Sleep Clinics: Treating the Exhausted
Over the centuries, sleep has been described as both a blessing and a curse. Lauded and lamented in song, verse and popular culture, scientists are just beginning to understand the purpose, the benefits and the importance of sleep.
The official definition of sleep, according to the Merriam-Webster Dictionary, is “the natural periodic suspension of consciousness during which the powers of the body are restored.”
But a Tennessee sleep specialist has a more colorful description. “It’s a mysterious missing piece of your life that you know nothing about, because you’re unconscious when it happens,” offered Neal Aguillard, MD, medical director of the Methodist Sleep Disorders Center at Methodist University Hospital in Memphis.
THE IMPORTANCE OF SLEEP
He and other experts agree that while learning more and more about the “what,” science is still trying to answer the “why” of sleep. Beyond the circadian rhythms, REM and non-REM sleep and the five sleep stages, there are conflicting ideas on what is accomplished when we sleep. Some say not much, other than restoration and energy conservation; others theorize we are getting rid of waste products and restarting our neurological systems; still others believe it’s an instinct that harkens back to our “evolutionary” nature, keeping us still and silent to protect us from nocturnal predators. The one thing researchers agree on: sleep is vital to our lives and well being.
“When you don’t get enough, you feel irritable, you’re drowsy, your body is telling you (that) you need to sleep; almost like being hungry or thirsty, it’s one of those clear biological drives we have,” explained Beth Malow, MD, director of the Vanderbilt Sleep Disorder Center in Nashville and a board certified specialist in sleep medicine. “So even through we’re still trying to figure out exactly why we sleep, we do know it’s important.” Ultimately, she said, experiments have shown if we don’t sleep, we die.
How much sleep we need is another controversial point; conflicting theories and studies exist as to whether we need more or less sleep, whether sleep needs vary from person to person and whether our individual sleep needs can be willfully changed. Recommended averages from our experts ranged from six to eight hours. The sleep specialists we interviewed also agreed that as a whole, our society is sleep deprived, with varying theories on the reasons for the exhaustion.
“The invention of the light bulb ruined us,” stated Dr. Aguillard. “In times past, (when) it got dark, you went to sleep; you woke up when the sun came up. Now you can stay up all night; there’s light; you have a computer you can be stimulated by.”
Srinath Bellur, MD, a certified sleep specialist working with Dr. Aguillard, further described it as an offshoot of urbanization. “We have a demanding productive society that makes your sleep habits contrary to what would naturally be ideal in synch with our evolution,” he explained, adding the pursuit of personal gain and economic productivity gave rise to shift work, one of the main causes of sleepiness and sleep deprivation in our society.
A third specialist on the team at Methodist Sleep Disorder Center said sleep problems are often the result of a vicious circle caused by our lifestyle, especially in the South. “Culturally, with the kind of foods we eat, our lack of exercise and high stress levels, we get into some major sleep problems,” said Rob McCann, MD, a diplomate of the American Board of Sleep Medicine.
SLEEP DISORDERS & TREATMENT
Healthy sleep is elusive for an estimated 70 million Americans. There are some 85 detailed categories of sleep disorders, with the two most common being insomnia and sleep apnea; lesser disorders include Periodic Limb Movement Disorder, such as Restless Leg Syndrome (RLS) or other problems with involuntary movements of the limbs, narcolepsy, night terrors and sleepwalking.
Fortunately for those who don’t sleep well, sleep medicine has made great strides in the study, diagnosis and treatment of sleep disorders. Once thought of as luxury or “fluff” field, it has made the leap to serious multidisciplinary medicine, utilizing the expertise of internists, cardiologists, pulmonologists, critical care and respiratory care specialists, neurologists, pediatricians, psychiatrists, and allied providers including psychologists, polysomnographic technologists and even dentists. In Tennessee, there are no less than 20 sleep disorder centers accredited by the American Academy of Sleep Medicine. (See “Related Links – Accredited Sleep Centers in Tennessee”)
One of them is the Methodist University Hospital Sleep Disorder Center in Memphis, where Drs. Aguillard, Bellur and McCann work with two other MD sleep specialists and 14 polysomnographic specialists. They staff a six-bed unit seven days a week and perform some 2,200 sleep studies annually. Ninety percent of the patients treated there are diagnosed with Obstructive Sleep Apnea Syndrome; five percent have Narcolepsy; three percent have Periodic Limb Movement Disorders; and the rest have various other sleep disorders, according to a patient breakdown provided by Center Manager Kristin Lester.
Another is the Vanderbilt Sleep Disorder Center. Newly accredited in 2003, it is the first hotel-based sleep center in Middle Tennessee. The laboratory is described as state of the art, using six regular hotel rooms at one end of the 5th floor of the Vanderbilt Marriott, with additional rooms for monitoring and program support. It boasts a staff of four board-certified MD sleep specialists, supported by 13 participating specialists and technicians and five consulting specialists.
For both clinics, procedures are similar. Patients are referred by their primary care physicians, specialists or seek help on their own. They undergo an initial evaluation to determine the nature of their problem, i.e., whether they are getting enough sleep, what factors might be disturbing their sleep and whether there is a medical problem that occurs during sleep that needs to be corrected. In many cases, a sleep study is required to determine the problem. Patients are hooked up to respiratory monitors and electroencephalogram (EEG) equipment and fall asleep under the watchful eye of video surveillance. Sleep stages, arousals, breathing, oxygenation, electrocardiogram and leg movements are monitored. The results are then analyzed, hopefully leading to the proper diagnosis and treatment.
Sleep apnea is the number one complaint cited by our experts. “Most people come in with their spouse, who may be concerned they’re snoring really loud, like a freight train, or the spouse themselves may have sleep interfered with, or they may be worried that their husband or wife is stopping breathing at night,” said Vanderbilt’s Dr. Malow.
