Type of Sleep Disorder
- Sleep Apnea
- Restless Leg Syndrome
Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night's sleep.
There are two main types of sleep apnea:
- Obstructive sleep apnea, the more common form that occurs when throat muscles relax
- Central sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing
If you think you might have sleep apnea, see your primary care doctor. Treatment is necessary to avoid heart problems and other complications.
The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:
- Excessive daytime sleepiness (hypersomnia)
- Loud snoring, which is usually more prominent in obstructive sleep apnea
- Episodes of breathing cessation during sleep witnessed by another person
- Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
- Awakening with a dry mouth or sore throat
- Morning headache
- Difficulty staying asleep (insomnia)
- Attention problems
When to see a doctor
Consult a medical professional if you experience, or if your partner notices, the following:
- Snoring loud enough to disturb the sleep of others or yourself
- Shortness of breath that awakens you from sleep
- Intermittent pauses in your breathing during sleep
- Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving
Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence.
Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.
Causes of obstructive sleep apnea
Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils, the side walls of the throat and the tongue.
When the muscles relax, your airway narrows or closes as you breathe in, and you can't get an adequate breath in. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so you can reopen your airway. This awakening is usually so brief that you don't remember it.
You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.
People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, some people with this type of sleep apnea think they sleep well all night.
Sleep apnea can affect anyone. Even children can have sleep apnea. But certain factors put you at increased risk:
- Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop this disorder, too.
- Neck circumference. People with a thicker neck may have a narrower airway.
- A narrowed airway. You may have inherited a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.
- Being male. Men are twice as likely to have sleep apnea. However, women increase their risk if they're overweight, and their risk also appears to rise after menopause.
- Being older. Sleep apnea occurs significantly more often in adults older than 60.
- Family history. If you have family members with sleep apnea, you may be at increased risk.
- Race. In people under 35 years old, blacks are more likely to have obstructive sleep apnea.
- Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.
- Smoking. Smokers are three times more likely to have obstructive sleep apnea than are people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking.
- Nasal congestion. If you have difficulty breathing through your nose — whether it's from an anatomical problem or allergies — you're more likely to develop obstructive sleep apnea.
Sleep apnea is considered a serious medical condition. Complications may include:
- High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) is greater than if you don't. The more severe your sleep apnea, the greater the risk of high blood pressure. Also obstructive sleep apnea increases the risk of stroke, regardless of whether or not you have high blood pressure. If there's underlying heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event. Studies also show that obstructive sleep apnea is associated with increased risk of atrial fibrillation, congestive heart failure and other vascular diseases.
- Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems.
- Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea and how it's treated.
- Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep-deprived as well.
People with sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (nocturia), and a decreased interest in sex. Children with untreated sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD).
If you or your partner suspects that you have sleep apnea, you'll probably first see your primary care doctor. Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements that you're taking.
- Try to sleep on your side. Most forms of sleep apnea are milder when you sleep on your side.
- Avoid alcohol close to bedtime. Alcohol worsens obstructive and complex sleep apnea.
- Avoid sedative medications. Drugs that relax you or make you sleepy can also worsen sleep apnea.
- If you're drowsy, avoid driving. If you have sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving at all.
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep.
For mild cases of sleep apnea, your doctor may recommend only lifestyle changes, such as losing weight or quitting smoking. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.
- Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP, the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring. Although CPAP is the most common and reliable method of treating sleep apnea, some people find it cumbersome or uncomfortable. Some people give up on CPAP, but with practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that's comfortable. Some people benefit from also using a humidifier along with their CPAP system. Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings may need to be adjusted.
- Adjustable airway pressure devices. If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping. For example, units that supply bilevel positive airway pressure (BPAP) are available. These provide more pressure when you inhale and less when you exhale.
- Expiratory positive airway pressure (EPAP). This is the most recent treatment approved by the Food and Drug Administration (FDA). These small, single-use devices are placed over each nostril before you go to sleep. The device is a valve that allows air to move freely in, but when you exhale, air must go through small holes in the valve. This increases pressure in the airway and keeps it open. The device helped reduce snoring and daytime sleepiness when compared to a sham device. And, it may be an option for some who can't tolerate CPAP.
- Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more reliably effective than oral appliances, but oral appliances may be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.
Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for those few people with certain jaw structure problems, it's a good first option. The goal of surgery for sleep apnea is to enlarge the airway through your nose or throat that may be vibrating and causing you to snore or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include:
- Tissue removal. During this procedure, which is called uvulopalatopharyngoplasty (UPPP), your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring.
