Monday, 28 March 2011

Sleep interrupted, Test while you rest



Sleeping while standing ... serious sufferers of sleep apnoea are so tired during the day that they can fall asleep at any time. – File photo
Sleep interrupted

By TAN SHIOW CHIN    starhealth@thestar.com.my



We often fail to realise how important sleep is to us until we don’t get enough of it.
WE spend about a third of our lives sleeping. Some of us enjoy escaping into this restful oblivion, while others  resent the intrusion of this act into the conscious part of our waking lives.

However, as studies (and torture methods) have shown, depriving oneself of sleep is a sure-fire way of losing one’s grip on reality.

I remember the last time I stayed awake for more than 24 hours – a couple of friends and I were having one of those deep, insightful conversations that lasted throughout the night during our college days.

I had an appointment the next morning, so off I went without a wink of sleep to meet another friend at a fast food restaurant. When I got there, the door of the restaurant refused to budge despite my Herculean efforts to pull it open, as per the sign on the door.

It took several minutes before my sleep-deprived brain caught up with the fact that while I had read and interpreted the sign properly as “Pull”, somewhere along the way, the scrambled neurons communicating with my arm were convinced that the act of pushing was actually pulling.

So there I was, trying to push the door open, while totally convinced that I was actually pulling it.
Fortunately, my body got its second wind after that, and I managed to stay sensible and fairly alert throughout the meeting and the journey back to my hostel, before I crashed out on my bed to pay my sleep debt.

 Inadequate sleep

While staying awake for more than 24 hours is not the norm for most people, the fact is, in our fast-moving, instant gratification and instant communication society, sleep is increasingly being sacrificed in order to do more, accomplish more, “live” more.

Says Philips Home Healthcare Solutions senior vice-president and chief medical officer Dr David White in an email interview: “People are simply too busy, do not manage time well, and have too many 24-hour entertainment options. Thus, sleep gets lost.”

Of course, like in most other countries, many Malaysians are caught up in trying to balance work, family and recreation, with sleep time often paying the price.

In the Philips Index for Health and Well-being: A Global Perspective Report 2010 published last November, 81% out of the 800 Malaysian adults interviewed said that they did not get enough sleep at night.

In comparison, the average number of adults who gave a similar answer was 69% out of over 31,000 respondents from 23 countries.

Over half of the Malaysian respondents blamed their lack of sleep on going to bed late at night and getting up early the next day.

Other less significant reasons included bring a poor sleeper (13%), and being worried or stressed out over life (8%).

While sleeping less might seem to be just a lifestyle choice, studies have shown that a chronic lack of sleep can lead not only to poor performance and decreased productivity, but also significant health consequences.

Among the possible effects of inadequate sleep are increased hunger and subsequent weight gain, decreased immune function, poor glucose control (contributing to the development of diabetes), increased blood pressure, and higher incidences of heart problems.

Sleepy people are also grumpy, irritable and unable to focus properly, which can lead to social problems, as well as cause work or car accidents.

Awareness of these effects seems to be generally low among Malaysians in the report, with only 35% saying that a lack of sleep affects their job performance a lot, and 42% agreeing that decreased sleep significantly affects their physical health.

Thirty-six percent of respondents also think that less sleep affects their mental health a lot, while 35% say it really affects their home life, and 30%, their relationships with others.

The lack of sleep is also a contributor to the stress levels of around 37% of the Malaysian respondents, with other contributing factors including losing their job, the economy, healthcare costs, their boss and having enough money to pay the bills.

Overall, an average of 42% of respondents from the 23 countries involved in the report said that trying to get enough sleep contributed a lot to the stress that they might feel.


Breath-less pause

The lack of sleep does not just mean not sleeping enough hours for your body to recharge properly, but also the quality of sleep you are getting.

For example, you may think that you are getting around eight hours of shut-eye every night, but if you keep waking up every other hour – even if you go back to sleep immediately after waking up – then, you’re not getting the quality sleep that you need.

While some people are aware of the disruptions to their sleep, others may be oblivious to it.
Consultant ear, nose and throat (ENT) specialist Datuk Dr Kuljit Singh says that the two major complaints usually relating to sleep are sleeping too well, and not being able to sleep.

The former problem is usually related to sleep apnoea, a medical condition where the patient stops breathing while he is asleep.

