Improving Sleep: A guide to a good night's rest

 | October 1, 2007

Improving Sleep: A guide to a good night's rest

Some nights, sleep comes easily, and you sail through the night in a satisfying slumber. Waking up after a night of good sleep feels wonderful you're refreshed, energized, and ready to take on the world. Other nights, sleep comes slowly or not until the wee hours. Or you may fall asleep, only to awaken throughout the night.

If you have trouble sleeping, you're not alone. Almost everyone occasionally suffers from short-term insomnia. According to the National Institutes of Health, about 60 million Americans a year have insomnia frequently or for extended periods of time. About half of all people over 65 have frequent sleeping problems, and an estimated 40 million Americans have a chronic sleep disorder such as sleep apnea, restless legs syndrome, or narcolepsy. We pay a high price for all the sleep deprivation caused by sleep problems. For example:

• Insufficient sleep is directly linked to poor health, with research suggesting it increases the risk of diabetes, heart disease, obesity, and even premature death. Even a few nights of bad sleep can be detrimental.

• The combination of sleep deprivation and driving can have deadly consequences. A 2006 review by the Institute of Medicine of the National Academy of Sciences found that almost 20% of all serious car accidents and 57% of fatal accidents are associated with driver sleepiness.

• Sleep deprivation played a role in catastrophes such as the Exxon Valdez oil spill off the coast of Alaska, the space shuttle Challenger explosion, and the nuclear accident at Three Mile Island.

Sleep problems affect virtually every aspect of day-to-day living, including mood, mental alertness, work performance, and energy level. Yet few Americans seek treatment for their sleep problems. If you aren't getting your share of sleep, you needn't fumble about in a fog of fatigue. This report describes the complex nature of sleep, the latest in sleep research, the factors that can disturb sleep, and, most importantly, what you can do to get the sleep you need for optimal health, safety, and well-being.

Sleep mechanics

For centuries, scientists scrutinized minute aspects of human activity, but showed little interest in the time that people spent in sleep. Sleep seemed inaccessible to medical probing and was perceived as an unvarying period of inactivity a subject best suited to poets and dream interpreters who could conjure meaning out of the void. All that changed in the 1930s, when scientists learned to place sensitive electrodes on the scalp and record the signals produced by electrical activity in the brain. These brain waves can be seen on an electroencephalogram, or EEG (see Figure 1), which today is captured on a computer screen. Since then, researchers gradually came to appreciate that sleep is a highly complex activity. Using electrodes to monitor sleepers' eye movements, muscle tone, and brain wave patterns, they identified several discrete stages of sleep. And today, researchers continue to learn how certain stages of sleep help to maintain health, growth, and functioning.

Scientists divide sleep into two major types: rapid eye movement (REM) sleep or dreaming sleep, and non-REM or quiet sleep. Surprisingly, they are as different from one another as sleeping is from waking.

Figure 1: EEG brain wave patterns during sleep These brain waves, taken by electroencephalogram, are used by sleep experts to identify the stages of sleep. Close your eyes and your brain waves will look like the first band, "relaxed wakefulness." Theta waves indicate Stage N1 sleep. (The "N" designates non-REM sleep.) Stage N2 sleep shows brief bursts of activity as sleep spindles and K-complex waves. Deep sleep is represented by large, slow delta waves (Stage N3).

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Quiet sleep

Sleep specialists have called non-REM or quiet sleep "an idling brain in a movable body." During this phase, thinking and most physiological activities slow down, but movement can still occur, and a person often shifts position while sinking into progressively deeper stages of sleep.

To an extent, the convention of describing people "dropping" into sleep actually parallels changes in brain wave patterns at the onset of non-REM sleep. When you are awake, billions of brain cells receive and analyze sensory information, coordinate behavior, and maintain bodily functions by sending electrical impulses to one another. If you're fully awake, the EEG will record a messy, irregular scribble of activity. Once your eyes are closed and your nerve cells no longer receive visual input, brain waves settle into a steady and rhythmic pattern of about 10 cycles per second. This is the alpha-wave pattern, characteristic of calm, relaxed wakefulness.

The transition to quiet sleep is a quick one that might be likened to flipping a switch that is, you are either awake (switch on) or asleep (switch off), according to research. Some brain centers and pathways stimulate the entire brain to wakefulness; others promote falling asleep. One chemical, hypocretin, seems to play an important role in regulating when the flip between states occurs and keeping you in the new state. Interestingly, people with narcolepsy often lack hypocretin, and they consequently flip back and forth between sleep and wakefulness frequently.

Snoozing News While the average American adult spends about 7.5 hours a day sleeping, cats snooze about 15 hours a day. Horses sleep 3 hours a day, and bats log 20 hours.

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Dreaming (REM) sleep

Dreaming occurs during REM sleep, which has been described as an "active brain in a paralyzed body." Your brain races, thinking and dreaming, as your eyes dart back and forth rapidly behind closed lids. Your body temperature rises. Your blood pressure increases, and your heart rate and breathing speed up to daytime levels. The sympathetic nervous system, which creates the fight-or-flight response, is twice as active as when you're awake. Despite all this activity, your body hardly moves, except for intermittent twitches; muscles not needed for breathing or eye movement are quiet.

Just as slow-wave sleep restores your body, scientists believe that REM or dreaming sleep restores your mind, perhaps in part by helping clear out irrelevant information. Studies of students' ability to solve a complex puzzle involving abstract shapes suggest the brain processes information overnight; students who got a good night's sleep after seeing the puzzle fared much better than those asked to solve the puzzle immediately. Earlier studies found that REM sleep facilitates learning and memory. People tested to measure how well they had learned a new task improved their scores after a night's sleep. If they were roused from REM sleep, the improvements were lost. On the other hand, if they were awakened an equal number of times from slow-wave sleep, the improvements in the scores were unaffected. These findings may help explain why students who stay up all night cramming for an examination generally retain less information than classmates who get some sleep.

About three to five times a night, or about every 90 minutes, a sleeper enters REM sleep. The first such episode usually lasts only for a few minutes, but REM time increases progressively over the course of the night. The final period of REM sleep may last a half-hour. Altogether, REM sleep makes up about 25% of total sleep in young adults. If someone who has been deprived of REM sleep is left undisturbed for a night, he or she enters this stage earlier and spends a higher proportion of sleep time in it a phenomenon called REM rebound.

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Sleep architecture

During the night, a normal sleeper moves between different sleep stages in a fairly predictable pattern, alternating between REM and non-REM sleep. When these stages are charted on a diagram, called a hypnogram (see Figure 2), the different levels resemble a drawing of a city skyline. Sleep experts call this pattern sleep architecture.

In a young adult, normal sleep architecture usually consists of four or five alternating non-REM and REM periods. Most deep sleep occurs in the first half of the night. As the night progresses, periods of REM sleep get longer and alternate with Stage N2 sleep. Later in life, the sleep skyline will change, with less Stage N3 sleep, more Stage N1 sleep, and more awakenings.

Figure 2: Sleep architecture When experts chart sleep stages on a hypnogram, the different levels resemble a drawing of a city skyline. This pattern is known as sleep architecture. The hypnogram above shows a typical night's sleep of a healthy young adult.

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Your internal clock

Scientists have discovered that certain brain structures and chemicals produce the states of sleeping and waking.

A pacemaker-like mechanism in the brain regulates the circadian rhythm of sleeping and waking. ("Circadian" means "about a day.") This internal clock, which gradually becomes established during the first months of life, controls the daily ups and downs of biological patterns, including body temperature, blood pressure, and the release of hormones.

The circadian rhythm makes people's desire for sleep strongest between midnight and dawn, and to a lesser extent in midafternoon. In one study, researchers instructed a group of people to try to stay awake for 24 hours. Not surprisingly, many slipped into naps despite their best efforts not to. When the investigators plotted the times when the unplanned naps occurred, they found peaks between 2 a.m. and 4 a.m. and between 2 p.m. and 3 p.m.

Most Americans sleep during the night as dictated by their circadian rhythms, although many nap in the afternoon on the weekends. In societies where taking a siesta is the norm, people can respond to their bodies' daily dips in alertness with a one- to two-hour afternoon nap during the workday and a correspondingly shorter sleep at night.

