Desperately Seeking Sleep

If you are 40 winks shy of a good night's rest, it is probably time to put some of your bad sleep practices to bed.

by Sarah Lifton

f you have spent more than a few nights tossing and turning in bed, it might be some small consolation to know that you are in fine company. Sleep did not come easily to many of history’s most celebrated figures, whether statesmen or scientists, writers or film stars. Among the luminaries who reportedly found it hard to nod off were William Shakespeare, Sir Isaac Newton, Benjamin Franklin, Abraham Lincoln, Thomas Edison, Ernest Hemingway, Marilyn Monroe and Henri Matisse.

Some had most curious ways of dealing with the problem. Winston Churchill reputedly had two twin beds, and when he could not fall asleep in one bed, he switched to the other. Charles Dickens, practicing his own brand of Victorian feng shui, could only sleep in a bed with its head pointing due north, and with his body dead-center on the mattress—a position he ensured by using his arms as calipers and wriggling until he achieved perfect placement. Vincent Van Gogh doused his mattress and pillow with camphor, best-known as the active ingredient in mothballs.

Modern science has largely rendered such bizarre strategies obsolete, but it still has not made a dent in the number of people who have trouble drifting off to sleep. The National Center on Sleep Disorders Research (NCSDR), part of the National Institutes of Health, estimates that 70 million Americans suffer from sleep problems, and nearly 60 percent of those have a chronic disorder.

That is a whole lot of sleep deprivation and a major hit on quality of life. Poor or inadequate sleep interferes with the ability to concentrate and handle minor irritations, as well as perform tasks involving memory, learning, logical reasoning and coordination. It is a significant predictor of employee absenteeism, and lost productivity due to sleepiness has been estimated to cost the national economy as much as $100 billion annually. Each year, the NCSDR notes, sleep disorders, sleep deprivation and sleepiness add roughly $15.9 billion to the national health-care tab alone.

And then there is the safety toll. The National Highway Traffic Safety Administration estimates that drowsy driving is responsible for some 100,000 police-reported highway crashes each year, leading to 71,000 injuries and 1,500 deaths in the United States; its monetary costs are estimated at $12.5 billion annually. That means the person driving in the lane next to you may, quite literally, be doing it in his sleep.

Sleep disorders encompass a broad range of conditions that include sleep apnea, narcolepsy, insomnia, parasomnias (disturbances such as sleepwalking), jet-lag syndrome and disturbed biological and circadian rhythms. The USC Sleep Diagnostics Program is helping to diagnose and treat the array of conditions that can keep patients from getting a decent night’s sleep or that impinge on normal daytime functioning.

Typically, when a patient goes to the Sleep Diagnostics Program, physicians will take a complete medical history and conduct a physical exam. If appropriate, they will then schedule a comprehensive sleep study, called a polysomnogram, in the sleep lab. The study tracks an array of physical functions, including brainwave activity, heart rate and rhythm, breathing and nasal air flow, eye and chin muscle activity and arm and leg movements. If a patient is suffering from excessive daytime sleepiness, they also may ask the patient to return the following day for a multiple sleep latency test, which records sleep patterns during a succession of naps. Based on the results, physicians will recommend a course of treatment.

“We have multiple channels for performing a comprehensive sleep study,” says Ricardo Juarez, M.D., assistant professor of medicine and medical director of the USC Sleep Diagnostics Program. “In addition to obstructive sleep apnea, which is the most common disorder we see in the sleep lab, we’re able to pick up other disorders such as nocturnal seizures, narcolepsy or periodic limb movement disorder.”

The Sleep Diagnostics Program is currently headquartered in the USC Ambulatory Health Center building, but when the new Healthcare Consultation Center II opens in April 2004, it will move into a brand-new sleep lab with twice the capacity of the current one.

Juarez points out that even with approaches as technologically advanced as the sleep lab, an overnight sleep study is not especially helpful in determining the cause of a patient’s insomnia. Physicians are usually able to determine the origins of insomnia from a patient’s history and physical exam. Furthermore, most insomniacs have trouble sleeping in a strange environment like the lab.

But of all the sleep disorders, insomnia—defined as difficulty falling asleep, waking up frequently during the night, waking up too early and not being able to get back to sleep or waking up feeling unrefreshed—is by far the most common. Its causes are varied but, according to Michael Wincor, Pharm.D., associate professor of clinical pharmacy, psychiatry and behavioral sciences in the USC School of Pharmacy and the Keck School of Medicine and an expert in the physiology of sleep, sleep disorders, insomnia and hypnotics, they tend to fall into several different categories:

• situational factors that are major stressors, such as a life trauma or an upcoming important event;

• environmental factors, such as too much noise, temperatures that are too hot or cold, or working a night shift;

• factors related to medications, both prescription and nonprescription (especially central nervous system stimulants);

• medical problems, such as pain, angina and endocrine disorders; and

• psychiatric disorders, such as depression and anxiety disorders.

