Sleep Center Education

Sleep Apnea

Sleep apnea is a common sleep disorder that causes frequent pauses in breathing during sleep and is often accompanied by snoring, poor sleep and daytime sleepiness. About 2% of women and 4% of men in the U.S. suffer from the condition.

The word apnea means "stop breathing." Patients with the usual form of sleep apnea (obstructive sleep apnea) actually repetitively close off their airway at night for a few seconds at a time. The airway closure occurs either behind the tongue or behind the nose. Patients continue to make efforts to breathe. Then after several seconds, the brain, realizing it is not getting any oxygen, arouses or "wakes up." This allows the upper airway to open and allow breathing. The brain goes to sleep again and the cycle may repeat itself several hundred times a night. The sleep disruption can cause the sufferer to wake up several times an hour, preventing deep, restful sleep. Patients are often not even aware that they are doing this (although the bed partner often notices these symptoms).

Patients with sleep apnea are at higher risk for high blood pressure, heart failure, stroke and high blood sugar. In addition, patients are often sleepy during the day. Sleepiness is associated with inability to concentrate, remember or think. There is a significantly higher risk for falling asleep while driving, using heavy machinery or other activities that require attention.

The most common and efficacious way of treating this disorder is by using a device termed as CPAP (Continuous Positive Airway Pressure). This device is actually a blower that drives compressed air down the airway via a tight fitting mask and helps to splint the airway open during sleep, thereby preventing the apneas.           

A few patients may be candidates for surgery on the upper airway. In the usual upper airway surgery the uvula, tonsils and some of the surrounding soft tissue is removed to enlarge the air passage. Sometimes a dental device designed to move the lower jaw outwards slightly may be worn at night. In a few cases, treatment is begun with an emergency tracheotomy when sleep apnea is considered to be immediately life-threatening.

Central sleep apnea is a less common disorder. In this condition, the brain does not send the right signals to control breathing during sleep. This may be seen in patients with heart failure, past history of stroke or on narcotic medications. Treatment is more difficult and may include a combination of CPAP/BPAP, oxygen and/or certain medications.

Sleep Apnea and Heart Disease

People with sleep apnea can develop high blood pressure and heart disease. In patients with sleep apnea and a heart condition, sleep apnea can worsen their condition.

Sleep apnea can cause the heart rate and blood pressure to increase. Sleep apnea increases the risk of high blood pressure (which is the main cause of heart disease) plus the events that occur during apnea can add stress to the heart. People with sleep apnea have higher risk of coronary artery disease.  Sleep and breathing disorders can increase the risk for heart failure. Sleep apnea has also been associated with increased risk for stroke. Several studies have shown that patients with heart failure and sleep apnea have a higher incidence of irregular heart rhythms (atrial fibrillation and ventricular arrhythmia's).

Sleep apnea may be deadly

Researchers have found that there is risk of premature death that increases as the severity of sleep apnea increased. Findings also suggest protection from risk of death with proper treatment of sleep apnea, such as the use of continuous positive airway pressure (CPAP) to prevent pauses in breathing. Other interventions include weight loss if the patient is overweight, avoidance of substances that increase the risk of apneas such as certain sleeping pills and alcohol.

Restless Leg Syndrome

Restless legs syndrome (RLS) is a neurological disorder often described as a creeping, crawling, tingling, aching, burning, pulling, cramping in the calves, thighs, feet or arms. The sensation is commonly described as a "creepy" or "crawly" sensation and is typically relieved by movement of the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours. RLS can disrupt sleep, leading to daytime drowsiness. RLS is common, affecting 5-10% of adults and increasing with age.

Prescription medications are available to reduce the restlessness. Also, self-care, coping skills and avoidance of caffeine can help reduce symptoms. Pregnancy and iron deficiency are associated with an increased frequency of this disease. Iron replacement therapy is used if patients are iron deficient. Drugs used to treat Parkinson's disease, including pramipexole and ropinirole, are very effective in treating most cases. Medications such as clonazepam or analgesic medications related to morphine can also be used. In some cases, anti-seizure medications may be effective.

Periodic Limb Movement Disorder

Periodic limb movement disorder (PLMD) is a condition where the person moves or kicks his/her legs during sleep leading to sleep disruption. The disorder is similar to restless legs syndrome with the exception that the leg kicks occur during sleep rather than before sleep. A sleep study can confirm the diagnosis. A person may suffer from excessive daytime sleepiness because these movements may fragment sleep, leading to poor quality, non-refreshing sleep. Periodic limb movement disorder can occur as an isolated problem, often reported by the bed partner. The treatment is similar to Restless Leg Syndrome (see above).

Narcolepsy

Narcolepsy is a chronic sleep disorder that often begins during adolescence but may not be diagnosed until a later age. It is characterized by excessive daytime sleepiness with daytime ‘sleep attacks’. Other characteristic features that may or may not be present, include cataplexy, sleep paralysis and hypnogogic hallucinations. Narcolepsy can run in families, but can occur in the absence of any family history.

• Cataplexy is the sudden loss of muscle tone, commonly associated with strong emotions. It may be a subtle sensation of weakness in the jaw, neck, arms or legs or a complete loss of strength with a fall to the ground.
• Sleep paralysis is a sensation of not being able to move on waking, usually for a few seconds.
• Hypnogogic hallucinations are very vivid and sometimes violent or bizarre sensations that occur upon waking or falling asleep.

