Sleep Problems

It is said that Americans have the worst sleep habits in the world.  Sleep problems are rampant in our society and I see patients with sleep problems of one type or another multiple times each day.

Sleep science and physiology have come along way over the past 20 years.  We have learned all kinds of interrelationships between sleep and the rest of the body's functions. 

The human brain requires a certain minimum amount of "deep sleep" every night.  If it doesn't get it, the brain lets you know about it in a number of various ways.  Inadequate deep sleep can cause the obvious problem of excessive daytime sleepiness, but it can also aggravate weight gain, lower pain thresholds, reduce immune function, increase depression and anxiety, worsen chronic back and neck muscle tension, and cause foggy thinking and forgetfulness. 

Inadequate deep sleep makes people feel sleepy during the day.  So then they crank up their caffeine intake which then continues to erode their nighttime sleep patterns.  Daytime sleepiness can get so bad that people can sometimes experience "microsleep:"  Tiny, brief episodes of sleep where people just nod off for just seconds.  Mostly, though, they just fight to stay awake and feel irritable, and without much mental energy to tackle more challenging tasks. 

Inadequate deep sleep contributes to weight gain (or sometimes inability to lose weight) by stimulating the production of cortisol (a weight-promoting stress hormone), decreasing the production of leptin (a hormone that reduces the sense of hunger), increasing the production of ghrelin (a hormone that increases hunger).  Also, people who are sleep deprived often just lack the motivation to exercise because they are tired. 

I remember as a medical student and resident, when I'd have to work nights at the hospital, the night shift nurses and techs would always keep tons of junk food around--donuts, cake, rolls, cookies--usually high carb, high calorie stuff.  They used to claim they had to eat to stay awake. 

It has now become the third question I ask when assessing a patient with weight problems:  Diet, exercise, and now--sleep adequacy. 

Deep sleep deprivation reduces pain thresholds.  Why this is so is not known.  It has huge implications, though.  For people with chronic pain problems, it drives a vicious cycle--these patients don't sleep well due to their pain problems, which reduces deep sleep time, which reduces pain thresholds, increasing the perception of pain, which worsens the sleep situation.  Quite often, when I work with someone with chronic pain of any type, one of my primary goals will be to maximize their sleep potential. 

Another vicious cycle occurs in the depressed or anxious person. One of the hallmark symptoms of depression or anxiety is awakening in the night being unable to get back to sleep.  This, of course, decimates deep sleep time, and dramatically adds to the lack of mental energy, irritability, and fuzzy cognition that accompanies these entities.  Sometimes just breaking the sleep deprivation cycle in anxiety or depression can make huge strides in improving how patients feel. 

The brain sends nerve impulses continuously to muscles of the body when it is awake.  Even in shallower sleep phases, signals are still telling the muscles what to do, especially the "postural muscles" of the neck and back.  (We've all seen sleeping dogs make running movements and even small yips and barks.) The ONLY time these nerve signals cease is during deep sleep.  Therefore deep sleep is the only time these postural muscles get a "break" from the boss (the brain) and a chance to really loosen up and carry out their essential "metabolic house-keeping" and repairs.  So shortening deep sleep time tends to worsen tightness and spasm of the muscles of the back of the neck, the upper back (especially the muscles of the trapezius group between the shoulder blades) and the lower back.

This excessive muscle tension of the back, combined with the reduction in pain thresholds, means that I can practically guarantee that patients with chronic sleep problems are also going to have chronic neck and back muscle tightness, tenderness, and pain.

Okay, so now that we know the effects of inadequate deep sleep, what are the kinds of sleep problems people face? 

Inadequate time alotted to sleep:  Some people just don't let themselves sleep enough hours.  This is what I call "self-inflicted" sleep deprivation.  It is especially common among teens and young people in their 20s and 30s.  The 20-something guy who is addicted to on-line computer games and stays up until 2 a.m., then gets up at 7 a.m. to get to work by 8 a.m.  The over-worked executive who is up working on his business project until the wee hours.  The harried mom who just gets her kids to bed at 10 p.m. then stays up until 2 getting the other things done around the house that didn't get done during the day. 

These people view sleep as a tradable commodity.  And they don't seem to value it very highly--or perhaps more accurately, value other activities much greater.  So they short-change their sleep and often play "catch-up" on the weekends.  It is true--people do develop a sleep "debt."  After three or four days of short sleep time, the effects of sleep deprivation accumulate and can, to some extent, be "repaid" to the sleep bank by sleeping longer hours on the weekends.

