T

o fully understand sleep-related breathing disorders, their causes and their consequences, it is helpful to place them in proper context sleep. Understanding the different stages of sleep gives us more awareness on how disorders can invade during this time.

Understanding sleep disorders and sleeping problems

Sleep can often be a barometer of your overall health. In many cases, people in good health tend to sleep well, whereas those suffering from repeated sleeping problems might have an underlying medical or mental health problem, be it minor or serious. Sleeping well is essential to your physical health and emotional well-being. Unfortunately, even minimal sleep loss can take a toll on your mood, energy, efficiency, and ability to handle stress. Ignoring sleep problems and disorders can lead to poor health, accidents, impaired job performance, and relationship stress. If you want to feel your best, stay healthy, and perform up to your potential, sleep is a necessity, not a luxury. Its not normal to feel sleepy during the day, to have problems getting to sleep at night, or to wake up feeling exhausted. But even if youve struggled with sleep problems for so long that it seems norm al, you can still learn to sleep better. You can start by tracking your symptoms and sleep patterns, and then making healthy changes to your daytime habits and bedtime routine. If self-help doesnt do the trick, you can turn to sleep specialists who are trained in sleep medicine. Together, you can identify the underlying causes of your sleeping problem and find ways to improve your sleep and quality of life. Sleep is divided into the following 2 categories, each of which is associated with distinct patterns of central nervous system (CNS) activity: 1. Non-Rapid Eye Movement (NREM) Sleep (also known as quiet sleep) 2. Rapid Eye Movement (REM) Sleep (also known as active sleep or paradoxical sleep) Non-REM sleep further subdivided into 4 progressive categories, termed stages 1-4 sleep characterized by high-amplitude slow waves covert REM sleep (don't have the intensity of REM dreams) REM sleep Stage 5 characterized by muscle atony, episodic REMs, and low-amplitude fast waves dreaming occurs

Table 1. Non-REM sleep versus REM sleep

Sleep Cycle
Stage 1 Introduction to Sleep
Your eyes fight to stay open. Your muscles begin to relax. The physical world starts disappearing around you.

Sleep Disorders

This first stage of sleep is called the introduction into sleep. It is frequently observed by watching someones head nod when they are listening to a dull lecture. This stage is marked by a slowing down of brain

activity and a beginning of muscle relaxation. You can be easily awoken from this stage, which is why you find yourself jumping awake for seemingly no reason. Fun Fact: That jump you experience that makes you feel suddenly wide awake is called a myclonic jerk.

Stage 2

Beginning of Sleep
Light, dreamless sleep. A relaxation takes over the body to prepare for the dreams that are coming.

This stage of sleep is the official beginning of sleep and lasts for approximately 20 minutes. There is a further slowing down of brain and muscle activity. Also, the body temperature starts to decrease and heart rate begins to slow. Fun Fact: In whales and dolphins only one brain hemisphere falls asleep at a time so that they can still surface from the water to breathe.

Stage 3

Slow wave sleep

Deep sleep begins. Brain begins to generate slow delta waves.

Deep, slow brain waves known as delta waves begin to emerge during stage 3 sleep. Stage 3 is a transitional period between light sleep and a very deep sleep. Fun Fact: If it takes you less than 5 minutes to fall asleep, then you could be sleep deprived. It should take closer to 10 minutes.

Stage 4

Delta sleep
Very deep sleep. Rhythmic breathing. Limited muscle activity. Brain produces delta waves.

Stage 4 is sometimes referred to as delta sleep because of the slow brain waves known as delta waves that occur during this time. Stage 4 is a deep sleep that lasts for approximately 30 minutes. Bed-wetting and sleepwalking are most likely to occur at the end of stage 4 sleep. Fun Fact: When people are snoring, they're not dreaming.

Stage 5

Rapid Eye Movement

Rapid eye movement. Dreaming. Improves brain function and creates long term memories.

Sleep Disorders

REM, or rapid eye movement sleep, is the time of sleep when dreaming occurs. During REM sleep the brain is very active, and yet, with the exception of the heart and lungs, the muscles of the body are paralyzed. This muscle paralysis has significant implications for sleep apnea or sleep suffocation sufferers. Since they experience complete muscle relaxation or paralysis in REM sleep, their airways can easily completely collapse. Most importantly, these people have far more difficulty resuming normal breathing after the airway has collapsed.

