by Michelle Meadows
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 (see "Tips for Better Sleep").
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 (see "The Stages of Sleep").
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."
This article originally appeared in the November-December 2002 FDA Consumer and contains revisions made in October 2003.
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