Tossing and Turning All Night

Trade Counting Sheep for Amazing Medical Advances

By Hilda J. Brucker

Editor’s Note: Last month, Points North revealed that sleep is not just about rest — rather, it profoundly affects your appetite, immune system, hormone levels, memory, learning capacity, emotional stability, mental acuity and overall metabolism. Our bodies are largely ruled by circadian rhythms that follow natural cycles of light and darkness, but these are easily disrupted by our modern lifestyles. As a result, nearly everyone has occasional trouble sleeping. This can often be corrected by good sleep hygiene, but sometimes medical help is needed. This month, we explore the leading sleep disorders and what can be done about them.

    “I have known that I snore for quite some time. My husband tells me. And I take a lot of trips with my girlfriends and they all tell me that I sound like a wild animal. It was a joke for a while, and then after a while my husband said it wasn’t funny anymore,” recalled Libby Scarr. At age 50, she’s 28 years into what she describes as a very happy marriage, so it troubles her that her husband frequently moves to the couch to get a good night’s sleep. “The best conversations are pillow talk; it’s more fun to sleep in the same room,” she said. Another problem is that she’s not waking up feeling rested, and she has less energy than she needs to get through the day.
     Recently, Scarr spent the night at WellStar Sleep Disorders Center, located at Windy Hill Hospital. Her doctor had referred her there for a polysomnogram, or sleep study — a test that collects physiological data during the night, so sleep disorders can be diagnosed and treated. The study simultaneously measures blood oxygen levels, respiration, muscle tone, limb movements and brain waves.
Once Scarr was comfortably clad in plaid pajama bottoms, a white T-shirt and slippers, a perky technician named Tiffany began the process of wiring her with electrodes, which are held in place by a sticky substance and tape. As the two chatted, Scarr was visibly relaxed; she’d been relieved to find she’d be monitored through the night via video camera, and not through the big glass-viewing window she’d imagined. When the technician finished, Scarr took a peek at herself in the mirror. “I look cute!” she said and then quipped that she resembled a suicide bomber with all the different-colored wires taped in bundles on her head and body.
     Scarr is just one of the many Americans who are benefiting from an increased awareness that sleep disorders exist and can be treated. Though sleep medicine is still in its infancy, it’s very much a rising trend to combat that dragging, droopy feeling that many of us experience every day. And often, say experts, the quantity and quality of sleep can be improved once the underlying problem is identified.

The Quest for Rest
    Sleep needs vary from person to person and they change drastically from childhood through middle age. In general, sleep specialists agree that healthy adults need between seven and nine hours per night. Yet, we’ve all heard some people claim they get by just fine on six hours, while others insist they only feel refreshed when they can get the 10 hours they really need. So how do you know if you’re getting enough rest? According to the National Sleep Foundation (NSF), signs of insufficient sleep include trouble staying alert during the day, feeling overly irritable with family and coworkers, and having a hard time concentrating on tasks or remembering things. These can often be indicators of insomnia or another sleep disorder.
     Chronic insomnia, which by definition lasts for a month or more at a time, affects 10 to 15 percent of adults, according to the NSF. Sleep specialist Dr. David Schulman of the Emory Clinic explains that insomnia can manifest itself in four different ways. Some people may have trouble falling asleep. Others may wake up too frequently during the night, wake up far too early in the morning, or wake up not feeling refreshed, subsequently dragging through the day with drooping eyelids. “I think there’s a lot of evidence that daytime sleepiness is really prevalent in our society,” Schulman said.
     Until recently, the medical community saw insomnia not as a disease, but as a symptom. “Years ago, insomnia was always regarded as being secondary to another problem; you know, you have some depression or anxiety, you have some stress in your life. Treat the problem and insomnia will go away,” explained Dr. David Westerman, medical director of the Atlanta Pulmonary Group Center for Sleep Disorders located in Dunwoody. “Now over the years, the approach to insomnia has evolved. [We] realize that some people are going to have so-called primary insomnia.”

The Scoop on Sleeping Pills
     Over-the-counter sleeping pills are readily available at pharmacies and grocery stores. These are often antihistamines that are used to treat allergies, but commonly cause drowsiness as well. While they are relatively safe and may be useful for some people, they also have some drawbacks. Many people feel “hung over” and unable to wake up fully the next morning; others quickly become resistant to antihistamines and can no longer use them to promote sleepiness.
     Prescription pills that promote sleep are called hypnotics. Increasingly, they are the sleep aid of choice. A study conducted by managed care company Medco Health Solutions found that sleeping pill use among adults doubled between 2000 and 2004. That’s probably because newer drugs were introduced and touted as being safer, less addictive, and less likely to cause troublesome side effects than older drugs. Until the 1970s, sleeping pills were primarily barbiturates, which are especially dangerous. A class of drugs known as the benzodiazepines (BZDs), which includes Valium and Xanax, replaced those. But they also have side effects: morning hangovers, short-term memory loss, dependence, and withdrawal symptoms that may include rebound insomnia (a worsening of sleep troubles after discontinuing the drug). The Food and Drug Administration (FDA) classifies all the BZDs as addictive and has approved them only for short-term use.

