How Well Are You Sleeping?
It's a horrible feeling to be captain of the
ship when the ship goes down. That's how Antonina Radzikowski,
55, says she felt after falling asleep while driving down
a Maryland highway one afternoon in 1994.
Radzikowski and her husband, Phillip, were
heading home after dropping their teen-age son off at a
gifted and talented summer program. Roughly 60 miles away
from home on I-70 near Hagerstown, Md., the car Radzikowski
was driving smashed into the guardrail, flew over it, and
fell 30 feet before landing on railroad tracks on the opposite
side of the highway. Radzikowski's husband died and she
was left with severe brain injuries that shortened her attention
span and led to her retirement from teaching.
"I sometimes felt drowsy before, but I never
knew why until after the accident," Radzikowski says. A
sleep study revealed that she suffers from obstructive sleep
apnea, a condition in which her breathing stops for about
10 seconds to as long as a minute while she's sleeping.
Her effort to breathe wakes her up, and this stop-and-start
cycle of waking to breathe can repeat hundreds of times
a night. A person with sleep apnea isn't aware of the frequent
awakenings, but is likely to feel overwhelming sleepiness
during the day.
There are many reasons for sleep deprivation.
Each year, there are about 40 million people in the United
States who suffer from sleeping disorders. An additional
20 million have occasional sleeping problems, according
to the National Institute of Neurological Disorders and
Stroke.
People who work nights, for example, probably
never completely adapt because our bodies want to be awake
during the day and asleep at night. We are governed by the
circadian rhythm, an internal clock that regulates sleep
and wake cycles. Sleep deprivation can also result when
people choose to skimp on sleep in favor of work, parties
or late-night television.
Whatever the reason for sleep loss, research
has shown that it takes a toll on us both mentally and physically.
While we sleep, our bodies secrete hormones that affect
our mood, energy, memory, and concentration. Testing has
shown that with a driving simulator or a hand-eye coordination
task, sleep-deprived people may perform just as badly as
intoxicated people.
Sleep deprivation and fatigue have long been
issues for professions that have traditionally held long
work hours. Pilots have federal regulations that limit their
work hours to eight hours of flying time within a 24-hour
period. Truck drivers can't drive more than 10 hours without
a mandatory eight-hour break. Physician advocacy groups
are pushing for the passage of the Patient and Physician
Safety Protection Act, currently under consideration in
Congress, that would set limits nationwide on the number
of hours worked by medical residents.
According to the American Medical Student
Association, residents sometimes work 100-120 hours a week
in 24- and 36-hour shifts. Some have reported making mistakes
with medication, falling asleep while driving home, and
experiencing health problems, such as depression. The bill
would limit residents to 80 hours per week with at least
10 hours off between shifts, among other provisions.
Recent research suggests that if sleep deprivation
is long-term--whether because of lifestyle choices or sleep
disorders--it may increase the severity of age-related chronic
disorders such as diabetes and high blood pressure. In a
study published in the Oct. 23, 1999, issue of The Lancet,
Eve Van Cauter, Ph.D., professor of medicine at the University
of Chicago, led researchers who restricted 11 young men
to four hours of sleep for six nights, and then recorded
their bodily functions. The researchers then allowed the
same young men to spend 12 hours in bed per night for six
nights, and compared their bodily functions to those recorded
earlier. The researchers found negative effects on metabolic
and endocrine functions when the men were sleep-deprived
similar to those seen in older people as a result of normal aging.
In another study, published in the Sept. 25,
2002, issue of the Journal of the American Medical Association,
Van Cauter and colleagues found a marked decrease in the
response to flu vaccination in young, healthy people who
were immunized after four days of sleep restriction, compared
with those whose sleep was unrestricted.
"There's a need to look at sleep on the same
level of importance as diet and exercise," says Carl Hunt,
M.D., director of the National Center on Sleep Disorders
Research, part of the National Heart, Lung, and Blood Institute.
"All three are equally important for good health."
Here's a look at some common sleep problems
and what you can do about them.
Can't Fall Asleep--Can't Stay Asleep
Most people experience short-term insomnia
at some time. Insomnia includes having trouble falling asleep,
having trouble getting back to sleep, and waking up too
early. Insomnia is more common in females, people with a
history of depression, and in people older than 60.
