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APPROXIMATELY one in four Australian adults complain of sleep difficulties on a nightly basis or several times a week.
About half of these problems can be accounted for by specific sleep disorders, such as obstructive sleep apnoea (OSA), insomnia and restless legs syndrome. The balance appears to be attributable to inadequate sleep by choice or circumstance because of competing work, social or family demands.
The pressure on sleep time has been exacerbated by the proliferation of social media and other internet-based distractions, with adolescents particularly vulnerable to these influences.
The effects of sleep loss are varied and easily misdiagnosed. Tiredness, lethargy, cognitive impairment, psychomotor deficits and mood disturbances are common manifestations, separately or together.
In children and adolescents sleep problems may present as behavioural disturbances or learning difficulties.
Apart from these potentially disabling symptoms, other common comorbidities of disrupted sleep include hypertension, vascular disease, metabolic disorders, heightened inflammatory responses, depression, increased accident risk and reduced productivity.
While these are well recognised consequences of OSA, it has become increasingly evident that they can also result from other forms of sleep disturbance. The all-cause mortality rate of short (less than 6 hours a night) sleepers is above that of those in the 6‒9 hours a night range.
There are bidirectional relationships between depression and sleep loss, with depression a cause of disturbed sleep and disturbed sleep a driver for depression. Depression and sleep disorders such as OSA share symptoms, with the attendant risk of misdiagnosis of OSA, which is an equally underdiagnosed disorder.
Bidirectional relationships also exist between pain and sleep loss. Pain disturbs sleep and disturbed sleep aggravates pain. Failure to identify specific sleep disorders in patients with chronic pain may result in poorer pain control.
Similarly, obesity and sleep problems interact: disturbed sleep from shift work and other sources is a contributor to obesity and, conversely, obesity is a risk factor for sleep problems such as OSA. Importantly though, OSA is not restricted to overweight people — a common misconception.
There needs to be increased attention given to sleep needs by both the community and their medical advisers.
On average, sleep occupies one-third of adult existence and, with exercise and sensible eating, is a basic component of a healthy lifestyle. Problems with sleep need a systematic approach.
Duration, timing and quality of sleep are the three broad considerations. Key questions for medical practitioners to ask patients include:
- Do you regularly get the sleep you need?
- Are you refreshed on awakening?
- Do you suffer from excessive daytime sleepiness?
- Do you snore?
- Has anyone witnessed breathing pauses during your sleep?
- Do you wake up repeatedly? If so, are these associated with momentary choking episodes?
- Is your sleep restless?
- Do you have morning headaches?
Assessment of hypertensive patients, patients with depressive symptoms and those complaining of lethargy or fatigue is incomplete without an assessment of sleep quality generally, and consideration of the possibility of a sleep disorder specifically.
Highly effective treatments exist for most sleep disorders. The first step is identifying them and, collectively, we are not nearly good enough at doing this.
Professor David Hillman is the Chair of the Sleep Health Foundation and sleep physician in the Department of Pulmonary Physiology and Sleep Medicine at Sir Charles Gairdner Hospital, Perth.
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Sleep restriction and sleep disruption have long been unrecognised risks for poor health outcomes. It is not only adolescents who are subject to the pressures and distractions of the 24 hour eworld. Most health practitioners claim too few hours in the land of nod, and that’s before considering the impact of sleep disorders. We need to seriously consider sleep allowance (preferably uninterrupted by work factors) and circadian factors in our shift allocations and on call rosters. Before we can help our patients, we need to acknowledge and address the “sleep problems” in ourselves!
sleeping hot (using doonas, waterbeds, etc) is an unrecognised cause of much dermatological and psychiatric morbidity. If you never ask, you will never ever know….my record was a teenaager with severe acne who slept fully clothed in a sleeping bag covered with 2 doonas and a blanket…and still felt cold! Another patient was a post menopausal lady with similar heating problems, who committed suicide, despite care from the local psychiatric servise.