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Sleep throughout life

To a certain extent, heredity determines how people sleep throughout their lives. Identical twins, for example, have much more similar sleep patterns than nonidentical twins or other siblings. Differences in sleeping and waking seem to be inborn. There are night owls and early-morning larks, sound sleepers and light ones, people who are perky after five hours of sleep and others who are groggy if they log less than nine hours. Nevertheless, many factors can affect how a person sleeps. Aging is the most important influence on basic sleep rhythms from age 20 on, it takes longer to fall asleep, you sleep less at night, Stages N1 and N2 sleep increase, Stage N3 sleep and REM sleep decrease, and nighttime awakenings increase (see Table 1).

TABLE 1: Sleep changes during adulthood
As people age, it takes longer to fall asleep (increased sleep latency). And sleep efficiency or the percentage of time spent asleep while in bed decreases as people grow older.
	Age 20	Age 40	Age 60	Age 70	Age 80
Sleep latency	16 minutes	17 minutes	18 minutes	18.5 minutes	19 minutes
Total sleep time	7.5 hours	7 hours	6.2 hours	6 hours	5.8 hours
% of time in Stage N2 sleep	47%	51%	53%	55%	57%
% of time in Stage N3 sleep	20%	15%	10%	9%	7.5%
% of time in REM sleep	22%	21%	20%	19%	17%
Sleep efficiency	95%	88%	84%	82%	79%
Sleep Source: Ohayon MM, et al. "Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan," (2004), Vol. 27, No. 7, pp. 1255-73.

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Childhood

For an adult to sleep like a baby is not only unrealistic but also undesirable. A newborn may sleep eight times a day, accumulating 18 hours of sleep and spending about half of it in REM sleep. The REM to non-REM cycle is shorter, usually lasting less than an hour.

At about the age of 4 weeks, a newborn's sleep periods get longer. By 6 months, infants spend longer and more regular periods in non-REM sleep; most begin sleeping through the night and taking naps in the morning and afternoon. During the preschool years, daytime naps gradually shorten, until by age 6 most children are awake all day and sleep for about 10 hours a night.

Between age 7 and puberty, nocturnal melatonin production is at its lifetime peak, and sleep at this age is deep and restorative. At this age, if a child is sleepy during the day, parents should be concerned.

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Adolescence

In contrast, adolescents are noted for their daytime drowsiness. Except for infancy, adolescence is the most rapid period of body growth and development. Although teenagers need about an hour more sleep each day than they did as young children, most of them actually sleep an hour or so less. Parents usually blame teenagers' busy schedule of activities for their grogginess and difficulty awakening in the morning. However, the problem may also be biological. One study indicated that some adolescents might have delayed sleep phase syndrome, where they are not sleepy until well after the usual bedtime and cannot wake at the time required for school, producing conflicts between parents and sleepy teenagers as well as with secondary schools, which usually open earlier than elementary schools. It is unknown whether this phase shift occurs primarily as a physiological event or as a response to abnormal light exposure.

Snoozing News The average length of time Americans spend sleeping has dropped from about 9 hours a night in 1910 to about 7.5 hours today.

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Adulthood

During young adulthood, sleep patterns usually seem stable but in fact are slowly evolving. Between age 20 and age 30, the amount of slow-wave sleep drops by about half, and nighttime awakenings double. By age 40, slow-wave sleep is markedly reduced.

Women's reproductive cycles can greatly influence sleep. During the first trimester of pregnancy, many women are sleepy all the time and may log an extra two hours a night if their schedules permit. As pregnancy continues, hormonal and anatomical changes reduce sleep efficiency so that less of a woman's time in bed is actually spent sleeping. As a result, fatigue increases (see "Getting a good night's sleep during pregnancy"). The postpartum period usually brings dramatic sleepiness and fatigue because the mother's ability to sleep efficiently has not returned to normal, because she is at the mercy of her newborn's rapidly cycling shifts between sleeping and waking, and because breast-feeding promotes sleepiness. Researchers are probing whether sleep disturbances during pregnancy may contribute to postpartum depression and compromise the general physical and mental well-being of new mothers.

Women who aren't pregnant may experience monthly shifts in sleep habits. During the second phase of the menstrual cycle, between ovulation and the next menses, some women fall asleep and enter REM sleep more quickly than usual. A few experience extreme sleepiness. Investigators are studying the relationship between such sleep alterations, cyclic changes in body temperature, and levels of the hormone progesterone to see whether these physiologic patterns also correlate with premenstrual mood changes.

Getting a good night's sleep during pregnancy According to a National Sleep Foundation poll, nearly 8 in 10 women reported disturbed sleep during pregnancy. Here are some tips to help you get a better night's sleep when you're expecting: Avoid spicy, fried, or acidic foods (such as tomato products), which contribute to heartburn. If you have heartburn, elevate your pillow or raise the head of your bed by placing blocks under the bedposts. Prevent nausea by eating frequent snacks during the day. If you feel drowsy, take a midday nap. Exercise regularly, which will help reduce leg cramps and improve sleep. Cut down on fluids before bedtime to reduce nighttime trips to the bathroom. Use pillows or special pregnancy cushions to support your abdomen.

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Middle age

When men and women enter middle age, slow-wave sleep continues to diminish. Nighttime awakenings become more frequent and last longer. Waking after about three hours of sleep is particularly common. During menopause, many women experience hot flashes that can interrupt sleep and lead to chronic insomnia. Obese people are more prone to nocturnal breathing problems, which often start during middle age. Men and women who are physically fit sleep more soundly as they grow older, compared with their sedentary peers.

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The later years

Like younger people, older adults still spend about 20% of sleep time in REM sleep, but other than that, they sleep differently. Slow-wave sleep accounts for less than 5% of sleep time, and in some people it is completely absent. Falling asleep takes longer, and the shallow quality of sleep results in dozens of awakenings during the night. Doctors used to reassure older people that they needed less sleep than younger ones to function well, but sleep experts now know that isn't true. At any age, most adults need seven and a half to eight hours of sleep to function at their best. Since older people often have trouble attaining this much sleep at night, they often supplement nighttime sleep with daytime naps. This can be a successful strategy for accumulating sufficient total sleep over a 24-hour period. However, if you find that you need a nap, it's best to take one midday nap, rather than several brief ones scattered throughout the day and evening.

Sleep disturbances in elderly people, particularly in those who have Alzheimer's disease or other forms of dementia, are very disruptive for caregivers. In one study, 70% of caregivers cited these problems as the decisive factor in seeking nursing home placement for a loved one.

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Consequences of sleep deprivation

Many people don't realize that lack of sufficient sleep can lead to a range of ill effects, triggering mild to potentially life-threatening consequences. There are several different types of sleep deprivation that vary in duration and severity. These can be broadly categorized as complete or partial sleep deprivation.

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Complete sleep deprivation

Normally, you go about 16 or 17 hours between sleep sessions. Complete sleep deprivation happens as the hours extend beyond this point. First you feel tired, then exhausted. By 2 or 3 a.m., many people have a hard time keeping their eyes open, but the effects extend throughout the body. Simple tasks that you would normally have no trouble accomplishing start to become difficult.

In fact, a number of studies of hand-eye coordination and reaction time have shown that such sleep deprivation can be as debilitating as being intoxicated. In one study, volunteers stayed awake for 28 hours, beginning at 8 a.m., and periodically took driving simulation tests. At a different time, the volunteers' driving ability was tested after drinking 10 to 15 grams of alcohol at 30-minute intervals until their blood alcohol content (BAC) level reached 0.10. The study concluded that 24 hours of wakefulness had the same deleterious effect on driving ability as that of a BAC of 0.10 enough to be charged with driving while intoxicated in most states.

Sleep deprivation also leaves you prone to two potentially dangerous phenomena, microsleeps and automatic behavior (see below), which play a role in thousands of transportation accidents each year. When complete sleep deprivation extends for two or three days, people have difficulty completing tasks demanding a high attention level and often experience mood swings, depression, and increased feelings of tension.

