good afternoon, first of all i'd just liketo get a show of hands how many people in this group either have sleep issues orknow people that do have sleep issues? wow okay so you're in the right place and hopefully i will i'll get this someof your questions at the end of this. so today,i'm gonna be covering three basic topics. i'm gonna cover need for sleep, and theni'm gonna focus on two sleep disorders. these two sleep disorders happen to bethe most common sleep disorders out of the almost 90 differentsleep disorders. so in regards to the need for sleep,we look at the prevalence of sleepiness.
and it's estimated that over a third ofthe population suffers from sleep loss. and this includes onethird of young adults, secondary to chronicpartial sleep deprivation. it also includes about 7% of adults,secondary to sleep disorders. and lastly, there's about 2% of adults that havesleep issues secondary to shift work. now if you go into it further,and look at daytime sleepiness, one-third of adults sleep less than6.5 hours during the workweek. and approximately one-third of adults fallasleep in less than maybe five minutes.
how we know this, you have to have test called the multiplesleep latency test in our lab. and this test is found in allother labs throughout the world. what it is is there's five scheduled labs. so it starts at 9:00 in the morning,and it goes 9, 11, 1, 3, 5. each lab lasts about 20 minutes, and we see how long it takesa person to fall asleep. and then we average how longit takes them to fall asleep. if they fall asleep inless than eight minutes,
they're considered to havesignificant daytime sleepiness. so you can see here that approximatelyone-third of normal adults fall asleep in less than five minutes during the daytime. and that's consideredpathologic sleepiness. now when you look at it further,when total sleep time, normally young adults are reduced justby 1- 1.5 hours just for one night, you get decreases up to one-third inobjective alertness the next day. so just one night of partial sleepdeprivation can have profound effects the next day, so now i'm gonna talka little bit about sleep stages.
so as most of you probably know,there are two different states of sleep. there is non-rem sleep and rem sleep. rem sleep stand for rapid eye movementsleep and rapid eye movement sleep, about 90% of dreams occurduring that state of sleep and also it's a time ofcardiorespiratory instability. what that means is that that's a time whenyour heart rate becomes irregular and also your breathing becomes shallow andirregular. and that's also the time when mostof obstructive sleep apnea occurs. now non rem sleep you can seeis divided into three stages.
it used to be called one, two, three andfour but they lumped three and four within stage n3. so as you go down that list, n1, n2, n3,that reflects the deeper stages of sleep. so n3 is actually the deepeststage of sleep and thus the hardest to wake a person up from. now if you look at how sleepchanges over the lifespan it actually doesn't look too great. as you get older whathappens is your sleep amounts tend to decrease not onlyrem sleep and non-rem sleep and
you can see when your first born thatyou can have 16 to 18 hours of sleep. and of that,about 50% of that is rem sleep. that's why some people believethat rem sleep is responsible for brain maturation andgrowth and development. and as you can see,it slowly decreases over time. and if we look at it a different way,you can see this. and what it shows is it shows thatchildren, they're really good sleepers. so their sleep tends to, the rem tendsto increase as the night goes on. and the deepest time of their sleep is inthe first third, first half of the night.
so this portion is when theyget the most deep sleep. young adults are also consideredpretty efficient sleepers, meaning that of the time that they're inbed, most of the time they're asleep. and you can see theyhave very few awakenings. and there's also the logicalprogression of rem sleep. the rem sleep periods get longer andmore intense as the night wears on. now as you get older what happens isthat your sleep become more fragmented, you start decreasing the amount ofnon rem sleep and rem sleep and this sleep patter, very much approximatesa person that has insomnia because
they have difficulty falling asleepas well as difficulty staying asleep. and consequently what happens is, duringthe daytime they tend to be more sleepy. and also, there's a nucleus inthe brain called the suprachiasmatic nucleus that's responsible forthe sleep wake cycles. and as the person ages, sodo the cells in that nucleus. and because of that the circadian clock,meaning the sleep wake clock, tends to shift. and because of that you tend to wannasleep earlier and get up earlier. now two large groups met to decide onwhat is a total sleep requirement.
and they met just last year. one was the american academyof sleep medicine, the other wasthe national sleep foundation. and for the academy of sleep medicine,what happened is they basically brought in a groupof sleep experts in a large room. and basically what happened is we reviewedall the relevent articles regarding sleep need andhow many hours a person should sleep. basically we came out to the conclusionthat a person an adult should sleep seven or more hours per night on a regularbasis to promote optimal health.
now you can see some of the repercussionsof sleeping less then seven hours on a regular basis it increasesyour chance of having weight gain, obesity, diabetes,high blood pressure, heart disease, stroke, depression,increase risk of death as well. now if you sleep more than nine hours ona regular basis, it may be appropriate for some young adults, individuals whoare coming from sleep debt and individuals with illnesses. now people concerned that theyare sleeping too little or too much should always consult their primarycare physician or sleep specialist.
and what's kinda interesting isif you look at some of the data more closely what you find out is thatthere's a u shaped survival curve. so people that sleepless then four hours and greater then 10 hours on a regular basisthey have a higher risk for mortality. and you might think this might be a fluke,but it's actually been replicated in about four large epidemiologic studies, and theytried to control for as many factors as possible such as things like age,smoking, eating habits, alcohol use. but, you know, i think it'simpossible to control for everything. that's why based onthe american academy of sleep medicine,
we didn't really setan upper bound of bounds. well, one of the thingsthat sort of drives sleep. melatonin is something thathas improved the timing of sleep andyou can see the melatonin in the body, hence the increase during the night,and also in the early morning hours. and that very much coincideswith core body temperature. so when your core body temperaturetends to decrease, and your melatonin rises in your body, that's the timethat you tend to be very, sleepy and this subjective scale looked at where 100is very alert, and zero is not alert.
and you can see that when you're mostsleepy coincides with the melatonin peak. as well as a decrease in body temperature. now, one thing that welook at in the clinic is your tendency to be sleepyduring the daytime. and you can find thisscale on the internet. and it's called epworth sleepiness scalebecause murray johns, who developed this scale,actually is from epworth, australia. basically you look at these eightsort of real-life situations, and you put zero, one, two, or three.
