THE MYSTERY. When a bed partner snores or makes other noises, such as teeth grinding, or exhibits abnormal sleep behaviors such as sleepwalking (like Lady Macbeth) or restlessness, whose sleep is the most affected?
The Case of the Snorer’s Wife
Patients often come to the sleep clinic with someone accompanying them. Children come with parents, adults with bed partners, and the very elderly with a spouse, a friend, or a child. Sometimes, the doctor’s challenge with a new patient is figuring out whether the patient is the one with the sleep problem, such as the time when a husband and wife came into my examination room. The husband took the seat closest to my desk because he considered himself the patient. I asked him a series of questions about his sleep habits, and he answered yes to only one of them: he snored. But his wife had never observed him stop breathing while he slept, he did not feel sleepy during the daytime, he never fell asleep when he did not want to, and he had no trouble staying awake at movies or plays. He had no medical problems that I could discern. His blood pressure was normal. He did not smoke. His caffeine intake was reasonable. He drank alcohol only once in a while, although the snoring was worse on such occasions.
I glanced at the woman and saw that she was looking at the floor. The bags under her eyes were clearly visible. I asked how her husband’s snoring was affecting her. After a few minutes, it became apparent that the husband was not the one with the problem. The real patient was the wife.
Who Has the Sleep Problem?
When a bed partner or other family member makes noise or exhibits other sleep-related behavior, it can affect the sleep of others as well. Caring for children, spouses, and elderly parents can leave the caregiver sleep deprived and unable to function effectively. In this chapter I review how sufferers can recognize and manage their own sleep deprivation and their family’s sleep problems.
Three universal truths I’ve discovered about sleeping are:
1. There is perhaps nothing more comforting than watching a loved one sleep comfortably and peacefully.
2. There is perhaps nothing more distressing than observing a loved one’s struggle to breathe or battle to achieve restful sleep.
3. There is perhaps nothing more frustrating than having sleep disturbed by a family member whose sleep habits are disruptive but not life threatening.
Coping with the Sleep Problems of Bed Partners
When people share a bed or sleeping quarters, a person with a sleep disorder can severely disrupt the sleep of others. In a barracks, such as a prison or military accommodation, the sleep of many can be disturbed. Most often, though, only a bed partner suffers.
Sleepers snore when air attempts to flow through an obstructed breathing passage, making the tissues in the nose and throat vibrate. The sound can vary from a whisper to a noise loud enough to be heard throughout the entire house. The only person who does not hear it is the snorer, who frequently denies that he or she snores. For everyone within earshot, however, the noise can be a form of torture.
I recall interviewing a military officer whose spouse left him to return to her family in Texas. One of the main reasons she left was that she could not stand his snoring and had been unable to get a good night’s sleep. People who don’t sleep properly are tired, irritable, and snappy; some sufferers in this situation have clinical responses consistent with depression. Such symptoms can affect a marriage.
When both members of a couple snore, a contest seems to develop to see who will fall asleep first. In these snoring relationships, the two keep waking each other up, and after a while one of them usually retreats to another room to snore in peace.
When I treat snoring in a person who does not have a serious health problem such as sleep apnea, what I am really treating is the impact of the noise on the family and others who might suffer as a result of the snoring. Thus, the goal is not to improve the snorer’s health, but to help the person most affected by the snoring—the listener! But when the “patient” is not ill, the question arises of how invasive the treatment should be. Should it include surgery, which has risks and may cause a great deal of pain? Can less severe methods lessen the snoring enough to enable family members to get their own needed sleep? The interests of both the snorer and those affected by the snoring must be considered.
The most reasonable approach in this situation is to start with the treatment that is most likely to result in a permanent cure. I counsel snorers to work on reducing their weight (if appropriate), since being overweight often leads to snoring, and to avoid alcohol, which is known to make snoring worse. In fact, snorers should avoid getting into the habit of using any drugs to knock themselves out. Both sleeping pills and alcohol carry the risk of turning snoring into sleep apnea. Sleeping pills and alcohol relax the muscles of the throat that keep the breathing passage open and will worsen breathing. So snorers should avoid alcohol before bedtime.