Performance is also highly influenced by fluctuations in circadian rhythms. For example, sleep-deprived people may still function fairly well during the morning and evening. But during the peaks of sleepiness in the afternoon and overnight hours, people often literally cannot stay awake and may fall asleep while standing, sitting, or even while talking on the telephone, working on the computer, or eating. A small percentage experience paranoia and hallucinations.

Microsleeps and automatic behavior Microsleeps are brief episodes of sleep that occur in the midst of ongoing wakeful activity. They usually last a few seconds but can go on for 10 or 15 seconds. Brain wave monitoring by EEG of someone experiencing microsleeps shows brief periods of Stage N1 sleep intruding into wakefulness. During this time, the brain does not respond to noise or other sensory inputs and you don't react to things happening around you. "Nodding off" can be the result of a microsleep. Automatic behavior refers to a period of several minutes or more during which a person is awake and performing routine duties but not attending to his or her surroundings or responding to changes in the environment. Examples include a driver who keeps his car on the road but misses his intended exit and a train engineer who can continue pressing a lever at regular intervals but doesn't notice an obstruction on the track.

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Partial sleep deprivation

Partial sleep deprivation occurs when you get some sleep, but not 100% of what you need. Experts refer to this as building up a sleep debt. An example would be when a person who needs 7.5 hours of sleep a night hits a stretch of several days in a row in which he or she only gets four to six hours.

After a single night of short sleep, most people function at or near their normal level. They may not feel great, but they can usually get through the day without others noticing that anything is amiss. After two or more nights of short sleep, people usually show signs of irritability and sleepiness. Work performance begins to suffer particularly on complicated tasks and people are more likely to complain of headaches, stomach problems, and sore joints. In addition, people face a far higher risk of falling asleep on the job and while driving.

Long-term partial sleep deprivation occurs when someone gets less than the optimal amount of sleep for months or years on end a common scenario for insomniacs and people with sleep disorders. But even healthy people who can't resist the round-the-clock commerce, communication, and entertainment opportunities our 24/7 society now offers may fall prey to this problem.

A growing number of studies have linked long-term sleep deficits with significant health problems.

Obesity. A 2006 study found that over 16 years, middle-aged women who reported sleeping five hours or less per night were 32% more likely to gain 33 pounds or more than women who slept seven hours or more. Another study found that men limited to four hours of sleep for two consecutive nights experienced hormonal changes that made them feel hungry and crave carbohydrate-rich foods such as cakes, candy, ice cream, and pasta.

Heart health. Middle-aged people who sleep five hours or less a night have a greater risk of developing high blood pressure, compared with people who sleep seven to nine hours a night. Women who averaged five hours of sleep a night were 39% more likely to develop heart disease than women who slept eight hours.

Mental health. A number of studies have found that persistent insomnia raises the risk for anxiety, depression, and other mood disorders.

Mortality. A study of almost a million people over age 30 found that men who reported usually sleeping less than four hours a day were nearly three times as likely to die within six years as men who said they averaged seven or eight hours of sleep.

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Sleep as part of a healthy lifestyle

Clearly, getting enough sleep is just as important as other vital elements of good health, such as eating a healthy diet, getting regular exercise, and practicing good dental hygiene. In short, sleep is not a luxury but a basic component of a healthy lifestyle.

Just like purchasing healthy foods, taking an after-dinner walk, or flossing your teeth, getting adequate sleep requires time and discipline. Mentally block off certain hours for sleep and then follow through on your intention, avoid building up a sleep debt, and take steps to set up an ideal sleep environment. Seek a doctor's help if conventional steps toward good sleep don't work.

This doesn't mean that you can't have any fun, or that you need to beat yourself up if you don't get eight hours of sleep 365 days a year. Just as an occasional ice cream sundae won't make you obese, staying up a few extra hours for a party or to meet a deadline is perfectly acceptable as long as you make plans to compensate the next day by sleeping in, taking a short afternoon nap, or going to bed earlier. If you have to get up at 7 a.m. to be at work by 9, you'd best forgo late-night talk shows or record them to watch the next evening. If you don't get to bed until 2 a.m. one night, allow time over the next day or two to catch up on lost sleep. But over the long haul, you need to make sure you consistently get enough sleep.

Sleep decisions are a quality-of-life issue. Whatever your interests and goals, getting enough sleep puts you in a better position to enjoy and achieve them.

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General ways to improve sleep

Many things can interfere with sleep, ranging from anxiety to an unusual work schedule. People who have difficulty sleeping often discover that their daily routine holds the key to nighttime woes. Before examining specific sleep problems, let's look at some common enemies of sleep and some tips for dealing with them.

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Medical conditions and sleep problems

People who feel they sleep perfectly well may still be troubled by excessive daytime sleepiness because of a variety of underlying medical illnesses, including kidney or liver disease and respiratory disorders. A sleep disturbance may be a symptom of underlying medical illness itself or an adverse effect of therapy to treat the problem. The stress of chronic illness can also cause insomnia and daytime drowsiness. Common conditions often associated with sleep problems include heartburn, diabetes, cardiovascular disease, musculoskeletal disorders, kidney disease, mental illness, neurological disorders, respiratory problems, and thyroid disease.

Snoozing News About 10% of adults report that they use prescription sleep medications, and the number of adults ages 20 to 44 who take them doubled from 2000 to 2004.

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Insomnia

People with insomnia may be plagued by trouble falling asleep, unwelcome awakenings during the night, and fitful sleep. They may experience daytime drowsiness, yet still be unable to nap, and are often anxious and irritable or forgetful and unable to concentrate.

In a poll conducted by the National Sleep Foundation, more than half of adults said they experienced one or more symptoms of insomnia at least a few nights a week. Although it's the most common sleep disturbance, insomnia is not a single disorder, but rather a general symptom like fever or pain. Finding a remedy requires uncovering the cause.

Nearly half of insomnia cases stem from psychological or emotional problems. Stressful events, mild depression, or an anxiety disorder can keep people awake at night. With proper treatment of the underlying cause, the insomnia usually recedes. If it doesn't, additional treatment focusing on sleep may help.

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Types of insomnia

One way doctors classify insomnia is by its duration. Insomnia is considered transient if it lasts only a few days, short-term if it continues for a few weeks, and chronic if the problem persists.

The causes of transient or short-term insomnia are usually apparent to the sufferer the death of or separation from a loved one, nervousness about an upcoming event (such as a wedding, public speaking engagement, or move), jet lag, or discomfort from an illness or injury. Chronic insomnia may be caused by a number of medications or medical conditions (see "Medical conditions and sleep problems"). In these instances, treating the condition or changing the medication may relieve the insomnia.

One common form of persistent sleeplessness is learned insomnia. After experiencing a few sleepless nights, some people learn to associate the bedroom with being awake. Taking steps to cope with sleep deprivation napping, drinking coffee, having a nightcap, or forgoing exercise only fuels the problem. As insomnia worsens, anxiety regarding the insomnia may also worsen, leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia.

Snoozing News The National Institutes of Health estimates that in the United States the annual direct cost of treating insomnia including money spent on insomnia remedies, health care services, and hospital and nursing home care is nearly $14 billion. The agency reports that indirect costs due to property damage from accidents, lost productivity, and transportation to medical appointments tally about $28 billion.

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First-line treatment: Behavioral changes

For chronic insomnia, the treatment of choice is to change your lifestyle and habits. A careful evaluation can pinpoint habits that keep you up at night. A sleep specialist trained in behavioral medicine can help people with learned insomnia replace their bad habits with positive ones.

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Medications and other insomnia treatments

A variety of products including prescription medications and over-the-counter preparations can treat insomnia (see Table 2). But their effectiveness varies and some may carry unpleasant side effects, so talk to your doctor about which option is best for you.

Antihistamines . Most over-the-counter sleep aids contain antihistamines, which are also used to treat allergies and motion sickness. But physicians don't usually encourage these drugs for sleep problems because they're often ineffective and may cause dizziness, blurred vision, constipation, nausea, and next-day grogginess. (For more on over-the-counter products, see "Nonprescription sleep aids.")

