Patients

1. What is normal sleep?
Normal sleep consists of cycles of non-rapid eye movement (NREM) sleep alternating with rapid eye movement (REM) sleep. NREM sleep consists of light sleep and deep sleep. REM sleep is also known as “dream” sleep. The function of sleep is believed to be restorative, a time of rest and repair for the body. Adults need 7-9 hours of sleep (range 6-10 hours). It is normal to fall asleep within 10 to 20 minutes of going to bed, to wake up spontaneously once or twice in the night then fall back to sleep readily, and wake up feeling refreshed. Children need more sleep and tend to have more deep sleep, while the elderly have more frequent awakenings and less deep sleep.

2. What happens when we do not get enough sleep?
The serious short and long term consequences of sleep deprivation reflect the important restorative functions of sleep. When we do not get enough sleep, our memory, concentration, alertness and mood are affected. Daytime sleepiness leads to poor school or work performance and can result in serious accidents. Left untreated, long term sleep disturbances decrease quality of life, and can lead to increased morbidity and mortality.

3. What are sleep disorders?

Sleep disorders are sleep-related disturbances due to underlying medical problems, lifestyle and environmental factors which usually cause sleep disruption, leading to insufficient or poor quality sleep.The most common symptoms of sleep disorders are:
• excessive daytime sleepiness
• insomnia
• breathing disturbances in sleep (eg. snoring)
• abnormal behaviour during sleep

4. What causes excessive daytime sleepiness?
Common causes:
• Insufficient sleep: many people do not get sufficient sleep because of lifestyle choices leading to voluntary sleep deprivation
• Obstructive sleep apnoea, which refers to cessation of breathing during sleep: Patients may be obese or have blockage of their breathing passages due to problems in their nose or throat.Uncommon but important cause:
• Narcolepsy: a sleep disorder which is associated with sudden loss of muscle tone, hallucinations and muscle paralysis on waking.People with excessive daytime sleepiness severe enough to cause social or occupational disruption should undergo formal evaluation by a physician. Those with suspected sleep apnoea or narcolepsy usually need to undergo sleep studies.

5. What causes insomnia?
Insomnia refers to difficulty falling or staying asleep, or a perception of unrefreshing sleep
Common causes:
Psychological and lifestyle factors, including:
• Stress, Depression, Anxiety
• Excessive caffeine consumption
• Irregular sleep habits

Patients with persistent insomnia should be evaluated by a physician to rule out underlying depression, which often presents with early morning waking. Patients who are unable to sleep without sleeping pills may need to be referred to a Sleep Disorders Clinic. Most patients with insomnia can be managed with lifestyle modifications and medication, and do not usually need a sleep study.

6. What causes abnormal behaviour in sleep?
Abnormal behaviour in sleep often does not require specific treatment unless there is risk of injury, or if the abnormal movements disrupt sleep. Examples of abnormal movements disturbing sleep are restless legs syndrome and periodic limb movement movements in sleep, in which excessive leg jerking before or during sleep causes insomnia or excessive daytime sleepiness.

The parasomnias are abnormal behaviours during sleep which can occur in children or adults:
• Sleep terrors
• Nightmares
• Sleep talking
• Teeth grinding
• Sleep walking
• Acting out dreams

A sleep study is frequently required to evaluate these conditions, which must be distinguished from seizures occurring during sleep, which can appear very similar.

7. Who are at risk for sleep disorders?
Some sleep disorders have a genetic component and may run in families, such as restless legs syndrome, obstructive sleep apnoea, narcolepsy and the parasomnias.

People who have irregular sleep schedules, including shift workers and those who travel across multiple time zones frequently are also at increased risk of developing sleep related problems.

Lifestyle factors such as excessive caffeine consumption, lack of regular exercise, poor stress management and smoking all contribute to sleep disturbances.

In general, the quality of sleep declines with age. As a result of this, as well as degenerative changes and weight gain which increase with age, sleep related disorders tend to become more frequent as we grow older.

8. How is a sleep disorder diagnosed?
Most sleep disorders can be diagnosed with a good sleep history, including questions about the patient’s sleep habits, lifestyle, medications and a physical examination. A sleep study may be required in some patients.

9. What is a sleep study?
Sleep patterns can be studied in the laboratory using machines which record brainwave activity, breathing, heart rate and limb movements during sleep. The most common types of sleep studies are:
• Overnight Polysomnography (PSG)
• Daytime Nap test (multiple sleep latency test or MSLT)

PSG involves staying overnight in the sleep laboratory and being hooked up to a machine which is monitored by sleep technologists. At least 6 hours of sleep are recorded using electrodes attached to the scalp and limbs, special belts across the chest and abdomen, airflow monitors and ECG leads. PSG is usually indicated in patients in whom sleep related breathing disorders and abnormal movements in sleep are suspected.

The MSLT follows the overnight PSG, comprising four 20-minute naps at 2 hour intervals throughout the day. It is indicated for the diagnosis of narcolepsy and also to assess the severity of sleepiness in patients who complain of excessive daytime sleepiness.

10. How are sleep disorders managed?
Most sleep disorders can be managed conservatively with a combination of good sleep education, medication and behavioural modification. In certain conditions like obstructive sleep apnoea, specific therapy may include positive airway pressure therapy (pressurised air delivered via a mask) or upper airway surgery. Difficult cases are referred to physicians trained in the management of sleep disorders from a variety of perspectives, including paediatricians, neurologists, respiratory physicians, ENT surgeons, psychologists and psychiatrists.

1. Why is sleep important?
The purpose of sleep is believed to be rest and restoration for the mind and body, with lack of sleep affecting most profoundly our brain functions. The amount of sleep in normal healthy adults ranges from around 6-10 hours, some require more, others less. Once we have adequate amounts of good quality sleep, we should wake up feeling refreshed. This means that we can function mentally and physically at our peak potential. Regular good quality sleep greatly enhances quality of life and overall health, and allows us to perform our best.

2. How much sleep is considered sufficient? Is it true that people sleep less as they age?
Sleep needs vary with age. A newborn may need as much as 14-17 hours spread throughout day, an infant may sleep 12-15 hours with most of sleep consolidated to the nocturnal sleep period, while toddlers may require 11-14 hours or more. Primary school going children should get 9-11 hours of sleep, while teenagers should get 8-10 hours. In adults, sleep requirement ranges from 6-10 hours, with a recommended range of 7-9 hours. Although some people take pride in getting by with very little sleep, many people who get fewer than 5-6 hours of sleep are probably not getting enough sleep. (Source: National Sleep Foundation Sleep Duration Recommendations 2015)

Sleep quality declines with age, so that a person may appear to sleep less, often going to bed and waking up earlier. The body’s natural “sleep hormone”, melatonin, also declines with age. A person who has worked in the same shift work job for decades since young may develop insomnia as they grow older in the same job, because they are able to tolerate changing shifts less well than in the past. Menopause in women is associated with insomnia, related to declining hormone levels, mood changes and physical symptoms like hot flashes. Overall elderly people have more propensity to develop sleep disturbances because they have more medical problems which also affect sleep, as well as take more medications which affect sleep.

3. What are the factors affecting sleep? Quality vs quantity of sleep?
The most important factors affecting sleep are behavioural and lifestyle related. Unfortunately many people are not aware of the importance of sleep and the serious consequences of sleep deprivation. Hence it is a common lifestyle habit for people to sleep too little, and prioritize other activities, shortchanging themselves on sleep. Typical behaviours include drinking a lot of caffeine to stay alert, working till late at night, poorly managed stress, lack of exercise, smoking as a form of relaxation, drinking alcohol as a sleep aid, abusing sleeping pills. Many people have hectic schedules and multiple demands on their time, a very common example being full-time working mothers with young children. For people with busy daily agendas, finding time to get at least 6-8 hours of sleep seems an impossibility. “Sleep Education” is important for this group of people ie letting them know that depriving oneself of sleep whatever the reason is in the longer term counterproductive because it exacts a significant toll on mental, emotional and physical health. Sleep education is the key to people making better choices for themselves.

4. What are the consequences of not getting enough sleep?
Lack of quality sleep affects alertness most immediately, with daytime sleepiness and increased risk of accidents (eg. driving, operating machinery on the job) being an immediate consequence. This impaired mental function, with diminished attention and vigilance, leads to poorer school and work performance. The brain is most immediately and severely impacted by sleep loss. Over time, there are physical health consequences as well. These include increased risk of heart disease, weight gain, tendency to develop diabetes, depression, and ultimately a shorter lifespan. In children and adolescents, lack of sleep impairs normal growth and development, leads to behavioural disturbances and more mood disorders like depression.

5. Who’s most at risk of disrupted or interrupted sleep?
There is increasing recognition of sleep disorders which is partly due to the growing awareness of the impact of sleep on health in general, because of more widespread media exposure regarding sleep related issues. In the past, people may simply have regarded sleep as unimportant, or attribute symptoms like insomnia as being an inevitable consequence of “stress”, and simply to be accepted as “normal”. As more information is widely disseminated through the media, more people are coming to see doctors for poor sleep and related health issues. The risk of sleep disturbance tends to increase with age since we have more responsibilities (and stress) with age, and also develop more health problems, take more medication and also tend to put on more weight as we grow older. Sleep issues are most often the result of a lack of enough knowledge of what constitutes good sleep habits, a balanced lifestyle and healthy stress management techniques. Prevention of sleep disorders and attaining good health in general requires regular exercise, healthy eating habits, and good sleep hygiene. Those at risk of poor sleep include:

• People who lack of awareness of the profound importance of sleep to physical and emotional wellbeing, so they do not prioritize sleep, or perhaps might even take pride in sleeping very little.
• People whose lifestyle habits are not conducive to good sleep, such as excessive caffeine use and smoking, lack of exercise, working or exercising till late in the night, use of alcohol as a sleeping aid, poorly managed stress, shift work, frequent long haul travel (which leads to jet lag related sleep problems).

6. When should one seek help? What are the treatment options?
Patients should be encouraged to seek medical attention early for sleep related problems to nip them in the bud, rather than wait for years until the problems become chronic and intractable, and much harder to treat successfully. Please see your family doctor if your sleep quality or quantity is disturbed to such an extent that you are unable to function optimally in the daytime, such as feeling too sleepy, or unable to concentrate, or if you are sleeping a lot and still feeling tired which usually indicates poor quality sleep. If you have a serious or complex sleep disorder, your doctor may need to refer you to a sleep specialist. The treatment depends on the cause:

The 2 largest groups of patients seen are those with insomnia and excessive daytime sleepiness:

• Insomnia refers to a difficulty falling or staying asleep (recurrent awakenings) or a perception of unrefreshing sleep.

Insomnia has a variety of causes which can usually be sorted out during a comprehensive sleep evaluation in the Sleep Clinic. The common causes are psychological stress, depression and anxiety. Often there may be an acute precipitating factor, usually a stressful life event such as relationship problems, financial difficulty or illness. The common symptom is inability to fall asleep readily at bedtime, tossing and turning in bed, feeling tired but unable to sleep because the mind is too “active”, thinking about problems and being unable to have peace of mind. Patients with depression may complain of recurrent early morning awakenings and inability to fall back to sleep readily. Patients with insomnia usually wake up with a feeling like they hardly slept, or report unrefreshing sleep, and complain of tiredness or low energy throughout the day, yet feel unable to successfully nap in the afternoon even if they want to. Depression can also be characterized by poor appetite, weight loss, poor concentration, feelings of guilt, lack of interest in social or recreational activities, or even suicidal thoughts. Depression is often associated with anxiety, and patients report constant worrying and unease about a range of daily life events, sometimes out of proportion to the degree of severity of the event. Depression and anxiety may run in families, and their manifestation is affected by life events and coping skills. Some patients have an inherent predisposition to depression, which only becomes apparent when they are also overwhelmed by psychosocial stressors. Common types of environmental stress factors are marital discord, work related demands, financial problems and lack of social support.