zero is no chance of dozing,one is slight chance of dozing, two is moderate chance of dozing,three is high chance of dozing. so for each one of these real-lifesituations you put zero, one, two, three and you add them up. now, the cut-off is ten. so if you add up all those points, and you're greater than or equal to tenpoints, then it might not be a bad idea to talk to your primary care physician orsee a specialist. the only caveat forthat is that if there are other things
that sort of influencethe daytime sleepiness. for instance, if you have a very bigwork and family life, and you find out voluntarily that you're only sleepingfour to six hours during the night, well obviously,that would cause daytime sleepiness. so this assumes that you're trying toallow yourself adequate amounts of sleep, at least seven hours of sleep a night. but still you're feelingsleepy during the day time. and if you fall asleep in thesesituations, and it's greater than ten, then you probably wouldwanna have that checked out.
because there's two main things thatinfluence the amount of daytime sleepiness. one is the sleep quantity,the other the sleep quality. sleep quantity, i mentioned,you have some control over, but sleep quality may be influenced bythings like medical and sleep disorders. so that's a very quick summary ofsort of sleep and the need for sleep. now i'm gonna shift on to a disorderof excessive daytime sleepiness, and it's called obstructive sleep apnea. it's actually been around, ornoticed, for a long period of time.
and even to the time of charles dickens,when he wrote pickwick papers, he wrote, and on the box sat a fat andred-faced boy, in the state of somnolency. and he actually referred tothe character as fat boy joe. now the reason why i show that, is that about 30 to 67% of the peoplethat have sleep apnea are overweight as defined by body mass index of25 kilograms per meter squared. but the rest are not, and forreasons that i'll detail later, that can be some of the reasons forcausing obstructive sleep apnea. but obesity is definitelyone of those factors.
so what are the symptoms? well, you'd have loud, disruptive snoring. your bed partner notices that youhave pauses in your breathing. and you, yourself, might wake up withgasping, gagging, choking, snorting sounds during your sleep, and that can bea tip off that you might have it as well. and also,you have excessive daytime sleepiness. now, i wanna sort of contrast that withthings like fatigue, tiredness, and exhaustion. so excessive daytimesleepiness means that,
going back to the epworth sleepinessscale, is ten or greater. that you definitely fallasleep during the daytime. now i contrast that with peoplethat have things like insomnia, which i'll be talking about. where you feel rundown, you feel fatigued,you feel tired, but you try to go to take a nap during the daytimeand the same mechanisms that prevent you from falling asleep at night also preventyou from falling asleep in the daytime. so you're not able to fall asleepduring the daytime as well. and you contrast that with peoplethat have obstructive sleep apnea.
so people that have obstructivesleep apnea would fall asleep at the drop of a hat, so to speak. we see many of the people that haveobstructive sleep apnea in our clinic, and if we go to the waiting room, they'reoften with their head back falling asleep. >> [laugh]>> so you can fall asleep at any situation. so that distinction is very important. people that have obstructive sleep apneadefinitely are sleepy during the day. and given the opportunity to fall asleep,and if they're put in a bedroom with
a dim light during the daytime,they definitely fall asleep. so this is a child that has sleep apnea. and if you listen very carefully,you can hear the pauses in breathing. and then you can hear the capturebreaths afterwards, after the apneas. and you can see that the child reallyis struggling to take a breath. as the airway is trying to go down, she's trying to take a breathpast that closed airway. and you just heard one just a second ago,that sort of pause in breathing. and it's no surprise that in the daytime,these children,
when they wake up,they're often drenched in sweat, because they have a real majorworkout during the night. and also during the day time,it's not unusual for them to complain ofheadaches in the morning. now, one thing that's sort of interesting, is that children really manifestsleep apnea differently from adults. does anyone here have anythoughts as to how the children manifested differently from adults? i mentioned for adults,they're definitely sleepy,
so they'll fall asleep during the daytime. but how do children who have sleep apnea,how might they behave during the daytime? any thoughts from anyone? >> short fuse. so they're definitely irritable,they're moody. any other thoughts? okay, yeah, so the difficulty is withattention, focus, and concentrating. so these children very much mimic children that have attentiondeficit hyperactivity disorder.
because their sleep is being fragmented somuch, they have this tendency to be hyperactive, have difficulty focusingand concentrating during the daytime. and they can be very moody or irritable. and i'll come back tothat a little bit later. so if we look at the prevalenceof people that have sleep apnea, it's about a quarter of adult men and9% of adult women have sleep study evidence of having obstructed sleepapnea between the ages of 30 and 60. and about 40% of all patientsin a primary care setting have evidence of having sleep apnea.
and the risk factors, or predisposingfactors, for sleep apnea are middle age, but children can still have it,as you saw. and forchildren it's about 3% of the population. i mentioned obesity is a risk factor. male gender, interestingly,is also a risk factor. so men tend to have it more often thanwomen, except when women reach menopause. then the numbers tend to equalize, so women tend to get itjust as equalized as men. if you make a decision to go onhormone replacement therapy,
then these numbers becomesimilar to that after menopause. hypothyroidism is also a risk factor,and certain medications, such as benzodiazepines. benzodiazepines are mild tranquilizers,and they can be things like valium or adavan. what happens is, just like alcohol,these medications relax the upper airway. when it relaxes the upper airway it makesit more predisposed to collapsing, and when it is more predisposed to collapsingyou'll get these apnea periods of more fragmented sleep.
and then there's anatomic abnormalities,which i'll also cover a little later. so besides the epworth foridentifying the sleepiness, you can also see if you haveany of these other symptoms. so this is what's calleda stop questionnaire. it was developed by one of my colleagues,francis chung in toronto. and if you have two or more of thesesymptoms, you're at high risk. so you have the snoring,you have the sleepiness, you have the observed apnea andhigh blood pressure of unknown cause. then you're more likelyto have a sleep apnea.
now, going back tothe anatomic abnormalities. so i mentioned that if you're overweight, what tends to happen is that,that causes the airway to be scrunched. and when it becomes scrunched,it becomes more susceptible to collapse. also, if you have a smallairway to begin with. that can also lead to obstructive sleepapnea and i'll go into that, as well. but one thing i wanted toreally emphasize is that, one of the things that we're reallyaggressive about in our clinic, is to catch nasal obstruction,especially in children.