If the snoring continues, bed partners can consider some behavior modifications to reduce the disturbance to their own sleep. Here are the most common; some have proven more effective than others.
Go to bed first. Some people find that if they fall asleep before the snorer, they are less likely to be awakened by the snoring during the night. Bed partners of snorers might find this effective, but in my experience, it does not tend to work on a regular basis.
Adjust the bed partner’s sleep position. People more commonly snore when they sleep flat on their back. Bed partners can encourage snorers to sleep on their side by gently pushing on them or elbowing them in the ribs. Although some sleep experts recommend having snorers sleep with a backpack or a tennis ball sewn to the back of the pajamas (this was the focus of a 2009 research study in sleep apnea patients) to keep them on their side, this approach seems unreliable, and it can cause a sore back. Only 10 percent of patients used the treatment long term. Other gadgets are available to induce people to sleep on their side.
Another option is for the snorer to try sleeping in a comfortable chair in a semi-upright position. When people are in this position they snore less, and even some people with sleep apnea can have more normal sleep when they sit rather than lie down to rest.
Wear earplugs. Research reported in 2012 has shown that male apnea patients are more likely to have hearing loss, a finding that suggests that loud snoring might damage the hearing system. This might also be the case for bed partners of snorers. Earplugs can give both bed partners and family members a better night’s sleep; they might also help prevent loss of hearing. Earplugs work extremely well for some people, and there are many different types on the market. They are sold in drugstores, stores that sell industrial and safety clothing, and stores that sell loud machinery such as chainsaws. The earplugs designed for industrial use can be less expensive and might be more effective than some of the earplugs available at other types of retail stores. The wearer should experiment to find the type that fits best, is the most comfortable, and is the least likely to fall out of the ear during the night. It might take a couple of nights for wearers to get used to the earplugs, but the resulting quiet will be worth the effort.
Sleep with a noise machine. Noise machines, which generate “white” noise or other soothing noises, are now readily available to drown out the sound of snoring. In addition to machines, such noises are available as apps for download on iPads, iPhones, and other smartphones.
Sleep in separate beds. Sleeping in separate beds might seem likely to be ineffective, but some snorers also move around a great deal to keep their breathing normal. Thus it is not always the noise that keeps the bed partner awake; sometimes the movements associated with the breathing are more disruptive. Especially if they have slept together for many years, some couples view sleeping in separate beds as a failure of their relationship. But if it enables a normal sleeper to cope with a bed partner’s problem, it might actually strengthen the relationship.
Sleep in a separate room. Some sufferers from noisy bed partners leave the bed and find a quieter place to sleep. Ironically, they sometimes do this because they are afraid that their sleeplessness might awaken their snoring bed partner—who is sleeping deeply. Because sleeping on a couch is uncomfortable and unlikely to promote good rest, many sufferers eventually move to another bedroom, often the most distant one from the bed partner.
Buy the property next door. Although I mention this in jest, it has been effective. Since some snoring, particularly at a very low rumbling pitch, can be heard throughout a dwelling, even sleeping in another room might not block out the sound. This was the case with one couple, each of whom snored loudly, who eventually bought the house next door. The two would retire to their respective homes at night. Though drastic, the move saved their sleep—and their marriage.
Although listeners can find a bed partner’s snoring annoying and disruptive, there is probably nothing more disturbing to them than thinking that their loved one is about to take his or her last breath. Many people cannot get used to sleeping next to someone who stops breathing on a regular basis. They find themselves constantly alert, listening to their partner, waiting to hear him or her take an effective breath. (I review this common problem in depth in Chapter 12.) Sufferers from this kind of sleep disruption should not seek ways to avoid hearing the stopped breathing; rather, they need to insist that the person who stops breathing receives proper medical evaluation. If a patient is diagnosed with sleep apnea and is treated with a continuous positive airway pressure device, bed partners are likely to find the gentle noise of the machine conducive to their own sleep as well.
