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

problem.

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

Rubinstein.

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

music.

Create a sleep-conducive environment that is dark, quiet, comfortable,

and cool.

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

before bedtime.

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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