It’s America’s favorite weekend activity: catching up on sleep. But when you sleep in, are you really making up for lost sleep?
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Snoring, restless sleep, frequent nighttime urination, daytime fatigue–the list of possible sleep apnea symptoms is long. And sometimes the connection between the symptom and the disorder may seem obscure. A common challenge with diagnosing sleep apnea is that many of its symptoms are stand-alone conditions and/or often misattributed to other ailments.
Dr. Kent Smith, a Diplomate of the American Board of Dental Sleep Medicine, testified before the US House of Representatives regarding alternative treatments for people who suffer from sleep-related issues, such as sleep apnea and other problems like snoring and general fatigue.
According to the Institute of Medicine, an estimated 50-70 million Americans suffer from a sleep-related disorder. The most commonly diagnosed disorder is obstructive sleep apnea (OSA).
It’s America’s favorite weekend activity: catching up on sleep. But when you sleep in, are you really making up for lost sleep?
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By TOBI SCHWARTZ-CASSELL In Part I of our two-part series, we dealt with the dangers of untreated sleep apnea. In Part II, we’ll describe the treatments now available.
The lack of a good night’s sleep can create more problems than meet the eye. According to those in the know, sleep apnea, and the more severe version—obstructive sleep apnea (OSA)—can also cause headaches, fatigue, mood swings, depression, weight gain and surprisingly, ADHD. Two studies even show there is a connection between sleep apnea and cancer (see “The Truth About Sleep Apnea: It’s More Than Just Extreme Snoring” on page 13 of the July/August 2012 issue of Girlfriendz).
Though the National Sleep Foundation reports that more than 18 million American adults suffer from sleep apnea, the American Sleep Apnea Association (ASAA) says it is only one of 84 different sleep disorders (SDs) including: circadian rhythm SDs (determined by the body’s internal clock), insomnia (the most prevalent of all SDs), narcolepsy, restless legs syndrome and night terrors.
The original diagnostic tool, according to Kent Smith, DDS, of 21st Century Dental, is the polysomnogram, which is “an attended study at a sleep center. But it’s expensive because the tech overseeing the study has to be paid, and the patient has to be provided with a place to sleep. Some insurance companies are actually moving to ambulatory studies (home studies) and some are even saying they will only pay for a full polysomnogram if the patient is incapable of undergoing an ambulatory study.”
Once diagnosed, a number of treatments are available, ranging from the severity of surgery to the first line of defense—weight loss. Stephen J. Markus, DMD, of the Centre for Dentistry of Haddon says, “For some people, losing weight is going to tone down the snoring. The thinner the neck and the less fat in the body, the easier breathing’s going to be. Also, those who are obese often experience very shallow breathing because the stomach has gotten so large it’s pushing the diaphragm up so they can’t take deep enough breaths.”
“Sleep position training can help,” adds Dr. Smith, “as do nasal decongestants, the use of over-the-counter remedies like Breathe Right® Strips and tilting the head of the bed.”
“The surgical approach, uvulopalatopharyngoplasty or UPPP, entails the use of a laser to cut back the tissue in the soft palate and remove the uvula. This allows more space for the tongue, so it does not obstruct the airway,” says Dr. Markus. “But UPPP can be very painful, kind of like a pizza burn, for at least two weeks. I also understand that in a lot of cases the tissue grows back.” ASAA reports the success rate of UPPP is 50%.
With those odds, many doctors recommend CPAP (continuous positive airway pressure) machines that use mild air pressure to keep patients’ airways open. The National Heart Lung and Blood Institute, a part of the National Institutes of Health, explains on its website that CPAP machines have three main parts:
“Most people think CPAP for moderate to advanced sleep apnea is the only solution, but it’s not,” affirms Dr. Markus. “It is, however, the best solution. The mask is very difficult for people to sleep with, which is why most of the referrals I get for nighttime sleep appliances are from doctors whose patients are non-compliant.”
