Easy Tips to Combat Summertime Insomnia

Don’t you love summer?  All the barbecues, outdoor festivals, vacations; school’s out, with all the freedom that goes with that.

I love summer as much as the next guy.  Many of my sleep patients don’t, however.  I’ve found that there are a couple of times of the year in which my patients experience a spike in their insomnia:  during the holidays, and during the summer.

There are several reasons why summertime can trigger or worsen difficulties falling and/or staying asleep.  First, many people and many families experience lifestyle changes during the summer as compared to during other times of the year:  kids can sleep in in the morning; vacations with jet lag; modifications in work hours or work timing; late-night parties and alcohol use.  These changes tend to dysregulate sleep schedules, leading to insomnia.  Second, it’s hot!  It’s hard to sleep when you’re sweltering and sweating in bed every night; we here in Seattle have been in a month-long heatwave, a major problem because most homes here have no air conditioning!  Third, because of the tilt of Earth’s axis during the summer, it’s light out late.  As most can easily understand, if the sun is still up in the evening, it feels naturally for YOU to stay up.  Exposure of your eyes–and hence your brain–to light has a profound impact on your sleep/wake cycles.  No wonder why people tend to have insomnia during these precious summer months!

So here are some pointers to improve your sleep for the remainder of this summer:

1.  Choose a time to awaken each morning, and stick with it.  Even if you’re not in school or not working, determine a preferred awakening time, set your alarm clock or smart phone for that time, and awaken and get out of bed that same time every morning, including weekends.  Your body clock “wants” regularity, no matter what your personal situation.  Sleeping in by several hours can throw off your body’s circadian rhythms, dysregulate your sleeping patterns, and promote delayed sleep phase.

2.  Keep your sleeping environment DARK.  Usually Venetian blinds suck at keeping out substantial light from your room when the sun is out late.  I recommend getting thick black curtains that completely cover up your bedroom window.

3.  Keep your sleeping environment QUIET.  Whether it’s motorcyclists or firecrackers outside your bedroom window, summertime often means lots of noise outside your bedroom.  Insulate your bedroom from the noise the best you can.  A fan near the bed can create a white-noise effect to drown out noises from outside.  Some may resort to sleeping in another, quieter room in the home, one that is further away from the street for example.

4.  Keep your sleeping environment COOL.  The fan in the room helps with this, obviously, if you don’t have AC.

5.  Avoid naps if you can.  Naps are tempting if you have the time and opportunity, particularly if you’re chronically sleep-deprived.  However, naps during certain times of the day–particularly the mid- to late afternoon–can cause substantial subsequent problems falling asleep later at night.

6.  Don’t spend too much time in bed.  Remember, most adults need about 7-8 hours of sleep per night, and your body generally won’t let you sleep more than what your body needs.

School is starting back up before you know it.  Enjoy the remainder of your summer!

 

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Alaska Airlines Cargo Worker Falls Asleep in Plane Cargo Compartment

Here’s a recent story from right here in my home base of Seattle, Washington:

Six days ago, as Alaska Airlines flight #448 took off from SeaTac International Airport, passengers heard someone pounding from below the cabin.  A cargo worker was trapped in the cargo compartment of the now airborne Boeing 737.  This as-of-yet unidentified man, an employee of contractor Menzies Aviation, called 911 upon realizing he was trapped in the belly of the plane.  Upon learning of the presence of someone in the compartment, the pilot turned around for a hasty but safe emergency landing back at SeaTac.  No one was injured.

 

Turns out that this man had fallen asleep in the cargo compartment and he later awakened to find himself–and the plane–airborne and on its way to Los Angeles.  The Federal Aviation Administration is investigating the incident, and by report the man is on administrative leave; furthermore, according to an Alaska Airlines spokesperson he has been “permanently banned from ever working again on an Alaska Airlines operation.”