Fun Fact: A study shows that people who get 6-7 hours of sleep have a longer life expectancy than those who get 8 hours. The Sequence of Sleep Stages It is important to realize, however, that sleep does not progress through these stages in sequence. Sleep begins in stage 1 and progresses into stages 2, 3 and 4. After stage 4 sleep, stage 3 and then stage 2 sleeps are repeated before entering REM sleep. Once REM sleep is over, the body usually returns to stage 2 sleep. Sleep cycles through these stages approximately four or five times throughout the night. On average, we enter the REM stage approximately 90 minutes after falling asleep. The first cycle of REM sleep might last only a short amount of time, but each cycle becomes longer. REM sleep can last up to an hour as sleep progresses.

Figure 1. Summary of Sleep Cycle

Sleep Disorders
According to the American Psychiatric Association, sleep disorders are major disturbances of normal sleep patterns that lead to distress and disrupt functioning during the day. Not only are sleep disorders extremely common, affecting virtually everyone at some point in their lives, but they can also lead to serious stress and other health consequences. Disturbed sleep includes the inability to fall asleep, the inability to go back to sleep, and frequent waking up during the night. Sleep disorders can make you feel tired, fatigued, and irritable, making it difficult for you to concentrate during the day. Anyone at any age can develop a sleep disorder/disturbance. Depending on the cause and the treatment, sleep disturbances can be short-term or long-term. Sleep disorders may be divided into the following 2 broad categories: 1. Parasomnias These are unusual experiences or behaviors that occur during sleep; they include sleep terror disorder and sleepwalking (which occur during stage 4 sleep) and nightmare disorder (which occurs during rapid eye movement [REM] sleep).

Sleep Disorders

Paramsonmias may include the following: a. Sleep Enuresis (Bedwetting) Sleep Enuresis or Nocturnal Enuresis is an inability to control the flow of urine at night. There are two kinds of enuresis: primary and secondary. In primary enuresis, a person has been unable to have bladder control from infancy onward. In secondary enuresis, a person has accidental wetting after having had bladder control for six or more months.

b. Sleep Walking (Somnabulism) Sleepwalking, or somnambulism, is perhaps the best-known arousal disorder. Sleepwalking occurs when a person appears to be awake and moving around but is actually asleep. Sleepwalkers have no memory of their actions. Sleepwalking most often occurs during deep nonREM sleep (stages 3 and 4 sleep) early in the night. It can occur during REM sleep in the early morning. Sleepwalkers are usually children, although the disorder can occur in adults. Sleepwalking appears to run in families. The sleepwalker simply may be confused or disoriented for a short time upon awakening. c. Sleep Talking (Somniloquy) Sleep talking is a sleep-wake transition disorder. Sleep talking or somniloquy, is harmless and usually temporary. Although it usually is harmless, sleep talking can be disturbing to sleep partners or family members who witness it. Talk that occurs during sleep can be brief and involve simple sounds, or it can involve long speeches by the sleeper. The sleeper usually has no memory of their action and it does not affect sleep. Sleep talking can be caused by external factors including fever, emotional stress or other

d. Sleep Related Painful Erections Erections are a normal component of REM sleep for men. In some cases, however, erections become painful and cause a man to wake up. The treatment of sleep-related painful erections may involve drugs that suppress REM sleep. e. Teeth Grinding (Bruxism) Most people probably grind and clench their teeth during sleep from time to time. Occasional teeth grinding, medically called bruxism, does not usually cause harm, but when teeth grinding occurs on a regular basis, the teeth can be damaged and other complications can arise, such as jaw muscle discomfort or TMJ pain. Although the causes of bruxism are not really known, several factors may be involved. Stressful situations, an abnormal bite, and crooked or missing teeth appear to contribute. Sleep terrors/ Night Terrors A person experiencing a night terror or sleep terror abruptly awakes from sleep in a terrified state. The person who has a sleep terror will have signs of intense fear, such as wide eyes with dilated pupils, racing heart, sweating, and rapid breathing.
Sleep Disorders 4

f.

