Author Archives: sleephelpdesk

Restless Leg Syndrome Treatments

 

Hi all!

I’ve received numerous messages in response to my recent restless leg syndrome (RLS) post, some of which asked about treatments.  So let’s address that now, shall we?

One important thing to know, first of all, is that not all cases of RLS require treatment.  Like most other medical disorders, there is a spectrum of severity with RLS; mild cases, only slightly annoying or easily made better with a brief walk up and down the hall, may not need medications.  Me, I consider treating RLS patients whose qualities of life are compromised by the problem:  difficulties participating in activities; ongoing difficulties falling and/or staying asleep; chronic discomfort; bed partners unable to sleep because of the movements.

Typically I first explore if an RLS sufferer has iron deficiency.  Iron deficiency is quite common; it’s estimated that 1/3 of iron-deficient people have RLS.  20% of RLS sufferers have iron deficiency.  There’s a lot that is still not understood about exactly what causes RLS, but it appears that RLS is related to dysfunction associated with a specific neurotransmitter called dopamine.  Iron is a mineral co-factor associated with the production of dopamine in your brain.  I check a serum ferritin level when assessing an RLS patient.  Ferritin is an iron storage protein.  It’s known in the medical literature that ferritin levels of 50 or less are associated with an increased propensity to having RLS. Iron supplementation (such as with ferrous sulfate or ferrous gluconate) thus may be very helpful in improving RLS symptoms.

For those with RLS of unknown cause, here are the FDA-approved medications to treat RLS symptoms:

1.  Ropinerole (Requip).  This is a dopamine agonist, which means it activates dopamine receptors in your brain.  You take it by mouth.  This medication is the first FDA-approved medication for RLS treatment.  It’s available generically now, which means the potential for cost-savings.

2.  Pramipexole (Mirapex).  This is also an oral dopamine agonist medication, available generically.

3.  Gabapentin enacarbil (Horizant).  This is an extended-release tablet that you take once per day, around 5 p.m.  Unique features:  it’s not a dopamine agonist (it is the pro-drug to gabapentin); and it’s long-acting.

4.  Rotigotine Transdermal System (Neupro).  This is also a dopamine agonist medication, but the unique feature here is that it comes in a patch, which you apply once each day to the skin.

My practice is to use the minimal medication that provides the maximal effect in stopping the RLS symptoms.  The orally-dose dopamine agonist medications typically are taken in the evening.  I generally recommend that the medication be taken roughly 1-2 hours prior to the projected onset of symptoms; it’s better to try to prevent the symptoms from happening than to try to tamp the symptoms down once they’ve started.

Other medications have historically been used, including benzodiazepines, sedative agents, and, particularly in the case of severe, difficult-to-treat RLS, narcotics.  Non-medicinal treatments used over the years are legion, and include mild to moderate exercise prior to bedtime and hot baths or compresses prior to bedtime.  Avoiding caffeine and alcohol use in the evening may also be helpful; I recently had a patient whose RLS completely went away by stopping her late afternoon caffeine consumption.

No medication is perfect or without side effects.  Dopamine agonists can be associated with daytime sleepiness in some, but so can Horizant.  In addition, there is the potential for something called augmentation (a gradual worsening of symptoms due to or related to ongoing treatment), which may occur particularly in the setting of dopamine agonist use.  As always, you need to weigh benefits and risks when considering treatment, and you should have a clear, open discussion with your doctor regarding the nature and severity of your symptoms, as well as longterm management of the RLS.

I will post some fun sleep topics in the coming days.  Thanks, everybody!

Do Your Legs Drive You Crazy at Night?

 

Ever get that creepy crawly sensation in your legs when you’re in bed, that feeling that just makes you want to move or kick your legs to feel more comfortable?  If so, you’re not alone.  Millions of Americans suffer from a clinical disorder called restless leg syndrome (RLS).  It’s a very prevalent–but often underrecognized and underdiagnosed–problem in which you feel compelled to move your legs at night due to the discomfort that comes when the legs are still.  It’s a form of neurologic movement disorder, really, but it is also a sleep disorder because it’s hard to fall and stay asleep when your legs are moving and kicking all evening long.

Nothing fancy is necessary to diagnose the problem; sleep study testing is usually not needed.  Proper diagnosis requires an astute physician who listens to your problem and understands the nature of your symptoms.  There are four essential clinical criteria necessary to make the diagnosis of RLS (¹,²):

1.  An urge to move the legs, usually accompanied or caused by uncomfortable and/or unpleasant sensations in the legs.  Sometimes the urge to move is present without much preceding discomfort and sometimes the arms or other body parts are involved in addition to the legs.

2.  The urge to move or unpleasant sensations begin or worsen during periods of rest or physical inactivity such as lying down or sitting.

3.  The urge to move or unpleasant sensations are partially or completely relieved by movement, such as kicking, walking or stretching, at least as long as the activity continues.

4.  The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night; in other words, there is a diurnal nature to the symptoms.  When symptoms are severe, the worsening at night may not be noticeable but have been present earlier in the day.

RLS is more common in women than in men.  There can be a family history of RLS; many RLS sufferers have family members with similar or identical symptoms.  If there are family members that also have RLS, the age of onset for RLS for an individual is generally earlier than for those without a family history of RLS.  For most people the age of onset is generally in the 40’s to 50’s, and generally the prevalence and the severity of RLS tend to increase with advancing age.