The treatment of narcolepsy requires a combination of drug therapy and behavioral modification. Stimulant medications may be used to alleviate symptoms of daytime sleepiness. Other medications, such as certain anti-depressants and sodium oxybate, are used to treat cataplexy, sleep paralysis and hypnogogic hallucinations. Naps scheduled at specific times during the day are also helpful. Treatment for each patient must be individualized and each patient with his/her physician needs to discuss this on a case-by-case basis.

Excessive Day Time Sleepiness

Excessive daytime sleepiness may include mild sleepiness, unrecognized episodes of "micro sleep" or uncontrolled sleep attacks, falling asleep while in conversation, reading or watching television, or even more seriously, while driving.

Excessive daytime sleepiness may be caused by not getting enough hours of sleep, or enough quality hours of sleep. Generally, a person needs about eight continuous hours of sleep per day. Other causes are sleep apnea, narcolepsy, psychiatric disorders, RLS, periodic limb movement disorder, poor sleep hygiene, sedating medications or chronic drug or alcohol abuse.

Insomnia

Insomnia is a condition in which the patient has trouble falling or staying asleep. It is a common condition that can cause daytime sleepiness and lack of energy. In most cases insomnia, the inability to sleep or inability to sleep well at night, is a symptom, not a disease. Insomnia can be caused by:

• Stress
• Depression or anxiety
• Prescription drugs such as antidepressants, high blood pressure and corticosteroid medications, and over-the-counter pain medications, decongestants and weight-loss products.
• Shift work
• Long-term use of sleep medications
• Pain
• Sleep apnea
• Restless leg syndrome
• Physical illness
• Poor sleeping environment
• Day time napping

Insomnia is best treated with cognitive-behavioral therapy. This simply involves education about sleep, and adopting good sleep habits that may help patients sleep. Cognitive Therapy and good sleep habits are methods used to correct common misconceptions about sleep. Sleeping medications may also be used.

See Tips for Better Sleep

Cognitive-behavioral therapy for insomnia targets the thoughts and actions that can disrupt sleep. Besides encouraging good sleep habits, this type of therapy may use several methods to relieve sleep anxieties, including:

Relaxation training and biofeedback at bedtime to reduce anxiety. These strategies help you better control your breathing, heart rate, muscles, and mood.

Replacing worries about not being able to fall asleep with more positive thinking that links being in bed with being asleep. This method also teaches you what to do if you're unable to fall asleep within a reasonable period.

Talking with a therapist individually or in group sessions to help you consider your thoughts and feelings about sleep. This method may encourage you to describe thoughts racing through your mind in terms of how they look, feel, and sound. The goal is for your mind to settle down and stop racing.

Limiting the time you spend in bed while awake. This method involves setting a sleep schedule and, at first, limiting total time in bed to the typical short length of time you're usually asleep. At first, this schedule may make you even more tired because some of the allotted time in bed will be taken up by difficulty sleeping. The resulting fatigue (tiredness) is intended to help you get to sleep more quickly. Gradually, the length of time spent in bed is increased until you get a full night of sleep.

For success with this type of therapy, you may need to see a therapist who is skilled in this approach weekly over 2 to 3 months. Cognitive-behavioral therapy is as effective as prescription medicine for many types of chronic insomnia. It also may provide better long-term relief than medicine alone. Our sleep center offers cognitive behavior therapy for insomnia.

Sleep medicines can also help treat insomnia, but these medicines may make you feel groggy after you wake up.

Sleep Disorders in Mental Illnesses

Many people with mental illnesses, e.g. depression, anxiety, post-traumatic stress syndrome, and panic attacks, develop sleep disturbances. Insomnia is a common symptom in many people with these problems. Evaluation and treatment by a health care provider skilled in these disorders, usually in conjunction with an evaluation by a sleep specialist, often brings about great improvement.

Good Sleep Hygiene

Personal Habits

• Keep a regular sleep schedule. Get up about the same time every day.
• Go to bed only when sleepy.
• Avoid napping during the day.
• Keep your bedroom dark, quiet and just the right temperature. A cool (not cold) bedroom is often the most conducive to sleep.
• Avoid bright lights if you have to get up at night.
• Block out all distracting noise
• Reserve the bed for sleep and sex. Don't use the bed as an office, workroom or recreation room. Let your body "know" that the bed is associated with sleeping.
• Do not watch TV, read or eat in bed.
• Keep your clock turned away from the bed.
• Exercise regularly. Mild exercise—such as simple stretching or walking—at least four hours prior to bedtime can deepen sleep. Avoid exercising close to bedtime. Note: Strenuous exercise within the 2 hours before bedtime, however, can decrease you ability to fall asleep.
• Avoid ingestion of caffeine (coffee, tea, sodas, chocolate etc) 6-8 hours before bedtime.
• Avoid alcohol 4-6 hrs prior to bedtime, as alcohol will disrupt your sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in your blood start to fall, there is a stimulant or wake-up effect.
• Avoid smoking close to bedtime. Nicotine is a stimulant and will keep you awake.
• Avoid sleeping pills. These can worsen some sleep disorders. Discuss with your sleep physician first.

Getting Ready for Bed

Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.

Don't take your worries to bed.>Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a "worry period" during the evening or late afternoon to deal with these issues.

Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading in dim light, can help you sleep.

Get into your favorite sleeping position. If you don't fall asleep within 15-30 minutes, get up, go into another room, and read something dull (in dim light) until sleepy. Do not fall asleep on the couch. Return to bed to sleep.

Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read in dim light or do some quiet activity. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television. Do not watch the clock!