Temporary insomnia can be caused by noise
or a stressful event like the loss of a job or a death in
the family. A National Sleep Foundation poll of 993 adults
over 18 found that close to half of the respondents reported
symptoms of insomnia as they tried to sleep in the nights
immediately following the terrorist attacks on September
11, 2001.
Certain medications could keep you awake,
particularly those that treat colds and allergies, heart
disease, high blood pressure, and pain. And some of us practice
bad habits that sabotage our sleep. This includes drinking
alcohol and eating too close to bedtime, says James Walsh,
Ph.D., president of the National Sleep Foundation and executive
director of the Sleep Medicine and Research Center in Chesterfield, Mo.
"Alcohol works as a sedative, but it's also
metabolized quickly--within two to three hours for moderate
doses," Walsh says. "So you'll have a rebound effect. You
may sleep soundly for the first couple of hours but then
toss and turn later." And large meals in the two hours before
bedtime could cause indigestion
Short-term insomnia lasts only a few days
and is usually not a cause for concern. For example, with
jet lag, your internal body clock will readjust itself within
several days. It's wise to read labels carefully and check
with your doctor before using over-the-counter (OTC) sleep
medicines for short-term insomnia. These drugs use sedating
antihistamines to make you drowsy. Examples include Nytol
(diphenhydramine) and Unisom Nighttime (doxylamine).
People with breathing problems, glaucoma,
or chronic bronchitis, pregnant or nursing women, and people
who have difficulty urinating due to an enlarged prostate
should not use these medicines. People with sleep apnea
shouldn't take sleep-promoting medicine because it could
suppress their respiratory drive, making it harder to wake
up when they experience an episode of interrupted breathing.
Insomnia is considered chronic when it lasts
most nights for a few weeks or more. This longer-term condition
deserves professional attention, says Tom Roth, Ph.D., head
of the Sleep Disorders and Research Center at Henry Ford
Hospital in Detroit. If you're unsure about whether you
have chronic insomnia, Roth suggests looking at it like
a headache. "If it goes on day after day and nothing you
do makes it go away, then you should see a doctor," he says.
"Ask yourself: Do you know the cause?"
Sometimes insomnia is caused by an underlying
illness that needs treatment, such as a thyroid disorder,
anxiety, depression, arthritis, or asthma. Georgi Moyer,
60, of Gaithersburg, Md., has had problems with insomnia
for 38 years because of restless leg syndrome, a condition
that causes tingling and crawling sensations in the legs.
"It feels like ants crawling around inside your legs," says
Moyer. "The only thing that helps is moving your legs. So
I end up pacing the floor or kicking my husband in bed."
Moyer, who is a nurse, chooses to work nights
because her problem is at its worst from about 8 p.m. until
3 or 4 in the morning. There are no drugs approved by the
FDA for restless leg syndrome. Moyer says she has found
some relief with drugs that treat symptoms of anxiety.
For others, the cause of insomnia may be a
combination of factors and hard to pinpoint. Mike Shockey,
Ph.D., 52, of Stafford, Va., has had a severe case of insomnia
for 30 years. There have been times when he's slept only
15-20 hours during a week. A sleep test indicated that he
hasn't been reaching the deepest--and most restorative--stages
of sleep for years.
As a result, Shockey has felt both the mental
fog and a physical slowdown from sleep deprivation. "Sometimes,
my legs have felt like stone," says Shockey, who is a college
professor and novelist. "I've had to hold onto the podium
to stay up. Or I might drive somewhere and sit in my car
for awhile because it's a huge effort to get across the
parking lot." He says he's often jealous of his wife. "She
falls asleep soon after she hits the pillow and I look over
and think--it sure must be nice."
About 85 percent of people who have insomnia
can be helped with a combination of behavioral therapy and
medicine, says Marc Raphaelson, M.D., a neurologist with
the Greater Washington Sleep Disorders Center in Rockville, Md.
