Restless nights

Sleep disorders can have an enormous impact on health. But doctors can offer relief to the weary.

sleep disorder 88 (photo credit: Courtesy)
sleep disorder 88
(photo credit: Courtesy)
'I have to drive from Kfar Saba to Haifa every day and I started to fear falling asleep at the wheel," says Moshe Shalev, who sought treatment six months ago after he began to fall asleep at work. "Sleeping in a lab with 10 electrodes glued to my skin was not a very nice experience, but my quality of life has immeasurably improved." Now, after six months of treatment at the sleep clinic at the Chaim Sheba Medical Center, Shalev is resting easier with the help of a Continuous Positive Air Pressure mask (C-PAP), a small device that fits over the nose and pushes air into the nasal passageway. Shalev says he never spends a night without it, even away from home. One of the first things the sleep clinic asks potential patients to do is rate their likelihood of falling asleep in a meeting, in front of the television, in the car, in the afternoon or in a one-on-one conversation. If they have already arrived at the clinic, their family physician has probably determined that they may be suffering from a sleeping disorder, but the severity of their problem gives the first clues necessary for proper diagnosis. To treat cases of suspected sleep apnea - a common breathing-related problem that is one of the most dangerous and prevalent sleeping disorders - researchers need to examine data from the patient that can only be obtained from the source of the trouble: their sleep. Dr. Yaron Dagan, a certified physician and psychologist who heads the sleep clinic at Chaim Sheba and tests over 400 patients a month, explains that four "families" of sleeping disorders exist. The first category includes insomnia, where problems falling asleep and waking earlier than desired are common complaints. "Para-Somnia" problems consist of sleepwalking, teeth grinding and bed-wetting, while "Sleep-Wake Schedule" disorders affect natural biological rhythms, often making it difficult to fall asleep at night and wake up in the morning. In all of these cases, patients are usually aware of the disorder and seek treatment. The last group, called "Hyper-Somnia," involves disorders that are easy to detect once patients have sought testing, but remain highly undiagnosed due to the simple fact that people are generally not aware of their own sleeping patterns. The symptoms of excessive daytime fatigue and lower attention spans are not usually correlated to nighttime sleep, and this makes it difficult for physicians to pinpoint the source of the trouble. It is often a spouse or friend, habitual snoring or a dry mouth that alerts people to their potential problem. But despite the overwhelming growth in the field of sleep medicine and heightened awareness in the population, less than 10 percent of the patients with clinically significant sleep apnea are actually diagnosed, according to a recent study conducted by Dr. Ariel Tarasiuk of the Sleep-Wake Disorders Center at Soroa Medical Center and Dr. Chaim Reuveni of the Faculty of Health Sciences at Ben Gurion University. Part of the problem in Israel relates to policy-making, and not all medical insurance pays for the average NIS 1,200 required to participate in a sleep study for the night, or the cost of buying a C-PAP, which ranges from a few thousand shekels all the way up to NIS 17,500 for the most expensive models. According to Tarasiuk, politicians are not well-informed enough about the dangers of sleeping disorders and the high costs of sleep studies, which translates into the fact that some health care plans do not cover treatments. Thus, people in low socio-economic brackets often suffer the most from these disorders and remain undiagnosed. "We need to bring about changes in the way HMOs regard sleeping disorders, and in order to lower costs, we need to increase the awareness of family-care physicians," says Dr. Tarasiuk. Sleep apnea, which affects between 2-4% of the working-age population, causes as many as 400 "awakenings" from sleep in one night. This fragmentation of nightly rest has serious side effects, both physical and mental. For many patients suffering from sleep apnea, proper diagnosis and treatment can prevent cardiovascular disease, hypertension, ischemic heart disease, cardiac arrhythmia and congestive heart failure. According to Dr. Arie Oksenberg, the director of the sleep disorder unit at Loewenstein Hospital in Ra'anana, treatment can sometimes be as simple as the "tennis ball technique," in which patients are required to sleep with a tennis ball attached to the back of a belt. "Some people can solve the problem by sleeping on their side instead of their back, and this is an easy change to implement," he explains. Since 1987, Dr. Oksenberg has been seeing patients with sleeping disorders of all kinds, but the majority of cases he treats, like in other clinics across Israel and the world, are due to sleep apnea. "The results of proper treatment are overwhelmingly positive," he says. "My patients often tell me that their lives have changed completely. They can go to the movies again without falling asleep, they can read books and they can drive without being afraid of having an accident because they nod off at the wheel. And proper treatment represents a significant change in their cognitive abilities and physical health, too," he adds. D., a 58 year-old Israeli driving instructor, waited months before seeking treatment, and only went to see Dr. Oksenberg after his wife