Sleep Better — Get Smart about Your Smartphone

By Dr. David O. Volpi, M.D.

Smartphones, iPads, and other personal electronic devices are great ways to communicate and entertain ourselves, but they may also be negatively impacting the quality and quantity of our sleep.

As personal electronic devices have become more ubiquitous, the bright-light emitting screens that allow the use of mobile devices in dimly lit rooms have become a more common reason for sleep disruption, whether users realize it or not.

Why is that? Melatonin is a hormone produced by the pineal gland at night and when it is dark. It is a “timer” that tells the body that it is nighttime, and time to go to sleep. Exposure to light at night, such as that in the brightly-lit screens of many personal mobile devices, can interfere with melatonin, the hormone that helps control our sleep and wake cycles.

But rest easier: New research from the Mayo Clinic in Scottsdale, AZ explains a way to reduce the impact of electronic devises on sleep cycles.

Lois Krahn, M.D., a psychiatrist and sleep expert at the Mayo Clinic and co-author of the study said, “In the old days, people would go to bed and read a book. More commonly, people go to bed and they have their tablet on which they read a book or newspaper or look at material. The problem is it's a lit device, and how problematic is the light source from the mobile device?"

That question prompted Dr. Krahn to wonder, is the light from screens always a negative factor for sleep?" To find out, Krahn and his colleagues experimented with two tablets and a smartphone in a dark room, using a meter on its most sensitive setting to measure the light the devices emitted at various settings when held various distances from a person's face.

They discovered that when the brightness settings were lowered and the devices were held just over a foot from a user's face, it reduced the risk that the light would be bright enough to suppress melatonin secretion and disrupt sleep.

Explains Krahn, “We found that only at the highest setting was the light over a conservative threshold that might affect melatonin levels. If it's at the mid setting or at a low setting, it's bright enough to use."

The new Mayo Clinic research, which was presented in June at SLEEP 2013, the 27th annual meeting of the Associated Professional Sleep Societies LLC, in Baltimore, Md., also suggests things you can do to help prevent screen light from interfering with melatonin and affecting sleep.

These tips include dimming the smartphone or tablet brightness settings and holding the device at least 14 inches from your face while using it.

Other general tips include moving the TV and computer out of the bedroom, or at the very least, do not watch TV or work on the computer to bedtime.

With so many electronic distractions in our lives, it's important to re-claim the bedroom for its intended purpose: rest, relaxation, and sleep.

Untreated Sleep Apnea: The Quiet Danger on the Road

By Dr. David O. Volpi

It is common knowledge that untreated sleep apnea can have dire health effects, but researchers in England found out that loss of sleep also increases a person’s risk of nodding asleep at the wheel, and getting in a car accident. That endangers not only the person suffering from the sleep disorder, but any person driving around them at any given time.

The study, which was organized by the European Respiratory Society and the European Sleep Research Society, and presented April 12, 2013 at the Sleep and Breathing Conference in Berlin, determined that people with untreated sleep apnea are more likely to fail a driving simulator test, and report nodding asleep while driving.

Let’s review: What is sleep apnea?

Sleep apnea is a breathing disorder that causes a person’s breathing during sleep to be paused and/or shallow. The pauses generally last 10 to 20 seconds, and in severe cases, can occur hundreds of times a night. With obstructive sleep apnea (OSA), the airway is blocked and/or collapses while sleeping. Air squeezing by the blockage can cause loud snoring and interrupted sleep.

As a result of the paused breathing and/or snoring, many sleep apnea sufferers are woken up throughout the night and spend more time in light sleep, rather than deep, restful REM (rapid eye movement) sleep. This chronic sleep deprivation results in daytime sleepiness, and can negatively affect job performance, mood, reflexes, concentration, and it can lead to hypertension, heart disease, and memory problems.

Testing and results of the study

To determine the effect of untreated sleep apnea on driving, the researchers conducted two separate studies. The first was a driving simulation test where 133 patients with untreated sleep apnea and 89 without sleep apnea were asked to “drive” 90 km—about 55 miles.