Prescription hypnotic drugs act in areas of
the brain to help promote sleep. There have been advances
with the development of more short-acting drugs to decrease
drowsy spillover effects in the morning. Sonata (zaleplon),
for example, is a drug designed to help you fall asleep
faster, but not for keeping you asleep. Ambien (zolpidem)
is an example of a drug indicated for both getting to sleep
and staying asleep.
Insomnia has traditionally been viewed as
a symptom of an underlying medical or psychiatric illness,
and drugs to treat insomnia are approved for short-term
use only, until the primary condition can be treated.
Hypnotic drugs are potentially addictive.
Generally, their use is limited to 10 days or less, and
the longest that they are approved for use is about 30 days,
says Paul Andreason, M.D., a drug reviewer in the FDA's
Division of Neuropharmacological Drug Products. "Drug sponsors
have not done longer-term studies that evaluate the drugs'
effectiveness for longer periods," he says.
Raphaelson says there is a gap in approved
treatments because some people with this chronic condition
may need long-term treatment. About 20 percent of people
with chronic insomnia have a primary form of it, which means
it's not associated with another medical condition.
"Most people I've seen are frightened of the
medications for fear of addiction," Raphaelson says. "But
there is little indication that people with insomnia abuse
these medications."
As with any prescription medication, it's
important to not increase doses or stop taking hypnotic
drugs without consulting a doctor. No drugs that promote
sleep should be taken with alcohol. And because of the sedating
effects, caution must be used when getting out of bed, driving,
or operating other machinery.
Sleepy During the Day
Feeling tired every now and then during the
day is normal. But it's not normal for sleepiness to interfere
with your routine activities. For example, you shouldn't
be dozing off while reading the newspaper, during business
meetings, or while sitting at a red light. Slowed thinking,
trouble paying attention, heavy eyelids, and feeling irritable
are other warning signs.
If you're feeling sleepy frequently during
the day, you might simply need to make more time to sleep.
"Every year, a couple of people will come see me and say
that they go to bed late and wake up early, and ask if I
could give them a pill to help them feel more refreshed,"
Raphaelson says. "I tell them to sleep."
Experts say that most adults need at least
eight hours of sleep every night to be well rested, but
this varies from person to person. The bottom line is that
you should sleep for the number of hours it takes for you
to feel rested, refreshed, and fully alert the next day.
If you've had a good sleep, you shouldn't feel drowsy during
the day.
Naps can be good, but the American Academy
of Sleep Medicine recommends napping before 3 p.m. and for
no longer than an hour so that it doesn't interfere with
falling asleep at night.
If you are sleeping an adequate amount and
you still feel drowsy going about your day-to-day routine,
or if adjusting your sleeping habits hasn't helped, then
you should talk with your health-care provider.
Overwhelming daytime sleepiness could be due
to a number of sleep disorders. For example, people with
narcolepsy experience excessive sleepiness even after a
full night's sleep. "Some people may be able to sleep, but
the sleep quality is no good," Raphaelson says. "If you
look at the brain as a rechargeable flashlight, some people
don't hold the charge very well." They may have sleep attacks,
sometimes at very inappropriate times such as while eating
or talking. But not all cases present this way.
Richard Bernstein, 46, of Baltimore, says
he can remember always falling asleep very easily, wanting
to take naps, and having a hard time getting up. "When I
was a child, my mother used to say that waking me up was
like moving mountains." Even after sleeping all night, he'd
wake up too tired to get out of bed, which often meant missing
school or work. "I've lost jobs over this," says Bernstein,
who works as an airline customer service representative.
Bernstein was diagnosed with narcolepsy after
taking a multiple sleep latency test, which measured how
quickly he fell asleep. Most people take between 10 and
20 minutes to fall asleep. People who do it in less than
five minutes may have a serious sleep disorder.
"There's definitely a stigma to it," Bernstein
says. "People used to tease me or call me lazy and say that
I was sleeping my life away." He says he's found some improvement
since taking Provigil (modafinil) for the past two years.
The drug is approved by the FDA to improve wakefulness in
people with narcolepsy. Potential side effects include headaches
and nausea.
Some people with narcolepsy experience episodes
of cataplexy, a condition characterized by weak or paralyzed
muscles such as buckling knees. In July 2002, the FDA approved
Xyrem (sodium oxybate or gamma hydroxybutyrate, also known
as GHB) to treat this condition.
