Dr Vedavati Purandare discusses in-depth how sleep is beneficial to your wellbeing.A case studyMr Shyam, a 58-year-old-gentleman with Type 2 Diabetes and obesity, presented with excessive daytime sleepiness and uncontrolled blood glucose levels despite multiple oral anti-diabetic drugs. He has been diagnosed to have obesity for the last 8 years and his weight has been increasing progressively. He has a sedentary lifestyle, does not follow any diet and his BMI is 34 with excessive abdominal obesity. Also, his HbA1c was 9.5. On examination, the physician suspected that Mr Shyam, who was already obese with excessive daytime sleepiness, probably suffers from Obstructive sleep apnoea (OSA). To diagnose this condition, he was advised sleep study. Mr Shyam underwent a sleep study and the reports suggested of severe OSA. It has been the reason for his daytime sleepiness and also for his uncontrolled blood glucose levels. The physician counsels Mr Shyam that because of his daytime sleepiness he is just not able to remain physically active but he can definitely improve his symptoms by losing weight. The physician then explained to him that he needs a continuous positive airway pressure (CPAP) device to treat his OSA.Mr Shyam was given a trial of CPAP machine, which effectively helped his OSA and he was more physically active during the daytime. On a 3-month follow up Mr Shyam lost 10 kg of weight and his HbA1c reduced by 2 per cent and it's now 7.5 per cent.Lack of sleep can affect the physical and mental wellbeing of a person and can lead to stress, heart disease, hypertension and depression. Obstructive sleep apnoea can exert excessive pressure on the lungs to inhale more air than the normal and may affect the functioning of the lungs in the long term. Diagnosing theunderlying cause of sleeplessness can help take timely measures to improve the quality of sleep and prevent further complications. Lifestyle changes, regular physical activity and diet can help resolve sleeplessness in most cases.CPAP device helps to improve the quality of sleep by resolving obstruction in the breathing and decreasing movement during sleep. Normal sleep patternsHuman beings need normal sleep for their physical and mental wellbeing. Most adults sleep 7-8 hours per day usually at night. The time and duration of sleep may differ in people depending on their age and health. Children sleep considerably more than older people.Majority of adults sleep only during the night for 7 to 8 hours whereas some divide their sleep into two parts - an afternoon nap and night sleep. Irregular sleep is normally observed in the extreme age groups such as infants and in older people.Human brain comprises two circuits - one is the arousal circuit which keeps a person awake and second is the sleep-promoting circuit which leads to sleep. The relation between these circuits is like a switch.When the switch is 'on', a person is awake and when the switch is 'off', a person sleeps. This sleep-wake cycle is regulated by the circadian rhythm of the human body. Circadian rhythm is the internal body clock of a person that regulates the external 24- hour process of the body..Sleep CycleSleep is not uniform. Instead, over the course of the night, your total sleep is made up of several rounds of the sleep cycle, which is composed of four individual stages. In a typical night, a person goes through four to six sleep cycles. Not all sleep cycles are of the same length, but on average they last about 90 minutes each. It is normal for sleep cycles to change as you progress through your nightly sleep. The first sleep cycle is often the shortest, ranging from 70 to 100 minutes, while later cycles tend to fall between 90 and 120 minutes. In addition, the composition of each cycle - how much time is spent in each sleep stage - changes as the night goes along.There are four sleep stages, including one for rapid eye movement (REM) sleep and three that form non-REM (NREM) sleep. These stages are determined based on an analysis of brain activity during sleep, which shows distinct patterns that characterize each stage..NREM sleep is composed of three different stages. The higher the stage of NREM sleep, the harder it is to wake a person up.Stage 1Stage 1, also called N1, is essentially when a person first falls asleep. This stage normally lasts just one to seven minutes. During N1 sleep, the body has not fully relaxed, though the body and brain activities start to slow with periods of brief movements. There are light changes in brain activity associated with falling asleep in this stage. It is easy to wake someone up during this sleep stage, but if a person is not disturbed, they can move quickly into stage 2. As the night unfolds, an uninterrupted sleeper may not spend much more time in stage 1 as they move through further sleep cycles.Stage 2During stage 2, or N2, the body enters a more subdued state including a drop in temperature, relaxed muscles, and slowed breathing and heart rate. At the same time, brain waves show a new pattern and eye movement stops. On the whole, brain activity slows, but there are short bursts of.activity that actually help resist being woken up by external stimuli. Stage 2 sleep can last for 10 to 25 minutes during the first sleep cycle, and each N2 stage can become longer during the night.Collectively, a person typically spends about half their sleep time in N2 sleep.Stage 3Stage 3 sleep is also known as N3 or deep sleep, and it is harder to wake someone up if they are in this phase. Muscle tone, pulse, and breathing rate decrease in N3 sleepas the body relaxes even further. The brain activity during this period has an identifiable pattern of what are known as delta waves. For this reason, stage 3 may also be called delta sleep or slow-wave sleep (SWS).Experts believe that this stage is critical to restorative sleep, allowing for bodily recovery and growth. It may also bolster the immune system and other key bodily processes. Even though brain activity is reduced, there is evidence that deep sleep contributes to insightful thinking and memory. You spend the most time in deep sleep during the first half of the night.During the early sleep cycles, N3 stages commonly last for 20 to 40 minutes. As you continue sleeping, these stages get shorter, and more time gets spent in REM sleep instead..REM SleepDuring REM sleep, brain activity picks up, nearing levels seen when you are awake. At the same time, the body experiences atonia, which is a temporary paralysis of the muscles, with two exceptions: the eyes and the muscles that control breathing. Even though the eyes are closed, they can be seen moving quickly, which is how this stage gets its name. REM sleep is believed to be essential to cognitive functions like memory, learning, and creativity. REM sleep is known for the most vivid dreams, which is explained by the significant uptick in brain activity. Dreams can occur in any sleep stage, but they are less common and intense in the NREM periods. Under normal circumstances, you do not enter a REM sleep stage until you have been asleep for about 90 minutes. As the night goes on, REM stages get longer, especially in the second half of the night. While the first REM stage may last only a few minutes, later stages can last for around