It’s not clear from the news reports why the contractor was asleep in the cargo compartment; by report he passed a drug test subsequent to the event.  However, this incident took place around 2:30 in the afternoon on a Monday.  From a physician sleep specialist’s perspective, here are some important potential reasons for someone to end up snoozing in the wrong place at the wrong time:

Irregular sleep schedules, which could be related to a wide variety of causes, from insomnia to some late weekend nights to flip-flopping work shifts (it’s not yet clear if this man’s particular work scheduling involved occasional or recent night-time work).

Chronic sleep deprivation.  Most adults require 7.5-8 hours of sleep per night regularly to feel fully rested during the day, and the most common cause of sleepiness in the U.S. is sleep deprivation.

Undiagnosed and/or untreated sleep disorders.  There are about 100 sleep disorders, ranging from breathing disorders (such as obstructive sleep apnea) to movement disorders (such as periodic limb movement disorder).  Commonly associated with excessive daytime sleepiness, these intrinsic sleep disorders often can persist for many years before coming to the attention of a healthcare provider.

I should note here that it’s not necessarily abnormal to feel a little sleepy or “let down” in the mid-afternoon.  Our natural tendency to become slightly drowsy or fatigued during that time of day is called the “circadian dip” or “circadian low;” it also provides the reasoning for the “siestas” commonly found in some cultures.  However, warningless sleep attacks and irresistible urges to sleep during that time suggest that more than just the circadian low may be at work.

 

Though I understand that Alaska Airlines does not permit people to “sleep on the job,” my real concern here is why this person experienced a sudden sleep attack or felt compelled to take a nap in the compartment in the first place.  I hope that this gentleman has been or will soon be properly evaluated in this regard.

Help Your Child Sleep Well While “Back to School”

All you parents know what’s right around the corner, if it hasn’t already happened: the start of the new school year! At least for us in the Pacific Northwest, school doesn’t start for another week, so we have one more glorious week of sun and freedom before the beginning of fall classes.  But for many of you elsewhere, school has already started in earnest.

 

One of the many concerns parents have as they transition back into the school year is how their children’s sleep habits will change. Many of us know the drill, from our children’s experiences or our own: all the staying up late on weekends, sleeping in ’til noon on Saturdays and Sundays, the Herculean effort necessary to get out of bed in the morning, especially on Mondays. Though this ritual is very common, particularly for teenagers, the stress and conflict arising from this chronic problem can wreck your family life, not to mention your grades.

This pattern, called delayed sleep phase, arises from the adolescent brain’s natural tendency to cycle its sleep-wake rhythms in a timing scheme that is longer than the 24-hour day. Many of us recall what it was like to be younger and wanting to stay up later and sleep in later if given the chance. The problem with this tendency is that children and teenagers usually engage in activities (i.e., school) that obligate them to entrain their sleep-wake behavior to the 24-hour clock. This conflicts with their biological inclination to go to bed later, resulting in sleep deprivation which makes it more difficult to awaken early in the morning and be awake and alert for classes. Friday night comes ’round, they stay up late, sleep in big-time on weekend days, and then find it impossible to fall asleep early Sunday night because their body clock’s sleep-wake phase has now been delayed from all the sleeping in, so all the sleep debt and sleep deprivation then roll into the new school week, perpetuating the cycle.

There is ongoing controversy about what can and should be done to improve this problem for young people and their families. Though some schools around the country have options of starting classes later in the day, many or most of us parents are obliged to ensure that our children are out of bed and ready for school at times earlier than what they, and their body clocks, “want.”

So what can be done? We can’t change our kids’ brains, though sometimes it’d be great if we could, right? Here are a few tips to help weary parents get their kids sleeping better as we kick off this new school year. As you will see below, these recommendations may be quick to read and absorb, but whether they are easy is another matter. The unfortunate reality is that making these sleep problems substantially better likely will be difficult, at least at first, requiring communication, motivation and insight from the child and patience and support from the parent.  Ready? Here goes.