Benzodiazepines. Doctors often prescribe these medications, which enhance the activity of GABA, a neurotransmitter that calms brain activity. Different benzodiazepines vary in how quickly they take effect and how long they remain active in the body. Taken at night, benzodiazepines can lead to next-day drowsiness and sedation. If your main problem is getting to sleep, your doctor may prescribe one that begins working quickly and is short-acting, such as triazolam (Halcion). If your problem is staying asleep, a drug that lasts longer such as estazolam (ProSom) or temazepam (Restoril) may be necessary. Some drugs in this class also act as muscle relaxants and may be prescribed for this purpose. Benzodiazepines also treat anxiety, so they are useful for patients with anxiety and insomnia that results from it.

One drawback of benzodiazepines is that they reduce how much deep sleep you get. Also, many people who use benzodiazepines develop tolerance the need for more and more of the drug to obtain the same effect. After a few weeks, the drugs may no longer promote sleep. Another risk is that stopping the medication abruptly after long-term use can cause insomnia that's even worse than the insomnia you had before you started taking the drug (a phenomenon known as rebound). These medications should be discontinued under a doctor's supervision because withdrawal may lead to muscle tension, restlessness, irritability, or, in rare cases, convulsions.

Nonbenzodiazepines. These medications resemble benzodiazepines in their ability to enhance the sleep-inducing activity of GABA, but they have a slightly different chemical composition. While benzodiazepines affect multiple brain receptors, the nonbenzodiazepines act only on the sleep receptors in your brain, which means they cause fewer side effects. They also appear to have little or no effect on deep sleep.

Many physicians now prescribe these drugs in situations where they formerly prescribed benzodiazepines. Zolpidem (Ambien) was the first to gain FDA approval, in 1992, followed by zaleplon (Sonata) in 1999 and eszopiclone (Lunesta) in 2004.

All three medications make you fall asleep quicker, but only Ambien and Lunesta lengthen total sleep time. Sonata and Ambien both act quickly (within 20 minutes) and, for the most part, wear off before your typical waking time. Sonata wears off especially quickly, so it may not keep you asleep the whole night if you take it before bed, but you can take one if you wake up in the middle of the night and can't fall back asleep. Lunesta takes a little longer to take effect and also lasts longer. A long-acting version of Ambien, called Ambien CR, became available in 2005 for problems with staying asleep as well as falling asleep.

While Ambien and Sonata are both approved only to treat short-term insomnia (for up to 30 days), Lunesta is approved to treat insomnia for up to six months. This does not mean Lunesta is necessarily superior just that its manufacturer took the time and expense to conduct studies to show the drug is safe and effective for longer use.

While nonbenzodiazepines have fewer drawbacks than antihistamines or benzodiazepines, they're not perfect for everyone. Some people find the drugs aren't powerful enough to put them to sleep. And they may still cause morning grogginess, tolerance, and rebound insomnia, as well as headache, dizziness, nausea, and, in rare cases, sleepwalking and sleep eating (see "Sleeping pills and sleep eating," below). We also don't yet know the long-term effects of nonbenzodiazepines. Even so, they have quickly become more commonly prescribed than benzodiazepines.

Antidepressants. Physicians increasingly prescribe certain antidepressant medications to people with insomnia, usually at a lower dose than typically would be used to treat depression. The serotonin modulator trazodone (Desyrel) and the tricyclics amitriptyline (Elavil, Endep) and doxepin (Sinequan) are among the most commonly prescribed for insomnia. However, antidepressants are neither approved for insomnia nor proven effective for it. Some doctors believe antidepressants have fewer side effects and are safer for long-term use than benzodiazepines, and that insomnia is often related to depression. However, no convincing evidence supports these beliefs. Also, antidepressants have fewer regulatory restrictions than benzodiazepines, so they're easier to prescribe.

Still, antidepressants do seem to help some people. Studies of depressed people who also have sleep problems show that the medication reduces sleep latency and nighttime arousals. How they work isn't clear, but sleep may result from a sedative effect. Or the drugs' ability to ease anxiety and mild depression may make it easier for people with these problems to relax and fall asleep.

Antidepressants' effect on sleep quality varies; in general, they reduce REM sleep but have little impact on deep sleep. Side effects namely dizziness, dry mouth, upset stomach, weight gain, and sexual dysfunction are common. These drugs also can increase leg movements during sleep. Some people find certain antidepressants make them feel nervous or restless, so the medication can actually exacerbate insomnia. It's not clear if these medications lead to tolerance or rebound insomnia.

Melatonin receptor agonist. Ramelteon (Rozerem) is a melatonin receptor agonist the first new sleep medication class in 30 years. Rozerem is approved to treat insomnia for people who have trouble falling asleep at bedtime.

Rozerem works by attaching to the same receptors on the suprachiasmatic nucleus that the body's naturally produced melatonin does. The suprachiasmatic nucleus controls the circadian cycle of sleep and wakefulness. Rozerem has a more potent effect than ingested melatonin, which helps some people fall asleep faster and can be used to change the circadian sleep phase.

Rozerem's most common side effect is dizziness, and it may also worsen symptoms of depression. People with severe liver damage or who use the antidepressant fluvoxamine (Luvox) shouldn't take it. Rozerem has a short half-life of two to five hours. Citing clinical studies that found Rozerem did not cause tolerance, dependence, or rebound insomnia, the drug's manufacturer promotes it for long-term use.

The drug may be more likely to benefit older rather than younger people, since people produce less melatonin as they age. However, older people's primary sleep problem tends to be waking up during the night, not falling asleep at the beginning of the night, suggesting Rozerem's usefulness may be limited. More studies and clinical experience should help clarify the picture.

Sleeping pills and sleep eating Several news reports in 2006 drew attention to a strange side effect of Ambien use: sleep eating. People were seen foraging for food at night but were unable to remember the episodes in the morning, or they reported finding evidence of a midnight feast with no recollection of the event. Several people even gained quite a lot of weight. Other unusual side effects seen with Ambien and related drugs include sleepwalking, short-term amnesia, and, rarely, sleep driving. Some of the driving cases occurred when people took sleep medication after drinking alcohol. As a result of these incidents, in 2007 the FDA ordered the drugs' manufacturers to issue strong new label warnings about the risks of unusual behavior and to produce brochures about safe use. Although rare, these incidents highlight the need for people who use sleep medication to be aware of the potential side effects and to use them properly. Always allow enough time for sleep, use only as directed, and avoid alcohol. If you experience any unusual occurrences, talk to your doctor right away.