an hour. In total, REM stages make up around 25 per cent of sleep in adults.Importance of sleepSleep plays an important role in keeping fit and prevents many health conditions. It reduces stress, improves memory, prevents fatigue and improves activity level. Disturbed sleep and daytime sleepiness may ay affect metabolism and may lead to weight gain, irritability, forgetfulness and depression. In rare cases, people may also exhibit aggressive movements such as sleep talking, sleepwalking and grinding of the teeth. Institute of Medicine has declared sleep deficiency and sleep disorders as 'an unmet public health problem'.Correct sleep posturePosture is a relationship among various parts of the body, and how well one holds the body. Mattress and pillows play an important role in keeping the natural curves of the spine. When lying on the back, try and lie symmetrically rather than with a twisted pelvis or with your legs to one side. If this isn't comfortable, you can try and keep a pillow or two under the knees to keep them in line with your spine.Avoid placing multiple pillows under your head when lying on your back or side as it can raise your head up, straining all the muscles and joints in your neck. Ideally, your pillow should only be under your head and not under the shoulder. The pillow should fill up the gap between your head and shoulder, keeping your head in line with your spine..Sleep disordersInsomniaInsomnia is one of the commonest sleep abnormalities. Many people complain of difficulty in initiating sleep or maintaining a normal sleep. It is more commonly observed in people as they age. Insomnia affects the quality of life of individuals. Due to a poor quality of sleep, people suffering from insomnia experience tiredness, irritability, depression and daytime headaches. Many factors contribute to insomnia. Many people with insomnia may be suffering from an underlying psychiatric disorder. Medical conditions leading to constant pain, burning, breathing difficulty and cough may also cause sleeplessness.Restless leg syndrome (RLS)Restless leg syndrome (RLS), also known as Willis-Ekbom disease, is a disorder of the nervous system which causes a strong urge to twitch and shake legs intermittently. It causes an unpleasant sensation in the calves, feet and thighs. As these symptoms cause sleep disturbance, most people with RLS may experience daytime sleepiness. It is more commonly seen in women and in older adults. Consumption of alcohol, caffeine, antidepressants, a presence of iron deficiency and kidney disease may further worsen the condition. Iron deficiency is a common treatable cause of RLS.NarcolepsyNarcolepsy is excessive daytime sleepiness due to inability to regulate sleep-wake cycle. People might experience dream-like hallucinations at night, sudden loss of muscle strength and cataplexy when they are awake. Cataplexy is triggered by strong emotions. An individual laughing at a joke may suddenly collapse on the ground in an awake and immobile situation. Sleep study helps diagnose such conditions and can be relieved by doctor consultation and timely medical intervention.Obstructive sleep apnoea (OSA)People with Diabetes, hypertension and obesity are more likely to have Obstructive Sleep Apnoea (OSA).OSA refers to complete or partial obstruction in the upper airway due to decreased space for the neck muscles to contract and expand during sleep. This leads to shallow or paused breathing. This causes the body to work harder to pull more air. The symptoms of OSA include snoring at night, excessive daytime sleepiness, early morning headache and tiredness. In OSA, the body starts accumulating fat which leads to an increase in the blood glucose levels, blood pressure and an increased risk of heart disease. OSA worsens Diabetes management as it leads to severe insulin resistance..Insomnia and mental healthSleep is extremely important for your mental health. During sleep, your body is able to repair itself. Your brain sorts through information, and your nervous system gets a much-needed break. If you live with insomnia (meaning you consistently have trouble falling or staying asleep) your body misses out on these healing processes.Insomnia and mental illness commonly occur together. Asignificant lack of sleep can trigger or worsen mental health symptoms. In turn, mental health conditions can lead to insomnia.The link between insomnia and mental health can run both ways. A psychiatric disorder can lead to insomnia, and insomnia can worsen or trigger a mental health condition. However, in many cases, there is no direct cause-and-effect, but rather a situation where both conditions are different symptoms of the same condition. For instance, unbalanced blood glucose levels in people with Type 2 Diabetes can lead to both insomnia and anxiety.Insomnia can be a primary or secondary condition.Primary insomnia isn't caused by another medical or psychological condition.Secondary insomnia is the result of other conditions, such as depression, thyroid problems, or asthma.Mental health conditions that are commonly seen with insomnia or other sleep disturbances:Depression: Insomnia is a core symptom of depression. In a 2018 study, more than 90 per cent of people with major depressive disorder (MDD) reported insomnia-related sleep disturbances. People with insomnia may develop depression more often compared to those who sleep well.Anxiety: According to a 2020 study, up to 36 per cent of participants with insomnia had anxiety.Obsessive-compulsive disorder (OCD): A Swedish population study in 2020 found that people with OCD are nearly 7 times more likely to receive an insomnia diagnosis or be given medication for insomnia.Post-traumatic stress disorder (PTSD): Disrupted sleep is a core component of PTSD. This may be related to anxiety or nightmares..Substance use disorder (SUD): Substance use, intoxication, and withdrawal can disturb sleeping patterns.Schizophrenia: A 2012 study suggests up to 80 per cent of people with schizophrenia have disturbed sleep.Bipolar disorder: Sleep problems can be linked to depression or mania. Mania in bipolar disorder is often directly related to a sudden and dramatic decreased need for sleep.Social jet lag: It occurs when you stay up later and then sleep in later on the weekends than you do on the weekdays. Changing the hours that you sleep from day-to-day affects your body's circadian rhythm or its natural internal clock. Social jet lag affects the body similarly to travel jet lag. When you shift your sleeping hours, your body feels as though it is in a different time zone. This can make falling and staying asleep difficult.Treatments for insomnia may involve:. sleep medication. Cognitive Behavioural Therapy (CBT). daily exercise. treating underlying conditions that are worsening sleep quality. sleeping aids like melatonin gummies, chewable foods and pillsResearch in 2018 shows that among people with both a mental health condition and insomnia, treating the mental health condition can help improve sleep and treating sleep disturbances can have a beneficial effect on mental health treatments, too..you answer yes to three or more you are at risk of sleep apnoea:1) Snore most nights2) Often tired3) Bed partner observes you stop breathing during sleep4) High blood