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Life is so short and we apparently spend about one third of our lives doing nothing... sleeping. But is sleep really doing nothing? It looks like it. Our eyes are closed and we do not respond. Quality sleep is necessary to replenish our bodies and lack of sleep can adversely affect how we function during the day. This issue of our newsletter is about a silent killer of sleep that affects some individuals - acid reflux. For more info, read on...

Sleep is an odd phenomenon. No one really understands it, but we all need it. Each of us must interrupt our busy lives every night and go into a strange state of unconsciousness to refresh our bodies and replenish our energy. Everyone is different. Some individuals need more sleep than others, but as a whole, we are a sleep-deprived society.

In fact, in the last 60 years, Americans have lost an average of two hours of sleep each night. In the 1940's, most adults got about nine hours of sleep. Now the average is less than seven hours with many individuals sleeping no more than five to six hours per night. We all know that sleep plays a vital role in our overall health and quality sleep is central to a healthy lifestyle. Most of us try to get a good night's sleep when possible. But what if you thought you were getting plenty of deep sleep each night, when in fact, you were secretly being robbed of sleep - without knowing it? How is this possible?

The normal cycles of sleep
To explain this further, we need to explore what a typical night of sleep is like. Scientists analyze sleep using a procedure called a polysomnogram, or "sleep study." This test measures the electrical activity of the brain and heart, and the movement of the muscles and eyes during sleep, and usually requires an overnight stay at a sleep clinic. Using these measurements, scientists are able to divide a night's sleep into stages from light sleep (stage 1) to deep sleep (stage 4).

During a normal night's sleep our brains travel on a bit of a "roller-coaster" through these different stages of sleep. As we drift off to sleep, we first enter stage 1 sleep. After a few minutes, we descend down to stage 2, then stage 3, then stage 4 deep sleep. Then it's back up again ... then it's back down again, and back up again, and down again. Each of us cycles through these stages about every 90 minutes until we awaken. During these cycles, major changes occur in our brain waves that are necessary for healthy refreshing sleep.

Sleep fragmentation
If something repeatedly arouses us during sleep, even for a brief time, the sleep cycles are interrupted and sleep is fragmented. Fragmented sleep is less effective in replenishing our energy and we are tired the next day. Many things can fragment sleep such as a new baby in the house or frequent urination caused by an enlarged prostate. Many individuals snore loudly and suffer from sleep apnea, or upper airway obstruction, during sleep. These are obvious examples.

Waking up with heartburn
Another obvious cause of fragmented sleep is gastroesophageal reflux (GERD), more commonly called acid reflux. Those with acid reflux suffer from the uncontrolled backsplash of stomach acid upward into their esophagus. Acid reflux typically causes heartburn - a burning feeling, rising from the stomach into the lower part of the chest toward the neck. Studies on patients with daytime acid reflux have shown that many of these same individuals also suffer from acid reflux during the night. Much of the time, this painful heartburn will fully awaken them and force them to get out of bed and search for a remedy, such as a glass of milk or an antacid tablet, and then go back to sleep. This is another obvious example of fragmented sleep.

Silent sleep killer
There is also a more subtle silent killer of sleep that affects some people. Nighttime acid reflux need not be severe enough to fully awaken an individual. Mild reflux may just be severe enough to briefly arouse them and interrupt their sleep cycles, but not severe enough to fully awaken them from sleep. Each episode may only last a few seconds, but occurs dozens of times during the night. The total sleep time remains normal, but the quality of sleep is markedly diminished. Since the individual does not fully awaken, they have total amnesia for these episodes. If asked the next day, they will tell you that they slept well all night, when in fact their sleep cycles were severely fragmented by these amnestic arousals. They can't understand why they feel so tired during the day.

Why does acid reflux occur at night?
Most of us are familiar with heartburn that occurs after a heavy meal. But, why would you have heartburn at night. It is really a matter of offense vs defense. If the sphincter valve between the lower esophagus and stomach malfunctions, stomach acid has the opportunity to travel backwards and attack the delicate inner lining of the esophagus. Your best defense is gravity. When acid refluxes into the esophagus during the day, gravity helps clear the acid from the esophagus back into the stomach. When you lie down, gravity is unable to clear acid from the esophagus back into the stomach. Another defense is saliva which has an acid buffering quality and the act of swallowing pushes acid back down into the stomach. When asleep, you produce less saliva and swallow less often making you more vulnerable to acid reflux.

Diagnosis
Diagnosis requires a high index of suspicion. If a person who suffers from acid reflux also reports frequent tiredness or episodes of irresistible drowsiness during the day, they may be suffering from sleep fragmentation due to acid reflux. In this circumstance, the simplest course of action is to aggressively treat the acid reflux and see what happens. In confusing cases, a formal nighttime polysomnogram is sometimes necessary with simultaneous measurements of acid reflux using a thin pH probe placed in the esophagus overnight.

Effective Treatment
Fortunately, of all the many types of sleep disorders, arousal from nighttime acid reflux is one of the easiest to treat. For many years we have had a class of drugs called Proton Pump Inhibitors (PPIs) that are very effective in reducing stomach acid production and lessening both daytime and nocturnal symptoms. Numerous studies have shown that when a PPI is taken on a daily basis, both daytime and nighttime acid reflux are diminished.

Symptoms of a sleep disorder

1. feel irritable or sleepy during the day
   
2. have difficulty staying awake when sitting still, such as when watching television or reading
   
3. fall asleep sometimes while driving
   
4. have difficulty paying attention or concentrating at work, school, or home
   
5. often get told by others that you look tired
   
6. have difficulty with your memory
7. feel like taking a nap almost every day
8. require caffeinated beverages to keep yourself going

Symptoms of acid reflux

1. burning pain beneath breastbone that travels upward
   
2. regurgitation of bitter stomach contents
   
3. painful or difficult swallowing
   
4. unexplained hoarseness or persistent clearing of throat
   
5. unexplained persistent cough
   

Summary
Getting a good night's sleep is essential for feeling refreshed and alert during the day. Unfortunately, not everyone is able to get the restorative sleep they need. If you feel that you are falling asleep promptly and sleeping through the night but still have feelings of lethargy and tiredness through the day, you may be suffering from sleep fragmentation. If you are a heartburn sufferer, acid reflux may be the cause. If that is the case, you should consult with your doctor.