Feature: The Science of Sleep

The Science of Sleep

BY RACHEL FARRELL

At the UIC Sleep Science Center, a team of specialists is putting patients, and their sleep problems, to rest P h o t o g r a p h y

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◗ Tonight, Robert Fletcher ’03

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will become a lab rat. Not in the literal sense, of course, but in the sense that he’ll be confined to a laboratory, hooked up to sensors and monitored by a team of technicians.

You see, lately Fletcher has been feeling groggy all the time. He is forgetful, feels depressed, has trouble concentrating when talking to someone and isn’t producing like he used to as an architect at Aumiller Youngquist. And for a 26-year-old who’s healthy, active and sleeps at least eight hours a night, that’s not normal.

To determine the source of his problem, Fletcher visited the UIC Sleep Science Center earlier today and saw Dr. James Herdegen ’82 UIUC, the Center’s medical director and associate professor of pulmonary, critical care and sleep medicine.

Herdegen recommended that Fletcher undergo a sleep study—a painless, 10-hour procedure in which a patient’s heart rate, brain wave activity, eye movements, muscle activity and body position are monitored during sleep. This data will ascertain whether Fletcher has a sleep disorder.

Twenty-two wire-connected sensors are attached to Robert Fletcher’s forehead, cheeks, scalp and legs in preparation for his sleep study.

Now dressed in a white undershirt, white socks and plaid pajama pants, Fletcher is sheepishly waiting in one of the Center’s laboratory rooms for his study to begin. The room, however, looks more like a hotel suite than a medical lab.

Its walls are painted an eggshell hue and its floors are covered with plush, knit carpeting. On one wall hangs a framed painting of a beach, on another is a plasma TV. In the center of the room is a queen-sized bed covered with a mustardcolored blanket. What throws off the Holiday Inn vibe is the camera hanging from one wall and some unidentified medical equipment on a desk.

With a copy of the book Six Degrees in hand, Fletcher lays down on the bed and props his head upon two starchy pillows.

The mattress sinks under his weight as he opens the book, turns to where he last left off and comfortably crosses his ankles.

A petite woman enters the room dressed in chocolate-brown scrubs. She introduces herself as a sleep technician and, in one hand, carries a pile of rainbow-colored wires the size of vermicelli noodles.

“OK, Robert, I’m going to get you set up for your study,” she says cheerfully. She pats a swivel chair to coax Fletcher out of bed. He moves quietly to the chair and sits down, folding his hands in his lap. For the next 45 minutes, the technician engages in what looks like some cruel practical joke—attaching 22 wire-connected sensors to points on Fletcher’s forehead, cheeks, scalp and legs. Afterwards, she wraps a seatbelt-like strap around his chest and stomach, tapes a small microphone to his throat and covers his index finger with a plastic clamp.

By 9:55 p.m., the process is complete and Fletcher says he’s ready for bed. He crawls under the covers while the technician connects the sensors to a computer tower. As soon as the lights go out, the study begins.

Weeks later, Fletcher learns that he has sleep apnea and periodic leg movement.

The former, because it’s mild, can be treated with an oral appliance; the latter

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responds well to medication. Fletcher’s future looks optimistic, but what about the other 50 million to 70 million Americans who chronically suffer from sleep problems?

An unmet public health problem According to Herdegen, 80 to 90 percent of people with sleep problems don’t get diagnosed or treated. Several factors are to blame for this. For one, sleep studies—the “gold standard” procedure for diagnosis—are expensive and time-consuming, and most U.S. communities don’t have the resources to provide them. In the United States, for example, approximately 2,310 sleep studies per 100,000 people are needed annually to satisfy the demand for diagnosis and treatment of sleep apnea; on average, only 427 studies per 100,000 people are performed. In an April 2006 report, the Institute of Medicine declared sleep disorders and sleep deprivation “an unmet public health problem.”

To make matters worse, demand for treatment is increasing in the United States as the prevalence of sleep deprivation and sleep disorders continues to rise. The obesity epidemic, in particular, is contributing to the growth. “We think that obesity is driving the prevalence of sleep disorders [such as] sleep apnea,” explains Herdegen, a tall, lean man with wire-rimmed glasses. “And until we make some public inroads on obesity, sleep apnea is not going to go away. It will probably get worse before it gets better.”

Changes in the work force are another contributor. More than 20 million Americans perform shift work, which can cause sleep deprivation and circadian rhythm disorders (a syndrome in which the “internal body clock” is disrupted). In addition, technological advancements are reducing our sleep. “In 1910, for example, people functioned through light and dark cycles,” says Herdegen. “The incandescent bulb wasn’t widely available and we didn’t have TV, so people were getting about two more hours of sleep than they are now. Today, we’re pretty much a sleep-deprived society.”

