Sleep and Aging - Research on Aging

the sam and rose stein institute for research on aging is committed to advancing lifelong health and well-being through research professional training patient care and community service as a non-profit organization at the university of california san diego school of medicine our research and educational outreach activities are made possible by the generosity of private donors it is our vision that successful aging will be an achievable goal for everyone to learn more please visit our website at aging.ucsd.edu [Music] this evening we're going to talk about sleep and aging and i'm going to ask you one one favor don't fall asleep on me we'll try to get through this whole thing and hopefully we'll share some of the knowledge that we've gained about sleep and it turns out to be not everything that we want to know but we're going to look into what happens to sleep as we age now everything that has life sleeps one way or another and and some of these creatures and organisms have ingenious ways of sleeping for example take the dolphin there a dolphin breathes air like you and i has lungs yet lives in the water and has to sleep when you sleep you sort of slow down and you stop swimming and so what's it going to do so the dolphin actually has this ingenious way that half of the brain sleeps at one time and half with the other so you can still run around and sleep at one time or the other you have fish the birds sleep and this right here represents a bacteria even bacteria sleep now they don't sleep like you and i sleep but they do have a quiescent time in their cycle daily or yearly or monthly whatever the bacterium is that you can consider this as possible sleep even viruses go dormant to a certain degree so everything that has life that's the point of this slide sleeps so therefore sleep must be important it turns out that roughly about a third of our lives is spent sleeping now some of us maybe a quarter of our lives and we'll talk about that too because it's important for health but and um for the longest time we never paid attention to sleep we all took it for granted we went to sleep and we we took um paid attention to the time that we are awake but it turns out that sleep instead of just a time where the brain turns off let's say a computer you turn it off it doesn't just turn off actually some aspects of sleep the brain is extremely active in fact the brain actually warms up and some what we call sleep stages and it turns out that sleep is a very dynamic behavior that has specific categories of sleep that we call sleep stages i sort of try to put them up here as stage 1 stage 2 stage 3. now they call them n1 and 2 and m3 and rem sleep everybody remembers rem sleep this is a very sexy word right rem sleep rapid eye movement and it turns out to be very important for health and we'll talk a little bit about rem sleep too if all of you right now are sitting here and i ask you just to look forward quietly and close your eyes just for a second now you can open it now all right if i had eeg electrics in your brain your your brain would do this exactly you would you would right now you when you have your eyes open your brain looks like this your eeg your electroencephalogram as soon as you close it you get what is called alpha waves just pure alpha rhythm and 90 of you will have this some of you do not have this but 90 of us will have this alpha rhythm and if your eyes start slowly to a slow rolling eye motion like this don't do that because that means you're about to fall asleep you're getting groggy so that's why i only had you two seconds with your eyes closed then after that you go into alpha dropout you go to stage one sleep then you have these very specific packets of very fast frequency of the brain called sleep spindles and there's other big waves called k complexes and that makes it stage two sleep and you can actually rest in stage two sleep stage one sleep it's like a transition we can still hear a few things maybe 50 of us can still hear sweet nothings in our ears others are out already for the count and then you get into deep sleep when you get these big tall waves and and that is a very deep restful sleep the body is is basically breathing the breathing mechanism is now being guided by our metabolic rate very steady very stable and then you get into the chaotic part of rem sleep rem sleep that's when the brain actually warms up we tend to cool down as we go to sleep but it warms up and the body cools down and you have this rabbit eye movements it's very interesting they were first discovered in children it was actually a fellow physician fellow that just looking at his little sun and the little eyes kept on moving and they did an eeg and you have these rapid eye movements during sleep and that's rem sleep so it's a very controlled elaborate precise mechanisms and each one of these stages we've discovered that they have physiological significance and that's more than what we need to get into right now there's the gamut as far as what people think about sleep now this lady some of you may know ethel pf who's a famous french singer and actress and this is what she said about sleep for me sleep is a waste of time i'm afraid to sleep it's a form of death now if you look at the scriptures various religions you'll see that death is is equated or it's an allegory to sleep because it's sort of similar you're unconscious when you're when you sleep really good okay and you wake up in the morning all of a sudden you wake up it's eight hours have gone by it's like you were dead you have no sense of time and but it's really not dead as i already mentioned sleep is a very very active process where we are doing certain physiological functions that later on i'll tell you what they do but this is the way i i i look at sleep a good laugh a long sleep are the two best cures for anything there's an irish proverb and it's true if you don't sleep well nothing works well your brain doesn't work well your heart doesn't work well your veins don't work well your arteries you don't feel good your muscles your skin deteriorates that's why people talk about their beauty sleep so sleep is very important that's why one third of our lives is spent sleeping that's what we've discovered so far so um it's important now the question always happens why do we sleep i remember back in medical school i had a professor who was looking for substance s and the spinal fluid some place trying to see you know if he could do good work and eight hours per day what if he could be awake 24 hours a day and not having to sleep he could do a whole lot more work well i like my sleep i i don't like to stay awake all day long but but we found a few things that sleep does and and one of the things that we know for sure is that sleep has physical and mental restorative properties literally when we go to sleep the brain repairs itself and that means that when we're awake through this lecture here what you're learning you're putting in information but it literally depletes your brain it uses up atp energy that we