so we'll look at the turbinates andjust so orient things. this is the nasal septum andthis is looking into the nostril. and you'll see this tissue, this not too far into the nostril,called the inferior turbinate. and if you have allergies,or especially allergies, what will happen is that,this turbinate tends to get very enlarged. and that will cut off some ofyour breathing through your nose. now, the reason why that's important,especially, in children is if, you don't catch that early.
a lot of times the children will turninto an obligate mouth breather. meaning that during the night,as well as during the daytime, they'll tend to breaththrough their mouth. and that can add profound changesinto the facial skeleton. so what happens is that, the child tends to have more jaw ormandible that's pushed back. so this angle, and this is what'scalled a cephalometric x-ray. it's x-ray of the child's bony features. and what happens is when this mandible,the lower jaw, is put back,
pushed back, this angle,in this direction. in addition, there's a greater inclinationof the mandible and occlusal planes. what that means, is that this angleof the angle of the lower jaw. and where the teeth meet,this angle can increase. so this angle increases meaning that thechild will tend to have a longer mandible. a wider mandible meaning that thislower jaw dimension will increase. lastly, it could have a greaterinclination of the upper incisors, meaning that their front teethwill tend to be split out more. now, the consequence of that, is that youend up with facial profile like this.
where you tend to have a really long face. and you tend at rest lots of timeyour lips don't completely close. and that's because of the changesin the facial skeleton. that caused remodeling of the skeleton, based primarily on becoming an obligatemouth breather, and the nose is occluded. so that's one thing that can resolve it,but the other thing is also obesity. and i mentioned that when the person'soverweight, especially in men, it tends to translateto the neck thickness. so people that have a neck thickness, or
men that have a neck thickness greaterthan seven inches in circumference. they're at a higher riskof developing sleep apnea. and the reason is this, sothis black area is the airway. we can see it over here. what happens is that, there's thesetwo lateral parapharyngeal fat pads. so there's two fat pads that lieon either side of the airway. and they increase in sizedepending on your body weight. so as the body weight increases, theselateral parapharyngeal fat pads increase in size andthey put pressure on the airway.
and cause it be morepredisposed to collapse. and you can see the difference between, this is a person without apnea,and this is a person with apnea. and if you look at a 3dreconstruction of the airway. what you see is, rp stands forretropalatal, or behind the soft pallet,or behind the uvula. retroglossal, just means behind it,facing the tongue. and what you can see is, the personthat has apnea, has a narrow airway. extending from the soft palate allthe way down to the base of the tongue.
so how can you tell if youmight have sleep apnea? or physical markers that mightpredispose you to sleep apnea? well, one easy way is just togo in front of the mirror, stick out your tongue, and say. and this is fairly routinein a physician offices. and what we look for is we,first of all, look at the uvula. and we see if it's red and enlarged. also, we look at the freeedge of the soft palate. is this area also red and enlarged?
now, if this entire structure is red and enlarged, you might just berecovering from a case of the flu. but if you see it all the time, what thatcould mean is that, you're a heavy snorer. and that you might have sleep apnea. because this area is verysusceptible to vibration. so when you get a lot ofredundant soft tissue here, what happens is itcreates a vicious cycle. and that area tends to vibrate a lot andbecomes very reddened and swollen. and that is responsible for some ofsnoring, as well as some of the apnea.
now, another thing that you can do, isyou can look at your edge of the tongue. one of the things that we look foris called scalloping. what that means is that one of the thingsthat might also cause sleep apnea, i mentioned,is a lower jaw that's pushed backwards. and when it's pushed backwards orif the tongue is too big. you're in development, what happens is the tongue doesn'tquite fit that lower jaw space. and because of that,the tongue is constantly hitting the back of the teeth andso you'll get scalloping.
and the reason why that's bad, is because the tongue can't fitwell into that smaller space. it gets displaced backwards andthat in turn, can make it more predisposingto collapsing the airway. so scalloping on the edge of the tongue issomething that we, definitely, look at. now, if you open up your mouth,stick out your tongue and say. and you don't see any of these structures,then please give me a call. >> [laugh]>> because that probably means, that you probably havea pretty bad case of apnea.
because what that means is duringdevelopment, these structures, the soft palate is actually divingdown behind the base of the tongue. and that means that,the airway itself is very compromised. and you can get an idea,if you look over here. this is the uvula. and you can see the uvula is so elongated,that it's actually doubled over. and this whole tongue areais called the genioglossus. you can see, it's actually encroachingon this airway so this black here, is the airway.
you can see that the base of the tongueis actually being pushed into airway. so you can see with thesedifferent areas of obstruction, this can result in sleep apnea. and what are the consequences? well, with sleep apnea you can haveproblems with daytime functioning. you can have a daytime sleepiness. you're more predisposedto motor vehicle crashes. you can have depression, anxiety,irritability, all these types of problems. you can also have decreasedcognitive function.
so your ability to processing memory,attention vigilance, and even the higher executive functionslike driving a car will be impaired. you also have reduced quality of life and a big thing is this cardiovascular andcerebrovascular disease. so you have an increasedrisk of high blood pressure. increase of coronary heart disease, increase of heart attack,congestive heart failure and stroke. and there's also evidence that you canhave increase of chance of diabetes. if you look at mortality, this is a very
large cohort of patients andit's called the wisconsin cohort study. and they looked at patientsover the course of 10 years. and, what they found out was that,they looked at severity of sleep apnea, so if you have less than five abnormalbreathing events per hour of sleep, you're not considered to havethe diagnosis of obstructive sleep apnea. if you have 5 to 15 abnormalbreathing events prior to sleep, you're considered to have a mild case. 15 to 29.9 is moderate. anything greater than 30 is severe.
