healthiersleepmag.com July/August 2021 | Insomnia Issue
Insomnia 1991-2021:
How Treatment Has Changed
My Child Can’t Sleep:
Managing Pediatric Insomnia
Sleep
in Athletics
Healthier Sleep A publication of World Sleep Society Publisher World Sleep Society Issue Reviewers Lourdes DelRosso, MD Melissa C. Lipford, MD Robert J. Thomas, MD Rochelle Zak, MD Sales Manager healthiersleep@worldsleepsociety.org Designer Brook Lanz Copy Editor Wendi Kitsteiner Content Contributors Shanti Argue Matteo Cesari, PhD, MSc Rachel Ngon Yin Chan, PhD Leila Emami, MD Colin Espie, PhD, DSc(Med) Michael Grandner, PhD Paul Glovinsky, PhD Shona Halson, PhD Yuichi Inoue, MD, PhD Wendi Kitsteiner Clete Kushida, MD, PhD Shirley Xin Li, PhD Charles Morin, PhD Jason Ong, PhD Judith Owens, MD, MPH Charles Samuels, MD Rosei Skipper, MD Yun Kwok Wing, MBChB, MRCP
ABOUT
For advertising or editorial contact information, email healthiersleep@worldsleepsociety.org or visit healthiersleepmag.com for current rates. Healthier Sleep is published up to six times per year by World Sleep Society, 3270 19th Street NW, Suite 109, Rochester, MN 55901 and distributed to sleep medicine and research professionals as well as the public. No part of this publication may be reprinted or reproduced without written permission. Healthier Sleep does not necessarily endorse the claims or content of advertising or editorial materials. All advertisements and editorial material included represents the opinions of the respective authors. World Sleep Society/Healthier Sleep Magazine does not provide or offer medical advice. All content within the magazine, such as text, graphics, information obtained from sleep experts, and other material, is for informational purposes only. The content is not intended to be a substitute for medical diagnosis, advice or treatment. Relying on information provided by World Sleep Society and/or any of its employees, experts within the material, or other writers is solely at your own risk.
©2021 World Sleep Society. All rights reserved. Printed in the U.S.A.
CONTENTS July/August 2021 | Insomnia Issue
|4| Insomnia 1991-2021 How treatment has changed.
|8| My Child Can’t Sleep Managing pediatric insomnia.
| 12 | Sleep in athletics.
16
How to Find Help for Your Insomnia
18
Insights into Insomnia
19
Quiz: Have you been worried about insomnia?
20
Artificial Intelligence in Sleep Medicine
22
Short & Long Sleeper
24
CBT-I: What to Understand
26
CBT-I: Key Components & Treatment Targets
27
Ways to Get Through the Day on Little Sleep
29
Consequences of Poor Sleep Quality
34
World Sleep Society's Road to Better Sleep
IN EVERY ISSUE The BuZZZ about Sleep
Right Now in Sleep Science
Bedtime Reads
Ask the Sleep Doc
PAGE 15
PAGE 28
PAGE 29
PAGE 30
Your latest buzzwords are Process C/Process S
Social media use and short sleep in teens
Sleep Disorders For Dummies
Your questions answered by sleep professionals
Supported by an independent educational grant from Eisai 3 | healthiersleepmag.com
Insomnia 1991-2021 How treatment has changed.
V
iews on insomnia and "trouble sleeping" have undoubtedly changed throughout the past few decades. As it became more culturally acceptable to talk about insomnia, treatments began being requested. Three World Sleep Society sleep experts have watched the field grow, expand and change from the 90s to today.
From "Z Drugs" to CBT-I For 44 years, Clete A. Kushida, MD, PhD has been working in the field of sleep medicine and research. Currently acting as Associate Chair, Division Chief and Medical Director of Stanford Sleep Medicine, he began working in the realm of insomnia in 1991. “Starting in July of 1991, I was a neurology resident at the University of California San Diego,” Dr. Kushida recalls. “I was fortunate in being able to evaluate sleep medicine patients under the supervision of Dr. Sonia Ancoli-Israel. At that time, many of the patients I saw with Dr. Ancoli-Israel were managed for their insomnia with antidepressants and benzodiazepines, including triazolam (Halcion).” In 1992, the FDA 4 | July/August 2021
approved Zolpidem (Ambien) and it was the first of the "z drugs" (zolpidem, zopiclone, zaleplon) that rapidly became the first-line pharmacologic treatment for short-term insomnia. “Since that time,” Dr. Kushida explains, “there have been other pharmacologic treatments for short-term insomnia, including ramelteon and suvorexant. However, the most important treatment for insomnia that has grown during the last two decades is cognitive behavioral therapy for insomnia (CBT-I), which has helped countless individuals with chronic insomnia.”
WHAT IS CBT-I? Cognitive behavioral therapy for insomnia is a course of therapy that runs 6, 8 or 10 weeks in length. Around 70-80% of patients will benefit from CBT-I and up to 50% can experience a full remission of insomnia symptoms.
In the last ten years, there has been a virtual explosion in the need for CBT-I providers. At Stanford, Dr. Kushida has watched the increase to eight clinical psychologists, four behavioral sleep medicine fellows, and a nurse Dr. Clete Kushida practitioner in two behavioral sleep medicine programs/ clinics. Dr. Kushida states, “Even with this number of providers specializing in CBT-I, we have high demand for these services and are in the process of hiring additional providers. Given the prevalence of insomnia and these troubled times, I expect that the need for behavioral sleep medicine programs will continue to increase worldwide.” Dr. Kushida sees the major inventions or advances that changed how we diagnose/treat insomnia as: • Online and mobile CBT-I, particularly for those in geographical areas where a CBT-I provider is not necessarily accessible. • The growth of consumer wearable devices as it helps to heighten awareness of sleep problems, including insomnia, in users, prompting them to seek help from sleep specialists. • The use of actigraphy within sleep clinics to pinpoint sleep problems that may be circadian rhythm disorders, insomnia, or a combination of both.
Increased stress levels and insomnia symptoms associated with the COVID-19 pandemic has undoubtedly resulted in new and worsening cases of insomnia. Dr. Kushida remarks that the next few years will be interesting since wearable and homebased measures of sleep will show on a large-scale what impact the pandemic has had on the world’s population and will most likely result in even better treatments for insomnia.
Measuring Insomnia
Yuichi Inoue, MD, PhD began his career as a sleep researcher 35 years ago in hypersomnia and sleep apnea but came to work in insomnia, parasomnia and movement disorders around 2000. Currently Dr. Inoue is a Professor in the Department of Somnology at Tokyo Medical University.
According to Dr. Inoue, when he began his career, society paid minimal attention to the field of sleep medicine. Dr. Inoue states, “The clinical significance of insomnia was not sufficiently acknowledged, and many researchers (mainly psychiatrists) gave as much attention to insomnia as a comorbidity of psychiatric disorders. From the late 90s, the results of many epidemiological studies have revealed the clinical significance of insomnia and the importance of appropriate treatment on the disorder. Many physicians also came to know the harmful effect of long-term use of benzodiazepines or Z-drugs at that time.” Dr. Inoue believes that in the past, patients relied too much on pharmacotherapy, especially GABAergic drugs. However, the enlightenment of sleep hygiene education, implementation of CBT-I and development of newer hypnotics such as melatonin receptor agonists and orexin receptor antagonists have changed the patients’ cognition and the outcome of treatments. From 2005 forward, Dr. Inoue has been working with clinical psychiatrists specialized in CBT-I and created a series of papers on the efficacy of the treatment. Dr. Inoue states, “I truly believe that CBT-I is absolutely essential for the Dr. Yuichi Inoue improvement of insomnia.” Currently, Dr. Inoue and his colleagues are conducting CBT-I via telemedicine, but the reliable outcome has not been obtained, despite there being some positive feelings. “We are also now studying the utility of sleep trackers—a conventional device—for the severity evaluation of insomnia and hope that this kind of easier testing would become a useful tool for the diagnosis of the disorder.” Dr. Inoue sees the next step being to accumulate studies on the difference in psychological and physiological characteristics, as well as treatment strategy between objective and subjective insomnia. “I believe this will help the improvement of insomnia medicine,” he concludes.
