Healthier Sleep Magazine May/June Sleep Disorders by World Sleep Society

healthiersleepmag.com May/June 2021 | Sleep Disorders Issue

Sleep

in Space

Better Sleep Better Immunity

The Case for Later School Start Times

Healthier Sleep A publication of World Sleep Society Your Trusted Source for Improving Sleep Publisher World Sleep Society Editor Gina Dewink dewink@worldsleepsociety.org 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 Contributing Writers Shanti Argue Gina Dewink Monika Haack, Phd Wendi Kitsteiner Robin M. Lloyd, MD Arezu Najafi, MD Aric A. Prather, PhD Rosei Skipper, MD Robert J. Thomas, MD

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.

CONTENTS

May/June 2021 | Sleep Disorders Issue

|4| Sleep in Space

| 28 | The Case for Later School Start Times

| 12 | Better Sleep, Better Immunity

8 10 14 15

Sleep Disorders in Kids How You Spend Your Days Can Affect Your Nights Nightmares & Sleepwalking New Treatment For PTSD-Related Nightmares

18 20 22 25

Melatonin How to Know if You Have a Sleep Disorder What is “Regular” Sleep? Patient Organization Highlight

24 26 30 36

Epilepsy & Sleep Social Rejection & Sleep When Breathing During Sleep Isn’t Normal Sleep Tracker

IN EVERY ISSUE The BuZZZ about Sleep

Right Now in Sleep Science

Bedtime Reads

Ask the Sleep Doc

PAGE 17

PAGE 32

PAGE 11

PAGE 33

Your latest buzzword is Hypnic Jerk

Sleep deprivation tied to higher risk of dementia

How to Sleep

Your questions answered by sleep professionals

3 | healthiersleepmag.com

In addition to the misaligned night and day, there are other issues associated with sleeping on the Moon or Mars that are similar to issues that individuals on Earth might experience. 4 | May/June 2021

Sleep in Space Can we adapt to a new night and day? By Gina Dewink

ASA is planning a mission to the Moon in 2024. After several lunar missions, NASA plans to send astronauts to Mars. This series of missions for exploration is called Artemis 1. While many potential concerns arise, one is already being studied by sleep researchers. How will astronauts sleep in space—and specifically, on Mars? “I have always been a space enthusiast,” says Erin E. Flynn-Evans, PhD, MPH, who is currently the Director of the Fatigue Countermeasures Laboratory at NASA Ames Research Center. A circadian physiologist and epidemiologist, Dr. Flynn-Evans has worked in the sleep field for 20 years. “When I was training, I was asked if I would consider working on a study to assess sleep in space. That study eventually led to my position at NASA.” SLEEP ON MARS After sending human explorers 250,000 miles to the Moon, NASA intends to then send astronauts 140 million miles to Mars sometime in the 2030s. As of now, the plan is that astronauts will remain on Mars for 30-45 days. But from there, people are already imagining what life on Mars could mean for humans. And one potential health challenge that has arisen is a misaligned night and day. “There are numerous challenges that humans will face when sleeping on Mars,” Dr. Flynn-Evans begins. “The biggest challenge is that Mars rotates with a period of 24 hours and 39 minutes, compared to the 24-hour rotation of the Earth. As a result, astronauts living on Mars will need to shift their sleep-wake timing by 39 minutes every day to stay aligned with Mars.” To many, thirty-nine minutes may not seem like a large-scale reason to worry, but sleep experts see more. “In order to be awake when the sun is out and asleep when it’s night,” Dr. Flynn-Evans continues, “astronauts will

have to shift their schedules 39 minutes later every day. If the astronauts do not shift appropriately, they would live in a circadian misaligned state, which would feel like perpetual jet-lag or doing shift work. This is concerning because sleep loss and circadian misalignment are associated with reduced alertness and performance and the astronauts living and working on Mars will need to be able to perform at their best.” BLUE LIGHT ON THE RED PLANET Fortunately, studies on Earth have shown that most people can shift to a Mars Sol—a solar day on Mars—if exposed to bright, blue-enriched light at the right times. Research has shown that the human circadian system is the most sensitive to light in the blue-wavelength spectrum; and the intensity, pattern, duration and timing of light also influence how one will be affected by light. On Mars, astronauts will be exposed to dimmer light that is shifted from blue into the red end of the spectrum. Since this natural light exposure pattern on Mars may not be sufficient to facilitate human adaptation to the Mars day, Dr. Flynn-Evans suggests providing astronauts with special lights inside their habitat that help their bodies align to the Mars Sol. “We wouldn’t want them to follow their natural rhythms because everyone has a slightly different circadian period,” Dr. Flynn-Evans explains. If the astronauts did not receive light to help them stay aligned with Mars time, they might start to desynchronize their schedules from each other, which would not be good for maintaining team cohesion and work schedules while there. Dr. Flynn-Evans states, “We still have more work to do in order to ensure we can provide astronauts with tailored countermeasures that will allow them to maintain stable circadian alignment on Mars.” In

Sleep in Space continued on page 6 5 | healthiersleepmag.com

Sleep in Space continued from 5 SHOULD SLEEP BE A CONCERN FOR MARS SETTLERS? Getting enough sleep at the right time is important for short-term alertness and performance and for longterm health outcomes. Whenever a person is engaged in complex, safety-sensitive tasks, they should ensure that they get enough sleep to function at a high level. In situations such as a space mission, one mistake can have major consequences. Based on research that has been done on Earth, experts believe most humans will be able to adapt to a Mars Sol. Since most people have a circadian period that is a little longer than 24 hours, many people will probably not have much difficulty adapting to the Mars Sol. On the other hand, some people, especially those with a circadian period that is shorter than 24 hours such as some early birds, may find it difficult or impossible to adapt to a stable Mars schedule. NASA and its researchers are learning more about sleep during spaceflight and sleep in space all of the time. Dr. Flynn-Evans expects that much will be observed and learned about sleep in space during the upcoming lunar expeditions and that will help us prepare for future deep space exploration. Erin Flynn-Evans, a research psychologist and director of the Fatigue Countermeasures Laboratory at NASA's Ames Research Center, holds electrodes that measure brain wave activity. Her team uses the electrodes as one tool in its studies of the way fatigue affects people on the job in diverse fields such as aviation, spaceflight and NASA mission operations.

addition to the misaligned night and day, there are other issues associated with sleeping on the Moon or Mars that are similar to issues that individuals on Earth might experience. Dr. Flynn-Evans uses the examples of astronauts maintaining good sleep hygiene practices by going to bed on time and reducing environmental sleep disrupters like light and noise pollution, which might be more difficult under the extreme circumstances. In addition, the astronauts will live and work in isolated and confined environments, which could also influence sleep. “Additionally,” Dr. FlynnEvans says, “we don’t yet understand how other factors in space—such as microgravity, partial gravity and radiation—might affect sleep.”

6 | May/June 2021

Erin E. Flynn-Evans, PhD, MPH is the current Director of the Fatigue Countermeasures Laboratory at NASA Ames Research Center. A circadian physiologist and epidemiologist, Dr. Flynn-Evans has worked in the sleep field for 20 years. Her current primary area of interest is studying the influence of work hours on alertness, performance, and sleep in a variety of occupational cohorts. At the NASA sleep lab she performs characterization studies. Previously, she has done basic laboratory studies assessing the influence of light on the circadian system and long-term health consequences of shiftwork and circadian misalignment. Gina Dewink has been working and writing for nonprofit health organizations since 2004. With a degree in communications, her career history includes the American Academy of Neurology and the RLS Foundation.

