Pillow Fight: Sleep and Chronic Illness (Part 1)
Trouble tossing and turning? Experts offer tips for getting better sleep, plus an overview of sleep disorders and sleep testing, from A to Zzzzzzzzzzz.
Timothy Morgenthaler, M.D., president of the American Academy of Sleep Medicine (AASM), and professor of medicine at Mayo Clinic, discusses sleep and chronic illnesses, including pulmonary hypertension, Huntington’s disease, and narcolepsy, and gives tips on regulating sleep, and testing for sleep disorders.
There’s growing public awareness of the importance of sleep. Sufficient sleep is definitely considered one of three pillars of a healthy lifestyle, as important as good nutrition and regular exercise.
Public awareness is also growing of just how common sleep illness is. More than 70 million Americans suffer from a sleep problem, and over two-thirds of them have chronic sleep disorders that can actually affect their overall health. To learn more about that, sleepeducation.org is a very good site with further links to good sleep education.
Along with this awareness, there’s more and more research about how important our circadian biology is in our performance and in our quality of life, and in things like regulation of weight.
I think most people are aware of our obesity epidemic, and it’s probably only been in the last few years that people are really beginning to connect the dots, that part of the obesity epidemic is the insufficient sleep epidemic. We know that there’s a tight linkage there.
Obstructive sleep apnea is a serious medical illness, affecting as much as 20 percent of the Medicare-age population. Along with already existing effective treatments, new technologies are being developed to treat sleep apnea. These advancements in treatment techniques will offer more and perhaps better ways to manage this illness.
Research in the pathophysiology of narcolepsy is also leading to the development of new therapies for sleep. There are advances in circadian biology, treatment of sleep-disordered breathing, diagnostic capabilities, and the neurobiology of sleep.
Patients with chronic illnesses should really value their sleep. They should strive hard to achieve adequate sleep, first making sure they’re following healthy sleep habits.
If they are not rested, despite their best efforts, they should seek help from their physicians, and in many cases, they would benefit from referrals to a sleep specialist at an American Academy of Sleep Medicine (AASM)-accredited center. We have over eight-thousand sleep specialists in the United States. Sleep is important, and we can often help. We have very good capabilities to diagnose and treat sleep.
For people both with and without chronic illness, many of the same things apply in regulating sleep.
- It’s best to set a specific bed time and not really vary from that bedtime more than about 30 minutes either side of that time, from night to night, from weekday to weeknight.There are two main forces that help us sleep. One is our circadian rhythm, and the other is sleep pressure. Circadian rhythm depends upon our brain’s internal clock, and that clock is influenced by light and by food, to a large extent.
- It’s important that we try to keep regular schedules, with our timing of both sleep and meals, as much as possible. People should really try to set a wake time that’s 7 to 8 hours after their bedtime. And once they establish that pattern and get it worked out, they should try to adhere to that as much as possible.
- Naps are not a bad thing, but if you do take a nap, you should do it when you’re sleepy, and you should probably limit it to only 30 or 40 minutes. If need be, set an alarm clock, so that you don’t rob a lot of the sleep debt that then would allow you to sleep at night, when you were maybe preferring to sleep.The problem is when people are sleep deprived, because they haven’t allowed enough time to sleep at night, and then they sleep multiple hours during the day. When it’s time to go to bed at night, they can’t get to sleep, and that becomes a problem.
- People who exercise regularly tend to sleep better. It doesn’t mean that you have to do intense exercise, but exercise like walking or bicycling, anything that would get you moving around regularly throughout the day.
- Avoiding coffee, let’s say more than four hours after your wake time, would be wise for people who are having hard times sleeping.
- Avoid alcohol within three hours of bedtime. Alcohol can make one drowsy, but it fragments sleep, and people tend to wake up more, and sometimes have more difficulty getting a good night’s sleep.
- Try not to go to bed with a full stomach. Have your last meal three or four hours or more prior to bedtime. But there’s nothing wrong with a light snack right before bed. In fact, some people advocate light snacks of things like milk, yogurt, eggs, meat, or nuts. If you tend to be hungry at night, you might try this and keep a diary, so you study what happens when you do these things to your sleep. Does it help or not? And then you can make a judgment and ask, ‘Are these extra calories that I’m taking at night worth it to me?’
- Other substances that can get in the way of sleep include tobacco, either chewing or smoking tobacco, or now, e-cigs. All of those have nicotine. Nicotine is a very potent drug that speeds your heart rate, raises blood pressure, and stimulates brain activity. If you’re a regular smoker, there’s also withdrawal effect that can wake you up inappropriately and fragment your sleep, so it’s a bad substance.