Insomnia continued on page 6 5 | healthiersleepmag.com
Insomnia continued from 5
Recognition of Insomnia Dr. Colin Espie PhD, DSc(Med) is a Professor of Sleep Medicine at University of Oxford, UK who saw his first patient with insomnia in 1980, not long after qualifying clinically. Dr. Espie recalls a primary care physician asking at that time, “Can you not do anything to help these people who can’t sleep?” Dr. Espie had not received any training on sleep or sleep disorders but became fascinated to find out. He has been working to answer that question throughout his entire career. “In the 90s, I think insomnia was seen mostly as a symptom of something else—most commonly depression—so the focus of professionals was upon treating what was thought to be the primary disorder. This never made Dr. Colin Espie sense to me. After all, depression is a dysfunctional mental end state that is more likely a result than a cause.” Dr. Espie noticed ‘impressive epidemiological research’ from the late 80s and 90s which demonstrated that insomnia was a risk factor for the development of depression (and other mental disorders). Moreover, he saw many patients who said sleep was fundamental to how they were feeling. “Unfortunately,” Dr. Espie comments, “it has taken us a long time to recognize what was always true—that sleep is of primary importance in the regulation of our emotional health.” The publication in 2013 of DSM-5 and the inclusion of insomnia disorder as a disorder in its own right was a landmark event, according to Dr. Espie. “The evidence had been there for quite some time that insomnia should be actively addressed whenever it presented,” Dr. Espie states. “Indeed, we were seeing strong evidence that it could be effectively treated, particularly using CBT, but the clear direction given by DSM-5 brought insomnia out from under the coat tails of a very traditional psychiatry view of the world.” Other landmarks to note in the field of insomnia are the NIH state-of-the-science statement on insomnia (2005), the publication of AASM practice parameters 6 | July/August 2021
(2006) and further iterations of ICSD (2005, 2014). “These all played a part in gathering momentum to take the insomnia field forward,” says Dr. Espie. “I also remember in the 2000s, noticing at scientific meetings that the insomnia sessions were getting better attended, were being held in larger halls, and becoming much more prominent rather than appearing on the last day when folks were about to head for home.” Dr. Espie would “love to say that the patient’s experience has changed dramatically,” and notes that it has for some patients and in some places, but does feel we still have a long way to go to treat insomnia based upon clinical guideline care. Many in the field remember that in the early 90s, the default action would have been to pick up the prescription pad and use hypnotic drugs. There is more reluctance to do that nowadays, and sleep hygiene is at least being discussed in most clinics. Unfortunately, there is little evidence that sleep hygiene is an adequate standalone treatment for chronic insomnia, and the majority of people are still prescribed medication. Dr. Espie explains, “All guidelines recommend CBT-I as a first-choice treatment for persistent insomnia in adults of any age, and although provision of CBT-I has increased, it still falls dramatically short of what would be required to meet population need.” CBT-I has proven to be very adaptable to a wide range of delivery formats. Traditionally, clinicians would meet with patients on a one-on-one basis, but CBT-I is also effective when delivered in small groups, or in abbreviated format, and using technology such as telehealth and digital (web mobile) tools. “I have for a long time advocated for the adoption of a stepped care model of insomnia treatment delivery so that patients can be triaged to accessible help based on clinical need, coupled with personal preference,” Dr. Espie explains.
It has taken us a long time to recognize what was always true—that sleep is of primary importance in the regulation of our emotional health.
“The therapies that comprise what I now call cognitive behavioral therapeutics (CBTx) to emphasize that CBT is a class of intervention, have proven extraordinarily adaptable to different means of presentation, whilst retaining noticeable clinical effectiveness.” Dr. Espie also notes that digital CBT (dCBT) has the potential to transform service provision because fully automated software is as scalable as drugs. “I anticipate that within five years dCBT will replace sleeping pills and off-label prescribing as the most commonly used insomnia treatment,” Dr. Espie relays. “We are entering the era of ‘digital medicine’ as a direct alternative to pharmaceutical medicine, and this is the most likely way in which clinical guideline care for insomnia can be delivered nationally and internationally. I am hopeful also that novel CBTx and pharmacotherapy interventions will continue to be developed because around one-third of our patients do not respond to the treatments we have. There is no room for complacency.”
PRESENTS
Am I sleep deprived?
How much sleep do I need?
ADVANCING PUBLIC SLEEP HEALTH
Why won’t my child sleep? Does exercise really help sleep?
What is the impact of pregnancy & menopause in women?
What are the consequences of poor sleep?
Do women need more sleep than men?
How do I sleep better?
DO I HAVE SLEEP APNEA?
bit.ly/WSSyoutube
HAVE SLEEP QUESTIONS?
VISIT THE WORLD SLEEP SOCIETY YOUTUBE CHANNEL TO GET THE ANSWERS FROM SLEEP EXPERTS IN A SERIES OF LECTURE-BASED PRESENTATIONS 7 | healthiersleepmag.com
PEDIATRIC
My Child Can’t Sleep How to manage pediatric insomnia. By Rosei Skipper, MD
J
udith A. Owens, MD, MPH, is an internationally recognized authority on pediatric sleep and the author of numerous original research and review articles in peer-review journals on the topic. Her particular research interest is in the neurobehavioral and health consequences of sleep problems in children, and what to do about them. Every parent knows the struggle of getting kids to sleep–the sheer number of books on the subject is evidence for how tough it can be! While some kids are easy sleepers, many little ones struggle with getting or staying asleep, which can be incredibly challenging for parents. “NORMAL” SLEEP Just like adults, kids vary when it comes to sleep patterns— and sleep needs change as children grow. In general, Dr. Owens says that most babies over the age of six months can get through the night without needing to be fed, and kids aged 12 months and older can definitely go overnight without needing to eat. Some children are more naturally morning larks, while others burn the midnight oil. WHEN KIDS CAN’T OR WON’T SLEEP According to Dr. Owens, behavioral insomnia of childhood falls into two categories: sleep onset type and limit-setting type. Children with the first type have “learned to fall asleep requiring a parental intervention,” explains Dr. Owens. That could mean needing a parent to fall asleep with them, needing to sleep in a parent's bed, or needing to fall asleep while feeding. While there is nothing wrong with snuggling your little one while they get drowsy, this can become problematic if your child is unable to get to sleep without your help. This becomes especially challenging when kids need help getting back to sleep after waking up in the night. All humans wake up periodically during normal sleep, but if your child requires parental help multiple times per night, chances are the whole household won’t be getting as much rest as they need. 8 | July/August 2021
The second type of behavioral insomnia involves limit setting, and often occurs in older children. All kids push boundaries when it comes to bedtime, but Dr. Owens emphasizes that Dr. Judith Owens structure is good for kids, and that bodies of all ages feel best when they have a regular schedule. It is normal for children to ask for “one more story” or to put off sleeping when they are having fun, but lack of routine can result in big bedtime battles and big misery for parents. WHAT TO DO Dr. Owens recommends that parents “always start with behavioral interventions,” and stresses that there are “no prescription medications approved for sleep in otherwise healthy children.” Although melatonin is a common over-the-counter supplement, Dr. Owens does not recommend its use in children, though other pediatric sleep physicians do. Fortunately, most children respond well to limit setting and bedtime routines—and there are many resources for parents to learn different methods. The important thing, according to Dr. Owens, is to be consistent, have patience, and understand that things might get worse before they improve, something called the “extinction burst.” This is to be expected, so don’t get discouraged when the going gets tough! If do-it-yourself techniques aren't working, consider speaking with your pediatrician. He or she should be well-versed in childhood sleep issues, but a referral to a specialist or sleep psychologist may be needed if problems persist. In rare cases, a sleep medicine doctor might be needed to check for any medical conditions that require treatment, such as sleep apnea or restless legs syndrome. Fortunately, these are rare in children. With patience, consistency and a little ingenuity, parents can eventually find solutions to these common problems—and the whole household will be sleeping better.
