LAS VEGAS – Marcy Fadness, PA-C, of Gundersen Lutheran Health Center in La Crosse, Wisc., took the dais at the American Academy of Physician Assistant 39th Annual PA Meeting with the Everly Brothers singing “Wake Up Little Susie” in the background. This left little doubt as to the topic of her presentation.
“My job is to shock and awe you and leave you with a few things to remember,” Fadness told the audience here.
A 2007 Sleep in America poll showed that 60% of women are tired during the day. Sleepiness can be divided into three problem areas: not getting enough sleep (quantity); not getting enough good sleep (quality); and shift-work disruptions in sleep (circadian rhythm abnormalities).
“Women are sleepy because we work very hard, and we work a lot,” Fadness explained. Women work an average of 41.7 hours per week (compared with 48.8 hours for men), but when you add in the work they do around the home the total comes to 65 to 85 hours per week.
“We are getting so much less sleep than we were 100 years ago,” said Fadness. This can be attributed to snoring spouses, children, job stress and domesticated animals.
Single women who work full-time spend the least time in bed. Dual-income, those without kids and empty-nesters get better quality sleep than most groups, but get the least amount of sleep.
Seventy-four percent of stay-at-home moms rarely get a good night’s sleep. Interestingly, mothers who work part-time are the best sleepers because they nap frequently. Working mothers, who Fadness described as “briefcases with backpacks,” get the least sleep – 72% have insomnia. Women aged 50 years and older have the highest rates of sleep disorders.
A woman’s physiology can be divided into three segments of life, the menstrual cycle, pregnancy and menopause, and each can affect a woman’s quality of sleep.
Menstruating women get about two days of good sleep a month. During pregnancy, 79% of women have disturbed sleep.
On average, sleep was disturbed every eight minutes among menopausal women with hot flushes and once every 18 minutes in women without. “Imagine getting poked every eight minutes all night long,” Fadness described, adding that sleep disorders are twice as prevalent after menopause as well.
Other factors that affect sleep quality include medications and poor sleep hygiene.
“One of the worst things you can do is to check your e-mail right before bed,” Fadness warned. “Make sure anyone with insomnia is not watching television right before bed. That stimulates the light receptors in the eyes and makes the brain think it’s time to be awake.”
Aside from these disturbances, a number of medical conditions and illnesses can interfere with sleep, too. Obstructive sleep apnea is one condition. In very simple terms, obstructive sleep apnea (OSA) is an airway collapse causing the absence of breath. “Sleep apnea is not a snoring problem,” Fadness explained. “Snoring is sometimes a symptom of OSA.”
OSA is a lower-airway problem in which the tongue collapses back and keeps the air from moving. If there is no air circulating, the oxygen level in the blood drops. “The brain then says, ‘I can’t let you go into deep, restful sleep because you might die.’ So you stay in these light-sleep modes all night long,” she said.
Continuous positive airway pressure (CPAP) therapy is the gold-standard treatment of OSA. Surgery and oral devices are only about 40% effective and are rarely paid for by insurance. “You can get a person to do well on CPAP 99.9% of the time,” Fadness said.
So who gets OSA? Among men, 24% have OSA, compared with 9% of women. But this gender discrepancy may be influenced by provider perceptions. “Women are less likely to be diagnosed with OSA because the preconceived notion that OSA is a short, fat, man problem,” Fadness said. “We need to get over that.”
Consequences of OSA
OSA is a risk factor for cardiovascular disease (CVD). The worse the patient’s CVD, the more likely he or she has OSA. In both men and women, 30% to 70% with hypertension will develop OSA, and the risk for stroke rises 55% with OSA. Seventy percent of strokes and 40% of heart attacks are caused by untreated sleep apnea.
While it is known that the likelihood of developing diabetes rises with the severity of OSA, there is no relationship between the two conditions. After controlling for obesity, data has shown that an independent relationship exists between diabetes and sleep apnea. This suggests a complex interaction that researchers are still looking into.
OSA and insomnia are also related – data from a 2002 study 75% of postmenopausal women with OSA have insomnia. This is because insomnia is a symptom, not a disease process, according to Fadness.
Insomnia is one of the most common medical complaints in the industrialized world, and 50% to 95% of people with insomnia also have depression. Insomnia decreases the quality of life in these patients and impairs response to depression therapy. “Antidepressants, particularly selective serotonin reuptake inhibitors, will knock out your REM sleep,” Fadness said.
Indications for pharmacologic intervention of insomnia include patients under acute stress, shift workers or those with jet lag, chronic insomnia and instances of predictable stress. Options include benzodiazepine receptor agonists, antidepressants, antihistamines and melatonin.
“It’s all about educating the patient,” Fadness explained. “You do what you have to do to get people to sleep.”
Nonpharmacologic therapy is more effective than sleep aids in the treatment of insomnia. Cognitive behavioral therapy (CBT) includes such common sense techniques as not going to bed unless you are tired, not watching television before going to bed and not drinking coffee late at night.
CBT also includes building the sleep drive up enough to tip the patient into sleep. This can be achieved through sleep restriction, which works well for some. “If you are in bed for more than 15 minutes without falling asleep, get up and do something relaxing, like reading or knitting,” Fadness advised. “When that wave of sleepiness comes back, go back to bed.”
Treatment of insomnia should include medications for sleep onset, hygiene counseling, CBT and frequent follow-up.
“The hardest thing about all this is that it takes time,” Fadness said. “These patients are needy. But if you work with them – especially if they’re willing to do some of these behavior techniques – you often can get them off sleep aids. They will feel so much better and thank you for it.”