- Jaw repositioning. In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure, which is known as maxillomandibular advancement, may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
- Implants. Plastic rods are surgically implanted into the soft palate while you're under local anesthetic. This procedure may be an option for those with snoring or milder sleep apnea who can't tolerate CPAP.
- Creating a new air passageway (tracheostomy). You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.
- Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea and possibly central sleep apnea. Try these tips:
- Lose excess weight. Even a slight loss in excess weight may help relieve constriction of your throat. Sleep apnea may be cured in some cases by a return to a healthy weight.
- Exercise. Getting 30 minutes of moderate activity, such as a brisk walk, most days of the week may help ease obstructive sleep apnea symptoms.
- Avoid alcohol and certain medications such as tranquilizers and sleeping pills. These relax the muscles in the back of your throat, interfering with breathing.
- Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.
- Keep your nasal passages open at night. Use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using any nasal decongestants or antihistamines because these medications are generally recommended only for short-term use.
- Stop smoking, if you're a smoker. Smoking worsens obstructive sleep apnea.
Insomnia is a persistent disorder that can make it hard to fall asleep, hard to stay asleep or both, despite the opportunity for adequate sleep. With insomnia, you usually awaken feeling unrefreshed, which takes a toll on your ability to function during the day. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life.
How much sleep is enough varies from person to person. Most adults need seven to eight hours a night.
Many adults experience insomnia at some point, but some people have long-term (chronic) insomnia. Insomnia may be the primary problem, or it may be secondary due to other causes, such as a disease or medication.
You don't have to put up with sleepless nights. Simple changes in your daily habits can often help.
Insomnia symptoms may include:
- Difficulty falling asleep at night
- Awakening during the night
- Awakening too early
- Not feeling well rested after a night's sleep
- Daytime tiredness or sleepiness
- Irritability, depression or anxiety
- Difficulty paying attention, focusing on tasks or remembering
- Increased errors or accidents
- Tension headaches
- Distress in the stomach and intestines (gastrointestinal tract)
- Ongoing worries about sleep
Someone with insomnia will often take 30 minutes or more to fall asleep and may get only six or fewer hours of sleep for three or more nights a week over a month or more.
When to see a doctor
If insomnia makes it hard for you to function during the day, see your primary care doctor to determine what might be the cause of your sleep problem and how it can be treated.
Common causes of insomnia include:
- Stress. Concerns about work, school, health or family can keep your mind active at night, making it difficult to sleep. Stressful life events — such as the death or illness of a loved one, divorce, or a job loss — may lead to insomnia.
- Anxiety. Everyday anxieties as well as more-serious anxiety disorders, such as post-traumatic stress disorder, may disrupt your asleep. Worry about being able to go to sleep can make it harder to fall asleep.
- Depression. You might either sleep too much or have trouble sleeping if you're depressed. Insomnia often occurs with other mental health disorders as well.
- Medical conditions. If you have chronic pain, breathing difficulties or a need to urinate frequently, you might develop insomnia. Examples of conditions linked with insomnia include arthritis, cancer, heart failure, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, stroke, Parkinson's disease and Alzheimer's disease.
- Change in your environment or work schedule. Travel or working a late or early shift can disrupt your body's circadian rhythms, making it difficult to sleep. Your circadian rhythms act as an internal clock, guiding such things as your sleep-wake cycle, metabolism and body temperature.
- Poor sleep habits. Poor sleep habits include an irregular sleep schedule, stimulating activities before bed, an uncomfortable sleep environment, and use of your bed for activities other than sleep or sex.
- Medications. Many prescription drugs can interfere with sleep, including some antidepressants, stimulants (such as Ritalin), and corticosteroids. Many over-the-counter (OTC) medications — including some pain medication combinations, decongestants and weight-loss products — contain caffeine and other stimulants.
- Caffeine, nicotine and alcohol. Coffee, tea, cola and other caffeine-containing drinks are well-known stimulants. Drinking coffee in the late afternoon and later can keep you from falling asleep at night. Nicotine in tobacco products is another stimulant that can cause insomnia. Alcohol is a sedative that may help you fall asleep, but it prevents deeper stages of sleep and often causes you to awaken in the middle of the night.
- Eating too much late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down, making it difficult to get to sleep. Many people also experience heartburn, a backflow of acid and food from the stomach into the esophagus after eating, which may keep you awake.
