Sleep Medicine
Sleep is a vital, often neglected component of your health and well-being. Good sleep is important in enabling the body to repair itself and be ready for another day. Adequate rest may prevent excess weight gain and heart disease. It will also improve how you feel during the day.
AMARA sleep is the one of the first comprehensive sleep disorders center in India. It provides advanced diagnosis and treatment of sleep disorders in both adults and children. Let us be your partner in getting a good night of sleep.
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Dr. Ramadevi Gourineni
consultant sleep medicine specialist
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CONDITIONS
Most people have difficulty sleeping at some point in their life. If you have frequent difficulty sleeping, you may have chronic insomnia. Insomnia is associated with both night-time and day-time symptoms.
Night-time: difficulty falling asleep, waking up at night with difficulty returning to sleep, or disturbed and light sleep.
Day-time: feeling tired, sleepy, irritable
Snoring is a harsh sound that occurs when air flows through a narrow airway, causing muscles and soft tissue to vibrate. It becomes problematic when it disturbs your partner’s sleep. It can also be a source of embarrassment, especially during travel on train, or when sharing a room during travel. 87% of people who snore regularly may have Obstructive Sleep Apnea (OSA)
Restless legs syndrome (Willis Ekbom Disease)
I started dreading every day because I knew that by evening I would have this burning sensation in my legs that just wouldn’t quit. I couldn’t sleep”: Patient with Restless Legs
Do I have RLS?
Do strange and unpleasant sensations in your legs keep you up at night? Are you bothered by an irresistible urge to move your legs when you lie down or relax? Do you feel better when you get up and move around? If so, you may have restless legs syndrome (RLS), which is a nervous system disorder.
Not all people with RLS have the same symptoms. Common descriptions include:
- “creepy-crawly” feeling, tingling, itching, pricking, burning, pulling, tugging and aching.
- bugs are crawling up my legs
- fizzy soda is bubbling through my veins
- deep bone itch
- “painful”, uncomfortable, disturbing
Symptoms are occasionally seen in the arms, chest and other areas of the body. RLS can lead to sleep difficulty, daytime tiredness, and overall poor quality of life. People with RLS may have difficulty sitting for long periods of time, and with long travel on the bus and plane.
RLS is seen more in older adults and women, but is present in all age groups including children. Mild symptoms may start in early adulthood and become more severe with age.
Although 1 out of 10 people suffer from RLS, the diagnosis is often missed and people with this condition may not receive proper treatment. Part of the problem is that symptoms are hard to explain and sufferers are often dismissed as being “nervous.” Even doctors may not take it seriously, if they fail to recognize the symptoms.
Experts believe that low levels of iron in the brain may be responsible for RLS. An imbalance of dopamine is also believed to contribute. About 60% of people with restless legs have a family member with the condition, indicating a strong genetic component.
Vitamin deficiencies such as vitamin D and folate have been implicated.
Medications such as antidepressants, antipsychotic medications, anti-nausea medications can precipitate RLS symptoms. People with back pain, varicose veins, diabetes, kidney disease and peripheral neuropathy and neurodegenerative disorders like Parkinson’s disease are more likely to have RLS. It is also commonly seen during pregnancy (approximately 40% of pregnant women experience it).
What treatments are available for RLS?
Whatever the cause of your restless legs syndrome, it’s important to know that help is available. If you have only mild symptoms, lifestyle modification may be enough. However, if your symptoms are bothersome and disruptive, you will most likely require a medication.
What lifestyle modifications will help reduce my RLS symptoms?
Manage stress
RLS symptoms get worse when you are under stress or anxious. Practice yoga and meditation. Develop relaxing habits to help you feel more calm.
Cut down on or stop drinking Alcohol
Alcohol is known to worsen RLS symptoms, so be cautious about drinking in the evening.
Stop Smoking
Nicotine is a stimulant that impairs blood flow to muscles and can make restless legs worse, so it’s best to avoid smoking.
Caffeine
For some people with RLS, caffeine is a trigger. However, in others, caffeine may improve symptoms. To understand your response, try cutting out coffee, tea, and soft drinks and monitor your symptoms.
