Sleep Disorders

The amount of sleep needed each night varies from person to person, but most healthy men need 8 to 81/2 hours of sleep per night to be fully alert during the day. If a man does not get enough sleep—even for one night—he may experience drowsiness that disrupts his daily routine.

Certain medical conditions and drugs also can interrupt sleep and cause daytime drowsiness. Problems such as asthma (see page 245), congestive heart failure (see page 233), and rheumatoid arthritis (see page 309) or any other painful condition can keep you from getting a good night's sleep. Medication used to treat high blood pressure or heart disease, and asthma medications such as theophylline, also can interfere with sleep. Alcohol can help you to fall asleep but causes sleep disruption later in the night and can produce early morning headaches. The sedative effects of alcohol also can put you at increased risk for motor vehicle collisions if you drink and drive. Caffeine, which stays in the body for 3 to 7 hours after ingestion, makes it harder to fall asleep and stay asleep. The nicotine in cigarettes and nicotine patches is a stimulant that also can disrupt sleep.

Many men who work the night shift have difficulty sleeping. Most night-shift workers get less sleep overall than day workers. The human sleep-wake cycle is designed to prepare the body for sleep at night and wakefulness during the day. These natural rhythms make it harder for a person to sleep during the day and to work at night. In addition, lights, noise (such as from telephones), and family members can be annoying distractions that disrupt daytime sleep.

If you have problem with sleepiness, monitor your sleep-wake patterns. If you are consistently getting fewer than 8 hours of sleep per night, try to get more sleep by gradually moving to an earlier bedtime. If your schedule does not permit you to go to bed earlier, try to squeeze in a 30- to 60-minute daily nap. If you are sleepy, do not drive; sleepiness will increase your risk of having a collision.

If you think you are getting enough sleep but still feel sleepy during the day, you may have a sleep disorder. Talk to your doctor, who can evaluate your symp- 355

toms and prescribe appropriate treatment. Mental

Some men have medically recognized sleep disorders. The most common sleep Dis°rders disorders are insomnia, sleep apnea, narcolepsy, and restless legs syndrome.


Most people need a full 8 hours of sleep, while some can function well with less. Many people, however, are unsatisfied with the amount of sleep they get. Insomnia refers to inadequate or poor-quality sleep, usually the result of difficulty falling asleep, frequent waking during the night, or rising too early in the morning. Once the person wakes during the night or early in the morning, he or she has difficulty going back to sleep. Insomnia can cause fatigue, lack of energy, difficulty concentrating, and irritability.

Insomnia that lasts only a few weeks or less is called transient insomnia. If episodes of insomnia occur from time to time, the problem is called intermittent insomnia. Insomnia that occurs on most nights and lasts a month or longer is called chronic insomnia.

Factors that may contribute to insomnia include being older and having a history of depression (see page 345). Although insomnia occurs in men and women of all ages, it seems to be more common in women and older people. Transient insomnia and intermittent insomnia often occur in people who are experiencing temporary problems such as stress, noisy sleeping conditions, extreme heat or cold, jet lag, or side effects of medications.

The causes of chronic insomnia are more complex, often involving a number of underlying disorders. One of the most common causes of chronic insomnia is depression (see page 345). Other causes include arthritis (see page 308), kidney disease (see page 288), heart failure (see page 233), asthma (see page 245), sleep apnea (see next page), narcolepsy (see page 357), restless legs syndrome (see page 358), Parkinson's disease (see page 337), and hyperthyroidism (see page 374).

Lifestyle factors such as overuse of caffeine, alcohol, or other drugs; shift work; smoking cigarettes before bedtime; excessive daytime napping; or chronic stress also have a role in the development of insomnia. Stopping these behaviors may help eliminate insomnia.

If you have insomnia, your doctor will take a complete health history (see page 82) and a sleep history. To obtain a sleep history, the doctor will ask you to keep a sleep diary or interview your sleep partner to find out how much sound sleep you typically get each night. Transient and intermittent insomnia may require no treatment because it often clears up when the underlying problem, such as jet lag, is resolved. If your daytime performance is adversely affected by transient insomnia, your doctor may prescribe a short-acting sleeping pill for a brief period.

