Sleep is essential to a happy, healthy life, so why do so many people struggle to get enough of it? Without proper sleep, brain function is impaired and we’re grumpy, morose and more susceptible to serious health issues like heart disease, stroke and premature death.
[sleep apnea: it’s serious]
Experts have an acronym for identifying sleep apnea risk: ‘STOP BANG.’ It stands for Snoring, Tired, Obstructed breathing, Pressure (high blood pressure), Body mass index (BMI of 30 or more), Age (50 or older), Neck circumference (16 inches or greater for women, 17 or greater for men) and Gender (men are twice as susceptible). People with three or more of these characteristics are at risk for sleep apnea.
wake-up call
“If you have sleep apnea, your (death) risk is about six-fold higher than a person without it,” says Dr. Joseph Espiritu, codirector of the SLUCare Sleep Disorders Center. The condition is characterized by recurrent episodes of partial or complete obstruction of the airway during sleep. Dr. Kelvin Yamada, director of the Washington University Sleep Medicine Center says somewhere around 5 to 10 percent of the population have clear-cut sleep apnea. “But if you look at men over a certain age, it can approach 20 percent or more,” he says.
“When these people sleep at night, the muscles of the throat relax, so they either completely close down or become tight,” Espiritu says. “When they become tight, the person will stop breathing and oxygen levels may drop. However, the brain doesn’t allow you to stop breathing completely, so it wakes up briefly without you knowing in order to re-establish the airway, and those arousals interrupt your sleep.” So instead of getting a deep, refreshing sleep, these people have fragmented, shallow sleep. “They have poor concentration and trouble with their memory and vigilance; the risk of car accidents goes up,” Espiritu says.
Those night awakenings also release adrenaline, which raises blood pressure and increases the risk for heart attacks, stroke and diabetes. Once the likelihood of apnea is established, the next step is a sleep study, the gold standard being polysomnography, a measure of the variables while a patient is sleeping, including brain waves, breathing cessation and oxygen levels.
open the airways
The treatment of choice is continuous positive airway pressure (CPAP), a machine that forces air through a mask over the nose to improve airway flow. Patients with milder sleep apnea may be helped by a less-invasive method: a mandibular advancement device that gradually adjusts the protrusion of the jaw, moving the tongue and soft palate forward to open the airway.
Only 50 percent of patients who need it agree to use CPAP, Espiritu says. “That’s the biggest problem with the treatment. It’s a bit of a hassle,” Yamada says. “You have to get used to it. Some people take to it really well, and if it helps alleviate symptoms, they really, really like it. The morning after a sleep test, they’re begging for a machine. Others can’t tolerate it at all.”
when cpap is not for you
For some, CPAP can dry nasal passages or fill the stomach with air, causing discomfort, Yamada explains. Also, it can be problematic with cardiac patients. “If they have heart problems, you don’t want to put a lot of air pressure into their chest because that can interfere with their hemodynamics,” he says.
In such cases, a low-pressure CPAP setting is used. Some patients also have to sleep with their head and torso elevated, or even in a seated position, like in a recliner. “Some people can’t sleep flat, because airway anatomy works against you,” Yamada says. Since excess weight is often a contributing factor, weight loss is highly recommended. “It’s something we almost always discuss with our patients,” Yamada notes. The thing to remember, he stresses, is, “If you have severe sleep apnea and you don’t treat it, it will take years off your life.”
[a good night’s sleep]
Much has been said about the amount of sleep people of various ages need. But the figures can be confusing since they seem to change says depending on who’s offering the advice. So what are we to do?
a moving target
“That’s a hard one,” says Dr. Margaret Whitcraft, an internist with Mercy Clinic Internal Medicine. “An adequate amount of sleep for an adult is at least seven to nine hours a night.” Earlier this year, the National Sleep Foundation convened a panel of experts and issued an extensive paper concerning sleep times. The study concluded that sleep requirements vary greatly. “Even within the science of sleep, we’ve got the issues of how much sleep do individuals need and how much sleep do population groups need,” says Dr. Joseph Ojile of Clayton Sleep Institute. “How much sleep you need is determined by your genetics.”
Ojile describes sleep needs as a bell-shaped curve. “There’s a range, with people generally falling in the center of that curve,” he says. “Younger children need significantly longer sleep times than adults over age 25. There is some reduction in sleep needs as you get older.”
rule out issues
Whitcraft sees about 20 patients a week—one-fifth of her practice—who have sleep issues. Sleep-deprived people have clear symptoms, she says, including headaches upon waking, feeling sick, low energy levels and needing naps during the day. “The next step is to categorize why they aren’t getting enough sleep,” she says. “Are they having difficulties falling asleep, or staying asleep? There could be a number of other disorders, like sleep apnea, that are really prevalent now because of the increase in obesity in our nation.”
