Why are Australians struggling with sleep issues in 2022?

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Introduction

Sleep is a state of altered consciousness characterized by inhibited sensory and reduced muscle activities. There is inhibition of voluntary sleep with reduced interaction with the surroundings in accordance with the sleep cycle, an oscillation between deep sleep and REM sleep.

Sleep enables the body’s system to go into an anabolic state. In this way, it restores the immune, nervous, skeletal and muscular systems while prolonging their degeneration. Sleep also helps in maintaining mood, memory, stamina and other cognitive functions of the human body with adequate functioning of the endocrine and immune systems.

Sleep regulators and centres

The circadian clock and the hypothalamus play an important role in regulating the sleep cycles of the body. The hypothalamus contains groups of nerve cells that act as control centres affecting sleep and arousal, while the brain stem, in coordination with the hypothalamus, produces the GABA chemicals that aid in sleep. Apart from GABA,  another group of neurotransmitters called Orexins also help in sleep. Apart from stimulating neurotransmitters like histamine, adrenaline, cortisol and serotonin, Orexins or Hypocretins play a role in the sleep pathway. It is a dysregulation in the GABA levels and orexin with Cytokine receptors that affect the sleep cycle in human beings.

Australians and their struggle with sleep issues

Australians, as highly functional groups, have always had sleep issues. A recent survey has shown that the incidence of sleep issues that was previously 40-45% has gradually increased to 65%. In a survey conducted about the incidence of sleep problems among adults in Australia, around 60% reported at least one sleep symptom occurring three times or more in a week. 59.4% of the respondents had trouble falling asleep, staying asleep or waking up too early without being able to get back to sleep again. 14.8% of them reported experiencing symptoms severe enough to result in a diagnosis of clinical insomnia. Despite the acknowledgement, very few were willing to get medical help.

The same survey found that chronic sleep disorders persisting for more than three months were present in 50.4% of the respondents. Females reported a higher incidence of sleep problems than men. The overall result of the study concluded that both working pressure and lifestyle played important roles in disturbed sleep for Australians.

Other studies about sleep health and its outcomes

Another Australian study conducted in 2016 about the sleep health of Australians yielded significant results as well. Out of 1011 participants, inadequate sleep and its daytime consequences affected 33-45% of the adults. Diagnosed sleep apnea was reported by 8% of the participants. The incidence of insomnia was even higher at 20%, while restless legs were slightly less at 18%. Poor sleep habits were observed in a lot of these people.

Average participants reported a sleep time of 7 hours. 12% slept for less than 5.5 hours, while  8% recorded a sleep time of more than 9 hours. 76% of those who slept for 5.5 hours reported daytime impairments and other sleep-related symptoms. Additionally, sleep impairments and subsequent impairments at work were reported by participants using the internet or working late till bedtime. 29% of adults in the studies reported less productivity at work owing to sleepiness. 29% reported drowsy driving, 20% had nodded off while driving and 5% had had a history of an accident in the time span of one year owing to dozing off while driving. The study concluded that sleep problems with the consequences of disturbed sleep during the daytime had become endemic. Public focus with awareness was crucial for the betterment of the population.

What exactly are the sleep issues?

Sleep issues cover a wide range of spectrum from insomnia or inability to sleep to narcolepsy or excessive sleepiness. Insomnia is trouble falling asleep at night, staying asleep or frequent sleep disturbances that make you lethargic and irritable the next day. Based on its frequency, insomnia can be acute or chronic. Acute insomnia occurs due to stress, changes in place or schedule and lasts for a few days or weeks. Chronic insomnia is a problem caused either on its own or as a result of any associated factor. Anxiety, depression, and ADHD are some of the psychological factors causing Chronic Insomnia, while Parkinson’s, diabetes and hyperthyroidism are some of the medical causes for the condition.

Apart from these two main categories, other insomnias like Onset insomnia (difficulty in falling asleep) and maintenance insomnia (difficulty staying asleep) are some of the other insomnia patterns prevalent among insomniacs. A lot of factors contribute to these sleep issues. Stress occupies a major role. If untreated, physical factors like obstructive sleep apnea and restless leg syndrome are additional triggers that convert acute insomnia phases to prolonged chronic episodes.

Alcohol and insomnia – what is the connection?

Alcohol and insomnia have complex dynamics. Studies indicate that insomnia is responsible for a relapse into alcoholism. Alcohol provides sedative results; around 15-30% of people drink to manage insomnia when other treatment options provide unsatisfactory results. This leads to self-treating the condition with alcohol. An increase in the tolerance level of the sedative effects of alcohol gradually leads to chronic insomnia with alcoholism. Sleep deprivation combined with alcoholism puts individuals at high risk for accidents while driving, at home and even at work. Even moderate alcohol use in shift workers with shift work-related disorders can accelerate the risk of accidents.

Is age a factor as well?

With age, circadian rhythm changes impact the quality of sleep. As per reports, the sleep cycles are most affected with age resulting in an approximate loss of 27 minutes of sleep per decade. These changes further lead to fragmentation of sleep with early morning awakenings. Precipitating factors to the condition include age-related nocturia, dyspnea and poor physical functions. Lifestyle changes after retirement, polypharmacy and social isolation act as catalysts or aggravating factors. Furthermore, caregiving situations, bereavement and loneliness add to the problem.