WSO.fullpage.11-20 1

7 | healthiersleepmag.com 23/11/2020 11:23

PEDIATRIC

Sleep Disorders in Kids are Common Differentiating the usual from the unusual. By Rosei Skipper, MD

ll parents are familiar with the stress of trying to get kids to sleep—as well as the worry that comes when that sleep isn’t sound. Children often experience more sleep disturbances than adults, but parents may still be surprised to see their child walking around the house at night, or frightened when a child screams during a sleep terror. We spoke with pediatric neurologist and sleep specialist Shelly Weiss, MD, FRCPC, to better understand the common sleep disorders known as disorders of arousal. WHAT ARE DISORDERS OF AROUSAL? Also known as non-rapid eye movement (NREM) parasomnias, these are abnormal episodes that occur during a stage of sleep known as N3, and are more common in children. The episodes include confusional arousals, sleep terrors and sleep walking. They can occur during any period of sleep, including naps. According to Dr. Weiss, they have three factors in 8 | May/June 2021

common—they occur during non-rem sleep, children are not aware of their behavior during them, and children do not remember them in the morning. CONFUSIONAL AROUSALS Confusional arousals are just what they sound like— your child may appear to be awake, but have unusual behavior, such as speaking slowly, or saying nonsense. These events are very common, and are most frequent between the ages of two and five. Dr. Weiss says that parents should not be concerned about these types of awakenings. SLEEP TERRORS Pediatric sleep terrors (also known as night terrors) can be extremely distressing for parents. Dr. Weiss says that a parent will observe what seems like an abrupt awakening, though the child will not actually be awake or responsive. He or she may seem terrified,

may scream out loud and may be sweaty and have a fast heart rate. Parents will be unable to soothe the child, and trying to calm the child might actually make him or her become more agitated. Episodes typically last between 5 and 30 minutes. Although frightening for parents, children do not remember these terrors in the morning. According to Dr. Weiss, about 30% of young children experience sleep terrors, and almost all outgrow them by their teenage years. SLEEPWALKING Sleepwalking is also quite common, occurring in about 15% of children aged 5-12. Dr. Weiss says that sleepwalking is the most likely disorder to persist into adulthood, with about 1% of adults continuing to sleepwalk. Sleepwalking can appear to be purposeful to parents, but just like the other parasomnias, the child will not respond normally and will not remember the incident in the morning. Children may injure themselves by leaving their bed and can even fall off of landings or out of windows. Sleepwalking can be associated with bedwetting or rising to use the wrong area as a toilet. Though they may be distressing to parents and to children, they are not signs of serious illness, and most children eventually outgrow them. SAFETY FIRST Non-rem parasomnias are not dangerous in and of themselves and rarely signify any underlying illness, but Dr. Weiss emphasizes that it’s important for parents to take steps to keep kids safe. Doors and windows should be secured (though a child should never be locked in a bedroom due to risks such as a house fire), and parents

should remove dangerous objects from reach if needed. Parents can purchase systems which alert them if a child has left the bed so they can observe and intervene if necessary. Usually, caregivers should not try to wake up the sleeping child. WHEN TO SPEAK TO A PEDIATRICIAN Dr. Weiss explains, “If your child experiences a dramatic change in their sleep, begins having these disorders at an unusual age or more frequently, or simply isn’t Dr. Shelly Weiss doing well during the day by feeling too sleepy or having emotional problems, then it’s a good idea to speak to your child’s care provider.” Pediatric non-rem parasomnias can almost always be diagnosed, and primary care providers are well-versed in their management. Only very rarely would a child need to be seen by a specialist since children do not need to be evaluated via sleep study for non-rem parasomnias. Reassurance and simple behavioral steps are generally the most effective treatments. Because disorders of arousal are affected by stress levels and sleep deprivation, Dr. Weiss recommends setting a consistent bedtime routine and sleeping environment. Ask your child about emotional stressors, and provide reassurance as needed. Be aware that these disorders tend to be worse while traveling (especially across time zones), and be prepared for more episodes when sleeping away from home. Parents can help by preparing friends and family for the possibility of sleep issues. With time, your child’s sleep should become more regular, and everyone will be getting a better night’s rest. ............................................................... 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.

9 | healthiersleepmag.com

How You Spend Your Days Can Affect Your Nights From night owls to morning larks. By Shanti Argue

ircadian rhythms are our body’s time keeper, differentiating day and night, telling us when it is time to eat and releasing sleep hormones like melatonin when it is time to sleep. Psychologist and PhD candidate Hailey Meaklim explains that our bodies tend to follow a 24-hour cycle, however, “We are influenced by our environment and behavior. Light is the most important factor for regulating our circadian rhythms, but timing of meals, social cues and activity levels also play a role.” Many important bodily processes are influenced by our circadian rhythms, which is why Meaklim warns that, “If we expose ourselves to light at night or change our sleep-wake or meal schedules, this can really disrupt our circadian rhythms and lead to poor sleep, as our body gets confused about what time it is.” DISORDERED SCHEDULES At St. Vincent’s Hospital Sleep Centre in Melbourne, Australia, Meaklim sees patients dealing with sleep disruption, excessive sleepiness and insomnia. Circadian Rhythm Sleep-Wake Disorders (CRSWD) occur when there is a misalignment between a person’s circadian rhythms and the sleep-wake schedule required by the person’s environment or work commitments,” says Meaklim. “People often report feeling like they are constantly jet-lagged and are operating on a different time zone then their family, friends and workplace.” “These conditions are often misdiagnosed as insomnia (difficulty falling asleep, staying asleep or waking too early), but a key difference with CRSWDs is that if you let people sleep at a time consistent with their body clock, they can sleep! This is different from insomnia where people struggle with sleep no matter the time.” NIGHT OWLS In Delayed Sleep-Wake Phase Disorder (DSWPD),

10 | May/June 2021

people often refer to themselves as night owls. “We see that a person’s body clock is delayed by several hours,” Meaklim explains. “They feel like a normal sleep cycle would be something like going to sleep at 3:00am and waking at 11:00am.” “A common example that we see in the clinic,” Meaklim goes on to explain, “is a referral from a frustrated parent because their teenager cannot get to school on time, with implications for their school performance. Whilst elements of behavior such as mobile phone use late at night can really delay a person’s body clock and sleep, there is often an underlying DSWPD at play.” According to Meaklim, DSWPD affects around 7-16% of young adults due to a natural delay in the

Why am I so tired?

body clock that occurs after puberty. This means that the teenager is actually incapable of falling asleep at a reasonable hour, and not be able to sleep until early in the morning. “Perhaps not surprisingly, these teens typically struggle to get up at 7:00am after only four hours of sleep!” says Meaklim. “Treating the underlying DSWPD through sleepwake scheduling and bright Dr. Hailey Meaklim light therapy can really help get circadian rhythms back on track, improve sleep and ultimately provide better school attendance and performance.”

Bedtime Reads Looking to learn even more? Each issue, we highlight one book about sleep.

EARLY BIRDS On the other hand, people with Advanced Sleep-Wake Phase Disorder (ASWPD) are referred to as early birds or morning larks. In this condition, a person’s body clock is timed too early. For example, they feel sleepy at 8:00pm and wake at 4:00am. “ASWPD is more common in the elderly population.” Meaklim says, “which is often why grandparents eat dinner so early.” SETTING YOUR CLOCK Sharing the advice she gives patients, Meaklim emphasizes regularity. “As much as you can, keep a consistent sleep-wake routine, going to bed and getting up at around the same time each day. If you sleep in for three hours on the weekend, that is like crossing a time zone when you try to get up at your normal time on Monday morning. Also, try to keep your meals at the same time to reinforce this message to your body.” “In addition, we need bright light during the day to help our circadian rhythms know it is daytime.” In the evening, Meaklim suggests keeping light levels low, and warmer in color once the sun goes down. “Our bodies did not evolve with artificial light, so try to avoid bright light from devices like mobile phones or energy efficient light bulbs in the evening. Aim for bright days and dark nights.” Finally, if you have tried these basic sleep hygiene tips and sleep is not getting any better, or for any other sleep concerns, Meaklim suggests consulting with your doctor. ..................................................................................... Shanti Argue is a freelance writer who loves researching and writing about a variety of topics.

How to Sleep by Rafael Pelayo, MD Anyone having trouble sleeping has heard the “sleep hygiene” rules: Don’t drink caffeine after 2:00pm, use the bedroom only for sleeping, put down screens an hour before bed. But as the millions with poor sleep can attest, following one-size-fits-all directives doesn’t work. How to Sleep rewrites the rules to help you get to sleep—and stay asleep—every night. Dr. Rafael Pelayo, a clinician and professor at the Sleep Medicine Clinic at Stanford University: • Offers a medically comprehensive and holistic approach to issues affecting sleep • Discusses changes to daily routines to induce sleepiness. Available on workman.com/products/how-tosleep and from other book retailers. 11 | healthiersleepmag.com

WELL-BEING

Better Sleep, Better Immunity By Monika Haack, PhD

was always fascinated by the conventional wisdom and personal experience that sleep Dr. Monika Haack helps fight infections. And isn’t it interesting that, on the other hand, not sleeping enough makes us more susceptible to get infected? There is something happening during sleep that makes the immune system stronger or more successful in the fight against viruses and other pathogens. HOW SLEEP POSITIVELY IMPACTS IMMUNITY The many animal studies that have been done over the past decades have clearly shown that sleep helps an animal survive an infection. In humans, the chances of getting infected with respiratory viruses, for example, are much higher in those with short sleep (generally less than 6 hours per night) or those who suffer from insomnia. Short sleep or not sleeping at all for just one night also leads to lower antibody responses to vaccination, for example, against the flu.