First line treatment for sleep apnea is CPAP, or continuous positive airway pressure – pressurized air is delivered through a mask to open up the patient’s airway as they sleep. While there are no side effects, the treatment does take some getting used to; patients must learn how to put on the equipment at night and clean it every morning. The clinics work with patients to teach them how to use CPAP equipment and conduct overnight sessions to get the airflow just right. Additional treatment options can include surgical correction, dental devices and weight loss
Insomnia is the second most frequent complaint, although statistics say it is the most common disorder.
“One of the more common causes for insomnia is depression; things like poor sleep hygiene practices, such as keeping regular sleep hours, use of alcohol and caffeine and smoking, certainly disrupt the normal ability to fall asleep, wake up in time and get a refreshing night’s sleep,” said Dr. Bellur. “Medications also play a major role in disturbing sleep. Medical illness, urinary frequency, itching and pain are other factors that can disrupt sleep,” he added.
Insomnia treatment can vary, depending on the cause.
“My approach is always to start with behavioral therapy,” said Dr. Malow, who said she quizzes patients on their sleep habits and sleep hygiene, stress levels, etc., before attempting to diagnose the problem. If the cause is still a mystery or a medical problem is suspected, the next step is to conduct a sleep study. If there is no medical condition causing the sleeplessness, patients are coached on sleep hygiene and behavioral techniques. Sedatives or sleeping pills are rarely prescribed by our experts, due to their tendency to lose effectiveness after eight-to-10 days, the danger of addiction and a rebound effect of even worse insomnia.
For less common disorders, such as narcolepsy, RLS and sleepwalking, the treatment is usually medication. “There are very good medications that can control most of these patients and interestingly, these are anti-Parkinsonian medications; most are safe and needed in smaller doses than Parkinson’s Disease patients and you can improve the quality of life, both night time sleep and daytime alertness,” said Dr. Bellur.
Tennessee’s sleep clinics are well equipped to help the exhausted population, but specialists said they could help a lot more people with the assistance of proper screening by primary care doctors.
“We’re missing a lot of cases that could be referred to sleep centers if the screening process is utilized,” added Dr. McCann, who said sleep evaluation is important because what may present as insomnia could actually turn out to be sleep apnea or narcolepsy, particularly among women.
“Just ask the patient why he’s not sleeping well,” suggested Dr. Aguillard, “and they’ll usually tell you, ‘I’m hurting,’ or ‘I’m waking up and I’m short of breath,’ or ‘My legs are killing me when I go to sleep at night.’ Most of the time you’ll find out without having to do some exhaustive workup.” He added if a physician feels their patient is spending enough time in bed but the sleep is not satisfying, they should refer them to a sleep specialist.
One primary care doctor in Memphis said he sees a lot of sleepy people. “Ninety percent of the things I treat can be fixed with proper sleep hygiene and exercise,” stated family practitioner Lee Berkenstock, MD, who said that includes patients with osteo and rheumatoid arthritis, fibromyalgia and morbid obesity, as well as those suffering from depression, anxiety and other psycho-social issues. He makes frequent referrals to sleep clinics but said for a lot of his patients, the issue is self discipline.
“The child in everybody bucks against that and says, ‘You’re limiting my choices,’ but you get to choose between good sleep hygiene and feeling great, or spending your money on copays, deductibles, medications, extra tests and lost productivity at work,” Dr. Berkenstock emphasized.
SLEEP HYGIENE
Our experts say the key to healthy sleep is to develop and practice good sleep hygiene. (See “Eleven Rules for Better Sleep Hygiene”)
The rules are simple but as mentioned before, require discipline and some element of self-will to break the cycle of bad sleep habits that can lead to poor or disrupted sleep.
“People often times start learning to associate the bedroom with not sleeping,” said Dr. Malow. “For example, they’ll have a big clock by the bed and they keep waking up, see the clock and say, ‘Oh my gosh, it’s 3:00 in the morning and I’m never going to get to sleep.’ I tell them to turn the clock around.” Or the patient has gotten into the habit of sitting at the computer or watching TV when they can’t sleep; these activities offer too much stimulation for the brain, making it harder to fall back to sleep. And the cycle continues.
Such was the case with Julie Griffin of Nashville, who said her insomnia began at age 19 following a tragic family event and was exacerbated by several emotional incidents, poor health and ultimately a stressful job. “It didn’t hit all at once; it kind of came on and grew for me to the point that even a year ago, I was averaging maybe five to 10 hours of sleep a week,” she said. “Nobody understands what it’s like when you can’t get sleep,” she added. “They can’t comprehend how devastating it can be to every aspect of your life.”
Now in her 30s, Griffin is working with her primary care physician to change her sleep habits: she has eliminated most caffeine, avoids eating large meals late in the evening and tries to stay away from the TV and computer late at night. She said a job change also led to a major reduction in stress and as a result, she is sleeping better and losing weight; she now averages four to five hours of sleep a night.
“This is not something you can fix overnight,” Griffin stated. “I’m not fixed now – I’m not getting eight hours and don’t know that I ever will; part of that may be my personality. But I’m striving to get there.”
Our experts say lack of sleep will catch up eventually and can wreak havoc on emotional and physical well being. It’s especially important for shift workers who are on the job when the rest of the world is sleeping … or trying to. That can include doctors, as well as their patients.
“It’s like a bank account; if you know you’ll have a period of time where you’ve got to stay wake, you’ve got to make a sleep deposit,” advised Dr. Aguillard. “You’ve got to pay the piper – at some point, you’ve got to get some sleep.”
