Last partial update: September 2019 - Please read disclaimer before proceeding.
What is sleep and what causes tiredness and sleepiness?
Sleep is a necessary period of rest and recuperation for the body that is regulated by the brain according to day-night cycles. There is no correct amount of sleep. The important issue is how a person feels about the quality of their sleep during the night and whether he or she is tired the next day. Sleep need vary with age and tend to decrease throughout life. (See table) Deep sleep is the most important type of sleep and this occurs in the first five hours after falling asleep.
Sleep requirements according to age |
|
Age group |
Sleep requirement |
Preschool children |
10 to 13 hours |
Primary-school-aged children |
11 hours |
Adolescents |
8 to 10 hours |
Adults |
7 to 8 hours |
Elderly |
6 hours |
Sleep is very important to health
An adequate amount of good quality sleep is probably just as important as a good diet and a healthy amount of physical activity in determining good health. Many people suffer from sleep deprivation and it is estimated that as a population we are sleeping about 20 per cent less than we did two generations ago. Problems associated with sleep deprivation include daytime sleepiness, fatigue, poor memory, poor concentration, delayed reaction time, reduced coping skills, irritability and mood changes. In short, relationships and work suffer and people are at greater risk of accidental injury. It is estimated that about 20 per cent of workers are functioning below optimum because of sleep deprivation and fatigue related workplace accidents cost Australia billions of dollars each year. The Exxon Valdez oil spill is an example of how serious the consequences of sleep deprivation can be.
Brain' rest time' occurs in the first three hours of sleep when slow wave / deep sleep occurs. This is the most important part of sleep and occurs no matter what time a person goes to sleep; as long as they stay asleep for the full fthree hours. (The commonly held perception that sleep before midnight is more beneficial is not true as long as the person can wake later in the morning. Sleeping from 1am till 8am would be fine for many adults.)
Twenty to 30 per cent of motor vehicle accidents are due to fatigue with shift work being a major contributor. (A person responsible for a MVA cannot use fatigue as a ‘legal defense’ and it is worth mentioning that a woman in Melbourne was jailed for 5 years after killing a cyclist when driving after being up most of the previous 24 hours.)
Interestingly, poor sleep has recently been shown to be associated with an increase in body resistance to the hormone insulin. This is the process that causes most cases of diabetes and some people with chronic sleep deprivation develop a pre-diabetes condition, which significantly increases the risk of heat attacks. People with chronic sleep deprivation also tend to become overweight, mainly because their tiredness leads to poor food choices and poor dietary habits such as snacking and binge eating.
(Back to top)
Causes of tiredness / sleepiness
There are many causes of feeling excessively sleepy or tired including:
1. Insomnia (poor sleep). This is by far the most important cause and will be discussed later in this chapter. It often is associated with worry / life stresses but can be present without any obvious cause, in which case it is often longstanding and dates back to childhood. In some cases insomnia can be caused by an underlying medical problem, termed secondary insomnia. Common medical causes of insomnia include:
- Mental illness. Sleep disturbances are common symptoms in all psychiatric disorders. Depression and anxiety are common causes of insomnia and tiredness, with sleep problems being the major complaint in 30 per cent of people presenting with depression. As well as the classic symptom of waking early in the morning, depression can cause problems getting to sleep and frequent waking during the night.
- Nocturnal asthma. This usually occurs around 4am and is a sign that asthma is poorly controlled.
- Heart failure. Some people with heart failure suffer from shortness of breath at night. (This symptom is often relieved by sleeping on several pillows.)
- Chronic pain, most commonly due to arthritis, cancers, headache and toothache.
- Movement disorders such as Parkinson’s disease.
- Epilepsy. Seizures are not uncommon at night.
- Dementia patients often sleep / nap during the day and this disrupts their sleep pattern.
- Drugs and medications. The most common drugs causing insomnia are alcohol, caffeine and amphetamines.
2. Other medical problems can cause tiredness without sleep disturbance, including an under-active thyroid and anaemia.
3. Shift work (Discussed below.)
4. Drugs and medications. Those causing most problems are alcohol, caffeine and antihistamines (sedating types). Illicit drugs use is also a cause in some people. Some prescribed medications can cause sleep problems, including SSRI medications that are commonly used for treating depression.
5. Environmental factors, such as disruptions from other family members (crying babies) or neighbours, or a poor sleeping environment (too light, hot, noisy etc).
6. Other sleep disorders including;
- sleep apnoea; a common problem, especially in men over 30 and in the obese;
- restless legs syndrome, where irritation is felt in the legs, especially the calves, and the person feels they have to regularly move their legs;
- rarer sleep disorders, including sleep walking and narcolepsy, a disorder where extreme tiredness causes involuntary napping during the day.
(Back to top)
Who needs medical assessment / help for their tiredness / sleep problems?
