Sleep Disorder

Normal Sleep :

There is no definition for the normal sleep. However, in general, sleep is considered normal when:
• You get the sleep easily after going to bed
• Sleep is largely maintained for the whole night
• You wake up fresh in the morning
• You are able to follow a sleep schedule
• You don't have frequent awakenings in the night
• You do not feel sleepy during the day
• You do not show any behavior such as talk, walk, or make any other movements during sleep

INSOMNIA:
What is insomnia?
Insomnia can be understood as absence of normal sleep. If you are not able to sleep, or your sleep disrupts frequently, or you wake up earlier than your usual time in the morning, you are suffering from insomnia. Another feature of insomnia is lack of refreshing sleep despite adequate duration.

How common is this problem?
Data for the Indian population is limited but available scientific literature around the world suggests that approximately 15% people suffer from insomnia at a given time.
Only Indian study conducted by Gupta et al (Indian Pediatrics, 2008) in adolescents show that sleep problems (not exactly the insomnia) are common during adolescence and it increases with the increment of the grades. In this study nearly half of the adolescents had symptoms suggestive of insomnia.

Who suffers from insomnia?
Although nobody is immune to develop insomnia, but elderly persons and females are especially prone to develop the insomnia. In the presence of any triggering event they catch this illness more easily than others. Most of the time triggering event is subtle and often go unnoticed.

What causes this problem?
There are a number of reasons that contribute to the development of insomnia. The causative factors are not mutually exclusive and most of the times they are present together to compound the diagnostic and therapeutic exercises. For better understanding we can divide them as follows:
• Environmental Factors: extremes of temperature, overcrowded room, mosquitoes, noisy surroundings, poor ventilation, bright lighting
• Medical Disorders: pain anywhere in the body, difficulty breathing in lying down situation, certain brain tumors
• Psychiatric illnesses: depression, stress, anxiety, psychotic episode, effect of substances of abuse e.g. alcohol, cannabis etc
• Primary Insomnia: Idiopathic insomnia, sleep state misperceptions, psycho-physiological insomnia, Poor sleep hygeine etc.
These factors not only induce the insomnia, but also perpetuates the problem. Hence, their identification is very important.

How do you diagnose the problem?
Most of the time history provided by the patient and his bed partner is sufficient for the diagnosis. To uncover the whole information sometimes more than one meetings are necessary. You may be asked to fill a sleep-log before final management plan to find out the gravity of the problem.
Sleep study (polysomnography) is usually not recommended and not helpful in the diagnosis of these cases except in selected cases.

How to combat it?
Fighting with insomnia is the joint work of sleep-specialist and the patient. Both must be willing and committed to diagnose the underlying problem and treat it. Sometimes, what your physician suggests may not appeal to you, but you must talk to him more about your queries and fears at that time only, to help yourself.
Always remember, pills are good for transient insomnia but they are not the answer to chronic insomnia. Rather change in environmental, cognitive and behavioral factors are more useful in such cases. In cases of secondary insomnia, mainstay of therapy is treatment of underlying disorder.

Can I prevent occurrence of this disease?
Yes, you can. Most of people pop-up sleeping pills or alcohol when they do not get the sleep. Long term use (more than few days) of these agents actually aggravates the problem by disrupting your natural sleep. In our opinion, best step is to avoid the behaviors that may induce or augment the sleep problem. Sleep promoting behaviors are (also known as good sleep hygiene) are helpful not only during therapy but also for prevention of insomnia. What should you do and what should you avoid is mentioned in the following table:

Do s	Don’t s
Maintain a regular sleep-wake schedule	Do not take caffeinated beverages/ coffee/ tea before four hours of bed
Should take adequate amount of food before going to bed	Do not indulge in heavy exercise before going to bed
Indulge in physical exercises during the day	Avoid daytime sleeping/ frequent naps
Take balanced diet	Surrounding environment should not be crowded, very cold or hot, noisy etc.
Go to bed only when sleepy	Avoid alcohol close to bedtime
Always leave the bed at the same time in the morning	Avoid doing your work in the bed
	Should not be hungry or do not eat too much in the dinner
	Do not watch TV while in bed

NARCOLEPSY:
What is narcolepsy?
This is ne of those sleep disorders where sleep is increased in amount. The affected person gets the irresistible sleep during the day at unusual locations. Other symptoms of disorder are disturbed sleep in the night, sleep-paralysis, cataplexy or loss of body muscle tone (appears as sudden fall) with emotional excitement, hallucinations while going to sleep or waking up.

How prevalent is this disorder?
Data for the Indian population is not available. But pooled literature suggests that it may be found in 14/million people.

Who suffers from narcolepsy?
Narcolepsy is common disorder in children and adolescents. Once developed it persists throughout life in absence of therapy.