• Excessive daytime sleepiness is most often due to not getting enough sleep at night, which if not voluntary, is commonly due to obstructive sleep apnoea (OSA), which causes sleep fragmentation due to recurrent awakenings and prevents the patient from entering deep sleep which is most restorative.
In OSA there is blockage to the upper airways during sleep, which causes sleep disruption due to difficulty breathing at night. This may present most commonly as snoring, or excessive daytime sleepiness due to the poor quality sleep that results when breathing is interrupted during sleep. OSA results from blockage of the air passages during sleep, so a frequent complaint is snoring, usually from a bed partner. This is the sound of air moving through a blocked air passage, and can be very disruptive to others. During sleep, when the passage of air into and out of the lungs is blocked, the body struggles to overcome this and usually the brain becomes aroused from sleep. These recurrent arousals may occur many times an hour, and the patient is prevented from entering sustained deep sleep. The result is waking up feeling tired, because the quality of sleep which was disrupted by breathing difficulty, is overall very poor-mainly light, non-restorative sleep.

OSA is often, but not always seen in patients who are overweight or obese, with the excessive fat tissue in the neck causing blockage of the upper air passages. Some people have blocked air passages due to large tonsils, nasal congestion, a small jaw or a large tongue. Some of these problems are correctable by surgery.

Insomnia is managed with a combination of sleep education, behavioural modification techniques, psychological support and medication. Sleeping pills which are addictive and associated with a long list of problematic side effects are seldom required in the long term. Sleep education is an important part of insomnia management, during which patients are taught basics of good sleep health, and how to manage lifestyle factors for ideal sleep. Sleep hygiene instruction and a range of “Cognitive-Behavioural Therapy (CBT)” techniques refer to specific methods of managing sleep habits to achieve good sleep in the long term without drugs. CBT encompasses a range of skills taught to patients to achieve a relaxed state and peace of mind conducive to sleep. It been shown to provide the best long-term benefits in chronic insomnia patients.

A variety of non-addictive medications can be helpful to enhance sleep, and are tailored to the individual patient. For example, a depressed patient with insomnia would benefit most from a sedating anti-depressant, while someone with anxiety may do well with a predominantly anxiety-relieving drug. All medications are prescribed and monitored by a doctor, and long term use of addictive sleeping pills should be avoided in general, and closely supervised.

OSA is managed depending on the cause. Weight loss is important for overweight and obese patients. Upper airway surgery may be beneficial in patients who have a surgically correctable narrow upper air passage. Oral splints are devices which are placed in the mouth to expand the narrow air passage and may be suitable in milder cases of OSA. The most common treatment for moderate to severe cases of OSA is continuous positive airway pressure (CPAP) which comprises a device which keeps the air passages open using a stream of air which is delivered from a small portable device through a mask placed over the nose and/or mouth. The CPAP provides a pneumatic “splint” which holds the airway open while the patient is sleeping at night.

7. What are the pros and cons of medical treatment, versus natural remedies for sleep disorders?
The treatments for insomnia and OSA described above are “evidence-based” ie they have been proven in large, well-conducted scientific studies to improve outcomes in these conditions. Alternative therapies such as traditional medication; or the use of devices such as special pillows or scents etc which have not been put through the same rigorous testing are of uncertain benefit, since there is no medical research based “evidence” for their effectiveness. The risk of taking alternative therapies or herbal medicine which are generally less well-regulated in terms of their preparation than prescription drugs, should also be weighed against their potential benefit, if any. Use of unregulated drugs can lead to serious problems such as toxic side effects.

Just as importantly, failing to get one’s sleep problem properly diagnosed and then properly treated with scientifically rigorously studied and proven therapy also means that you have suffer needlessly for longer, even if whatever alternative therapy does not cause dangerous side effects. Patients are encouraged to seek the advice of healthcare professionals before trying out any over-the-counter supplements. Patients should try as much as possible to be discerning consumers, and seek out credentialed health care providers, and use only drugs or products which have approval from established authorities like HSA (Health Sciences Authority, Singapore), FDA (Food & Drug Administration, USA).

Patients should also pay attention to good basic sleep habits before trying out such products which do not have evidence for benefit or authorized approval.
Prevention of insomnia requires a good knowledge of what constitutes good sleep habits, a balanced lifestyle and good stress management techniques. Prevention of sleep disorders and preservation of good health in general requires regular exercise, healthy eating habits, and good sleep hygiene. Once we learn to understand our sleep needs and patterns, and to recognize problems early like depression and anxiety (then seek treatment), we can probably avoid chronic insomnia. Patients should be encouraged to seek medical attention early for sleep related problems to nip them in the bud, rather than wait for years until the problems become chronic and intractable, and much harder to treat successfully.

OSA due to obesity can be prevented by a healthy lifestyle of regular exercise and eating habits as described above. OSA due to excess weight can be improved by attaining healthy weight, and as such is potentially preventable.

8. Tips on getting a good night’s sleep:
Good “Sleep Hygiene” refers to the basic “rules” for good sleep, an essential part of sleep education every patient needs to know:

• Try to go to bed and wake up at around the same time. Our sleep-wake patterns are regulated by an internal “clock” which dictates when we feel sleepy. We are usually sleepiest at bedtime, and again sometime in the mid-afternoon. This internal clock runs in an approximately 24 hour cycle, in a regular manner. People who have good sleep habits are well synchronized with their internal clocks, and fall to sleep and wake up like clockwork. When our lives are in-synch with our internal clocks, we tend to function best. People who routinely vary their sleep-wake times, like shift workers, tend to have poorer quality sleep, and sleep less overall than others. When our daily life schedules are nicely synchronized with our internal clocks, we will naturally sleep better. If we keep changing our bed and wake times, there is desynchronization which is stressful for our bodies, and not conducive to good sleep.

• If you already have difficulty falling to sleep, do not lie in bed tossing and turning indefinitely, watching the clock. If you keep doing this, your mind and body become “conditioned” to struggle with sleep every night in the same manner, and will associate the bedroom with stress and reinforce the difficulty with sleep. In order to “break” this conditioning, you should make it a point to get out of bed if you are unable to sleep within 15 to 20 minutes. You should leave the bedroom and go somewhere else to do something relaxing, such as reading, listening to music or watching TV. You should only return to bed when you are sleepy again, however long it takes. You need to develop the reverse conditioning, whereby you associate the bedroom with sleepiness and sleep, so that you will fall asleep readily when you go to bed.

• Following on the above, the bedroom should ideally be a place only for sleep and sexual activity. If you have a problem with insomnia, you should not read, watch TV or work in bed. Associating the bed with other types of activities, especially if they are stimulating, will make it harder to fall asleep.

• Avoid caffeine and stimulating activities close to bedtime. Caffeine can stay in your body for over 10 hours, and can affect sleep because it is a stimulant. People with problems sleeping should not drink caffeinated beverages from the afternoon or at night. Smoking and alcohol should also be avoided close to bedtime. Stimulating activities such as vigorous exercise, intense work and exciting or violent TV programmes should be avoided close to bedtime. The higher our level of arousal at bedtime, the harder it is to fall asleep. However sleepy and tired we are, this can be counteracted by high levels of arousal.

• Long afternoon naps make it difficult for us to fall asleep at night and should be avoided. Our ability to sleep is related to our sleep “drive” which builds throughout the day in proportion to how long we stay awake. So the longer we stay awake, the sleepier we get. If we blunt this drive to sleep by taking a long afternoon nap, we may have difficulty falling asleep at night. People who lack sufficient sleep may benefit from a short nap in the afternoon to refresh them, but those who have difficulty falling asleep in general should avoid daytime naps.

• A daily ritual to help us relax at the end of the day is a good lead-up to falling asleep easily. This can take the form of a warm bath, dimming the lights, reading quietly, a relaxing TV programme, soft music or just about any pleasurable activity that is something you look forward to at the end of the day. If we can learn to wind down after a day of stresses, our natural sleep drive which has built up over the day of wakefulness takes over, and allows us to fall asleep.

1. Roughly what percentage of Singaporean population suffers from insomnia?
There are no formal statistics from large scale population studies in Singapore. But we probably are not very different from the rest of the world, with about 30% suffering insomnia at some point in their lives, and about 10% with symptoms severe enough to affect daytime function.

2. Please name and elaborate a little on each type of insomnia.
There are several types of insomnia, with the most common forms being “Adjustment Insomnia”, “Psychophysiological Insomnia” and “Insomnia Related to Depression or Anxiety”.
Adjustment or acute insomnia is that which is associated with an identifiable stressor, such as relationship problems, work stress, bereavement or moving to a new location. It usually lasts a few days to a few weeks, and typically resolves when the underlying stress is resolved.
• Psychophysiological insomnia is also known as “conditioned insomnia” or “learned insomnia”. People who have this are predisposed to developing insomnia (eg. habitual light sleepers, those with an anxious overconcern for health), having a physiologically heightened arousal state. Usually there is a precipitating event, usually a stressor of some kind. What follows is the development of learned behaviours not conducive to sleep, such as tossing and turning in bed for hours, watching the clock, excessive consumption of caffeine to stay alert in the daytime, and overconcern about the inability to sleep. Such patients have a state of “hypervigilance” at bedtime, and often describe themselves as having a “racing mind”, or an “active mind which cannot be switched off”, typically describing being filled with all manner of trivial thoughts.
• Insomnia can also be a presenting symptom of depression or anxiety. Anxious patients may describe being unable to fall asleep at night, and feeling tense and worried in the daytime about many things. Depressed patients more typically older, and report early morning awakenings or difficulty staying asleep, with recurrent awakenings. Depressed patients may report a range of symptoms such as low energy, lethargy, poor appetite, lack of interest in activities of daily living, social withdrawal, excessive rumination and in severe cases, suicidal thoughts.

3. What are the main causes and who are among the most vulnerable? Are there more men or women insomniacs. Why?
Older people, women, those with psychiatric disorders, patients with medical conditions on multiple medications or suffering discomfort (eg. pain) and those who do shift work or travel long distances frequently (ie. have jet lag) are most vulnerable to developing insomnia. People with poor sleep-related habits are also more prone to having difficulty with sleep, such as excessive consumption of caffeine, smoking, late-night exercise, late night eating, long afternoon naps, irregular sleep-wake times and working or excessive use of electronic devices and activity on social media till late at night.Insomnia affects women more for several reasons. Women are more affected by anxiety and depression than men. Women also go through changes at different times of their reproductive cycle such as pregnancy and menopause which affect sleep. In pregnancy, insomnia can occur because of back pain, frequent urination and marked hormonal changes which can affect mood. In menopause, hormonal fluctuations, accompanying symptoms (eg. hot flashes) and mood disturbances can disturb sleep.

4. What are consequences for such sleep deprivation – both physical and mental?
Sleep deprivation affects alertness most immediately, with daytime sleepiness and increased risk of accidents (eg.driving, operating machinery on the job) being an immediate consequence.This impaired mental function, with diminished attention and vigilance, leads to poorer school and work performance. The brain is most immediately and severely impacted by sleep loss. Over time, there are physical health consequences as well. These include increased risk of heart disease, weight gain, tendency to develop diabetes, depression, and ultimately a shorter lifespan. In children and adolescents, lack of sleep impairs normal growth and development, leads to behavioural disturbances and more mood disorders like depression.