Episodes usually occur during the first hour of falling asleep, the point at which deep sleep begins, and last about 15 minutes. After the episode, the person returns to sleep, unable to remember the incident in the morning because he or she was never fully awake. Night terrors usually occur during stage 3 or stage 4 sleep, the deepest stages of sleep, and children have more deep sleep than adults. Night terrors are similar to nightmares, but night terrors usually occur during deep sleep. g. Nightmare Nightmares are repeated awakenings from sleep caused by vivid and distressing recall of dreams. Nightmares usually occur during the second half of the sleep period. Upon wakening from the dream, the person rapidly reorients to time and place.

h. Impaired Sleep Related Penile Erections This disorder occurs among men who are unable to maintain a penile erection during sleep that would be sufficiently severe enough to engage in sexual intercourse. Men usually experience erections as a part of REM sleep, and impaired sleep-related erections may indicate erectile dysfunction. i. Nocturnal leg cramps Nocturnal leg cramps are sudden, involuntary contractions of the calf muscles that occur during the night or periods of rest. The cramping sensation may last from a few seconds to 10 minutes, but the pain from the cramps may remain for a longer period. The cramps can affect persons in any agegroup, but they tend to happen in middle-aged and older populations. Nocturnal Paroxysmal Dystonia (NPD) Nocturnal paroxysmal dystonia (NPD) is a complex motor attack arising abruptly during sleep, especially nonrapid eye movement sleep. NPD is characterized by sudden arousal followed by motor agitation with dystonic posturing, and semi purposeful activity returning several times per night. Most evidence points to NPD being a form of epilepsy. Nocturnal Seizures These seizures, which occur only during sleep, can cause the sufferer to cry, shout, walk, run about, or curse. Like other seizures, these are usually treated with medication. REM Behaviour Disorder (RBD Rapid eye movement behavior disorder, or RBD, is a serious REM sleep disorder that can cause injuries. The body usually experiences atonia, or a temporary paralysis, during dreaming. This is a safety precaution that prevents us from physically acting out our dreams The exact cause for the disorder is unknown. People can usually remember their dreams, but have no awareness of moving around while asleep. The condition can cause injuries to both the dreamer and family members.

j.

k.

l.

Sleep Disorders

m. REM Sleep Cardiac Arrhythmias A cardiac arrhythmia is a change from the regular rate or control of the hearts contractions. People who have coronary artery disease and whose blood oxygen is lowered by sleep-disordered

breathing may be at risk for arrhythmias, which take place during REM sleep. Continuous positive airway pressure (CPAP) treatment may reduce this risk. n. Sleep Paralysis It is a condition characterized by paralysis of the body shortly after waking up (known as hypnopompic paralysis) or, less often, shortly before falling asleep (known as hypnagogic paralysis). o. Restless Legs Syndrome (RLS) It is a neurologic sensorimotor disorder that is characterized by an overwhelming urge to move the legs when they are at rest. The urge to move the legs is usually, but not always, accompanied by unpleasant sensations. It is less common but possible to have RLS symptoms in the arms, face, torso, and genital region. RLS symptoms occur during inactivity and they are temporarily relieved by movement or pressure. Symptoms of RLS are most severe in the evening and night time hours and can profoundly disrupt a patient's sleep and daily life. p. Snoring It is noisy breathing during sleep. It is a common problem among all ages and both genders, and it affects approximately 90 million American adults 37 million on a regular basis. Snoring may occur nightly or intermittently. Persons most at risk are males and those who are overweight, but snoring is a problem of both genders, although it is possible that women do not present with this complaint as frequently as men. Snoring usually becomes more serious as people age. It can cause disruptions to your own sleep and your bed-partner's sleep. 2. Dyssomnias These are characterized by abnormalities in the amount, quality, or timing of sleep. Dyssomnias may include the following: a. Insomnia It is by far the most common sleep disorder, affecting nearly 60% of U.S. adults at least one night each week. It is the inability to get the amount of sleep you need to wake up feeling rested and refreshed, is the most common sleep complaint. Insomnia is often a symptom of another problem, such as stress, anxiety, depression, or an underlying health condition. It can also be caused by lifestyle choices, including the medications you take, lack of exercise, jet lag, or even the amount of coffee you drink. Insomnia can be: Initial insomnia (also referred to as early insomnia or sleep-onset insomnia) is characterized by difficulty in falling asleep, with an increase in sleep latency (ie, the time between going to bed and falling asleep). Initial insomnia is frequently related to anxiety disorders. Middle insomnia (also referred to as sleep-maintenance insomnia) refers to difficulty in maintaining sleep. Decreased sleep efficiency is present, with fragmented unrestful sleep and frequent waking during the night. Middle insomnia may be associated with medical illness, pain syndromes, or depression.