Insomnia becomes more common with age. As you get older, you may experience:
- A change in sleep patterns. Sleep often becomes less restful as you age, and you may find that noise or other changes in your environment are more likely to wake you. With age, your internal clock often advances, which means you get tired earlier in the evening and wake up earlier in the morning. But older people generally still need the same amount of sleep as younger people do.
- A change in activity. You may be less physically or socially active. A lack of activity can interfere with a good night's sleep. Also, the less active you are, the more likely you may be to take a daily nap, which can interfere with sleep at night.
- A change in health. The chronic pain of conditions such as arthritis or back problems as well as depression, anxiety and stress can interfere with sleep. Older men often develop noncancerous enlargement of the prostate gland (benign prostatic hyperplasia), which can cause the need to urinate frequently, interrupting sleep. In women, menopausal hot flashes can be equally disruptive.
Sleep problems may be a concern for children and teenagers as well. However, some children and teens simply have trouble getting to sleep or resist a regular bedtime because their internal clocks are more delayed. They want to go to bed later and sleep later in the morning.
Nearly everyone has an occasional sleepless night. But your risk of insomnia is greater if:
- You're a woman. Women are much more likely to experience insomnia. Hormonal shifts during the menstrual cycle and in menopause may play a role. During menopause, night sweats and hot flashes often disturb sleep. Insomnia is also common with pregnancy.
- You're older than age 60. Because of changes in sleep patterns and health, insomnia increases with age.
- You have a mental health disorder. Many disorders — including depression, anxiety, bipolar disorder and post-traumatic stress disorder — disrupt sleep. Early-morning awakening is a classic symptom of depression.
- You're under a lot of stress. Stressful events can cause temporary insomnia. And major or long-lasting stress, such as the death of a loved one or a divorce, can lead to chronic insomnia. Being poor or unemployed also increases the risk.
- You work night or changing shifts. Working at night or frequently changing shifts increases your risk of insomnia.
- You travel long distances. Jet lag from traveling across multiple time zones can cause insomnia.
Sleep is as important to your health as a healthy diet and regular exercise. Whatever your reason for sleep loss, insomnia can affect you both mentally and physically. People with insomnia report a lower quality of life compared with people who are sleeping well.
Complications of insomnia may include:
- Lower performance on the job or at school
- Slowed reaction time while driving and higher risk of accidents
- Psychiatric problems, such as depression or an anxiety disorder
- Overweight or obesity
- Increased risk and severity of long-term diseases or conditions, such as high blood pressure, heart disease and diabetes
- Substance abuse
What you can do
- Make a list of any symptoms you're experiencing, including any that may seem unrelated to the reason for the appointment.
- Take key personal information, including new or ongoing health problems, major stresses or recent life changes.
- Make a list of all medications, vitamins, or herbal or other supplements that you're taking, including dosages. Let your doctor know about anything you've taken to help you sleep.
- Take your bed partner along, if possible. Your doctor may want to talk to your partner to learn more about how much and how well you're sleeping.
Your doctor will likely ask questions to look for signs of other problems that may be causing insomnia. A blood test may be done to check for thyroid problems or other conditions that can cause insomnia.
If the cause of your insomnia isn't clear, or you have signs of another sleep disorder, such as sleep apnea or restless legs syndrome, you may need to spend a night at a sleep center. Tests are done to monitor and record a variety of body activities while you sleep, including brain waves, breathing, heartbeat, eye movements and body movements.
Changing your sleep habits and addressing any underlying causes of insomnia, such as medical conditions or medications, can restore restful sleep for many people. If these measures don't work, your doctor may recommend medications to help with relaxation and sleep.
Behavioral treatments teach you new sleep behaviors and ways to improve your sleeping environment. Good sleep habits promote sound sleep and daytime alertness. Behavior therapies are generally recommended as the first line of treatment for people with insomnia. Typically they're equally or more effective than sleep medications.
Behavior therapies include:
- Education about good sleeping habits. Good sleep habits include having a regular sleep schedule, avoiding stimulating activities before bed, and having a comfortable sleep environment.
- Cognitive behavioral therapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
- Relaxation techniques. Progressive muscle relaxation, biofeedback and breathing exercises are ways to reduce anxiety at bedtime. These strategies help you control your breathing, heart rate, muscle tension and mood.
- Stimulus control. This means limiting the time you spend awake in bed and associating your bed and bedroom only with sleep and sex.
- Sleep restriction. This treatment decreases the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.
- Light therapy. If you fall asleep too early and then awaken too early, you can use light to push back your internal clock. You can go outside during times of the year when it's light outside in the evenings, or you can get light via a medical-grade light box.
