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ADHD and Sleep in Children

How common are sleep problems in children with ADHD?

Up to 70% of children with ADHD suffer from problems with their sleep. Almost half the parents of a child with ADHD say that their child has moderate to serious sleep problems. Children with ADHD may have behavioural sleep problems or medically-based sleep problems.

What are some behavioural sleep problems experienced by children with ADHD?

Children with ADHD can find it hard to get to sleep at night. They may find it hard to stay asleep through the night as well. Behavioural sleep problems in children with ADHD are very much like those any other child might suffer from. Some examples include –

  •  Not being willing to go to bed: the child stalls or refuses to go to sleep at night-time.
  •  Being anxious at night: the child may be worrying about being alone in his or her bed. They may be scared of the dark. Or it might be that they worry about things that took place that day.
  •  Delayed Sleep Phase Syndrome this is when a child goes to bed later at night. He or she then sleeps in later in the morning.
  •  Insomnia: the child cannot get as much sleep as wanted or needed. He or she may find it hard to get to sleep or stay asleep, or may get up too early in the morning.
  •  Sleep associations: the child may need the presence of a parent or an object, like a TV, to feel able to fall asleep or stay asleep overnight.

What is the impact of behavioural sleep problems in children with ADHD?
Moderate to serious sleep problems in children with ADHD are linked with many other problems. For example their quality of life might not be as good, they might not function well during the day, or they might not go to school as much as they need to. This in turn can have an impact on whoever looks after them. A parent might miss work or suffer from stress because of their child’s sleep issues.

Why do children with ADHD have these behavioural sleep problems?
There can be many reasons. Medication may play a part. Stimulants are often used to treat ADHD and these can cause insomnia as a side effect. But even if children with ADHD are not on stimulants they may still suffer from sleep problems. This is because they are at greater risk of problems such as conduct difficulties, anxiety and depression, all of which can disturb sleep in themselves.

How can you treat these behavioural problems?
This can be done with the same methods used for any other child – see Sleep Problems and Sleep Disorders in School Aged Children. For some children, these methods may not work and there continue to be sleep problems. If so, melatonin may be of use and this should be discussed with the treating doctor (see Melatonin and Children).

My child just doesn’t seem to be able to switch off their mind at bedtime. What can I do to help?
Like any other child, a child with ADHD needs a calm and structured bedtime routine. This will help them get ready for sleep. Starting 30 to 60 minutes before bed, there are a number of things that your child should avoid e.g. computers, mobile phones, console games, TV and other stimulating activities. Bedrooms should be free of TVs, phones etc. The aim is to help them to be relaxed for bed. Reading stories and/or some deep, slow breathing can help children to relax and settle at bedtime.
You also need to make sure that your child is going to bed at the right time (see Sleep Needs Across the Lifespan). Going to bed too early will make it hard for children to settle during the night. Going to bed too late can make them over tired and less cooperative.

What are some of the medically-based sleep problems experienced by children with ADHD?
Children with ADHD seem to have a higher risk of a variety of sleep disorders such as Obstructive Sleep Apnea, Restless Legs Syndrome and Periodic Limb Movements of Sleep (PMLS). Obstructive sleep apnoea is when the throat obstructs repeatedly during sleep, disrupting breathing and sleep. A child with restless legs syndrome feels discomfort in the legs which is accompanied by a strong desire to move them. This happens when trying to get to sleep and also during the night. Children with periodic limb movement disorder move their legs repeatedly during the night. They find it very hard to control this. If you have concerns about any of these, you should speak with a doctor.

I need more help with my child’s sleep, what should I do?
If you need help with your child’s sleep, you can get in touch with your GP or a paediatrician. Some children may need a Sleep Specialists.

Ageing and Sleep

If you are over 60 it will come as no surprise to hear that sleep changes as we age. Nearly a third of our life is spent asleep. Infants spend most of the day asleep. Through youth and young adulthood the pattern of sleep that we have come to accept as “normal” or “good” develops. As we grow older sleep becomes lighter and more interrupted and other factors may impact on our ability to get that “good” night’s sleep. Poor sleep impacts on our ability to enjoy daytime activities. Importantly, there are things that you can do to improve this situation.

How does sleep change as we grow older? There are three important phases of sleep that go to make up a normal nights sleep; these are quiet sleep (called non-REM sleep), deep sleep (called slow-wave or delta sleep) and REM (rapid eye movement) sleep which is often associated with dreaming. From young adulthood to old age there is a steady decline in the amount of deep sleep and increase in quiet sleep although the amount of REM sleep remains much the same. It may surprise you to know that in adulthood the total amount of sleep remains the same or slightly increased. Perhaps more importantly to how you feel about your sleep, is that the number of
awakenings from sleep increases as you age.

What is “normal” sleep in the elderly? Although there is no simple answer to this, most people sleep between 7 and 9 hours each day. In the elderly, this sleep may not all occur at night. The afternoon nap that becomes possible when you retire and the after dinner snooze in front of the television also contribute to your total sleep need for the day. One study found that around 40% of elderly take at least one nap a day. Most naps tend to be 30 minutes or longer and at age 80 lengthen to 60 minutes. If you do nap, perhaps you should not be surprised if you sleep less than 8 hours each night. The good news is that 80% of the elderly say they wake refreshed – if you don’t perhaps something can be done.

It is not unusual to take some time to fall asleep. One third of women and one sixth of men report taking longer than 30 minutes to fall asleep. This may be for a number of reasons including medical or psychological reasons, or just simply that you may be going to bed when you think you should, but your body isn’t ready. Research has shown that as we grow older the body secretes less of a sleep promoting substance called melatonin. As a result the urge to sleep that is controlled by melatonin is released is not so strong in the elderly.

It is not unusual to wake up during the night. Partly as a result of lower melatonin levels, sleep becomes more shallow, fragmented and variable in duration with age. The lighter sleep pattern makes you more likely to get woken by the neighbour’s dog or the passing traffic. The ageing bladder can also contribute a couple of awakenings each night. In women hot flushes of menopause may also occur at night and cause awakenings.

PERSISTENT TROUBLE FALLING ASLEEP AT NIGHT OR FEELING SLEEPY IN THE DAY IS NOT A NORMAL RESULT OF AGEING AND SOMETHING CAN BE DONE.

Medical conditions that are more common in the elderly may affect sleep. Some of the conditions that have been shown to impact on sleep include arthritis, osteoporosis, Parkinson’s disease, incontinence, indigestion, heart disease and lung disease such as asthma or emphysema. For example, a survey found that 60% of arthritis sufferers over 50 years of age experience night-time pain and on average lost 2 hours sleep 10 times per month. If you suffer from any medical conditions that are affecting your sleep it is important that you tell your doctor as it may be possible to change your medication to give you more relief at night.

Dementia or Alzheimer’s disease will impact on sleep. Both the sufferer’s and the caregiver’s sleep may be significantly disrupted as a result of dementia. In fact, many caregivers cite sleep disturbances, including night wandering and confusion, as the reason for institutionalising the elderly. Unfortunately, two-thirds of those in longterm care facilities suffer from sleeping problems. Inactivity during the day and some drugs may make night-time problems worse for the dementia patient.

Sleep disorders are more common in the elderly. Sleep apnea and periodic limb movement disorder are more common in the elderly, affecting up to 25% of people to some extent. Often the partner is affected as much as the person with the condition. You may be blissfully unaware of any problems during the night, but both of these conditions may have a significant impact on your sleep, cause frequent arousals and result in daytime tiredness and other ill health. These conditions are discussed in other fact sheets.

Insomnia can be treated. Up to 40% of people report some problem sleeping, with 10% having persistent or chronic insomnia (difficulty sleeping). Long-term insomnia may be a symptom of another problem which might be stress, depression or other medical conditions. Frank discussions of your problem with your doctor should always be the first line of approach.

Sleeping tablets. Insomnia that lasts for only a few days may result from some life stresses such as family issues and sleeping tablets may have a role to get over a difficult period. However, sleeping tablets lose their effect after a few weeks and should not be prescribed for longer than four weeks. If you have used sleeping tablets for a long time you may have difficulties in stopping them. For the first few nights your sleep will likely be worse and you may need to reduce slowly rather than abruptly. Ask your doctor about this.

Simple lifestyle habits can improve your sleep. Young and old alike can benefit from following some simple rules about getting a good night’s sleep. These rules are often called sleep hygiene. For the elderly, in particular, following some of these suggestions may help.

  • Regular Bedtime – A regular sleep schedule is the most important aid to a good night’s sleep. Go to bed at about the same time every night, but only when you are tired. Set the alarm clock to wake you at about the same time every morning. Don’t sleep in because you have had a poor night’s sleep. If you wake early consider getting out of bed and starting your day.
  • Daytime Naps – Naps should not be used as a substitute for poor sleep at night. Some people find they sleep better with an afternoon nap but if your night-time sleep is disrupted, you may want to try and skip the nap. Avoiding a nap late in the evening might also be a good move. Experiment to find your best combination and try and stick to it.
  • Exercise – Regular exercise benefits sleep, but not just before bedtime. The best time to exercise is in the morning or early afternoon.
  • Bedtime Snacks – a light snack before bed might help you sleep, unless it causes problems with indigestion. You should avoid heavy meals and caffeine containing drinks late in the evening. A glass of warm milk before bed is a well tried remedy that may also help, providing that it does not mean you wake up to urinate.
  • Alcohol – Alcohol in the evening does not help sleep. You may fall asleep more easily but the chances are it will be a fragmented sleep and you may well wake in the middle of the night.
  • Make sure your sleeping environment is good – If early morning light bothers you, your mattress is uncomfortable or your bedroom is too hot or too cold, fix it. You spend a lot of time in bed, if you’re having trouble sleeping don’t put up with a suboptimal bedroom.

DISCLAIMER – Information provided in this fact sheet is general in content and should not be seen as a substitute for professional medical advice. Concerns over sleep or other medical conditions should be discussed with your family doctor.

Anxiety and Sleep

How do I stop feeling anxious about my sleep?
It is important to understand that waking up at night is normal. Everyone does it to a greater or lesser extent. Some people remember waking up and may worry about it. Others do not remember waking up. Worrying about sleep usually makes the sleep worse. Do not think “I won’t be able to function tomorrow unless I get back to sleep”. Instead try: “I’ve been able to function on less sleep before and I will get by OK again tomorrow”. Relaxation exercises before going to bed may help. If sleep anxiety continues, a doctor should be consulted. A referral to a specialist sleep psychologist may also be needed.

I haven’t slept well for years but don’t think I have anxiety.
You do not need to have general anxiety for an overactive mind to get in the way of a good night’s sleep. It is true that some people do not sleep well due to stress in their lives. But others have mostly stress free lives, except that they worry about their sleep. By itself, this can disrupt the quality of sleep. You must aim to lower overall levels of worry or ‘stress’. Being fit and having a healthy diet also play a part in how well you sleep.

Can alcohol help with sleep? Should I give up caffeine altogether?
Caffeine and alcohol can be bad for sleep. It is important to have both of them in moderation. This will result in better sleep quality. However they should be avoided for at least 4 hours before going to bed. Using alcohol to relax and de-stress before going to bed will not help your sleep. It may help to get you off to sleep, but will interrupt your sleep during the night. Too much caffeine will make you too alert to sleep well.

Can medication help make me worry less about sleep?
Medicines (e.g. Sleeping Tablets or anti-anxiety drugs) will not always work. Their effectiveness decreases with time and they can be habit forming which makes it difficult to stop taking them. The best way to lower anxiety about sleep is to try to alter how you think about sleep. They will help you to learn new ways of dealing with being awake or with being nervous about the night falling. There are many methods to learn new ways to think about your sleep, or lack of it. These include Cognitive Behavioural Therapy (CBT) and Mindfulness. These have been proven to be effective.

What can be done about a mind that doesn’t seem to shut down? I’m not worrying, just thinking a lot, often about mundane things.
There are many things you can try if your mind seems overactive e.g. CBT for insomnia and mindfulness. If you learn to notice when your mind is racing you can use methods to relax and aim not to feel too alert or worried. These can work across the whole day. Most importantly, don’t do the thinking or worrying in bed. Many people find that setting aside a ‘worry time’ during the day is helpful. Choose a time during the day when you are usually free and do your worrying, thinking and planning at that time. Bed is for sleep, so if you are not asleep or likely to fall asleep, it’s not where you should be. Aim to gently let go of the thoughts and not let them distract you. This is just like people living next to railway lines learn to not notice the train noise after a while. It takes time and practice but can be done.

Can some people suffer from anxiety but sleep well?
Yes. If you suffer from anxiety it does not mean you won’t sleep well. Very anxious people can still sleep well and not feel too tired or sleepy. But if the person with anxiety starts to sleep poorly, this will make them feel tired. They can then start to worry about lost sleep. This can set up a vicious cycle resulting in chronic sleep problems.

I am having problems with my sleep. What should I do?
Talk to your GP. There are also Sleep Specialists that can help. There are psychologists who are trained to help people sleep better. They can explain to you about the mental factors involved. In the meantime:

  • Do not try too hard to sleep
  • Let sleep come to you when the timing is right
  • Keep a regular daily routine when possible, with consistent times for eating, sleeping and doing other things
  • Make sure you can learn or get taught some methods to relax
  • Realise that part of the reason why you don’t sleep well might be that you worry about sleep too much
  • Don’t blame every little thing that goes wrong on your poor sleep
  • Do not lie in bed awake for a long time. Give yourself about 20 minutes, then get up and go and sit in a quiet, dark room somewhere, not doing anything, until you feel sleepy again
  • Know that Sleeping Tablets are not as helpful as you might think
  • Also know that there is a chance that you might actually be getting more sleep than you think you are
  • Make sure you don’t have too much alcohol and caffeine.
  • See also Good Sleep Habits.
Behavioural Sleep Problems in School Aged Children

What are some common behavioural sleep problems in children?

The most common issues are: not getting into bed; not settling into sleep; not staying in their own bed; waking up at night; getting up in the morning and / or not getting enough sleep.

What can you do to get your child into bed at the right time?
Set up a bedtime routine. Stick to it each night. Be consistent with it. This helps your child’s body and mind to get ready for bed. They will go to sleep more easily if they go to bed at about the same time each night. They are more likely to wake at about the same time each morning as well. Parents must always be ready to be firm if their child acts up around bedtime.

What is a bedtime routine?
It is best to start with a 30 to 60 minute quiet time. Keep your child away from computers, TVs and anything else that is too stimulating. It is normal to include a bath / shower, pyjamas, a drink, cleaning teeth, a toilet visit, a bedtime story, a goodnight kiss and then lights out as parents leave the bedroom. Put limits on what you let your child do here. Don’t let them stall for time. Make sure that lights are out at an appropriate time. This will give your child the sleep they need. The next day they are more likely to wake up refreshed and be better behaved.

How do you determine lights out time so your child gets enough sleep?
Lights out time depends on sleep need (see Sleep Needs Across the Lifespan). It also depends on when they wake up. For example, if your child needs about 11 hours of sleep and has to wake up at 7am, then lights out would be at about 8pm.

Your child is finding it hard to go to sleep. What can you do?

  • Make sure that your child prepares for bed in a way that helps them relax and feel ready for sleep. Think about what should and should not be in the bedroom. You want it to be a relaxing place. (see Sleep Tips for Children)
  • Make sure there are no noises that disturb your child’s sleep such as TV noise.
  • Make sure your child can switch off their thinking after lights out. This will make settling into sleep easier. You can teach your child things such as simple breathing or relaxation exercises. These distract the mind and slow it down, so sleep can come. Quiet time with no technology before bed time will help. Soft quiet music may also help.
  • Make sure that your child is not going to bed too early or too late. Both can make it hard to settle into sleep. Try to be aware of when your child gets sleepy in the evening. This will let you know when the sleep processes are starting to kick in. From this you can work out when the best time to go to bed is. Remember, as your child gets older their switch on for sleep will be a bit later. This means bedtime is a bit later too.
  • Make sure that your child does not grow to need you to help them to go to sleep. They need to learn how to settle into sleep alone. (See question 7 below).

Why does your child keep waking you up during the night?
Your child can naturally several times a night. These disturbances last a few seconds to a few minutes. They should be able to self settle back into sleep. But if your child has not learned how to self settle, they may wake you or come to your bed to seek your help to go back to sleep. It’s worth teaching your child to self settle at the start of the night. This will help them to be able to self settle through the night. You will get a much better night’s sleep from this.

How can you teach your child to self settle into sleep?

  • To teach them how to do this, you need to go out of the room with the lights out. You should do this before they are asleep. This gives them the chance to fall asleep with no help from you and when you’re not in the room with them. It usually takes 15 to 20 minutes for them to fully get to sleep. Try to avoid doing things in or around your child’s bedroom during this time.
  • If your child has never gone to sleep without you, explain to them what is going to happen. Be firm but reassuring to your child about being able to go to sleep when you’re not in the room.
  • Some children will get worried about this or try not to let you leave the room. Some will get out of bed to find you. In this case you can take things more slowly. You can go back into the room on and off, for a short time. If you need to, you can put them back into bed, get them to lie down and tell them to go to sleep. When this is done, you leave the room. You may need to do this over and over. Each time, spend longer and longer out of the room. If you are consistent and stick with this, then you will succeed. Remember to keep a lid on your emotions when in the bedroom. Also be as boring as possible.
  • One more thing you can do is to put a stretcher bed or mattress next to your child’s bed. Be there, but have very little interaction with your child. The only thing you should do is tell them to go to sleep. Remember that this should only be a temporary thing. Once they are used to this they will go to sleep without being told to. Then you should start to gradually get out of the bedroom. It is important that once you start this not to give in. Don’t go back to old ways. This will confuse your child and make it harder the next time you try to change. You can also use this if they have been sleeping with you and you want to teach them to sleep in their own bed.
  • You might find teaching your child to self settle into sleep is causing distress to you and your child. Or you might not be sure of what strategies to use. If so, it is recommended that you seek professional help. See a Sleep Specialists.

Are there other reasons why my child may wake up or stay awake at night?
After waking up at night, your child may find it hard to get back to sleep. This is due to their brain starting to think about things and keeping them awake. Your child may not tell you about this and lay awake in bed for some time. In the morning they can be hard to wake or still seem tired even though they had enough time in bed to get the sleep they need.
Remember to ask them in the morning if they had a good sleep. This lets them tell you if they have any problems with their sleep. Help them to learn how to deal with sleep problems. If necessary, see a Sleep Specialist.
There are other reasons why your child might wake up at night. These include illness, being too hot or cold, hunger, nightmares and sleep terrors.These tend to get better with time and don’t last. To learn how to deal with this see Nightmares and Sleep Terrors

What can you do if your child is anxious, is scared of the dark or has night-time fear about bedtime?

  • A small dim night light can help. When your child wakes during the night, having some light helps them work out where they are and know they are safe. Taking a comfort object to bed, like a teddy bear, can help your child not feel so alone at night. Remember to reassure them that nothing will hurt them. Sometimes a baby monitor in their room (linked to you) will help.

How can you help your child to stay in their own bed?

  • Be consistent and assertive about your child staying in their own bed. If you do not want them to sleep in your bed, always take them back to their own bed when they come to your bed. Remember to always remind them that you expect them to stay in their own bed all night.
  • Build a consistent habit of your child going to sleep in the place where your child will sleep for the night. It is best if this is their own bed. It can be disturbing for them to wake up somewhere other than where they remember going to sleep. This can make them get out of bed and wake you.
  • Remember to praise your child for successfully staying in their own bed all night. It can help to have a reward system if they behave well at bedtime. Keep the rewards small and frequent. Stickers often work well.

You can’t deal with your child’s sleeping problem. What can you do?
If you are not sure about why your child has a sleep problem or you can’t deal with it, contact your family doctor or paediatrician. Some children may need a Sleep Specialists If you feel your child may have a sleep disorder, please see the page on this topic, Childhood Behavioural Sleep Problems and Childhood Snoring and Sleep Apnea

Caffeine, Food, Alcohol, Smoking and Sleep

How can caffeine affect my sleep?
Caffeine is a drug that acts as a stimulant, both mentally and physically. It is found in many drinks and foods that are common in our everyday life. These include tea, coffee, chocolate and cola drinks. Many people do not think of it as a drug. It can be bad for your sleep in three ways. Firstly it can make it harder to go to sleep. Secondly it can make you sleep more lightly and wake up more often during the night. Thirdly, it may make you have to get up to go to the toilet during the night.

Some people need more caffeine than others to have the same effect. As a rule, caffeine takes about an hour to reach peak levels in your body. Its effects can last from four to six hours, but your body needs about 24 hours to completely eliminate it. Many people who consume a lot of caffeine think that it no longer stops them from being able to go to sleep, because they have become immune to this effect. However research shows that, even if they think otherwise, their sleep is impaired and they would sleep much better if they abstained from it.

How much caffeine is in common foods and drinks?
The amount of caffeine in a drink will vary with its strength. The table below shows the amount of caffeine in the most common sources. Note that normal tea has a lot more caffeine than many people think.

SUBSTANCECaffeine Content (Milligrams)
Coffee (250ml or 1 small to average sized cup)
Instant coffee
Brewed coffee
Iced Coffee
Decaffeinated coffee
Depends on brand and strength
65-100 mg
80-350mg
Up to 150mg per carton
2-4mg
Tea (250ml or 1 small to average sized cup)
Herbal tea
Green tea
Normal tea
0-30 mg
30-50mg
50-70 mg
Soft Drinks (375ml can or medium sized cup)
Coca-Cola, Pepsi or similar
Red Bull (250ml)
V
Mother
50 mg
80 mg
80 mg
150 mg
Chocolate
Most Chocolate Bars (Dark chocolate has more caffeine)
Cocoa and Hot Chocolate
20 – 60 mg per 200 mg serve
10 – 70 mg per cup
Caffeine Tablets
NoDoz (Regular strength, per tablet)
100mg

How much caffeine should I have?
If you are having trouble sleeping, you should try to limit the amount of caffeine that you have. It is best to have no more than 200mg per day. You should not have any for at least 4 hours prior to bedtime. Many people will find that their sleep improves with just this change. But you should also keep in mind that caffeine is addictive. This means that if you stop suddenly, you may suffer from headaches, tiredness and anxiety. In this case, gradually cutting down may be better.

How can food affect my sleep?
Both what you eat in your meals and when you eat them can affect your sleep. As a rule, a healthy, balanced diet will be good for your overall health and well-being. You will have more energy during the day and sleep better at night. It is best if you allow 2-3 hours between having your last main meal of the day and going to bed. You should not go to bed hungry, nor just after you have had a meal. If you have a long time between dinner and bed, you may find that eating a small, light snack (e.g. a piece of fruit) or having a milk drink prior to going to bed helps you to sleep better. Some people find that rich or spicy foods in the evening make it more difficult to sleep well at night.

Will alcohol help my sleep?
Although alcohol will make you feel sleepy and may help you fall asleep at night, it actually disrupts your sleep later. In the second half of the night, sleep after drinking alcohol is associated with more frequent awakenings, night sweats, nightmares, headaches and is much less restful. It is best to avoid alcohol for at least 4 hours before bedtime. Binge drinking will affect your levels of melatonin for up to a week. Melatonin makes us feel sleepy at night, helps us to sleep better and regulates our body rhythm.

Will a cigarette help my sleep?
You may think that having a cigarette before bed or in the middle of the night relaxes you, but this is not the case. Nicotine is a stimulant and makes it harder to fall asleep and to stay asleep. Cigarettes should ideally be avoided altogether, and certainly for at least 2 hours before bed.

Central Sleep Apnea

What is Central Sleep Apnea?

While asleep, there may be pauses in breathing, which are called apneas. Up to 5 brief apnoeas an hour may be seen in normal adults. For people with central sleep apnea (CSA), the apneas last longer and occur more frequently. The body does not make an attempt to breathe during these pauses. This is different to the more common Obstructive Sleep Apnea(OSA). Patients with OSA struggle to breathe against a blocked airway. For patients with CSA, the airway is not blocked, there is just a pause in breathing efforts.
About 10% of people with breathing problems during sleep have CSA. This affects the quality of sleep and they feel sleepy during the day. The person might also complain of Insomnia or other sleep problems. Loud snoring is not as common in CSA as it is in OSA.

What causes Central Sleep Apnea?
The brain may be slow to respond to changes in oxygen and carbon dioxide levels in the blood when breathing slows down. This may occur in people who have had sleep apnea for a long time. This is due to blunting of the breathing reflex. CSA may also be due to a slow circulation from heart failure having an effect on the normal breathing reflex pathway. This causes a pattern of over-breathing and then under-breathing (periodic breathing) or stopping breathing. Other causes of this pattern of CSA include some drugs (e.g. narcotics such as morphine) or having cerebrovascular disease (e.g. a stroke). These affect the breathing control centres in the brain.
CSA can also be due to weakness of the muscles that make the lungs expand and contract, such as in neuromuscular disorders like polio. It can be also be caused by an abnormality in the shape of the chest wall or the lungs being too stiff. This can lead to under breathing, called hypoventilation.
CSA can disturb your sleep. It can also make your body retain carbon dioxide. This can lead to morning headaches or confusion.

Assessment of Central Sleep Apnea
This requires a thorough evaluation of all the possible causes and also a Sleep Study. This is done by a Sleep Specialists

What can be done about Central Sleep Apnea?

  • Drugs (e.g. narcotics) which may cause CSA may need to be reduced or stopped if you can. There are some other drugs which stimulate breathing. You might be able to try these.
  • Positive airway pressure therapies can help many forms of CSA. CPAP – Continuous Positive Airway Pressure(CPAP) may work. Adaptive servo ventilation is useful for periodic breathing. Sleep hypoventilation responds well to bilevel ventilatory assistance.
  • Oxygen therapy at night may be beneficial.
  • Where heart failure is a factor, treatment of this with medications is important.
  • Rarely a diaphragm pacemaker is used. This has been used in spinal cord injury patients or in congenital hypoventilation syndrome.
Chronic Fatigue Syndrome and Sleep

Are people with CFS just tired?
People with CFS are more than “just tired”. They suffer from an intense fatigue and exhaustion that won’t go away. Physical or mental activity can make their CFS symptoms worse. To recover, the person must rest for longer than usual. People with CFS have less energy to do everyday tasks. This can apply to both physical things (e.g. to go for a walk), and mental things (e.g. to focus at work).
This is not the same as feeling sleepy during the day. People with CFS feel fatigue rather than sleepiness. People who feel as though they could fall asleep at any time may have different issues, see Excessive Daytime Sleepiness. This is not the same as CFS.
It is not uncommon for CFS patients to sleep for periods of 12 hours or longer. But even if they sleep for this long, they still don’t feel refreshed. Some have headaches when they wake up. For many people with CFS, it can help if they sleep in and nap during the day. This helps them to control their feelings of exhaustion and get back some of their energy. This assists in performing daily tasks.

Can people with CFS also have sleep problems?
Some people with CFS have sleep difficulties as well. These can include finding it hard to get to sleep, waking up often during the night and/or waking up too early in the morning. Having a bad night of sleep can make it harder to remember things. It can also be harder to focus on tasks and increases moodiness or irritability. Poor sleep can also increase sensitivity to pain. For people with CFS, poor sleep can make the feelings of being fatigued even worse. It can help to obtain as much sleep as possible. However, it is important to avoid sleeping in in the morning and then going to bed late at night. This pattern – Delayed Sleep Phase Syndrome– has its own problems.

What happens if you don’t get enough sleep?
Sleep deprivation can be a big problem for people with CFS. It can make your symptoms worse and delay recovery from CFS. CFS sufferers should try to have at least 8 to 9 hours of sleep every day. If a late night is planned, a nap during the day is good preparation.

How can you improve your sleep?
Most people with CFS find that their sleep improves when the other CFS symptoms start to improve. If you find it hard to go to sleep at night, your “sleep hygiene” may need some work. See Good Sleep Habits for a list of things that can help.

Common Sleep Disorders

TEN COMMON SLEEP DISORDERS

1. Insomnia
Insomnia is when it is hard to get to sleep or stay asleep. Often, the cause is discomfort from an illness. Other times, it can be feeling upset, sad or stressed. In these cases, what needs to be done is to get rid of the cause. But in other cases, there is no obvious cause. Here it can help to adopt good sleep habits. If this is not enough, there are more complex treatments. One of these is known as cognitive behaviour therapy. This needs a skilled therapist. Sedative drugs will, at best, only work in the short term.

2. Snoring
Snoring is a common problem. It affects up to 40% of men and 20% of women on a regular basis. It gets worse with age and weight gain. Someone who snores can disturb their partner’s sleep. This can cause distress for both of them. As well, many regular snorers also have obstructive sleep apnoea.

3. Obstructive Sleep Apnoea
This means losing your ability to breathe freely. It happens over and over while asleep. It is caused by a narrow, floppy throat. Most people who have sleep apnoea snore too. The period when the sleeper has trouble breathing ends with them waking up. This arousal is often very brief with no memory of it. But arousing over and over like this disrupts sleep and causes excessive tiredness during the day. There are treatments that work. These include weight loss, cutting down on alcohol, dental devices and continuous positive airway pressure (CPAP) therapy.

4. Sleep Hypoventilation
The muscles that we use to breathe need to be told to do so by the brain. When we sleep, there is less drive to do this from the brain. This means that people who have breathing muscles that are weak or under excessive load from severe lung disorders or obesity may not breathe strongly enough during sleep. This is known as sleep hypoventilation. With no treatment, this can lead to breathing and heart failure during the day. Devices to help breathing during sleep will work in treating this. This treatment is called non-invasive positive pressure ventilation.

