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Why we can't sleep it all off

Call it the curse of the double latte. Ours is a sleep-deprived society and our health is suffering for it
By Dr. Shafiq Qaadri, MD

'Doc, I've been up for three days. I need something for sleep -- I feel like a dead man walking," a 26-year-old accounting student said as he was preparing for his CA exams. Though he's suffering the full effects of insomnia, his sleep difficulty is short-term, and should resolve quickly.

That's fortunate for him, as adequate sleep has long been recognized as a marker of good health. Indeed, sleep deprivation is considered one of the cruellest methods of torture yet devised. Shakespeare, the master chronicler of human frailty, called sleep "the balm of hurt minds," and he was right. It is the body's daily R&R, a time for repair, restoration, wound healing, blood production and growth. Restful sleep even consolidates learning, helping to encode newly acquired knowledge into memory. Yet unlike the accounting student's situational insomnia, our society is collectively suffering from a persistent lack of sleep.

Chronic insomnia is a signature of the modern world. It is an irony that as life expectancy continues to increase -- one of the triumphs of science -- we are also spending less and less time asleep. There are many causes: spending your life next to a snoring or kicking bed partner, shift work, jet lag, a crying infant, deadlines, chronic pain, nightmares, light and noise pollution, or just plain thinking too much. Some cultures value sleep so highly they have built-in afternoon siestas. But North American society is too driven to recognize the need for proper rest.

Our caffeinated, drive-through, push-button, always-open, touch-screen, leave-a-message, call-waiting, kiss 'n' fly, 500-channel world is toxic to restful sleep. Armed with double lattes, it is no wonder that our society suffers from a chronic sleep deficit.

The vast costs of insomnia -- in money, lives and lost productivity -- are gaining more attention. A sleep-challenged society will not have optimal alertness and concentration. Poor daytime performance due to lack of sleep was implicated in three dramatic accidents: Chernobyl, Three Mile Island and the Exxon Valdez oil spill. But there is much quiet suffering also, which shows up as traffic mishaps, work injuries, poor job performance, or the general fatigue that plagues the sleep-deprived.

And the number of people suffering is enormous. "The rate of chronic insomnia [is] fairly stable at about 10 per cent of the population," say psychologists Shawn Currie and Keith Wilson in their guide 60 Second Sleep-Ease: Quick Tips to Get a Good Night's Rest.

Yet despite these numbers, sleep management is a topic largely ignored in the majority of medical schools.
"There is a lack of adequate training in the area of sleep disorders," says Dr. Charles Samuels, professor at the Canadian Sleep Institute in Calgary. That's why only 50 per cent of Canadian physicians routinely screen their patients for sleep disorders, according to research published in the Canadian Journal of Continuing Medical Education.

But insomnia patients want relief urgently. "I want to be rested and refreshed, ready for the next day," says a 40-year-old night-shift manager, whose fragmented sleep affects his job performance. So keeping up with all the therapeutic developments, in order to make the best recommendations, is a keen challenge faced by caregivers.

Sleep medicine has become an industry in itself, and can be quite confusing for patient and professional alike. Definitions keep shifting, but doctors currently define chronic insomnia as taking longer than 30 minutes to sleep, or waking up for longer than 30 minutes after first falling asleep, for at least one month.
There is a full spectrum of insomnia-management options: Some believe in herbal, over-the-counter or prescription medications; some rely on talk-therapy, workshops and manuals, or want to spend a night in a sleep lab for assessment.

But before any specific recommendation is offered, the health-care professional must gather information and address the specific concerns of the patient.

People often ask: "How much sleep do I really need?" The answer varies according to each individual's biological clock, but six to eight hours a night is generally considered adequate.

The sleep therapist must also determine if insomnia is the primary problem, or is it a passenger or marker of another condition. For example, poorly controlled asthma, heartburn, sugar diabetes, prostate enlargement, or heart disease are all conditions known to wake people up at night. Most heart attacks and chest-pain episodes, for example, occur between midnight and 6 a.m.

Occasionally, the problem is purely physical. People who snore excessively, for example, have partially blocked airways and can suffer from sleep apnea (literally, "air-hunger"). These patients can stop breathing for several seconds, hundreds of times a night, and partially wake up each time. Treatment can involve surgery, but patients often do well with a special device called CPAP, continuous positive airway pressure, which forces the oxygen past the blocked nasal tissues.

But sleep disorders are most often psychological, and anxiety and depression can be both cause and effect: Depressed or anxious patients can't sleep, and patients who can't sleep get depressed or anxious. The sleep therapist must decipher this causality.