Various criteria was recorded, including the participants’ ability to complete the driving distance, their time spent in the middle lane, and any participation in an unprovoked crash or a “veer event” crash.

The results of the driving simulation test showed that:

• Patients with untreated sleep apnea were more likely to fail the driving simulation test—24 percent of the sleep apnea patients failed the test, compared to 12 percent of those without sleep apnea.
• In addition, many patients with untreated sleep apnea were unable to complete the test at all, had more unprovoked crashes, and were unable to follow the clear driving instructions given at the beginning of the simulation test.

In the second study, 118 people with untreated sleep apnea and 69 without sleep apnea completed a questionnaire about their driving behavior, and also took the 90 driving test on the simulator.
The results showed that:

• 35 percent of those with untreated sleep apnea admitted to nodding asleep while at the wheel, and 38 percent of this same group failed the driving simulation test.
• By comparison, only 11 percent of people without sleep apnea said they have nodded off while driving, and none of this group failed the simulator test.

Key differences in the reasons for failure

While some people in the control group (those without sleep apnea) also failed the driving simulator test, the researchers noted key differences in why they failed the test:

• 13 people with untreated sleep apnea did not finish the test because they fell asleep or veered completely off the road.
• 5 people with untreated sleep apnea failed because they spent more than 5 percent of the study outside the lane they had been instructed to stay in.

But in the control group, no one failed the simulation for either of these reasons. Again, no one in the “without sleep apnea” group failed the driving simulation due to falling asleep, veering completely off the road, or driving outside the lane.

Dan Smyth of Sleep Apnea Europe noted, "The dangers of untreated sleep apnea and driving are highlighted in both studies. These studies give weight to the need for provision of sufficient resources for early diagnosis and treatment.

While further investigation is needed to examine the reasons for failure of the simulator tests, I acknowledge the researchers for bringing light to this very dangerous side effect of untreated sleep apnea. of sleep apnea, where effective treatment ensures a return to acceptable risk levels for road users."

Are you at risk for sleep apnea?

So how do you know you may have obstructive sleep apnea? Some common symptoms include snoring, paused breathing during sleep and excessive sleepiness during the day. Increased blood pressure is another sign you may have sleep apnea.

While sleep apnea is more common in men, OSA increases in women after age 50. Being overweight may also increase a woman’s risk of having sleep apnea. Menopausal women are three and a half times more likely to get OSA, possible due to reduced amounts of progesterone.

If you experiencing one or more of the above sleep apnea symptoms on a regular basis, see a qualified sleep doctor to get diagnosed and treated properly. There are multiple options and minimally invasive techniques available today to treat your sleep disorder.

Sleep apnea causes systemic inflammation: CPAP can help

By Dr. David O. Volpi

If you, or someone you know, have been diagnosed with obstructive sleep apnea (OSA), you’re probably familiar with a treatment called CPAP, or Continuous Positive Airway Pressure.

While some people find the mask worn for CPAP treatment uncomfortable—more on that later—it has been proven to be a highly effective way to keep the airways open that become obstructed in sleep apnea patients, and reduce or prevent snoring and paused breathing.

There’s a new study that found that CPAP treatment also reduces the systemic inflammation caused by sleep apnea, usually in the bronchial and nasal passages.

Systemic inflammation is the chronic biological response, or inflammation, of blood vessel tissues due to dangerous or foreign elements, such as pathogens or damaged cells. It is increasingly being recognized that systemic inflammation is a risk factor for a number of health complications, including atherosclerosis, and is a well-established factor in the development of cardiovascular disease.

The new study published March 22 in the Journal of Inflammation found that treating OSA with a CPAP machine helps to lower systemic inflammation, which might prevent some of the other problems associated with OSA. The source of the research was the PubMed, Embase and Cochrane library.

Here’s a refresher on how CPAP machines help OSA patients: When you fall asleep, your muscles relax, and the soft palate at the back of the throat may sag. When this happens, the upper airway can become obstructed, causing the soft palate and uvula to vibrate, causing snoring.