An excellent sign of someone who is sleep-deprived (especially deep-sleep deprived) is that they tend to fall asleep "the minute my head hits the pillow."  The time it takes to fall asleep is called "sleep latency time."  I think the average sleep latency is between 15-25 minutes.  If someone is deep-sleep deprived, they'll often fall asleep in just a few minutes. 

Sleep initiation disorder:  There are some patients who come to me complaining that they just can't fall asleep.  They lay in bed, wide awake, tossing and turning and getting frustrated.  They'll tell me that once they do get to sleep, they are fine and stay asleep fine.  They just can't get to sleep in the first place. 

Sleep maintenance disorder:  This has got to be the most common presentation.  "Doc, I fall asleep fine, no problem.  But then I wake up at 2 or 3 a.m. and just can't get back to sleep.  My mind is going and I toss and turn and I sometimes just get back to sleep and half an hour later my alarm is going off." 

I read a great quote by a famous sleep researcher (and I can't recall the name):  She said, "If we all got the right amount of sleep, we would never need an alarm clock." 

This is the classic form of insomnia seen with anxiety.  People will awaken for any of several reasons, then once they are awake, their minds start working and the adrenaline (epinephrine) levels start rising and they get more and more worked up.  Sometimes they'll even start to get warm and sweaty as they lay there thinking about stressful stuff.  Then they look at their bedside clock, realize it has been an hour since they awoke, think frustratedly, "I can't believe I'm still awake!" (Sometimes post a quick Facebook note to that effect.) Now their adrenaline is really cranking.  I tell patients, "The minute you think 'I have got to get to sleep!' you are pretty well done sleeping."

Interventions for sleep problems:

From my point of view, I need to know what is keeping the person awake. 

1.  Is there poor sleep hygiene?  Sleep hygiene is the term doctors use to describe the basic habits that we develop regarding sleep.  A long list will be presented shortly that describes good sleep hygiene habits. 

2. Is there a pain issue?  Is the person awakening because of pain somewhere?  Can we address that issue directly? 

3.  Is there anxiety or depression?  Anxiety is the single largest cause of sleep maintenance problems in our society.  Can we address the anxiety with counseling, exercise, stress reduction, or medication?

4. Are there medications causing sleep problems?  Many medications can have negative effects on sleep.  And I'm not just concerned with prescription medications.  Alcohol has an adverse effect on sleep--some people use it to help get relaxed at night, but at about 2 or 3 a.m., brain alcohol levels fall, and can cause a little mini-withdrawal which incites an increase in epinephrine (adrenaline) levels which can wake people up.  Caffeine can have effects for up to 12-18 hours in some people. 

5.  Are there obvious sleep interrupters?  Are there young children needing assistance in the night?  Patients having to get up to urinate at night (from bladder or prostate problems, perhaps). 

Sleep Hygiene Rules: 

The following list is what we refer to as basic sleep hygiene points that I want anyone with sleep problems to consider as basic first-line recommendations for improved sleep.

1.  Keep regular sleep hours.  Try to head off to bed pretty close to the same time every night. 

2.  Keep your bedroom dark and comfortable.  Your brain responds to light by waking up.  If you get up at night to use the bathroom, try not to turn on bright lights. 

3. Avoid obvious nighttime interruptions.  Personal story: our pets, with the exception of our terrier, have been banned from our bedroom because our cats would wake up in the middle of the night and have a party under our bed.  If small children are waking you up through the night, address those issues with their doctor.  Most children over the age of 1 year should not be requiring you to get up in the night except occasionally.  If you have to get up at night to urinate (from prostate problems or bladder problems) these should also be addressed by your physician.

4.  Mask unpredictable noises.  I recommend sleeping with a noise generator such as a fan or electronic sound device.  I actually use an iPhone app connected to my bedroom stereo system that plays sounds of gentle waves breaking on the shore all night long (among other options).  I also will sometimes use a fan, especially in the summer.  These noise maskers will keep me from hearing street sounds, or cats (out in the hallway) or other intermittent noises. 

5.  NEVER look at the clock. It instantly sends a jolt of adrenaline through your body and brain, making you anxious and waking you up.  You are either thinking, "I can't believe I'm still awake," or, "I've only got 2 more hours before my alarm goes off." 

6.  Exercise at least 20 minutes every day.  Physical exercise burns off excess adrenaline and stress issues.  It makes your body physically tired. 

7.  Avoid eating a large meal within 2-3 hours of bedtime.

8.  Avoid caffeine after noon. 

9.  Avoid alcohol after dinner time.

10.  If you find your mind is thinking about all kinds of things, keep a diary or journal at the bedside, and jot notes about what you are worrying about.  The idea is to take the worries out of your mind and put them down on paper.  Think, "I can stop thinking about these issues--there is nothing I can do about them at 2 a.m. anyway.  They are now in the book so I can deal with them in the daytime." 