pressure5) Overweight - BMI > 35 kg/m26) Age > 50 years7) Neck size > 40 cm.ParasomniaIn parasomnia, people exhibit abnormal movements, behaviours, emotions, perceptions and dreams that occur while falling asleep, sleeping, between sleep stages or while waking up from sleep. For example, sleep terrors, nightmares and rapid eye movement (REM) sleep disorders.SymptomsSymptoms mainly are of two types - the complete inability to sleep well or the inability to stay awake during the day time. The reasons for these symptoms could differ. In some people, insomnia is an isolated condition or is related to a condition like hypertension or Diabetes.With daytime sleepiness, OSA could be the reason. Sleep apnoea is a common problem. Narcolepsy and excessive sleepiness can cause sleep apnoea..Treating sleep disordersInsomnia can be caused by a lifestyle disorder which first needs to be treated. This will help regularise the sleep-wake pattern to naturally coordinate with the day- night cycle. People with insomnia also need to be informed about good sleep practices - making sure that the sleep environment is dark when they are trying to sleep and avoid loud, disturbing noises. It doesn't necessarily need to be quiet because background noise like white noise might be beneficial. A relatively cool bedroom is beneficial for sleep quality.There are a lot of options to treat chronic insomnia. Cognitive behavioural therapy (CBT) is talking therapy which changes the way you think and behave. This type of treatment goes on for a few months and people work with a therapist every week for maybe 4 to 8 sessions. It is focused on practical changes that people can make.Sometimes, temporary use of sleep restriction, sleeping later than usual can slowly help to resume normal sleep time. Keeping track of the sleep-wake cycle for a period of many weeks can also help.Medications like benzodiazepine and non- benzodiazepine medications are used to treat insomnia. Some work on the melatonin system, some work on the histamine system and some work on other newly discovered systems..Curbing sleep deprivationMaintaining a conducive sleep environment could involve soothing lighting as light has a profound effect on our circadian rhythm which in turn affects our ability to fall and stay asleep at certain times. A lot of light in the evenings which many people are exposed to, maybe room lights or screen light from a smartphone, laptop or computer is stimulating and has a biological effect. Blue light tends to suppress our melatonin which is crucial to facilitate sleep. Lights defeat the potential value of melatonin. So, minimising bright light in the evening could be helpful.White noise devices are soothing as they have a comfortable sound and also block outside traffic noises and other household noises.Wearables with in-built activity monitors estimate when somebody is moving. They have an algorithm that estimates when sleep has occurred because they measure movement and breathing patterns. They assess when the sleep has occurred and when somebody might be in the REM sleep during the night..Sleep AnxietySleep anxiety is a feeling of stress or fear about going to sleep. Some people also have a distinct phobia or fear about sleep called somniphobia. They may think something bad will happen to them while they sleep or that they shouldn't sleep because they need to stay alert and watchful.Symptoms of sleep anxiety can vary from person to person, but the common thread is experiencing anxiety at night. These symptoms may include the following and occur at or during bedtime or when you anticipate going to sleep:physical: fast heart rate, palpitations, shortness of breath, rapid breathing, chest pain, dizziness, sweating, nausea, shakingcognitive: fear of losing control, physical injury, or negative evaluation from others; frightening thoughts, altered sense of reality, confusion, poor concentrationbehavioural: bedtime avoidance, pursuing safety reassurance, agitation, pacing, freezingaffective: nervousness, tension, feeling frightened, edginess, impatient, frustratedsleep: trouble falling or staying asleep, tossing and turning, inability to get comfortable, avoiding sleepEveryone experiences anxiety differently. Those that have anxiety when falling asleep may have that problem for their own unique reason. Some of the causes include:Focus on the day - For some people, anxiety while falling asleep is caused by over-focusing on the stress caused by anxiety due to events occurring throughout the day. There also may be an anxious focus on what is to come the next day.Feeling scared or afraid - Some people feel scared or afraid for no apparent reason, although it may be linked to the dark.Those that have a fear of death or mortality may also have moments where they just feel scared, afraid, or sad in some ways.The act of falling asleep can sometimes feel scary for those with anxiety.Falling - Known as Hypnic Jerks, these muscle sensations that occur in the arms, legs, or whole body can create the sensation of falling or "not breathing". Often occurring during the first stage of sleep it can cause someone with anxiety to awaken in a panic. That anxiety can sometimes stick around.Rapid thought patterns - Those with anxiety tend to have thoughts that keep them awake and are difficult to calm. The longer those thoughts go on, the more anxious they may become.Poor sleep cycle - If you have had anxiety or trouble falling asleep for a long time then a pattern of poor sleep may have developed. Anxiety can cause you to not sleep well.Lack of sleep makes your more susceptible to stress. Stress causes anxiety and then anxiety leads to a lack of sleep and possibly insomnia. This cycle may leave you feeling as if you may never sleep, making sleep that much more difficult to attain..Sleep-Diabetes linkThis link is multifactorial. Chronic inflammation, autonomic dysfunction (dysfunction of the autonomic nervous system which affects the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels) and lifestyle problems contribute to sleep disorders.Lifestyle issues like irregular sleep-wake patterns and stressful lives can cause the onset of Diabetes.People with Diabetes often wake up at night because of hypoglycaemia (low). Timely medical intervention can eliminate this issue. But the real problem is when the reverse occurs and chronic sleep disorders can lead to an increase in blood glucose levels over time.A lot of cross-sectional studies have shown that there is a close association between glucose intolerance, insulin insensitivity and diagnosis of Diabetes with sleep disorders and vice versa. Many studies have shown a direct relationship between the heightened prevalence of Diabetes among people with insomnia and the presence of insomnia in people with Diabetes.Some longitudinal studies demonstrated that people without Diabetes who have insomnia are at a greater risk of developing Diabetes in the future. This was demonstrated by a Swedish study with 12 years of follow up.A study conducted in the USA on a population of 80,000 pre-diabetic people showed that people who were diagnosed with insomnia were at a heightened risk of developing Type 2 Diabetes in the future compared with people who did not have insomnia. Aspects of sleep disruption and