This post was written by one of our contributors; post-doctoral research fellow at Adelaide Institute of Sleep – Emma Wallace.
“Sleep is the single most effective thing we can do to reset our brain and body health each day – Mother Nature’s best effort yet at contra-death”
Matthew Walker: Why we sleep, unlocking the power of sleep and dreams
Sleep is vital for our health, as well as eating well and exercising regularly. However, as a society, we are spending less and less time in bed and the prevalence of sleep disorders is on the rise. According to the Great British Bedtime Report (1) 33% of individuals survive on less than seven hours sleep a night, and only 1% of individuals sleep more than 9 hours.
The consequences of this growing ‘sleep debt’ are concerning for our physical, emotional and cognitive health. Chronic sleep deprivation increases risk of cardiovascular disease, heart disease, diabetes, obesity, psychiatric illnesses and cognitive decline. Lack of sleep also costs the UK economy up to £40 billion a year due to higher mortality risk and lower productivity levels among the workforce (2).
Why are we so adverse to sleep?
There are a number of reasons for this growing ‘sleep debt’. The growing use of smart phones and technology is associated with poor ‘sleep hygiene’ (how many of us are guilty of drinking an extra coffee at 3 pm or scrolling through Instagram in bed when we should be sleeping?), our 24/7 society, work cultures (such as night shift workers) but in many cases, the cause of this ‘sleep debt’ can be more sinister and the symptom of an underlying sleep disorder.
Sleep disorders can be broadly classified into:
- Insomnias – meaning “sleepless”, or disorders resulting in an inability to sleep.
- Hypersomnias – disorders resulting in excessive day-time sleepiness.
- Circadian Rhythm Sleep Disorders – disorders that cause disruption of a typical sleep-wake cycle.
- Parasomnias – undesirable motor events during sleep, e.g. sleep walking, sleep terrors, nightmares.
Insomnia:
Insomnia is the most common sleep disorder, with a prevalence as high as 37% in the UK (4). Symptoms of insomnia include:
- Difficult falling asleep
- Difficult maintaining sleep
- Early morning awakening
To be diagnosed with insomnia (according to the DSM-V) these symptoms must occur three times a week, for at least three months. Difficulty sleeping must occur despite adequate time to sleep and sleep difficulties must cause significant distress or impairment in social, occupational, educational, academic, behavioural or other important areas of functioning.
Acute insomnia can be associated with an identifiable stressful situation (e.g. a school exam, a new job, bereavement). Many people will be familiar with this type of temporary sleep disruption. Removal of the stressor will generally resolve acute insomnia. Most cases of insomnia are chronic and are often associated with psychiatric disorders (such as anxiety, depression, eating disorders etc.). Up to 40% of insomnia sufferers have a coexisting psychiatric condition (5).
Consequences of Insomnia:
Insomnia has a range of adverse consequences, such as memory problems, poor performance at work, impaired concentration, moodiness, accidents caused by insufficient sleep, as well as health related problems associated with chronic sleep deprivation (e.g. cancer, cardiovascular diseases, diabetes).
“Inadequate sleep—even moderate reductions for just one week—disrupts blood sugar levels so profoundly that you would be classified as pre-diabetic.”
Matthew Walker: Why we Sleep, Unlocking the Power of Sleep and Dreams
Treatment for Insomnia:
Treatment for insomnia involves a combination of behavioural and pharmacological interventions due to the complexity of the disorder. Treatment for insomnia typically begins with attempts to eliminate any contributing factors or illnesses that prevent optimal sleep (e.g. poor sleep hygiene, substance abuse, medical conditions, psychiatric illnesses), followed by behavioural counselling and stimulus control. Pharmacological treatment may be used for patients who continue to have burdensome insomnia.
- Non-pharmacological treatments
Cognitive behavioural therapy – psychotherapy aimed at changing beliefs and attitudes about sleep and insomnia (e.g. unrealistic sleep expectations, fear of sleeping, negative connotations about the bedroom). This is the preferred first-line treatment for chronic insomnia.