Exercise and Stretch
Daily exercise including both aerobic and muscle stretching can significantly improve RLS symptoms. Try to exercise for at least 30 minutes on most days of the week. Be patient since symptoms will first become worse, before you start to notice an improvement. If vigorous exercise makes your symptoms worse, avoid it and stick with lower intensity exercise.
Simple stretching exercises can be very helpful in reducing your symptoms.
Restless legs syndrome (Willis Ekbom Disease)
I started dreading every day because I knew that by evening I would have this burning sensation in my legs that just wouldn’t quit. I couldn’t sleep”: Patient with Restless Legs
Do I have RLS?
Do strange and unpleasant sensations in your legs keep you up at night? Are you bothered by an irresistible urge to move your legs when you lie down or relax? Do you feel better when you get up and move around? If so, you may have restless legs syndrome (RLS), which is a nervous system disorder.
Not all people with RLS have the same symptoms. Common descriptions include:
- “creepy-crawly” feeling, tingling, itching, pricking, burning, pulling, tugging and aching.
- bugs are crawling up my legs
- fizzy soda is bubbling through my veins
- deep bone itch
- “painful”, uncomfortable, disturbing
Symptoms are occasionally seen in the arms, chest and other areas of the body. RLS can lead to sleep difficulty, daytime tiredness, and overall poor quality of life. People with RLS may have difficulty sitting for long periods of time, and with long travel on the bus and plane.
RLS is seen more in older adults and women, but is present in all age groups including children. Mild symptoms may start in early adulthood and become more severe with age.
Although 1 out of 10 people suffer from RLS, the diagnosis is often missed and people with this condition may not receive proper treatment. Part of the problem is that symptoms are hard to explain and sufferers are often dismissed as being “nervous.” Even doctors may not take it seriously, if they fail to recognize the symptoms.
Experts believe that low levels of iron in the brain may be responsible for RLS. An imbalance of dopamine is also believed to contribute. About 60% of people with restless legs have a family member with the condition, indicating a strong genetic component.
Vitamin deficiencies such as vitamin D and folate have been implicated.
Medications such as antidepressants, antipsychotic medications, anti-nausea medications can precipitate RLS symptoms. People with back pain, varicose veins, diabetes, kidney disease and peripheral neuropathy and neurodegenerative disorders like Parkinson’s disease are more likely to have RLS. It is also commonly seen during pregnancy (approximately 40% of pregnant women experience it).
What treatments are available for RLS?
Whatever the cause of your restless legs syndrome, it’s important to know that help is available. If you have only mild symptoms, lifestyle modification may be enough. However, if your symptoms are bothersome and disruptive, you will most likely require a medication.
What lifestyle modifications will help reduce my RLS symptoms?
Manage stress
RLS symptoms get worse when you are under stress or anxious. Practice yoga and meditation. Develop relaxing habits to help you feel more calm.
Cut down on or stop drinking Alcohol
Alcohol is known to worsen RLS symptoms, so be cautious about drinking in the evening.
Stop Smoking
Nicotine is a stimulant that impairs blood flow to muscles and can make restless legs worse, so it’s best to avoid smoking.
Caffeine
For some people with RLS, caffeine is a trigger. However, in others, caffeine may improve symptoms. To understand your response, try cutting out coffee, tea, and soft drinks and monitor your symptoms.
Exercise and Stretch
Daily exercise including both aerobic and muscle stretching can significantly improve RLS symptoms. Try to exercise for at least 30 minutes on most days of the week. Be patient since symptoms will first become worse, before you start to notice an improvement. If vigorous exercise makes your symptoms worse, avoid it and stick with lower intensity exercise.
Simple stretching exercises can be very helpful in reducing your symptoms.
My son walks, talks, eats and fights in his sleep
There are 3 states of consciousness: Wakefulness, NREM (nonrapid eye movement) and REM (rapid eye movement) sleep (link to learn about your sleep). Each state has its own features in respect to alertness, breathing, and muscle tone. There are clear boundaries between these states, and a person can never be in more than one state at a time.
What are CRSD (circadian rhythm sleep disorders)?