1.  Minimize the “sleeping in” on non-school days by setting the alarm clock for reasonably similar times each day to the extent you can.  Kids hate this most of all.  Sleeping in dysregulates your body clock, causing nocturnal insomnia and daytime fatigue.  Sleep schedule dysregulation is why we have jet lag, for example.  If your child has to awaken for school at 6 a.m., say, but sleeps in ’til noon on weekends, and then tries to go to sleep early Sunday night, such abrupt changes in the brain would be the equivalent of flying from the west coast to the Bahamas, for example, and back, every week.  Regulating the wake-up time may well require a hard sell to the teenager; I’d rather the teen sleep in until 8 a.m. than until noon.  This lifestyle modification (and it’s a big one) gets substantially easier if done diligently for a couple weeks, but I won’t lie, it’ll be painful for all involved at first.  The child may need some, er, parental assistance in getting up on weekends.  A second alarm clock is also an option.  Put one alarm clock on the nightstand, and then put the second one further away, set for 2 minutes after the first clock, so that your teen will need to physically get out of bed to turn it off.  Make sure the second alarm clock is loud, and the more obnoxious the better.

2.  Don’t go to bed until substantially sleepy.  If the first step is done properly and done the same way every day, then this second step should fall naturally into place eventually, because the resulting sleep deprivation should make your teen become drowsy gradually earlier in the evening on weekends.  Force your child to go to bed too early, however, and residual insomnia results.  Taking advantage of children’s sleep needs allows them to fall asleep quickly and earlier (including on Sunday nights) and at the same time get proper amounts of sleep (which for children and teens can be 9-10 hours per night), both of which are important in physical and cognitive development and proper performance in school.

3.  Declare a curfew from light and technology.  Light exposure greatly impacts our levels of wakefulness and alertness; add to this the perceived need to always be constantly “plugged in” socially through mobile devices, and you have a recipe for “up all night.”  Shield your child’s bedroom from outside light and noise, such as with black thick curtains, particularly as these summer months continue to wane.  Start dimming your home’s ambient light several hours prior to the projected bedtime.  And, finally and importantly, I recommend laying off lit-screen gadgets (including iPads, laptops, and smart phones) 2-3 hours prior to the projected bedtime.

Now that I think about it, I’m pretty sure this last recommendation is actually what kids hate the most.  But complete these 3 steps, and utilize them consistently, and chances are your child will sleep better.

Best of luck to students and parents alike this upcoming school year!

 

Chicago O’Hare Train Accident Thought Related to Operator Sleepiness

You probably have heard by now about the recent commuter train derailment at Chicago’s O’Hare International Airport.  In the early morning of Monday, March 24, a Chicago Transit Authority (CTA) blue line train jumped its rails and crashed into an escalator, injuring more than 30 people.

 

It is so weird to see photos of such destruction in a place that I am so familiar with.

Anyhow, this morning it was announced that the train operator informed investigators from the National Transportation Safety Board (NTSB) that she had fallen asleep at the controls before the accident.

Here is the surveillance video that captured the incident:

According to lead investigator Ted Turpin, the train operator indicated that she had “dozed off prior to entering the [O’Hare] station and did not awake again until the train hit close to the end of the bumper.”  She also told investigators that in an earlier incident, in February, she had fallen asleep at the controls and subsequently overshot a train stop.

This accident at O’Hare occurred at 2:50 a.m. CST.

It kind of goes without saying that drowsy driving is dangerous, but you may be surprised as to how big of a deal this problem actually is.  According to the National Highway Traffic Safety Administration (NHTSA), roughly 100,000 police-reported motor vehicle accidents occur in the United States each year; of these, roughly 40,000 injuries occur and 1,550 people die.  These statistics don’t include the accidents that are never reported.  Unfortunately, work and driving accidents in the early morning are far too common, though usually not quite as dramatic as this particular event.  Many of these NHTSA-reported vehicular accidents occur in the early morning, between 2 and 7 a.m.

Further complicating matters is the fact that this tendency toward drowsy driving can be related to many potential underlying causes:  work schedules (particularly schedules that rotate in terms of the timing), home circumstances and social obligations, chronic sleep deprivation, a need to work two jobs, undiagnosed sleep disorders, and irregular sleep schedules.  Many of us can relate to most, if not all, of these causes, which again speaks to how common and problematic drowsy driving can be.

