Patient Education

Caffeine is found naturally in over 60 plants including the coffee bean, tea leaf, kola nut, and cacao pod. People all over the world consume caffeine each day in coffee, tea, cocoa, chocolate, energy drinks and some soft drinks. Caffeine is also found in some drugs and supplements. There is no nutritional need for caffeine in the diet. Caffeine is a central nervous system stimulant. Its main effect on the body is to make you feel more alert and awake for a while. Because it is a stimulant, most people consume it after waking up in the morning and to stay alert and awake throughout the day. Caffeine cannot replace sleep but it can make us feel more alert by blocking sleep-inducing chemicals in the brain and by increasing adrenaline production.

How long do the effects of caffeine last? 
Caffeine enters the blood stream though the stomach and small intestine. It can have a stimulating effect as soon as 15 minutes after it is consumed. It peaks in about one hour. Once in the body, the caffeine persists for several hours.

How much is too much caffeine? 
Moderate amounts of caffeine are not thought to be a health risk for adults. This is described as 200 – 400 mg of caffeine per day or about 1 to 3 eight ounce cups of coffee. Over 500 mg of daily caffeine is felt to be excessive.

Caffeine is not recommended for children. It can have a negative impact on nutrition when chocolate and soft drinks replace more nutrient filled foods. It can also either add unneeded calories or suppress appetite. Teenagers should have limited amounts in their diets and be taught about the caffeine content in energy drinks.

Effects of Caffeine 
Caffeine changes the way your brain and body work and can:

• Make it hard to fall asleep, stay asleep, or get a good night's sleep.
• Make you jittery and shaky.
• Make your heart beat faster or cause an uneven heartbeat.
• Raise your blood pressure.
• Cause headaches, nervousness and/or dizziness.
• Have a dehydrating effect, especially after exercising.

Tolerance 
If you drink caffeine regularly to help you stay awake and focused, you will likely find that you need increasing amounts to get the same effects. This occurs because your body is building a tolerance to caffeine.

Sensitivity 
Some people are very sensitive to the effects of caffeine. It takes small amounts to feel the effects and they may last much longer than expected.

Sleeping Problems 
If you are having difficulty getting to sleep, staying asleep or having a good night's sleep, focusing on and adjusting your caffeine intake may be very helpful. At first it may seem hard to break the cycle of not feeling rested and having large amounts of caffeine to "keep going."

Helpful Steps 
In order to limit or reduce the amount of caffeine, you need to first know how much you are consuming.

• Check into the foods and drinks that you regularly have and the amount of caffeine they contain. The amount of caffeine can vary in different coffee and tea preparations.
• Caffeine may be in certain foods or drinks that you do not expect such as non-cola soft drinks.
• Measure the number of ounces in the cup or glass that you usually use or order. Most contain more than 8 ounces, which is equal to one cup.
• Check the medications, including over-the-counter, you take to see if they contain caffeine.

You can decrease your amount of caffeine in several ways:

• Limit the number of cups you drink.
• Alternate your caffeinated drinks with water.
• Change to drinks with less caffeine – tea and soft drinks usually contain less caffeine than coffee.
• Choose a time of day to stop having caffeine and make this time earlier in the day over time.

Withdrawal 
Depending upon how much caffeine you take in and your body's sensitivity to it, you may have withdrawal symptoms if you cut back quickly or abruptly cut out caffeine. The most common symptoms are headache, fatigue and muscle pain.

Take time to cut back on your amount over several days or longer. Some people find that they need to cut out all or almost all of their caffeine to avoid problems with sleep.

Talk with your healthcare provider if you have questions or concerns about the effects of caffeine or about your sleep.

While newborns start life sleeping 16 to 18 hours, the amount of sleep decreases over the years. Preschool-aged children need 11 to 12 hours and school-aged children need about 10 to 11 hours of sleep.

Despite this important need, bedtime and sleep can be a challenge for children and parents. Most often, feeling afraid of the dark or of being alone makes falling asleep difficult for some children.

Guidelines for Parents 
Starting in the toddler and preschool years, use these guidelines to help your child develop good sleep habits.

• Be consistent with bedtime.
• Do not let your child sleep in the same bed with you.
• Set up a calming routine for bedtime – bathing, reading a story or listening to quiet music.
• Allow your child to take a favorite thing to bed, but make certain it is safe from choking hazards such as buttons, ribbons, loose parts, or leaking stuffing.
• Make certain your child is comfortable but don't let needs such as a drink of water extend the bedtime routine longer than 30 minutes.
• Don't return to your child's room every time he complains or calls out. Instead:
  • Wait several seconds to let your child know you are there and make your response time longer each time.
  • If you do need to go into the room, don't turn on the light or stay too long. Use a quiet calming voice.
  • Remind your child each time that it is time to go to sleep.

As your child grows older you can include a quick pick-up of toys or books before bedtime. You can also allow your child to read alone for a set amount of time. Remember that scary books and electronic devices are stimulating and need to be avoided.

Children may need a night light or the door cracked open to feel secure. Try to have their room as dark as possible for sleep and brightly lit in the morning. This helps cue the body for sleep and wakefulness.

Never give your child medication (over-the-counter or prescription) for sleep. Always talk with your child's doctor.

Nightmares and Night Terrors 
Children can have nightmares at any age. These usually occur during the second half of the night when dreaming is most intense. Children may wake up crying and feeling afraid. When this happens:

• Go to your child quickly and assure him that you are there and won't let anything harm him.
• Encourage your child to talk about what happened in the dream and remind him that dreams are not real.
• Once your child is ready, encourage him to go back to sleep.

Night terrors are different from nightmares and are most common in toddlers and preschoolers. They happen during the deepest sleep, which is usually early in the night. During a night terror, your child may:

• Cry uncontrollably or scream.
• Shake, breathe fast or sweat.
• Thrash about or kick.
• Look confused or glassy eyed.
• Not recognize who you are.
• Try to push you away.

Night terrors are scary for parents but it is important to stay calm. Don't try to wake your child. Make certain your child can't hurt himself – gently keep him in bed if he tries to get out.