5. Please give some details on how people suffering from insomnia can be helped to drift into a restful sleep.
The most important behaviours conducive to good sleep are: A regular sleep and wake time (a relatively fixed wake time is most important for anchoring our internal “body clock” which is important for healthy sleep), limiting time in bed to sleep and sexual activity, limiting the consumption of caffeine to the morning hours, avoiding long daytime naps and a relaxing wind-down routine before bedtime. Exercise is very good for health in general and promotes deep sleep naturally, but should not be undertaken late at night.

6. Can medication, hypnosis or other psychological intervention help?

Medication can be helpful, though behavioural changes are the most healthy and natural long term. Anxious and depressed patients can improve with antidepressants. Sleeping pills can be useful in the short-term in patients who have acute or adjustment insomnia. Doctors need to monitor the use of sleeping pills closely because of the risk of addiction. Psychological intervention is also helpful. Depressed patients, for example can benefit from counselling or “talk therapy” during which they are given the opportunity to express their concerns, and receive guidance. “Cognitive-Behavioural Therapy (CBT)” is a well-established psychological method which is helpful for psychophysiological insomnia. CBT usually takes the form of several weekly sessions during which patients are taught about good sleep promoting habits, natural relaxation techniques (eg. progressive muscle relaxation, visual imagery) and their misperceptions about sleep addressed and corrected. Hypnosis has not been rigorously studied and is outside of the realm of mainstream sleep medicine.

7. Please mention some of the wrong ways people with sleep problems resort to, to go to sleep and why these are ill-advised methods.
Amajor problem among patients is an excessive reliance on sleeping pills, without correcting poor sleep habits, or even a proper diagnosis as to the cause of their insomnia. Some self-medicate and obtain sleeping pills from unregulated sources, then end up using sleeping pills for weeks, months and even years, eventually becomingaddicted to the sleeping pills. Another problem in patients who take sleeping pills to sleep (then become addicted), is when actually they have an undiagnosed depression and/or anxiety, for which the correct treatment is antidepressant therapy. Another common habit is to lie in bed for hours tossing and turning, believing (incorrectly) that this form of “resting” is the next best thing to actual sleeping. In fact, excessive time in bed but not actually sleeping is not good and reinforces Psychophysiological (also known as Learned or Conditioned) Insomnia. Many people are unaware that late night exercise or working right up to bedtime may be too stimulating, and prevent them from falling asleep immediately after such activating or stressful activity. Overall most people who suffer insomnia would benefit from sleep “education” – ie learn what constitutes good sleep practices, and what is not healthy and perpetuates chronic insomnia, and the dangers of over-reliance on sleeping pills.

8. There are people, especially the elderly, who say they can get by with about four hours of sleep. Is this really true? Why do the elderly need less sleep?
Once we reach adulthood, the amount of sleep we need generally stays about the same (about 7-9 hours). The older adult (65+) needs about 7-8 hours, but generally may have poorer quality sleep (more light sleep and less deep sleep, and more frequent awakenings), and also will tend to sleep earlier and wake up earlier. There are some people who are what is called “short sleepers”, who routinely (and normally) require less than 5 hours a night. This type of short sleep requirement is uncommon. Most adults need 6 to 10 hours of sleep nightly (average of about 6 to 8 hours), and most people sleeping less than 4 to 5 hours a night are probably not getting enough sleep.

9. Are there any new breakthroughs in sleep therapy?
There are some more recent drugs on the market which are said to be either less or non-addictive, and have a better safety profile than the older sleeping pills. However not all of these are available in Singapore. Research efforts in the field of insomnia are generally aimed toward an effective, non-addictive sleeping pills with no next-day hangover effects.

One of the recent advances in sleep treatment has been the improvement in the safety and efficacy profile of drugs for insomnia. Traditionally used sedatives like the benzodiazepines (eg. Valium) have significant problems associated with them like dependence (ie. addiction), which has spurred the development of newer drugs which have a better safety profile and shorter half-lives so that there is less carry-over effect into the next day. There are several non-benzodiazepine “sleeping pills” which have been introduced in the market in recent years, with shorter acting ones for people with sleep-onset insomnia, and longer acting ones for those with sleep-maintenance insomnia. These newer drugs are said to be less addictive and disturb the normal sleep “architecture” less, unlike the older benzodiazepines which are habit-forming and actually do not promote restorative deep sleep, rather provide mainly light sleep. Other additions to the sleeping pill market are the melatonin agonists, which are drugs which simulate the effect of melatonin (the body’s natural “sleep hormone”), and provide sleep inducing effects without being addictive.

Unfortunately not all of these new drugs are available in Singapore. The newer non-benzodiazepine sleeping pills are prescribed for adults and should not be used for more than 2-4 weeks, typically under the supervision of a physician.

10. Is sleep apnoea a form of insomnia? How are they related?
Sleep apnoea refers to the cessation of or reduction in breathing during sleep caused by obstruction to the upper air passage. This can be considered one of the causes of insomnia, which is defined as any difficulty falling or staying asleep. Sleep apnoea can cause recurrent awakenings which is a form of sleep maintenance insomnia. However more commonly, sleep apnoea will present with snoring, excessive daytime sleepiness and unrefreshing sleep rather than insomnia characterized by difficulty falling asleep.

11. Are we set to see more people in Singapore becoming insomniacs with the opening of the Integrated Resorts, more pubs and night clubs remaining open till the small hours and many factory jobs that put workers on shift duties etc.?
Yes, it is likely that more late night or overnight shift work will create more problems with insomnia, since healthy sleep is best achieved with a fixed sleep-wake schedule, and most adults tend to sleep better around conventional times, which are relatively fixed and regular eg. From 10 to 12 midnight, till about 6 to 8 am. In times of financial and political instability, an increase in depression and anxiety is to be expected as stressors build, with the likely outcome being more patients suffering from insomnia.

12. How many Singaporean adults are getting sufficient sleep (7-9 hours) each night? Do you have earlier statistics or a ballpark figure on this?
On average, most adults require 7-9 hours of sleep a night. We do not have formal local statistics, but are likely to approximate figures in America, where 20-50% of people may not be getting the amount of sleep they need.

13. What are the top factors that prevent Singaporeans from sleeping well and sleeping enough at night?
From local experience, patients in Singapore with insomnia (difficulty falling or staying asleep) most commonly are unable to sleep well because of stress or emotional distress, depression and/or anxiety, combined with poor sleep hygiene. The other big group of patients with difficulty sleeping well have obstructive sleep apnoea, which refers to difficulty breathing in sleep due to a blocked air passage, leading to disturbed sleep at night. A list of common factors which disturb sleep is given below.

(a) Lifestyle choices: Drinking too much coffee during the day (or other caffeinated beverages), poorly managed stress, exercising or working late in the night close to bedtime (any stimulating activity), lack of exercise, irregular sleep-wake times
(b) Psychological factors: Chronic and excessive stress, depression, anxiety. All of these affect our ability to fall asleep and get good quality sleep.
(c) Unrecognized sleep disorders eg. Insomnia (various types), obstructive sleep apnoea. Many people do not seek medical attention early, and some people do not get the correct diagnosis or treatment.
(d) Medication factors. Many older people are on multiple medications, some of which can affect sleep eg steroid therapy, asthma medication. Drug effects should always be considered in patients who have sleeping problems.
(e) Sleeping pill overuse: It is unhealthy to be dependent on sleeping pills to sleep for the long term.

14. How can a good mattress help with these problems?
The bed surface, even if merely adequate or average in quality, which is the case in most instances, does not have a major impact on sleep in most normal sleepers. Most people will feel sleepy and fall asleep readily, and sleep well, after they have been up most of the day, unless the bedding is somehow extremely unacceptable. This is natural. In people who suffer sleep disturbances eg. chronic insomnia from depression, more effort may be needed to make the bedroom environment especially conducive to sleep. This could include airconditioning, soft (or firm) pillows…whatever that the patient prefers. There is no compelling evidence that any specific kind of mattress can promote better sleep. Part of the reason is that most people who do not sleep well suffer because of psychological issues, ie it is not the physical environment which prevents sleep, so a “better” mattress is not usually the answer to getting better sleep.

15. How has the economic downturn affected our sleep quality and hours?
The economic downturn has affected many people’s lives, and some who have experienced profound emotional distress or become depressed or anxious may also develop insomnia. Examples include people who have been retrenched, or fear losing their jobs, or have become depressed because they are unable to find new jobs. In America the National Sleep Foundation (NSF) 2009 Sleep in America poll, has shown that more than a quarter of Americans (27%) say their sleep has been disturbed at least a few nights a week in the past month due to personal financial concerns (16%), the US economy (15%), and/or unemployment (10%). We have no formal local statistics, but trends may be similar to American statistics.

16. What are the consequences of not sleeping well and enough?
Lack of quality sleep affects alertness most immediately, with daytime sleepiness and increased risk of accidents (eg. driving, operating machinery on the job) being an immediate consequence. This impaired mental function, with diminished attention and vigilance, leads to poorer school and work performance. The brain is most immediately and severely impacted by sleep loss. Over time, there are physical health consequences as well. These include increased risk of heart disease, weight gain, tendency to develop diabetes, depression, and ultimately a shorter lifespan. In children and adolescents, lack of sleep impairs normal growth and development, leads to behavioural disturbances and more mood disorders like depression.

17. What are some ways to sleep better at night? How do pillow mists and aromatic candles help people to sleep better?

Good Sleep Habits
1. Sleep-wake Schedule: Go to bed and get up at about the same time every night and morning respectively, including weekends. Try to have a regular schedule of going to bed and waking up. This will help you to anchor your circadian (“biological”) clock and establish a consistent rhythm of sleep.
2. Stimulus Control: Go to bed only when you are feeling sleepy. If you are not asleep after 20 minutes, then get out of the bed and engage in a relaxing activity like light reading. Go back to bed only when you feel sleepy again.
3. Food & Drink: Avoid heavy meals within two hours of bedtime. Try not to go to bed hungry either. Avoid fluids close to bedtime to prevent awakening to go to the toilet. Avoid caffeine after lunch and using alcohol as a sleep aid. Limit caffeine use to one or two beverages a day.
4. Bedtime Routine: Establish a relaxing pre-sleep routine while getting ready to go to bed, eg. reading, listening to music. Set time aside to relax and practise natural relaxation techniques, eg. deep breathing, progressive muscle relaxation.
5. Napping: Avoid taking long daytime naps unless you are very sleep deprived. Afternoon naps, if taken, should not exceed 20 to 30 minutes.
6. Exercise: Regular physical exercise is encouraged but vigorous physical activity should be avoided too close to bedtime. Do not engage in vigorous exercise four hours before sleep.

These are good sleep habits to follow daily. Environmental enhancements which create a more restful atmosphere conducive to sleep, such as comfortable pillows and ambient temperature, quiet surroundings or calming music or aromas can all contribute to improved sleep. However the use of aromatherapy for insomnia is not well studied and lacks robust scientific evidence for its effectiveness. Conversely, any form of discomfort (eg. physical pain, shortness of breath) or environmental disturbance (eg. loud noise, bright lights, too hot or too cold temperature, unpleasant smells) will certainly make it difficult to have a good night’s sleep.