deficiency do contribute in moving from being a pre-diabetic to a diagnosis of Diabetes.In healthy young adults, partial sleep deprivation with only 4 hours of sleep every day has higher fasting glucose and impaired insulin sensitivity. Lack of sleep causes acute and chronic effects. If someone doesn't sleep well then brain functioning is affected. Though we may be able to function, it may lead to poor concentration and fatigue. Shift work, for instance, is associated with increased risk of diseases, even increasing the risk for cancer.People with Type 2 Diabetes have an increased risk of developing sleep disorders. This could be due to associated comorbidities like obesity, hypertension or also could be because of associated complications of diabetes like heart disease, kidney disease. Certain sleep disorders like OSA, insomnia and restless legs syndrome are diagnosed more frequently in people with Diabetes as compared to those who don't have Diabetes.Sleep disorders and heart diseasePeople with OSA have an increased risk of heart disease and stroke. This is due to low oxygen in the blood caused by an obstruction of airway. This leads to inflammation, increased heart rate, hardening and blockage in the arteries. An adequate and good quality of sleep is essential to reduce the risk of heart disease.Sleep studyPolysomnography (or sleep study) is a test used to diagnose sleep disorders. It records the brain waves, the level of oxygen level in the blood, heart rate and breathing, as well as eye and leg movements during the sleep. Polysomnography test continuously monitors the different stages of sleep and sleep cycle and is reported by a sleep specialist. It provides information to the physician about the quality of a person's sleep and the reason for disturbed sleep.A person may be recommended sleep study if he or she appears to have sleep apnoea or other sleep related breathing disorders, narcolepsy, rapid leg syndrome, acting or movement disorder during the sleep, unusual behaviour during sleep such as sleep walking and sleep talking and other reasons for insomnia.Obesity and Type 2 Diabetes are closely associated with each other and they lead to a less recognised condition called Obstructive sleep apnoea which means a stoppage of breathing during sleep due to obstruction of the respiratory pathway.Excess fat in the neck region leads to a constriction of the upper airways. This is especially noticeable during sleep or in a lying down posture. People with OSA also exhibit excessive and often loud snoring.This repetitive obstruction of breathing, which may occur every 30 minutes at night time during sleep leads to disturbed sleep. This goes unrecognised by the person himself who suffers from OSA. A lack of proper sleep at night leads to daytime sleepiness which makes a person less active during the daytime, thus worsening obesity.Continuous Positive Airway Pressure (CPAP) is a portable device which supports breathing by providing a positive pressure when connected to a person. The CPAP machine has a small chargeable ventilator with a flexible pipe connected to a mask strapped to the person's face. This mask covers the mouth and nose; however, there are masks which cover only the nose called nasal masks. The masks vary in sizes and shapes according to the requirement of people. The machine is preferably attached at bedtime just before sleep. The machine when turned on delivers air with a positive pressure which is adjusted as per the requirement of a person. This positive pressure keeps the airway clear and thus the person has uninterrupted breathing during the sleep.Most people do tolerate CPAP machine, more so ever now with the availability of better masks. Some may get drying of nose and mouth which can be taken care of using humidifiers. The benefits of CPAP in treating sleep apnoea are many, and this is the only proven effective non-surgical way to take care of sleep apnoea. Eventually, with substantial weight loss, one can cure obstructive sleep apnoea.Lack of sleep can affect the physical and mental wellbeing of a person and can lead to stress, heart disease, hypertension and depression. Diagnosing the underlying cause of sleeplessness can help take timely measures to improve the quality of sleep and prevent further complications. Lifestyle changes, regular physical activity and diet can help resolve sleeplessness in most cases. CPAP device helps to improve the quality of sleep by resolving obstruction in the breathing and decreasing movement during sleep.Before going for studyDo not drink caffeinated drink or foods that may keep you awake.Try to follow a normal routine and avoid daytime napping.Wash and dry your hair well and do not apply any oil, gel or spray before the study.Pack comfortable clothing and other essentials if taking the study at a clinic.Inform your doctor about your medications before the study.During the studyChange into comfortable clothing and try to stay calm and relaxed.Follow your usual bedtime routine such as reading a book before going to sleep.Understand well why sleep study is necessary for you and how CPAP device is helpful to you.Inform the sleep technician about any other external devices you wear such as hearing aids.After the studyThe monitor will record the functioning of the brain, breathing pattern, sleep pattern and any movement of body parts during sleep.The study will monitor heart rate and changes in oxygen intake during sleep.The study will also monitor unusual behaviour and movement during sleep such as sleepwalking and sleep talking.When to visit a doctor?Insomnia or sleeplessness may occur due to many reasons. It is important to first look out for the reason to sleeplessness. Simple modifications in lifestyle, regular exercise and sleep and wake up timings may help resolve insomnia in many people. If the sleep disturbances are persistent and are affecting the quality of life, then it is advisable to consult a sleep specialist. The specialist may first counsel you and try to understand your daily schedule and lifestyle. You may also be recommended sleep study to understand in more detail your sleep pattern. Inform your doctor about your medications as certain medications may also cause disturbed sleep..Tips for a good night sleepDo's. Improve sleep hygiene.. Relaxing techniques 30 minutes prior to bedtime e.g. listening to light music, meditation etc.. Take a warm bath before sleep.. Bedtime snacking if you have Diabetes and doctor has advised bedtime snacks to avoid hypoglycaemia at night.. Go to bed and wake up at the same time every day, including weekends, to avoid confusing your body.. Keep it cool - between 60 and 67 degrees in your bedroom and minimize noise and light in your sleep sanctuary to get the best rest possible.Don'ts. Distractions such as smartphones, televisions, computers etc. Blue light can stimulate your system and keep you awake.. Thinking about stressful situations. Heavy eating, vigorous exercise, smoking. Afternoon naps. Wake-promoting substances like caffeine 2-3 hours before bedtime. Exercising within two to three hours of bedtime. Dr Vedavati Purandare is Consulting Physician and Diabetologist. She is Head of Clinical Services at Chellaram Hospital: Diabetes Care and Multispecialty, Pune