Most night terrors last a short time and your child will fall right back to sleep. In fact, he was not actually awake and will not remember it.

Sleep Diary 
Keep a sleep diary for 1 – 2 weeks if you are concerned about your child's sleep habits. Track:

• When your child sleeps.
• How much sleep he normally gets.
• What he needs to fall asleep (favorite toy or blanket).
• How long it takes for him to fall asleep.
• How often he wakes up during the night.
• What you do to comfort and console when he wakes up.
• Time and length of naps.
• Any changes or stresses in the home.

Bring the sleep diary with you when you talk with your child's doctor. You may also want to write down any questions or concerns you have about your child's sleep.

Keep in mind that sleep problems are very common. With time and guidance from your child's healthcare team, you and your child will work through sleep problems.

GERD (Gastroesophageal Reflux Disease) occurs when stomach contents flow back up into the esophagus – the tube that carries food and liquids. The muscle at the base of the esophagus should keep the stomach contents from backing up, but when it is relaxed, weakened, or damaged it is not able to stop the backflow of fluid. This backflow is called reflux.

Occasional reflux, also called acid reflux because the stomach juices contain acid, is common. When the stomach acid touches the lining of the esophagus, it can cause heartburn or acid indigestion. This is an uncomfortable burning in the mid-chest behind the breastbone or the upper abdomen.

When reflux or heartburn occurs more than twice a week for a few weeks it could be GERD – gastroesophageal reflux disease.

Symptoms of GERD 
Besides reflux or heartburn, symptoms of GERD may include:

• Nausea, vomiting
• Dry, chronic cough
• Sore throat
• Hoarseness
• Wheezing
• Trouble or pain with swallowing

Diagnosis 
Over time GERD can lead to more serious health problems so it is important to see your doctor if you think you may have it. Your doctor may want to order some testing and/or refer you to a gastroenterologist – a doctor who treats diseases of the digestive tract.

Treatment 
Often your doctor may first suggest you try reducing your symptoms by making these lifestyle changes:

• Limit or avoid these foods and drinks that cause the muscle in the lower esophagus to relax:
  • Chocolate
  • Coffee
  • Peppermint - including candy and gum
  • Greasy or spicy foods
  • Tomato based foods and drinks
  • Citrus fruit and juices
  • Alcohol
  • Carbonated drinks
• Eat slowly and eat smaller meals.
• Do not lie down for 2 to 3 hours after eating.
• Losing weight if needed.
• Wearing looser fitting clothing around the waist.
• Raising the head of the bed 6 to 8 inches by placing wood blocks under the bedposts. (Extra pillows will not help.)

Medications to treat GERD are available both over-the-counter and by prescription. These include:

• Antacids like Maalox®, Mylanta® and Alka-Seltzer®.
• H2 blockers such as cimetidine (Tagamet®), famotidine (Pepcid®) and ranitidine (Zantac®), which decrease acid production.
• PPIs (proton pump inhibitors) include omeprazole (Prilosec®) and esomeprazole (Nexium®) also block acid and can help heal the lining of the esophagus.

Other medications can also be prescribed as needed. Talk with your doctor or pharmacist about your questions and concerns.

Sometimes when severe GERD cannot be managed with lifestyle changes and medication, surgery is recommended.

Ongoing Care 
Your doctor will need to see you regularly to prevent or treat long term complications. Changes in the cells in the lining of the esophagus can lead to cancer. GERD can also affect swallowing and breathing. Pneumonia and asthma may occur.

GERD is seen in some people with sleep apnea. When there is a long pause in breathing with sleep apnea, the brain triggers the person to breathe through regaining muscle tone in the throat. As the person quickly pulls in air through the wind pipe (trachea), fluid in the stomach may travel up the esophagus sometimes reaching the wind pipe. The body responds by closing the airway to protect it from the stomach acid, which further stops breathing.

By making some changes and working with your doctor, you can have GERD managed. You will learn over time what seems to worsen your symptoms and what treatment works best for you.

Insomnia is a common sleep disorder. People with insomnia have problems getting to sleep and/or staying asleep. Most adults need about 7 – 9 hours of sleep each night. Some people are fine with less than 7 hours per night while others need more sleep. The quality of sleep is important.

Symptoms

When you have insomnia, you may:

• Lie awake for a long time before falling asleep.
• Sleep for short amounts of time – waking up often during the night.
• Be awake for much of the night.
• Wake up too early.
• Feel like you haven't slept at all.

Because of this you may:

• Be sleepy or drowsy during the day.
• Have a lack of energy.
• Feel anxious, irritable or depressed.
• Have trouble focusing, paying attention, learning and remembering.

These symptoms can impact how you perform during the day – both at work and home. Insomnia may also affect your relationships with family and friends. Daytime sleepiness is a major safety concern for driving.

Types and Causes

Insomnia is divided into types based on the cause of the insomnia.

Primary Insomnia 
The cause of primary insomnia is not well understood. It can be triggered by long term stress, change in work shift, or travel. Once these are resolved, the insomnia may not go away. It may persist due to habits that have been formed such a naps, going to bed early and worrying about sleeping.

Secondary Insomnia 
This type of insomnia is due to a side effect or a symptom of another condition. These include:

• Emotional disorders such as anxiety, depression, and post-traumatic stress disorder (PTSD).
• Neurological diseases like Alzheimer's and Parkinson's
• Medical conditions including:
  • An overactive thyroid
  • Heartburn or other gastro-intestinal problems
  • Asthma
  • Long-term pain with arthritis or headaches
• Menopause or peri-menopause
• Other sleep-related disorders such as restless leg syndrome or breathing problems
• Substances that contain caffeine, nicotine or other stimulants.
• Alcohol or sedatives.
• A side effect of certain medicines such as some asthma, allergy and cold medications.

Diagnosis and Tests

If insomnia is affecting your daily life, talk with your doctor. Your doctor will do a physical exam. He or she will discuss your health conditions, medicines and symptoms with you. You may be asked to keep a diary about your sleep patterns - when and how long you sleep, how long it takes to get to sleep and how often you wake up.