11.  Your bed should be for sleep or for sex.  It should not be associated with the misery of tossing and turning and not sleeping.  If you truly cannot sleep and you've been awake for quite awhile, get out of bed, find a comfortable place where it would be ok to fall asleep, and read a book or magazine that is not too stimulating or exciting.  Get your mind off the fact you are not sleeping. 

12.  Keep the one hour prior to bedtime as a protected "wind-down" period.  This period should be free of work, free of stressful interactions, free of worry.  Do not balance your checkbook in bed.  Don't lay in bed reading your laptop and catching up with Facebook or Twitter.  When laying in bed with your spouse, don't get into discussions about the stressful events of the day or family issues or finances.  Consider a warm bath in the hour before bed.  Consider a gentle stretching regimen before bed. 

13.  While laying in bed, make sure you (and your muscles) are relaxed.  Starting at your toes, clench the muscles moderately for a few seconds and then let them really relax. Use the differentiation between contracting and relaxing to identify what "relaxed" really feels like.  Work your way up through your legs (careful if pointing toes at the ankle--can trigger some mean calf cramps if too hard), buttocks, hips, abdomen, lower back, hands, arms, shoulders, upper back, and neck.  I try to imaging that my body is gradually weighing several hundred pounds and is literally "sinking" into the bed.  (Actually, I imagine I am falling asleep on a large planet where gravity is 2-3 times stronger than Earth--I am a nerd!).

Relax neck muscles as much as possible.  See if your head wants to roll a certain direction.  Adjust your pillow to prevent your head from rolling too far once muscles relaxed.  We often maintain tension in our neck that is unconscious to prevent unwanted head movement. 

Check your back teeth.  Upper and lower molars should never be in contact.  This suggests that you are clenching your teeth unconsciously. 

14.  Do not watch TV if you can't sleep.  Numerous studies have concluded that TV actually increases heart rate and excitement levels and overall stimulates you to be more awake. 

15.  Do not nap during the day. 

                                 Medications for Sleep

Over the Counter:  There are several over-the-counter (OTC) medications or supplements for sleep problems.  None of the OTC meds are dangerous or habituating.  Most of my patients have tried one or several of these prior to seeing me.  I don't usually care if my patients try these options as they are across the board safe. 

Antihistamines:  Benadryl (diphenhydramine) at doses of 25 to 50 mg is the mainstay of the OTC market.  Other brand names make use of the fact that antihistamines make people drowsy.  Unisom and others use other antihistamines.  ZzzQuil similarly uses an antihistamine.  Tylenol PM and Advil PM simply add antihistamines to their product to promote drowsiness. 

Melatonin: This is a brain hormone that signals to the brain the need to sleep.  It is available as a supplement OTC.  Doses range from 2-6 mg typically.  I suggest people try it--it is safe, and sometimes works well depending on the situation. 

DreamWater:  this is a relatively new liquid supplement containing GABA, melatonin, and 5-HTP.  I found a good review of this:

http://supplement-geek.com/dream-water-review-side-effects/



               Prescription Medications for Sleep

I only consider prescription medications if ALL OTHER avenues have been exhausted.  There are really only a limited number of medications for sleep.  They fall into roughly 3 families.

Tricyclic Antidepressants (TCAs):  These are also discussed in my post on anxiety and depression.  At low doses, TCAs such as amitriptyline, nortriptyline, doxepin, and a related medication called trazodone improve sleep through an anticholinergic effect much like the antihistamines.  They also increase levels of serotonin in the brain somewhat.  These medications are relatively safe, not habit-forming, and can be used for years with no adverse effects other than possibly dry mouth, dry eyes, slower bowels, and some morning grogginess that usually goes away with continuing use.  Trazodone is probably our most-used version--it seems to have less morning grogginess effect. Typical doses of trazodone are 50 to 100 mg at bedtime.  

Ambien and Lunesta:  These are relatively new on the sleep medication scene.  Ambien is available generically as zolpidem, but Lunesta as of the time of this writing is not generically available.  These medications are best used at low doses for intermittent use.  They are potentially habituating.  

Ambien should be used at as low a dose as possible, typically 2.5 to 5 mg (maximum dose of the regular-release product is 10 mg) at bedtime as needed for significant trouble sleeping.  It has a common side effect:  amnesia for events that occur in the first few hours after taking it.  I tell my patients who start on it--"Do not do anything except go to bed once you've taken it."  Patients may not make memories of events that occur within 15-30 minutes of taking the medication.  For example, I have had patients take it and then suddenly realize they did not have food for breakfast the next day, so drove to the store to get groceries.  In the morning, they come down to find food in the refrigerator and have absolutely no recollection of how it got there.  They don't recall driving to the store or anything related to that event.  This usually does not extend past the morning, but rarely it can. 