need and it may even have some some structural damage that when we go to sleep it repairs itself there's good evidence on this um there's something called adenosine as a drug that we actually use in the intensive care unit but it is a a product of atp atp as you know is the high energy compound that we have that that's what makes our muscles move and that's the energy that we have in our bodies it's actually a chemical and when that gets metabolized you get atp adenosine and adenosine accumulates in the brain as we go through the day and at night when we go to sleep is the highest and in the morning we wake up it's the lowest so it turns out that the tight blood-brain barrier that we have that keeps certain drugs from our brain and protects our brain during the day at night sort of loosens out up a little bit and it's able to get rid of some of these chemicals and byproducts and wastes that accumulate in the brain there's also certain genes that turn on only when we sleep not when we're awake and these genes it's been described very well in animals repair the schwann cells schwann cells our cells are a type of brain cells that that cover the axons think of those as the wires going through our body and the myelin membrane which is the insulation it repairs it when you don't have insulation you get into trouble that's what multiple sclerosis does the myelin membrane sort of breaks down and now you got short circuits everywhere and you got multiple sclerosis so the brain literally repairs repairs itself when we're asleep therefore sleep is important and if nothing works at least when we get up in the morning we no longer feel sleepy it cures sleepiness that's that's one of the good things about sleep now why do we sleep sleep is also a state of cardiovascular relaxation uh even when you take a nap even those 20 minutes you know a hour and a half 15 minutes 30 minutes your your heart rate your blood pressure your metabolic rate drops by about 10 to 20 percent that's everybody and that's and the literature is called dipping uh 85 of us are dippers when we go to sleep our blood pressure drops and we feel that that is important for cardiovascular health even that little bit of a break of 15-20 minutes may be beneficial for the heart to get a break the blood vessels to get a break from the high pressure blood pressure that we have and we feel that it is a good prevention for cardiovascular disease and indeed a sleep disorder that we'll talk about tonight obstructive sleep apnea those people tend to get hypertensive and hypertension is one of the first steps for developing cardiovascular disease atherosclerosis and then heart attacks strokes and things of that nature so that's another whether at least that we can say is a reason why we sleep other than repairing the brain and this one is a very intriguing i don't don't want to call it a reason uh to sleep but it's something that happens during sleep it has to do with processing of the information that you're getting right now that you got throughout the day and memory consolidation it turns out that 80 percent what you're going to remember tomorrow or what you've learned tonight it'll be it'll depend on how good a night of sleep you have tonight 80 that's quite a bit and it turns out that when you sleep after you study you're able to remember things and do well in a test i'm not talking about 30 40 up to 50 70 percent improvement your ability to recall things and it turns out that the rem sleep is good for the just of things so you will do very well in a multiple choice question you may not be able to write down the answer but if i give you choices you say that's the answer and if and deep sleep the one with the big tall waves i saw you called delta waves delta sleep that one is very good for a spatial type of learning for example a surgeon learning a a procedure a pianist learning a piece a gymnast learning a routine that will consolidate that memory of that exercise that person was doing and so and in the morning they'll be able to perform even better so to learn you have to be well-rested but to remember things to consolidate your memory you have to also sleep well after you learn so it's better to study and sleep and then take the test than to study and take the test you'll do a whole lot better by doing it just by getting those hours of sleep and getting some rem sleep and deep sleep in those cases when i first learned about this you know and people who are doing this kind of work it's amazing and how many hours we wasted uh studying all night long and it comes a time that it's diminishing returns you just have to go to bed and um be trustful that what you learned is going to be there and indeed sleep will help you do that there are a few forces that drive us to sleep and the one that everybody knows is the circadian force but we're going to talk about the circadian homeostatic force those two in red the neural hormonal forces not so much but you know there's a hormone that comes out it's called melatonin when we first go to sleep you turn out the lights melatonin comes on if you turn on the lights melatonin goes away and so melatonin is pretty weak but it does help us sleep it it helps us we use it in the clinic to move sleep around the sleep phase somebody's sleep delayed or sleep advanced we use melatonin sometimes to help them that and social cultural forces there's some some some um some countries or or people that there is their habit to take a nap siesta in the evening if you care i go to visit my parents in mexico and they take their siesta even if they're in the field working you go under a tree and take a siesta and and that may be also good for somebody's health taking a siesta but circadian forces circadian forces have to do with a suprachiasmatic nucleus this is a nucleus this is a little ball of cells that sits in the anterior hypothalamus which is sort of in the front mid part underneath your brain and it's directly attached to the optic nerves and to the eyes and what rules this this this nucleus is bright light actual light and every cell in your body has a clock a circadian clock so if you take a cell and you make it alive to stay alive in a petri dish that cell will keep a certain rhythm uh that may not be 24 hours but it has its rhythmicity but the the clock that rules them all is the suprachiasmatic nucleus and this is an important clock because um you probably noticed this clock when you go to europe or asia not south america or north america but you travel east or west you're out of sync even your bathroom necessities are saying there's very bothersome you're trying to have a good time and you know what you used to go in the morning now has the middle of the day and it's very difficult very bothersome and and that's the super cosmetics eventually you become like the natives as long as you stick to the sun and go out there and act with the nades pretty soon you do it in fact you you can move this clock about an hour a day you just be acting with the natives so if you're eight hours away it'll take about a week to get to become