and you can see this lineartrend over a 10 year period that people that tend to havemore severe cases of sleep apnea. they tended to have a lowersurvival probability over the course of those ten years. so, how do we diagnose sleep apnea? well, the minimum things that weneed are a measure of the airflow through the nose and the mouth. we also need to look at the chest wall orabdominal wall movement. and then we need to look at the oxygensaturation in the blood and
it's often measured by a pulseoximeter that's placed on the finger. this is what we actually see in our lab. so the first two channelsare brain wave activity, or eeg. this channel measuresthe chin muscle activity. this measure the right andleft eye movements. this measure left and right anterior. we measure latent movement. we also look at ekg, we measurethe snoring and we look at the oxygen saturation in the blood by using thatpulse oximeter i was mentioning.
you look at nasal airflow, oral airflow,chest abdominal wall movement, and then in some cases,we put a small catheter. it's called an esophageal pressuremonitor into the nose, and it goes into the esophagus through a tube. and that picks up transmittedchest wall pressure so we can see what the workof breathing is like. so what happens is from hereto here is two minutes. and you can see that all of suddenthis person started having a decrease in air flow through the nose andthe mouth, and then the chest and
abdomen started trying tofrantically form a breath. and finally, there was a tiny awakening. now these awakenings can occur 60,100 times per hour, in a person that has sleep apnea. but the person typically only remembersmaybe one or two, if they're lucky. because these awakenings are so brief, they're just enough toget the breathing restarted. and so you can see the personwoke up briefly, and then the breathing cycle returned.
but then had another pause in breathing. and you can see the oxygen saturation starts dropping each one ofthese abnormal breathing events. and normal oxygenation is about 90% orhigher. sometimes we see patientsthat are down to like 30%. which almost seems incompatible with life,but we do see these types of things occurring. and it makes you wonder if this can beresponsible for some of the strokes and for some of the heart attacks thatoccur in the middle of the night.
and there have been studies thathave been trying to lead that. so what are the treatments? well, there's positive airway pressure. there's different types of this,and i'll go into this in a second. there's also different types of surgerieswhere you can cut some of the soft tissue that can also cut some ofthe bony tissue to split forward. there's oral appliances, which i'll show a little bit later,as well as hypoglossal stimulation also. show that later.
there's also these nasal valves andstents. you might have heard of thisthing called progenfer. it's a tiny adhesive valve thatyou put on both nostrils, and basically you can breathe in but you can't breathe out because when youtry to breathe out through the nose, it blocks it so it puts pressure backinto the airway and pops it open. there is also a nasal stent,that i'll talk about later. there's a pressure device,a device called winx. it's basically an oral appliance that youstick in your mouth before you sleep,
and it sucks your tongue forwardby negative pressure, and then moves your tonguea little bit forward. so it's opposite from cpap. which provides positive pressureinto the airway to prop it open. there is also weight loss, which is pretty ineffective in the sense thatit can't in most cases cure apnea. but it does improve apnea. so if the person is overweight and loses weight it can actually improveapnea, but rarely can it ever cure it.
behavior modification isjust a fancy name for telling the person to either sleep ontheir sides or sleep at a 30 degree angle. and sometimes that canhelp in very rare cases. medications are primarily respiratorystimulants, things like acetazolamide. but they haven't been reallyshown to be that effective. now these are the different devices,this is just the most common devices. there's continuous positive airwaypressure, which is the most common. it's just a device that deliverspressure into the airway. bilevel pressure is mainly for
bpap have difficulty toleratinghigh cpap pressure and that delivers more pressure as you breathein less pressure as you breathe out. apap is becoming more and more prominent. in fact, that constitutes most ofthe devices that are prescribed. and basically what that is,is you set a pressure range. and then the device automaticallyadjusts by your breathing to give you more pressure when you need it andless pressure when you don't. asv is adaptive pressure supportservoventilation, and this is for people that have a different typeof apnea called central apneas.
and that can be due to heart failure, it can also be due to issues withthe brain stem, like breathing. and because of that, what happens isthere's this device that actually provides some ventilation during sleep. now, the problem with any ofthe positive pressure devices is that there's an issue with actuarysupport complaints to the device. this is one of the largeststudies that i conducted with five different centersacross the united states. and we looked at over 1,000 patients.
and we measured their adherenceobjectively by using their devices. and what we found out, as you can see, the most dense usage isbetween 300-500 minutes. which you consider a lotof people that use it. less than that. so that's one of the big problems withinto this positive person devices. is that,it is somewhat that covers some device. and it's hard forpatience to get used to it. but once you get used to it.
they can actually see dramatic effects. in all those aca mentionsi showed earlier. these are some of the side effects. you can have nasal congestion,sore throat, irritation in the eyes and skin on the face. you can have mask leakagethrough the side of the mask. you can have abdominal bloating,nightmares and excessive dreaming,headaches and rare meningitis. that only occurs if you havea base of the skull fracture.
and what happens is the air might goin the brain, but it's very rare. this slide shows the positiveaffects of cpap. so this was a study that lookedat patients that were given therapeutic cpap and patients that weregiven a sham device, or placebo device. and the placebo devicelooks like a cpap device. it gives a little bit of air andit also sounds like a cpap device, but it doesn't deliver therapeutic pressure. so this was a baseline period and what youcan see is when the individuals are awake, their blood pressure's highercompared to when they're asleep.
but when they're placedon a cpap device and they have high blood pressure, you cansee a separation of their blood pressure. so their blood pressuredecreases during the night. but interestingly, you can also see that when youwear a cpap just during the night, it also has a positive effect on your highblood pressure during the daytime as well. that's why it is considered an independentrisk factor of the development and also continuation of high blood pressure. this is an oral appliance.
it's basically a retainer ormouthguard that you wear in your mouth. it clips on your upper and lower teeth andthis is just an example of one of them. and so what happens is whenyou wear it during the night, these tabs on the upper and lower pieces. prevent your lower jaw frombeing pushed backwards. so you can open up your mouth, you can move it from side to side, youjust can't push your lower jar backwards. it actually protrudes your lower jar,and because of that, it opens up the airway compared towhen you're at the natural position.