Nonprescription sleep aids Your drugstore carries a bewildering variety of over-the-counter (OTC) sleep products, and there's clearly a market for such products. One small survey of people ages 60 and over found that more than a quarter had taken OTC sleeping aids in the preceding year and that 1 in 12 did so daily. But do these products work? And if you try them, should you choose a sleeping pill, an herbal remedy, a dietary supplement, or a mechanical device? Standard OTC sleeping pills. Behind the riot of competing brands, this class of products is surprisingly straightforward. Each one whether a tablet, capsule, or gelcap contains an antihistamine as its primary active ingredient (see "Medications and other insomnia treatments"). Most OTC sleep aids including Nytol, Sominex, and others contain 25 to 50 milligrams (mg) of the antihistamine diphenhydramine. A few, such as Unisom SleepTabs, contain 25 mg of doxylamine, another antihistamine. Others including Aspirin-Free Anacin PM and Extra Strength Tylenol PM combine antihistamines with 500 mg of the pain reliever acetaminophen. OTC antihistamines have a sedating effect and are generally safe. But they can cause nausea and, more rarely, fast or irregular heartbeat, blurred vision, or heightened sensitivity to sunlight. Complications are generally more common in children and people over age 60. Alcohol heightens the effect of these medications, which can also interact adversely with some drugs. If you take OTC sleeping pills, be sure to ask your physician about the possibility of interactions with other medications. Because of their side effects and because these OTC medications are often ineffective in relieving sleep problems sleep experts generally advise against using them. Dietary supplements and alternative medicines. A 2004 study of alternative medicine use discovered that in the past 12 months, 36% of adult Americans had used alternative medicines, including herbal sleep aids. Your local drugstore probably shelves these products alongside other herbal remedies and vitamins. As with other dietary supplements, the FDA does not regulate these products, so they aren't tested for safety, effectiveness, quality, or accuracy of labeling. Although marketed as "natural," these products may contain biologically active substances that can have side effects or interact with other medications or supplements. If you're thinking about using such products (or already do so) be sure to tell your doctor. Many herbal products include a variety of active ingredients. Before using these products check with your doctor or pharmacist to see whether the ingredients might interact with other medications you're taking. Even a single herb is a complex chemical stew. Valerian root extract, for example, contains more than 100 specifically identified substances. Researchers don't know precisely which of these accounts for the herb's effect, nor can they say exactly how they might interact with other medications. Finally, the per-dose price of these remedies varies far more than that of standard sleeping pills. Scientific understanding of these substances is limited, and what we know generally comes from small, short-term studies. Thus, most doctors discourage the use of herbal medicines as sleep aids. But the market for such products is booming. Readily available alternative sleep remedies include the following: Valerian (Valeriana officinalis). Journal of Clinical Sleep Medicine A few studies suggest that valerian is mildly sedating and can help people fall asleep and improve their sleep quality. However, a 2005 review in the pointed out that most of the studies were small and flawed, and that even the positive studies showed only a mild effect. Also, the National Institutes of Health's 2005 State of the Science Conference statement on insomnia notes that "limited evidence [on valerian] shows no benefit compared with placebo." The most common reported side effects are headaches, dizziness, itching, and gastrointestinal disturbances. As with other unregulated remedies, the quality of valerian-containing products varies widely. A report by ConsumerLab a commercial laboratory that periodically tests the quality of herbal remedies found that nearly a quarter of valerian-based products appeared to contain no valerian whatsoever, and an equal number had less than half the amount claimed on their labels. Kava (Piper methysticum). Kava comes from a plant cultivated in the South Pacific islands. The German Commission E which tests the quality and effectiveness of herbal remedies marketed in Germany has found it effective in the treatment of anxiety. Some studies also report a benefit for treating insomnia. But scientists don't understand how kava works. High doses over prolonged periods can cause skin reactions and liver failure, and in 2002 the FDA warned users of the potential risk of liver damage after a previously healthy 45-year-old woman took kava, suddenly developed liver failure, and required a liver transplant. Chamomile. Tea made from this flower, a member of the daisy family, is a traditional remedy long used to help people relax and become drowsy. Chamomile is both mild and safe although rare allergic reactions, including bronchial constriction, can occur. If you're allergic to plants in the daisy family, which includes ragweed, you should probably avoid this herb. There are no scientific studies showing chamomile is effective in treating insomnia. Synthetic melatonin. The brain's production of the hormone melatonin peaks in the late evening, in conjunction with the onset of sleep. Since the 1990s, a synthetic version has been widely available in the United States as a supplement at health food stores and pharmacies. In Great Britain and Canada, melatonin is classified as a medicine and available by prescription only. Despite some initial enthusiasm for synthetic melatonin, most subsequent research has been disappointing, finding either minimal benefits or none at all. A 2004 review of the melatonin research by the federal Agency for Healthcare Research and Quality (AHRQ) concluded that the supplement "is not effective in treating most sleep disorders." However, a subset of people do appear to benefit: those whose insomnia results from delayed sleep phase syndrome (see "Delayed sleep phase syndrome"), a circadian rhythm disorder in which people don't start to feel sleepy until hours after the traditional bedtime. The AHRQ review found that melatonin enables people with this disorder to fall asleep an average of nearly 40 minutes faster than they would with a placebo. Melatonin has a short half-life (one or two hours) and does not appear to pose any major health risks when taken for a short time. The most commonly reported side effects are nausea, headache, and dizziness. Its long-term effects are unknown. Mechanical devices. Specially designed orthopedic pillows may help people with insomnia sleep better. For people with sleep problems due to snoring or nasal congestion, adhesive-backed nasal strips (such as Breathe Right) or devices such as NoseWorks, a small plastic nasal support, may provide relief. Manufacturers contend that such products help keep nasal passages open, reduce snoring, and increase airflow, thus improving sleep. But little independent research has evaluated these claims, and many people who try them find they don't work.

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Breathing disorders in sleep

Although relaxed and steady breathing is natural for most sleepers, some people snore so loudly that they literally wake the neighbors. Loud snoring may be a sign of sleep apnea, a life-threatening condition marked by frequent interruptions in breathing. In most cases, however, people who snore only suffer from simple snoring produced when the muscles of the airways relax during sleep a condition that doesn't cause medical complications but may disrupt others sleeping nearby.

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Snoring

With the onset of sleep, muscles in the airway relax and the airway narrows. Snoring occurs when the airway narrows too much, causing turbulent airflow. This, in turn, makes the surrounding tissue vibrate, producing noise. More than one-third of adults in one survey said they snored at least a few nights a week in the previous year.

When a person's nasal passages are swollen by a cold, allergies, or a reaction to smoking, temporary snoring may occur. For someone with a deviated septum, the problem is ongoing. A particularly large uvula; enlarged tonsils, adenoids, or tongue; an elongated soft palate; or a very small jaw may also contribute to snoring.

In yet other people, excess fat in the neck area may reduce the width of the air passage and promote snoring. The hormones progesterone and estrogen may play a protective role; before menopause, women snore less than men, but snoring increases among women later in life. Many women snore late in their pregnancies, a phenomenon attributed to hormone-related swelling of airway tissues.

Although snoring is rarely life-threatening, sleep specialists take even simple snoring seriously. A person who snores heavily deserves a thorough examination of the throat, mouth, palate, tongue, and neck and may need to undergo sleep studies.

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Sleep apnea

Sleep apnea is a life-threatening condition in which breathing stops or becomes shallower hundreds of times each night. It affects approximately 18 million adults in the United States and is most common among overweight men. By far the most common form is obstructive sleep apnea (OSA), in which the airway becomes blocked during sleep.

New England Journal of Medicine Untreated, sleep apnea can have serious consequences. The relentless daytime fatigue that often results may lead to failed careers, broken marriages, and automobile and workplace accidents. It can even be life-threatening, leading to the development of hypertension, heart failure, and stroke. A 2005 study found sleep apnea doubles a person's risk of stroke over a seven-year period.

Sleep apnea used to be considered uncommon, and it often remained undiagnosed. Physicians rarely checked for it except in the stereotypical patient an overweight, middle-aged man who snored. But in 1993, researchers at the University of Wisconsin School of Medicine learned that apnea is more common in both men and women than previously thought. They looked for sleep apnea in 600 state employees, ages 30 to 60, as part of a larger sleep study, and were surprised to find that 9% of women and 24% of men had at least five episodes of reduced breathing, or hypopnea, per hour. About 4% of men and 2% of women were estimated to have the full syndrome of sleep apnea, which includes abnormal breathing events and daytime sleepiness.

Screening for sleep apnea This six-question test can help you and your physician determine if you need to be tested for sleep apnea. Yes (2) No (0) Do you snore on most nights (more than three times per week)? Yes (2) No (0) Is your snoring loud (can it be heard through a door or wall)? Never (0) Occasionally (3) Frequently (5) Has anyone ever told you that you stop breathing or gasp during sleep? less than 17 inches (0) 17 inches or greater (5) less than 16 inches (0) 16 inches or greater (5) What is your collar size? Men: Women: Yes (2) No (0) Have you had, or are you currently being treated for, high blood pressure? Yes (2) No (0) Yes (2) No (0) Do you occasionally doze or fall asleep during the day when: you are not busy or active?you are driving or stopped at a light? Score 9 points or more: See your physician or a sleep specialist to assess need for a sleep study. 68 points: Uncertain; physician must use clinical judgment. 5 points or less: Low probability of sleep apnea. Reprinted with permission from Dr. David White, Sleep HealthCenters, Boston, Mass.

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Movement disorders and parasomnias

Sleep is not always as quiet and peaceful as we'd like it to be. Some people are troubled by uncontrollable leg movements, while others experience parasomnias, or unusual behaviors during sleep.

