What happens to South Africans when they have sleep disorders?

Newswise — The first facility of its kind in South Africa, the Restonic Ezintsha Sleep Clinic combines the research capabilities of Wits University's Ezintsha with the bedding brand’s mission to enable wellbeing and success through the power of sleep.

Ezintsha, a sub-division of Wits Health Consortium, is a multidisciplinary research centre that focuses on advancing research in HIV and non-communicable diseases (NCDs) – and now the intersection of these with sleep. Ezintsha specialises in clinical trials, medical technologies, and peer reviewed research publications.

As a Centre of Excellence for sleep analysis, the Restonic Ezintsha Sleep Clinic will service patients with sleep problems, advance local sleep research and the interplay of sleep with other health conditions, and train other doctors to diagnose and treat sleep disorders.

Dr Alison Bentley is a sleep disorder specialist in practice for some 30 years. She ran the first diagnostic sleep laboratory in South Africa from 1990 to 1998. A Wits alumna, Bentley is a medical doctor at the Restonic Ezintsha Sleep Clinic, which was launched on 14 September 2023.

“Sleep touches every area of medicine and remains under-researched in South Africa. There is no other academic facility that is research focused, that is clinical focused, that is aimed at finding out how sleep works in South Africans,” says Bentley, and explains that the Restonic Ezintsha Sleep Clinic will fulfil three key functions: clinical, research and training.

Clinical offering

The clinic offers four overnight sleep rooms for patients with a sleep problem who have been referred by their doctor for sleep analysis, including a dedicated bedroom for sleep studies focusing on children.

Patients are also able to book a consultation to discuss their sleep issues with a doctor who understands and has training in the sleep field.

“In future, the Restonic Ezintsha Sleep Clinic hopes to offer lectures and group treatment options for the public on topics ranging from snoring to sleep apnoea and insomnia,” says Bentley.

Understanding sleep in South Africans

Bentley says the development of sleep studies is important in Africa for three reasons:

“Firstly, we do need a Centre of Excellence that’s looking at the academic interest - the real detail - behind sleep. Secondly, it’s really important to understand that as South Africans we are different from everybody else – we just are. There’s very little research done on NCDs and how they link to sleep so there’s really a big gap in the information about what happens to South Africans when they have sleep disorders. [Thirdly], we need to get creative about how we are going to treat patients in the public sector, because it is extremely frustrating to be able to diagnose a sleep disorder and not treat it. So we do need to come up with solutions to both diagnose and treat those patients, and part of that is training doctors.”

Research capabilities

Dr Nomathemba Chandiwana is a Director and Principal Scientist at Ezintsha. She says: “Ezintsha is known for being an infectious diseases site. HIV is mostly what we’ve been doing for 10, 20+ years. However, in one of our flagship trials a couple of years ago, called ADVANCE, we found that people were gaining weight, and this got us into non-communicable diseases, and actually that’s what’s killing most South Africans,” says Chandiwana, whose passion is obesity, an NCD.

“We believe we have an opportunity to explore how sleep potentially affects other major healthcare concerns in the country, such as HIV, obesity, cardiovascular disease and diabetes," she says.

The sleep clinic is perfectly placed to undertake large-scale research projects to gather more and better data, she says, as there is currently very little known about how sleep impacts other medical disorders in the South African population.

“We do not have an academic sleep lab on the continent and that’s not acceptable. As Africans, with all the issues that we have, we also need our own solutions,” she says.

“From a research perspective, if you are changing policy, you need evidence, and evidence that is locally relevant. Other trials have been done in North America, but when they come to Africa, we’ve seen totally different things because we’re a different population – we’re younger, we’re seeing our people are having diabetes much younger.”

The clinic will also enable research and explore alternatives to the use of the current (expensive) treatments for sleep disorders, such as the CPAP machine for obstructive sleep apnoea [OSA]. CPAP is 'continuous positive airway pressure', a machine that delivers just enough air pressure to a mask on a person's face to keep the upper airway passages open. This prevents snoring and sleep apnoea.

