Can't count sheep?
Sleep disorders are a common yet treatable problem, say Dr. S.S.K. AYYAR and Dr. SURESH KUMAR in the conclusion of a two-part article.
SLEEP is an active process essential for maintaining our mental and physical health everyday. In the article last week, we looked at the sleep cycle and sleep disorders like insomnia and the Restless leg Syndrome. This week, more examples and possible solutions are dealt with:
"Doctor, my son is obese and suffers from excessive sleepiness during the day. Even at school he falls into deep sleep for a few minutes and sometimes has to be woken up by friends or the teacher."
Narcolepsy is a disorder in which excessive daytime sleepiness occurs in the form of sleep attacks lasting a few seconds to minutes which occur during different parts of the day while watching TV, reading the newspaper while travelling, riding a cycle or driving. These naps begin with drowsiness and very soon lead to sleep and can lead to accidents at work or while driving. Other symptoms such as cataplexy (sudden loss of muscle tone) with bucking of the knee and fall or drooping of the neck which may be provoked by emotions like laughter, amusement or anger can occur. Occasionally, sleep paralysis and hallucinations (auditory, visual or tactile) may be experienced.
Recent investigations have revealed a deficiency of neurochemical substance called "hypocretin" in the hypothalamus of patients with narcolepsy which promises new therapeutic interventions.
An interesting condition related to narcolepsy is the Klein Levin syndrome, characterised by periodic hypersomnia and hyperphagia (over eating). The patient is usually a man who sleeps for nearly 20 hours a day and awakens only to eat and go to the toilet. These episodes last from three to four days to several weeks and can be compared to Kumbakarna of mythological fame. These patients are helped by stimulant drugs.
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Mrs S, 47:
"Doctor, my husband snores loudly, stops breathing for a few seconds and then suddenly become restless and starts snoring again. This sequence repeats itself several hundred times during the night. He does not feel fresh in the morning and has frequent episodes of daytime sleepiness at work, while reading, watching TV or sometimes even while driving. His colleagues say that he has to be woken up frequently to continue his office work."
The condition is obstructive sleep apnoea (OSA). Apnoea means cessation of airflow and respiration lasting 10-30 seconds and occuring several times during sleep. This causes disturbed nocturnal sleep with frequent awakening and excessive daytime sleepiness. OSA is due to occlusion of the upper airway at the level of the oropharynx, caused by flabby dilator and abductor muscles of the airway which collapse during inspiration. This causes progressive axphyxia leading to brief arousals from sleep when the airway patency is restored and the air flow is resumed and the patient goes to sleep. This sequence is repeated 400 to 500 times per night resulting in gross fragmentation of sleep and loss of slow wave sleep.
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Ms. M, 26, software professional:
"Doctor, I suffer from terrible dreams which wake me up and frighten me and then disturb my sleep. My mother has noticed that I get up and walk in my sleep, which I am not aware of."
The description is suggestive of Parasomnia. It refers to episodic physical phenomena that arise or occurs during sleep. In the condition called REM sleep behaviour disorder, mainly affecting middle-aged and older men, agitated and violent behaviour occurs during sleep with sometimes causes injury to the patient or the bed partner. On awakening, the patient has a vivid, but unpleasant, dream imagery.
Sleep walking occurs in NREM sleep stage IV and consists of complex behaviour followed by sleep walking. This is more common in children than in adults, boys more than girls. There is partial or total amnesia for the event.
In the condition called sleep terrors, inability to move the limbs and hallucinations occur; the patient manifests terror behaviour with perspiration, screaming, body movements and urination or defecation. Sleep bruxism is forceful grinding of the teeth during sleep and about which the subject is unaware. It can occur under severe stress. Sleep enuresis or bed wetting at night is normal up to the age of five to six years but may persist in adolescents and rarely into adulthood. Bladder training exercises, behaviour therapy and certain drugs are useful. However it is essential to investigate the patient for urinary tract infections, nocturnal epilepsy, sleep apnoea or cauda equina lesions. Nocturnal head banging, sleep talking and nocturnal leg cramps are other rare forms of parasomnia.
Sleep disorders (medical disorders of sleep) are eminently treatable conditions. It is necessary for our country to gather data on sleep disorders, create expertise, study them and adopt appropriate therapeutic and preventive strategies.
How to sleep well
Get up about the same time every day.
Go to bed only when sleepy.
Create an environment conducive to sleep
Avoid noise, light and vigorous exercise which may disturb sleep onset or sleep maintenance.
Exercise regularly. Confine vigorous exercise to at least six hours before bedtime and do simple exercises such as stretching or walking four hours prior to bedtime.
Follow a regular schedule for meals, medications, chores, and other activities.
Develop relaxing pre-sleep rituals such as having a warm bath and a light bedtime snack, listening to soft music or 10 minutes of reading.
Avoid seeing adventure movies, having arguments and smoking close to bedtime
Have food containing tryptophan (wheat germ, cottage cheese, milk, eggs, almonds, avocado) which increase the level of serotonin and promote sleep.
Avoid ingestion of caffeine within six hours of bedtime.
Don't drink alcohol, especially when sleepy. Even a small dose of alcohol can have a potent effect on a person who is tired.
Avoid sleeping pills. Most doctors avoid prescribing them for periods longer than three weeks.
The first part of this article appeared in The Hindu, Sunday Magazine, issue dated January 12, 2003.
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