To sleep, perchance to … sleep better

Over many years, I had the honor of teaching other healthcare staff about the urgent care of patients. One of the very special aspects of urgent and emergent care is the team approach to the management of the patient. Because patient flow can be so fast, and decisions at times have to be made so quickly, it is critical that every member of the healthcare team stay aware, watch each other and work together to provide all that is needed. I wouldn’t even dare to try and count how many times a nurse approached me and said that “Mr. X is not looking well, his vital signs are becoming erratic and he needs an immediate assessment”. This collegial environment, based on mutual respect of all members of the healthcare team, is critical to the welfare of the individual being treated.

As part of the initial assessment of the patient in such a high paced environment, it is essential to ask pointed questions that identify higher versus lower risk patients. Both when I taught nursing staff and other physicians, I would state and then restate the significance of getting a sleep history. Very simply, I emphasized the need to ask the patient how he or she had been sleeping over the previous period of time. If in fact the sleeping pattern was erratic, I then told the staff to delve into this point. Was the patient not sleeping due to stress at work, or due to an illness and so on. The obvious question is why I was so focused on this one specific aspect of the patient’s behavior. Clearly, there are many other questions that should be even more important when trying to assess the patient’s state of illness.

Sleep is a fascinating physiological process which is far more than simply physically resting our bodies. A person can lie in bed an entire day, yet still need to sleep. There is a tremendous amount of neurophysiological research that has been done on sleep. There is a general consensus that the purpose of sleep is to allow the brain to reset itself. However, it is definitely not yet clear if this is some type of chemical reset, or the physical need to form new connections within the brain, or some other totally different process. It is known that a person denied sleep can literally reach a state of psychosis, becoming totally out of control, hallucinatory and dangerous to others as well as him or herself. Therefore, despite our lack of understanding of the true function of sleep, we definitely must respect it.

A person who manages to sleep well is usually not in any acute danger. Contrarily, sleep difficulties may very well be a general but critical warning sign of present or impending illness. That is why a sleep history can quickly help physicians determine the acuity of a patient’s complaint.

Problems with sleep are actually a very common cause of visits to a physician. Whatever the cause, the patient may present to the doctor with the very simple complaint that their sleep is disturbed and thus they are unable to properly function. One way of categorizing problems with sleep is to divide them into two general groups.

One group of sleep problems would be related to a clear disease process. For example, a patient with congestive heart failure may often wake up in the middle of the night  coughing, due to the collection of fluid in the lungs. Patients who suffer from chronic pain may very well be woken up multiple times over the course of the night. I should point out that night time is in fact one of the worst times for patients with chronic pain. Generally speaking, there are far fewer distractions than there are during the day, and the result is an enhanced perception of the pain. It literally can be hell on earth.

The second group of sleep problems could be classified as “primary insomnia”. What this means is that a person struggles with achieving a full, restful and proper night’s sleep for no apparent reason. The patient does not have a disease process that wakes them in the middle of the night. There are no medications being taken that have a known side effect of interrupting sleep. These individuals can become horribly frustrated by their inability to sleep. The psychological strain on them can dramatically reduce their productivity and can definitely interfere with their normal emotional state. Unless such individuals find a solution, chronic insomnia can literally destroy their lives.

When a patient tells a doctor that he or she suffers from insomnia, it is in many ways similar to complaining of back pain. While the physician recognizes that the complaint is extremely disturbing to the patient, more often than not, classical medicine has little to offer in the way of a fix. For back pain, it is possible to prescribe a wide range of painkillers. The patient is then often referred to an orthopedist and/or physiotherapist for further evaluation. Even if the back sufferer undergoes surgery, this still may not solve the problem. And thus the patient is left with the pain and possibly very depressed. Similarly, insomnia may be secondary to a whole variety of reasons that are very difficult to pin down. Rather than do an extensive workup, including potentially  a full psychological evaluation, it is far easier to simply give the patient a sleep aid.

Such medications, that enhance sleep, are by no means a panacea. They are medications like every other, which means that they have side effects and may potentially be addictive. If a clear reason for the insomnia is determined, then the medications can be given for short period of time until the insomnia resolves. But if the medications are used on a long-term basis without any attempt to find an alternative management of the insomnia, the patient may eventually be left in a worse situation than before.

Modern technologists are aware of the need for a non-pharmaceutical solutions to sleep problems. As it turns out, there are a number of ways to affect brain function and sleep activity, without any direct physical contact with the patient. Auditory and visual stimuli can have a profound effect on the way in which the brain functions. There are groups of developers presently looking into the possibility of using such stimuli to trigger better sleep. I personally hope that these groups of technologists and researchers succeed in developing the digital version of the mythological “Sirens”, who would charm people by their song, and lull them to sleep. The developers of such technologies have access to tools like PET-CTs and MRIs that allow them to literally observe how the brain responds, in real time, to various stimuli. Hopefully, with this kind of information, the time will soon be when a restful sleep is only a short Siren’s song away.

Thanks for listening.