- Your bedroom really should be used only for sleeping, reading, and sex, not for watching a lot of television, or answering your cell phones, or for playing computer games. It should be as comfortable and dark and quiet as possible.
- A good nighttime ritual is helpful. I think, especially in people who have chronic illnesses, not uncommonly, they do have more difficulties with anxiety and depression. Taking some cognitive behavioral approaches, like learning and practicing relaxation techniques, and where necessary, medical management of anxiety and depression, can really help people with their sleep. People should be screened for those conditions and treated appropriately for them.
If even after following good sleep hygiene, you have sleep apnea, either obstructive or central, you’re still not going to sleep as well as you might, and you really should seek treatment for your sleep condition.
Also, with some of these disorders, people tend to have more chronic anemia, and anemia can be associated with restless leg syndrome, which can also cause problems for sleep. That’s another sleep condition that can be appropriately diagnosed and treated, usually very effectively.
The sleep misconception we hear the most that is the least true is: ‘I can get by just fine with only five or six hours, and then I make it up on the weekend.’
What most studies show about how sleep deficit affects us, is that it’s very much like alcohol, like being out with a friend who has had one drink too many, but they don’t think they have. They think they’re just fine. But you know them well, and you’re watching them, and their mental acuity, judgment, and coordination aren’t so good.
Sleep deprivation is a lot like that. Studies show that we’re very poor at really detecting how our lack of sleep is affecting our performance. We don’t actually feel as sleepy as we are. We don’t realize that we’re not thinking as well as we should. What study after study shows, is that you really do need about seven hours or more of good quality sleep to be at your best.
When you get less than that, you tend to crave the wrong foods, and it tends to be associated with the development of medical illnesses. It tends to decrease your cognition, reaction time, coordination, mood, and judgment. People can become very convinced that they really don’t need that.
They’ll often say, ‘Well, I’ve read about people who are short sleepers.’
There are a few, very few people who can get by and not show detriments until they get quite a bit less sleep. But that’s very few people, and it would kind of be like suggesting, ‘I know people who can run the marathon in less than four hours, and so I can.’ That isn’t going to happen.
Board certification for sleep specialists is given by the same American Board of Medical Specialties that certifies critical care medicine, pulmonary medicine, and neurology. It’s a medical specialty, like any other.
Accreditation of a sleep center basically takes into account a review of the facilities. What is the physical plant of the place like? Is it safe for patients? Of the processes, are referral patterns, records, treatment pathways, and emergency procedures best practices?
There’s also a third leg that looks at the diagnostic and therapeutic procedures. Any facility that’s accredited by the American Academy of Sleep Medicine (AASM) must follow the standards that are laid out in our treatment guidelines and practice parameters.
When facilities are AASM accredited, they have to be able to demonstrate that they are already following the current practice parameters and treatment guidelines. We very tightly link accreditation with state-of-the-art practice
Finally, there’s an important emphasis on quality improvement, so that they’re monitoring quality and have active programs to improve their quality.
Different diagnostic tests that might be used at a sleep center would include actigraphy, which is a way to add to a sleep diary and learn more about the sleep patterns of a patient.
A polysomonogram (PSG) is typically an in-facility monitored test that measures brain waves, muscle tone, eye movements, oxygen saturation, EKG, efforts to breathe, and air flow, so it’s the most comprehensive test of sleep.
The multiple sleep latency test (MSLT)offers five nap opportunities during the day, and we measure how long it takes for a patient to fall asleep and what stages of sleep they fall into.
The maintenance of wakefulness test (MWT) is similar to the MSLT, but kind of the opposite instructions are provided to the patient: Please stay awake in a very boring environment, and we see how effective they are with that. There can be home sleep apnea tests that are applicable to many patients who might have sleep apnea.
There are blood tests that are sometimes useful in evaluating, for example, restless leg syndrome, or sometimes narcolepsy, or thyroid disease. We might look at blood tests to help us make those diagnostic assessments, and depending on the history and the presentation, we might look at other tests of cardiac and pulmonary function as well.
In management of all chronic illnesses, there’s a component where you want to use lifestyle changes and non-pharmacologic approaches to the illness, and then sometimes it’s wise to add a pharmacologic component.
As a sleep specialist, we use medications often to help with sleep, but you might be surprised. [With] many patients who come to us for insomnia, we would prefer to use cognitive behavioral type of therapies, which are actually safer, at least as effective and don’t involve controlled medications. You have to really develop a comprehensive picture of patient needs and then pull out all the tools to serve those needs.
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