12 | May/June 2021

In some people, the antibody response is so low that they are not sufficiently protected against the virus anymore. To keep in mind, both good sleep before and after a vaccination help to develop a strong antibody response against pathogens. There are different ways sleep can support immunity. One way is that sleep protects against the development of low-grade inflammation. If inflammatory markers increase in the body, as has been seen with short or disturbed sleep, various immune cells are much less sufficient in fighting viruses and other pathogens. There are also many hormones— such as cortisol, melatonin or epinephrine—that can suppress or promote inflammation. The secretion of these hormones can be circadian or sleep-dependent, so that is another way sleep can affect pathogen defense. There is also recent evidence that sleep promotes optimal functioning of T cells. T cells are a type of white blood cell that are key to the immune system. If the person is sleep deprived, T cells have difficulties attaching to virus-infected cells and consequently, cannot destroy them as they should.

STUDYING SLEEP & THE IMMUNE SYSTEM Generally, researchers experimentally manipulate the amount of sleep, by completely sleep depriving animals or human participants or reducing the amount of sleep, most often to 4 hours of sleep per night over one or more nights. This can be done (and has been done) prior to and/or after exposure to a virus or vaccine to study how sleep-deprived cells respond to such a challenge. In addition to studying immune responses, we also look at the development of classical sickness symptoms—such as fatigue or body pain—when sleep deprived. Another important topic is recovery. There are more and more data suggesting that recovery of biological processes from insufficient sleep can take longer. There are also now methodologies by which deep or slow wave sleep can be intensified through acoustic stimulation. Slow wave sleep is thought to be the sleep stage that is most critical for the immune supportive actions of sleep. This all aims to narrow in on the connection between sleep and immunity.

Because of COVID-19, 2021 will likely continue to be a year with high infection risk but also a year in which millions of people will get vaccinated. While there is not a lot of data yet specifically on sleep and COVID-19 infections, it is most likely that getting sufficient sleep around the time of infection can reduce the severity of the infection and promote a successful recovery. And in the case of vaccination, sufficient sleep will most likely increase clinical protection status, as we have seen with other vaccinations. I think an important question is also the role of sleep in those individuals who do not recover from the infection. For

those who continue to suffer from fatigue, body pain, headache and other sickness symptoms long after the virus is under control, I would be interested to see data on sleep in these long-haulers. Perhaps sleep interventions could potentially help recover from these symptoms more quickly. TAKE ACTION I hope people see that they can take control over their own immune health by changing their behavior; by making more time for sleep so the immune system can function at its best. For the average adult, this means 7 or more hours of undisturbed sleep per night, best with regular bed and wake times.

I actually think that many people know that already, but don’t do it because behavioral changes are generally difficult to make and to maintain. Let’s choose to better our sleep to better our immunity. ....................................................... Monika Haack, PhD is an Associate Professor of Neurology at Harvard Medical School Beth Israel Deaconess Medical Center who has been working in the field of sleep medicine & research for 18 years.

KEY TAKEAWAYS

RESEARCH HAS SHOWN US…

Chances of getting infected with viruses are higher in those with less than 6 hours of sleep per night Sufficient sleep will most likely increase clinical protection status when receiving a vaccine against the coronavirus, as seen with other vaccinations Short sleep (or not sleeping at all for just one night) leads to lower antibody responses to vaccination, meaning it could be less effective Sleep promotes optimal functioning of T cells, the white blood cells key to destroying virus-infected cells 13 | healthiersleepmag.com

Nightmares & Sleepwalking When is there cause for concern? By Rosei Skipper, MD

elieve it or not, sleepwalking and excessive nightmares are related—and both could potentially require a visit to the doctor. Learn more about these common sleep disorders, and when to seek treatment.

Individuals living with sleepwalking disorders often notice that being overly tired, jet lagged or changing a sleep environment can make sleepwalking more likely. Ironically, there is evidence to suggest that common sleep aids like zolpidem can cause sleepwalking.

What is sleepwalking? According to Sleep Specialist Liyue Xu, MD, sleep walking and nightmare disorder fall under the umbrella category of “arousal disorders,” meaning partial arousal from deep sleep. “Deep sleep,” Dr. Xu defines, “is a prolonged and restorative sleep stage during which we are quiet and difficult to wake. Sleepwalking episodes start with a confused partial awakening.” During a sleepwalking episode, speaking to the individual affected will not cause them confusion or disorientation. They will likely seem coherent and reply. Often, the individual will return to bed on his own, and won’t remember the episode the next day.

Is treatment necessary? Dr. Xu says that most people don’t need to see a doctor concerning arousal disorders, and adds that there are no specific medical treatments. However, if a person is experiencing other problems, Dr. Liyue Xu like daytime sleepiness, it’s a good idea to talk to a provider. The main course of treatment involves reducing stress, maintaining a regular sleep schedule and not skimping on sleep, in addition to safety measures.

Can sleepwalking be dangerous? The biggest safety concerns withs sleepwalking are risks of falling, bumping into objects and even leaving the house. Dr. Xu says that sleepwalkers are almost never violent, but family members should be careful intervening, as sleepwalkers may push, hit or kick if they are touched. For this reason, it is better to let the sleepwalker make their own way back to bed.

When are nightmares more than just bad dreams? According to Dr. Xu, “Nightmare disorder is when nightmares happen excessively, cause distress, disrupt sleep, cause problems with daytime functioning and/or lead to fear of going to sleep.”

So what exactly causes sleepwalking? Truthfully, sleep specialists haven’t narrowed down the exact cause of sleepwalking disorders. Although stress tends to make sleepwalking worse, psychological problems are not thought to be the cause. Dr. Xu says it’s likely that genetic factors and brain maturation play a role—sleepwalking tends to run in families, and most children grow out of it. Sleepwalking is fairly common, occurring in about 5% of children and 1.5% of adults. 14 | May/June 2021

Where do nightmares come from? The exact cause of dreams and nightmares is not known, nor is their function. But Dr. Xu says that “abnormal nightmares are common in people suffering from post-traumatic stress disorder (PTSD), or after an accident. For children, nightmare disorder is most likely to occur in those exposed to severe psychosocial stressors at home or school.” A recent study also suggested that recurrent nightmares occurred more often in those who habitually slept less than eight hours per night. Insomnia and sleep deprivation can make nightmares worse, and so can certain

Your sleep physician will carefully discuss your symptoms, and evaluate you for other sleep disorders if indicated. medications, use of drugs, and withdrawal from alcohol. When should I talk to my doctor? Dr. Xu says that it is important to get evaluated by a provider if nightmares are causing problems. “Your sleep physician will carefully discuss your symptoms, and evaluate you for other sleep disorders if indicated. You may need an overnight sleep study in a lab.” If nightmares are affecting your or your child’s quality of life, there is treatment. According to Dr. Xu, the recommendations will depend on the underlying cause of the nightmares, but include therapy, medications and sleep hygiene practices. With treatment and time, nightmare disorders can improve. ..................................................................................... 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.

NEW TREATMENT FOR PTSD-RELATED NIGHTMARES A college student watching his father deal with nightmares due to post traumatic stress disorder (PTSD) created a smartwatch app that was recently approved by the US Food and Drug Administration. Using his father as the test subject, Tyler Skluzacek was able to create an app that issues a gentle vibration to pull the dreamer out of the REM cycle yet continue to sleep. This initiative caught the eye of Grady Hannah, who is now the CEO of NightWare, the name of the company as well as the app. “I learned of NightWare in 2015 through local media,” Grady explains. “I reached out to Tyler, the inventor, and offered to help him build a business together.” In Grady’s opinion, this new app technology has changed the scope of sleep in PTSD. Nightmares are a serious presentation of PTSD that previously had no effective treatment. “Those living with PTSD are often re-experiencing a trauma that happened to them. Prescribers and patients alike are reaching out proactively because NightWare is serving such a critical need,” Grady states. NightWare is only available when prescribed by a physician and the application has a formula that is customized to each individual. Grady finishes by adding, “NightWare is excited and humbled to be able to treat patients suffering from Nightmare Disorder and nightmares resulting from PTSD. This is a serious problem and to be the only on-label treatment for nightmares is exciting.” World Sleep Society does not endorse specific products or services, but rather aims to spread awareness about new and varied forms of treatment for sleep disorders. 15 | healthiersleepmag.com

MISSION

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.

