Treating a sleepless nation: More than 50 million toss and turn

Adequate sleep and good health go hand-in-hand, but patients should be cautioned not to panic over an occasional bad night.

By Susan J. Landers — Posted Aug. 20, 2007

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The quest for a good night's sleep brings many patients to their physicians' offices. As well it should. Sleep's virtues have long been known. Consider Shakespeare's lines from Macbeth:

Sleep that knits up the ravelled sleave of care,
The death of each day's life, sore labour's bath,
Balm of hurt minds, great Nature's second course,
Chief nourisher in life's feast.

Sleep is all that and more.

Science has delved into its mysteries in recent decades and found that sleep is essential to survival. Some experts believe sleep allows the body to repair itself. Many cells increase protein production during this time and important biochemical and physiological processes also take place, according to the National Sleep Foundation, a Washington, D.C.-based nonprofit group.

"We now have a lot of data that tell us that sleep is important for good health," adds Michael Sateia, MD, director of the Dartmouth-Hitchcock Medical Center Sleep Disorders Center in Lebanon, N.H. Beyond the all-too-familiar mental blur that overtakes the drowsy and affects job performance, interpersonal relationships and driving skills, a lack of sleep can cause physiological distress, said Dr. Sateia, a former president of the American Academy of Sleep Medicine.

"This may include impairment in immune function and in carbohydrate metabolism. There is some interesting work suggesting that sleep deprivation may be associated with disturbances in appetite regulation and conceivably contribute to obesity," he noted.

In addition to playing a role in the nation's already burgeoning obesity epidemic and its accompanying chronic illnesses such as diabetes and hypertension, chronic sleep loss appears to interfere with the immune and endocrine systems. Evidence is building that sleep loss is associated with a rise in blood pressure during the night that lasts through the following day. An association also exists between too much or too little sleep and an increased risk of coronary heart disease in women, according to information from the sleep foundation.

A 2006 Institute of Medicine report on sleep disorders adds cardiovascular disease, anxiety symptoms, moodiness, depression and alcohol use to the list of ills caused by sleep deficiency -- defined as less than seven hours a night. Plus, these ill-effects build as sleep loss accumulates.

Lack of sleep is a big problem in the United States. The number of sleep-disordered people is estimated to be between 50 million and 70 million, according to the IOM report, "Sleep Disorders and Sleep Deprivation." Among the most common disorders are insomnia and sleep apnea, with frequent reports also of narcolepsy, restless legs syndrome and a set of bizarre and complex behaviors known as parasomnias. These include sleepwalking, night terrors and bed-wetting.

Pamela Kushner, MD, a family physician in Long Beach, Calif., believes that 20% of the patients seen by primary care physicians on a typical day have sleep disturbances of some kind.

The survey findings prompted the researchers to conclude that sleep complaints are highly prevalent in primary care populations.

Many patients come to their physicians for help with sleep problems after having seen ads for medications, particularly for insomnia and restless legs syndrome. While these direct-to-consumer ads can alert patients to the importance of sleep, they also encourage requests for medications that might not be needed, said Dr. Kushner.

Plus, the ads describe only one aspect of treatment -- medications, said Dr. Sateia. "Cognitive-behavioral techniques are also valuable for some patients," he said. "A core element for those with chronic sleep problems is a learned pattern of negative expectations about sleep and arousal, regardless of whether it came from stress, pain, a medical problem or depression."

Cognitive-behavioral therapy can help ease patients' concerns that they must get eight hours of sleep each night and it helps establish good "sleep hygiene" that includes getting up at about the same time each day, including weekends.

"Patients can become so agitated about getting enough sleep that sleep itself eludes them. When it comes to insomnia, my first take on it is that people should lighten up," noted Barbara Phillips, MD, MPH, a professor of pulmonary critical care and sleep medicine at the University of Kentucky's College of Medicine. "We've blurred the lines between the person who does not set aside enough time to sleep and the person who spends way too much time in bed and has learned not to sleep because of anxiety about it."

Before writing a prescription, experts on sleep disorders advise asking questions. One of the biggest conundrums, said Dr. Phillips, is the failure of nearly everyone to distinguish between lifestyle-imposed lack of sleep, such as that caused by staying up late to watch TV or play video games, and insomnia.

There is a difference between the 22-year-old working single mother who doesn't get to bed until the chores are done at midnight and then has to get up at 5:30 or 6 a.m. to get the kids off to school, and the 45-year-old woman who goes to bed at 9 p.m. and spends 10 hours in bed hoping to sleep for eight of them, she said. The former has sleep restrictions and the latter has insomnia.

Insomnia is the most commonly reported sleep disorder, according to the IOM panel. It is defined in their report as difficulty initiating or maintaining sleep, waking too early and not being able to get back to sleep, or waking feeling unrefreshed and lethargic.

Almost everyone occasionally experiences short-term insomnia from stress, jet lag or diet. Chronic insomnia is more problematic.

Successful treatment for long-term insomnia could include uncovering the reason for the sleep problem, said Dr. Kushner. Explore possible behavioral changes, including giving up caffeine, and determine whether the sleep disorder is associated with an illness.