insisted that he take care of his sleeping problems. "I got to an absurd situation before getting help," he says. "I was falling asleep everywhere I sat, even behind the wheel of a car, and I was afraid to do anything for fear of falling asleep." And although the treatment is not always covered by medical insurance and the fact that participating in a sleep study can be scary, D., who now sleeps with a C-PAP, says that he would pay 1,000 times more than he did for the improvements in his life. "The change was immediate, and it is more than amazing, it's the mother of amazing," he says with enthusiasm. He went from a walking zombie to a functioning individual again. He feels better physically and has much better relations with his family, especially his wife, who can also sleep again now that the snoring has ceased. "I'm going to Cuba on vacation next week and I'm going to share a hotel room with my wife without worrying about us both being awake all night," he laughs. "I am a new man, and I cannot say enough about Dr. Oksenberg and his assistants for their empathy and help throughout the process." But not only adults suffer from sleep apnea. In children, the problems can be even more serious. Dr. Giora Pillar, a pediatrician and physician at the Lloyd Rigler Sleep Apnea Research Laboratory at the Technion-Israel Institute of Technology in Haifa, explains that recent increases in parental awareness of child sleep apnea and knowledge of the severity of untreated cases has brought a flood of new patients to his doorstep in recent years. While rises in adult sleep apnea may be linked to higher obesity levels, in children it is often related to obstructions in the breathing pathways. "In 90% of the cases, surgery can solve the breathing problem for children," says Dr. Pillar. "Other solutions involve good sleep hygiene or habits and regulations and psychological support." In children who suffer from sleep apnea, the side effects are also severe. They may experience growth delays, low scholastic achievements in school, suffer from attention deficit disorder (ADD) and even higher levels of aggression. Dr. Pillar urges parents to seek treatment if they see symptoms of sleepiness during the day, if the child snores or has loud breathing, if they have restless sleep or if they move a lot during the night. "The consequences of sleep apnea in children are severe and they include both medical and developmental problems, but it is an easy problem to solve once diagnosed," says Dr. Pillar. The overwhelming increase in sleeping disorders over the last two decades in Israel spawns common misconceptions that it is due to the terrorism in this region. People often assume that the problems here are worse because of the constant threats and high stress levels, but Dr. Dagan points out that while these issues may be manifested in other areas, it is not the case for sleeping disorders. "One very important thing to emphasize concerning sleep disorders in Israel is that, generally speaking, there is no greater instance of problems here than in other Western countries," says Dr. Dagan regarding the 10-fold increase in Polysomnography tests conducted within Israel over the last decade. In other words, the dramatic escalation here mirrors the rest of the world, and Dr. Dagan speculates that this is due to public awareness and the higher recognition of symptoms by family physicians. Dr. Dagan adds that many problems with sleep are actually manifestations of other disorders, and can only be solved by finding the true source. For example, insomnia may be an indication of a problem with waking up due to depression, stress or anxiety rather than an actual difficulty sleeping, in which case Dr. Dagan recommends psychological treatment rather than sleeping pills. "The best approach to these problems is often to find the underlying reason first," he explains. "Sometimes it can be treated with medication that elevates serotonin levels or, as is the case with some menopausal women, it can be solved with hormone treatment. In other cases, alternative medicine like relaxation therapy helps." In cases of sleep disorders due to trauma, the treatment and diagnosis is much harder to pinpoint. Dr. Dagan, whose PhD dissertation studied Post Traumatic Stress Disorder (PTSD) and its effect on the sleep of prisoners who were held captive in the Yom Kippur War, says many of the patients who suffered from sleep disorders did not report having difficulties with their sleep, but showed excessive problems in the studies conducted. The opposite was true of soldiers in the Lebanon War, who reported very bad sleep but did not objectively show any worse sleep than a normal subject. David Aboudaram, one of Dr. Dagan's patients who was held captive in Egypt for two months after the Yom Kippur War, says he tried everything from medication to a C-PAP, but has never been able to sleep for more than two hours a night. "I never knew it was a problem," he explains. "After being in captivity, where the Egyptian soldiers awakened us at night for interrogations, my body learned not to sleep." Aboudaram thought his sleep, albeit not much, was fine. But when he participated in the sleep study, they found that he was waking about 61 times per hour and never entering a deep sleep. "My daily functioning is not affected," he says, "I'm continuing as I did before I knew it was a problem. It's about a positive attitude for me, and all of my friends who experienced the same things I did have learned to live with it. Not sleeping much is just another part of life," he adds.