Dr Vedavati Purandare discusses in-depth how sleep is beneficial to your wellbeing.A case studyMr Shyam, a 58-year-old-gentleman with Type 2 Diabetes and obesity, presented with excessive daytime sleepiness and uncontrolled blood glucose levels despite multiple oral anti-diabetic drugs. He has been diagnosed to have obesity for the last 8 years and his weight has been increasing progressively. He has a sedentary lifestyle, does not follow any diet and his BMI is 34 with excessive abdominal obesity. Also, his HbA1c was 9.5. On examination, the physician suspected that Mr Shyam, who was already obese with excessive daytime sleepiness, probably suffers from Obstructive sleep apnoea (OSA). To diagnose this condition, he was advised sleep study. Mr Shyam underwent a sleep study and the reports suggested of severe OSA. It has been the reason for his daytime sleepiness and also for his uncontrolled blood glucose levels. The physician counsels Mr Shyam that because of his daytime sleepiness he is just not able to remain physically active but he can definitely improve his symptoms by losing weight. The physician then explained to him that he needs a continuous positive airway pressure (CPAP) device to treat his OSA.Mr Shyam was given a trial of CPAP machine, which effectively helped his OSA and he was more physically active during the daytime. On a 3-month follow up Mr Shyam lost 10 kg of weight and his HbA1c reduced by 2 per cent and it's now 7.5 per cent.Lack of sleep can affect the physical and mental wellbeing of a person and can lead to stress, heart disease, hypertension and depression. Obstructive sleep apnoea can exert excessive pressure on the lungs to inhale more air than the normal and may affect the functioning of the lungs in the long term. Diagnosing theunderlying cause of sleeplessness can help take timely measures to improve the quality of sleep and prevent further complications. Lifestyle changes, regular physical activity and diet can help resolve sleeplessness in most cases.CPAP device helps to improve the quality of sleep by resolving obstruction in the breathing and decreasing movement during sleep. Normal sleep patternsHuman beings need normal sleep for their physical and mental wellbeing. Most adults sleep 7-8 hours per day usually at night. The time and duration of sleep may differ in people depending on their age and health. Children sleep considerably more than older people.Majority of adults sleep only during the night for 7 to 8 hours whereas some divide their sleep into two parts - an afternoon nap and night sleep. Irregular sleep is normally observed in the extreme age groups such as infants and in older people.Human brain comprises two circuits - one is the arousal circuit which keeps a person awake and second is the sleep-promoting circuit which leads to sleep. The relation between these circuits is like a switch.When the switch is 'on', a person is awake and when the switch is 'off', a person sleeps. This sleep-wake cycle is regulated by the circadian rhythm of the human body. Circadian rhythm is the internal body clock of a person that regulates the external 24- hour process of the body..Sleep CycleSleep is not uniform. Instead, over the course of the night, your total sleep is made up of several rounds of the sleep cycle, which is composed of four individual stages. In a typical night, a person goes through four to six sleep cycles. Not all sleep cycles are of the same length, but on average they last about 90 minutes each. It is normal for sleep cycles to change as you progress through your nightly sleep. The first sleep cycle is often the shortest, ranging from 70 to 100 minutes, while later cycles tend to fall between 90 and 120 minutes. In addition, the composition of each cycle - how much time is spent in each sleep stage - changes as the night goes along.There are four sleep stages, including one for rapid eye movement (REM) sleep and three that form non-REM (NREM) sleep. These stages are determined based on an analysis of brain activity during sleep, which shows distinct patterns that characterize each stage..NREM sleep is composed of three different stages. The higher the stage of NREM sleep, the harder it is to wake a person up.Stage 1Stage 1, also called N1, is essentially when a person first falls asleep. This stage normally lasts just one to seven minutes. During N1 sleep, the body has not fully relaxed, though the body and brain activities start to slow with periods of brief movements. There are light changes in brain activity associated with falling asleep in this stage. It is easy to wake someone up during this sleep stage, but if a person is not disturbed, they can move quickly into stage 2. As the night unfolds, an uninterrupted sleeper may not spend much more time in stage 1 as they move through further sleep cycles.Stage 2During stage 2, or N2, the body enters a more subdued state including a drop in temperature, relaxed muscles, and slowed breathing and heart rate. At the same time, brain waves show a new pattern and eye movement stops. On the whole, brain activity slows, but there are short bursts of.activity that actually help resist being woken up by external stimuli. Stage 2 sleep can last for 10 to 25 minutes during the first sleep cycle, and each N2 stage can become longer during the night.Collectively, a person typically spends about half their sleep time in N2 sleep.Stage 3Stage 3 sleep is also known as N3 or deep sleep, and it is harder to wake someone up if they are in this phase. Muscle tone, pulse, and breathing rate decrease in N3 sleepas the body relaxes even further. The brain activity during this period has an identifiable pattern of what are known as delta waves. For this reason, stage 3 may also be called delta sleep or slow-wave sleep (SWS).Experts believe that this stage is critical to restorative sleep, allowing for bodily recovery and growth. It may also bolster the immune system and other key bodily processes. Even though brain activity is reduced, there is evidence that deep sleep contributes to insightful thinking and memory. You spend the most time in deep sleep during the first half of the night.During the early sleep cycles, N3 stages commonly last for 20 to 40 minutes. As you continue sleeping, these stages get shorter, and more time gets spent in REM sleep instead..REM SleepDuring REM sleep, brain activity picks up, nearing levels seen when you are awake. At the same time, the body experiences atonia, which is a temporary paralysis of the muscles, with two exceptions: the eyes and the muscles that control breathing. Even though the eyes are closed, they can be seen moving quickly, which is how this stage gets its name. REM sleep is believed to be essential to cognitive functions like memory, learning, and creativity. REM sleep is known for the most vivid dreams, which is explained by the significant uptick in brain activity. Dreams can occur in any sleep stage, but they are less common and intense in the NREM periods. Under normal circumstances, you do not enter a REM sleep stage until you have been asleep for about 90 minutes. As the night goes on, REM stages get longer, especially in the second half of the night. While the first REM stage may last only a few minutes, later stages can last for around an hour. In