Beyond these, Wincor notes, people who suffer from insomnia actually seem to have a predisposition for it.

“What makes certain people more vulnerable than others?” he asks. “We know there are some factors that appear to be significant. One is age. The older you are, the more likely it is that you will have sleep disturbances. Another is personality. Some people don’t handle external stressors as well as others. Circadian rhythms also contribute—how sensitive a person’s biological clock is to changes in time to bed and time to wake up.”

What scientists do not know is whether age-related sleep problems derive from associated medical problems and the medications that older people are more apt to take, or whether there is something in the brain that interferes with sleep or regulates sleep less efficiently as people age. It also is not clear whether sleep problems predispose certain people to particular psychiatric conditions or whether the conditions themselves create the sleep problems.

Juarez points out that most often, insomnia is a short- or mid-term problem brought on by a life event or stressor that makes it hard for a person to sleep. With chronic insomnia, lasting more than a month, however, psychological issues are usually the culprits. It simply takes some people much longer to get over an acute life event; anxiety or depression may also be present.

Beyond such specific causes of insomnia, however, many people practice poor sleep “hygiene,” which can shut out shut-eye. Anything that stimulates the brain, such as caffeine and chocolate, can make slumber elusive if it is introduced too late in the day. Conversely, anything that depresses the brain, such as alcohol, can lead to withdrawal syndrome. Although alcohol induces sleep, as it wears off, paradoxically, it creates a chemical imbalance that lightens sleep—an effect that is also true of sleeping medications (known as hypnotics) if they are taken routinely.

“If you drink a sufficient amount of alcohol prior to sleep, it suppresses dreaming,” Wincor says. “Its effects are of relatively short duration, and then you go through withdrawal and end up with disrupted sleep.”

In addition, Juarez says, people routinely ignore a number of practices that can improve their sleep. At the top of the list is waking up at the same time each day, which resets the biological clock.

“The bedrock for good sleep is making the final awakening time consistent,” says Juarez. “It’s very important for stabilizing a patient’s overall sleep-wake cycle.”

Insomniacs should also avoid daytime naps. Although the biological clock makes many people sleepy in the middle-to-late afternoon, those who give in to the urge to catch a few Zs spend less time sleeping at night.

Other measures are a matter of common sense. Regular aerobic exercise can help improve sleep but should not be done any later in the day than three or four hours before bedtime. Bringing work home in the evenings can stimulate the brain, and eating heavy or spicy foods late in the evening may give some people heartburn once they lie down. Drinking large quantities of fluids likely will awaken them during the night to go to the bathroom.

People struggling with insomnia often find that creating an appropriate sleep environment is key to getting a good night’s rest. Both Juarez and Wincor recommend that the bedroom be reserved for sleep and sex; other activities, such as paying bills or watching TV, should be relegated to outside the bedroom.

Equally important is transitioning to bedtime well in advance of actually turning in. Juarez urges his patients to take an active role in managing their sleep schedule by slowing down and unwinding beforehand.

“An hour before going to bed, you need to make sure you are decelerating,” Juarez says. “Relax and prepare for bed and sleep. All light is stimulation, so try lowering the level of the lights in your home. Don’t watch TV or work on the computer. Try doing relaxation exercises like meditation or stretching. Listen to easy music, read, take a warm bath or shower. You have to find the right approach for your particular lifestyle.”

In a culture where “you snooze, you lose” has become both admonition and motto, a good night’s sleep may be, above all, a victim of scheduling conflicts: People simply are not building enough time for sleep into their days.

“Insufficient sleep is rampant,” Juarez says. “In our society, which doesn’t place much importance on sleep, it’s common to have inadequate sleep. People maintain busy schedules, working one or two jobs or taking care of children. They should make sleep as important as their daytime duties, scheduling when it’s going to take place and making sure there are enough hours.”

All of which means most of us should prop open our eyes and take a long, hard look at our sleep habits. If we are more than 40 winks shy of a good night’s rest, it is probably time to put some of our assumptions and bad practices to bed. W.C. Fields said it best: “The best cure for insomnia is to get a lot of sleep.”

For more information about the USC Sleep Diagnostics Program, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).

DREAMY DRUGS

Insomnia—episodes of abnormal wakefulness, poor-quality sleep or an inability to sleep that last anywhere from a few days to a few weeks—can be mentally and physically draining. It can cause excessive daytime sleepiness, irritability and poor concentration. Treating underlying conditions such as depression or modifying behaviors such as reducing caffeine intake may alleviate the problem. But when insomnia persists, medications may be needed.

