October Mini-Medical School #5
Stephanie Taylor MD PhD
More than twenty years ago Dr. William Dement gave a Community Hospital Grand Rounds on Sleep Medicine. Dr. Dement is one of the founders of the field. At the time it was new and without much professional recognition. His efforts to convince the Traffic Safety officials that drowsy driving was as dangerous as drunk driving met with no success. Somewhat disheartened and at the end of a long day, he settled into his back yard with a beverage to contemplate his next step. Within a few minutes, a car crashed through his fence and safely came to rest in his yard. The driver had, of course, fallen asleep at the wheel. This event was a bit misplaced, since he, himself, did not need convincing, but rather the local officials down the road. It does make a good teaching point, however, as we now have a greater appreciation of the risks of sleep deprivation to both airline and road traffic safely. There has been significant progress since Dr. Dement’s backyard incident. In 2010, the National Transportation Safety Board appointed its first trained sleep scientist, Dr. Mark Rosekind. In 2003, the accrediting agency for graduate medical education approved Sleep Medicine as a formal training program.
Sleep medicine is a vast topic, and this essay will be an introduction to the field with some helpful practical advice.
The two most common sleep complaints are sleep apnea and insomnia.
Sleep apnea (OSA) is defined as the cessation of regular breathing during sleep, usually attributable to a collapse of the airway. The prevalence is variable and can be as high as 20% of the general population. The health risks associated with sleep apnea are: daytime sleepiness, heart failure, hypertension, lung disease, obesity, stroke, depression, and diabetes. Associated morbidities are decreased work performance and an increase in work and leisure time injuries. The cost of untreated OSA is high with OSA related traffic accidents alone reaching $15.9 billion and 1400 lives in the year 2000. OSA is successfully treated with positive pressure ventilation or dental appliances. The difficulty is in getting individuals in to be diagnosed and treated. Common questions on diagnostic questionnaires are: Do you snore? Is your snoring loud? Does your bedpartner notice you not breathing or gasping during sleep? Have you fallen asleep during the day? Do you have high blood pressure?
Insomnia is even more common than OSA. The incidence varies depending on the severity, ranging from 20-40% of adults. Insomnia is commonly treated with oral prescription medications. In the last year surveyed, 2011, there were 60 million prescriptions written, amounting to $3.7 billion in sales. Alcohol is also commonly used for relaxation and will induce sleep, but there is usually a recurrence of insomnia between 1 and 3 AM. Taking a sleeping pill regularly is not a solution. Most sleep medications can induce dependence, both psychological and physical. Furthermore, the quality of medication induced sleep is uncertain and is the subject of much research.
Some think it is fashionable to brag about not needing much sleep. This brag is unwise. There is a newly discovered mechanism in the brain called the glymphatic system. It seems to be the “trash collector” for the brain and is most active during sleep. Part of that trash includes beta-amyloid, which is associated with the development of Alzheimer’s disease. It is possible that deliberate reduction of sleep duration will increase risk of dementia. Indeed, the diagnosis of dementia is often preceded by several years of sleep disorder.
There are many more sleep disorders, but OSA and insomnia are the most common and familiar. Here are some practical suggestions for better sleep.
The ideal sleep duration is different for individual adults, but is 7-8 hours is ideal. If you suspect sleep apnea, that requires evaluation by a sleep specialist, but occasional insomnia will respond to home remedies. Pre-sleep preparation is very important. Here are some basic tips:
Minimize stimulants after 2 PM. That would include caffeinated beverages and some nasal decongestants. Do not exercise or eat within 3 hours of bedtime. There is clear association of poor sleep quality and use of cell phones, computers and pads before bed. Not only is the information stimulating, but the blue light prevents the normal release of sleep inducing neuro-chemicals. There are some pads that have a blue filter scheduled to apply at 8 PM, and these are worth investigating if you need to keep working in the evening.
Psychological issues-tension and stress. Avoid stressful activities before bed. This would include listening to the evening news, paying bills, arguments and general worry. You are not going to get anything solved between midnight and 7 AM, so just let it go for the evening.
Plan to go to sleep and arise at a regular time each day. This help train your body to a regular cycle. Stop eating 3 hours before you plan to go to bed. If your gut is busy, your brain will not have a chance to relax. If you get home late and need to eat, try something very light and digestible.
If you are having difficulty sleeping, stop trying after 30 minutes, and leave the bed and do something relaxing, and not computer based. Reading with a small focused light is helpful. Too much illumination will reduce the neuro-chemicals that are needed to induce sleep. If you are fretting, try writing down your worries. You can keep a self-illuminating pen and journal near the bed.
Your best sleep environment is a dark room with no disturbing noises. Background white noise or a HEPA air filter are soothing. Electromagnetic fields are not helpful to sleep, and you should be 8 feet away from those fields. You can assess your environment with a Tri-field meter, and common sources are clock radios, cell phones and computer screens.
Your bed should be a source of comfort, and good mattress, bed linens and blankets contribute to a positive sleep experience. Ariana Huffington wrote a lovely book called The Sleep Revolution that I highly recommend. There is a great list of sleep friendly hotels in the back. Very handy for your next travel adventure. Her TED talk is available at: https://www.ted.com/talks/arianna_huffington_how_to_succeed_get_more_sleep?language=en
Supplements that help sleep are very popular and fairly effective. You may need to try several before you find the right combination for your own chemistry. These are sold over the counter, and like all OTC supplements, you need to be sure you are buying good quality. Popular herbs are Valerian, ashwaganda and passion flower. Supplements that are also effective and safe are glycine, taurine, magnesium, l-theanine and melatonin. If you are on antidepressants, do not take 5-HTP for sleep as it would be contraindicated, but it is otherwise helpful.