Apnoea can be divided into central apnoea, which is caused by a failure in the brain to properly regulate the breathing process, and obstructive apnoea, which is caused by the physical blockage of air into the lungs by the body’s own muscles and soft tissues.
Dr Kuljit estimates that around 75% to 80% of cases in his experience are obstructive apnoea, with the remainder being central apnoea or a combination of both.

While central apnoea comes under the purview of neurologists, obstructive apnoea is treated by ENT specialists.

Dr Kuljit explains that patients with obstructive apnoea suffer from a significant collapse of the muscles and soft tissues around their air passage (ie within their nose and throat) when they sleep – such that they cease to breathe adequately for the body’s needs.

When this happens, the body either wakes itself up, or moves from a deeper level of sleep into a more shallow one, to kickstart breathing again. (See Stages of sleep)

As many patients do not actually wake up during their apnoeic episodes, they are not aware that they have this problem. Oftentimes, it is their bed partner who notices their apnoeic episode.

According to Dr Kuljit, most people with this condition tend to feel groggy, irritable and tired throughout the day, despite having had six to eight hours of so-called uninterrupted sleep the night before.

“They feel so tired that they can fall asleep anywhere, at any time of the day,” he says.

Other warning signs of this condition include an irregular snoring pattern (although some apnoeic patients might not snore at all), obesity, especially with abdominal fat and a collar size of 17 inches or more, and other medical problems like heart conditions, diabetes and high blood pressure.

Dr Kuljit adds that this is a condition that can affect children, as well as adults, and the solution is usually surgical or the application of continuous positive airway pressure (CPAP) through a machine while sleeping.

No rest for the weary

On the other hand, many people are aware they have a problem when they face trouble falling asleep – a condition known as insomnia.

Stedman’s Concise Medical and Allied Health Dictionary (Illustrated Third Edition) defines insomnia as the “inability to sleep, in the absence of external impediments, such as noise, a bright light, etc, during the period when sleep should normally occur”.

The degree of insomnia can vary from restlessness during sleep to absolute wakefulness.
Dr White, who is also a Professor of Sleep Medicine at Harvard Medical School, explains that there are a number of causes of insomnia.

They include:
  • ·Psychiatric disorders: The main ones being depression or anxiety states.
  • ·Medical conditions: This would include pain syndromes, respiratory disorders (asthma and emphysema), neurological disorders (Parkinson’s disease), etc.
  • ·Conditioned or psychophysiologic insomnia: These patients have a predisposition to insomnia (probably mild anxiety), and when faced with a stressful situation, develop insomnia. They then become so concerned about their sleep that further anxiety develops and a chronic insomnia develops.
  • ·Circadian rhythm disorders: Trying to sleep when your circadian clock says you should be awake. The most common examples are jetlag and shift work.
  • ·Other causes like drugs, etc.

As such, insomnia cases generally come under the area of psychiatry or neurology, with the exception of respiratory disorders, which will be managed by a respiratory physician.

Dr White says: “If a specific condition can be identified (eg depression), that should be treated specifically (ie with antidepressant medication). When that is not the case (conditioned insomnia), there are two general approaches.”

One approach is Cognitive Behavioural Therapy (CBT), which tries to modify the patient’s behaviour so that he or she will be able to sleep well; for example, through relaxation techniques and teaching the patient to associate their bed only with sleeping.

And the other is prescribing sleeping pills to the patient for the period they require.

When asked what is considered good quality sleep, Dr White says that good sleep quality is not a technical term, but simply means:
  •  ·Sleep was of adequate duration.
  • ·The individual was not waking up frequently (less than two to three times over the course of the night).
  • ·That there was acceptable sleep stage distribution with normal amounts of stages N1, N2, N3, and REM.
  • ·The person felt well rested the next morning.




Test while you rest

WHEN a doctor suspects a patient of having a sleep disorder, the next step is usually to send the patient for a sleep study.

This diagnostic test, also called a polysomnograph, monitors several physical and physiological parameters while the patient is asleep over the period of one night.

The most comprehensive test monitors the patient’s brain waves, heart rate and rhythm, eye movements, airflow, chin muscle tone, chest and abdominal movement, leg movement, body position, and oxygen saturation rate.

Previously, sleep studies could only be performed at sleep labs in medical centres, where a sleep technician would monitor them throughout the night.