If your doctor feels your insomnia may be related to another sleep disorder, a sleep study may also be ordered.

Treatment

Medication for sleep is not intended for long term use and does have side effects. If your doctor prescribes sleep medicine, be sure to ask about the side effects.

Over the counter medicines for sleep are available without a prescription, but consult your doctor before taking them. These are also not to be taken long term.

Supplements like melatonin are advertised for sleep treatment. Studies have not shown that they are effective or the long-term effects of using them. Talk with your doctor before you use one of these supplements.

Lifestyle Changes & Sleep Habits
These lifestyle changes can improve your sleep:

• Avoid caffeine and nicotine.
• Avoid naps. If you do take one, limit it to 5-20 minutes and don't take it after 3pm.
• Being active during the day and exercising regularly are helpful, but don't exercise too late in the day.
• Go to sleep and wake up at the same times each day – even on weekends
• Set a relaxing routine for going to sleep – take a warm bath or listen to soothing music.
• Avoid large meals and drinking a lot of fluids in the evening. Avoid drinking alcohol before bed.
• A light snack with dairy products (milk, cheese), or carbohydrates (crackers, cereal) or protein (turkey) 30-60 minutes before bedtime can hasten sleep. A small bowl of
• cereal or a small cheese or turkey sandwich is a good choice.
• Avoid using your computer or other electronics for 30-60 minutes before bed.

Making Your Bedroom Friendly for Sleep

• Keep your bedroom as quiet and dark as possible. A fan or other type of "white noise" may help. A cool room temperature is also helpful.
• Do not have a TV or radio on while trying to sleep. It is known that the light from the television will cause you to have less restful sleep. The noise from a TV or radio can cause brief awakening that you may not recall the next day.
• Do not watch TV or work in the bedroom. This can cause the brain to no longer associate the bedroom with sleeping. It is best not to have a TV in the bedroom.

Behavioral Therapy for sleep can be very effective. It focuses on learning ways to relax and not worry as much about sleep. You can also learn relaxation techniques such as focusing on breathing slowly and deeply and tightening and relaxing muscle groups in your body.

Dealing with insomnia can be challenging. Learning ways to improve your sleep and seeking the help you need are worth the effort.

Narcolepsy is a brain disorder that involves poor control of normal sleep-wake cycles. It is a long term condition that usually starts in the teens or early adult years. It affects males and females equally.

For adults, about 4 to 6 cycles occur during a night's sleep of 8 hours. The cycles are divided into Non-REM (non-rapid eye movement) and REM (rapid eye movement). When we fall asleep, we first enter a light stage of sleep and then progress into increasingly deeper stages. Non-REM sleep occurs in both light and deep sleep stages.

After about 90 minutes, we enter the first stage of REM sleep. This is the dreaming portion of sleep. Throughout the night we alternate between stages of REM and non-REM sleep.

For people with narcolepsy, sleep begins almost immediately with REM sleep following quickly and fragments of REM occurring involuntarily throughout the waking hours.

Symptoms

Excessive Daytime Sleepiness (EDS) is usually the first symptom to appear in people who have narcolepsy. The urge to sleep is so strong that someone who has narcolepsy is prone to fall asleep while talking, eating dinner, driving or at other times. A "sleep attack" usually lasts about 15 minutes and most often is followed by feeling refreshed. The sleepiness occurs in spite of a full night’s sleep and may persist throughout the day.

Cataplexy is a sudden loss of muscle tone that makes a person go limp or unable to move. It can be triggered by strong emotions such as laughter, surprise, or anger. Most attacks are very brief (less than 30 seconds) and can be missed, but they can last several minutes in severe cases. Cataplexy may involve all muscles resulting in collapse or only affect certain muscle groups and result in slurred speech, buckling of the knees, or weakness in the arms.

Dream-like hallucinations occur between wakefulness and sleep. They involve seeing and hearing and may be bizarre or frightening experiences.

Sleep paralysis involves not being able to move when falling asleep or waking up. It may last for a few seconds to several minutes.

Other symptoms include:

• Waking up often throughout the night
• Restlessness
• Nightmares
• Leg jerking

Not all people with narcolepsy have all of these symptoms. Despite common beliefs, people with narcolepsy do not sleep more than average. They sleep a normal amount but cannot control the timing of their sleep. The quality of their sleep during the night can be poor.

Causes

The exact cause of narcolepsy is unknown. In some patients, narcolepsy is linked to lower amounts of hypocretin, which is a protein made by the brain. It is not clear what causes the brain to make less hypocretin.

Although not frequent, narcolepsy can run in families. Certain genes are linked to narcolepsy. It may also possibly be an autoimmune disorder – the body's immune system mistakenly attacks healthy tissue.

Diagnosis

Narcolepsy is not rare but it is an under-recognized and under-diagnosed condition. People often endure years of sleepiness before seeking treatment. If you have any of the symptoms of narcolepsy, see your doctor.

Your doctor will do a physical exam and may order blood work to check for other conditions that may be causing your symptoms or to look for the narcolepsy gene. Tests may include:

• ECG (measures the heart's electrical activity)
• EEG (measures the brain's electrical activity)
• Sleep study (polysomnogram)
• Multiple Sleep Latency Test (MSLT) - measures how fast it takes to fall asleep during a daytime nap

Treatment

There is no known cure for narcolepsy. The goal of treatment is to control the symptoms.

Medication
Stimulants may be prescribed to help you stay awake during the day. These need to be taken as prescribed. Antidepressant medications can help reduce episodes of cataplexy, hallucinations, and sleep paralysis. Sometimes, medication to take at night is also prescribed.

Lifestyle Changes
These changes can help you during your work, school and social times:

• Eat light or vegetarian meals during the day. Avoid heavy meals before important activities.
• Plan naps to control daytime sleep and decrease the number of unplanned sleep attacks.
• Schedule a 10 – 14 minute nap after meals if possible.
• Talk with your teacher or supervisor about the condition so you are not punished for being sleepy at school or work.