To treat chronic insomnia, your doctor will first diagnose and treat any



Concerns underlying medical or psychological problems you may have. He or she may prescribe a sleeping pill, but only for a brief period to minimize unwanted side effects or dependence on the pills for sleep. Certain behavioral techniques also are often used to improve sleep. One such technique is relaxation therapy, which is used to eliminate anxiety and muscle tension. Some people with insomnia benefit from sleep restriction, which at first allows only a few hours of sleep each night, and gradually increases sleep time to a more normal span of time. Another helpful treatment is called reconditioning, which teaches the affected person to associate the bed and bedtime with sleep by avoiding use of the bed for any activity other than sleep or sex.

Sleep Apnea

Sleep apnea is a serious, potentially life-threatening breathing disorder that is characterized by brief, involuntary interruptions of breathing during sleep. There are two types of sleep apnea: obstructive and central. Obstructive sleep apnea, the most common type, occurs when air cannot flow into or out of the person's nose or mouth because of an obstruction caused by a relaxed and sagging tongue or a sagging uvula (the small piece of tissue that hangs from the center of the back of the throat) during sleep. Central sleep apnea, which is less common, occurs when the brain fails to send the proper signals to the muscles used in breathing to continue regular inhalation and exhalation during sleep.

During any given night, a person with sleep apnea may involuntarily stop breathing 20 to 30 times per hour. These pauses in breathing are usually accompanied by snoring, although not everyone who snores has sleep apnea. The snoring occurs because, although the person continues to try to breathe, air cannot flow easily in and out of the mouth. Choking also can occur.

During the pause in breathing, the person is unable to inhale oxygen and exhale carbon dioxide, resulting in increased levels of carbon dioxide in the blood. This increase in carbon dioxide alerts the brain to wake the person. Breathing often resumes with a loud snort or a gasp. The frequent arousal prevents the person from getting enough sleep and often causes early morning headaches and daytime drowsiness. Daytime concentration and performance suffer due to sleep deprivation.

Sleep apnea occurs in all age groups but is more common in men than in women. More than 12 million people in the United States are estimated to have the disorder. People most likely to have sleep apnea are those who snore loudly and also are overweight, have high blood pressure, or have a physical abnormality inside the nose or upper airway. The problem appears to run in families, suggesting a possible genetic cause.

To diagnose sleep apnea, doctors use two tests, performed either at a sleep center or at home. One test is polysomnography, which records various body functions—such as the electrical activity of the brain, eye movement, muscle activity, heart rate, and blood oxygen levels—during sleep. A test called the mul- 357

tiple sleep latency test measures how fast a person falls asleep. (It takes most Mental people 10 to 20 minutes to fall asleep; people who habitually fall asleep in fewer Dis°rders than 5 minutes are likely to require treatment for a sleep disorder.)

Treatment for sleep apnea depends on the underlying cause. Lifestyle changes are enough to reverse the disorder in some people. Such changes may include avoiding the use of alcohol, tobacco (see page 107), and sleeping pills, all of which can make the airway more likely to collapse during sleep. Overweight people can benefit from losing weight (see page 73). People in whom sleep apnea occurs only when they sleep on their backs are advised to sleep on their sides. The most common treatment for the disorder is called continuous positive airway pressure, in which the person wears a mask over the nose during sleep so that pressure from an air blower can force air through the nasal passages. The process also helps prevent the airway from collapsing during sleep. Side effects may include nasal irritation and drying, facial skin irritation, sore eyes, headaches, and abdominal bloating. Dental appliances can reposition the lower jaw and tongue during sleep to reduce the risk of airway obstruction. Medications are generally not effective for treating sleep apnea.