5. Restless Legs Syndrome
People with restless legs syndrome have uncomfortable feelings in the legs. The only way they can stop these is to move their legs. How severe it is tends to vary over the day. The worst time is from the evening through to the early hours of the morning. For some people, it can make their sleep a lot worse. Sometimes it is caused by the body not having enough iron. There are several medications that can stop it.

6. Bruxism
This involves grinding of the teeth during sleep. It is quite common. If not treated, it can cause permanent damage to the teeth. Sometimes it causes jaw discomfort. But often the
people who have it aren’t aware of anything. If they use dental guards they can protect their teeth.

7. Narcolepsy
About 1 in 2000 people has Narcolepsy. It relates to unstable switching between being awake and asleep. People who have it can feel more sleepy more often than they would like, but may have disrupted sleep as well. People with it can also hallucinate. This happens when falling asleep or waking up. Sometimes when they wake up, they can’t move for a moment. This is called sleep paralysis. They can also have what is known as cataplexy. This means sudden feelings of muscle weakness. They only last a moment and happen after laughing or feeling a strong emotion. Not everyone with Narcolepsy has all these problems. Drug therapies can work very well. Sleep paralysis can occur by itself with no relation to Narcolepsy.

8. Sleep talking, sleep walking and other automatic behaviours
There are many things that we normally only do when we’re awake. These include walking and talking. But some people do these things while asleep too. This happens when they only partially wake up. It is common for this to happen in children. These problems usually go away by the time they become adults. But sometimes they don’t. There are other complex behaviours that can happen while asleep e.g. binge eating and sexual behaviour. They can be embarrassing or worse for both the person who does them and their partner. There are treatments that work for these problems.

9. Nightmares and night terrors
These also happen because of not fully waking up. Again, they are much more common in children than adults. They can be very disturbing for the person who has them and those around them. They can also make people anxious about going to bed. Poor sleep habits make them worse. In general, counselling will make things better. Every now and then, medications are needed.

10. Rapid eye movement behavior disorder
The period when we sleep can be split up into several phases. Dreams happen most often in a phase called REM sleep. REM stands for Rapid Eye Movement. At this time all limb muscles are usually relaxed. However in REM sleep behaviour disorder the muscles are active. People who have this will act out their dreams. This can involve violent movement and lashing out. There is a threat of injury to both the person who has it and their partner. There are treatments that work well for this.

CPAP Making it Work for You

Why is it important to use CPAP?
If you suffer from Obstructive Sleep Apnoea (OSA) and need treatment, the most effective option we have at the moment is CPAP. Full details about this treatment can be found on our Continuous Positive Airway Pressure (CPAP) page.

CPAP can improve health of people with OSA in many ways, although these may not be obvious straight away. CPAP has been shown to improve blood pressure and diabetes. It may also reduce the risk of heart attacks and strokes. Many people feel much better and enjoy life more after they start using CPAP. They wake up feeling more refreshed in the morning and are less sleepy during the day. Energy levels are improved, they are able to concentrate better and get more things done. Mood is increased and their libido may be restored. Often, the bed partner is able to sleep more soundly when the person with OSA starts using CPAP. Some partners worry about their loved one having breathing pauses during the night. The partner will stay awake to make sure that they start breathing again. With CPAP, the person with OSA breathes throughout the night and is no longer keeping their bed partner awake with their snoring and restless sleep.

What if my sleep apnoea symptoms seem to be coming back?
After using CPAP for a while, some people notice that their original symptoms are returning. They start snoring again, feel tired or have difficulty concentrating during the day. If this happens to you, you should contact your sleep specialist. There are many reasons for symptoms returning. It might just be that your sleep apnoea is changing. The machine pressure setting may need to be adjusted or there may be a problem with your mask. Your sleep specialist will be the best person to help. They are used to dealing with these problems. After the treatment is adjusted, you will get back on track.

What might cause the need for pressure change?
If there has been a weight gain, a higher pressure is often needed. Just the process of getting older can change how much CPAP pressure is needed. For some people, their sleep apnoea is worse when sleeping on their back than on their side. If sleep habits change, the CPAP pressure may need adjusting. Some people need to change their sleeping position due to pain from a medical condition e.g. arthritis. A change in any drugs that you take to treat another illness may make your sleep apnoea worse. This can mean that you may need to adjust the pressure, or it may help to speak with your doctor about changing the time you take the drugs. Don’t forget that expert help is available and you do not have to solve these issues by yourself.

What are the key messages to remember when using CPAP?

  •  Using CPAP means you can sleep safely and well.
  •  You are in charge of the treatment and can take off the mask and stop the machine at any chosen time. You are able to choose how far your therapy will go. But keep in mind that this treatment is the best option at this point in time and it only works when it is being used.
    Get used to handling your mask and feel comfortable with it. This is a vital part of learning to using CPAP. You could even put your CPAP mask on your face when you’re doing things such as watching television. This will help you get used to having the mask on. Make CPAP a key part of your health, with the aim of turning it into just something that you need to do every night – like cleaning your teeth.
  •  A ramp is a useful device on most CPAP machines. It allows less pressure when you first turn on your machine. This will slowly build up to the pressure you need, sometimes not reaching the full pressure until after you are asleep. A ramp may make it easier to use your CPAP machine on a nightly basis.
  •  There are many options available on modern CPAP machines to improve comfort. Newer machines are quieter, smaller and equipped with ways to decrease the sensations of pressure. Some automatically adjust pressure throughout the night, seeking the lowest effective pressure for the type of sleep and body position you are in. Others will lower the pressure a little when you are breathing out.
  •  There are many styles of mask available including some very small and lightweight models. Your CPAP supplier will help you choose the one that is best for you.
  •  You may wake and find your mask is off. This happens for many CPAP users. It may mean that you need to have either the pump pressure or your mask adjusted. You should see your doctor or your sleep physician to discuss this. After improving what you can, it may still occur from time to time. If you continue to wake up with the mask off, the important thing is what you do next. Put your mask back on and gently and slowly slide back into sleep as the CPAP works.
  •  Taking a “night off” is not a good idea because it can often lead to “two to three nights off”. You may end up only using it one or two nights per week. This pattern of treatment is not good for your health or snoring!
  •  Have realistic expectations about using CPAP. To succeed with CPAP you may need to be patient and stick with it. CPAP will not “cure” all aspects of your health problems but it will help you to feel so much better and get more out of life. You will be a safe sleeper at night. You should take responsibility for your equipment, cleaning and maintaining it. At times, you may need to seek help and work through technical problems that may come up. If you control your sleep apnoea with CPAP, you will enjoy a healthier life. See also Travelling with CPAP.
Dementia and Sleep

How can we best understand dementia?
Dementia causes a set of problems that are related to each other. These include memory loss, trouble communicating, confusion and difficulty with walking around. There might be difficulty with recognising people they know, even if they are close friends and family members. Although it is a medical issue, it is better to think in terms of a change in how the person experiences the world. The aim is to try to understand what the person is experiencing. Then the physical and social environment can be adjusted to be safe and not distress them. Since no two people have dementia in the exact same way, what needs to be done will also not be the same for any two people with dementia.

How is sleep different for people with dementia?
Up to half the people with dementia will have a sleep pattern that is not normal. They are often sleepy during the day and have difficulty with sleeping for long periods at night. They may have less deep, restful sleep and a lighter sleep. This could be due to dementia directly or due to changes in how they perceive the world. Some forms of dementia can disrupt the Body Clock. See also Ageing and Sleep.

What are the causes of these changes in sleep?
There are many possible causes of these sleep changes. The way that the brain controls sleep may be changed. The person may have unmet needs or problems such as pain. They may have had sleep problems in the past, or they might be living in a place where it is hard to sleep well.
It is also possible that their poor sleep may be linked to breathing or other sleep related problems such as Obstructive Sleep Apnea, Snoring or Periodic Limb Movements.
Some medications may affect sleep, including those that are used in dementia. These include pain relievers, drugs to treat Parkinson’s disease and antidepressants.

What do these sleep problems lead to?
Not getting enough sleep will lead to a lower quality of life and greater difficulty with functioning during the day. The person may be tense, sleepy, have problems focusing, fall over or have mood problems such as depression. They may talk in their sleep, wake up often and may wander around during the night.
Wandering is of great concern for carers. It disturbs the carer’s sleep and may be a danger for the person with dementia. This means that the at-home carer also has trouble getting enough sleep.

What can be done to make sure a person with dementia gets enough rest?
As a rule –

  • Try to get them to have sleep and wake patterns that reflect their sleep habits from the past that they found helpful. For example, if they used to fall asleep to music, then they should be allowed music. Or, if they typically got up early, then they should still keep getting up at the same time.
  •  The use of Melatonin has been tried with people living with dementia and did not help.
  •  Massage has been found to help for some people.
  •  Keep the same getting-ready-for-bed routine from the past.
  •  See also Good Sleep Habits.

During the day

  • It is important to stay active.
  •  Being exposed to bright light or sunlight controls Melatonin levels and sends the brain a message to be awake. Outdoor light in the morning and in the evening helps keep the Body Clock on a stable routine.
  •  Older people need fluids but these should be reduced in the afternoon and evening.
  •  About 4 in 10 older people have naps. Short naps may be helpful if there is inadequate sleep at night. It is better if the naps are before lunch so the person is more tired when they go to bed.

During the night –

  •  The sleep room should be dark and quiet at night. Often people with dementia wake up and think it is morning if there is light.
  •  For safety and finding the way at night, use red or amber lighting. Lights of these colours are less alerting.
  •  You could try acting out a “going to bed” routine for them to copy.
  •  If a person really wants to be up at night, do not force them to be in bed or to sleep. They need an accepting environment that helps them feel safe.

How can we help people who wander at night?
When people living with dementia wander at night they don’t get as much good sleep. This lowers their quality of life. Don’t just assume that wandering is a result of dementia. Often things can be done to help. You could try the following:
First think about the history of the person. If they have had different sleep patterns in the past, they may be trying to get back to that routine.
It could be that there is a ‘cause’ that makes them wander. There might be something around them that disturbs them. Some experts believe that people with dementia get disturbed by things around them more easily. This could be the case if they wander at the same time every night. It is also likely if others in the same room or house are having trouble sleeping.
Finally, wandering may stem from a problem or unmet meed. The person may not be able to express what is wrong using words. They may be moving due to pain, lack of comfort, feeling lonely, fear, not being familiar with what is around them, or many other things. The behaviour can be aiming to meet the need. For example, they might be pacing because they are bored. If they are saying the same thing over and over, it may be that they are trying to tell you about an unmet need. Finally, abnormal behaviour may be the result of an unmet need e.g. screaming from frustration or pain.

What are the effects on the family carers of people with dementia?
There are six main things that disrupt the sleep of family carers:

  •  Having to provide physical care
  •  Being ready to give care
  •  Keeping an watch over them
  •  Disruptions because of what the person with dementia does
  •  Worry
  •  Continued sleep disruption even after care duties end
  • It helps if carers know about these concerns and understand they are not unusual. They can start to deal with them with support from helpers or health care providers.
Drowsy Driving

Have you ever driven while drowsy? 
Many people drive while they are drowsy. Some are able to recognise that there is a problem, but most are unaware that their driving is being affected. Sleepy drivers start yawning, their eyes go out of focus and they cannot remember driving the last few kilometres. A survey in the US found that as many as six in ten drivers drive while they are drowsy. The problem is that people are very bad at knowing whether it is affecting their driving and whether they are too drowsy to drive. Falling asleep happens quickly and without much warning.

How bad can it make your driving?
If you drive after 17 hours without sleep, your performance is as bad as driving with a blood alcohol level of 0.05 percent. Getting up at 7 in the morning, staying awake during the day, going out in the evening and then driving home at midnight gets you to this level.
Twenty four hours without sleep is as dangerous as driving with a blood alcohol level of 0.10 percent.

Who is most at risk?
Statistics show that more than half of the drowsy driving accidents involve people 25 years or younger. Shiftworkers are also at high risk, as are long distance truck drivers. People with sleep disorders such as Central Sleep Apnoea and Obstructive Sleep Apnea have a much higher risk of having an accident that is due to their sleepiness.

What are the warning signs?
Usually, there are warning signs that indicate that there is a high risk that an accident will occur. These are:

  •  Sleepiness
  •  Eyes closing or going out of focus
  •  Trouble keeping the head up
  •  Cannot stop yawning
  •  Wandering thoughts, difficulty concentrating on driving
  •  Cannot remember driving the past few kilometres
  •  Drifting between lanes, off the road or miss signs
  •  Very heavy eyelids
  •  Slow blinking

What strategies can help prevent drowsy driving?
If you need to drive a long distance, particularly at night or in the sleepy period straight after lunch, make sure you have had plenty of sleep the night before. Most accidents happen when you have had less than 6 hours sleep. If you have to drive for long periods of time, try to take a short power nap after lunch. A buddy system is a great idea and works well – share the driving and share keeping each other awake. Have a break every two hours, get out of the car and walk around for a few minutes. Don’t rely on coffee, loud music, open windows or passengers to keep you awake. The best cure for drowsiness is sleep. If the warning signs are there, you should stop driving and take a break.

How long should a “power nap” be?
A short nap may refresh you enough to continue driving for another couple of hours. Pull over to a quiet spot, put the seat back and take a nap of about 15-20 minutes, no longer. After your nap get out of the car, walk around for 5 minutes and then drive on. Be aware of the signs of drowsiness and avoid the temptation to go just that little bit further.

Does caffeine help?
Caffeine does offer some short term help with alertness which may help for an hour or two. Sugar is not helpful and can make you sleepier after 30-90 minutes than if you had no sugar.

How many accidents are caused by drowsy drivers?
Road accident statistics show that at least one in six crashes are mainly the result of drivers not concentrating and paying attention to the road. Up to one in four accidents on country roads that involve only one car are due to the driver falling asleep. In Australia, the cost to the community of drowsy driving road accidents is estimated to be $2 billion every year.

Facts About Dreaming

We all dream every night
Our brains are active throughout the night. But after we wake up, we often don’t remember much about our dreams.

We dream most vividly during Rapid Eye Movement (REM) sleep
Some of our sleep has vivid, structured thoughts – or dreams. These occur during a stage of sleep that is called REM sleep. REM sleep occurs in short episodes across each night each about 90 minutes apart. Our longer dreams are in the morning hours.

We are specially wired not to act out our dreams
During REM sleep many of our muscles relax completely and this prevents us acting out our dreams. If this system doesn’t work properly we may try to act out our dreams, especially if the dreams involve strong emotions.

Many dreams are bizarre because part of our brain shuts down
When we are awake the front part of our brain controls how we make sense of the world. This shuts down during dreaming. Because of this, the dreaming brain puts together ideas that normally do not go together.

Most dreams relate to recent awake experiences
Dreams are often linked to real life events from the past. Usually these are events or thoughts from one to two days before the dream.
We dream in pictures
About two thirds of dreams are mainly visual, with fewer that involve sounds, movement, taste or smell. Colour is only in about a third of all dreams. It has been said that when we are awake we think in ideas, but when asleep we think in pictures.

We can learn to control our dreams
Many people have bad dreams or nightmares. These can happen over and over again. But people can change the events in these dreams to be less frightening. First, write down memories of the scary dream. After this think about how it might end differently.

Scientists disagree about the meaning of dreams
Some people say our dreams mean nothing. They say we have them only because parts of our brain are stimulated when we sleep. Other people say dreams have value. They say it is a kind of therapy for when we’re feeling down. Having and remembering vivid dreams about stressful things in our lives may help deal with stress. Many people think that dreams contain messages, but the evidence for this is weak.

Fatigue as an Occupational Hazard

Do ‘sleepiness’ and ‘fatigue’ mean the same thing?

Often people use them as if they do mean the same thing. Both are linked with feeling “tired”, but are two distinct conditions.

Sleepiness is when you feel that you need or want to sleep. It happens because of not getting enough good quality sleep. Sleepiness is one of the main symptoms of fatigue. But fatigue is more than just feeling sleepy. It also refers to physical and mental symptoms such as slower reaction times, poor mood, inattention and trouble focusing. As well as not getting enough sleep, fatigue can be due to (or made worse by) things to do with work, such as undertaking long hours, shiftwork, stressful or boring tasks and the work environment. The risk goes up if your workplace has a lot of noise, heat, cold, vibration or poor ventilation.

How can fatigue affect your work performance or safety?

Fatigue is recognised by relevant government authorities as a workplace health and safety risk and must be treated as such.Fatigue impairs you as if you were drunk or on sedative drugs. In fact, studies show that 17 hours without sleep impairs your driving in the same way as having a blood alcohol level of 0.05 percent.

In addition to this, fatigue worsens your hand-eye coordination and makes it harder for you to communicate. Your brain does not process information or solve problems as well as it should. You also tend to take more risks. This means that your chance of making errors goes up. In turn this can be a danger to the health and safety of you and those around you. To make things worse, as you become sleepier, you are less aware of your reduced performance.

Fatigue has been found to played a role in many well known serious industrial events, such as when the Chernobyl and Three Mile Island nuclear power plants blew up, the Exxon Valdez ran aground, the Challenger space shuttle crashed and when Shen Neng ran aground on the Great Barrier Reef.

Who is most at risk?

Anyone who has sleeping problems, untreated sleeping disorders or who is just not getting enough sleep may be fatigued.

Shift workers are especially at high risk. They often need to work at a time when their body clock says they should sleep. They may also have to try and sleep when their body clock is geared to being awake and active. In fact, research has found that shift workers have 1-2 hours less sleep on average per 24 hours than non-shift workers.

If you do safety-critical work (such as driving and using heavy vehicles and machinery) then you are also at risk. So are people making important business decisions.

If you have a long commute to and from work, your risk may also be higher because of  less time for rest and sleep.

Also, if you often travel across time zones for work, you are at risk of jet lag. Travellers may also suffer due to getting poor sleep in unfamiliar places.

Who is responsible for managing fatigue at work?

Managing fatigue in the workplace is a shared responsibility. Under Work Health and Safety laws, all people in the workplace are legally responsible for preventing fatigue.

The employer is responsible for making sure the work conditions are safe. This applies to things such as roster design.  They must be able to clearly explain how they control risks linked to fatigue.

The worker is responsible for turning up to work fit for duty including not being impaired by fatigue. This means making sure that you have enough sleep between work shifts. You must also let your employer know if you think that you may be fatigued.

What should I do if I feel sleepy or fatigued at work?

Stop! Take a break. If you need to, let your supervisor know. It’s important that you know your organisation’s policies and procedures relating to fatigue management. Depending on the case, you may need to take a 15-20 minute ‘powernap’. Caffeine may also help.

Herbal Remedies and sleep

Why try herbs to help your sleep?
About 40% of people use alternative or complementary medicines at least occasionally. This can be for many reasons, including problems with sleep. Some people who are concerned about using sleeping pills will turn to herbal remedies to help them sleep (see our page on Sleeping Tablets). Melatonin is not a herbal remedy (for more information see Melatonin).
Has the effectiveness of herbs in treating sleep problems been adequately studied?
Studies of the effectiveness of herbs for sleep problems have not always been as thorough as they should have been. Sometimes it seems that the treatment works well, however with any new treatment it is important to check that this effect is not simply a placebo (or dummy) effect that could have occurred if a sugar pill had been taken. Many studies of herbal remedies have failed to properly compare outcomes with those from a placebo treatment.
For some herbal remedies disappointingly few studies have been done. One reason for this is that herbs cannot be patented, only an active chemical ingredient of the herb. Trials testing effectiveness are expensive and, without a patent, companies may not be able to recover their costs through guaranteed sales, even if the herb has potential.
However there have been studies of some of the herbs used for insomnia and anxiety. Here we focus on herbs where reasonable information exists from clinical research trials. We only examine herbs that have been studied as a single product, rather than blended with other substances.
What does the evidence say about herbs helping sleep?
In the table below, we look at the effectiveness of nine herbs in the treatment of insomnia. The order in which they are listed is based on the strength of the evidence that they are effective (strongest first). The first column shows whether the herb has been found to work in a trial in humans, comparing the herb to a placebo. This is the best type of study to see if it helps or not. The second column shows whether there are other (animal or laboratory) research findings that the herb helps insomnia, but this evidence is not as strong as evidence from a human trial. The third column shows the strength of results across all the trials for insomnia. There are three possible levels of evidence that can be found. If well-run studies have found consistently good results, the level is High. If the results are mixed but mainly good, the level is Medium. If there is a mix of both good and poor results, the level is Low.
If we look at the first column of the Table we can see that of the nine herbs listed, the first four have been shown to help with insomnia in some human clinical trials. These are Kava, Valerian, Passionflower and Hops. Three of these also have some support from animal or laboratory studies. The third column summarises the evidence and the findings suggests that, on the whole, the supporting evidence for treatment of insomnia with these herbs is Low. In many cases a conclusion has not been reached because insufficient quality research has been done to make a judgment about their role. The overall conclusion is that the evidence for any of these herbs helping with insomnia is fairly weak.

INSOMNIA
Herbal MedicineSome support via human clinical trials?Some support via animal or test tube studies?Evidence level for helping insomnia
Kava (Piper methysticum) YesYesMore research needed
Valerian (Valeriana spp.)YesYesLow
Passionflower (Passiflora spp)YesNoLow
Hops (Humulus lupulus)YesYesMore research needed
Sour date (Zizyphus jujube)NoYesMore research needed
Mimosa (Albizia julibrissin)NoYesLow
Lavender (Lavendula spp.)NoYesMore research needed
California Poppy (Eschscholzia californica)NoYesMore research needed
Chamomile (Matricaria recutita)NoNoMore research needed

What about these herbs and anxiety?

We know that some people have difficulty sleeping due to anxiety (see Anxiety and Sleep). Clinical trials in humans has shown that three herbs perform reasonably well in reducing anxiety These are Kava, Passionflower and Chamomile. It was concluded that Kava had a High evidence level for its anxiety reducing effects, while Passionflower and Chamomile had Medium evidence levels.

What kind of things may affect the results of a study?
Not all researchers use the same methods to select people for their studies and they might not assess all types of insomnia. It is possible that herbal remedies may be more effective for some types of insomnia than others but more research is needed to confirm this. As well as this, we can’t be sure that all of the studies used the same strengths of extracts from the herb.

Can I expect herbal cures to work straight away?
Most studies look at the effect of the herbs over a number of weeks. Hence it is best to not expect results after one or two nights. Valerian, in particular, is known to take time to start to work. Thus, if it is going to help sleep at all, it tends to take two or three weeks before there is an improvement.

Are the herbal remedies safe to use?
There have been some worries about the safety of Kava. A 2002 review of its safety found that Kava extracts seem to be safe for most users. However this is only when taken in the short term and at doses that are not too high. Unfortunately, some Kava users have been found to suffer serious side effects, e.g. liver problems. More research needs to be done on this. Also, studies have found that it might not be safe to take Kava together with benzodiazepines (the type of drug in many sleeping tablets).

Main Reference Source:
J. Sarris, A. Panossian, I. Schweitzer, C. Stough, A. Scholey (2011) Herbal medicine for depression, anxiety and insomnia: A review of psychopharmacology and clinical evidence. European Neuropsychopharmacology, Volume 21, Issue 12, December 2011, Pages 841–860.

Additional Reference Sources:
D. Wheatley (2005) Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability. J Psychopharmacol, Volume 19, Pages 414-421.
C. Stevinson, A. Huntley, Ernst E. (2002) A Systematic Review of the Safety of Kava Extract in the Treatment of Anxiety. Drug Safety, Volume 25, Number 4, Pages 251-261.

Incontinence (Nocturia)

What is Nocturia?

Nocturia is the need to get up during the night to urinate, thereby interrupting sleep. Sleep occurs before and after each time you wake up.

What are the most common types of nocturia?
There are three main types of nocturia: 1) nocturnal polyuria (or overproduction); 2) bladder storage problems; and 3) mixed nocturia.

Nocturnal polyuria
People with nocturnal overproduction (polyuria) make excessive urine during sleep and less during the day. This may be due to a problem with the body clock or sleep apnoea. There are a few other conditions that can also play a part, e.g. diabetes, kidney problems, heart trouble, too much caffeine and some drugs.

Bladder storage problems
In this case, the bladder either cannot store enough urine or does not empty completely. The result is that you go to the toilet more often, but pass little urine each time. In men, it may be due to having an overly large prostate (which blocks the bladder outlet).

Mixed nocturia
The third type of nocturia is known as ‘mixed nocturia’. This is a mix of both nocturnal polyuria and bladder storage problems. It is often associated with chronic medical problems.

Common causes of nocturia?
How to treat nocturia depends on the cause. This needs to be worked out in order to plan treatment. Some of the possible causes of nocturia are

  •  prostate problems, a very common cause in men.
  •  hormonal imbalance, such as a lack of oestrogen in women.
  •  pregnancy. Pregnant women often have to go to the toilet several times during the night because the womb presses on the bladder. This resolves after the baby is born.
  •  side effects of some medications.
  •  problems with the kidney and/or bladder.
  •  heart disease.
  •  sleep disorders, such as sleep apnoea, body clock problems, insomnia.
  •  lifestyle factors, such as having too much caffeine and alcohol.
  •  drinking too much fluid, particularly at night. This may sometimes be due to medications taken at night.
  •  menopause, which weakens bladder control.

What is the impact of nocturia?
Nocturia can be an indicator of a medical problem and underlying causes need to be looked for. As well as this, nocturia can cause problems due to broken sleep. This will affect how people function during the day. It may lead to tiredness, undue sleepiness, irritability, or not being able to concentrate. These are all problems for work, study, health and enjoyment of life.

Is nocturia the cause or the result of poor sleep? 
Sometimes other causes of disturbed sleep, such as sleep apnoea and insomnia can cause nocturia simply because waking up prompts you to go to the toilet. In such cases, treating the cause of the disturbed sleep fixes the problem. To get to the bottom of why you have nocturia, it is best to discuss the matter with your doctor.

What might you do?
Many people think that nocturia is a ‘normal part of getting old’ and that little can be done to treat it. This is not true. Sometimes it can occur suddenly and it is obvious that there is a problem. Often it comes on gradually and is too readily accepted.

There are some things that you can do to try to help tackle your nocturia. For example you should try cutting down how much alcohol and caffeine you have; quit smoking; lose weight; post-menopausal women can do pelvic floor exercises; manage constipation; reduce the stress in your life and deal with poor sleep patterns. Limiting fluids in the 2 hours before bed can help, but restricting fluids should not be overdone. If a ready answer is not there then you should discuss the problem with your doctor. Sometimes specialist help is needed.

Where and when should you seek help?
Not every person with nocturia needs treatment. Whether or not a person seeks help often depends on how much it is getting in the way of good sleep. Most people find it is a problem if they need to get up to go the toilet twice or more each night.

If it does not bother you, then you may not need treatment. But you should still keep in mind the link between nocturia and other health issues.

How is it checked out?
Your doctor will need to work out the cause. This will require a medical history including screening for sleep problems (especially sleep apnoea), a physical check and a urine test. The doctor may ask you to keep a record of your trips to the toilet during the night. This is often known as a frequency volume chart or voiding bladder diary. In it, you record when you go to the toilet at night and how much urine you pass. You should keep it for at least 24 hours, and ideally for at least three days. You also need to record what fluids you have and when you have them. Based on this, your doctor can work out what type of nocturia you have and can refer you to the right service or specialist e.g. a urologist, sleep specialist or endocrinologist.

Melatonin

What is melatonin?
Melatonin is a hormone that is produced by the pineal gland in the brain. Melatonin levels vary in 24 hour cycles and are controlled by our body clock. Normally its production is reduced by being in bright light. Levels increase at night. This is why it is often called ‘the hormone of darkness’. But in fact the word melatonin itself means ‘skin whitening’. This is due to how it affects skin in some animals. But it does not change the skin colour of humans. Some plants have small amounts of melatonin as well. These include plants we use as food.

Where is it found?
Once it gets into the blood melatonin goes to all parts of the body.

What does it do?
Melatonin appears to be important in helping regulate the internal body clock’s cycle of sleep and wakefulness. Other claims are made for it: it has anti-oxidant and free radical scavenging properties and some say it has anti-cancer and anti-ageing effects, but there is no proof for this in humans.
In regards to sleep, your blood melatonin level starts to go up about 2 hours before you go to sleep. It helps establish the conditions for sleep and your core body temperature to go down slightly at this time.

What can you use it for?
Melatonin is used to treat insomnia. There are two ways that you can use it. The first is as a sedative, to make you feel sleepy. This is the most common use. The second is to help reset your internal body clock to a different time in conditions where it is out of synchrony with time of day, such as with jet lag or advanced or delayed sleep phase syndrome. In these cases melatonin therapy at night is often combined with Bright Light Therapy. Light is applied in the morning (usually using outdoor light) in the case of jet lag or delayed sleep phase syndrome or in the evening (using special lights) in the case of advanced sleep phase syndrome (see also Delayed Sleep Phase Syndrome). Recently a synthetic form of melatonin has also been developed to treat depression.

How much should you take?
Daily doses of 0.5mg to 5 mg appear similarly effective, although sleep onset may be quicker at the higher dose. There does not appear to be any advantage in taking more than this. The most commonly available preparation in Australia contains 2 mg. It is in a slow release form to last throughout the night, much like the naturally-occurring melatonin. However the slow release formulation does not allow a short high peak level which some argue helps with sleep onset. All melatonin tablets need a doctor’s prescription in Australia (but not in North America).

When should you take it?
If you take melatonin to go to sleep, the best time (for the slow release type particularly) is about an hour before you go to bed. However, some people feel a “wave” of sleepiness some 20 minutes after taking it and make the most of this by being in bed ready to sleep at this time. You may have to experiment a bit with when you take it. Discuss this with your prescribing doctor.