Many people with tiredness due to insomnia can be helped by improving their sleeping habits. Importantly, people who have long-standing problems with tiredness require help to exclude any underlying medical cause (see above) and gain assistance with techniques that will help improve sleep. The best sources of help are a GP or a clinical psychologist. (A GP will probably be able to recommend a good one. If not, contact the Australian Psychological Association or a specialist sleep clinic. These are usually located at larger hospitals.) Specifically, people should get help when:
- sleeping problems are long-standing (more than a few weeks)
- tiredness is interfering with work or home life (Repeatedly falling asleep is a more worrying symptom than just feeling tired.)
- they have had or almost had an accident or injury due to tiredness
- their tiredness is associated with excessive snoring, indicating that sleep apnoea may be a problem
- sleeping problems are associated with mood changes or other symptoms of depression/anxiety. Early morning waking is common in depression.
- pain or other medical symptoms, such as cough or shortness of breath, are the cause of insomnia
- prescription medications are interfering with sleep.
(Back to top)
Assessing the impact of sleepiness - The Epworth Sleepiness Score
Sleep deprivation can significantly alter a person's ability to function and mood and in some situations can be dangerous, such as when driving or in the workplace. The Epworth sleepiness scale can be used to assess the degree of impairment caused by sleepiness / tiredness.
An important symptom is actually falling asleep repeatedly during the day. If this is occurring, then sleep breathing disorders such as sleep apnoea should be looked for carefully.
Epworth sleepiness score |
|
Directions How likely are you to doze off or fall asleep in the following situations? (In your usual way of life in recent times.) Even if you have not done some of these things recently try to work out how they would have affected you. Use a scale of 0 to 3 0 = no chance of dozing; 1 = slight chance of dozing; 2 = moderate chance of dozing; 3 = high chance of dozing. Then add up your responses to give a total score. (The range of scores is from 0 to 24) |
|
Situation |
Chance of ‘doziness’ (Score 0 to 3) |
1. Sitting & reading |
|
2. Watching TV |
|
3. Sitting inactive in a public place |
|
4. As a passenger in a car for an hour without a break |
|
5. Lying down in the afternoon when circumstances permit |
|
6. Sitting and talking to someone |
|
7. Sitting quietly after a lunch without alcohol |
|
8. In a car, while stopped for a few minutes in traffic |
|
|
|
Total score (out of 24) |
|
|
|
Grading of scores:
|
|
Insomnia
Insomnia is a common problem, regularly affecting 33% of people from time to time and most people occasionally. About 10% of the population has insomnia that causes daytime symptoms, principally sleepiness and overall about 10% of people say they are dissatisfied with their sleep.
(Daytime sleepiness occurs in less than half these people.) Women are more commonly affected than men. Insomnia can be either short or long term. Short-term insomnia is usually associated with a specific cause, such as a stressful event, an illness, overseas travel, or taking stimulants, such as coffee.
Chronic insomnia occurs when the a person has problems falling aslepp or staying asleep persists for longer than three months, occurs at least three times a week and interfers with normal functioning during the day.
Most people (about 80%) with chronic sleep problems have problems that result from worrying, either about problems that they have in their lives or just about the fact that they can’t sleep. This leads to anxiety with accompanying thoughts which can’t be turned off at bed time, often racing about in the person’s mind. It is more common as people get older. About nine per cent of people in their twenties report sleep problems, with the incidence gradually rising to above 20 per cent for people over 60 years of age; although older people tend to get daytime sleepiness relatively less commonly. Anxiety and depression are commonly associated with insomnia (in adults and children) and pre-existing insomnia is strong risk factor for depression.
Chronic insomnia can be divided into two groups:
- Primary insomnia: Here there is no obvious cause. It may arise in childhood and may be associated with maladaptive response to a previous life situation. This group often complain of general fatigue rather than daytime sleepiness.
- Secondary: Here there is a cause for the insomnia and these people often complain of tiredness, not just fatigue. Common causes include;
- a current psychosocial stress,
- current lifestyle habits that impair sleep e.g. daytime napping, late afternoon / evening exercise, working late into the evening on the computer, being available for work 24 hours per day
- shift-work sleep disorder
- a mental health problem,
- caffeine, alcohol or nicoteine use
- recreational drug / substance use / abuse,
- prescription medications,
- other medical conditions e.g. obstructive sleep aponea (discussed below), thyroid disorders, chronc pain, restless legs syndrome, hot flushes, nocturnal cough etc.
One reason that insomnia is so common is that it is not given adequate priority in people’s lives. Sleep needs to be viewed positively as it is an integral part of preparing for each day’s activity.
Diagnosing the type of sleep problem is often aided by a self-reported sleep diary, where a detailed record of the person’s sleeping habits, including details of going-to-bed and wake up times and interruptions during the night, is kept; usually for a two week period. Such diaries are also helpful in monitoring progress during treatment for insomnia. Extra information gained from a spouse is often a great benefit.