Though often RLS is “primary,” in other words, not clearly caused by another medical problem, there are some clinical entities that can be associated with RLS.  The most common of these is iron deficiency.  Pregnancy and kidney disease can also be associated with RLS.  RLS can in some cases be made worse in the setting of alcohol or caffeine use.

The actual discomfort can be difficult for patients to describe; in fact, when I ask my patients how they would describe it, the most common response is, “Well, I can’t really quite explain it to you, how it feels.”  People often use “creepy-crawly” or “heeby-jeeby” to describe the sensation.  My friend Brad Vaughn, a preeminent physician sleep specialist at the University of North Carolina School of Medicine, has a humorous lecture slide that lists the dozens of descriptive terms his patients have used over the years; the ones I particularly like are “soda bubbles,” “jimmy legs,” “Elvis legs,” and “crawling bones.”

It’s important to recognize that a lot of things can look like RLS.  Vascular disease, for example, can cause leg discomfort, but this is usually localized to a specific area of the leg, and in the case of claudication, in which a leg artery is compromised, physical movements make the leg feel worse, not better.  Arthritis is localized to the joints as opposed to other parts of the legs.  Cramping refers to a sustained, painful muscular contraction (often involving the calf muscles) as opposed to voluntary, brief leg movements that arise due to RLS.  And then, finally, there are those who simply make those repetitive “nervous” movements of the leg; we’ve all seen that.  Such movements are not generated by leg discomfort, but often occur out of habit and are not physically abnormal per se.

Every time I give a public talk about sleep and ask who in the audience has these symptoms, it’s always surprising how many hands shoot straight up. Often this problem does not come to the attention of the doctor because people “learn to live” with it through the years, even though their leg movements are driving their spouses or bed partners crazy. You wouldn’t believe what some people go through, living with this disorder. In severe cases, lifestyles completely change. RLS tends to occur in the setting of “imposed rest.” So imagine trying to sit through a movie while your legs are moving the whole time. Or being stuck in the middle seat on a plane. Or having a formal dinner or other important evening occasion. The RLS can make you miserable in such settings.

RLS is imminently treatable if you inform your doctor of what is happening to you at night. Many times patients come to see me for some other matter pertaining to sleep, and the presence of RLS turns out to be an incidental finding, or sometimes even the underlying root cause for the primary problem. People have visited me for severe insomnia, for example, and the underlying RLS, never before mentioned to anybody, turned out to be the cause.

I’ll save discussion regarding workup and treatment for another entry.  The bottom line for this post, however:  if you have the symptoms consistent with the four RLS criteria above, do yourself a favor and inform your doctor.  Treatments can really be a lifechanger.

¹.  Allen RP et al.  Sleep Med.  2003;4(2):101-119

².  Garcia-Borreguero D et al.  Sleep Med. Rev. 2006;10(3)153-167

Hung Out With My Dad Last Night . . . In My Dreams

I wasn’t planning on writing about what I’m going to share today, but your dreams come upon you when they do.  My father appears in my dreamlife now and then, perhaps once a month or so.  Though sometimes he is a silent, peripheral character somewhere in the background of the strange moving pictures that are my dreams, there are times in which he plays a starring role, such as he did unexpectedly last night.  I awakened briefly from deep non-REM sleep around 3 a.m. this morning and fell back to sleep, and then my movie promptly started.  Here’s what happened.

It’s the dead of night.  Everything is still.  I’m walking down a dimly lit, gently sloped paved driveway carved through a wooded thicket, tall green trees on either side.  It’s a casual, peaceful walk, which I’m taking with my dad, who strides next to me on my right.  We’re having a conversation.  He tells me, in his characteristically direct and blunt manner, that I need to stop walking with my hands in my pockets.  “It doesn’t look good to do that,” he tells me.  I consider his words.  I’m a little taken aback by this reprimand; I don’t put my hands in my pockets anyway, and they aren’t even in my pockets now!  But he’s my dad, and one thing I’ve always known is that he cares for me more than anything and just wants the best for me.  I assure him that I will do my best to keep my hands out in the open.

We enter a home.  It’s not our home, but it feels like it should be, and we enter it as if it is.  The hallways are dark.  We approach the light at the end of the main hall.  It’s the kitchen, small and modest, reflecting the home’s rustic nature, darkened wood throughout, including the furniture and walls.  Dad and I walk instinctively toward the rectangular dinner table inside.  The only light in the room emanates from the small chandelier above us.  It shines like an orange halo around the table, creating a hazy effect on the rest of the kitchen.  I stand behind what must be my designated chair near the wall; Dad stands behind his near the kitchen entrance opposite me.  We look down at the mounds of white rice on plates at the table.  There is a plastic bottle of furikake (a Japanese seasoning made of sesame seeds and dried seaweed bits) on the table.  Still standing, Dad takes the bottle, shakes some seasoning on his rice, and slips the bottle in his right pants pocket.  I watch this and laugh, asking him why he’s putting the furikake in his pocket.  He answers that he wants to bring it with him on his upcoming trip to New York, sheepishly pulling it out and placing it back on the table.  It’s news to me that he will be traveling soon.