You can also take it to adjust the body clock, for example when you are crossing time zones to minimise jet lag. You should take it close to target bedtime at your destination. The benefits are greater where more time zones are crossed and for eastward flights more than westward flights. (See Tips to Combat Jet Lag)

Can it cause problems?
Melatonin can cause sleepiness and so should not be taken before driving or operating machinery.
Melatonin’s main benefit is in reinforcing external cues for sleep or as a tool to help shift sleep-wake rhythms. Long term use of melatonin is only appropriate if prescribed because of a significant, underlying sleep disorder.
Side effects are uncommon. These and its compatibility with your other medicines should be discussed with your prescribing doctor.

Menopause and Sleep

How does sleep change during the menopause?
Many women report that it is more difficult to sleep well during the menopause. They say that it is not as easy to get to sleep or to stay asleep and they also tend to wake up earlier than planned. This may be due to less oestrogen in the body. After the menopause, sleep will improve.

What about hot flushes, cold sweats and night sweats?
During the menopause, the levels of hormones in the body change. This means that the body temperature is less stable and sometimes there are surges of adrenaline. When this happens, a hot flush is felt. All of these can happen during the day or at night. Women tend to wake up just before a hot flush occurs. Experts think that both the waking up and the hot flushes are caused by the same thing.

Does this happen to all women as they go through menopause?
Before menopause, about 30% of women say they have some type of problem sleeping more than three times a week. But for women in menopausal transition, this percentage goes up by two to three times. It can take a long time for sleep to settle down again for women after the menopause. We do know that women in menopausal transition who find it the hardest to get to sleep and stay asleep are also the ones who tend to have other problems, particularly hot flushes and sweats.

Is poor sleep at this time of life always due to hormonal changes?
It can be hard to know how much sleep difficulties are linked to hormonal changes rather than just getting older (see Ageing and Sleep). We also know that women’s risk of depression is higher in menopause. Hormonal changes may not be the only reason for this (see Depression and Sleep). Menopausal hormonal changes may be linked with Obstructive Sleep Apnoea. This leads to trouble breathing which can get in the way of your sleep and be bad for your health. Oestrogen loss around the time of menopause makes body fat move more to the stomach area. This increases the chances of snoring and having sleep apnoea. For some women Restless Legs may affect their sleep. However it is not certain that this is linked with menopausal symptoms.

What can help?
There is a view that hormone therapy (HT) may help with sleep during menopause, but there is no proof for this yet and the issue needs more study. Some studies have found HT is slightly helpful for sleep but others have shown no consistent benefit. If you are thinking of HT it is best to discuss this with your doctor and weigh up the pros and cons.
It can help if you sleep in a cool room where air can flow through freely (e.g. using a fan). Avoid heavy bedclothes or tight bedspreads. If you can put your feet outside the blankets, it will help cool down from a hot flush. Sleep in light sleep wear. Cotton is best.
Make sure that you have good sleep routines. This will help you get the best sleep that you can (see Good Sleep Habits).

Napping

Why nap?

If we don’t have enough good quality sleep, we may feel tired and sleepy during the day. This can make it difficult to do our normal daily activities. Naps may help to make us more alert, active and better able to cope during the day.

When can naps be good?
Sometimes we know in advance that we will not be able to sleep when we usually do, for example when going out in the evening and staying up late. A nap beforehand can improve performance at this time and help you to enjoy what you are doing. Such naps can also help in the case of night shift work – a nap before the shift can help you stay awake at work. Also, if you know that you have a long drive ahead, a preparatory nap may help you to stay awake for longer and drive more safely.

Naps can also be good at times when you feel sleepy and you are worried about how well you can do things if you continue without rest. If you feel drowsy during a long drive in the car, a short nap can be taken in a rest area. This will make you more alert during the next phase of the drive.

Some studies have found that if you start to feel sleepy while driving, it helps to have a cup of coffee, immediately followed by a nap of about 15 minutes. The caffeine takes about 30 minutes to start working so when you wake up both the nap and the caffeine will start to make you feel more alert.

How long is a good nap?
When you feel sleepy, it is best to nap for 15-30 minutes. This will improve your alertness and concentration. It is often called a power nap. A short nap of this length may reduce the risk of falling asleep. Sleeping for a longer time is not as effective. After a long nap, you may wake up feeling groggy. This is called sleep inertia. It can make it more difficult to do things well. It may last for a few minutes but can last much longer. Having sleep inertia is more likely if you are not getting enough sleep at night, if you have taken a long nap, or if you have been woken suddenly from a deep sleep.

How can I make my nap better?
Not all people are able to nap during the day. Here is some advice that may help you to nap.

  •  If you nap regularly, you should try to nap at the same time each day. We often feel most sleepy in the early afternoon, around 2 – 3pm. Being able to sleep during a nap may be easier at this time of day than trying to nap at another time.
  •  You should nap in a quiet, dark place that is at a comfortable temperature. Close the curtains or wear an eye mask to make it as dark as possible.
  •  Set the alarm for no longer than 30 minutes, so you know that you won’t sleep for too long.

What care should be taken with napping?
When you get ready to take a nap you should make sure you are in a safe place. If you are in your car, make sure you park away from the road, preferably at a rest stop.

Be mindful of the risk of feeling disoriented (i.e. sleep inertia) after waking from a nap. At the end of every nap, be sure to take enough time to wake up fully before starting anything that might be a danger. If you nap during a break from a long drive, take a few minutes to walk around the car after your nap and only get back behind the wheel when you are fully alert.

Do not spend too much time napping during the day. This can make it more difficult to sleep well at night. Naps too late in the day can also be bad for your sleep at night. They may make it harder to fall asleep at your usual time.

A nap during the day does not replace good quality sleep at night. You should make sleep during the night a priority and use napping only when night-time sleep is not enough. If you have a problem with your sleep at night (that is not due to too much napping during the day) consult our other information pages (e.g. Good Sleep Habits or Excessive Daytime Sleepiness) and talk about it with your doctor.

Nightmares

What are nightmares?
Nightmares are vivid scary dreams. They tend to wake you up. They may often also stop you going back to sleep due to fear. Many children have them, but they tend to stop between ages 9 to 11. If they keep going past this age and are not due to stress or trauma, then the person might keep having them for the rest of their life. These are known as idiopathic nightmares (start in childhood and not from trauma). They can also start at any age after periods of stress, trauma, and the start of a mental or physical illness. A child will often dream of frightening imaginary creatures e.g. monsters or ghosts. An adult may dream images of events which either threatening or harmful in some way. These can be real or imaginary. Nightmares with a link to trauma tend to have vivid images from the event e.g. assault, bushfire, accident, war etc. No matter what the cause, they tend to have the same effects:

  •  Waking up suddenly due to the nightmare. This often occurs about 90 minutes after going to sleep. It can occur over and over for the rest of the night. The time between them is often around 90 minutes.
  •  Rapid heart rate as well as fear. The person may sweat.
  •  Seeing vivid images or scenes where something bad was done to the person e.g. humiliated, threatened or harmed.

If a child or adult becomes very distressed in their sleep but has no memory of this in the morning they may be experiencing a Sleep Terror.

2. What causes them? 
Nightmares tend to occur in the same stage of sleep when you dream. This is known as dreaming sleep or REM sleep. REM stands for Rapid Eye Movement. In REM sleep normal dreams occur. This may play a part in how we remember and process information that we took in during the day. In a child, REM sleep may be more intense. Their imaginations may be more vivid too. This may lead to some of their dreams causing high levels of fear or confusion. In adults, nightmares are far less common. But they can still happen as a result of stress or trauma (see Post Traumatic Stress Disorder and Sleep). People with a mental illness e.g. schizophrenia, may have them as well. There are other things that can set them off too such as sickness, medicine and drugs.

3. How common are they?
10% to 50% of children have them. The number of adults who have nightmares is much less, from 2.5% to 10%.

4. How do they affect people?
Nightmares wake you up suddenly. This can make it hard to go back to sleep. If they happen a lot, you might not get enough sleep at night. A few people get so scared of nightmares that they try to avoid sleep. This can affect your mood during the day. You may feel anxious and depressed. This is especially so with nightmares due to trauma.

5. How can nightmares be dealt with? 
In a child, they tend to just be part of growing up (i.e., not due to any major trauma). If so, the parents should simply reassure the child after a nightmare. With time they should go away. In adults there are ways to treat them such as counselling as well as methods to teach how to change the nightmare (e.g., learning to change the story line). There are also medicines that make dreams less intense or occur less often. These work both with nightmares due to trauma and other types. Teaching how to control dreams (e.g. story line alteration) works quite well in adults and even better in children.

6. What could you do to help?
There are ways to make nightmares happen less often. You should be sure to relax enough in the hours before bed and keep regular sleep and wake hours (see Good Sleep Habits). Try to reduce overall anxiety. Avoid alcohol. Parents can make sure that your children have some quiet time before bed.

7. Where and when should you seek help?
If you or your child keep having nightmares and this is having an impact on well being (e.g. not getting enough sleep at night, being in a bad mood during the day) then you should talk to your GP. If the nightmares are from trauma, illness (physical or mental), medicines or drugs you could speak to your doctor about these issues.

8. What might your doctor do?
Your doctor can refer you to psychologist or sleep specialist. From them, you can get treatment to control your nightmares as well as information to help you sleep more soundly. They may also train you on how you can change what happens in your dreams to make them less threatening or frightening. If your nightmares are due to trauma in your life you should get counselling for this. There are also paediatric sleep specialists or child psychologists who can treat children.

Oral Appliances to Treat Snoring and Obstructive Sleep Apnea

What are oral appliances?
Oral appliances are one of the options that you can use to treat mild or moderate obstructive sleep apnea, as well as snoring. They are also called Mandibular Advancement Splints (MAS) or Mandibular Advancement Devices (MAD) or Mandibular Repositioning Appliances (MRA). They look a bit like a mouth guard. At night, before you go to bed, you put it in your mouth. There is no need to wear it during the day.

How do they work?
They push your lower jaw forwards. Your airway will open up more and there will be less of a risk that it will vibrate (snore) or obstruct.

How well do they work?
As with all treatments, some people respond better than others. The oral appliance will work best if you have mild to moderate sleep apnea, if your sleep apnoea is a lot better when you lie on your side than when you lie on your back and if you are not overweight. If you have central sleep apnea (less common than obstructive sleep apnoea), then oral appliances will probably not help. But until you have tried it, no one can say for sure how well it will work for you.

How well do they work compared to CPAP?
CPAP (Continuous Positive Airway Pressure) will stop sleep apnea straight away in almost all people who use it. An oral appliance will usually improve your sleep apnea, but it may not completely stop it. So if you have moderate or severe sleep apnoea, CPAP may be a better option.

Does it have any side effects?
If fitted correctly, it should be comfortable most of the time. Because it pushes your jaw forward, some people feel discomfort initially, but this tends to get better with prolonged use. Mostly, any discomfort is in the joint at the back of your jaw, just in front of the ear. This should soon go away when you take the appliance out in the morning. Other people find that it causes saliva to build up in the mouth, or makes the teeth feel tender. Again, these symptoms settle quickly with continuing use. Over the long term, there may be tooth movement, changes in your bite or problems with the joint and muscles of the jaw. It is important to have a regular check up with the dentist who supplied the appliance to detect these problems early so they can be dealt with.

How can I get one?
Your GP can refer you to a sleep specialist. They will work out how bad your sleep apnea is and what can be done about it. You will probably have an overnight sleep study. You can do this either at home or in a sleep lab. It takes one night. After the sleep study, you will have another appointment with your sleep specialist to talk about which treatment will be best for you. If you decide on an oral appliance, your sleep specialist will refer you to a dentist who specialises in the treatment of sleep apnea. You will continue to be looked after by both the sleep specialist and the dentist.

Does it need to be specially fitted for me, or is there a one size fits all oral appliance?
Each person has a different mouth and jaw shape, so you should have one made to fit you. Your dentist will take an impression of your teeth and send the mould away for the appliance to be made. This usually takes 2 or 3 weeks. When it is fitted into your mouth, it will be adjusted so that it moves your jaw forward to a position that will be effective but is still comfortable. The device will have a screw adjustment to allow further fine tuning of the position over the next few weeks. Your dentist will help supervise this.
There are some kinds of dental devices that you can buy over the counter. These are cheaper, but they usually do not work. You will be wearing a appliance for a long time, so it is best to have one fitted especially for you. This will make it work better and help avoid any side-effects. After the appliance is fitted, follow-up visits with your dentist or sleep specialist will be needed.

Can it be used to stop snoring?
Yes. If it is fitted properly, it works well for snoring.

How should I look after an oral appliance?
You should brush and floss your teeth before you put it in each night. Plaque can build up on an appliance just like on your teeth, so you need to wash it carefully each day. Make sure you dry it out fully. Also keep it in a place when children and pets can’t get at it.

I am using one, but I think it doesn’t work as well as it used to. What should I do?
Perhaps you have started snoring again, or feel tired during the day. If so, then you need to have it checked out. Your dentist might be able to adjust the appliance further. If it comes out when you are asleep, then you should have it looked at. It might not be fitted right. After a number of years some people using an oral appliance find they need to consider other treatments for their sleep apnea.

Post Traumatic Stress Disorder

How might PTSD affect sleep?
There are many sleep problems that may be associated with PTSD. For more information on the disorders metioned below see the relevant pages on our website.

  •  The extreme anxiety of PTSD (caused by trauma or catastrophe) can seriously disrupt sleep. In some cases this starts a few months after the event. You might suffer from horror or strong fear and feel helpless. See Anxiety and Sleep.
  •  People with PTSD have higher rates of depression and this is often associated with poor sleep. See Depression and Sleep.
  •  Side effects of medications used to treat symptoms of PTSD, such as those used to treat depression and anxiety, may cause sleep problems. Talk to your doctor about this.
  •  Nightmares. These may be ‘nocturnal flashbacks’ of the event that caused the PTSD. The nightmares may be linked to the PTSD in a symbolic sense, or they can be frightening and not make any sense.
  •  You may experience other problems with how you sleep such as sleep terrors, sleep walking, sleep talking, upsetting dreams and night sweats or REM Sleep Behaviour Disorder, where dreams are acted out.
  •  Insomnia. People with PTSD may have difficulty with getting to sleep or staying asleep. They may wake up frequently during the night and be unable to get back to sleep.
  •  Issues linked to the body clock, such as Delayed Sleep Phase Disorder may occur in a person with PTSD. If you can’t get to sleep until very late at night and then need to sleep in you may be experiencing this problem.
  •  Obstructive Sleep Apnoea may be caused by weight gain due to the life style changes associated with the PTSD. If the sleep apnoea is serious, medications such as Seroquel can be an additional danger.
  •  It is important to remember that poor sleep can make the other symptoms of PTSD worse.

How might these sleep disorders be treated in people with PTSD?

  • For many such problems it is important to keep Good Sleep Habits. People who are most at risk of PTSD include many professions where shiftwork may also be common, such as police officers, people in the armed forces, and those who work emergency services (e.g fire fighters and ambulance personnel). A person with PTSD who does shiftwork may need to pay special attention to maximising their sleep time and sleep quality. A sleep psychologist may be able assist.
  • Nightmares can often be successfully treated with Image Rehearsal Therapy (IRT). IRT is not much more than writing a script of the nightmare. The only thing is that the ending is changed to something happier. Every night as you go to bed, you read the script out aloud a few times. Then as you fall asleep you use a technique to relax. The nightmare happens, except that now it does not end badly. In time, it will go away. Success depends on the choice of the new ending. This means that it needs to be chosen carefully and a sleep psychologist can help.
  • REM Sleep Behaviour Disorder also responds well to Image Rehearsal Therapy. Often, treatment with the benzodiazepine Clonazepam (Rivotril) may be used.
  • Sleepwalking and talking can be dealt with by hypnosis. Often as part of the treatment you might learn methods to relax as you go to bed.
  • For military people with sleep disorders and PTSD, sleeping tablets often don’t work well. This is because their training has taught them to be alert around the clock. In brief, being on patrol means that it is hard to find the chance to sleep deeply at night. Hypnosis can work to help un-learn this.
  • Delayed Sleep Phase Disorder (DSPD), where the hours of sleep are later than usual, is common in those who have served in wars. A former soldier might not let himself / herself sleep until near dawn. The reason they do this is that they worry they will get nightmares if they sleep in the dark. So, over the years the body clock gets stuck on a sleep wake cycle that is not at the normal times. Or it can be that DSPD stems from years of military “shiftwork” schedules of army guard duty or ever changing watches in the navy at sea. Sleeping pills cannot change this body clock. All they do is mask the underlying problem, often without providing refreshing sleep. Melatonin may help with such problems.
REM Sleep Behaviour Disorder

What is RBD?
RBD happens when you sleep. It can lead to talking and shouting. It can make you move vigorously. You might have vivid, striking dreams as well. When this happens, people with RBD are seen to suddenly move or call out. They can look like they are acting out their dreams. The episode usually doesn’t go on for long. Often you might be able to recall what your dream was about when you wake up.

RBD can be a danger to both people with it and their bed partners. This can be due to the person with RBD responding violently to an imagined attack or because of vigorous movement of their arms and legs.

What causes RBD?
There are several types of sleep that occur every night. One of these is called rapid eye movement, or REM sleep. This is the time when you have your most structured dreams. Normally in REM sleep, the muscles should relax totally. But if you have RBD, your brain sends the wrong signals to your body muscles so they fail to relax during sleep. This means that when you have dreams you can act these out with bodily movement.

There are two forms of RBD. The first often occurs later in life (over 50 years of age) and more often in males. The cause is unknown. People with this form of RBD should be checked for the possibility of the development of neurological conditions such as Parkinson’s disease. The second form of RBD occurs as a side effect of medicines, such as a high dose of antidepressants.

RBD can be made worse if you also have another sleep problem, such as obstructive sleep apnoea.

How is RBD diagnosed?
The first step is to work out if the RBD is the side effect of a medication or if there is another obvious cause for it.

If no readily identifiable cause can be found, you need to see a sleep specialist for further investigation. He/she will check if you have any other sleep problems contributing to the RBD, for example obstructive sleep apnoea. Most of the time this assessment will involve an overnight sleep study. This is done in a hospital and includes a video recording.

How do you treat RBD?
This depends on the cause. If it appears to be due to a medication side effect, the drug responsible should be stopped if possible. If no specific cause is found there are drugs that can help, such as clonazepam which is generally effective in low doses. If you have been diagnosed with obstructive sleep apnoea or another sleep disorder then treatment of this may help the RBD.

Where and when should you seek help?
If you or your bed partner has symptoms of RBD then you should discuss this with your GP. He or she is likely to refer you to a sleep specialist, who might suggest an overnight sleep study.

Schizophrenia and Sleep

What is Schizophrenia?

Schizophrenia is a mental illness. About 1 in 100 people have it. It affects thoughts, behaviour, per-ceptions and emotions. It tends to start in the late teens or early 20s. People with schizophrenia can suffer from ‘psychosis’ when unwell. This means a loss of contact with reality. It includes problems such as:

  • delusions (fixed, false beliefs inconsistent with their social or cultural background).
  • hallucinations (e.g. hearing voices when no one is there).
  • strange actions (e.g. abnormal posturing).
  • trouble putting thoughts together to make sense and expressing ideas.

What sleep problems are common in people with psychosis?

Sleep hours tend to be less regular. Sleep may occur at any time of the day or night rather than for 7-8 hours overnight like most people.

Sleep hours may be too few or too many. Sometimes this can be due to the drugs used to treat the psychosis. It can also be due to the lack of a regular daytime routine. Such a routine helps our bodies know when to sleep and when to wake up.

It can be hard to get to sleep or stay asleep because of psychotic symptoms that cause fear or anxiety.

The patterns of sleep can change. There may be less deep sleep and more shallow sleep. This can make sleep less refreshing so that there is increased tiredness during the day.

A change in sleep patterns can be the first sign of the start of psychosis. Or it can mean that psy-chosis is coming back again after a period of being well. In other words, it can be a warning sign.

People with psychosis have a higher risk of Obstructive Sleep Apnoea (OSA) or Sleep Disordered Breathing. This is especially so if they have put on extra weight. OSA can worsen other health problems (both physical and mental).

Why do you need to get help for sleep problems in schizophrenia?

  • If you are already at risk of psychosis, sleep problems can increase this risk.
  • Sleep problems may be the first sign of onset or relapse of illness.
  • Sleep problems make it harder to get better.
  • Sleep problems cause other health issues.

How are sleep problems diagnosed?

Your doctor or health worker will ask questions about your sleep. They will ask about your mental health too. They may ask you to fill out some questionnaires. This is to help to work out the prob-lem.

They might ask you to keep a sleep diary. This is to keep track of your sleep. It tends to be done over two or more weeks.

They might refer you for a sleep study if they suspect something. This is done for one night.

They might ask you to wear an actigraph watch. This helps to monitor when you are active and sleeping all through the day and night.

How might the sleep problem be treated?

Tell your doctor about your sleep problem. They can’t fix a problem if they don’t know about it. Once they understand the cause of your poor sleep they will be able to help you.
Often sleep can improve with changes in sleep habits. See our link Understanding and helping poor sleep.
Short term use of sedatives (sleeping tablets or sedative antipsychotics) can help when you are very unwell and your symptoms stop you from sleeping. Melatonin and bright light can help reset your body clock.

Changing the type, dosage or timing of your psychosis medication may help your sleep problems (e.g. some schizophrenia medications tend to make you sleepy). Be sure to discuss possible changes with your doctor first. If you are too groggy in the morning, you might need to take it earli-er at night. Or you can change when you do things each day so that you do not have important things to do in the mornings.

Sleep Mistakes

1. Not going to bed and getting up at consistent times each day
Some of us can get away with changing the times we go to bed and get up. However many people cannot. These people do far better with regular hours of sleep. This lets our internal body clock build a strong sleep wake cycle. Going to bed and getting up at similar times is good. This goes for both weekdays and weekends.

2. Poor sleep environment
The bedroom should be quiet, dark and comfortable. It’s important that it is not too cold or too hot. Comfortable mattress, pillows and blankets are also essential. Electronic equipment can distract you. These include computers, TV and mobile phones. It is best to leave them outside the bedroom. Do not have a clock that you can see overnight, turn it around to face the wall.

3. Not getting ready for sleep
Many of us need to wind down before sleep. Steer clear of vigorous exercise in the late evening. Make sure your last meal of the day is at least two hours before bed. In the hour before bed, avoid computer games. TV shows that disturb or stimulate you are also not a good idea. Relaxation routines can help, as can quiet music. If you need a snack, make it a light one.

4. Spending too much time napping during the day
Long daytime naps can get in the way of a good night’s sleep. They can make it hard to break bad sleep habits. Only nap if you really need to. If so, keep the nap short, no more than 20 minutes. Naps longer than an hour can make you feel groggy afterwards. You might find it hard to get going straightaway. Do not nap after mid afternoon.

5. Frequent use of sedative drugs
Sedatives do not deal with the cause of sleep problems. You can become addicted to them and it can be hard to suddenly stop. Also the longer you take them, the less they will work. This means they are really only a short term solution for a short term problem, such as severe grief or stress.

6. Using alcohol to help sleep
Alcohol is a “downer” like sedatives. It can help you get to sleep. But the problem is that it disturbs the quality of sleep. Overall, it is bad for your sleep.

7. Television in the bedroom
TV can stimulate you. It is a distraction in the bedroom. If you fall asleep with the TV on, you will often wake up again. Then you may start following the show again. This does not build good sleep habits. Get the TV out of the bedroom.

8. Staying in bed when unable to sleep
Staying in bed if you can’t sleep can make you annoyed and frustrated. It is better to get out of bed and go to another room. Stay there until you feel sleepy. Eventually, you will start to want to sleep. Sleepiness comes in waves, wait for yours and go back to bed then. To stay in bed feeling upset is to start to build a link in your mind between the bed and lack of sleep. This is the opposite of what you need.

9. Thinking the problem with your sleep is worse than it really is
Many people who find it hard to either get to sleep or stay asleep become worried about it. They think they have less sleep than they really do. Often poor sleepers are not good at knowing whether they are awake or asleep. Use relaxation as one of the techniques to help. Tell yourself that rest is good, even if you are not asleep.

10. Ignoring the possibility of having a specific sleep disorder that needs attention
Some people with sleep problems have something specific that is causing this. It could be obstructive sleep apnoea or restless legs syndrome, or it could be a drug side effect. If you think this applies to you, discuss this with your doctor.

Sleep Needs Across the Lifespan

How do our sleep needs change with age?

It is well known that as children get older they need less sleep. Different people have different sleep needs. The advice in the table below is only a guide. You can make a good guess if a person is sleeping enough at night – observe how they act and function during the day.

AgeRecommendedMay be AppropriateNot Recommended
Newborns
0-3 months
14 to 17 hours11 to 13 hours
18 to 19 hours
Less than 11 hours
More than 19 hours
Infants
4-11 months
“12 to 15 hours “10 to 11 hours
16 to 18 hours
Less than 10 hours
More than 18 hours
Toddlers
1-2 years
11 to 14 hours9 to 10 hours
15 to 16 hours
Less than 9 hours
More than 16 hours
Preschoolers
3-5 years
10 to 13 hours8 to 9 hours
14 hours
Less than 8 hours
More than 14 hours
School-aged Children
6-13 years
9 to 11 hours7 to 8 hours
12 hours
Less than 7 hours
More than 12 hours
Teenagers
14-17 years
8 to 10 hours7 hours
11 hours
Less than 7 hours
More than 11 hours
Young Adults
18-25 years
7 to 9 hours6 hours
10 to 11 hours
Less than 6 hours
More than 11 hours
Adults 26-64 years7 to 9 hours6 hours
10 hours
Less than 6 hours
More than 10 hours
Older Adults
≥ 65 years
7 to 8 hours5-6 hours
9 hours
Less than 5 hours
More than 9 hours

The above sleep duration recommendations are based on a report of an expert panel convened by the US based National Sleep Foundation and published in 2015 in their journal Sleep Health. 

How does napping change with age?

From birth to two months of age, the length of one period of sleep can be from 30 minutes to 3 – 4 hours. This is throughout the day and night. Babies fed from the bottle tend to sleep for longer at a time than breast-fed babies (3-4 hours versus 2-3 hours). See also Tips to Help Babies Sleep Better.

From 2 months onwards babies start to sleep for longer at a time. This is especially so at night between 12 midnight and 5am. The reason for this is that they start to develop their internal day-night (circadian) rhythm that favours sleep at night and being more awake during the day.

By 6 months of age, babies can get 5 – 8 hours of sleep at night. However 25-50% of 6 month olds still wake up at night. There are things that can be done to counteract this including ensuring that they learn to go to sleep in their cot by themselves at the start of the night. Then they are more able to self-soothe themselves back to sleep after waking up during the night.

From 2 months to 12 months, the number of daytime naps goes down from 3 – 4 naps to two naps. Morning naps usually stop between 12 and 18 months of age. Always give a chance for an afternoon nap after lunch and before 4pm. Daytime naps become less common from about 2 or 3 years onwards.

Consistent daytime naps after 5 years of age are not normal. The child might not be getting enough sleep at night. This may be due to poor sleep routines, sleep problems or sleep disorders. It may need to be followed up with a Sleep Specialist. See also Behavioural Sleep Problems in Children and/or Sleep Disorders in Children.

Why do teenagers want to stay up later?

In this age group, there is a change in the timing of sleep. It is natural for them to want to go to bed later at night and to sleep in. However this needs to be within reason and teenagers often need to be taught good sleep habits. They need to know that they won’t function as well during the day if they miss sleep and fail to catch up on it. See also Teenage Sleep.

Adult Sleep

Sleep requirements stabilize in early adult life, around the age of 20. Individuals vary in their sleep needs but most adults require between 7 and 9 hours a night to feel properly refreshed and function at their best the next day. Many try to get away with less sleep. There are some who are genuine short sleepers while other may require considerably more than the average requirement. The reasons for this individual variability in sleep requirement are not well understood.

Older adults spend more time in bed but unless a sleep problem has developed the requirement for sleep is similar to that in their younger adult life.

Sleep Specialists

The Australasian Sleep Association, the national professional body of sleep specialists and sleep scientists, maintains a list of sleep services offered by its members. These include services for adults and children.
This list can be found at: http://www.sleep.org.au/information/sleep-services-directory
The list specifies the services the individual specialist provides and covers all sleep disorders. Adult and paediatric sleep physicians (medical sleep specialists dealing with a range of sleep disorders), sleep psychologists (who specialise in insomnia and body clock disorders) and dentists (specialising in dental treatments for snoring and sleep apnoea) are listed.
Some of these services are located within hospitals. Many are not. Your GP will usually know of appropriate, good quality sleep services near to where you live. A referral from the GP or other specialist is required before an appointment can be made to see a sleep specialist. It is sensible to discuss your problems with your GP in the first instance.

Sleep Terrors

What are sleep terrors?
Sleep terror disorder means very strong feelings of terror and panic during sleep. You have them while you are in deep sleep. They are also sometimes called ‘night terrors’. They tend to happen fairly soon after going to sleep. Two thirds of the time, they are in the first period of deep sleep. Sleep terror is not as well known as nightmares. The reason for this is that they are not as common. They are sudden and intense but don’t last long. At most, they go for a few minutes. After they finish, the person doesn’t remember much about the episode, if anything at all. They tend to start before the age of 10. Most of the time, they will stop when the child is a teenager. Sleep terrors may occur as often as several times a week.

  •  A person going through a sleep terror might make noises, move their body and have tremors and sweats. They will tend to have more fear and worry than if they were having a normal nightmare.
  •  People who have sleep terrors often sleepwalk as well.
  •  If a person doesn’t stop having sleep terrors after the age of 10, the chances are they will still have them when they are an adult.

