Insomniacs should get out of bed for better sleep

Getting out of bed may be the key to helping insomnia, a new study published in the Archives of Internal Medicine suggests.

The study, done by a team of researchers at the University of Pittsburgh school of Medicine and led by Daniel Buysse, followed 79 adults with chronic insomnia who averaged 72 years of age.
Buysee wanted to find out if cognitive behavioral therapy for insomnia, which is just as effective as a pill according to previous research, could be shortened and simplified at lower costs. In the past, these pill-free therapies have been very involved and too pricey for the general population.

One conclusion from the behavioral study stated by Buysee, “When you are sleeping poorly, the most important thing you can do is spend less time in bed.”

Insomnia is defined as the difficulty in initiating, or maintaining, sleep and an estimated 30%-50% of the general population are affected by this sleep disorder. Statistically insomnia seems to affect more women than men and it’s incidence tends to increase with age.

Insomnia can affect a person’s ability to function during the day which can lead to accidents, and a wide range of various physical symptoms, including hypertension and inflammation.

The study focused on using cognitive behavioral therapy for the participants that were unable to get to sleep. The participants were given either printed educational materials about sleep, or 2 brief behavioral in-person treatment sessions followed by 2 phone call sessions.

The mental health nurse practitioner conducting the sessions focused the sleep instruction on restricting time in bed and setting regular sleep and wake-up schedules. The practitioner also gave instructions on the biological reasons for the particular sleep strategies utilized in the behavioral therapy study.

Thomas Neylan of the University of California, San Francisco, gave comment to this research stating, “A lot of insomniacs spend a lot of time lying in bed worrying about their sleep, among other things. They expect to have insomnia.”

Neylan gave further recommendations for insomniacs by suggesting, “If you’re not ready to fall asleep, don’t lie down in bed and try to force yourself to sleep. And if you wake up in the middle of the night and don’t fall back asleep easily, get out of bed. You don’t want to have any linkage between the experience of lying in bed and being awake. “

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Body Position Affects Sleep Apnea Among Young Children

Sleep Apnea and Children

Children aged three and younger who have a sleeping disorder known as sleep apnea show more respiratory disturbance when they sleep on their backs, according to a study in the November issue of the Archives of Otolaryngology – Head and Neck Surgery, one of the JAMA/Archives journals.

Obstructive sleep apnea syndrome (OSAS) is a serious medical problem affecting an estimated half a million children per year in the United States, according to background information in the article. Pediatric OSAS is most commonly caused by enlarged tonsils and adenoids. It is characterized by episodes of partial or complete upper airway obstruction that occur during sleep, including snoring, cyanosis (a bluish color of the skin and mucous membranes), and poor quality of sleep. Symptoms during the day can include mouth breathing, behavior problems, hyperactivity, and excessive daytime sleepiness. While research among adults has shown a significant decrease in OSAS episodes when patients avoid sleeping on their backs (the supine position), the issue of sleep position is not as well understood among children with OSAS.

Kevin D. Pereira, M.D., and colleagues at the University of Texas Health Science Center at Houston conducted a retrospective chart review to evaluate the association between body position and OSAS events during sleep in children aged three and younger. The study included 60 children who underwent polysomnography (PSG, the continuous recording of physiologic variables during sleep) to evaluate OSAS, and later had surgery to remove their tonsils and adenoid tissue, between December 1, 2000, and November 30, 2003. The PSGs were analyzed for data on the respiratory disturbance index (RDI, an index measuring respiratory events that disturb sleep), time spent in each body position during sleep, the number of apneic events in each position, oxygen saturation, and time spent in each stage of sleep.

The authors found there was an increase in the RDI with increased time spent in supine sleep. “The mean RDI increased from 5.6 to 8.5 when more than 50 percent of the time was spent in supine sleep,” they write. “There was a further increase to 10.5 when supine sleep increased to 75 percent of the total sleep time.” The most significant finding was that the RDI in the supine position was greater than in all other positions combined.