I look to my right, where the kitchen counters and sink are.  There’s Mom.  She is facing away from us and toward the counter, cutting up vegetables.  Dad walks over to her.  They are silent together as Mom continues her work.  I follow and slowly wedge myself between them.  “I wish you wouldn’t go,” I tell Dad plaintively as I stand snuggling with my parents, feeling the warmth of both of them close to me.  “Please don’t go.  Please, Dad.  Don’t go.”  Mom smiles silently as I speak, looking down at her cutting board.  I understand that Dad doesn’t have a choice; he has to go away.  Nonetheless, it is satisfying to tell him his presence is wanted, needed.  I am the only person or thing that disrupts the silence in the room.  There is increasing desperation and welling emotion as I continue to implore him not to leave.  

That’s when I awakened abruptly, about 5:30 this morning, wondering how it felt so real, the surroundings, the house, the immediate presence of my dad, when in my real waking life I know that what happened in the dream could never actually happen.  But for the short, precious time I convened with my dad last night, it did happen.  It was real in the moment.

It’s been a rather emotional morning for me.  This sudden, raw conversion back to reality upon awakening overwhelmed me with sorrow, as it does every time Dad costars in my dreams.

Who knows where all this comes from.  I don’t put my hands in my pockets, as a general rule.  I did, however, gently reprimand one of my boys last week for having his hands in his pockets on the court just before the start of his team’s basketball game, telling him he needs to have his hands out and ready for play.  Dad, who lived to 81, lived his entire adult life with remnants of his old war survival mentality; he would take wads of napkins from fast food restaurants, for example, and stuff them in his pockets to take home in the event of a future napkin shortage in the house.  I think the biggest message, though, is how much I miss my dad every day.  Cancer took him from us almost three years ago.  A dream like this reminds me of how much of a presence he still is in my life and the lives of those in my family, especially my mom.  I have photos, videos, and countless memories, of course, but my abilities to interact with him through those media are limited, if not impossible.  As sad as I am awakening from such dreams, I am comforted by knowing that somehow, until the day I die, I will always at least have this one way, however vague and unpredictable, of still interacting with my father from time to time.  It’s kind of a tragic gift, isn’t it, to dream like this.

There will be more to say about my dad, a great man, in future posts, in part because he had REM behavior disorder, an important sleep disorder to discuss.  For now, I need to recover from last night’s proceedings.  However painful it was to awaken, it was good to hang out with Dad again.

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Sleepy Residents: The Tricky Business of Medical Education

 

This morning one of my patients was telling me about her recent sleep deprivation; recently retired, she has been going to bed late and getting about 5 hours of sleep most nights.  I mentioned to her my own experiences in sleep deprivation, specifically when I was a resident in neurology years ago.  I explained how my frequent long work days and on-call nights resulted in frequent sleepiness and fatigue, sometimes to the point in which I dozed during lectures and grand rounds.  Her reply was, “How is that allowed, for new doctors to work such long hours? Isn’t that dangerous?”

How much and how long a resident should be allowed to work have long been a challenging issue in the realm of medical postgraduate education, and one not without controversy.  Certainly when I was training, there was a pervasive sense of machismo associated with working your white-coated tail off, as if spending every waking moment in the hospital made you superhuman, worthy of admiration and respect.  In addition, a certain culture has developed over the centuries regarding the “coming of age” of the young American doctor, “paying your dues.”  As academic institutions go, it is often difficult to break such deeply entrenched, longstanding traditions, particularly when the professors have long ago paid their dues.  The medical school where I completed my residency was built in 1797, so as one may imagine there were many time-tested, conservative traditions we were expected to follow.  Me, I found the training process and the hallowed traditions associated with it absolutely fascinating, and sometimes even thrilling, but there were times (usually around 2 a.m.) in which I really questioned why things had to be the way they were, such as being up all night every third night for months on end.

There’s another oft-overlooked reason why interns and residents have been so overworked, and it is purely economic.  In reality, a postgraduate trainee and a training hospital enter into a business partnership agreement of sorts the July following the trainee’s graduation from medical school.  The trainee needs the postgraduate education in order to become board-certified in a selected medical or surgical specialty and to practice medicine independently someday in that specialty.  The hospital system needs the trainee’s hard work, without having to pay that trainee the salary that an attending physician would command–the polite way of saying cheap labor.  There needs to be a consistent, large stable of doctors to make everything run properly at a large tertiary care center, and without interns and residents to do much the work, such large, complex institutions would simply grind to a halt, go bankrupt, or both.  And with the steadily declining margins of hospitals in recent years (and undoubtedly more to come), how much a hospital must pay for a doctor’s work becomes an increasingly important consideration.

Understand:  I don’t write any of this in a pejorative way.  Both trainee and hospital have legitimate needs and they need each other, so the relationship is forged on “Match Day” and it continues until the end of the training.  When I first found out my first-year salary as a newly minted intern–$28,500–I was overjoyed, frankly; it was better than paying to be there, like I had been in medical school.  With each subsequent year of training my salary jumped by $1000-2000 per year.  And through it all I spent countless hours in the hospital, often well over 80-90 hours per week, making my income less than minimum wage.  There was no questioning it, no raging against it; it just had to be so.  So what gets sacrificed most easily and most commonly in such a system?  The trainee’s sleep.