    
     Today, however, there are other choices. The latest drugs on the market include Ambien, Lunesta and Sonata. They work on the same neurotransmitter, called GABA, as the older drugs, but they have fewer side effects. They target specific sub-types of GABA receptors in the brain instead of dimming the lights across the entire central nervous system. “Now that you have ‘safer’ medications, you feel more comfortable using medications, for two reasons. One, they don’t have the addictive potential that the Valium and the benzodiazepines have. Two, you realize that some patients need it; they’re not depressed or anxious, but they still having trouble sleeping,” Westerman said.
    As the baby boomers grow older, and since the likelihood of insomnia increases with age, the market for safer sleeping aids will expand. And the next class of prescription sleeping pills will likely have even fewer side effects, as researchers develop therapies that work in ways other than targeting GABA. The FDA approved the first of these, Ramelteon, in July of 2005. Ramelteon is truly a different type of medication. It works by mimicking the action of melatonin, a hormone that’s produced by your body and is essential to regulating your natural circadian rhythms. Studies show that Ramelteon can shorten the time it takes to fall asleep and somewhat increases the total duration of sleep time. And, side effects appear to be minor; mild headaches were the most common complaint from study participants who were treated with Ramelteon, and, at this point, it doesn’t seem to cause addiction or withdrawal symptoms. 
    The bad news is that it doesn’t work for everyone. And sleeping pills in general, no matter how safe, are not always a suitable therapy. “In many cases insomnia can be a sign of something else, and simply throwing medication at somebody to try and make them feel better may not be the optimum way of treating them,” Schulman pointed out. The NSF also notes that any drug can interact with other medications, so it’s important to tell your doctor and pharmacist about all the over-the-counter drugs or herbal supplements you take.

Sleep Disorders — How Serious Are They?
If you feel very drowsy during the day even though you fall asleep easily and spend a full eight hours in bed, you may have a sleep disorder. Your bed partner may be the first to notice signs of a problem, so take their complaints seriously!

Snoring: According to the NSF, 45 percent of adults snore at least occasionally, and 25 percent are habitual snorers. Snoring is more prevalent among men, overweight people, and those who sleep on their backs. It can grow worse with age. The cause? Anything from a stuffy nose to poor muscle tone in the tongue and throat (muscle relaxants and alcohol can make your throat even more “floppy,” increasing the likelihood you will snore). Interestingly enough, there are more than 300 registered patents for devices purported to cure snoring. Some work by opening nasal air passages, others reposition the lower jaw forward, a few try to condition users not to sleep on their backs. They may be worth a try, especially if your snoring is keeping your partner awake; however, when snoring is very loud and very frequent, experts suggest that you get tested for sleep apnea.

Obstructive Sleep Apnea (OSA): This is a disorder that causes a person to repeatedly stop breathing for at least 10 seconds at a time throughout the night. It’s caused by blockages in the airways that literally take your breath away, though your body is trying to breathe normally. And it creates two problems: fragmented sleep patterns that typically result in excessive daytime sleepiness, and lowered levels of oxygen in the blood, which, in turn, is linked to high blood pressure, heart disease, stroke, and mood and memory problems. It can be life-threatening.
     Sometimes anatomy is the problem. Risk factors for apnea include having a large tongue, tonsils or uvula; a small upper airway; neck size greater than 17 inches; or pronounced overbite. However, smoking and being overweight are the primary culprits. It’s usually diagnosed during a polysomnogram. The treatment of choice is a medical device called a continuous positive air pressure device (CPAP) — a mask that fits over your nose and mouth and gently blows air through your airways to keep them open while you sleep. While this therapy is highly effective, it can be difficult for some to cope with at first.

Restless Legs Syndrome (RLS): According to the NSF, this neurological disorder affects up to 12 million Americans. Unpleasant sensations occur while the legs are at rest, causing an overwhelming urge to move them, which makes it impossible to fall asleep. Many people find the sensations difficult to describe, but they can include tingling, twinges and “creepy-crawly” feelings. The exact cause is unknown, but RLS seems to have both a primary form that’s not related to other disorders, and a secondary form that’s linked to another condition like pregnancy, anemia or certain medications. Some very recent research on the primary form suggests it could be related to an iron or folic acid deficiency, either because of poor diet or a metabolic problem.
     There is no diagnostic test for RLS. If you read a description of it and feel you have this problem, talk to a doctor. Go to your appointment armed with a sleep log of your symptoms. Describe them as best you can, noting when they occur, how severe they are, and whether anything seems to make them better or worse. You’ll also want to note how long it takes you to fall sleep, the severity of any daytime sleepiness you experience, and which medications you take regularly.
     In the past, sleeping pills or painkillers were prescribed for RLS sufferers. In May of 2005, a drug called Requip became the first FDA-approved treatment for RLS. Requip is a common therapy for Parkinson’s Disease, but at lower doses, it can relieve restless legs. Other ways to manage RLS include a walking regimen, massage, stretching, using hot or cold packs, taking a warm bath at bedtime, and practicing relaxation techniques like meditation or yoga.

Periodic Limb Movement Disorder (PLMD): While restless legs syndrome occurs when a person is awake, PLMD can make you twitch or jerk involuntarily in your sleep. The movements are frequent enough to disturb sleep, both yours and that of your partner. Treatment is similar to that for RLS.

Bruxism: If it’s not detected by a bed partner, this involuntary grinding of the teeth during sleep can result in serious tooth damage over time. It can also cause jaw pain, facial pain, gum inflammation, heat or cold sensitivity in the teeth, headaches and earaches. Often it’s caused by stress and can be treated with relaxation techniques. But the primary line of defense is protecting your teeth from wear and tear. A dentist can fit you with a custom mouth guard, which is generally more effective and comfortable than one bought over the counter.

Seeking Help
Sleep medicine is still an emerging specialty. Among doctors practicing general medicine today, few have been trained to recognize and treat sleep disorders. As a result, it may take years to be diagnosed with a specific disorder after you first develop symptoms, unless you proactively seek treatment. The first step? Realizing that feeling tired all day is not just a part of life; that the “laziness” you feel may have physiological origins; that snoring may be a symptom of a much more serious problem.