A few take home pointers on INSOMNIA:
• Insomnia is an important and common medical problem which requires evaluation if it is persistent and affects daytime function – patients should not self-diagnose or self-medicate.
• People should seek medical attention if their insomnia persists for more than 1-2 weeks.
• Insomnia is a symptom for which an accurate diagnosis must be determined. The treatment is aimed at correcting the underlying cause eg. antidepressants for depression.
• Sleeping pills are not the “cure-all” for insomnia. They are generally only to be used for no more than 2-4 weeks, under the direction of a physician, and only indicated for certain specific types of insomnia.
• Good sleep habits (eg. stable wake/sleep times, regular exercise etc) are the cornerstone of healthy sleep. Unhealthy sleep practices are a common factor in most insomnia sufferers.
• Sleep deprivation is a common and under-recognized cause of poor daytime performance at school or work, mood disturbances and increased accidents. Most people voluntarily do not get enough sleep because they do not realize the high cost of sleep deprivation in terms of physical and emotional wellbeing.
• The consequences of chronic sleep deprivation can be very serious. People should be made aware that chronic sleep deprivation affects their brain function, impairs their mood and physical health.

Good quality (and enough) sleep is as important a part of good health as regular exercise and a healthy diet. These 3 form the triumvirate of good health: Quality Sleep, Regular Exercise, and Good Nutrition (William Dement, The Promise of Sleep).

1. Has there been a trend of more people having sleep disorder or insomnia?
More patients are seeking help for sleep problems now than before. This could be a reflection of the global financial downturn and unrest, and the impact of stress on sleep; or could also partly be attributed to the growing awareness of sleep disorders in general, because of much more widespread media exposure regarding sleep disorders. In the past, people may have regarded sleep as unimportant, or insomnia as being a “normal” consequence of stress. More people are now coming to see doctors for poor sleep as more information on sleep health is widely disseminated through the media.

2. Apart from insomnia, what other common sleeping disorders are there? What are the common causes of such problems?
The 2 largest groups of patients seen are those with insomnia and excessive daytime sleepiness.

Insomnia refers to a difficulty falling or staying asleep (recurrent awakenings) or a perception of unrefreshing sleep. Insomnia has a variety of causes which can usually be sorted out during a comprehensive sleep evaluation in the Sleep Clinic. The common causes are psychological stress, depression and anxiety. Often there may be an acute precipitating factor, usually a stressful life event such as relationship problems, financial difficulty or illness. The common symptom is inability to fall asleep readily at bedtime, tossing and turning in bed, feeling tired but unable to sleep because the mind is too “active”, thinking about problems and being unable to have peace of mind. Patients with depression may complain of recurrent early morning awakenings and inability to fall back to sleep readily. Insomnia patients usually wake up with a feeling like they hardly slept, or report unrefreshing sleep, and complain of tiredness or low energy throughout the day, yet feel unable to successfully nap in the afternoon even if they want to. Depression can also be characterized by poor appetite, weight loss, poor concentration, feelings of guilt, lack of interest in social or recreational activities, or even suicidal thoughts. Depression is often associated with anxiety, and patients report constant worrying and unease about a range of daily life events, sometimes out of proportion to the degree of severity of the event.

Excessive daytime sleepiness is most often due to not getting enough sleep at night, which if not voluntary, is commonly due to obstructive sleep apnoea (OSA), which causes sleep fragmentation due to recurrent awakenings and prevents the patient from entering deep sleep (which is most restorative). In OSA there is blockage to the upper airways during sleep, which causes sleep disruption due to difficulty breathing at night. This may present most commonly as snoring, or excessive daytime sleepiness due to the poor quality sleep that results when breathing is interrupted during sleep.

OSA results from blockage of the air passages during sleep, so a frequent complaint is snoring, usually from a bed partner. This is the sound of air moving through a blocked air passage, and can be very disruptive to others. During sleep, when the passage of air into and out of the lungs is blocked, the body struggles to overcome this and usually the brain becomes aroused from sleep. These recurrent arousals may occur many times an hour, and the patient is prevented from entering sustained deep sleep. The result is waking up feeling tired, because the quality of sleep which was disrupted by breathing difficulty, is overall very poor, mainly light, non-restorative sleep.

OSA is seen in patients who are overweight or obese, with the excessive fat tissue in the neck causing blockage of the upper air passages. Some people have blocked air passages due to large tonsils, nasal congestion, a small jaw or a large tongue. Some of these problems are correctable by surgery.

3. What are the treatments available for common sleep problems like insomnia and obstructive sleep apnoea (OSA)?
Insomnia is managed with a combination of sleep education, behavioural modification techniques, psychological support and medication. Sleeping pills which are addictive and associated with a long list of problematic side effects are seldom required in the long term. Sleep education is an important part of insomnia management, during which patients are taught basics of good sleep health, and how to manage lifestyle factors for ideal sleep. Sleep hygiene instruction and a range of “Cognitive-Behavioural Therapy (CBT)” techniques refer to specific methods of managing sleep habits to achieve good sleep in the long term without drugs. CBT encompasses a range of skills taught to patients to achieve a relaxed state and peace of mind conducive to sleep. CBT been shown to provide the best long-term benefits in chronic insomnia patients.

A variety of non-addictive medications can be helpful to enhance sleep, and are tailored to the individual patient. For example, a depressed insomnia patient would benefit most from a sedating anti-depressant, while someone with anxiety may do well with a predominantly anxiety-relieving drug. All medications should be supervised by a doctor, and long term use of addictive sleeping pills can usually be avoided.

OSA is managed depending on the cause. Weight loss is important for overweight and obese patients. Upper airway surgery may be beneficial in patients who have a surgically correctable narrow upper air passage. Oral splints are devices which are placed in the mouth to expand the narrow air passage and may be suitable in milder cases of OSA. The most common treatment for moderate to severe cases of OSA is continuous positive airway pressure (CPAP) which comprises a device which keeps the air passages open using a stream of air which is delivered from a small portable device through a mask placed over the nose and/or mouth. The CPAP provides a pneumatic “splint” which holds the airway open while the patient is sleeping at night.

4. How bad can insomnia be, and how dangerous?
Chronic insomnia is a common and disabling problem which diminishes the quality of life. When we do not get enough sleep, our brain function is impaired the most severely. Concentration, attention, vigilance and mental performance are all decreased when we do not get enough sleep. Sleepiness in the daytime can lead to accidents while driving or on the job. Mood is also greatly affected by lack of quality sleep. Insomnia can be caused by depression, and conversely, can also lead to an increased risk of depression in the future if left untreated. Besides mental function and mood, studies also suggest that people who do not get enough sleep may suffer more problems with their heart health, immune system, breathing and blood sugar control. So insomnia can result in sleep deprivation, and is associated with serious physical and mental health issues.

5. There are lots of products in the market: memory foam pillow, magnetic mattresses, neck support pillow etc, are these helpful? What should consumers look out for when buying such products?
The treatments for insomnia and OSA described above are “evidence-based” ie they have been proven in large, well-conducted scientific studies to improve outcomes in these conditions. Alternative therapies such as traditional medication; or the use of devices such as special pillows or scents etc which have not been put through the same rigorous testing are of uncertain benefit, since there is no “evidence” for their effectiveness. The risk of taking alternative therapies or herbal medicine which are generally less well regulated in terms of their preparation than prescription drugs, should also be weighed against their potential benefit, if any.Patients should also pay attention to good basic sleep habits before trying out such products which do not have evidence for benefit or authorized approval.

Prevention of insomnia requires a good knowledge of what constitutes good sleep habits, a balanced lifestyle and good stress management techniques.. Patients should be encouraged to seek medical attention early for sleep related problems to nip them in the bud, rather than wait for years until the problems become chronic and intractable, and much harder to treat successfully.OSA due to obesity can be prevented by a healthy lifestyle of regular exercise and healthy eating habits. OSA due to excess weight can be improved by losing weight naturally, through improving diet and regular exercise.

6. I’ve heard that several studies have found that less sleep may lead to excess weight gain. Is this true? Why do you think that people who don’t have enough sleep are more prone to putting on weight? After all, isn’t it reasonable to believe that people tend to burn more calories while they’re awake, so why does less sleep cause them to pile on weight?

Yes it is true. Several studies have shown that people who sleep less tend to gain weight. This has been attributed to several reasons: Sleep deprivation increases levels of a hunger hormone and decreases levels of a hormone that makes you feel full, leading to overeating and weight gain. People who do not sleep enough may be tired and exercise less; and sleep deprivation may alter our basal metabolic rate. Sleep deprivation is a stressful state which alters our body’s hormonal environment, and is associated with a range of physical and mental disorders.

7. In Singapore, how common are sleep disorders?
The most common problems seen in Singapore are insomnia (10-30% of the general population) and obstructive sleep apnoea (OSA) which affects up to 15% of Singaporeans. Insomnia refers to a difficulty falling or staying asleep (recurrent awakenings) or a perception of unrefreshing sleep. In OSA there is blockage to the upper airways during sleep, which causes sleep disruption due to difficulty breathing at night. This may present most commonly as snoring, or excessive daytime sleepiness due to the poor quality sleep that results when breathing is interrupted during sleep.

Other frequently encountered sleep related issues are chronic sleep deprivation, jet lag, shift work related sleep problems and dependence on sleeping pills. All of these conditions are treatable, but unfortunately are often overlooked because many people may not be aware of the significant impact of sleep disturbance on health, or accept the typical symptoms of sleep disorders such as daytime tiredness, unrefreshing sleep and snoring as normal or part of “stress”. Greater awareness of sleep disorders is needed.

8. What are some reasons or factors that affect quality and quantity of sleep among Singaporeans?
Insomnia and OSA are not an inevitable part of old age, but our predisposition to these problems does increase with age since we have more responsibilities (and stress) with age, and also develop more health problems, take more medication and also tend to put on more weight as we grow older. Sleep issues are most often the result of a lack of good knowledge of what constitutes good sleep habits, a balanced lifestyle and good stress management techniques. Prevention of sleep disorders and preservation of good health in general requires regular exercise, healthy eating habits, and good sleep hygiene. Patients should be encouraged to seek medical attention early for sleep related problems to nip them in the bud.

The most common reasons people sleep poorly or do not get enough sleep include:
• Lack of awareness of the profound importance of sleep to physical and emotional wellbeing, so they do not prioritize sleep, or even take pride in sleeping very little.
• Failure to recognize sleep disorders as medical problems, so do not seek medical attention soon enough. Stress and unrecognized anxiety or depression are common reasons for inability to sleep.
• Lifestyle habits such as excessive caffeine and smoking, lack of exercise, working or exercising till late in the night, use of alcohol as a sleeping aid.

9. What constitutes a “good night’s sleep?” And how much sleep should an adult have each night?
A good night’s sleep is simply, one from which we wake up naturally (without an alarm clocks) feeling refreshed, without an overpowering need for a mid-day nap. Enough good quality sleep leaves us feeling refreshed and alert throughout the day, as well as able to function at peak mental performance.

Sleep needs vary with age. Newborn, infants, children and teenagers need more sleep than adults. In adults, sleep requirement ranges from 6-10 hours.

10. Please give some advice, tips on how a person can have a good night’s sleep?
Good “Sleep Hygiene” refers to the basic “rules” for good sleep, an essential part of sleep education every patient needs to know:
1. Try to go to bed and wake up at around the same time. Our sleep-wake patterns are regulated by an internal “clock” which dictates when we feel sleepy. We are usually sleepiest at bedtime, and again sometime in the mid-afternoon. This internal clock runs in an approximately 24 hour cycle, in a regular manner. People who have good sleep habits are well synchronized with their internal clocks, and fall to sleep and wake up like clockwork. When our daily (social, occupational) lives are in-synch with our internal body clocks, we tend to function best. People who routinely vary their sleep-wake times, like shift workers, tend to have poorer quality sleep, and sleep less overall than others. When our daily life schedules are nicely synchronized with our internal clocks, we will naturally sleep better. If we keep changing our sleep and wake times, there is desynchronization (ie our internal clock being out-of-synch with the external environment) which is stressful for our bodies, and not conducive to good sleep.