Bentley says, “The nasal CPAP machine – you’ll see there’s one in every bedroom [of the sleep clinic] – but that’s a cost, and it’s about R10-R15 000 per machine. Sure, they go for 10 to 15 years, but we can’t see the Department of Health paying for that for 23% of the adult population.”

Training for medical professionals

The Restonic Ezintsha Sleep Clinic is also an ideal environment to train doctors in the broad field of sleep medicine. “Given the prevalence of sleep disorders and their effects on other medical disorders, it is essential that most doctors are exposed and trained on these problems,” says Bentley.

Doctors residing in Johannesburg are able to attend in-person case presentations, while those further afield can attend remote video call discussions or arrange to visit for a week or more. The Sunnyside Hotel is conveniently located adjacent to the clinic in Parktown, allowing for residential visits.

Bentley says, “From training point of view, we’d love to have doctors come in here, work with us, we’d love doctors who are interested in sleep medicine to come and have a consulting room, see patients with insomnia for a morning. Let’s educate doctors, let’s get doctors knowing about sleep.”

Chandiwanda concurs: "Once we have locally relevant data, you can do so many things: you can write guidelines that work for us, we’re able to train doctors for an environment that works for us because right now, all the training we’re doing we’re doing based on North American standards – we don’t know if that actually works for our populations here.”

HOW DO YOU KNOW IF YOU HAVE A SLEEP DISORDER?

This seven-question survey will help you to assess whether you should consult a medical professional:

1. How many hours of sleep per night do you usually get?

 The average is 7 to 8 hours per night but this may not be normal for everyone. The correct number can vary from 4 to 9 hours per night, as long as you wake feeling refreshed and have no daytime problems related to your sleep. The number of hours you sleep at night is less important than the daytime function. If there is no drop in concentration and no daytime fatigue then sleep duration may be satisfactory even if slightly less than 7 to 8 hours.

2. Do you usually feel well-rested when you wake up in the morning?

Not feeling rested is either a result of too few hours of sleep or enough hours but a poor quality of sleep. You should feel rested and ready for the day on waking. Alternative reasons for not feeling rested are that you are waking too early for your natural rhythms or, if you are taking sedative medications, they are still working when you wake up.

3. Does daytime sleepiness or fatigue interfere with your daytime functioning?

Falling asleep during the day is not normal if you have had the correct duration and quality of sleep at night. An Epworth sleepiness scale score of > 10 is considered excessively sleepy.

4. Do you snore loudly and appear to stop breathing during your sleep?

This may indicate obstructive sleep apnoea, which causes poor quality of sleep with excessive daytime sleepiness. It also increases your risk of cardiovascular disease. Answer the STOP BANG questionnaire and if you score 4 or more, take this information to your doctor. They will probably recommend a home-based apnoea study to check how bad the breathing difficulties at night are.

5. Do you get an urge to move your legs with an uncomfortable feeling in the evening before going to sleep?

This may be an indication of Restless Legs Syndrome (RLS), which can be diagnosed with four questions. Answering yes to all four indicates you have RLS, in which case you should consult with a medical professional:

i. Do you have an urge to move your legs often with an uncomfortable sensation?

ii. Is it worse or only at night?

iii. Does it only occur at rest?

iv.  Is it partially or wholly relieved on movement (once you stop moving and are at rest again the sensation tends to come back)

6. Do you have difficulty in getting enough hours of sleep when you go to bed?

Insomnia is defined as allocating the right amount of time for sleep but battling to get enough hours of sleep with a compromise on daytime function. There are many causes and most can be treated. Even insomnia with no cause can be treated quite well with a behavioural programme (called Cognitive Behavioural Therapy for Insomnia [CBT-I]). Medications to help sleep should only be used as a temporary measure until the correct treatment is implemented. A proper assessment is critical, so please let your doctor know if you are battling to sleep.

7. Are you worried about your sleep?

The questions above indicate what symptoms to look for if you suspect you may have a sleep disorder. If you are concerned, please let your doctor know – take them the information you have obtained here. You should also keep a sleep diary (time of going to sleep, waking during the night, how long you are awake for and when you wake up) for a week or so, including a score out of 5 for your daytime function, to share with your doctor.