Dear Dr. B: What is insomnia and how much sleep do I need to stay healthy?

Answer: Insomnia is defined as chronic inability to fall asleep or remain asleep for an adequate length of time.

It is estimated that 10 to 40 per cent of people suffer from some sort of insomnia. This is only an estimate as nobody has yet defined what constitutes normal sleep.

Most adults sleep seven to eight hours a night. Newborns and children may sleep up to 16 hours a day. Older people may sleep only six hours a night. There is no magic number. If you are tired the next day or are yawning all the time then you need more sleep.

The quality of sleep you get is also important. The quality and quantity of sleep depend on many factors like your health, your lifestyle and your environment.

In a survey done in the United States, it was found that many patients with insomnia have other medical problems. Thirty per cent of the patients have depression, 20 per cent have other mental disorders, and 19 per cent have other illnesses. But 31 per cent of the patients have primary insomnia (i.e. they have no medical condition contributing to insomnia).

Sometimes insomnia may be the first symptom of depression.

“The prevalence of insomnia has also been reported to be higher in women, women in minority groups, people who are unemployed or separated, lower socioeconomic groups and in those with medical or psychiatric (particularly substance abuse) disorders,” says an article in the Canadian Medical Association Journal.

Workaholics spend many sleepless nights to accomplish their tasks. They ask, “Why do we need to sleep?”

I have experienced this first hand when I used to be surgeon-on-call, sometimes several nights in row. I never thought I needed more than four to five hours of sleep. My ego was driven by the amount of work I did. I did not have insomnia. But I thought I did not need too much sleep. My adrenaline level was pretty high.

Now I realize sleep is important. Not only the quantity but the quality of sleep is important. Experts say we need sleep to rest. Sleep allows the brain and the body to recover and restore itself. So we can be fresh for the next task.

It is very important that you consult your doctor if you have trouble falling asleep or cannot remain asleep for an adequate length of time. The cause of your insomnia could be stress, depression, anxiety, panic attacks, spastic bladder, arthritis, hyperthyroidism, congestive heart failure, obstructive sleep apnea, or lung disease. You may be overindulging in caffeine or alcohol. Or there may some other cause.

Your physician can help you sort some of these problems by recommending regular daytime exercise, avoiding large meals at night, avoiding caffeine, tobacco and alcohol; reducing evening fluid intake; maintaining a consistent wake-up time; avoiding or limiting daytime napping and avoiding bright lights (including television), noise and temperature extremes. In some circumstances he may recommend medications.

So, if you have insomnia, do not panic. Talk to your doctor.

Jokes for the week:

Why did the University of Calgary researcher stay awake every night?
He was trying to find a cure for insomnia!

Doctor, Doctor, with all the excitement of spring I can not sleep.
Try lying on the edge of your bed…you’ll soon drop off!

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Restless Leg Syndrome

Dear Dr. B: My mother-in-law is 60 years old. She is quite healthy. But she is having cramps in her legs. From the toes to the side of her legs, inside and up to her hips. What can she do to relieve this pain?

A concerned daughter-in law sent me this question. It is not an uncommon complaint among women and some men. My own mother has had a similar complaint for many years.

So, I was quite interested in a recent issue of the New England Journal of Medicine (NEJM) which had a clinical practice article called Restless Legs Syndrome (RLS).

The article gives an example of a 45-year-old woman having had nightly insomnia for years. She reports having uncomfortable sensations in her legs when she lies down at night. She describes a feeling of needing to move her legs, which is relieved only by getting up and walking around.

This lady has RLS. It is also known as Ekbom’s syndrome. It is a neurological disorder. About three to 15 per cent of the population is affected. It is more common in women than men. The prevalence increases with age. There may be a family history of the condition.

The following features should be present to make a diagnosis of RLS:
-A distressing need or urge to move the legs, usually accompanied by an uncomfortable, deep-seated sensation in the legs that is brought on by rest (sitting or lying down), relieved with moving or walking, or worse at night or in the evening.
-Features frequently associated with the syndrome are: involuntary limb movements while patient is awake and/or periodic limb movements while patient is asleep.

