Sleep Disorders
Sleep is a behavioural state that is a natural part of every individual’s life; essential for optimal brain function and enabling us to feel well-rested and alert. A sleep disorder is a medical condition relating to disrupted sleep patterns that can seriously interfere with normal physical, mental and emotional functioning. Problem sleepiness can have serious consequences, such as drowsy driving or workplace accidents and errors.
Sleep disorders can be managed and the serious symptoms and long term outcomes improved if conditions are diagnosed and treated early enough. However, 95% of patients with sleep disorders have not been diagnosed or treated for their disorder, and may be unaware that it even exists. The need for recognition, accurate diagnosis and appropriate treatment is therefore paramount in order to prevent serious and long term outcomes. This article outlines the symptoms, causes and treatment options for three of the most common sleep disorders.
Sleep apnoea
Sleep apnoea is a serious and progressive sleep disorder that occurs when breathing is repeatedly obstructed for 10 seconds or more during sleep. Those suffering with sleep apnoea will wake many times a night to regain breathing, but usually remember nothing at all about the awakenings. As a result, many people don't know that they suffer from sleep apnoea and a family member and/or bed partner is often more likely to notice the signs first.
In obstructive sleep apnoea a patient’s airways are blocked or narrowed during sleep. This can be due to a variety of factors including excessive relaxation of the muscles around the base of the tongue, enlarged tongue and tonsils creating an obstruction or thickening of the wall of the windpipe in overweight patients. Those most likely to suffer from sleep apnoea will often snore loudly and frequently have a family history of the condition.
The airway obstruction causes a reduction in the level of oxygen in the blood and increases the stress on the heart, increases risk of blood pressure and prevents the patient from entering the restful and restorative stage of sleep (also known as Rapid Eye Movement or REM).
Repeated interruptions to a sleep pattern in this way will result in the patient feeling very tired the next day. As well as extreme sleep deprivation, sleep apnoea can be life-threatening as it temporarily results in a complete stoppage of airflow.
This condition can not generally be prevented as it is often inherited. However the serious consequences of this condition can be reduced.
Positional therapy: Aponeas tend to be worse when sleeping on the back (the supine position) as gravity makes it more likely for the tongue to fall back over the airway and/or for the airway muscles and other tissue (like the tonsils) to collapse and block the airway. Hence not sleeping on the back may reduce the number of aponeas. To avoid the supine position, some people use homemade remedies, such as putting tennis balls in a tube sock and pinning the sock to the back of the nightshirt. Others purchase products such as a tube or cushion designed specifically to prevent supine sleeping. A number of companies have registered with the FDA pillows for snoring and mild sleep aponea; it is meant to position the neck so the airway is more likely to remain open. Positional alarms are also on the market: they are intended to prevent supine sleeping by making a noise when one begins to sleep on the back. However, they may disrupt sleep so much that the subsequent sleep fragmentation causes a concern.
One study found sleeping on the back but with the back elevated from the waist up may also reduce the collapsibility of the airway and therefore reduce the aponeas. Foam wedges, not soft pillows that can actually push the chin towards the chest and worsen aponea, should be used.
Weight loss: Sleep aponea can be weight-related. Additional fat around the neck may make the airway narrower, making obstructions more likely to occur. For some overweight people, especially those with mild cases, losing weight can be an effective treatment. Or weight loss may reduce the severity of the sleep aponea. However, it may be hard to lose weight when you have untreated sleep aponea: you may be too tired to exercise and you may eat to stay awake. Also, it may take some time before the weight loss is achieved, so in light of the potential consequences of untreated OSA, using another treatment option while working towards the weight loss goal may be an option. Losing weight may also improve your health in other ways, but it is always advisable to talk to your doctor before beginning a weight-loss program.
Remember that sleep aponea occurs in thin people as well; the airway can close during sleep for a number of reasons, not just excess weight.
Avoiding alcohol and other CNS depressants: Alcohol and medications that act as central nervous system (CNS) depressants-such as pain killers, sedatives, and muscle relaxants-can worsen sleep aponea by relaxing the airway muscles further and/or by reducing the respiratory drive and causing more aponeas to occur. Hence avoiding alcohol and CNS depressants close to bedtime may be helpful. Ask your doctor or pharmacist if medications you take prescription or over-the-counter or herbal, affect your sleep aponea. The prescribed sleep aponea treatment may be adjusted to take into consideration the use of medications that are CNS depressants.
Oral appliances: Oral appliances, sometimes called dental appliances, are intended to treat aponea by keeping the airway open in one of three ways: by pushing the lower jaw forward (a mandibular advancement device or MAD), by preventing the tongue from falling back over the airway (a tongue-retaining device), or by combining both mechanisms. Oral appliances are typically more effective for people with mild sleep aponea and for non-obese people but can, for some, be effective for moderate and severe sleep apnea. The most common type of oral appliance, a MAD is often adjustable so that the dentist can move the jaw further or reduce the advancement as necessary. The goal is to find the most comfortable and effective position for the patient. On occasion oral appliances may worsen the aponea. Not all dentists have the necessary knowledge of sleep aponea, so if you wish to pursue this therapy, ask your sleep doctor to refer you to a dentist who is familiar with aponea and who works with oral appliances.