Safety Measures
If you have narcolepsy, you may have driving restrictions. Check your state law. Take precautions with activities that could be dangerous if episodes occur.

Counseling
Living with narcolepsy can be challenging. Seeking counseling and learning ways to cope can be very helpful.

Research

Research is being done by various components of the National Institutes of Health (NIH):

• Neurological Disorders and Stroke (NINDS)
• National Heart, Lung, and Blood Institute (NHLBI)
• National Center on Sleep Disorders Research (NCSDR)

Studies are focused on better understanding the causes including genetic factors, developing new treatments to control symptoms, and eventually finding a cure.

For More Information

Talk with your doctor about your questions and concerns. You can also learn more at:

Brain
800-352-9424
www.ninds.nih.gov

Narcolepsy Network, Inc.
888-292-6522
www.narcolepsynetwork.org

National Sleep Foundation
703-243-1697
www.sleepfoundation.org

National Heart, Lung and Blood Institute (NHLBI)
301-592-8573
www.nhlbi.nih.gov

Restless Legs Syndrome (RLS) is a nervous system disorder that involves uncomfortable feelings in the legs and an almost uncontrollable urge to move them. It affects both men and women and can occur at any age (including childhood).

In many cases, the cause of RLS is not known. Restless leg syndrome may be related to another condition such as pregnancy, kidney failure, or low blood levels of iron, folate, or magnesium. Restless leg syndrome may run in families.

Symptoms

Feelings in the legs may be described as throbbing, tingling, burning or "creepy-crawly." Moving your legs may make the feeling go away for a few minutes, but it returns when you are still again. The symptoms can make sleeping difficult. Twitching in the legs can also occur as you go to sleep. Some people have periods – days to weeks – without symptoms.

Diagnosis

Talk to your doctor if you think you have RLS. You may want to keep a record of your symptoms to share with your doctor. Include when and how long the symptoms occur. Your doctor will examine you and may have blood drawn for lab tests.

Treatment

RLS is a usually long term condition with no known cure. Treatment is aimed at relieving symptoms and improving sleep.

Lifestyle Changes 
You can make changes in your lifestyle to help decrease your symptoms:

• Quit smoking. Talk with your doctor about this.
• Decrease your amounts of caffeine and alcohol.
• Exercise regularly but avoid vigorous exercise late in the day.
• Take a warm bath and/or massage your legs before bed.
• Apply warm or cool packs.
• Get enough sleep each night. Try to go to sleep and get up the same time each day.

Treatment may include a supplement if your symptoms are related to a deficiency such as iron. Medication for RLS may include muscle relaxants, opioids, and sedatives. Medications used to treat Parkinson's disease may help with twitching and tremors in the legs. Talk to your doctor about possible side effects. Sometimes more than one type of medication is needed. Your doctor may try several medications before finding the one that works best for you.

For more information and treatment ideas, visit the Willis-Ekbom Disease Foundation website at www.rls.org.

Research is being done to better understand RLS, improve diagnosis and treatment, and find ways to prevent it. Talk with your doctor about your questions and concerns.

Along with the physical changes that occur as we get older, changes to sleep patterns are a part of the normal aging process. This doesn't mean that poor sleep is a normal part of aging. Older adults continue to need about the same amount of sleep as younger adults – 7 to 9 hours each night. Learning about the changes and ways to deal with them is helpful.

Changes in Sleep Patterns 
There are two kinds of sleep – REM (rapid eye movement) sleep and non-REM sleep. We dream mostly during REM sleep and have the deepest, most refreshing sleep during non-REM sleep.

As people age, they spend less time in deep sleep, which may be why older people are often light sleepers. This can lead to a more fragmented sleep and feeling less rested.

Older adults often feel sleepier and go to bed earlier in the evening and get up earlier in the morning. These night time sleep changes may lead to napping during the day. Seniors and small children are the only 2 groups for whom it is OK to take daytime naps.

Other Factors 
Life events that change routines and involve stress or grief often affect sleep. These include:

• Retirement
• The death of a loved one
• Moving from a family home

Aging may result in other changes that impact sleep:

• Being ill or in pain
• Taking certain medications
• Having physical limitations

These can lead to spending less time outdoors and being less active, which also affect sleep.

Impact of Poor Sleep 
Poor sleep affects both physical and emotional health and wellbeing. It can lead to:

• Difficulty staying awake during the day, like when in church or driving a car.
• Being irritable.
• Having memory difficulties or trouble solving problems.
• Feeling depressed.
• Having more falls or accidents.

Improving your Sleep
There are ways to improve your sleep. Certain substances and habits can impede a good night's sleep. Things to avoid include:

• Caffeine in the late afternoon and evening hours.
• Nicotine within an hour of bedtime or if you awaken during the night.
• Alcohol near bedtime.
• Large meals and drinking a lot of fluids in the evening.
• Naps - if you do take one, limit it to 15-20 minutes and don't take it after 3pm.

Ways to help going to and staying asleep:

• Set a relaxing routine for going to sleep – take a warm but not hot bath or listen to soothing music.
• Try eating a light snack with dairy products (milk, cheese), carbohydrates (crackers, cereal), or protein (turkey) 30-60 minutes before bedtime. A small bowl of cereal or a small turkey or cheese sandwich is a good choice.
• Keep your bedroom as quiet and dark as possible. A fan or other type of "white noise" may help. A cool room temperature is also helpful.
• Do not have a TV, radio or other electronic devices on while trying to sleep. The light from a television will cause you to have less restful sleep, and noise from a TV or radio will cause brief awakenings that you won't recall the next day but will make you sleepy.
• Try relaxing your body by starting at your toes and slowly moving up your body. You can also try counting backward from 100 or thinking of things you find calming.

Safe Sleep
It is also important to be safe while sleeping or when getting up.

• Keep a telephone with emergency phone numbers by your bed.
• Have a lamp within reach that you can turn on easily.
• Put a glass of water next to the bed in case you wake up thirsty.
• Use a nightlight in the bathroom.
• Remove area rugs so you won’t trip if you get out of bed in the middle of the night.
• Never smoke in bed.
• Don’t use a heating pad in bed.