The diagnosis of RLS is based on the clinical history. RLS may be a symptom of iron deficiency therefore the iron status should be assessed. No other laboratory tests are routinely indicated.

What about our reader’s mother-in-law?

She may have RLS – but we do not know all her symptoms. There are many other conditions which cause leg pains and cramps especially at the end of the day or at night.

Some common causes are: muscle fatigue, strain, injury, or depletion of certain minerals such as potassium, calcium, sodium, and magnesium (particularly when taking diuretics). Trouble with the veins and arteries; arthritis or gout; neuropathy (nerve damage) or Sciatic nerve pain (radiating pain down the leg) caused by a slipped disk in the back. There may be other causes as well. Medications like steroids can induce leg pain.

The article says that despite the distinctive clinical features of RLS, there remains substantial variability in responses to treatment and in clinical progression and outcome.

It seems all patients with RLS do not present with classical symptoms. Therefore, my impression is, many patients with leg pain go undiagnosed or inadequately treated.

Is there good treatment for the condition?

For RLS, there are few medications in the market. But the NEJM article says that there is currently inadequate information on the efficacy of medications other than the group of drugs known as dopaminergic drugs. The management of RLS in patients who are pregnant or undergoing dialysis is not clear.

For unexplained leg pain, rest as much as possible. Elevate the leg and take pain medications which you are familiar with. Gentle massage may improve comfort. Heat or cool soaks may help. If pain persists or swelling develops, see your family physician.

For leg pain caused by varicose veins, leg elevation and compression with elastic bandages or support hose can help. Walking is the best way to keep the blood flowing back to the heart from the legs.

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Surgery for Snoring

Surgery for snoring – is it available in Medicine Hat?

Yes, it is done by Dr. Neil Harris, ear, nose and throat surgeon (Otolaryngologist). I asked him about his approach to patients who snore. This is his response:

Hi Noorali:

My approach to the management of sleep apnea and snoring is to first get a detailed history of the patient’s problem. This includes general health, daytime activity, daytime nasal obstruction, hours of sleep, frequency and severity of snoring, and frequency and duration of any witnessed breath-holding spells.

General health considerations include fatigue, excessive drowsiness, hypertension, obesity, any respiratory or cardiac illness and smoking.

It is also important to assess how disruptive the patient’s problem is on family members. Severe snorers tend to become hypertensive so treatment is not only for the benefit of the spouse or family.

Medications, alcohol consumption, and dietary considerations are important. If weight is contributing to snoring and apnea, weight management is discussed.

If true obstructive or central sleep apnea is suspected on the basis of the history, then the patient should be referred for sleep lab testing. If the results confirm sleep apnea then the patient should try CPAP. Surgical treatment for sleep apnea is also an option but surgery works better for snoring without significant apnea.

Most patients with poor sleep, fatigue, and daytime drowsiness are simple snorers and these patients generally do very well with surgical treatment.

Patients are advised before surgery that swallowing will be different for a short while after surgery and few patients have temporary nasopharyngeal reflux, or regurgitation of fluids into the back of the nose if they drink too fast. This has never been a permanent problem for anyone.

Most patients have no trouble at all. Also it is explained that the procedure is not a guarantee that the patient will not make any more noise when sleeping or that snoring will be eliminated forever.

Snoring can return as aging causes further laxity of throat tissues.

The operation is called uvulopalatopharyngoplasty or just pharyngoplasty, and takes about fifteen minutes. It can be done by laser with only local anaesthesia or under general anaesthetic in the operating room using electrocautery. The actual technique is similar with either method. I prefer to do the surgery with the patient asleep to ensure careful trimming of lax tissue and placement of dissolving sutures.

The rim of the soft palate is injected with local anaesthesia and steroid to prevent post-operative pain and swelling. The mucosal rim of the soft palate, the uvula and the part of the posterior tonsillar pillars are trimmed, and sutures are placed, leaving a smooth arch at the back of the throat.

The patient is routinely discharged from hospital on the day of surgery, with a prescription for a liquid antibiotic to prevent infection and a liquid analgesic.