2. If you already have difficulty falling to sleep, do not lie in bed tossing and turning indefinitely, watching the clock. If you keep doing this, your mind and body become “conditioned” to struggle with sleep every night in the same manner, and will associate the bedroom with stress and reinforce the difficulty with sleep. In order to “break” this conditioning, you should make it a point to get out of bed if you are unable to sleep within 15 to 20 minutes. You should leave the bedroom and go somewhere else to do something relaxing, such as reading, listening to music. You should only return to bed when you are sleepy again, however long it takes. You need to develop the reverse conditioning, whereby you associate the bedroom with sleepiness and sleep, so that you will fall asleep readily when you go to bed.

3. Following on the above, the bedroom should ideally be a place only for sleep and sexual activity. If you have a problem with insomnia, you should not read, watch TV or work in bed. Associating the bed with other types of activities, especially if they are stimulating, will make it harder to fall asleep.

4. Avoid caffeine and stimulating activities close to bedtime. Caffeine can stay in your body for over 10 hours, and can affect sleep because it is a stimulant. People with problems sleeping should not drink caffeinated beverages from after 12 noon, or at night. Smoking and alcohol should also be avoided close to bedtime. Stimulating activities such as vigorous exercise, intense work and exciting or violent TV programmes should be avoided close to bedtime. The higher our level of arousal at bedtime, the harder it is to fall asleep. However sleepy and tired we are, this can be counteracted by high levels of arousal, resulting in difficulty falling asleep;

5. Long afternoon naps make it difficult for us to fall asleep at night and should be avoided. Our ability to sleep is related to our sleep “drive” which builds throughout the day in proportion to how long we stay awake. So the longer we stay awake, the sleepier we get. If we blunt this drive to sleep by taking a long afternoon nap, we may have difficulty falling asleep at night. People who lack sufficient sleep may benefit from a short nap in the afternoon to refresh them, but those who have difficulty falling asleep in general should avoid daytime naps.

6. A daily ritual to help us relax at the end of the day is a good lead-up to falling asleep easily. This can take the form of a warm bath, dimming the lights, reading quietly, soft music or just about any pleasurable activity that is something you look forward to at the end of the day. If we can learn to wind down after a day of stresses, our natural sleep drive which has built up over the day of wakefulness takes over, and allows us to fall asleep.

1. What are the statistics of Singaporeans who have trouble sleeping?
We do not have formal statistics, but about 10-30% of the general population may experience insomnia, with 5-15% severe enough to cause daytime impairment.

2. What are the statistics of Singaporeans who do not sleep enough each night?
Again there are no formal statistics in local adults, but inadequate sleep (less than 6-8 hours routinely) inadults is probably common. In our local survey of sleep among teenagers, as many as 80% of Singaporean adolescents were not getting enough sleep on weekdays routinely.

3. What is the ideal number of hours of sleep one should be getting?
In adults the normal range is between 7-9 hours, children and teenagers need much more sleep routinely, for example an infant may need up to 15 hours of sleep daily, while a primary school child will need 9-11 hours daily.

4. Is there a difference between men and women, and the amount ofsleep they should get?
No there is no gender difference regarding sleep requirement.

5. Why is sleeping well so important to our overall wellbeing? Andwhat happens to our body when we fall asleep (ie. is it repairing itselflike our skin repairs itself while rest)?
Sleep deprivation is associated with increased mortality, as well as increased risk of medical conditions like heart disease, depression and metabolic abnormalities. Lack of sleep affects our daytime performance in tasks requiring attention and vigilance, and increases risk of motor vehicle and industrial accidents. Sleep is a period of rest and restoration for the mind and body, and vital to our physical and emotional health.

6. Reports have also said that lack of sleep can lead to manyhealth problems. What are some of these health problems and how does the lack of sleep lead to them?
Lack of sleep is a stressful state for the body, and is associated with depression in the long term, increased cardiovascular disease, metabolic problems like diabetes, and higher mortality.

7. What constitutes good sleep or sleeping well?
Good sleep is sleep which is refreshing. A reliable indicator of adequate good quality sleep is waking up naturally feeling refreshed, and without excessive daytime sleepiness in the mid-afternoon.

8. What can you do to help yourself fall asleep faster?
Avoid the use of stimulants such as caffeinated beverages, mentally activating pursuits such as work, or heavy physical exertion such as vigorous exercise close to bedtime. A relaxing bedtime routine which helps winding down before bedtime is also helpful, comprising soothing activities such as reading, listening to music.

9. What can you do to help yourself sleep better?
Follow good sleep hygiene instructions:Sleep Hygiene Instruction:
1. Sleep-wake Schedule: Go to bed and get up at about the same time every night and morning respectively, including weekends. Try to have a regular schedule of going to bed and waking up. This will help you to anchor your circadian (“biological”) clock and establish a consistent rhythm of sleep.

2. Stimulus Control: Go to bed only when you are feeling sleepy. If you are not asleep after 20 minutes, then get out of the bed and engage in a relaxing activity like light reading. Go back to bed only when you feel sleepy again.

3. Food & Drink: Avoid heavy meals within two hours of bedtime. Try not to go to bed hungry either. Avoid fluids close to bedtime to prevent awakening to go to the toilet. Avoid caffeine after lunch and using alcohol as a sleep aid. Limit caffeine use to one or two beverages a day.

4. Bedtime Routine: Establish a relaxing pre-sleep routine while getting ready to go to bed, eg. reading, listening to music. Set time aside to relax and practise natural relaxation techniques, eg. deep breathing, progressive muscle relaxation.

5. Napping: Avoid taking long daytime naps unless you are sleep deprived. Afternoon naps, if taken, should not exceed 20 to 30 minutes.

6. Exercise: Regular physical exercise is encouraged but vigorous physical activity should be avoided too close to bedtime. Do not engage in vigorous exercise four hours before sleep.

10. Is it better to find natural remedies (like using aromatherapy oils etc.) or take medication to help yourself sleep better?
Natural sleep remedies like behavioural changes (good sleep hygiene) are good long term solutions for chronic insomnia. The use of medications should be directed by a physician and is generally limited to short term and intermittent use. In general the specific cause of the insomnia needs to be determined before any course of therapy is recommended. “Natural” remedies like melatonin, Valerian, suanzaoren may have limited effectiveness, but many have no evidence base for robust benefit. Caution should be exercised when taking over-the-counter sleep aids of unproven benefit because unlicensed supplements do not fall under strict safety regulations for their manufacture.

11. What are some things you should avoid doing or eating if you want to get a restful sleep that night?
Activities not conducive to good sleep:
• Highly variable morning wake times and bedtimes
• Excessive time in bed
• Frequent and long daytime napping
• Routine use of substances near bedtime which disrupt sleep, eg. caffeine, alcohol and nicotine
• Late night exercise or other stimulating physical activity too close to bedtime
• Mentally stimulating or emotionally upsetting activity too close to bedtime, eg. working, excessive worrying, thinking, planning, computer games, stimulating television shows
• Using the bed for activities unrelated to sleep, eg. watching TV, reading, eating, studying
• Failure to maintain an environment conducive to sleep, eg. uncomfortable bed or room temperature, too much light or noise

12. Is taking power naps during the day beneficial to how we function?
Yes, anyone who is sleep deprived will benefit from a refreshing short nap at mid-afternoon to catch up on lost sleep. Repaying this sleep debt will enhance our mental function and performance in tasks if we are sleep deprived.

13. How long should a power nap be? When does it become too long?
About 20-30 minutes should be enough. Anything longer than 30-60minutes may affect that night’s sleep, unless the person is extremely sleep deprived.

14. Why do our parents tell us to count sheep in order to fall asleep? Does this even work or help?
Counting sheep is just one way to distract our minds from worrisome thoughts which may be preventing sleep. This may be effective for some people.

15. Ok, you’ve counted sheep, you’ve had a warm bath, you’ve drunkwarm milk etc. but you still can’t fall asleep. So should you still stayin bed, tossing and turning, or should you do something else?
No, you should get out of bed if unable to fall asleep within 15-20 minutes and do something else which is relaxing, preferably in a dark and quiet environment outside of the bedroom. Tossing and turning in bed fosters and perpetuates anxiety toward sleep, and in the long term leads to “learned” or conditioned insomnia.

16. When it comes to picking the right bed or tools (ie. blanket,bedsheet, pillow etc.) for a well rested sleep, what are some things you should take into consideration? Should your room even be a certain temperature to help you feel more at ease, thus helping you fall asleep faster?
The bedroom environment is entirely a matter of personal preference. The temperature, bedding, lighting, quietness etc should be whatever the person prefers that is specific to their personal comfort, and conducive to their sleep.

17. With the recession happening around us, are there more people losing sleep? How can these people try to cope with their restless sleep or even insomnia?
Yes, the stress of the recession has led to an increase in patients with sleeping difficulty. Such people may develop anxiety and depression, which disturb sleep. They should seek medical attention sooner rather than later. Antidepressants or anti-anxiety medication may be appropriate. The longer the insomnia is untreated, or improperly self-medicated inappropriately with sleeping pills, the harder the insomnia is to treat. Long term use of sleeping pills also leads to worse problems of addiction and withdrawal.

18. When do you know you need to seek medical and professional help in coping with your lack of or inability to sleep (ie. how serious should your sleep problem be)?
You should seek medical attention when the sleep disturbance lasts longer than 1-2 weeks, and has begun to affect your daytime performance in school or work, or has had negative impact on your relationships

19. Is dreaming an important part of sleeping well?
Yes, dreaming is a part of normal sleep.

20. If I can remember my dreams when I wake, was my sleep considered a well rested one?
Remembering one’s dreams simply means that you probably have woken up during a dream sleep cycle, it does not necessarily indicate that your sleep was good or bad.

1. How many hours of sleep is the optimum and why?
Normal adults generally require between 6 to 10 hours of sleep, with about 7 to 8 hours a night being the average. Generally, we become tired and sleepy after about 16 hours of continued wakefulness. Sleep is believed to be a time for rest, repair and restoration of the body, as well as for consolidation of learning and memory. People who do not get enough sleep long term will suffer the consequences, such as sleepiness, impaired attention and concentration, increased risk of accidents, medical problems (eg. increased risk of heart disease, depression, obesity and diabetes) and shortened life-span.

2. When in the morning is the best time to wake up and why?
It is best to wake up naturally in the morning, when we have had enough sleep. When we wake up is governed by our body clock. It is different for different people. Morning “larks” may fall asleep early (eg. at 9pm) and wake up early eg. at 5am. Night “owls” may fall asleep late (eg. 3am), and wake up late (eg. 11am). The wake time should be relatively stable, and follows the internal clock in the brain which determines the time when the body naturally wakes up, but can be affected by external factors (such as setting the alarm clock to be woken up early). A stable wake time helps to anchor our body clock, which leads to a more regular and constant wake (and falling asleep) time, which is most healthy for our bodies.

3. When in the night is the best time to go to bed?
Again this is different for different people, some are morning larks, others night owls and many are somewhere in between. For adults, the usual sleep times are around 10pm to 12midnight. The optimal sleep time is between sunset and sunrise, following our natural body clock, and keeping a regular sleep-wake cycle which fits into our daily work/school/social schedule would be ideal.

4. At what time in the day are we at our most alert or most productive?
We are generally most alert and productive in the late morning, and again in the late afternoon.

5. At what time in the day are we most sluggish or least productive?
We are least alert in the mid-afternoon, and late at night right around our usual bedtime.

6. At what time in the day are we at our highest mood levels?
People who are depressed tend to have better mood in the late afternoon and evening, and are lowest in mood during the morning.