“Sleeping aids are effective for short-term insomnia but generally shouldn’t be used on a regular, long-term basis,” says Michael Z. Wincor, Pharm.D., USC associate professor of pharmacy, psychiatry and behavioral sciences. “Patients can develop tolerance to and dependence on some medications and experience withdrawal symptoms.”

Barbiturates—often referred to as downers—were among the first prescription hypnotics used to treat moderate insomnia. These agents are no longer prescribed because they have a high abuse potential and a narrow margin of safety, and patients become tolerant after only 14 days of use, Wincor says.

Today, the most commonly prescribed hypnotics are benzodiazepines such as Halcion, and benzodiazepine-like drugs that include Ambien and Sonata.

“Benzodiazepines can induce and maintain sleep,” Wincor explains. “When taken at the recommended dose for short periods of time, they are relatively safe with respect to dependence and withdrawal symptoms.”

Over-the-counter relief for mild insomnia can be found in antihistamines, present in Nyquil or Tylenol PM, which induce sleepiness as a side effect.

“The downside of antihistamines is that they often cause excessive drowsiness that results in a ‘morning hangover,’ which can lead to falls and other accidents,” Wincor says. “Antihistamine use is especially dangerous for elderly people, who can develop constipation, difficulty urinating and visual impairments.”

Some people believe herbal remedies such as kava and valerian or the hormone supplement melatonin are the answer to a good night’s rest. Wincor says there is little scientific evidence to support their benefits, with the exception of melatonin for jet lag, over other available options. He says the purity and quality of herbal products vary from brand to brand because they are not FDA-regulated.

Wincor’s bottom line: if you have trouble sleeping, work with your doctor and pharmacist for the remedy that is right for you.

—Alexis Bergen

Mouth Peace

Every night at least 18 million people across the country suffer from sleep apnea, the noisiest “silent” epidemic in America, according to the National Institutes of Health.

Recurrent narrowing or blockage of the throat causes apnea during sleep. The muscles that hold the throat open relax during sleep, which is of no consequence in normal people. However, in people who have a narrow throat, this can tighten their air passage to a slit, producing the vibration and noise of snoring, or blocks the throat completely.

Those who have a mattress mate who stops breathing during the night may know what apnea is, even if they do not know its name. An “apneac” snores, gasps for air as the throat is blocked, then resumes snoring without ever consciously waking. And—after all that noise, followed by sudden quiet and the sound of their partner choking for air—most bedmates also suffer from sleep deprivation.

The cessation of breathing can happen hundreds of times through the night, which disrupts deep rest and often leads to excessive daytime sleepiness. Recent studies have associated apnea with irregular heartbeat, high blood pressure, heart attack and stroke.

For Victor Dorff, a network news producer, the snoring-silence-gasping cycles were not a lullaby for him or his new wife. Dorff underwent outpatient laser surgery to widen his throat passageway. He tried somnaplasty, which uses radiowaves to tighten the tissue in the soft palate of the mouth that can vibrate and cause snoring. When these procedures failed to stop his sleep apnea, he had surgery to move his tongue forward. But subsequent sleep tests showed that Dorff had as many apnea episodes as before any of the surgeries.

He then tried less permanent solutions. For many apneacs, the Continuous Positive Airway Pressure (CPAP) machine is the nightly solution. The CPAP is a small air pump attached to a mask that fits over the nose and mouth and forces air through the airways during sleep. For Dorff, though, it disturbed his sinuses, so he pulled off the mask in his sleep.

As a last resort, Dorff investigated mouthpieces. He did some homework on different options and found out that the inventor of one of the mouthpieces worked in Southern California. Enter Glenn Clark, D.D.S., professor and director of the Orofacial Pain and Oral Medicine Graduate Programs at the USC School of Dentistry, who recently came from UCLA.

For 17 years, Clark has been making anterior mandibular positioning devices specifically fitted to the patient’s mouth. After impressions are made of the lower and upper bites, a mouthpiece is made to conform to the patient’s teeth and jaw. “It is an easy and effective treatment for sleep apnea,” Clark says. “Not only do my patients thank me, I get thank-you cards from their spouses.”

When Dorff first used his new mouthpiece from Clark, he feared he would wake with headaches and jaw-aches. Instead, Dorff woke refreshed for the first time in years. Months later, he is still waking refreshed. He says, “Dr. Clark calls it a mouthpiece, but my wife and I call it a ‘mouth-peace.’ We are finally having silent nights and sweet dreams after many noisy years.”

—Lisa Sonne

Lisa Sonne is a freelance writer living in Los Angeles and is married to a former apneac.