so you can see the airway's enlarged. and this shows some ofthe advantages of oral appliances, in that it is more convenient, there ismore patient and bed partner acceptance, there is more tolerance andmore adherence. the only downside is it is lesseffective in treating the apnea. that's why we tend toprescribe it only for people that have mild tomoderate cases of apnea. and across the boardit's about 60% effective. now, if you look at upper airway surgery,
this is what's calledbimaxillary advancement. so they made cuts in the upper andlower jaws and displace it forward. and you can see what an effectit can make to the upper airway. it can dramatically increasethe size of the upper airway. this is hypoglossal stimulation. basically what it is is you havea stimulating electrode in the tongue and a neurostimulator thatdetects the breathing cycle. so when you have decreasesin your breathing, it will give a small shock to your tongue to moveit forward and to open up the airway.
this is a fairly new device, but we have been using over visit patientswith so far with good results. we've also tested this other device,it's a measle stint. it's a lubricated open stintthat you place into your nose, and basically what it does isit props open the soft pallet. it doesn't extend tothe base of the tongue that's why it might notbe completely effective. and we're just evaluating it now, andshould have the results early next year. so now i'm gonna shift to insomnia.
as you can see,there's various causes of insomnia. anything from medications to psychiatricconditions to medical conditions. and there's even some sleepdisorders that can result. secondarily to insomnia,such as restless legs syndrome, which is the urge to move your legs, that's worsewhen you're at rest or at bedtime. there's also periodic limbmovement during sleep, when your leg movements kick,and can also fragment your sleep. sleep apnea can also in somecases result in insomnia. but the basic symptoms are an inability tofall or stay asleep when desired and you
have a conditioned arousal to the bedroomenvironment or sleep-related activities. what that means is youstart to get kind of tired when bedtime approaches and then you startfeeling really tired right after dinner. and then the moment your head hitsthe pillow, suddenly you're wide awake. so that's the condition,arousal to the bedroom environment. and they also have increasedsomatized tension at bedtime. what that means is,you might feel physically, emotionally, or mentally tense more andmore as night approaches. these are two common types of insomnia.
one is calledpsychophysiological insomnia. and it's kind of an interesting name, because it might be both psychologicalas well as physiological. and an example of this is, forinstance, someone that was a pretty good sleeper and then all of a sudden hadsome type of traumatic emotional event so say they underwent a divorce orthey lost their job and their sleep was really poor forabout two or three weeks but then what happened was then they had saya better relationship or a better job. so the initial trigger that triggeredoff the insomnia improved, but
they still had the insomnia. so what we think happens is that a psychological behavioral eventtriggered off this insomnia. but then it somehow alteredthat brain chemistry or the neurons in the brain, andresulted in more persistent insomnia. now idiopathic insomnia is,we'll see a person that will come in and say, well i haven't slept since 1960. >> [laugh]>> and you realize well, this is kind of a lifelongcase of insomnia.
and generally, it has something to dowith control the sleep-wake system. so, what can you do? well, we have our techniques iuse first and i'll go into that. relaxation, stress management, stimulus control,which i'll go into can also be effective. and an occasional mildhypnotic may be used and i'll cover some of thesehypnotics in a few minutes. psychologic or psychiatric counseling maybe useful, particularly in people who have depression oranxiety disorders in addition to insomnia.
so relaxation therapy is onething that can be tried, and it can improve the sleep efficiency, meaning that it can improve the timespent asleep over the time in bed. and you can see it can improve the sleepefficiency up to about 72% meaning that, it enables the person to sleep moreof the time that they're in bed. and one of the techniques isprogressive muscle relaxation. you might have heard these tapes before. what they tell you to do, these tapeswill go on a very soothing voice and tell you to tense up your thumb,relax your thumb, and it'll tell you,
you need to do that for a few seconds. and also, then do it for your hand,do it for your elbow, do it for your shoulders, and so on. and, by doing that, you can decreaseyour wait time by 20 to 30 minutes. meditation, self hypnosis, biofeedback,can also improve your sleep efficiency. sleep restriction isa more advanced technique. what it can do is reduce your wakeafter sleep onset by over 50% and improve your sleep efficiencyby about a quarter. and this tells you how to do it, but
basically what we tell patients isto standardize their wake time. so if they normally will get up at 6:00you tell them to keep that anchor at 6:00. then what we tell them to do is if theynormally go to bed at say 9:00 pm, tell them next week to go to bed at 9:15. next week, 9:30. and then keep on doing that untilthey reach a point whenever they're never sleepy during the daytime. and when it approaches,then back off by 15 minutes. and by doing that, as i said,you can improve your sleep parameters.
you can make your sleep more efficientbecause it's actually squeezing out your awakenings that youhad during the night. now, temporal and stimulus control techniques,i mentioned the stimulus control earlier. you can expect a 52%improvement after one year. so what these control techniques mean,is you standardize the waking time, avoid daytime naps, you turn offthe light immediately upon retiring, you avoid reading, watching television,eating or working in bed. and he's tried to follow this 20 minuterule, in that if you can't fall asleep in
20 minutes or can't fall back asleepin 20 minutes, you should get up, go to another room, do something that willmake you drowsy whether that's meditation, stretching, whatever will make you drowsy. when you feel drowsy,then go back to that. and you should estimate the 20 minutes, you shouldn't constantlylook at your watch. because that in and of itself,is non-sleep promoting. now one thing that's veryimportant is photo=therapy. and what that means is that ifyou get bright light in morning,
you can advance your sleep onset. meaning that it will make yoursleep onset a little earlier. bright light in the evening can phasedelay in sleep onset meaning that if you get bright right in the evening,you can actually make it harder for you to fall asleep. so for the morning what we recommend is alight intensity of at the least 2,000 lux for 30 to 45 minutes. and we tell patients within fiveminutes of getting up go outside, because you'll get a lot of bright light.
now if you get up before sunlight,what happens is you can get these bright light boxes off ofthe internet, and you just wanna make sure that it can deliver, and mostof them do deliver, about 10,000 watts. and ultimately you should sit about 18inches away from that device, and then, if you get about 30 minutesof bright light exposure, that can affect that suprachiasmaticnucleus, that i was telling you about, that's in the brain,that governs your sleep-wake cycle. so, by doing this it can,actually, help you to fall asleep. on the flip side, you shouldavoid any bright light at night.