Drs. Markus and Smith agree that oral appliances are a safe, non-invasive way of dealing with sleep apnea. “The appliances we work with are designed to create more space at the back of the throat so the tongue and soft palate don’t touch one another,” says Dr. Markus. “The one we’ve had the best results with are the SomnoMed® appliances. You may have seen ads for appliances selling for $19.99, but there are problems with those because they aren’t made by a professional and they’re not monitored. They are made from soft, pliable material so they can act orthodontically and therefore move teeth and create TMJ problems. So there’s a lot of frustration in the marketplace by people who want to find a way to sleep and not disturb the other person in the room and not jeopardize their own lives. These appliances can be a good solution to those with very mild sleep apnea, but for anyone more advanced than that, consultations with a sleep MD and a dentist well-versed in oral sleep appliances would be indicated.”
Dr. Markus continues, “To get the process started, we need a prescription from their sleep doctor, or the results of a sleep study showing they are mild to moderate, because the last thing we want to do is jeopardize someone’s health because they haven’t tried CPAP.”
Equally important to diagnostic studies and treatment is follow-up, says Dr. Smith. “Follow-up sleep studies to assess the effectiveness of the appliance are the standard of care. An MD would not prescribe a drug for hypertension and then never take the patient’s blood pressure again. He would want to make sure the drug was serving the purpose, and was properly calibrated for the patient’s condition. This is no different with oral appliances used to treat snoring and sleep apnea.”
Dr. Smith stresses the importance of follow-up because, “There is a condition called ‘silent apnea’ characterized by someone who may stop snoring. But assuming the condition has been treated effectively simply because the snoring has ceased is a dangerous proposition.” The frequency of follow-up sleep studies depends on several things, says Dr. Smith, including “Severity of the disorder, availability of monitors and the curiosity of the patient or dentist. If the stars are aligned properly, and the first ambulatory study says the patient’s sleep apnea is abated, the patient is then sent for a full polysomnogram as a final assessment, which also proves success. However, often several intermediate studies are needed before the appliance has reached maximum clinical effectiveness.”
Stephen J. Markus, DMD Center for Dentistry, Haddon Heights, NJ
Kent Smith, DDS 21st Century Dental, Irving, Texas www.sleepdallas.com
One of the most common sleep disorders is insomnia and according to a recent report published in the Journal Sleep, it may be linked to sleep apnea. Researchers in Albuquerque interviewed 20 men and women with chronic insomnia, all of whom denied having any sleep breathing disorders. The researchers found that chronic insomniacs woke on average 30 times a night. Hypoxia or a brief drop in the volume of oxygen inhaled caused by a narrowed airway closely followed 90 percent of those interruptions.
In the study, sleep researchers asked participants about their causes of their nightly awakenings. Surprisingly, none of the participants mentioned breathing as a reason for their awakening. Of the most popular responses were racing minds, nightmares, a need for the bathroom and pain.
However, after analyzing their sleep, it became clear that their awakenings were triggered by a respiratory event. Each participant underwent a polysomnography test while spending a night at a sleep clinic. Using wired sensors that tracked brain waves and breathing, researchers and lab technicians were able to chart and monitor every awakening, when brain waves shifted to a waking state for at least 16 seconds, and every breathing issue causing oxygen intake to dip well below normal.
In the study, researchers separated hamsters into two groups: one group experienced a standard light/dark cycle, while the other group was exposed to a dim light at night—on par with city lights outside your window or the glow of a TV screen. After four weeks, hamsters who slept with some light showed signs of depression. (Depressed hamsters? Yup. Researchers tell by observing the rodents’ interest in sugar water.)
The reason? The sleep hormone melatonin helps brain neurons function properly. “But the brain can’t produce melatonin if it detects light,” says study author Tracy Bedrosian, a Ph.D. candidate in neuroscience at The Ohio State University. Hamsters exposed to light at night had less complex neurons in areas of the brain, such as the hippocampus, which is associated with mood. (Diagnose any major sleep problem at the brand-new Men’s Health Sleep Center.)
Human studies are needed to confirm the findings, but there’s enough research connecting nighttime light with disease that it’s a good idea to keep light dim when the sun goes down, Bedrosian says. Her advice: Install black-out curtains if there’s light outside your bedroom window and turn off your computer monitor and TV screen when you go to sleep
Sleep problems could run in families. In a 2007 study published in the journal Sleep, researchers found that out of 953 adults who said they were good sleepers, had insomnia symptoms or suffered from insomnia, about 35 percent of those with insomnia had a family history of insomnia. According to a 2008 study, teens with parents who have insomnia have an increased risk for using prescribed sleeping pills, and having mental problems.
