DorlandHealth

Some Therapies Help When Sleep Eludes Us

Sleep deprivation is a common occurrence in our 24 hour, on-the-go society. One hundred years ago folks averaged a full hour more sleep than we do now. Although the actual, underlying function of humans’ need for sleep remains a mystery, the effects of lack of sleep are seen on a daily basis.

The functional effects of mild sleep deprivation can be subtle. However, many studies have shown decrements in cognitive function and performance even with low levels of sleep loss. Unfortunately, the effects of sleep deprivation are cumulative. For example, a person who is one-hour sleep deprived each work day will have experienced five hours of total loss by the end of the work week. Such decrements have been shown to increase driving risks, decrease cognitive skills, worsen mood and increase irritability.

Sleep deprivation has been implicated in major industrial accidents such as the Three Mile Island nuclear event in Pennsylvania and the Exxon Valdez shipping oil spill disaster off the coast of Alaska. The incidence of driving mishaps has been shown to increase with sleep deprivation. Indeed, studies of driving performance using tools such as “Steer Clear” have documented the risks of drowsy driving. In fact, research shows that a sleep-deprived driver may run a risk similar to that of an intoxicated individual. Compulsive behavior has also been shown to increase, as has loss of sexual desire. Elevation of blood pressure has been found in sleep-deprived patients with possible implications for long-term cardiovascular events.

Counting Sheep

Sleep loss is a problem among all age groups and in many occupations. Teenagers and young adults are particularly vulnerable. Teenagers may be unable to fall asleep before one or two a.m. on school nights. Intrinsic problems with sleep timing and the effects of a stimulatory bedroom environment with exposure to television, computers and cell phones play particular roles in such sleep loss.

The effect is to worsen school performance and to exacerbate behavioral problems. Airline pilots, especially on long intercontinental or transcontinental flights, have been shown to experience sleep loss on a regular basis. Recently, speculation arose about sleepiness causing two pilots on a commercial flight to overshoot their airport landing location while out of contact with flight. Whether this was true or not, the fact that the public easily accepted that possibility suggests that most people are aware of their own difficulties functioning when sleep deprived.

Other occupations experiencing chronic sleep loss include physicians, nurses and other hospital personnel, and other emergency first responders. Shift workers in many occupations suffer chronic sleep loss. The sensitive nature of their work in many of these fields increases the risk to the public. In fact, legislation in New York was passed to prevent interns and residents from working excessive hours after a legislator from the state experienced the loss of a family member which was attributed to an error by medical staff who reportedly was sleep deprived.

While simple sleep loss is commonly understood to impair daytime function, a less widely known cause of sleep deprivation includes disorders which interfere with the quality of sleep or interfere with the ability to sleep. Insomnia is a common condition which affects up to 17 percent or more of the population. Insomnia does not have a single cause, and often multiple factors are implicated. These factors include chronic anxiety, depression, use of stimulant or sedative drugs, pain, other underlying medical or psychiatric problems, environmental issues such as noise in the bedroom, television, cell phones and computer work in the bedroom. Timing issues may interfere with sleep. Such disorders are caused by a mismatch between a person’s desired sleep time and the internal hormonal control of sleep by a center in the brain which regulates sleep timing and is affected by light via the visual pathway. If the timing is incorrect the person may be unable to fall asleep at the desired time, resulting in inadequate sleep.

Such timing issues may occur with shift work, long air flights, or may be intrinsic to the patient. Teenagers frequently suffer from a delay in the sleep-timing mechanism and are unable to fall asleep at the desired time.

Primary sleep disorders, the most common of which is sleep apnea may interfere with the quality and quantity of sleep. This condition, which is essentially a repetitive blockage of the upper airway during sleep, affects between 4-8 percent of adults and about 2 percent of children in our society. Some subgroups of people, such as obese adults and children, may have much higher prevalence of the disorder (up to 30 percent).