like a native i have here um again talking about super super charismatic nucleus this is more or less the propensity to fall asleep this is falling asleep and going up is waking up or being more aroused more awake awaken and this is our circadian rhythm through the day and somebody who's well rested and is sleeping well in a regular wake sleep schedule we're most awake around nine in the morning we sort of wake up again around nine pm and we're most sleepy around one to two p.m this is after you eat your meal you sit down and we take a nap and then your sleepiness around one to three in the morning or so and this is why you can get up and go to the restroom and go right back to bed and fall back asleep unless you have insomnia everybody can do this if you get up to go to the restroom you know earlier than that or before that you may not be able to fall asleep or after that may not be able to fall asleep as easily this propensity to fall asleep is very much tightly associated with our core body temperature where the warmest when we're awake and where the cold is when we are very sleepy and we wake up as we're warming up and we fall asleep as we're cooling down this is why when uh your doctor tells you well you have insomnia take a hot shower and then go to bed well so that's warming you up you said well it's gonna wake me up but now after you get out of the shower you start cooling down and that is what supposedly makes you promote sleep so that's a little trick that we use but this is the circadian rhythm it is about 24 hours a day in fact the suprachiasmatic nucleus the rhythm is not 24 hours a day it's closer to 25 hours a day if i put you in a dark cave there's no light nothing whatsoever you will sleep and be awake in a rhythm that it's about 25 hours a day but we live in a world that is 24 hours a day therefore we need to i'm going to show it again we need the sun we need to be out there to entrain us into a 24-hour day and that gets our clock in sync with our world by the way what planet in our solar system has a 25 hour day it's a question no one knows i guess mars mars actually has 24 hour day or close to it as compared to earth as 24-hour days all the others are either too fast or too slow uh and some of them don't even turn they just sit there like like mercury but um that's why some people say that we came from mars at least men came from mars that's what i say this is called the hypnogram if we do a sleep study on you go to the lab we put the electrodes into the eeg and we plot the time here that you were in the lab sleeping and then your sleep stages you see a very nice pattern here every 90 minutes or so you go into a rem period and notice the rim periods are getting longer and longer and longer and they actually when we look at the rem gets let's call it deeper or rem density increases you're reminding your brains out you're you're you're moving your eyes faster and faster as you go and the last rem period can be half an hour it can be 45 minutes and rem sleep 80 of our dreaming we do it in rem sleep and this is why most of us will wake up out of a dream in the morning and they're interesting when you wake up out of rem sleep you're wide awake you know exactly where you are you know exactly what you need to do when you wake up at a deep sleep you're like headachy and you're wondering what's going on what time it is what day is it and eventually it takes a few minutes to get your bearings and luckily we most of the time wake up out of rem sleep notice a deep sleep takes place mostly in the first half first third of the night and rem sleep most of it happens in the last half last third of the night and so we have a few cycles of rem and contrary to what people think that they should sleep like logs we wake up around 10 times an hour that's normal pretty much normal you're not aware they're awakening it's tiny ones lasting 15 seconds or less and but that's enough to keep your muscle tone move around a little bit prevent deep venous thrombosis clots in your legs so the design is quite good that if you sit there without moving you will get muscle damage and skin damage in the icu when we sedate somebody we don't turn them around within a day or two they develop a pressure sore and so it's important for us to maintain that muscle tone those awakenings and every 90 minutes when you go to a rim period we tend to wake up fully we'll wake up maybe a minute or so you may not even remember you woke up but you may turn around take a big sigh and go right back to sleep or in some cases like men when we get older we get up and go to the restaurant because that prostate is killing us and there's a few more changes that are normal in sleep that i need to just mention to you before we get into as we get older but temperature when we go into rem sleep we become poi kilothermic that means that you tend to go to room temperature we cannot control our temperature when we're in rem sleep we become colder we do not sweat we do not shiver when we're in rem sleep and we become like amphibians you know they need to be in the sun to get warm up um luckily we don't stay there that long we cannot move when we're in rem sleep this is why when you're having that nightmare and lion is chasing you you don't just bolt out of the room and then you'll crash into the window or something we just don't move although i'll show you there's the final if um hopefully we'll get to everything the final sleep disorder has to do with people who can move during rem sleep blood pressure we talked about the dipping already hypoventilation we we don't breathe as deeply when we're asleep and that's okay for most of us you know right now if i do an oximetry look at how much oxygen you have in your blood most of you will be 97 98 99 the younger ones will be 99 100 all right and when we go to sleep so it'll drop to 96 95 who cares it's perfectly normal but if somebody has copd or interstitial lung disease or pulmonary hypertension then going to sleep can be deleterious or dangerous because their their oxygen saturation may drop enough to cause other problems all right so that's normal sleep and what happens when you have abnormal sleep this is a survival curb where you show here years they follow these patients for 10 years and everybody is alive at first you know people die so even normal these are normal people by the time 10 years goes by you know a good what is it i don't know 15 died or something like that and but compares to people who had sleep apnea this is severe this is moderate and this is mild sleep apnea the point of this slide is this that when you have abnormal sleep in this case obstructive sleep apnea people snore and choke and gasp all night long at the end of 10 years there is a significant difference between normal and mild versus those who had severe sleep apnea as to their survival so sleep and good sleep quality appears to be important for our survival as we have gone through the years in the last 50 years we have as a group slept less and less and there's people have discussed why you know there's a number of