GOAL & PURPOSE

World Sleep Society developed the following programs that consist of promoting sleep education, awareness and member services and include World Sleep Congress and World Sleep Day.

WSS

International Sleep Disorder Specialist

EXAMINATION PROVIDING SLEEP MEDICINE COMPETENCE

ANNUAL AWARENESS EVENT WITH CALL TO ACTION

• Austrian Sleep Research Association (ASRA)

ONLINE LIBRARY OF EDUCATIONAL CONTENT

GUIDELINES HEALTHIER SLEEP PATIENT SLEEP MAGAZINE

• German Sleep Society • Hong Kong Society of Sleep Medicine • Indian Association of Surgeons for Sleep Apnoea • Indian Sleep Disorders Association • Indian Society for Sleep Research • Integrated Sleep Medicine Society Japan (ISMSJ) • International Pediatric Sleep Association (IPSA)

• Brazilian Sleep Society

• International RLS Study Group

• British Sleep Society

• Chinese Sleep Research Society • CMDASM -Chinese Medical Doctor Association Sleep Medicine Specialized Committee

• EURLSSG

INTERNATIONAL SLEEP

Official journal of World Sleep Society & International Pediatric Sleep Association

• Australasian Sleep Association

• Czech Sleep Research and Sleep Medicine Society

PROMOTING SLEEP MEDICINE & RESEARCH WORLDWIDE

OFFICIAL JOURNAL OF WORLD SLEEP SOCIETY

• Asian Society of Sleep Medicine

• Canadian Sleep Society

MEETINGS

RECOMMENDATIONS FOR DIAGNOSIS & TREATMENT

• 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

The BuZZZ about Sleep Your Latest Buzzword is Hypnic Jerks. When you are falling asleep and your body suddenly jerks, jolts or startles, this is a hypnic jerk or benign myoclonic jerk. Some people refer to them as a twitch, start or involuntary contraction, but all words are describing the same activity. As it is thought that up to 60% of people experience hypnic jerks, it is listed in the International Classification of Sleep Disorders, but sleep experts agree hypnic jerks are not cause for worry. This involuntary muscle movement often happens when the body is between asleep and awake. It is generally accepted knowledge that a hypnic jerk is a body’s way of signaling sleep deprivation and that a good night’s sleep is much needed.

17 | healthiersleepmag.com

Melatonin

From hormone to over-the-counter supplement. By Wendi Kitsteiner

r. Lourdes DelRosso is passionate about helping people find good rest. She has a particular interest in restless sleep and restless legs syndrome. Along with her work in sleep medicine, Dr. DelRosso has often been asked to discuss melatonin and its role in helping provide healthier sleep. According to Dr. DelRosso, melatonin is a natural component of our circadian regulation— circadian referring to our natural inner clock or cycle of sleep and wake. “Melatonin is a hormone produced in the pineal gland under conditions of darkness, such as in the evening,” Dr. DelRosso explains. “The production of melatonin is blocked by light exposure during daytime.” Dr. DelRosso explains that there are two main things that regulate Dr. Lourdes DelRosso our sleep circadian timing. “One is melatonin and one is light exposure,” she states. “When our circadian clock does not match our social sleep requirements such in situations of jet lag, we can use melatonin and light to adjust to the

18 | May/June 2021

new time. Similarly, we sometimes have a ‘delayed sleep cycle’ and a low dose of melatonin can help regulate or set up the new time.” There is sensible caution against using high doses of melatonin. What constitutes a high dose is debatable, but perhaps more than 3 mg/night. In a sleep clinic setting, patients may be treated with higher doses for specific sleep conditions, under MD supervision. Unfortunately, sometimes self-administration doses exceed 20-30 mg. Melatonin has become a buzzword–especially for parents desperate to help their child find much-needed rest. But Dr.

DelRosso cautions that there is a time and place for introducing this particular therapy into a child’s sleep regimen and to do so with help from your physician or pediatrician. “Our bodies naturally produce melatonin when its dark,” she details. “The circadian rhythm is designed in a way that light signals our brain that it is daytime, and so melatonin is not produced. However, in the absence of light, our sleep clock (the suprachiasmatic nucleus) knows that it is time to sleep, and melatonin starts being produced.”

Before introducing melatonin, Dr. DelRosso suggests establishing a regular sleep schedule first • Start dimming the lights 1-2 hours before bedtime. • Have a relaxed bedtime routine. • Keep the bedroom cool and dark. • Avoid caffeine for at least six hours before bedtime, remem bering that chocolate and iced tea can have caffeine also. • Do not engage in vigorous activity close to bedtime. • Turn off all electronics and keep them out of the bedroom.

If, after establishing a solid routine, you or your child fail to find relief for difficulties with sleep, a doctor should be consulted. There are several different sleep disorders that affect sleep and can mimic insomnia including restless legs syndrome, obstructive sleep apnea and behavioral insomnia in childhood. “It is very important to diagnose sleep disorders early to avoid consequences. Also, there may be other reasons affecting sleep including medical conditions, depression or anxiety, social issues or environmental problems,” she goes on to explain. “And the physician can help identify and address these issues.”

causes her great concern. She explains that this means the doses may vary or other substances may be used during preparation. “In fact, a research article on melatonin preparations published in the Journal of Clinical Sleep Medicine showed that the melatonin content in the products analyzed varied significantly from -83% to +478%! Other substances not reported to be in the preparation included serotonin, present in 8 out of 30 preparations in this study.” Melatonin can be made from hormone secretions of animals or microorganisms, but more often are made with synthetic melatonin. Currently, there is not very much research in the field of melatonin. “We definitely need more research studying the long-term consequences of melatonin,” she says. Side effects, however, are not usually prevalent, with nightmares and headaches being the chief complaints that Dr. DelRosso has seen in her office. It is also unlikely you will become dependent on melatonin or have a diminished response after repeated use. Aging adults will naturally create less melatonin. Children can also use this supplement. Dr. DelRosso often recommends melatonin for short-term use in children. She specifically notes that children with autism spectrum disorder

can benefit from melatonin. Dr. DelRosso states, “Recently published guidelines from the American Academy of Neurology recommend physicians to offer melatonin if behavioral strategies are not helpful.” Other sleep disorders are also prevalent in children and it is very important to consult with your pediatrician or sleep physician before starting using melatonin. Lourdes DelRosso is a sleep physician at Seattle Children's Hospital and Associate Professor in the department of Pediatrics at the University of Washington School of Medicine. Originally from Peru, she earned her medical degree at the University of Miami and then went on to complete a residency in Family Medicine at Kaiser Permanente/UC Irvine, a Sleep Medicine fellowship at Louisiana State University and a Masters in Medical Education at the University of Pennsylvania.

....................................................... Wendi Kitsteiner is a former high school English and Journalism teacher who has worked as a writer/editor for the RLS Foundation and as an editorial assistant for a cardiovascular researcher at Mayo Clinic. She is currently homeschooling her four children on a farm in East Tennessee. *Citations available on healthiersleepmag.com.

Dr. DelRosso says that the fact that melatonin is not regulated by the U.S. Food and Drug Administration and is simply sold over-the-counter as a “supplement”

19 | healthiersleepmag.com

How to Know if You Have a Sleep Disorder What is a sleep disorder?

Simply put, a sleep disorder is a problem or condition that results in lack of quality sleep. Lacking quality sleep impacts daytime function and a myriad of physical and mental elements. Sleep is a basic human need, much like eating and drinking, and is crucial to our overall health and well-being.

What is quality or healthy sleep?

World Sleep Society defines quality sleep as consisting of three basic elements. Three elements of quality sleep are: • Duration: The length of sleep should be sufficient for the sleeper to be rested and alert the following day. • Continuity: Sleep periods should be seamless without fragmentation. • Depth: Sleep should be deep enough to be restorative.

Healthy sleep is sleep which restores and energizes a person so he or she feels wide awake, dynamic and energetic all day long. Health and disease are opposites, and therefore, when a disease or disorder of sleep does exist, sleep investigation is needed to identify and treat it. Sleep disorders are not rare, and they can cause serious problems if left untreated. Though up to 45% of the world may live with a sleep disorder, most are treatable.

Why should I care about sleep disorders?