9 | healthiersleepmag.com
Dr. Owens’ Quick Tips •
Remember that improving a child’s sleep starts with the parent. The whole family may need to cut down on screen time, increase physical activity and maintain a more consistent bedtime routine.
• No screens should be in children’s bedrooms and screens should be turned off at least one hour before bedtime. • Maintain a regular sleep/wake cycle, even on the weekends. • Getting enough exercise will help everyone sleep better—bonus points if you can get the exercise outdoors! • Beware of hidden sources of caffeine such as chocolate. • Avoid doing homework or other activities in bed. • Think carefully before bringing a child into your bedroom because it may be very difficult to get them out again. • Have patience. Sleep issues can be extremely challenging, but your family will get through it. ...................................................................................................... Rosei Skipper, MD completed her Psychiatry residency and Child fellowship at the Mayo Clinic in Rochester, MN. She is currently pursuing further training in psychoanalytic therapy.
OPINION
Mindfulness Can Improve Your Sleep, But Not How You Think It Will By Jason Ong, PhD
M
indfulness is bringing your full attention and awareness to the present moment…then just watching each moment unfold without trying to control it. REGULAR MINDFULNESS BENEFITS Mindfulness is usually practiced during meditations, which can be a quiet meditation such as breathing meditations, a movement meditation such as yoga or walking meditation, or an informal meditation such as eating mindfully.
when the mind and body are ready for sleep and when it might be more helpful to stay out of bed and do a soothing activity until your mind and body are ready. The purpose of mindfulness is just to do the practice and see how each moment unfolds. It is not to use it for any particular purpose— whether it be for sleep, mental health or anything else.
PROGRAMS AVAILABLE There are many mindfulness programs that are taught inperson or online. The One of the biggest most popular program misconceptions is that is mindfulness-based Dr. Jason Ong mindfulness is another stress reduction relaxation strategy in which people (MBSR), which typically involves are able to “meditate themselves to an 8-week class where participants sleep.” That is NOT the intention are asked to practice the of mindfulness practices. Instead, mindfulness meditations at home. these practices can help promote In our lab, we have developed a sleep health by developing a version of this program tailored greater awareness of sleepiness and to people with insomnia called regulating cognitive arousals such MBTI (mindfulness-based therapy as negative or racing thoughts. for insomnia). There are other Ideally, formal mindfulness online programs and apps, such as meditation practices are done Headspace or Calm, which are also during the daytime—not when good ways to become acquainted you get in bed. In this way, regular with mindfulness principles and mindfulness meditation can help meditations. These programs do improve the regulation of sleep by a nice job of making mindfulness cultivating a greater awareness of more “digestible” by leading
10 | July/August 2021
participants through shorter 10-minute meditations. Most people who ask me about this topic think I will tell them how to relax themselves to sleep using meditations. Even those who take mindfulness classes often comment that MBTI isn’t quite what they signed up for, and some do drop out. I would like people to understand that practicing mindfulness involves a commitment and takes time and patience. It is not intended to be a quick solution or something you use to make yourself feel better. This is quite contrary to how most of us in Western societies are trained, but this is exactly why it is so powerful. Mindfulness gets us back to the essence of how we are as human beings without being clouded by the constant need to achieve, strive and multitask. .................................................................. Jason Ong, PhD is the Behavioral Sleep Medicine Director at Nox Health, as well as an Adjunct Associate Professor at the Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine. Dr. Ong has been working in the field of sleep medicine & research for 17 years.
WAYS TO STAY POSITIVE WITH CHRONIC SLEEP ISSUES Engage in activities & practices that boost your mood. Studies have linked a positive outlook with better sleep
MIND
BODY
SPIRIT
• Practice gratitude. By being thankful for what you have, you pay less attention to what you do not have.
• Engage in light exercise. By choosing yoga, an outdoor walk or other light exercise, you are working toward better sleep.
• Try mindfulness or meditation. Research has linked spending time "doing nothing" with better health of the body and mind as well as healthier sleep.
• Practice good sleep hygiene. Understanding that light, bedding, noises and shared spaces all contribute to a good night’s sleep. Put a plan in place to get the best rest possible.
• Relax. Consider a bubble bath, warm tea, quiet room or other way to relax after a stressful day. Give yourself time to unwind before getting into bed.
• Calm negativity. Practice being more aware of negative thoughts. Purposely try to change your thinking patterns by replacing negative thoughts such as, “I will never fall asleep” with positive thoughts such as, “I choose healthy sleep."
• Listen to your body. Instead of living by the clock, try a few nights of going to bed when sleepy. Perhaps you are not listening to your natural circadian rhythm.
• Lessen worries. By writing in a journal, praying or keeping a list of things to do the next day, there will be less for you to worry about at night. • Choose sleep. Make a promise to yourself to put sleep at the top of your priority list. Then keep that promise.
Finally, a complete telehealth solution for sleep apnea.
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IN THE NEWS
Sleep in Athletics
R
ecently, the International Olympic Committee (IOC) included sleep health as part of its first official mental health position statement. Additionally, the National Collegiate Athletic Association (NCAA) in the US published its first position paper on sleep health for athletes with recommendations. Three professionals comment on these strides in sleep health.
"OVERTRAINING SYNDROME"
Dr. Charles Samuels is the Medical Director of the Centre for Sleep & Human Performance and The Sleep Institute Ltd., as well as a Clinical Assistant Professor Dr. Charles Samuels of Medicine and Adjunct Professor at Kinesiology University of Calgary. Dr. Samuels has been in the field of sleep medicine for 25 years. “Since the late 1990s,” Dr. Samuels begins, “I have been seeing elite athletes from all types of sport for sleep-related issues. Universally, athletes have recognized and appreciated that they can get help with sleep which translates into better physical and mental health as well as training capacity and
12 | July/August 2021
competitive performance.” Dr. Samuels notes that from the beginning, it was a challenge to educate athletes, coaches and support staff about the role of sleep in recovery of athletes. Recovery is key in improving training capacity, sport performance, and resilience. In recent years however, sleep has become a recognized and important factor in managing athletes. “At the beginning, it was myself, Cheri Mah and Shonna Halson who brought sleep to the forefront in athletics. However, our efforts fell on the heels of Drs. Tom Reilly and James Waterhouse who were instrumental in developing this field of research,” Dr. Samuels explains. In 2005, Dr. Samuels was approached by the Sports Science group at the University of Calgary to help address an emerging problem the sport physiologists and physicians had recognized in National Team and Olympic Team athletes. The issue was dubbed “overtraining syndrome,” but has since become known as under-recovery rather than overtraining. Dr. Samuels says, “Overtraining syndrome was a consistent finding of sleep disturbance in these athletes. For the most part, at the beginning, this was seen in swimmers and cross country skiers. This led to the parallel development of a Sleep Education Program and Research Project on sleep, recovery and performance supported by the Canadian Sport Centre Calgary and the University of
Calgary Sports Medicine Program.” Dr. Samuels was asked to create a research program to develop a sleep screening tool which has since become the Athlete Sleep Screening Questionnaire© (ASSQ). Though the initiative began in 2005, it took 13 years to complete, with a fully-validated sleep screening questionnaire and intervention application in 2018. The ASSQ is now the worldwide standard sleep screening tool for elite athletes, and Dr. Samuels and his team are embarking on a Post-Doctoral Research project to validate the ASSQ in student athletes and adolescents, as well as professional video gamers (eSport athletes). Going forward, Dr. Samuels is working with Red Bull eSports. “Surprisingly,” Dr. Samuels relays, “the eSport athletes at the professional level identify sleep as the number one barrier to performance. As they are highly committed to managing sleep issues, we have developed a specific approach to the eSport athletes and are involved with numerous teams and athletes to manage the negative impact of screen time and light exposure on their sleep. This has been the most rewarding of all my experiences interestingly enough because the challenge is immense!”
OFFICIAL RECOGNITION
In 2002, Shona Halson, PhD began working with elite athletes and sleep at the Australian Institute of Sport. The now Professor at Australian Catholic University began noticing how many athletes were complaining of not sleeping well and realized this was an important issue. Dr. Halson explains, “When I looked at the literature and could not find any publications on elite athletes, we started a series of studies to measure sleep in athletics.”
