Opening eyes to sleep disorders

September 24, 2008

Robert Pugliese, 64, remembers with regret the days when he used to fall asleep while driving. “I’d snap out of it. I didn’t know where I was,” he says. “That got a little scary.” He was also snoring a lot back then, but this wasn’t new. His wife would punch him in the ribs at night, telling him to turn over. Sure he was tired during the day, but Pugliese attributed it to getting older. During a physical in 2007, Pugliese, of Rocky Hill, told his primary care doctor about his fatigue. Just one year later, Pugliese says his life has completely changed, thanks to a small CPAP (continuous positive airway pressure) mask he wears at night to treat the culprit, a condition called obstructive sleep apnea that robbed him of sleep and potentially, his life.

Pugliese is one of about 1,900 people annually who visit The Hospital of Central Connecticut’s Sleep Disorders Center to be tested for sleep disorders, namely sleep apnea and narcolepsy.

Increasing sleep apnea awareness

We spend nearly one-third of each day sleeping. That’s a lot of sleep over a lifetime but for many people,a lot of time lost, blanketed by a sleep disorder. “Obstructive sleep apnea is the most common sleep disorder,”says neurologist Marc Kawalick, M.D.,medical director of the Sleep Disorders Center.Symptoms include snoring,gasping arousals from sleep and non-refreshing sleep which leads to daytime sleepiness.“Your physiology changes when you’re asleep vs. awake,”adds Kawalick. Normally, when awake, your airway muscles remain stiff to stay open; during sleep, those muscles relax.With sleep apnea, the airway walls begin to vibrate against each other, creating the sound of snoring. Ultimately, the moist surfaces can seal tightly, creating a complete obstruction and apnea, which means “loss of breathing.” The body’s sympathetic nervous system then goes in high gear, awakening the brain to open the throat muscles, explains Sleep Disorders Center neurologist Andre Lerer, M.D.He adds that apnea also makes the heart work harder, increasing blood pressure and the risk of a heart attack, stroke, diabetes and death.

More than 12 million Americans likely have sleep apnea, according to the National Heart Lung and Blood Institute (NHLBI), with the typical sufferer a male age 30 to 60, often overweight or obese. Other risk factors include people with a small upper airway, small jaw, large neck and who smoke or drink. Postmenopausal women may suffer from the condition, as can children,most often those with big tonsils or adenoids. “Apnea can happen hundreds and hundreds of times may be asleep eight hours but your brain is waking up all night long to open your airway.” The resulting fatigue carries through during the day. In Pugliese’s case, daytime sleepiness affected his driving and forced him to give up his woodworking hobby. Pugliese is not alone. Untreated sleep apnea and narcolepsy sufferers make up one of three groups at highest risk for drowsy driving and crashing, according to the National Highway Traffic Safety Administration.

Night owls at work

More than ready to resume restful nights, Pugliese came for an overnight sleep study at the Sleep Disorders Center earlier this year. The center conducts 35 to 40 studies weekly and is accredited by the American Academy of Sleep Medicine. About two weeks before a study, the patient is interviewed by a polysomnographic (sleep study) technologist, views a sleep disorders video and tours the center. It has six bedrooms, five with a full-size bed and TV, and one room with a hospital bed. Patients also see equipment they’ll be connected to during the study, enabling a polysomnographic technologist to continually monitor and record brain waves, limb movements, heart rate, oxygen level, and chin muscle tone to determine the different sleep stages. Many patients coming for sleep studies are curious about the procedure, says Donna Cone, a registered polysomnographic technologist and center supervisor.“An initial visit before the study informs patients of what to expect the night of their sleep study and gives them information about sleep disorders and their treatment.”

Patients arrive between 8:30 and 9:45 p.m. for their studies, which end when they are awakened between 5:30 and 6:30 a.m. the next day. The center also accommodates varied work schedules. About two weeks later, patients are contacted to discuss their findings, interpreted by sleep center neurologists, as well as treatment, if necessary. “Man, did I snore,”recalls Pugliese of his study.“I stopped breathing about 29 times per hour.” Based on his apnea diagnosis, Pugliese received a CPAP machine, and started feeling better within days of using it. The CPAP device gently delivers air pressure through a mask to keep the airway open during sleep. Patients who snore or have mild apnea may be referred to a dentist for an oral appliance that pulls the jaw forward so the tongue doesn’t block the airway; or an otolaryngologist who can surgically correct nasal obstruction caused by a deviated septum or swollen nasal linings, as well as pendulous soft palates that can obstruct the upper airway. “The difference is like day and night,”Pugliese says of using CPAP. “I’m not tired anymore, whatsoever.” He also has a renewed appreciation for good health, noting his blood pressure has dropped. His outcome is common. “Patients are very happy to have found the solution,”says Cone, adding many patients attend quarterly sleep apnea support group meetings at the hospital. With renewed energy, Pugliese is eager to return to woodworking. “I’m ready. I can feel it.”

