The great thinkers have pondered for ages the mysteries of that dark place we go every night when we close our eyes and drift off. Most view sleep as a blissful respite. Some curse it as a waste of time. Yet others approach it with dread, for they spend the night restlessly tossing and turning. No matter what we think of sleep, it is as inevitable—and necessary—as death and taxes.
sleep: what is needed?
Only recently have we learned the physiological secrets of sleep. The four stages of quality sleep based on brain wave activity, while common knowledge today, were unknown until 1937. So what is all the fuss about? Does it really matter whether we get six hours a night or eight?
sleep on it
“People who are chronically sleep-deprived inevitably have cognitive impairments, mood disorders and systemic problems, along with actual diseases such as high blood pressure and increased risk of heart attacks,” says Dr. Dayton E. Dmello, a pulmonologist in the Mercy Clinic at Mercy Hospital-St. Louis. “They are at the highest risk for impairment in intellectual functioning, depression, irritability and emotional stability.”
Dr. Oscar A. Schwartz agrees. “A lot of studies in the past 30 years have looked at how much sleep people need. Some of the things we worry about in later life—strokes, dementia, Parkinson’s disease—are increased in people who average less than seven hours of sleep per night,” says the pulmonologist at the Center for Sleep Medicine at Barnes-Jewish West County Hospital.
Those sleeping hours are used by the brain to consolidate memories and manage the body’s functions. “Hormonal regulation is part of our sleep cycles,” Schwartz says. “People with short sleep times tend to have changes in hormones that promote weight gain, so one of the things related to sleep is obesity. Sleep affects how we deal with insulin, so another issue would be diabetes.” The brain also does its mandatory housekeeping during sleep, he says, “getting rid of the odd proteins that are part of everyday life but need to be washed out.”
fooling mother nature
We all know people who swear they get by on a few hours of sleep. Really? “The textbooks say seven to eight hours each night is the average,” Dmello says. “There are ‘short sleepers’ who can get by with six to seven hours, but those are exceptions. It has not been determined what makes them different. I think they are genetically wired to get into the deeper stages of sleep very quickly.”
Many who consider themselves ‘short sleepers’ simply have become accustomed to a foggy state of mind, Dmello says. “From my experience, the people who say they do well with six hours are not really doing well; they just have learned to establish a different level of normalcy,” he explains. “When they actually get a good night’s sleep, they feel better and often realize that what they were perceiving as normal is not good.” Schwartz finds the same to be true. “Some people come into the sleep medicine practice and say, ‘I don’t know what the fuss is—I’ve always slept five to six hours, and I feel fine,’” he says. “Then they fall asleep right in front of you. You wake them and tell them they were sleeping, and they say, ‘I just had my eyes closed.’ ”
plan ahead
Spending more time in bed does not compensate for a bad night of sleep, Schwartz says. “It’s a misconception that you should spend a longer time in bed, even if you’re not sleeping, thinking that just resting will be of some benefit. It does the exact opposite. The longer you stay in bed, the more fragmented your sleep is going to become.”
A healthful night begins with planning, Dmello suggests. “The concept is sleep hygiene. A good bedtime routine is the same every night—turn the lights off when it’s time, and that’s it.” Today we have all kinds of bright gadgets that mess with the body’s sleep instincts, Dmello says. “We get into bed but we are not ready to sleep,” he points out. “We are on our phones and laptops and iPads. Those are big distractors because any kind of blue-light screen triggers the same reflex that wakes us up in the morning. At night that prevents us from getting into a deep sleep easily.”
sleep studies
While sleep problems are, no doubt, as old as mankind, the field of sleep medicine is very new. Thirty or 40 years ago, few had heard of sleep apnea or understood its impact on general health. Today, we know millions of Americans who suffer from its effects—and researchers are aggressively pursuing more knowledge to improve the misery of sleeplessness.
to sleep, perchance to dream
“Sleep apnea is not a new problem, but it was underdiagnosed,” says Dr. Mesfin T. Mitike, a neurologist and medical director at SSM Center for Sleep Disorders. “Many studies have shown that sleep apnea has major effects on health—congestive heart failure, heart attacks, stroke, high blood pressure, weight gain, low libido or low testosterone levels,” he says, adding that sleep is now considered the primary or secondary treatment for many of these. “Because of this, many sleep labs are needed.”
A sleep study is the standard for diagnosing sleep issues and identifying causes. Patients referred to a sleep study center usually arrive after dinner and are wired head to toe. “They sleep their regular hours, during which their brain waves, breathing, movements and heart rhythms are monitored,” says Dr. Yo-El S. Ju, a neurologist at the Washington University Sleep Medicine Center in Brentwood.
