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HindustanTimes Sat,25 Oct 2014
Can't sleep? Sound the alarm!
Rhythma Kaul, Rachel Lopez and Aasheesh Sharma, Hindustan Times
June 27, 2013
First Published: 18:52 IST(27/6/2013)
Last Updated: 17:37 IST(29/6/2013)

Six years ago, when 36-year-old software engineer Mehul Kohli scored a job with a US-based multinational, he was both ecstatic and relieved. He’d struggled to get this far and that dream job was finally his. Sure, the hours were erratic, but the pay made it all worthwhile. Or so it seemed at first.

Then, things started to go wrong. “I’d come back from work at 3am, and it would be at least an hour before I’d get into bed,” Kohli recalls. “By the time I actually slept it was 4.30am. Though I had time till noon, the light and noise meant I didn’t get sound sleep.” He’d find himself waking up at 7.30am every day, unable to return to bed even though he’d only had three hours of actual shut-eye. It took its toll – poor concentration and sluggishness had no room in the corporate world – and Kohli ultimately had to seek professional help.
Sleepless
Even two decades ago, someone like Kohli would have had no recourse but to see a psychiatrist. Regular doctors were unprepared to deal with sleep problems, and even those diagnosed with any of the 80-odd sleep disorders had no place for specialised testing or treatment. Today, however, almost every Indian hospital has a sleep centre equipped to diagnose and treat sleep-related problems. Some 300 sleep clinics have sprung up in our cities. Kohli went to one, and after a year of mediation and specially designed therapy,  his sleep patterns returned to normal.

THE LIE OF THE LAND
It used to be that sleep was just something you did at the end of the day. Man rose with the sun, milked the cows, tilled the fields, napped during the hottest hours, worked some more and still had plenty to yawn about by twilight. Then, as most Western sleep researchers believe, the Industrial Revolution came along and ruined it all. A long, continuous workday cancelled out the siesta, turning the urban worker from a bi-phasic to a mono-phasic sleeper, forced to recharge in a single nocturnal stretch.

Indian sleep experts believe that the recent rise in India’s sleep problems (or at least our recent willingness to seek help for them) stems from the same switch. Bedtime isn’t when the sun sets, it’s when we’re done with TV, laptop, overtime or 10pm dinner reservation. Bedroom lights stay on later in cities, alarm bells ring earlier – everything eats into sleep time. “This kind of lifestyle has wreaked havoc on our biological clock, which is controlled by sunlight,” says Dr JC Suri, professor and head of Safdarjung Hospital’s department of respiratory and sleep medicine. “Our body normally gets the signal to sleep when it’s dark, but that hardly happens these days, which leads to sleep disturbance.”

Others agree. Dr Preeti Devnani of Jaslok Hospital’s Sleep Disorders Clinic, says that while the body’s daily rhythms do dip in the afternoon (making you crave a nap), urban life buzzes unceasingly until 1am. Neurologist and director of Delhi’s Neurology and Sleep Centre Dr Manvir Bhatia adds that most of us see sleep issues as non-issues. “While self-medication for sleep is rampant, people don’t discuss it,” she points out “Even physicians didn’t take sleep into consideration until recently.” To make matters worse, India equates rest with laziness, claims Prasad Karnik, technical director at Mumbai’s International Institute of Sleep Sciences (IISS). “We’re a nation in denial,” he says. “We think nothing’s really wrong if we can’t sleep.”

AlarmFor most of us, there really might not be anything wrong. A normal adult needs seven to eight hours of sleep daily and a child needs about nine. Dr Suri says it’s quite normal to have the occasional sleepless night, or a week or two of troubled bedtime. “However, think of consulting a doctor if the symptoms last for more than a month,” he advises.

SNOOZE OPERATORS
At a sleep centre, doctors typically start by ascertaining your sleep history – how you sleep, how often, how long, your snoring patterns - and looks for underlying causes like medication or existing conditions like diabetes or hyperthyroidism. You may also undergo a sleep study, in which tiny electrodes are strapped on to your head, face, chest, arms and legs while you are encouraged to sleep for eight hours. The electrodes record electrical impulses to the brain, eyeball movements, nasal flow and pressure, heart rhythm, stress or tension in the chest, snoring, oxygen saturation and limb movement, offering real-time data for an expert to analyse.