Taking prescription sleeping pills — such as zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata) or ramelteon (Rozerem) — may help you get to sleep. Doctors generally don't recommend relying on prescription sleeping pills for more than a few weeks, but several medications are approved for long-term use.
Nonprescription sleep medications contain antihistamines that can make you drowsy. Antihistamines may initially make you groggy, but they may also reduce the quality of your sleep, and they can cause side effects, such as daytime sleepiness, dizziness, urinary retention, dry mouth and confusion. These effects may be worse in older adults. Antihistamines also can worsen urinary problems, causing you to get up to urinate more during the night.
No matter what your age, insomnia usually is treatable. The key often lies in changes to your routine during the day and when you go to bed. Good sleep habits promote sound sleep and daytime alertness. These tips may help.
- Exercise and stay active. Activity helps promote a good night's sleep. Get at least 20 to 30 minutes of vigorous exercise daily at least five to six hours before bedtime.
- Check your medications. If you take medications regularly, check with your doctor to see if they may be contributing to your insomnia. Also check the labels of OTC products to see if they contain caffeine or other stimulants, such as pseudoephedrine.
- Avoid or limit naps. Naps can make it harder to fall asleep at night. If you can't get by without one, try to limit a nap to no more than 30 minutes and don't nap after 3 p.m.
- Avoid or limit caffeine and alcohol and don't use nicotine. All of these can make it harder to sleep. Avoid caffeine after lunchtime. Avoiding alcohol can help prevent restless sleep and frequent awakenings.
- Don't put up with pain. If a painful condition bothers you, make sure the pain reliever you take is effective enough to control pain while you're sleeping.
- Stick to a sleep schedule. Keep your bedtime and wake time consistent from day to day, including on weekends.
- Avoid large meals and beverages before bed. A light snack is fine. But avoid eating too much late in the evening to reduce the chance of gastroesophageal reflux disease (GERD) and improve sleep. Drink less before bedtime so that you won't have to urinate as often.
- Use your bed and bedroom only for sleeping or sex. Don't read, work or eat in bed. Avoid TV, computers, video games, smartphones or other screens just before bed, as the light can interfere with your sleep cycle.
- Make your bedroom comfortable for sleep. Close your bedroom door or create a subtle background noise, such as a running fan, to help drown out other noises. Keep your bedroom temperature comfortable, usually cooler than during the day, and dark. Don't keep a computer or TV in your bedroom.
- Hide the bedroom clocks. Set your alarm so that you know when to get up, but then hide all clocks in your bedroom, including your wristwatch and cellphone, so you don't worry about what time it is.
- Find ways to relax. Try to put your worries and planning aside when you get into bed. A warm bath or a massage before bedtime can help prepare you for sleep. Create a relaxing bedtime ritual, such as reading, soft music, breathing exercises, yoga or prayer.
- Avoid trying too hard to sleep. The harder you try, the more awake you'll become. Read in another room until you become very drowsy, then go to bed to sleep.
- Get out of bed when you're not sleeping. Sleep as much as you need to feel rested, and then get out of bed. If you can't sleep, get out of bed after 20 minutes and do something relaxing, such as reading. Then try again to get to sleep.
Although in many cases, safety and effectiveness have not been proved, some people try therapies such as:
- Melatonin. This over-the-counter (OTC) supplement is marketed as a way to help overcome insomnia. Your body naturally produces melatonin, releasing it into your bloodstream in increasing amounts starting at dusk and tapering off toward the morning. Older people seem to have a greater benefit from melatonin. It's generally considered safe to use melatonin for a few weeks, but the long-term safety is unknown.
- Valerian. This dietary supplement is sold as a sleep aid because it has a mildly sedating effect, although it hasn't been well studied. Some people who have used high doses or used it long term may have increased their risk of liver damage, although it's not clear if valerian caused the damage. When it's time to stop using valerian, it must be tapered down to prevent withdrawal symptoms.
- Yoga. Some studies suggest that the regular practice of yoga can help improve sleep quality, and the risks are limited. Be sure to start slow and work with an instructor who listens to you and helps adapt poses to your needs and limitations.
- Meditation. Several small studies suggest that meditation, along with conventional treatment, may help improve sleep. Some research suggests that regularly practicing meditation may have other positive health effects, such as reducing stress and lowering blood pressure.
Because the Food and Drug Administration does not mandate that manufacturers show proof of effectiveness or safety before marketing dietary supplement sleep aids, talk with your doctor before taking any herbal supplements or other OTC products.