Talk to Your Doctor 
If you feel tired and are not able to do your normal activities or are having problems sleeping for more than a few weeks, see your doctor. Your doctor will do an exam, talk with you about your symptoms, review your medications and may order testing. Treatment for a sleep disorder or another health condition may be needed.

Sleep problems do not have to be part of your golden years.

Resources
To learn more:

American Academy of Sleep Medicine 
2510 North Frontage Road 
Darien, IL 60561 
1-630-737-9700

National Institute on Aging Information Center 
PO Box 8057 
Gaithersburg, MD 20898 
800-222-2225 
www.nia.nih.gov

Humans are programmed to sleep during the night and be awake during the day. Working night shift disrupts the normal sleep patterns and body rhythms. This results in problems sleeping during the day, which can lead to sleepiness at work. It's hard to concentrate and focus when you are sleepy and safety becomes an issue at work, at home and when driving. Errors, accidents, and injuries occur much more often. Mood and personal relationships can be affected.

There are ways to promote sleep during the day and wakefulness when working during the night.

Sleeping Well during the Day

• Do not over use caffeine and limit it to the first half of your shift. Avoid caffeine for at least 5 hours before you plan to go to sleep.
• Wear sunglasses before going outside to drive home so your brain doesn't signal your body that daytime is ahead.
• Set a routine – go to bed and get up at the same time each day. Schedule appointments outside of your sleep time.
• If you nap, keep them short; 10-15 minutes. Longer naps can make you groggy. A short nap late in the day before your night shift may be helpful.
• Don't do activities, exercise or run errands before going to sleep. These are stimulating and make sleep difficult.
• Do something relaxing before going to bed like taking a warm bath or shower.
• Don't drink alcohol before bed. It disturbs sleep patterns.
• Eat a light snack with milk, cheese or turkey. This may make you drowsy and help with staying asleep.
• Try wearing eye shades or ear plugs.
• Create a restful room:
  • Turn down the thermostat.
  • Block light with room darkening shades.
  • Use a white noise machine or a fan.
  • Turn off or unplug your phone and remind your family and friends not to call you during your sleep time.
  • Turn your radio and TV off.
  • Put a do not disturb sign on your door.

Staying Awake and Alert at Work
You may not be able to do all of these depending on the work you do, but try to:

• Talk with your coworkers.
• Keep your work area brightly lit.
• Take short breaks throughout your shift.
• Walk, exercise, climb stairs or go outside during your breaks.
• Eat healthy meals. Avoid overeating and fatty foods, which can lead to stomach upset and drowsiness.
• Night shift workers often hit their energy low point around 4 am so plan a break around that time and do something stimulating.
• Don't save your most tedious or boring work for the end of your shift when you are wearing out.

Driving Home Safely

• Take a 10-15 minute nap before leaving work to drive home.
• Playing loud music or having your car windows open is not certain to keep you awake. If you feel sleepy, pull over and rest with a brief nap.

For More Information
Talk to your doctor if you have questions or concerns about sleep issues and your health.

National Sleep Foundation
703-243-1697
www.sleepfoundation.org

National Heart, Lung and Blood Institute (NHLBI)
301-592-8573
www.nhlbi.nih.gov

Sleep apnea is a potentially serious disorder in which a person stops breathing for short amounts of time while sleeping. In medical terms this means that a patient will stop breathing for at least 10 seconds, 30 or more times, during 8 hours of sleep. Sleep apnea is more serious and easier to treat than you may think.

Consult a doctor if you experience or if your partner observes any of these signs of sleep apnea:

• Waking up tired
• Feeling sleepy in the daytime
• Having morning headaches
• Waking up often during the night
• Snoring loudly
• Being told you stop breathing while you sleep
• Waking up suddenly and gasping for air

Sleep apnea can have a significant impact on your health. This may include:

• Extreme daytime sleepiness
• Memory changes
• Loss of concentration
• Depression
• Irritability
• Weight gain

For some people, sleep apnea may even lead to:

• High or worsening blood pressure
• Heart attack or heart failure
• Stroke – you are 2 times more likely to have a stroke with untreated sleep apnea
• Difficulty controlling blood sugar levels if you have diabetes

Sleep apnea is a very treatable condition. The most common methods of treating it are:

• Continuous positive airway pressure – CPAP (SEE-pap): If you have moderate to severe sleep apnea, you may benefit from a CPAP machine that delivers air pressure through a mask placed over your nose while you sleep. The CPAP air pressure is high enough to keep your upper airway open to prevent snoring and sleep apnea.
• Surgery: Surgery for sleep apnea involves removing excess tissue from your nose or throat that may be blocking your upper airway and causing your sleep apnea.
• Losing weight
• Quitting smoking
• Avoiding alcohol and sleeping pills
• Sleeping on your side.

There are many more options you may discuss with your doctor.

Answer these questions to check your sleep apnea risk:

• Do you snore loudly or have you been told that your snoring is loud enough to disturb others? (Y/N)
• Do you snort or gasp in your sleep or does your snoring awaken you? (Y/N)
• Do you wake up throughout the night or constantly turn from side to side? (Y/N)
• Have you been told that you have “pauses” in your breathing or stop breathing during sleep? (Y/N)
• Do you have headaches in the morning? (Y/N)
• Do you awaken feeling not rested in the morning? (Y/N)
• Do you have trouble staying awake if you are not moving about such as at the computer, in meetings, during movies or when driving? (Y/N)

If you have answered yes to any or all of these questions, you could have sleep apnea. It is important that you tell your doctor about your symptoms. Protect your health.

Sleep is a vital part of staying healthy throughout our lives. Just as we need to nourish our bodies, we also need to allow them to rest. While there are some differences as we grow and age in our sleep needs and patterns, many of the factors that affect sleep and ways to improve sleep are similar.

Sleep Cycles
There are two kinds of sleep – REM (rapid eye movement) sleep and non-REM sleep. We dream mostly during REM sleep and have the deepest, most refreshing sleep during non-REM sleep.