I can’t emphasize the following take-home points enough:

1.  NEVER DRIVE OR OPERATE MACHINERY (including any kind of vehicle) IF YOU ARE DROWSY!!!  It simply isn’t worth it to retain your job or get somewhere on time by risking your life or the life of others around you.  Pull over, stop your work, speak with your supervisor, whatever it takes.

2.  ALWAYS STRIVE TO GET PROPER AMOUNTS OF SLEEP (which for most adults is between 7.5 and 8 hours per night) AND KEEP YOUR SLEEP SCHEDULES REGULAR.  In other words, get as much sleep as your body needs, and get this much sleep regularly, every day at around the same time of day, even if you work night shifts.

3.  If you don’t know WHY you are drowsy when you’re supposed to be awake, SEEK MEDICAL ATTENTION.  If you are sleepy despite proper amounts of sleep and regular sleep timing, you may have an intrinsic sleep disorder.  Fixing abnormal sleepiness is one of the functions of a physician sleep specialist.

In closing, I want to give a shout-out to our nation’s first responders.  May we never take them for granted.  We’ve had a lot of disasters recently, it seems, including one geographically very close to me (the tragic, huge March 22 mudslide in Oso, Washington).  Here is a link for those who wish to help in the Oso landslide relief efforts:

http://www.king5.com/news/breaker1/Northwest-Response-Oso-Mudslide-Relief-252007821.html

Stay SAFE, everyone.

“Why is My Mouth So Dry With CPAP Use?”

I must have struck a chord with yesterday’s post on dry mouth, given the responses I’ve received.  Dry mouth is a very common symptom associated with sleep.  So let’s continue this topic, but with a little twist.  Do you awaken with your mouth feeling dry during a night of CPAP use?

As mentioned briefly yesterday, obstructive sleep apnea (OSA) is a sleep disorder of breathing associated with episodic collapse of your upper airway while you are sleeping; sleep disruption, gasping sensations at night, witnessed breathing pauses during sleep, substantial snoring, and daytime sleepiness are common clinical features of this very prevalent but under-recognized medical illness.  CPAP (continuous positive airway pressure) is a primary form of treatment for OSA.  CPAP is an electronic device which pressurizes room air and gently sends it down the throat via a mask to keep the airway open all night.  If properly used, CPAP stops the snoring and breathing pauses, deepens your sleep dramatically, and therefore makes you feel much better and more awake and alert during the day.

 

Some still think of CPAP use as a primitive, invasive, or unavoidably uncomfortable medical therapy based on what they’ve seen or heard a decade or more ago; this is unfortunate, in part because many people end up foregoing medical evaluation and treatment for their sleep apnea for many years based on an erroneous perception of what their treatment may be like.  There are now dozens of mask interfaces available, each with different sizes; the CPAP devices themselves are much smaller and quieter than they used to be, with lots of bells and whistles to make them more comfortable and easier to use.  If used properly and if you are willing to use it, CPAP can be an absolute game-changer; untreated sleep apnea can wreck your life, and proper treatment can dramatically turn things around.

Having said that, though, there are lots of potential ways for CPAP use to go wrong, causing people to have difficulties using it or to stop using it altogether.  I will write about these problems more in later posts, but one problem some CPAP users may have is dry mouth.  The majority of CPAP users don’t have substantial problems with this, but if this is relevant to you or someone you know, read on.

Presuming that your dry mouth isn’t caused by one of the problems I wrote about in yesterday’s post, and if the dry mouth started or became much worse after having started CPAP, most likely this symptom is caused by oral leak or oral breathing.  Your jaw muscles naturally tend to relax when you fall asleep.  In some cases, the lower jaw (mandible) may then drop slightly due to gravitational forces.  If you are using a nasal mask (i.e., a mask that covers your nose but NOT your mouth) or nasal pillows (i.e., soft prongs which are placed gently at the entrance of your nostrils), and if the mouth opens a little, then air from the CPAP device may then divert and escape out of your mouth.  This is obviously a problem.  The air dries your saliva, first of all, causing you to awaken more from sleep with that uncomfortable, parched, “Sahara desert” feeling in your mouth.  Just as importantly, though, if air is leaking out of your mouth and escaping into the open space instead of going down your throat the way it should be, then you aren’t being adequately treated because your airway may again be predisposed to collapse due to insufficient air pressure.  So due to sleep disruption and inadequate treatment, oral leak can lead to a perception that CPAP doesn’t work because you may still feel sleepy during the day despite CPAP use.