It’s an essential tool to determine the problems you have, or confirm that there are problems in the first place. “If you think you’ve stayed up all night but were actually asleep, a sleep study will prove paradoxical insomnia,” says Dr Ashim Desai of the Nova Specialty Surgery chain, which has tied up with Norway’s Eurosleep to establish India-specific sleep data and raise awareness about sleep disorders.  
The most common of the 80-odd sleep disorders is insomnia – trouble falling asleep, sleeping through the night or waking up earlier than the intended hour. Other diagnoses include apnoeas or breathing problems during sleep, insufficient sleep syndrome (which creates a condition called absenteeism – you’re physically present, but not “quite there”), or delayed sleep phase syndrome, (in which the day-night sleep cycle has shifted, making it hard for the person to function). Many diagnoses also include bruxism (gnashing of teeth in sleep), restless leg syndrome, sleepwalking or chronobiological disorders like jet lag.

“A lot of the cases are referred by endocrinologists, cardiologists and neurologists, as these diseases are directly linked with sleep deprivation,” says Dr MS Kanwar, senior consultant, chest diseases, critical care and sleep disorders at Indraprastha Apollo Hospital. “Sleep disorders can independently lead to diabetes and other metabolic disorders.”  Insomnia is particularly worrisome. Dr Bhatia warns that not only can it be a precursor to depression, but long-term insomnia can actually cause depression. Similarly, many people think stress causes insomnia. “Often it is insomnia that causes stress,” says Karnik.

PILLOW TALK
pillowsThe science of sleep itself is relatively recent.  Modern interest in the subject was kicked off only 100 years ago with scientist Henri Pieron’s Le Probleme Physiologique Du Sommeil, and professor Nathaniel Kleitman’s studies on sleep patterns, regulation and deprivation in the 1920s. We didn’t discover the all-important rapid-eye-movement sleep until the late ’50s and the world’s first sleep research centre was set up at Stanford University only in 1970. India’s first sleep centre wasn’t set up until 1991. Even today, most sleep doctors cite awareness as the biggest hurdle between patients and treatment.         
             
But India seems to be waking up to the idea that good sleep is essential, and with medical help, achievable too. Dr Devnani reports an increase in patients in the last two years. “There are more adolescents, more young professionals, more awareness and a greater prevalence of the problems,” she says. Bhatia sees more middle-aged and elderly patients – more women than men – who’ve had trouble sleeping for over a decade, experimented with cocktails of as many as six types of soporific pills and now realise they need someone who knows better.

OPEN YOUR EYES
sleepAt Mumbai’s IISS, where the clinic is open 24/7 and patients visit three times a week even from Pune and Nashik, databases on chronic sleep deprivation and its effect on cognitive brain function are already being built for India. They treat disorders with new technologies like audio-visual entrainment (AVE), which deploys flashes of lights and tone pulses to guide the brain into various states of brainwave activity. Nova has specialised apnoeagraphs that “can tell you exactly which part of the respiratory system is causing snoring in your case,” says Dr Desai. And for three years now, Indian medical schools have included sleep fellowships in their curriculums.

It’s no longer seen as a privileged person’s problem either. Karnik admits that while the affluent are more likely to seek help, sleep disorders are common across the economic spectrum. “Good sleep is a function of your mental state and environment,” Bhatia says. “The poor often have trouble with the latter.” Devnani explains that some ethnic groups like the people of the North-East, have cranial features that are predisposed to apnoea. The obese are more prone to breathing problems. “There are stronger demographics than economics.” 

A BEDTIME STORY 
And sometimes it’s not the shape of your skull or the size of your wallet that’s the problem. When 12-year-old Manav Mishra’s class teacher complained to his parents that he’d be sleepy through the first half of the school day, the problem lay elsewhere entirely. “We would finish dinner around 10.30pm and then retire to our rooms,” said Manav’s mother Meenal. “We assumed that Manav also went off to sleep. But when we kept a watch over him without him realising, it turned out, he was spending time on the computer till 1am, chatting with friends.” Meenal started sleeping in his room, ensuring he was in bed no later than 11pm. “After a couple of months, the teacher also noticed a change.” she says.