Snoring
Snoring is noisy breathing during sleep that
occurs when relaxed structures in the throat vibrate and
make noise. Most snoring is harmless, though it can be a
nuisance that interferes with the sleep of others. Some
snoring can be stopped with lifestyle changes, particularly
losing weight, cutting down on smoking and alcohol, and
changing sleeping positions. This generally means keeping
snorers off their backs and on their sides as a way to keep
the airway more open during sleep. There are over-the-counter
nasal strips that are placed over the nose to widen the
space in the nose and make breathing easier. Read labels
carefully because these strips are only intended to treat
snoring. The labels point out certain symptoms that require
a doctor's care.
The trick is figuring out the cause of snoring.
It could be related to allergies or structural abnormalities
such as nasal polyps or enlarged adenoids, which are lymphoid
tissue behind the nose.
If your snoring is loud and frequent and you
also have excessive daytime sleepiness, you could have sleep
apnea. People with sleep apnea tend to also be overweight,
and it's more common among men than women.
When a person with sleep apnea tries to breathe
in air, it creates suction that collapses the windpipe and
blocks the flow of air. Blood oxygen levels fall and the
brain awakens the person, who then snorts or gasps for air
and then resumes snoring. This cycle is typically repeated
many times during the night. It results in frequent awakenings
that prevent people from reaching the deepest stages of
sleep, which leaves them sleepy during the day.
"In this case, snoring is not just noisy,
but could be a silent killer," says Jeffrey Hausfeld, M.D.,
the author of a book titled Don't Snore Anymore and
an associate professor of surgery in the department of otolaryngology
at George Washington University School of Medicine and Health
Sciences in Washington, D.C. "Sleep apnea has been linked
to heart disease, high blood pressure, and stroke," says
Hausfeld, whose father suffered from sleep apnea and died
of a stroke at age 66.
Hausfeld says that recognizing the signs of
sleep apnea in children is a challenge because unlike adults,
kids push through daytime sleepiness and keep going. "Sometimes
you might see the child struggling to get air or moving
around a lot in bed," Hausfeld says. "Rather than being
noticeably tired, kids with sleep apnea may do poorly in
school."
Doctors use an all-night sleep study to make
a definitive diagnosis of sleep apnea. During the test,
sensors are attached to the head, face, chest, abdomen,
and legs. The sensors transmit data on how many times the
person being tested wakes up, as well as changes in breathing
and in blood oxygen levels.
Medications generally aren't effective for
sleep apnea. There are about 20 FDA-approved devices available
by prescription for snoring and obstructive sleep apnea,
says Susan Runner, D.D.S., branch chief for dental devices
in the FDA's Center for Devices and Radiological Health.
"These work for some," she says. "The devices pull the tongue
or jaw forward to open the airway." There are no similar
over-the-counter devices approved by the FDA. Potential
side effects include damage to the teeth and jaw joint.
The most common treatment for sleep apnea
is continuous positive airway pressure (CPAP) with a device
that pushes air through the airway at sufficient pressure
to keep the airway open while sleeping. Radzikowski says
using CPAP makes her feel rested during the day. It involves
wearing a mask over the nose while sleeping. A blower attached
to the mask pushes air through her nasal passages.
Surgery also is an option to treat snoring
and sleep apnea. This may include removal of the tonsils
or adenoids. To treat snoring, a laser-assisted procedure
called uvulopalatoplasty is used to enlarge the airway by
reshaping the palate and the uvula, making them less likely
to vibrate. For sleep apnea, a laser procedure called uvulopalatopharyngoplasty
is used to remove excessive tissue at the back of the throat.
If you're troubled by sleep problems, ask
your health-care provider about how your problem should
be evaluated and which treatments may be appropriate for
you. Experts say it's important to know that you don't have
to suffer through sleep problems. Radzikowski says she had
never heard of sleep apnea before the car accident that
killed her husband.
"I was overweight and I knew I snored loudly.
But snoring was like a big joke in our family," she says.
"I didn't really take it seriously, and I wish I did."
Michelle Meadows is a staff writer for FDA Consumer.