For nearly 20 years, Dr. Halson has continued to be involved in both research and education in this area. Dr. Halson states, “I have always believed that sleep is one of the pillars for high performance athletes alongside training and nutrition. I advocate for athletes and their staff to prioritize sleep and consider it just as important as the training they do.” Though Dr. Halson and teams of professionals like her have been pushing for this acceptance of sleep’s importance since the 1990s, she believes sleep moved to the forefront as an important factor in athletics and sports in Australia over the Dr. Shona Halson last 10 years. “I have noticed that elite athletes are more interested in optimizing sleep and are paying more attention to sleep as a tool to enhance performance,” Dr. Halson states. “Coaches and support staff are now thinking about ways to protect sleep by looking at training and travel schedules with more scrutiny.” Of the IOC and NCAA including sleep in its official statements and recommendations, Dr. Halson says, “We know sleep and mental health are intricately linked. Having an organization such as the IOC recognizing this is an important first step. Of course, there is more to do in this area. As with the NCAA, this is also an important initial step. Student athletes often have very challenging schedules, and we need to make sure sleep is protected in these individuals. Hopefully, the messages are being heard by decisionmakers and individuals who have influence in this environment.” Dr. Halson cites tools to manage stress and organize schedules and advice around caffeine and screen time as the most important recommendations needed for young athletes to perform their best. She finishes by adding, “As a scientist, I believe we have an important role in educating our athletes regarding the importance of sleep. Not just for performance but for lifelong health and wellbeing.” Athletics continued on page 14 13 | healthiersleepmag.com
Athletics continued from 13
A NEW CONVERSATION
Michael Grandner, Director of the Sleep and Health Research Program at the University of Arizona College of Medicine has been working Dr. Michael Grandner in the sleep field for about 20 years, with his work surrounding sleep and sports beginning in 2013. Dr. Grandner has watched sleep in athletic circles go from being just time spent not training or improving, to sleep becoming a primary driver of athletic recovery. Dr. Grandner explains, “I have been working to push sleep into the sports mainstream for several years by interacting with athletic organizations like the NCAA, MLB, and the Olympics, as well as teams and—most importantly— individual players, support staff and training staff.” After the introduction of the NCAA Mental Health Best Practices document that prominently included sleep, Dr. Grandner noticed a change in the conversation that gave athletes and organizations the opportunity to talk about their own sleep challenges. “I think this is a great step forward for the field,” Dr. Grandner
14 | July/August 2021
says. “The Olympics are an international role model for promoting cooperation and helping people strive to be better. Their recent attention towards the importance of mental health is a welcome and exciting development. The inclusion of sleep health in this document is a key factor in not just mental health but also physical health and performance helps to start a global conversation about sleep and sport in places where that conversation has not yet begun.” Similarly, Dr. Grandner watched as the NCAA has taken a bold leadership position on the importance of sleep for student athlete health and well-being. “As the first such organization to take an official position specifically on sleep— as well as including thoughtful recommendations,” Dr. Grandner states, “they are showing care for student athletes. They are serving as a model for other organizations who are looking to take a similar stand on an issue that supports health and performance.” Dr. Grandner notes that “a lot of the progress” of sleep health in athletics is owed to Dr. Brian Hainline, who is the Chief Medical Officer of the NCAA. It was Dr. Hainline who included sleep in the first mental health best practices, and he was also a key leader in the IOC effort.
The BuZZZ about Sleep Your Latest Buzzwords are Process C & Process S. The two processes that regulate the timing and length of sleep.
PROCESS C PROCESS S Where does Process C and Process S come from? Process C refers to our internal clock—our body’s natural sleep and wake times. This clock regulates and controls the 24-hour sleep-wake cycle via the influence of light and melatonin. In the absence of light (as during the evening hours), melatonin is produced which promotes sleep. However, in the presence of light, the production of melatonin ceases, signaling our brain that it is daytime, and we need to wake up.
Process S promotes sleep based on the previous amount of time spent awake. During wakefulness, our brain accumulates substances that promote sleep. We need to sleep to clear these substances and feel alert again. The best sleep is when we synchronize our sleep/wake times to our internal clock (Process C) and our need for sleep (Process S), finding the perfect equilibrium.
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How to Find Help for Your Insomnia By Wendi Kitsteiner
P
aul Glovinsky, PhD has been working in the field of sleep medicine for more than 35 years. His study began in 1979 when he met Arthur Spielman, PhD, one of the founders of behavioral sleep medicine. Active on Dr. Glovinsky’s dissertation committee, their collaboration would continue until Dr. Spielman passed away five years ago. Together they wrote papers, chapters and entire books focused on insomnia and its treatments. In 1985, Dr. Glovinsky became connected with Dr. Aaron Sher, and together they took on the role of Co-Directors of a sleep disorder center in Albany, NY until recently. Today, he maintains clinical practices in New York City and Albany. WHEN TO REACH OUT Nearly everyone experiences bouts of insomnia now and then. But when are those episodes worthy of needing medical attention? According to Dr. Glovinsky, insomnia usually resolves on its own and Dr. Paul Glovinsky rarely progresses to chronic insomnia. He explains that three months is usually the “cut-off” between determining acute and chronic cases of insomnia.
Nearly everyone experiences bouts of insomnia now and then. But when are those episodes worthy of needing medical attention? FINDING A SLEEP SPECIALIST Dr. Glovinsky notes that there is a shortage of specialists trained in treating insomnia (when compared to other sleep disorders like sleep apnea.) His first bit of advice is to talk to an accredited sleep disorder center which can help direct you to a specialist if they do not have one on staff. According to Dr. Glovinsky, “There has been a push to develop ‘pyramids of care’ with broadly available resources such as books and internet-based treatment programs at the base; intermediately-trained practitioners who added coursework on insomnia and other sleep disorders to their general medical, nursing or psychological training in the middle; and certified behavioral sleep medicine specialists at the top.” The Society of Behavioral Sleep Medicine also maintains an international listing of providers on its website (behavioralsleep.org).
FACTORS TO CONSIDER WHEN DECIDING WHETHER TO SEEK HELP
•
How much is your insomnia affecting your functioning while awake?
• Is anxiety about not being able to sleep
creating a cycle of sleeplessness?
• Are hypnotic medications first prescribed to
help cope with time-limited stress turning into a long-term regimen?
16 | July/August 2021
INSOMNIA TREATMENT OVERVIEW If you decide you need to seek treatment for your insomnia, your journey will probably look something similar to the outline below: Filling out paperwork over a period of days/weeks and at home which may contain things like: Questionnaires | Rating scales | Sleep logs/diaries A consultation with a sleep specialist where you will share a detailed history of things like: • Are you sitting or lying down in the evening? • Is the overhead light on when you go to the bathroom in the middle of the night? • What time do you consume afternoon coffee? • What are your personal relationships like? • What are the stressors in your life? • How do your moods vary? Out of this consultation will come a treatment plan. This will usually include things like: • A course of cognitive behavior therapy for insomnia (CBT-I) • Interventions aimed at circadian rhythms that can often underlie sleep • Short-term focus: 4-8 sessions that may initially be spaced fairly close (possibly 1-2 week apart in the beginning) and then increasing in length between appointments as time goes on Overnight sleep studies are generally not needed but if necessary, usually occur later down the road
The most important point to understand is that insomnia is treatable. Sleep is a necessity for health and wellness. If you or someone you love are living with chronic insomnia, please reach out to a professional. Healthy sleep is achievable.
...................................................................................................... Wendi is a former high school English teacher and writer/editor for the RLS Foundation who is now homeschooling her four children on a farm in East Tennessee. 17 | healthiersleepmag.com
WELL-BEING
Insights into Insomnia By Shanti Argue
S
leep. We all know it is important. Sleep is when your body heals itself, both mentally and physically. Getting adequate sleep is linked to better mood, memory, and immune function, while poor quality sleep is associated with higher body weight and an increased risk of diabetes, depression, heart attack and stroke.