TOSSING AND TURNING
When one bed partner tosses, turns, gets out of bed, walks around, gets back into bed, and takes half an hour to several hours to fall asleep, the other one is generally feeling angry and frustrated because he or she is not getting any sleep either. Couples may also find that one partner continues moving even after falling asleep, perhaps twitching every twenty or thirty seconds or moving the bedclothes around or kicking. Some partners sweat a great deal. These can be symptoms of a movement disorder (see Chapter 11), and most patients with such a disorder can be treated. If the treatment does not work, separate beds can be a solution.
Some people grind their teeth while sleeping, a condition known as bruxism. The sound can be one of the most annoying noises for a bed partner to deal with—it sounds as if there is a chipmunk in the bed. Bed partners can try the same techniques suggested for coping with snoring: earplugs, changing bedrooms, and so forth. But bruxism can also indicate a serious dental-health issue: if the teeth grinding becomes severe, it can wear down the teeth to the point that they no longer function well and have to be removed. Teeth grinders should be encouraged to see a dentist, who might fit them with a mouth guard that will minimize the damage that grinding can inflict on the teeth—and their partners’ sleep.
TALKING OR WALKING DURING SLEEP
Some people intermittently speak gibberish, moan, or make other strange noises while they sleep. One patient I knew would sit up, sing the national anthem, and then go back to sleep, with no recollection of the event the next morning. These behaviors do not represent anything serious, and in most cases the bed partner becomes used to it. If the bed partner’s sleep is continually disturbed, he or she should try the remedies listed above under snoring.
Sleepwalking can also be a disturbance to a bed partner. Some sleepwalkers get out of bed, walk around, even get a snack while sound asleep. They generally return safely to bed and wake up in the morning with no recollection of what they have done. The activity can awaken the bed partner and be a cause of concern. Other sleepers might find themselves waking up in another room of the house. Although most of the time this is not anything to be concerned about because the activities are not dangerous, bed partners disturbed by sleepwalkers can suggest ways to reduce the likelihood of sleepwalking. People are more likely to sleepwalk after they have consumed alcohol and when they are sleep deprived, so sleepwalkers should try to get a lot of rest and avoid alcohol before going to bed. If a bed partner starts doing dangerous things while sleepwalking (leaving the house, cooking on a stove), it is time to seek medical help.
NIGHT TERRORS AND NIGHTMARES
One of the more frightening behaviors for bed partners is when the soundly sleeping person next to them suddenly lets out a bloodcurdling scream and sits bolt upright, pouring with sweat, eyes wide open. Although the bed partner gets a shock, the person experiencing the sleep terrors often retains no memory of what happened. Upsetting as it is for the bed partner, this disorder is not dangerous. It is a variant of sleepwalking and is treated in the same way.
Nightmares, however, when they recur or are particularly violent, can be another matter for both the sleeper and the bed partner. If a sleeper frequently wakes up sweating, sometimes screaming, with heart pounding, and breathing hard, because he or she was frightened by a terrifying dream, especially if the nightmare is recurrent and violent, he or she should be evaluated by a doctor. Nightmares of this type are common among military veterans, who might be suffering from posttraumatic stress disorder (see Chapter 16); such nightmares also occur among people who have suffered various other types of trauma (rape, devastating hurricanes). We now know that PTSD with nightmares can occur after many types of trauma and last for decades.
Patients with REM sleep behavior disorder (covered in more detail in Chapter 14) physically and sometimes aggressively react to their dreams. If they are dreaming that they are being attacked, they might attack their bed partner. They also might punch the walls, throw objects, or jump out of bed, and could hurt themselves and others. This is a serious condition that requires medical treatment.