Adults have about 4 to 6 cycles during an 8 hour night's sleep. The cycles are divided into Non-REM (non-rapid eye movement) and REM (rapid eye movement). When we fall asleep, we first enter a light stage of sleep and then progress into increasingly deeper stages. Non-REM sleep occurs in both light and deep sleep stages.

After about 90 minutes, we enter the first stage of REM sleep. This is the dreaming portion of sleep. Throughout the night we alternate between stages of REM and non-REM sleep.

The Body's Internal Clock
Our body has its own internal clock called the circadian rhythm. This controls wakefulness and sleepiness. It is much easier to go to sleep at certain times of the day – especially later in the evening if you work during the day.

Amount of Sleep
Newborns begin life sleeping about 16 to 18 hours. The amount of sleep we need decreases through childhood and the teenage years until we reach adulthood.

During our 20's the amount of sleep we need becomes set at a level that stays the same throughout the rest of our lives. The older we get though, the more likely roadblocks to getting a good night's sleep occur. These include such things as stress, medical problems, and medications.

Sleep needs vary even within life's stages so the following are average needs:

• Preschool-aged children: 11 - 12 Hours
• School-aged children: 10 -11 hours
• Teens: 9 hours
• Adults - including seniors: 7- 9 hours

Effects of Poor Sleep
No matter our stage of life, getting too little sleep or a poor quality of sleep has effects on our functioning during the day. It affects our ability to stay awake and makes it harder to focus and concentrate. These effects can lead to poor performance at school or work.

Safety is also affected. We are more prone to injuries and falling asleep while driving is a common cause of accidents. Poor sleep also worsens our mood, which can then impact our social, school and work lives.

Ways to Improve Sleep
There are certain things that you can do to improve sleep at any age.

• Get up and go to bed the same time each day. This helps strengthen your inner clock and your ability to fall asleep.
• Stay active during the day and include regular exercise.
• Avoid naps. Daytime naps are ok for small children and seniors. If you are ill, you may need extra rest during the day.
• Avoid activities and/or substances that are stimulating before bedtime. This can range from coffee and chocolate to scary books or movies. The lights from electronic devices are also stimulating and need to be avoided before bedtime.
• Set a relaxing routine for bedtime – bathing, reading, listening to music quietly are helpful ways to prepare your body for sleep.
• Make the bedroom sleep friendly. Keep the bedroom as quiet and dark as possible. A fan or other type of "white noise" may help. Make sure the room temperature is comfortable – cooler is often better.

Special Concerns - Life's Stages

Children
Bedtime and sleep can be a challenge for children and parents. Most often, feeling afraid of the dark or of being alone makes falling asleep difficult for some children. Starting in the toddler and preschool years, use these guidelines to help your child develop good sleep habits.

• Be consistent with bedtime.
• Do not let your child sleep in the same bed with you.
• Set up a calming routine for bedtime – bathing, reading a story or listening to quiet music.
• Allow your child to take a favorite thing to bed, but make certain it is safe from choking hazards such as buttons, ribbons, loose parts, or leaking stuffing.
• Make certain your child is comfortable but don't let needs such as a drink of water extend the bedtime routine longer than 30 minutes.
• Don't return to your child's room every time he complains or calls out. Instead:
  • ­Wait several seconds to let your child know you are there and make your response time longer each time
  • ­If you do need to go into the room, don't turn on the light or stay too long. Use a quiet calming voice.
  • ­Remind your child each time that it is time to go to sleep.

Children may need a night light or the door cracked open to feel secure. Try to have their room as dark as possible for sleep and brightly lit in the morning. This helps cue the body for sleep and wakefulness.

Never give your child medication (over-the-counter or prescription) for sleep. Always talk with your child's doctor.

Nightmares
Children can have nightmares at any age. These usually occur during the second half of the night when dreaming is most intense. Children may wake up crying and feeling afraid. When this happens:

• Go to your child quickly and assure him that you are there and won't let anything harm her.
• Encourage your child to talk about what happened in the dream and remind him that dreams are not real.
• Once your child is ready, encourage him to go back to sleep.

Night terrors
Night terrors are different from nightmares and are most common in toddlers and preschoolers. They happen during the deepest sleep, which is usually early in the night. During a night terror, your child may:

• Cry uncontrollably or scream.
• Shake, breathe fast or sweat.
• Thrash about or kick.
• Look confused or glassy eyed.
• Not recognize who you are.
• Try to push you away.

Night terrors are scary for parents but it is important to stay calm. Don't try to wake your child. Make certain your child can't hurt himself – gently keep him in bed if he tries to get out. Most night terrors last a short time and your child will fall right back to sleep. In fact, he was not actually awake and will not remember it.

Sleep Diary
Keep a sleep diary for 1 – 2 weeks if you are concerned about your child's sleep habits. Track:

• Where your child sleeps.
• How much sleep he normally gets.
• What he needs to fall asleep (favorite toy or blanket).
• How long it takes for him to fall asleep.
• How often he wakes up during the night.
• What you do to comfort and console when he wakes up.
• Time and length of naps.
• Any changes or stresses in the home.

Bring the sleep diary along and a list of your questions when you talk with your child's doctor. Keep in mind that sleep problems are very common. With time and guidance from your child's healthcare team, you and your child will work through sleep problems.

Teens

Lack of Enough Sleep
Many teens don't get enough sleep. They often stay up late and start the school day early. Recent studies have shown that the body's internal clock (called circadian rhythm) is reset during the teen years. This reset cues the teen's body to stay up later and sleep later. It may be due to the brain's hormone melatonin being produced later at night for teens than it is for children and adults. This can make it hard for teens to fall asleep early, but there are ways to fall asleep earlier and to improve sleep during the teen years. Allowing your mind and body to wind down before bedtime is a key to success. It is helpful to:

• Dim the lights as bedtime nears. Turn them off completely for sleep and turn bright lights on in the morning.
• Stick to a schedule. Try to go to bed and get up the same time each day – even on weekends. Plan ahead with activities and homework
• Avoid naps. Although a brief 30 minute nap after school may seem helpful, too much daytime sleep can make it harder to fall asleep at night.
• Limit the amount of caffeine you have throughout the day and stop having any several hours before bedtime.
• Have a relaxing routine before bed. Shower, read something soothing or do other relaxing activities. Do not do stimulating activities for 1 – 2 hours before bed. These include vigorous exercise, loud music, and using electronic devices like smart phones or readers.