When patients return for follow-up in about three weeks most are pleased with the results. They generally have longer periods of deep, restful and quiet sleep. They wake easier and have greater daytime energy and stamina.

Many have told me that their mood has improved. Some have been able to discontinue blood pressure medicine. Spouses sleep better, too. The results are not quite as good in true obstructive apnea but surgery can still be done in addition to the use of CPAP or if CPAP cannot be tolerated. Central apnea should be managed medically.

Pharyngoplasty is an easy, safe and effective operation. In properly selected patients it significantly improves the quality of life.

Noorali, I hope this information will be useful to readers of your column.

Neil Harris

This is the third column dedicated to the subject of snoring and sleep apnea. I hope after this people will get help and sleep in silence and keep their spouses happy. Good luck and sweet dreams!

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Sleep Apnea

Dear Dr. B: I snore and my doctor says I have obstructive sleep apnea. Can you please tell me more about this? Yours, Mr. Snorer.

Dear Mr. Snorer: Normally, breathing is regular. Apnea means cessation of breathing. Sleep apnea is a condition that interrupts breathing during sleep.

Sleep apnea may be central – that is due to instability of the feedback system that regulates breathing. Or sleep apnea may be obstructive – due to recurrent obstruction of the upper airway. Or it can be mixed – central followed by obstructive.

Today, we will confine our discussion to obstructive sleep apnea.

Obstructive sleep apnea affects two percent of women and four percent of men. It is a condition of middle-aged adults.

A typical individual with obstructive sleep apnea starts snoring shortly after going to sleep. The snoring proceeds at a regular pace for a period of time, often becoming louder, but is then interrupted by a long silent period during which no breathing is taking place (apnea). The apnea is then interrupted by a loud snort and gasp and the snoring returns to its regular pace. This behaviour may recur repetitively and frequently throughout the night.

Obstructive sleep apnea causes frequent night awakening, feeling of tiredness in the morning, abnormal daytime sleepiness, headaches, memory loss, poor judgement, personality changes and lethargy. It may also raise the blood pressure.

Who suffers from obstructive sleep apnea?

Obstructive sleep apnea occurs most frequently in obese middle-aged men. Contributing factors may include use of alcohol or sedatives before sleep, anatomically narrowed airways, and massively enlarged tonsils and adenoids. Genetic and environmental factors may also adversely affect airway size. The condition may run in some families.

Diagnosis of sleep apnea is made by sleep studies. One article on this subject says that a sleep study should be strongly considered for two groups of patients: those who habitually snore and report daytime sleepiness, and those who habitually snore and have observed apnea (regardless of daytime symptoms).

Are there any medical or physical side effects to obstructive sleep apnea?

Once upon a time, sleep apnea was thought to imply poor prognosis. It was thought to arise from the diseases of the brain and heart. It is now known that periodic breathing generally occurs during sleep. That it may occur in healthy persons.

During periodic breathing, there is change in the partial pressure of carbon dioxide and oxygen in the blood and this results in the fluctuation of heart rate (with irregular rhythm) and blood pressure and in the autonomic nervous system. Heart failure, heart attack and stroke are other likely complications.

Chronic sleep deprivation caused by sleep apnea increases risk for motor vehicle accidents. The accident rate for such patients has been reported to be seven times that of the general driving population.

Does obstructive sleep apnea really damage our health?

In 1997, a review article in the British Medical Journal evaluated all studies published between 1966 and 1995 on the association between obstructive sleep apnoea and mortality and morbidity, and on the efficacy of nasal continuous positive airways pressure. The authors concluded that there was limited evidence of increased mortality or morbidity in patients with obstructive sleep apnea.

They also concluded that the evidence linking the condition to cardiac irregular rhythm, coronary artery disease, heart failure, high blood pressure, pulmonary hypertension, stroke, and automobile accidents was conflicting and inconclusive. They concluded, that there were insufficient data to determine its effect on quality of life, morbidity, or mortality.

So, is there a need to do anything about snoring and obstructive sleep apnea? Well, Mr. Snorer, stay tuned for an answer next time!

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