Tag Archive: sleep


Walking while asleep

sleepwalkingSLEEPWALKING (somnambulism) is not uncommon among children and is a reason for a medical consulataion. The children find themselves in a state of transition from one sleep cycle to the next, non-rapid eye movement (NREM), to wakefulness.

During this transition state, there is a high arousal threshold, mental confusion and unclear perception.

It usually occurs in the first or second sleep cycle during the deeper stages of NREM sleep.

When the child awakens there is no recollection of the sleepwalking. It is sometimes associated with nonsensical talking. The child’s eyes are often open with a characteristic “looking right through you” appearance.

K_sleepwalking1As somnambulism occurs more often in children, there are suggestions that it is indicative of immaturity of the central nervous system.

It is estimated to occur in about 15% of children aged between four and 12. Somnam­bu­lism can sometimes start in their teens but is usually resolved by the late teenage years. How­­ever, it also occurs in adults.

Some children may hit objects while sleep­walking and injure themselves occasionally. The effects in adolescents and adults may be of more concern as there have been reports of behaviours like driving a car, cooking and eating, with consequent injuries.

Causes

There are several causes of sleepwalking. It is more common in identical twins and is 10 times more likely to occur if a first degree relative also sleepwalks.

In adults, the frequen­cy of sleepwalking increases during menstruation and pregnancy. Sleepwalking may be triggered by disordered sleep schedules, sleep deprivation, fever, stress and excessive alcohol consumption.

Certain medicines can cause sleepwalking. They include sleeping pills (hypnotics), allergy pills (antihistamines), antidepressants, some antibiotics (fluoroquinolone) and calming pills (tranquilisers).

Sleepwalking is associated with medical conditions like fever, nocturnal asthma or fits, abnormal heart rhythms (arrhythmias), regurgitation of food from the stomach into the oesophagus (reflux), psychiatric conditions (panic attacks and post-traumatic stress) and when there is temporary stoppage of breathing during sleep (obstructive sleep apnoea).

Somnambulism episodes vary and can range from walking quietly around a room to disturbed running. The patients may later tell of attempts to run away from dangerous situations. They have a typical clumsy, staring and dazed appearance with their eyes opened as they walk about.

When questioned, their responses are slow or absent with simple or nonsensical words uttered. There is no recollection of the event if the person returns to bed without awakening. Older children are more likely to be awakened at the end of the episode of somnambulism.

Somnambulism has to be distinguished from night terrors (or sleep terrors) which are similar to somnambulism in that they occur in the first or second sleep cycle during the deeper stages of NREM sleep.

However, night terrors present with sudden screams associa­ted with a panic-like appearance. The eyes are opened wide, there is sweating and increased heart and respiratory rates. This may be follow­ed by movements such as running around the room.

By itself, night terrors are not dangerous but injuries to the child or others may result if the child is violent. Night terrors may occur for many consecutive weeks, stop completely and then recur later. They usually cease when the child reaches adolescence but may occasionally persist until the child is mature.

A similar condition is confusional arousals. They occur in the first or second sleep cycle during the deeper stages of NREM sleep. There are short episodes, lasting about 10 minutes or so, of disorientation, inconsolable crying and thrashing movements in bed.

The child typically does not remember the event. The condition is common in younger children. Attempts to awaken the child frequently prolong the episode.

However, if the child is awakened, the episode typically ceases. Unlike night terrors, there are no changes like sweating and increased heart and respiratory rates.

Diagnosis and management

imagesNo treatment is needed in most instances of somnambulism because it is rarely an indication of a medical or psychiatric problem.

Somnambulism usually disappears in most children at puberty although it sometimes persist into adulthood. A medical consultation is advisable if it occurs frequently, if there is injury or if the behaviour is violent.

The doctor will carry out a physical examination to exclude any medical causes. Some­times, a specialist referral may be made for an assessment to determine whether a psychia­tric condition is the cause.

Reassurance is all that is needed in most instances. Several general measures can be taken by someone affected by somnambulism which includes getting sufficient sleep and avoiding any precipitating factors like visual, tactile or auditory stimuli just before bedtime.

To reduce the likelihood of injury, remove obstacles and sharp objects from the bedroom and avoid bunk beds. Lock windows and doors of the bedroom. It may be useful to have an alarm placed on the window or door.

Any underlying medical condition such as fever, nocturnal asthma or fits, cardiac arrhyth­mias, obstructive sleep apnoea, gastro-oeso­pha­geal reflux, panic attacks or post-trau­matic stress, would be treated appropriately.