What causes sleep terrors?
Sleep terrors might seem to just come out of the blue. But there are several things that can play a part in causing them. They may run in families. Not getting enough sleep can also lead to sleep terrors. Chopping and changing the times you get up and go to bed is a risk as well. Some drugs have been linked to sleep terrors. In children, sleep terrors may be just a part of how they grow up (rather than from any major trauma).
There are also some disorders that are associated with sleep terrors. These include obstructive sleep apnoea, seizures, gastric reflux and fevers. You can also set off a sleep terror in a person who is vulnerable to them if you disturb them when they are asleep e.g. by touching them or with noise.

How common are sleep terrors?
Most children never have sleep terrors. They occur in between 1% to 5% of children. In adults it is even less, about 1% to 2%.

How does it affect people?
Sleep terrors can wake you up suddenly. You might feel confused. The quality of your sleep is worse. Every now and then it can lead to problems going back to sleep. People who have sleep terrors may not get enough sleep. This can make them not function as well during the day. Changes in the sleep pattern due to sleep terror can lead to anxiety and depression.

How is sleep terror treated?
Parents should be able to comfort or send the child back to bed after a sleep terror, and as time goes on they usually stop by themselves. In adults with sleep terror, there are methods that can make them less common. These aim to establish the right frame of mind before bed. Often teaching good sleep habits is a part of this. However, in some cases sleep terrors happen often and lead to injuries. If so, sedatives can be prescribed.

What might your doctor do?
Your family doctor can refer you to psychologist or sleep specialist. They can treat you to make sleep terrors occur less often. As part of this, they might tell you things to help you sleep more soundly and set regular times to go to bed and get up. For adults, your doctor may prescribe short acting sedatives. These may stop sleep terror.

What could you do to help with symptoms?
If you avoid stress and have good sleep habits, then sleep terrors will happen less often. Also avoid stimulants (e.g. caffeine).

Where and when should you seek help?
If you or your child has been having sleep terrors and this is having a big impact on wellbeing, then you should talk to your GP.

What else might cause the symptoms?
Some adults do not grow out of sleep terrors, but there are ways to make them happen less often. Stress, trauma, some illnesses (including sleep apnoea), some medications and illicit drugs may also cause sleep terrors.

Sleep Tips for New Mothers

1.Plan for the fact that your sleep pattern is going to change

Babies are not born with a day-night wake-sleep cycle.  They develop this over the first 3 months following birth.  So whilst a newborn baby may sleep a lot, they will also wake up a lot for feeds and other attention and will do so at all hours.  Once the wake-sleep cycle is established they will usually start sleeping for longer periods through the night.  Prepare yourself for their first weeks without this and for the effects it will have on your sleep.  Discuss this with others and think about how you will cope with a lot less sleep than usual.

2.Make your sleep a priority for you and for others around you.

Your partner, other children, family, friends and workplace must understand your need to sleep where and when you can.  They will need to be flexible and willing to help you.

3.Minimise other responsibilities, especially for the first 3 months.

Learn to say ‘no’ to requests for your time other than those that are strictly necessary.

Think about making a sign for your front door saying “Mother and baby asleep” – put this sign out every time your baby has a sleep if you do not want visitors!

4.Sleep when the baby sleeps

Broken sleep is better than none and naps can help you catch up on some sleep.

Best sleep time is overnight.  Early afternoon (siesta time) is another time of the day when our body naturally wants to go to sleep, helping you get off to sleep.

Sleep during the day is more difficult.  Make sure your bedroom is set up for sleep – blocking out light with heavy drapes helps, as does making it quiet and comfortable.  Air conditioning helps on hot days, heating on cold ones.  Eye masks and ear plugs are a cheap way to block out light and loud background noise.

If you get behind on sleep you may be able to manage for a bit but at some stage catch up sleep becomes necessary.  Use weekends or other times when you have ready help to get some extra sleep.

5.When the baby is awake organise so that you can do other things whilst staying in range of your baby.

The right equipment can help: a bassinet, cot or baby rocker can be used to have baby near, but safely accommodated.

6.Let a few things go

Do not obsess about house tidiness, elaborate meals or entertaining others.  Let others help you.  Ask them. You may do the same for them one day!

7.Do not over react

All babies cry.  Crying time generally peaks at 6-8 weeks and then decreases. The usual reasons for crying include hunger, wet or dirty nappy, being over tired, the need to socialise, or being too hot or cold.  However, sometimes babies cry for no obvious reason at all!  Within limits, see if they will settle before going to them.

Providing they are reasonably close by you will hear your baby cry.  Do not worry that you will sleep through when your baby needs attention.

If you are concerned about how unsettled your baby may be, seek sensible advice.  The Raising  Children’s Website is an excellent starting point http://raisingchildren.net.au/sleep/babies_sleep.html

8.Demand vs timed feeds

There are arguments for each.  In the first 8 weeks or so demand feeders may find themselves feeding 2 hourly.

When feeding at night, do so in a quiet, dimly lit environment so that you can go back to sleep more easily when finished.  This is not a time for socialisation with baby or with others.  Avoid internet, mobile phone and TV at these times.  These are alerting activities that can stop you getting back to sleep.

9.Can others help with feeds?

For bottle fed babies, get someone else to feed baby from time to time (eg overnight).  For breast fed babies, it may be possible to express milk (breast pump) for someone else to give overnight.  This should not be done until a good milk flow has been established.

10.General Sleep Problems

Do not ignore the possibility of a sleep disorder if you are very sleepy despite having a reasonably long amount of sleep.  Sleep apnea is common, including during pregnancy and after delivery.

11.Depression

The symptoms of sleep loss and depression are very similar and can be confused.  If you have serious “blues” that go on for more than a couple of weeks, discuss these with your doctor or nurse.

12.Remember: it will get better!

Baby will acquire a day-night wake-sleep cycle over the first 3 months after birth.  They then start sleeping for longer periods through the night and so will you.

Sleeping Better in Your Hotel

1. Get the Environment Right

  • Your room should be quiet. Hotel rooms are usually well sound proofed to help you sleep well. Use the “do not disturb sign” to prevent unwanted interruptions and take care with the time you set on your alarm clock for the morning. Ear plugs may help if you have a noisy partner.
  •  Your room must be dark. Close the curtains or shutters before going to bed and turn all the lights off. Some find using an eye mask helpful.
  •  The room temperature must be right. Adjust the air conditioner to your liking as soon as you arrive in your room.
  •  Your bed must be comfortable. A good mattress, pillow and blankets help you to get a good night’s sleep.
  •  The room should be clean and pleasant. Most hotels take pride in their housekeeping. Let them know if there are any problems.
  •  Non-smoking rooms. Make your preferences known as soon as possible, preferably when you book, so that the hotel can meet your requests.

2. Manage your Jet Lag

  •  If you have travelled across time zones, you can help your body clock adapt more quickly to the time at your destination. See our separate “Jet Lag” brochure.

3. Prepare for Sleep

  •  Exercise. during the day and in the early evening, exercise is part of a good sleep-wake routine. Avoid exercise close to bedtime.
  •  Food. ensure you are neither hungry nor over-full when going to bed. A light evening snack may be helpful.
  •  Alcohol. avoid excessive alcohol intake. While some find that a drink helps them to go off to sleep, it will cause sleep disruption during the night.
  •  Caffeine. Do not overuse caffeine (tea, coffee and other caffeinated drinks including the colas) as they will keep you awake.
  •  Sleep Strategies. Where possible, stick to a regular sleep routine. There are a number of things that you can do to improve your sleep. See our separate “Good Night’s Sleep” brochure.

4. Unfamiliar Surroundings

  • For some, sleeping in unfamiliar surroundings is difficult, no matter how comfortable it is. Keep to familiar routines. A few personal items from home (e.g. a photograph, a coffee mug, reading material) may help.

Let hotel staff know if there are problems, they may be able to help.

Sleepwalking

What is sleepwalking?
Sleep walkers tend to move about in their deep sleep. They may get out of their bed and sometimes even leave the house. Sleep walking usually occurs for just a few minutes at a time and may occur up to 3 or 4 nights per week. However some people sleep walk for longer periods of time and less often. When it is over, most people are able to remember very little of what they did, if anything at all. Usually, sleepwalking starts in childhood, becomes less common as a teenager and stops as a young adult. However for some people, it may continue for most of their life. The longer a child keeps sleepwalking into their teenage years, the greater the chance that it will go on into early adulthood.

What causes sleepwalking?
For some people, sleep walking is an inherited condition. For children it may also be related to a stage of development. Not getting enough sleep, having irregular sleep hours, stress, drugs and some medicines increase the risk of sleepwalking. In addition, medical conditions such as sleep apnoea, seizures and fever can contribute to the likelihood of sleepwalking. If you are prone to sleepwalking, then sounds that disturb your sleep can also make you sleepwalk. However, not uncommonly a cause cannot be found.

How common is sleepwalking?
Surveys suggest that 2 or 3 children in 100 sleepwalk often and approximately 5 in 100 children sleep walk sometimes. In adults, 3 or 4 in 100 say that they have sleepwalked at least once in their lives, but only 4 in 1000 are still sleepwalking. Of those who sleepwalked as a child, less than a quarter continue to do so as adults. Some people may stop sleepwalking after childhood, but it may come back if they are unwell or stressed.
How does it affect people?
If sleepwalkers wake up suddenly, they may be confused. Sometimes they may not be able to quickly go back to sleep. This will prevent the sleepwalker from having a good night’s sleep and make them tired during the day. It can also cause anxiety and depression. Sometimes an injury may occur by bumping into objects or leaving the house. However, the number of injuries is less than you might expect, given the number of people who sleepwalk.

How is sleepwalking treated?
In a child, sleepwalking may just be part of growing up. Parents should be able to comfort the child and direct him/her back to bed after they sleepwalk. With time, they tend to grow out of it. Action should be taken only if it happens too often and has a big impact on the child. This might be if
they feel tired during the day from a lack of sleep or they are at risk of injuring themselves. In adults who sleepwalk, it is important to have good sleep habits (see Good Sleep Habits). This may reduce the frequency of sleepwalking. Occasionally, sleeping tablets may be used, but this should be discussed with a doctor..

What might a doctor do?
A doctor can give advice about improving sleep habits, having a better night’s sleep and making it less dangerous for the sleepwalker. Occasionally, a referral may be made to a psychologist or sleep specialist. There are treatments to control how often you sleepwalk. Adults may also be prescribed sedatives for short term use. These can stop sleepwalking.

What could you do to help with symptoms?
There are ways to make it happen less, (see Good Sleep Habits). Try to reduce your stress levels. Stay away from caffeine and other stimulants before bedtime. Try to stay safe when you sleepwalk. Lock windows so you won’t try to go out through them. You may want to put bells on doors to wake up other people in the house. Baby monitors can also be useful so others can hear you if you start moving around at night.

Where and when should you seek help?
If sleepwalking is affecting how you or your child functions during the day, you should talk to your local doctor.

Surgery for Obstructive Sleep Apnea (OSA)

What is surgery for OSA ?
Surgery in adults with OSA should only be a last resort. As a rule, it is only worth it if you can’t wear CPAP (despite persistent effort) or use an Oral Appliance. Surgery might also be used in certain cases to help you wear these. On the other hand, surgery is normally one of the main options to treat a child with OSA.

How does surgery work ?
It works by opening up the upper airway. This makes it more stable so it will not narrow and obstruct during sleep. The symptoms of OSA should then get better e.g. snoring, feeling sleepy during the day. Normally, the goal of surgery is just to lessen the symptoms of OSA, not “cure” it.  A second option is surgery on the nose. This is known as “pre phase” surgery. It can be done to help CPAP, oral appliances or other treatments work better.

Who should seek an opinion about surgery ?

  •  Children with OSA.
  •  Adults who have tried but cannot tolerate CPAP or an oral appliance.
  •  Adults with the right anatomy e.g. large tonsils.
  •  Adults with an anatomy that makes it hard for a CPAP device to work e.g. problems in the nose.
  •  Adults who don’t want to wear a CPAP device (but we strongly suggest at least trying it out).

When should you think about surgery ?
Studies suggest that surgery should only be thought of if you have already tried other treatments and failed. A surgeon will need to do a lot of tests on you to be sure that it will work. Usually this will be an Ear, Nose and Throat Surgeon or a facio-maxillary surgeon.

Surgery is more often done on children than adults. This may involve taking out the adenoids and tonsils. The child should snore less and have more restful sleep. In turn, this will make them more active during the day, improve concentration and they will be happier, brighter and healthier.

What types of surgery can be done in adults ?
Adults will usually have surgery on either the nose, the upper airway or sometimes both. There are a number of options for surgery on the nose. One is on the part of the nose that separates the two nostrils. This is known as the nasal septum. There may be a problem with how straight it is. Surgery can fix this. The surgery may also be on other bones in the nose e.g. the turbinates, which are on the outer walls of the nasal passages. Other options include sinus surgery and an operation to re-shape the nose (rhinoplasty). Patients often need to use sprays and other treatments after the operation for some time.

There are also many options for surgery on other parts of the upper airway. Often a number of these are done together e.g. on the tongue, tonsils, jaw and roof of the mouth. In some cases, these are done all at once. In other cases, it will be done “bit by bit” i.e. you have several operations. Exactly what is done depends on your anatomy. It depends on what you want as well. A “one size fits all” approach does not work. Even if you know a person who has had a particular kind of surgery, what works for them might not work for you. Some patients choose to have weight loss surgery, such as laparoscopic banding. By losing weight, sleep apnea may improve.
A very infrequently used option is airway bypass (tracheostomy).

What tests do I need before surgery ?
Adults need a full sleep study. This is done before and after most operations.  For surgery on the nose, you might need to have blood or skin prick tests, X-rays, CT scans or nasal pressure measurements.

For other types of surgery, you may need a special X-ray or CT scan. You will almost always need to try out CPAP, and an oral appliance or both before any surgery.

Your sleep specialist will not suggest surgery until they are sure that these other treatments will not work for you.

Does surgery have side effects ?
Surgery and anaesthetics always carry a risk of side effects. But with more modern types of surgery the risk is low. In most cases, the side effects do not last for long.  Some  types of surgery have a greater risk, (e.g. “Laser” surgery).  Your surgeon will discuss all the risks with you in detail. This means that you can weigh up the pros and cons for yourself before deciding whether to proceed.

Where can I get help ?
The first thing to do is to see your GP, who can refer you to a specialist. This will usually be a sleep physician. If not, it will be an Ear, Nose and Throat Specialist who works closely with a sleep physician.

Teeth grinding/bruxism

What is bruxism?

Bruxism is the habit of clenching, gnashing or grinding your teeth. Your teeth are not meant to be clenched and in contact all the time. They should only briefly touch each other when you swallow or chew. If they are in contact too often or too forcefully, it can wear down the tooth enamel. This is the outer layer that covers each tooth. Without this to protect the inner parts of your teeth, you may have dental problems. Clenching or grinding your teeth regularly can also lead to pain in the jaw or in the muscles of the face. Bruxism happens during sleep, but some people also suffer from this when awake.

Who has bruxism?
It is thought that about half of the community grinds their teeth from time to time. But it may be serious in only about 1 in 20 cases. About 30% of children grind or clench their teeth. Most children grow out of this and suffer no lasting effects to their adult teeth.

How do I know if I have it?
You may not know that you grind your teeth while you are asleep. A bed partner may be the first person to notice grinding sounds and noises. Other clues may be morning symptoms of a dull headache, jaw muscles that hurt or are tight, trouble opening the mouth wide, long lasting pain in the face, damage to the teeth and broken dental fillings.

Your dentist can help to work out if you have bruxism. You will be asked a series of questions and your overall dental health will be checked. This may include looking for any wear and damage to your teeth, checking the muscles in and around your jaw and the function of the jaw joints, which are just in front of your ears. They may need to look at changes to your teeth and mouth over a number of visits to work out whether the cause is bruxism.

To be sure that you suffer from sleep bruxism, a sleep study may be needed. This will show how much you move your jaw while asleep. A sleep study looking for bruxism by itself is not common, but it may uncover other sleep problems.

What causes it?
There are many reasons for bruxism such as emotional stress (e.g. anger and anxiety), drug use (e.g. stimulants), having to concentrate hard, illness, not having enough water in your body, the wrong diet, sleep problems, teething (in babies), bad tooth alignment and problems with dental work. Some people can also get bruxism as a side effect of antidepressants. If you let your doctor know of this side effect, you may be changed to a different drug.

How is bruxism treated?
There are many treatments available for bruxism, including relaxation and awareness techniques. Counselling may help to relieve stress in your life. Improving the quality of your sleep can be of benefit. This may include reducing the use of stimulants such as caffeine and nicotine, having enough sleep, making sure you have a good bedtime routine and relaxing before bed. Treating sleep apnoea in some people may also help to control sleep bruxism.

There are no medications that will stop sleep bruxism. A grinding mouthguard can be made. This is like a sports mouthguard, but harder. It will help protect the teeth, muscles and jaw joint from the pressure of clenching and grinding. It will not stop bruxism and in some cases can make the actual grinding worse, but it will lessen the damage to your teeth.

Can it get worse? 
Many cases of bruxism are mild and cause little harm. If so, the person usually does not know that they are grinding their teeth. But more serious cases may damage the teeth and result in facial pain and poor sleep. Nightly sounds can also wake other people sleeping nearby (e.g. roommates and sleeping partners). If you know that you have this problem, then you should take action to prevent any serious consequences.

Tips to Help Baby Sleep Better

1. Establish a regular sleep time
During the first weeks of life your baby does not yet have a set day-night rhythm. You can help create this rhythm by setting regular times for going to bed and waking up. These need to allow plenty of time for sleep. The more regular the hours, the stronger the sleep-wake cycle will be. This helps you predict when they need sleep. Regular hours are important for older children too.

2. Night time is for sleep
You need to help your baby understand this. You do this by socialising as little as you can at night. Save stimulating social interaction for daylight and evening hours. Attend to your baby and feed in low light overnight. Also avoid rushing to the cot at the first sign of stirring. Your baby may well resettle if left for a moment or two.

3. A bedtime routine
Get into the habit of doing the same things before bed. This helps prepare your baby for sleep. It also helps him or her understand that the time has come for sleep. Simple things like a bath, some quiet time including reading to your baby, a final feed and a kiss can be part of this routine.

4. Get your child used to being put into bed awake
This helps your baby learn to fall to sleep without your help. It’s best for your baby to be sleepy and relaxed when they are placed in the cot. You don’t need to wait for your child to be asleep before putting him or her to bed.

5. Daytime naps
Babies and young children need a lot of sleep. They will need daytime naps. Get into a routine with these as much as you can.
6. Keep it simple
Don’t go over the top to get your baby to sleep. Rocking, pushing your baby around in a stroller and other things may help at first. But the risk is that your baby will learn to need these things to sleep. If this happens, they won’t go to sleep without them. From the start, take steps to help your baby learn to sleep alone. Don’t rely on external aids.

7. Be consistent
Your baby will learn good sleep habits if you take a consistent approach. You may find it quite tough at first, but there will be long term rewards for you and your baby.

8. The family bed
Think about whether you really want your baby to sleep in your bed. While some parents prefer this sooner or later the infant will need to move out. You might then find that it is hard to break the habit. Babies sleeping in the parents’ bed has also been linked to a higher risk of sudden infant death syndrome in some cases. If you do choose to have your baby sleep in bed with you, make sure you position your baby with care. You don’t want them covered by bedclothes or too hot. Also think about where you and your partner sleep so that you don’t roll onto your baby by accident.

9. Posture in bed
Babies sleeping on their tummies has been linked to sudden infant death syndrome. The safest position for your baby is on their back, face up.

10. Time for you
Young parenthood is greatly rewarding and exciting. But it can be a very tiring and demanding time for you. Make sure you have plenty of downtime too. When your baby is awake, you want to be able to enjoy the interaction. Use the time your baby is sleeping to rest. Arrange with your partner to have some time off. This will mean that you will be happier, brighter and better able to cope. Because of this, you will enjoy raising your baby more.

Travelling with CPAP

1. Can I travel with CPAP?
CPAP treatment for sleep apnoea may not be the most convenient thing to use. But it doesn’t need to get in the way of your lifestyle. There are a number of things that can be done that you should know about. These let you travel, go camping and get out and about while still using your CPAP at night.

2. Do I need to use CPAP every night? 
When your doctor found you had sleep apnoea, you had probably already had it for a number of years. During this time, it wouldn’t have been treated. One more night with no CPAP probably won’t put you at risk. But you need to know that as soon as you stop using CPAP, your breathing during the night will get worse. This means your daytime symptoms will come back. Think back to how things were before you started CPAP. There is a risk of going back to feeling this way. You may suffer from morning headaches and feel tired and moody during the day. Everyone is different, but these can come back after the first night with no CPAP. Feeling tired during the day is a problem. This will raise your risk of road and other accidents. If you are driving for your holiday then this could be deadly. If you are tired, do not drive as you and others will be at risk.

3. Can I use my CPAP in other countries?
Before going abroad you should talk to your sleep clinic or supplier of CPAP machines. You need to know how suitable the machine is for use in another country. As a rule, most machines these days are able to run on other voltages, such as 110V in the United States without modification, as they have an inbuilt “switch mode” power supply. For some, you need to use a switch to adjust them, others adjust on their own. You must check this. Some machines can’t run on other voltages. In this case you might need to buy a transformer. Or you could hire a machine that works in the place you are going. If what you have now is suitable, don’t forget adaptor plugs.

4. Will the air pressure I get change in different countries?
This depends on the type of machine that you use. If you are at a higher altitude (e.g. the mountains), the air pressure around you is less. Some machines give less pressure in this case. Others will adjust to make up for this. How much pressure you need may vary too. This is due to how your sleep varies with altitude. In general the effects are quite small. It is better to use the CPAP, even if it is not at the best pressure, than not to use it.

5. Can I use my CPAP on a ship or plane?
On a cruise ship or long haul flight, there will be power points. You can use these with most CPAP machines. You need to know what voltage you will be getting while on board. Consult with the airline or shipping line you are going with to find this out. Then talk with your clinic or supplier to make sure that the pump will work at this voltage. As a rule, the airline will need a medical certificate from your doctor. They may also only let you use specific units on board the flight. Getting all this ready can take some time. This means it is best to start these well before the date you leave. You might be worried about looking strange by using CPAP on the flight. If you are, then think about the alternative. This may be an extremely disrupted sleep with loud snoring. Both you and the other people on board would be far better off with a quiet CPAP machine.

6. What should I watch out for when transporting my CPAP equipment?
Make sure your CPAP isn’t damaged in transit. If it is your holiday may be difficult and unhappy. Even if you won’t use your CPAP on the flight, take it on board as part of your hand baggage. Make sure that it is in a sturdy, protective bag. Airlines are used to people with medical equipment. Explain things to them. They will probably let you have this as another piece of cabin baggage. To be even safer, you might want to get a letter explaining things. It is best if this is from a specialist doctor. You can use this if you run into any problems with customs or airlines. A lot of countries use languages other than English. If you are going to one of these, you should get these translated.

7. Can I use my CPAP while camping?
If you will have access to normal mains power you should always use your CPAP. Some people worry about the air being much colder than at home. If you do, you should discuss this with your sleep clinic or supplier before you go. There are many simple things you can do to help. Running CPAP tubes under the bedclothes may be enough to warm the air. On the other hand, you may need a heated humidifier.

8. Can I use my CPAP with a battery?
This needs some planning. You have to talk with your CPAP supplier well in advance of your holiday. Some newer CPAP machines can run straight from a battery. In this case you will only need the adaptor from car to CPAP machine. Others will work if you use a suitable inverter. This makes power from a battery (12V DC) into a form that is like normal mains power (240V AC). You should know that not all of them are the same. Some may be better than others for use with your CPAP machine. If you use the wrong one, it may shorten the life of the CPAP machine. This is because there is more stress on the motor. You must talk to the supplier of your CPAP to find out which inverters you need.

9. How long will my CPAP run on a battery?
This depends a lot on the type of CPAP machine. It also depends on the pressure it gives. Older ones tend to use more power. When the pressure goes up, they use more power. A modern CPAP machine can run off a car battery for at least about 8 hours. But take care not to be stuck with a flat battery. You might want a second battery if you can afford it. A deep cycle marine or recreational vehicle battery would be good. You can have this charging while you’re driving. Talk to an auto electrician to set this up. In this way you will not be dependent on your CPAP battery to start the car. You can use mains power to recharge as well. For this you need a battery charger.

10. Can I use a heated humidifier with a battery and inverter?
In general for older humidifiers this is NOT a good idea as they consume a lot of power. Some may not control how hot it is when you use an inverter. But there are newer units that can be used with an inverter. If you feel you have to use one you should talk with your CPAP supplier before you try to use it with a battery. There may be other things you can try such as an unheated humidifier

11. If I use oxygen with CPAP can I still use a battery power source?                                                                                                      Unfortunately, this is not a good idea. A spark from the equipment can cause a fire if oxygen is in use. If you use oxygen, even at night, you must talk with your specialist physician before doing things which might place you at risk e.g. camping.

12. Are there special batteries made for use with CPAP/APAP?

Some manufacturers supply batteries made specifically for their machines. These batteries are sealed Lithium ion batteries and are certified for use on planes. These batteries usually last an average 12-13 hours on CPAP only, about 6 hrs using CPAP and humidifier and about 3-4 hrs using CPAP, humidifier and heated tubing. The battery will be used up quicker at higher pressures or if the mask leaks. Mask leaks result in the machine working harder as it tries to compensate for the leak.

The batteries are charged from mains power and take around 4 hrs to be charged from completely flat to fully charged.

13. IMPORTANT – CHECK WITH YOUR CPAP SUPPLIER
Use of CPAP with other than normal mains voltage may pose special problems or risks. It may void your warranty. The supplier of your CPAP machine should always be consulted before using non-mains power supplies unless an approved battery and inverter.

Understanding and helping poor sleep

1.       Maximise your sleep drive

Your sleep drive (or pressure for sleep) is low in the morning when you wake up and rises steadily across the waking hours so that it should be high at bedtime. It is usually easiest to fall asleep when your sleep drive is high. Sleep drive falls while you sleep (either overnight or in a nap). So, if you sleep in for a few hours in the morning, have an afternoon nap, or go to bed too early in the evening your sleep drive might not be high enough to help you fall asleep and/or stay asleep.

  • Learn to recognise whether you are tired or sleepy in the evening and only go to bed when you are sleepy.
  • Most Australians sleep for between 7 and 8 hours at night. If you spend much longer than this in bed you risk being wakeful when you really want to be asleep. Your body will develop a habit of wakefulness before sleep onset, during the night or before getting up time. So limit your time in bed to no more than the total time you are likely to sleep, e.g. 8 hours or less.
  • Understand that naps, or falling asleep in front of the evening TV, will reduce your sleep drive at bedtime.
  • Try to stick to the same waking up time in the mornings, even on weekends.

2.       Look after your body rhythm

Your body rhythm can be thought of as acting like a single wave that is high during the day and dips at night. Good sleep is more likely if the wave rides high during the day, helped by activity and exercise and getting good outdoor light. Morning light is especially critical, so consider breakfast by a window or outside. A strong dip at night is also important and this is helped by setting a regular sleep/wake routine and not spending more time in bed than your daily sleep need (e.g. 7.5 to 8 hours).
If you are a person who is very alert at night, can’t fall asleep until the wee hours of the morning, sleeps well once asleep and then has real trouble getting up at a normal morning time, learn about Delayed Sleep Phase Disorder to see if it is the timing of your internal body clock, in relation to the times you expect to sleep, that is your problem.

3.       Minimise internal disruptions (mind or body)

Most disruptions that create poor sleep are internal to you and caused by your mind (mental disruption) or your body (physical disruption).  One important physical disruption causing poor sleep may be a breathing problem. You may have pauses in your breathing during the night, normally due to a partial or complete blockage of your airways.  You may or may not be aware of such pauses, but it will cause your sleep to be very light with frequent interruptions during the night.  Bed partners are often aware of these breathing pauses, and they are often associated with snoring.  This breathing problem during sleep is called obstructive sleep apnoea.  If you think you may have this problem, ask your GP whether you may need a referral to a sleep specialist for an overnight sleep study.  One of the ways of treating obstructive sleep apnea is a device called a Continuous Positive Airway Pressuremachine (CPAP).  It is important to treat sleep apnoea to improve your sleep and avoid cardiovascular and other health problems.  Other internal physical problems interfering with sleep are the jerks associated with Periodic Limb Movement Disorder or the creepy, crawly sensation of Restless Legs Syndrome.

For many people their mind is too active to fall asleep, either at bedtime or when they have woken up during the night.  This can be due to many different things.

  • During the day and evening it is important to keep stimulants such as caffeine, nicotine and alcohol to a minimum.  Each will act as a stimulant to keep you awake.  Caffeine can take 24 hours to be eliminated from the body.
  • It is important to have a buffer zone of 1-2 hours between any stimulating evening activities and going to bed.  During this wind-down time ensure you turn off computers and similar electronic devices.  Their light suppresses a hormone, melatonin,  that helps you sleep. Undertake relaxing activities like watching pleasant TV programs, reading, listening to music, chatting, reading magazines, having a warm bath or shower, or drinking a warm non-caffeinated, non-alcoholic drink.
  • Don’t take your worries to bed.  Choose a time earlier in the day when you write out your main worries and then some options for dealing with them (even if it is just to think about them later in the week). Then, fold the ‘worry page’ over and remind yourself when in bed that you will make time to revisit those worries the next day.  Try not to worry about things you can’t change or are not your problem.
  • Once in bed have some strategies that help you turn your thoughts to relaxing things.  You may create a calm imaginary place or imagine a wonderful holiday.  Some people listen to relaxing audio files at bedtime.  Try the free ones at www.calm.auckland.ac.nz  (select Downloads link).  Progressive muscle relaxation is especially helpful for sleep. It provides relaxation for both the body and mind.  You can practice during the evening listening to the file and then do it on your own in bed when wakeful.
  • Depression and ongoing anxiety will often create sleep difficulties and you may need to seek help on managing such emotional problems.  Be sure your GP is aware of how these might be affecting you.

