Hay Tench, a retired nurse from North Miami, had a chronic sleeping disorder many will find familiar.
“My thoughts would not shut down. If one thought came in, another was flowing in my head,” she said. “I’ve done everything. The darkened room, turn off all the lights. Even with all of that, the thoughts would not shut down. I could not function through the day.”
New medications for insomnia and more awareness of disorders like sleep apnea give new hope for the millions like Tench, a mom to three grown sons. Tench, 67, had suffered from insomnia for years, a common sleep disorder that makes it difficult to fall, or stay, asleep. It affects about 60 million Americans.
Tench’s insomnia began in post-menopause, a common occurrence because of hormonal changes, Tench was told by her doctor. She started taking Xanax, from a class of medications that act on the brain and central nervous system. But Xanax didn’t help Tench for long, even though she took it for six years.
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Medications like Xanax, Lunesta and Ambien work by stimulating the body’s neurotransmitter gamma aminobutyric acid (GABA) in the central nervous system. GABA blocks the brain chemicals that cause you to get excited. As brain cells calm, the idea is that sleep follows.
But these medications are designed for short-term use and carry risk factors, among them depression, feelings of lightheadedness or sleepiness during waking hours.
About a year ago, the Food and Drug Administration approved a new type of drug called Belsomra, which has proven successful with Tench, said Dr. David Seiden, the neurologist and medical director for Baptist Sleep Center Hollywood, who treated her. Belsomra, the brand name for the drug suvorexant, targets other receptors in the brain by inhibiting orexin, a neurochemical that keeps the brain awake.
“The old approach said, ‘Let’s increase the transmitters that help our brain go to sleep.’ But the new drugs are looking at it from a different side of the equation,” Seiden said. “Now let’s give a drug that shuts the waking part of the brain. The neurotransmitter responsible for this is orexin, a relatively newly discovered neurotransmitter.”
Narcolepsy, a chronic neurological disorder in which the brain's ability to regulate sleep-wake cycles is askew, helped in the development of Belsomra, Seiden said.
“The hallmark of the disease is you sleep too much and fall asleep in inappropriate places. Turns out narcoleptics do not produce enough orexin. If you don’t have enough orexin, or it’s not working properly, then you will sleep more. That’s how [Belsomra] started. Someone sort of figured out that if orexin is deficient in narcoleptics and they sleep a lot, why don’t we give a drug that blocks orexin? If you are not narcoleptic and have a normal amount of orexin, then that is what suvorexant does.”
The risk factors for Belsomra are similar to the drugs that work on the GABA neurotransmitters — lightheadedness, sleepiness, and sometimes sleep paralysis, a kind of behavior in that transition between being awake and asleep when you feel paralyzed. “That can be frightening to people,” Seiden said. “You can have a type of hallucination called a hypnagogic hallucination — you hear things in the room that aren’t there.”
Seiden said Tench had no serious side effects from her new treatment of Belsomra.
“I’m doing very well with it. It made a big change in my life,” she said. “It took a little longer than the other medicine for me to fall asleep but I do fall asleep and the thoughts shut down and I can get some rest. This is a much calmer, relaxing medication.”
The National Sleep Foundation estimates that roughly 30 percent of the general population complains of sleep disruption, and approximately 10 percent have associated symptoms of daytime functional impairment — like drowsy driving — consistent with the diagnosis of insomnia.
Drowsy driving causes up to 6,000 fatal car crashes each year, according to the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration.
Individuals who snore or sleep six or fewer hours per day were more likely to fall asleep while driving, and it’s not just falling asleep at the wheel that happens, the CDC reports. A driver’s reaction time and ability to make decisions can also be impaired by sleep problems.
Obstructive sleep apnea is a potentially dangerous sleep disorder in which breathing is briefly and repeatedly interrupted, for up to 10 seconds or more at a clip, during sleep, according to the National Sleep Institute. Sleep apnea happens when the muscles in the back of the throat weaken and fail to keep the airway open, which hampers your intake of air. The result is fragmented sleep and low blood oxygen levels. The brain recognizes that the body isn’t breathing and zaps you awake to take a breath. More often than not, its sufferers aren’t aware they are being awakened until they wake in the morning with headaches and drowsiness. The resulting loud gasping and snoring-like sounds from the halted breathing awaken bed mates.
The danger zone here is this oxygen starvation can lead to hypertension, heart disease, obesity, and mood and memory problems. Sleep apnea also increases the chances for drowsy driving. In some cases, though rare, sleep apnea can be fatal and has been linked to the deaths of actors John Candy and Divine, Grateful Dead guitarist Jerry Garcia and football player Reggie White. The disorder is also associated with depression and other ailments like erectile dysfunction and poor work performance.