“The results of our study indicate that supine sleep does correlate with an increase in RDI as well as with OSAS in pediatric patients younger than three years,” the authors write. “This finding is in contrast to previous studies that have demonstrated no correlation between sleep position and OSAS in children.”

The authors urge clinicians who use PSG to diagnose and manage sleep disorders in children to take into consideration the variables that may affect the validity of the results. “Lack of adequate supine sleep may be an important factor in symptomatic children with normal sleep study results.” (Arch Otolaryngol Head Neck Surg. 2005;131:1014-1016)

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Physicians seek to improve the quality of sleep in ICU

Restorative Sleep

The sleep patterns of patients in the intensive care unit are so superficial that they barely spend any time in the restorative stages of sleep that aid in healing, UT Southwestern Medical Center physicians have found.

“Current clinical-care protocols routinely and severely deprive critically ill patients of sleep at a time when the need for adequate rest is perhaps most essential,” said Dr. Randall Friese, assistant professor of burn/trauma/critical care at UT Southwestern and lead author of a study appearing in today’s issue of The Journal of Trauma: Injury, Infection and Critical Care.

“We haven’t recognized the importance of prescribing sleep,” said Dr. Friese, whose study is one of the first to examine the sleep patterns of surgical and trauma patients. “Patients in the ICU may look like they are sleeping, but they’re not sleeping well. They are not getting the restorative stages that are required.”

Sleep typically occurs at night in successive cyclical stages. Sleep begins in very superficial stages. These stages are followed by deeper, more restorative states, including rapid eye movement (REM) sleep. Although researchers continue to investigate exactly what happens in the brain during REM sleep, they do know that it is critical for restorative sleep.

Dr. Friese monitored the sleep patterns of 16 patients in the ICU at Parkland Memorial Hospital who had suffered traumatic injuries or had undergone intra-abdominal surgical procedures. The patients had been in the ICU two to 10 days. Patients suffering brain injuries were excluded from the study because such injuries typically illicit abnormal sleep patterns.

After monitoring the patients’ brain waves in a specially equipped bed for up to 24 hours, Dr. Friese found that patients in the ICU received an acceptable amount of sleep time, but that the sleep patterns were fragmented and significantly abnormal. Patients in the ICU spent 96 percent of their sleep cycle in superficial stages, compared to normal sleep, in which up to 50 percent is spent in the restorative stages.

The next step, Dr. Friese said, is to design a clinical trial that makes the ICU environment more conducive to sleep and then monitor the patients’ outcomes. Some proposed steps to decrease disturbances in the ICU include adjusting monitoring machines so that alarms don’t wake up sleeping patients, providing patients ear plugs and eye shields, dimming the lights, and using pharmacological sleeping aids.

“There are two major things contributing to abnormal sleep in these patients – the pathophysiology of the disease process itself and the stressful environment of the ICU,” Dr. Friese said. “If we can neutralize the stressful environment, maybe we can shorten the hospital stay, lower infection risks and increase patient wound healing.”

Dr. Ramon Diaz-Arrastia, professor of neurology and one of the study’s authors, said the investigation demonstrated “that surgical patients in the ICU have essentially no restorative sleep.

“Restorative sleep is most abundant during the later part of sleep – it is sometime between 3 a.m. to 6 a.m. that the bulk of this stage of sleep occurs. It is likely that with some straightforward measures, such as changing the schedule of nursing intervention, we may help these patients attain the restorative sleep that could improve their outcomes.”

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Anesthesia More Similar to Coma than Sleep

When explaining the process for general anesthesia, physicians often correlate the process with deep sleep. However, a review written this week for the New England Journal of Medicine finds that the brain is in a state more similar to a reversible coma than sleep. While this may sound scary, the findings could lead to positive results such as new approaches to general anesthesia, improved diagnosis and treatment for sleep abnormalities, and helping patients emerge from a coma.