total, REM stages make up around 25 per cent of sleep in adults.Importance of sleepSleep plays an important role in keeping fit and prevents many health conditions. It reduces stress, improves memory, prevents fatigue and improves activity level. Disturbed sleep and daytime sleepiness may ay affect metabolism and may lead to weight gain, irritability, forgetfulness and depression. In rare cases, people may also exhibit aggressive movements such as sleep talking, sleepwalking and grinding of the teeth. Institute of Medicine has declared sleep deficiency and sleep disorders as 'an unmet public health problem'.Correct sleep posturePosture is a relationship among various parts of the body, and how well one holds the body. Mattress and pillows play an important role in keeping the natural curves of the spine. When lying on the back, try and lie symmetrically rather than with a twisted pelvis or with your legs to one side. If this isn't comfortable, you can try and keep a pillow or two under the knees to keep them in line with your spine.Avoid placing multiple pillows under your head when lying on your back or side as it can raise your head up, straining all the muscles and joints in your neck. Ideally, your pillow should only be under your head and not under the shoulder. The pillow should fill up the gap between your head and shoulder, keeping your head in line with your spine..Sleep disordersInsomniaInsomnia is one of the commonest sleep abnormalities. Many people complain of difficulty in initiating sleep or maintaining a normal sleep. It is more commonly observed in people as they age. Insomnia affects the quality of life of individuals. Due to a poor quality of sleep, people suffering from insomnia experience tiredness, irritability, depression and daytime headaches. Many factors contribute to insomnia. Many people with insomnia may be suffering from an underlying psychiatric disorder. Medical conditions leading to constant pain, burning, breathing difficulty and cough may also cause sleeplessness.Restless leg syndrome (RLS)Restless leg syndrome (RLS), also known as Willis-Ekbom disease, is a disorder of the nervous system which causes a strong urge to twitch and shake legs intermittently. It causes an unpleasant sensation in the calves, feet and thighs. As these symptoms cause sleep disturbance, most people with RLS may experience daytime sleepiness. It is more commonly seen in women and in older adults. Consumption of alcohol, caffeine, antidepressants, a presence of iron deficiency and kidney disease may further worsen the condition. Iron deficiency is a common treatable cause of RLS.NarcolepsyNarcolepsy is excessive daytime sleepiness due to inability to regulate sleep-wake cycle. People might experience dream-like hallucinations at night, sudden loss of muscle strength and cataplexy when they are awake. Cataplexy is triggered by strong emotions. An individual laughing at a joke may suddenly collapse on the ground in an awake and immobile situation. Sleep study helps diagnose such conditions and can be relieved by doctor consultation and timely medical intervention.Obstructive sleep apnoea (OSA)People with Diabetes, hypertension and obesity are more likely to have Obstructive Sleep Apnoea (OSA).OSA refers to complete or partial obstruction in the upper airway due to decreased space for the neck muscles to contract and expand during sleep. This leads to shallow or paused breathing. This causes the body to work harder to pull more air. The symptoms of OSA include snoring at night, excessive daytime sleepiness, early morning headache and tiredness. In OSA, the body starts accumulating fat which leads to an increase in the blood glucose levels, blood pressure and an increased risk of heart disease. OSA worsens Diabetes management as it leads to severe insulin resistance..Insomnia and mental healthSleep is extremely important for your mental health. During sleep, your body is able to repair itself. Your brain sorts through information, and your nervous system gets a much-needed break. If you live with insomnia (meaning you consistently have trouble falling or staying asleep) your body misses out on these healing processes.Insomnia and mental illness commonly occur together. Asignificant lack of sleep can trigger or worsen mental health symptoms. In turn, mental health conditions can lead to insomnia.The link between insomnia and mental health can run both ways. A psychiatric disorder can lead to insomnia, and insomnia can worsen or trigger a mental health condition. However, in many cases, there is no direct cause-and-effect, but rather a situation where both conditions are different symptoms of the same condition. For instance, unbalanced blood glucose levels in people with Type 2 Diabetes can lead to both insomnia and anxiety.Insomnia can be a primary or secondary condition.Primary insomnia isn't caused by another medical or psychological condition.Secondary insomnia is the result of other conditions, such as depression, thyroid problems, or asthma.Mental health conditions that are commonly seen with insomnia or other sleep disturbances:Depression: Insomnia is a core symptom of depression. In a 2018 study, more than 90 per cent of people with major depressive disorder (MDD) reported insomnia-related sleep disturbances. People with insomnia may develop depression more often compared to those who sleep well.Anxiety: According to a 2020 study, up to 36 per cent of participants with insomnia had anxiety.Obsessive-compulsive disorder (OCD): A Swedish population study in 2020 found that people with OCD are nearly 7 times more likely to receive an insomnia diagnosis or be given medication for insomnia.Post-traumatic stress disorder (PTSD): Disrupted sleep is a core component of PTSD. This may be related to anxiety or nightmares..Substance use disorder (SUD): Substance use, intoxication, and withdrawal can disturb sleeping patterns.Schizophrenia: A 2012 study suggests up to 80 per cent of people with schizophrenia have disturbed sleep.Bipolar disorder: Sleep problems can be linked to depression or mania. Mania in bipolar disorder is often directly related to a sudden and dramatic decreased need for sleep.Social jet lag: It occurs when you stay up later and then sleep in later on the weekends than you do on the weekdays. Changing the hours that you sleep from day-to-day affects your body's circadian rhythm or its natural internal clock. Social jet lag affects the body similarly to travel jet lag. When you shift your sleeping hours, your body feels as though it is in a different time zone. This can make falling and staying asleep difficult.Treatments for insomnia may involve:. sleep medication. Cognitive Behavioural Therapy (CBT). daily exercise. treating underlying conditions that are worsening sleep quality. sleeping aids like melatonin gummies, chewable foods and pillsResearch in 2018 shows that among people with both a mental health condition and insomnia, treating the mental health condition can help improve sleep and treating sleep disturbances can have a beneficial effect on mental health treatments, too..you answer yes to three or more you are at risk of sleep apnoea:1) Snore most nights2) Often tired3) Bed partner observes you stop breathing during sleep4) High blood pressure5) Overweight - BMI > 35 kg/m26) Age > 50 years7) Neck size > 40 cm.ParasomniaIn parasomnia, people exhibit abnormal movements, behaviours, emotions, perceptions and dreams that occur while falling asleep, sleeping, between sleep stages or while waking up from sleep. For example, sleep terrors, nightmares and rapid eye movement (REM) sleep disorders.SymptomsSymptoms mainly are of two types - the complete inability to sleep well or the inability to stay awake during the day time. The reasons for these symptoms could differ. In some people, insomnia is an isolated condition or is related to a condition like hypertension or Diabetes.With daytime sleepiness, OSA could be the reason. Sleep apnoea is a common problem. Narcolepsy and excessive sleepiness can cause sleep apnoea..Treating sleep disordersInsomnia can be caused by a lifestyle disorder which first needs to be treated. This will help regularise the sleep-wake pattern to naturally coordinate with the day- night cycle. People with insomnia also need to be informed about good sleep practices - making sure that the sleep environment is dark when they are trying to sleep and avoid loud, disturbing noises. It doesn't necessarily need to be quiet because background noise like white noise might be beneficial. A relatively cool bedroom is beneficial for sleep quality.There are a lot of options to treat chronic insomnia. Cognitive behavioural therapy (CBT) is talking therapy which changes the way you think and behave. This type of treatment goes on for a few months and people work with a therapist every week for maybe 4 to 8 sessions. It is focused on practical changes that people can make.Sometimes, temporary use of sleep restriction, sleeping later than usual can slowly help to resume normal sleep time. Keeping track of the sleep-wake cycle for a period of many weeks can also help.Medications like benzodiazepine and non- benzodiazepine medications are used to treat insomnia. Some work on the melatonin system, some work on the histamine system and some work on other newly discovered systems..Curbing sleep deprivationMaintaining a conducive sleep environment could involve soothing lighting as light has a profound effect on our circadian rhythm which in turn affects our ability to fall and stay asleep at certain times. A lot of light in the evenings which many people are exposed to, maybe room lights or screen light from a smartphone, laptop or computer is stimulating and has a biological effect. Blue light tends to suppress our melatonin which is crucial to facilitate sleep. Lights defeat the potential value of melatonin. So, minimising bright light in the evening could be helpful.White noise devices are soothing as they have a comfortable sound and also block outside traffic noises and other household noises.Wearables with in-built activity monitors estimate when somebody is moving. They have an algorithm that estimates when sleep has occurred because they measure movement and breathing patterns. They assess when the sleep has occurred and when somebody might be in the REM sleep during the night..Sleep AnxietySleep anxiety is a feeling of stress or fear about going to sleep. Some people also have a distinct phobia or fear about sleep called somniphobia. They may think something bad will happen to them while they sleep or that they shouldn't sleep because they need to stay alert and watchful.Symptoms of sleep anxiety can vary from person to person, but the common thread is experiencing anxiety at night. These symptoms may include the following and occur at or during bedtime or when you anticipate going to sleep:physical: fast heart rate, palpitations, shortness of breath, rapid breathing, chest pain, dizziness, sweating, nausea, shakingcognitive: fear of losing control, physical injury, or negative evaluation from others; frightening thoughts, altered sense of reality, confusion, poor concentrationbehavioural: bedtime avoidance, pursuing safety reassurance, agitation, pacing, freezingaffective: nervousness, tension, feeling frightened, edginess, impatient, frustratedsleep: trouble falling or staying asleep, tossing and turning, inability to get comfortable, avoiding sleepEveryone experiences anxiety differently. Those that have anxiety when falling asleep may have that problem for their own unique reason. Some of the causes include:Focus on the day - For some people, anxiety while falling asleep is caused by over-focusing on the stress caused by anxiety due to events occurring throughout the day. There also may be an anxious focus on what is to come the next day.Feeling scared or afraid - Some people feel scared or afraid for no apparent reason, although it may be linked to the dark.Those that have a fear of death or mortality may also have moments where they just feel scared, afraid, or sad in some ways.The act of falling asleep can sometimes feel scary for those with anxiety.Falling - Known as Hypnic Jerks, these muscle sensations that occur in the arms, legs, or whole body can create the sensation of falling or "not breathing". Often occurring during the first stage of sleep it can cause someone with anxiety to awaken in a panic. That anxiety can sometimes stick around.Rapid thought patterns - Those with anxiety tend to have thoughts that keep them awake and are difficult to calm. The longer those thoughts go on, the more anxious they may become.Poor sleep cycle - If you have had anxiety or trouble falling asleep for a long time then a pattern of poor sleep may have developed. Anxiety can cause you to not sleep well.Lack of sleep makes your more susceptible to stress. Stress causes anxiety and then anxiety leads to a lack of sleep and possibly insomnia. This cycle may leave you feeling as if you may never sleep, making sleep that much more difficult to attain..Sleep-Diabetes linkThis link is multifactorial. Chronic inflammation, autonomic dysfunction (dysfunction of the autonomic nervous system which affects the functioning of the heart, bladder, intestines, sweat glands, pupils, and blood vessels) and lifestyle problems contribute to sleep disorders.Lifestyle issues like irregular sleep-wake patterns and stressful lives can cause the onset of Diabetes.People with Diabetes often wake up at night because of hypoglycaemia (low). Timely medical intervention can eliminate this issue. But the real problem is when the reverse occurs and chronic sleep disorders can lead to an increase in blood glucose levels over time.A lot of cross-sectional studies have shown that there is a close association between glucose intolerance, insulin insensitivity and diagnosis of Diabetes with sleep disorders and vice versa. Many studies have shown a direct relationship between the heightened prevalence of Diabetes among people with insomnia and the presence of insomnia in people with Diabetes.Some longitudinal studies demonstrated that people without Diabetes who have insomnia are at a greater risk of developing Diabetes in the future. This was demonstrated by a Swedish study with 12 years of follow up.A study conducted in the USA on a population of 80,000 pre-diabetic people showed that people who were diagnosed with insomnia were at a heightened risk of developing Type 2 Diabetes in the future compared with people who did not have insomnia. Aspects of sleep