Identifying when the insomnia started can often help with identifying an underlying precipitating cause that has perhaps been forgotten.
“Sleeping is no mean art; it is necessary to stay awake for it all day.”
Friedrich Nietzsche
(Back to top)
Improving sleep
Achieving a good night’s sleep involves developing good sleeping habits and a regular sleeping routine and the successful treatment of insomnia requires time and effort to achieve these aims. Once better sleeping habits have been adopted, it takes about four to six weeks for noticeable improvements to occur. During this time people should try not to judge their sleep on a night-to-night basis. It will just cause more worry. Below is some general advice regarding improving sleep.
It is important to recognise that this advice is general in nature and that everyone’s sleep problems are different / individual. As mentioned before, anyone suffering from long-standing sleep problems should discuss their problem with a doctor so that secondary causes for their problem can be excluded and they can devise an appropriate program to fix their problem. As these programs often last several months, maintaining them can be difficult and the support of a physician to help with motivation and monitoring progress can be the difference between success and failure.
It is also important to realise that trying to change sleeping patterns for the better may involve a temporarily getting less sleep and thus day-time sleepiness may be temporarily worse. This may be a significant problem for work and social activities where sleepiness can be a health hazard e.g. driving, operating machinery etc.
Finally, it goes without saying that part of any successful insomnia treatment program needs to incorporate sorting out work / home problems that are causing stress and treating psychological / addiction problems, such as anxiety / depression and alcohol / cannabis abuse. If present, resolving such issues will require the help of a psychologist and / or GP, especially if they are longstanding.
General sleep advice (improving ‘sleep hygiene’)
1. Leading a healthy lifestyle is an important part of sleeping well.
- Exercise
- 30 minutes per day at least. At least 30 minutes per day of moderately active exercise is important for remaining healthy. It helps improve mood and reduces muscle tension and physiological arousal, promoting better sleep.
- Early morning and early evening are the best times to exercise. Exercising outside in the early morning sunlight is very helpful as light exposure at this time helps strengthen normal sleep rhythms. Exercise before dinner has been shown to reduce depression symptoms and, for overweight people, it actually reduces appetite.
- Avoid doing exercise close to bedtime. Exercise increases core body temperature, which increases alertness and thus prevents sleep onset. It takes three to four hours for core body temperature to return to normal after exercise and it is therefore best not to exercise after say 6pm to 7pm.
- Eating
- Avoid having large meals close to bedtime. People should also consider stopping smoking and cutting down your alcohol consumption if it is excessive. Foods with a high-protein content, such as cheese, should be avoided as they tend to keep people awake.
- Avoid going to bed hungry (A small carbohydrate snack and some milk is useful if dinner was some time before bedtime.)
- Stimulants - Coffee and cigarettes
- Reduce excessive intake of stimulants, such as caffeine containing foods and drinks and cigarettes, and refrain from taking any stimulants after lunchtime. (Caffeine containing foods include coffee, tea, caffeinated soft drinks, energy drinks and chocolate). Caffeine has a long half-life of about 8 hours and thus should not be taken after lunch. Also, it is wise to keep consumption down to one to two cups per day. As well as being a stimulant, caffeine also makes people pass urine more often and this may cause waking during the night. People who need to reduce caffeine intake should do it slowly as a sudden withdrawal can cause symptoms such as headache, irritability and tiredness. Nicotine is also a stimulant that can affect the ability to get to sleep and thus it is best to avoid smoking before bedtime (and every other time). In excess, it can also cause nightmares.
- Alcohol
- Avoid alcohol in the three hours prior to going to bed
- Do not use alcohol to promote sleep onset. The use of alcohol close to bed time can interfere with normal sleep patterns, exacerbate sleep apnoea if present, and cause early morning wakening. Alcohol does make people drowsy and its consumption close to bedtime is used by some to help them fall to sleep. However, tolerance soon develops and this effect is lost after about a week.
- Fluids
- Avoid taking any fluids after dinner as the need to go to the toilet may cause waking during the night. It is also useful to make going to the toilet part of the ‘going to bed’ routine.
- Work
- Some time off is vital for everyone. It is important that work is not a 24 hour a day commitment. Problems associated with work need to be well sorted out before bedtime and, where possible, instruct work colleagues not to phone after a certain hour.
- Avoid an unrealistically excessive workload: Stress can be due to committing to an unrealistic load of work/activities. Solving sleeping problems requires priorities to change and factors benefiting sleep being given a higher priority.
- Avoid work close to bedtime, especially computer work
2. Ensure that you have a good sleeping environment
- A quiet, dark and well ventilated bedroom is essential
- Noise, which is often a problem for shift workers who need to sleep during the day, can be reduced by the use of earplugs or if necessary, sound-proofing.