Coping with Children’s Sleep Problems
When children have sleep problems, their caregivers usually lose sleep as well. Children can develop sleep problems at any age, though the types of disorders vary with age. Caregivers who can help their children solve their sleep problems will have a better chance of getting a good night’s sleep themselves.
SLEEP PROBLEMS AMONG NEWBORNS
New babies can cause everyone in the house to lose sleep. Until the baby begins to sleep through the night without feedings, the parents, in particular, especially the one who does the night feeding, can expect to suffer sleep deprivation. This is normal. But parents can shorten the period by helping the newborn develop regular sleep habits early. According to Dr. Jodi Mindell of the Children’s Hospital of Philadelphia, author of Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep, parents can start helping their baby develop positive sleep habits as early as three months of age. These practices will help the baby start sleeping for longer stretches at night. The most important steps are
· developing a regular sleep schedule that is the same every day;
· establishing a consistent bedtime routine; and
· putting the baby to bed drowsy but awake.
Once babies learn to soothe themselves to sleep at bedtime, they will be able to fall back asleep on their own when they wake up at night.
Some problems that arise among babies in their first year are more serious and can have an impact on the entire family. One of the most common is colic; one of the most devastating is sudden infant death syndrome (SIDS).
Colic. At around two weeks of age, about 10 percent of newborn babies start to have unexplained episodes of crying that might occur on a daily basis. Between the episodes of crying, the baby seems fine. These episodes can last for hours and can occur at any time, causing distress for the parents or care-giver and keeping them from getting much-needed sleep. Such behavior is often an indicator of colic. Pediatricians often use the “Rule of 3” to judge whether a baby is colicky: the crying lasts for three hours or more per day, for three days or more per week, for three weeks or longer. Medical science has not found the cause of colic, but some important facts are known. Colic is not caused by gas or abdominal pain. Children with a large amount of gas or problems with excessive diarrhea might be allergic to cow’s milk. And it is certainly not the result of bad parenting.
Babies often get over their colic at three or four months, but in the meantime, parents are likely to experience sleep deprivation. Most parents try cuddling and rocking the baby early on, but they should concentrate on trying to normalize their child’s sleep habits so that the baby will learn to fall asleep on her or his own.
Establishing a healthy sleep pattern is essential to good sleep. Parents should make sure that their baby wakes up at roughly the same time every morning and goes to bed at roughly the same time every night. Some children who have colic have trouble sleeping even after the colic is gone, a problem that may be related to the parents’ not having established a regular sleep schedule.
Some parents have difficulty in tolerating the crying and become angry; they might even violently shake and thus harm the baby. In such situations, parents should take to heart the words of a researcher in 2016: “When a baby won’t stop crying despite your efforts, leave and make yourself relaxed first.” An excellent source of information about dealing with colic can be found at the Period of Purple Crying website (http://www.purplecrying.info). Although colic can be bad news, the good news is that not every child develops it—and it does go away.
Sudden infant death syndrome (SIDS). Sudden infant death syndrome (SIDS) is the unexpected death of an infant who appeared perfectly healthy. Although the precise mechanisms that lead to SIDS are as yet unknown, SIDS deaths usually occur while the baby is sleeping. One theory holds that babies’ nervous systems are not adequately developed so that they are not able to respond when they stop breathing or when their blood oxygen levels dip. SIDS strikes one out of every thousand babies and is more common among babies who are born prematurely and those who are abnormally small at birth. The time of highest risk is when the baby is between two and four months old. Roughly 90 percent of babies who succumb to SIDS die before they reach six months of age. Research has shown that in the United States, the rate of SIDS might be twice as high for African American babies than for the rest of the population. The reasons behind this discrepancy are unclear, although many scientific articles have reported that it may be the result of socioeconomic factors that lead to babies’ being put on unsafe sleep surfaces, sharing beds, or other risky behaviors. Parents can reduce the risk to their child by following such steps as putting the baby to sleep on its back, using pacifiers, and breast-feeding.