Circadian in Latin means “approximately” (circa) “a day” (diem). Circadian rhythm is the name given to your 24 – hour internal rhythm which controls your sleep – wake cycle. Your internal rhythm is actually 24 hours and 11 minutes, but light will set your internal clock to the external light – dark cycle (24 hours). (link to learn about your sleep, circadian rhythm)
CSRD are a group of disorders caused by a misalignment between the body’s internal sleep – wake cycle and the external light – dark cycle. This can happen due to an altered phase (internal) or work schedule/ travel (external).
Altered phase
Advanced sleep wake phase disorder (ASWPD)
I wake up very early (3-4am) and feel 'fresh' in the morning hours. I feel tired in the evening starting 5pm, and have difficulty with evening chores like cooking dinner and helping children with homework. I can fall asleep by 7pm. Even if I stay up late, I still wake up by 4am.
You probably have ASWPD, which is caused by an advance in your internal clock phase in relation to your desired sleep-wake times.
People with ASWPD are also known as larks or early birds. They fall asleep (6–9pm) and wake up (2-5am) very early. They describe feeling very tired in the evening, leading to difficulty with their evening chores and activities like parties, marriages, school functions and dinner meetings. Even if they manage to delay their bedtime, they still wake up between 2-5am, and will feel sleepy during the daytime due to reduced sleep time.
Delayed sleep wake phase disorder (DSWPD)
I have difficulty waking up in the morning and am frequently late for my 8am class. I am sleepy during the daytime and fall asleep frequently, especially during my morning classes. Although I am sleepy all day, I get a 'second wind' between 9pm and feel great during this time. I have difficulty falling asleep till 2-3am. During weekends and holidays, I am unable to sleep till 2-3am, and can sleep till 2-3pm unless someone wakes me up, and can sleep till 2-3pm unless someone wakes me up.
You probably have DSWPD, which is caused by a delay your internal clock phase in relation your desired sleep-wake times. People with DSWPD fall asleep (2-4am) and wake up (10am to noon) very late. They may feel sleepy all day, due to not sleeping enough, but become energetic in the evening and night starting 6-9pm.
Due to difficulty waking up, they are frequently late for morning classes and work. DSWPD teenagers are frequently told by their parents, “go to sleep on time so that you are not late for classes”.
Non 24 -hour sleep wake rhythm disorder is characterized by delay in sleep time by 1-2 hours every day. This is seen mostly in blind individuals since their clock cannot be set by the light-dark cycle, but is also seen rarely in sighted individuals.
Work schedule or travel
Jet lag is seen in association with travel involving rapid time zone changes. Due to this you may find yourself trying to sleep and wake up at the wrong circadian time.
Shift-work sleep disorder is seen in rotational shift workers (especially when they work night shifts). Shift work is associated with difficulty sleeping and sleepiness during work. This is the result of trying to sleep and stay awake at the wrong circadian time.
If you are comfortable with your sleep-wake times, treatment is not required. However, if you are having difficulty adjusting with your school work, job or home responsibilities, then treatment is required. Treatment will depend on the specific CRSD.
Goal of treatment is to fit your sleep-wake pattern to match your lifestyle. Treatments include:
1. Bright light therapy to reset your rhythm
2. Sleep habits to feel more relaxed at bedtime.
3. Lifestyle changes: appropriately timed light exposure and exercise, avoiding caffeine and nicotine late in the day.
4. Medication such as melatonin
Understanding your condition and appropriate timing of therapy is important for treatment to be successful. If you feel that you have a CRSD, make an appointment with AMARA Sleep ( make an appointment) today.
Altered phase
Advanced sleep wake phase disorder
Delayed sleep wake phase disorder
Non-24 hour sleep wake rhythm disorder
Work schedule or travel
Jet lag disorder
Shift-work disorder
Advanced sleep wake phase disorder (ASWPD)
I wake up very early (3-4am) and feel ‘fresh’ in the morning hours. I feel tired in the evening starting 5pm, and have difficulty with evening chores like cooking dinner and helping children with homework. I can fall asleep by 7pm. Even if I stay up late, I still wake up by 4am.
You probably have ASWPD, which is caused by an advance in your internal clock phase in relation to your desired sleep-wake times.