When the airway is completely obstructed, breathing stops for a period of time, until the body is jerked awake in reaction. This is known as obstructive sleep apnea. OSA can cause interrupted breathing hundreds of times a night, usually around 20 seconds per pause. This paused breathing causes waking through the night, preventing deep, restorative sleep. This often leads to a host of problems, from daytime sleepiness and reduced job performance to hypertension, heart disease, mood, and memory problems.

A CPAP machine helps this condition by pumping a continuous flow of air into the nasal passages—via a mask worn at night—keeping the airway open—and preventing or greatly reducing snoring and paused breathing.

To find out if CPAP treatment reduces inflammatory symptoms or “markers” in OSA patients, the researchers pooled data from 24 trials involving more than 1,000 patients. The resulting data suggested that treating OSA with CPAP significantly reduces levels of two proteins associated with systemic inflammation: tumor necrosis factor and C-reactive protein (CRP).

While more study is needed, the researchers believe that reducing systemic inflammation in OSA patients with CPAP treatment may be one way to reverse some of the long-term health disorders associated with OSA.

If you or someone you know is considering Continuous Positive Airway Pressure (CPAP) treatment, you'll need a sleep study to diagnosis whether or not you have sleep apnea, and a sleep specialist will recommend the correct CPAP machine, or treatment, for you.

Sleep Improves Children’s Ability to Absorb Information and Learn

By Matthew D. Mingrone, M.D. of eOs Sleep

It has been common scientific knowledge for some time that when people sleep, our brains consolidate the information we subconsciously absorb during the day, and process it into explicit, conscious knowledge.

Both children and adults do this, but an interesting new study out of Germany shows that during sleep, children's brains convert subconsciously absorbed information—known as implicit learning—into active, useful knowledge even more effectively than adult brains do.
Implicit learning is typically considered subconscious learning; the acquisition of knowledge independent of conscious attempts to learn. For example, a child can say a sentence without understanding the rules of English grammar.

Explicit learning, on the other hand, is deliberate, conscious learning; the active and aware acquisition of skills and/or knowledge. Typically, explicit learning is accompanied by “meta-awareness,” a person can explain how they acquired the skill and/or knowledge.
When we sleep, implicit knowledge becomes explicit memory, making it easier for us to recall and use the information we have previously absorbed.

In a new study conducted by Dr. Ines Wilhelm of the University of Tübingen's Institute for Medical Psychology and Behavioral Neurobiology in Germany, and colleagues, the researchers studied 35 children between the ages of 8 and 11 years old, as well as 37 adults between 18 and 35.

For the test, the subjects were asked to press a sequence of buttons after they lit up. Half of the subjects did the test before sleep, the other half after sleep. They were then asked to recall the sequence of buttons/lights 10 to 12 hours later. Following a night of sleep or a day awake, the subjects’ memories were tested.

An article explaining the results of the study, entitled, “The sleeping child outplays the adult's capacity to convert implicit into explicit knowledge,” is published in the February 24, 2013 online edition of Nature Neuroscience.

The authors observed that after a night’s sleep, both age groups—8 to 11 and 18 to 35—remembered a larger sequence of buttons/lights than those who did not sleep. It also showed the children were better at it than the adults—almost all of the children could remember the sequence they had pressed perfectly, while adults experienced smaller gains.

Lead author Dr. Ines Wilhelm wrote, “In children, much more efficient explicit knowledge is generated during sleep from a previously learned implicit task. And the children’s extraordinary ability is linked with the large amount of deep sleep they get at night. The formation of explicit knowledge appears to be a very specific ability of childhood sleep, since children typically benefit as much or less than adults from sleep when it comes to other types of memory tasks.”

Children absorb massive amounts of information every day. They also generally sleep longer and deeper, and experience three times more slow-wave sleep and higher electrical activity in the brain during sleep than adults. This may help them “convert” the information they take in every day into knowledge they can recall and use. This is yet another important reason why parents should ensure their children are getting enough uninterrupted sleep every night.