Certainly there is the argument that the trainee’s education would be enhanced by allowing proper amounts of sleep and off-work time, and there is clearly truth to that.  However, it takes more than that to change a longstanding, proud institution like American postgraduate medical training; there is much more to consider than the trainee’s education.  I recall a general surgery resident friend telling me once that he had fallen asleep, standing, earlier that day in the middle of a case; he just shrugged, knowing there was nothing that could be done about that until he finished his training.  I remember myself often struggling to stay awake in the middle of the night sitting in the ER writing up a history and physical, looking at the unoccupied ER bed in front of me and literally lusting for it, wishing I could curl up and get some much-needed sleep before our morning rounds.

In 2003, Accreditation Council for Graduate Medical Education (ACGME) limited work duty hours went into effect, reducing the maximum amount of time allowable for postgraduate training work.  Among the policies was a call for an “80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities.”  I trained in the early- to mid-nineties, so this change came too late to benefit me and my brethren.  I deeply appreciate all of my postgraduate medical training, and I remain very grateful for having had it.  I do believe strongly, however, that I would have learned more, and would have been happier, had I been allowed more sleep per night on average.

I lead a very busy life; it’s hard, in fact, to find someone with a crazier life than me.  However, I get my 7-8 hours most of the time (I’d be a hypocrite if I didn’t, right?).  I find that proper sleep allows me to maintain my very busy life and to enjoy it.  And, importantly, I know that most everybody can get their 8 hours if they allow it.  Unless, perhaps, you happen to be a young doctor in training.

Is Snoring “Normal?”

 

Millions of Americans snore substantially. The ubiquity of snoring is pervasive in our culture; TV and radio shows depict people snoring for a laugh, or simply to demonstrate they are sleeping. For many, there is a simple one-to-one relationship between snoring and sleeping, such that it seems like you’re supposed to snore when you’re asleep.  It’s almost like it’s an inevitable part of the human condition.

Well, the problem is that snoring is not necessarily “normal.” On the most fundamental level, snoring is just the noise resulting from vibration of soft tissues in your throat while you breathe during sleep.  However, there is the potential for health effects with longstanding log-sawing.  Nonetheless, it’s very common for people to blow off concerns for their snoring.  Some potential reasons:

1. It’s so common. Millions of people in the U.S. are obese too, but that fact doesn’t make obesity normal, either.
2. You’re not awake to hear the snoring. By definition you don’t snore unless you’re sleeping, and you’re unaware of what is happening while you are asleep, so frequently people don’t think they snore, even when their spouses or bed partners complain bitterly about their nightly snoring noises.

Through the years I’ve heard all sorts of comments from incredulous loud snorers dragged into my clinic by angry spouses (usually wives, but husbands too). Some examples, often resulting in a dirty look or a punch in the arm by the spouse:

“Well, SHE snores loudly too!”
“She has a tendency to exaggerate things.”
“I don’t have that.”
“It’s really not a problem. She’s just making it a problem.”
“I’m telling you, I don’t snore. I don’t remember ever snoring.”
“Nobody has ever told me I snore except for HER.”

One time a man came to see me with his wife, who pulled out her iPhone and played back some audio of his intolerable snoring, only for him to reply, in all seriousness, “That wasn’t really me.”

On another occasion, a gentleman visited me in my clinic and told me when first sat down to talk, “I’m here as a birthday present for my wife.”

There are some very real reasons to take snoring seriously:

1. Marital and relationship discord. I’ve had patients actually get divorced in part because of the snoring, not necessarily because of the noise itself, but because of the spouse’s frustration in not being believed or taken seriously. That’s extreme, of course, but think about the millions of bed partners whose sleep is constantly disrupted by loud, open-mouthed snoring in close proximity. It would be maddening, right?  Many have to sleep elsewhere in the house or time their bed schedules just right to minimize prolonged awakenings.  Slowly, insidiously, this problem can wreck a whole family’s quality of life.
2. Loud snoring is often associated with obstructive sleep apnea.  Sleep apnea is a breathing disorder in sleep, in which one’s upper airway actually collapses or closes episodically during sleep.  This is a medically dangerous problem, associated with an increased risk for heart disease, early stroke and heart attack, hypertension, and sudden cardiac death.  Though you don’t need to snore loudly to have sleep apnea and you don’t have sleep apnea just because you snore loudly, often sleep apnea and loud snoring can go hand in hand, and the snoring can be a tipoff for your doctor to a problem with your breathing.
3. Snoring itself may be associated with medical problems. This is the subject of intense research at the moment, but there are suggestions now in the medical literature that snoring may be an independent risk factor for metabolic diseases and cardiac problems.

How can you tell if your snoring is loud? Loudness is a relative term; I’ve had patients who delayed medical evaluation for years, for example, despite very substantial snoring, because the spouse is hard of hearing and unaware of the snoring and breathing pauses during sleep. Some general benchmarks that suggest loud snoring:
1. If it can be heard in other rooms, or other floors, of the house. I’ve had patients whose neighbors next door or ACROSS THE STREET (no joke) called them to complain of their snoring.
2. If it regularly awakens the bed partner from a sound sleep.
3. If it is louder than an ordinary, casual conversational voice.

Bottom line from tonight’s post:  loud snoring is not normal just because many people snore loudly.  My recommendation is that loud snoring be reported to one’s primary care physician. In future posts I’ll discuss what to do to help the “heroic” snorer. If a loved one is having clearly witnessed breathing pauses during sleep, I strongly recommend that the snorer see someone like me, a physician sleep specialist, for the consideration of breathing problems during sleep.

Have a great evening, all!