People with ASWPD are also known as larks or early birds. They fall asleep (6–9pm) and wake up (2-5am) very early. They describe feeling very tired in the evening, leading to difficulty with their evening chores and activities like parties, marriages, school functions and dinner meetings. Even if they manage to delay their bedtime, they still wake up between 2-5am, and will feel sleepy during the daytime due to reduced sleep time.
Delayed sleep wake phase disorder (DSWPD)
I have difficulty waking up in the morning and am frequently late for my 8am class. I am sleepy during the daytime and fall asleep frequently, especially during my morning classes. Although I am sleepy all day, I get a ‘second wind’ between 9pm and feel great during this time. I have difficulty falling asleep till 2-3am. During weekends and holidays, I am unable to sleep till 2-3am, and can sleep till 2-3pm unless someone wakes me up, and can sleep till 2-3pm unless someone wakes me up.
You probably have DSWPD, which is caused by a delay your internal clock phase in relation your desired sleep-wake times. People with DSWPD fall asleep (2-4am) and wake up (10am to noon) very late. They may feel sleepy all day, due to not sleeping enough, but become energetic in the evening and night starting 6-9pm.
Due to difficulty waking up, they are frequently late for morning classes and work. DSWPD teenagers are frequently told by their parents, “go to sleep on time so that you are not late for classes”.
Non 24 -hour sleep wake rhythm disorder is characterized by delay in sleep time by 1-2 hours every day. This is seen mostly in blind individuals since their clock cannot be set by the light-dark cycle, but is also seen rarely in sighted individuals.
Jet lag is seen in association with travel involving rapid time zone changes. Due to this you may find yourself trying to sleep and wake up at the wrong circadian time.
Shift-work sleep disorder is seen in rotational shift workers (especially when they work night shifts). Shift work is associated with difficulty sleeping and sleepiness during work. This is the result of trying to sleep and stay awake at the wrong circadian time.
How are they treated?
If you are comfortable with your sleep-wake times, treatment is not required. However, if you are having difficulty adjusting with your school work, job or home responsibilities, then treatment is required. Treatment will depend on the specific CRSD.
Goal of treatment is to fit your sleep-wake pattern to match your lifestyle. Treatments include:
1. Bright light therapy to reset your rhythm
2. Sleep habits to feel more relaxed at bedtime.
3. Lifestyle changes: appropriately timed light exposure and exercise, avoiding caffeine and nicotine late in the day.
4. Medication such as melatonin
Understanding your condition and appropriate timing of therapy is important for treatment to be successful. If you feel that you have a CRSD, make an appointment with AMARA Sleep (link to make an appointment) today.
How sleepy am I?
Do you wake up feeling tired? Are you drowsy? Do you have difficulty staying awake during the day? Is it causing difficulty with your work or at school? Is it affecting how you feel? Do you find yourself spending less time with people and activities you enjoy because of sleepiness? Are you sleepy while driving? Is this happening frequently?
What are the causes of DS (daytime sleepiness)?
Sleep loss
Reduced sleep times will create a ‘sleep debt’
Poor quality sleep
Sleep can be disturbed due to:
1. noise, uncomfortable temperature and light or a poor bed
2. snoring, restless legs
Medical conditions
Hypothyroidism can cause daytime fatigue and conditions like pain, breathing difficulty, gastric upset may disrupt sleep.
Medication
Pain pills such as opiates and anti-anxiety pills like alprazolam, can cause daytime sleepiness, while corticosteroids, diuretics can disturb sleep at night, causing you to feel sleepy during the day. Substances such as alcohol may also contribute to DS.
Primary hypersomnia
Narcolepsy, Idiopathic hypersomnia
Do you feel that sleeping longer does not help you feel better? There are several reasons why you may be experiencing this:
- If the quality of your sleep is light and disturbed, sleeping longer will not help you feel better.