- Comfortable bed
- Make sure that the bed gives good support and is comfortable
- The bedding should allow adequate temperature regulation. Thick doonas are often a cause of feeling uncomfortably hot in bed. Thicker sleep wear and socks can help when feeling cold.
3. Going to bed
- Try to establish a regular sleeping routine
- Go to sleep and wake up at about the same time each day, including on weekends. (This is important as the sleep-wake cycle is governed by an internal clock that keeps a person’s sleep pattern to the same time each day, more-or-less.) Such a program often needs to be kept up for up to two months to re-establish a good sleep pattern and maintaining this program for a sufficient period is probably the most important step in improving insomnia. Most people sleep between 8pm and 8am and thus ‘going-to-sleep time’ should be between 8pm and midnight and ‘waking time’ should be roughly eight hours later. (A good way of deciding on an appropriate time to spend sleeping in bed is for the person to think back to how much sleep he or she was getting when sleeping well.) Even after a bad night’s sleep, people should avoid sleeping in as it is likely to make them go to bed later the following evening and means that they are not exposed to early morning light, which is very important in setting their body clock. (Bear in mind that such a time frame may need adapting for people suffering from circadian rhythm problems. See boxed section.)
- Go to sleep only when drowsy: Having said the above, getting to sleep is much more likely when you are drowsy and it is best to go to bed when sleepy. This may mean staying up a bit later than usual some nights. If you do go to bed a bit later, do not change your waking time. It is best to keep this the same. (This advice will also obviously not be of benefit for people with delayed sleep phase insomnia as their whole problem is that the time that they get tired is too late at night. See boxed section on circadian rhythm problems.)
- Try to establish a ‘going to bed’ routine.
- Relax prior to going to bed. Make the time immediately before going to bed relaxing by doing a relaxing activity, such as having a bath, meditating or listening to relaxing music. Try not to read an exciting book or watch a stimulating TV program or do physical activity. Work related activities should be avoiding close to bedtime and using the computer at this time is also often not relaxing / helpful. Computer use before going to bed is particularly a problem as its interactive nature and closeness to the screen stimulates the mind. (It is also often work / problem related.)
- Partners should try to go to bed at the same time. This will, however, not be appropriate for some couples.
- Go to the toilet just before going to bed. This will reduce the likelihood of needing to get up during the night to go.
- Only sleep at night
- Do not take long naps during the day. Experiencing deep sleep outside normal sleeping time can disrupt normal sleep. Deep sleep starts about 20 minutes after falling asleep and thus, for most people, naps longer than 20 minutes should be avoided during the day. (There are exceptions to this rule, the main ones being do shift works (whose normal sleeping time is during the day), the very young, the elderly and the ill.) Trying to make up for missed night time sleep during the day actually makes regaining a healthy night time sleep pattern more difficult and stocking up on sleep in preparation for a late night also does not help. Short 'power naps' that last no longer than 20 minutes can, however, be beneficial in getting through the day when tired. (See 'power naps' below.)
4. Getting to sleep / remaining asleep in bed
- Bed should only be for sleep and sex
- No TV, radio, computers, mobile phones, iPads, or reading. People with problems initiating sleep should not watch TV, listen to the radio or use computers or mobile phones in bed and should also avoid reading in bed (especially work related reading).
- Do not work or read in bed during the day. It is also best not to read or work in bed during the day and bed is not a place for eating or drinking (or smoking!!).
- Do not clock-watch in bed as it can increase anxiety about not sleeping. Just set the alarm and forget the clock.
- Try not to worry about not sleeping or other problems
- A common problem is that people keep themselves awake worrying about their sleep or about other problems. About 50% of people who have trouble sleeping report worry / anxiety as an important cause. If sleep does not occur in roughly twenty minutes, get up, go into another room and do something relaxing for a short time (10 to 20 minutes) until feeling sleepy again. (Keep the light level low in the room and no TV, computer use, work or household chores.) A similar approach should be taken when problems occur with getting back to sleep after waking during the night. This process may need to be repeated but of course cannot go on all night and if a person just can’t get to sleep after getting up once or twice, it is best to just lie quietly in bed as this is an important part of sleep anyway. (Generally speaking, it is unwise for a person to spend less than five hours actually in bed.) As much as possible, avoid moving about restlessly in bed.
- Sort out problems WELL BEFORE going to bed. Worrying at bedtime can be reduced by sorting out problems and tomorrow’s schedule well before going to bed. People who worry about such issues in bed at night should dedicate a period of the day for these activities.
- Seek help regarding stress / anxiety problems. There are several very helpful and easily learned techniques for reducing anxiety / stress. These are outlined briefly below. They do require professional help, so please see a doctor or a psychologist if stress or anxiety are causing problems.
