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Sleep

Our guest expert in September 2010, was Dr. Anu Tandon, respirologist and sleep medicine specialist at Women’s College Hospital in Toronto.

Dr. Anu Tandon completed medical school at the University of Toronto, and followed that with training in internal medicine and adult respirology. As a respirologist, Dr. Tandon became interested in sleep disordered breathing, which led her to pursue further fellowship training in sleep medicine. She is presently practices both general respirology and sleep medicine at Women's College Hospital.

Here are her answers on Sleep.

Q: Our society depends on shift workers to ‘keep the wheels rolling.’ Does research point to specific shift rotations that are better for securing sufficient sleep – i.e. days, then onto evenings, then onto nights, and back to days?

A: Given we all have a circadian rhythm, ideally the best ‘shift work’ is days to evenings. That being said, a consistent sleep schedule is best for the body. Studies have shown that restricted sleep (less than six hours sleep per 24 hours) can lead to increased health concerns such as diabetes. While we cannot eliminate shift work as this is an integral part of the work force, the hope would be we could target more sleep time in the time we are off.

 


Q: Do red night lights disturb melatonin production less than other types of light when you get up to ‘use the loo’ during the night ?

A: In general, melatonin is a hormone naturally produced in the brain to help regulate your circadian rhythm. It is normally secreted in darkness. When looking at the various lights, it is mainly blue light that causes suppression, however all colours do suppress melatonin to a certain degree. The degree of suppression also depends on the length of exposure, which is likely minimal when waking up to use the ‘loo.’

 


Q: I am a new mother and am sleep deprived. I used to get about seven or eight hours a night but now I’m lucky if I get four. I’m worried about the long-term effects of sleep deprivation. Is it true that if I get a total of eight hours over the duration of the day then that is healthy, or does it have to be consecutive?

A: First of all, congratulations. As a mother, I have experienced sleep deprivation first hand and had a similar question lying in bed awake at 4 a.m. Many of the studies looking at long-term effects of sleep deprivation as it pertains to your general health followed their subjects for years. Those studies showed increased risk of diabetes and possibly heart disease. The short-term effects of sleep deprivation you have likely already experienced, including lack of concentration, difficulty with short-term memory, and fatigue. While consolidated sleep is always best to preserve sleep architecture, given the circumstances you need to do the best you can and I think targeting a total of eight hours is ideal.

 


Q: How can I ensure a restful sleep? Some nights I toss and turn and wake up a lot through the night. In the morning I feel exhausted. Any strategies to ensure a good long sleep?

A: A restless night can be quite anxiety provoking while also leaving you somewhat dysfunctional during the day. Often when patients present to me with similar situations I have them outline their schedule and we work on what is termed ‘sleep hygiene.’ This comprises improving scheduling, environment and certain practices related to your sleep to improve its quality. The first piece of advice I give is to have a consistent routine with not only a set wake time but a set bedtime as well. Next is the environment that you sleep in. In this day and age, technology is slowly creeping into the bedroom with television, smart phones and laptops, all of which can lead to further distractions and poor sleep. Caffeine can also be a culprit given it does stay in your system for approximately 12 hours. That coffee you have at 3 p.m. may be what’s waking you up at 3 a.m. Often people do wake up at night and I usually counsel patients that if they cannot get back to sleep after 20 minutes they should actually get out of bed and bedroom and engage in a relaxation exercise that could include deep breathing or listening to classical music. Turning on the TV or reading a good book are not good solutions given they distract you from the task at hand, which is sleep. If these practices have been implemented and you continue to have disruptive sleep and daytime fatigue, it is important that you seek further consultation given these may be symptoms of another sleep disorder such as obstructive sleep apnea.

 


Q: For decades I've been sleep deprived. Started with my first child about 25 years ago. I am an ‘owl,’ going to sleep at 3 or 4 a.m., but getting up at 7 a.m. I function well (I think!) and now and then grab a nap during the day if I can. Once in a while (now that my youngest is 12 years old) I sleep in on a weekend, and I can sleep for 12-14 hours or more if I let myself. I would like to get seven or eight hours per night starting before midnight, but just can't sleep before the wee hours. Have tried all the usual recommendations for improving sleep, but nothing works – the habit is seriously ingrained. I find I ‘drift’ toward a 25- or 26-hour day, rather than 24! Once awake I'm good for 20 hours – but that leaves me only four for sleep and it's not enough. I am always tired during the day, and while my responsibilities get taken care of, I'm left suffering. Any ideas? Would any type of formal ‘sleep therapy’ help me?