Sleep Disorders

Terminal insomnia (also referred to as late insomnia or early morning wakening insomnia), patients consistently wake up earlier than needed. This symptom is frequently associated with major depression. Hypersomnia, or excessive daytime sleepiness, is often attributable to ongoing sleep deprivation or poor-quality sleep arising from causes ranging from sleep apnea to substance abuse or medical problems. b. Narcolepsy It is a neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. The main features of narcolepsy are excessive daytime sleepiness and cataplexy. The disease is also often associated with sudden sleep attacks, insomnia, dream-like hallucinations, and a condition called sleep paralysis. Its prevalence in the developed world is approximately the same as that of multiple sclerosis or Parkinson's disease. c. Sleep Apnea Obstructive sleep apnea is a disorder in which breathing is briefly and repeatedly interrupted during sleep. The "apnea" in sleep apnea refers to a breathing pause that lasts at least ten seconds. Obstructive sleep apnea occurs when the muscles in the back of the throat fail to keep the airway open, despite efforts to breathe. Another form of sleep apnea is central sleep apnea, in which the brain fails to properly control breathing during sleep. Obstructive sleep apnea is far more common than central sleep apnea.

d. Delayed Phase Sleep Disorder It is officially called circadian rhythm sleep disorder, delayed sleep phase type, is an inability to fall asleep at a desired, conventional clock time and awaken at a socially acceptable morning time. e. Nocturia A frequent need to get up and go to the bathroom to urinate at night is called nocturia. It differs from enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder empties anyway. Nocturia is a common cause of sleep loss, especially among older adults.

EPIDEMIOLOGY
Approximately one third of all Americans have sleep disorders at some point in their lives. Between 20% and 40% of adults report difficulty sleeping at some point each year, and about 17% of adults consider the problem to be serious. Sleep disorders are a common reason for patient visits throughout medicine. Approximately one third of adults have insufficient sleep syndrome. Twenty percent of adults report chronic insomnia. Age- and sex-related demographics Increasing age predisposes to sleep disorders (5% incidence in persons aged 30-50 years and 30% in those aged 50 years or older). People who are elderly experience a decrease in total sleep time, with more frequent awakenings during the night. Elderly persons also have a higher incidence of general medical conditions and are more likely to be taking medications that cause sleep disruption.

Sleep Disorders

People who are elderly may have widespread or multisite pain that is associated with sleep difficulty, according to the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly study (MOBILIZE) study. Primary insomnia is more common in women, with a female-to-male ratio of 3:2. Hormonal variations during the menstrual cycle or during menopause may cause disruptions in sleep. Obstructive sleep apnea (OSA) is more common in men (4%) than in women (2.5%).

PATHOPHYSIOLOGY

SLEEP DISORDER .
Disturbances in the pattern and periodicity of REM and NREM sleeps Abnormalities in the balance of all chemical messengers systems

Dopamine is associated with wakefulness

Pineal gland secretes less melatonin in bright light

Suprachiasmatic nucleus is responsible for the release of melatonin

Disturbances in the pattern and periodicity of REM and NREM sleep are often found when people admit to experiencing sleep disorders. Sleep-wake cycles are governed by a complex group of biologic processes that serve as internal clocks. The suprachiasmatic nucleus, located in the hypothalamus, is thought to be the bodys anatomic timekeeper, responsible for the release of melatonin on a 25-hour cycle. The pineal gland secretes less melatonin when exposed to bright light; therefore, the level of this chemical is lowest during the daytime hours of wakefulness. Multiple neurotransmitters are thought to play a role in sleep. These include serotonin from the dorsal raphe nucleus, norepinephrine contained in neurons with cell bodies in the locus ceruleus, and acetylcholine from the pontine reticular formation. Dopamine, on the other hand, is associated with wakefulness.
Sleep Disorders 8

Abnormalities in the delicate balance of all of these chemical messenger systems may disrupt various physiologic, biologic, behavioural, and EEG parameters responsible for REM (ie, active) sleep and NREM (slowwave) sleep.