Medicines are prescribed if there is a likelihood of injury, excessive sleepiness during the day, significant disruption of family life, and general measures have been unhelpful.

The medicines that have been reported to be useful are the benzodiazepines, tricyclic antidepressants and serotonin reuptake inhibitors. Low-dose clonazepam before going to bed for three to six weeks have also been reported to be usually effective.

The medicines can be stopped after three to six weeks without recurrence of symptoms.

Other treatment like relaxation techniques and anticipatory awakenings have been reported to be useful.

These techniques are usually carried out by a psychologist. Antici­patory awakenings involve waking up the affected child about 15 minutes prior to the usual time the somnambulism occurs and keeping the child awake throughout the time the episode usually occur.

Somnambulism can be prevented by avoiding sleep deprivation, avoiding stress and avoiding alcohol consumption.

Source: Dr Milton Lum

Getting some sleep

 

Restful: Normal adults need six to 10 hours of sleep.

Restful: Normal adults need six to 10 hours of sleep.

A look at ways to manage insomnia.

 

THE body rests and recovers from previous activities during sleep. Normal sleep comprises cycles of non-rapid eye movement (NREM) and rapid eye movement (REM). NREM sleep is followed by REM sleep, which occurs four to five times during the usual eight-hour sleep period.

The first REM period of the night may be last less than 10 minutes, while the last may exceed an hour. The NREM and REM cycles vary in length from 70 to 100 minutes initially, to 90 to 120 minutes later in the night.

During the first third of the night, deep NREM sleep predominates, while REM sleep predominates in the last third of the night. REM sleep takes up 20% to 25% of total sleep time.

Insomnia

Insomnia refers to the disturbance of a normal sleep pattern. The different types of insomnia are:

·Difficulty getting to sleep (sleep onset insomnia) which is most common in young people.

·Waking up in the night which is most common in older people.

·Waking up early in the morning, which is least common.

·Not feeling refreshed after sleeping, leading to irritability, tiredness and difficulty concentrating during the day.

·Waking up due to disturbances such as noise or pain.

The duration of insomnia varies. It may be:

·Transient, lasting two to three days

·Short-term, lasting more than a few days, but less than three weeks

·Chronic, that is, it occurs on most nights for three weeks or more.

Everyone has experienced insomnia. It is generally accepted that about one-third of the population has insomnia.

 

ZZzzzzz

ZZzzzzz

How much sleep?

 

The need for sleep varies with age. A newborn may sleep 16 to 20 hours, and an infant 12 to 14 hours. Toddlers may sleep 10 hours or more. Primary schoolchildren need nine to 10 hours of sleep, while normal adults need six to 10 hours of sleep.

It takes an adult about 10 to 20 minutes to fall asleep. Most of those who have less than five to six hours of sleep are probably not getting enough sleep.

After a good sleep, a person would feel refreshed on waking and can stay alert throughout the day, without the need for naps or sleeping in on weekends.

Symptoms and causes

The symptoms of insomnia vary. They include lying awake for a long period at night prior to sleeping, waking up several times at night, waking up early in the morning and not being able to go back to sleep, feeling tired and not refreshed, inability to function properly during the day, and feeling irritable.

The causes of insomnia:

·Physiological: working at night, light, noise, snoring, partner’s movements, and jet lag.

·Medical: pain or discomfort caused by arthritis, headaches, back pain, menopausal hot flushes, gastrointestinal disorders and pruritus (excessive itching).

·Psychological and psychiatric: examination stress, work worries, relationship problems, anxiety, depression, bereavement and dementia.

·Sleep disorders: sleep apnoea and sleep walking.

·Medicines: antidepressants, appetite suppressants, beta-blockers, corticosteroids and decongestants.

·Alcohol.

Management

Consult a doctor. He will look into the history of your condition and conduct a physical examination. The doctor will enquire about your sleeping routines, previous and current medical conditions, psychological or psychiatric conditions, if any, consumption of caffeine, medicines and alcohol, substance abuse including narcotic drugs, diet and exercise. The cause may be detected through this approach in many instances.

If the cause is not obvious, the doctor will ask for a sleep diary to be kept. This involves recording the time when one goes to sleep, when one wakes up in the morning and when one wakes up at night.