WHAT CAN CONTRIBUTE TO INSOMNIA? Insomnia is often related to a series of conditions, such as:
But what if getting plenty of restorative sleep isn’t as easy as it sounds? For those familiar with lying awake in bed dreaming of drifting off, it will come as no surprise that insomnia is the most commonly reported sleep problem.
• Anxiety, depression or other mental health disorders.
WHAT IS INSOMNIA? Insomnia is a condition in which it is difficult to fall asleep, stay asleep or fall back to sleep after waking. Up to one-third of adults are struggling with insomnia at any given time, compromising their health and performance.
• Neurological conditions like Alzheimer’s and Parkinson’s.
Doctors use the duration of symptoms to classify insomnia as either short-term or chronic: • Short term insomnia is more common, typically lasting a few days or weeks. • Chronic insomnia involves sleep disruption of at least three times per week for three months or more, and occurs in about 10% of adults. It will occur in all ages with increased prevalence in older adults and elderly.
• Poor lifestyle and sleep habits. • Stressful life situations, such as divorce or job loss. • Chronic illness or chronic pain. • Side effect of a medication. • Untreated sleep disorders, including sleep apnea.
• Hormonal changes, like those during pregnancy and menopause.
Sometimes, the symptoms are not attributable to any other identifiable cause. Doctors consider this primary insomnia. This type of insomnia is generally life-long, and episodes often begin in childhood. NOT SOMETHING TO IGNORE One of the more immediate symptoms of insomnia is daytime fatigue and drowsiness. A single night of tossing and turning can increase the risk of car accidents, work-related mistakes and moodiness. Too many nights of insomnia can weaken the immune system and affect memory and concentration. Feeling lethargic, some people turn to caffeine or sugar for a quick burst of energy. Sometimes people skip workouts because of feeling too tired to exercise. These habits can interfere with the next night’s sleep, turning one bad night into multiple. Nobody wants to fall asleep at an inconvenient time— at a meeting, during a movie. But dozing off while driving is downright dangerous, as are the many other health hazards of not getting enough sleep.
18 | July/August 2021
Sleep is as important to health and well being as exercise and nutrition. If insomnia is keeping you up at night, your doctor can help you understand what might be causing it and find a solution so you can be your happier, healthier, more well-rested self.
Q
z i u
FROM THE EXPERTS Insomnia is a highly prevalent, persistent and distressing problem that affects at least 10% of the adult population. However, it is often underdiagnosed and under-treated. There is effective non-pharmacological treatment for insomnia— cognitive behavioral therapy for insomnia. It could produce similar short-term but more durable effects as compared to sleep medications. Thus, seeking appropriate help is important to improve your insomnia.
Have you been worried about insomnia?
In addition, establishing the following healthy sleep hygiene tips will be your first step towards a good night sleep:
Below are some questions that a doctor might ask to help determine whether you are at risk for insomnia. If these issues concern you, contact your primary care physician. Please remember that insomnia is treatable.
• Maintain a regular sleep-wake routine. • Have a 60-90-minute wind-down before bedtime. • Use your bedroom for sleep and sex only. • Only go to bed when you feel sleepy. • No gadgets near bedtime.
⃝ Yes ⃝ No I often have difficulty falling asleep. ................................................................................................................. ⃝ Yes ⃝ No I rely on over-the-counter sleeping pills or other self-medications to sleep well. .................................................................................................................
• Avoid stimulants such as coffee and tea 4–6 hours before bedtime.
⃝ Yes ⃝ No I often wake up in the night unable to fall back to sleep. .................................................................................................................
• Regular daytime exercise can improve sleep quality, but you should avoid rigorous exercise near bedtime.
⃝ Yes ⃝ No I live with depression and/or anxiety. ........................................................................................................................
• Develop relaxing routines such as reading a book, taking a warm shower or brushing your teeth.
⃝ Yes ⃝ No I often experience racing and/or negative thoughts when trying to sleep. .................................................................................................................
Special commentary provided by Prof. Yun Kwok Wing, Chairman, Department of Psychiatry, Director of Li Chiu Kong Family Sleep Assessment Unit, Faculty of Medicine The Chinese University of Hong Kong; Dr. Shirley Xin Li, Assistant Professor, Department of Psychology, The University of Hong Kong; Dr. Rachel Ngan Yin Chan, Research Assistant Professor, Li Chiu Kong Sleep Assessment Unit, Department of Psychiatry, Faulty of Medicine, The Chinese University of Hong Kong.
⃝ Yes ⃝ No I often wake too early. .................................................................................................................
......................................................................................................
⃝ Yes ⃝ No
⃝ Yes ⃝ No People in my life have noticed mood swings and/or irritability in me. ................................................................................................................. ⃝ Yes ⃝ No I have noticed problems with my memory. ................................................................................................................. I often experience sleepiness or fatigue during the day.
Shanti Argue is a freelance writer who loves researching and writing about a variety of topics.
19 | healthiersleepmag.com
Artificial Intelligence in Sleep Medicine How AI is changing the field. By Matteo Cesari, PhD, MSc
A
rtificial Intelligence (AI) consists of computer programs that perform decision-making and pattern-recognition tasks previously done by humans. Classical automatic Dr. Matteo Cesari algorithms are programmed to recognize events and patterns. By learning from data, AI algorithms can reproduce what humans do, but can also identify new patterns and give more insight into the data. As recently stated by the American Academy of Sleep Medicine, sleep medicine is well positioned to benefit from AI due to the amount of data recorded in clinical practice. In my everyday research work, I use and program AI algorithms with the aim of providing better understanding of sleep and sleep disorders. AI IN SLEEP Currently, sleep data recorded in sleep labs with polysomnography sleep studies (i.e. the gold standard sleep examination consisting of the simultaneous monitoring of brain waves, eye movement, muscular activity and cardiorespiratory functions) are visually inspected, and sleep stages and events are manually scored by experts. This is a time-consuming process which is also prone to inter-rater variability (when two human scorers do not agree on the identification of a sleep stage or event). Many studies have shown that AI algorithms can perform these tasks faster than humans and sometimes more precisely. As an example, an AI algorithm has been shown to identify with very high precision sleep stages, sleep apneas and periodic limb movement during sleep on over 15,000 polysomnography recordings. Other AI algorithms have been developed to automatically identify sleep disorders. In a study, we have shown that patients suffering from REM sleep behavior disorder (abnormal muscle activity and dream enactment 20 | July/August 2021
during REM sleep) could be automatically identified from polysomnography data with an AI algorithm. COMMON TYPES OF AI Recent years have shown an increasing number of sensors and technologies to monitor sleep in home environments, in addition to the AI currently being used in the sleep field for evaluating data and verifying sleep disorders. Such technologies generally give information on sleep patterns and sleep quality. Several will inform on the amount of time spent sleeping and the percentages of deep and light sleep. In general, these technologies use AI algorithms to produce these outputs. However, many of these wearables have not been verified for clinical use. Therefore, attention should be paid in interpreting the outcomes of these AI technologies, and a consultation with a sleep expert is always necessary in case of sleep issues. WHO IS USING AI? Despite the current advancement of AI, AI algorithms are seldom employed in clinical practice. This is because the field is still growing, and there is lack of regulatory frameworks on how to implement and use these algorithms. In the next years, there is the need to have standard procedures in order to validate AI algorithms for clinical use. AI algorithms for clinical practice should also be transparent on how the data are processed and how the outputs are created. The goal for the future is to have the best synergy between machines and human. Collaboration between clinicians, researchers and manufacturers is the basis to construct the future of AI in sleep medicine and research. *Citations available on healthiersleepmag.com
............................................................................................................... Matteo Cesari, PhD, MSc has been working in the field of sleep medicine & research since 2016. Dr. Cesari is currently at the Sleep Disorder Unit, Department of Neurology, Medical University of Innsbruck in Austria.
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Short Sleeper & Long Sleeper
Lesser-known sleep disorders may alter how long you sleep. By Leila Emami, MD
B Dr. Leila Emami
ased on research and diagnosis, only around one percent of the population will be diagnosed with short sleeper. Likewise, one percent will be diagnosed with long sleeper.
What is short sleeper?