How to Sleep Well After the Super Bowl

Howdy y’all!  I’m still licking my wounds following the Kansas Jayhawks’ tough loss in basketball yesterday.  The only thing that makes me feel better about that is that no college team is infallible right now, including Michigan, who also lost yesterday.  The increased parity of teams this year should make for a great NCAA tournament come March.  I’ll probably have a sleep-deprived night or two during the Big Dance, and hopefully for good reasons!

 

Today America turns its attention once more to football and bids farewell to the 2012-2013 NFL season with the Super Bowl game between the San Francisco 49ers and the Baltimore Ravens.  Now personally, me, my teams are, in order, the Seahawks, the Packers, and the Patriots, so with no horses in the race I’m not feeling particularly invested in today’s game (though I am curious to see if Beyoncé actually sings during the halftime show). I’m rooting for the Ravens because I respect Ray Lewis’ longevity (he’s an ancient 37 years of age, and he’s still kickin’ it all the way to the end), I love O.J. Brigance’s heartbreaking but inspiring story (he has Lou Gehrig’s Disease, he’s 43, and he still works, serving as the Ravens’ director of player development), and I’m not a big fan of that Kaepernick arm-kissing thing.  I know a lot of people who are very emotionally invested, however, and particularly for them, as well as millions of other football fans ’round the country, there will be a high potential for subsequent problems sleeping, win or lose.  So here are a few quick tips to prevent a sleepless night tonight.

1.  Mind your timing.  The game starts at 6:30 p.m. east, 3:30 p.m. west.  Keep this in mind as you plan your bedtime routine tonight, because for most people life and work will go on tomorrow, Monday morning, as per usual.

2.  “Come down” after the game.  Whether your team wins or loses, the Super Bowl is exciting, and all of that adrenalin and dopamine has a stimulatory effect.  I would suggest not jumping into bed right after the game, particularly after a night of partying and cheering on your team.  Give yourself an hour or two to decompress from the game.  Relax, read a bit, take a hot bath or shower.  Shoving yourself into bed all hyped up will make it difficult to fall asleep quickly.

3.  Time your caffeine use.  Many people don’t realize that caffeine can last in your system for up to 8-12 hours after you drink it.  Drinking that Red Bull may enhance the excitement at your Superbowl party, but I would suggest drinking it early on, particularly if you live on the east coast.

4.  Time your alcohol use, and drink responsibly.  Alcohol can have both excitatory (owing to emotional disinhibition) and sedative effects for the first 2-4 hours after it’s consumed, but after that it tends to be a sleep disruptor.  I suggest taking it easy on the booze, man, it’s Sunday night.  I’m not in my twenties anymore, however, so understand where my words are coming from, a place of age and hard-earned wisdom.

5.  Eat early if you can.  All those buffalo wings, all that pizza . . . you’re not gonna enjoy that bubbling up your esophagus tonight.  Indigestion, heartburn, and reflux tend to happen more if you go to bed shortly after a big old spicy meal.  Give all that pub grub some time to travel from your stomach and into your intestines.  If you have to eat late, you may want to prop yourself up with a couple pillows before you go to sleep.

6.  Try to awaken at the time you usually do on Monday morning.  It may be a late night for you tonight, particularly if you live in Maryland and the Ravens win.  However, if you sleep in Monday morning, it might be difficult to fall asleep at your desired time Monday night.  We’re generally built to tolerate a night of sleep deprivation if necessary.  That’s usually preferable to a protracted bout of insomnia.

Enjoy the game, all!  Hoping for great things for the Seahawks in the 2013-2014 season.  12th Man!

 

Sleep Song #1: “When You Dream” by Barenaked Ladies

There are countless songs containing sleep as a theme. From time to time I will showcase some of my more favorite sleep-related or sleep-flavored songs for your enjoyment!

I’ve been a Barenaked Ladies fan for the past twenty years or so. I love their clever lyrics, hook-filled melodies, and frenetic, spontaneous, audience-centric live shows. Plus, their bassist, Jim Creeggan, is an absolute badass on standup bass. I highly recommend their live performances.  I’ve seen them numerous times.  The show that stands out in my memory most was one held in a teeny club in Northampton, Massachusetts, circa 1996. In between songs Ed Robertson called a couple up to the front, and the guy proposed to his girlfriend on stage. While she stood there silent and mortified, the guys in the band all leaned in to hear her response, and they came up with a song in which they chanted something like, “Will she say yes?” Finally she accepted the proposal, and the band busted into a speed-metal vamp, screaming their on-the-spot chorus, “She said yes!” over and over while the crowd went nuts.

So this song, “When You Dream,” is a great tune near the end of their 1999 album Stunt. The singer imagines what his infant boy is thinking about while he dreams peacefully. It’s a wonderfully crafted piece, conjuring many of those fuzzy, fanciful images we think of when we try to recall our dreams.

There is much we do not understand about rapid eye movement (REM) sleep, but REM sleep and dreaming are the focus of very intense sleep medicine research at the moment. I will write more about dreaming in a future post. We know REM sleep has restorative effects and has some role to play in things such as memory consolidation. However, there are still many mysteries yet to be unlocked.

Enjoy!  I can’t find an official video, but click above to hear the song.