Making these changes will help improve your sleep and have a positive effect during on your activities during the day. Talk with your doctor if you have questions about or abrupt changes in your sleep patterns.

Seniors

Changes in Sleep Patterns
Along with the physical changes that occur as we get older, changes to sleep patterns are a part of the normal aging process. As people age, they spend less time in deep sleep, which may be why older people are often light sleepers. This can lead to a more fragmented sleep and feeling less rested. This doesn't mean that poor sleep is a normal part of aging. Older adults continue to need about the same amount of sleep as younger adults – 7 to 9 hours each night.

Older adults often feel sleepier and go to bed earlier in the evening and get up earlier in the morning. These night time sleep changes may lead to napping during the day. If you do take a nap, limit it to 15-20 minutes and don't take it after 3pm.

Life events that change routines and involve stress or grief often affect sleep. These may include retirement, the death of a loved one or moving from a family home.

Aging may result in other changes that impact sleep such as being ill or in pain, taking certain medications, or having physical limitations. These can lead to spending less time outdoors and being less active, which also affect sleep. Poor sleep affects both physical and emotional health and wellbeing. It can lead to:

• Feeling depressed
• Having memory difficulties or trouble solving problems
• Having more falls or accidents.

Safety
It is also important to be safe while sleeping or when getting up.

• Keep a telephone with emergency phone numbers by your bed.
• Have a lamp within reach that you can turn on easily.
• Put a glass of water next to the bed in case you wake up thirsty.
• Use a nightlight in the bathroom.
• Remove area rugs so you won’t trip if you get out of bed in the middle of the night.
• Never smoke in bed.
• Don’t use a heating pad in bed.

Talk to Your Doctor
If you feel tired and are not able to do your normal activities or are having problems sleeping for more than a few weeks, see your doctor. Your doctor will do an exam, talk with you about your symptoms, review your medications and may order testing. Treatment for a sleep disorder or another health condition may be needed. Sleep problems do not have to be part of your golden years.

Resources
To learn more:

American Academy of Sleep Medicine
2510 North Frontage Road
Darien, IL 60561
1-630-737-9700
www.aasmnet.org

National Institute on Aging Information Center
PO Box 8057
Gaithersburg, MD 20898
800-222-2225
www.nia.nih.gov

Sleepwalking (somnambulism) is a disorder that occurs when people walk or do other activities while they are still asleep. It usually occurs during deep sleep early in the night – not during dream periods. Sleepwalking can occur at any age, but is more common in children ages 5 through 12 years than it is in adults. Sleepwalking appears to run in families.

Causes 
The cause of sleepwalking in children is usually not known. Factors that can be related to sleep walking include fatigue, lack of sleep and anxiety. In adults it can also be related to:

• Alcohol, sedatives or other medication
• Some medical conditions such as partial complex seizures
• Mental disorders

Symptoms 
Sleepwalking activity can range from sitting up and looking around, walking, going to the bathroom, getting dressed, or even driving a car – all while still sleeping. Episodes can be brief – a few seconds to minutes. Most episodes are less than 10 minutes, but they can last 30 minutes or longer. Symptoms include:

• Opening eyes during sleep
• Having a glassy-eyed or blank look on the face
• Sitting up and appearing awake during sleep
• Speaking or moving in a clumsy way
• Not remembering the episode after awakening

Treatment 
Most people do not need specific treatment for sleepwalking. It is common to think that you should not awaken a sleepwalker. This is not necessarily true. First try to redirect the person in a firm, loud (not yelling) voice. Try not to restrain or physically move the person. Some sleepwalkers have been known to lash out at the person touching them. If you do need to awaken the person, be aware that he/she may be very difficult to awaken and may be confused for a while. Most sleepwalkers go back to sleep quickly although it may be in a different place.

People can get hurt when sleep walking. If anyone in your home sleepwalks, safety measures need to be taken to prevent injuries. You may want to move cords or furniture out of the way. Stairs may need to be blocked with a gate. In severe cases, some medications have been known to change the sleepwalker's deep sleep enough that sleepwalking does not occur. Although treatment is not needed in most cases, talk with your healthcare provider if you have questions or concerns.

Snoring is very common in adults. It may not mean you have a serious health problem, but it can affect your sleep and that of your sleep-partner. The hoarse or loud sounds occur when your airway is partially blocked. When you fall asleep, the muscles in the roof of your mouth (soft palate), tongue and throat relax. The airflow causes the relaxed tissue – now partly blocking the airway – to vibrate and noise is made as the air comes in and out of the nose and/or mouth.

Causes 
The exact cause of snoring is not always known. Some things make snoring more likely to occur:

• Age – the tone of the tissue relaxes as we grow older.
• Anatomy changes – enlarged adenoids or tonsils, nasal polyps, deviated nasal septum (that separates the nostrils) may be the cause.
• Obesity – being overweight especially around the neck contributes to snoring.
• Alcohol use – alcohol is a potent muscle relaxer and drinking it in the evening may cause snoring.
• Sleep position – sleeping on your back leads to snoring in some people.
• Medication – muscle relaxants can result in snoring.

Measures to Reduce Snoring

• Sleep on your side instead of your back
• Try over-the-counter nasal strips.
• Limit your alcohol in the evenings.
• Raise the head of your bed about 4 inches.
• Lose weight if you are overweight.

See your doctor. 
If your snoring is disrupting your sleep or that of your sleep-partner, see your doctor. Your doctor may:

• Examine you.
• Ask you questions about your sleep patterns, daytime sleepiness, and any other symptoms.
• Review all of the medicines you are taking including over-the-counter ones.
• Order a sleep study if sleep apnea is suspected.
• Order X-rays, CAT scan or MRI to check the structure of your airway.
• Order one of many medical devices that can help keep your airway from collapsing, so your snoring may be reduced or eliminated.