A big breakthrough occurred in the 1990s when research showed that babies sleeping in the facedown position were more likely to die of SIDS than those sleeping on their backs. It has been estimated that one-third of SIDS cases are related to sleeping on the stomach. A child sleeping on its stomach might be unable to lift its head if the breathing passage is obstructed, for example, by pillows or blankets. Smoking by the mother before birth and exposure to cigarette smoke after birth have been linked to an increase in the risk of SIDS. Research by a Harvard University group in 2012 showed that secondhand smoke is a risk factor for SIDS: about 20 percent of SIDS cases were probably related to smoking. A study from the United Kingdom showed that alcohol consumption by either parent was also associated with an increased SIDS risk.
Caregivers should follow these 2016 recommendations from the American Academy of Pediatrics to reduce their child’s risk of SIDS:
· Place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
· Avoid soft bedding, including crib bumpers, blankets, pillows, and soft toys. The crib should be bare.
· Have the baby share a bedroom, but not a bed, with the parents for the first year, or, at the least, for the first six months. (This has been shown to decrease the risk of SIDS by as much as 50 percent.)
· Avoid exposing the baby to cigarette smoke, alcohol, or illicit drugs.
In addition, make sure the baby does not overheat. This can occur if the room is too hot, the baby is wearing too many clothes, or the bedclothes are too heavy, especially when the baby has a fever or an illness such as a cold or other infection. The American Academy of Pediatrics has made available for download the 2016 policy statement with detailed recommendations for creating a safe infant sleeping environment (see the Bibliography).
Since the campaign to have children sleep on their backs began, there has been a 40 percent reduction in the number of SIDS deaths. Besides reducing SIDS, sleeping on the back has been reported to reduce episodes of fever, stuffy nose, and ear infections.
CAUTION: Be careful about gadgets that claim to help babies maintain a safe sleeping position. A November 2012 report from the Centers for Disease Control indicated that these may lead to suffocation and death. Parents should check with their pediatrician before using any gadget making such claims.
SLEEP PROBLEMS AMONG YOUNG CHILDREN
Most young children do not have difficulties sleeping regularly. Their parents have established a regular sleeping pattern for them, and they usually sleep through the night. This enables the parents to get a good night’s sleep too. But some children have sleep problems that can affect the parents’ sleep as well as their own. One of the most common is an inability to fall asleep without a parent.
Children who have learned to associate sleep with being held or rocked may have a great deal of difficulty falling asleep on their own. Some children will crawl into the parents’ bed or insist on sleeping in the parents’ room. Failure to deal with this problem when the child is young can have long-term implications—I recall a couple who asked me for strategies on how to remove their thirteen-year-old from their bed!
Dr. Richard Ferber of Harvard University discusses this problem in Solve Your Child’s Sleep Problems, which helps parents teach children to fall asleep on their own. Dr. Ferber’s approach works for many families, and I recommend his book highly. The three key steps are:
1. Establish a nightly routine before bedtime that is relaxing to the child. This could include taking a bath, rocking or singing to the child, or ending the day with storytelling or a bedtime book.
2. Put children to bed in their own crib or their own room (if the child has a separate bedroom) while they are still awake but beginning to show signs of sleepiness. This enables children to learn to fall asleep on their own.
3. Leave the room after the child has been put to bed. This is the most difficult part. If the child cries, the parent should wait before going into the room, make the visit brief, and not hold, feed, sing to, or rock the child. The amount of time the parent waits before going into the child’s room should become longer and longer on progressive nights. In this way, the child learns that crying brings only a brief visit from the parent, and eventually learns to go to sleep on his or her own. Parents who adhere to the process consistently usually find that within a week or sometimes two the child will establish a regular sleeping schedule. A research study published in 2016 confirmed the effectiveness of this method.
Getting a slightly older child who is sleeping in the parents’ bed to move can be more complicated. The child may claim to be frightened to sleep alone. Is “frightened” an excuse or is the child really afraid? One technique that sometimes works when the child is claiming to be frightened is to offer to let the child sleep on the floor next to the parents’ bed. After a while, the child will learn that sleeping on the floor is a lot less comfortable than sleeping in his or her own bed. If the child persists in claiming to be frightened, parents should check with a pediatrician to see whether professional help is necessary.