Pushing dreams aside

Sometimes awakening from sleep, Julia* would suddenly sense that her body was frozen in place, her muscles still dozing, symptoms of a condition called sleep paralysis. “It lasted minutes or seconds but it felt like forever,”says the 33-year-old Waterbury resident.She had other symptoms, some persisting since her teen years:falling asleep within several minutes at inappropriate times and constant fatigue.“I had a lot of trouble throughout high school waking up. I was always tired, exhausted.” Julia’s symptoms created havoc in her life, affecting her socially and professionally. But the day her knees buckled triggered Julia, then 28, to see a doctor and be tested at the Sleep Disorders Center. Her history, including the muscle weakness symptom, known as cataplexy, helped confirm narcolepsy. Narcolepsy patients experience pathologic sleepiness, the inability to stay awake regardless of how much sleep they’ve had; sleep attacks which are sudden, irresistible urges to sleep; and dreams that intrude on wakefulness. A condition marked by low levels of the protein hypocretin, narcolepsy often starts in the teens or 20s. The NHLBI estimates 150,000 or more Americans have narcolepsy, which may be hereditary and can be triggered by infection. Diagnosis is based on a person’s history and sleep study outcome.

There are three distinct brain states: wakefulness, sleep and dream sleep. Normally, these states do not overlap.“With narcolepsy, the normal boundaries of wakefulness, sleep and dream sleep dissolve,”Kawalick says. When you dream, a switch in your brain shuts off all muscle activity, except the diaphragm, which allows breathing, and eye muscles which permit rapid eye movement (REM), indicative of dream sleep. In narcolepsy, the brain switch that should be active only during sleep and dreaming goes on while the person is awake, causing cataplexy. Sleep paralysis occurs when the switch stays on after the dream sleep stage and while awakening. Without the switch, we would act out our dreams. Some people with a defective switch suffer from REM behavior disorder, which can lead to injury to themselves or their bed partner.Patients being evaluated for narcolepsy remain at the Sleep Disorders Center after the initial study for a multiple sleep latency study in which five nap trials are conducted every two hours, 9 a.m. to 5 p.m. Narcolepsy is confirmed if the patient falls asleep in under eight minutes, on average, during the trials and starts dreaming within 15 minutes in at least two naps.

Even before her 2004 study, Julia started feeling relief after watching a center video on narcolepsy.“I actually cried,”she says.“I was able to identify with the people in the movie.” “The big thing for narcolepsy is to make the correct diagnosis,”says Lerer, noting sufferers may be labeled with a psychiatric disorder, seizure or heart disorder.“It relieves the stigma of what you don’t have and leads to appropriate treatment.” Julia started feeling better within weeks of treatment with two medicines, Provigil®, to keep her awake during the day, and Xyrem®, which treats cataplexy and improves daytime sleepiness. People feel relieved when they have a diagnosis, says Cone.“And then they’re treated and feel like they just woke up.”

To learn more about the Sleep Disorders Center, call (860) 224-5538 or visit www.thocc.org/services/sleep.

SLEEP DISORDERS

How to get some good shut eye

What defines a good night’s sleep?

You’ve had one if: you fall asleep within 30 minutes, are awake less than 30 minutes during the night, and sleep for more than 6.5 hours, feeling refreshed upon waking. So says Susan Rubman, Ph.D., a behavioral sleep medicine specialist at The Hospital of Central Connecticut Sleep Disorders Center. Insomnia – when you just can’t sleep is a behavioral condition, not a sleep disorder, says Rubman, who offers these tips to get some good shut eye:

• Avoid caffeine within six hours of bedtime and alcohol four to six hours before bedtime.
• Make your bedroom conducive to sleep. Keep it dark, quiet and at a comfortable temperature.
• Exercise in late afternoon or early evening, finishing at least four hours before bedtime.
• Try not to use the bedroom for activities other than sleep or sex (e.g.,office).
• Don’t go to bed when you’re not sleepy.