- Regular exercise can help reduce stress
- Judging sleep too closely is not helpful. Try not to examine sleep on a day-to-day basis
- Be flexible regarding sleep expectations. Not everyone needs eight hours sleep each night; some people cope quite well on much less. And it is not necessary to get a good night's sleep every night. People will usually still cope the next day when their previous night's sleep was not perfect.
Psychological treatments for insomnia - Reducing worry and stress
Cognitive behavioural therapy (CBT) - The most effective treatment
CBT is the most effective treatment for insomnia and should be the first line treatment for most people. It is important to understand that CBT tends to improve the quality of sleep and is very effect at consolidating sleep i.e. people sleep well when they are sleeping. It usually does not result in people sleeping for longer.
Insomnia is serious problem and CBT therapy for insomnia is best addressed with the help of a sleep therapist (usually a psychologist). There are online CBT treatments for insomnia but these are best used inconjunction with help and support from a health profesional used to dealing with this problem; usually a psychologist or your GP (especially in remote areas).
There are four components to CBT for insomnia.
1. Addressing anxiety symptoms caused by not being able to get to sleep.
Many cognitive (thinking) factors can influence / cause insomnia. Worry and stress are common to everyone and are important causal factors in at least 50% of people suffering from insomnia.
The stress / anxiety may be related to real problems that require specific actions for the situation to improve (e.g. stress due to alcohol abuse in the home). However, it is probably more common for problems to cause worry because of the way they are perceived.
Generally, the way a person feels and acts regarding a situation depends on the way he or she thinks about the situation and his or her underlying beliefs about the situation. Unfortunately it is very common for people to have unhelpful beliefs that are not based in fact and to think in unhelpful ways, and both these mental processes can cause us to worry unnecessarily.
This can occur in all types of problems, including problems people think they have regarding sleep itself. For example, people may believe that they must get eight hours sleep per night to function well the next day or that their lack of sleep will cause them to have a nervous breakdown, and this causes them to worry about not getting to sleep / waking during the night. Challenging such untrue beliefs, for example by recognizing that in the past he or she has coped quite reasonably on less than eight hours sleep and that their past poor sleep has not caused a nervous breakdown, can help people overcome their worry and help restore better sleep patterns. This type of psychological intervention is called Cognitive Behavioural Therapy and it can be used for treating all manner of ‘everyday’ problems with great success.
Solving these problems can be a difficult task and is likely to require the assistance of a doctor or psychologist, especially if the problem has existed for a long time. CBT can be done individually or in group sessions.
The technique is discussed in detail in the Achieving Lifestyle Change section of this web site. A very helpful book on this topic (one that just about everyone should read) is Change your thinking by Australian psychologist Sarah Edelman (published by ABC books).
2. Muscle relaxation therapy:
This can also be useful in people suffering from excessive stress.
The following two CBT therapies are specific to the treatment of insomnia and have been found to be the most important reducing insomnia.
Adopting these two therapies is best undertaken with the help of a sleep therapist and research has shown that at least four to six therapy sessions are required to achieve the best results. It is difficult to deliver the four components of CBT for insomnisa in less time.
3. Stimulus control therapy as part of CBT
Here the aim is to associate the bed with 'good' successful sleep, with the bed only being used for sleep and sex. (No TV, reading or listening to music.) The person should go to bed only when drowsy and if sleep does not occur within 15 minutes, the person should get up, go to another room that is fairly dark and do something restful until drowsy again, and then return to bed to try and fall asleep again. This process should be repeated within reason until sleep occurs. (Obviously this process cannot continue all night and if repeated attempts are unsuccessful then the person will need to stay resting in bed. Generally speaking, it is unwise for a person to spend less than five hours actually in bed.) The person should still get up at the same time each morning.
4. Sleep restriction:
Another technique used by therapists to help difficult cases of insomnia is sleep restriction therapy, which actually restricts the time spent in bed so that a greater percentage of time in bed is spent asleep. This is usually used when people are spending too much time in bed trying to get sufficient sleep, creating a fragmented sleep pattern. The process commences by slowly reducing the time spent in bed, usually by about 30 minutes per day every 3 to 4 days. This reduction can be made either at bedtime or at waking time, although it is best if the wake up time is not significantly changed. Good sleepers usually spend over 85% of their time in bed asleep and the aim of this technique is to increase the proportion of time in bed when the person is actually asleep to greater than 85% and to promote rapid sleep onset. Sleep is restricted for a couple of weeks and then time in bed is gradually lengthened again, the whole process taking about four to six weeks. Time in bed should never be less than 5 hours per night. People should only attempt this under the supervision of a sleep therapist.
Muscle relaxation therapy:
This can also be useful in people suffering from excessive stress.