- Are you sleeping less on weekdays due to your work and lifestyle? If so, you are accumulating a sleep debt (hours of sleep required minus actual hours slept) during the work days. Are you planning to sleep longer on weekends 'to catch up on sleep'? This recovery sleep can help you feel better if the sleep debt is low, but may not be enough to overcome the huge sleep debts. For instance, if you require 7.5 hours of sleep, but sleep 4-6 hours on the weekdays, you may accumulate a sleep debt of approximately 11- 12 hours, and sleeping a few hours longer on your days off may not be enough to 'recover your debt'.
- If you are sleepy even after sleeping soundly for 7-8 hours (depending on your sleep requirement) (Please see how much sleep do I need?), you may have a primary hypersomnia such as Narcolepsy or Idiopathic Hypersomnia.
Narcolepsy is characterized by daytime sleepiness and 1 or more of the symptoms listed below, which are caused by intrusion of muscle paralysis and dreams (usually seen in REM sleep) into wakefulness.
People with narcolepsy find it hard to stay awake for extended periods of time. They describe overwhelming drowsiness and sudden attacks of sleep, which will affect their work, performance, social activities and mood. They are prone to accidents and depression.
Symptoms of Narcolepsy. This includes sleep hallucinations etc.
Sleep hallucinations (SH)
Sleep paralysis (SP)
Cataplexy
Do your muscles suddenly become limp or weak, causing your legs and body to drop or fall? Does this occur in response to strong emotions like laughter, surprise, fright or anger? You may be having Cataplexy.
Cataplexy is characterized by a sudden loss of muscle tone which is triggered by strong emotions like laughter. This may involve weakness of the face, arms or legs. Sometimes droopy eyelids, mouth falling open, tongue protrusion and head bobbing may be seen. Some people may fall to the ground during an attack, or may experience difficulty smiling or speaking.
It usually lasts < 1 minute, but may last longer. This is seen in both adults and children and is caused by the intrusion of the muscle paralysis of REM sleep into wakefulness.
Narcolepsy is a neurological disorder caused by destruction of cells of the lateral hypothalamus which produce a neuropeptide called orexin. Orexin (also known as hypocretin) regulates wakefulness and hunger. There are 2 subtypes of Narcolepsy (type 1 and 2), depending on the presence of cataplexy. Type 1 patients have cataplexy, while SH and SP may be seen in both types. People with Narcolepsy also have increased incidence of REM behavior disorder (Please see REM behavior disorder in parasomnias section), restless legs syndrome (Please see to restless legs syndrome) and disturbed sleep at night.People who live with sleepiness most of their life, may feel that it is normal. In addition, people with SH, SP and cataplexy may be misdiagnosed as having a psychiatric disease such as psychosis or hysteria.
IH (idiopathic hypersomnia) is characterized by severe daytime sleepiness, which starts during adolescence and young adulthood, similar to narcolepsy. Patients with IH sleep very deeply at night and have a difficult time waking up in the morning and after naps. This is known as sleep inertia or ‘sleep drunkenness’. They also do not have SH, SP or cataplexy.While we understand what causes narcolepsy well, we do not understand IH very well.
If you have any of the above symptoms, make an appointment with AMARA Sleep.
How is it evaluated?
If you have any of the above symptoms, make an appointment with AMARA Sleep. (link to make an appointment). AMARA Sleep is one of the few Sleep Centers in India which has the expertise to diagnose and manage these conditions.
When you visit AMARA Sleep, our doctor will perform a thorough medical and sleep evaluation to look for underlying medical causes for your daytime sleepiness. You will be asked to keep a sleep diary (link to AMARA sleep diary), so that we can understand your sleep times and sleep pattern.
Further tests include:
Sleep study (link to sleep study) to make sure that you do not have other underlying sleep disorder.
MSLT (mean sleep latency test) (link to MSLT) to measure how sleepy you are. An MSLT must be performed to diagnose Narcolepsy.
What are the treatments available?
Not sleeping enough
Increase your sleep time
Underlying medical, neurological or
psychiatric conditions or sleep
disorder
Treat the underlying condition
Medications
Methylphenidate, modafinil, armodafinil, sodium
oxybate are used to treat daytime sleepiness.
Behavioral methods
– Scheduled naps will help people with Narcolepsy feel better, for an hour or more after nap.
– Learning to recognize and handle sleepiness.
