The most common problems seen in specialist Sleep Disorders clinics in Singapore are insomnia and obstructive sleep apnoea (OSA). 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.

Lack of quality sleep affects alertness most immediately, with daytime sleepiness and increased risk of accidents (e.g. 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.

Sleep needs vary with age. A newborn may need as much as 16-20 hours spread throughout day, an infant may sleep 12-14 hours with most of sleep consolidated to the nocturnal sleep period, while toddlers may require 10 hours or more. Primary school going children should get 9-10 hours of sleep, while teenagers should get 8-9.5 hours. In adults, sleep requirement ranges from 6-10 hours. Although some people take pride in getting by with very little sleep, most people who get fewer than 5-6 hours of sleep are probably not getting enough sleep.

Enough good quality sleep is essential for physical and emotional well being. Enough sleep, regular exercise and a balanced diet are the basic triumvirate of good physical and emotional health, basic prerequisites for looking and feeling our best. Chronic lack of sleep increases our risk of diseases such as heart disease, diabetes, obesity, and depression, as well as shortens our lifespan. Overall not having enough sleep is a stressful state which increases our risk of diseases associated with ageing.

The most common reasons for difficulty falling or staying asleep are psychological, such as excessive stress, depression or anxiety. Often lifestyle factors contribute to poor sleep, such as working, eating or exercising late into the night, taking substances which adversely affect sleep close to bedtime such as caffeine, alcohol or smoking, or having poor sleep habits, such as irregular sleep-wake times.

Sometimes medical conditions such as chronic pain and side effects of common drugs (e.g. asthma medication, steroids) can be a cause of insomnia. People who have difficulty sleeping should seek medical attention to determine the cause, so that appropriate treatment can be given, which is dependent on the underlying cause. Routine or long term use of sleeping pills, without proper identification of the cause of insomnia, is not recommended.

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.

It is unusual to be needing more than 10 hours of sleep a day. Too much sleep. Like too little, is also associated with increased mortality. Some people who seem to need a lot of sleep may have an underlying primary sleep disorder such as obstructive sleep apnoea (OSA) (blockage of the upper air passage during sleep) or a much less common primary sleep disorder called “narcolepsy” characterized by excessive daytime sleepiness and sleep attacks. Some people normally routinely sleep for longer than the usual 6-8 hours a night – such people are called “long sleepers”. Long sleepers routinely need more than 10-12 hours of sleep a day to feel refreshed. Notwithstanding, we do recommend that adult persons who have unusually prolonged sleep duration (needing more than 10 hours or sleep a day and still feeling tired) should seek medical attention, as this may be an indicator of underlying disease such as OSA.

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. Another once popular psychological theory (Sigmund Freud) suggested that dreams reflect repressed unconscious conflicts. Conversely dreaming may be entirely random and serve no specific purpose. Overall much more work is needed in the field of Sleep Medicine to understand the process of dreaming.

We spend about 20-25% of our total sleep time dreaming (about 2 hours), with most vivid dreaming occurring during 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.

Nightmares are frightening dreams which occur during REM sleep, and are associated with arousal, increased heartbeat and breathing rates. The dream content is often threatening, and there is vivid recall of the bad dream, with accompanying intense fear and anxiety.

Sleepwalking is a disorder of arousal, which is considered an abnormal behaviour in non-REM (deep) 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, when their brains are not fully mature, during which they are able to initiate complex behaviours while in a state of altered consciousness, yet not fully awake. The person may appear to be doing something purposeful, or even talk, but usually they are confused, disoriented and are very difficult to arouse. 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 and to avoid triggering factors such as getting enough sleep on a regular basis.

Sleep talking commonly occurs 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 (blockage of air passages in 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.

Most of the time, simply waking the child and giving physical (e.g. 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 (e.g. paediatrician, Sleep Medicine specialist) consultation may be needed.

This means that there is some air leaking from the top of the mask and going into the eyes and irritating it. Generally this means adjusting the mask to avoid leak and using commercially produced eye drops to keep the eyes moist.

PAP therapy works by physically splinting the airways open by the radial pressure exerted by the air on the walls of the airway.

There are 2 types of PAP machines, the auto-adjusting type (APAP) and fixed-pressure type. The APAP automatically adjusts the pressure depending on the needs of the person while they sleep i.e. the pressure can go up and down. In the fixed-pressure type, the pressure is fixed during the whole night. The fixed-pressure machines are generally cheaper than the APAP machines.

It is quite common for this to happen. Nasal obstruction can cause the mouth to open and let the air escape through the mouth making PAP use suboptimal. Hence in these instances a full face mask (FFM) which covers both the nose and mouth would be useful. Specifically for the nasal obstruction, several remedies exist including using heated humidification on the machine, nasal saline spray or intranasal steroids. In some cases, when it is intractable even surgery may be required to relieve the obstruction. You should talk to your doctor about the various options.

There are many different types of PAP machines (under the APAP type) that give some sort of pressure relief during exhalation (breathing out). This could be helpful.

Other machines have a “ramp” function, i.e. the pressure is set very low for a prescribed amount of time, allowing the person to fall asleep before the pressure readjusts to the required level. Others “get used” to the pressure after sometime. Your vendor will be able to advise you on the various types of machines.

There is possibly more than one cause. You maybe a mouth breather, either naturally or if the nose gets blocked the mouth may open. In any case when the air comes out of the mouth, it is generally cold and less humid. This causes the dryness. This same cold air which goes through the nostrils is sometimes responsible for the nasal blockage. Mouth leaks are treated either by using a FFM or by using a chin strap (i.e. an elastic band which is worn under the chin and up over the head which keeps the mouth closed. Heated humidification in the form of either a built-in humidifier or an externally attached humidifier helps to moisten the air coming out of the machine. This can reduce mouth leaks as well as reduce nasal blockage. Again check with the vendor before buying the machine if you require one with humidification.

The water collects in the tube because of over-humidification. Generally reduction of the humidity setting on your machine will reduce this problem.

The main reason for this is some of the air goes into the stomach instead of fully going into the airway. Usually this will improve with time, but if there is stomach discomfort, various antacid mixtures can be tried.

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 medications 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 5-15% of the population, and insomnia (difficulty initiating and maintaining sleep) which affects between 10-30% of people to varying degrees of severity.

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 medications 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 distubance. There is a long list of drugs which affect sleep, including antidepressants, PD drugs, steroids etc.

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 become unable 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.

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 i.e. simply asking them how much 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 (e.g. 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.