Researchers looked at nearly 800 teens and found that, compared with teens whose parents had no insomnia problems, those with insomnia parents were more than twice more likely to report insomnia, daytime sleepiness, and pill use.
These teens were also more likely to develop depression, anxiety, and possibly consider suicide.
Other animals, such as bugs, can’t exactly complain of having insomnia, but some studies suggest animals suffer from sleep disorders just like humans.
In one study, researchers at Washington University School of Medicine in St. Louis bred insomniac flies, which only get a small fraction of the sleep of normal flies, and found they resembled people with insomnia in several ways.
After generations of breeding, researchers produced flies that spent only an hour a day asleep less than 10 percent of the 12 hours of sleep normal flies get.
These insomniac flies lost their balance more often, were slower learners and gained more fat all resembling symptoms that also occur in sleep-deprived humans.
If you’re having trouble waking up on Monday morning, you could have “social jet lag,” a habit of following a different sleep schedule on weekdays versus the weekend.
A recent study showed that people with different weekday and weekend sleep schedules were three more times likely to be overweight. Previous research has also linked increased weight with sleep deprivation and irregular sleep schedules.
Even an hour difference in the time you get up or go to bed can affect your sleep, said Colleen Carney, a sleep psychologist at Ryerson University in Canada.
We’re like toddlers who need a consistent schedule, Carney said.
The rate of sleeping pills use in the U.S. continue to rise, studies show.
One in four Americans take some type of medication every year to help them sleep, according to the National Sleep Foundation.
But these pills may not be leading to better sleep.
There’s no evidence that proves sleeping pills can cure insomnia, said Jack Edinger, a sleep specialist at National Jewish Health hospital in Colorado.
In fact, only cognitive behavioral therapy> (“talk therapy”) has been shown to work, Edinger said.
In a study published in February journal BMJ Open, researchers found that people taking prescribed sleep medications were almost five times more likely to die over the 2.5-year study, compared with those who didn’t take sleep medication.
Women are two times more likely to have insomnia than men, according to the National Sleep Foundation.
Experts speculate that the reason may have to do with women’s hormones. Sleepless nights and daytime sleepiness have been linked with hormonal changes in a women’s life, including pregnancy, menopause, and the menstrual cycle.
According to a National Sleep Foundation’s 1998 poll, almost 80 percent of women reported more disturbed sleep during pregnancy than at any other time.
For women experiencing menopause, when hormone levels are erratic, sleep problems are a common complaint.
But along with hormone changes, insomnia has also been linked with conditions such as anxiety, depression, problems breathing while asleep and restless legs syndrome.
Fatal familial insomnia is a rare genetic disease that prevents a person from falling asleep, eventually leading to death.
Experts have identified it as a prion disease, caused by an abnormal protein developing from a genetic mutation, which affects brain function, causing memory loss, no control over muscle movements and hallucinations.
In 1986, researchers writing in the New England Journal of Medicine reported a case of a 53-year old man who suffered from lack of sleep getting only two to three hours per night.
Two months later, he could sleep only one hour per night, and was frequently disturbed by vivid dreams. After three to six months, normal sleep became impossible, causing him severe fatigue, body tremors and breathing difficulty.
After eight months, he fell into a stupor and eventually died.
The researcher’s analysis of the family’s history revealed the man’s two sisters, and many of his relatives, also died of a similar disease.
People who drink alcohol to help them get to sleep could wind up developing a drinking problem, research suggests.
People use [alcohol] to self treat, Edinger said. Over time, you need more alcohol to help you sleep.
According to a 2001 study published in the American Journal of Psychiatry, researchers looked at 172 men and women being treated for alcohol dependence.
They found that participants with insomnia were about twice as likely to report using alcohol to sleep, compared with those without insomnia.
Attempting to self-medicate insomnia with alcohol, however, will ultimately worsen insomnia, the study authors said.