Good quality and restorative sleep is essential for dayto-day functioning. Sleeping better may be a struggle for some, but much like diet and exercise, it should be considered an important part of a healthy life. Since the majority of sleep disorders are treatable, the poor mental and physical consequences of lack of sleep do not have to be tolerated.

20 | May/June 2021

Who is likely to have a sleep disorder?

While anyone can have a sleep disorder, a person's age, gender and genetics play a part. There are some populations at higher risks of sleep disorders and include those who are overweight, living with genetic syndromes, the elderly or individuals with comorbidities that affect sleep such as depression.

How can a sleep disorder affect physical health?

Physically, lack of sleep or poor-quality sleep is known to have a significant negative impact on our health in the long and short term. Poor quality sleep or sleep deprivation has been associated with significant health problems, such as obesity, heart disease, diabetes, weakened immune systems and even some cancers.

How can a sleep disorder affect mental health? Lack of sleep is related to many psychological conditions such as depression, anxiety and psychosis. Next day effects of poor-quality sleep include a negative impact on attention span, memory recall and learning. Recently, a link between poor sleep and Alzheimer’s disease has been reported.

What are general vs. obscure sleep disorders? Though there are close to 100 classified sleep disordered, the most common are sleep apnea and insomnia. The prevalence of sleep apnea in the adult population aged 30 to 70 years is approximately 26% to 34% in men and 17% to 28% in women. Sleep apnea is a breathing disorder. With insomnia, it is estimated that up to 30% of people may have intermittent or some episodes of insomnia, with chronic insomnia affecting around 10-15% of the global population. Insomnia is a disorder involving inability to fall or stay asleep.

How do I know if I have a sleep disorder? The first step is to be evaluated by a sleep expert. Generally, after a patient has visited a physician about symptoms pertaining to a suspected sleep disorder, a sleep study will be recommended. Sleep study, or polysomnogram, is an overnight clinical investigation of sleep disorders usually performed in a dedicated facility. The patient is scheduled to arrive for sleep study 60-90 minutes before his/her usual bedtime. Before electrode application, the technologist offers an explanation of sleep study procedure. The sleep study will be performed overnight. When the patient wakes in the morning, the technologist obtains the patient’s impression of the night’s sleep; this information will be linked to the sleep study results. In some patients, the presence of overwhelming daytime sleepiness requires adequate daytime assessment, which would require for a patient to remain in a facility the day following overnight sleep study. What should I do if I think I have a sleep disorder? If you suspect you or a loved one may be living with a sleep disorder, the first step could be tracking symptoms at home. A sleep diary is often recommended to track bedtimes, waketime, number of nocturnal wakings and how you felt upon waking up and throughout the day. Sample sleep diaries are available online to print. Once you have data on your sleep, it is good to make an appointment with your primary care physician to discuss next steps.

SLEEP DISORDER CATEGORIES Besides breathing disorders and insomnia, other sleep disorders generally fall into the remaining categories of: Circadian rhythm disorders: Problems with sleep and wake times being inconsistent or misaligned. Hypersomnias: Issues with excessive sleepiness Movement disorders: Troubles with unwanted movements prior to or during sleep. Parasomnias: Complications with unwanted experiences when falling asleep or waking. 21 | healthiersleepmag.com

What is “Regular” Sleep? Understanding the definition and why it’s important for our health. By Robert J. Thomas, MD

egular sleep can be explained as being “not irregular” and vice versa. Sleep is naturally prone to be irregular, as it occurs in “chunks” that are loosely linked together, and these chunks occur preferably during the time we typically sleep—though more than an hour of variability in night-to-night sleep timing is probably abnormal. The timing of sleep during the night is largely dependent on the light-dark cycle and the various rhythms linked to the 24-hour cycle, also known as circadian rhythms. Every day, there is a small “jiggling” of this overall positioning of the sleep chunks (or sleep cycles). Thus, what we consider regular sleep is actually a little bit irregular. Each night is not exactly the same. Exposure to light, noise, and too much temperature change while sleeping can also result in less regularity of sleep. Regular sleep most importantly needs regular wake time and ample exposure to light on awakening. Darkness in the late evening after 8pm and during sleep is also important. Spending too much time in bed will make sleep less regular as the links between these sleep chunks will loosen and periods of wakefulness will emerge during the night. Some healthy individuals are naturally very regular, while some are irregular. Variable wake times and bedtimes make sleep irregular, somewhat like jet-lag without the need to travel. The extremes of age are less regular, with newborns sleeping in chunks around the clock and the elderly at risk for irregularity.

Dr. Robert J. Thomas

However, diseases such as depression, bipolar disease, pain, restless legs and sleep apnea can make sleep irregular. Increased irregularity of sleep timings have been associated with weight gain, depression, diabetes and heart disease.

Regularity of sleep can be tracked in many ways these days. Examples include sleep diaries, activity monitoring devices, smartphone applications, cell phone/e-mail/social media use, smart mattresses and non-contact devices which use Wi-Fi or radar technology to track breathing, heart beats and body movements and estimate sleep and wake. Simple ways to ensure regularity of sleep is to keep a stable light/dark cycle, have a consistent wake and bedtime, avoid eating late or during the night, and not spending more time in bed than one can sleep. Reducing time watching movies or using electronic media in bed—and certainly avoiding these if there is an awakening at night—is also a good idea. Sleep promoting drugs such as “sleeping pills” make sleep more regular, but we do not know if this is good or bad as more research is needed in this area. But what research has shown is that regular sleep leads to a healthier future. I look forward to a time when regular sleep is as common a phrase as balanced diet. .............................................................. Robert J. Thomas, MD is an Associate Professor of Medicine at Harvard Medical School, Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center. He has been working in the field of sleep medicine and research for 26 years. 22 | March/April 2021

YOUR TRUSTED SOURCE FOR IMPROVING SLEEP A MAGAZINE FROM WORLD SLEEP SOCIETY Join the 18,000 individuals, sleep clinics, hospitals and other professional sleep businesses receiving Healthier Sleep Magazine to their inboxes.

• Instant online access available • Up to six issues per year, each issue highlighting a different subtopic in sleep We are a trusted source within the sleep community, now bringing our worldwide expertise to the patient level.

Welcome to Healthier Sleep. IN EVERY ISSUE

ISSUE TOPICS • INSOMNIA • HYPERSOMNIA & NARCOLEPSY • RESTLESS LEGS SYNDROME

• • • •

SNORING & OSA BETTER SLEEP FUTURE OF SLEEP BABY & SLEEP

Healthier Sleep is published up to six times per year by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide.

CONTACT US For more information or to subscribe, visit Healthiersleepmag.com. For questions, contact healthiersleep@worldsleepsociety.org.

Epilepsy & Sleep Five things you should know. By Shanti Argue

octors have long recognized a complicated dynamic between sleep and seizure activity in people with epilepsy. As a neurologist who specializes in treating epilepsy, as well as sleep disorders, Dr. Nancy Foldvary-Schaefer is on the cutting edge of research into novel ways to improve the lives of patients with seizure disorders. At the Cleveland Clinic in Ohio, where Dr. FoldvarySchaefer is the Dr. Nancy Foldvary-Schaefer Director of the Sleep Disorder Center, physicians have found that one effective and often overlooked avenue for treatment is simply helping patients get a good night’s sleep. Dr. Foldvary-Schaefer explains the most important highlights to know.

DAYTIME SLEEPINESS IS THE MOST COMMON COMPLAINT For anyone experiencing excessive daytime drowsiness, every aspect of life can feel difficult. Grumpy 24 | May/June 2021

moods can affect relationships. Lack of energy can make it hard to exercise or complete to-do lists. Poor concentration can lead to mistakes and difficulty at work. “Among people with epilepsy, excessive daytime sleepiness is the number one complaint,” says Dr. Foldvary-Schaeffer. “Many medications used to treat epilepsy can cause drowsiness, but chronic untreated sleep/wake disorders are a huge contributing factor, as well.” It is estimated that 85-90% of patients with seizure disorders are not getting treated for sleep issues.

MANY PEOPLE WITH EPILEPSY STRUGGLE WITH SLEEP In a recently published paper, Dr. Foldvary-Schaefer says, “Sleep/ wake disorders are 2–3 times more common in adults with epilepsy than in the general population. These include insomnia, restless legs syndrome and sleep disordered breathing. These comorbidities are associated with poorer quality of life and may impact seizure control.”