Sufficient sleep has a critical role in brain and body function, and it is difficult to recommend a fixed amount of sleep at any age. According to the most recent research, normal duration of required sleep for adults (18-60 years old) is seven hours or more. However, bodily processes vary from person to person, including the normal hours of needed sleep. Around one percent of the population are short sleepers, meaning they sleep six hours or less each night, yet still function normally. They feel refreshed and well-rested with a shorter amount of sleep and without the need to catch up on sleep. In contrast to short sleepers, people with sleep deprivation, sleep restrictions or insomniacs feel tired and irritable the day after a poor night’s rest. Habitual or diagnosed short sleepers go to sleep and wake up easily, while keeping their own routine pattern. We have found that short sleepers tend to sleep for four to six hours a night on both weekdays and weekends. These people keep the same habits throughout their lives, from childhood to old age. 22 | July/August 2021
Some research studies indicate that rare mutations and specific genes are more common among these people. Short sleepers are usually not the only people in their family who have this sleep pattern, leading us to believe short sleeper can run in the family. Do patients seek treatment for this?
Short sleepers normally do not seek help. The reason is that, unlike insomniacs, they are functioning and behaving normally and feeling well. We should keep in mind that although short sleepers feel fine subjectively, we are not sure they are doing fine objectively. Some functional MRI imaging studies have indicated that short sleepers show signs of inaccurate perception in comparison to people who sleep for normal time durations. Many studies have proved that reduced hours of sleep (less than six hours) is accompanied by negative outcomes in the areas of: • Cardiovascular health: Hypertension & heart disease • Mental health: Mood & psychiatric disorders • Metabolic health: Obesity, diabetes mellitus type 2 and appetite dysregulation • Immunologic health: Immune cell dysfunction, infection susceptibility following germ exposure and vaccine immune response • Cancer: Elevated risk of breast cancer • Pain
It is highly recommended that everyone create the proper time and environment for sleeping at night. Many people cannot seem to dedicate enough time to get the proper amount of sleep their body needs because of family responsibilities, stress or highpressure jobs.
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What is long sleeper?
Long sleepers are people who need more hours of sleep to function well compared to the typical person of the same age. Adults are called long sleepers if they need 10 hours or more each night. The quality and architecture of sleep is normal in this group. If habitual long sleepers get 10 hours of sleep per night, they feel refreshed and have no complaints. This amount of sleep is usually not doable because of social and work restraints, so they show symptoms similar to insomnia or sleep deprivation such as excessive daytime sleepiness, irritability and impaired function. What is the treatment or suggestion for those living as a long sleeper?
First, they should consult a sleep specialist to make sure they are true habitual long sleepers and that they do not have a different sleep disorder. In order to diagnose these normal variants correctly, doctors need a complete history, physical exam, completed twoweek sleep diary and required lab tests or sleep studies. These are necessary to rule out other causes of excessive daytime sleepiness such as depression, narcolepsy, sleep apnea, iron deficiency anemia and hypothyroidism. It is important to note that for teenagers, the normal requirement for sleep is longer than adults—around eight to ten hours. Because they have to restrict their sleep during school days, they catch up by sleeping long hours on weekends. If other causes of sleepiness have been ruled out, then long sleepers should simply get the proper amount of sleep their body needs. Some studies show that sleeping for long hours can have some compensating effect for consequent sleep deprivation.
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*Citations available on healthiersleepmag.com
...............................................................................................................
Dr. Leila Emami is an anesthesiologist and sleep specialist working at the Otolaryngology Research Center in Tehran University of Medical Sciences in Iran. She has been working in the field of sleep medicine and research for 10 years. She supervises three sleep labs in Tehran.
23 | healthiersleepmag.com
FROM THE PROFESSOR
CBT-I
What to understand about the gold standard in insomnia treatment. By Charles Morin, PhD
I
f you are experiencing insomnia—or finding it difficult to fall asleep several times per week, you may be told by your healthcare provider about cognitive behavioral therapy for insomnia (CBT-I). Throughout my over 30 years in the field of sleep medicine and research, I have treated hundreds of patients in this way and supervise clinicians in treating many more. WHAT IS CBT-I? Cognitive behavioral therapy for insomnia is a brief form of psychotherapy. It is a pragmatic approach based on problem solving, sleep-focused, and it gives control to the patient. If coming to me for CBT-I, my job is to make sure you’re in control of implementing changes in your schedule and—though I am there to 24 | July/August 2021
guide you—you are responsible as the patient. While I am there to guide you, I will not police you. I can check in and suggest ideas, but the work must be done by the individual. As the name implies, CBT-I is recommended for changing behaviors and cognitions. Think about the statements you give yourself, the internal monologues, thinking patterns and beliefs. They are not always conscious and your beliefs about sleep and what will or will not happen when you get into bed and how you might feel the next day may need to be talked through. Cognitive behavioral therapy is used to change behavioral and thinking patterns about factors that perpetuate or exacerbate sleep disturbances. It has
also been used with anxiety, eating disorders, depressive disorder and more. It guides you to a new pattern of behavior and has nothing to do with psychoanalysis. You must be willing to invest time and efforts in this form of therapy. An overnight "quick fix" it is not. But when CBT-I is implemented properly, it will let you achieve long-term sleep improvements. That’s not to say that overnight fixes such as sleeping pills cannot be used in conjunction with CBT-I, it’s just that the course of therapy will run 6, 8 or 10 weeks in length and this should be understood when beginning. FIRST-LINE TREATMENT Many medical and sleep organizations now agree that CBT-I is the first line of treatment, as well as the gold standard. It has been tested worldwide. Around 70-80% Dr. Charles Morin of patients will benefit from CBT-I and up to 50% can experience a full remission of insomnia symptoms. I think the first message patients should receive is one of hope. So many come in as a last resort and are hopeless after years of suffering or are discouraged and think they’ve tried everything. Then after we’ve been together for a few weeks, we evaluate things. And—if they do not give up after a week—we begin to see changes. Some of the components I often hear are habit-based. One cannot work on a cell phone in bed up until the last second and then expect to fall asleep instantly. This is something I even have to remind myself. With CBT-I, I remind patients that waking up in the middle of the night to plan out the details of the next day can be done later. We need to plan time for enough sleep, plan time to schedule and plan for the next day before we are in bed. Living in a constant state of sleep deprivation will not get you ahead.
supplement to it. If mild insomnia exists, perhaps teletherapy sessions may work. But I’m hesitant to recommend it for those with ongoing insomnia issues along with other psychological difficulties and chronic hypnotic usage. Most will continue needing face-toface guidance. If using something like an app, this is fully automated and not necessarily the best option for all patients. If you are experiencing insomnia, I urge you to talk to your doctor about CBT-I. After a few weeks, you will begin to remember how good it feels to be well-rested. You invest a few weeks for your physical health with a diet or exercise program, why not also invest in sleep? ...............................................................................................................
Charles Morin, PhD has been working in the field of sleep medicine and research since 1986. Currently, he is a Professor in the Department of Psychology at Laval University in Canada. He is the past-president of World Sleep Society.
Cognitive behavioral therapy is used to change behavioral and thinking patterns about factors that perpetuate or exacerbate sleep disturbances.
ACCESSIBILITY With the pandemic came an influx of telehealth and teletherapy options. While this is undoubtably a good thing in areas where accessibility and affordability could be barriers to getting treatment, I see this not as a substitute for in-person treatment but as a 25 | healthiersleepmag.com
COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA
Key Components & Treatment Targets
BEHAVIORAL Sleep Restriction | Stimulus Control Relaxation • Excessive time in bed • Irregular sleep schedules • Sleep incompatible activities • Hyperarousal
COGNITIVE Cognitive Therapy Paradoxical Intention • • • •
Unrealistic sleep expectations Misconceptions about sleep Sleep-related worries Poor coping skills
EDUCATIONAL Sleep Hygiene Education Sleep Information
26 | July/August 2021
Most typically implemented in the context of 4 to 6 consultation visits. Morin C.M. 2019
• Inadequate sleep hygiene (caffeine, alcohol, exercise, environmental factors)
OPINION
Ways to Get Through the Day on Little Sleep Jason Ellis, PhD, EBSM
T Dr. Jason Ellis
here are many indicators of poor sleep quality. While many warning signs are sleep sensitive—such as irritability, poor mood, worse performance, difficulties concentrating—most could also be explained by other factors.
