SLEEP 101 A Sleep Specialists Guide to Better

SLEEP 101: A Sleep Specialist’s Guide to Better Sleep Joya Paul, MD, MS North. Shore University Health. System Department of Neurology, Sleep Disorders November 17, 2017

Objectives • Review background on sleep and wake • Answer some of the most frequently asked questions about sleep • Review pearls on how to get better sleep • Identify factors that can worsen sleep

Importance of Sleep • 25 -30% of adults suffer from a sleep disorder • Excessive daytime sleepiness leads to loss of productivity, errors and accidents • Sleep disorders and deprivation lead to other health problems (cardiovascular disease, weight gain, neurological disorders)

Two Process Model of Sleep • Clock: Circadian Rhythm (Process C); vary by time of day • Hourglass: Homeostatic Drive for sleep (Process H); accumulate sleep need

Circadian Rhythm • Internal body clock which cycle with a recurring periodicity of approximately 24 hours • Generated by the suprachiasmatic nucleus (SCN) located in the anterior hypothalamus; master clock • Controls sleep-wake cycle, body temperature, feeding, hormone secretion, glucose homeostasis and cell-cycle regulation

Circadian Signals • Promotes arousal and wakefulness • Alerting signal is dominant during wake period and increases throughout the day • Attenuated in the evening (partly by melatonin)

Homeostatic Drive for Sleep • Sleep Hunger • Builds the longer you are awake • Dissipated by sleeping

Integrating Homeostatic & Circadian Signals

MOST FREQUENTLY ASKED SLEEP QUESTIONS

How much sleep do I need? • At least 7 hours of sleep per night • 6 hours or less sleep per night is inappropriate to support optimal health in adults • Appropriateness of 9 or more hours of sleep per night is uncertain but certain studies suggest that longer sleep duration may be harmful • Applies to all adults (18 -65) • Varies for infants, children, teenagers and the elderly

Do we need less sleep as we get older? • No! • Sleep quality worsens as we age but that does not mean we need less of it • May take longer to fall asleep, may sleep more lightly, wake up more often, spend less time in deep sleep • Usually due to other medical illnesses, less exercise, medication effect, napping or sleep disorders (insomnia, osa, etc)

Is it good or bad to nap during the day? • Good as long as it is no more than 20 -30 min • May improve mood, memory, reduce fatigue and stress if done right • Keep it brief and preferably 1 -2 hours after lunch when blood sugar and energy levels naturally drop • Naps greater than 30 min may leave you more groggy and prevent you from sleeping at night

What is the ideal temperature for sleep? • Between 60 -67 degrees Fahrenheit • The body’s core temperature must drop 2 -3 degrees to initiate sleep • If the core temperature is too high, the brain may not make the switch from awake to sleep or create the best quality of sleep • Hot bath/shower before bed may bring circulating blood to surface and cool down core

Is it bad to eat just before going to bed? • Depends on what you eat • Try to eat dinner 2 -3 hours before bedtime • Particular foods to avoid: spicy ones, heavy or rich foods that are difficult to digest, fatty foods (fried), citrus fruits, carbonated and caffeinated drinks • Light meals that do not cause intestinal discomfort may be okay • Consider elevated head with two pillows to prevent GERD

Does exercise effect sleep? • Yes and it’s great! • As little as 10 minutes of aerobic exercise regularly can improve the quality of sleep and increase sleep duration • May reduce stress and tire you out • Best time would be early morning/afternoon and outdoors to boost your body temperature in the morning and allow you to absorb natural sunlight • Exercising too close to bedtime may over-stimulate the body for some and cause insomnia but not everybody

Will a “night cap” aide in sleeping? • No; if you booze, you lose • Alcohol may help you fall asleep faster due to it’s sedative effects and provide more deep sleep during the first part of the night • BUT this wears off and sleep quality including REM sleep is negatively affected the second half of the night • Women are more likely to be affected perhaps because they metabolize alcohol faster • Moderate alcohol earlier in the evening may be okay

How does Melatonin help sleep? • It helps regulate your sleep cycle • Taking a low dose at the same time every evening helps the body keep a routine • Too much taken at once can cause headaches, nausea, dizziness or irritability