Sleep hygiene education – general guidelines about health practices (e.g. diet exercise, alcohol intake) and environmental factors (e.g. light, noise temperature) that promote sleep.
Stimulus control – a set of instructions to establish a consistent sleep-wake schedule: go to bed only when sleepy, get out of bed when unable to sleep, use the bedroom for sleep only (no reading, TV, phone), get up at same time every day, and no napping.
- Pharmacological treatments
hypnotics – such as benzodiazepines (BZDs), zopiclone, zolpidem, zaleplon will induce ‘sleep’, but the state of sleep is not natural sleep (more like a sedation). Pharmacological treatment are not long-term solutions for insomnia and provide short-term relief of symptoms. There are a number of risk factors of frequent sleeping pill use including rebound insomnia, amnesia, dizziness, depression, impaired intellectual functioning, dry mouth, drowsiness. Sleeping pills are also associated with a shortened life-span and cancer (6).
Hypersomnia
Falling sleep reading a book, in a conversation with a friend, at the wheel of a car or constantly waking up feeling unrefreshed to a point that it interferes with everyday life are the hallmark signs of hypersomnia, or excessive daytime sleepiness. In the absence of a primary medical/psychological condition (e.g. neurological disorder, mental health disorder, metabolic disorder, endocrine disorder), or poor sleep hygiene, the most common cause of hypersomnia is obstructive sleep apnea (OSA), which is a sleep related breathing disorder.
The Epworth Sleepiness Scale is a common clinical tool to identify individuals with excessive daytime sleepiness. A score of > 10 on the following 8 questions indicates excessive daytime sleepiness.
Epworth Sleepiness Scale:
| SITUATION | CHANCE OF DOZING (0-3) |
| Sitting and reading | |
| Watching TV | |
| Sitting, inactive in a public place (e.g theatre or a meeting | |
| As a passenger in a car for an hour without a break | |
| Lying down to rest in the afternoon when circumstances permit | |
| Sitting and talking to someone | |
| Sitting quietly after a lunch without alcohol | |
| In a car while stopped for a few minutes in traffic |
*please note: this is not a diagnostic test and is used only as a screening tool
Instructions:
How likely are you to dose off in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times.
0 = would never doze off
1 = slight chance of dozing off
2 = moderate chance of dozing off
3 = severe chance of dozing off
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is a growing epidemic, effecting 1.5 million people in the UK and almost 1 billion people worldwide. OSA is when the airway repeatedly closes or narrows during sleep, causing a person to stop breathing. This can happen hundreds of times in a single night. The reasons for why the airway closes during sleep are not fully understood and more research is desperately needed in this field. Over-weight males are at higher risk of sleep apnea, but sleep apnea can effect anyone, including children.
Worryingly, up to 80% of people with sleep apnea are undiagnosed and untreated (7). These individuals are at risk of cardiovascular diseases (e.g. stroke, coronary heart disease), weight gain, increases in blood pressure, memory impairment and fatal road traffic accidents or work related accidents due to severe, chronic fatigue.
Signs and Symptoms of OSA:
- Excessive daytime sleepiness
- Chronic fatigue
- Un-restorative sleep
- Reports of snoring, choking, gasping sounds in sleep
- Frequent night-time urination
“It is disquieting to learn that vehicular accidents caused by drowsy driving exceed those caused by alcohol and drugs combined.”
Matthew Walker: Why we Sleep, Unlocking the Power of Sleep and Dreams
Treatment for OSA
Treatment for OSA represents an ongoing challenge. This is primarily because the reason for repeated airway closure and narrowing during sleep are still not fully understood. Some common treatments are outlined below, but more research is desperately needed in this field.
- Continuous positive airway pressure (CPAP) is a commonly used treatment for OSA. It involves individuals wearing a face mask that supplies positive pressure to the airway to keep it open and prevent it from collapsing during sleep. The problem with CPAP is that it is poorly tolerated by many individuals.
