Jaypee Brothers Medical Publishers (P) Ltd

4838/24, Ansari Road, Daryaganj

New Delhi 110 002, India

Phone: +91-11-43574357

Fax: +91-11-43574314

Email: jaypee@jaypeebrothers.com

J.P. Medical Ltd

83, Victoria Street, London

SW1H 0HW (UK)

Phone: +44 20 3170 8910

Fax: +44 (0)20 3008 6180

Email: info@jpmedpub.com

Jaypee-Highlights Medical Publishers Inc

City of Knowledge, Bld. 237, Clayton

Panama City, Panama

Phone: +1 507-301-0496

Fax: +1 507-301-0499

Email: cservice@jphmedical.com

Jaypee Medical Inc

The Bourse

111 South Independence Mall East

Suite 835, Philadelphia, PA 19106, USA

Phone: +1 267-519-9789

Email: jpmed.us@gmail.com

Jaypee Brothers Medical Publishers (P) Ltd

17/1-B Babar Road, Block-B, Shaymali

Mohammadpur, Dhaka-1207

Bangladesh

Mobile: +08801912003485

Email:jaypeedhaka@gmail.com

Jaypee Brothers Medical Publishers (P) Ltd

Bhotahity, Kathmandu

Nepal

Phone: +977-9741283608

Email: kathmandu@jaypeebrothers.com

Website: www.jaypeebrothers.com

Website: www.jaypeedigital.com

© Copyright 2015 by The Indian College of Physicians, Academic Wing of Association of Physicians of India

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.

All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.

All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.

Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.

This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.

Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

First Edition: 2015

The importance of normal sleep has been emphasized by the scientists as well as the common people. The sleep from times immemorial is known to rejuvenate and recoup the body. The human clock has been so tuned that we work during the day and sleep during the night but with the complexity of world and the way we work and live, circadian rhythm of the body is disturbed leading to many sleep disorders. These disorders are progressively and rapidly increasing in their magnitude and have profound effect on the lives of the society. Therefore, there is an increased need to heighten the awareness of various sleep disorders among primary physicians and general public. The effort of Professor (Dr) Shyam Narayan Arya to bring out a monogram on normal pattern of sleep and its various disorders is timely and welcome effort.

Lastly, yoga and its impact on improving the sleep disorders has been discussed separately. The monogram is comprehensive, well written and edited by Dr Professor Syam Narayan Arya. He deserves to be complimented for the effort he has put into place the importance of sleep disorders on right footing. Let us be aware and attentive to diagnose these disorders so that we can prevent the morbidity and mortality associated with these disorders. The effort of Professor (Dr) Shyam Narayan Arya will be amply rewarded.

There are approximately 85 types of sleep disorders known today. Humans spend approximately one-third or more of their life (about 8 hours per night) sleeping. Sleep is a rapidly reversible state of reduced responsiveness, motor activity, and metabolism. Sleep is essential for normal functioning of both mind and body. Not only sleep duration but also the quality of sleep plays an important role in preservation of an individual's mental and physical health and quality of life. Loss of sleep results in abnormal hormone rhythm. Insomnia was previously viewed as a sleep disturbance that was secondary to a medical condition, psychiatric illness, or medication, and would improve with treatment of the underlying disorder. It is now recognized that insomnia may be an independent disorder. Some common sleep disorders include sleep apnea, narcolepsy and hypersomnia, cataplexy, sleepwalking, night terrors and bed wetting.

Management of sleep disturbances include therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia. Patients should also receive basic behavioral counseling about sleep hygiene and stimulus control. Long-term treatment with medication alone is not the optimal treatment strategy for patients with insomnia. Professor (Dr) Shyam Narayan Arya has invited Indian and overseas experts and compiled an outstanding monogram.

These experts have included all the aspects of sleep and sleep disorders in this monogram. All different disorders, hypersomnia and parasomnias are also covered. Different topics in different section are covered including restless leg syndrome, bruxism, shift work disorder, idiopathic hypersomnolence, jet lag, etc. The correlation between sleep and depression is also well discussed. One of the oldest therapy—Yoga, is a treatment modality that alleviates the insomnias is also kept. Besides yoga, the monogram also talks about other management therapies.

My heartiest congratulations to Professor (Dr) Shyam Narayan Arya for coming out with this monogram which is an in-depth source of knowledge about sleep and sleep disorders that can be used as a handbook for all health professionals to help the patients deal better with such disorders. It is a comprehensive compendium covering all the areas pertaining to sleep and sleep disorders which will be a collectors item in 2015.

It is a great pleasure that Professor (Dr) Shyam Narayan Arya is editing a monogram on a new subject “Sleep and Disorders of Sleep”. Sleep disorders are still under diagnosed. It is one of the major cause of morbidity and mortality in the community. It is new and young discipline however, many sleep/walk disorders are already known and a lot to be discovered in due course. Actual prevalence is also not known since, there is a huge gap in the number of people actually suffering from this entity versus who report to the hospitals and clinics. However, there is increasing awareness for recognition of it in the community. Fortunately major advances have occurred in understanding the patho- physiology and management of this disease. Nonpharmacological therapy, medical and surgical therapeutical options are available today as per need of the patient.

With this backdrop, Indian College of Physicians of Association of Physicians of India decided to bring out a monogram technical series on “Sleep and Disorders of Sleep” and entrusted Professor (Dr) Shyam Narayan Arya for this difficult task. Professor (Dr) Shyam Narayan Arya who is the teacher of teachers had enlightened his experience in this monogram along with the learned authors which will enrich the clinical knowledge and expertise of the pulmonologist, psychiatrist, cardiologist and primary physicians in managing this disease in a scientific manner and improving patient health care. This comprehensive update deals with three main aspects, basics of sleep, technical considerations and clinical aspects. It relates how to diagnose and manage this entity in early stage so that various complications can be avoided there by reducing morbidity and mortality. It has also dealt in details, the most common disorders and sleep, i.e. Obstructive sleep apnea syndrome (OSAS).