THE RELATIONSHIP IS BI-DIRECTIONAL “Sleep is a very active state for our brains,” explains Dr. Foldvary-Shaffer. “REM sleep is actually very neuro-protective.” In patients with epilepsy, sleep can activate seizures causing arousals and prevent patients from getting adequate REM. “This means that sleep is unrefreshing,” Dr. Foldvary-Shaffer states. Epilepsy interferes with good quality sleep, and lack of sleep is known to make epilepsy worse, making it a bidirectional relationship. Because of this, improving sleep quality can reduce overall seizure activity and reduce the dosages needed for some medications.

TREATING OSA COULD PREVENT SUDEP Sudden Unexpected Death in Epilepsy (SUDEP) is a frightening possibility for anyone who has, or loves someone who has, epilepsy. To prevent SUDEP, many doctors advise patients to sleep on their backs. However, back sleeping can exacerbate obstructive sleep apnea (OSA), a disorder where the airway repeatedly becomes blocked when the throat relaxes during sleep,

disrupting sleep. According to Dr. Foldvary-Schaeffer, OSA is 2.4 times more common among adults with epilepsy. Treatment with a CPAP machine can help keep the airway open during sleep, as well as during a seizure, making it safer for epilepsy patients to sleep on their backs.

TREATING SLEEP DISORDERS CAN IMPROVE SEIZURES

“Treatment with CPAP had 5-fold odds of improved seizure

outcomes,” says Dr. FoldvarySchaeffer, referencing a meta-study in patients with OSA. She also wants more people to be aware of “a recent surge in research” connecting epileptic events with circadian rhythms. By focusing on good quality sleep routines and treating underlying sleep disorders, patients with epilepsy can experience fewer seizures, less drowsiness and an improved quality of life.

Per a study done in February 2021 that followed 222 participants through 10 years, the prevalence of circadian (approximately 24 hours) seizure cycles was 89%. Circadian seizure cycles showed five peak times of seizure occurrence: morning, mid-afternoon, evening, early night and late evening through brain wave monitoring. Peaks were also noticed around 7, 15, 20 and 30 days. *Citations available on healthiersleepmag.com

..................................................... Shanti Argue is a freelance writer who loves researching and writing about a variety of topics.

PATIENT ORGANIZATION HIGHLIGHT

The Hypersomnia Foundation The Hypersomnia Foundation, Inc. is a nonprofit, patient advocacy organization working on behalf of people with idiopathic hypersomnia and related rare sleep disorders. Diane Powell, the current Chair of the Board of Directors and CEO, explains, “Idiopathic hypersomnia (IH) is a chronic, neurological sleep disorder. It’s often called a rare sleep disorder, but we suspect that it is more likely “rarely-diagnosed,” since it is not yet well known.” Powell goes on to explain that IH can easily “hide in plain sight” since feeling tired and sleepy is a common complaint for many. The Hypersomnia Foundation was founded in 2014 to give IH patients a voice, to raise awareness of the disorder, to advocate for more research and to provide information and resources. The foundation offers a wealth of resources for providers, researchers, patients and advocates through their website, conferences and webinars. LIVING WITH HYPERSOMNIA “IH is a very different kind of tired,” Powell states. “People with IH suffer from excessive daytime sleepiness, which is not eased by a full night sleep or a nap. They may also struggle to wake up (“sleep drunkenness”) and/or have cognitive issues (“brain fog”).” Obviously, symptoms such as these can interfere with day-to-day living and make work, studies and

relationships difficult to maintain. Powell says of The Hypersomnia Foundation, “I have been most struck by how long people with this disorder struggle on their own—often blaming themselves for their need to sleep and bearing the blame of others—before getting a diagnosis. For many people, it takes years to get a proper diagnosis. Often the news they have a sleep disorder is received with relief and emotion. One newly-diagnosed patient exclaimed, ‘I thought everyone was as sleepy as I was, I just figured they somehow dealt with it much better than I did!’ Our Foundation is here to help.” At this time, there are no FDA-approved treatments for IH, but patients are commonly treated with “off-label” medications usually prescribed for narcolepsy. The efficacy of these treatments varies among patients. Powell finishes by adding, “The Hypersomnia Foundation is just seven years old, and we are proud of how far we have come, but our work has really just begun. We will continue to work on behalf of people with IH and related disorders for a long time to come—until everyone with these sleep disorders is #BeyondSleepy.” —hypersomniafoundation.org 25 | healthiersleepmag.com

MENTAL HEALTH

Social Rejection & Sleep Is there a connection? By Aric A. Prather, PhD

umans are social creatures, yet the research on how sleep is related to many social processes has been largely unexplored. Social rejection seemed like an easy one Dr. Aric A. Prather to investigate because interpersonal stressors—like social rejection—have routinely been associated with sleep disturbance and insomnia. We also know about the development of psychiatric conditions where poor sleep is common, such as depression and anxiety disorders. Perceived social rejection—or one in which the participant imagines or builds up the interaction in one’s mind—is also a driver of loneliness, which many have already found to correlate with poor sleep. POINTING FINGERS AT THE CONNECTION The data suggest a bidirectional, or two-way, relationship between sleep and social rejection. For example, we find that when we experimentally manipulate the experience of social rejection prior to bedtime, such as making participants feel left out or more explicitly exposing them to negative feedback, those individuals have a hard time getting to sleep, get less sleep overall, and in some cases show more fragmented sleep. This is particularly true among individuals who are already prone to ruminate when

bad things happen. It also seems to work the other way around. Several studies have found that poor sleepers may react more strongly when faced with social rejection, both emotionally and physiologically. This shows us examples of how social rejection and sleep can go hand in hand. SOCIAL DISTANCING The importance of social distancing during this pandemic cannot be overstated; however, reports of depression and insomnia are rising. Social distancing may rob many of us of the supports we need to cope with the barrage of stressors we face on a day-to-day basis. Social slights may sting more than usual, which can lead to feelings of loneliness that negatively impact our sleep. It is also possible that with social distancing, each interaction takes on more meaning and if we haven’t been sleeping well, then negative interactions, including even perceived rejections, may be amplified. During this time, it is even more important to protect our sleep health and cultivate meaningful relationships whether they occur at 6+ feet or over Zoom. *Citations available on healthiersleepmag.com

..................................................................................... Aric A. Prather, PhD is an Associate Professor of Psychiatry and Behavioral Sciences at the University of California, San Francisco. He has worked in the field of sleep medicine and research over 10 years.

Experiencing social rejection prior to bedtime was shown to: • Cause participants to feel more left out • Make participants feel more exposed to negative feedback • Result in having a hard time falling asleep 26 | May/June 2021

• Instigate less sleep overall, and/or show more fragmented sleep

2021-2022 EDITORIAL CALENDAR JULY/AUGUST 2021

INSOMNIA

Ads Due: 4/28/21

• Insomnia • Pediatric sleep disorders • Chronic lack of sleep/effects of sleep deprivation • Anxiety • Insomnia & mental health

• • • • •

NOVEMBER/DECEMBER 2021

Ads Due: 6/30/21

Ads Due: 8/26/21

Narcolepsy Hypersomnia Parasomnias Depression Non 24 Sleep Wake Disorder

RLS

• Restless Legs Syndrome • Periodic limb movement disorder • Alzheimer’s disease • Parkinson’s disease • Sleep & sports performance & injury

JANUARY/FEBRUARY 2022

MARCH/APRIL 2022

BETTER SLEEP

FUTURE OF SLEEP

Ads Due: 10/25/21

Ads Due: 12/22/21

Ads Due: 2/2021

SNORING & OSA

• • • • •

SEPTEMBER/OCTOBER 2021

HYPERSOMNIA & NARCOLEPSY

Sleep Breathing Disorder Bruxism or teeth grinding Sleep & Memory CPAP Sleep & women (pregnancy to menopause)

• • • • •

Sleep disorder treatments Expert recommendations World Sleep Day Sleep & health outcomes Mental health & sleep

MAY/JUNE 2022

• Artificial intelligence in sleep • Sleep technology • Tele medicine • Treatment projections

IN EVERY ISSUE

ABOUT HEALTHIER SLEEP MAGAZINE

Healthier Sleep is published six times per year by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide. Welcome to Healthier Sleep.

CONTACT US For more information, visit healthiersleepmag.com. For a custom quote, contact healthiersleep@worldsleepsociety.org.