General Anesthesia is Essentially a Reversible Coma

Study authors Dr. Nicholas D. Schiff, Dr. Emery Brown, and Dr. Ralph Lydic reviewed previous studies plus work of their own over the course of three years and conclude that activity in the fully anesthetized brain is closer to the deeply unconscious, low-activity state seen in coma patients than that of a person who is asleep. There is only a slight overlap between the deepest states of sleep and the very lightest phases of anesthesia.

Also, while sleeping involves moving through a series of phases, patients under general anesthesia are taken to a specific phase or state and kept there during surgery, more closely resembling coma.

Read: Nurse Anesthetists Salary Outpacing Primary Care Doctors

While the brain activity pattern is more similar to a coma, because it is drug-induced, it is reversible. Also, the states differ on time scales. Recovery from general anesthesia takes minutes to hours while recovery from coma takes hours to months – or even years.

The understanding of how these two states are more common than different “is very exciting, because it gives us new ways to understand each of these states,” Says Dr. Schiff, who is a professor of neurology and neuroscience at Weill Cornell Medical College and a neurologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr. Schiff also specializes in recovery from coma.

He hopes the findings can make general anesthesia even safer, especially for the elderly who can experience effects such as slower recovery time and impaired cognitive function afterwards.

Read: Sleep Deprived Doctors Should Tell Patients Before Surgery

Dr. Emery Brown, of Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard Medical School, hope that the findings will also give new insights into how the brain works in order to develop new sleep aids. The drug zolpidem (Ambien) for example is used to treat insomnia by slowing brain activity in order to allow sleep. But it has also been shown to be useful in restoring communication and behavioral responsiveness in some severely brain injured patients.

“Consciousness is a very dynamic process,” says Dr. Schiff, “and now we have a good way of studying it.”

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Breastfeeding Doesn’t Negatively Impact New Mom’s Sleep

Breastfed babies may wake up more often during the night than bottle-fed babies, but overall this does not negatively impact a new mother’s sleep. A small study from West Virginia University has found that women who breastfeed appear to sleep just as long and just as well as women who choose bottles.
No Differences in Sleep Quantity, Fatigue, or Daytime Sleepiness

Currently, about 70% of women in the United States breastfeed their babies initially, but just 33% of them continue for a full 6 months, according to the Centers for Disease Control and Prevention. A prevailing myth that may keep new mothers from breastfeeding is the suspicion that they would get even less sleep than usual if they breast-fed instead of opting for formula.

Read: 2010 CDC Breastfeeding Report Shows Improvements

Dr. Hawley Montgomery-Downs and colleagues asked 80 new mothers to record how often they woke up and how rested the felt during their first 12 weeks post-partum. 27 of the women breast-fed exclusively, 18 formula-fed and 35 used a combination of bottle and breast. For objectivity, the researchers had the women wear sensors that measured how long and efficiently the slept.

Overall, the women slept about the same amount of time whether they were breast-feeding or bottle-feeding. In addition, there were no differences in fatigue and daytime sleepiness.

The babies who were breast-fed did wake up more often, because breast milk is more quickly digested than formula, but those nighttime feedings had less of an impact on sleep because women who bottle-fed have more tasks to accomplish for the feeding (ie: preparing the formula, warming the bottle). Also, women who breastfeed have higher levels of prolactin, a hormone that facilitates sleep.

Read: Not Breastfeeding Raises Type 2 Diabetes Risk

Dr. Montgomery-Downs hopes that the findings will encourage new mothers to choose to breastfeed their infants because of the number of health benefits for both mom and baby. She suggests to women to try techniques that will achieve a more consolidated sleep, such as expressing breast milk so that someone else can take a feeding or two during the night.

“Women sometimes use the rationale of wanting and needing more sleep as a reason not to breast-feed, but breast-feeding is so important for both the mom and the baby’s health. The first couple of months are going to be tough, regardless of which feeding method you choose. Better sleep really is not a reason not to breastfeed,” she concluded.

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