Some people with sleep apnea undergo surgery to increase the size of their airways. Common surgical procedures include removal of the adenoids (tissue at the back of the nasal cavity that helps the body fight infection), tonsils, nasal polyps, or uvula and part of the soft palate. People with life-threatening sleep apnea may need a tracheostomy, in which a small hole is made in the windpipe and a tube is inserted through which air can flow directly into the lungs while the person sleeps.


People who have narcolepsy experience such overwhelming daytime sleepiness—even after adequate sleep at night—that they become drowsy or fall asleep at inappropriate times and places during the day. Such "sleep attacks" can occur repeatedly during a given day and may come on without warning. Another classic symptom of narcolepsy is cataplexy (sudden episodes of loss of muscle function that cause the person to collapse suddenly or his or her neck to go limp). Sleep paralysis often occurs, preventing the affected person from moving while falling asleep or waking up. Some people also have vivid hallucinations while falling asleep. Such symptoms can seriously disrupt the person's life and limit his or her activities.

Narcolepsy occurs in both men and women and can begin at any age. As many as 200,000 people are affected, although the problem is often underdiagnosed or misdiagnosed as depression, epilepsy, or side effects of medication. Doctors think that a disturbance in the normal order of sleep stages causes narcolepsy. Most people first go through a stage of nonrapid eye movement (NREM) when



Concerns falling asleep, followed by a stage of rapid eye movement (REM), when dreaming and muscle relaxation occur. In people with narcolepsy, these stages are reversed.

To diagnose narcolepsy, doctors perform two tests—polysomnography and the multiple sleep latency test (see page 356)—at a sleep center or at the person's home.

There is no cure for narcolepsy, but certain treatments can relieve symptoms. Drugs called central nervous system stimulants (such as methylphenidate, dextroamphetamine, or modafinil) can help manage the excessive daytime sleepiness caused by narcolepsy. Antidepressants (such as amitriptyline or fluoxetine) also are prescribed. An important part of treatment is scheduling short naps two to three times per day to help relieve daytime sleepiness. Some people with narcolepsy and their families find it helpful to join a support group where they can learn to deal with the emotional effects of the disorder, talk about occupational limitations, and find out how to avoid situations that could cause injury.

Restless Legs Syndrome

Restless legs syndrome is a sleep disorder in which a person experiences unpleasant sensations in the legs. People who have this disorder often describe the sensations as creeping, crawling, tingling, pulling, or painful feelings in the calves, although the entire leg can be affected. These sensations can occur when the person lies down or sits for long periods, such as in bed, at a desk, or riding in a car. Moving, rubbing, or massaging the legs brings relief, at least briefly. People with restless legs syndrome find it difficult to relax and fall asleep, often sleeping best during the morning hours. A lack of sufficient sleep at night causes daytime drowsiness and affects performance at home and at work. Many people with restless legs syndrome have periodic limb movement, which is characterized by involuntary jerking or bending leg movements that occur every 10 to 60 seconds during sleep.

The cause of restless legs syndrome remains unknown, but certain factors have been linked to the disorder. They include a family history of the disorder; pregnancy; low levels of iron in the blood; diseases such as kidney failure (see page 291), diabetes (see page 365), and rheumatoid arthritis (see page 309); and a high caffeine intake.

Both men and women can develop restless legs syndrome, which is more common and more severe among older people. An accurate diagnosis often depends on how well the person can describe his or her symptoms because there is no visible abnormality in the legs and there is no diagnostic test to detect the disorder. Mild cases of restless legs syndrome respond well to self-treatments such as taking a hot bath, massaging the legs, using a heating pad or an ice pack, exercising, and eliminating caffeine. More serious cases are treated with benzodiazepines (such as clonazepam or diazepam) and opioids (such as codeine or propoxyphene). These drugs do not cure restless legs syndrome but only treat 359

the symptoms. Some people respond well to a nondrug treatment called transcu- Mental taneous electric nerve stimulation (TENS), in which electrical stimulation is Dis°rders applied to the legs or feet for 15 to 30 minutes before bed to reduce leg jerking during sleep.

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