The main test I use is to ask: How do you feel about an hour after waking up? If you feel tired, sleepy or drained, then there is likely an issue with the quality, quantity or timing of your sleep, which is something that needs to be investigated further. Beyond asking yourself this important question and listening to your body’s response, how quickly you fall asleep at night is a second way to discover you’re not getting enough sleep. While it may sound good to fall asleep immediately upon getting in bed, it can also indicate that you are sleep deprived. WHEN POOR SLEEP IS PRESENT Unfortunately, there isn’t a magic bullet for dealing with short sleep, but there are a few things that can help. • Trying to keep your schedule ‘as normal’ as possible often helps. As we are biologically and behaviourally tied to routine, structure around food timing, for example, can help us keep pace with the day. If you’re tired, you may want to eat at different times through the day, but I recommend trying to do the same as you would have done if you’d gotten excellent sleep.
• Exercise is great for increasing alertness. Though you may feel tired, I would certainly suggest using it to help get through the day. Plus, because of its positive impact on nocturnal sleep, it makes it a doublyattractive option. • Perhaps controversially, I also favor the use of caffeine to increase alertness during the day, as long as you are mindful about the timing so it does not impact sleep. • Avoid clockwatching during the day. Just as we know it can be detrimental to our sleep to clock-watch at night, I think it can be just as detrimental during the day when you haven’t got enough good quality sleep. Instead of counting down the hours and minutes before you need to get up whilst in bed, we count down the hours and minutes before we can go back to bed. Both can leave us feeling anxious. • Do nothing. When I don’t get enough sleep or have the odd bad night, I do the easiest and hardest thing… absolutely nothing! I know, from experience, that if I try to compensate, I am likely to make the situation worse, but if I do nothing my sleep will correct itself. We have an amazing biological capacity to self-regulate sleep. It is largely when we focus on it, worry about it and change our behaviors to try to get more sleep that things go wrong. My main philosophy around sleep is that one poor night does not a sleep disorder make. ...............................................................................................................
Jason Ellis is Professor of Sleep Science at Northumbria University in the United Kingdom. He has been working in the field of sleep medicine and research for 22 years. Professor Ellis is also author of The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems. 27 | healthiersleepmag.com
Right Now in Sleep Science 3,008 adolescents aged 10–18 years were surveyed to develop a new self-reporting index to measure the difficulty of disengaging from social media at night. The index of Nighttime Offline Distress (iNOD) showed that youth with higher scores on the index reported using social media after they felt they should be asleep and experienced shorter sleep duration and poorer sleep quality. Results show a struggle to disconnect and stay disconnected from social interactions to allow sufficient uninterrupted sleep. In essence, iNOD shows the trade-offs young people make between social connections and sleep. Scott H, Biello SM, Cleland Woods H. Nodding off but can't disconnect: Development and validation of the iNOD index of Nighttime Offline Distress, Sleep Medicine, Volume 81 (2021). doi.org/10.1016/j.sleep.2021.02.045
28 | July/August 2021
CONSEQUENCES OF POOR SLEEP QUALITY
Bedtime Reads Looking to learn even more? Each issue, we highlight one book about sleep.
What happens if you regularly sleep less than seven hours per night and/or usually live with disrupted sleep to the point of sleep deprivation? Sleep professionals are often asked, “Why should I care about my sleeping habits?” The reason you should care is because research has linked poor sleep quality with several preventable and modifiable health consequences such as: • Daytime sleepiness and fatigue may lead to conditions such as hypertension, ischemic heart disease, stroke and diabetes. • Short-term lack of sleep usually causes fatigue, poor concentration and reduced memory. • Stretching one poor night into chronic sleep loss can lead to irritability, mood swings and several mental disorders such as depression. • Short sleep has been identified as a risk factor for obesity. • Poor attention while driving caused by sleepiness increases the risk of motor vehicle accidents.
Available at most book retailers.
Sleep Disorders For Dummies by Max Hirshkowitz & Patricia B. Smith
An easy-to-follow guide to help you get a good night’s rest. Sleep Disorders For Dummies is for anyone who has trouble sleeping— or has a loved one who suffers from a sleep disorder. Written by a sleep specialist and a medical reporter, this no-nonsense guide helps you:
• Because sleep deprivation shortens telomere length in DNA, which facilitates chaotic cellular growth, it can increase the risk of various forms of cancer. • Lack of sleep is related to many psychological conditions such as depression, anxiety and psychosis. • Sleep deprivation has been shown to increase risk taking. • Sleep loss impacts hormones involved in appetite regulation in the direction of promotion of food intake, meaning reduced sleep can lead to increased appetite.
The good news is that most sleep disorders are preventable or treatable. Set up a healthy sleep schedule, a comfortable sleep environment and arrange a consultation with a sleep specialist if concerns arise. It’s a good time for good sleep.
• Prevent and manage sleep disorders • Improve your sleep habits • Find relief from your symptoms • Ask your doctor the right questions • Enhance the quality of sleep 29 | healthiersleepmag.com
Ask the Sleep Doc
As answered by our issue reviewers. Lourdes DelRosso, MD
Melissa C. Lipford, MD
Robert J. Thomas, MD
Rochelle Zak, MD
30 | July/August 2021
Q: What are some warning signs of sleep deprivation? Dr. Thomas: Waking up tired, needing more than two cups of coffee, feeling tired, yawning, having difficulty focusing during the middle of the afternoon and needing to nap are reasonable red flags. Dr. Lipford: Most adults need 7-9 hours of good quality sleep each night. If you regularly obtain less than 7 hours sleep or if your sleep quality is poor, you may be sleep deprived. This can lead to many different symptoms including: daytime sleepiness or fatigue, trouble with concentration and multi-tasking, memory problems, mood issues or irritability. Beyond these symptoms, there are many harmful health effects that can be associated with chronic
sleep deprivation—including high blood pressure, weakened immunity and weight gain. People who are sleep deprived are also at an increased risk for automobile accidents. It is vital that we all get adequate, good quality sleep on a regular basis. If you struggle with sleep or experience symptoms suggesting sleep deprivation, reach out to your doctor for advice. Dr. DelRosso: The first and most common sign is excessive sleepiness during the day. You may also think you feel tired but not necessarily sleepy. Some people may feel irritable, moody and unable to concentrate. Studies have shown that we cannot always properly estimate the severity of our sleepiness and in fact may actually underestimate it, so the risk of accidents increases when we are sleep deprived.
Dr. Zak: You are likely asking about insufficient quantity of sleep, but one can argue that sleep deprivation can be divided into two parts: insufficient quantity or quality of sleep (or both). In general, people who have insufficient quantity of sleep can awaken refreshed after a short sleep time, but then get drowsy later in the day—perhaps dozing off while at the computer or while viewing entertainment, generally with sedentary or more passive activities. Insufficient quantity of sleep can also be manifest by the desire to take a nap, and siesta cultures were designed to have a shorter nocturnal sleep period with a scheduled daytime nap that would provide the additional sleep time, or by spontaneously sleeping longer on weekends. Of note, people can really push themselves and not always be aware that they have gone past their limits. In fact, many car accidents from
insufficient quantity of sleep occur close to home as the eyelids drop oh so briefly, but just long enough. Signs of insufficient quality of sleep include never feeling refreshed regardless of the quantity of sleep and should prompt clinical investigation by a healthcare provider to look for potential causes.
Q: I wake up at 5:00am for work so I sleep in on the weekends. Is this bad for me? Dr. DelRosso: There are benefits to regular sleep, yes. But in this case, we recommend trying to keep a sleep schedule that will allow you to sleep at least 7 hours nightly. In this case, I would recommend establishing a bedtime routine that will allow you to be asleep by 10pm at the latest to wake up at 5am to be able to feel refreshed and restored during the day.