Surgery: The intention of surgery is to create a more open airway so obstructions are less likely to occur. There are several different surgical procedures with different effectiveness rates, and surgery can also sometimes worsen the aponea. In addition, there are also several non-surgical procedures that can remove excess or obstructive tissue or harden the soft palate by inserting three small polyester rods.
Continuous Positive Airway Pressure (CPAP): CPAP works by gently blowing pressurized room air through the airway at a pressure high enough to keep the throat open. This pressurized air acts as a "splint." The pressure is set according to the patient's needs at a level that eliminates the aponeas and hypopneas that cause awakenings and sleep fragmentation. Pressure that is too low will not be as effective in eliminating the aponeas and hypopneas.
CPAP is the most effective method for treating obstructive sleep aponea. It can sometimes be hard to use, but any complaints about the comfort of the machine or mask can usually be addressed easily. Talk to your doctor or home care company representative about any discomfort you may have.
Discuss with your doctor all of your options to find the one best for you. Which treatment you use is not important; being treated properly is.
Note: Combined treatment is best for some patients. For example, you may be able to use an oral appliance to lower the number of aponea with a CPAP machine at a lower pressure. Another possibility may be to undergo less extensive surgery, which may reduce the number of aponeas, and then use an oral appliance or a CPAP machine at a lower pressure.
Because sleep aponea is a medical disorder any devices used should be approved by your doctor. Please consult your GP for specialist advice before trying any treatments.
Sleep Paralysis
Sleep paralysis is a condition characterized by paralysis of the body shortly after waking up or (less frequently) shortly before falling asleep. Physiologically, it is closely related to the normal paralysis that occurs during REM sleep (the deepest level in sleep cycles) to prevent bodily movements and block sensory input. This is necessary to prevent the body from carrying out movements caused by dreams.
Sleep paralysis is a frightening form of paralysis that occurs when a person suddenly finds their brain fully awake but they are still unable to move their body for a few minutes. In addition, this state is usually accompanied by certain specific kinds of hallucinations associated with REM sleep when dreaming occurs. The hallucinations can be very frightening and may feel like someone is in the room and sometimes strangling you or sitting over your body.
This state usually lasts no more than a few minutes before a person is able to either return to full REM sleep or to become fully awake. It can be hereditary and brought on by stress, fatigue and sleep deprivation. Keeping a journal of episodes of paralysis can be a useful way for affected patients to identify and help to avoid possible triggers (including emotional state at the time of the experience, sleeping position and the time that it occurred). Knowing what causes this disorder can help to reduce fear and sometimes the frequency of the attacks, and is useful information for patients to provide their GP when seeking medical advice.
Sleep paralysis is most often related with narcolepsy, a neurological condition in which the person has uncontrollable naps. All patients with sleep paralysis and narcolepsy need medical attention and treatment.
Narcolepsy
Narcolepsy is a chronic disease of the central nervous system that causes excessive sleepiness and uncontrolled daytime sleep attacks. Sufferers will fall asleep up to ten times a day- even after adequate night time sleep- with attacks lasting from a few seconds to several minutes. In rare cases they may last over an hour.
Sleep narcolepsy involves the intrusion of REM sleep when the brain is very active and the muscles of the body are relaxed (paralysed). Many sufferers therefore experience hallucinations as they fall asleep or start to wake and inability to move or talk (see sleep paralysis). In non-narcoleptic individuals the REM stage of sleep does not occur until they have been asleep for some time. However, in people with narcolepsy REM sleep often occurs soon as they fall asleep on even while they are awake.
The onset of narcolepsy usually occurs between the ages of 15 and 30 and affects both sexes equally. The first symptom to appear is excessive and overwhelming daytime tiredness, with the other symptoms following. Genetic factors may influence its occurrence. Other factors such as infection, trauma, hormonal changes, immune-system dysfunction and stress may also be present before the disease develops.
The condition is difficult to diagnose without medical tests and frequently goes unrecognised for many years. People with narcolepsy often have problems with memory and attention. The problems may be due to the abnormal neurotransmitter functioning within the brain that causes the narcolepsy itself, as well as due to general tiredness. This condition is very dangerous for the sufferer and others. They may be restricted in their daily lives, due to the risk of losing control during an attack. People with Narcolepsy are very prone to accidents.
Although there is no cure, narcolepsy is a treatable condition. Stimulant medication, a regular night time sleep schedule and scheduled naps during the day can be effective. Narcolepsy symptoms like excessive daytime sleepiness generally persists throughout life but sleep paralysis and hypnagogic hallucinations may not.
Conclusion
These sleeping conditions are the most prevalent in the population. Sleep is an essential requirement for people to enjoy a happy and energised life and sleep interruption and deprivation can have serious health and wellbeing consequences. If you suspect that you or a partner or relative may suffer from one of these conditions or any other sleeping conditions, help and support is available. Please visit your GP and get assistance and treatment.
For tips on improving sleep patterns and managing insomnia, please also see our help sheet on sleep hygiene.
References
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