reasons why but i can tell you know there's gadgets in our home that we look at all the time and um so we we've slept less and less and it turns out that how long you sleep it's emerging as a very important health factor in their study these some of these studies i'm talking about thousands of people this one is about 7000 individuals this one's about 73 000 individuals this one was about a million it was from ucsd right here obviously when you're talking about these kinds of studies that are huge we're talking about a questionnaire and asking people how long they sleep and then correlating that with their health status it turns out that if you sleep less than six hours in this study less than five hours in this study higher risk of high blood pressure coronary artery events heart attacks and in this one here if you could graph that it would be like a u-shape where if you slept less than seven to eight hours your health is worse if you slept more than seven to eight hours your health also is worse and including death you can put anything there so it's a u-shaped topic or curb so sleep becomes very important it appears that there is a specific number of hours that are best for adults seven to eight that's the recommended uh sleep for adults that it's it's um puts you in the in a plane where you're more likely to have better health it turns out that those who sleep long are probably already sick but those who sleep short sleep uh those are still healthy that may get sick or have more problems because they don't sleep long enough so aging and sleep what gets us from this to that all right so that's what that's what we're gonna be talking a little bit about today and um and the three factors that for a good night's sleep is really three is schedule duration and quality of sleep we don't have a whole lot of control over our quality of sleep some you know for example if you drink three beers and then go to sleep your sleep quality is not going to be that good all right if you drink a bunch of water and then go to sleep you're going to wake up a lot to go to the restroom so there's some control but other than that not a whole lot but the schedule and duration we do have control over those aspects of our lives sometimes you know we have we're ruled by the clock sometimes we're actually ruled by the late night show we have to watch stephen colbert or whoever these guys are all right um but you know what i'll tell you a secret these guys are in um on youtube and just go there you can watch them there at any time you want all right so instead of in the middle of the night um and um so we're creatures to have it we need to be able to have a specific time to go to sleep especially as we get older because there's so many things you want to do how many of you are retired most of you well most of you okay so you have the whole world and you have time right in your hands and money hopefully uh so you can go anywhere you want you can think of all kinds of things but you still need your habits of sleep because we call sleep hygiene doesn't mean you don't bathe before you're going to be it means that you have good rules of sleep and so going to bed at the same time and getting up at the same time as a habit sometimes you're going to stay late because or whatever but that's very important for our health preparing for bed making making it auspicious so that you can sleep you know it's somebody with insomnia they finish watching i don't know csi or something like that you can't sleep after watching that especially you have insomnia you watch a couple murders you can't sleep that so you have to prepare yourself to go to sleep and wake up at the same time in the morning um and uh and by all means something that i may not have here but it may be sprinkled throughout there if you get at least 30 minutes to half an hour bright light in the morning outdoors no sunglasses in the morning the sun won't give you cancer okay it won't give you cataracts either it's coming from the side but it's bright it's beautiful it's the strongest one of the strongest natural anti-depressants we have it gives you energy gives you strength and don't go in the noonday sun only mad dogs and english men do that don't do that but in the morning it's beautiful do that and i will probably be out of a job you do that all right so the national sleep foundation has a few recommendations for how long should we be sleeping and as you notice here the trend when we're young we need lots of sleep uh 14 to 17 for a newborn but the way their sleep is not quite like ours only have two stages when they're newborns by the time they're six months old now they're getting their four stages like we all have and then the sleep duration drops drops drops down and for us down here older adults seven to eight hours of sleep per night pretty similar to the to the i'm still a young adult my goodness okay that's good or just an adult i'm sorry not a young adult and um but seven to eight hours of sleep per night is what is recommended so it's time to go home and make an assessment of your sleep habits your sleep hygiene and make a few healthy changes and and i think it's going to reward you tremendously now as we age we look at eegs our pattern of sleep what we call the sleep architecture also changes and there's a few changes that every study has shown that are pretty much engraved in stone one is the decline in the total sleep time notice here how when somebody is less than five years old or so this is the total sleep time they do in the night and minutes and when we are aged we sleep less also the wazo the wazo is the wake after sleep onset how consolidated your sleep is that also goes up so there's more aches and pains and prostates and hot flashes and things like that that wakes us up and so we end up more awake at night rem sleep actually doesn't suffer that much it stays pretty much okay but deep sleep slow wave sleep this one really drops and by the way i'm sorry to say this but most of the drop has to do with men we do about 20 25 deep sleeping where i under an adult but as we age men by the time they're 85 they'll probably have less than 5 percent deep sleep as compared to women they still keep probably 15 18 they drop but not as much as men we still don't know why i blame testosterone i don't know we still don't know why that happens because our brains do atrophy as we go as we get older and that may have something to do with it but i don't think men's brain atrophy more than women's but we do lose it quite a bit there are few things also that we lose but that's one of the major ones for sleep now also um the others stage one may go up a little bit stage two a little bit but other than that those are the major changes that we see as we get older with sleep and so if we can't change some of these things we can do other things around sleep such as the hygiene if you have a sleep disorder take care of it and to improve the quality of our sleep to the best of our ability and therefore improve our health now these are some common sleep disorders that we like to get