A: Thank you for the question. Often people accept sleep deprivation for years, however inevitably it catches up. It is true that after years of working on a sleep cycle such as yours, your pattern does get ‘ingrained.’ Given it has taken years to develop this pattern, it will most definitely take a while to undo the pattern set forth. There have been studies showing that cognitive behavioural therapy can be quite beneficial, and almost equally beneficial when compared to sedatives, to help improve sleep cycles. It is also important to ensure that you don’t have any other underlying sleep disorder that may be contributing to the fatigue and the lack of sleep. It sounds to me that you would definitely benefit from cognitive behavioural therapy, and this can be arranged either through your family physician or through a referral to a sleep clinic for a more formal evaluation.

 


Q: I am a 58-year-old woman. I have been to our sleep clinic for chronic insomnia. Both times the doctor said the insomnia is related to anxiety and depression. That was it – no solutions offered. I know to avoid caffeine and exercise, have a dark quiet cool room, etc. I go to bed around 10 or 11 p.m. and don't fall asleep till 3 or 4 a.m. I get up every half hour do something in dim light (flip through a magazine, play solitaire) and go back to bed when I feel sleepy. This goes on until 3 or 4 a.m. I get up at about 9 a.m. exhausted and totally unrefreshed. I take zopiclone 5 mg and 7.5 mg and three valerian pills and herbal teas to promote sleep. I have tried meditation. Sometimes at about 2 a.m. my body, arms, neck and shoulders get all jumpy like bugs are in me or on me. I am so tired of all of this – there must be something to allow me to sleep like a baby.

A: Chronic insomnia is often related to poor sleep hygiene or possible underlying conditions such as anxiety or depression, and can prove quite debilitating. The first step, however should always be to rule out any other sleep disorder with a careful history and possibly an overnight sleep study. If the insomnia is thought to be due to depression, often therapy through a psychologist or the use of an antidepressant is needed to help the insomnia. Often sleep aids such as zoplicone or herbal remedies are ‘band-aids’ but rarely treat the heart of the matter. If other sleep disorders have already been ruled out then it may be best to address the possible anxiety and depression through your family physician or a psychologist to see if addressing these conditions may improve your sleep.

 


Q: My husband was a shift worker for over 20 years and now is retired. His sleeping pattern has not improved after a year and a half. What is a safe medication to promote a good night’s sleep?

A: Many shift workers face similar dilemmas when they retire. The first step would be to try and follow a set schedule of sleep times and wake times with no naps during the day. This can prove difficult at first but is at the heart of trying to improve your sleep patterns. The next step would be to ensure no other underlying sleep disorder is present, i.e. sleep apnea or restless legs syndrome, that could be preventing a consolidated sleep. With respect to medication recommendations, it would be best to follow up with your family physician who knows your husband’s medical history best.

 


Q: I have severe rheumatoid arthritis. I am in constant pain 24/7. My doctor has not been able to find anything that can control my RA. If I move while I am asleep, the pain and stiffness wakes me up. I have tried sleeping with a heating pad but that doesn't help. Is there anything that I can do to help to keep me asleep?

A: Chronic pain can be quite debilitating and unfortunately can lead to poor sleep. It is a vicious circle of events given studies have repeatedly shown that poor sleep can lead to worsening pain during the day. Unfortunately the treatment for this is remedy of the underlying pain and stiffness. This can often require a consultation with a rheumatologist or possibly a pain clinic, both of whom could address your pain and hopefully improve your quality of life as a whole.

 


Q: I am completely sleep deprived. I have arthritis, ankylosing spondylitis, fibromyalgia and endometriosis. I have not slept in years. I sometimes sleep one or two hours a night, and also sometimes get no sleep – just wander from the bed to the couch and pace the floor, from discomfort, pain, insomnia. For example the last two nights I’ve had no sleep, just pain. I have tried all the usual: exercise (even makes things worse), relaxation, yoga. I do not consume caffeine or drink alcohol. Years ago, I was given sleeping pills for a few days, and that did nothing. I don't know what else to do. I feel exhausted every minute.

A: Very similar to the previous question, treatment is really targeting the underlying condition. A consultation with either a rheumatologist or a pain clinic may be beneficial to help address the pain issue. If, however, you are finding that you wake up at night independent of pain symptoms, what you are describing may be secondary to a sleep disorder that is best evaluated by a sleep clinic and a possible overnight sleep study.

 


Q: I am currently taking Remeron RD to help me sleep at night (and for depression). Will I always have to take it in order to assure a full night’s sleep?

A: Chronic insomnia is often related to underlying depression or anxiety. Treatment therefore becomes based on targeting the underlying condition. As you mentioned, Remeron is an antidepressant as well as a sleep aid and often needs to be taken as long as depressive symptoms exist, one of which is chronic insomnia.

 

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