4.       Minimise external disruptions

If you are a light sleeper or have trouble returning to sleep be sure you remove, reduce or avoid any persistent problems that could disrupt your sleep.  This includes disturbances from pets, morning light too early, being too warm or cold, feeling unsafe or a partner snoring.  Ear plugs, eye covers, better curtains, heating, fans or air-conditioning, night lights, door locks and separate bedrooms are all worth considering in dealing with these issues.

5.       Develop a positive attitude to sleep

Many people don’t realise that healthy sleep is NOT one big ‘down-time’.  Instead we have a rollercoaster of lighter and deeper sleep across the night and brief awakenings are a very normal part of a night’s sleep.  The key is really to get back to sleep within a reasonable time.  Many people feel they spend a large part of the second half of the night being quite wakeful.  We all have thoughts going through our mind continuously during sleep and studies have shown that many poor sleepers believe they are awake when they are really in light sleep.

  • The more relaxed you are about being dozy and moving in and out of sleep, the more likely you are to move towards a better sleep.
  • Think ‘rest is good’ and don’t watch the clock.  Be patient and don’t expect too much – you can’t force sleep.
  • If you are lying awake feeling frustrated then get out of bed and do something relaxing until you feel more ready for sleep.  Keep the lights dim.
  • Avoid doing things in your bedroom that are not part of getting sleep.  Don’t regularly fall asleep in front of a TV while in bed.  If you do, you will have trouble falling asleep again during the night without it.
  • Don’t think of yourself as having insomnia, instead focus on developing good sleep habits.
Advanced Sleep Phase Disorder (ASPD)

What is ASPD?

This is a sleep disorder where you keep going to bed and waking up too early.  For example, you might find it hard to stay up until a normal bed time such as 10pm. You might feel a strong urge to go to bed as early as 8-9pm. Once in bed you fall asleep quickly and sleep well for a few hours. However, you then wake up very early (e.g. 3-4 am) and find it very hard to go back to sleep. You often feel you don’t get enough sleep, due to waking up so early in the morning. Importantly, if you went to bed even earlier (e.g. 6-7pm), you would be able to go to sleep then. But you would probably wake up even earlier after a few nights of this early-to-bed pattern.

What causes ASPD?

A vital part of what makes us feel sleepy is our 24 hour body clock. This is located deep inside our brain, behind the eyes. It controls when we feel sleepy and alert. For most adults their body clock makes them feel sleepy between the hours of 11pm to 7am and alert at other times, including the early evening (6-9 pm) and morning hours (8-11 am). Those with ASPD have an early timed body clock that shifts those alert and sleepy zones to earlier clock times. This makes them feel very sleepy in the early evening and alert as early as 3-4 am. How the ASPD body clock timing shifts in this way is not well understood.  It may be due to a shorter than normal cycle length, tending to complete the sleep-wake cycle in less than 24 hours.

How common is ASPD?

ASPD is more common as we become older. This is in contrast to delayed sleep phase disorder that mainly affects young people. Roughly 1% of middle aged to older people experience ASPD.

How does it affect people?

Apart from being inconvenient, ASPD can cause insomnia in the early morning, insufficient sleep, daytime sleepiness and fatigue. It can also increase the risk of depression.

How is it treated?

Based on the knowledge that ASPD relates to an early timed body clock, the aim of treatment is to change the body clock to a more normal timing. Two treatments can re-time the body clock: getting bright light visual stimulation and taking melatonin.

The timing of when you have these is vital. Bright light visual stimulation should occur in the evening before you go to bed. The light should be brighter than normal indoor lighting. You can obtain it from specialized light boxes, or portable devices that you can wear, e.g. eye glasses. A few examples can be found by a web search for “bright light therapy”. You may need an hour or two of bright light therapy before bed.  Some will benefit from nightly use for a week.  Others will need longer, sometimes several weeks, to get maximum benefit.  It is best used late in the evening, perhaps turning the bright light device off half an hour before bed.

Melatonin(the hormone of sleep) also helps to reset the body clock.  One option is to take a 2mg slow release melatonin tablet (Circadin™) as close to your new (later) bedtime as possible.  A second option is to take a small dose of melatonin (0.5 mg), about half way through your sleep period. This could be at a time when you wake up on your own.

To change your hours of sleep, you should gradually delay your bed time (e.g. 20 minutes later each night) until you get it to the time that you want.  As you delay your bedtime, you will also be delaying the time of your bright light exposure and melatonin intake.

As you can see, this treatment is quite complex. You may want to consult a sleep specialist, especially if you don’t have success treating ASPD by yourself.

Can I prevent it coming back?

The reason that your body clock “sped up” in the first place may still be present, even after you move your sleep period back to the time you want. When you stop treatment, your sleep period may then slowly creep to be earlier again. So you may need to use the bright light and / or melatonin every now and then. To prevent relapse, you may also want to avoid bright light for the hour or two after you get up in the morning.  Wearing sunglasses in the morning when outside can help, especially in the sunnier summer months.

What might your doctor do?

It would be easier for your doctor to be sure of this disorder if you keep a sleep diary for a least a week. Also record the times across the day and night that you feel most sleepy and most alert. Your doctor would be able to prescribe melatonin and, if felt necessary, refer you to a sleep specialist.

Anaesthesia, Sleep and Sleep Apnea

How are sleep and anaesthesia the same? How do they differ?

Sleep is natural.  When you have met the need for it, it will finish by itself. Anaesthesia is caused by drugs. It will only finish when the drugs wear off.  These drugs work by acting on the same parts of the brain that control sleep.  Both anaesthesia and sleep reduce your breathing efforts.  They also cause your muscles, including throat muscles, to relax.  Because of these changes there is a risk of under-breathing or blocking of the throat in both sleep and anaesthesia.

What problems can OSA cause during anaesthesia? What about after?

People who have OSA are at risk of their throat blocking when sedated or under anaesthesia, just as can happen during sleep.   This situation is worse with sedation and anaesthesia because they interfere with the ability to respond to the blocking by arousing or waking up.  Anaesthetists can best cope with this if they know you have, or might have OSA.  Your anaesthetist will be with you throughout your operation to look after you, and there are extra options to deal with OSA.  These include special anaesthesia methods, a longer period of close monitoring after surgery and applying CPAP when you are sedated or asleep.
What should I tell my anaesthetist prior to the surgery?

Anaesthesia and surgery can affect many body functions. Thus your anaesthetist needs to know about any health issues which could affect your wellbeing when you have surgery.  You will meet your anaesthetist before the surgery to discuss these matters.

OSA can create special problems.  If you have OSA, or think that you might have it, be sure to let your anaesthetist know before your surgery.

There are other issues that you normally talk about before the surgery e.g. previous illnesses (such as recent problems with your lungs or throat), smoking, any drugs you may be taking (both legal and illicit, as well as herbal and alternative treatments), how much alcohol you drink, allergies (to drugs and dressings), previous problems with anaesthesia (including postoperative nausea and vomiting and postoperative pain), a family history of anaesthesia problems and pregnancy or the possibility of it.

How do I get ready for surgery? 

You should learn about the surgery you are having. You need to know what it will do for you, as well as the risks.  This includes the care plan for after the operation, including pain relief.  Unless it is an emergency, you should fast before the surgery according to the instructions you are given.

What should I do about my CPAP therapy?

If you use CPAP or other treatment for sleep apnea, you must let your anaesthetist know.  If you are using CPAP, your familiarity with it is helpful as it makes it easier to apply after the operation.  Bring your equipment with you on the day of your admission.  You should know your pressure settings and mask type. This is in case hospital equipment needs to be used.

Bedwetting

How common is it?

It is very common.  Most children need to wear a nappy or protective pants at night to avoid wetting their bed up until at least age five. At four years of age nearly one in three children wet, and this falls to about one in 10 by age six. Some teenagers wet the bed too. This is especially common if a parent or other close family member wet their bed at this age as well.

What causes it?

  • There are a number of causes of bedwetting (or enuresis). We don’t know all of them.
  • Some children wet the bed due to being in deep sleep. They do not wake up to go to the toilet in time.
  • Other children have smaller bladders that cannot hold on to a lot of urine overnight.
  • Some children don’t make enough of a hormone called Anti-Diuretic Hormone, known as ADH. This hormone helps to concentrate urine overnight. Children who don’t make enough ADH have a lot of dilute urine and so wet the bed.
  • Children with constipation may have problems with bedwetting. They may have problems with daytime wetting too.
  • Bedwetting can run in families, but we have not yet found the gene that ‘causes’ bedwetting.
  • In rare cases, there is an underlying medical cause. So always have your child checked by a medical doctor before you start any treatment.
  • Bedwetting is NOT due to underlying behavioural problems. Never scold or punish a child for bedwetting. They are asleep when it happens and cannot help it.

Will my child grow out of it?

Yes, most children grow out of bedwetting. But, from the age of 6 years there are treatments that you may want to consider. This is especially so if your child feels shame about their bedwetting.  It can also be a problem for children who want to sleep over at a friend’s house.

What treatments are there?

The treatment which seems to work best is the pad and alarm. There are many types on the market and some hospitals and pharmacies hire them out. They work through a pad that senses when your child starts to wet the bed. This then sounds an alarm to wake up your child (and the whole family!). Your child then needs to get up, turn the alarm off, go to the toilet, empty their bladder, go back to bed and re-set the alarm. It is VITAL that your child takes control and does these steps for himself/herself. If you do it instead, it will take longer for the child to learn to wake when he/she starts to pass urine. You may need to help your child through these steps for the first few nights. But then he/she should be able to manage the steps themself.

Most experts suggest using the alarm until your child has had 14 dry nights in a row. After 7 dry nights, some of them suggest ‘over learning’ i.e. increasing how much fluid your child drinks in the evening for 7 nights. This makes sure they are ready to stop using the pad and alarm.

Reward your child (e.g. with stamps, stickers) when they get up and go to the toilet. The pad and alarm treatment may take up to 12 weeks to work, so this will help them stay motivated during that time.

A synthetic form of ADH is also available. This is mostly used for short overnight stays (see below) or if the pad and alarm treatment fails.

Some useful tips

Make sure your child drinks plenty of fluid spread evenly all through the day. There is NO evidence that you can help them get dryer sooner if you limit their fluid intake – it may even be a bad thing!

Don’t give drinks with caffeine (e.g. coffee, hot chocolate, Coca-Cola) late at night.

Try to have your child wear a pyjama top or nightie and no bottoms during the process. In this way the alarm will sound as soon as they start to pass urine.

What can I do for short overnight sleepovers e.g. school camps?

This is where drugs can help. DDAVP is a man-made form of ADH. It works by substituting for the natural hormone. It comes in a tablet, nasal spray and wafer form.

DDAVP is safe as long as you do two things. The first is to stay within the suggested dose. The second is not to have too much to drink in the evening after dinner.

DDAVP can work quickly. Some children will be dry after the first night. Many doctors suggest using DDAVP for 3 months, and then taper it off to see if the child can stay dry without it. If your child starts bed-wetting when you stop the drug, they may need to start again. Talk to your doctor about this.

Body Clock

What makes you tick?

It might surprise you to know that your brain has a kind of clock in it. This keeps things ticking over every day. As humans, we prefer to sleep at night and be up during the day. This isn’t due to habit or work schedules or convenience. It is driven by the body clock. Even if we don’t know what time it is, we still do things in cycles that go for about 24 hours. We sleep for part of every 24 hours and our body temperature rises and falls with a cycle length of about 24 hours. We have hormones and other systems in our body that go through this daily cycle as well. Exactly the same pattern is seen in almost every living thing on the planet. They all have some kind of clock that controls when they do things. The daily rhythms are known as circadian rhythms. Our health and wellbeing depends on this ticking all the time. This also needs to tick at the same time as everything around us. This is called being ‘synchronised’.

Where is the clock?
Scientists have known for a long time that daily rhythms are driven by some kind of clock in our bodies. But they didn’t work out exactly where it was until the middle of the 20th century. They found this out when they did surgery on hamsters. They took out a tiny part of the brain of hamsters called the suprachiasmatic nucleus (SCN). After this, the hamsters totally lost their rhythm – and not just on the hamster wheel. It used to be easy to predict when the hamsters would run on a wheel. But after they lost the SCN, they ran at any and all times of the day and night. That was the first big step in understanding.

How does it work?
How the rhythms are produced is complex. But we can sum things up as follows: special clock genes in the SCN switch on which cause proteins to be made. As these proteins accumulate, along with other chemicals, they switch off the clock genes. The level of proteins then drop to point where the genes are able to switch on again and the cycle restarts. This cycle of switching off and on happens about once every 24 hours. The SCN sends out signals to the rest of the body that vary according to this cycle. The cycle is not just determined by the SCN itself: it responds and adapts to signals from outside the body (principally light and dark) to keep the organism synchronised with the world around it – that is, ticking at the right time.

Is light important to how the body clock works?
The most important external signal for the biological clock is light. When the eye senses light, it sends signals to the SCN. This resets the clock every day. Our body does this to make sure rhythms don’t drift out of line with the environment. Although our rhythms cycle about once every 24 hours, without light and dark (for instance with total blindness) humans actually tick a little more slowly – about 24.1 hours. Thus, if we didn’t have daylight we would get out of synchrony with night and day.
People with Delayed Sleep Phase Syndrome have trouble adjusting and go to bed and wake up late, which can be inconvenient when trying to schedule activities such as work and school. Shiftwork often have trouble totally adjusting to being up at night and sleeping in the day. The external light/dark cycle and tends to keep them on a day shift pattern. The influence of light also explains why we can adjust to a new time zone if we fly abroad. The light in the new time zone sends a signal to our clock which causes it to get synchronised with the new time zone. This usually takes several days. Of course, while we adjust we suffer from symptoms of Jet Lag, which aren’t much fun. (see our tip sheets).

Why is the clock important for sleep?
The cycle of sleep and wake is one of the most obvious circadian rhythms in humans. Sleepiness is highest at night and lowest in the day. At night, we get the best quality sleep, and the longest blocks of sleep without waking up. Sleep during the day is more broken up. It tends to be lighter as well. This means we sleep less. Melatonin and body temperature are also driven by the body clock. These are also well known circadian rhythms. At night, core body temperature is low and levels of melatonin are high. Getting these rhythms aligned with each other as well as the external environment gives us the best chance for good quality sleep.

Caring for your CPAP Equipment

Many patients with respiratory problems use positive airway pressure therapy.  This can be for a problem that affects movement of air into and out of the lungs (e.g. obstructive sleep apnea, obesity or a respiratory muscle disorder) or the lungs themselves (e.g. chronic obstructive pulmonary disease or cystic fibrosis).

Some of this equipment provides continuous positive airway pressure therapy (CPAP) to help keep airways open. Other equipment gives an extra pulse of pressure when you breathe in, as a form of breathing assistance.  The type used depends on what is being treated.  For all equipment there are a few things you need to do to keep it in good condition.

Taking care of masks, straps and tubing

Weekly cleaning of masks, straps and tubing is a good idea. This helps hygiene. It will also extend their life. Before you do this, the parts should be separated. You should also disconnect the tubing from the machine and humidifier. Use mild soapy water, rinse and air dry.  Hang the tubing over a rail to help this.  Avoid using water that is too warm, harsh detergents and direct sunlight when drying. These tend to damage plastic and elastic straps.

Looking after humidifiers

It is common to use humidifiers with these devices. This is to moisten and condition the air you receive.  Some people do not need them. But they improve comfort for those that do. If you do use one, then you need to follow a few basic hygiene rules. The water in the humidifier should be changed daily.  Empty the chamber in the morning and rinse.  Leave the chamber empty during the day. In the evening before using it, refill it with fresh water. De-mineralised or distilled water is best. This stops minerals from building up on the inner wall of the chamber. These might slowly eat away at the metal parts. As well as this, you should wash the chamber thoroughly. Do this weekly with warm soapy water before rinsing.  A monthly soak in diluted (1 in 10) white vinegar can help to get rid of deposits that remain, but these are not harmful.

Remember: clean, rinse and re-fill the water chamber with clean water every day.  You need to make sure that water does not stand for a long time.

Checking filters

You need to check the machine inlet filter regularly too.  Surface dust can be removed with a damp cloth. You can wash some filters.  In other cases, the filter should be changed every six months. If it is dusty, then you might need to do this more often.

Maintaining the machine

The pumps are robust.  Look at the maker’s recommendations for how to maintain them.  Usually you can use them for years with no problem.  Problems become more likely as they get older. Some manufacturers suggest a routine check after using them for 5 years.  Of course, if you notice anything unusual (e.g. noisy operation or change), you should tell your supplier straight away.

Childhood Snoring and Sleep Apnea

How are snoring and sleep apnea related?
A child with sleep apnea almost always snores. They may struggle to breathe and have restless sleep. There are often breathing pauses which may end with a gasping or choking noise. As the child struggles to breathe, they may wake up briefly. In young children the chest may be sucked in at this time. This may lead to the child sleeping in strange positions. They may sweat a lot when they sleep. In some cases they will wet the bed. In the morning they may wake up with a dry mouth, a headache or confusion.

What is sleep apnea?
Sleep apnoea is where the child stops breathing for a short time when they sleep. It tends to happen repeatedly during the night. Each time lasts from 10 seconds to a minute or so. Usually such apneas occur due to the airway being blocked. In children, the cause is most often big tonsils and adenoids. This is called Obstructive Sleep Apnea. A less common form of apnea is called Central Sleep Apnea Central Sleep Apnea results from a problem with the way that the brain controls breathing.

What are the symptoms of sleep apnea during the day?
Because of the events during sleep, the child with sleep apnea may have a number of problems during the day. Infants may feed poorly, fail to gain weight and be delayed developmentally. Older children may have problems with their behaviour, e.g. being hyperactive, aggressive, having trouble learning and/or not being able to focus well. Being sleepy during the day may lead to personality changes, not doing well at school and problems with how they get on with others. A child with sleep apnea may lag behind in many areas of development. They may get frustrated and depressed. In the long term, if sleep apnea is not treated it may cause heart problems and high blood pressure.

How does this affect the child’s family?
Sleep apnea in a child may be very worrying for the family. Possible behavioural problems, combined with potential problems at school, can be stressful for the whole family.

What is the cause of sleep apnea?
In a child, the most common cause of snoring and sleep apnea is larger than normal tonsils and adenoids. Obesity can play a part as well. Other risk factors are the shape of the skull and the size of the tongue e.g. a child with Down syndrome has a larger tongue that may block the airway.In children with a small or receding jaw, sleep apnoea is more common. Children who have had surgery on a cleft palate may also be at a higher risk for sleep apnea.

How is sleep apnea diagnosed?
A doctor might suspect this if they see large tonsils and adenoids and certain symptoms are reported. This could include the child snoring, feeling sleepy and possibly having episodes of breathing obstruction. However the best way to be really sure about the problem and its severity is with a Sleep Study. The study is conducted in a special area of the hospital. The child has some fine wires attached to the skin, which are connected to a computer which measures sleep, breathing and oxygen levels. Studies may be done at night in older children or in the daytime in babies. None of the measurements are uncomfortable or painful and children usually manage to sleep. Parents generally stay with the child.

How is sleep apnea treated?
If a child’s sleep apnea is thought to be due to the size of their tonsils or adenoids, the first thing that is normally done is to take them out. In many cases this will cure the sleep apnea. If the reason is an abnormality of the facial bones, surgery may sometimes be done to fix this. If surgery is not an option, then the best treatment is CPAP – Continuous Positive Airway Pressure. This involves a small a pump that provides air under gentle pressure through a mask worn over the nose. It only needs to be used at night and the treatment starts working straight away. With the right support, most children do well with CPAP. If the sleep apnea is due to the child’s weight, losing weight may help or even cure the apnea.

Can it be treated with drugs?
To date there is no effective drug for treating sleep apnea although a number have been tried. Other remedies havebeen marketed, but none has been shown to be effective.

What about sleep habits?
Although sleep apnea usually requires a treatment such as already outlined, it is also very important that the child has good sleep habits. A regular time to go to bed and to wake up should be set. Before bed, the child should be away from anything that stimulates them (e.g. games, TV). The bedroom should be quiet and dark. In the afternoon and evening you should avoid giving caffeine drinks (including cola and hot chocolate) to your child. See Good Sleep Habits or more on this.

What other sleep problems can a child suffer from?
Although snoring and sleep apnea are common conditions, children may also suffer from other sleep disorders. Parasomnias such as Sleep Walking and Sleep Terrors are common in childhood and can be distressing to the child and parent. Underlying medical conditions such as epilepsy, asthma or cystic fibrosis may also cause sleeping problems. See these pages for more; Sleep Problems and Sleep Disorders in School Aged Children and Behavioural Sleep Problems in School Aged Children

Should I seek help.
If you are worried about snoring or sleep apnea in your child, you should speak with your GP. A referral will be needed to see a sleep physician. See our Sleep Specialists page.

Common Causes of Inadequate Sleep

COMMON REASONS WHY PEOPLE DON’T GET ENOUGH SLEEP

1. Taking sleep for granted
Many people do not realize how important sleep is. Instead, they may think of it as a waste of time. Time spent in bed asleep is time well spent. There are many very important things that the brain needs to do while asleep. These include forming memories and going through the day’s events. Give it a chance to do these things, make sure that you spend enough time in bed.

2. Too much caffeine, alcohol and sleeping tablets
The caffeine in tea and coffee is a stimulant that prevents you sleeping well. Alcohol may make you drowsy, but your sleep will be very restless. Sleeping tablets are OK to use occasionally, but not regularly. They stop working well and you may become addicted.

3. Shift work
Many workers have shifts that keep changing. This makes it harder to get into a regular sleep pattern. Some people adjust to shift work better than others.

4. Jet lag
Changing time zones can disturb the sleep pattern a lot. The internal body clock will readjust to the new zone, but will take a few days.

5. Eating and drinking Late
Eating too close to bedtime can cause heartburn and discomfort in the chest. Avoid late meals. Any snack before bedtime should be small and light. Try to limit your fluids before bedtime so that you don’t have to get up to go to the toilet during the night.

6. Failing to wind down before bed
Exercising, computer games and TV can disturb sleep if too close to bedtime.

7. Stress
Day to day living can be stressful. This can interfere with sleep. Give yourself a chance to relax and unwind before going to bed. Look at ways to make your life less stressful.

8. Sleep disorders
Sleep disorders such as insomnia, sleep apnoea and restless legs can be very bad for your sleep. They may not be recognized for years. See our separate brochures on each of these at www.sleephealthfoundation.org.au

9. Other medical conditions and pregnancy
There are many other things that can disturb sleep. It could be a medical condition such as asthma or painful arthritis. Or it could be something psychological. The key here is find the causes and deal with them. Pregnancy can disturb for your sleep, especially in the final months. Leg cramps, discomfort in the chest and having to go to the toilet often all play a part in this.

10. Drug side effects
Many over the counter and prescription drugs can disturb sleep. If you feel this may be the case, talk to your doctor. There may be other options for you.

CPAP – Continuous Positive Airway Pressure

What is CPAP?
CPAP is Continuous Positive Airways Pressure. It is the most effective way to treat sleep apnoea. If you have Obstructive Sleep Apnea, your Sleep Specialists may give you a range of treatment choices and CPAP may be one of these.

How does CPAP work?
CPAP is a simple concept. The equipment has three basic parts. The first is an air pump. The second is a mask that covers the nostrils or nose and sometimes the mouth. The third is a tube to link the two. The CPAP pump takes air from the room and gently pressurises it. The air blows through the tube and mask into the throat. The pressure of the air keeps the throat open while you are asleep.
The pump should not stop either you or your partner from sleeping well during the night. In fact, it is designed to do the reverse and should help both of you to sleep better. It is very quiet and makes you quiet as well. You do need to make sure that the mask fits comfortably without any leak (apart from that coming from the exit port in the mask). If it leaks, this can be noisy and air may blow into your eyes or at your partner.
There are many different types of pumps and masks, so there will be one that suits you.

How long does CPAP take to work?
CPAP will stop your sleep apnea straight away. You might start to feel better on the day after your first night of using it effectively. But some people find it takes a bit longer. It might take some time for both you and your partner to get used to CPAP. At first, you might not be able to use it for the whole night. This is common. It is better to build up use slowly than to try very hard too early and give up. What you need to do is to get any problems you are having seen to by your CPAP supplier and to keep trying. Be patient with yourself and with the device. Ask for help. Almost all the problems with CPAP can be solved with a little help and persistence

How do I start on CPAP treatment?
The pressure delivered by the pump needs to be adjusted to the right level to hold your airway open. Some people need more pressure than others. There are two ways to find out how much you need:

  • Sleep Laboratory CPAP study.
    • You will have an overnight Sleep Study. This may be like the one used to diagnose the sleep apnea. With this sleep study, you will sleep in a Sleep Laboratory with the CPAP on. There will be someone there who will gradually turn up the pressure on the pump. They will do this until it is just enough to keep your airway open. In the morning, you will get a prescription. You can take this to a CPAP supplier. This will tell them what mask is likely to fit well. It will also say what pressure you need on your pump.

or

  • Home CPAP study.
    • You will meet with a CPAP therapist during the day. He or she will show you how to use the CPAP pump. They will fit you with a comfortable mask as well. You then take the pump and mask home to use at night. You might have it for only 1 night, or you might have it for a week or two. The machine will work out how much pressure you need and keeps a record of this. When you go back to the CPAP therapist, they will download the information from the machine. You will be given a prescription for the pressure and best mask for you. With many CPAP suppliers you can hire a CPAP machine for several weeks to make sure that it is the right one for you.

Two basic types of CPAP Pump
There are two basic types of CPAP pump: those that deliver a fixed pressure and those that automatically adjust the pressure. Fixed pressure pumps run at a pressure that has been set to suit your needs. They have a ramp function (see below) which allows this pressure to increase slowly to this level after it is put on, if you prefer. They are cheaper than auto-adjusting devices and highly acceptable to many patients, particularly for those with average pressure requirements. Auto-adjusting devices monitor airflow and continuously adjust pressure overnight to keep the throat open. They are very useful in patients where pressure requirements vary a lot during sleep and are high at times. Your sleep specialist and CPAP therapist can help you decide which is best for you

Does it have any side-effects?
CPAP is very safe. It has few side effects. The most common problems are:

  • Mouth leakage.
    • Some people find it hard to sleep with a nose mask and keep their mouth closed. For them, when the machine goes on, the air goes in through their nose but then rushes out through their mouth. This can be uncomfortable and may wake them. Or this extra flow of air can also go unnoticed at night and lead to drying of the nose and throat, a runny nose, a stuffy nose or sneezing. One way to solve this is with a chin strap. This is a band of fabric that goes around the head and holds the mouth closed. Another solution is to use a mask that covers both your mouth and your nose.
  • Nose and throat difficulties.
    • Another way to solve problems with airway drying or a stuffy or runny nose is with a humidifier which fits onto the pump. It is filled with water. When the pump goes on, the water heats up and warms and moistens the air. Not everyone needs it. Some people only need it in cold weather. Some people need it every night.
  • Water in the mask and tubing.
    • This often happens in cold weather. If you are using a humidifier, the air that is being blown into the tubing is warm and moist. If the air in your bedroom is cold, this warm, moist air condenses in the cold tubing and the water is left in the tube and mask. To prevent this, the tube must be kept warm. An easy way to do this is to insulate it. You can wrap some aluminum foil and a towel around it, run it under your blanket or use a commercial tubing “cosy”. Most CPAP manufacturers offer an adjustable heating wire in the tubing which helps to prevent the problem. When you are using this heated tubing it should not be wrapped in insulation.
  • Leaking mask.
    • If your mask does not fit well, it will leak. You can often solve this by adjusting the mask and straps, but you may need to change your mask. CPAP should be very quiet. When patients complain that it is not, it is usually due to a leaking mask.
  • Manufacturer’s User Guide/Manual
    • As with any medical device, make sure you read the user guide for your pump before using it so that you understand it well.

Are there any dangers with CPAP? 
CPAP is extremely safe. If you are having surgery, talk with your surgeon and anaesthetist about your CPAP treatment and when it is safe to use it.  Postoperative use is delayed by some operations that involve the nose or airways. In general CPAP use is important during recovery from operations and you should take your CPAP into hospital with you.

How long will I need to use CPAP? 
Unfortunately, CPAP does not cure sleep apnoea. All it does is keep the airway open to control the symptoms. If you stop using CPAP, your airway will once again repeatedly obstruct during sleep. Sometimes if you lose a lot of weight, you may need less pressure or even be able to do without CPAP. But you should talk about that with your sleep specialist.

Do I need to use CPAP all night? 
Almost as soon as you stop CPAP your sleep apnoea will come back. You should use your CPAP whenever you sleep, including if you take daytime naps. Some people find this hard, but you should try to use it all night, every night. Remember that if you don’t use it, it does not work. Recent studies show that the more you use it, the more you get out of it.

What happens if I can’t use CPAP for one or two nights? 
One or two nights with no CPAP (e.g. if you are on holidays) is not likely to be a big problem to you. Most people with sleep apnoea have had it for years before they knew and during this time they didn’t have any treatment. But you need to know that all your symptoms will come back very quickly. You will snore at night and feel tired during the day. You may need to adjust your lifestyle (e.g. not drive) if you are sleepy or tired during the day. If you have a cold with a blocked nose, use a nose spray which is available from your chemist. It is fine to use these across-the-counter sprays for up to a week, but avoid more prolonged use of them. Sometimes CPAP with the humidifier can help the blocked nose. Using a full face mask is an alternative if you have prolonged nose obstruction. Your CPAP supplier may have one for you to use temporarily if needed.