Oral leak is a very fixable problem.  Don’t turn your CPAP device into a very expensive doorstop because of it.  Before reading how to repair oral leak below, though, make sure you’ve determined where the dryness is; this is particularly important because people often don’t actually feel the air coming out of their mouths, because the leak happens while they’re asleep (when you awaken your muscles abruptly regain their tone and the mouth usually closes).  If the sensation of uncomfortable dryness is in the nasal passages and/or the back of the throat, but NOT in the mouth, oral leak is probably NOT the problem; I would suggest increasing the heated humidity in your CPAP device if this is the case.  However, if the dryness is clearly localized to the mouth chamber–with a pasty sensation in the mouth, for example, a feeling of having to “peel” your tongue from the roof of your mouth, dryness of the lips and teeth–oral leak is then likely the cause.

1.  If you’re using a nasal mask or nasal pillows and you like your current setup, a chinstrap is usually effective.  When wrapped gently around the head, it mechanically keeps your mouth gently closed.  It does not need to placed tightly; it should be just secure enough to be effective, but not so tight it’s uncomfortable.  People usually become accustomed to chinstrap use pretty quickly.  Many straps are made of thin neoprene.  However, particularly for my patients who are more heavyset or who have larger neck circumferences, I prefer a “deluxe” or “heavy-duty” chinstrap, which is wider and made of less stretchy material and therefore more likely to be effective.  An added bonus:  in some cases chinstrap use can be temporary; over time you may find that tendency toward oral leak has stopped after having discontinued the use of the strap.

2.  Another way of addressing oral leak is with the use of a full face mask, which covers both the nose and the mouth.  There are now many different full face masks available on the market.  Potential issues with full face masks, however:  since they’re larger masks, they may be more prone to leak than smaller masks; also, they don’t keep the mouth from opening, so you can still have some dry mouth if air continues to go in and out of your mouth (though usually substantially better).  Try increasing the heated humidity (which usually comes standard) in your CPAP device should this be the case.  But if you’re already using a nasal mask or nasal pillows and you’re comfortable with your current setup, a chinstrap usually does the trick with relative ease.

3.  Finally, as mentioned in yesterday’s post, addressing problems causing decreased airflow through the nose (such as seasonal allergies, hay fever, sinusitis, or anatomic nasal disorders) may well reduce the tendency to open the mouth during sleep.  Consider a visit to your primary care physician or an ear, nose, and throat doctor should you have symptoms that suggest such problems.

Sleep well tonight, everyone, and stay warm!

“Why is My Mouth So Dry at Night?”

Many of us have experienced this problem at one point or another during our lives:  awakening with that nasty sensation of uncomfortable dryness in the morning.  Your saliva–or what’s left of it–feels like paste; there’s that funky, faintly cheesy taste in your mouth that you’re sure doesn’t smell good either.

 

Dry mouth, or xerostomia, can be a particular problem at night.  Saliva is necessary to protect and lubricate the structures of the mouth and throat, as well as their fragile mucosal linings, from friction, foreign particles (food), and virulent organisms (viruses and bateria).  While sleeping, your salivary glands naturally and normally slow down production of this saliva, and so in some respects it may be natural to awaken feeling like your mouth is a little dry.  In some, however, dry mouth at night or in the early morning can be a substantial problem and a source of genuine discomfort; the words “Sahara desert” and “bone dry” are often used by my patients, for example, to describe this unpleasant sensation.