Dr. Thomas: This is “social jet lag” with or without chronic partial sleep deprivation. Some catch up—say two hours—which clears out the sleep debt is probably okay, but a 5am wake time is best compensated by an earlier bedtime. Long-term social jet lag has been associated with weight gain, pre-diabetes and depression, so it's worth keeping an eye on.
Q: I nap every day. Is this okay or does it mean I’m not sleeping well? Dr. Thomas: If a nap is needed every day, that is abnormal and reflects excessive sleep drive. This may be from inadequate sleep at night, poor quality sleep, or a disorder of daytime alertness such as narcolepsy. Formal evaluation is recommended. Dr. DelRosso: This depends on how old you are and where do you live. Napping or siesta can be culturally acceptable in some parts of the world. Plus, power naps can be restoring and refreshing. Usually, children stop napping by ages 3-4, and in the United States we usually do not nap and therefore consider a return to napping a sign of insufficient sleep or daytime sleepiness secondary to another cause.
Ask the Doc continued on page 32 31 | healthiersleepmag.com
Ask the Doc continued from 31 It is important to differentiate a planned nap time from dozing off watching TV or after lunch. If dozing off occurs, you may be having insufficient sleep or a sleep disorder that is contributing to daytime sleepiness. Dr. Zak: Daily napping is fine and likely reflects a divided total sleep schedule with a shorter period of sleep at night (and shorter is relative, for a long sleeper, a 7-hour sleep period can be insufficient and necessitate a daily nap) and is the practice in some cultures (although fewer these days). In fact, our biology would encourage that since it is normal to have an opening of the so-called "sleep gate" in the afternoon at siesta time in addition to night time. It is a problem if you are unable to maintain alertness when you need to, such as during conversation, work or driving. In addition, frequent daytime napping could indicate an underlying disorder of alertness, such as narcolepsy or medication-induced hypersomnia, and should be evaluated by a clinician.
Q: My grandson is still going into his parents’ bed to sleep part of each night and he’s 6. Isn’t this bad for everyone’s sleep? Dr. Thomas: There are strong social and intrafamily norms which determine if a child sleeping in the bed with parents is considered a problem or not. If the child has his/her own room and initiates sleep without fuss, then this could be a reaction to nightmares, fears of being alone after a normal brief awakening or disrupted nighttime sleep, as examples. This “arrangement” may work well enough that no one’s sleep is disturbed, but can also become a point of conflict, when everyone’s sleep is interrupted. If problematic, consulting with a healthcare provider with expertise in childhood behavioral sleep approaches should provide a solution.
Dr. DelRosso: Usually this kind of behavior in children represents “sleep association insomnia” and is the result of the child not being able to fall asleep independently. When the parents stay in the room until the child falls asleep and then leave the room, the child usually wakes up in the middle of the night seeking parental presence. We can help in this situation by slowly removing the parent from the bedtime routine to allow the child to fall asleep independently. Other causes that can contribute to this behavior include anxiety and/ or a sleep disorder waking the child up in the middle of the night.
HAVE A QUESTION FOR THE SLEEP DOCS? Submit your questions by email to healthiersleep@worldsleepsociety.org. Questions are selected based on space & applicability. 32 | July/August 2021
World Sleep Society’s Road to Better Sleep 10. Reserve your bed for sleep and sex, avoiding its use for work or general recreation. 9. Block out all distracting noise and eliminate as much light as possible.
8. Find a comfortable sleep temperature setting and keep the room well ventilated.
7. Use comfortable, inviting bedding.
1. Establish a regular bedtime and waking time.
10 TIPS FOR BETTER SLEEP
6. Watch your workout routine.
5. Change up your bedtime snack.
2. Allow yourself to take a nap if you’re tired.
3. Adjust to a healthier lifestyle regarding your substance use.
4. Create a caffeine cut-off time.
3 ELEMENTS OF QUALITY SLEEP
Created by World Sleep Society’s committee of internationally-renowned experts in the field of Sleep Medicine and Research.
DEPTH
DURATION
CONTINUITY
DURATION
The length of sleep should be sufficient for the sleeper to be rested and alert the following day.
CONTINUITY
DEPTH
Sleep periods should be seamless without fragmentation.
Sleep should be deep enough to be restorative.
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The mission of World Sleep Society is to advance sleep health worldwide. World Sleep Society will fulfill this mission by promoting and encouraging education, research and patient care throughout the World, particularly in those parts of the world where the practice of sleep medicine isless developed.
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• Czech Sleep Research and Sleep Medicine Society
MEETINGS
RECOMMENDATIONS FOR DIAGNOSIS & TREATMENT
• Asian Society of Sleep Medicine
• Canadian Sleep Society
EXAMINATION PROVIDING SLEEP MEDICINE COMPETENCE
Official journal of World Sleep Society & International Pediatric Sleep Association
• Asian Sleep Research Society
• Bulgarian Association of Obstructive Sleep Apnea & Snoring
ENDORSED SOCIETY
MENTORING & TRAINING SLEEP RESEARCH LEADERS
• American Academy of Sleep Medicine (AASM)
• Australasian Sleep Technologist Association
OPERATING PROGRAMS
THE BEST OF SLEEP MEDICINE & RESEARCH BIENNIAL MEETING
In an effort to increase global awareness of sleep issues, World Sleep Society has formed relationships with the following sleep societies or regional federations.
• ASEAN Sleep Federation
The goal and purpose of World Sleep Society is to advance knowledge about sleep, circadian rhythms, sleep health and sleep disorders worldwide, especially in those parts of the world where this knowledge has not advanced sufficiently
CONGRESS
ASSOCIATE SOCIETY MEMBERS
• European Academy of Dental Sleep Medicine (EADSM)
• Israel Sleep Research Society • Italian Association of Sleep Medicine • Japanese Society of Sleep Research • Minnesota Sleep Society • Peruvian Association of Sleep Medicine (APEMES) • Portuguese Sleep Association • Romanian Association for Pediatric Sleep Disorders • Russian Society of Somnologists
• European Sleep Research Society
• Serbian Sleep Society
• Federation of Latin American Sleep Societies
• Sleep and Wakefulness Medicine Moroccan Federation
• Finnish Sleep Research Society
• Sleep Research Society
• French Society for Sleep Research and Sleep Medicine
• South East Asian Academy of Sleep Medicine
• Georgian Sleep Research and Sleep Medicine Society
• Taiwan Society of Sleep Medicine • Turkish Sleep Medicine Society
UPCOMING WORLD SLEEP MEETINGS
VIRTUAL MEETING 2021
CONNECT WITH US
IN PERSON MEETING 2022
IN PERSON MEETING 2023
Save the Date
MARCH 18
rld Sleep Day 2022
Hosted by World Sleep Society
ABOUT
45+ COUNTRIES 200+ ACTIVITIES
WORLD SLEEP DAY 2022
World Sleep Day is an annual event intended to be a CELEBRATION OF SLEEP and a call to action on important issues related to sleep. Hosted by World Sleep Society, it is an opportunity for sleep experts to inform the public about the importance of sleep in all aspects of health.
Dozens of delegates in countries around the world participated in World Sleep Day 2021, holding in-person, online, and media events that promoted the theme of “REGULAR SLEEP, HEALTHY FUTURE.”
The next World Sleep Day is FRIDAY, MARCH 18, 2022. Sign up for updates at worldsleepday.org to follow the latest developments regarding the annual theme and activities.
worldsleepday.org
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twitter.com/_WorldSleep
Brazil
facebook.com/wasmf
India
Russia
Romania
HEALTHIER SLEEP MAGAZINE 3270 19th Street NW, Suite 109 Rochester, MN 55901 USA
UNDERSTANDING CAFFEINE & SLEEP A majority of adults begin the day with caffeine. Drinking caffeine 4-6 hours before bed has been shown to impact the ability to fall asleep & sleep quality. Research shows consuming caffeine before bedtime can suppress the production of melatonin, a hormone that assists in a good night’s sleep. The FDA recommends keeping daily caffeine dosage under 400MG. Average caffeine content in: Coffee is 65-350mg depending on type and amount (lowest being decaf and instant) Tea is 30-250mg Soda is 35-375mg