The editor and all learned authors deserve commendation and congratulation in bringing out this monogram in time during Platinum Jubilee Year of APICON-2015.

Sleep and disorders of sleep have been orphan topics in medical curriculum both at the undergraduate and postgraduate levels. Scant attention is given on the neuronal circuits responsible for nature's choicest gift of sleep and wakefulness in the preclinical course of MBBS. In the clinical course also recognition and management of various sleep disorders remain neglected subjects. A simple glance at the number of pages in the voluminous textbooks of internal medicine published in India, UK and USA devoted to the physiology of sleep and pathophysiology of sleep disorders will ratify my contention. Editors and contributors of this “Sleep and Disorders of Sleep” monogram do not claim to be specialists in sleep-medicine. Sleep medicine is a super speciality of medicine. However, a number of sleep laboratories in Bihar and rest of India are indicators of a new awaking. Doctors of modern medical science are eager to have at least a basic knowledge about the art and science of normal sleep and sleep disorders. We spend one-third of our life in sleep but we still do not know the ‘Whys’ and ‘Hows’ of sleep. There are conflicting view and research data on the optimal period of sleep for good health. A study of more than 1 million adults by University of California, San Diego found that people who sleep for 6 to 7 hours each night live the longest. Another study on “sleep duration and mortality risk in women” showed similar results. A published observation on this topic also concludes that sleeping more than 7 to 8 hours per day has been consistently associated with increased mortality.¹ Insomnia or lack of sleep occurs in 30–45% adults and is 1.5-2 times commoner in females than males. Thanks to the advent of polysomnogram which records the EEG, ECG, electro-oculogram, air-flow velocity, oxygen saturation, respiratory efforts and leg movements and EMG. We now know something about biological equivalents of sleep and its structure, i.e. the ultradian rhythm of NREM (stage 1,2,3,4) and REM sleep. Still, how the circadian rhythm by the suprachiasmatic nucleus of the hypothalamus, and the sleep awake centres in forebrain and brainstem coordinate with sleep-homeostasis, to organize our sleep-wake cycle eludes precise understanding.²

Sleep, no doubt, serves a restorative function and we recharge the battery of our functional capacity during sleep. The clinical abnormalities in brain, cardiovascular system and endocrine system resulting from sleep deprivation are being recognized lately. Other bad effects of sleep deprivation or insomnia are being unravelled only recently. Lack of sleep leads to cognitive impairment, memory lapses, hallucinations, impaired immunity, risk of type 2 diabetes, increased heart rate variability, increased risk of heart-diseases, obesity and growth hormone suppression.

The first chapter of this monogram deals with physiology of normal sleep and its polysomnographic structures. A short but graphic description of the roles played by the suprachiasmatic nucleus, sleep homeostatic mechanism and sleep centres in sleep onset, sleep maintenance and sleep-offset (waking) will be found in this chapter. The subsequent chapters 2 to 8 deal with commonest abnormalities of sleep like insomnia, and its cardiovascular complications like coronary artery disease, hypertension, stroke, type 2 diabetes, etc. In these chapters, the various syndromes which disrupt sleep are discussed. These are sleep disordered breathing fm13(sleep apnea) and abnormal movements during sleep (restless leg syndrome, and periodic limb movement disorders). Their management are highlighted. Under the head of parosmia, the readers will find brief description of somnambulism, sleep-terrors (night terrors), nightmares, bruxism, and REM-sleep behavior disorder. Description of circadian rhythm disorders are dealt with in its utmost possible clarity in subsequent chapters.

The relationship between insomnia and depression has been dealt with in great details as it has been found that patients of chronic insomnia at times develop major depressive disorder with high rate of suicidal deaths. If we treat insomnia timely and appropriately, these deaths can be prevented. The chapter on role of yoga in ensuring deep and refreshing sleep and in treatment of chronic insomnia has been written by an acclaimed expert on yogic-science.

We are confident that young graduates, looking for a career in a new superspeciality of medicine, will be attracted towards post-doctoral courses in sleep medicine after going through this monogram.

Speciality of cognitive behavior therapy (CBT) will grow amongst clinical psychologists only if internists of tomorrow are endowed with elementary knowledge of sleep disorders. Only then, medical professionals will know when to refer patients of chronic insomnia and other sleep disorders to experts of CBT. According to exponents of sleep-medicine, CBT should be first line of therapy. However, it is time taking and thus compliance is poor. Besides our patients demand a pill for every ill and chronic insomnia, somnambulism, etc. are no exceptions. Hence, what to speak of general practitioners or internists, even clinicians of other specialities like, surgery, obstetrics and gynecology, ENT and eye diseases, etc. have to have a clear knowledge about drug therapy of primary and secondary insomnia.

This text should be able to deliver a take-home message that chronic insomnia is a hitherto relatively unknown risk factor for coronary artery disease, stroke, peripheral vascular disease, type 2 Diabetes mellitus, hypertension and major depressive disorders and that proper treatment of insomnia² will be life saving. Only then we will consider our efforts in bringing out this monogram worthwhile.

 

1. Sleep Wikipedia, the free Encyclopedia http://en.wikipedia.org/wiki/sleep.

2. Sivertsen B, SaloP, Mykletu A, et al. The bidirectional association between depression and insomnia: The HUNT Study. Psychosomatic Medicine. 2012;74:0000(2012)0033-3174/12/7407-0000.