I don’t need a sleep study to diagnose a sleep disorder. The diagnosis is in the history,” says Gregory Ferriss, the grandfather of sleep medicine in New Orleans. Ferriss became interested in sleep disorders as a neurologist and now limits his practice to that sub-specialty. His trademark is his listening and detailed history taking. One patient told me a visit to see Dr. Ferriss is like stepping back into a Norman Rockwell painting.
Sleep complaints are common. Like most internists, hardly a day goes by that I don’t see someone with a sleep problem.
Most sleep complaints center around the inability to fall asleep or stay asleep. But many sleep disorders aren’t so easily recognized.
Insomnia, defined as a problem falling asleep or staying asleep, can be an occasional, recurrent event specific or longterm. My favorite therapeutic tool for treating occasional insomnia is a bottle of sleeping pills in the medicine cabinet.
I say “in the medicine cabinet,” as the mere presence of a relief close at hand is often enough to tackle the fear of not going to sleep before an important event or trip.
Next to insomnia, the most common sleep problem bringing patients to internists is being too sleepy during the day.
Other sleep problems handled by primary care physicians include those related to working irregular hours and traveling across time zones. Except for restless leg syndrome, sleep disruptive disorders, such as sleepwalking, nightmares and adult bed-wetting, are less common.
When someone tells me that they need a sleeping pill every night to get to sleep, my concern rises. A person can become dependent on the hypnotic activity of sleeping medication, and their sleep quality suffers from a lack of restorative sleep. Such folks may pass the night in a drug-induced state, but they often never awake fully refreshed.
When nature calls during the night, persons under the influence of sleeping pills are more likely to fall and break bones.
Longterm nightly medication to induce sleep is akin to white washing a termite-infested house. It is necessary to diagnose the cause of the sleep disorder before rational treatment can be addressed.
Daytime inactivity seems related to increased insomnia in the elderly. Too many older adults take nightly sleeping medication, and these numbers have grown as pharmaceutical companies embraced direct consumer advertising. Each generation of sleeping pills is labeled as safer and more effective than earlier editions. Sleeping medications of today are less likely to be implicated in suicides and attempted suicides than the Nembutal and Seconal of yesteryear; however, there’s nothing safe about longterm nightly hypnotics.
The occasional inability to fall asleep at night is at the very tip-top of the iceberg of sleep disorders. Severe sleep disorders, such as the classic fat, red-faced card player asleep at the poker table (Pickwickian syndrome) or the narcoleptic bus driver, are easy diagnostic pickings. But the majority of sleeping disorders are less obvious versions of obstructive sleep apnea.
Most folks with obstructive sleep disorders have vague sleeping-related complaints. An early and common symptom of obstructive sleep apnea is fatigue. Other common complaints include insomnia, depression, excessive daytime drowsiness, snoring and a dry mouth upon awaking from breathing through an open one. When asked about snoring, the answer is often but not always “yes.” Other complaints related to sleep disorders include morning headaches, increased irritability, heartburn, obesity and difficult to control hypertension.
Obstructive sleep apnea describes the abnormal breathing during sleep, causing a decrease in circulation of oxygen-rich blood. Persons suffering from sleep apnea may stop breathing hundreds of times a night, often for a minute or longer. The classic sign of complete cessation of breathing ending with a grunt and a deep breath only occurs in a minority of the persons with this disorder. Most at risk are overweight persons with large necks. In addition, it’s a condition that accelerates with age, being uncommon in men less than 40 years old and in women before menopause, as tissues in the back of the throat sag with age.
Even mild cases of obstructive sleep apnea deserve attention as persons with sleep disorders are at high risk for other significant health problems involving every major system, from the brain to the bones. Poor sleep quality is associated with increased markers of inflammations and abnormal hormonal shifts. The diverse medical problems associated or made worse by sleep disorders aren’t surprising when you consider that all organs and tissue systems need some down time for rest (see box).
“Take my wife, take my dog, but please don’t take my CPAP machine,” a physician who now practices out of town once told me. A CPAP machine keeps floppy airways open with a small pressure head of airflow, thus the name: continuous positive airway pressure. The early machines were bulky, loud and hard to use. With proper instruction, training and supervision, most patients do adjust to CPAP and begin feeling much better in a couple of weeks. The resultant decrease in daytime fatigue and increase in weight loss give early and important positive feedback.
“It is nice to be able to verify a diagnosis in a sleep lab with data such as whether the patient is sleeping on his or her side or back, but sleep labs have gotten so expensive they are pricing themselves out of business. Now the trend is toward more home diagnosing and monitoring.” Dr. Ferriss continues, “In the past, we needed the technician to wake the patient up to test various pressure CPAP settings, but now we have the AutoPAP. The AutoPAP systems today are so sensitive that they automatically adjust the machine pressure to match the needed pressure without specific settings.”
The Protean Nature of Sleep Disorders
Poor sleepers have more: attention deficit disorders, fibromyalgia, fatigue, multiple sclerosis, memory impairment, depression, dyslexia, bipolar disorder and increased anxiety. Their hypertension and congestive heart failure are more difficult to control. They have a higher incidence of strokes, heart attacks and irregular heart rhythms. Their bones are more prone to osteoporosis. Diabetes and heartburn are more common.
Perils of Sleeping Pills
A Louisiana State University student returned to his apartment from brunch one Sunday morning to find his complex flooded with a SWAT Team. He was taken into custody and charged with attempted robbery of a drugstore a few blocks from where he lived; a crime he vehemently denied. They showed him the video surveillance tape. There he was with a pistol stuck in his pajama bottoms. According to the drugstore employees, he fled after they expressed bewilderment with his request to “give me all your drugs.” The employees recognized him as a frequent customer, but it took several hours before the police could come up with a name.
A local physician in his 30s received a telephone call from the emergency department at Touro Infirmary one weekend morning asking how he was feeling and if his treatment the night before had been satisfactory. He had no idea what they were talking about. He later called a friend who worked in the emergency department. Turns out that the physician patient had driven himself to the hospital telling the emergency room staff that he was worried about his blood pressure. He registered as a patient, saw the ER physician and then drove himself home awaking a few hours later with no memory of the nocturnal adventure.
A physician on a trans-Atlantic trip took an Ambien to help him sleep as he crossed the great pond. He woke up two days later in a panic thinking he had slept through his scheduled lecture. He called his host colleague who congratulated him on giving just a sterling lecture before he had the chance to apologize. He remembered nothing and was an early victim of Ambien amnesia.
The LSU student and the physicians share a common link: Both took Ambien, a frequently prescribed hypnotic, on a regular basis. I believe the first report of amnesia associated with Ambien was published as a letter in a medical journal more than a decade ago.