through but we'll talk about obstructive sleep apnea insomnia advancedly facial kidney disorder and rem sleep behavior disorder these are sleep disorders are quite common as we get older and this is why i brought these so what's obstructive sleep apnea it's intermittent repetitive obstruction or collapse of the upper airway it's a mechanical process in most cases although there's other reasons for it to other than mechanical associated with a drop of blood pressure because you're not breathing you're completely choking you're not breathing oxygen drops and i tell you some of these happiness can last two two and a half minutes and uh very long you sit there when is this guy gonna breathe you know should i go in and shake him and that's what happens the bed partner ends up shaking them away because it's bothering them you know this bird this guy is not usually the man this guy is not not breathing and so um because they're trying to breathe against a closed throat that activity makes them sweat they sweat they wet the usually the pillow and and then it wakes them up and luckily that's what saves them uh because that by awakening up they snore and choke and gasp and carry on do that four or five times uh breaths and then they fall back and sleep do it again repeat the whole thing again heart rate also goes down as you have to have the apnea and um and it's it's like stepping on the brakes and the gas at the same time on a car because the heart rate goes down but the blood pressure starts going up and when you start breathing again you no longer are stepping on the brakes not just the gas and then the heart rate really shoots up and blood pressure really goes up and that's a tremendous amount of stress in the cardiovascular system i actually have a graph here from one of our patients this is about 10 years ago here at ucsd this person has severe objective sleep apnea we're just going to focus on this by the way this patient is in rem sleep rem sleep gets worse when urine and apnea gets worse when you're on ramps because you're paralyzed totally choked out and there are two channels for airflow two channels for um effort respiratory effort and this channel is for for saturation how much oxygen you have in your in your blood notice there's lack of air movement at all here almost a minute in this case notice how the effort is crescendo and the patient is also paradoxical meaning that the chest is going in the belly is going out because there's no air movement and the belly has to move somehow the belly is stronger than the chest when we breathe and notice the saturation from 95 94 down to 66 percent tremendous amount of stress in the cardiovascular system so this patient has severe obstructive sleep apnea especially in this case during rem sleep and you can't see the heart rate here but it speeds up here and then it slows down again there are other cases that that is more prominent than in this one so how many of us have obstructive sleep apnea i just highlighted two here and this graph of the prevalence of specific populations older veterans i i am the chief of sleep medicine at the va hospital if i walk in the warts or in the hallways anybody i see eighty percent of time gonna be correct saying this has sleep apnea has sleep apnea sleep apnea because they're older they're overweight blood pressure hypertension diabetes um a number of other risk factors and so eighty percent will have significant obstacles that needs to be treated addressed and the elderly fifty to seventy percent just in this the fact that we're getting older we tend to get obstructed sleep apnea as we get older things get bigger you know the ears get bigger the nose get bigger things start sagging okay the uv leather the soft palate is floppy and there's very easy to choke the tongue gets bigger and if you're overweight it's even worse and so the elderly we tend to also get obstructive sleep apnea as you can see the risk factor is also for women and for men and i didn't put in the reference here but it just goes to show that aging has a lot to do with the prevalence of a flux sleep apnea it tends to level off around the age of 65 70. and that is probably just a survival effect because people have died off and now it's just the strongest survive and they don't change so who gets obstructive sleep apnea it is really a public health problem because in epidemic proportions you saw 80 70 percent of us when we get older we get it young people have it i believe that there's two types of sleep apnea one that i call malignant sleep apnea hasn't picked up in the literature yet those who are 30 to 60 strongly associated with being obese and that has very prominent or very important cardiovascular complications they will get a heart attack or a stroke sometime the younger and then you have the sleep apnea happens just because we get older you know the the floppiness that i described that's exactly and and so that one is not as bad but when somebody is sleepy we do treat them but you know people who are like this this gentleman actually gave us permission to use this picture and it's got short thick neck um truncal obesity skinny arm skinny legs maybe hypertensive diabetes and but what about her do you think she would get sleep apnea okay most people say nah she's young she's thin and but i tell you up to 25 to 30 of patients who have sleep apnea are thin i have people patients who look like her and it is a social problem they can't keep a boyfriend or or in the family they go on trips with their girlfriends and they have to rent a room by themselves because yeah because they snore too much and they say you go out there and so it can become a social problem including this the consequences you can dress them up comb their hair bathe them but you can't take them out anywhere because they fall asleep and even back in the times of flintstones uh this guy you know got into trouble because he fell asleep at the wheel save a tooth tyler and up to 20 percent of car accidents um sleepiness had to do with it the cop doesn't ask about it but research has been showing that 20 25 these folks fell asleep and they just didn't tell anybody and how many of you had bumped under the car because he fell asleep okay so he fell over with me all right i didn't do any damage okay and consequences other consequences lack of concentration you crash your car because he wasn't paying attention changes in personality men not just sleep apnea if men we are sleep deprived we tend to be bad we were angry we're impatient we chew the heads of people off and uh when we treat them they're like little lambs and women and the other hand they tend to be more like lack of energy they just don't have the desire to do anything they're tired men just get angry and upset and erectile dysfunction depression fatigue family discord usually is the man hitting but here's the woman's one got upset and um somebody had those on the internet you know just the various features of sleep apnea so i picked them up there but the consequence that we're most afraid of because it takes time it's very