Other treatments
Sleeping tablets
Sleeping tablets are generally not a solution for sleeping problems, although some are used as a short-term treatment. (The most commonly used medications are non- benzodiazepine GABA-receptor agonists such as zolpidem and zopiclone and benzodiazepines that have a short half-life such as triazolam and temazepam). Generally speaking, they should not be used for longer than two to four weeks as tolerance and addiction can occur with some medications. They do not help in restoring good sleeping patterns or improve quality of life. They may also increase the risk of both work related and motor vehicle accidents and the risk of falls in the elderly. Also, 'rebound' sleep problems can occur when the medication is ceased. Over-the-counter medications that cause drowsiness, such as sedating antihistamines, should also be avoided.
Power naps
If a person is tired during the day, a power nap can be helpful in 'freshening them up'. These naps need to be at least 10 minutes long but no longer than 30 minutes. Longer sleeps can cause people to wake up feeling tired and can cause disruption of night time sleeping. It is important that power
Sleep apnoea
Sleep apnoea is an important cause of daytime tiredness, occurring in over five per cent of Australians. (It is more coomon inmales with some studies showing an incidence of up to 25%.) It is a condition where relaxation of throat and tongue muscles causes a prtial or complete obstruction in the throat above the larynx (voice box), resulting in regular episodes where the person stops breathing for short periods. Each time this happens, the brain wakes the person just enough so that the person takes a breath, often as a snort or a gasp. The person then falls back to sleep, usually unaware that he or she has woken. In this way, sleep is continually disrupted, sometimes up to hundreds of times, during the night. People with sleep apnoea are often tired despite seeming to get enough time in bed sleeping.
The severity depends on the number of interruptions, with less than 5 per hour being normal and over 50 per hour indicating severe sleep apnoea. Snoring is a common symptom, occurring in about 95% of people with sleep apnoea. (However, snoring is common in the adult community (40% of women and 50% of men), and thus most people who snore do not have sleep apnoea.) Day-time tiredness commonly occurs and is associted with fatigue, memory impairment, poor concentration, poor work performance , irritability and morning headaches. The presence of snoring in association with day-time tiredness symptoms suggests that sleep apnoea may be present and that investigation is warranted. Witnessed apnoeas and waking at night with a sense of choking or gasping are also very suggestive symptoms. Most people with sleep apnoea do not have problems getting to sleep. Physical indicators that sleep apnoea is likely to be present in these individuals include structural abnormalities in the upper airway (e.g. large tongue or tonsils), a small mouth opening (e.g. due to small jaw) and obesity. (A waist measurement greater than 127cm indicates a high risk of sleep apnoea.) Neck / shirt measurement/size is also a very good indicator with a size greater than 43cm indicating an increased risk and greater than 48cm indicating a high risk. A size less than 37cm indicates a low risk.) High blood pressure is often found in people with sleep apnoea.
The day-time tiredness and reduced nocturnal oxygen supply that sleep apnoea causes create numerous health problems, including a high incidence of motor vehicle, occupational and other accidents, intellectual impairment (due to reduced learning / concerntrating ability), memory loss, personality changes, depression and cardiovascular problems such as abnormal heart rhythms, hypertension, coronary artery disease and heart failure. (Death in sleep, due to these heart problems, is also more common in sleeep apnoea.
Men over 30 years of age are more commonly affected, especially if obese. (Testosterone increases airway collapsibility and is thus tought to be a comtributing factor.) However, the rate in women increases significantly after menopause. Causal factors include the following:
- Age and male gender.
- Excess weight (due to additional fat tissue around the neck). This is a very important cause and just a 10% increase in weight can increase risk by as much as six times. Conversely, even a small weight loss can dramatically improve the problem. (Lossing 10% of body weight can reduce sleep apnoea incidence by between 25 and 45%.)
- Alcohol. Alcohol, especially in the evening, causes the throat muscles to relax, worsening the problem.
- Conditions that block the upper airway, such as enlarged tonsils, nasal obstruction, or an enlarged thyroid gland (goitre).
- Medications, including oral prescribed steroids, sedatives and drugs for epilepsy.
- Asian men have a relatively higher incidence for a given weight / age (due to differences in craniofacial features).
Diagnosis of sleep apnoea requires investigation in a specialist hopsital-based sleep clinic, which usually requires observation / monitoring overnight.
Treatment includes weight loss, reducing alcohol consumption, machines that assist with breathing by providing continuous positive airways pressure (CPAP machines), mouth splints and, occasionally, surgery to correct upper airway blockages. Losing weight is the best and healthiest solution but for those who can’t or who are a normal weight CPAP machines are very effective.
Sleeping in a supine position ('on your back') can increase sleep apnoea and avoiding this position can sometimes help.
It was hoped that CPAP treatment would also reduce the incidence of cardiovascular eventssuch as heart attacks and strokes in people with sleep apnoea. Unfortunately recent evidence (2016) has found this not to be the case.