ETIOLOGY
Sleep problems can be caused by various factors. Although causes might differ, the end result of all sleep disorders is that the body's natural cycle of slumber and daytime wakefulness is disrupted or exaggerated. a. Genetics Narcolepsy is the only major sleep disorder with a known genetic cause (i.e., hereditary). b. Night shift work Night shift workers often experience sleep disorders, because they cannot sleep when they start to feel drowsy. Their biological clock tells their body to sleep while they are going to or at work. People who work at night are at an increased risk for heart conditions and digestive problems, as well as emotional and mental problems. c. Blindness The inability to detect light and darkness may cause disruptions in the biological clock, which can result in sleep disorders.

d. Mental Illness Most patients with mental illness experience some type of sleep disorder. Depression often causes patients to wake up early in the morning, unable to go back to sleep. e. Physical Many physical illnesses and diseases cause sleep disorders. Difficulty sleeping can result from chemical changes in the body caused by disease or by the medications used to treat the disease. f. Aging About 50% of adults over the age of 65 have some type of sleep disorder. It is not clear whether this is a normal part of aging, or a result of medications. g. Medications Many drugs can interfere with sleep, such as certain antidepressants, blood pressure medication, and over-the-counter cold medicine.

h. Diet (Coffee) Coffee has caffeine that can interfere with sleep up to twenty hours after you consume it.

SIGNS AND SYMPTOMS

Pay attention to these warning signs, as they could mean you're struggling with a sleep disorder. Once you know what you're up against, you'll soon be on your way to a better night's sleep.

a.

Difficulty falling asleep at night or getting back to sleep after waking during the night

Sleep Disorders

b. Waking up frequently during the night

c.

Your sleep feels light, fragmented, or exhausting

d. You need to take something (sleeping pills, nightcap, supplements) in order to get to sleep

e.

Sleepiness and low energy during the day

f.

You sleep for eight hours and still wake up groggy and unrefreshed. During a normal sleep cycle, the body alternates between deep and light sleep that should leave you feeling awake and alert. If you're still sleepy after a full night in bed, chances are something is happening to prevent your body and brain from entering those deep, restorative levels of sleep.

g.

Snoring. Snoring may be harmless, but it could also be a warning sign for sleep apneaa dangerous condition in which your airway becomes obstructed and you stop breathing in your sleep.
Sleep Disorders 10

h. You suffer from another chronic health condition or experience mysterious symptoms that keep you awake. It makes sense that people dealing with other health issues, such as depression, illness, or chronic pain, would have a harder time sleeping peacefully.

i.

Difficulty concentrating at work, school, or home

j.

Weight gain. If youre feeling sleepy at work, you may be tempted to reach for a cup of coffee (or several cups) and a doughnut for a quick shot of energy. Later you may skip the gym and pick up takeout on your way home to your family -- no time to cook. When you finally find yourself back in your bed, you are too wound up to sleep.

RISK FACTORS
a. Gender Overall, insomnia is more common in women than men, although men are not immune from insomnia. Sleep efficiency deteriorates equally in men and women as they get older. Hormonal fluctuations that occur during menstruation, pregnancy, and menopause put women at higher risk of insomnia. Women are also more likely than men to suffer from anxiety and depressive disorders, which can cause insomnia. b. Age Insomnia is more common in older people than younger people. As people grow older, sleep patterns change. Elderly adults tend to wake up frequently during the night, wake up earlier, and report waking up feeling unrefreshed. Elderly people are more likely than younger people to have medical conditions that cause pain or night time distress. These conditions include arthritis, gastrointestinal distress, frequent urination, lung disease, and heart conditions. Neurologic conditions, such as Parkinsons and Alzheimers, can also affect sleep patterns. Consequences of poor sleep in the elderly include increased risk of falls.