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Movement disorders

Sleepers typically shift position every 15 to 30 minutes, and it's normal for muscles to jerk at the onset of sleep. But people with certain neurological disorders that trigger excessive limb movements may find it impossible to obtain a restful night's sleep.

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Parasomnias

People with parasomnias may wake up enough to carry out complex behaviors, but not enough to realize what they are doing. These sleep-disrupting behaviors include sleepwalking, sleep eating, and night terrors.

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Narcolepsy

Narcolepsy is a disorder of sleep/wake regulation whose hallmark is daytime sleepiness. A variety of other symptoms may also be present, but abnormalities of REM sleep seem to underlie each one. Instead of occurring normally after a steady progression through the other stages of sleep REM sleep intrudes at unusual and unwelcome times, such as immediately after sleep begins, as soon as a person lies down, or even in the midst of daytime activities.

Willpower or better nighttime sleep habits cannot overcome the profound drowsiness of narcolepsy. As a result, people with narcolepsy often have great trouble completing tasks.

About 1 in 2,000 people has this condition. It affects both sexes and all races equally, and it has a genetic component; having a close relative makes a person 20 to 40 times more likely to have it.

In the late 1990s, researchers discovered that many cases of narcolepsy result from the lack of a brain chemical called hypocretin (sometimes called orexin) that normally maintains wakefulness and helps regulate sleep. People with narcolepsy lose the cells that make hypocretin. The discovery of the gene that makes hypocretin and the location of its production in the brain has spurred research focused on new ways to diagnose and treat this disorder.

Narcolepsy usually becomes apparent during adolescence or young adulthood, although symptoms sometimes appear in early childhood or middle age. On average, it takes five years of symptoms and visits to five physicians before a diagnosis of narcolepsy is made. This is because sleepiness may be the only symptom, or cataplectic attacks (see "Cataplexy") may be misdiagnosed as epilepsy or fainting.

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Symptoms of narcolepsy

Narcolepsy may manifest in any of several ways:

• Excessive sleepiness. People with narcolepsy often feel extremely tired and struggle to stay awake during the daytime.

• Sleep attacks. A person may suddenly fall asleep for 5 to 10 minutes when relaxing or even while carrying on a conversation. If REM sleep and dreaming occur immediately, the individual sometimes makes conversation that is appropriate to the dream instead of the actual situation.

• Cataplexy. In cataplexy, the brain mechanism that paralyzes muscles during REM sleep becomes activated during the day. Thus, you may be fully alert but suffer partial paralysis or a complete muscle collapse, often brought on by laughter, anger, or other strong emotions. Cataplexy may set in several years after daytime sleepiness first appears, although sometimes it's the first symptom of narcolepsy. In mild cataplexy, your knees may buckle, or the muscles of your jaw or neck may become weak and difficult to control. When it's severe, the muscles become completely paralyzed, and you may fall to the ground. You are usually fully awake and aware of what's going on, but unable to talk. Although a few people then fall asleep, most recover spontaneously after several seconds or minutes.

• Sleep paralysis. A terrifying feeling of paralysis may occur during the transition between wakefulness and sleep if the REM stage begins before a person is fully asleep. Although muscle control usually returns within a few minutes, such episodes can cause great anxiety.

• Hypnagogic hallucinations. When REM dreaming occurs during wakefulness, the vivid and often frightening images, known as hypnagogic hallucinations, are difficult to distinguish from reality. A person may see prowlers or believe that his or her house is on fire. This usually happens just at sleep onset or upon awakening. This condition can be confused with mental illness because its symptoms resemble those of some psychotic disorders.

• Disturbed nighttime sleep. Just as sleep intrudes during the day, unwelcome awakenings can occur at night, depriving narcoleptics of restorative rest and exacerbating daytime drowsiness. Some feel as if they have hardly slept at all.

• Automatic behavior. Because of their profound sleepiness, people with narcolepsy perform many routine tasks without being fully aware of what they are doing. For example, one man washed and dried the dishes and then stacked them in the refrigerator but had no recollection of doing so.

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Treatments for narcolepsy

Treatment for narcolepsy is geared toward improving wakefulness during the day and preventing REM-related symptoms.

Most people require stimulant medications such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) to counter sleep attacks and drowsiness (see Table 5). Because these medications have been abused as recreational drugs and misused as diet pills, drug enforcement agencies often require physicians to provide extensive documentation when they prescribe them. Even with medication, however, people are never as alert as they would be if they didn't have this condition.

Modafinil (Provigil), a once-a-day medication to promote wakefulness, has a different mechanism of action than the older stimulants. It doesn't cause such side effects as euphoria or weight loss, so there's less concern about its misuse or abuse. However, it is less potent.

In most people, antidepressants that suppress REM sleep such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), clomipramine (Anafranil), or venlafaxine (Effexor) can also prevent cataplexy and other REM-related symptoms.

Another medication for cataplexy is sodium oxybate (Xyrem), also known as gamma hydroxybutyrate (GHB). This medication helps decrease the number of cataplexy episodes and may improve nighttime sleep and reduce daytime sleepiness as well. Because of its chemical properties, it must be taken at bedtime and again during the middle of the night. Xyrem is tightly regulated because of its potential for misuse; it has been associated with criminal acts such as date rape.

Table 5: Medications for narcolepsy
Generic name (brand name)	Use	Side effects, comments
Stimulants I
dextroamphetamine (Dexedrine, Adderall) methylphenidate (Ritalin, Metadate, Concerta)	To counter daytime sleepiness	Nervousness, insomnia, loss of appetite, nausea, dizziness, irregular heartbeat, headaches, changes in blood pressure and pulse, weight loss. Potential for abuse. Should not be used by people who take monoamine oxidase inhibitors (MAOIs) or who have glaucoma.
Stimulants II
modafinil*	To counter daytime sleepiness	Anxiety, headache, nausea, nervousness, insomnia. Less potential for abuse than other stimulants.
Tricyclic antidepressants
clomipramine (Anafranil) desipramine (Norpramin) imipramine (Tofranil) protriptyline (Vivactil)	To prevent cataplexy and other REM-related symptoms	Dizziness, dry mouth, blurred vision, weight gain, constipation, trouble urinating, drowsiness, disturbance of heart rhythm. Should not be used with MAOIs or during immediate recovery from heart attack.
SSRI antidepressants
fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft)	To prevent cataplexy and other REM-related symptoms	Nausea, dry mouth, headache, loss of appetite, nervousness, diarrhea or constipation, sweating, and sexual problems. Should not be used with MAOIs.
Anticataplectic
sodium oxybate (Xyrem)*	To prevent cataplexy, improve nighttime sleep, and reduce daytime sleepiness	Abdominal pain, chills, dizziness, abnormal dreams, drowsiness, stomach discomfort. Must be taken at bedtime and again during the middle of the night. Potential for abuse.
*Modafinil and sodium oxybate are FDA-approved to treat narcolepsy symptoms. Other medications in this chart are not, but physicians have found they often help people with narcolepsy and therefore prescribe them.

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Disturbances of sleep timing

When their internal clocks are disturbed, people may long for sleep when they need to be awake or may stay up until the wee hours of the morning without feeling tired.

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Delayed sleep phase syndrome

Almost everyone is programmed for a day that lasts slightly longer than 24 hours, but "night owls" are less sensitive to the environmental cues that help most people maintain the usual 24-hour cycle. Left to their own devices, they would generally go to sleep and wake up much later each day. Only by relying on external cues, such as alarm clocks, do they manage to stay in sync with a more conventional schedule. Night owls have trouble getting anything done in the morning.

They may be able to gradually synchronize their schedule with others by going to bed and getting up at the same time every day. However, it's easy for their sleep patterns to go awry when they go on vacation or retire. Night owls often find that a minor shift in sleep/wake cycles such as the onset of daylight savings time, a coast-to-coast trip, or a weekend of late-night parties can throw them off kilter unless they force themselves to get up at the same time every day.

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Advanced sleep phase syndrome

People whose body rhythm cycles are shifted much earlier go to bed earlier, wake up in the early morning, and eventually can't stay awake past early evening. This condition, called advanced sleep phase syndrome, is more common among older people. Treatments being studied include bright light therapy in the evening, which helps reset the body's clock, and carefully timed doses of melatonin.