"Perhaps they are sleeping in a chair because they have heart failure or emphysema," she said. "Or maybe it's depression, since early morning awakening is one of the first symptoms of that disease." Treating the underlying condition could well solve the sleep problem.

Do you snore?

"The one thing I wish primary care doctors knew about insomnia, especially in women, is that it can be a symptom of sleep apnea. That's pretty new information," said Dr. Phillips.

Men with sleep apnea complain of daytime sleepiness, since they tend to sleep through their episodes of interrupted breathing. Women, however, often wake up when they have the same degree of breathing disturbances as men, but they report their symptoms as insomnia. Women seem to have a lower arousal level than men, which is likely biologic in origin, Dr. Phillips said.

It has become known in recent years that sleep apnea -- most commonly obstructive -- can have serious health consequences. While it is becoming less likely to be overlooked, it can be mistaken for other conditions.

Take a typical patient, as described by Dr. Sateia. He's a 50-year-old man who complains to his physician that he gets up four or five times during the night to urinate. He is tired during the day. He might also have had an occasional unusual disturbance where he got out of bed during the night and did not remember it, or he has swatted his wife while sleeping. He has had some hypertension in the past year and has gained 20 or 30 pounds.

"The patient might be worked up for a prostate problem because he is up all night urinating. He is at risk for cardiovascular problems and there are behavioral disturbances that are kind of odd," said Dr. Sateia. "It turns out that the key question is, 'Do you snore?' " And the answer: " 'My wife says I snore like a locomotive.' "

His wife also may say he seems to stop breathing while sleeping. And, importantly, he is tired and irritable during the day, sometimes falling asleep at work. He is also having trouble staying awake while driving.

Treatment for sleep apnea, which most frequently involves using a continuous positive airway pressure machine, can lead to welcome changes for the patient, said Dr. Sateia. "They begin sleeping with much less interruption at night, their moods brighten, their productivity increases dramatically, their quality of life is increased, and the cardiovascular risk factors they have been accumulating are now eliminated."

They may even experience the joy of sleep as described in Captains Courageous by Rudyard Kipling: "It was the 40-fathom slumber that clears the soul and eye and heart, and sends you to breakfast ravening."

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Sleep patterns change with age

  • Newborns sleep about 16 to 18 hours per day. Sleep is discontinuous, with the longest period lasting only 2.5 to 4 hours, and without distinction between night and day. Circadian rhythms are established at around 2 to 3 months. Newborns have three types of sleep: quiet, similar to non-rapid eye movement; active, analogous to rapid eye movement; and indeterminate sleep.
  • Young children need less sleep than infants but the amount they get depends as much on culture as physiology. At about 6, children begin to emerge as night owls or morning people. Nightmares become more likely.
  • Adolescents exhibit complexities in sleep. Most need 9 to 10 hours of sleep a night, but few get it. The stage of puberty, rather than chronological age, determines sleep needs. At mid-puberty daytime sleepiness increases significantly. For more mature adolescents, sleepiness is most pronounced in late afternoon. With age, the total time spent sleeping decreases as does the duration of REM.
  • Adults experience ongoing sleep changes, such as a trend toward earlier bedtimes and wake times. Older adults, ages 65 to 75, typically awaken 1.33 hours earlier and go to bed 1.07 hours earlier than do adults ages 20 to 30. Gender-based differences in sleep and circadian rhythms also exist, with men spending more time in the first stage of NREM and experiencing more awakenings. Men are more likely to complain of daytime sleepiness while women report more trouble falling asleep. Women's sleep patterns are affected by pregnancy. Women have a higher risk for restless legs syndrome.
  • Elderly people typically show an increase in disturbed sleep that can have a negative impact on quality of life, mood and alertness. The ability to sleep becomes more difficult, although the need to sleep does not decrease. Older people experience a drop in melatonin levels, perhaps due to deterioration of the hypothalamic nuclei that drive circadian rhythms. Other sleep-disturbing factors may be irregular meal times, inconsistent external cues such as light exposure and decreased mobility leading to a reduction in exercise.

Source: "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem," Institute of Medicine, 2006

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Physiologic changes in sleep

During a regular night's sleep, people cycle through stages of non-rapid eye movement sleep and rapid eye movement sleep. Why this happens isn't understood, but irregular cycling or no cycling is associated with sleep disorders. NREM sleep occurs 75% to 80% of the time. REM sleep makes up the rest. Research shows:

  • Brain activity decreases during NREM sleep and increases in motor and sensory brain areas during REM sleep.
  • Heart rate slows during NREM sleep and increases and varies during REM sleep. There is an increased risk of myocardial infarction in the morning due to the sharp increases in heart rate and blood pressure that accompany waking.
  • Blood pressure decreases during NREM sleep. It increases up to 30% and also varies during REM sleep.
  • Sympathetic nerve activity decreases during NREM sleep and increases significantly during REM sleep.
  • Muscle tone is similar to wakefulness in NREM sleep and absent during REM sleep.
  • Blood flow to the brain decreases during NREM sleep. It increases and varies during REM sleep, depending on the brain region.
  • Respiration decreases during NREM sleep. During REM sleep, it increases, becomes more erratic and even may stop briefly.
  • Airway resistance increases during NREM sleep. It increases and varies during REM sleep.

Source: "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem," Institute of Medicine, 2006

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