- Mandibular Advancement Splint: a custom made device that advances the jaw to increase the size of the upper airway for individuals with a small, or ‘collapsible’ airway. This treatment can be very expensive, and often unsuccessful at resolving sleep apnea.
- Surgery: In children, removal of tonsils and adenoids can resolve sleep apnea symptoms. Surgery in adults (e.g. removal of some of the soft palate) can present risks for swallowing and speech.
- Weight loss can be effective in reducing the severity of OSA. However, despite the stereotype, not all patients with OSA are overweight.
Circadian Rhythm Sleep Disorders
Modern day society has given rise to circadian rhythm sleep disorders, such as shift work disorder and jet lag. We don’t typically associate these as sleep disorders. However, they are associated with chronic societal ‘sleep dept’.
“Humans are not sleeping the way nature intended. The number of sleep bouts, the duration of sleep, and when sleep occurs has all been comprehensively distorted by modernity.”
Matthew Walker: Why we Sleep, Unlocking the power of Sleep and Dreams
Shift work disorder
Health-care workers, emergency workers (e.g. police, fire-fighters), the army, transport workers will be familiar with the perils of shift work disorder. The medical profession historically prided themselves on sleep deprivation. However, according to a study, over 100 thousand deaths can be attributed to medical errors due to sleep deprivation, suggesting this mindset needs to change (8).
In 2007, the World Health Organisation classified night shift work as a carcinogen due to the circadian disruption. Shift work causes disruption to the sleep-wake cycle, body temperature rhythm and hormone rhythm, with the hormone rhythm taking the longest to recover (up to 3 weeks). Shift workers also experience extreme sleep deprivation for a number of reasons:
- Differences in the quantity and quality of sleep due to sleeping during the day-time (e.g. differences in REM and non-REM sleep patterns)
- Environmental reasons such as light, noise, temperature, and social events that prevent daytime sleep.
- Societal and family commitments that prevent daytime sleep.
Managing shift work:
While shift work cannot necessarily be avoided, there are strategies you can put in place to minimise the effects of shift work and maximise the duration and quality of your sleep.
- Go to bed immediately after your shift to avoid becoming more awake.
- Have a light meal (something high in protein, e.g. oats and yogurt) before you go to sleep so you don’t wake up because of hunger pangs.
- Avoid alcohol – it will diminish sleep quality and leave you feeling unrefreshed (even if you get adequate sleep time).
- Avoid smoking – nicotine is a stimulant.
- Avoid caffeine – also a stimulant.
- Make your room cool, dark and quiet.
- Advise you family and close friends of you working schedule so you are less likely to be disturbed.
Jet Lag Syndrome
The number of travellers taking long distance flights for professional or recreational reasons every year is growing. Most travellers and flight attendants are effected by jet lag syndrome, caused by rapidly changing time-zones. The features of jet-lag can be variable and can depend on the number of time zones crossed the direction of travel (eastbound flights are
associated with more severe jet-lag than westbound as they shorten the day, causing a phase advance), departure and arrival times, and individual factors.
Signs and symptoms of jet lag:
- Mood disorder, irritability
- Increased anxiety
- Depressive symptoms
- A drop in cognitive performance
- A drop in sports performance
- Gastro-intestinal disturbances (i.e. diarrhoea, constipation)
Management of jet lag:
- Caffeine – effective for maintaining adequate levels of day time wakefulness with no adverse effects.
- Phototherapy – artificial light can have positive effects in synchronising the circadian rhythm. There are a number of evidence-based products (e.g. re-timer glasses: https://www.re-timer.com/) that draw on phototherapy research to enhance sleep for circadian rhythm sleep disorders.
- Pre-synchronisation – modifying your sleep pattern for a few days before you fly (e.g. going to bed and getting up an hour earlier for an eastbound flight, or delaying it for a westbound flight) may alleviate some jet lag symptoms.
- Immediately adapting to time-zone on arrival – avoid naps, especially at inappropriate times (e.g. late in the afternoon).
- Pharmacological treatments – hypnotics can induce periods of “sleep” (more accurately sedation) during a flight or after a flight. However, these can have negative side effects as described above.