There are a number of potential causes for substantial dry mouth.  Aging into your 70’s and 80’s, for example, often further slows down saliva production.  Dehydration and metabolic imbalances may cause dry mouth as well.  Certain medical disorders, such as Sjögren’s Syndrome and lupus, often are associated with dry mouth, as are a variety of different medications, such as antihistamines, certain blood pressure lowering drugs, diuretics (“water pills”), and anti-depressants.

Another important thing to think about is whether your mouth is open while you are sleeping.  For many open-mouth breathers, the lower jaw (mandible) may naturally fall a little due to a combination of gravitational effects and jaw muscle slackening while asleep; some may be predisposed to this tendency more than others, and other factors–like body weight, neck circumference, and body position(s) of sleep–may influence mouth opening during sleep as well.  However, it’s important to know if there are other problems that may cause chronic mouth opening during sleep as well, in particular things that can cause nasal congestion or other decreases in airflow through the nasal passages–such as chronic allergies, a substantially deviated nasal septum, and sinus infections.  It stands to reason that if you can’t breathe properly through your nose, your mouth may be more likely to open during sleep to maintain proper airflow.

Another problem is that obstructive sleep apnea (a breathing disorder in which the airway collapses during sleep) is commonly associated with open-mouth breathing and, hence, mouth dryness and throat and oral irritation at night or in the morning.  People with sleep apnea often snore loudly.  Now keep in mind that you can snore with your mouth or closed (try simulating snoring with your mouth open and then with your mouth closed; you’ll see what I mean), but the snoring is generally louder with your mouth open.  As a result, sleep apnea can be more noticeable to a bed partner, because the snoring is more bothersome and the loudness of the snoring provides a greater sound contrast when you sound like you stop your breathing during sleep (which is what the sleep apnea does, due to blockage of the upper airway).  So as a clinician, I actually look at the open-mouth breathing as, in a paradoxical way, a good thing:  it makes the sleep apnea more bothersome to both the patient and the bed partner, thus making it more likely to be brought to the attention of a physician (studies demonstrate that in the United States, about 85% of sleep apnea cases are still not yet diagnosed!).

So here are my first take-home points of 2014!  I recommend that you consider these possibilities if you frequently awaken with xerostomia.  Bring symptoms consistent with reduced airflow through your nose to the attention of your doctor when you speak with him/her about the dry mouth.  If your oral symptoms are accompanied by a history of substantial snoring, and certainly is someone is telling you that you sound like you’re also stopping your breathing during your sleep, I strongly urge you to discuss these important issues with your doctor and consider an evaluation by a person like me, a physician who specializes in sleep medicine.

Have a great week, everyone!

 

“You’re Gonna Hear Me SNORE!”

I hope your holiday season has been great so far!  And it’s not over yet!

I recognize I’m posting this video late–it aired originally during the Thanksgiving holiday–but it’s worth posting now anyway; we’re still in holiday mode, after all, aren’t we?, and lots of people eat turkey at Christmas time!  Jimmy Fallon, Rashida Jones, and Carrie Underwood gave a hilarious musical performance about Thanksgiving traditions on Late Night With Jimmy Fallon.

Please pay particular attention to what Rashida sings 1:29 into the clip.  She parodies Katy Perry’s song “Roar,” singing, “you’re gonna hear me SNORE!”

Drowsing and falling asleep in front of the television or fireplace after a big ol’ hyper-caloric meal are so common, they seem like natural components to our American holiday tradition.  The degree to which L-tryptophan in the turkey triggers an after-dinner snooze is questionable, actually.  However, there are so many reasons for sleep to take you over after a huge holiday meal:  sleep deprivation due to wrapping things up at work; family and friends coming into town; irregular work and sleep schedules; parties keeping you up late; alcohol, particularly when combined with certain medications; underlying medical problems; and undiagnosed sleep disorders.  Untreated sleep apnea, for example, may leave you both sleeping and snoring like a bear in your recliner, disturbing your house guests.

It’s always easier to say than to do, but keeping your sleep schedules as regular as possible and getting proper amounts of sleep during the holidays may well improve your levels of wakefulness and alertness during this time of year and may bring forth even more holiday cheer!  Have a great holiday week, everyone!