There is a myriad of sleep disorders, of which the most recognisable are insomnia and snoring. Almost everyone has experienced it sometimes, but the actual incidence of problematic insomnia is not known. There is little data on snoring as well, but a local study in 1999 found that 24% of local adults snore and 15% have obstructive sleep apnoea. Sleep apnoea is a condition where there is not only snoring, but also blockage of the air passage during sleep, leading to repeated drops in oxygen level and poor sleep quality.
Insomnia
Most causes of insomnia are related to mental and psychological well-being, like anxiety, stress and depression. Sometimes, the causes are physical, like pain from other medical conditions, diseases like an overactive thyroid gland or medications like decongestants that excite the body. Poor sleeping habits like irregular sleep times or stimulating activities before sleep, eg. playing computer games, may also contribute to insomnia.
To improve insomnia, the most important step is to identify the cause, so your doctor will take a detailed history of your pattern of daily activities and sleep. It is a good idea to keep a daily activity and sleep pattern diary over a few weeks, so that this information is available during your consultation. Tests are rarely necessary, but if there is a suspicion of a medical problem like thyroid disease, a blood test may be ordered.
Other problems that keep you awake or wake you up at night like chronic pain, frequent urination, blocked nose etc may require medical opinion from other specialists. A sleep study, either in the hospital or at home may be necessary if other sleep disorders are suspected.
Tackling insomnia
The most important step in treating insomnia is to adopt good sleep habits. These are:
- Maintaining a regular sleep pattern.
- Avoiding stimulating activities just before sleeping.
- Not using the bed for other activities like reading or watching TV, etc.
- Avoiding stimulants like caffeine or decongestant medications.
- Sufficient physical activity, preferably early in the day.
- Not lying in bed for a long time if unable to fall asleep.
Other behavioural methods like relaxation techniques and minimising stressors are usually helpful as well.
Medications for insomnia include sleeping pills and other medications that induce sleepiness, like anti-histamines. These may be helpful in the beginning, to break the cycle of insomnia and allow a good sleep pattern to be established, but they should not be used long term as there is a potential for addiction.
Snoring and obstructive sleep apnoea (OSA)
Snoring is more than a social problem that affects your sleeping partners. It may be a sign of a more serious problem called obstructive sleep apnoea (OSA). This is when the airway blocks up during sleep, leading to repeated drops in oxygen and poor sleep quality.
Research has found a strong link between OSA and cardiovascular diseases like high blood pressure, heart disease and stroke. In fact, for patients with severe OSA, their risk of heart attack and stroke may be higher than 3 times the normal risk.
A study in Singapore found that above 65% of patients suffering from heart attack had undiagnosed moderate to severe OSA. In children, OSA may lead to poorer school performance and difficulty concentrating and learning. It also increases the risk of developing cardiovascular disease and diabetes in future.
Warning signs of OSA
You should seek an opinion from an ear-nose-throat (ENT) surgeon or sleep physician if you have the following symptoms on top of snoring:
- Your sleeping partner notices that you stop breathing sometimes during sleep.
- Excessive sleepiness in the day.
- Waking up at night with shortness of breath or a choking feeling.
- Morning headaches.
- Irritability, difficulty concentrating and poor memory.
- Frequent urination at night or bedwetting in children.
Your doctor will order a sleep study to determine if OSA is present. This may be performed in the hospital or even at your own home. You will also require a simple outpatient endoscopy (a procedure in which your doctor uses a long, thin tube to observe an internal organ of your body) to look at the points of obstruction. This may occur either in the nose, at the soft palate of the tongue, or at the back of the tongue.
In the nose, blockage may be caused by soft tissue swelling or a bent nasal septum, the divider in the middle. The soft palate and tonsils may cause obstruction at the second level. At the lowest level, the back of the tongue may fall backwards causing obstruction as well.
The sleep study will assess the severity of your OSA. Based on that and the findings on outpatient endoscopy, treatment can be recommended. In children, the first line of treatment for OSA is removal of the tonsils and adenoids and sometimes a reduction of the soft tissue of the nasal.
Treating OSA
Treatment for adults is more complicated. For mild OSA, simple procedures to open up the airway, like radiofrequency to reduce soft tissue in the nose and stiffen up the soft palate or oral appliances to bring forward the jaw or retain the tongue may be sufficient.
For moderate to severe OSA, use of a continuous positive airway pressure (CPAP) device gives the best results. It consists of a pump that pressurises air via a mask strapped to your face when sleeping. The problem with CPAP is that most patients are not willing to use it. In that case, surgery is the next best option. It should be tailored to the points of obstruction.
Article contributed by Dr Tay Hin Ngan, ENT specialist at Mount Elizabeth Hospital
References
Jean-Louis, G., Zizi, F., Clark, L. T., Brown, C. D., and McFarlane, S. I. (2008). Obstructive sleep apnea and cardiovascular disease: role of the metabolic syndrome and its components. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 4(3), 261–272. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18595441
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Puvanendran, K, Goh, K L. (1999) From snoring to sleep apnea in a Singapore population. Sleep Research Online, 2(1), 11-4. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11382877