The consequences are greater than you i

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Dr. James Herdegen, director of the UIC Sleep Science Center, says that 80 to 90 percent of people with sleep problems aren’t properly diagnosed or treated.

might think. In the long term, sleep disorders and sleep deprivation are associated with an increased risk of hypertension, diabetes, obesity, depression, heart attack, stroke and even premature death. According to the Institute of Medicine, 20 percent of all serious motor vehicle crash injuries are associated with driver sleepiness, inde-

pendent of alcohol effects. And Americans spend hundreds of billions of dollars each year on doctor visits, medical services, prescriptions and over-the-counter medications to treat their sleep problems.

The UIC Sleep Science Center is trying to help address this public health problem. It annually treats more than 1,500 patients,

Banno K, Kryger MH. 2004. “Factors limiting access to services for sleep apnea patients.” Sleep Medicine Reviews 8(4):253-255.

Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatly J. 2004. “Access to diagnosis and treatment of patients with suspected sleep apnea.” American Journal of Respiratory and Critical Care Medicine 169 (6):668-642.

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COMMON SLEEP DISORDERS Can’t sleep? You may be one of the estimated 50 to 70 million Americans suffering from a sleep disorder. Here’s a breakdown of the four most common conditions.

SOURCES: National Heart, Lung and Blood Institute Diseases and Conditions Index, http://www.nhlbi.nih.gov/ health/dci/index.html. Sleep-Wake Cycle: Its Physiology and Impact on Health, National Sleep Foundation, 2006.

CONDITION

Insomnia

Narcolepsy Restless Legs Syndrome

Sleep Apnea

DEFINITION

SYMPTOMS

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TREATMENT

◗ Behavioral Approach: Decrease caffeine and alcohol intake, increase exer◗ Accidents and injuries cise, regulate diet, maintain ◗ Difficulty initiating or main- ◗ Problems at work or school the same sleep patterns ◗ Impaired mood or judgment ◗ Pharmacologic Approach: taining sleep ◗ Waking too early and not ◗ Difficulty concentrating, Over-the-counter sleep learning and remembering ◗ A condition in which a per- being able to get back to aids, such as melatonin, or ◗ Lack of energy sleep son has trouble falling or prescription pills, such as ◗ Feeling lethargic after sleep ◗ Depression staying asleep benzodiazepines

◗ A disorder that causes a person to have an overwhelming and recurring need to sleep at inappropriate times, such as during the day

◗ Suddenly losing muscle tone and control when awake ◗ Being unable to move or speak while falling asleep or waking up ◗ Having vivid dreams while falling asleep or waking up

◗ Behavioral Approach: Regularly scheduled daytime naps and nighttime ◗ Accidents and injuries sleep schedule, avoidance ◗ Problems at work or school of heavy meals and alcohol ◗ Social problems ◗ Pharmacologic Approach: ◗ Impaired memory, thinking Use of stimulants, antidepressants and other medications or ability to concentrate

◗ Uncomfortable sensations ◗ Behavioral Approach: in the legs, including creepEat a balanced diet, avoid ◗ Difficulty concentrating, ing, tingling, cramping, caffeine and alcohol, take learning and remembering burning and pain. Moving vitamin B12 if an iron things the legs temporarily eases deficiency is detected ◗ A sensory disorder causing these feelings, but also pre- ◗ Social problems ◗ Pharmacologic Approach: vents a person from falling ◗ Problems carrying out an irresistible urge to Use of dopamine-based asleep and staying asleep. move the legs drugs daily activities

◗ A common disorder in which a person’s breathing stops or gets very shallow ◗ Snoring ◗ Daytime sleepiness during sleep due to a closed airway ◗ Problems concentrating

ranging from ages 6 to 90, for a range of sleep disorders such as obstructive sleep apnea, restless legs syndrome, insomnia and narcolepsy. In May 2007, the Center moved its facility from the over-crowded outpatient clinic at the University of Illinois Medical Center to the Tech 2000 building at the corner of Harrison and Leavitt streets in Chicago. At this new, larger location, the Center can see more than 150 patients per month, instruct medical students in clinics five times a week, offer as many as 10 sleep studies per night (compared to four at the hospital) and

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EFFECTS

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◗ High blood pressure ◗ Increased risk of heart attack, stroke and diabetes ◗ Depression ◗ Continuous Positive ◗ Irritability Airway Pressure therapy ◗ Falling asleep while at work, ◗ Oral appliances ◗ Surgery on the phone or driving

provide one-on-one treatment consultations for sleep apnea patients.