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c.

Shift workers Shift workers are at considerable risk for insomnia. Over half of shift workers report one or more symptoms of insomnia at least a few nights a week. Workers over age 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night-shift workers also have a high rate of sleeplessness. Night-shift workers are at risk for falling asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher risk for health problems in general.)

COMPLICATIONS
Mood and anxiety disorders may develop from untreated sleep disturbances, and current medical literature supports the theory that these brain-based mental status changes are risk factors for morbidity and mortality from a host of medical conditions (eg, cardiovascular disease). Sleep problems may lead to daytime problems such as poor memory and concentration, irritability, behavioural problems, aggression, emotional distress, depression and increased accident rates.

DIAGNOSIS
If your sleep disturbances dont clear up after several days, you may want to see your doctor to find out if there is a serious underlying cause. After an exam, your doctor may recommend the following tests: a. Polysomnography (PSG) It is a study or test done while a person is fully asleep. You will be observed while you sleep so that your doctor can record data about your sleep patterns and identify any sleep disorders. Your doctor will measure your brain waves, blood oxygen levels, heart and breathing rates, and eye movement during polysomnography to help chart your sleep cycles.

b. Electroencephalography (EEG) It is used for studies of sleep and sleep disorders where recordings are typically done for one full night, sometimes more. It can also identify apnea events while sleeping but it is not always done since it is still under the investigation. c. Genetic blood testing in the rare case of narcolepsy It is used to confirm if the patient is positive for narcolepsy.

d. Oximetry Oximetry may be performed during sleep to examine blood oxygen levels for clinically important desaturations suggestive of sleep apnea or other forms of sleep-disordered breathing. e. Beck Depression Index A Beck Depression Index or similar clinical screening tool may be used to detect an underlying depressive illness as a contributing factor in insomnia.

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Sleep Disorders

f.

Actigraphs Actigraphy is useful for assessing daytime sleepiness in situations where a laboratory sleep latency test is not appropriate. It is used to clinically evaluate insomnia, circadian rhythm sleep disorders, excessive sleepiness and restless legs syndrome. It is also used in assessing the effectiveness of pharmacologic, behavioural, phototherapeutic or chronotherapeutic treatments for such disorders. Multiple Sleep Latency Test The Multiple Sleep Latency Test (MSLT) is a sleep disorder diagnostic tool. It is used to measure the time elapsed from the start of a daytime nap period to the first signs of sleep, called sleep latency. The test is based on the idea that the sleepier people are, the faster they will fall asleep. The MSLT is used extensively to test for narcolepsy, to distinguish between physical tiredness and true excessive daytime sleepiness, or to assess whether treatments for breathing disorders are working. Its main purpose is to discover how readily a person will fall asleep in a conducive setting, how consistent or variable this is, and the way they fall asleep in terms of REM sleep and other brain patterns. This can be used to identify and differentiate between various sleep problems.

g.

TREATMENT
Treatment for sleep disturbances depends on the causes. In general, teach the patient first with good sleep hygiene. Then, if necessary, consider medication. Sleep medications are most effective when used sparingly for short-term situations. If medications are used over the long term, they are best used as needed instead of on a daily basis to avoid dependence and tolerance. NON-PHARMACOLOGICAL TREATMENT 1. Sleep Hygiene Educating patients in good sleep hygiene is the keystone of treatment since you can address many common sleep problems through lifestyle changes and improved sleep hygiene. The following advice should be given to patients: a. b. c. d. e. f. g. h. i. Use the bed for sleep and sex only (no television watching or reading in bed) Avoid caffeine, especially late in the day; avoid activities that will get you stimulated and upset late in the day; practice relaxation techniques before bedtime Exercise each day. Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia. Consumption of tryptophan-containing foods may help induce sleep; the classic example is warm milk. Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus. Maintain a regular schedule for bedtime and wakening; avoid naps. Do not watch the clock while in bed; avoid struggling to fall asleep in bed instead, get up and spend quiet time out of bed until sleep comes. Eat a meal of starchy rice four hours before bedtime because it may solve your insomnia problems, new research from the University of Sydney has found. Decrease evening water consumption.

