That Elusive Forty Winks

Losing sleep over sleep disorders? Dr Kanwar has just the cure for you.

If youre in the habit of nodding off at meetings, dont blame it entirely on the agenda. Chances are that youve spent a restless night and that you dont even know it. You will have no memory of these awakenings the next morning, of course. But these brief wakeful interludes could be early warning signals of diseases as diverse as impotence or diabetes or Parkinsons disease.

Now ringing the alarm on the realities of sleep-related disorders is the new sleep research centre at New Delhis Indraprastha Apollo Hospital. In March 1997, Dr Manjit Singh Kanwar set up a new facility at the Sleep Lung Heart disorder Institute. It was a full fledged state-of-the art Sleep Lab, billed as Asias most sophisticated centre for sleep medicine.

 

The morning blues could also be a symptom of Obstructive Sleep Apnoea (OSA), which is a little-known breathing disorder that occurs during sleep due to some obstruction in the throat. It can be fatal if untreated. Typically, a person with OSA is a heavy snorer, followed by long pauses of approximately 10 to 60 seconds one actually stops breathing during this period.

Sometimes the brain stops sending the signal to breathe. This can cause death. The prevalence of OSA is as high as four per cent among adult males in India as in the US. It is less common among females, according to Dr Kanwar.

While the developed nations have known about the symptoms of OSA, which was labelled the sleep disorder of the century, in the early 1970s, it was recognised as a dangerous syndrome in the Indian context only last year.

Sleep labs study sleep patterns and stages like deep sleep (the delta wave sleep) as well as other disorders like insomnia and behavioural disorders like sleep-walking. Usually a sleep-lab consists of a sound-proof room where a patient requires to sleep for one night.

The patient is wired up with sensors and electrodes which records the various sleep stages and the signals are processed by computers in the adjoining room. There are four computers in the Apollo Sleep Lab.

The sensors and electrodes are EEG (electroencephalography), EMG (electromyography, placed on the chin to record the tone of the muscles), air flow sensors, EOG (electro-oculography, used to record dreaming phases), ECG, chest and abdominal sensors and Oximetry Finger Probe to measure the oxygen saturation in blood, as well as chest and abdominal sensors. A microphone is attached to the Adams apple to record snoring. To view any leg movements, a CCTV camera is fixed in the sleep lab. No one is allowed to disturb the patient.

As the patient dozes off in the carpeted, sparse room (besides the cot, almost the only other piece of furniture is a television), activity increases in the adjoining room. It is equipped with four terminals where the night assistant pores over the multiple tracings. A night study constitutes about 25-30 megabytes of recording which translates into 1,000 pages of data. About five to six packages are available for sleep study. Charges are between Rs 3,000 to Rs 9,300 (with Cpap monitoring) for a night, inclusive of room charge, dinner and breakfast next morning.

The tracings are usually monitored by the method of the split night protocol established by the US-based Mayo Clinic, which is Kanwars Alma Mater.

The first half of the night is used for diagnosis; later on, the person is hooked up to a Cpap (continuous positive airways pressure) where oxygen is delivered from a fan pump via a nasal mask. It blows open the pharynx to allow unobstructed breathing and abolishes blood pressure swings. By midnight we know the problem, says Kanwar.

While snoring is not good for health, it is not as if every snorer is is a OSA case, Kanwar points out. But heavy snoring is not simply associated with daytime lethargy and disturbed sleep but could result in blunted memory. It could also, warns Kanwar, spark off car accidents resulting from poor evasive response of the patient. The other symptoms are acidity, heartburn and nausea.

In milder cases of OSA, simple behavioural changes like diet, exercises and changes in body posture can be sufficiently effective. There is an odd remedy for mild OSA symptoms when the trigger is sleeping in the supine position. Sufferers can simply wear a tennis ball vest, which is a jacket with a tennis ball inside the back pocket!

The narrowing of the upper airway, the main cause of OSA, can often be traced to excess weight and consumption of alcohol before sleep. In its severe cases however, merely controlling eating and drinking habits does not help the OSA patient.

The key question often asked is whether we wait for the person to register ideal body weight before starting therapy. Losing weight helps melt away excess fat tissue lining in the upper airways behind and below our tongue opening the air passage just enough to prevent its closure during sleep leading to choking and arousals of the brain. But the answer is no, we dont wait for body-weight to drop before starting treatment, says Kanwar.

Among sleep disorders, insomnia is the most common, followed by sleep apnoea, sleep walking and narcolepsy, a term used when a person can fall asleep at work, while talking and driving the car. Narcolepsy is a chronic disorder affecting the brain where regulation of sleep and wakefulness take place. Its onset can occur at any age and it is sometimes inherited. It affects about 0.03 per cent of people.

OSA requires surgery sometimes, which involves removal of enlarged tonsils. It can also mean an operation that youll have more difficulty pronouncing than undergoing: uvulopalatopharyngoplasty. In more user-friendly terms, that means removal and reshaping of the soft palate and pharynx. But Kanwar says that surgery is effective only in about 50 per cent of the cases.

The bulk of OSA spells occur during the dreaming phase. The REM (rapid eye movement) phase of sleep which brings our dreams also leads to the lowest tone of our muscles, including the throat muscles, which normally keeps the upper air passage open. Alcohol and sedatives tend to narrow the upper airway. Decrease in muscle tone leads to increased choking during dreaming phase, says Kanwar, who is also a senior consultant in respiratory medicine and critical care.

Kanwars clients have been mostly NRIs, though he has also tried to keep a former steel minister and last month, a foreign dignitary from Bangladesh from losing sleep. While there have been lots of studies in the West, the Indian public is only just getting to know of its dangers. In the US there are thousands of sleep labs. In India, it is yet to find a place in the medical curriculum. And doctors and surgeons are in general, vague about the subject.

Kanwar is now set to open more sleep labs in the country. Two months ago, he organised a conference to kickstart a certification programme on sleep medicine. The idea was to acquaint specialists in sleep medicine. It offered lessons on electrode placement, interfacing with computers and interpreting graphic data for starters.

American Dr Nathaniel Kleitman laid down the law about sleep and wakefulness in the 1950s. Ideally one must try to sleep at a regular time, given 45 minutes to one hour here and there. The quality of sleep affects our performance as well as lack of sleep, according to him.

In the 20th century, sleep disorders are on the rise. Electricity allowed us to change our lifestyles, but nobody told our biological clocks. People live more unhealthy and stressed out lifestyles and often have sleep deprivation over long periods. Often they dont know they are chronic sufferers. It maybe worth spending a night finding out.