Here are the Barenaked Ladies song lyrics (written by Ed Robertson and Steven Page, copyright Warner/Chappell Music):

With life just begun
My sleeping new son
Has eyes that roll back in his head
They flutter and dart
He slows down his heart
And pictures a world past his bed
Its hard to believe
As I watch you breathe
Your mind drifts and weaves
When you dream
What do you dream about
When you dream
What do you dream about
Do you dream about music
Or mathematics
Or planets too far for the eye?
Do you dream about Jesus
Or quantum mechanics
Or angels who sing lullabyes?
His fontanelle pulses
With lives that he’s lived
With memories he’ll learn to ignore
And when it is closed
He already knows
Hes forgotten all he knew before
But when sleep sets in
History begins
But the future will win
When you dream
What do you dream about?
When you dream
What do you dream about?
Are they colored or black and white
Yiddish or English or languages not yet conceived?
Are they silent or boisterous?
Do you hear noises
Just loud enough to be perceived?
Do you hear Del Shannon’s “Runaway”
Playing on transistor radio waves?
With so little experience
You might not get cognizant
Are you wise beyond your few days?
When you dream
What do you dream about?

Sleepy Teen? Read On

You have a teenager in the house. He’s 15. Great kid, popular, happy, fun to be around. Problem is, recently, with several months of school under his belt, he is sleepy too, all the time, falling asleep in front of you at the dinner table.

 

Excessive daytime sleepiness is increasingly prevalent in our society. Certainly social and academic pressures represent a potential cause. I’m constantly astounded with what so many parents now expect of their children: all the activities, sports, school projects, social outings . . . it is all just so different compared to when I was young:  everything is more, crazier, faster, more wired (or wireless), more complicated. My wife and I get caught up in that as well, I’m afraid, and though we do our best to maintain a reasonable balance to our children’s lives, their after-school hours remain dominated by what feels like an endless cascade of commitments: tae kwon do, basketball, skiing, adventure guides, student council, math olympiad, latin root class, on and on. For the most part our boys enjoy these activities and participate with relish, but I really do wonder how they’re going to find the time for additional activities or expanding interests as they get closer to high school, not to mention that all-important, precious time that should be spent with family.  Back in the day, we kids had time and space to relax, even laze from time to time. Time is just such a precious commodity now for us all.

Our planet’s population continues to grow, and subsequently so do the challenges for our children, who now must compete with a huge army of peers for a limited number of scholarships, college placements, internships, jobs, and resources. It thus seems natural–crucial, even–to push your kids to do more, accomplish more, dig deeper, become exposed to more things to give them a leg up in an increasingly competitive world. However, there’s still only 24 hours in a day. So what time is often easiest to sacrifice? You guessed . . . the time usually allocated for sleep.

Adults typically need 7.5-8 hours of sleep per night to feel fully rested during the day. Teens often need more sleep than adults, such as 9 hours per night. Teenagers need proper amounts of sleep like adults do, obviously, and in fact in many ways they need their sleep even more than adults do, considering they are still growing and developing. The effects of chronic sleep deprivation for a teenager can completely wreck one’s quality of life: daytime sleepiness, tendencies to fall asleep in class, lethargy, headaches, poor academic performance, depression, social withdrawal.

There’s another important cause of daytime sleepiness in teenagers, and it’s related to their sleep schedules. Here’s a scenario many of you will know well: Sunday night your teen has terrible difficulties falling asleep, and then finds it bloody impossible to awaken early the following morning for school. There is sleepiness all day long Monday at school, and for one or two additional nights there are residual difficulties falling asleep early, compounding the sleep deprivation. You pull your hair out as you cajole and shove your teen out of bed to get to school on time. Finally Friday night comes ’round, but your teen stays up until 1 a.m., and sleeps in like the dead until noon. This happens again Saturday into Sunday, and the cycle repeats itself, with another sleepless Sunday evening. Sound familiar?

Leaving the biochemistry out of it for now, here’s the reason why this occurs. We as humans are generally creatures of habit when it comes to sleep. Our internal body clocks are designed for us to do and feel things at certain times to coincide roughly with the 24-hour period. Our circadian rhythms dictate and regulate the timing of various inner biological processes, such as when we become sleepy or when we feel awake and alert.  When it comes to sleep, many of us have a natural tendency to become drowsy just slightly longer than every 24 hours (which can help explain why many prefer to go to bed later at night as opposed to earlier).  We are usually able to stay on the 24-hour clock because of the environmental cues (like daylight) and social cues (such as work) that “entrain” us to running our sleep every 24 hours. However, adolescents are particularly susceptible to this tendency for a delay in their bedtimes, leaving them prone to feeling awake at night and making it very difficult for them to get out of bed early for school. Things then are made worse when they allow themselves to go to bed very late on weekends and sleep in on weekends, because when Sunday night rolls around it becomes very difficult to fall asleep early. This is called delayed sleep phase syndrome.

 

So, parents, though this routine of trying to get your kid to bed at night and then fighting with them to wake up in the morning gets old quickly and can drive you bats**t crazy, in many ways what you’re seeing is the manifestation of normal adolescent brain biology, essentially a clash between teen physiology and our fast and furious society’s modern expectations.  I mean, if teens didn’t have to awaken at 6 a.m. to get ready for school, but instead could awaken whenever they please, this wouldn’t be nearly as big of a deal, right?  In this real world of ours’, though, it’s still a problem that needs to be addressed:  countless report cards, interpersonal relationships, and family dynamics have been affected negatively by delayed sleep phase syndrome particularly in recent decades.  And if there is pre-existing sleep deprivation due to all the other stuff your teen does after school, this only compounds the problem, worsening daytime sleepiness and all of the sequelae from it.