Internists will prescribe sleep aids or try to determine disruptors like anxiety, but serious cases usually call for a sleep study done by a specialist, Whitcraft advises. “With sleep apnea, sometimes people will be in bed for nine or 10 hours, but they’re actually not getting nine to 10 hours of good sleep because their body is waking them up due to periods of low oxygen.”
night owls
What about people who claim they need only five to six hours of sleep a night? “There are indeed people we call short sleepers,” Ojile says. “However, the number of those who need less than six hours of sleep per night and are healthy is 1 percent or less. There are a few people who win the biology contest of life and can exist on short amounts of sleep, but it’s relatively uncommon, and not nearly as common as people would lead you to believe.”
Of those who claim to need less than the recommended amount of sleep, some are supplementing with daytime naps, a bimodal schedule Whitcraft calls the “perfect sleep pattern.” Or, as Ojile says, they’re using significant amounts of caffeine or other stimulants. The stimulant approach is not recommended. “Long term, it poses health risks,” he says. And if a generic warning about ‘health risks’ isn’t enough to scare you into better sleep habits, Ojile adds, “People who don’t sleep enough, or sleep too much, have higher rates of heart disease and weight gain, and higher mortality.”
[sleep meds: risks vs. rewards]
When counting sheep isn’t bringing sleep, the only way to get by might be with a little help from your ‘friends’: the host of pharmaceuticals that are either revered or reviled, depending on how they work for an individual.
it’s complicated
“When we prescribe medication, we should know which type of insomnia we are dealing with,” says Dr. Mesfin Mitike, a neurologist at SSM Health St. Mary’s Hospital. If it is associated with depression, for instance, there are medications that will treat depression and improve sleep, he explains. Other issues like anxiety, chronic pain, sleep apnea or restless leg syndrome also should be considered to determine the proper medication.
“We try and figure out if there’s an underlying cause for chronic insomnia,” says Dr. Anthony Masi, a pulmonologist with Lung and Sleep Medicine in Ballwin. “If I can figure out what’s causing it, then I try and address that issue, which often will improve the insomnia.” If the sleeplessness doesn’t improve after addressing the underlying cause, or if the insomnia is idiopathic, meaning it has no apparent cause, then Masi will discuss sleep medicine options.
“I’ll ask patients if they would like to start a mild sleep aid or consider cognitive behavioral therapy, a type of relaxation-based therapy usually done by a counselor or psychologist,” Masi explains. “It addresses the hyper-arousal that is present in many of these insomnia patients that prevents them from falling asleep. Cognitive behavioral therapy is really considered the first line of treatment.”
pick your poison
The three sleep aids Mitike most commonly prescribes are Sonata, Ambien and Lunesta. Sonata is the treatment of choice for people who have trouble initiating sleep, he says. It has no residual sleepiness in the morning. Ambien is typically prescribed for people who have difficulty initiating and maintaining sleep. If a longer period of effectiveness is required, Lunesta is used. Masi has had success prescribing Trazodone, an antidepressant also effective for insomnia.
The most common adverse side effect of most sleep medicines is grogginess upon waking. If that occurs, Masi will reduce the dose or try a different medication. In rare cases, the patient may experience “complex sleep behavior, where he may get up in the middle of the night without any recollection,” Masi says. This can include sleep walking or cooking, eating or even driving while asleep. “I have a lot of patients who are on Ambien and are responding nicely to it without any side effects,” Masi says. To better avoid problems, the smallest effective dose should be used. It’s also important, Mitike adds, not to combine sleep medicine with alcohol or any other medication, as this could dangerously affect breathing. Also, be prepared to go to sleep right after taking the dose.
the natural route
Melatonin, a natural sleep aid, can be used as a supplement in 3, 5 or 10 mg doses two hours before intended bedtime to transition into a relaxed state, Mitike says. And there is always cognitive behavior therapy, which many have success with. “It takes a lot of patience and dedication to practice the skills you learn through the counselor or therapist,” Masi says. “But people who get good at it will improve their insomnia and often can stop sleep aids.”
As much as possible, doctors prefer patients not become reliant on medications for sleep. “Most sleep medications work by affecting one of the systems in the brain,” says Mitike. “But all of them have an effect on the breathing center.”