IN THE NEWS

The Case for Later School Start Times Why starting school later is healthier for our teens. By Robin M. Lloyd, MD

y helping the next generation maximize their potential, decrease risk-taking behaviors, improve driver safety and improve quality of life, adjusting school start times can have a positive effect on an entire society. I became interested in later school start times when I realized what a positive impact a change like this could have on our society. The majority of press on the topic of pushing school start times later involves adolescents. Current research on early school start times shows that there is a correlation with insufficient sleep opportunity resulting in chronic sleep deprivation. There are biological and lifestyle issues that are at the root of the issue. Biologically, there is a natural delay in sleep phase during adolescence. Additionally, the process S, or homeostatic sleep drive, is slower to accumulate so the natural sleep onset for teens is usually around 11pm on average. Lifestyle factors related to technology use, homework demands, extracurricular activities such as sports and clubs, work, social activities, etc. also impact the amount of sleep a teen is able to get.

28 | May/June 2021

If left unchecked, chronic sleep deprivation may lead to a level of sleepiness consistent with sleep disorders such as narcolepsy. A National Sleep Foundation poll found that almost 90% of high school students were getting less than the recommended amount of sleep, with high school seniors typically getting less than 7 hours of sleep on school nights. Sleep experts agree that adolescents aged 12-18 years should be sleeping 8 to 10 hours. INSUFFICIENT SLEEP HAS BEEN ASSOCIATED WITH: • Lower academic performance • Higher absentee and tardiness rates • Mood difficulties • Inattention • Memory impairments • Decreased quality of life • Drowsy driving crashes • Abuse of stimulants • Increased long-term cardiometabolic risks • Obesity

Later school start times have proven to promote healthier lifestyles for teens since they facilitate sufficient sleep opportunity. By pushing school start time later, teens are able to stay awake until their body clock tells them it’s time for sleep. Having sufficient time for sleep often positively Dr. Robin Lloyd impacts the quality of sleep, as well as quantity, which improves physical health with reduced obesity risk and long-term cardiometabolic impacts. There is also improvement in mental health with lower rates of mood disorders, safety with decreased drowsy driving crashes, academic performance and overall quality of life. In my opinion, later school start times for middle and high school students is an obvious choice. While it is important for parents and students to mediate lifestyle issues that facilitate good sleep practices regardless, later school start times promote sufficient sleep opportunity by accommodating for the biologic changes in sleep that occur with adolescence. Insufficient sleep is a significant public health issue with serious impacts on health and well-being in our adolescents. By advocating for the next generations, we benefit society as a whole.

GET ACCESS TO THE LATEST IN SLEEP MEDICINE & RESEARCH WITH ON DEMAND SESSIONS FROM OUR DECEMBER 2020 VIRTUAL MEETING PLUS NEW CONTENT ARRIVING IN FEBRUARY 2021 AND CONTINUING THROUGH THE END OF THE YEAR FOR JUST $29

Program Topics • MENTAL HEALTH • FATIGUE & ALERTNESS • RLS DEVELOPMENTS & TREATMENTS

• OSA DIAGNOSIS & MANAGEMENT • CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS • HEALTHIER SLEEP

Upcoming Virtual Meetings JUNE 24, 2021 | SEPTEMBER 16, 2021 | DECEMBER 2, 2021

To register and for more information visit worldsleepsociety.org/2021-virtual-meeting

....................................................... Robin M. Lloyd, MD works at the Mayo Clinic Center for Sleep Medicine has been working in the field of Sleep Medicine about 13 years. 29 | healthiersleepmag.com

When Breathing During Sleep Isn’t Normal Hypoventilation & hypoxemia. By Arezu Najafi, MD

HYPOVENTILATION Ventilation is the process of breathing air in and out. In this process, carbon dioxide is exhaled from the lungs and oxygen enters the blood stream after inspiration of air into our lungs. We Dr. Arezu Najafi ventilate air during both our wakefulness and sleep. In individuals with normal sleep, ventilation is reduced slightly during sleep. Thus, oxygen and carbon dioxide levels do not change significantly to disturb our sleep. Several diseases cause disturbance of ventilation and lead to reduced ventilation or hypoventilation. Sleep-related hypoventilation is a breathing problem during sleep. It is described by reduced ventilation during sleep. Thus, these patients experience reduced oxygen and increased carbon dioxide in their blood. These two processes disturb sleep of patients with sleep-related hypoventilation. Accordingly, these patients experience fragmented sleep, excessive daytime sleepiness, reduced performance, insomnia and difficulty breathing during their sleep. Patients often seek treatment because of the aforementioned problems as well as breathing difficulty during sleep and sometimes while awake. A blood test is performed to assess levels of oxygen and carbon dioxide in the blood. Then, a sleep study is performed to confirm reduced ventilation during sleep and to find any other sleep problems such as sleep apneas. Other causes such as obesity, hypothyroidism, lung diseases, neurologic diseases and muscle weakness are also evaluated. Treatments of sleep-related hypoventilation include weight loss and/or cause-specific management. In some cases, using positive airway pressure devices 30 | May/June 2021

during sleep such as CPAP may be required to guarantee a good oxygen level and ventilation during sleep. HYPOXEMIA Our body needs oxygen during both wake and sleep. If oxygen levels decrease in our blood, it is called hypoxemia. Sleep-related hypoxemia is a problem of decreased oxygen levels during sleep. Patients with sleep-related hypoxemia may have symptoms similar to patients with sleep-related hypoventilation including fragmented sleep, excessive daytime sleepiness, reduced performance, insomnia and difficulty breathing in sleep. The diagnosis of hypoxemia is made by performing a sleep study. If no specific cause is found, nocturnal oxygen therapy or positive airway pressure may be prescribed by the physician for treatment. Otherwise, the major cause of hypoxemia would be addressed for management. In conclusion, both sleep related- hypoventilation and hypoxemia result in disturbed sleep and reduced performance. Thus, if you have symptoms suggestive of these two disorders, further evaluation by a physician is required. If you have these conditions, it is recommended to seek help and follow management plans. Treatment of these two disorders will improve your performance and quality of life, so you will have healthier sleep and a happier life and future. ..................................................................................... Arezu Najafi, MD is an Occupational and Sleep Medicine Specialist, Faculty of Occupational Sleep at the Research Center at Tehran University of Medical Sciences in Tehran, Iran. She is also a current Mentee of World Sleep Society’s International Sleep Research Training Program (ISRTP) at University of Pennsylvania. She has been working in the field for seven years.

RATES & REQUIREMENTS ADVERTISING RATES COLOR RATE FREQUENCY

B&W RATE FULL PAGE

1/2 PAGE

1/4 PAGE

$1,200

$700

$400

$1,920

$1,120

$2,880

$3,600

5x 6x

FREQUENCY

FULL PAGE

1/2 PAGE

1/4 PAGE

$1,080

$630

$360

$640

$1,728

$1,008

$576

$1,680

$960

$2,592

$1,512

$864

$2,100

$1,200

$3,240

$1,890

$1,080

$4,200

$2,450

$1,400

$3,780

$2,205

$1,260

$5,040

$2,940

$1,680

$4,536

$2,646

$1,512

Full page

1/4 page Horizontal

AD SIZES

COVER & PREMIUM PLACEMENT INSIDE FRONT COVER

$1,800 per page

TABLE OF CONTENTS PAGE

$1,800

CENTER SPREAD (1-2 PAGES)

$1,800 per page

INSIDE BACK COVER

$1,800

BACK COVER

$2,400

COVER TIP PER ISSUE * NOT FULL PAGE

$600 add on (must purchase additional interior pages)

7.375” wide x 9.833” high

FULL PAGE WITH BLEED

Image area: 7.875” wide x 10.375” wide Trim area: 8.375” wide x 10.875” high Bleed: 8.625” wide x 11.125” high

1/2 PAGE HORZ

7.375” wide x 4.833” high

1/2 PAGE VERT

3.604” wide x 9.833” high

1/4 PAGE HORZ

7.375” wide x 2.333” high

1/4 PAGE VERT

3.604” wide x 4.833” high

1/2 page horizontal

1/4 page Vertical

1/2 page Vertical

FILE SPECIFICATIONS

INSERT RATES FREQUENCY

FULL PAGE NO BLEED

2-PAGE

4-PAGE

8-PAGE

$1,920

$2,400

$4,800

$3,072

$3,840

$7,680

$4,608

$5,760

$11,520

$5,760

$7,200

$14,400

$6,720

$8,400

$16,800

$8,064

$10,080

$20,160

ABOUT HEALTHIER SLEEP MAGAZINE Healthier Sleep is published six times per year by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide.