The man behind the mask Imagine standing before a shelf lined with mannequin heads. On each one is a different plastic mask—some white, some turquoise, some with tubes sticking out like tentacles. You envision that these masks might be worn during scuba diving or used in the emergency room.

Then you’re told that you have to wear one of these to bed. And sleep with it.

For the rest of your life.

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For patients diagnosed with obstructive sleep apnea, this is the harsh reality. Sleep apnea sufferers stop breathing during sleep because their airways collapse; to keep them open, they need to wear a nasal mask attached by tube to a Continuous Positive Airway Pressure device, which generates a positive-pressure air flow.

(Other treatment options, which include surgery and oral appliances, are typically less effective than CPAP.) Mark Eley, the Center’s “durable medical equipment coordinator,” is responsible for getting patients accustomed to

Mark Eley takes a therapist-like approach when teaching sleep apnea patients how to use the CPAP device.

CPAP therapy. A slight man with a thick moustache and polite manner-ofspeech, he takes a gentle, therapist-like approach when meeting with patients during their one-hour consultations.

Eley lets patients touch the masks before putting one on; he encourages them to feel the air flow before breathing it through the mask. But some patients vehemently refuse to use the therapy.

“So I put on my salesman hat,” says Eley with a little smile. “I say, ‘At a minimum, would you at least be willing to give it a try?’ Almost always, they’re going to agree to at least try. We take baby steps.”

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hopes that more patients will stick to CPAP. “Studies have shown that one of the key components of patient compliance is the interaction that he or she has with the technician,” he explains. “If you have a technician who is very compassionate and patient and knowledgeable, you’re going to persevere. If you have a technician who says, ‘Here’s your mask, good luck, see ya,’ that’s not going to work. There’s no success with that.”

After the consultation, Eley provides “an aggressive follow-up,” calling the patient a few days later, one week later and a month later to make sure that he or she is using the device. “It’s for their well-being,

whether they realize it or not,” says Eley.

By working so intensely with patients, Eley may be saving lives. In a 2005 study, individuals with untreated sleep apnea were far more likely to die from cardiovascular disease than individuals who received CPAP therapy for at least five years (14.8 percent versus 1.9 percent).

In addition, when patients with severe sleep apnea were treated with CPAP, the rates of cardiovascular events and cardiac deaths dropped to control rates. iii

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Air effects In her high-rise apartment on Chicago’s South Side, Veronica Coleman, 58, has

Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. 2005.“Obstructive sleep apnea as a risk factor for stroke and death.” New England Journal of Medicine 353(19): 2034-2041.

Marin JM, Carrizo SJ, Vicente E, Agusti AG. 2005. “Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study.” Lancet 365(9464):1046-1053.

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Veronica Coleman was forced to go on disability in 2004 because of her health problems, which include central sleep apnea and insomnia.

decorated her home for the holidays.

There’s a Christmas tree covered with homemade decorations, a table topped with red candles and a cluster of stockings ready to be stuffed. Yet Coleman isn’t feeling so festive.

Diagnosed with chiari malformation (structural defects in the brain), intracranial hypotension (spinal fluid leak), central sleep apnea and insomnia, Coleman suffers from chronic headaches, dizziness, fatigue and balance problems. She falls asleep as early as 7 p.m., wakes up several times during the night, and gets up around 3:30 a.m. feeling just plain “crappy,” she says. In 2004, her health problems became so severe that she had to go on disability, leaving her 30-year job as an auditor for United Healthcare.

Since last summer, the Center has been working with Coleman to treat her sleep apnea and insomnia. Herdegen put her on a sleeping pill, Sonata, and fitted her for a nasal mask; he’s now monitoring her daily use of CPAP through a microchip that’s planted in the device. Getting used to the nasal mask hasn’t been easy for Coleman.

“It makes so much doggone noise with the air blowing,” she says, groaning. “It keeps me up. And how am I supposed to get a boyfriend with this thing on my face? I’m going to scare him away!”

But Coleman doesn’t have much of a choice in the matter: Without CPAP, she stops breathing during sleep 28 times an hour. With CPAP, “I can tell the difference—I feel better in the morning,” she admits.

For this, Coleman is grateful. “I mean, what did my parents and grandparents do?” she says. “They didn’t have any sleep clinics. Grandpa snored; he probably had sleep apnea. But back then, nobody knew what sleep apnea was. They probably had pulmonary problems when they died. I hate to say it...” Her voice trails off, but her point is made: If sleep centers, such as UIC’s, had existed back then, would her relatives have lived longer, healthier UIC lives?

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