Sleep Apnea 
If snoring includes loud snorts or gasps, it may be a sign of sleep apnea, a serious medical condition in which your airway collapses and prevents air from entering your lungs when you try to breathe. If sleep apnea is diagnosed, your doctor will prescribe treatment. The typical continuous, 'log-sawing' type of snoring is usually not a sign of sleep apnea and insurance does not cover treatments for just snoring. Talk with your doctor about any questions or concerns.

Getting the right amount of sleep is important at all ages. Most teens need about 9 hours sleep each night, but many don't get enough sleep. A lack of sleep and daytime alertness can impact performance in school and sports as well affecting mood and social interactions.

Teens have often been blamed for staying up late and their lack of sleep. Recent studies have shown that the body's internal clock (called circadian rhythm) is reset during the teen years. This cues the teen's body to stay up later and sleep later. This may be due to the brain's hormone melatonin being produced later at night for teens than it is for children and adults. This can make it hard to fall asleep early.

Early start times in some schools may play a part in lost sleep. Teens who fall asleep later may get only 6 or 7 hours of sleep. Over time this results in a noticeable sleep deficit, which leads to drowsiness, poor focus and problems with concentration and coordination.

There are ways to fall asleep earlier and to improve sleep during the teen years. Allowing your mind and body to wind down before bedtime is a key to success. It is helpful to:

• Dim the lights as bedtime nears. Turn them off completely for sleep and turn bright lights on in the morning.
• Stick to a schedule. Try to go to bed and get up the same time each day – even on weekends. Plan ahead with activities and homework.
• Avoid naps. Although a brief 30 minute nap after school may seem helpful, too much daytime sleep can make it harder to fall asleep at night.
• Limit the amount of caffeine you have throughout the day and stop having any several hours before bedtime.
• Have a relaxing routine before bed. Shower, read something soothing or do other relaxing activities
• Do not do stimulating activities for 1 – 2 hours before bed. These include vigorous exercise, loud music, scary books or movies, and using electronic devices like smart phones and readers.

Making these changes will help improve your sleep and have a positive effect during on your activities during the day. Talk with your doctor if you have questions about or abrupt changes in your sleep pattern.

There are some simple habits that you can do each day to improve your sleep.

Avoid Stimulants

• Avoid caffeine for at least 12 hours before bedtime. Caffeine is found in coffee, tea, soft drinks, chocolate and many energy drinks.
• Do not smoke or use tobacco products for several hours before you go to bed. Nicotine is a strong stimulant.
• Avoid any over-the-counter medicines or products that may disturb sleep such as decongestants, diet pills, and pain medicines that may contain caffeine. Be sure to check labels.
• Talk with your doctor or pharmacist about your prescription medicines to see if they may be affecting your sleep.

Wake Up at the Same Time Each Day

• Follow this even on weekends to strengthen your internal body clock.
• Expose yourself to bright sunlight (or indoor light as needed) when you awake for 30 – 60 minutes each day. This can keep your body clock "on time" and is especially helpful for young adults who have a slower internal clock.

Exercise Daily

• Over time this will improve your quality of sleep. Even walking 30 minutes each day improves sleep.
• Finish exercising at least 2 hours before bedtime. This gives your body time to "wind down" before sleeping.

Avoid Naps

• If you have a health condition or long-term pain, you may need to rest in the late morning or early afternoon.
• If you do take a nap, limit it to 5-20 minutes and don't take it after 3 pm.

Set a Relaxing Bedtime Routine

• Turn down your lights, take a warm bath or listen to soothing music.
• Give yourself 30 – 60 minutes to unwind before going to sleep. Avoid things that are stimulating such as:
  • Using computer or electronic devices.
  • Reading thrilling books.
  • Watching scary movies or TV shows.
  • Arguing with family or friends.
  • Thinking about upsetting things.

Make Your Bedroom Sleep-Friendly

• Check that your bed and bedding are comfortable.
• Keep your bedroom as quiet and dark as possible. A fan or other type of "white noise" may help.
• Make sure the room temperature is comfortable – cooler is often better.
• Consider sleeping alone if your bed partner disturbs you with snoring or being an active sleeper.

Talk with your doctor if your sleep problems continue or worsen over time.

Whether you "just can't get to sleep" at times or have this problem often, it helps to understand why and what you can do to manage it.

The Need for Sleep 
The need for sleep is similar to the need for food or water. The longer you go without these, the more you need them. If you are doing things that decrease the need for sleep such as napping during the day, you will be less tired and able to go to sleep at bedtime. Sleeping in late on some days also affects getting to sleep at night.

The Body's Internal Clock 
Our body has its own internal clock called the circadian rhythm. This controls wakefulness and sleepiness. It is much easier to go to sleep at certain times of the day – especially later in the evening if you work during the day. Going to bed and awakening the same time each day helps strengthen your inner clock and your ability to fall asleep. Other things that may affect the internal clock include:

• Travel that involves time changes – "jet lag."
• Changes in the time for sunrise or sunset throughout the year.
• Daylight Savings Time changes.
• The light from a TV in the bedroom.
• Some medications and over the counter supplements.

Mental Arousal and Anxiety 
Increased mental arousal will prevent sleep. When the mind becomes alert and aroused when danger is present, it is a helpful response. But when this state of being very alert is ongoing and not related to true danger, it is a general anxiety that can affect sleep. Certain substances like caffeine and nicotine also stimulate or arouse the brain, which can prevent falling asleep or staying asleep. Medications such as diet pills, cold medicines, steroids, and some anti-depressant medications can also affect sleep.

Long term sleep problems can cause anxiety at bedtime. When people struggle to get to sleep, they often begin to dread bedtime. When this occurs, their state of mental alertness rises as bedtime nears, which further interferes with sleep. Do not lie in bed awake for long periods of time. Get out of bed and do something relaxing while keeping the lights and noise level low. When you become drowsy again, return to bed.

Talk to your doctor if you are having problems with sleep. There are things you can do and a variety of treatments to improve your sleep.