A referral to a specialist may be necessary if the cause is still not obvious. Laboratory tests and polysomnography may be carried out. The latter is used in the diagnosis of sleep apnoea and sleep disorders. This involves recording many parameters when one is asleep, including brain electrical activity; movements of the eye, jaw and leg muscles; and heart and lung functions. The doctor will discuss with the patient prior to any videotaping which may be considered necessary.

Once a diagnosis of the underlying condition has been made, the cause will be treated. For example, if the cause is anxiety or depression, the problem will go away once it is treated.

General measures which do not involve the use of medicines are preferred. It may involve counselling if the insomnia is due to stress or bereavement. Cognitive behavioural therapy which involves changes in thinking and behavioural patterns is useful. Measures like limiting caffeine or alcohol intake, exercise and keeping to a regular sleep routine are helpful.

Sleeping pills may be considered by the doctor for severe or short-term insomnia if general measures do not work. Doctors are usually reluctant to prescribe sleeping pills as they relieve the symptoms but do not address the underlying cause. An individual can also become dependent on sleeping pills, which are not without side effects.

Many of the sleeping pills available belong to a group of medicines called benzodiazepines which require a doctor’s prescription. Benzodiazepines are anxiolytics and hypnotics, that is, they reduce anxiety and promote calmness and sleep. Benzodiazepines can lead to dependence and side effects like a hangover and drowsiness during the day. This can lead to accidents when driving. Examples of benzodiazepines include lormetazepam and temazepam.

The short-acting “Z-pills” that is, zopiclone and zolpidem, act on the same receptors as benzodiazepines but are not classified as such because their molecular structures are different. They were initially thought to be less addictive and habit forming than benzodiazepines but this view has changed with reports of addiction in the past few years. The side effects are similar to benzodiazepines.

The lowest possible dose of sleeping pills should be taken for the shortest possible time. One should only take them under medical supervision. There is no place for self-medication. Do not stop intake abruptly as this may cause withdrawal effects. The doctor’s advice is crucial here.

Melatonin is a hormone that is involved in the regulation of the sleep cycle or circadian rhythm. It is a short-term medicine for insomnia and cannot be consumed for more than three weeks. Although side effects are uncommon, they include dizziness, migraines, irritability, constipation and abdominal discomfort.

Getting good sleep

Getting a good night’s sleep is vital. This can be achieved by various means:

·Having a routine facilitates sound sleep. This means going to bed and getting up at about the same time every day. It is important to relax before getting into bed as activity just before bedtime may keep one awake.

·Having an early dinner helps. The digestive system goes to sleep at about 7 o’clock. A light dinner is helpful.

·Avoid caffeine after lunch as caffeine keeps one awake.

·Avoid alcohol as its breakdown produces chemicals that stimulate the individual. It also increases the likelihood of snoring as it relaxes the muscles. This leads to lighter and less refreshing sleep.

·Avoid naps. The afternoon nap may keep one awake at night.

·Avoid light. This is because melatonin, the hormone that helps a person sleep, is produced in the dark.

Source: Dr Milton Lum

A Healthy Snooze / Sleep.

Sleep is needed for the body to rest and repair.

SLEEP is something none of us can do without. However, the reason why everyone needs sleep is not well-elucidated. During sleep, the brain is more responsive to internal stimuli than external stimuli like sound and light. The metabolic demand of the brain is also reduced and this is reflected in a general decrease in the blood flow to the brain.

Most of the knowledge about sleep has come from sleep deprivation experiments. It is generally accepted that good sleep is crucial for optimal intellectual performance and helps in realising a person’s mental potential.

Sweet dreams are made of these: REM sleep, which is also known as ‘dream sleep’, has tonic and phasic components.
Sweet dreams are made of these: REM sleep, which is also known as ‘dream sleep’, has tonic and phasic components.

Normal sleep comprises of cycles of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep consists of progressively deeper stages of sleep. As NREM sleep progresses, stronger stimuli are needed for awakening. REM sleep, which is also known as “dream sleep”, has tonic and phasic components.

There are no rapid eye movements in the former. There are rapid eye movements, muscle twitches, pupil dilatation, increased heart rate variability and increased breathing rate in the latter. The muscle tone is decreased throughout REM sleep. The length of REM sleep and the intensity of the eye movements increase throughout the sleep cycle.

NREM sleep is followed by REM sleep, which occurs four to five times during the usual eight hour sleep period. The first REM period of the night may be last less than 10 minutes, while the last may exceed an hour. The NREM and REM cycles vary in length from 70 to 100 minutes initially to 90 to 120 minutes later in the night.