Effect of Covid on sleep

There are two ways how the recent pandemic has led to sleep issues in Australians and the rest of the world. Firstly, insomnia has been associated as a post- covid symptom, especially in survivors with long term symptoms. Termed pandemic fatigue by some and COVID burnout by others, the inability to do normal activities or lead a normal life post a covid attack has worsened the situation. Secondly, the work stress at home, job uncertainty, and other challenges inflicted mark an increased prevalence of insomnia. Coronasomnia has resulted in lowering immunity and further increased the susceptibility risk of the virus. The stress associated with lack of proper sleep or vice versa has worsened cardiovascular and metabolic risks with that of weight gain, diabetes and high blood pressure.

Treatment options

Treatment options for sleep disorders vary on the basis of the type, duration and severity of the problem. Before initiating the treatment, a proper sleep disorder diagnosis is made through a detailed questionnaire and a medical evaluation. After ascertaining the cause of your insomnia, i.e. whether it is isolated or associated with other conditions, the practitioner starts his line of treatment as per your symptoms. Insomnia treatment, especially chronic, can be either in the form of cognitive-behavioural therapy or medication therapy.

Cognitive-behavioural therapy focuses on the psychological aspects of the problem and provides treatment options on the following patterns-

Sleep Education and hygiene- Encourages sleep-friendly behaviours that improve sleep quality by discouraging or eliminating bad sleep habits. For e.g., encouraging regular sleep schedules with discouraging caffeine use prior to sleep time. Sleep education aims at making people aware of their condition by suggesting ways of dealing with it.

Stimulus control After prolonged suffering of complications associated with insomnia, many people panic at the mere prospect of sleeping. This further worsens their symptoms. In stimulus control, you are counselled to take some steps to reduce these panic attacks and anxieties.

Sleep restriction Sleep restriction curtails the time in bed while sleep compression looks into the matter in a more gradual manner. Both of these methods have been designed as a part of cognitive-behavioural therapy for insomnia.

Relaxation Include activities like breathing exercises, aromatherapy, meditation and muscle relaxation. These activities indirectly work on insomnia by working on the related factors associated with it like heart rate, blood pressure, and other parameters.

Medications for sleep issues work on the neurotransmitters of the brain involved in sleep regulation for more effective dealing of the problem. Some of the medications associated with sleep issues are

  • Benzodiazepines- Benzodiazepines are a group of psychoactive drugs that work on the brain’s neurotransmitters to produce anxiolytic and sedative effects. Depending on their half-lives, benzodiazepines are classified into short-acting, intermediate-acting, and long-acting. Apart from providing sedation, they also act as antidepressants and uplift the overall mental state of the users.
  • Nonbenzodiazepines – Nonbenzodiazepines are medications that provide the same sedative, anxiolytic and antidepressant properties as that of Benzodiazepines, minus their serious adverse reactions and addiction potential. Like benzos, nonbenzodiazepines are positive allosteric modulators of the GABA receptors. In simple words, they regulate the GABA receptors by binding to the other sites except for the active site.

Which one is better?

Studies have shown that traditional Benzos, though considered the first line of treatment for sleep issues, have a lot of adverse effects associated with them. Altered sleep architecture, psychomotor and motor impairment, rebound insomnia are some of the effects associated with their long-term use. Nonbenzodiazepines, especially Zopiclone, with the same quality of sedation and other qualities, have a much better tolerance potential. Psychomotor and memory impairments, rebound insomnia and other withdrawal symptoms occur with a considerably reduced frequency with Zopiclone. Additionally, they produce minimal respiratory depression because of which they are safe to be used.

Is there any other effective medication for the condition?

Apart from nonbenzodiazepines, Etizolam has also made its name as a successful sedative with minimal complications associated with its use. Etizolam belongs to a group of Benzodiazepine analogues called Thienodiazepines. It acts on the same binding site as other benzodiazepines. But because of its chemical structure, it has lesser addiction potential associated with its use. Etizolam produces marked sedative and anxiolytic effects with potency six times greater than that of Diazepam. It additionally takes much less time to start working, further increasing its efficacy. Studies have shown that it is an effective muscle relaxant as well. This makes it suitable for conditions of restless leg syndrome and insomnia due to muscle induced pain tendencies.

Apart from these two medications, orexin receptor antagonists and melatonin agonists are some treatment options preferred by medical practitioners. Orexin receptor antagonists act on orexin, the main neurotransmitters regulating sleep. Melatonin agonists stimulate the production of melatonin, a hormone inducing relaxation and sleepiness. Though unique in their approach, due to the lack of extensive research regarding their effectiveness, Etizolam and nonbenzodiazepines like Zopiclone remain the preferred treatment options for insomnia.

Other factors

Medications can provide short term relief from the problems associated with sleep disorders. But a healthy lifestyle can go a long way in the prevention of the condition. Sticking to your sleep schedules and regular activity regulates the circadian clock and other sleep mechanisms in a positive manner. Healthy meals, timely checkups and understanding the root cause of the problem at early stages limit the severity associated with the problem. Most importantly, getting timely help for your problem ensures that you do not have to suffer the consequences for a prolonged period.

Conclusion

Sleep issues may seem trivial but have long-lasting and far-reaching consequences. Sleep issues have the potential to impact your social and professional lives severely and even cause life-threatening conditions either directly through drowsiness and the accident rate attached to it or indirectly through misuse or overuse of the treatment options. Judicious use of the medications is important to successfully solve your problem without impacting your health or other conditions. Further research is required to decide the effectiveness of other treatment options and spread general awareness among the public regarding the situation.

References

  1. https://en.m.wikipedia.org/wiki/Sleep
  2. https://pubmed.ncbi.nlm.nih.gov/11347777/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775419/
  4. https://www.sleepfoundation.org/insomnia/treatment