insidious is cardiovascular disease so whatever you you want you know obesity hypertension hypersonic stroke metabolic syndrome insulin resistance activated chemorectal dysfunction angina hypercoagulability and you fall asleep okay and so that's the point now how do you know if you have sleep apnea there should be a high index of suspicion one time i i think i landed in boston someplace like at two in the morning and i'm walking it was empty and uh they're trying to find my bags and there was this worker the guy who cleans the place but i sleep and a bench like this choking i woke him up and gave him a card and and that's because i had a high level of suspicion that this man probably had obstructive sleep apnea and so um in that case we send them to the lab and nowadays we do sleep studies in the home in the lab it's a very good study but it's expensive it's cumbersome as a funnel you know you know bottleneck of going to the lab and nowadays for sleep apnea we can do a home study the va we've been pioneering sleep studies home studies for the last 25 years and now everybody is is agreeing with us that yes sleep studies the home can diagnose sleep apnea and we've used all of these except for this one devices to do a sleeve so it's not important to know what they are other than you can diagnose sleep apnea in the home now how do you treat it well there's a few things obviously weight loss because six seventy percent of the patients are overweight or obese so weight loss is important exercise is important in fact aerobic exercise 12 weeks in a study a little muscle exercise and aerobic exercise decreases decrease the appeal severity by 25 percent and also good habits of sleep avoiding uh certain things like alcohol for going to bed alcohol very specifically relaxes the throat muscles what we call the pharyngeal dilators and you will snore if you don't have apnea or snore and you drink and go to sleep you'll snore that night and if you snore but don't have apnea you drink you'll have acne at night if you have apnea it'll be more severe it just goes that way so avoid drinking alcohol before going to bed now here is the dreaded cpap continuous positive airway pressure but it is the best therapy we have so far there's all kinds of other things you may have some questions about inspire or some other things out there right now but this remains in the gold standard that we have it it is effective 100 of the time if you're able and willing to use it rarely do we have to do something else and that has to do with people who are extremely big otherwise it's quite effective but cumbersome it splints the throat open that's all it does it's not a ventilator doesn't give you oxygen it just keeps your throat open and you do the rest there's other treatment options this is called a mandibular repositioning device or mrd or a mandibular advancement device or jaw advancement whatever you're going to call it goes in your teeth and pulls your jaw forward you have to have good teeth it's good for people have mild maybe moderate apnea and young good teeth otherwise it'll knock your teeth out and it has problems with tmj issues it is definitely a second to sleep apnea to cpap but probably a distant second some people use it extensively but when we take them to the lab and see how effective it is is not that effective at least at the va hospital is not very very good because of the population we have and there's other other therapies i mentioned the inspire therapies it's actually surgery it's a pacemaker you put in goes in your a wire goes to your tongue a wire goes to your ribs there's these little barb pieces of plastic you put in your throat that's basically for snoring doesn't work very well this one you stick a needle in the back of your tongue and you cook it with microwaves and then as it heals it it decreases in volume becomes stiff because that's the part of the tongue that blocks you again for snoring doesn't do much for a sleep apnea and this one you put these little plugs in your nose it's a one-way valve when you inhale it's open when you exhale it's partially closed so put the back pressure i haven't made it be able to work in anybody that i've tried it and some people say it works but i tell you my patients just just cannot even be awake with that thing on and it turns out that exercising the tongue is important i don't mean talking all right i don't mean talking i mean exercising the tongue uh decreases the apnea severity if you do it correctly up to 50 percent so 20 20 minutes a day of the didgeridoo keeps the sleep doctor away and so this gentleman is a middle-aged adult male probably needs it he probably has sleep apnea nicole kidman does not have sleep apnea this guy definitely needs it and by the way when you play this thing exercise you don't have to dress the part you just use it like that and you'll just be fine uh but i'd be surprised i do have a patient maybe four that are using this and um one is very cute because he lost weight and i thought yeah he actually cured his sleep apnea lost weight and using the didgeridoo and so the study knows apnea but now the wife is upset because he's making noise all day long and um so he goes he goes on vacation with the wife and he forgets the blessed that you do two weeks later he starts snoring the wife said when we get home you better start that thing again so it may work insomnia what's insomnia it's difficulty initiating sleep difficulty maintaining sleep and awakening too early early and not able to fall back asleep that's what insomnia is all of us are going to have insomnia one time or another almost 100 of us but only 15 percent of us will have it so that it affects our activities of daily living and and i tell you people with insomnia i have um compared it to a person a man or a woman who's drowning in the middle of like what's that person doing drowning still alive is yelling and screaming and kicking right asking for help and the more they move the further they sink they don't realize that if you just stop i know it's easier said than done stop what happens when you're in the water you float and if you stand up the water is only to level your navel that's insomnia you have the ability you have the brain the brain works and and i have adopted this this this philosophy step out of the way and let the brain do what it's supposed to do but insomniacs are so upset and so angry and so well uptight about it that they're looking every day the whole day is spent thinking what am i going to do so that i can have a good night's sleep and guess what happens that night they try something else and does it work no it does not work you have to step out of the way and give it time and the brain eventually will recover there's a few tricks that we use but eventually we'll recover and and the whole point of till my insomniacs is this i'm going to be able to help you become a perfect sleeper and don't compare yourself with your spouse or your bed partner whatever is you're a different person but the goal is for you to be satisfied with what you got that's the beginning