There are a couple of recommendations that can help.  One is something your kid is guaranteed not to like:  wake up around the same time every morning, including on weekends.  This is generally much easier for adults than it is for teens, but if you don’t sleep in by 3-5 hours on weekends any longer, you will naturally become drowsier sooner at night (including Sundays), making it easier to achieve more sleep and awaken in time for school; you’re essentially then forcing your body clock into regularity, which can then improve the insomnia and total sleep time at night.  The key, however, is persistence, which sometimes can be lacking in some kids.  When I am counseling my teenage patients with delayed sleep phase, I basically become their coach, working to help them understand that they can do it, that they will do it, for the sanity of everyone around them, including themselves.  The other helpful management tool is bright light therapy, such as with a light box (2000-2500 lux) early in the morning, and the avoidance of bright light in the late afternoon to evening.  Certain medications may be useful in severe cases, like melatonin or modafinil, but these are teenagers we’re talking about, and my clinical practice has generally been to try to do things as naturally as possible in this setting.

Take-home message today:  help your teen get proper amounts of sleep by examining his or her bedtime schedules and discussing openly what could be modified to make everybody happier in the house.  As with everything else within the realm of parenting, love, communication, and the constant quest to understand are cornerstones in helping your adolescent achieve good sleep.

There will be more to say regarding circadian rhythm disorders in future posts.  It’s time for dinner now, though, so ’til next time . . . sleep well!

 

May the PAP Be With You

Good evening!  My final act of the night before taking off for REM City:  to share a couple of great photos sent to me this afternoon by my good ol’ college friend and former bandmate, Ken, a Kansas Citian, bassist, fellow Jayhawk hoops fan, and Star Wars obsessive.

My last post featured photos of a bunch of bad guys in masks.  Here now are some good guys.

Where do you think all of Han Solo’s energy came from?

 

And why do you think the Force is so strong with Princess Leia?

 

Again, keep in mind, most people don’t need full face masks and can get away with small nasal masks or nasal pillow systems.  And you don’t need to use the CPAP device until you’re in bed and ready to sleep.

More serious posts will resume shortly.  Enjoy your dreams tonight, y’all!

Darth Vader: Really? Popular Misconceptions About CPAP

Obstructive sleep apnea is a common breathing disorder, in which the airway in the throat and neck collapses during sleep.  It’s very important to diagnose and treat this problem properly, not only because treating it can make you feel much more awake and alert during the day and stop your terrible snoring at night, but also because untreated sleep apnea increases the risk for substantial medical problems, including hypertension, heart failure, cardiac rhythm abnormalities, and early heart attack and stroke.

Problem is, it’s estimated that out of the millions of people in the U.S. with sleep apnea, about 85% of them have not yet been diagnosed.  Why is that?  There are probably several reasons.  First, symptoms can be insidious.  You’re not awake to hear your own snoring or witness your own pauses in breathing; if you’ve felt tired for years, the fatigue can just feel “normal,” to the point in which falling asleep while driving or during conversations at parties becomes your “normal.”  Secondly, medical care in general is expensive, particularly with the increased deductibles many now have to pay, and in today’s economy some people elect to put off non-emergency medical care. Thirdly, and importantly, there are a lot of presumptions regarding testing for and treatment of sleep apnea which are inaccurate or simply untrue.

When I see someone in my clinic for the first time for possible sleep apnea, I make it a point to discuss thoroughly the nature of the disorder, the procedure of diagnostic testing, and all standard accepted treatment options.  A primary and common form of treatment for sleep apnea is continuous positive airway pressure (CPAP), a device that takes room air, pressurizes it at a pressure prescribed by the physician, and delivers it via a small mask into the nose and into the airway.  CPAP is not designed to push or force air into the lungs.  The air from the device acts as a splint for the upper airway, keeping it patent (open) all night and thus allowing air to travel into the lungs, where it’s supposed to go.  This then dramatically deepens sleep, because the brain no longer arouses constantly due to low oxygen levels, thereby making the patient much more awake and alert during the day.  The success rates in resolving the sleep apnea with CPAP are incredibly high, provided that 1) the device is utilized properly, and 2) the patient is willing to utilize the device.

Most of my patients come to me very open-minded regarding how to fix their breathing problems during sleep.  There are times, however, in which my first mentioning of CPAP in clinic is met with reluctance, or a flat-out refusal.  In some ways, it’s perfectly natural to have initial reservations.  We are designed biologically always to protect our airways, so it seems counterintuitive to cover your nose or nostrils with something that it meant to make you breathe better.  This can be a source of an initial sensation of claustrophobia for some.  In addition, there is not only a mask involved, which may seem daunting to the uninitiated, but also a change in night-time habits, and we, the humans that we are, are naturally inclined to hate lifestyle changes thrust upon us by someone else.  But I’m struck by the responses I get when I ask why there is such immediate pushback to the consideration for CPAP use, when the patient hasn’t even seen or touched the device.  Among the most common of these is, . . . “I don’t want to look like Darth Vader.”

Come on.  Really?  I’ve heard this, or the equivalent (“Oh yeah, that Darth Vader thing,” or “That’s the Darth Vader mask, isn’t it?,” or some other such statement), so many times, I wonder who are these people out there telling everybody they’ve become Sith lords after starting CPAP and inviting others to join the Dark Side by getting treated too.