Finally, it is worth noting that snoring is a common occurrence and its presence without apnoea or day-time tiredness is not a cause for concern.
Other causes of apnoea during sleep in adults
Central Sleep Apnoea. Recurrent episodes of apnoea during sleep can also occur due to abnormalities in the body's conrol of breathing. This called Central Sleep Apnoea. It is usually not associated with evidence of upper airways obstruction. Diagnosis requires investigation in a hospital sleep unit. There are many causes including heart failure, stroke, some medications, chronic kidney failure, low levels of thyroid hormon and musculoskeletal problems such as muscular dystrophy and kyphoscoliosis. It ca also occur at high atlitudes. Snoring is uncommon and sufferers often have problems getting to sleep. Treatment depends on the cause.
Nocturnal hypoventilation: This occurs when people under-breathe all the time rather than in discrete episodes to the point where their blood oxygen levels fall and carbon dioxide levels rise. It occurs in people with chest wall deformities, chronic lung disease (e.g. chronic bronchitis / emphysema, cystic fibrosis), brain abnormalities and in very obese people.
Sleep apnoea in children
Snoring affects about 10% of children and about 20 per cent of these have obstructive sleep apnoea (i.e. greater than five episodes of respiratory disturbance per hour). These children will snore most nights rather than just occasionally and this is the most important symptom of the condition and one that parents should mention to their child's doctor. (Other symptoms include difficulty breathing when asleeep, witnessed nightime apnoea during sleep, and frequent daytime mouth breathing.) These children are not overweight and they tend to snore continuously during their sleep. They are often not tired during the day. It occurs equally in boys and girls.
The main problems relate to impaired learning and memory and poor behaviour. Child sleep apnoea has also been shown to cause increased blood pressure and this may persist into adult life.
Most cases occur in the two to four year age group and are due to enlarged tonsils or adenoids. Removing them cures the problem. The use of antiinflammatory treatments, usually in the form of intranasal steroid sprays to help reduce adenoid size / allergy-caused nasal obstruction, is also an option in some milder cases. Other anatomical abnormalities in the upper airways can also be cause the problem and may need surgical treatment.
Restless legs syndrome
This syndrome is defined by the presence of the following:
- An urge to move the legs, usually with an uncomfortable feeling
- Symptoms begin or worsen during periods of rest and are relieved, at least partially, by movement
- Symptoms occur mostly at night and include problems falling asleep or inability to stay asleep.
Who needs to be referred to a sleep specialist / sleep clinic?
- Patients with suspected sleep apnoea
- Patients with restless legs syndrome
- People who are not improving with initial therapy from their GP or psychologist.
(Back to top)
Sleep in children
Good sleep is important for normal growth and development and helps improve a child's mood and behaviour, which in turn facilitates learning. It is also very important for parents.
How much sleep do children need?
- Young babies (first few months of life) - About 16 hours per day in short cycles
- Preschooler - 11 to 12 hours
- Primary school -aged child - 10 hours
- High school adolescent - 8 to 9 hours (They often do not achieve this due to TV, and computer / internet use.)
- Adult - 7 to 8 hours
These figures are approximate and can vary in individuals by up to an hour or two either way and it is therefore important to ask about tiredness, behaviour and ability to concentrate during the day when assessing whether a child is getting adequate sleep.
Establishing a good sleeping routine and environment
There are several factors that are important in ensuring children have a good night's sleep.
- Providing a good sleeping environment: The room should be quiet, dark and well ventilated. The bed should be comfortable and have appropriate bedding so that they are not too hot or too cold. Socks are a good option for cold feet. Hot water bottles should not be used due the risk of scalding.
- Establishing a regular sleeping routine: Children should go to bed at roughly the same time each night. Both parents need to be consistent with this policy. There should be a routine of cleaning teeth and going to the toilet before going to bed and a story that does not cause them to become too excited or scared.
- Avoiding needing to go to the toilet during the night: The best way to do this is to avoid having excessive amounts of fluids before bedtime and making going to the toilet immediately before going to bed part of their 'bedtime routine'.
- Ensuring that their bedroom is a TV / computer free zone: One of the most important ways to improve family life is to make sure that TVs and computers are NEVER allowed into bedrooms. This prevents older children staying up late at night watching TV, playing computer games or being on the internet. Mobile phones should also be left outside the bedroom after bedtime. Such a policy will be difficult to police in adolescents if it has been allowed at a younger age.
Children who have problems getting to sleep
- Avoid stimulants before bedtime if getting to sleep is a problem: Caffeine-containing foods, including chocolate, tea and coffee products, should be avoided for several hours before bedtime if children are having problems going to sleep.
- Increasing activity: Tiring the child out by increasing afternoon physical activity can be very helpful in improving sleep and helps regarding health in general.