During the first third of the night, deep NREM sleep is present more whereas REM sleep predominates in the last third of the night. REM sleep takes up 20 to 25% of total sleep time. Light NREM sleep is the transition between sleep and awakening.

Infants sleep more than any other age group. The newborn baby can sleep 14 to 16 hours in a day. As the baby grows, the sleep time decreases so that by about six months of age, there is usually an overnight sleep period with at least a nap during the day. There is more REM sleep in an infant.

Senior citizens take a longer time to fall asleep and have more frequent awakenings. This sleep fragmentation may be aggravated by medical problems. There is less deep sleep and the total time in bed may increase leading to complaints of insomnia.

How much sleep?

The need for sleep varies with age. A newborn may sleep 16 to 20 hours throughout a day and an infant 12 to 14 hours with most of the sleep at night. Toddlers may sleep 10 hours or more. Primary school children need nine to 10 hours of sleep. Normal adults need six to 10 hours of sleep. It usually takes an adult about 10 to 20 minutes to fall asleep. Most of those who have less than five to six hours of sleep are probably not getting enough sleep.

After a good sleep, a person would feel refreshed on waking and is able to be alert throughout the day, without the need for naps or sleeping in on weekends.

The body has a “biological clock” called the circadian rhythm which is set by the hypothalamus in the brain. It is set at about 24.2 hours and the body is used to a regular routine of light and darkness at certain times. Light is called zeitgeber, a German word meaning time-giver, because it sets the clock in the hypothalamus.

A practical explanation for the circadian rhythm is that the brain is analogous to a battery charging during sleep and discharging during the time a person is awake.

It is believed there is a downswing in the circadian rhythm from evening till it reaches the lowest point (nadir) in the early morning.This makes it possible for a person to remain asleep overnight by preventing premature awakening, which is facilitated by the morning upswing. The upswing peaks in the early evening after which there is a downswing. This explains the stable cognitive function during the time a person is awake.

The body temperature is controlled by the hypothalamus. It is increased during the daylight hours and decreased at night, thus mirroring the sleep rhythm. Melatonin, prolactin, testosterone and growth hormone also have a circadian rhythm with maximal secretion during the night.

Sleep deprivation

Much knowledge about sleep has come from sleep deprivation experiments. Studies of individuals deprived of sleep for more than 24 hours have shown that there is a decrease in the brain’s metabolic activity by up to 6% for the whole brain and 11% for specific areas in the brain. There is also a decrease in body temperature, release of growth hormone and immunity as well as an increase in heart rate variability.

As sleep has a restorative function, deprivation leads to short and long term serious consequences. There are significant effects of sleep deprivation on brain functions like memory, concentration and mood.

Higher order cognitive function like language and numerical skills is affected early and disproportionately. There may be memory lapses, blurring of vision, slurring of speech, disorientation and poor co-ordination of body movements. Mood changes like depression are common.

Short term sleep deprivation has been reported to contribute to obesity and poor control of type II diabetes. Chronic partial sleep deprivation is the commonest cause of daytime sleepiness, which can impair performance at school or work and increases the risk of accidents especially when driving or operating machinery.

Long term sleep deprivation decreases the quality of life and leads to increased morbidity and mortality. There are effects on cardiovascular, respiratory and endocrine function. Coronary events have been found to be more common in those who have less than seven hours sleep compared to those with eight hours or more.

The subtle cognitive changes with small amounts of sleep loss (less than an hour each night for many nights) may not be recognised by the affected individual. Sleep loss for a week leads to marked cognitive deficits which may also be unrecognised by the affected individual. Research and education is ongoing to address this lack of recognition of the effects of sleep deprivation.

Sleeping well

Getting a good night’s sleep is vital for everyone. There are several ways of achieving this and they include: 

  • Having a routine facilitates sound sleep. This means going to bed and getting up at about the same time every day.  
  • Having an early dinner is helpful. The digestive system goes to sleep at about 7pm. A light dinner is helpful.  
  • Avoiding caffeine after lunch is helpful as caffeine keeps one awake.  
  • Avoiding alcohol is helpful as its breakdown produces chemicals that stimulate the individual. It also increases the likelihood of snoring as it relaxes the muscles. This leads to lighter and less refreshing sleep.  
  • Avoiding naps. The afternoon nap may be what keeps one awake at night.  
  • Avoiding light can be helpful. Not going to bed immediately after turning off the television. This is because melatonin, which is the hormone that helps a person sleep, is produced in the dark.

Source: Dr Milton Lum