so, within two to three hours of bedtime,you should avoid any bright light. and that includes in smartphones, laptops. because not only can that be mental,in terms of just using a mental activity. what it also does is it produces bluewavelength of light, and that can also re synchronize your circadian ribbons andmake it harder for you to fall asleep. now if you do need medication,there are some prescription medications that actually workpretty well for the short term. one is eszopiclone or lunesta. and we might prescribe this for peoplethat have difficulty staying asleep,
because it has a pretty long half life. now, ambien and sonata,you notice they're fairly similar in terms of, they're fairly quick acting,and their half-life is short. so they don't stay around a long time. so that's why we tend to use it for peoplewho have sleep initiation difficulties. now zolpidem release issort of between ambien and lunesta in terms of the half life. so it can help in certain cases. but there's always adverse events, and
these are just some ofthe ones that can happen. you can also have, one thing that has become very muchin the news is these parasomnias. you can have sleepwalkingwith some of these, you can have confusion in the morning. so it's very importantto be careful of these. so in the remaining minutes,what are some of the do's that you can do? well, as i said maintain regularbedtimes and awakenings. try to optimize your sleep amounts,make it at least seven hours.
use a bright light in the morning,create a comfortable, quiet, dark, and temperature controlledbedroom environment, establish a regular pattern of relaxingbehaviors within an hour before bedtime. so go to a ritual thatwill help you go to sleep. try to get exercise on a regular basis,but avoid it within two to three hours beforebedtime because it can be stimulating. now, don't take a nap. there's always exceptions. and the exceptions are, if you're aboutto get behind the wheel of a car,
you're sleepy, or, if you take a napeveryday, at the same time, for the same amount of time, then you'rebody is used to it and it's okay. but if you have to take a spontaneous nap, you should try to take it forabout 20 minutes. if you take it longer than 20 minutes, what will tend to happen is you'llhave this thing called sleep inertia, which means that you end up very groggy,after taking an extended nap. and the reason is, is that you're gonna gointo the very deep sleep, the n3 sleep. what you wanna do is you wanna get intothe n1, n2 sleep which is the lighter
sleep and that will be restorative foryou for the next couple of hours, but it will prevent you fromgetting the sleep inertia. you should avoid eating ordrinking heavily before bedtime. you should set a limit,the 20 minutes i talked about, just in your mind estimatewhat the 20 minutes is. and if you can't fall asleep, or can't fall back asleep within 20 minutes,just get up and go to another room. do something that makes you drowsy. try to avoid disturbances,you should avoid reading or
watching television unless theseactivities definitely make you drowsy. and then you should avoid the useof alcohol, caffeine or nicotine. so, this is a slide tellingliterally about our center. i'd be happy to answer any questionsthat you might have at this point. >> [applause]>> yes my name is art. can you recommend orprint any research where, you just touched upon it in the talk about,i might call it high tech sleep hacking where you might usesome kind of electrical stimulated. because as we get older,we get less deep sleep, and
if we could increase the deep sleep,that would probably be beneficial. but we don't want to take drugsto do that, particularly. >> right.>> so do you know of any researchthat we could look to? >> the only thing thattends to work consistently in improving insomnia iscognitive neurotherapy. and those are the slides thataren't showing you the end, to behaviorally improve your sleep. >> beyond that.
beyond the behavior therapy, like high tech cerebralelectrical simulation that one? >> so there have been circumstanceswhere transcranial stimulation of the brain and i just had a look atsome of the articles a few days ago. but that work did not showconvincing improvement. >> well, anything brand new can't haveshowed anything in the long term, so that's not necessarily condemning, andit just says that there's not enough data. >> there's probably enoughdata at this point, but other than that, other than medications,other than cognitive behavioral therapy.
there have been really technological improvements for helping sleep. my lab are actually partneringwith a tech firm here in the area and hopefully we'reworking on a model that might well, in about maybea couple months to a year. if this study works out,it might have some promise. but certainly along the lines of what iwas talking about, a simulating device. >> thank you. >> yes, is there, first of all,
any correlation between heavyphysical activity and sleep need. for instance, professional athletes,do they need more sleep? or could physical activitybe actually therapeutic? as we grow older, we do less physical activity andperhaps that affects our ability to sleep. and the second is there anycorrelation between heavy mental activity andtense mental activity and sleep need? for instance, kids that play video games,age 14 to 19, and do nothing else, i understandsleep an average of 14 hours a day.
>> in answer to your first question, there has been studies that have lookedat the effect of exercise on sleep. and particularly if it is administeredin the morning or afternoon. it can improvement in sleep, can improve sleep efficiency as wellas your ability to fall asleep. and actually i think there wasan article within the last month. they have looked at actually patientsthat were elderly above 80 years of age. and what they showed was,even with a moderate exercise and consistent stretching as wellas some kinetic exercise,
both of those types of exercise hadan effect on sleep in a positive way. so, excercise, yeah,absolutely can improve sleep. now, your other questionwas about children. >> little activity, video games intense,and then they sleep 14 hours a day. >> yeah, sowe tend to recommend against that if a child oradult has difficulty sleeping. if they don't have difficulty sleeping or if they don't sleep a long period of time,then that's why. but interestingly, there have been
studies that have looked at the effectof video games on some sleep disorders. for instance, restless leg syndrome, i was just talking about that,is a pretty common sleep disorder where you have an urge to move yourlegs that can disrupt your sleep. they've had subjects play video games and it actually improvesthe restless leg syndrome and that could be related to distraction orother processes. but i thought it was kind ofinteresting that in some cases, using video games canactually improve sleep.