The therapist must also ask detailed questions about the exact nature of the sleep disturbance: Is the difficulty in falling asleep, staying asleep, waking in the early morning, being unable to return to sleep, or waking up feeling unrested? With full information, health-care professionals are better able to tailor treatment strategies to each patient's needs.

Medical science is also revealing that sleep is actually a rich and puzzling process. Specialists in the field speak about a "five-stage sleep architecture," and note that the goal of therapy is to maximize the fifth stage -- deep, dreaming sleep, known as REM (rapid-eye movement). Research has revealed that everyone dreams every night, whether we remember the dream content or not. And it is the amount of this high-quality REM sleep that we have, not the number of hours spent in bed, that determines how rejuvenated we feel.

What are the eyes doing? "It appears," says Prof. Michael Wincor, a sleep-disorder specialist from the University of Southern California in Los Angeles, "as though the sleeper is watching a movie or actively observing some activity." Strangely, the more time we spend watching our own internal DVD player, surveying dream imagery of our own making, the better rested we feel.

Treatment strategies include practising good sleep hygiene -- a set of protocols that help maximize a patient's potential for a full night of refreshing and restorative sleep. These recommendations include: following a routine; avoiding alcohol, meals, caffeine, or vigorous exercise in the late evening and using the bed only for sleep or sex, not for watching TV or doing work. Alcohol, for example, may help a person to fall asleep, but it actually diminishes the restorative REM sleep.

There are also a number of self-help books for insomniacs. Psychologists Currie and Wilson, for example, detail an entire self-management program in Sleep-Ease. This program includes written exercises, self-talk, tests, worry-control techniques, imagery, keeping a sleep log, and a bedroom protocol.

If these initial strategies are unsatisfactory, patients turn to medications. "I usually act as a first-line counsellor to people who have problems sleeping," says Christina Lam, a Toronto-area pharmacist. "Often the over-the-counter products are enough." These products include various well-known brands and herbal agents.

If the insomnia persists, patients may then request prescription medications. This is a minefield for prescribing doctors. The physician must determine if a patient has a legitimate medical need, and is not seeking a drug for recreation or street resale. The doctor must then choose a medication strong enough for the patient to fall asleep, but not to lead to daytime sleepiness -- the groggy, hung-over feeling -- and certainly not to cause addiction.

Before a physician writes a script for sedatives, he must be reasonably assured that the patient will not overdose, making the doctor an unwitting accomplice in a suicide attempt. The newer sleeping pills are somewhat safer and less addictive than Valium and its cousins. But doctors must always continue to re-evaluate a patient's potential for abuse, addiction, side effects and withdrawal.

"Doctor, my computer has a sleep button, why don't I?" an insomnia patient asked.

Though medical science hasn't quite discovered such a precise detail of human sleep hardware, muchprogress has been made. An informed health-care professional who has taken a detailed patient history can best help guide the sleep-challenged to a better night's rest.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education (CME) lecturer. www.doctorQ.ca

Are you sleep deprived?

In a typical week:

Are there nights when it takes you more than 30 minutes to fall asleep?

Are there nights when you wake up through the night and have trouble getting back to sleep?

Are there mornings when you wake up earlier than you wanted to and have trouble getting back to sleep?

Do you wake up feeling like your sleep was not restful?

Do you feel your sleep problem is a direct cause of significant distress for your missing time at work, notdoing your job well when at work, missing social functions, or not getting along with friends, family or co-workers?

Have your sleep difficulties been going on for more than one month?

If you have one or more of these problems, at least three times a week, you may have insomnia.

-- Adapted from 60 Second Sleep-Ease: Quick Tips to Get a Good Night's Rest, by Shawn Currie andKeith Wilson.

HOW TO GET A GOOD NIGHT'S REST

Set a regular time to go to bed and a regular time to wake up.

Avoid daytime napping.

Don't clock watch and don't try to sleep on demand.

Make the bedroom as comfortable, secure, dark and quiet as possible.

Avoid alcohol, late meals, caffeine, and exercise in the late evening.

Use the bed for only sleep or sex, not for watching TV or doing work.

If you wake up at night, don't lie there worrying about not sleeping. Get out of bed, go to another room and engage in a relaxing activity.

Psychotherapy, relaxation techniques or hypnosis may be useful.

Consider medications: non-prescription and prescription.

Sleep aids

Herbals:
Valerian root, catnip, scullcap, chamomile.

Over-the-counter:
Calmex, Nytol, Sleep-Eze, Sominex, Unisom.

Prescription Sedatives/Hypnotics:
Lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), clonazepam (Klonopin), diazepam (Valium).
Newer agents (reputed to be safer, with fewer side effects):
zaleplon (Starnoc), zopiclone (Imovane).

-- Adapted from Prof. Michael Wincor, University of Southern California Schools of Pharmacy and Medicine.

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