Lookit.  I was a disciple of Star Wars growing up.  I was ten years old when the first Star Wars movie (now known as Episode IV:  A New Hope) was released in 1977.  In terms of pure love and sheer personal impact, I rank it right behind The Godfather on my list of all-time favorite films.  As a kid I studied it religiously, including its philosophies and characters.  I memorized the presentation, clothing, and mannerisms of all the characters through scrutiny of books, magazines, and my precious trading cards.  So trust me when I say, there are no CPAP masks that are remotely similar to Darth Vader’s mask.

Vader’s mask isn’t even really just a mask.  It’s a full-on helmet, covering the entirety of the head, designed and utilized not only for protection but also as a contained respiratory support system required due to massive injuries sustained following Anakin Skywalker’s unfortunate battle with Obi-Wan Kenobi on Mustafar.  Take a look:

 

Uh, the typical CPAP user is not using CPAP for these reasons.  All the CPAP device does is simply allow air to pass freely through the upper airway so oxygen can get to where it needs to go:  into the lungs and thus into the bloodstream so you can, you know, live.  In most cases all that’s needed is a small nasal mask that just covers the nose, with headgear to secure it in place:

 

Or small “nasal pillows,” soft prongs which are placed gently in the entrance of the nostrils:

 

OK.  So you don’t look glamorous with these things on, and it can take a little while to get used to; that’s the reality of it.  However, your bed partner or spouse isn’t going to care much how you look while asleep; he or she presumably will care more about your health and longevity than how you appear while you’re sleeping, and will appreciate that your heroic snoring is now completely gone.  My patients generally become accustomed to CPAP use quickly, and these mask interfaces are more comfortable and tolerable than one may think.  With proper support from the sleep physician, the sleep center, the durable medical equipment service providing you with the materials, and your family, nightly use of this device can be a complete game-changer, dramatically improving the way you feel (and thus, the quality of life) and the way you sleep.

Another reason why people may relate CPAP use to Darth Vader is the presumption that the device is noisy, with some loud, pervasive inhale/exhale sound that keeps everybody awake all night.  Since the CPAP machine is at its core essentially a blower, there is some noise, but the devices now are incredibly quiet, in many cases virtually imperceptible, and the tonal differences between inhalation and exhalation can be adjusted with the new technologies built in to modern devices.

Ultimately, my sense is that some people have heard from someone–Uncle Frank, or Bill down the street–in the distant past about some negative experience with CPAP, and the resulting conjured images just get stuck.  As we all know, once an image is lodged in your brain it’s hard to unstick it.  And it’s true that ten years ago CPAP machines were loud and bulky, with limited choices of available masks.  But think of how technology in general has changed and improved over the past decade.  Look at our cell phones now, our desktop and laptop computers, our TVs.  Of course everything is better and smaller (well, the TVs are bigger, but thinner and lighter).  Same goes for CPAP use.  The devices are now very small and whisper quiet, with lots of built-in bells and whistles to make them more comfortable and easier to use.  There are dozens and dozens of different masks available now, all in different sizes, so it’s very rare now for my patients to have difficulties finding a mask that fits well.  I’d also ask that you look at this from a different perspective:  the companies that produce these machines and accessories are all competing in a race to make the best, most comfortable, most popular products.  As such, new products come out all the time.  You, the consumer, therefore have an advantage, with an ever-expanding circle of choices for products to use to optimize your treatment experience.  Ahh, capitalism at its finest!

Having said all of this, there are plenty ways for CPAP use to go sideways (literally and figuratively), limiting one’s abilities to tolerate and use the device.  Virtually all of these potential problems are fixable, however, and I will discuss these issues in future posts.

Some think that full face masks must be used when using CPAP (these masks cover both the nose and the mouth).  Though these masks are available and may be necessary or desired in some very specific circumstances (a topic for another blog entry), the substantial majority of CPAP users just need a simple small nasal mask or nasal pillows.  Full face mask or not, you will not end up looking like Bane from the Batman series:

 

. . . or another of my favorite bad guys, Hannibal Lector:

 

I also sometimes hear, “Won’t I suffocate with the mask on?”  My reply to that is, “No, quite the opposite.  You’re suffocating every night without the mask on.”

You know what would be cool?  Since George Lucas recently sold the Star Wars franchise to Disney, maybe I should approach someone at Disney about creating and marketing an actual Darth Vader CPAP full face mask.  You know, paint it black, have it play John Williams’ ominous Darth Vader theme music when you put it on.  Then all of these references to Darth Vader could actually become true!  I’ll look into it.  Wish me luck on that one.

So here’s my take-home point for today:  don’t deny yourself the diagnosis and treatment of an important medical problem because of what you think the treatment might be like.  Explore, speak with your doctor, keep your mind open to trying something that can actually change your life.  Insurance companies rent the CPAP device on your behalf for the first several months of use, because they don’t want to pay for a CPAP machine you don’t end up using.  If you really hate the machine no matter what is done to try to make things better, you can return it.  In other words, you have very little to lose and a lot to gain by at least trying it, if it’s recommended by your sleep doctor.  You’ll never know how much it can help you unless you try.

“You’re disoriented.  You just woke up.  You’re in the future.  You’ve been asleep for eight hours.” — Jarod Kintz