What is a ramp?
Most CPAP machines can be set to start with a lower pressure. This then goes up over 15 to 30 minutes until it gets to the pressure you need to control your sleep apnoea. Starting at this lower pressure can help make CPAP more comfortable for you as you fall asleep. It is a personal choice whether to use the ramp function or not.

Can I take my CPAP on holidays? 
You should certainly try to use CPAP on holidays. It will help you and those you travel with enjoy the holiday more. Most CPAP machines work on both 110 and 240 volts. Many can also run on a 12 volt battery. This means they can be used when overseas and while camping. To learn more, see Travelling with CPAP.

Sources of help and information
If you are concerned about sleep apnoea, you should talk with your GP. They can refer you to a Sleep Specialists. Patient support groups such as Sleep Disorders Australia have branches throughout Australia. They hold information sessions as well.

Delayed Sleep Phase Syndrome (DSPS)

What is delayed sleep phase syndrome?
Delayed Sleep Phase Syndrome (DSPS) is a disorder where you find it harder to go to sleep until very late at night. This can be as late as 4AM. In the morning, you will want to sleep in for longer, perhaps until the early afternoon. If you have to wake up earlier than this, then you will feel groggy, but as the day goes on, you will get more energy. Even if you wake up early, in the evening your body will still only want to go to sleep late at night. On the weekend, many people with DSPS will sleep in even later in the afternoon.

What causes delayed sleep phase syndrome?
Your body contains a kind of internal clock that tells you when to wake up and when to go to bed. Scientists think that if you have DSPS, this clock is not running properly. A hormone called Melatonin might be involved here. Your lifestyle can also be involved. Young adults often don’t feel very sleepy ay night, so they stay up too late, and this moves the timing of their Body Clock.

What is Melatonin?
This is a hormone that your body makes to help control your body clock. Having the wrong amount of Melatonin at the wrong time can cause problems with your sleep. Melatonin levels increase at night and makes you feel sleepy. The blue light from computer screens can suppress your natural melatonin levels and stop you feeling as sleepy at night.

How common is DSPS?
It is most common in teenagers. About 7% of teenagers have it. It can occur at other ages, but it is less likely.

How does it affect people?
If you have DSPS, you have a higher chance of getting depression and Insomnia. Also, many people have to get up early in the morning for work or study. This can cause problems if DSPS is present.

How is it treated?
For some people DSPS will go away by itself. If not, then you can see a Sleep Specialist. The specialist will suggest changes in your sleep routine to regularise the hours of sleep. He or she might suggest bright light therapy – either from morning sunlight or from a light box that is designed for the purpose. This is normally done for about an hour after you wake up. The specialist might also suggest that you take Melatonin just before your bedtime. A further treatment for DSPS is called chronotherapy.

What is chronotherapy?
This involves going to bed at slightly later times each day. You will also wake up at slightly later times each day. You will keep doing this until you are going to sleep in the evening and waking up early in the morning. For example, say you are going to bed at 5AM each night, and waking up at 1PM. On the first day of chronotherapy, you might stay up until 8AM, waking up at 4PM. On the second day, you would stay up until 11AM, waking up at 7PM. On the third day, you would stay up until 2PM, waking up at 10PM. You would keep staying up 3 hours later each day, until after a week you were going to bed in the evening and waking up in the early morning. Some people take things more slowly and might stay at the same bedtime for more than one day, to help them adjust.
People with mild symptoms may find it possible to gradually move their hours of sleep to an earlier time of night, allowing them to avoid chronotherapy. See Teenage Sleep.

Can I prevent it happening again?
Once you are at the right bedtime and wake-up time it is very important that you keep the time of getting up as constant as possible. This includes week days and weekends. It is also important that you get plenty of good light in the mornings. This will lower your melatonin levels. Open your curtains and have your breakfast next to a brightly lit window. Stop using your computer any closer than an hour before your planned bedtime.

What helps to cope with DSPS?
Some people find it very hard to overcome their DSPS. Some changes to your lifestyle may help you cope. These changes won’t stop DSPS, but will make your life easier. You can try to work in the evening, or do night shifts. If your work hours are flexible, then DSPS will be less of a problem. Some people with DSPS find that naps are helpful but they need to be kept short. If you are feeling sleepy during the day, then try to avoid driving. The same goes for using dangerous machinery.

What else might cause the symptoms?
Some people with DSPS think they have Insomnia. This is because they can’t fall asleep at the expected time. If you have a good night’s sleep when you are allowed to chose your own sleeping and waking times then DSPS is a more likely diagnosis.

When should you seek help?
Sleepiness in the mornings, including when driving, can be a major problem. If the timing of your sleep is affecting the quality of your life and/or your safety then you should get help (see Drowsy Driving).

What might your doctor do?
Your GP might see if you can change your sleep and wake times using Melatonin at night and light exposure in the morning. They can refer you to a Sleep Specialist if this doesn’t work. To get an accurate diagnosis you will need to keep a sleep diary. This is where you write down all the details about your sleep, every day.

Depression and Sleep

I think I’m depressed, how do I know? 
If you keep feeling hopeless, helpless and sad, then you could have clinical depression. You may have low motivation and low energy. It might seem like there is no joy in life anymore. Changes in how you sleep and eat are also a sign of depression. Some depressed people feel shame, guilt or low self esteem. ‘Clinical depression’ is a serious condition. It is more than feeling sad or ‘blue’ sometimes. If you are unsure whether or not your feelings could be clinical depression, discuss your concerns with your doctor.

When I have slept well, I don’t feel depressed. What does this mean?
It could be that your mood is linked to how well you sleep and how much sleep you have. Depression and not getting enough sleep are two different things. But it is easy to confuse the two. It’s often hard to know which one came first. If the depression seems to go away with good sleep, it may mean that in fact you don’t have depression. You should seek help with making your sleep better.

I haven’t slept well for years but don’t think I’m depressed
Although sleep problems can lead to depression, this is not always the case. A lot of people with Insomnia do not have depression. There may be another reason that you are unable to sleep well. See our Tip Sheet on Common Sleep Disorders. Not everyone with depression has a problem with their sleep.

Should I cut out all caffeine and alcohol?
Both of these can be bad for sleep. We recommend having as little of these as you can. Then they will not impact on how well you sleep. Small amounts of these are not a problem, but try not to have them for at least 4 hours before going to bed. For some people caffeine in the afternoon can still affect their sleep. Remember that there is caffeine in cola drinks and chocolate, as well as in tea and coffee. Watch out for how much caffeine is in your food and drinks.

What can be done about insomnia and depression occurring together?
The best treatment for Insomnia is cognitive behavioural therapy, known as CBT. A sleep psychologist will help you to look at how your behaviours, thoughts, and feelings affect how you sleep. It does not involve any drugs. CBT usually requires several sessions over a period of weeks or months. It will help you learn lifelong strategies for better sleep. It can also be used to help with depression. Psychologists who specialise in either sleep problems or depression may work with both problems. It is not unusual for such treatment to happen alongside a course of antidepressants. Ask your GP about seeing a psychologist, either linked to a sleep centre or specialising in sleep and depression. Contact details for insomnia treatment centres can be found via our Sleep Specialists page.

My depression is worse in winter. Can light help?
Bright light therapy works with sleep problems with a link to the Body Clock It also helps with depression that is caused by a lack of bright light. This type of depression is seasonal, and much more of a problem when daylight hours are short. Outdoor, natural light is best to help with seasonal depression. But such light may not be easy to get in winter months in some parts of the world. Artificial bright light can be used in this case. For how much artificial light you need and when you need it, it is best to speak to a Sleep Specialists For many people, increasing the amount of outdoor light they get, especially in the morning, is a good start to help with seasonal depression and sleep problems.

I’ve heard antidepressants make sleep worse. Is this true?
There is a type of antidepressant medication called SSRIs. SSRIs work to make mood better in many people. But they may also cause or worsen insomnia in a few patients. This is not the case for all people. It is best to discuss the pros and cons of each type of drug with your doctor. Sometimes changing the time of day of taking the tablet to the morning can help your sleep. It is common for patients to use a mix of medication and other treatments.

Are naps bad? How long should a nap be?
It is normally best to avoid daytime naps as this can make it harder to fall asleep at night. This is especially so after 2-3 PM. If you do need a nap then keep it short; no more than 15-20 minutes. It is best to set an alarm to avoid long naps. Your naps should total less than 30 minutes for the whole day.

I am having problems with my sleep. What should I do?
There are things you can do yourself to help. See Good Sleep Habits. Talk to your doctor. There are Sleep Specialists who can help.

Excessive Daytime Sleepiness

What is excessive daytime sleepiness?
Everyone has days when they feel more sleepy than normal. Sometimes you know why this is the case. Often it’s to do with a busy lifestyle or too many late nights. But some people feel sleepy day in and day out and cannot work out why. In fact, they may fall asleep at times and places where they really should stay awake, such as on the train home or during a conversation. Obviously it is unsafe to feel sleepy while driving. This often alerts us to a problem.

What may cause it?
This is often the hard part. You will need to try to work this out. Often this will involve your GP too. Usually the cause of your sleepiness can be worked out just by talking to your GP.
Some possible reasons for being sleep during the day are:

  •  Your lifestyle. Are you burning the candle at both ends? Do you wish you could spend more time in bed? Are you trying to do too much and not looking after your need for sleep? Enough sleep is important for good health – make it more of a priority. Remember that if you have enough sleep, you will be able to do a lot more during the day.
  •  Poor sleep habits. Some people spend enough time in bed but are unable to have good quality sleep. This can make them sleepy during the day. See Insomnia and Good Sleep Habits. You might sleep well once you have fallen asleep, but find it hard to go to sleep until late at night. This could be due to exercise, coffee or cigarettes in the evening, too much napping during the day or Delayed Sleep Phase Syndrome (DSPS). See also Common Causes of Inadequate Sleep.
  • Your physical health. There are many reasons why you may feel tired, fatigued or sleepy. They are not always due to sleep disorders. The cause could be another problem with your physical health. Talk to your GP about a thorough check up. There are a lot of things that could be causing it e.g. heart problems, diabetes, lung disease, iron levels or an underactive thyroid. Arthritis or other pain may make it difficult to sleep well at night. Some people have to get up several times at night to go to the toilet, which interrupts their sleep. All of these and many other health problems may be the cause of being sleepy during the day.
  •  Your mental health. If you are anxious you will often find it hard to get to sleep and/or stay asleep. Depression can also have a big effect on your sleep. Your GP can talk about treatment options. Part of this could be a referral to a psychologist for help.
  •  Shiftwork. Is changing shifts confusing your body clock? It is best to be consistent with when you go to bed. This can be hard if you work shifts. How well you sleep and how much sleep you have can both suffer with shiftwork. See our information on shiftwork and/or the body clock.
  •  Your breathing at night. Some people do not breathe normally at night. Often they are not aware of it, but their bed partner may notice that they move around the bed a lot at night, snore or even stop breathing for short periods of time. This will make their sleep lighter. It will be hard to stay asleep for a long time as well. These symptoms suggest obstructive sleep apnoea. If it seems like this could be the case, you should be sure to ask your doctor about it. It is important to treat sleep apnoea and there are very effective treatments available, e.g. CPAP, oral appliances.
  •  A sleep or neurological disorder. There are some sleep disorders with no link to breathing problems that can interfere with your night time sleep. This will make you sleepy in the daytime (see Common Sleep Disorders). The key neurological problem that makes you sleepy during the day is narcolepsy.
  •  The fatigue of Chronic Fatigue Syndrome is not the same as sleepiness. See Chronic Fatigue Syndrome and Sleep for more information.

Where and when should you seek help?
If you have been struggling with feeling sleepy and cannot explain it then you should talk to your GP. Together, you can try to work out why this may be. Tests may be a part of this. If your GP thinks it is a sleep problem, you may be referred to a sleep specialist.

How do they work out how sleepy you are?
Your GP and sleep specialist will ask you questions about your sleep patterns, your sleep habits and the things that you are finding it difficult to do during the day. For example, if you are falling asleep when sitting in a boring meeting, there is less likely to be a problem than if you are falling asleep during a meal. There is a list of questions called the Epworth Sleepiness Scale. A sleep specialist may ask you to fill this out. http://www.sleepapnoeanz.org.nz/the_epworth_sleepiness_scale.shtml. They may decide to refer you for an overnight sleep study. This will show if there is any problem with your night sleep. In some cases they may ask that you stay there for the next day so that you can also have a Multiple Sleep Latency Test. The page on narcolepsy discusses this more.

Facts about Sleep

Sleep need varies

Different people need different amounts of sleep.  Eight and a quarter hours is the average for adults.  Some people can cope very well with much less and some need much more every night.

Sleep is an active state

We used to think that everything shuts down when we sleep.  But over the last 60 years scientists have discovered that our brains are very active while we sleep.  In fact, some parts of the brain use more oxygen and glucose while asleep than when awake.

Deep sleep happens first

The first three hours of sleep have the deepest stages of sleep (Slow Wave Sleep).  Later on in the night we have more of the sleep stage with vivid dreams (Rapid Eye Movement Sleep, REM sleep).

Sleep changes in cycles

Sleep changes across the night in cycles of about 90 minutes.   There is REM (dreaming) sleep in every cycle, even if only for a short time.  We also have very brief arousals many times across the night. We are not aware of most of these arousals and we forget most dreams.

A body clock affects our tiredness

The timing of our need for sleep is based on two things.  The first is how long we have been awake.  The second is our body clock.  If we stay awake all night we will feel more tired at 4am than at 10am.  Scientists call the time between 3am and 5am the ‘dead zone’. It’s when our body clock makes us ‘dead’ tired.

Falling asleep can be hard

You cannot make yourself fall asleep – just like you can’t digest your food faster. Sleep onset is not something we can control.  We can only create the right conditions for sleep – both in our minds and in our environment.

Lack of sleep can bring you down

Some people cope with a lack of sleep much better than others.  But everyone who is very sleepy loses concentration easily and experiences mood changes.   The usual mood changes are feeling more depressed and irritable.

Genetics and sleep

We now believe that many aspects of sleep are genetically controlled.  Recent breakthroughs may have identified the gene that makes some people cope more easily with a lack of sleep.

Why do we sleep?

Scientists don’t yet understand exactly why we need sleep so badly.  They believe it restores us physically and helps us organise things in our brain. We do know, however, that we can’t live well without it.

Good Sleep Habits

1. What are good sleep habits?
Good sleep habits are often referred to as good sleep hygeine. There are many things that can be done to improve sleep. Here, we will give you some guidelines for what you should and should not do for a good night’s sleep. Many people have trouble with their sleep. If you are one of them, some of these simple things may help.

2. What should I do in the evening?
Try to go to bed at the same time each night. The body has an internal clock and hormones that control sleepiness and wakefulness. This clock works best if there is a regular sleep routine. When working well, you will feel sleepy at bed time. Try not to ignore this by staying up, as this is a window of opportunity for sleep. Going to bed too early can also disturb your sleep. In the hour before going to bed, it is important to have a relaxing sleep routine. Athlough this will vary from person to person, some things that you may find relaxing include having a warm bath, reading quietly or a warm milk drink. Going to the the toilet is important to avoid having to get up in the night. It is also recommended to turn off all screens (e.g., computers, smartphones) 1-2 hours prior to bed, and if possible, not have them in the bedroom.

3. Are there things that I should not do in the evening?
Caffeine should be avoided at least 2 hours before going to bed. This isn’t just coffee and tea. It is also found in colas and soft drinks. Smoking also makes it difficult to go to sleep, so there should be no cigarettes before going to bed or during the night. Alcohol might help you get to sleep, but it will make it harder to stay asleep. It makes sleep problems like snoring and sleep apnea worse as well. Activities that are stimulating should be avoided in the hour before bed. This includes moderate exercise, computer games, television, movies, having important discussions, using social media and responding to emails and text messages. Being in a brightly lit environment or the blue light of the computer can reduce evening levels of the a sleep-promoting hormone, melatonin. Don’t fall asleep on the couch during the evening as it reduces your sleep pressure and makes it harder to fall asleep when you go to bed.

4. What about meals and sleep?
It is important to not be hungry at bedtime. But having a full stomach makes it difficult to sleep. The evening meal should be at least 2 hours before bedtime. Some people find that having a small snack at bedtime helps them to sleep better.

5. What should I do when I’m in bed?
The bed must be comfortable. Avoid being too hot or too cold. The mattress, pillow and blankets should be comfortable and restful. There should be no distractions in the bedroom. This may mean removing the television, radio and hand-held devices such as phones and laptop computers. If there is a clock in the bedroom, it should be covered to avoid clock-watching. If possible, don’t allow children and pets to be a disturbance.

6. What should I do during the day?
One very important thing is to stay out of bed. Some people use the bedroom as a living room, where they study, watch television, make phone calls and read books. This will make it harder to sleep. It is important to train the brain to link the bed with sleep. The bedroom should be used for sleeping and intimacy only. As a rule, exercise is good for sleep, but not just before going to bed. The best times are in the morning and before the evening meal, however any exercise is better than none. Being out in the natural daylight during the day will improve sleep at night. This will help with your body clock and the melatonin levels in the body. It is best to be outside in the early part of the day.

7. What should I do if I can’t get to sleep?
Sleep is not something that you can force to happen. If you are not asleep within 20 to 30 minutes of going to bed you should get up. Go to another darkened room and sit quietly. Do not have screen time (e.g., television, smartphone, computer) eat, drink or do household chores. When you feel tired and sleepy again go back to bed. This helps your mind link bed with sleep – not with being frustrated and not sleeping. Rest is good – it does not have to be sleep. Don’t label yourself as an insomniac as this will increase your worry and frustration.

8. What if you can’t shut off your mind?
Some people lie awake in bed at night and cannot switch of their thoughts. If this is a problem, set aside a ‘worry time’ during the evening. Use this time to think about what has been happening during the day, make plans and possible solutions. Then don’t think about these things until the next day. Keep the hour before bed as your wind down time – develop a routine that prepares your body and mind for sleep. Listen to quiet music or do relaxation. Remember that we can never shut off our mind. Our thoughts continue all the time, so try to make them calmer thoughts. Create a favourite fantasy place. Or daydream of your favourite holiday spot. If other thoughts come in, consider them for a moment and then try to gently replace them with calm thoughts. If you still can‘t sleep despite your best attempts at relaxing and trying to calm your thoughts, go out of the bedroom and wait until you’re sleepy and tired and then try again.

9. Are naps good or bad?
It depends. Remember that the average adult sleeps for between seven and eight hours a day. If you are taking naps without any problems, and they are short naps (around 30 minutes) then this will not be detrimental to your night time sleep. On the other hand, naps in the evening, or dozing in front of the TV, can make it harder to get to sleep at night.

10. What about prescription medicines and sleep?
Some of these will make it easier to get to sleep. But others will keep you awake. It is best to take them only when your doctor or pharmacist says so. Sleeping pills are designed for short term or intermittent use only, and always under the supervision of your medical doctor. But they are only a short term fix.

11. How much sleep do I need?
Most adults need between seven and eight hours sleep each day. Be realistic about your needs. Younger people have different sleep needs. If you are a poor sleeper it is very important you do not spend too long in bed. Spend no more than 8 or so hours in your bed. If you spend more time in bed, you will be telling your body that it’s OK to drift in and out of sleep all night. Going to bed later at night may be the single best thing to help reduce your wake time during the night in bed.

12. How important is a routine?
Try to stick to a good sleep routine. Improved sleep will not happen as soon as changes are made. But if good sleep habits are maintained, sleep will certainly get better. It is not possible to do the same thing every day, but it should be most days. Different things work for different people. Find what works for you and stick with it. If you try everything and your sleep still doesn’t get any better, then see your GP (see Insomnia).

13. What might your doctor do?
The first thing that your doctor will do is have a talk about your sleep. Depending on what they think is the cause, they might suggest the things listed above or they migtht refer you to a sleep specialist.

Idiopathic Hypersomnia

1. What is idiopathic hypersomnia (IH)?

The main symptom of IH is feeling sleepy during the day. There are two forms of IH. In one, the person has a normal amount of sleep at night (i.e. up to 9 hours). In the other, they sleep for longer than usual at night (e.g. 12-14 hours). In both forms, people also sleep during the day, usually in long naps of 1-2 hours. However these naps are not refreshing and they wake up still feeling tired. Many people with IH also have a lot of trouble waking up in the morning. They may feel quite groggy as they surface from being asleep.

2. What causes IH? 
IH is quite rare. The cause is not well understood, but it is probably related to a problem in the parts of the brain that regulate sleep and wakefulness. Recent research suggests it may be to do with malfunction of the same systems in the brain that sleeping pills act on. People who have taken sleeping pills and wake up before they have worn off, tend to be groggy and confused. This is how people with IH often feel when they wake up.

3. How does it affect people?
IH usually starts in younger people, aged less than 30. It tends to come on gradually, over months or years. People have difficulty with being able to work normally because of excessive sleepiness. Others may mistake this for lack of interest or motivation. Close friends and family need to understand how hard it is for sufferers to fight feeling sleepy. It may also cause depressed feelings. It is not safe to drive a car unless the symptoms are under control with medication.

4. Where and when should sufferers seek help?
If you are always feeling sleepy and cannot explain why, you should talk to your doctor (see excessive daytime sleepiness). You probably don’t have IH if you feel tired or fatigued without the urge to sleep during the day. If you wake up refreshed after having a long sleep, then you probably don’t have IH.

5. What might your doctor do?
If your GP feels you may have a sleep problem you will be referred to a sleep specialist. Many patients have IH for many years without knowing it. To determine if you have IH or another sleep disorder (e.g. narcolepsy), you may have a “Multiple Sleep Latency Test” in a clinic that does sleep studies.

6. What is the Multiple Sleep Latency Test?
After your sleep is monitored overnight, you will be asked to try to nap every two hours throughout the day. While you are doing this, your sleep is measured. You will be given 20 minutes to sleep every two hours – often at times such as 9am, 11am, 1pm and 3pm. There are two things being looked at. One is how long it takes you to go to sleep. The other is what type of sleep you have when you go to sleep (See Facts about Sleep to read about REM sleep). If you go to sleep quickly, but not into REM sleep, you might have IH.

7. What else might cause the symptoms?
There are many possible reasons for feeling sleepy or tired (see excessive daytime sleepiness). IH is often diagnosed by ruling out other causes of sleepiness. This means that doctors need to be sure that people diagnosed with IH are not sleepy because of some other problem related to sleep or general health.

8. How can we treat IH?
There is no cure but many people can control the symptoms of IH symptoms (at least in part) with medication. As more is learnt about the systems in the brain that control sleeping and waking, there is the promise that new drugs will be developed for IH. In most cases, IH persists but it seems that in 10-15% of cases it will resolve by itself.

9. What can you do to help with symptoms?
You need to adapt your lifestyle. Try to work out a system for being able to wake up in time for things you need to do during the day (e.g. using more than one alarm, asking friends and family to help, morning light). Avoid situations where it is a danger to be sleepy, such as driving (see drowsy driving). If you plan your naps during the day, this may help. But how much this works varies from person to person. Keep the same sleep hours each night. If you feel depressed about being sleepy, then seek help.

Insomnia

What is insomnia?
Insomnia is said to be present when you regularly find it hard to fall asleep or stay asleep. It has several patterns. You may have trouble getting to sleep initially. Or even if you can fall asleep, you might not be able to stay asleep for as long as you would like. Also you may wake up during the night and not be able to go back to sleep for a long time. Many people have two of the above problems, or even all three. Because of these, you might feel tired during the day.

What causes insomnia?
Insomnia has many causes which can include:

  •  Some medicines and drugs e.g. asthma or blood pressure medication, caffeine, alcohol or smoking.
  •  Chronic pain and other uncomfortable illnesses
  •  Stress at work or in your personal life
  •  Depression
  •  A friend or loved one passing away
  •  Anxiety and worrying, including worrying about not getting enough sleep
  •  Another sleep problem (see Ten Common Sleep disorders)
  • Sometimes there is no clear cause for insomnia, in which case it is called primary insomnia

How common is insomnia?
Most people have experienced insomnia symptoms at some time of their lives. At any given time around 10% of people have at least mild insomnia.

Who is at risk?
Older people with poor health have a higher risk. Also women have twice the rates compared to men. This may be related to higher rates of anxiety and depression, which can be associated with insomnia. Shiftworkers have a higher risk too.

How does it affect people?
You might feel that it’s harder to focus and remember things. But most people think their memory is worse than it really is. The same goes for concentration. Your risk of a traffic accident or other injury may be higher (see Drowsy Driving). You may be more emotional and a lack of sleep can cause depressed mood. Some people feel sleepy during the day, but this can be caused by many things (see Excessive Daytime Sleepiness).

How is it treated?
This depends on what is causing the insomnia.

  •  If poor sleep habits are the cause then these need to be improved (see Good Sleep Habits).
  •  If your sleep habits seem to be okay but you are still having problems then you may need more specialist help. Cognitive-behavioural therapy for insomnia has been shown to be more effective in the medium and long term than sleeping tablets. (See the information under the final three subheadngs for treatment services.)
  •  Stress, depression and anxiety are best treated by specialists, but taking steps to improve your sleep can also help with these.
  •  Sometimes sleep specialists will suggest a sleep study to be sure they understand what may be causing the poor sleep and also check for sleep apnoea.

What about sleeping pills?

If you only take them occasionally, sleeping pills can get you a good night’s sleep. However if you take them often, you will get used to them and they will stop working as effectively. Also they can be habit-forming and it can then become difficult to stop taking them.

Where and when should you seek help?
If you are having ongoing trouble sleeping, persistent problems with mood, restlessness in bed, severe snoring or wakening unrefreshed, make sure that you go and see your doctor. Your GP can refer you to a sleep specialist or psychologist.
Insomnia treatment services in Australia are listed here in the Sleep Services Directory: http://www.sleep.org.au/information/sleep-services-directory

Is there online help available? 
Yes, on-line, low cost, sleep improvement programs are available, such as:

Sleep Better without Drugs – This Australian program consists of a book and three CDs. It was first developed and tested in Australia in the 1990s by psychologist Dr David Morawetz and subsequently updated. A full downloadable version for smartphones etc is newly available here.

Sleepio – An on-line program developed and tested in the UK by the insomnia researcher and clinician, Professor Colin Espie.

SHUTi – This online program was developed by the University of Virginia, USA and tested in several countries, including Australia.

(Note:  The above commercial programs have published, peer-reviewed research supporting their effectiveness. The Sleep Health Foundation does not endorse programs or products and the above list is provided for information only.)

Melatonin and Children

What is melatonin?
For general information on melatonin please see our melatonin web page.

What can children use melatonin for?
In children, melatonin is typically used to treat difficulties with going to sleep or staying asleep. It may benefit children who are developing normally as well as children with Attention Deficit Hyperactivity Disorder, autism, other developmental disabilities or visual impairment.

For most children with sleep problems, there is a specific cause which should be identified and treated before melatonin is considered as an option. For example a child might not be able to get to sleep due to their anxiety. If the child is anxious, there are things to try first such as relaxation techniques and visual imagery. See our Anxiety and Sleep page. In some cases, the sleep problem may be related to the child’s behaviour. If this is the case the parents should try to change the child’s behaviour at bedtime. See our Behavioural Sleep Problems in School Aged Children page for some tips on how to do this. Other sleep disorders in children are described in our Sleep Problems and Sleep Disorders in School Aged Children page .

How much melatonin should my child take?
If your child’s paediatrician or sleep specialist has prescribed melatonin, the dose will depend on your child’s age. A young child needs less than an older child.

Amounts may vary from 0.5 mg to 6 mg. There does not seem to be any reason to take more than this. All forms of melatonin need a doctor’s prescription in Australia. The most common preparation in Australia is 2 mg in a tablet form and this is available from chemists with a prescription. It is a slow release form to last all through the night. This is much like the melatonin that occurs naturally. Melatonin is also available in liquid form or in immediate release tablet form from compounding pharmacies.

When should my child take it?
To help your child go to sleep, the best time to take the melatonin is around 30-60 minutes before you want them to go to bed. You may need to try giving it at different times to work out when is best for them. Discuss this with your child’s doctor. Be sure to use it along with a good pre-bed routine. The bedroom should be dark and comfortable. It is important that it is free from electronic media (such as TVs, electronic games and phones) which may distract the child and make it difficult to sleep. See also Good Sleep Habits. Children should not use computers for at least an hour before going to bed. A light snack before bed is OK, but drinking and eating should be avoided if possible for at least 2 hours before bed.

Can melatonin cause problems?
In the short term, melatonin seems to work well and be safe. Only a few studies have looked at its long term use in children. But those that have, suggest that it is safe. Long term use is only appropriate if it is because of an specific sleep issue, such as may be seen in children with developmental problems or visual impairment. Side effects in children are very rare. When people report them, it is not yet certain if they are caused by melatonin or by something else. You should talk about this with your doctor.

Menstral Cycle and Sleep

Does sleep quality change across the menstrual cycle in women?
Up to 7 in 10 women say that their sleep changes just before their period. The most common time for this is 3 to 6 days before having the period.

Are sleeping problems a common part of Premenstrual Syndrome (PMS)?
Yes. Most women with menstrual cycle related problems have particular sleep issues just before the period. Some women suffer from a range of premenstrual symptoms as well sleep problems. For others, sleep problems are the only PMS symptom. Sometimes women suffer from sleep problems regularly at other times of their menstrual cycle.

