Sleep appears to be on the decline in America, and Americans who are
chronically tired or who have insomnia are looking for help. And the
medical and pharmaceutical establishments are there to assist-with
newer medications, with advice about good sleep hygiene, and with new
clinics to diagnose the source of sleep problems. One of these is the
eight-year-old Princeton Sleep Program at the University Medical
Center at Princeton, and there are four others nearby that are listed
by the American Academy of Sleep Medicine: in Trenton, Capital Health
System’s Snoring and Sleep Apnea Center of Mercer County at its Fuld
campus, accredited since 1996, and Mercer Sleep Disorders Center at
its Mercer campus, accredited since 1993; and St. Francis Medical
Center’s Sleep Disorder Program, accredited since 2001. In New
Brunswick is Robert Wood Johnson University Hospital’s Comprehensive
Sleep Disorders Center, accredited since 1993.
The Princeton Sleep Center treats men, women, seniors, and children
for all types of sleep disorders, although sleep apnea and insomnia
are the most common. Teodoro Santiago, the center’s medical director
as well as chief of pulmonary critical care medicine and professor at
the Robert Wood Johnson Medical School, estimates that 60-70 percent
of the clinic’s patients have breathing disorders during sleep like
sleep apnea; about 20-25 percent are persons who cannot sleep. The
remainder is a mixture of narcolepsy, sleepwalking, restless leg
syndrome (where patients get pins and needles in their legs as they
are lying down), and other abnormalities.
When patients come in with a sleep problem, the first step is to
evaluate them: "We take a sleep and medical history and examine them
and decide what the next step is," says Santiago. About 65 percent of
the patients are referred by their primary doctors and 35 percent come
directly to the sleep center.
Mitchell Rubinstein, a registered polysomnographic technologist
(RPSGT) and the program director of the sleep center, says that the
number of sleep apnea patients they see has grown 14 percent over the
last year: "Sleep apnea is getting more media attention so patients
and physicans have become more aware of it," he says. Patients with
sleep apnea stop breathing for periods of 10-20 seconds and then
resume with a snort or gasp. This can happen relatively often, without
patients even being aware of it, but the result is sleep that is
fragmented and not restorative, "so they wake up feeling lousy."
If a sleep study is indicated, the patient stays overnight in a room
"set up like a little hotel room." One of the center’s technologists,
either Rubinstein or Daniel Reed, stays up all night and monitors the
patient’s sleep (including brain wave activity, eye movements, muscle
activity of the limbs, and heart rate) and breathing (air flow going
in and out of the nose and mouth; respiratory effort, via bands around
the chest and abdomen; and blood oxygen level, through a noninvasive
sensor that goes on the finger) throughout the night.
"If they stop breathing," he says. "We can see what happens to the
heart rate and blood oxygen and how it affects their sleep." If a
patient has sleep apnea in the first half of the night, a technologist
may even try out a treatment for it later that same night.
When someone is diagnosed with severe sleep apnea, one of more
effective treatments is the nasal CPAP, which uses a mask over the
nose to blow air in and keep the airway open. "The biggest problem
with the machine is that some patients find difficulty sleeping with
the mask," explains Santiago. So the next step is to investigate why a
particular patient can’t tolerate it and find appropriate solutions.
If they have septal deviations or are claustrophobic, a different
attachment may help, for example, one that goes inside the nose. Or
sometimes the mask is uncomfortable and Rubinstein or Reed will give
them acclimation sessions and try a variety of masks. "One of the
technological advances," explains Santiago, "is that we have many
different types of attachments. Tolerance of this machine is many
times related to the mask or what the patient feels, so finding the
right mask is important for staying with the treatment."
Rubinstein adds that when the machine works, patients are usually
happy to continue using them at home: "It takes a little getting used
to, but once people do, people who are really symptomatic notice such
a difference in the way they feel during the daytime that they are
willing to wear it at night."
Other more conservative measures may also be recommended to treat the
sleep apnea – like changing the sleep position; avoiding alcohol and
sedatives, which tend to relax the muscles in the airway and increase
the likelihood that it could close off; and losing weight, because
extra weight narrows the airway. "Losing a few pounds can make the
difference between the airway closing or not," says Rubinstein.
Another possibility is oral appliances that work either by pulling the
tongue or jaw forward a little bit, thereby increasing the space in
the airway. Surgery may also be an option, depending on the anatomical
Insomnia – which includes difficulty falling or staying asleep, waking
frequently, or waking early and not going back to sleep – can be a
symptom of a variety of underlying conditions. "It takes sitting down
with doctor who understands all possible causes – ranging from poor
sleep hygiene to depression or anxiety to stress to medication-caused
insomnia – and try to isolate the most likely ones," observes
Santiago feels that drugs are overused in the treatment of insomnia:
"There is too much reliance on giving sedatives and hypnotics, because
it’s the easiest thing to do" he maintains. The reason is that many
internists do not have special training in sleep medicine and may not
be knowledgeable about behavioral therapies for insomnia.
But, given the need for short-term sleep aids, says Santiago, "There
are fortunately newer pills that may be safer and less habit forming."
In the 1970s the only available medications were sleeping pills, which
taken in overdose could kill. Then came the benzodiazepines, which,
when taken chronically are habit forming, depress breathing, worsen
sleep apnea, and create nonrefreshing sleep. "We can see EEG changes
when they are taken over the long term," he says, "although these do
go away when a patient stops taking the drug." But for short term use,
they are cheap, and good for situational insomnia, for example, jet
lag or in the wake of a family tragedy.
The clinic does sometimes prescribe sleeping pills, however, says
Santiago. "The ideal way to use them is as a temporizing measure to
try to treat a patient with insomnia while pushing other behavioral
treatments," which take a little time to implement. Patients who in
the interim can’t sleep, have busy schedules, or have to go to work
may take pills to tide them over. Also in the case of someone who has
phase delay insomnia, where a person’s biological clock is moved
forward and the treatment is bright lights in the early morning, he
continues, "we might use a sleeping pill to allow the patient to go to
sleep earlier until the clock gets readjusted."
Princeton HealthCare System, University Medical Center at Princeton,
253 Witherspoon Street, Princeton 08540. 609-497-4000; fax,
609-497-4991. Home page: www.princetonhcs.org
Advice for Insomniacs
According to the National Sleep Foundation’s web page, sleep hygiene
involves the following:
Maintain regular bed and wake times, including weekends.
Establish a regular, relaxing bedtime routine such as soaking in a hot
bath or hot tub and then reading a book or listening to soothing
Create a sleep-conducive environment that is dark, quiet, comfortable,
Sleep on a comfortable mattress and pillows.
Use your bedroom only for sleep and sex. It is best to take work
materials, computers, and televisions out of the sleeping environment.
Finish eating at least 2-3 hours before your regular bedtime. Exercise
regularly, but try to complete your workout at least a few hours
Avoid caffeine, including chocolate, close to bedtime, because it can
keep you awake.
Avoid nicotine close to bedtime, because it can lead to poor sleep.
Avoid alcohol close to bedtime, because it can lead to disrupted sleep
later in the night.
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