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Jet lag

Many people find that crossing several time zones makes their internal clocks go haywire. In addition to having headaches, stomach upset, and difficulty concentrating, they may suffer from fitful sleep.

Younger people usually adapt more quickly to time changes than older people. It takes about a day to adjust for every time zone crossed. Many people have more difficulty traveling eastward, but older people may have more symptoms traveling westward.

The standard way to handle jet lag is to try to sleep only at night upon arrival and to get up early in the morning, although it may be difficult the first few days. This way your body can start adjusting to the new time zone as soon as possible (see "Ways to avoid jet lag"). Short-term use of timed doses of melatonin or Rozerem to shift circadian rhythms or over-the-counter or prescription sleep aids to help you sleep at night also can be helpful.

Ways to avoid jet lag Don't time-shift. On a brief trip just one or two time zones away, it may be possible to wake up, eat, and sleep on home time. Schedule appointments for times when you would be alert at home. Gradually switch before the trip. An hour at a time, move mealtimes and bedtime closer to the schedule of your destination. Even a partial switch may make the trip easier. Switch as rapidly as possible upon arrival. On a long trip, don't turn in until it's bedtime in the new time zone. For the first day or two, spend as much time outdoors as possible to let daylight reset your internal clock. Use the sun. If you need to wake up earlier in the new setting (flying west to east), get out in the early morning sun. If you need to wake up later (flying east to west), expose yourself to late afternoon sunlight. Drink plenty of fluids, but not caffeine or alcohol. Caffeine and alcohol promote dehydration, which worsens the physical symptoms of jet lag. They can also disturb sleep.

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Sunday insomnia

People often have trouble falling asleep on Sunday nights. While anxiety about work or school on Monday is a potential cause, often the most important factor is weekend changes in sleep habits. When you stay up later Friday night and sleep in Saturday morning, you are primed to stay up even later Saturday night and sleep in the next day. By Sunday evening, your body's clock is programmed to stay up late. People who have developed a pattern of Sunday insomnia may feel their anxiety mount as they anticipate a difficult night ahead.

The best way to avoid the Sunday blues is to maintain the same wake-up and bedtime on the weekends as during weekdays. If this isn't possible and you end up staying up later than usual on Friday and Saturday, the next best thing is to force yourself to get up at your weekday wake-up time and take an early afternoon nap on Saturday and Sunday. This way, you maintain the same wake-up time while still compensating for your sleep deprivation.

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Shift work

More than 20% of American workers including health care workers, police officers, security guards, and transit workers are on the evening or night shift. About 60% to 70% of shift workers experience sleep disturbances. These people fall asleep on the job two to five times more often than day-shift workers do. Sleepiness can be catastrophic for people in these vital roles. Sleep-deprived physicians, for example, make a greater number of errors than their better-rested colleagues, and it's common for fatigue to play a role in overnight rail, plane, truck, and maritime accidents.

Shift workers' sleep disorder can be eased somewhat by incorporating scheduled breaks, by rotating shifts from day to evening to night rather than the other way around, or by maintaining the same schedule seven days a week. Shift workers can also benefit from practicing good sleep hygiene (see "Tips for a better night's sleep"). Dark curtains or eyeshades can keep daylight out, and running a fan can help block external noise. Shift workers need to enlist the help of family members to get enough sleep while maintaining a schedule at odds with the rest of the world. The most successful shift workers are those who block out time for sleep in advance and then are vigilant about protecting their sleep time from outside intrusions. Light therapy is sometimes recommended to help people get used to a new schedule, as is the short-term use of sleep medications.

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Seasonal affective disorder

In some parts of North America, winter means less exposure to sunlight. As the days get shorter, some people find themselves depressed, sleepy, and drawn to high-carbohydrate foods.

Researchers speculate that people who suffer from this condition, called seasonal affective disorder (SAD), produce too much melatonin (or are extra-sensitive to normal amounts of this drowsiness-inducing hormone) and don't make enough serotonin, which may induce the craving for carbohydrates. Exposure to bright light in the morning for 30 minutes may alleviate the symptoms of SAD and help people wake up in the mornings. Antidepressants can also be helpful.

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Evaluation of sleep disturbances

Although two-thirds of Americans have sleep problems, the vast majority of people with sleep disturbances suffer in silence. They enjoy life less, are less productive, and endure more illnesses and accidents at home, on the job, and on the road.

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When to seek help

The American Academy of Sleep Medicine recommends seeking medical advice if sleep deprivation has compromised your daytime functioning for more than a month.

Don't hesitate to ask for help when you're sleeping badly following a death in the family or other stressful event. A physician may suggest the short-term use of a sedative to help you sleep at night and thus cope better during the day and prevent development of a long-term sleep disorder.

It's not always easy for people to get evaluation and treatment for a sleep problem. Doctors trained in the United States receive just over two hours of instruction on this topic during four years of medical school. According to a National Sleep Foundation survey, most primary care physicians do not routinely ask their patients about sleep. And while most of the physicians who took part in the survey admitted they had limited knowledge about sleep-related matters, more than half did not consult with an expert in sleep medicine. So it's in your best interest to seek out the help you need.

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Sleep laboratory evaluation

Most people with sleep problems don't need to visit a sleep laboratory. Insomnia and circadian rhythm disorders, for example, can be diagnosed by a thorough history and physical examination. However, when a doctor suspects a sleep disorder such as narcolepsy, periodic limb movement disorder, sleep apnea, or one of the parasomnias (see "Parasomnias"), he or she may recommend formal sleep testing.

Fees depend on the level of testing required. Some people require a one-time consultation with a sleep specialist, which may run a few hundred dollars. Staying overnight in a sleep laboratory costs between $800 and $1,500. Check with your insurance company in advance because reimbursement varies and may depend on your diagnosis.

The American Academy of Sleep Medicine has a listing of more than 1,100 accredited sleep disorder centers and more than 3,000 board-certified sleep specialists (see "Resources"). Some centers will make an appointment directly with you, while others require a physician referral. The center will request medical records and may send you a sleep questionnaire or diary to use before your visit. You may also be asked to change your sleep habits in certain ways before scheduling the visit. Sometimes these changes alone correct the problem.

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Home-based tests

Some sleep-monitoring equipment can be used at home. Physicians, however, disagree about whether the information collected is reliable enough to use for diagnosis and treatment. Portable recordings may be useful when polysomnography is not available and symptoms indicate that immediate treatment is needed, or when a patient is bedridden or medically unstable and cannot be moved. Home-based tests may also be used when a physician wishes to evaluate the effectiveness of treatment.

Apnea detectors. To detect breathing disturbances during sleep, a patient is sometimes equipped with apnea detectors that can measure heart rate, snoring sounds, body position, nasal airflow, and the amount of oxygen in the blood. Although these devices have been used to estimate how many people suffer from breathing disturbances, the information they provide isn't as accurate as sleep lab evaluations and may not be complete enough to diagnose and plan treatment for an individual.

Wrist actigraphy. A wristwatch-sized monitoring device that automatically records arm or leg movements can be used to track periods of sleep and wakefulness at night. Although it cannot determine the stage of sleep, it can help clarify ambiguous aspects of a sleep diary such as entries reporting long hours of sleep but exhaustion the next day or assess the effectiveness of medical treatment. The actigraphy device may reveal that brief awakenings during the night are unknowingly disturbing sleep. In some studies, wrist actigraphy accurately determined whether a person was asleep almost 90% of the time.

The American Academy of Sleep Medicine recommends polysomnography, done in a sleep lab, as the best method for diagnosing sleep apnea and determining its severity. Portable home devices can miss mild apnea and other sleep disruptions, and they don't provide the sleep stage information needed to rule out other sleep disturbances. Accordingly, they should only be used when the patient's physician is familiar with the devices' benefits and limitations and has experience interpreting the results.