How does PMS affect sleep?
Women may feel that it is harder to get to sleep and stay asleep. They may have restless sleep in the days leading up to their period. Some women say they are sleepier during the day. We know that the amount of REM sleep – which is when we have most of our dreams – is less in this part of the menstrual cycle. Hormonal changes at this time (e.g. sudden drops in progesterone) affect the body’s temperature control. In turn this affects sleep quality.

What should I do first?
Many women find that it helps to keep a diary of their symptoms for three months or so. This should list their symptoms day by day. It should also list when their period starts and stops. This is so that it can be confirmed that the sleeping problems have a link to PMS. The first step is to understand! It will also let individuals predict when they are most likely to have symptoms in the future. This means that you take action to help yourself – see below. You may want to discuss your symptoms with your GP. If so, your diary would be a good starting point.

What can I do to help my sleep?
Once you are sure your sleeping problems have a link to your menstrual cycle you will know when they are likely to appear the next month. In the days before this time, aim to get plenty of rest and sleep. Hints on our Good Sleep Habits page may help. Be sure to cut down on caffeine and alcohol at this time. You should also stay active and maintain a good diet. Try to have less sugar and salt and more calcium. Before and during your PMS try to get lots of outdoor light. Keep in mind that your poor sleep (and mood) will get better once your ‘problem time’ is over. This may mean you have less frustration and anxiety about your sleep.

What else might help?
Some women with PMS (but not all) may have low Melatonin levels. If this is the case then taking melatonin may help your sleep symptoms. You should discuss this with your GP.

Should I go to my GP about this?
If your PMS problems are having a big impact on your quality of life talk to your GP. You can discuss ways to make the PMS symptoms better. If you do this then your sleep will usually get better too.

Narcolepsy

What is narcolepsy?
Narcolepsy is a chronic neurological disorder of excessive daytime sleepiness. It may occur with other symptoms such as cataplexy, sleep paralysis and hallucinations.
All people with narcolepsy have excessive drowsiness. You may have a lack of energy. Strong urges to nap can happen at any time of the day. Naps might last for minutes or up to an hour or more. After a nap you may be alert for several hours. While this may happen every day it is not because you aren’t sleeping enough at night. Sometimes these develop years after the sleepiness, and sometimes they don’t occur at all.
Cataplexy is a sudden loss of muscle function while conscious. You may have a total collapse or just weakness in the knees or face muscles. It may last from a few seconds to a few minutes. Cataplexy is triggered by sudden emotions such as laughter, anger or fear.
Occasionally you may wake up momentarily unable to move any part of your body. This is called sleep paralysis. Usually it lasts between a few seconds and a few minutes. You may feel frightened by it, although it will not cause you harm. Sleep paralysis also happens in people without narcolepsy. While narcolepsy is uncommon (see below) isolated episodes of sleep paralysis can occur in about 15% of the population.
Some people with narcolepsy also report hallucinations. You may see or hear things that are not really there, especially if you are drowsy.

What causes narcolepsy?
The part of the brain which controls falling asleep functions abnormally. During the day when normally awake and active, you might fall asleep with little warning, rapidly going into a stage of sleep called Rapid Eye Movement (or REM) sleep. During normal REM sleep there is both dreaming and temporary loss of muscle tone. In narcolepsy normal REM sleep may become disrupted and there might be hallucinations, cataplexy and sleep paralysis. It is thought that narcolepsy is related to lack of a brain chemical called hypocretin. In some cases (but not all) it is an inherited condition.

How common is narcolepsy?
It affects about 1 person in 2000. Both men and women get narcolepsy. It can occur at any age but is usually first noted between the ages of 10 and 30.

How does it affect people?
Onset may be gradual or sudden. You may notice the irresistible sleepiness first and other symptoms only appear many years later. Working and learning is likely to be difficult because of sleepiness. Others often mistake your sleepiness for lack of interest or motivation. You may also feel depressed. You should only drive a car if your symptoms are well controlled with medication.

Where and when should you seek help?
If you have been struggling with unexplained sleepiness you should talk to your doctor (see Excessive Daytime Sleepiness). Any symptoms that could be cataplexy should not be ignored. You are not likely to have narcolepsy if you feel tired and/or fatigued without the urge to sleep across the day.

What might your doctor do?
If your GP feels you may have a sleep disorder they will refer you to a sleep specialist. Many patients have had narcolepsy for many years before it is diagnosed. To be diagnosed with narcolepsy you are likely to need a “Multiple Sleep Latency Test” in a clinic that conducts sleep studies.

What is the Multiple Sleep Latency Test?
After doing a night-time sleep study you will be asked to try to nap every two hours throughout the day while your sleep is measured. You will be given a 20 minute opportunity to fall asleep at times at two-hourly intervals – often at times such as 9am, 11am, 1pm and 3pm. There are two things being measured. One is how long it takes you to fall asleep. The other is whether you go straight into REM sleep when you fall asleep. (See Facts about Sleep to read about REM sleep). Falling asleep quickly and going quickly into REM sleep are likely to indicate narcolepsy.

What else might cause the symptoms?
There are many possible reasons why you may be feeling sleepy or tired. Think about all the possible options (see Excessive Daytime Sleepiness). If you have eliminated all other possible reasons and you do not meet the criteria for narcolepsy you may be diagnosed with idiopathic hypersomnia.

What is idiopathic hypersomnia?
Unlike people with narcolepsy, people with this condition do not fall rapidly into REM sleep following the onset of sleep and do not have other symptoms like cataplexy. There are a number of potential causes of idiopathic hypersomnia but the condition is not well understood. See Idiopathic Hypersomnia.

How is narcolepsy treated?
There is no cure for narcolepsy but some of the symptoms may be controlled with medication. Stimulants are prescribed to help with sleepiness. Anti-depressant medications may be used to control cataplexy. You will feel more alert if you can build in power naps across the day.

What could you do to help with symptoms?
You need to adapt your lifestyle. Avoid situations where sleepiness is dangerous, such as driving. Planned daytime naps will help control the urge to sleep. Keep regular night sleep hours. Cataplexy may be reduced by learning to flatten your emotional responses.Ensure family and friends understand how the condition affects you.

Obstructive Sleep Apnea

1. What is it?
Patients with obstructive sleep apnea (OSA) have repeated episodes of partial or complete obstruction of the throat (also known as the “pharynx” or “upper airway”) during sleep. A narrow floppy throat is also more likely to vibrate during sleep, which causes snoring. If partial or complete obstructions occur breathing is reduced or stops for a short time – from 10 seconds up to a minute or more – and blood oxygen levels fall as a result. A brief interruption to sleep (an arousal) that lasts for as little as 3 seconds then occurs, allowing breathing to start again but your sleep is disrupted as a result. These episodes of obstruction may happen many times – even hundreds of times – overnight. Some people know that their breathing is not normal at night, but may be unaware that this is a medical problem that is causing them harm. Fortunately, good treatments are available.

2. What are the symptoms of obstructive sleep apnea?
If you have OSA you may snore, toss and turn and others may notice that you stop breathing during the night. Because of the disruptive effects of OSA on sleep you may find yourself waking up often during the night, sometimes gasping or choking, although this does not always happen. However, even if there are few awakenings overnight, sleep is disturbed and you may be unrefreshed by it because of this. As the day goes on, you may struggle to stay awake, especially in the afternoon. Grumpiness and other mood changes are common in untreated OSA.

3. Obstructive sleep apnea affects families
Snoring can keep a bed partner awake and sometimes people in other parts of the house. Some partners try to stay awake to make sure that the person with OSA starts breathing again after a breathing pause. Lack of sleep may make people who are living with a person with OSA more grumpy and irritable. OSA is a problem not only for the person with it, but also other family members.

4. Why you should worry if you have obstructive sleep apnea symptoms
There is strong evidence that people with untreated moderate to severe OSA have other health problems. If you have OSA, you are more likely to have high blood pressure and other cardiovascular disease than someone without it. Each time you stop breathing, your blood pressure may go up. Over time, this may also contribute to high blood pressure during the day (hypertension). There is also evidence that having OSA, particularly if severe, may increase the risk of diabetes, heart attack, stroke or depression. Treating sleep apnea may reduce these risks.

5. Obstructive sleep apnea causes motor vehicle accidents
People with OSA are approximately two and half times more likely to have a motor vehicle accident than others. Broken night-time sleep leads to less alertness, slower reaction times, poorer concentration and more chance of falling asleep at the wheel. The risk of work accidents is increased if your job involves operating machinery or transport.

6. Who gets obstructive sleep apnea?
OSA can occur at any age. In children, it is often the result of enlarged tonsils or adenoids (see Childhood Snoring and Sleep Apnea). In adults, OSA is more common in middle age and in older people. It is also more common in men than in women, although after menopause the risk becomes similar. Many, but not all, people with OSA are overweight. Being overweight can cause a narrowing of the throat due to fatty tissue. Also, having a large waistline can make the lungs smaller during the night, which makes the throat more likely to collapse. Some people are born with a narrow throat or have a facial structure which leads to narrowing.

7. How is obstructive sleep apnea diagnosed?
Signs and symptoms such as snoring, obesity, observed breathing pauses and sleepiness during the day may suggest that a person has OSA. The best way to be really sure is with an overnight sleep study. This measures your sleep, breathing and oxygen levels. Your GP can refer you for a sleep study.

8. How is obstructive sleep apnea treated?
For people with a mild level of OSA and few symptoms, losing weight, decreasing the amount of alcohol consumed in the evening or adjusting the sleeping position may be all that is needed. Most people have more OSA episodes sleeping on their backs.

However, for those with moderate or severe OSA more active treatment is often required. This is particularly so if daytime tiredness is present or there is a background of heart disease, stroke or high blood pressure that has been difficult to control. The two most commonly used treatments for moderate to severe OSA are nasal continuous positive airway pressure (CPAP) or an oral appliance.

CPAP uses a small, quiet air pump that takes air from the room and delivers it under gentle pressure to a mask that covers your nose. This acts to hold your throat open during the night. You only use CPAP at night in bed. It is very good in controlling the symptoms and the long term effects of sleep apnea. It stops the snoring and the machine noise is very much quieter than the snoring was. Sometimes it takes a while to get used to CPAP and tips to help can be found on our CPAP- Making It Work For You fact sheet.

For some people an oral appliance (or mandibular advancement device), fitted by a specialist dentist, is suitable. It is like a double mouthguard that goes over both the upper and lower teeth. The upper and lower mouthguards clip together, so that the jaw is held forward during the night and this helps keep the airway open. These devices are particularly useful for snoring and milder forms of sleep apnea.

There are several surgical operations available for sleep apnea. These are not usually offered unless both CPAP and oral appliances have not worked. It is important to select the right operation and an experienced surgeon is essential.

A number of other remedies have been marketed, some of which have value for selected patients while many others have been shown to be of no benefit. Your doctor will be able to advise you.

9. Other things you can do if you have sleep apnea
In many people, being overweight contributes to sleep apnea. Losing weight may help or even cure the OSA and is extremely beneficial for other health problems, including high blood pressure, diabetes, high cholesterol and joint problems.

If you are diagnosed with OSA, it is a good time to make sure that you are doing everything right to improve your sleep. Alcohol and sleeping tablets relax muscles and may worsen sleep apnea. Their use should be minimised. It is also important to make sure that you are having a regular sleep pattern and sleep as well as possible. See Good Sleep Habits.

Periodic Limb Movements of Sleep (PMLS)

What is PLMS?
Periodic Limb Movements of Sleep (PLMS) is when your legs or arms move when you’re asleep. It happens every 10 to 60 seconds and is out of your control. There are various ways this can happen such as flexing of the toe or foot, bending of the ankle or knee or twitching of the hip. This tends to occur over and over. It can last from a few minutes to a few hours. PLMS is mainly seen in the first third of the night, during the deepest type of sleep.

Often, the way people know that they have PLMS is when their bed partner complains of being kicked. The blankets may be all over the place in the morning. Some people may move their legs in this way hundreds of times per night. In some cases this can disrupt the sleep of the person with PLMS or that of their bed partner. For others, PLMS may not be a problem at all. It only needs to be treated if it is causing a problem.

How common is PLMS? 
PLMS is more common in older age. It affects only 2% of people aged less than 30, 5% of 30 to 50 year olds, and 25% of those between 50 and 60 years old. About 40% of people 65 or older may have PLMS. Both men and women have the same chance of getting it.
As many as 80% of people with Restless Legs Syndrome also have PLMS. These problems mean they may find it hard to both fall asleep and stay asleep and they may feel fatigued or sleepy during the day.

How do I know if I have PLMS? 
This can be tested with an overnight Sleep Study. Leads are put on the legs and/or arms while sleep is measured. In some cases, records may be made over a longer period of time (1-2 weeks). In this case a monitor is worn around the ankle and/or wrist.

What causes PLMS? 
The problem originates in the nervous system. The exact cause is not yet known.

How can PLMS be treated? 
PLMS can disrupt sleep. This can interfere with how you function during the day by making you tired. If so, you need to consider treating it. The same drugs that are used to treat Restless Legs Syndrome may be used. Cutting down on caffeine, alcohol, and smoking can also help.

Is PLMS the same as myoclonus? 
In the past, PLMS has had other names e.g. restless legs, nocturnal myoclonus, periodic leg movements and periodic limb movement disorder. The usual name now is Periodic Limb Movements of Sleep.

How can I get help?
If you are worried about PLMS, you should consult your GP. If required they can refer you to a Sleep Specialist.

Pregnancy and Sleep

Is sleep important when you are pregnant?
Pregnancy is a time when you need to pay particular attention to your health. During pregnancy, the mother’s body changes rapidly. Any health issues may impact on the development and growth of the baby. Most people know that you need a balanced diet and enough exercise, but having enough sleep is vital as well. Many pregnant women feel tired. This is most common in the first few months of pregnancy and again towards the end of pregnancy. This means that women will often need to spend more time resting or sleeping.

How does sleep change during pregnancy?
Along with the changes to the body that occur during pregnancy, there are also changes in sleep patterns. These are quite normal. As the pregnancy progresses, women have less deep sleep and wake up more often during the night. Sleep is less refreshing, which is why expectant mothers should spend more time in bed asleep. Sometimes an afternoon nap of an hour or two will help.

Is snoring linked with pregnancy?
You may start to snore during pregnancy. You don’t need to worry about this if it only occurs occasionally. But if it occurs often, is very loud or interrupts sleep, you should speak to your doctor or midwife. Snoring during pregnancy may indicate breathing problems during the night. Sometimes mothers who start snoring have also developed high blood pressure. For the health of both you and your baby, you need to look into this.

Are breathing pauses during sleep normal in pregnancy?
It is normal to have very occasional breathing pauses during the night, whether or not you are pregnant. However they may become more frequent and noticeable during pregnancy. Sometimes these breathing pauses end with a snore or gasping. The sleep disruption may cause excessive sleepiness during the day. If you or your partner have noticed breathing pauses, you should mention it to your doctor.

Are leg movements linked with pregnancy?
As pregnancy proceeds, some women (or their partners) notice that they move their legs a lot just at the time that they go to sleep. There may be small jerks and kicks, or there may be quite large movements that keep going all through the night. If this gets in the way of sleep, you should see a doctor to treat it. The symptoms usually get much better or go away after the baby is born. See our page on Periodic Limb Movements during Sleep. Some mothers-to-be also experience Restless Legs Syndrome.

How may sleep disorders affect the health of the mother?
Breathing pauses, snoring and other sleep disorders can increase the health risks of pregnancy to the mother. This may include high blood pressure, diabetes or even pre-eclampsia. Mothers who don’t have enough sleep may feel anxious and depressed. This may persist after the baby is born. Acting on these problems early helps simplify treatment. See Depression and Sleep and Anxiety and Sleep.

How may sleep disorders affect the health of the developing baby?
The baby might not grow normally if the mother has health problems such as high blood pressure or diabetes. If the mother has breathing pauses and variable oxygen levels during the night, the baby might be smaller and not be as healthy at the time of birth.

How can I improve my sleep during pregnancy?
Most expectant mothers need more sleep than usual and should try to optimise the quality of their sleep while they are pregnant. You should follow the simple tips in our Good Sleep Habits page. Sleep may be particularly bad during the third trimester. In these last 2 or 3 months, women often have frequent trips to the toilet at night, indigestion, leg movements or discomfort from the pregnant belly. There are some simple things to do that can help each of these problems:

  •  To manage indigestion, raising the head of the bed or sleeping on more pillows is helpful. Antacids may be used, but in moderation.
  •  To reduce the number of toilet trips during the night, be sure to go to the toilet just before going to bed and avoid drinking too much in the evening.
  •  If moving your legs during sleep is a problem, you should reduce the amount of tea, coffee and other caffeine drinks that you have. This may help.
  •  Obstetricians and midwives usually suggest that women try to sleep on their side during the later months of pregnancy. This may lessen discomfort and also help with the healthy growth of the baby.
  •  If there is loud, frequent snoring or breathing pauses, discuss this with your doctor. Sometimes a sleep study may need to be done.

Women should look after their health to have a healthy baby. Sleep is one of the three pillars of health – you need to have a good diet, moderate exercise and enough sleep.

Restless Legs Syndrome

What is RLS?
RLS is a problem where you feel significant discomfort in your limbs. People use a variety of words to talk about how it feels e.g. pulling, drawing, crawling, wormy, boring, tingling, itchy, pins and needles, prickly and painful. It tends to affect the legs much more than the arms. When it happens, you feel a very strong urge to move the affected limbs. Often there is no way to resist it.
People may experience RLS when they sit for a long time such as at a desk, in a car, seeing a movie or travelling on a plane. RLS can also affect you when you lie down to sleep.
RLS is always worse in the evenings. This may mean that it is hard to get to sleep. If you do get to sleep, you might wake up many times during the night, and not get as much sleep as you need. You can end up feeling irritable, anxious and depressed.

Who gets it?
RLS is found in 2% to 5% of people (both men and women). The risk of it goes up as you grow older, and it tends to be more serious in the elderly. But it can start at any age. It can be associated with pregnancy.

How do I know if I have it?
There is no lab test to work out if you have RLS. Tests and body examinations will not be able to pick up RLS in most cases. Your doctor is likely to ask you about your symptoms, medical and family history, and if you are on any medication.

What causes it?

  •  If your parents had RLS, your risk of having it is higher (30 – 50%).
  •  RLS may occur in pregnancy and is more likely in the last 6 months. RLS will usually go away after giving birth.
  •  Your diet can cause RLS. Problems may include not getting enough iron.
  •  RLS has been associated with too much caffeine, smoking and alcohol.
  •  Other health problems can also lead to RLS such as anaemia, kidney problems, diabetes, arthritis or Parkinson’s disease.
  •  It can also be due to nerve damage in your limbs.

How can RLS be treated?
There are many ways to make the legs feel better including walking, rubbing them, massaging them, doing knee bends or just moving them. If you don’t move them, your legs will often jump by themselves. Other things that might help for mild cases are a hot bath, a leg massage and exercise. Applying either a heat pad or ice pack, or alternating the two, can also be helpful.
It can help to cut down on your caffeine, nicotine and alcohol intake.
If your RLS stems from another problem (e.g. anaemia) then the thing to do is to treat that. Your GP may do a blood test to check your levels of a number of important indicators.
In serious cases, there are medications that you can take to control your RLS. Some of these can be habit forming, but this doesn’t tend to be an issue with the small doses used to treat RLS. Drugs used to treat Parkinson’s disease can also help RLS. The down side of all of these drugs is that they might stop working after you have been on them for a while. Talk to your GP about which treatment is best for you.

Can RLS get worse or better by itself?
For most people where there is not a reversible factor (such as iron deficiency) RLS gradually gets worse with age. Occasionally RLS can go away by itself, but often it will return.

Shiftwork

How can shiftwork affect my sleep?
Generally, the body is programmed to sleep best overnight and to be most alert during the day and early evening. If you work night shift, it might not be easy to sleep enough or to sleep well during the day. If you start work very early in the morning, it might be hard to sleep in the evening. The average shiftworker sleeps one hour a day less than someone who doesn’t work shifts. Some shiftworkers sleep up to four hours a day less than normal, but this is not common.

If I do shiftwork, am I more likely to be tired while I am awake?
Shiftworkers often complain of being tired, both on and off the job. It may be harder to concentrate and be alert while at work. This means there is more danger of accidents at work and on the road, driving to and from work. Sleep loss impairs performance: 17 hours without sleep is as dangerous as having a blood alcohol content of 0.05% and 24 hours without sleep, as dangerous as having a blood alcohol content of 0.08%.

Why does this happen?
The human body is designed to be active during the day and rest at night. There are many body hormones that work to keep this in balance. It is not always easy to switch to being active at night and resting during the day.

What can I do about it?

  •  Make time for enough sleep. Shiftworkers have to sleep when others are awake. Social and sporting events can sometimes be rearranged so that shiftworkers can still participate in these activities.
  •  Try to go to bed at the same time every day and get up at the same time also.
  •  Try to sleep in peace! Others in the house need to respect the need of the shiftworker to sleep. This may mean removing the telephone from the bedroom and having heavy carpet or curtains in the bedroom to help absorb any noise. Some shiftworkers find that wearing ear plugs to bed helps.
  •  A fan or “white noise” machine will help to muffle noise.
  •  Keep the bedroom cool and dark.
  •  Avoid caffeine, sleeping pills, alcohol or cigarettes before going to bed.
  •  If you can, sleep just before going to work. This is better than earlier in the day. If this is not possible, taking a nap before going to work may help.
  •  Some workers are allowed to take a break during their shift. This time can be used for a short nap.

What can my employer do about it?

  •  Avoid scheduling back-to-back shifts. After working double or triple shifts, the problems only get worse and safety will be reduced.
  •  Keep each worker on the same shift. The best thing to do is to go to bed at the same time every day. If this is possible, the body will adapt to shiftwork better. If shifts are rotated often, it makes it difficult to develop a good sleep pattern.
  •  When shifts do rotate, rotate them forwards (morning to afternoon to evening to night) instead of backwards. For example, if someone is working afternoon shift, it is easier for this person to rotate forwards to evening shift than backwards to a morning shift.
  •  Schedule the heaviest work that requires most concentration during day shifts.
  •  Schedule breaks during night shifts. This allows tired workers to take a nap.

How long should a nap be?
Fifteen minutes is best. Avoid napping for longer than this. When driving, pull over to a quiet spot and put the seat back. After the nap, walk around for 5 minutes to wake up properly before resuming other activities.

I am having problems with my sleep. What should I do?
Contact your doctor. There are sleep specialists that can help.

Sleep Myths

Myth 1: The brain shuts down and is inactive during sleep
In fact, the brain is very busy during sleep. Among other things, it sorts and processes information on what was going on that day. Then it cements these into your long term memory. This is a vital for learning and memory.

Myth 2: You can train yourself to get by with less sleep
How much sleep is needed each night varies between people. The average adult needs about 8 hours a night. Some need less, others more. Most of us know from our own experience how much we need to feel good the next day. Getting less than this builds a sleep debt. Sooner or later this will have to be paid back. You might not notice missing an hour or so every now and then, but it is not good to make a habit of it. If you do, you won’t be able to think or react to things as quickly as before. Even if you don’t feel sleepy, your brain won’t be working as well as it could.

Myth 3: Sleeping in on the weekend prevents the effects of sleep loss during the next week
Sleeping in will work when you haven’t been sleeping enough and you need to pay back a sleep debt. But you can’t bank sleep in advance. If you are behind on sleep, it will affect how well your mind works. Things won’t get better until you catch up on the sleep that you missed. Regular sleep habits help build a good, strong sleep-wake pattern and keep you at the top of your game.

Myth 4: Daytime sleepiness will always get better if you spend more time in bed
Good sleep needs the right length, timing and quality. There are a number of sleep problems that can worsen the quality of your sleep and cause sleepiness during the day. This can be the case even if you don’t notice any problems at night. Obstructive sleep apnoea is a common example of this. It is not normal to sleep for a long time at night and still feel tired during the day. If you do, a doctor needs to look into why this is happening.

Myth 5: Daytime naps don’t help and waste time
Adults usually don’t need daytime naps if they have slept well for long enough at night. But they are useful if there has been sleep loss at night. If you do need a nap, it is best not to have one later than mid afternoon. This is so you can still get a good night’s sleep. Also, naps that last too long (more than an hour) can make you feel groggy after you wake up. This is known as “sleep inertia”. Napping is normal in young children.

Myth 6: The brain adjusts quickly to changes in your sleep schedule
We all have an internal body clock. This clock is set by when we get (and don’t get) sunlight. This means we are at our most alert during the day. The time when we are the most tired is between midnight and dawn. Sometimes we need to change
the times when we go to bed and get up. This could be because of shift work or changing time zones (jet lag). Some people cope better with this than others. But we all take time to adjust to these changes. Until we adjust, our sleep quality suffers and we don’t function as well during the day.

Myth 7: We need less sleep when we are older
How much sleep children needs gets less and less as they grow up. But once they are young adults, their sleep needs stop changing. The amount of sleep they need will stay the same for the rest of their life. As we age through adult life, sleep can get less efficient. This could be from body aches and pains, among other things. Because of this, we might have to spend a bit more time in bed. But apart from this, sleep needs are stable throughout adult life.

Myth 8: If children don’t get enough sleep, this will always lead to them feeling too sleepy during the day
If a child doesn’t get enough sleep, this can cause many other problems apart from just sleepiness. It might be that they can’t concentrate well but don’t feel tired. In some cases they behave badly, are moody and get into trouble at school.

Myth 9: Regular snoring is normal
Snoring from time to time is a common problem. Loud snoring on most nights is not normal and should be checked out. It often means something is getting in the way of breathing during sleep, both in children and in adults. This is known as obstructive sleep apnoea.

Myth 10: If you find it hard to fall asleep or stay asleep, the usual cause is stress
Stress can certainly make it harder to sleep. But many other causes exist. These include a variety of sleep, medical and psychological issues. Often the issue is poor sleep habits. If so, these can and should be dealt with.

Sleep Problems and Sleep Disorders in School Aged Children

Sleep problems in school age children

There are a number of common sleep problems and sleep disorders that are known to affect children. 

These include:

You find it hard to get your child to settle into sleep at a reasonable time in the evening or your child wakes you more than once at night.

Your child might have a behavioural sleep problem.
These tend to be linked with some inappropriate behaviours around the time your child goes to bed. It means it is hard to get them to go to bed, go to sleep and stay asleep. See Behavioural Sleep Problems in Children.  For information on hours of sleep you could expect at different ages see Sleep Needs across the Lifespan.

You notice that your child snores at night, has very restless sleep and wakes in the morning but does not look refreshed.

Your child may have Obstructive Sleep Apnoea Syndrome. They will need to see a paediatric sleep specialist. This is to look at your child’s breathing and sleep.
Obstructive Sleep Apnoea Syndrome (OSAS)is a breathing problem during sleep. There are many things that may give clues that your child has OSAS e.g. loud snoring, noisy breathing, having to make more of an effort to breathe, or not breathing consistently with pauses and gasps every now and then. OSAS causes a restless sleep pattern. In turn, this leads to poor quality sleep. OSAS can also be linked with night sweats, mouth breathing, sleeping in strange positions and morning headaches. A young child with OSAS might grow and gain weight slowly. When children with OSAS wake up, they don’t look refreshed. They may have behaviour and learning problems during the day and perform poorly at school. OSAS in children tends to be caused by large tonsils and / or adenoids. A sleep study in a children’s sleep unit can work out how bad the OSAS is. This is done overnight. Surgery is a common way to treat OSAS in children. The tonsils and adenoids are taken out. Some children have a higher risk of OSAS. Risk factors are if he or she is obese, has narrow bone structure in their face, Down Syndrome, neurological problems, weak muscles or has had cleft palate. See also Snoring and Obstructive Sleep Apnoea in Children.

Your child may have Restless Legs Syndrome (RLS).
This is a movement disorder. It causes strange feelings in the legs. These come when the legs are at rest, or when your child is lying down ready for sleep. These feelings make the child want to move the legs or walk around. When they move their legs, they will feel better for a short time. But the feelings will come back after a short time. These tend to occur in the time before sleep. This means RLS can make it hard to get to sleep and stay asleep. It can make their sleep worse. This can lead to behaviour and learning problems during the day. A paediatric sleep specialist can tell if your child has RLS and if so how bad it is. They can then arrange to treat it, if your child needs it.

Your child may have periodic limb movements (PLMS) during sleep.
These are when your child moves a body part during sleep. It is most common in the legs. The limb moves or jerks over and over, then stays still for a time. After a while, the limb starts moving again. This can disturb their sleep. They might wake up at night. This can cause daytime problems with behaviour, learning and sleepiness. A paediatricsleep specialist needs to look at your child to be sure if they have PLMS or not. They will need to do an overnight sleep study. The sleep study can see how much of an impact the PLMS is having on sleep as well. There are a number of ways to treat PLMS e.g. iron supplements, exercise and / or medications. PLMS may occur together with Restless Legs Syndrome.

This may be due to a parasomnia.
Parasomnias are a group of night time sleep problems. They are most common from 2 to 8 years of age. Common types are sleep terrors, confusional arousals, sleep walking, sleep talking and nightmares.  Risk factors include if the child doesn’t get enough sleep or feels stressed. It can also run in families: a child has a higher risk if a parent had a parasomnia as a child. Parasomnias are usually thought of as normal in children. They do not normally need treatment, except if they are frequent or there is a risk that the child might hurt themselves. Parents should find out about these parasomnias. They should learn how to help their child during and after one. See Sleep Terrors, Sleep Walking and/or Nightmares.