Why does it occur?
This disorder is related to the problem with REM sleep generating apparatus in the brain. Biochemically, it is related to the deficiency of hypocretin in the hypothalamus, although exact pathophysiology is still unknown. Though most cases are spordiac but persons who share the gene pool of a narcolepsy patient are prone to have it. But genetic factors are neither necessary nor sufficient to develop the narcolepsy.

Is it dangerous?
Yes, it may be! Patients have episodes of irresistible sleep while driving, operating machinery or while studying etc., for minutes to hours. More often it causes socially embarrassment and among children this disorder is a frequent cause of poor academic achievements.

How do you diagnose it?
An adequate history often provides the complete information. But sometimes objective evidences are necessary and patient has to undergo MSLT (Multiple Sleep Latency Test) or MWT (Maintenance of Wakefulness Test).

Is it treatable?
Yes! Now we have a number of drugs that may induce complete remission. However, these drugs are to be taken for a prolonged period.

RESTLESS LEG SYDORME:

What is restless leg syndorme?
Restless leg syndrome is characterized by
• unpleasant sensations in the legs
• a strong desire to move the legs
• feeling worsen with the inactivity
• improves with leg movement or engaging in other metal tasks e.g., arguments, discussion
• increases in severity during the evening or night.
In some patients, this sensation is totally absent during the day. During the symptomatic period, if the patients are not allowed to move their legs, they develop intense anxiety. Few patients do not have sensory symptoms in the legs at all, but they are not able to sit without making any movement when not engaged in any activity.

Who are prone to this disorder ?
This is common in the females, usually after the age of 40 years. However, sometimes it may develop during adolescence or early adulthood, but in these cases usually a family history of similar problem is often found.
Certain states e.g., iron deficiency anemia, pregnancy, chronic renal failure etc. may precipitate this condition.

Does it require any testing?
Usually history alone is sufficient for the diagnosis. In some cases where the diagnosis is in doubt SIT test may be recommended. It also provides a measure of gravity of the problem. In addition, certain blood tests may also be ordered to uncover the disorder.

Is it treatable?
Yes, it is. Now we have a number of drugs that are helpful in management of primary RLS. However, patient’s compliance is very important as they are usually prescribed for long duration.
Secondary RLS may not require the drugs that are used for the treatment of primary form and adequate management of underlying illness offers good relief.

SLEEP APNOEA:
What is sleep apnoea?
Sleep apnoea is a sleep disorder where the breathing decreases or ceases for few seconds repeatedly during the sleep resulting in reduction of oxygen saturation in the body.

How prevalent is it?
Epidemiological data for India are not avaialble. However, according to Western literature, its prevalence is approximately 5%.

What are the risk factors for sleep apnoea?
It is more common in males, obese persons especially with truncal obesity, having small lower jaw (retrognathia), large tongue, and crowded oro-nasopharynx (tonsillitis etc.) Prevalence increases with advancing age. In addition, lessening of the muscle tone of pharynx (as occurs in myopathies and bulbar polio), blocked nose (deviated nasal septum, chronic rhinitis or any mass in the nose),restricted chest movements (as in COPD, restrictive
lung diseases), heart failure, diaphragmatic paralysis contribute to sleep apnea. Positive family history increases the chances of apnea. Risk increases further with increase in the number of affected family members. All kind of hypnotics e.g., alcohol and sleeping pills increase the risk of apnea.

How many types of sleep apnea are known?
It is of two types- Obstructive sleep apnea (OSA) and Central Sleep Apnea (CSA). Most of the time, patients have elements of both. OSA occurs due to the obstruction in the respiratory passage and CSA due to problems in the neural supply of ventilatory apparatus.

What are the common symptoms of sleep apnea?
Snoring is the most common symptom. Besides snoring, multiple awakenings during night (mostly micro-arousals), excessive daytime sleepiness, poor concentration, morning headaches, systemic and pulmonary hypertension, memory problems, nocturnal drooling, dryness of mouth, increases frequency of micturition during night, unusual limb movements, daytime fatigue etc. are common.

How to diagnose the sleep apnea?
Besides clinical history, whole night polysomnography is the gold standard technique for the diagnosis of apnea. However, American Academy of Sleep Medicine prescribes a caution against automated scoring and emphasizes that all repots should be read by a specialist manually.

Is this disorder dangerous?
Yes it is. Besides fatigue, poor memory, indecision, and daytime sleepiness induced problems (accidents, limitations in all activities) this disorder affects your heart to a large extent. Reports suggest that this disorder leads to treatment refractory hypertension, heart failure, heart-attacks, pulmonary hypertension and metabolic syndrome.

How is it treated?
This disorder is treated by two-techniques. Most importantly, underlying problems must be addressed (either medically or through surgery). When the underlying problems can not be dealt through these measures, positive pressure ventilation (CPAP or BiPAP) is instituted. However, this therapy is not suitable for everybody and subject selection is very important.