7. Why do we feel sleepy between 1 to 2pm?
The “mid-afternoon dip” in alertness is a natural phenomenon – our body clock (which also regulates sleep-wake times, body temperature, hormonal secretions etc) regulates our level of alertness throughout the day. Generally we tend to be least alert (or most sleepy) in the mid-afternoon and around bedtime.

“I get at least seven to eight hours sleep every night. I dream throughout my sleep and wake up feeling unrefreshed and I tire easily. Do I have a case of chronic fatigue? What should I do?”

Waking up unrefreshed is one form of insomnia. What happens usually is that our sleep is disrupted by recurrent arousals and we are prevented from entering a deep, refreshing state of sleep. Obstructive sleep apnoea (OSA) (a sleep related breathing disturbance due to blockage of the air passages during sleep) and depression are some common causes for recurrent awakenings.

Excessive and disturbing dreams are a relatively uncommon and less well understood cause of disturbed sleep. They can be caused by certain medications, related to sleep or psychological disorders.

Chronic fatigue syndrome is a condition in which there is persistent unexplained fatigue, and may be associated with symptoms such as muscle pains, headaches and disturbed sleep. It should not be considered as the definitive diagnosis unless other causes of tiredness (such as hormonal disturbances, depression) and unrefreshing sleep have been ruled out. Usually a comprehensive medical evaluation by a physician is required. In selected cases, investigations such as a sleep study may be needed to assess the quality of sleep, and identify any possible causes of sleep disruption.

Generally, for most adults, seven to eight hours of sleep is adequate. If you are experiencing tiredness despite sleeping seven to eight hours, you should seek medical attention. Your family physician will be able to guide you, and if necessary refer you to a Sleep Disorders Clinic for a comprehensive evaluation. Specific treatment will depend on an accurate diagnosis and directed toward the cause of your sleep problems.

1. Why do we dream?
Dreaming has no well understood function though there are several theories as to why we dream. For example dreaming may be a time during which we sort through information which we have received throughout the day, a process during which memory and learning are consolidated. Some people consider dreams to contain spiritual meaning, such as prophecy. Another once popular psychological theory (Sigmund Freud) suggested that dreams reflect repressed unconscious conflicts. Conversely, dreaming may simply reflect trivial day to day concerns, without deeper meaning. Overall much more work is needed in the field of Sleep Medicine to understand the process of dreaming.

2. Why do we have nightmares?
Nightmares are disturbances of dreaming which involve negative emotions such as fear or terror, with themes such as being attacked or pursued. Nightmares occur during Rapid Eye Movement (REM) sleep, and are more common in childhood (5-30% of children); decreasing through adolescence and young adulthood (2-5% of young adults). Some studies suggest that certain psychological factors are associated with nightmares, such as previous traumatic experiences or dysfunctional coping strategies. Nightmares have also been associated with certain types of medication such as blood pressure lowering drugs and antidepressants.

3. Who do dreams feel so real?
We spend about 20-25% of our total sleep time dreaming (about 2 hours), with most vivid dreaming occurring during rapid eye movement (REM) sleep. The content of dreams tends to vary between individuals but generally reflects one’s concerns and interests in daily life during wakefulness. Intensity of dreaming is associated with emotional arousal. We tend to remember our dreams if woken during dream sleep, and dreams can seem very vivid and real if they relate closely to our waking experiences or emotional stressors.

4. Why do nightmares feel so terrible?
Nightmares are dreams with vivid and disturbing content. They can feel “terrible” because they are associated with awakening, agitation, rapid heartbeat, sweating, and feelings of fear and agitation.

5. What happens in the body and brain when we dream?
Dreaming occurs during sleep, in both REM and non-REM phases of sleep, when the body is generally undergoes rest and restoration. Exactly how and why we dream is not well understood.

6. What happens in the body and brain when we have a nightmare?
Nightmares are frightening dreams which occur during REM sleep, and are associated with arousal, increased heartbeat and breathing rates. The content of nightmares is often threatening, and there may be vivid recall of the bad dream, with accompanying intense fear and anxiety.

7. When someone sleepwalks, is that considered as dreaming? Why? Is it a good idea to wake them up and why?
Sleepwalking is a disorder of arousal, which is considered an abnormal behaviour in non-REM sleep, as opposed to dreaming which is part of normal sleep which can occur either in REM or non-REM sleep. Sleepwalking occurs more commonly in children during deep sleep, at a young age when their brains are not fully mature, during which time they are able to initiate complex behaviours while in a state of altered consciousness, yet are not fully awake. The person may appear to be doing something purposeful, or even seem to talk, but usually they are confused, disoriented and are very difficult to arouse. Sleep deprivation, or other sleep disorders like obstructive sleep apnoea, may trigger abnormal behaviours such as sleep walking. Trying to wake the child who is sleepwalking is generally unhelpful. The sleepwalker can simply be guided into bed without waking them up. Sleep walking is a benign and self-limited condition for which no specific treatment is needed, except for advice to keep the bedroom environment secure (to avoid injury to self and to others) and to avoid triggering factors such as sleep deprivation, by getting enough sleep on a regular basis. If there is a suspected underlying sleep disorder, a sleep study may be needed, and appropriate therapy given.

8. Why do we sleep-talk? What causes it? Who is susceptible to sleep-talking?
Sleep talking may occur with other abnormal behaviours in sleep like sleepwalking. It can occur spontaneously or be elicited by talking to the sleeper. Sometimes sleep talking can be triggered by emotional stress, physical illness and primary sleep disorders which cause partial arousal such as obstructive sleep apnoea (OSA) (blockage of air passages during sleep). Sleep talking is generally harmless and does not require specific treatment, though it can be disturbing to bed partners and family members if it is very loud.

9. Is it good or bad to rouse someone from a nightmare? If yes or no, why?
Children who are having nightmares (which occur in REM sleep) can generally be easily roused, unlike sleepwalking which occurs in deep sleep from which it is difficult to arouse someone. A child with nightmares can be more easily awoken, comforted and helped back to sleep.

10. What activities or foods can lead one to dream and why? Eating cheese or too much is said to lead to nightmares. Is it true? If yes or no, why?
While many classes of drugs and alcohol can trigger nightmares and bizarre dreams, there is no well studied association between specific food triggers and dreaming. How drugs/other substances alter dreaming is unclear, but may be related to alteration in the brain chemistry (“neurotransmitters”) induced by drugs and food.

11. Who (in terms of age, gender and race) is most susceptible to dreams or nightmares? Why?
Dreaming is a normal phenomenon which occurs in all age groups. Nightmares are more frequent in childhood, and in female adolescents and young adults. Nightmares have also been reported to occur more frequently among alcoholics.

12. Can we do anything to prevent dreaming? If yes or no, why?
Dreams are considered normal phenomena, so are generally not a medical issue which necessitates prevention as such. Nightmares may reflect psychological disturbances, so may require psychological evaluation.

13. When a child wakes up from a nightmare, what can parents do to reassure him that it is not real?
Most of the time, simply waking the child and giving physical (eg. hugging) and emotional (calming their anxiety) reassurance may be all that is needed. If the nightmares are frequent and severe, there may be unresolved underlying conflicts or unidentified medical issues, for which a specialist (eg. paediatrician, Sleep physician, psychiatrist) consultation may be needed.

14. Some people say that they can control what happens in their dreams. Is that true?
Dreams occurs during sleep which is a transient state of unresponsiveness during which there is no conscious act of will, so a claim of being able to “control” one’s dreams would seem unlikely.

15. What are possible interpretations for the following common dream scenarios eg. falling or being stuck in one place and unable to move?
Dreams may reflect a person’s daytime pre-occupation, stressors or concerns. Interpretation of dreams has no well established scientific basis, so any attempt to do so is speculative. Psychological theories abound, such as falling representing insecurity or anxiety. Others have invoked spiritual meaning to dreams. Dreaming of being stuck and unable to move may represent a well known phenomenon called “sleep paralysis” which is a transient state of paralysis which occurs during sleep-wake transitional periods in some normal people, and in a rare primary sleep disorder known as “narcolepsy”.

SLEEPWALKING

1. One in how many Singaporeans sleepwalk?
There are no formal statistics on this in Singapore. Many sleepwalkers are children whose parents may not bring them to doctors if the problem is mild. In local sleep clinics, young adult patients are most commonly referred for sleep walking behaviours from the pool of young men recruited to national service, the majority of which are mild ie. occasional events which have not caused any injury to self or others. Internationally sleep walking has been reported to occur in 1-15% of the population.

2. Which age group does sleepwalking affect the most?
Sleep walking occurs most commonly in childhood, and decreases through adolescence, and is uncommon in adults. It usually starts between the ages of 4-8 years, but can begin anytime after the child learns to walk.

3. What do they usually do when they sleepwalk? Do they do potentially dangerous things?
Sleep walking behaviour occurs out of deep sleep, and can be as simple as sitting up in bed, to complex automatic behaviours such as wandering about the house, opening doors and eating. Patients may be agitated, violent and aggressive, and injury can occur during the sleep walking episodes. For example they may wander out of the house into the streets where there is traffic, or run about in a clumsy and uncoordinated manner, putting themselves at risk of injury. Although their eyes may be open and sleep walkers may appear awake, the brain is actually in deep sleep. They are difficult to awaken from this state. If aroused, they are usually confused and disoriented.

4. Are they aware they are in danger? Do they remember the incident when they wake up?
No, sleep walking occurs in a state of partial arousal from deep sleep. Therefore they are not aware that they are in danger, and patients usually have no memory of the event the next day.

5. What should family members do when they see someone sleepwalking? What precautions should they take?
Family members should not try to wake the sleep walker because this tends to prolong the event. They can simply try to guide the sleep walker back to bed. Overall the family should ensure that the bedroom and home environment is safe so that self-injury can be minimized. Doors and windows should be locked so that the sleep walker does not accidentally leave the house or jump out of an open window. Since sleep deprivation can trigger a sleep walking episode, sleep walkers should be encouraged to get enough sleep as a general rule.

6. What treatment they should seek?
Sleep walking behaviours occur when there are specific triggers (such as sleep deprivation, fever, noise) or in the presence of sleep disorders which interrupt deep sleep (such as obstructive sleep apnoea, urinary problems). The complex behaviours seen in sleep walkers must also be differentiated from night-time seizures, which are treated with medications used for epilepsy. Sometimes a sleep study is needed, which involves recording the brain wave activity, breathing and limb movements, as well as video-recording. This allows doctors to make an accurate diagnosis and plan treatment accordingly. The general rule of sleep walking management is establishing good sleep habits and keeping the environment safe to prevent injury as much as possible, Intervention during the episode should be minimal, because this may prolong the episode. Alarm systems can be installed to alert caregivers to an episode of sleep walking. Sleep walkers should be encouraged to get enough sleep and take daytime naps if needed. Emptying the bladder before bedtime and limiting fluids at night is helpful. Any fevers should be treated with the appropriate medication. Behavioural training is used in milder cases without self-injury. In severe cases which are frequent and associated with injury, drugs which sedate the patient and relax muscles can be used. These need to be closely supervised by a physician

1. How susceptible are sleep disorders among elderly population? How prevalent is it?
The elderly are more prone to sleep disturbances because there is a natural decline in sleep quality with age. Older people also tend to be on more medication which can affect normal sleep. With age, there is also an increasing prevalence of primary sleep disorders like obstructive sleep apnoea (OSA) (difficulty with breathing in sleep due to blockage of the upper air passage) and restless legs syndrome; as well as other conditions which can disturb sleep, like Parkinson’s disease, stroke and dementia. Certain other conditions like depression and anxiety also may occur more frequently with increasing age, associated with changes such as menopause, retirement, bereavement and other losses. The most common sleep related disorders in general are OSA, which affects 5 to 15% of the population, and insomnia (difficulty initiating and maintaining sleep) which affects between 10 to 30% of people to varying degrees of severity.

