Pulmonary and Sleep Medicine, University Pulmonary Associates
East Greenwich, Rhode Island
As a board-certified physician in pulmonary, critical care, and sleep medicine, Dr. Michael Stanchina specializes in the diagnosis and treatment of a variety of sleep disorders. His work at Epoch Sleep Centers is focused on improving the availability of screening tools and monitoring systems for treatment of patients with obstructive sleep apnea. We talked with him about how sleep disorders affect our health.
Q: It seems like a lot of people don't get enough sleep. Why is that?
A: It's estimated that 43 percent of patients express concerns about being tired during the day to their primary care doctors. Common causes of daytime sleepiness are often categorized in three groups of sleep disorders. First is chronic partial sleep deprivation, which is not achieving at least seven to seven and a half hours of sleep. It is frequently caused by self-imposed sleep restriction, or not getting enough sleep based on pressures in your job, your life, etc. The second group is sleep fragmenting disorders, such as obstructive sleep apnea, restlessness in the legs, and possibly insomnia, all which cause fragmented sleep and sleepiness. The third group is disorders of "sleep drive" such as narcolepsy, which is a genetic disorder leading a person to need more sleep than average in order to not be sleepy or have daytime fatigue.
Q: When it comes to sleep deprivation, are there symptoms or signs to look for?
A: The signs of sleepiness can be quite varied in different populations. Some people just simply complain of not being able to function during the day. They are fatigued and have a lack of concentration or a lack of focus. Others complain of actually having difficulty staying awake, even when doing things like driving. Still even more unusual, sometimes symptoms of sleepiness can appear as depressive type symptoms, especially in women. In children, often you have sleep disorders that may show up with hyperactivity, the complete opposite of what appears to be sleepiness. If someone thinks they might have a sleep disorder, their doctor is the first line of defense.
Q: What are the long-term health risks of sleep disorders?
A: In studies, getting too little sleep or too much sleep on a regular basis has been associated with cardiovascular problems and increased mortality. Obstructive sleep apnea has also been associated with cardiovascular disease, diabetes, high blood pressure, and stroke. Treatment of sleep apnea with continuous positive airway pressure (CPAP) machines has been shown to reduce some of the cardiovascular risk.
Q: What causes obstructive sleep apnea?
A: Obstructive sleep apnea is a disorder characterized by repeated closure of the airway during the night. It is caused by the combination of a narrowed upper airway (often associated with increased weight or increased neck size), and the drop out of upper airway muscle activity with the onset of sleep. So the combination of bad anatomy and loss of upper airway muscle tone contributes to the airway collapsing time after time during sleep.
Q: What can people do to get a good night's sleep?
A: To practice good sleep hygiene, or good sleep techniques, you should create a sleep environment that is adequately dark, quiet, comfortable, and promotes continuous sleep. You should avoid things that disrupt sleep such as drinking too much alcohol, eating too much too late, and probably most important is keeping a regular sleep schedule—waking up and going to bed at the same time each day. If you have concerns about your sleep, talk to your physician.
Q: If someone snores regularly, does it mean they have obstructive sleep apnea?
A: Almost all patients who have obstructive sleep apnea snore, but not everybody who snores has sleep apnea. If your snoring wakes you up, or if you wake up choking, that could be a sign of sleep apnea. Another sign would be someone you live with witnessing an apnea, which is when you stop breathing for a short period of time. Obstructive sleep apnea syndrome is defined by at least five periods per hour when you stop breathing (apnea) or have reduced airflow (hypoapnea) during a sleep study, along with sleepiness during the day.
Q: What exactly is insomnia?
A: Insomnia is a disorder characterized by difficulty getting to sleep, staying asleep, or poor perception of sleep quality. Patients who have lifelong insomnia have long-standing difficulty getting to sleep or maintaining sleep, often without any obvious precipitating cause. For other patients, sometimes we can identify an event or situation—such as a death in the family, going through menopause, or sometimes a head trauma-type incident—that can be a cause of insomnia. But again, oftentimes we aren't able to identify the cause. What frequently happens with insomnia patients is that they get into a cycle of poor sleep and poor habits around sleeping, such as staying in bed for long periods of time, tossing and turning. They'll eat at night. They'll expose themselves to bright lights like television and computer screens, which alters their circadian clock. Often the focus of treatment in these patients is to retrain the patient on how to practice good sleep hygiene and how to sleep well again.
Q: What are the signs of sleep disorders in children?
A: Sleep apnea or behavioral insomnias are common in children, although their symptoms often differ from adults. In infants and younger children, sleep difficulties noted by the parents can often be related to care of the infant at night. Nightly routines such as co-sleeping or always needing a bottle to sleep are learned behaviors. Once recognized, these behaviors can be changed to can improve sleep quality in children.
Sleep apnea can present slightly differently in children than adults. Sleepiness is still somewhat common (with snoring and witnessed apneas), but sleep apnea isn't always associated with sleepiness during the day. It can be associated with lack of concentration and more hyperactive behavior. Other risks for sleep apnea include obesity and having big tonsils. Thus if a child snores loudly, has hyperactive symptoms out of the ordinary, or demonstrates changes in behavior, they should be evaluated by their physician or a sleep specialist. If there's concern and question about the actual diagnosis, a sleep study is appropriate for children.
Q: How do you treat sleep disorders in adults?
A: Treatment will usually be dictated by how much impact there is on the patient's sleep, how they feel during the day, and risks to underlying disorders. Specific treatment plans would be set up with your doctor and sometimes that would also include a sleep specialist. Treatment for insomnia may include changing behavior and sometimes medication. For chronic partial sleep deprivation, it would involve sleep hygiene techniques to try to improve sleep quality. For sleep apnea, treatment would include efforts to keep the airways open. General treatment for narcolepsy focuses on keeping those patients awake with stimulant medication.
Q: What are the characteristics of the third category of sleep disorder, sleep drive?
A: The third category refers to disorders like narcolepsy, which is a genetic disorder related to the neurotransmitter systems in the brain. Two research groups, one in Chicago and one at Stanford University, have identified proteins and receptors for a neurotransmitter system called the orexin/hypocretin system, which is a series of neuron projections throughout the brain that promote wakefulness. In subjects with narcolepsy, these are absent or at least partially absent. The neurobiology is not completely worked out yet, but these disorders usually present in a person's 20s or 30s and are often associated with unusual symptoms such as loss of muscle control triggered by strong emotion, very vivid dreaming early in the night, and sometimes sleep paralysis, which is the inability to move after awakening from sleep for a short period of time.
Typically patients with narcolepsy have very significant sleepiness during the day and fragmented sleep during the night. Diagnosis of narcolepsy is done by recognizing the clinical signs and typically involve sleep studies where you do naps during the day to objectively determine the degree of patient sleepiness.