- Melatonin – is a sleep hormone that is produced naturally in our bodies. It can also be taken as a pill. In the UK and Australia, melatonin requires a doctor’s prescription, but melatonin is available over the counter in the US. Melatonin needs to be taken at the correct time of day for the correct time zone (e.g. for an eastbound flight, melatonin must be taken late in the afternoon on the day of departure and for the 4 following days at bedtime, local time). Routine use of melatonin should be avoided, as it may have negative effects on hormones and reproductive processes (9).
Parasomnias
The final category of sleep disorders are parasomnias, which refer to unusual motor behaviours during sleep. Types of parasomnias include:
- sleep walking
- sleep talking
- sleep terrors
- nightmares
- sleep paralysis
Parasomnias are often present in childhood, but can persist into adulthood. They represent complex behavioural/cognitive events that can occur intermittently or episodically during sleep.
Treatment for frequent parasomnias:
- In general, parasomnias do not require treatment, unless they are very frequent and severe.
- Protection of the individual – removal of dangerous objects, putting the mattress on the floor, covering windows with curtains, locking windows and doors.
- Avoid intense physical exercise before bed.
- Pharmacological treatment may be warranted in very severe cases.
What to do if you suspect you have a sleep disorder?
Speak to your GP
According to the Great British Bedtime Report, only 1 in 10 people reported consulting their GP about sleeping poorly, while 31% have taken medication to relieve a sleep problem. Sleeping pills are not long term solutions for a
sleep disorder. Consult your GP if you are concerned about your sleep.
Keep a sleep diary
Record your sleep-wake time, potential triggers of poor sleep and your bedtime routine. If you have a bed-partner – ask them about your breathing during sleep (e.g. do you snore, hold your breath, gasp during the night), or set up an audio recording on your phone to monitor yourself. This can be good information for your GP.
Practice good sleep hygiene
Monitor your caffeine intake, avoid exercising before bed, monitor alcohol intake, maintain a regular sleep-wake pattern (e.g. avoid sleep deprivation during the week and playing ‘catch up’ at the weekend).
Where to get further help:
The Sleep Council UK
https://sleepcouncil.org.uk/
The National Sleep Foundation
https://www.sleepfoundation.org/
British Sleep Society (for health care professionals)
https://www.sleepsociety.org.uk/
Matthew Walker: Why We Sleep, Unlocking the power of Sleep and Dreams
A highly recommended book on the importance of sleep and sleep practices: https://www.penguin.co.uk/books/295/295665/why-we-sleep/9780141983769.html
References
(1) The Sleep Council, The Great British Bedtime Report, 2013, Retrieved from: https://sleepcouncil.org.uk/wp-content/uploads/2018/04/The-Great-British-Bedtime-Report-2017.pdf
(2) Hafner et al (2016). Why Sleep Matters, The economic cost of insufficient sleep: A cross-country comparative analysis. Retrieved from: https://www.rand.org/pubs/research_reports/RR1791.html.
(3) Functional and Economic Impact of Sleep Loss and Sleep Related Disorders, National Centre for Biotechnology. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK19958/
(4) Morphy, H., et al., Epidemiology of insomnia: a longitudinal study in a UK population. Sleep, 2007. 30(3): p. 274-80.
(5) Ford, D.E. and D.B. Kamerow, Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? Jama, 1989. 262(11): p. 1479-84.
(6) Sivertsen, B., et al., Use of sleep medications and risk of cancer: a matched case-control study. Sleep Med, 2015. 16(12): p. 1552-5.
(7) Ho, M.L. and S.D. Brass, Obstructive sleep apnea. Neurology international, 2011. 3(3): p. e15-e15.
(8) Kramer, M., Sleep loss in resident physicians: the cause of medical errors? Frontiers in neurology, 2010. 1: p. 128-128.
(9) Lampiao F, Du Plessis SS. New Developments of the effect of melatonin on reproduction. World J Obstet Gynecol, 2013; 2(2): 8-15.