“The No. 1 cure is losing weight if you happen to be heavy; 75 percent of sleep apnea patients are obese and that is central in the development of sleep apnea,” said Dr. Samuel Gurevich, pulmonary and critical care sleep physician with Cleveland Clinic of Florida.
Call it a vicious cycle. Obesity leads to sleep apnea and sleep apnea leads to obesity.
“Whenever people are tired they are more likely to seek food and need more calories to feel satiated,” Gurevich said. “Sleep apnea begets obesity, which makes obesity worse and that’s the cycle. It’s the carbohydrate-driven hunger that has been borne out.”
Not all sleep apnea patients are overweight, however. Sometimes, Gurevich explained, 25 percent of patients have a normal body size appearance but still have apnea. That can be genetic, how you are built or how the back of the throat is designed.
South Florida healthcare facilities like Cleveland Clinic, Baptist Health South Florida, UHealth — University of Miami Health System and Mount Sinai Medical Center have sleep clinics that evaluate patients to determine the best methods of treatment. These outpatient centers offer treatments for sleep apnea, narcolepsy, insomnia, restless leg syndrome, circadian rhythm abnormalities, REM behavior disorders and other sleep issues.
In general, patients are referred to the sleep clinics by their physicians. For an overnight stay, patients are hooked to computers via bundled wires, and electrode pads are placed on the head, chest, abdomen, legs and finger. These electrodes test breathing and blood oxygen and brain-wave levels. A mic captures sounds in the room, like snoring or gasping. Technicians record how the patients sleep via infrared cameras.
In the morning, patients can shower, eat a light breakfast and be on their way. Technicians and medical personnel pore over many pages of data from about eight hours of recordings. If there are sleep problems, a treatment plan begins.
Home sleep test
One new addition: home sleep tests.
“You are sent home with a fancy lunchbox with everything in it. You can call an 800 number or go online for help to see what you need to do and how to wear it at night. These are becoming very popular,” Gurevich said. “The home sleep test is fairly accurate, though with some limitations as it looks exclusively for sleep apnea, not for other neurological conditions. And you have to be otherwise reasonably healthy. If you have a lung or heart condition, that can interfere with the machine.”
Home tests similarly use sensors attached to the body via a flexible belt around the chest or a sensor that looks like oxygen tubing you wear around the ears and nose.
“The basic home test looks at changes in air flow, oxygen, and heart rate to estimate if you are having episodes. For sleep apnea they do a good job and are practical. The problem is they are sometimes overused for patients with other conditions,” Gurevich said.
After a night’s sleep, the device is brought to the sleep lab where its data is downloaded and evaluated.
For sleep apnea, the most effective treatment, aside from weight loss if necessary, is a CPAP (Continuous Positive Airway Pressure) machine.
Gurevich explains how CPAP works: “Basically, a fancy air compressor, very quiet, that takes the air from the room that you’d be breathing anyway, adds a humidifier, and the hose and the mask connects to the nose and mouth. By delivering the air under pressure to the back of the throat it stents open the airway and keeps it from collapsing. This takes care of the snoring — a nice side effect — and you are able to sleep through the night.”
There is an asterisk, however, to the CPAP’s practicality.
“While it is over 95 percent effective, it is only effective if you can get used to it and that’s not so small an Achilles’ heel. This asks a lot of patients to wear a mask attached to a machine. The overall compliance success rate with getting comfortable with the CPAP is 65 to 75 percent,” Gurevich said.
The key is to make sure the mask fits properly. If air leaks, you aren’t deriving CPAP’s benefit. There are more than 100 kinds of masks, and the newest machines are now more sensitive to breathing rhythms and adjust the pressure automatically through the night.
Patients who lose weight can often come off the CPAP and feel relief from sleep apnea.
Other treatments include a device that pushes the jaw forward to open the airway. But its success rate is only about 40 to 50 percent and the device can change one’s bite radius since it pulls on the teeth.
Surgical options to remove soft tissue in the back of the throat are also available and were in vogue for awhile, Baptist’s Seiden said. But these, too, are only successful in about 50 percent of cases. “They are not as effective as we once thought they would be,” he said.
An implantable neurostimulator, similar to a pacemaker, can work the nerves that control the back of the throat. A side effect, however, is muscle pain not unlike overuse injuries from working out.
The CPAP is still the gold standard, experts say.
“It’s meant as a temporary fix to give you back the energy to restore your hormonal balance and decrease cardiovascular risk while you work to lose the weight,” Gurevich said. “Patients come back and do great. Now you have the responsibility to do something with that newfound energy you have — and that is to lose weight.”