Are You Aware of Body Clock?
Our sleep and wake cycles are driven by a 24 hour clock known as the circadian rhythm. At night in response to darkness our brain releases hormones (neurotransmitters) that help drive our sleep and in the morning in response to light our brain supresses those hormones and releases other hormones to drive wakefulness. Our sleep/ wake drive reduces as we get older but also is suppressed by our lifestyle. For-example shift workers may not be able to maintain regular sleep/wake times due to their work requirements. Routine particularly a regular wake time is important to drive our circadian cycle.
SLEEPINESS VS FATIGUE
Sleepiness and Fatigue are two common but different symptoms. Sleepiness is often described as a drive to sleep whereas fatigue a “lack of energy” or “a feeling of being washed out.” Often these symptoms co-exist and in any one individual there may be many factors (diagnoses) that are causing these symptoms. Causes of Sleepiness and Fatigue include
- Sleep Deprivation
- Mood Disorder (depression or anxiety)
- Irregular sleep wake rhythms
- Chronic medical conditions
- Infection (viral or bacterial)
- Iron Deficiency
- Problems with sleep including sleep apnoea, insomnia, periodic limb movement disorder
- Narcolepsy and Idiopathic Hyper-somnolence
If you are experiencing fatigue or sleepiness discuss with your general practitioner
OBSTRUCTIVE SLEEP APNOEA (OSA)
OSA is a common condition where a person will have repetitive obstruction of their upper airway when sleeping resulting in effects on oxygenation and sleep quality.
Symptoms of OSA may include
- Observation of pauses in breathing
- Choking at night
- Dry mouth in the morning
- Awakening from sleep
- Unrefreshing sleep
- Morning headaches
- Daytime sleepiness
- Difficulties concentrating
The significance of OSA is dependent on its severity and whether it is causing symptoms or likely to cause long term health risk.
Consequences of severe OSA include
- High blood pressure
- Cardio-vascular disease
- Impaired blood sugar levels
- Memory impairment
- Poor quality of life
OSA with sleepiness may be a risk factor for motor vehicle accidents.
OSA is diagnosed with a sleep study. This may be an in-hospital study or home based study. Results of the study need to be interpreted together with your clinical assessment.
The decision to treat OSA is dependent on whether the condition is impacting your quality of life or likely to cause long term risk.
There are many cases of OSA where active treatment is not required and the focus is on weight loss, alcohol reduction, smoking cessation and maintaining lateral position when sleeping.
If you require active treatment your options are
Continuous Positive Airway Pressure (CPAP) – this involves a pump and a mask (connected by tubing) with the pump pumping a pressure to splint open the upper airway. This is the most effective treatment for OSA and it is strongly recommended that if you have been diagnosed with significant OSA you give it a go.
Oral Appliance Therapy – this involves a custom fitted mouth guard for the top and bottom teeth that are interlocked and adjusted to move the lower jaw forward and increasing the space at the back of the throat. This is second line treatment for OSA and can be useful in treating snoring but is not a device I would consider in all patients with sleep apnoea
Provent – these are disposable nasal strips that with nasal breathing assist to generate a positive pressure at the back of the throat to assist in splinting the airway.
Surgery – in children surgery with adeno-tonsillectomy is the standard of management for OSA. In adults, the role of surgery is limited. In patients with OSA who have significant nasal obstruction, surgery to open up the nasal passages may assist in improving tolerance to CPAP or oral appliance therapy. Surgery with the aim of cure however is rarely performed. Unless patients with OSA have clear anatomical abnormalities that if corrected are likely to improve OSA (i.e. very large tonsils, lower jaw is set back) surgery should be avoided.
Insomnia is the difficulty initiating or maintaining sleep or early morning awakenings with effects on quality of life. There are many causes for insomnia. Often patient who suffer from chronic insomnia have a predisposition to developing the condition with symptoms often precipitated by a life event and the condition perpetuated by suboptimal sleep behaviours that result in frustration and anxieties that further drive the problem.
Medications often prescribed to manage insomnia do not treat the underlying cause which in most instances relate to sleep psychology and sleep behaviours. Therefore, it is strongly recommended that hypnotic medications are avoided in managing insomnia unless if used for short periods as part of a comprehensive cognitive behavioural therapy program for insomnia.
Guidelines for the Management of Chronic Insomnia in Adults
Driving and Sleep Disturbance – the Ausroads Fitness to Drive Guidelines discusses the risks associated with driving and sleepiness and outlines medical practitioners and drivers responsibilities.This is a very difficult issue in the non-compliant patient and the practitioners must not only consider the importance of the doctor-patient relationship but also the risk the patient poses to themselves and the community.
Fitness to Drive Guidelines