Merriam Webster defines sleep the natural periodic suspension of consciousness during which the powers of the body are restored. It is also a state of torpid inactivity. A state marked by diminution of feeling.
Sleep is a period where our conscious mind is resting and our subconscious mind is still working so all our involuntary muscles is working.
Sleep has been a major area of work in my space as a dentist and as a hypnotherapist, particularly since I am sleep challenged myself.
Sleep is the period of repair and rejuvenation, for the physical and the emotional body. It is a period of sorting for the mind. I shall talk about this over the week, but as of now, physiologically speaking we are talking about REM sleep, NREM sleep, detoxing of the lungs, the body cycles coming to a balance etc. Etc.
Emotionally speaking we are talking of sorting of thoughts eliminating the unwanted, preserving what we perceive as relevant. We are also talking about predictive dreams, venting of excess.
Being sleep deprived is one of the most, physiologically and psychologically dangerous states. Sleep disorders have entered the Indian population, contesting with the American. But the other side is that it is estimated that one third of the population goes t sleep where they are standing when it is time to sleep.
As of now the impact of sleep disorders on morbidity and mortality is not very widely appreciated.
With sleep disorders there is an increasing in daytime sleepiness and resultant increase in traffic accidents.
There is a study that states that disturbed sleep cycle during child rearing has its effects at a later stage.
Sleep disruption makes it difficult to cope with many medical disorders. It also reduces the attenuation of school and work ability, giving rise to psycho-social consequences and a constriction of leisure and pleasure time. There are specific effects linked with each condition.
Sleep apnoea increases risk of myocardial infarction and stroke. Cognitive deterioration, presumably on basis of repeated nocturnal hypoxia and sleep disruption has been described in a number of studies, and personality change is part of continuous fatigue leading to marital friction, divorce difficult interpersonal relation, etc.
Insomnia though often trivialized by doctors, is a common symptom albeit often self-limiting. In up to 80% of the cases insomnia reported in general practises due to anxiety and depression. Even in a specialized clinic one third of the cases are related to anxiety and depression. Many insomniacs tend to self medication, which could be ineffective and dangerous. When associated with other disorder this could be a trigger for suicidal behaviour. If the patient resorts to hypnotic medication to deal with sleep it could interact with alcohol intake. Long term use of benzodiazepines can impair cognitive powers particularly in elderly.
Narcolepsy is a disorder with the longest duration from onset of symptoms before diagnosis. It impacts the quality of life, in a study of impact of various disorders to the quality of life, narcolepsy rates second only to quadriplegia.
Historically we have a belief system or rather a misconception that sleep is a passive period, but contrary to it, sleep is the active restorative processes of the body. Some authors look at the small hours of the morning a high risk window for mortality. F.Scott Frtozgerald wrote in 1945, that in the real dark night of the soul it is always 3 O’clock in the morning. Many studies show an increased mortality in late sleep and early waking hours.
Studies have shown that nocturnal asthma is pronounced in the latter part of the sleep and particularly during the REM phase. Though asthma is not fatal in itself, people dying of asthma tends to do predominantly in the night. This could be due to patho-physiology of the sleep.
There are large number of medical disorders that exhibit peak mortality at night, then are specific though rare disorders associated with sleep… this is seen in south asian men and is thought to be REM related arrhythmia.
American cancer society shows, that deviation from age appropriate sleep that is two hours longer or shorter than normal leads to increased mortality, which is more pronounced in women than men. This effect increased with age.
A random survey of more variable sleep patterns was among young adults that are between 18-34yrs of age and older adults that are over 65, as compared to middle aged adults. People sleeping a normal duration of 7-8hrs reported lower rates of illness. There are patho-physiological changes during sleep which lead to increased morbidity, like hypercapnic and hypoxic drive is diminished particularly in REM sleep. There are patients for whom epilepsy is exclusively sleep related. Gastro-oesophageal reflux is more common at night. Certain patterns of headache such as cluster headaches have an onset during sleep.
Care giving of elderly person is associated with disruptive sleep for the caregiver causing patho-physicologic changes that sometimes becomes intolerable.
Many sleep related disorders appear in the hospital, sometimes even requiring hospitalization, present as diminished productivity, could be either circumstantial or direct consequence of fatigue related accidents.
Fatigue peaks occur in the early hours of morning and a second fatigue peak occurs in the mid afternoon. These peaks show up as increased incidence of road traffic accident. Studies suggest that 20% of all the drivers have fallen asleep behind the wheel at least once. One third of heavy trucking accidents are the result of the driver slipping into sleep deficit fatigue. Aircraft pilots flying jets have exhibited similar dips during electroencaphalograhic recordings.
There is a seven fold increase in road traffic accidents in patients with sleep apnoea, and in a study 60% of these patients describe falling asleep at the wheel at least once a week.
Sleep walking infrequently leads to accidents but occasionally leads to death it is very rare that sleep related homicide is reported.
Some statistics of sleep disorders.
- Narcolepsy about 0.15% manifests this.
- Obstructive sleep apnoea about most common in middle aged overweight people. 4-8% men and 2-4% women manifest it.
- Restless leg syndrome definitive data not available, 5-15% manifest it, of the subjects 11% were pregnant women 15-20% people with uraemia and about 30% with rheumatoid arthritis.
- Shift-worker sleep disorder about 2-5%
- Sleepwalking 1-15% though more common in children.
- Sleep terrors is seen in 3% of children and <1% of adults.
- Nocturnal leg cramps definitive data is not available, but about 16%of healthy people do present it.
- Nightmares are seen in 10-15% of children between 3-5 years, it is enough to disturb their parents about 50% adult, have occasional nightmares and 1% have frequent that is more than once a week.
- Isolated sleep paralysis is seen in 4-050% of patients, and 40% patients with Narcolepsy also present sleep paralysis.
- Impaired sleep related penile erections are in 10% of the men as chronic.
- Sleep enuresis is seen in 40% of 4 year olds, 10%6 year olds, 5% 10yr olds, 3% of 12year olds, 1-3%of 18yr olds. Primary enuresis comprises of 70 -90% of all cases while 10% of it is due to secondary enuresis.
- Insomnia is seen in 30% annually and one third of them complain that the problem is severe.
- Primary snoring is seen in 40-50% of the men and lover>65yrs.
- Sudden infant death syndrome is estimated to occur in 1-2 / 1000 live births.
Sleep disorders like sleep apnoea, particularly when associated with other medical diseases, are associated with increased mortality.
Sleep related problems can cause financial loss. Three is a loss of productivity as a consequence of shift work and the increased medical care of shift workers. Admission to the hospital of elderly people with sleep duration, the cost of sleep debt fatigue related accidents are all factored in and in a country like America it is about 16,000 million. Increase in work time, which is almost 8% over the last century has the consequence of decreased leisure and sleep time. The consequence of this is fatigue and a drop in the quality of life. This again does not manifest tangibly but it reduces productivity and impairs performance.
In adolescents there is a decreased ability to retain learning, and an increased sleepiness, in the severely sleep deprived aggressive anti-social behaviour is also seen.
Unfortunately neither the medical fraternity nor the society takes this aspect of human requirement seriously.
sleep apnoea workshop hosted by Elder Pharmaceuticals.
Impact and Epidemiology of sleep disorders by Colin.M.Shapiro,William.C.Dement.