There has been some new evidence that especially in women Ambien effects can "accumulate" and cause dizziness, drowsiness or cognitive dysfunction during the day after use.  Because of this, the FDA has put out a warning indicating that physicians should use lower doses than previously recommended. 

Lunesta works fairly similarly to Ambien.  Side effects are similar.  I often hear of Lunesta causing an unusual taste side effect.  I don't get many patients interested in it as it is more expensive. 

Both Lunesta and Ambien are potentially habituating--that is, the longer they are used, the more likely the brain is to become tolerant of the medication, and the desired effect of the medication starts to "wear off."  So not uncommonly, after many months or even years on these, patients will return to me and complain that they are only sleeping for 3-4 hours then they cannot remain asleep.  If that occurs, we are in trouble, because I won't increase the dose of the product. 

Benzodiazepines:  These were previously discussed in the post on Anxiety.  These are considered medications of "last resort." The usual benzodiazepine medications for sleep include lorazepam (Ativan), clonazepam (Klonapin), and temazepam (Restoril).  These have been used for decades, especially for short-term use.  In fact, they are really only recommended for short-term use (typically no more than 1-2 weeks).  Use beyond two weeks is associated with a significant increase in the risk of habituation.  These medications quickly become tolerated by the brain, thus they quickly lose their effectiveness, requiring escalating doses to maintain their effect. 

I will use this group (typically clonazepam) only if we are in a complete "bind."  That is, nothing else has worked and we are at the end of the line for medication trials.  If I get to this point, the medication will be monitored extremely closely.  I set a limit on the maximum dose and I will not cross that line.  These medications are associated with an increased risk of death from all causes.  They can contribute to confusion, fall risk, drug interactions, overdose (accidental/intentional) risk--numerous potential risk issues.  These risks get multiplied tremendously in older patients. 

Beyond this, someone with intractable sleep problems would need to see either a sleep specialist or a psychiatrist.  I have no further medications that I will or can use for sleep problems. 

Other Forms of Deep-Sleep Deprivation:

Sleep Apnea:  Sleep apnea occurs when a person stops breathing for long periods (several seconds) while sleeping.  This causes blood oxygen levels to fall precipitously, which then triggers survival signals in the brain to WAKE UP OR WE ARE GOING TO DIE!  The blood pressure can skyrocket, adrenaline levels shoot up, stress hormones crank out. The brain may actually not wake up entirely--it may just move from deep sleep into a shallower stage of sleep that restarts the breathing process, which improves oxygen levels, at least until the brain falls deep enough to sleep to start the cycle over.  There are two flavors of sleep apnea:  Obstructive sleep apnea and Central Sleep Apnea.  

Obstructive sleep apnea (OSA) is the case where someone stops breathing because the muscles of the neck and throat relax in deep sleep (remember?) and allow the patient to block their own airway.  This is usually accompanied by significant snoring.  OSA has several warning signs and symptoms that we ask about: 

--Is the patient observed to have persistent, consistent snoring that is not just positional or with a cold? 

--Has the patient had witnessed breath-stoppage by an observer?  Often a spouse will describe that while the person is raucously snoring, there will be periods of silence and lack of breathing movements. This will sometimes be followed by that spouse violently kicking and pummeling the snorer so they don't die. 

--Does the patient awaken with headaches?  This occurs due to the roller-coaster effect of the low oxygen levels (and perhaps the elevated blood pressures) that have occured through the night. If I have a migraine headache patient that is awakening with migraines, I am thinking obstructive sleep apnea until proven otherwise. 

--Does the patient awaken in the night with a sense of choking or not being able to breath?  This is pretty self-evident. 

--Does the patient have a neck circumference greater than 20 inches?  A heavy neck aggravates the collapse of the airway which contributes to snoring and airway obstruction.

--Does the patient have significant daytime sleepiness?  People with signifant sleep apnea will report difficulty staying awake through the day.  There is actually a sleepiness scale--the Epworth Sleepiness Scale--that we can use to quantify this issue:

http://www.stanford.edu/~dement/epworth.html

If my patient reports most or all of these "red-flag" symptoms, then I'll get them set up to see a pulmonary medicine specialist for a consultation for a sleep apnea evaluation, which almost always includes a formal sleep study. 