>> if you have been diagnosed withnarcolepsy, other than taking ritalin, are there any recommendations to keepyourself awake during meetings and sermons? >> yeah, so with narcolepsy, ritalin is one ofthe more common stimulants that are used. now, if the person doesn't have cataplexy,and cataplexy is that sudden loss of muscle tone that's associated with suddenemotions such as laughter, anger and surprise, if they don't have cataplexy,then stimulants and scheduled naps are considered first line.
the other type of treatment that'sa relatively new medication called xyrem. it's xyrem, andthe generic name is sodium oxybate. what that does is,it helps to consolidate sleep at night. so, it reduces the fragmentation ofsleep for people, who have narcolepsy. it also helps a little with the cataplexy. so, aside of ritalin,there are other medications, that could be tried, if the person hascataplexy, who doesn't have a cataplexy. it's something that should bediscussed with their sleep specialist. >> sure.>> i was curious as to why you didn't
mention taking synthetic melatonin? i've been taking it for 25 years. i estimate that it has increased mynightly sleep by an hour and a half, so 45 hours extra sleep a month. some friends say to me,well, don't do that, because your body is gonna produce less melatoninif you're taking the artificial stuff. and i say to them, well,i take time release melatonin. i fall asleep easily,even when i forget to take it. what it's doing is it's keepingme from waking up after,
at like four in the morning. >> mm-hm. >> instead of waking up at seven. >> absolutely. the reason i typicallydon't mention melatonin unless i'm asked a questionabout it is because it's not an fda approved medicationit's actually a substance. but with that said, can be helpful forpeople that have insomnia, also people that have shift work,and also non-sided individuals.
it can be very beneficial in helpingwith circadian rhythms and so using melatonin can be effective, thething about the administration is you have to be careful about when you take themelatonin because it's actually optimal at the time whenthe temperature curve is lowest. so the slide that i showed youwhere there's a peak of melatonin. it exactly coincides witha drop in body temperature. so when you take it close to that drop,it can help with your insomnia. >> extended release shouldsolve that problem. >> it should solve that problem.
but you might have to play aroundwith when to administer the dose. the other thing is that there isa medication called ramelteon, it goes by the name rozerem, but so far it hasn't been shown to bethat effective with insomnia, compared to cognitive behavior therapy orother medications. >> what about, well, taking melatonin, would that increase my body'scapacity to produce it? >> that's interesting. so taking melatonin can have an affecton your endogenous melatonin.
i don't think that's beenstudied enough to actually know whether or not that's true. but certainly, if you have insomnia or i think it does have a role at this point. >> has there been any study on cpap for people with insomnia orpeople with dementia? that it improves cognitive performance for those people that do not have obstructive,sleep apnea, just standard. >> okay, sopeople that have insomnia and it doesn't
improve their mental cognition by using->> mental cognition or improve their rem sleep. >> yeah, that's tricky, that's a very tricky question becausethere's some people that believe. that most insomnia cases,especially sleep maintenance insomnia, where you can't maintain your sleep, a lotof those cases are caused by sleep apnea. and, you know, what's interesting is,even from personal experience, you know, i've been doinga study over at the va, the. we're looking at a lot ofindividuals that are in their 70s or
80s who respond to an advertisement forsymptoms of insomnia. and i have to say that a large percentageof those patients actually have undiagnosed sleep apnea,even though they present with insomnia. now, with respect to your questionabout insomnia having effect on neurocognitive effects,there are some that do indicate that. that lack of sleep as well as insome patients that have insomnia that have been worn out forother causes or other sleep disorders, there can be a decreasein cognitive function. but i think by far,it's not definitive yet.
>> i'm curious about dreams. so i, on a near nightly basis,have incredibly vivid dreams. i'm not on anything. i'm sober. but like they're very, very vivid. and i remember dreams back towhen i was you know, 3, 4, 5, 6, 7 years old, 27, soit's not of that long but. and meanwhile, many of my partnersbarely remember their dreams at all, male partners, and i'm just curiouswhy i have such vivid dreams,
but others do not, andwhy i remember them so strongly. >> so one thing that might be responsiblefor it, and i'm not sure, but one thing that might be responsible forit is that 90% or more of your dreamsoccur during rem sleep. so if when you wake up in the morning, your sleep pattern of whenyou wake up is variable. it could be that you're catching itin the middle of rem period, and that's why you remember it. the other thing is that mostpeople don't have a 24 hour cycle.
so your 24 hour period isactually kinda like 24.6 hours. so that means that they have a naturaltendency to wanna go to sleep later and get up later. so if you do get up everymorning at the same time, and you're one of those you'regonna have an extended clock. that can also cause you toremember your dreams because your major rem period would tend tobe delayed each successive night. and the rem periods tend to get longer,more intense as the night wears on. so actually most of the rem sleepoccurs just before a person wakes up.
so that could explain, butotherwise i'm not sure. >> i vaguely remember dr. demen talking about lucid dreaming, but idon't think i was paying enough attention. >> [laugh]>> i'm wondering if it's detrimental overa long period of time to be required to get up every twohours to urinate in the night, if your total hours are about nine hours. is it bad over the period of time,maybe 40 years? >> right.>> [laugh]
>> well, the interesting thing is there's been studies that havelooked at bladder capacity and sleep. and what they've found out isthat the bladder would have to be extremely distended in order towake up the person from sleep. that's why whenever a patient comes in and has that as one of theirpriority complaints. we typically will->> it's been happening to me. >> sorry?>> very little. >> yeah, well->> every two hours.
>> right, right, butwhen we tend to do a sleep study, what we find out is that a lot of times,it isn't due to the urge to urinate. it isn't due to the bladder. more commonly, it's due to other factors. and one of the big ones isobstructive sleep apnea. it can also be periodic limb movementsthat are causing the person to wake up. but it can also be as simple as justsomething in the external environment, like noise or the bed partner. it can be many different causes, but
that's one of the things that we reallylook at because it's very unusual for a person to wake up just becauseof their bladder being distended. it would have to be very muchdistended to wake the person up. >> my question is,over a long period of time, do you find that's itdetrimental to your health? >> in the very few cases where it's causedjust by increasing bladder capacity waking the person up,there hasn't been any repercussions. >> but otherwise,you're not worried about it. >> yeah, otherwise,we don't really worry about it.
