Wake up to this simple fact: You are not supposed to be sleepy, with your feet draggin' and lids laggin' during the day. Do not let the notion that "I have always been this way" fool you into thinking it's OK. You should awaken feeling relatively refreshed and remain alert throughout the day -- every day.
Have you ever...
- ...awakened after seven to eight hours of sleep feeling unrefreshed?
- ...spontaneously fallen asleep during meetings or social events?
- ...gotten a creepy, crawly sensation in your legs, with an irresistible urge to move them, especially when you lie down in bed at night?
- ...found that your bed partner has vanished sometime in the night because your snoring was no melodic symphony, or you literally kicked your partner out of bed?
If any of this rings true, you may have a sleep problem, a medical sleep disorder, or a related medical condition for which treatment may literally change your life.
Waking after seven to eight hours of sleep and feeling unrefreshed could be a sign of poor quality sleep. The quality of sleep is as vitally important to our health and well-being as is the quantity. Our sleep has a complex pattern, or architecture, consisting of four stages that run through various cycles during the night. During certain stages and times of the sleep cycle, we secrete a variety of hormones and other substances that help regulate our metabolism and other health-related factors. If our sleep patterns are altered, it may leave us feeling unrefreshed, tired, and sleepy, as well as put us at risk for a host of serious medical conditions.
Let's first briefly distinguish among sleep problems, primary sleep disorders, and sleep disorders secondary to medical conditions.
Sleep problems often occur as the result of poor "sleep hygiene" or "bad habits." These are a range of practices and environmental factors, many of which are under your control. They include things like smoking, drinking alcohol or caffeine, vigorous exercise or eating a large meal before bed, jet lag from travel across time zones, and psychological stressors like deadlines, exams, marital conflict, and job crises that intrude on your ability to fall asleep or stay asleep. Designing and sticking with a good sleep hygiene program should alleviate these types of problems.
There are more than 85 recognized sleep disorders, the most recognizable of which may be insomnia, sleep apnea, narcolepsy, and restless leg syndrome. These and others may manifest themselves in various ways.
Your patient and empathic bed partner, with velvet hammer high overhead, notices that you suddenly cease not only your snoring, but your breathing as well. You actually stop breathing, for 10, then 20, then 30 seconds. Then, to their surprise and dismay, you begin to gasp for air, as if it were your last breath. This cycle repeats itself over and over, all night long. For your part, you may be totally unaware of all of that, as the alarm clock rings. You may wake with a dry mouth, a headache, and feeling hungover. You may also be sleepy during the day, have significant memory loss, concentration, attention, mood and other related problems. This rather horrifying scenario is typical for a disorder called sleep apnea.
There are two types of sleep apnea, obstructive (OSA) and central (CSA). In OSA the throat collapses during sleep, preventing the flow of air to your lungs. As your oxygen levels decrease, your brain gets an alert message to "wake up and breath." These apnea episodes may occur 20 to 60 to 100 or more times per hour.
Present in about 7% of the population, the prevalence of sleep apnea is on par with diabetes and asthma. It is also a primary risk factor for high blood pressure. Fortunately, with the proper diagnosis, it can be treated quite effectively.
There are three categories of treatment for obstructive sleep apnea:
- Physical or mechanical therapy
- Non-specific therapy
Which therapy is used depends on your specific medical, lab, and physical exams and other findings.
Physical or mechanical therapies only work at the time they are properly used. Apnea episodes return when they are not utilized.
- Continuous positive airway pressure (CPAP) is the most common treatment. With the use of a snugly fitted face mask or nasal plug, air is blown into the nasal passages, forcing the airway open and allowing air to flow freely. The pressure is continuous and constant and is adjusted so that it is just enough to open the airway.
- Dental or oral appliances reposition the lower jaw and tongue, moving them outward, creating something akin to a pronounced "underbite." Used in mild to moderate sleep apnea, this physically opens the airway, allowing the free flow of air. They are custom-made devices usually fitted by a dentist or orthodontist.
Surgery opens the airway by removal of tissues, like tonsils, adenoids, nasal polyps, and structural deformities that may obstruct it. There are several types of procedures, but none are completely successful and without risk. It is also difficult to predict the outcome and side effects.
- One procedure, called uvulopalatopharyngoplasty, removes tissue at the back of the throat. In addition to having low success rates of between 30%-60%, it is difficult to predict exactly which patients will benefit, as well as the long-term outcome and side effects.
- Other procedures include tracheostomy (creating a hole directly in the windpipe, for those with severe obstruction),surgical reconstructionfor those with deformities, andprocedures to treatobesity, which contributes to apnea.
Non-specific therapy addresses the behavioral aspects that may be an important part of a treatment program.