“We read the brain waves and look at eye movements and muscle tone to see what stage of sleep they are in,” she explains. “We also monitor air flow in and out of the nose and mouth. Oxygen measurements are taken, usually off a finger.” A technician in the next room records audio and video of the test.
“There are no needles, nothing invasive or painful, but it is very strange,” Ju says. “We expect people will not sleep as well as they do at home. If they have difficulty, we may have them take a sleep medication for the study. The majority of people toss and turn more than usual, but they do fall asleep and we do get enough data to be diagnostic.”
grading the test
Data gathered during the study are scored by a sleep technician and a sleep physician, Mitike says. “We will rate the overall quality of sleep and whether they have health-affecting situations that need to be treated.”
Poor sleep can result from periodic leg movement, seizures, insomnia or RBD, a REM sleep behavior disorder. REM (rapid eye movement) is one of the four sleep stages, and patients who have RBD may have vivid, intense dreams that are physically acted out.
“Identifying the problem is the first part of treatment. The solution comes from that,” Mitike says. “We try to diagnose the patient in the first two to four hours. If they have serious obstructive sleep apnea, we start CPAP right there, during the second part of the night.”
take-home test
Sleep studies are generally covered by medical insurance, but the increasing demand has led insurance companies to push for less-expensive home tests, Ju says. “The quality and amount of data we get with a sleep lab study is much better,” she says. “Home studies are used exclusively to determine if someone has obstructive sleep apnea, the most common diagnosis.”
The home study monitors just a few functions, she explains. “It is simple enough that the average person can attach the wires, and it monitors the air flow in and out of the mouth, the body’s effort to breathe, and blood oxygen levels. The patient turns on the recorder, sleeps, and brings it back the next day.”
treating apnea
F. Scott Fitzgerald observed many upheavals brought by modernity to early 20th-century society, among them: “The worst thing in the world is to try to sleep and not to.”
the stats
At least 25 million adults in the U.S. would agree.That’s how many Americans are plagued by obstructive sleep apnea, according to the American Academy of Sleep Medicine. An estimated 26 percent of adults between 30 and 70 years of age have sleep apnea. And the numbers are on the upswing, most likely due to increasing obesity.
Sleep apnea is the repeated interruption of breathing during sleep, explains Dr. Raman Malhotra, a neurologist at Saint Louis University School of Medicine and co-director of the SLUCare Sleep Disorders Center. “A variety of things puts you at risk for sleep apnea. One is being overweight; a large neck circumference puts weight on the back of the throat, and when you are sleeping that causes blockage of the airway,” he says. “Large tonsils are another risk factor. But there also is some genetic component. Some people’s airways are more apt to block at night, even if they are not overweight or don’t have large tonsils.”
Sleep apnea also increases with age, he says, “partly due to weight and partly to other medical problems.”
do i have it?
You might have sleep apnea if you snore or breathe loudly at night, Malhotra says. Another indicator is feeling tired or sleepy, regardless of how long you spend in bed. It doesn’t take a lot of extra weight to have a problem, he adds. “You don’t need to be extremely obese. When we see these people walking down the street, we would not necessarily call them obese,” he notes. “If you are concerned, speak with your primary care doctor or make an appointment with a sleep specialist. We usually need to do a sleep study to measure breathing and see if you are really experiencing sleep apnea.”
what next?
“It is very common for kids to completely outgrow sleep apnea as their airway matures,” Malhotra says. “Adults don’t typically grow out of it.” However, the available treatments are highly effective, he adds. “Losing weight in many patients will cure them or make it less severe so they don’t need treatment,” he says. “Some surgeries of the upper airways can be done by ear, nose and throat doctors.”
The majority of patients use CPAP , continuous positive airway pressure, a machine that supplies constant air pressure through a hose and face mask. Studies have found that CPAP successfully reduces breathing interruptions in 50 to 75 percent of patients. In some, breathing disruptions may diminish after they change their favored sleep position. “These patients only have sleep apnea if they are on their backs,” Malhotra says.
smaller & simpler
Another treatment option is an oral appliance, or mandibular advancement therapy. “These can be as effective as CPAP for mild or moderate sleep apnea,” Malhotra says. Oral appliances are custom-made by dentists trained in sleep medicine, explains Dr. Stacy Ochoa of Precision Dental Care, and consists of connected, adjustable, upper and lower retainers.
“When you are lying down, gravity pulls the jaw backward, the tongue falls into the airway, and the airway muscles collapse,” says Ochoa, a member of the American Academy of Dental Sleep Medicine. “The appliance brings the jaw and tongue forward, and there is a neurological reaction that increases the tone of the airway muscles.” As the patient becomes used to wearing the device, adjustments are made to advance the jaw slightly. It takes getting used to, she says, but studies have found higher rates of compliance with oral devices than with the much bulkier CPAP .