• The preferred file format is PDF, set to Print Quality • All 4-color files must be in CMYK; Black and white files must be in grayscale • All files must be the correct size as listed above • Additional bleed is required for all bleed ads • All files submitted must be final artwork • Fonts and images must be embedded and/or converted to outlines • All files and images must be at least 300 dpi

CONTACT US For more information, visit Healthiersleepmag.com. For a custom quote, contact healthiersleep@worldsleepsociety.org.

DIGITAL ADVERTISING AVAILABLE Email healthiersleep@worldsleepsociety.org for details.

Finally, a complete telehealth solution for sleep apnea.

Built for doctors, easy for patients. Comprehensive Convenient Flexible care.

For more details visit

OGNOMY.COM

Right Now in Sleep Science Does sleep impact dementia risk? A new study suggests that sleeping less than 5 hours per night is associated with a two-fold greater risk for dementia when compared to sleeping 7-8 hours per night. Additionally, taking longer than 30 minutes to fall asleep most nights of the week is associated with a 45% greater risk for dementia. The study included survey data from 2,812 individuals with the average age being 76.9, 60% of respondents being female and 72% respondents identifying as white. Aging. 2021. 32 | May/June 2021

doi.org/10.18632/aging.202591

Ask the Sleep Doc As answered by our issue reviewers. Q: Any tips on making time for sleep in a busy life? Lourdes DelRosso, MD

Melissa C. Lipford, MD

Robert J. Thomas, MD

Rochelle Zak, MD

Dr. Thomas: The key is to consider good and adequate sleep as necessary for health, just like optimal food, exercise, relationships and so on. Time will have to be made. If sleep is considered a nuisance and somewhat optional, it will be so denigrated. Some examples of making best use of time are to read work material while on an exercise machine, minimize meetings and keep them short/targeted, make trade-offs for a shorter commute, work from home, and yes, take vacations and intermittent off-days to keep fresh. Dr. Lipford: It seems the busier we get, the more tempting it is to shift our bedtime later to get those extra things done. However, this strategy just doesn’t pay off. Staying up late and working when we are sleepy leads to inefficiency and making mistakes. By prioritizing adequate sleep, we can get more done in less time, our

performance and accuracy improve, and we are more prone to reflect the best version of ourselves in our work and home relationships. One of the best ways to prioritize sleep is to set a consistent bedtime and rise time. As bedtime approaches, that is your cue to stop working, put away the screens, and have a few moments of quiet time to relax. This will help you fall asleep faster and get better quality sleep. Waking up at the same time every day also helps to preserve good sleep patterns. Adults should aim for 7-8 hours of sleep nightly. Getting adequate sleep fills your tank so you are ready to attack the busy day ahead. Dr. DelRosso: Remember that sleep is important for mental, physical and emotional wellbeing. Some tips would be to engage your family in prioritizing sleep with Ask the Doc continued on page 34 33 | healthiersleepmag.com

Ask the Doc continued from 33 you. Take simple actions to protect your sleep (i.e. avoid caffeine in the late afternoon, evening), reassess the demands of new projects before you decide to accept them and avoid unnecessary activities that may steal sleep hours (such as late night movies). Dr. Zak: Making sleep a priority is a challenge in our 24-7 culture that has been exacerbated by the ability to interact anytime and anywhere. Thus, it takes creativity and discipline. To the extent possible, it is best to block out the time on your calendar—the same way you would as for a meeting—for the 1.5 to 2 hours prior to bedtime to be reserved for you to have a "wind down routine" just as we do for our children. I have not truly answered the question because I think there is no answer—we cannot both work and wind-down at the same time— but having awareness and thinking about ways to carve out the time to allow for a winddown period will help with sleep. Until we can create a 27hour day, I think we can only do the best we can.

Q: Are over-the-counter sleeping pills okay to take? Dr. DelRosso: I do not recommend to take over-the-counter (OTC) sleeping pills before checking with your doctor. I recommend taking a picture of the label of the product you are planning to take and bringing it to your doctor for discussion. There are a couple of concerning issues with OTC medications/supplements:

• They are not free from side effects or interactions with other medications • They can have unwanted substances (contaminants) • They can cause sedation during the day

34 | May/June 2021

Dr. Thomas: There are two types of OTC sleeping aids—one type based on antihistamines and the other on various combinations of melatonin and herbs with sedative components like valerian. OTC antihistamines are potent, long-acting and often block a neurochemical called acetylcholine, which is important for memory. Any effective sleeping aid is a potent drug and so, should only be used with care, occasionally, and not when driving the next day. If you find yourself reaching for an OTC sleeping aid frequently or continuously, a trip to see your physician is probably necessary. For jet-lag, a prescription sedative is better, as the duration of action is shorter, while antihistamines can keep you groggy for several hours after awakening. Dr. Zak: The question should be extended to over-the-counter substances globally, including herbal supplements. This is a complicated question that has no global answer. Just be aware that herbal supplements have properties similar to prescription medications (for example, St. John's Wort has properties similar to Prozac and valerian has properties similar to Ativan) and, therefore, taking OTC substances is akin to taking prescription medications. Therefore, it is important to discuss any and all of these with your clinician.

Q: How long should it take to fall asleep? Dr. Thomas: These days, that is not a simple answer, as a phone/ tablet are frequent bed companions, never mind the television. However, more than 30 minutes after shutdown of distractors can be considered abnormal; 60 minutes is definitely abnormal. It is important not to get into bed and try to sleep if feeling wide awake or

Ask the Doc continued from 34 after substantial late bright light exposure– a long time to fall asleep is virtually guaranteed in those instances. Dr. DelRosso: Usually 10-20 minutes, but up to half an hour is considered within the expected range. Dr. Zak: This is an individual question and the same amount of time may feel normal to one person and an eternity to another. We generally consider 20 minutes or so as normal, such that more than 30 minutes is generally considered long and less than 8 minutes is considered short. That stated, normal sleep latency is almost as much a function of how one feels as opposed to an absolute number. In fact, some patients who feel they have a long sleep latency (too much time to fall asleep) get relief by just by going to bed closer to their natural bedtime as that decreases time in bed awake even though there is no change in the clock time at which sleep occurs.

Dr. DelRosso: You should not endure insomnia. In fact, insomnia is diagnosed when sleep symptoms are present for at least three times a week and for a duration of at least three months. Many things can affect your sleep temporarily. Stress, diet, medications, pain or social situations can hinder our ability to fall asleep at a reasonable time for a few days. But if the problem persists and interferes with your activities during the day, you should let your doctor know.

HAVE A QUESTION FOR THE SLEEP DOCS? Submit your questions by email to healthiersleep@worldsleepsociety.org. Questions are selected based on space & applicability.

Q: How many nights of insomnia should I endure before calling my doctor? Dr. Thomas: Insomnia for more than two nights a week is worrisome. Progressive worsening of insomnia usually needs evaluation. Persistence of insomnia for several weeks after a transient trigger requires evaluation. Cycles of insomnia are also a red flag and could be an early feature of depression. Rare and intermittent insomnia that has a logical trigger (obvious stressors, travel, exams, etc.) is best tolerated, but if a person has high sleep reactivity to stress, a prescription sleeping aid can be a useful preemptive strategy used occasionally if behaviorial strategies fail.

35 | healthiersleepmag.com

HEALTHIER SLEEP MAGAZINE 3270 19th Street NW, Suite 109 Rochester, MN 55901 USA

SLEEP TRACKER If sleep concerns arise, it is advised to track sleep for at least 7-days to take with you to a physician. Do not forget to include specific dates in your sleep diary.

M Went to bed | Time: Fell asleep | Time: Awakened in the night | Time(s): Spent awake in the night | Time: Woke up | Time: Got out of bed | Time: Total estimated hours of sleep: Other Items to Note in your Tracker (Any caffeine, alcohol and food consumption with timing that may have affected the sleep; Medications; Emotional or stress state; Exercise, etc.)

Healthier Sleep Magazine May/June Sleep Disorders

Articles inside

When Breathing During Sleep Isn't Normal

The Case for Later School Start Times

Social Rejection & Sleep

Sleep in Space

Epilepsy & Sleep

Nightmares & Sleepwalking

Better Sleep, Better Immunity

What is “Regular” Sleep?

How You Spend Your Days Can Affect Your Nights

Sleep Disorders in Kids

Melatonin

How to Know if You Have a Sleep Disorder