Along human history the mystery of sleep preoccupied the minds and souls of great philosophers and thinkers, poets and artists. The entire understandings regarding sleep were based on observation. Some observations serve as the basis for a branch of the medical science: Sleep Medicine. This relatively new field deals with the overlooked part of human life, sleep time, which represents grossly one third of our lives. People may be aware of how daily events and troubles impact their nights, but they are not necessarily aware of the opposite, how unnoticed sleep problems can influence their whole life including health, physical and mental performance, mood. Thus Sleep Medicine deals with sleep disorders.
Sleep disorders can be the result of an illness that is not directly the result of a faulty sleep- related function. For instance, any disease causing pain, be it an ear infection, tooth pain, or arthritis, may cause very significant sleep problems. Mood disorders, such as increased anxiety, can result in difficulty falling asleep; depression can result in prolonged sleep, but also in early awakenings.
Other sleep disorders originate within sleep itself. The most prevalent one is the Obstructive Sleep Apnea-Hypopnea Syndrome or Sleep Related Breathing Disorder. Others examples are Narcolepsy, REM Behavior Sleep Disorder, Periodic Limb Movement of Sleep.
1. Sleep related breathing disorders
Human muscles lower their level of basic activity during sleep; moreover, during REM sleep their activity is almost completely shut down. The decrease in the muscular activity level affects also the upper airways, which become naturally floppy during sleep, at a time when body position is recumbent. These changes cause the air passages to get narrower, so the inspiration becomes more difficult, resulting in different degrees of compromise of the air inflow.
The easiest form is just narrowing, which causes turbulence of the airflow that makes the surrounding soft tissues, such as the soft palate, vibrate and thus produce the bothering snoring sound. As the narrowing of the passages becomes more accentuated, the airflow is compromised and sometimes even stops, causing a hypopnea (partial decrease in airflow) or an apnea (airflow cessation). The resulting respiratory events end when the muscles increase their tone and the airways reopen and allow breathing in. For this to happen, the sleep is shortly interrupted by a short arousal lasting for a few seconds. This arousal is so short that one does not remember it, however when there are many respiratory events that end with an arousal, sleep becomes fragmented. This can lead to increased daytime sleepiness and other medical complications such as hypertension.
Respiratory events are related not only to sleep fragmentation;they are also accompanied by decrease in blood oxygenation, sometimes increase in the levels of carbon dioxide, and increased stress to the cardiovascular system. Thus sleep related breathing disorders have huge impact on health, being causally related to hypertension and other cardiac problems. The cognitive function may be affected, and so can be mood and memory. Another bothering effect is daytime sleepiness.
Breathing related sleep disorder, Obstructive Sleep Apnea-Hypopnea (OSA) syndrome, is prevalent. 4-10% of the population has OSAS and the prevalence increases with age. The disorder is treatable, and when effectively treated, the consequences can be reversed. The great majority (about 75%) of sufferers, however, remain undiagnosed, and thus untreated.
Snoring occurs when there is a narrowing of the airways during sleep, causing turbulence of the airflow and vibration of the soft tissue in the way, the soft palate, that make the well-known noise. The phenomenon is very frequent, a quarter to more than half the population snore sometimes or habitually, while supine or in every position. It bothers the bed partners. For some there is only snoring (primary snoring), while for others it is a sign of Obstructive Sleep Apnea. Snoring is also treatable, but first one has to rule out the coexistence of Obstructive Sleep Apnea.
When to see your doctor about your snoring, you should report whether:
- You wake up suddenly gasping on a snort at night and fall asleep almost instantaneously after this happens
- You snore so loud that your bed partner gets very annoyed and can’t sleep
- Your throat is dry and painful at night
- Your wake up non-refreshed
3. Periodic limb movement in sleep
This is a not so rare sleep disorder of unexplained etiology. The manifestation of this disorder consists of periodic jerks of the legs and or sometimes upper limbs. The jerks may be as subtle as a toe twitch, or as significant as a limb movement lasting around a couple of seconds and recurring every 20 to 60 seconds during light sleep mainly, and continuing for as long as an hour at times.
The cause remains unknown; it always accompanies Restless Leg Syndrome, but can be present on its own. It may coexist with other disorders, Obstructive Sleep Apnea included. It may be connected with many short arousals that cause sleep fragmentation and non-refreshing sleep, and it may disturb the sleep of the bed partner. The prevalence increases with age. Sometimes it is connected to iron depletion and treating iron deficiency anemia can improve the symptoms. There are additional medical remedies available and prescribed by sleep physicians or neurologists.
A sleep disorder that can manifest sometimes as extreme daytime sleepiness and poor sleep, or in its classical form as a tetrad including excessive daytime sleepiness with irresistible napping tendency, hallucinations upon falling asleep, sleep paralysis, and cataplexy. Cataplexy is a sudden partial or total loss of muscle tone caused by a sudden emotion, usually positive, typically laughing. The patient may fall down while being completely conscious, and then unable to move or talk. The disease may be sporadic or may have a genetic background uncovered a few years ago. Narcolepsy is treated behaviorally with planned naps and symptomatically, using vigilance promoting medications and drugs that can relieve catalepsy. It is a disabling disorder and it goes on for life.
Insomnia is defined as complaint of difficulty falling asleep and/or of maintaining sleep, usually leading to the subjective feeling of poor sleep quality and waking up non-refreshed. The disorder is prevalent, the frequency increases with age, and generally is higher in women. Insomnia has important negative consequences, including fatigue, irritability, cognitive problems and memory issues. Population surveys indicate that most Insomnia patients are reluctant to consult their doctor with regard to their sleep problem.
Insomnia may be frequent and occur almost on a nightly basis, or can have an intermittent course. The disorder can be primary or caused by a stressful life event, shift work or frequent travel across time zones. Insomnia can be present as a stand-alone disorder or it can coexist with other sleep disorders, such as Obstructive Sleep Apnea, Periodic Limb Movement of Sleep, or it may result from a medical problem, such as arthritis, acute or chronic pain, heart failure, liver disease, diabetes and more, or anxiety and mood disorders. The consequences are extensive, including absenteeism, poor job performance, social problems, inattention, increased accident tendency and more.
Usually people try different kind of self administered remedies, when the best approach would be to consult a professional. The doctor’s approach is to take a proper medical and sleep history, order tests if necessary rule out underlying medical problems, and refer to specific Insomnia treatment when no underlying disease is detected.
The treatment consists mostly of behavioral and cognitive therapy, which have been proved to be most efficient and with long lasting effects. These therapies include keeping a very regular sleep-wake schedule, sticking to sleep hygiene requirements, sleep restriction, stimulus control, stress reduction and certain relaxation procedures. The therapy may include a short course of prescription sleeping pills at the beginning. It is recommended to avoid self-medication with alcohol or other over the counter remedies. A healthy lifestyle including a regular sleep schedule, sleep routine, moderate exercise to keep fitness, avoiding coffee and caffeine-containing foods or beverages, avoiding alcohol at bedtime, are all required in order to maintain good night’s sleep in those who suffer from Insomnia.