2. What are the top sleep disorders among the elderly population? And why do elderly people experience these sleep problems?
The most common sleep disorders locally among the elderly are insomnia related to underlying medical or psychological conditions and OSA. Common neurological conditions like stroke and Parkinson’s disease (PD) are associated with sleep disturbances, because the parts of the brain which control normal sleep are also affected by these conditions. Sometimes the medication used to treat these conditions can also affect sleep. For example, PD drugs can cause both insomnia and sleepiness. Anxiety and depression are frequent causes of insomnia among the elderly, with common associated factors being the onset of illness (eg. stroke), loss of independent function, or relationship difficulties within the family. OSA in older patients is related to weight gain, and changes in the normal breathing mechanism as we age. Multiple medication use in elderly is another frequent cause of sleep disturbance. There is a long list of drugs which affect sleep, including antidepressants, PD drugs, steroids etc.

3. Are sleep problems part of the ageing process? What could be some underlying medical conditions or other reasons that could affect an elderly person’s sleep?
Sleep quality declines with age, so that a person may appear to sleep less, often going to bed and waking up earlier. The body’s natural “sleep hormone”, melatonin, also declines with age. A person who has worked in the same shift work job for decades since young may develop insomnia as they grow older in the same job, because they tolerate changing shifts less well than in the past. Menopause in women is associated with insomnia, related to declining hormone levels, mood changes and physical symptoms like hot flashes. Overall elderly people have more propensity to develop sleep disturbances because they have more medical problems which also affect sleep, as well as take more medications which affect sleep.

4. I understand that poor quality and lack of sleep can cause a lag in focus and lapses in memory. With elderly people who may be at risk of dementia, how can caregivers recognise the differences between a sleep disorder and dementia?
Dementia is a neurodegenerative condition in which there is a gradual decline in intellectual functions including memory. This can be associated with sleep disturbances because the parts of the brain which control normal sleep are also damaged. Patients with dementia will usually have a noticeable drop in mental functioning before they develop sleep disturbances. Conversely, the lack of good quality sleep or sleep deprivation as a cause of poor focus and memory should be evident by taking a history from the patient ie simply asking them how soundly they sleep regularly. Focus and memory problems associated with profound lack of sleep can be reversed by improving sleep quality and quantity. Dementia is a slow but progressive state of decline, which is not reversible, and in the most common forms (eg. Alzheimer’s disease) are not curable. It may not be easy for a caregiver to make a distinction. Usually a doctor will be able to make the diagnosis of dementia based on the pattern of mental decline, and investigations such as blood tests and brain scans (eg. MRI, PET). Generally caregivers should ensure that the patient gets good quality and adequate sleep regularly, and if there is any disturbance in the normal sleep pattern which is unexplained or prolonged, they should seek medical attention.

1. How do you define insomnia?
Insomnia is defined as difficulty falling asleep, difficulty staying asleep, or a perception of unrefreshing sleep.

2. When is a patient diagnosed with insomnia?
Insomnia is a symptom of an underlying disorder, rather than a diagnosis. Once a patient reports difficulty falling or staying asleep, or feeling unrefreshed in spite of getting enough sleep, this is called “insomnia”. The diagnosis of the cause of the insomnia then has to be determined, and specific therapy given for whatever that cause is. For example, insomnia due to anxiety is treated with medication and other therapies for anxiety.

3. Are there different types of insomnia, and if so what are they?
Yes, there are several types of insomnia, which can be acute or sudden in onset, or chronic and of longstanding. There are many causes of insomnia, with the most common forms being “Adjustment Insomnia”, “Psychophysiological Insomnia” and “Insomnia Related to Depression or Anxiety”. Adjustment or acute insomnia is that which is associated with an identifiable acute stressor, such as relationship problems, work stress, bereavement or moving to a new location. It usually lasts a few days to a few weeks, and may resolve when the underlying stress is resolved. Psychophysiological insomnia is also known as “conditioned insomnia” or “learned insomnia”. People who have this are predisposed to developing insomnia (eg. habitual light sleepers, those with an anxious overconcern for health), having a physiologically heightened arousal state. Usually there is a precipitating event, usually a stressor of some kind. What follows is the development of learned behaviours not conducive to sleep, such as tossing and turning in bed for hours, watching the clock, excessive consumption of caffeine to stay alert in the daytime, and overconcern about the inability to sleep. Such patients have a state of “hypervigilance” at bedtime, and often describe themselves as having a “racing mind”, or an “active mind which cannot be switched off”, typically describing being filled with all manner of trivial thoughts. People with an anxious predisposition may go on from acute insomnia to develop longer term psychophysiological insomnia. Insomnia can also be a presenting symptom of depression or anxiety. Anxious patients may describe being unable to fall asleep at night, and feeling tense and worried in the daytime about many things. Depressed patients may report early morning awakenings or difficulty staying asleep, with recurrent awakenings. Depressed patients may report a range of symptoms such as low energy, lethargy, poor appetite, lack of interest in activities of daily living, social withdrawal, excessive rumination and in severe cases, suicidal thoughts.

4. Does personality type predispose a person to insomnia?
Personality types which predispose patients to psychological disorders like depression and anxiety (eg. Melancholic, perfectionistic) may be more prone to insomnia. Older people, women, those with psychiatric disorders, patients with medical conditions on multiple medications or suffering discomfort (eg. pain) and those who do shift work or travel long distances frequently (ie. have jet lag) are most vulnerable to developing insomnia. People with poor sleep-related habits are also more prone to having difficulty with sleep, such as excessive consumption of caffeine, smoking, late-night exercise, late night eating, long afternoon naps, irregular sleep-wake times and working till late at night.

5. In your experience, do patients with insomnia tend to fit a certain profile?
(eg. High stress job, middle-aged men?)
Insomnia affects both men and women, usually related to stress, anxiety or depression. People who have an anxious disposition – who tend to worry excessively, and those regularly overwhelmed by stress may report sleeping difficulties more frequently. People who are depressed or have heavy work or family responsibilities also may have sleeping difficulties.

6. Is insomnia genetic? For example, if your parents have insomnia are you more likely to suffer from insomnia too?
Conditions such as psychophysiological insomnia, depression, anxiety, and a range of sleep disorders (eg. restless legs syndrome, obstructive sleep apnoea) – all of which can cause insomnia – do run in families. So yes, if your parents have one of these conditions and insomnia, you may also be more likely to have the same.

7. What are the health risks related to chronic insomnia?
Chronic insomnia leading to sleep deprivation affects alertness the following day, with daytime sleepiness and increased risk of accidents (eg. driving, operating machinery on the job) being an immediate consequence. This impaired mental function, with diminished attention and vigilance, leads to poorer school and work performance. The brain is most immediately and severely impacted by sleep loss. Over time, there are physical health consequences as well. These include increased risk of heart disease, weight gain, tendency to develop diabetes, depression, and ultimately a shorter lifespan. In children and adolescents, lack of sleep impairs normal growth and development, leads to behavioural disturbances and more mood disorders like depression.

8. How does a patient with insomnia decide which treatment is right for him (drugs, herbs, therapy etc)? And which should he try first?
The treatment of insomnia depends on the diagnosis. So the first step is to make the correct diagnosis of the cause of the insomnia. This should be done by a physician. People should avoid self-diagnosis and self-medication, because this can lead to the correct diagnosis being missed, and if this continues for a long time, the outcomes are poorer, and secondary problems may arise – such as developing poor sleep habits, and addiction to sleeping pills – which may occur if the patient “doctor hops” and goes from clinic to clinic collecting sleeping pills instead of having the problem thoroughly analysed and the correct treatment given. The specific type of treatment in persistent insomnia should decided by the doctor. Medication can be helpful, though behavioural changes are the most healthy and natural long term. Anxious and depressed patients can improve with antidepressants. Sleeping pills can be useful in the short-term in patients who have acute/adjustment insomnia. Doctors need to monitor the use of sleeping pills closely because of the risk of addiction. Psychological intervention is also helpful. Depressed patients, for example can benefit from “talk therapy” during which they are given the opportunity to discuss their concerns, and receive guidance. “Cognitive-Behavioural Therapy (CBT)” is a well-established psychological method which is helpful for psychophysiological insomnia. CBT usually takes the form of several weekly sessions during which patients are taught about good sleep promoting habits, natural relaxation techniques (eg. progressive muscle relaxation, visual imagery) and their misperceptions about sleep addressed and corrected.

9. I haven’t been sleeping well for the past few days. At what point should Isee a doctor?
People should seek medical attention if their insomnia lasts for more than 1 to 2 weeks. It needs to be emphasized that insomnia is merely a symptom (and not by itself a diagnosis) for which an accurate diagnosis must be determined. The treatment is aimed at correcting the underlying cause. Patients should not self-medicate and shop around for sleeping pills which are not a “cure-all” for insomnia. Such sleeping pills are only to be used for no more than 2-4 weeks, under the direction of a physician, for certain types of insomnia.

10. How do you decide when a patient is “cured”?
A patient is cured when he can sleep naturally without the aid of drugs, and has good sleep habits – getting enough sleep, waking up refreshed and feeling alert throughout the day.

11. In your opinion, what is the most effective cure for insomnia?
The most effective and safest long term methods to improve insomnia include practising healthy sleep habits (”good sleep hygiene”) and regular exercise which promotes deep sleep. These, in combination with an accurate diagnosis, appropriate treatment of the underlying cause of insomnia, and short term use of sleeping aids if needed under the supervision of a doctor are effective ways to manage insomnia.

12. Are there patients who just cannot be cured of their insomnia?
The patients who cannot be “cured” are generally those who have not been correctly diagnosed (and therefore the true cause of their insomnia is unrecognized and untreated), those who have an intractable addiction to sleeping pills (addictions which are hard to break), and those who are unable or unwilling to make lifestyle changes (eg. start an exercise programme, or change the lifestyle habits which disturb sleep) which would help their sleep.

13. How long does it take (on average) for a patient to be cured of their insomnia?
The longer the patient has suffered insomnia without getting the appropriate diagnosis or treatment, and the longer the patient has been addicted to sleeping pills, the harder it becomes to cure the insomnia. On average it takes a few weeks of practising lifestyle changes to effect a real change, it also takes a few weeks before antidepressants make take full effect. Generally one can anticipate improvement in 2-4 weeks, complete “cure” is possible if the motivation to do whatever it takes to recover is strong, and the ability to embrace lifestyle changes and comply with medication guidelines is high. Like regular exercise, practising good sleep hygiene is a choice which involves a combination of awareness, desire to change and discipline in taking action.

14. What does a sleep disorders clinic offer? And who is it targeted at?
Sleep clinics are targeted at anyone with sleep disorders severe enough to impair their work or school performance, or family life. Sleep Clinics offer comprehensive evaluation of sleep related symptoms, including diagnosis, testing (eg. with sleep studies) and treatment of the entire range of sleep disorders, encompassing insomnia, conditions causing excessive daytime sleepiness, circadian rhythm disorders and abnormal behaviours in sleep.

1. How much sleep is considered too much?
Normal adults usually require 7 to 8 hours of sleep a night, though the duration ranges from about 6 to 10 hours overall. Some people referred to as “long sleepers” require more than the usual amounts of sleep, in excess of 10 hours a day, but this is extremely rare. Such people may sleep for long hours in excess of 10 hours a day, but feel fresh if they get the daily amount of sleep they need. Excessive sleep is considered to be abnormal if a person feels sleepy all the time, in spite of getting at least 8-10 hours of sleep daily. Usually the excessive daytime sleepiness affects school or work performance, or results in accidents while driving or operating other machinery.