DREAM SEQUENCE
Don’t count sheep. Here’s how to get the perfect night’s sleep:

For mild insomnia, doctors recommend maintaining good sleep hygiene

Sheep* Make sure your day incorporates enough physical activity to make night a time for relaxation and relief. Especially if you have passed middle age.

* Avoid sleeping in the day. If you must, have a short nap no later than 3pm.

* Stay away from caffeine, tea, coffee, colas and chocolates after 5pm.

* Make sure you’re not overstuffed. Keep at least three hours between your last meal and sleep. 

* Don’t be overdrunk either. The aim is to fall asleep, not pass out. 

* Wind down with de-stressing activities before going off to bed. Your brainwaves need to go from high-frequency beta to a calmer alpha and this takes as much as 45 minutes to an hour. 

* Try a relaxing pre-sleep ritual like a warm bath, a light snack, or 10 minutes of reading.

* Dim the lights, in your room and on your gadgets. The backlight on your tablet suppresses the sleep-regulating hormone melatonin.
* Avoid strenuous physical activity just before bed. It raises body temperature.

* Stick to the same time for sleeping and waking up every day.

* Don’t put the laptop, computer, or television next to where you sleep. Respect the sanctity of the bedroom for sleeping. Gradually, the body begins to recognise it is moving into a zone where it is expected to sleep.

* Try not to take late night professional discussions into the bedroom. Keep them for early evening if possible.

* Doctors believe that the maximum sleep latency time (from the time your head hits the pillow until you’re actually asleep) should not be more than 10 to 15 minutes. Any longer and it’s worrisome. If you consistently fall asleep too quickly, that’s cause for concern too. 

* Cut non-productive time spent in the bed. Don’t force yourself into bed at 9pm. Hit the sack only when your body is sleep-deprived enough. The time spent in the bed should be decreased slowly to sync with when you are ready for sleep.

For chronic cases, you may need medicinal and behavioural therapy
* Most doctors will prescribe anti-anxiety pills and sedatives to calm you down so you’re not too keyed up at bedtime. Do not self-medicate and make sure you use these only for three weeks. 

* You could have an underlying health condition such as asthma that may be causing difficulty in sleeping. A good doctor may be able to diagnose this. 

wake up* Persistent problems require cognitive behavioural therapy (CBT). It aims at changing behaviours that may worsen insomnia and helping you learn new behaviours to promote sleep. These will include relaxation exercises, light therapy or reconditioning.

Wake up to the truth
Good sleep keeps you sane, fit, happy and alive. Here’s what happens when you scrimp on those crucial 8 hours

* Studies have shown that those who consistently get less than adequate sleep produced less insulin after eating and higher glucose levels, putting them at risk of diabetes. Conversely, good sleep has been proven to remove excess sugar from the bloodstream.

* Research consistently suggests that those who sleep better tend to burn up calories faster, make better dietary choices and fight weight gain. And since deprivation boosts the presence of an appetite-increasing molecule, those who sleep badly are likely to overeat too.

* Those who sleep longer tend to show fewer signs of ageing.

* Snoring makes you twice as susceptible to diabetes. 

* Sleep-deprived people have been found to be more vulnerable to common infections, high blood pressure and kidney diseases.
* A paper published in The Journal of the American Medical Association also suggests that sleep-deprivation among women may also be associated with mental decline and dementia.

* If you’re overweight, you’re probably at great risk while you sleep. There’s greater pressure on your abdomen, and the fat around the throat blocks the airway, making it a greater effort to breathe. Consequently, oxygen concentrations drop in the body, dipping so low that you wake up with a gasp before dropping off to sleep again, repeating the cycle. Each gasp also releases cortisol, which increases blood sugar and plays havoc with blood pressure.

* Sleep-deprived individuals are most vulnerable behind the wheel. They suffer from what doctors call microsleep – catching bits of sleep with their eyes open –  with dangerous consequences.

THE BIG TIP#2
If you’re thinking of taking a sleeping pill….
Try not to. It’s addictive and the effects are short-lived. You’ll end up upping the dose or experimenting with more medication, with dangerous consequences. Even prescription drugs shouldn’t be taken for longer than three weeks, experts say. So beware.

From HT Brunch, June 30

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