Tips for Better Sleep
- Keep a regular sleep-wake cycle. Try to go to bed
and wake up at the same time every day.
- Avoid caffeine, alcohol, and nicotine in the four
to six hours before bedtime.
- Don't exercise within two hours of bedtime. Exercising
five or six hours before bedtime may help you sleep
more soundly.
- Don't eat large meals within two hours of bedtime.
- Don't nap later than 3 p.m.
- Sleep in a dark, quiet room with a comfortable temperature.
- If you can't fall asleep within 20 minutes, do a quiet
activity somewhere else and return to bed when you're
sleepy.
- Wind down in the 30 minutes before bedtime with a
relaxing pre-sleep ritual such as a warm bath, soft
music, or reading.
Sources: American Academy of Sleep Medicine;
James Walsh, Ph.D., National Sleep Foundation
Kids and Sleep
When they're infants, it's middle-of-the-night
feedings. When they're toddlers and school-age, it's awakening
to give medicine or soothe them after a nightmare. It's
no surprise that, according to the latest poll from the
National Sleep Foundation (NSF), more people without kids
in the house rated their sleep as "excellent" or "very good,"
compared to those with children.
Some sleep interruptions come with the territory.
But experts say the best thing people can do for themselves
and their children is to develop a regular sleep routine
and bedtime for youngsters so that they get used to falling
asleep on their own. Experts say school-age children generally
need 9-12 hours of sleep each night.
According to the American Academy of Child
and Adolescent Psychiatry, many childhood sleep problems
are related to irregular sleep habits or anxiety about bedtime.
Young children view bedtime as a time of separation, which
is why they pull out a number of stalling tactics such as
repeated requests for water and trips to the bathroom.
Here are some sleep tips for children from NSF:
- Establish positive sleep habits with your child at
an early age. Have a set sleep schedule for bedtime
and waking. Keep the same schedule for weekdays and
weekends. Know how much sleep is appropriate for your
child's age.
- Establish a 20-30 minute nightly "calm-down" bedtime
routine that can include taking a bath, putting on pajamas,
reading, and other relaxing activities. TV viewing at
bedtime, especially having a television set in the child's
bedroom, may interfere with falling asleep.
Other childhood sleep problems include talking
during sleep and bedwetting. Many children get over sleep
problems as they grow. But if you have concerns, talk with
your child's doctor.
If you think your child may have a sleep problem,
ask yourself these five questions (remember them by the
acronym "BEARS"):
- Bedtime: Does my child have problems going to bed
or falling asleep?
- Excessive daytime sleepiness: Does my child seem sleepy
or overtired during the day? Is he or she difficult
to get up in the morning?
- Awakenings: Does my child awaken frequently during
the night or have trouble getting back to sleep?
- Regularity and duration of sleep: What time does my
child go to bed and get up on weekdays? Weekends? How
much sleep does he or she get? Need?
- Snoring: Does my child snore loudly? Does he or she
seem to have breathing problems at night?
The Stages of Sleep |
Stage 1:
Light sleep. We drift in and out and can be awakened
easily. Our eyes move slowly and muscle activity slows. |
Stage 2:
Our eye movements stop and our brain waves become
slower with occasional bursts of rapid waves called
sleep spindles. |
Stage 3:
Deep sleep. Extremely slow brain waves called delta
waves appear, interspersed with smaller, faster waves. |
Stage 4:
Deep sleep. The brain produces mostly delta waves.
There are no eye movements and no muscle activity. |
Stage 5:
REM sleep. Breathing becomes more rapid, irregular,
and shallow. Eyes jerk rapidly, limb muscles become
temporarily paralyzed. Dreams almost always happen
in this stage, but may occur in other sleep stages
as well. |
| We usually
pass through five stages of sleep. Each cycle takes
about two hours. Then the cycle starts over again
with stage 1. As the cycles repeat, deep sleep periods
get shorter and periods of REM sleep lengthen. Adults
spend half of their sleep time in stage 2, 20 percent
of the time in REM sleep, and 30 percent in the
other stages. Infants start out spending about half
of their sleep time in REM sleep.
(Source: National Institutes of Health) |