- Reduce sleeping time: A child may not need the amount of sleep that he or she is getting. If the child is not tired during the day then it is reasonable to try reducing sleep by:
- Reducing / stopping daytime naps if the child is still having them.
- Pushing back bed time
- Giving them their own room: Interaction with other siblings may cause problems getting to sleep.
- Addressing fears / anxiety about going to sleep: Many younger children have fears about being left alone in a dark room. Addressing these fears in a concerned manner rather than dismissing them as being silly will usually be sufficient to fix the problem. (It may well require ongoing discussion and reassurance.) Occasionally children with significant anxiety problems will need counselling.
Nightmares and Night terrors
Waking at night in fright is non uncommon in childhood and there are two principal causes.
Night terrors: These episodes involve the young child waking up very agitated and upset and sometimes actually screaming. The child is initially only partially awake and is not aware of his or her surroundings or the presence of others and may speak strangely. It takes about 5 to 15 minutes to become fully awake. They occur only once per night, usually within a couple of hours of going to sleep, and the child has no recollection of them in the morning. They often occur for several nights in a row and then go for a period of weeks or months. They are not significant and require explanation only. As the child has no recollection of the event, they can usually be put back to sleep.
Nightmares: These occur at all ages and differ from night terrors in that the child is initially fully awake (and upset) and has some recollection of the event, thus making it difficult for the child to get back to sleep. Parents need to talk about the episode with the child, explaining the cause and providing reassurance. They are less common than night terrors in young children.
In both cases it is best to try to keep to a policy of keeping children in their own beds most of the time. Regularly coming in to sleep in the parent's bed should be discouraged as it does not resolve the child's problem / fears and certainly does not help parents get a good night's sleep. If there is a specific cause of anxiety this can be discussed and removed if possible. Star charts with rewards can be used to keep children in their own beds. Again, children with chronic, deep seated anxieties may need some counselling.
Obstructive sleep aponea in children
Obstructive sleep aponea (OSA) is an interruption in breathing due to an anatomical blockage in the airway. Children of all ages can suffer from this condition but it is most common in the two to six year age group when tonsil and adenoid enlargement occurs at a greater rate than the normal growth of the surrounding pharynx, causing an upper airway blockage. Removal of tonsils and adenoids fixes the problem in 85% of cases.
Snoring is the most common symptom but it occurs in many children without OSA. Snoring that occurs in all sleeping positions and every night and is associated with pauses in breathing is more likely to indicate the presence of OSA. Frequent pauses in breathing at night together with altered behaviour and poor concentration during the day indicates a more serious problem exists. Only more troublesome cases require treatment and often mild cases can be conservatively managed, with the child gradually growing out of the condition over a period of years.
Diagnosis in cases where the problem appears significant is usually done through a sleep study. OSA that results in more than 10 to 15 breathing pauses per hour generally requires surgical removal of adenoids and tonsils. Occasionally continuous positive airway pressure via nasal prongs is also needed in more severe cases.
(Back to top)
Sleep deprivation in mothers after childbirth
Adequate sleep in the 4 months after childbirth is often difficult for mothers to achieve and many become exhausted and in some it causes syptoms similar to depression. A recent study found that, when there are special problems, women after childbirth get about 7 hours sleep but that this sleep is fragmented and the mother is usually awake for a couple of hours each night. Most of this time is spent feeding the new baby. This lack of sleep / sleep fragmentation can result in:
- decreased cognitive skills (equivalent to a having a blood alcohol of 0.1%)
- depression (depression occurs in about 10 to 15% of new mothers)
Sleep deprivation can still be present at 18 weeks, when new mothers often start thinking of returning to work.
Strategies that can help include;
- creating a good sleeping environment in the parental bedroom (See above)
- trying to be realistic about the number of visitors / other disruptions during the day and especially in the eventings.
- avoid prolonged feeding times at night
- avoid driving when feeling very drowsy
- avoid caffeine (and alcohol), especially when breast feeding
- read up on strategies to help get restless babies back to sleep
- being organised in the home (an important factor)
- mindfullness meditation Discuss this with your doctor first) (Headspace provide a free mindfullness app)
- cognitive behavioural therapy for insomnia (Discuss this with your doctor first)
Resources
Sleep patterns for babies: www.pregnancybirthbaby.org.au/sleep-patterns-for-babies
10 Tips to help your baby sleep better: www.sleephealthdfoundation. org.au/pdfs/Tips-To-Hel-Baby-Better.pdf
Cognitive behavioural therapy to help sleeping: www.sleepio.com/cbt-for-insomnia/
Further reading
Sharp, T.J. The Good Sleep Guide. Penguin Books Australia Ltd, 2001.
Ferber, R. Solve your child's sleep problems. Simon & Schuster, New York, 2006.
Norma Tracey, Beulah Warren and Lorraine Rose. Sleep for Baby and Family