2. What are some health problems that can be associated with having too much sleep?
Sleeping too much has been linked to increased risk of diseases like diabetes, obesity and heart disease, and ultimately increased mortality. However this link is not well understood, and may be related to “oversleeping” as a symptom of an underlying associated but undiagnosed conditions such as sleep apnoea (which is also associated with diabetes, obesity and heart disease, as well as depression) and depression. Generally, anyone who sleeps excessively, and still feels tired should be screened for the presence of primary sleep disorders and the presence of these medical conditions. People who sleep a lot and still feel sleepy usually have a sleep disorder which causes them to have poor quality sleep ie. sleep is not deep or refreshing. Such people have light, restless sleep, with frequent awakenings, and wake up unrefreshed. Therefore no matter how much they sleep, they are sleepy all the time, and doze off easily. The most common sleep disorder which leads to excessive daytime sleepiness is obstructive sleep apnoea (OSA), a condition in which there is blockage of the air passage during sleep, which manifests as snoring, unrefreshing sleep and excessive daytime sleepiness. OSA is associated with a range of common diseases like high blood pressure, heart disease, stroke and depression. A less common cause of excessive sleeping is depression. While most depressed patients present with insomnia and loss of appetite, a minority with “atypical depression” may present with eating and sleeping too much. Anyone who sleeps a lot and still feels tired all the time should consult their physician to rule out any health issues which may be underlying.

3. How is it that the human body is only conditioned to have a certain amount of sleep?
Precisely how and why we sleep is not well understood. Sleep is generally regarded as a time for rest and restoration of the body, and is regulated by sleep-wake centres in the brain, as well as a circadian or biological clock which is also located in the brain, in what is known as the suprachiasmatic nucleus. This “clock” determines when we feel sleepy, and ensures that normal adult sleepers wake up around the same time each day, feeling refreshed after 7 to 9 hours of sleep. Newborn babies require much more sleep, about double or up to 17 hours of sleep daily. This requirement decreases through childhood (9 to 11 hours) and adolescence (8 to 10 hours) and stabilizes on average to 7 to 9 hours in adulthood. All these sleep functions are regulated by the brain to ensure that the body gets the rest it needs.

1. Do women have more trouble falling asleep than men?
Yes, women more commonly present with insomnia (ie. difficulty falling or staying asleep) than men. This is partly because psychological conditions like depression and anxiety, common disorders associated with insomnia, are also more common in women. Women also exclusively undergo states such as pregnancy and menopause, 2 conditions also frequently associated with sleep disturbance.

2. How common are sleeping disorders among Singaporean women?
It is estimated that sleeping disorders like insomnia affect up to 30% of the general population, with women being more affected than men in general by difficulty falling or staying asleep.

3. Has the problem worsened over the years, and what sort of reasons contribute to this problem?
Sleep related problems have generally increased over the years, for many reasons. As society becomes more hectic, fast paced and complex – with increasing use of social media and availability of 24 hour services, people appear to be sleeping less and less. Sleep deprivation, which is chronic and voluntary, is probably one of the most common sleep related problems, so much so as to constitute a “silent epidemic”. There is a general lack of awareness of the health risks of lack of sleep long term, which has led to chronic sleep deprivation being a widespread yet unrecognized public health issue. Insomnia, which refers to the difficulty falling or staying asleep, or a perception of unrefreshing sleep, is most often related to psychological states of high arousal, such as when one has too much “stress”, is depressed or anxious. Insomnia is an increasingly frequent problem as stress levels rise, and people get more depressed and anxious. Excessive daytime sleepiness is commonly caused by obstructive sleep apnoea (OSA), which refers to the disruption of breathing in sleep caused by blockage to one’s upper air passage. OSA is associated with obesity which is also rising in frequency.

4. What effect does sleep deprivation have on our brain? Or rather, what’s the relationship between sleep and our brains?
Sleep deprivation affects alertness most immediately, with daytime sleepiness and increased risk of accidents (eg. driving, operating machinery on the job) being an immediate consequence. This impaired mental function, with diminished attention and vigilance, leads to poorer school and work performance. The brain is most immediately and severely impacted by sleep loss. Lack of sleep affects memory, learning and our functioning in tasks which involve vigilance. Over time, there are physical health consequences as well. These include increased risk of heart disease, weight gain, tendency to develop diabetes, depression, and ultimately a shorter lifespan. In children and adolescents, lack of sleep impairs normal growth and development, leads to behavioural disturbances and mood disorders like depression.

5. What should we do to keep our brain in tip-top condition?
Getting enough sleep on a regular basis is one of the most important requisites for optimal brain functioning. The brain also needs a balanced diet, as nutritional deficiencies (eg. lack of vitamins and other nutrients) can affect the nerve cell functioning. The brain also requires both physical and mental “exercise”. Regular robust physical exercise helps promote deep sleep, and also improves emotional wellbeing. Mental activity includes continued learning which involves both sides of the brain ie in diverse subjects as language, science, creative arts like music, dance, art etc. Activities which engage both our physical and mental faculties simultaneously, such as dancing are especially beneficial for the brain, because they involve moving the body, and learning/memory such as remembering intricate sequences of dance steps.

6. What about the foods that we eat? How much impact do they have over our brain health?
Caffeinated beverages tend to be alerting and can stay in our system for up to 10-12 hours. So coffee, tea and colas should not be consumed too close to bedtime, and should be avoided in people who already have difficulty sleeping. Alcohol also disrupts sleep and should not be used as a sleeping aid. Smoking, while perceived to be “relaxing” by smoker, has zero health benefits, disturbs sleep and is to be discouraged. Foods otherwise do not have a major direct impact on sleep. In general, a balanced diet which is replete with essential nutrients (ie. fats, proteins, carbohydrates, vitamins, minerals and trace elements) for normal brain function is important.

7. New mums tend to sacrifice sleep to care for their newborns. How can they make up for the lack of sleep?
People who do not get enough sleep can try to “catch up” as much as possible by eg. taking an afternoon nap, going to bed earlier the next day, or sleeping in on weekends. For sleep deprived people with busy schedules, any appropriate opportunity to catch up on lost sleep should be seized upon by taking catnaps whenever possible.

8. Some tips on keeping our brain active?
We can keep our brain active by making the effort to learn new things. Interesting examples are learning to dance, play a musical instrument, sports which develop balance and coordination. Other stimulating tasks include learning a new language, reading, writing, travelling, social interaction and taking up a hobby which interests you.

9. With Singaporeans being such workaholics, could you share any advice for helping “switch off” from work mode?
People who work for excessively long hours may do so of necessity or simply be uninformed about the physical and emotional health risks of chronic stress, sacrificing sleep and lacking a healthy balance in life. Often work is regarded by the workaholic as a “virtue”, when in fact the undue focus on work may actually mask problems in other aspects of a person’s life. The risk of working too hard and failing to develop a balanced approach to life is burnout and increased susceptibility to physical and emotional stress related problems like hypertension, heart disease, depression, anxiety etc. In fact nearly all commonly recognized medical conditions are made worse by chronic unremitting stress, lack of sleep and lack of exercise, all of which are typical for workaholics. General advice for workaholics is to become aware of the problem and take corrective action and make time for selfcare.

10. Have there been any studies on the sleep patterns of new mothers? Or even mothers in general?
Yes there have been a few studies looking at sleep patterns of new mothers. These studies using a combination of questionnaires and sleep monitors found that new mothers had more sleep disruption in the 1st month after delivery than during the last month of pregnancy. Mothers tended to have worse sleep disturbance than Fathers, getting less sleep at night, and more in sleep in the daytime compared to Fathers.

About 30% of mothers have sleep disruption after the birth of their baby, with more frequent awakenings at night. They also tend to sleep later in the morning, and take naps to compensate, so that the total sleep is not much decreased. Sleep studies in new mothers show greater deep sleep, and reduced light sleep, which may be due to hormonal changes.

Fatigue is another related problem after delivery, especially for first-time mothers. This is attributed partly to sleep disturbances, as well as social factors like family responsibilities and returning to work.

11. In what way can having a newborn affect the amount and quality of sleep of new mothers?
New mothers’ sleep is affected by breastfeeding and sleeping in close proximity with the newborn. Women who breastfeed have been found to have more wake time in the night. Bed sharing or sleeping in the same room as an infant is associated with poorer sleep for mothers, who experience less deep sleep, more light sleep and more frequent arousals from sleep. This is because newborns have short sleep cycles, and may require frequent feedings, and this awakens the mother. Even after this phase is over, mothers may still not be able to return to normal sleeping through the night because they have learned to be very light sleepers, and are very prone to recurrent awakenings.

12. What are the effects of sleep deprivation on a new mum?
Sleep deprivation has its greatest impact on brain function in general. The most obvious consequence of sleep deprivation is daytime sleepiness. Microsleep episodes lasting up to 10 seconds have been shown to occur in healthy human volunteers who are severely sleep deprived. Lack of sleep is also associated with worse performance, especially in tasks involving vigilance. Sleep deprivation may worsen mood and increase the risk of post-partum depression. Overall, sleep deprivation causes daytime sleepiness which may result in motor vehicle or industrial accidents (eg. from falling asleep at the wheel or on the job), poorer work performance and cause mood disturbances, all of which negatively impact on relationships and quality of life.

13. What factors can improve the sleep of a new mum?　Is it even possible to have any sort of sleep routine if you have a new baby? Can you recommend some steps to better sleep for a new mum? Please suggest tips and practical things she can do.

1) Minimize Sleep Debt (ie. try to get as much sleep as possible). A study of first time mothers vs. experienced mothers showed that the experienced ones got an extra 45 minutes to an hour of sleep each night:
• Plan, schedule and prioritize sleep
• First-time mothers should plan for sleep the same way they schedule their lives
• Sleep whenever possible, take daytime naps (“power naps”)

2) Put a nightlight in the bathroom instead of turning on the light to use the bathroom — this will be less arousing and help you return to sleep more quickly

3) Physical: Sleep on the side, decrease fluid intake at bedtime to reduce the number of awakenings to go to the bathroom.

4) Heartburn: Sleep with head elevated on pillows, avoid late night eating (eg.spicy , acidic foods)

5) Keep the bedroom comfortable: Quiet, dark and at the right temperature

General good sleep habits are:
(1) Have a standard relaxing bedtime routine, to wind down at the end of a busy day.
(2) Keep regular sleep-wake times whenever possible.
(3) Exercise: Exercise regularly, finishing at least 3 hours before bedtime. Exercise promotes deep sleep and is good for relief of stress.
(3) Avoid caffeine, nicotine, and alcohol before bedtime, which disturb sleep (breastfeeding mothers should not consume substances which may be harmful to their newborn anyway).

14. Have you seen many patients who are sleep-deprived new mothers? If so, can you give figures? If new mothers are having sleep problems, are they likely to seek help? Why?
Not many patients who are new mothers are referred to a Sleep Clinic. These patients are not routinely referred to sleep specialists for treatment, and are probably managed by their obstetricians and family doctors. Sleep disorders are generally overlooked by both lay people and healthcare professionals, and the significant toll of untreated sleep disturbances is not well recognized, adding to this problem. Untreated sleep related problems like chronic sleep deprivation, insomnia and sleep apnoea may lead to increased risk of major illnesses like hypertension, diabetes, heart disease, stroke, depression, obesity, attention deficit and behavioural problems in children, and decreased mortality. It seems likely that if more people were aware of the consequences of sleep disruption, they would seek medical attention more frequently.