disruption and deficiency do contribute in moving from being a pre-diabetic to a diagnosis of Diabetes.In healthy young adults, partial sleep deprivation with only 4 hours of sleep every day has higher fasting glucose and impaired insulin sensitivity. Lack of sleep causes acute and chronic effects. If someone doesn't sleep well then brain functioning is affected. Though we may be able to function, it may lead to poor concentration and fatigue. Shift work, for instance, is associated with increased risk of diseases, even increasing the risk for cancer.People with Type 2 Diabetes have an increased risk of developing sleep disorders. This could be due to associated comorbidities like obesity, hypertension or also could be because of associated complications of diabetes like heart disease, kidney disease. Certain sleep disorders like OSA, insomnia and restless legs syndrome are diagnosed more frequently in people with Diabetes as compared to those who don't have Diabetes.Sleep disorders and heart diseasePeople with OSA have an increased risk of heart disease and stroke. This is due to low oxygen in the blood caused by an obstruction of airway. This leads to inflammation, increased heart rate, hardening and blockage in the arteries. An adequate and good quality of sleep is essential to reduce the risk of heart disease.Sleep studyPolysomnography (or sleep study) is a test used to diagnose sleep disorders. It records the brain waves, the level of oxygen level in the blood, heart rate and breathing, as well as eye and leg movements during the sleep. Polysomnography test continuously monitors the different stages of sleep and sleep cycle and is reported by a sleep specialist. It provides information to the physician about the quality of a person's sleep and the reason for disturbed sleep.A person may be recommended sleep study if he or she appears to have sleep apnoea or other sleep related breathing disorders, narcolepsy, rapid leg syndrome, acting or movement disorder during the sleep, unusual behaviour during sleep such as sleep walking and sleep talking and other reasons for insomnia.Obesity and Type 2 Diabetes are closely associated with each other and they lead to a less recognised condition called Obstructive sleep apnoea which means a stoppage of breathing during sleep due to obstruction of the respiratory pathway.Excess fat in the neck region leads to a constriction of the upper airways. This is especially noticeable during sleep or in a lying down posture. People with OSA also exhibit excessive and often loud snoring.This repetitive obstruction of breathing, which may occur every 30 minutes at night time during sleep leads to disturbed sleep. This goes unrecognised by the person himself who suffers from OSA. A lack of proper sleep at night leads to daytime sleepiness which makes a person less active during the daytime, thus worsening obesity.Continuous Positive Airway Pressure (CPAP) is a portable device which supports breathing by providing a positive pressure when connected to a person. The CPAP machine has a small chargeable ventilator with a flexible pipe connected to a mask strapped to the person's face. This mask covers the mouth and nose; however, there are masks which cover only the nose called nasal masks. The masks vary in sizes and shapes according to the requirement of people. The machine is preferably attached at bedtime just before sleep. The machine when turned on delivers air with a positive pressure which is adjusted as per the requirement of a person. This positive pressure keeps the airway clear and thus the person has uninterrupted breathing during the sleep.Most people do tolerate CPAP machine, more so ever now with the availability of better masks. Some may get drying of nose and mouth which can be taken care of using humidifiers. The benefits of CPAP in treating sleep apnoea are many, and this is the only proven effective non-surgical way to take care of sleep apnoea. Eventually, with substantial weight loss, one can cure obstructive sleep apnoea.Lack of sleep can affect the physical and mental wellbeing of a person and can lead to stress, heart disease, hypertension and depression. Diagnosing the underlying cause of sleeplessness can help take timely measures to improve the quality of sleep and prevent further complications. Lifestyle changes, regular physical activity and diet can help resolve sleeplessness in most cases. CPAP device helps to improve the quality of sleep by resolving obstruction in the breathing and decreasing movement during sleep.Before going for studyDo not drink caffeinated drink or foods that may keep you awake.Try to follow a normal routine and avoid daytime napping.Wash and dry your hair well and do not apply any oil, gel or spray before the study.Pack comfortable clothing and other essentials if taking the study at a clinic.Inform your doctor about your medications before the study.During the studyChange into comfortable clothing and try to stay calm and relaxed.Follow your usual bedtime routine such as reading a book before going to sleep.Understand well why sleep study is necessary for you and how CPAP device is helpful to you.Inform the sleep technician about any other external devices you wear such as hearing aids.After the studyThe monitor will record the functioning of the brain, breathing pattern, sleep pattern and any movement of body parts during sleep.The study will monitor heart rate and changes in oxygen intake during sleep.The study will also monitor unusual behaviour and movement during sleep such as sleepwalking and sleep talking.When to visit a doctor?Insomnia or sleeplessness may occur due to many reasons. It is important to first look out for the reason to sleeplessness. Simple modifications in lifestyle, regular exercise and sleep and wake up timings may help resolve insomnia in many people. If the sleep disturbances are persistent and are affecting the quality of life, then it is advisable to consult a sleep specialist. The specialist may first counsel you and try to understand your daily schedule and lifestyle. You may also be recommended sleep study to understand in more detail your sleep pattern. Inform your doctor about your medications as certain medications may also cause disturbed sleep..Tips for a good night sleepDo's. Improve sleep hygiene.. Relaxing techniques 30 minutes prior to bedtime e.g. listening to light music, meditation etc.. Take a warm bath before sleep.. Bedtime snacking if you have Diabetes and doctor has advised bedtime snacks to avoid hypoglycaemia at night.. Go to bed and wake up at the same time every day, including weekends, to avoid confusing your body.. Keep it cool - between 60 and 67 degrees in your bedroom and minimize noise and light in your sleep sanctuary to get the best rest possible.Don'ts. Distractions such as smartphones, televisions, computers etc. Blue light can stimulate your system and keep you awake.. Thinking about stressful situations. Heavy eating, vigorous exercise, smoking. Afternoon naps. Wake-promoting substances like caffeine 2-3 hours before bedtime. Exercising within two to three hours of bedtime. Dr Vedavati Purandare is Consulting Physician and Diabetologist. She is Head of Clinical Services at Chellaram Hospital: Diabetes Care and Multispecialty, Pune
