Sleep disorders can spell misery for many people, but help is at hand, finds Sarah Eissa Getting a good night's sleep is essential to feeling alert during the day. Lack of sleep can also cause accidents and affect relationships, health and mental skills. It can make the sufferer feel disconnected from the outside world. Fortunately, sleep clinics are now available in Egypt to help people overcome sleep disorders. After having major surgery 10 years ago, Molly, 72, a British woman now living in Egypt, was prescribed sleeping tablets, as she was suffering from a long-term sleep disorder. "I was depressed and had insomnia, and since then I have found that I am totally dependant on these tablets," Molly said. Having worked for 20 years in the health services of her home country, Scotland, Molly came to live in Egypt seven years ago. "There were no sleep units on the British health service at that time," she said, and she was therefore particularly happy to hear that such units were available in Cairo. Following a series of visits to one of Egypt's private sleep clinics, Molly reports a remarkable improvement in her sleep habits. According to Ramez Mustafa, a lecturer in neurology and psychiatry at Ain Shams University in Cairo and the manager of a sleep clinic, the symptoms of sleep disorders can mislead some patients. The most common disorder is oversleeping, where people sleep during the day, meaning that they are in some way sleep deprived. Other symptoms include insomnia, where patients cannot sleep, or where patients wake up in the night and are unable to get back to sleep in a condition called sleep maintenance disorder. Other common disorders include restless leg syndrome, which, particularly affecting women, means that the patient moves her legs a lot before and during sleep. "This can be very annoying for the patient, and the same goes for snoring," Mustafa said. Professor Tarek Assad, director of the sleep lab at the Institute of Psychiatry at Ain Shams University Hospital, adds that in snoring breathing stops for few moments after each snore, meaning that there is a risk of decreased oxygen being available to the brain. This can lead to greater levels of carbon dioxide in the blood, which causes the patient to feel more awake, decreasing sleep efficiency. "Unsurprisingly, patients suffering from obstructed breathing while sleeping can wake up in the morning with a headache and feeling that they have not slept, even if they have been in bed for up to 10 hours," Assad said. External factors, such as taking medications for colds or blood pressure, can also affect sleep, Mustafa said, adding that stress can also cause insomnia. Different sleep disorders require different types of therapy, and according to Mustafa there are mixed views about treatment. Many patients think that sleep disorders are treated mainly through hypnosis, though this is by no means wholly true. "If you survey doctors working in different specialties, only a few of them will be aware of all the different types of sleep disorders and how they are treated," Mustafa said. The first step towards treating a sleep disorder is getting a proper diagnosis, during which a comprehensive history of the patient is taken. From there, specialists carry out a sleep study, or polysomnography, during which patients spend the night at a sleep clinic under observation while recordings are made of bodily and brain activity. Yet, sleep labs are not always available, and in making diagnoses of sleep disorders Shewikar El-Bakri, a lecturer in neuropsychiatry at Banha University, tends to investigate external factors that can cause episodic disorders. She asks patients to describe any changes that have happened in their lives, including travel, changing rooms or beds, going to a new job, or feeling anxious, and she also evaluates the patient's general physical condition. "Physiological issues can make patients feel sleepy, even if they sleep for long periods, as can nervous problems or ageing," El-Bakri said. The methods used to treat sleep disorders depend on the underlying problems causing them, Mustafa explained. "Drugs can be used to treat insomnia, for example," he said, "while restless leg syndrome can be treated with a mix of behavioural and medical treatments. Breathing disorders can be treated by putting a device inside the mouth, or, in more radical treatments, by surgery." One piece of equipment sometimes used in sleep labs is a continuous positive airflow pressure device, which blows air into the nostrils and keeps airways open. The air pressure can be adjusted to keep passages open, and many patients using this device feel that it has changed their lives, Assad said. When he first started working in sleep medicine, it would never have occurred to him to think that anyone could sleep wearing a mask, Assad said. But recent devices are portable and are adjustable to fit the patient's needs. They are easily worn and have good success rates, he said. Some patients revolt against using the devices. "For these patients, we use a different type of machine of which they are more tolerant. If we cannot use this kind of machine either, then we have to abandon this type of therapy and try asking the patient to lose weight or alter sleeping positions." One important consideration in broken sleep, or apnea, is the cycle of breaks experienced by the patient. Being overweight can cause apnea, and apnea, in turn, can contribute to being overweight. Reducing weight can improve the symptoms of apnea, and when the patient's weight goes down to the ideal then therapy can be stopped, Mustafa said. Despite the development of sleep medicine in recent years, it is not yet considered a separate branch of medicine in Egyptian universities, though sleep disorders are taught in different specialties. According to Assad, sleep medicine is taught to undergraduates who have not yet decided to specialise in any particular branch of medicine, though at present few then go on to specialise in sleep medicine, something that Assad attributes to institutional inertia. Sleep medicine can also confuse patients who are not sure about which specialist to consult if they have snoring or breathing problems, or if they are suffering from problems sleeping. According to Mustafa, it is difficult to know the number of people suffering from sleep disorders due to a lack of studies and data. However, estimates from other countries having a similar climate and population reveal that people suffering from sleep disorders can represent up to 25 per cent of the population. "This means that there are almost 20 million people suffering from sleep disorders in Egypt," Mustafa said, "with those suffering from severe disorders being within the range of five million and the undiagnosed representing 90 per cent of the total or above." Assad commented that he had conducted research on the subject, which, though unrepresentative, gave an idea of the extent of the problem. The research indicated that the prevalence of insomnia in patients suffering from other medical disorders could be in excess of 60 per cent. A small study conducted on university students indicated that the prevalence of insomnia could be up to 30 percent. Mustafa said that he treats some 20 patients monthly, while Assad, who has been working on sleep disorders since 1992, said that he was currently treating four patients on a weekly basis at his sleep lab. Can patients bypass treatment and treat their sleep disorders themselves, possibly by altering their lifestyles or other habits? El-Bakri said that some patients prefer to live with their disorder if treating it means taking drugs. In such cases, patients learn how to improve their sleep hygiene and to control any sleep-interrupting factors, as well as to look for factors behind the problem. "People should not give up looking for different solutions to their problems, and they should also check their sleep patterns in a sleep lab," El-Bakri advised. "We want to encourage people to go to a doctor, diagnose their sleep disorder, and get it treated," Mustafa said. According to El-Bakri there is little difference between private and public-sector sleep labs, since both use the same equipment and therapies. Mustafa agreed, saying that while in some public hospitals the steps involved might not be followed as scrupulously as in a private clinic, "in many public hospitals you find very adequate polysomnography and treatment." Assad also said that he uses "portable sleep labs", going to a patient's home to make an assessment. "It is better if the patient feels comfortable," he said, adding that there are now small, portable devices that patients can wear to monitor their sleep. In most cases, those suffering from sleep disorders do not need to see a psychiatrist. However, if a patient's professional or social life is being negatively affected by sleep disorders, then he or she should consider seeing a psychiatrist, El-Bakri said. Tips for quality sleep: - Take a warm bath before going to bed, and try massage or using aromatic oils in the bath to relax the body. - Reduce stress through breathing exercises. - Sleep in a cool room. - Make sure the room is dark and use a comfortable mattress and pillow. - Develop a routine before sleeping and while getting ready for bed. - If you cannot sleep, get out of bed rather than toss and turn in it. - Fix the alarm for the same time every day and get up even if you have not slept well. - Be active, especially in the mornings.