Primary hypersomnia is a lifelong condition and you need to learn to live with it. Here are some things to think about:
- It is important to have regular sleep wake times and ensure that you get enough sleep. Most people will feel sleepy if they do not sleep enough. However, patients with primary hypersomnia will experience severe sleepiness, even with appropriate treatment.
- Talk with your doctor before starting a new medication. Some medications can make your sleepiness worse or may interact with your hypersomnia medications. Make sure to tell your doctor that you have narcolepsy.
- Do not choose a profession which requires prolonged wakefulness, travel or shift work. These jobs are associated with sleep loss and you will have a difficult time functioning in these jobs.
HEALTH INFORMATION / QUESTIONS
What is sleep?
Although we spend nearly 1/3rd of our day sleeping, a proper definition for sleep is not available. Kryger, Roth and Dement textbook describes it as “a state of behavioral quiescence, where you are unaware and unresponsive to the environment.”
What is a normal sleep-wake cycle (SWC)?
Am I a lark (morning person) or an owl (evening person)?
Not all people’s circadian rhythm follows the same rest-activity pattern. At the 2 extremes are the early risers (who wake up with the larks) and the late night folks (who stay up with the owls). Most people have a tendency towards one end of the scale, though some people can be neither type.
For instance, someone who is always awake by 5:00am, even during holidays, and asleep by 9pm is a lark. On the other hand, one who can stay up all night and sleep till 3pm if left alone is definitely an owl.
If you love waking up early and feel the most energetic in the first part of the day, you are most likely a morning person. On the other hand, evening (or night) people like to wake up later and feel their best in the late afternoon or evening. They often describe a ‘second wind’ of energy in the evening or night.
A scientific term for your time preferences is called chronotypes.
Take a test to understand your chronotype: https://www.cet-surveys.com/index.php?sid=61524
Is your result what you expected? Some people may be surprised. For example, many owls develop a routine of going to bed early so that they can wake up in time for work or to take care of children in the morning. This shows how circumstances can overshadow our natural pattern.
Many times, owls are labelled as ‘lazy’ since they wake up late. Similarly, Larks are viewed as having no stamina or energy, if they choose to go home early rather than going out for a party or movie. Recognizing that different chronotypes have different ‘time tables’, will help you appreciate that this is not true.
Have you struggled trying to adapt to early or late activities or work patterns? Now is your chance to embrace your optimum creative time period, using your awareness of chronotypes. For instance, don’t bother freeing up time in the evening for important work, if you are a morning person. Similarly, don’t wake up an hour early to do work, if you are an evening person. It will take you that much time just to feel awake.
How much sleep do i need?
The sleep requirement varies based on age. For instance, a newborn baby sleeps almost 70% of the day, and school going children require 9 – 11 hours. In general, people are getting less sleep than they require due to longer work hours and the 24-hour availability of entertainment and other activities.
The amount of sleep you require, is not a one size fits all, and will depend on your age and individual sleep requirements.
How much sleep do you need?
If you continue to feel poorly,
make an appointment with a SLEEP DOCTOR
Sleep is a vital indicator of both physical and mental health and wellbeing
An occasional night without adequate sleep may leave you feeling tired and irritable the next day, but it will not harm your health. Several sleepless nights, may lead to serious cognitive (mental) effects such as difficulty with concentration, reasoning, learning and decision making. You may feel like your brain is in a fog. Risk of accidents at work, home and on the road will also increase.
Lack of sleep for long periods of time, can affect your overall health and make you prone to serious medical conditions, like obesity, diabetes and heart disease. Sleep loss (not getting enough sleep at night) is also associated with a shorter lifespan.
Tired of not sleeping?
Unhealthy habits and poor lifestyle choices can deprive you of the benefits of a good night’s sleep. Here are some tips to help you sleep better.
AMARA SLEEP CENTER OUTREACH CLINICS
Preetam Hospitals, Kongareddipally (Beside Bus stand Flyover), Chittoor
Contact: Mr. Hema Kumar @ 79939 32777
AMARA HOSPITAL, KARAKAMBADI, RENIGUNTA-KADAPA HWY, TIRUPATI
Contact: Mrs. Mamatha @ 73865 77701