How much caffeine should I drink? • A drop in adenosine signals the body to prepare for sleep • Caffeine mimics the effect of adenosine and tricks the body into thinking that it is not yet time for sleep • Caffeine lasts about 5 -6 hours before wearing off but this varies from person to person depending on tolerance, genetics, medications, etc • 500 mg/day (~ four 8 oz cups of brewed coffee) • Avoid caffeine after ~2 pm • Drink small amounts every few hours versus a large amount all at once

Sleep Hygiene Habits and practices that are conducive to sleeping well on a regular basis

Ways to Improve Sleep Hygiene • Increase Homeostatic Drive to sleep • Optimize Circadian factors • Be aware if drug effects • Avoid arousal in sleep setting

Improve Homeostatic Drive for Sleep • Go to bed only when sleepy • Avoid naps, except for a brief 20 -30 minutes nap not in evening • Restrict sleep period to average number of hours you have actually slept per night in the preceding week – Quality of sleep is important. Too much time in bed can decrease quality of subsequent nights • Get regular exercise each day, preferable 40 minutes each day or an activity that causes sweating – It is best to finish exercise at least six hours before bedtime • Take a hot bath to raise your surface temperature within two hours before bedtime

Drug Effects • Do not smoke to get yourself back to sleep • Do not smoke after 7: 00 pm, or give up smoking entirely • Avoid caffeine entirely for a four-week trial period; limit caffeine use to no more than 3 -4 cups no later than 12 -2 pm • Light to moderate use of alcoholic beverages; alcohol can fragment sleep over the second half of the sleep period

Optimize Circadian Factors • Keep a regular wake time out of bed 7 days a week • Get at least one half hour of sunlight within 30 minutes of your out -of-bed time • Do not expose yourself to bright light in the evening or if you have to get up in the middle of the night

Avoid Arousals in Sleep Setting • Keep clock face turned away, and do not find out what time it is when you wake up at night • Avoid strenuous exercise after 6: 00 pm • Do not eat or drink heavily for three hours before bedtime – A light bedtime snack may help • If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in the evening – Do not retire too hungry or too full. Head of bed may need to be raised • Keep your room dark, quiet, well ventilated, and at a comfortable temperature throughout the night – Earplugs and eyeshades are OK

Arousals cont. • Use a bedtime ritual • Reading before lights-out may be helpful if not occupationally related • List problems and one-sentence next steps for the following day – Set aside a worry time. Forgive yourself and others. • Learn simple relaxation techniques to use if you wake at night – Do not try too hard to sleep; instead, concentrate on the pleasant feeling of relaxation • Use stress management in the daytime • Avoid unfamiliar sleep environments

Arousals cont. • Be sure mattress is not too soft or too firm, pillow is right height and firmness • Try not to take sleep medications or aids as they may change normal sleep architecture • Use bedroom only for sleep or sex; do not work or do other activities that lead to prolonged arousal.

When to send to a Sleep Specialist? • Excessive daytime sleepiness despite sufficient sleep • Loud snoring/gasping at night with pauses in breathing – STOP BANG Questionnaire • Frequent nocturnal arousals • Difficulty falling or staying asleep

What patients can expect? • Extensive history regarding sleep problem, medical health and mood • Sleep logs/diaries • Overnight sleep study and/or daytime sleep study • Actigraphy

Common Sleep Disorders and Treatments • Snoring (oral device, ENT procedures) • Sleep apnea (CPAP machine, oral device, ENT procedures) • Insomnia (improve sleep hygiene, address stress/mood, cognitive behavioral therapy) • Parasomnia (safety and medications) • Sleep related movement disorders (medications) • Circadian rhythm disorders (light therapy) • Hypersomnia (stimulants, scheduled naps)

Which of the following is true regarding how much sleep a healthy adult (age 18 -65) should get per night to avoid the negative consequences from sleep deprivation? A. Adults should get less than 6 hours of sleep per night B. Adults should get at least 7 hours of sleep per night C. Adults should get more than 9 hours of sleep per night D. The amount of sleep an adult should get depends on their age Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med 2015; 11(8): 931– 952.

THANK YOU!