but what we do tend to stronglysuspect other causes for waking up due to inability to urinate. >> i see, thank you. >> sure. >> so if you have a similar question,but you have bph, does that, and it wakes you up,every couple hours, is that something that is causedby the bph or caused by apnea? >> bph is different in the sensethat if the person has bph, it would tend to maybe wake the person upin the middle of the night and then have
to go the bathroom because it would exertpressure and cause a person to wake up. so yeah, in those cases andthe same thing goes. i forgot to mention is if the personhas a chronic pain syndrome. as the person gets older, they might have some pain that mighttend to wake the person up as well. yes. >> i was talking to somebody todaywho said he never gets jet lag. he travels a lot, he said no,i exercise, i don't drink on the plane. i have a terrible time withit the first night or two,
and if i take something like sonata,it's wonderful, but i have a, problem with itthree days later when i quit. then i have a reaction. >> so for jet lag,one of the things that can be done and can help is what some people will do isthey try to stay awake during the flight. and that will help,especially if it's a long flight, to help adjust to the new time zone. and then the other thing that can bea benefit is to use bright light. so within five minutes of getting up atthe expected waking time at your new time
zone to make sure you get a lot of brightlight exposure within five minutes of getting up and then avoiding brightlight at night because that's one of the strongest stimulus to helpresynchronizing the internal clock. you can also try melatonin and suspension. so melatonin and bright light are some ofthe ways to help compensate with jet lag. the other way is what you mentioned,by taking medications. >> i really don't likethe medication idea. >> yeah, it can definitely cause problems. but bright light and melatoninare other things you might consider.
>> two questions, one is that you hadindicated if you can't got to sleep for like 20 minutes, go to another room. and the question is what do you do and how long would you do whatever dobefore you just kind of give up? >> right, so some people will meditate ordo very light stretching. some others would alsoread a very boring book. but if you read, you should definitelyread it in a very dim light and try to stay away from readingit on a tablet because you'll get that blue wavelength of light.
so these are some things that you can do. now, if you're the type of person that thereading doesn't really help you to fall asleep, then you should avoid that. but just things like meditation,light stretching, listening to soft music, anything that will normally tendto help you to fall asleep, you should do, but you should do itin a very dim or dark environment. >> how long would->> just until you start getting drowsy, until you start getting drowsy. and then if you don't, right, soyou would just keep on doing it.
and then what would happen is whenyou reach your normal awakening time, say you've been kept awake for two orthree hours, and your alarm goes off. then, what you should try anddo is to try and maintain your alertnessthe next day if you can. and if you can't,to take only a 20 minute nap. but if you can,extend it to your next bedtime. that would be the best thingbecause then you would really try to get in the habit of falling asleepat your desired bedtime and waking up. so put a little bit of sleep pressure,sleep onto your next cycle.
>> and the second question, as youindicated, no alcohol and no tobacco. but it seems like if you havea cup of coffee in the morning, one cup once in awhile,it wouldn't matter that much. and the same thing with alcohol,an occasional glass of wine. so could you kind of quantifyat what point it would tend to be too much to makea significant difference? >> yeah, so caffeine isn't bad ifyou take it in the morning and your body is used to it. and it doesn't necessarilyprevent you from falling asleep,
so in that context, it's okay. the reason why we tend to tellpeople to avoid it is that they have really bad insomnia,because even small doses of caffeine can cause a person to havedifficulty sleeping. alcohol, interestingly,can have a person fall asleep quicker. the downside is it cuts into rem sleep and non-rem sleep, andreduces total sleep time. in addition, if the person ispredisposed to apnea, as i mentioned, it can worsen apnea.
but if the person takes it early enough,before they fall asleep, and they do it consistently,and it doesn't really have that much affect on sleep,then it shouldn't be an issue. it's only if the person hasinsomnia that we tend to tell people to cut backon some of these things. >> my mother was in the hospital fora long time, and i was sitting there for a long time. and it seemed like there weremany interruptions and noises, and a very difficult environment for rest.
and i had always been told thatrest was conducive to healing. has anybody looked at sleep-optimizeddelivery of hospital care, maybe looking to see if it couldshorten hospital stays for people? >> yeah, that's a very good question. and there have been a few studies,but definitely not enough, because it's hard to actually do thesetypes studies within the icu environment. and that's where most ofthe studies they have been done. they've been done inthe intensive care unit. and the studies have shown a positiveeffect when they kind of limit
the amount of interruptions, and whenthey actually dim the lights in the area. so it can have a positive effect, butyeah, there has been very few studies. >> thank you.>> sure. >> so i've had all kinds of sleepdisorders, and i had what dr. used to call stage four, the sleepwalking,sleep talking, bed wetting. i had all of that when i was younger. so the first question is do you think thatthose kinds of sleep disorders can make you more likely to have something likeapnea, or are they just totally unrelated? and the second question is, so i dohave apnea, and i've got the overweight,
diabetes, high blood pressure,all of that stuff. lord knows how long i hadit before i was diagnosed. i now have been on my bilevel pap for[cough] about three years, and i'm pretty good aboutusing it regularly. so, can i reverse any of the bad stuffthat happened to me, or am i just screwed? >> yeah, no, it's kind of interesting,because the sleepwalking episodes that you mentioned,what happens is, in our current thinking, is that those episodes are actuallytriggered by either external or internal events inpredisposed individuals.
so if a person is predisposedto have sleepwalking and is subject to a really loudnoise within the bedroom, or has an apnea event during sleep, those types of things can actuallytrigger off a sleepwalking episode. so one of the things, especially in children, what we'll tendto do is we'll tend to screen them for apnea, and also other things thatmight be fragmenting their sleep. because it turns out that,it sounds counterintuitive, but these type of events,whether it's loud noise, or
bright light, or an apnea episode,can actually trigger off an episode. so it is kinda interesting. what we found out is that when we treatsomething like apnea in a child where their main complaint was sleepwalking, it can actually reduce the amountof sleepwalking episodes. >> interesting, butthe second question is, so let's assume i had apnea foranywhere from 5 to 40 years. who knows how long i had itbefore it was diagnosed, and now i've been on the bilevel pap for3 years.
i understand that, hopefully, i'm not gonna get anyworse because i'm treating the apnea. but you don't actually gain back anything,right? >> well, it puts a pause in the healthconsequences of sleep apnea. so by treating the apnea, it actually tends to improve thingslike the cardiovascular consequences, like the risk for stroke,heart attack, high blood pressure. it does tend to improve that, so that's why it's importantto get treated for that.
>> [inaudible]>> [applause]