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Sleep Disorders

j.

Avoid drinking alcohol before bedtime because alcohol creates the illusion of good sleep, but it adversely affects sleep architecture.

2. Weight Loss Sleep apnea can be alleviated by losing weight 3. Bed on the floor Bedrooms should be on the ground floor to prevent the RBD sufferer from falling downstairs and dangerous objects in the bedroom should be removed. 4. Mouth Guard Teeth grinding can be prevented with the use of a mouth guard. The mouth guard, supplied by a dentist, can fit over the teeth to prevent teeth from grinding against each other. 5. Alternative treatment a. Acupuncture Thin, sterile, stainless steel needles are inserted at specific acupoints on the body that lie in meridians or channels through which energy, or qi, flows. Stimulation of these points may activate key portions of the nervous system, resulting in the release of natural pain-killers and chemicals that can make your body relaxed and minimize stress.

b. Meditation It can help you overcome certain types of insomnia. Once you learn to meditate and have a daily meditation practice, you will know how to relax instantly how to do the breathing and do the mental focusing that allows you to relax within seconds. Use this meditation technique when you fall asleep and when you need to return to sleep, perhaps after getting up to go the bathroom or tend to a crying baby or sick relative. 6. Continuous positive airway pressure (CPAP) therapy It is a common treatment used to manage sleep-related breathing disorders including obstructive sleep apnea, central sleep apnea and hypoventilation and hypoxemia. CPAP uses a machine to help a person breathe more easily during sleep. A CPAP machine increases air pressure in your throat so that your airway does not collapse when you breathe in.

Figure 2. CPAP Therapy

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Sleep Disorders

SURGERY 1. Nasal Surgery This procedure is done for obstructive sleep apnea with nasal blockage. Nasal surgery is performed for mild apnea or snoring when no other structural or functional problem is identified. It may improve CPAP tolerance in patients with marked nasal blockage, and also may improve the success of other surgeries for obstructive sleep apnea.

Figure 3. Surgery for deformed septum

2. Palate Surgery Surgical referral may be indicated to correct some underlying medical conditions that cause insomnia, such as for palate surgery in some cases of sleep apnea.

Figure 4. Palate sugery

PHARMACOLOGICAL TREATMENT Many agents are useful in treating insomnia. Short-term drug therapy is preferred to restore a normal sleep pattern. Generally, hypnotic drugs are approved for 2 weeks or less of continuous use. In chronic insomnia, longer courses may be indicated, which require long-term monitoring to ensure on-going appropriate use of the medication. 1. Short-acting barbiturates and chloral hydrate They are seldom used now for insomnia, because of safety concerns related to their undesirably low therapeutic indexes. Side Effects:
Sleep Disorders 15

Drowsiness Dependence Respiratory depression

2. Zolpidem and Zaleplon They are the newest and, arguably, the safest agents that have been approved by the US Food and Drug Administration (FDA) for short-term hypnotic use. Zolpidem is available an extended-release version that lasts slightly longer than the original preparation. Side Effects: 3. Eszopiclone The FDA has approved eszopiclone as the first agent for long-term use in the management of chronic insomnia. Side Effects: Headache Dizziness Dry mouth Chest pain Headache Dizziness Nausea Vomiting

4. Benzodiazepines (Flurazepam) It is frequently chosen as a short-term treatment of insomnia. It enhances the inhibitory effects of the GABA neurotransmitter on neuronal excitability that results by increased neuronal permeability to chloride ions. The shift in chloride ions results in hyperpolarization and stabilization of the neuronal membrane. Side Effects: 5. Sleeping pills When taken for a brief period of time and under the supervision of your doctor, sleeping pills may help your sleeping problems. However, they are just a temporary solution. Insomnia cant be cured with sleeping pills. In fact, sleeping pills can often make insomnia worse in the long run. Also, they are best used as needed instead of on a daily basis to avoid dependence and tolerance. Side Effects: Dry mouth Dizziness Constipation Urinary retention Drowsiness Dizziness Ataxia Light-headedness

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Safety Guidelines for Sleeping pills: Only take a sleeping pill when you will have enough time to get a full seven to eight hours of sleep. Otherwise, you may be drowsy the next day. Read the package insert that comes with your medication. Pay careful attention to the potential side effects, dosage instructions, and list of food and substances to avoid. Never mix alcohol and sleeping pills. Alcohol disrupts sleep and can interact dangerously with sleep medications. Never drive a car or operate machinery after taking a sleeping pill, especially when you first start taking a new sleep aid, as you may not know how it will affect you.