Moreover, people will likely persist in their drinking, even if the insomnia worsens, because a person’s drinking behavior is ingrained and reinforcing, and they feel desperate for sleep.
I would like to say that I have a definitive answer for that question, but as it turns out, the answer is: “It depends”. There is a plethora of research out there on the effects of melatonin, and most studies show it to have benefits even beyond helping you sleep. However, I will keep my comments related to sleep, as this is the reason most of you are taking (or have taken) melatonin.
First, let’s talk about dosage. This study, primarily among older patients, showed that .1 mgs, was too little, while the typical pharmacologic dose (3 mgs) is too much, so .3 mgs appears to be the best. Speaking of dosage, this study showed that even if you get a perfect dosage for yourself, after a few weeks, if you begin to lose the effects, you may need to actually decrease the dosage (I’m sure that won’t make sense to you, but play along with the research, OK?). Speaking of finding the best dosage for you, this study showed that everyone is different, as various psycho-somatic conditions might require different dosages.
Another consideration is the presence of other sleep disorders. For example, if you also have sleep apnea, there is little chance melatonin will help you, as is shown in this study. Oh, and if you are a rat (I am unaware of any rodents with the ability to read, so maybe this is a moot point), you might get constipated if you take melatonin.
Now to what really matters. According to the literature, just how helpful will melatonin be? A meta-analysis was done, looking at 15 past studies to get an average, and these were the conclusions:
Basically, there is considerable controversy out there, but MOST believe that there is no negative feedback (down-regulation) that will slow down endogenous melatonin production. That means that your own body won’t necessarily make LESS melatonin just because you are taking it by mouth. However, with the minimal effects it has when looking at 15 studies (in the meta-analysis), with the narrowed (and confusing) window of dosages in some populations and with the limited use when other issues are present, I am not sure I can ever suggest long term use of melatonin to my patients. I can support taking it for the short term, but if you really want to take it every night over a long period of time, please consult your physician, and I hope he or she has some knowledge in the area of sleep medications beyond what the pharmaceutical salespeople have taught them.
Kent Smith DDS, D-ABDSM
Q: I know that quite a few board certified sleep physicians send you patients who are CPAP non-compliant or don’t qualify for CPAP. How did you gain their trust? I can’t find any in my area who will send me these patients!
Dr. Smith: I send letters after seeing every sleep patient to the MD who diagnosed the sleep apnea, detailing everything I checked, my findings, treatment attempts, etc.. . If there is one common complaint I heard from the sleep physicians at Sleep 2009 in Seattle, it’s the fact dentists do not follow up with the sleep physician after they receive the patient. That is so sad, after the grief we give them for not involving dentists. If you are a dentist reading this, PLEASE keep the sleep physician in the loop!
Working out especially cardio improves the length and quality of your sleep. Yes, getting sweaty during the day can help your slumber that evening….just be sure to take a bath or shower before crawling under the covers!
In the National Sleep Foundation 2013 Sleep in America Poll, up to 83 percent of exercisers reported getting fairly good or very good sleep, while only 56 percent of non-exercisers did.
A study out of Appalachian state showed that if you exercised in the morning (7AM), you had increased sleep efficiency over those who exercised at 11AM. However, regardless of the time you exercise, you will sleep better than if you didn’t.
A recent Finnish study showed that even if you ride a stationary bike for 3 hours right before bed, even though your heart would be accelerated, you would go to sleep faster and sleep more deeply.
Another recent Sleep Medicine study showed that exercising 4 times per week can increase sleep time over an hour per night.
Another study showed that moderate exercise in the older population with a sedentary lifestyle significantly improved sleep quality. Yet another showed the same with our teenagers.
Research by Feinberg School of Medicine at Northwestern University found that aerobic exercise resulted in the most dramatic improvement in patients’ reported quality of sleep, including sleep duration, on middle-aged and older adults with a diagnosis of insomnia.
How does exercise help you sleep better? Exercise releases endorphins that can boost mood and reduce stress, depression, and anxiety.
Whether you visit the gym, use a home elliptical, or just go for a walk and walk the dog, exercise can help you clear your mind, reduce the stress in your life, and get a better night’s sleep.
Oh, and no, tossing and turning all night is not considered to be an acceptable form of exercise.