Your child may have nocturnal seizures.
These can occur as the child goes to sleep, during sleep or just after waking in the morning. They can happen even if the child has never had a seizure during the day. They are much rarer than night terrors. The child may move in the same way over and over. They may jerk and shake. They may or may not wake up. However, they tend to get in the way of a good night’s sleep. This leads to daytime problems in behaviour and learning skills. If you suspect nocturnal seizures discuss this with your GP. They may refer your child to a paediatric sleep specialistor Neurologist.

Your child may have insomnia.
This is a sleep problem where it is hard to go to sleep and stay asleep. The cause is often behavioural sleep problems, anxiety, depression or stress. Or it could be that they cannot switch off the brain from thinking and let go of the day. This can cause daytime problems with behaviour and learning. Good sleep habits before and at the time they go to bed can make things better. See Sleep Tips for Children and/or Good Sleep Habits and/or Insomnia. This will fix the issue for most children. But if not then they should see your family doctor who may arrange a referral to a paediatric sleep specialist. They will look for more ways to improve your child’s sleep.

Your child is most likely suffering from delayed sleep phase syndrome (DSPS).
DSPS is a sleep problem with the internal body clock. This is also known as the circadian rhythm. It controls the sleep times of the body. With DSPS, the body clock has been trained to go to sleep later through habit. But you can retrain it so your child can go to sleep earlier. To do this, get them to go to bed 15 minutes earlier each night for a week. Changing things step by step is easier than a sudden change. Be sure they get plenty of bright light (e.g. outdoor) as soon as they need to wake up. See Delayed Sleep Phase Syndrome.  If this doesn’t work then they should see a paediatric sleep specialist.

Your child may be suffering from Narcolepsy
This is a neurological sleep problem. The brain can’t control the desire to sleep while it’s awake. If your child has it, they may feel very sleepy during the day. It may be linked with other symptoms such as cataplexy (sudden loss of muscle strength). In some people, it causes sudden sleep attacks during the day too. To work out if your child has it or not, they will need to visit a Children’s Sleep Unit. Here they will do an overnight sleep study and daytime nap studies. A paediatric sleep specialist needs to do this.  If they do turn out to have it, a management plan will be developed. Plans to manage behaviour and maybe some medication will be a part of this. See also Narcolepsy.

There are a lot of things that could cause this.  See Excessive Daytime Sleepiness. You may need to discuss this with your family doctor.

Your child may have a sleep problem or sleep disorder.
A child can have a sleep problems and a sleep disorder for some time before it is noticed. You need to look at your child’s sleep. Also look at how they function during the day. You need to see if you can find any clues that there may be a sleep problem. If you do suspect they have one, keep a diary of what you see and when you see it. You should see your family doctor to discuss your concerns. A referral to a paediatric sleep specialist may be needed.

Sleep Study

What is a sleep study? 
A sleep study is a medical test. Sleep is monitored to assist with the diagnosis of sleep problems. It may be done in the home or by staying overnight in a specialised sleep clinic, whichever is best for you.

What happens in a sleep study that is completed in a sleep clinic? 
Patients usually arrive in the early evening and go home on waking up in the morning. Trained scientists at the clinic will record signals from the brain and monitor breathing and oxygen levels in the blood. They will attach leads to do this. Most clinics will also record heart rate, leg movements, sleeping position and snoring.

What does a home sleep study involve? 
A number of hospitals and private clinics offer home sleep studies. Patients go to the clinic during the day and have monitoring leads attached. These leads are almost the same as those which are used for a study done overnight in the clinic. But patients can walk around and sleep in their own beds.

Which kind of study is the best?
A sleep clinic is a carefully controlled environment. The results from a study here will be the best they can be. The staff will constantly watch all the signals collected. However being in an unfamiliar environment can be difficult for some patients. For these people, the information from a home sleep study will be better than if they had to stay overnight in a sleep clinic. Both methods have their place and you should discuss this with your doctor.

What does the sleep study tell your doctor? 
The signals from the brain show when you are asleep and when you wake up from sleep. The breathing signals and oxygen levels give information about breathing during sleep. Some patients have stop-start breathing during the night, a disorder called sleep apnoea. The leg leads show if there is any movement or twitching, which may disturb sleep. A sleep study can also pick up other rarer sleep problems.

What are the risks of a sleep study? 
Using creams and tape, small leads are attached to your head and your body. In some people the cream may cause temporary skin irritation, but nothing done in a sleep study will hurt.

How do I know if I need a sleep study? 
If you are worried about your sleep or think that you may have a sleep problem, you should see your GP. Often, your GP can treat the problem. If not, you can be referred to a sleep specialist. This is the best person to work out if you need a sleep study. Having a sleep study without seeing a doctor is not the best way to do it. The wrong information may be collected and your sleep may not be helped. A sleep problem is a serious issue. It needs to be dealt with properly.

What do I need to do to get ready for my sleep study? 
The sleep study clinic will give you information about what you need to do and bring to your study. Usually, there are no special things that you need to do before your study – you should try and do exactly what you do on a normal day.

How much will a sleep study cost? 
This is very variable. You should check with the clinic before you book the sleep study.

Sleep Tips for Children

1. Establish a regular sleep pattern.
Regular hours of sleep are important. It will help your child understand when it is time to sleep. Also, your child will have better sleep. Bed time shouldn’t vary by more than an hour between school and non-school nights. The same goes for the time your child wakes up.

2. A consistent bedtime routine
It is good to have the same routine before bed each night. This will help prepare for sleep. Quiet activities are good e.g. reading a book or being read to or having a bath or shower. In the half hour before bed, there are some things you don’t want your child to do. These are more active games, playing outside, TV, internet or mobile phone social networking and computer games.

3. Make sure the bedroom is comfortable. 
The bedroom should be a quiet, comfortable and dark. Some children like a night light. This is fine. Make sure your child sees the bedroom as a good place to be. You can help do this by not using it as a place for punishment.

4. Bed is for sleeping, not entertainment. 
TV, computers, mobile phones and other things that distract your child are not good for their sleep. Keep them out of the bedroom. “Needing” the TV to go to sleep is a bad habit. This can easily develop, but you don’t want it to happen. It’s also better if you can check on what your child is watching.

5. A snack before bed may help
It’s harder to sleep on an empty stomach. A light snack can help. Your child should not have a heavy meal within one to two hours of going to bed.

6. Caffeine is a stimulant
Caffeine is found in many popular drinks. These include coffee, tea and cola soft drinks. It can make it harder to get to sleep. Your child should have as little of these as possible, and certainly not after lunchtime.

7. Take care with daytime naps. 
It is normal for young children to nap during the day. As your child gets older, they will need less sleep. This means they will need to nap less. The number and length of naps depends on your child. If your child naps after 4pm (except for the very young) it can be harder to get to sleep at night.

8. Exercise and time outside
Daily exercise is an important part of healthy living. It also promotes good sleep. Time spent in bright daylight does the same. Outdoor exercise achieves both things. However, it is best to steer clear of heavy exercise in the hour before sleep.

9. Work with your doctor
If your child is sick or isn’t comfortable, their sleep will suffer. Some children suffer from specific sleep problems such as frequent nightmares, snoring or sleep apnoea. It is important that these problems are dealt with. If you think ill health is involved, discuss this with your family.

Sleep tracker technology

Sleep Tracker technology

High tech wrist watches and smartphone apps have been developed to help monitor your sleep patterns. These trackers promise a lot, with some even claiming to measure the time you spend in each stage of sleep. Although it might be fun to pore over data you have collected about yourself, it is important to keep the pros and cons in mind when using these new sleep tracker technologies.

1. How do sleep trackers monitor sleep?
Most sleep tracker apps and watches use an accelerometer, a device built into most smartphones that senses movement. This device measures how much movement you make during your sleep and this data is then used in an ‘algorithm’ to estimate sleep time and quality. How sensitive each device is to movement and the algorithm used varies between products. This can greatly affect their accuracy.

Popular trackers, such as the Fitbit One, include a sleep mode that aims to provide sleep time and restlessness.

Some wrist sleep trackers claim to also estimate sleep stages – the Jawbone UP breaks down sleep time into deep and light stages. The new Jawbone UP3 has added sensors for measuring skin and room temperature to help indicate deep and REM sleep. The Basis B1 estimates REM sleep in addition to deep and light sleep stages by measuring heart rate.

Sleep trackers that only use an accelerometer (such as smartphone apps) cannot accurately measure sleep stages. That’s because an accelerometer only monitors movement, and there is little difference in movement between the sleep stages. You move a similar amount in deep sleep and lighter stages of sleep.

While most trackers can estimate fairly well when a person is awake versus asleep, they are prone to error. For example, you could be lying still but be awake. In the case of the phone apps Sleep Cycle or Sleep As AnDroid (which sit on the bed next to you), your bed partner, child or even your dog could impact the amount of movement and noise detected by the device, changing the sleep data.

2. How do these new technologies compare with the gold standard sleep test using brain waves?
Research on some of these sleep trackers suggests that they provide a general estimate of sleep but that they can give misleading information.
A 2012 study data with adults who wore an older version of the Fitbit tracker found that it overestimated sleep time by an average of 67 minutes (see reference 1).

Another study in 2014 found the opposite effect in children. The Fitbit One underestimated the children’s sleep by 105 minutes (see reference 2).

3. Can sleep trackers really measure sleep stages?
Users should not expect these devices to distinguish between sleep stages. This is because they rely on movements, whereas sleep stages are defined by brain wave activity and other body indicators (eye movements and muscle tension) measured in a laboratory sleep test.

The Basis B1 is one of the few trackers on the market that says it can track REM sleep in addition to light and deep sleep. The device claims it can do this because it includes a heart rate monitor in addition to an accelerometer. However the research on which this claim is based has not been published as yet and so cannot be properly assessed.

4. What are the potential dangers?
For most people, using a monitor to track sleep isn’t going to be a problem. In fact, it might help some people understand and review their sleep and wake patterns, and this may ultimately improve their sleep. For example, noticing a pattern of repeatedly going to bed late and sleeping less than required may help the user adjust their sleep habits to allow for longer sleep.

However, if you have a sleep disorder, tracking sleep with one of these monitors might give you some false reassurance. It could also create more anxiety about not getting ‘enough’ sleep and lead to more difficulty sleeping.

Also, most sleep trackers cannot provide much insight into the quality of sleep. For instance, a person with sleep apnea may stop breathing many times a night, but this wouldn’t necessarily be detected by a sleep tracker. Their sleep might be very fragmented but they could have remained relatively still in bed for eight hours, resulting in little movement. The sleep tracker data would therefore not accurately reflect this poor quality sleep.

In general the sleep tracker apps and devices will give you a good overview of how long you sleep but they can only tell you so much. You have to use the data to figure out what’s working for you and what isn’t. If you think there is a problem, regardless of what the sleep tracker data is telling you, talk to your GP.

5. What are the potential benefits?
These devices raise awareness of sleep health and sleep issues. Over time they could show if you are getting less or more disturbed sleep that you might expect. This might lead you to seek treatment or change lifestyle habits. See Understanding and Helping Poor Sleep as a good starting point.

6. Things to remember

  • These are consumer products and most have not undergone scientific evaluation. Don’t put too much trust in these devices to accurately monitor sleep.
  • A single night is not always a very accurate reflection of your general sleep; one night’s “data” shouldn’t be cause for alarm. If you tend to worry about your sleep then it might be best for you to avoid sleep trackers, or only look at the data occasionally.
  • Have fun! Collecting data about yourself can be very interesting. But just remember sleep trackers tend to point to general trends in your sleep. The specifics need more sophisticated assessment.
Sleeping Tablets

What Are Sleeping Tablets?

Sleeping tablets work on pathways in the brain which are important in regulating whether someone is awake or asleep. Most sleeping tablets make the ‘sleep pathways’ more active.  One of the newer medications works by making the ‘wake pathways’ less active.

Sleeping tablets generally start having an effect within 20-30 minutes of being taken, so they should be taken just before lights out. It is important that you get into bed after taking the sleeping tablet, as there is a risk of feeling unsteady once the tablet starts working.

Most sleeping tablets only work for a few hours, so are better at helping people get to sleep than stay asleep. Tablets which are better at helping people stay asleep need to work for longer and therefore may cause a morning ‘hangover’.

What Causes Sleep Problems?

Sleep can be affected by a large number of medical, physical and psychological problems. Treatment of insomnia will depend on an individual’s specific circumstances.

Most situations of acute (short term) insomnia are due to stressful life events. This can be managed with either supportive care or short-term use of sleeping tablets under the direction of your doctor.

In the case of chronic (longer term) insomnia, people will often experience problems with getting to sleep or staying asleep over months or even years. While stressful events can make such insomnia worse, there are often multiple issues affecting sleep.  These include sleep/wake patterns, behaviours and thought processes which make the insomnia continue. Non-medication approaches are therefore important for people with chronic insomnia (see Insomnia and Good Sleep Habits).

What Are Some Of The Commonly Used Sleeping Tablets?

  • Benzodiazepines and benzodiazepine-like medication. These are the most commonly used sleeping tablets in Australia and include temazepam (Temaze, Normison), zopiclone (Imovane) and zolpidem (Stilnox). They work by enhancing the activity of sleep pathways in the brain. They are recommended for short term use (less than 4 weeks).
  • Suvorexant (Belsomra). This works by reducing the activity of the wake pathways in the brain. It is more helpful for people with chronic insomnia who spend time awake during the night after initially falling asleep. It can be used for longer periods than conventional sleeping tablets
  • Melatonin (Circadin). This is a synthetic version of the chemical made by the brain each night. It has been approved for short term use in people aged over 55.
  • Sedating anti-histamines (e.g., Polaramine, Avil, Restavit). These medications are used to treat allergic disease. Although they can cause sleepiness as an unwanted side effect, they are not intended to be used as sleeping tablets.
  • Antidepressants and antipsychotics (e.g., Endep, Avanza, Seroquel). These medications are generally used for people with underlying mental health conditions and are not recommended for use in primary insomnia.

What Should I Do If I Am Taking Sleeping Tablets But Can’t Stop Them?

You need to talk with your doctor about this. Abruptly stopping sleeping tablets can cause problems such as withdrawal and rebound insomnia.

Non-drug strategies have proven effectiveness in the treatment of insomnia and can help people to stop their sleeping tablets. One important therapy (Cognitive Behavioural Therapy for Insomnia) involves targeting behaviours and thought processes which are contributing to the insomnia and the ongoing need for sleeping tablets. You may need referral to a Sleep Specialist or a sleep psychologist to help with this process.

Snoring

Why do people snore?
You snore when some parts of your throat vibrate. This only happens when you’re asleep. The part of your throat that vibrates is called the pharynx. It is right behind the tongue. Several small muscles hold it open. But when you sleep, these muscles relax. This makes it vibrate more easily. It also becomes narrower. When you breathe in, it will vibrate and make a noise. The narrower it is, the more easily it will vibrate and the louder you will snore.

How common is snoring?
About 40% of men have at least mild snoring, on at least some nights. This number is smaller for women (around 30%). About 15% of people snore on most nights. People of any age can snore. Even some children have a problem with snoring (see Childhood Snoring and Obstructive Sleep Apnea). But the age group most at risk are middle aged people.

What can raise my risk of snoring?

  •  Being overweight or obese will mean you have more fat around the neck. This will make your throat narrower and it will vibrate more easily.
  •  Drinking alcohol will relax the muscles in your throat. This will mean more vibration and more sound.
  •  People who breathe through the mouth are more likely to snore. This is because the walls of your throat at the back of the mouth vibrate easily. Walls at the back of your nose do not vibrate as easily.
  •  A blocked nose will mean that you have to breathe through the mouth. This will raise your risk of snoring. It also makes a vacuum inside the throat. This may pull the walls of your throat closer together.
  •  Sleeping on your back makes your tongue fall directly back. This can get in the way of your airflow. Snoring is almost always worse on the back.
  •  Some people snore because of narrowing caused by nasal polyps, a large tongue or thyroid swellings. These narrow the airway. Often children snore because of large tonsils and adenoids.
  •  Allergies, hay fever and smoking can make snoring worse. This is because they make it harder for air to flow in and out.
  •  Some medications make your throat muscles relax e.g. sleeping tablets, anaesthetic drugs, oral steroids and epilepsy drugs.
  •  Some people are born with a smaller airway than normal. These people will have a higher chance of snoring.
  •  Snoring is more likely in pregnancy (see Pregnancy and Sleep)

How does it affect people?
For many families snoring is a big problem. Often, the snorer has to sleep alone in another room. If not, then his or her family will have trouble getting a good night’s sleep. The family might be more tired during the day. This can mean that they can’t focus as well on work or study. Some snorers also have a condition known as sleep apnea. Over 10% of regular snorers have this condition to a significant degree. Sleep apnea is linked to high blood pressure, heart attacks and strokes.

How is snoring treated?
One treatment is called a Mandibular Advancement Splint. It looks a bit like a mouthguard. You wear it between your teeth while you sleep. It pushes your lower jaw forward. This gives you a wider airway. It needs to be specially fitted to you. You will need to see a dentist or oral surgeon for this. This is because different people have different mouth shapes. It works for some people but not for others. (See Oral Appliances)
Some treatments stiffen the roof of your mouth. This makes it vibrate less. This can be done using lasers, microwave rays or injections. Laser surgery on the throat may work for some people. But it can be painful. Only an Ear, Nose and Throat surgeon can do this.
For children who snore, it is common to take out the tonsils as tonsillar enlargement is a common cause. This often succeeds. (see Childhood Snoring and Obstructive Sleep Apnea) For adults with large tonsils, the same thing can also be done.
Some people snore because of the shape of their tongue or the roof of their mouth. Others snore because their nose is blocked. In all of these cases, surgery in the problem area can help. A type of surgery called uvulopalatopharyngoplasty (UPPP) used to be common. Here, the surgeon operates on the back of the throat to make it wider. But it only ever worked for some people and has a low success rate in the long term.
Positional therapies to encourage you to sleep on your side can be helpful, but are often ineffective in keeping you on your side throughout sleep.
Herbal or enzyme treatments might help with allergies. If this is why you snore, then they might help. But if you’re snoring for another reason, then they will do nothing.
Nasal dilator strips can unblock your nose. But by themselves they won’t stop snoring.

What might your doctor do?
Problem snoring may be an early warning signal that sleep apnoea is present. Your GP can refer you to a sleep specialist who will probably want you to do a sleep study. Sleep Apneais a serious health issue that needs attention.

What could you do?
If you are overweight, losing weight might help. Try and avoid alcohol for at least four hours before sleeping. If your snoring is made worse by an allergy, try and stay away from whatever sets it off.

Where and when should you seek help?
Get help if your snoring is bothering you or your household. If you see a doctor about snoring, you might want to bring your partner with you, if you have one. This is so that they can talk to the doctor about what happens when you’re asleep.

Teenage sleep

What is unique about teenagers’ sleep?

Teenagers’ sleep tends to be less regular than the sleep of adults and young children. This means that the times when you go to bed on the weekend are not at all the same as on school nights. On weekends, you may go to bed much later. You may also wake up much later on the weekends. Late bedtimes on school nights makes it hard to get enough sleep. This is because you need to wake up early for school. You should aim for at least 8 hours of sleep on school nights.

What makes teenagers’ sleep less regular?
Teenagers’ biology works to make them go to bed later. Individual lifestyles play a part in this too. As you grow, you can stay up longer. Your 24-hour ‘body clock’ can also move later, delaying the time that you feel sleepy at night and awaken in the morning. Up to a point these are natural changes. However there are other things that can also push the time you go to bed to later hours than desirable or make sense in terms of getting ready for the next day. These include using technology in the hour before going to bed (e.g., mobile phone, computer), and working too late (e.g. excessive homework, part-time evening job). On weekends, staying up too late and sleeping in too much can also upset your natural sleep wake rhythm, pushing your sleep patterns later.

How common are irregular sleep patterns in teenagers?
On weekends, about 90% of teenagers will go to bed later, and then sleep in. This can be OK if you do not change your weekend bedtimes by too much (no more than 2 hours). However about 40% of teenagers go to bed two or more hours later on weekends. This raises their chances of getting less than 8 hours sleep on school nights.

How do the sleep patterns of teenagers affect them?
While many teenagers cope with changing their hours of sleep some do not. Signs of not coping include if you are often late for school, feel sleepy during the day, feel moody or grumpy, and maybe not getting good grades at school.

What could you do to help cope?
There are ways to help your sleep to be more regular. At night, try to stop using technology earlier, dim the lights earlier, and start to relax earlier. Going to bed at a set time on school nights can help. On weekend mornings, try not to sleep in so long. When you do get out of bed on weekends, try to get a bit more outdoor light, and try to be a bit more active (e.g., get dressed earlier, have breakfast earlier, get moving earlier). See also Good Sleep Habits.

When should you seek help?
Teenagers may seek help with their sleep for many reasons. But the most common is to make their sleep more regular when they find it hard to get to sleep, and hard to wake up the next day. If you find this happening so that it is hard to get to school, or that it is bad for your school grades, it may be a good time to seek help. You might want to think about a sleep specialist.

How are irregular sleep /wake hours treated?
The time that you go to bed may have gradually moved later and later. For most teenagers the treatment involves doing the reverse of this i.e. gradually moving the time you go to bed to earlier hours. As part of the treatment, you go to bed 30 minutes earlier each night and wake up 30 minutes earlier in the morning. You need to make sure that the lights are very low at night and, most importantly, that you get enough bright light in the morning. Outdoor light can work well. These methods are known as Bright Light Therapy. Bright Light Therapy aims to move your internal 24-hour body clock earlier so that you will feel sleepy earlier in the night, and feel more awake in the morning. If your symptoms are ongoing and very severe you may have Delayed Sleep Phase Syndrome, where treatment is more complex, but again aims to re-program your internal body clock.

What else might cause the symptoms?
Irregular sleep patterns and getting less than 8 hours of sleep can be a feature of depression. In some cases, making sleep hours more regular can lead to an improved mood. If not, you should see your family doctor as you may have depression or anxiety.

Ten Tips for a Good Night Sleep

1. Have a regular sleep pattern
Try to go to bed at around the same time every evening and get up at around the same time every morning. Improved sleep will not happen as soon as changes are made. But if good sleep habits are maintained, sleep will certainly get better. Find what time works for you and stick with it.

2. Spend the right amount of time in bed
Most adults need about 7 to 8 hours sleep every night. Some require more and some less. Many poor sleepers spend much more than 8 hours in bed and this makes fragmented sleep a habit. Except if you have lengthy sleep requirements, limit your time in bed to no more than 8.5 hours. If you often take hours to fall asleep, go to bed later. Remember that children need more sleep than adults.

3. Bed is for sleeping, not entertainment
Hand-held electronic devices (e.g., smartphones) and other distractions can interfere with your sleep. It is better not to sleep with your TV or other devices on. Your mind needs to be in the habit of knowing that if you are in bed, you are there to sleep. Don’t stay in bed if you are wide awake.

4. Wind down and relax before going to bed
Have a buffer zone before bedtime. Sort out any problems well before going to bed. This may mean
setting aside a ‘worry time’ during the day. Use this time to go over the day’s activities and work out
a plan of action for the next day. Try to avoid using your computer or other electronic screens within one hour of bedtime. Exercise is fine, but not too late in the evening. Find a relaxation technique that works for you and practise it regularly, during your wind down period.

5. Make sure your bedroom is comfortable
You should have a quiet, dark room with comfortable bedding and good temperature control.

6. Alcohol, caffeine and cigarettes – to be avoided
Alcohol may help you to get off to sleep, but will disrupt your sleep during the night. Caffeine (tea,
coffee, cola drinks) and the nicotine in cigarettes are stimulants that can keep you awake.

7. Avoid daytime naps
Sleeping during the day will make it much more difficult to sleep well at night. If a nap is absolutely
necessary, for example because of a late night, then limit this to about twenty minutes. Make sure
that you are awake for at least 4 hours before going back to bed. Don’t allow yourself to fall asleep in front of the TV – not even for a minute.

8. Don’t lie awake watching the clock
Watching the time on a clock just makes you anxious about not being asleep. If possible, take the
clock out of your bedroom. If you need the clock for the alarm, turn it around so that you cannot
see the time. Resist the temptation to look at the time on your various electronic devices. These should ideally be charged outside of the bedroom overnight.

9. Avoid sleeping pills except in exceptional circumstances
They do not fix the cause of your sleeping problem.

10. You may need professional help
If you are still having trouble sleeping, if you have persistent problems with mood, if you have excessive daytime sleepiness, restlessness in bed, severe snoring or wakening unrefreshed despite what should be adequate length sleep, make sure that you go and see your doctor (See also our other Information Pages).

Tips to Help Combat Jet Lag

1. For short trips, stay on home time.
If you are away from home for a only a day or two, try to eat when you would usually eat at home, try to sleep when you would usually sleep at home and try to not go outside when it is dark at home.

2. For longer trips, change your time as soon as possible
If you are away for more than two or three days, start using the time at your destination as soon as possible. Change your watch on the flight. Try to eat and sleep on the plane at times when you would eat and sleep at your destination. The earlier you start, the easier it will be.

3. Give yourself time
Remember that you will still have a “slump time” when your body is telling you that you would be asleep if you were at home. Adjusting to your new time zone usually takes at least 2 or 3 days.

4. Take short naps
While you are adapting to your new time zone, short naps may help you feel more alert and perform better. It is important that you sleep for no longer than 30 minutes and that you are awake for at least 4 hours before you go to bed.

5. Caffeine may be helpful but ….
Do not overdo it. Tea and coffee can help improve alertness. Remember that they take about 20 minutes to have an effect, which then can last up to 4 hours. Do not have tea or coffee for at least 2 hours before going to bed.

6. Alcohol is not the solution. 
Although it may help you to get off to sleep, you will not sleep as well during the night.

7. Minimise use of sedatives and sleeping tablets.
They can become a habit, giving you more problems than temporary jet lag.

8. Melatonin 
This may help to re-set your body clock. Take it just before your planned sleep time.

9. Go outside
Take a walk. Sunlight is important to help your body adjust to the local time zone.

10. Do some exercise.
This will help to revitalise when you arrive and reset your body clock. You should exercise during daylight hours, particularly in the early morning or late afternoon and not too close to bedtime.

Treatment Options for Obstructive Sleep Apnea (OSA)

Important things to know about OSA treatments

  • As the causes of sleep apnea vary there is no single treatment that works for everyone.
  • Deciding which treatment is most appropriate is best done by talking to your doctor.
  • Weight loss is advisable in anyone who is overweight.
  • Reduction of alcohol consumption, avoidance of sleep on your back, and the use of nasal sprays can be helpful in some cases.
  • When the sleep apnea is mild, treatment may be optional and a range of options may be considered.
  • When the sleep apnea is moderate or severe, the use of CPAP is generally recommended.
  • Oral appliances generally work best in mild to moderate sleep apnea.
  • Surgery may be considered where there is a distinct obstruction to the nose and/or throat.

What is sleep apnea and how is it diagnosed?

Obstructive sleep apnea (OSA) is present when the airway at the back of the throat is repeatedly blocked, partly or completely, during sleep. Snoring, obesity, observed apneas and sleepiness in the day may suggest that a person has sleep apnea. See our OSA link. The best way to be really sure about an OSA diagnosis is with an overnight sleep study and a clinical assessment by your doctor.

What are the treatment options?

Once a diagnosis of OSA is established, talk with your doctor about the need for treatment and the options available for you. The circumstances often vary from person to person, since the underlying causes may be different. Generally speaking, the options can include one or more of the following:

  1. Weight loss – For anyone who is overweight, losing weight is recommended. While this may not necessarily cure the OSA, it usually improves snoring and OSA, and can help other treatments work more effectively. It also provides general health benefits.
  2. Reduce alcohol consumption – Alcohol usually worsens snoring and OSA due to the throat muscles relaxing. For some people drinking alcohol makes their OSA worse. If this is the case for you then less or no alcohol may be a useful treatment.
  3. Body position during sleep – Snoring and OSA are usually worse when lying on the back. This is because of the effects of gravity on the tongue. Avoiding sleep in this position can improve OSA. In some people it can completely control the problem. This is best achieved by wearing a device that makes it uncomfortable to sleep on your back. Some such devices can be purchased or it can be as simple as sleeping with a tennis ball sewn into a pocket on the back of your pyjamas.
  4. Managing blocked nose – A blocked nose causes mouth breathing, which can lead to snoring and OSA. The blocked nose can be due to different problems, such as allergies, sinus disease, and a deviated septum. Your doctor can assess and provide treatment, depending on the problem. This may involve the use of nasal sprays to relieve congestion. Sometimes surgery is required to correct anatomical problems.
  5. CPAP (Continuous Positive Airways Pressure) – This is generally considered to be the most effective way to treat OSA. It involves the use of a special machine during sleep, connected to a nose or face mask via tubing. The machine gently increases air pressure in your throat holding it open, thus preventing snoring and OSA. See our CPAP link.
  6. Oral Appliances – These are specially made dental plates that are worn during sleep. They push your lower jaw forwards so that your throat opens up, reducing the risk that it will vibrate (snore) or obstruct. The appliances have various names such as Mandibular Advancement Splints (MAS) or Mandibular Advancement Devices (MAD) or Mandibular Repositioning Appliances (MRA). Your suitability for this form of treatment is best discussed with your sleep physician, who will then refer you to a trained dentist. See our Oral Appliances link.
  7. Surgery – Surgery may help in cases of OSA caused by a discrete blockage of some part of the nose or throat. There are many types of operations depending on where in your nose and/or throat the problem lies. The decision about whether surgery is right for you may require the expert input of an ENT surgeon. The risks and benefits need to be weighed up in each case. In adults, surgery is often the last resort, after other treatments have been tried first. Nasal surgery may be useful to help CPAP treatment by allowing nasal masks once the nasal blockage is repaired. In children with OSA, surgery to remove tonsils and adenoids is quite commonly done and is often very helpful.