How sleepy are you? Sleep specialists often use this measure, called the Epworth Sleepiness Scale, to gauge a patient's level of daytime sleepiness. Imagine yourself in the following situations, and then select your likelihood of dozing using the 03 scale below. Add up these numbers. If you score 10 points or more, consider seeing a physician for an evaluation. Scale: 0 = would never doze 2 = moderate chance of dozing 1 = slight chance of dozing 3 = high chance of dozing Situation: ______ Sitting and reading ______ Watching TV ______ Sitting inactive in a public place, like a theater or meeting ______ As a passenger in a car for an hour without a break ______ Lying down to rest in the afternoon ______ Sitting and talking to someone ______ Sitting quietly after lunch (when you've had no alcohol) ______ In a car while stopped in traffic

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The benefits of good sleep

By now, you should have a solid understanding of the various sleep problems and their consequences. It's worth taking a moment to look at the flip slide: the benefits of routinely getting a good night's rest. Here, the encouraging news is that if you successfully conquer whatever is preventing you from sleeping soundly either on your own or with a sleep specialist's assistance you have a lot to look forward to.

Research documents the improvements that can come with treatment:

• Journal of the American Medical Association People with chronic insomnia who participated in six 50-minute sessions of cognitive behavioral therapy (CBT) improved their sleep efficiency (the percentage of time spent asleep while in bed) more than people who took a prescription sleeping pill, according to a 2006 study in the . The researchers also showed that people who underwent CBT increased their total time in slow-wave (deep) sleep.

• Chest People with sleep apnea who used CPAP for one year reported quality-of-life improvements (such as better energy, mental health, and social satisfaction) that brought them to the same level as the general population, according to a 2004 study in .

• Psychopharmacology People with narcolepsy treated with modafinil for six weeks reported significant improvements in energy and a significant reduction in daytime fatigue, according to a 2004 study in .

Patients treated by sleep specialists gain a number of benefits. Often, people with sleep disorders function without sufficient sleep for so long that they come to accept their constant fatigue as normal and assume they will always feel tired. After a few weeks of healthy sleep, some patients report feeling like a "whole new person," with newfound energy and an improved outlook on life. In some cases, such people are able to accomplish things they've always put off attempting, such as completing college or getting an advanced degree, switching careers, or finding a life partner.

So if you're struggling to get a good night's rest, there is much cause for optimism. While there's no guarantee you'll always get eight hours of uninterrupted sleep, with proper treatment you can reasonably expect improvements in both your nighttime sleep and your overall quality of life.

Sleep review For such a natural and necessary thing, sleep is the source of much anxiety. Here is a review of the basic steps to follow if you're having trouble maintaining normal, healthy sleep patterns: Practice good sleep hygiene, such as making sure your bedroom is sleep-friendly, avoiding caffeine and alcohol before bedtime, and going to bed and waking up at the same time every day (see "Tips for a better night's sleep"). Make sure you're getting proper treatment for any underlying illnesses such as cardiovascular disease or diabetes that may interfere with sleep (see "Medical conditions and sleep problems"). Keep a sleep diary to look for patterns you may not be aware of and to track progress. Make sure your primary care physician is aware of any over-the-counter or alternative medicines you take to help you sleep, and follow your doctor's recommendations about taking prescription sleep aids (see "Medications and other insomnia treatments"). If sleep problems persist despite your own efforts, consider seeing a sleep specialist for a thorough sleep evaluation (see "Evaluation of sleep disturbances").

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Glossary

advanced sleep phase syndrome: A daily sleep/wake rhythm in which the onset of sleep and the time of awakening are earlier than desired; the person wakes up earlier and wants to retire earlier each day.

apnea: See sleep apnea.

cataplexy: Sudden paralysis of some or all muscles brought on by laughter, anger, or strong emotions; a hallmark of narcolepsy.

central sleep apnea: Sleep apnea caused when respiratory control centers in the brain fail to activate breathing muscles.

circadian rhythm: The innate biological clock that regulates sleep and waking and controls the daily ups and downs of physiologic processes, including body temperature, blood pressure, and the release of hormones.

deep sleep: See slow-wave sleep.

delayed sleep phase syndrome: A daily sleep/wake rhythm in which the onset of sleep and wake times are later than desired; the person tends to go to bed later and get up later each day.

electroencephalogram (EEG): A recording of brain waves obtained by attaching flat metal discs (electrodes) to the scalp; it shows changes in brain wave voltage and frequency (in cycles per second).

hypnagogic hallucinations: Often terrifying dreamlike sounds or images occurring just before sleep; a symptom of narcolepsy that can be mistaken for psychosis.

hypnogram: A diagram that summarizes the stages of sleep recorded in the sleep laboratory.

insomnia: A condition marked by trouble falling asleep or staying asleep or sleep that is nonrestorative.

melatonin: A hormone produced in a predictable daily rhythm by the pineal gland.

narcolepsy: A sleep disorder marked by excessive sleepiness or sudden sleep attacks.

obstructive sleep apnea: Sleep apnea resulting from blockage of the airway.

parasomnias: Episodic disruptive behaviors occurring during sleep, indicating abnormal or partial arousal.

periodic limb movement disorder (PLMD): Syndrome characterized by periodic jerking of the limbs during sleep.

polysomnography: Simultaneous recording of brain waves and other measures of physiological functioning to assess sleep.

positive airway pressure (PAP): A treatment for sleep apnea in which a continuous stream of air is delivered through a mask worn over the nose to keep the sleeper's airway open.

quiet sleep: All sleep except REM sleep. In the quiet phase of sleep, thinking and most physiological activities slow, but movement still occurs. Also called non-REM sleep.

rapid eye movement (REM) sleep: A period of intense brain activity often associated with dreams; named for the rapid eye movements that occur during this time. Also called dreaming sleep.

restless legs syndrome (RLS): Achy or unpleasant feelings in the legs associated with a need to move. Most prominent at night, making it hard to fall asleep or stay asleep.

sleep apnea: Cessation of breathing during sleep, lasting at least 10 seconds and associated with a fall in blood oxygen or arousal from sleep.

sleep architecture: The pattern made when sleep stages are charted on a hypnogram.

slow-wave sleep: Non-REM, Stage N3 sleep; during slow-wave sleep, the brain becomes less responsive to external stimuli.

somnambulism: Sleepwalking.

somniloquy: Talking in one's sleep.

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Resources

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Organizations

American Academy of Sleep Medicine www.aasmnet.org www.sleepeducation.com 1 Westbrook Corporate Center, Suite 920 Westchester, IL 60154 708-492-0930 ;

This professional membership organization is dedicated to the advancement of sleep medicine and related research. The group's Web site includes information on sleep disorders as well as contact information for accredited sleep centers.

American Insomnia Association www.americaninsomniaassociation.org 1 Westbrook Corporate Center, Suite 920 Westchester, IL 60154 708-492-0930

This patient-based organization provides resources for insomnia patients.

American Sleep Apnea Association www.sleepapnea.org 1424 K St. NW, Suite 302 Washington, D.C. 20005 202-293-3650

This nonprofit organization offers information on sleep apnea via brochures, a newsletter, and videos. It also operates a network of approximately 200 support groups throughout the country.

Narcolepsy Network www.narcolepsynetwork.org P.O. Box 294 Pleasantville, NY 10570 888-292-6522 (toll free)

The Narcolepsy Network offers educational materials on narcolepsy, as well as referrals to accredited sleep centers and help in finding support groups.

National Sleep Foundation www.sleepfoundation.org 1522 K St. NW, Suite 500 Washington, D.C. 20005 202-347-3471

This nonprofit foundation helps consumers find a sleep center near them and provides information on a variety of sleep topics.

Restless Legs Syndrome Foundation, Inc. www.rls.org 1610 14th St. NW, Suite 300 Rochester, MN 55901 507-287-6465

This nonprofit organization distributes brochures and provides information on restless legs syndrome. It also publishes the quarterly newsletter NightWalkers and maintains a list of support groups located throughout the country.

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Books

The Harvard Medical School Guide to a Good Night's Sleep Lawrence J. Epstein, M.D., and Steven Mardon (McGraw-Hill, 2007)

Covers sleep physiology; sleep disorders such as insomnia, sleep apnea, and narcolepsy; sleep medications; childhood sleep problems; and coping with jet lag. The book includes a six-step plan for getting a good night's sleep.

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Review Date: 2007-10-01