Dzulkarnean (left) adjusts the sleep diagnostic system on Aida to ensure that it will not dislodge from the harness. Hidden are Thanapalan (in striped shirt) and Goodlabs Medical sales manager Low Meng Imm.
 
However, the availability of smaller and more mobile devices have enabled patients to undergo the test in the comfort of their own homes.

Sunday Metro reporter Aida Ahmad had the experience of undergoing a home sleep study, arranged by Philips Healthcare through their Malaysian distributor, Goodlabs Medical Sdn Bhd.

She shares her experience below:

“When I knew that I was going to participate in a sleep study, I was actually excited and was looking forward to it.

Moreover, I hadn’t been sleeping well, so this opportunity to find out why I was so sleep deprived was too good to miss. At first, I was told that it would involve me being hooked up to a machine and electrodes, while the sleep technicians, as they are called, would monitor my brain waves and sleep activity in a sleep lab.

A little too close for comfort, I thought, but I was willing to be the guinea pig in the name of science.

A sleep study is a test that records a variety of body functions during sleep. Instead of performing the test in a lab, the technicians decided that it would be better to conduct it in a place which would be more comfortable for me – my home. After all, this was a sleep study, and a conducive environment was essential to achieve proper results.

During the day, I was given specific instructions by the executive from the company which distributes the device, called the Alice PDx Sleep Diagnostic System. As I was supposed to be ‘hooked up’ at 9.30pm, specific instructions were to be followed on the day of the home sleep study.

One should not nap, consume coffee, tea or carbonated drinks, chocolates or any sleep aids (ie sleeping pills, sedatives, etc), wear any body lotion, face cream, make-up, jewellery, acrylic nails or nail polish.

So there I was, fresh after a shower and in my comfortable sleep wear. There were three people who came to my home – one sleep technician and two executives from the distribution company, Goodlabs Medical Sdn Bhd; although usually, only one sleep technician does the setting-up at the client’s home. I was also told that the gadget used to gauge all the essential functions was the mere size of an MP3 player with a few wires to boot.

Trying to fall asleep with the diagnostic system on.
 
I was wrong.
In the black bag (similar to a laptop bag) was the main gadget, sort of like a mini computer that stores and records data in a memory card.

This was followed by the unpacking of wires and electrodes (that were to be stuck on my head), adhesive gels, sensors and bands to go on one of my index fingers, chest and nose.

After a short briefing about the procedure, I began to wonder what I got myself into.
Unfortunately, it was too late to run far, far away, so I rose to the occasion and braced myself.

The sleep technician, Mohamad Dzulkarnean Mohamad Haniffa, first told me where the seven electrodes would be attached on my head. The entire procedure is actually painless. To attach the electrodes, he had to use a cleaning paste (like a facial scrub) to clean the areas on the back of my scalp, and my forehead. Then, the electrodes were dipped in a temporary adhesive paste and placed on my head.

About thirty minutes later, with seven electrodes on my head and two small sensor pads on my chest attached to colourful wires, I felt like I was part of a human cloning experiment.

Next, came the two bands, which were attached to my chest and waist to measure my breathing effort.
Lastly, I was hooked up with a temperature sensor to monitor airflow at my nostrils and mouth.

It took about an hour to attach everything, and when I looked at myself in the mirror, I thought I could really scare the staff at the American Embassy.

So, what is one supposed to do after this?
Sleep would be an appropriate answer. But actually, you can watch television, read a book or simply lie in bed until you fall asleep.

Don’t worry if you need to get up and use the bathroom in the middle of the night. But for convenience’s sake, try not to drink too much water before the procedure.

There is a way to interact with the device should you get up in the middle of the night. There is a Pause button you can press, so it doesn’t interrupt the data input.

In terms of sleeping positions, try not to roll onto your stomach for obvious reasons.
I slept quite well, I must say, despite all the wires and the fear that one or two might get entangled or dislodged from the device.

When I woke up, it took about 10 minutes to disengage myself from the shackles of medical research – meaning the electrodes and the sensor bands.

The device with all the accessory equipment was then picked up by Goodlabs Medical business manager (Sleep and Homecare Ventilation) B. Thanapalan to be taken back to the company for analysis and the production of the final report.

Thankfully, the results, which came back a few days later, showed nothing abnormal. So perhaps, I had just been sleep deprived, because sleep was a low priority for me. I know better now!”