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Sleep disorders—Part II


By Salvador Quiroz

A bad night is the prelude to a bad day. It is not unusual for insomniacs to tell physicians that they sleep for periods of six to seven hours but complain bitterly about the quality of sleep. In other words, the time spent in bed is no indication of a restful sleep.

Based on polysomnographic studies, sleep architecture is divided into two basic patterns: slow wave sleep and paradoxical sleep. The latter is accompanied by rapid eye movements (REM). Slow-wave sleep comprises four progressive stages: 1- sleep induction; 2- light but stable sleep; 3 and 4- deep and restoring sleep. The whole dream cycle is comprised of these four stages, plus the paradoxical pattern. The cycle has an average duration of 80 to 100 minutes. A normal night includes four to five cycles. The quality of sleep is essentially based on a well-balanced proportion of these stages. To make things more complicated, many patients insist on being insomniacs despite normal polysomnographic recordings. What is happening, then? Nowadays, more and more importance is being given to what sleep specialists call cyclic alternating patterns (CAPs). These are simply micro awakenings and people are not aware of their occurrence. They are then not to be confused with nocturnal awakenings of which the patient is definitely conscious. These CAPs are periodical during slow wave sleep but loose their symmetry during the paradoxical stage. They are a physiologic component of normal sleep but should occur no more than 37 percent of the time in the slow wave period. The number of CAPs correlates with the subjective perception of sleep quality, thus explaining why you may feel unrested after what would appear to be a normal sleep pattern.

I apologize to my readers for this cold, boring, scientific preamble, but it was necessary to understand that insomnia is not to be taken lightly. The repercussions of sleep disorders are substantial, both to the individual and to society.

Diurnal functions are impaired, sometimes to a high degree. There is a lowered job efficiency, memorys loss, low yield in scholarly or professional activities and a higher index of automobile accidents. The association of insomnia to pre-existing medical conditions like anxiety or depression is very high, both as a manifestation or a cause.

Because insomnia can be an important health problem, the general consensus is that the use of hypnotics (sleeping pills) is justified. However, the selection of these medications should always be in accordance to the type of sleep disorder being treated.

Most sleeping pills on the market today act in stage one of the slow-wave sleep pattern; that is to say, the induction phase. But ,because of their pharmacological action in other areas of the central nervous system, undesirable side effects may appear. These may range from rebound phenomena (worsening of the problem when the drug is discontinued) to tolerance (progressive increase in dosage needed to get the same effect). Dependence, habituation and even addiction are a danger. Hangover effect, drowsiness during the day, lethargy, mental fatigue, lack of coordination, depression, anxiety and even constipation are frequent complaints.

The newest drugs seem to work in all four stages of the slow-wave pattern, closely resembling physiologic sleep, with very few scattered side effects in the central nervous system.

So, when you think you require a sleeping pill, remember this and work with your physician so that the best drug is prescribed for your individual needs. If it works for you, it is good. If not, there has to be a change.

Dr. Salvador Quiroz, Internal Medicine and Kidney Disease, Hospital H+, Graduated from the Mayo Clinic. Tel: 152 2329.


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