- If you are overweight, weight loss can reduce the number of apnea episodes. One should avoid depressants, like alcohol and sleeping pills, which can increase the likelihood of and prolong apnea episodes. Some people have apnea events only when lying on their back. So placing a pillow or other device to help keep you on your side may also help.
Other Sleep Disorders
Restless Leg Syndrome (RLS)
Particularly around bedtime, many people (about 15% of the population) experience "pins and needles feelings," an "internal itch," or a "creeping, crawling sensation" in their legs, with a subsequent irresistible urge to relieve this discomfort by vigorously moving their legs. This movement totally relieves the discomfort. These symptoms are classic for restless leg syndrome.RLS makes if difficult to fall asleep and may also awaken you out of sleep, forcing you to walk around to relieve the discomfort. Though not considered medically serious, symptoms of RLS can range from bothersome to having a severe impact on you and your bed partner's lives.
Most people with RLS also have periodic limb movement disorder (PLMD), repetitive movements of the toe, foot, and sometimes knee and hip during sleep. They are often recognized as brief muscle twitches, jerking movements, or an upward flexing of the feet. As with sleep apnea, sufferers may be unaware that RLS and PLMD disturb sleep and produce symptoms similar to those noted above. Once again, it is often the bed partner that brings this to light, as movements awaken them throughout the night. It is important to note that RLS and PLMD are associated with several other medical conditions, including iron-deficiency anemia. So one should, as always, seek proper medical attention.
RLS generally responds well to medication, but since it may occur sporadically with spontaneous remissions, the continuous use of medications is generally recommended for symptoms occurring at least three nights per week. Sleep experts use three types or classes of medications for RLS and PLMD:
- Dopaminergic agents: This class enhances a brain chemical known as dopamine. Mirapex and Permax have become first-line medication, over older drugs like L-Dopa with Sinemet.
- Benzodiazepines are generally sleep experts' second-line medication. They must be used carefully due to the potential for addiction and the negative impact on sleep. This class includes such drugs as diazepam (Valium, Diastat), Klonopin, Restoril, and Halcion.
- Opioids represent the third-line of preferred medication generally and is reserved for those with more severe symptoms. They may be used alone or in conjunction with other medications. This class includes codeine (active ingredient in Tylenol #3), oxycodone (active ingredient in Percocet), Darvon, and methadone (in very severe cases only).
As one would expect, all of these medications are available by prescription only and should be taken only while under a doctor's care.
Falling asleep spontaneously may indicate the syndrome of narcolepsy. Excessive daytime sleepiness is typically the first symptom. It's the overwhelming need to sleep when you prefer to be awake. Narcolepsy is associated with cataplexy, a sudden weakness or paralysis often initiated by laughter or other intense feelings, sleep paralysis, an often frightening situation, where one is half awake yet cannot move, and hypnagogic hallucinations, intensely vivid and scary dreams occurring at the onset or end of sleep. One may also experience automatic behavior, in which one performs routine or boring tasks without full memory later.
There are both behavioral treatments and medications for this situation, which can make life livable again.
General behavioral measures include:
- Avoiding shift work
- Avoiding heavy meals and alcohol intake
- Regular timing of nighttime sleep
- Strategically timed naps
Medications typically involve stimulants in attempt to increase the level of alertness and antidepressants to control the associated conditions noted above. The effects of stimulant medications vary widely and their dosing and timing must be individualized.
- Provigil is a relatively new medication that improves alertness but does not act as a stimulant for other body systems. It has few side effects and low abuse potential.
- Stimulants include dextroamphetamine sulfate (Dexedrine, Dextrostat), methylphenidate hydrochloride (Ritalin, Concerta, others), and Cylert.
- Antidepressants include:
Seeing a sleep specialist is essential for proper diagnosis and treatment.
Many sleep disorders are secondary to a variety of medical and mental-health disorders, pain, and even the treatments for these disorders. Medical conditions like diabetes, congestive heart failure, emphysema, stroke, and others may have nighttime symptoms that disturb sleep. Depressive illnesses and anxiety disorders are associated with sleep disturbances, as is the pain from conditions like arthritis, cancer, and acid reflux, to name a few.
Recognizing and distinguishing among sleep problems, primary sleep disorders, and those secondary to or associated with medical conditions is critical to proper diagnosis and treatment. It is equally important, however, to realize that they often interact in a complex manner, with each impacting the other. For example, poor sleep can affect your mood, and your mood can affect the quality of your sleep. Poor sleep can contribute to obesity, and obesity can cause sleep disorders. Exactly how all these factors interact is not completely known, but we can target each aspect individually and achieve vastly improved interventions and treatments.
The magnitude of the impact of sleep disorders on our individual and public health, safety, and performance is truly enormous. Fortunately, increasing awareness is leading to more effective treatment, less suffering, and happier, more productive lives.
Originally published April 1, 2003.
Medically updated September 2004.