 449 9984
Email: nataliej@jnpr.co.za

[17 Nov 2008 07:54]