SLEEP PROBLEMS FOUND IN CHILDREN AT ANY AGE
Some children snore, and the causes tend to be different from those of adult snoring. For instance, snoring in children is not usually caused by obesity. Most often snoring or sleep apnea in children is caused by enlarged tonsils and adenoids, or a small jaw.
A child who snores loudly and stops breathing during sleep may have obstructive sleep apnea. If the child has large tonsils or is obese, these problems will probably have to be dealt with. Parents should consult with a doctor about the causes of their child’s snoring.
I have also seen many adult snorers whose sleep apnea was caused by an abnormally small jaw; often it turned out that their children also snored and had small jaws. If a parent with a small jaw has sleep apnea, his or her snoring child should be evaluated by a dentist or an orthodontist, as the obstructed breathing pattern may also be due to an abnormal jaw structure. If a child has a very small jaw, orthodontics can often improve the jaw structure and might help reduce the chance of significant sleep apnea years later. The first evaluation visit to an orthodontist is often free.
Other sleep problems in children, such as night terrors, sleep talking, and sleepwalking, are similar to those of adults and can be dealt with in the same ways.
Coping with Sleep Problems Among the Elderly
Many older people enjoy a normal night’s sleep. As reviewed in Chapter 2, abnormal sleep is often a sign of a medical condition or the result of a medication or medications. As with sleep problems related to bed partners and children, people who care for elderly ill family members usually experience secondhand sleep problems. Caring for older people who require an intervention at night, such as those who have had a stroke, are on a breathing machine, are incontinent, or require medications to be administered, can have a terrible effect on a caregiver’s sleep. Getting help at night from others is critical to maintaining the health of the caregiver.
One of the most common situations depriving caregivers of much-needed sleep is looking after a relative with the neurodegenerative disorder known as Alzheimer’s disease (see Chapter 15). More than 70 percent of those with Alzheimer’s disease live at home, and they put a great emotional and financial burden on their families and cause many sleepless nights for the caregiver (who is often the patient’s daughter). Because the woman is usually the care-giver in her family, she is the one who most often deals with a family member with Alzheimer’s disease. Eighty-four percent of caregivers of Alzheimer’s patients are women, and on the average the caregivers are sixty-five years old. The average patient lives about eight years after diagnosis. Some researchers believe that the single most important reason why patients with Alzheimer’s are institutionalized is that they wander at night and do not sleep. Their care-givers cannot cope with these nighttime activities, which exacerbate their own sleep deprivation. Caregivers of Alzheimer’s patients often have to coordinate medical care (medications, doctor visits) and personal care (hygiene, laundry, feeding). Such responsibilities often lead to sleep deprivation.
Caregivers who are experiencing sleep problems should seek help and find out what resources are available. A good place to start is their doctor’s office and social service agencies. Getting help from family members can restore sleep and well-being—at least temporarily. Caregivers who are dealing with Alzheimer’s patients should not be embarrassed to ask for help.
Back to the Snorer’s Wife
The snorer’s wife explained how much difficulty she had falling asleep because of the snoring and said that she felt terrible during the day. Her husband retorted that his snoring must not be that loud because it did not wake him up. I asked him whether he would have come to the clinic if his wife had not insisted. He replied no.
It now became apparent to all three of us that although the snoring patient did not have a medical problem, his wife had a serious sleep problem. After discussing different options, the husband agreed to wear a dental appliance that kept him from snoring and allowed his wife to sleep through the night next to him.
Just as patients do not always realize that they have sleep problems, sufferers from secondhand sleep problems might not recognize how a bed partner or family member’s sleep habits or disorders can affect their own sleep and health. It can be as important to find treatment for secondhand sleep problems as it is to diagnose sleep disorders in a patient.