If they have just a few of the symptoms, I might suggest a home "ApneaLink" study.  This is a home study using a pulse-oximeter and a breathing monitor that are easy to hook up and fairly nonobtrusive.  This home study will measure oxygen levels during the night, and how often the patient stops breathing during the night.  From this data we can get some idea of whether or not the patient has dangerous sleep apnea or is just snoring.

Patients with true blue, full-fledged OSA usually are treated with some form of CPAP: Continuous positive airway pressure. This involves some type of mask for the nose (or mouth and nose) that constantly blows air into the airway to keep it from collapsing and blocking airflow. I know, it sounds horrendous, but it works wonders the vast majority of the time. I have sleep apnea patients who sing the praises of their CPAP machines. I frequently hear testimonials like, "I don't know why I didn't do this 5 years ago!" "I sleep better now than I have in years!" "My wife can now sleep in the same bed with me!" " I have energy I never knew I could have." "I won't even go on an overnight trip without my CPAP!"

Other treatments for OSA:  Of course, the single largest factor in OSA is weight.  Almost all OSA patients are obese.  If we can get their weight down substantially, the obstructive process goes away.  However, that takes time.  

Surgery:  There is a surgery that Ear/Nose/Throat surgeons can do which shaves off the back of the soft palate and removes the uvula (the hangy-downy thing at the back of the throat), and also reduces the size of the back of the tongue, and removes the tonsils if still present.  Basically, everything that can be done to surgically open the back of the throat to improve air movement.  Since this is a surgery that is irreversible, I view it as a "last resort" for OSA, if the person is unable to use CPAP.  

Use of an oral apparatus:  There are devices which are sold that are purported to keep the tongue properly positioned to avoid snoring, but I have limited experience with these.  The problem is really farther down the hypopharynx than these devices can address, so I have my doubts as to their effectiveness.  However, if my patient wishes to try one I'll certainly let them, as long as it works and we can prove it works. 

Central Sleep Apnea:  This is a very rare disorder in which the brain during sleep just shuts off breathing and blood oxygen levels fall.  There are different forms and causes:  medications, heart failure, brain stem injuries, and others. It is treated by dealing with the underlying cause whenever possible.  Sometimes CPAP helps also. 

Undiagnosed or untreated sleep apnea can have serious and even life-threatening consequences.  Besides the obvious issues of the patient feeling tired all day and usually struggling with weight issues, there is an increased risk of high blood pressure, heart attack and stroke from the barrage of stress hormones released as well as the precipitous drop in blood oxygen levels.  There is the significant risk of falling asleep while driving or operating dangerous machinery.  We have no idea of the true numbers of traffic fatalities that have occured when a person has fallen asleep at the wheel because of undiagnosed sleep apnea. 

Other weird sleep problems:  There is a whole family of bizarre sleep disorders called parasomnias.  Sleepwalking is the most common, and is usually seen in kids and almost always disappears around puberty.  Sleeptalking is similar. 

More frightening but very rare is sleep paralysis:  The patient may awaken from sleep but still be unable to move or speak, for several minutes.  This can sometimes be misconstrued as the person is having a stroke.  There are other parasomnias like awake dreaming, where the patient is in sort of a half-awake state but still dreaming.  They can have the frightening experience of not knowing if they are awake or asleep and if the dreams are real or just--dreams. 

I have some patients who have "active dreaming."  They move and act out their dreams by flailing or even making directed body movements, such as pummeling or hitting.  I've had some terrified spouses say they were attacked by their husband or wife in their sleep.  This could be intentional, I suppose, or it could be this unusual parasomnia.  This problem is treatable with medication. 

What I find so fascinating about sleep is why we need it.  It is still not known completely why we must sleep.  The really weird thing about sleep is that if you continue to deprive a person of sleep for long enough, they start to become delirious, have hallucinations, perhaps have seizures, and ultimately, they will die.  Don't worry--it takes literally weeks of sleep deprivation to reach that point. 

It is also fascinating to me that as we age, we don't sleep as well. My elderly patients almost across the board don't sleep solidly through the night.  Increased daytime napping is a major contributor, aggravated by decreased physical activity.  However, even beyond simply increased napping, older brains just don't seem to have good, consolidated sleep patterns.  It was formerly thought that this was just a "normal" part of aging, and in some sense that is true.  But that does not mean it is well-tolerated by the older person.  The effects on the body and mind of chronic sleep deprivation are the same, perhaps worse, on an older, more frail population than on younger, more vigorous persons. 

Sleep is absolutely essential to our physical, mental, and emotional health.  Protecting the quantity and quality of sleep should remain a primary goal of any patient intent on promoting healthy living habits.