of healing even if it's four hours a night be satisfied eventually becomes five hours eventually six and maybe that's all you'll do but that's good enough by the way we need four core hours per day of sleep in the long term for us to stay alive and insomnia doesn't kill anybody well and there is one called you know lethal familial insomnia but none of you have that here he's very rare and but um if you just allow and step out of the way and start to relax and that's hard to do stop drinking that caffeine and eventually sleep will come even if it's not perfect but sleep will come we use the spilman model spillman's model to to look at insomnia something that i teach my residents and medical students and even other doctors because i tell you um you've probably gone to the doctor some of you to be treated for insomnia and this is what happens in most cases hopefully your doctor is a great guy but uh you said i have insomnia what do they do get the prescription pads okay ambien zolpidem here's uh uh soapy clump here it goes go home you're ready that's not the answer the answer you need to find out why you have insomnia so we have the three-piece insomnia predisposition we cannot change this very much we may be able to advise you about not worrying too much but precipitating factors sometimes we can intervene here there's usually some type of stress for example i had a colleague that came in and saw me at ucsd i called it from the va because i work in both places and he said i had insomnia for a year i've tried everything ah they work but i'm not satisfied i want to get off these things i want to stop so the next question is you know on year what what happened a year ago and he starts thinking ah he got promoted now he's chief of something or other he's got a bunch of lazy doctors under his belt and he has the pushing he's under a lot of stress and and so um i told him you know i think that's the cause um and um so we can work together you can cope or you can quit he went home and thought about it and guess what he decided to quit his insomnia we just asked for his old job back he got it insomnia went away and i lost a client so perpetuating factors this is where we most do our most intervention here we're most effective here and and we use something called uh cbti cognitive behavioral therapy for insomnia that that therapy can be used for pain for a number of things but we use it for insomnia and we try to change the maladaptive behavior such as well i don't sleep enough so i'm going to go to bed and stay there longer they still have insomnia and now it's worse because now they're 10 hours in bed they're sleeping for so it feels worse or the television who told you that television was a set of hypnotic television is designed to keep you awake they sell you the hamburgers and then they sell you the and the the rolaids or something you know to take care of the heartburn you get and then looking at the clock you know what's the point looking at every hour it's just frustration and anger so the first thing we do is get rid of the clock and the television by the way the bedroom is only for two things and we're talking about sleep uh maladaptic thinking i must get eight hours because laredo said that seven to eight hours is what i need and if i don't get it i'm gonna die and so we try to get this thinking and these behaviors out of the way step out just let the brain do what it's supposed to do and eventually they start sleeping it takes a good eight hours just to try to get them to understand that so that's that's how we look at insomnia there's drugs and things that we use outside that may cause insomnia alcohol by itself caffeine by the way caffeine and somebody who's sensitive to it even if you can fall asleep your sleep is not that great when you have caffeine on board so insomnia it behooves us to stop any stimulant that we take even if it's in the morning why don't they drink it in the morning it does not matter diet pills stimulants stuff that we find in in cold medications nicotine sometimes our patients wake up just to smoke because they're going to withdrawal so they wake up two hours later they smoke and then go to sleep and then you know the nicotine helps them sleep in a sense because they go through withdrawals and so kind of behavioral therapy just very quickly sleep hygiene just we talked about that good habits of sleep relaxation if you're tight tense by all means prepare for sleep relax stimulus control is something that teaches you when you're in bed you're supposed to be asleep that's a technique used for many other things and it's hard because we we think of the bedroom as sometimes the the war room we go in there to do all kinds of stuff don't do your your your financial things in the bedroom because you'll never sleep um whether you have too much money or it's a little money you'll never sleep and sometimes we use something called sleeper circus this is the strong this is the the the best intervention we have that is calling behavioral if you're sleeping only four hours and you're staying in bed 10 hours i tell you well only be in bed five hours and pretty soon now your sleep efficiency looks good and you feel good and so we tricked them into doing that and slowly we lengthened the time in bed and they'll sleep and then the cognitive behavioral therapy talked about of changing their mind just saying ah you're thinking it's having them accept the thinking is incorrect and change their thinking so if you compare as you notice i did not mention any drugs other than a few that i mentioned but no slides with drugs because i don't think that medications are the key or the answer for insomnia um they're all coming up there's new ones coming up there's one called bill sombra that that in a sense it's taken advantage of narcolepsy so it makes your brain like a narcoleptic brain and hopefully you'll sleep with narcoleptics are very sleepy and it doesn't work because it's uh the dose that they're using is too low anyway so it doesn't seem to work very well but when we compare drugs to cognitive behavioral therapy the effect size um it's about the same about 50 so if it took you an hour to fall asleep now it's going to be 30 minutes with both of them and but the important thing here is this at the end of six months of both therapies you'll have 30 40 percent of patients who are using cpti being good sleepers and drugs zero because they're all dependent on drugs they call me in the middle and i say i ran out of my medication i'm dying i need one and so it had to be dry medications at night and so the dependence on medications is actually one of the most distressing things for our patients other age-related changes in circadian rhythm and something that happens to the elderly advanced sleep face all right and so the guy goes out there and they don't care so what happens what happens as we get older the circadian rhythm as you remember that that drives us to sleep um it doesn't work very well and literally because the brain doesn't work as well when we get older the older brain when compared to