Dream Facts
People usually have several dreams each night, each one lasting for between 5 to 20 minutes. During a typical lifetime, we spend about six years dreaming. You always forget your dreams because the frontal lobes, the area that plays a key role in memory formation, are inactive during REM sleep, the stage in which dreaming occurs. People usually have several dreams each night, each one lasting for between 5 to 20 minutes. During a typical lifetime, we spend about six years dreaming. You always forget your dreams because the frontal lobes, the area that plays a key role in memory formation, are inactive during REM sleep, the stage in which dreaming occurs. Dreams of the blind: People born blind, and who never experienced visual imagery in waking life, have no visual images in their dreams. Instead of visual sensations, blind individuals' dreams typically include information from the other senses such as sound, touch, taste, hearing and smell. People who became blind before the age of five rarely experience visual imagery in their dreams. People who became blind between the ages of five and seven sometimes retain some visual imagery and experience it in their dreams. Most people who became blind after the age of seven continue to experience at least some visual imagery in their dreams, but the clarity and frequency of the imagery is often reduced with time.

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Sleep Disorders

References:
National Sleep Foundation. http://science.howstuffworks.com/life/inside-the-mind/human-brain/dream2.htm http://psychology.about.com/od/statesofconsciousness/a/SleepStages.htm http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/ http://www.webmd.com/sleep-disorders/guide/teeth-grinding-in-sleep http://www.sleepdisordersguide.com/sleep-paralysis.html http://www.sleepfoundation.org/article/sleep-disorders http://sleepdisorders.sleepfoundation.org/chapter-5-circadian-rhythm-sleep-disorders/delayed-sleep-phasetype/definition/what-is-delayed-phase-sleep-disorder http://psychology.about.com/od/statesofconsciousness/p/sleep_disorders.htm http://www.healthcommunities.com/sleep-disorders/causes.shtml http://www.webmd.com/sleep-disorders/sleep-disorders-causes http://www.health.com/health/gallery/0,,20502289,00.html# http://www.webmd.com/sleep-disorders/excessive-sleepiness-10/lack-of-sleep-weight-gain http://www.patient.co.uk/doctor/Sleep-Problems-in-Children.htm# http://www.healthcentral.com/sleep-disorders/insomnia-introduction-000027_4-145.html http://www.bayfamilymedicine.org/news/getting-to-bed-to-sleep/ http://www.webmd.com/sleep-disorders/sleep-apnea/continuous-positive-airway-pressure-cpap-forobstructive-sleep-apnea http://www.healthline.com/health/polysomnography http://en.wikipedia.org/wiki/Actigraphy http://en.wikipedia.org/wiki/MSLT http://www.northshore.org/sleep-center/procedures/ http://www.sleepeducation.com/disease-management/cpap-titration-study/overview http://sleepnosleep.wordpress.com/2010/05/18/a-bowl-of-rice-to-improve-sleep/#more-179 http://www.sleepdisordersguide.com/parasomnia.html http://www.froedtert.com/SpecialtyAreas/SleepDisordersProgram/ProgramsAndServices/SurgeryforSleepDis orders.htm http://emedicine.medscape.com/article/287104-medication#1 http://www.healthline.com/health/sleep/disorders#Overview http://www.sleepdisordersguide.com/sleep-disorders-treatments.html http://www.helpguide.org/life/sleep_disorders.htm http://psychology.about.com/od/statesofconsciousness/tp/facts-about-dreams.htm http://mentalfloss.com/article/22723/do-blind-people-see-things-their-dreams http://psychology.about.com/od/statesofconsciousness/tp/facts-about-dreams.htm http://www.secretstomeditation.com/meditation-sleep/

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Sleep Disorders