[Recent Actual Tests] - Dealing with Different Sleep Patterns

Sleep medicine is a relatively young field in the UK, with only a couple of centers until the
1980s. In the last decade a number of centers have sprouted, often led by chest physicians
and ENT (Ear, Nose and Throat) surgeons with an interest in obstructive sleep apnoea,
forcing neurologists and neurophysiologists to wake up and contribute to the non–respiratory
aspect of this neglected subject.

Within sleep, two states are recognized – non rapid eye movement (NREM) and rapid eye
movement (REM). These alternate cyclically through the night with cycle time of 90 minutes
(50 ~ 60 minutes in the newborn). NREM sleep evolved with the homeothermic state and is
divided into four stages: stage 1 and 2 which are considered light sleep, and stages 3 and 4
which are considered deep sleep with high arousal threshold.

REM is ontogenetically primitive with EEG (electroencephalo-graph) activity closer to wake

state, intermittent bursts of REMs and muscle atonia interrupted by phasic burst producing
asynchronous twitching. The atonia of REM sleep prevents acting out of dreams and is lost in
REM behavior disorder when dreams content becomes violent and patients act out their
dream, often resulting in injury.

REM behavior disorder can be a precursor of neurodegenerative disease including

Parkinsons.Dream content – pleasant or unpleasant – will be remembered on waking from
REM sleep but there is often little or no memory of the preceding mental activity on arousals
from NREM sleep, even when associated with complex behaviors and autonomic disturbance
as occurs in night terrors or sleep walking.

In the newborn, 50 percent of total sleep time is occupied by REM sleep, progressively
shrinking to 25 percent in the adult, the first block of REM sleep occurring about 90 minutes
after sleep onset. Abrupt withdrawal of alcohol and many centrally acting recreational and
non-recreational drugs can cause REM sleep to occur at sleep onset. This can also increase
total REM sleep, leading to intense vivid often frightening dreams, similar to that
experienced by patients with narcolepsy.

The NREM/REM sleep states are interrupted by brief arousals and transient awakenings. The
frequency of the arousals may increase with emotional disturbance or environmental
discomfort but also in many intrinsic sleep disorders such as periodic leg movements in
sleep, obstructive sleep apnoea and narcolepsy.

A basic rest/activity cycle originates in fetal life. The newborn sleeps an equal amount during
the day and night, the sleep/wake cycle organized around three to four hourly feeds. By the
second month favoring of sleep towards night time occurs and by six months the baby will
have about 12 hour of sleep at night in addition to a couple of daytime naps.

In general, children born prematurely have a tendency to be awake more at night in the first
year and breast-fed babies wake more frequently, but the difference disappears by the
second year. Persistent night awakenings in infants and toddlers usually reflect the child’s
inability to self-soothe back to sleep without parental attention and will respond to a well
supported behavioral programme.

The establishment of a consolidated night sleep pattern in children reflects brain maturation
and may be disrupted in children with developmental problems. Even in this group success
is possible by persisting with behavioral work, though many paediatricians prescribe
melatonin for these children with some success. But as the long-term safety of melatonin
remains unknown it should be used as a last resort.

There are now good studies looking at short term use of melatonin in sleep wake cycle
disorders such as delayed sleep phase syndrome. Its use as a hypnotic should be
discouraged, especially in the developing child as there is uncertainty on other cycles, such
as menstrual.

In addition to the NREM/REM cycles, there is a circadian sleep/wake cycle entrained by

intrinsic rhythms – melatonin and body temperature and extrinsic factors – light and social
cues such as mealtimes, work times.

The pineal hormone melatonin plays a role in entraining the sleep/wake cycle to the
light/dark cycle.Melatonin secretion is high in darkness and low in daylight hours, the
process beginning in the retina with the supra chiasmatic nucleus playing a major role as a
sleep regulator via melatonin.Blind people may lose this entrainment and develop a free
running sleep/wake cycle with progressive advancement of sleep onset time.

Polymorphism of the circadian clock gene has now been identified with the population
divided between morning types (larks) and evening types (owls). Those predisposed to later
sleep onset time are susceptible to developing delayed sleep phase syndrome especially
during adolescence when sleep requirement increases and there is a tendency towards later
time for sleeping and waking.

In delayed sleep phase syndrome, sleep onset is delayed to the early hours of the morning
with consequent difficulty in waking in time for school/work. Once established advancing
sleep onset time is difficult and requires treatment with appropriately timed melatonin or
bright light therapy, or chronotherapy – advancing sleep onset progressively forwards until
the desired sleep time is reached.

In contrast the elderly who are more susceptible to perturbation in their sleep/wake schedule
can develop advanced sleep phase syndrome with sleep onset occurring early in the
evening.Shift workers often struggle to cope with shift patterns as they grow older due to
difficulty in re-adjusting their circadian clock. In general, morning bright light exposure is a
more powerful synchronizer of the circadian rhythm than melatonin.

Questions 1 - 8:

Do the following statements agree with the claims of the writer in Reading Passage 1?

On your answer sheet please write:

TRUE if the statement is true

FALSE if the statement is false

NOT GIVEN if the information is not given in the passage.

1 Growing interest on sleeping disorder studies caused growing number of centers for
researching on sleep medicines.

2 People are often injured when dreaming aggressive scenes or sleepwalking.

3 Parkinsons is scientifically proved to be the only result of REM disorders.

4 REM sleep counts for less proportion of total sleep time for grownups than newborns.

5 Frightening dreams are considered irrelevant to alcohols and drugs.

6 According to the author, babies would sleep more at night from the second month of their
births.

7 During the night, children born prematurely wake as frequently as breast fed babies.

8 Children require more deep sleep and less disruption during their sleep in the first half of
the night.

Questions 9 - 14:

9-14

Complete the summary below. Choose your answer from the list below and write them in
boxes 9-14 on your answer sheet.

NB There are more words than spaces so you will not use them all.

rhythms shadow different identical

 paces bright body shift workers

entraining daylight elders blind

physiological cycle younger sight

Researchers had laid their eyes on using medicines in sleep-wake cycle disorders. The
NREM/REM cycles affect sleep along with human 9________ and outside factors. Melatonin
plays a determinant role in 10________ the sleep wake cycle to the day-night cycle. Scientists
found that melatonin is high within 11________ environment, with an exception
of 12________ subject who may build up a free cycle. Circadian clock genes
are 13________ between “morning people” and “night people”. It is difficult for people with
delayed sleep phase syndrome to wake in time. Conversely, 14________ are more susceptible
to sleep early in the evening.