younger brain we don't learn as much it's actually smaller it's shrunken and that's why i never get a ct in my head because i'm afraid it's going to look like that like homer symptoms but you can see the brain goes from a younger brain to an older brain there's lots of spaces there in fact when we fall down it's easy to get a bleed in the brain because the brain is shrunken the veins that attach to the skull a little tight and you fall down there and they shut the shear and now you've got to bleed and so the weaker synchronization weaker as a suprachiasmatic nucleus reduce amplitude melatonin output is not as good as before we have the pineal gland if you do some scans of the people the pineal gland gets calcified now it's a fossil it doesn't work doesn't produce the melatonin that's where melatonins produce and also weaker or non-existing zeitgebers zeitgeist are time givers it's a german word i'm not sure i pronouncing it correctly but the sun is the major one and elderly people in nursing homes live in the dark some of them never get outside to the bright sunlight and so it's important to get them out there to get their day in sync this is why they have lots of sun downing and this advancedly phase they fall asleep at seven pm and then they wake up at three in the morning bother everybody else in the household young people are the opposite they fall asleep at four in the morning they wake up at noon you can't get them up at all all right and so um but that's what happens as we get older the last one here is rem sleep behavior disorder this disorder is almost strictly in older men it has been described in women has been describing children but the great majority 99 percent is older men and these these folks remember that i told you that in rem sleep you you you lose muscle tone and you're paralyzed except for our breathing process well these folks are do not lose muscle tone they gain it and they have dreams and rem sleep they're very active dreams uh they're action-packed the violent dreams i found this nice little caricature here this uh drawing of this this old gentleman is fighting but he's dreaming that he's boxing out there and so often times they hit their wives i just saw a patient a couple today patient and his wife and when he came three years ago and i diagnosed him with this the the lady said you got to do something he had me in a headlock this morning now he did had him in a headlock and i had an uncle who passed away a few years ago but he i treated him for this for the last 20 years and and he he would fight dirty he would bite his wife in the middle of the night he is a street fighter and so um violent dreams then can cause injury to themselves and others some people dive off the bed because they're trying to get out of the way of whatever truck is coming and they hit themselves from something sharp and now they're injured and important thing is that 85 of them already have or will develop some type of neurodegenerative disorder the most common one is parkinson's disease and so we look very careful for that you can't do a whole lot about parkinson's when it comes it comes but at least we can talk to them and consult with them and tell them what what is to expect some of them don't get it at all my uncle did not get it at all this gentleman that i have has does not have any signs of parkinson's disease but those are the possible problems with rem sleep behavior disorder now how to be diagnosed with the clinical history you know headlock you know if you've got your wife in a headlock that's that's a tell-tale sign we do a polysomnogram remember when you're in rem sleep no no muscle tone well these guys all of a sudden they gain it back and you can see right even if they don't act out their dream you can see the the rem sleep and the muscle tone comes back and that is a sign also that they may have um the rbd or rem sleep behavior disorder we have a questionnaire that asks uh you know do you move in your sleep how many things are off you know the the bed stand you know your eyeglasses or glasses on the floor things like that and you get a score and we must rule out obstructive sleep apnea sleep apnea is the 800 pound gorilla and sleep medicine it can masquerade as many things as insomnia as rem sleep baby disorder as leg movements during sleep and uh because there is a syndrome where they just have severe sleep apnea they're not in brain but they act like rem sleep baby disorder and we treat the sleep apnea and it goes away and so and they will respond to cpap very well so the treatment make the bedroom safe sometimes go as far as having them sleep in on the floor put the mattress on the floor because if they roll out of bed they won't get hurt as much remove any sharp things around the bed you know the nightstands make them brown so they get a bum not a big hole i would just remove them and the windows they really can't get up and walk you know there's been murders where it has been attributed to rbd but if the man gets goes to the kitchen grabs a knife and stabs his wife it's permitted to the murder these folks can roll around and punch but they cannot really walk some of them do do karate really nice they can't do it and when they're awake but when they're asleep they're very good at kicking the therapy is actually quite quite good a little bit of clonopin clonazepam which is one of the benzodiazepines just a tiny there's a quarter milligram sometimes a half a milligram will take care of the problem we normally start with melatonin higher dose melatonin because klonopin can make give you sleepiness in the morning because the half-life is 42 hours in certain people and so it lasts for a long time and so you don't want the elderly person to be peeing the bed or doing something else in bed because you know it will suppress you from doing that you just can't wake up and but they seem to work very very well so it's quite rewarding treating them they're very happy wintering if it doesn't work if these medications do not work we got to start thinking it's something else it's not rem sleep behavior disorder so in conclusion aging does not really decrease the need for sleep we still need to sleep for seven to eight hours to sleep per night the problem is that aging may worsen our ability to fall asleep the aches and pains and prostates and menopausal things that come into our lives and there are certain disorders as i mentioned that are more prevalent in the elderly or as we get older obstructive sleep apnea insomnia advancedly face uh circadian rhythm disorder or rem sleep behavior disorder and the point is that good habits of sleep are still important bright light exposure in the morning will help me retire soon and maintaining good health may significantly improve the quality of your sleep as we both age thank you very much [Applause] [Music] [Music] you

Channel: University of California Television (UCTV)

Views: 1,135,415

Keywords: sleep, sleep apnea, sleep disorders, OSA, insomnia, circadian rhythms

Id: OtbgWhzI7bU

Length: 58min 48sec (3528 seconds)

Published: Thu Dec 07 2017