Snoring and daytime sleepiness are two of the most common symptoms of this disorder. Sleepiness is thought to occur because of disruption of normal sleep due to repetitive brief awakenings caused by signaling to the brain related to the obstruction of the air passage or to a fall in the oxygen content of the blood due to the obstruction. Such signaling can cause repetitive brief arousals and transient elevation of blood pressure. When this occurs, up to hundreds of times per night, a person may awaken feeling unrested and may complain of daytime sleepiness. Much as with sleep deprivation due to lack of sleep, sleep apnea is frequently associated with impairment in daytime function and long-term consequences like hypertension and cardiovascular diseases such as stroke and heart attack. Other conditions that can impair both the quality and duration of sleep are common, particularly as we age and include chronic pain, drugs for various medical conditions such as heart failure and others. As we age, our sleep needs do not decrease but the efficiency of our sleep is diminished. Some sleep medications can paradoxically increase daytime sleepiness if taken on a longterm basis.

Dreaming of Treatment

What then can we do about sleep deprivation? The answer is both simple and complex.

We must all be made more aware of the effects of sleep loss or impairment to our health, and we should make efforts to assure that we allow ourselves adequate time for sleep. Such awareness should serve to motivate us to take self-help measures like weight control, regular exercise in the morning or afternoon, avoidance of stimulant drugs such as caffeine in the afternoon and evening, avoidance of alcohol within four hours of bedtime and limitation of total alcohol intake.

We should also be trained to recognize the effects of sleep deprivation on ourselves and others. We should understand normal sleep needs but appreciate individual differences in such needs. For example, children under 5 may require up to 12-13 hours of sleep, teenagers commonly need around nine hours of sleep per night. Adults should allow themselves at least seven to eight hours of sleep per night. If unable to sleep sufficiently long during the night we should appreciate the benefits a catch-up nap in the late morning or early afternoon.

Caffeine is the most common stimulant drug in our society and is widely utilized and enjoyed. However, caffeine taken in the late afternoon and evening may interfere with our ability to sleep. Alcohol may cause disruptive sleep in a number of ways. Alcohol is a short-acting sedative which can help a person fall asleep but cannot be recommended. Alcohol can cause increased arousals from sleep and most people with chronic alcohol use have problems with insomnia. Teenagers might benefit by earlier bedtimes if able to sleep or later school start times if unable to fall asleep until a later time such as one or two a.m.

Patients with medical conditions like pain, anxiety or depression should receive appropriate treatment for these underlying issues that interfere with sleep. Specific sleep therapies exist for a variety of conditions which lead to sleep deprivation or nonrestorative sleep. Such therapies include appropriately timed bright light or melatonin for patients with sleep-timing issues as described above, positive air pressure treatment (commonly known as CPAP) for patients with breathing disorders, and sometimes specific medication. For example, teenagers and young adults who have delayed sleep timing as described above may benefit from bright light exposure in the early morning or from use of appropriate doses of melatonin in the late afternoon or early evening.

Night shift workers may also benefit from bright light exposure early in the night and avoidance of light exposure on the way home from work; use of dark glasses may be helpful. A darkened, quiet room on arrival home may be of benefit. Cognitive behavioral therapy is a combination of measures which, taken together, can help patients improve insomnia and avoid chronic use of sleeping pills. At least 11 controlled studies have validated this treatment for chronic insomnia. One should also be aware of the risks of incorrect treatment of most of these common disorders.

When simple measures as described are insufficient to resolve the issue of inadequate or impaired sleep, medical support available from board certified sleep specialists and sleep centers accredited by the American Academy of Sleep Medicine is advised. Using these strategies, most of us can look forward to improvement in the quality of our lives.

Dr. Dennis H. Nicholson, FCCP, D, ABSM, is the Medical Director of the Sleep Disorders Center at Pomona Valley Hospital in Pomona, Calif., as well as a private practitioner and a published researcher. He also serves on the accreditation committee of the American Academy of Sleep Medicine. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )