Healthy living guide
Sleep
Part of The
Body series
3
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Getting a good night’s sleep
For reasons that are not fully understood,
sleep is a basic human requirement and
one that is essential for continued mental
and physical wellbeing. Lack of sufficient
sleep has been shown to be linked with a
significant increase in the risk of car
accidents which is at least as high as
driving under the influence of alcohol. In
fact, it is thought that sleepiness and slow
reactions from lack of sleep contribute to
about 10% of serious accidents and an
even higher proportion of motorway
accidents.
Although it is hard to determine what
normal sleep is because it varies so much
from one person to the next, generally
speaking it consists of a period of going
off to sleep of no more than about 30
minutes followed by six to eight hours of
sleep during which the person will wake
briefly two or three times and then fall to
sleep again, feeling refreshed in the
morning. During sleep, we enter various
levels of sleep, including Rapid Eye
Movement (REM) sleep which is thought
to be essential for sleep to be truly
refreshing.
One of the problems with identifying
people with sleep problems is that not all
of them are aware that their tiredness is
due to lack of sleep. This is because
many people who complain of insomnia,
when studied, have often been found to
have many hours of good quality sleep,
whereas many people who think they are
sleeping well are in fact suffering from a
disorder such as sleep apnoea that they
may be unaware of.
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Getting a good night’s sleep
How common are sleep
problems?
This is a hard question to answer for a
number of reasons, including the
discrepancy described on the previous
page between those who think they
have a problem and those who are
unaware that they are not sleeping
properly. In addition, there are a great
number of people who do not consult
their doctor but simply adapt their lives
as best they can around their insomnia.
However, it is
It is thought that
thought that
about 5% of the
about 5% of the
population suffer
population
from Excessive
suffer from
Daytime
Excessive
Sleepiness
Daytime
(EDS).
Sleepiness
(EDS). These
people experience an overwhelming
desire to sleep during the day even
though they may feel that they have
had a good night’s sleep. Some of
these people will have a sleep disorder,
whereas others may be suffering from a
physical condition, resulting in
excessive tiredness.
continued
The most common sleep disorders are
insomnia (see next page), narcolepsy
(page 5), obstructive sleep apnoea (page 8)
and periodic limb movement disorder
(PLMD) which is sometimes called Restless
Leg Syndrome (page 9).
How are sleep problems
diagnosed?
It can be difficult to diagnose a sleep
disorder partly because there are so
many causes of fatigue and tiredness,
including physical, emotional and
mental sleep problems. The diagnosis
usually starts with the doctor listening
to a description of the symptoms the
individual is complaining of. This will
usually point the doctor in a particular
direction which could involve an
examination of the patient, further
physical tests (blood tests, x-rays,
scans etc if a physical problem is
suspected) or sometimes what are
called sleep studies where someone is
monitored while they sleep.
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Insomnia
Insomnia i.e. difficulty sleeping for a
sufficient amount of time each night to feel
refreshed and able to lead a normal life, is
thought to affect 10% to 15% of people at
any particular time. Sufferers may have
trouble getting to sleep, experience
frequent episodes of waking during the
night or wake up too early and are unable
to get back to sleep.
Causes of insomnia include anxiety (which
typically causes difficulty getting off to
sleep), worry or stress (which are common
causes of disturbed sleep) and depression,
which is frequently signified by early
morning waking i.e. waking before the
alarm clock goes. Severe insomnia i.e. only
sleeping a few hours or not at all day after
day is sometimes a symptom of a mental
illness such as schizophrenia or manic
depression (sometimes now called bipolar
disorder). However, in these instances there
are almost always other associated
symptoms.
Insomnia can also be the result of a
disturbance of the normal sleeping pattern
due to jet lag, constant sleep disturbance
from children, noisy neighbours or as a
result of shift work. Alcohol abuse may also
disturb normal sleep patterns by causing
daytime sleepiness or may make sleep less
refreshing since there is evidence that it
disrupts the amount of the good quality
(REM) sleep. Temporary insomnia may
accompany a period of grief (this is
essentially a normal reaction as long as it is
temporary).
Physical disruptions to sleep include night
sweats, itching, pain, having to get up at
night to pass urine or breathlessness.
Obviously, if these symptoms exist, medical
advice should be sought to establish
whether or not there is a significant
underlying physical problem.
Treatment of insomnia
The treatment of insomnia starts with
establishing an underlying cause (if one
exists). This may be as simple as
drinking too much fluid before bedtime
resulting in the need to pass urine at
night or may be more complex if a
significant mental or physical underlying
illness is thought to exist.
Once underlying issues have been
excluded, resolved or treated, sleep can
be improved, often by establishing a
bedtime routine that enables the
individual to physically and mentally
wind down at the end of the day.
continued
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3
Insomnia
continued
This may go something like this
Having a regular bed-time.
Avoiding day time sleeping.
Avoiding stimulating drinks such as
tea or coffee in the evening and,
perhaps, substituting them with a
warm milky drink.
Having a relaxing warm bath.
Reading something relaxing in bed
rather than watching the television
or doing paperwork.
Avoiding long lie-ins on a regular
basis since these can result in
disruption of the normal sleeping
pattern.
Use relaxation techniques such as
relaxation tapes regularly to help
relax.
Sleeping tablets
do exist and can Prescription
sleeping tablets
sometimes be
can become both
useful in the
short term to re- psychologically
and physically
establish a
addictive.
normal sleeping
pattern.
However, prescription sleeping tablets
can become both psychologically and
physically addictive and even over-thecounter sleeping tablets should
preferably not be seen as a long term
solution.
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Narcolepsy
What is it?
Narcolepsy is a disorder of the brain,
which scientists are beginning to
understand and which is a chronic
nervous system disorder affecting the
sleep/wake cycle. It can occur at any
age, although most often it first appears
during adolescence. Excessive Daytime
Sleepiness (EDS) is the most common
symptom and is usually the most serious
and obvious feature of the disorder. It
was first described by a French physician
in 1880 who coined the term ‘narco’
(sleep) and ‘lepsy’ (to be seized by).
Narcolepsy occurs equally in men and
women and there are thought to be
2,500 diagnosed sufferers in the UK,
with perhaps another 17,500
undiagnosed and untreated.
How does it occur?
In human sufferers, researchers have
recently found undetectable levels of a
protein (hypocretin 1) in certain nerve
pathways involved in wakefulness. It is
already known from other studies that
animals that cannot make hypocretin
cannot stay awake, even when engaged
in exercise. It is therefore thought that
there may be a genetic predisposition to
develop narcolepsy. However, it is also
clear that the environment plays a part.
What are the symptoms of
narcolepsy?
The main symptom is EDS – a constant
feeling of sleepiness with bouts of
unwanted sleep which recur throughout
the day. This is the most disabling feature
of narcolepsy. The attacks are
overpowering and usually last a few
minutes but can last about 30 minutes
or longer in certain cases. They often
occur in unusual circumstances – for
example, in the middle of a conversation.
Some sufferers, whilst apparently awake,
may perform complex, sometimes
irrational tasks with no recollection of the
event thereafter. These variations in
alertness can be dangerous.
The second major symptom of narcolepsy
is cataplexy. The Latin meaning of this is
‘to be struck down by fear’. This sudden
loss or decrease in muscle tone can
result in symptoms such as slurred
speech, arm drop or collapse and is most
frequently set off by an emotion such as
anger, laughing at a joke or even
anticipation of laughing at a joke.
Other symptoms include sleep paralysis
(a situation where the sufferer
experiences an inability to move on first
waking and may feel as if he or she can’t
breathe) and visual or auditory
hallucinations whilst dozing off or waking
up. These are called Hypnagonic and
Hypnopomic hallucinations.
continued
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5
Narcolepsy
continued
How is it diagnosed?
Sometimes the diagnosis can be made
on the history alone. Sleep laboratory
tests can help to rule out other sleep
disorders, such as obstructive sleep
apnoea (OSA) during which the
individual stops breathing for a period of
time followed by a gasp which can also
cause EDS but which does not cause
the other features of narcolepsy such
as cataplexy.
A number of tests may be needed
including a heart trace (ECG), a brain
trace (EEG) and breathing functions
whilst asleep. Other tests are also
performed to measure how quickly the
individual takes to fall asleep and
measurements of their daytime
sleepiness along with their ability to
stay awake.
What treatment and self-help
strategies are there?
Lifestyle
Changes to lifestyle are often
necessary. These can include changing
the times at which activities take place,
altering eating habits and avoiding
certain foods and alcohol.
Living with narcolepsy can be very
stressful and counselling or
psychotherapy support may be needed.
A regular night time routine and
planned daytime naps may be helpful.
6
Someone with narcolepsy should not
drive since the overwhelming urge to fall
off to sleep may occur without warning.
Therefore, the sufferer should inform
the DVLA (driving licence authority) of
the fact that they have the condition.
Drug treatment
A variety of drugs may prove useful.
These include stimulants such as
amphetamines, which raise alertness
and to some degree counteract the
feeling of sleepiness. Unfortunately,
these types of stimulants become less
effective with use and their side-effects
may make them unsuitable for
particular individuals.
A drug that has been found to be
effective in the treatment of narcolepsy
is Modafinil (Provigil). It promotes
wakefulness and restores alertness
without affecting the ability to sleep at
night. It appears to act on an area of
the brain (the hypothalamus) concerned
with keeping people awake and alert.
How Modafinil works is not precisely
known but it seems to lack the sideeffects of amphetamines.
Tricyclic antidepressants and a group of
modern antidepressants called the
SSRIs (which include the well-known
Prozac) have occasionally been found to
be useful in the treatment of cataplexy.
However, these antidepressant drugs
have no effect on EDS.
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Obstructive
Sleep Apnoea
Exercise continued
What is it?
Simple snoring is an inconvenience
(mainly for those who have to hear it!)
although it can sometimes cause
relationship difficulties if it is severe and
persistent enough to affect others in the
household. However, severe snoring can
be associated with a more serious
condition called Obstructive Sleep
Apnoea-hypopnoea Syndrome (OSAHS).
This is a disorder that causes a person
to snore but also to intermittently stop
breathing whilst asleep sometimes for a
worryingly long time.
The causes of
OSAH is far
OSAHS are the
more common in
same as those
overweight
for snoring.
people.
However, it
causes the
individual to get into a cycle of going to
sleep, snoring, stopping breathing due
to obstruction of the airway due to
relaxation of their airway, followed by
momentarily waking up in response to
the urge to breathe and then falling
asleep again.
The temporary waking may happen
hundreds of times a night. The effect of
this is that the sufferer does not get
restful sleep even though they may think
they have slept all night. OSAHS affects
about 4% of men and 2% of women
and is far more common in overweight
people.
What are the symptoms?
The result of OSAHS can be symptoms
of tiredness and lack of concentration
during the day, morning headaches and
excessive night time urination. It has
been linked with an up to seven-fold
increase in the chance of road traffic
accidents in sufferers, a higher risk of
high blood pressure and a greater
likelihood of developing heart disease.
What is the diagnosis?
The diagnosis of snoring is obviously
fairly easy since the individual’s partner
or others in the household will report the
symptom in no uncertain terms.
However, although sleep apnoea may be
suspected because the same partner
will have noted that the individual stops
breathing for a period of time, formal
confirmation of OSAHS requires further
tests, usually in the form of sleep
studies.
Sleep studies are usually done in the
patients own home using a sleep
monitor recording their sleep pattern
and blood oxygen levels.
continued
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Obstructive Sleep Apnoea continued
What is the treatment?
Initially, there are things each
person can do to help to reduce the
chances of snoring or developing
OSAH and these include
Avoiding excessive alcohol.
Reaching or maintaining a normal
weight.
Avoiding sleeping on the back since
this makes collapsing of the airways
less likely.
Using steam menthol or olbas oil
inhalations to keep the nasal
passages open.
Having taken these measures, if the
problem remains or is suspected, the
next step would be to see the GP for
further advice. They are then likely to
refer on to a specialist, usually an Ear,
Nose and Throat (ENT) consultant for
further advice and investigation. In other
cases, an appliance which pushes the
lower jaw forward may be tried, since
this has been found to help to open the
air passages at the back of the throat.
If the oral appliance fails to work, the
specialist may recommend something
called continuous positive airways
pressure (CPAP), which involves the
sufferer wearing a mask over the nose
and mouth which delivers air under a
slight pressure as they breathe. This
prevents the airways from collapsing
during sleep and can be very effective.
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Periodic limb movement disorder
(restless legs syndrome)
What is it?
Periodic limb
Periodic limb
movement
movement
disorder (PLMD)
disorder
(PLMD)
or restless legs
or
restless
legs
syndrome (RLS)
syndrome
(RLS)
is
is also
also sometimes
sometimes
referred to as
referred to as
Ekbom’s
Ekbom’s
syndrome, after
syndrome, after
the doctor who
the doctor who
first recognised
first recognised
it. It is a disorder it.
that affects up to
5% of the population but is still not
completely understood. It varies in its
severity from mild cases causing a
certain amount of discomfort to severe
forms that lead to significant distress and
sleep disturbance. RLS can develop at
any age although it is more common in
the elderly population and in about one
third of cases there is a family history.
What are the symptoms?
The most noticeable symptom of RLS is
the presence of an uncomfortable
fidgety, jittery or crawling sensation
deep in the legs. These sensations are
noticed most frequently in the calves
and are usually present in both legs
although one side may be worse than
the other. The
The most
symptoms are
noticeable
invariably worse
symptom of RLS
during rest,
is the presence
especially whilst
of an
the sufferer is
uncomfortable
lying down
fidgety, jittery or
before going to
crawling
sleep. Moving
sensation deep
the legs relieves
in the legs.
the symptoms.
In severe cases
the individual may be forced to spend
most of the night pacing up and down
in an attempt to keep moving to relieve
the sensations. The condition is often
worse after enforced rest such as long
journeys or having to sit for long periods
of time.
Another symptom, which some
individuals may notice, is involuntary
jerking movements of the legs during
sleep, which may be bad enough to
wake their bed partner.
What causes it?
The exact cause of RLS is not known but
there are some conditions with which it
is often associated and, if these other
conditions are treated, the leg
restlessness may also get better. For
instance, deficiency in iron or the
vitamin folic acid or B12 is associated
continued
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9
Periodic limb movement disorder
(restless legs syndrome) continued
with RLS as is pregnancy. Nerve damage
due to diabetes, kidney failure or
rheumatoid arthritis can also contribute
to RLS. Some types of medication have
been found to predispose to the
condition, including lithium, betablockers, some antidepressants and
some epilepsy drugs.
How is it diagnosed?
The doctor usually makes the diagnosis
from the description of the symptoms
given by the patient. He or she may
examine the sufferer mainly to rule out
other possible causes of leg pain and
restlessness such as some nerve
disorders. Blood tests may also be
performed both to exclude other illnesses
and to look for associated conditions
such as those described above.
In difficult cases the GP may refer the
individual on to a neurologist (nerve
specialist) to confirm the diagnosis and,
in those patients who have severely
disturbed sleep, sleep studies may be
performed in a special hospital setting.
How is it treated?
The type of treatment given will depend
on various factors, including how severe
the individual’s symptoms are, how long
they have had them and what else has
already been tried.
First, the patient may be given general
advice to help with sleep such as making
sure they have a bed time routine, a
comfortable bed and possibly a warm
drink (not tea or coffee) before bed.
Second, any associated conditions such
as iron or vitamin deficiency will be
treated. One third of elderly patients with
RLS have iron deficiency and its
correction will often reduce the
symptoms of RLS. The doctor also may
want to check what other medication the
person is taking in case they include one
or more drugs known to aggravate the
condition. The result may be a change in
medication to something more suitable.
Those with severe symptoms may be
offered medication. Several types of
treatment have been shown to benefit
people with RLS including medications
such as Levodopa, Bromocriptine,
Oxycodone, Clonazepam and various
others. Ropinirole (Requip) is an
alternative treatment that is being
prescribed off licence more and more
now for this issue. The choice of
medication will be advised by the GP or
specialist and may be an individual
thing. One patient will respond to one
type of medication but not another, so a
system of trial and error may be needed
before the best treatment is found for a
particular person.
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Further information
Apart from contacting your GP, the following organisations
may offer further help
British Sleep Society
PO Box 247
Huntington
PE28 3UZ
Web: www.sleeping.org.uk
The Narcolepsy Association UK (UKAN)
PO Box 13842
Penicuik
EH25 8WX
Tel: 0845 450 0394
Web: www.narcolepsy.org.uk
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Healthy Living Guides
For ease the Healthy Living Guides have been grouped into six different sections and have
been given a number which you can use to request them on the form overleaf.
Next to each guide is a list of the subjects that are described in each one. If you have
requested Healthy Living Guides in the past you will notice that there are now fewer guides.
However, all the subjects that we tackled in those guides are included in this new list along
with a number of new topics.
Healthy Living – our practical guides for living healthily
1 Healthy living – cholesterol, exercise, stress and relaxation
2 Healthy eating – diets, alcohol moderation and a height/weight chart
3 Sleep – how to get a good night’s sleep
4 Common allergies
5 Infectious diseases and their treatment
The Body – a look at some of the most common medical conditions
6 Back and spine – back pain, sciatica and slipped discs
7 Skeletal system – arthritis, osteoporosis, fractures and knee replacements
8 Ear, nose and throat – tinnitus, hearing loss, sinusitis, snoring and tonsillitis
9 Eyes – cataracts, long and short sightedness and macular degeneration
10 Brain – migraines, strokes and epilepsy
11 Heart – hypertension, angina, varicose veins and heart surgery
12 Intestines – irritable bowel syndrome, hiatus hernia and diverticular disease
13 Lungs – bronchitis and asthma
14 Skin – psoriasis and eczema
First aid – developed in association with the Red Cross
15 First aid for adults
16 First aid for children
Cancer and its treatment
17 Cancer – a general introduction
18 Male specific cancers
19 Female specific cancers
Life stages – advice on medical conditions specific to certain life stages
20 Childhood – head lice, chickenpox, whooping cough, mumps and rubella
21 Life begins at 50
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Other subjects include
22 A–Z of medical terminology and tests
23 Male and female fertility
24 Dealing with depression
25 Travel health guide
26 Diabetes
27 CT and MRI scans
28 Before and after an operation
29 Pregnancy and postnatal care
30 Dealing with the menopause
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the Healthy Living Guide series and many more.
These subjects are discussed in this guide:
insomnia
narcolepsy
obstructive sleep apnoea
restless legs syndrome.
These subjects are not discussed in this guide:
stress.
The Health at Hand team work with medical journalists to update its fact sheets and add
new subjects regularly so if you don’t see the subject you require further information on
then please give them a call and if they have a fact sheet they will send it to you.
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