A Good Night’s Sleep Can Be a Matter of Life and Death

Over the past three years, I have been writing the Wake Up! You’re Snoring blog with two main objectives: first, to educate you, the public, about sleep disorders, and second, to provide compelling reasons—preferably scientific evidence—why a person who may have a sleep disorder should get diagnosed and, if necessary, properly treated.

There is no shortage of scientific studies being released on a regular basis showing links between obstructive sleep apnea (OSA), insomnia, and other sleep disorders, and myriad negative health conditions, from daytime sleepiness to increased depression.

I wasn’t surprised to see a new study showing a link between insomnia, the loss of hope, and an increased risk of suicide. In a study led by Dr. W. Vaughn McCall, chair of the Medical College of Georgia at Georgia Regents University, researchers studied the mental state of 50 depressed patients between the ages of 20 and 80. More than half of the patients had attempted suicide, and most were taking an antidepressant.

It is established that insomnia and nightmares often go hand-in-hand, and are both known risk factors for suicide. The new study reaffirms that link, but researchers also wanted to find out what effect feelings of hopelessness about sleep had on suicide risk.

In the study, the researchers specifically focused on the relationship between insomnia and suicide risk by asking questions about dysfunctional beliefs about sleep, such as, “Do you think you will ever sleep again?” The scientists used psychometric testing to objectively measure the mental states and personalities of the 50 depressed patients.

Dr. McCall published the results of the study in the Journal of Clinical Sleep Medicine, the journal of the American Academy of Sleep Medicine. In the report, Dr. McCall stated, “It turns out insomnia can lead to a very specific type of hopelessness, and hopelessness by itself is a powerful predictor of suicide.” Dr. McCall also said, “The likelihood of being suicidal at least doubles when insomnia is a symptom.”

McCall and his colleagues have, in effect, discovered a new predictor for suicidal thinking. But why the link between lack of sleep and suicidal thoughts? Dr. McCall explained that, “It turns out insomnia can lead to a very specific type of hopelessness, and hopelessness by itself is a powerful predictor of suicide.” He continued, “If you talk with depressed people, they really feel like they have failed at so many things. It goes something like, ‘My marriage is a mess, I hate my job, I can’t communicate with my kids, I can’t even sleep.’ There is a sense of failure and hopelessness that now runs from top to bottom, and (insomnia) is one more thing. It was this dysfunctional thinking — all these negative thoughts about sleep — that was the mediating factor that explained why insomnia was linked to suicide,” said McCall.

The significance of this study, like many others, is that it not only educates people about the risks associated with insomnia and other sleep disorders, but it challenges the medical community to look at things a little differently when diagnosing and treating.

In this case, examine lack of sleep and insomnia when treating depression and suicidal thinking.  The finding also is a reminder to physicians that depressed patients who report increased sleep problems should be asked if they are having suicidal thoughts, McCall said.

If you’re having trouble sleeping, here are some tips to increase your chances of getting a good night’s sleep.

• Use the bedroom for sleep. With so many electronic distractions in our lives, it’s important to re-claim your bedroom for its intended purpose: rest and sleep. Move the TV and computer out of the bedroom, or at the very least, do not watch TV, work on the computer or check your blackberry close to bedtime.
• Stick to a bedtime routine. Try to go to sleep before 10:00 pm at night, and wake up around the same time every day, even on weekends. Try to keep to within 20 minutes of the same time each morning and night.
• Do activities that will get you ready for bed. Before bed, do activities that will promote sleepiness, such as a taking a warm bath, or reading a book or magazine.
• Maintain a cool temperature in your bedroom. A cool but comfortable temperature is ideal for sleep. Too warm and you will be fitful, too cold however can be uncomfortable and disturb your sleep.
• Exercise regularly but not after the late afternoon. Even though exercise helps regulate sleep, rigorous exercise causes endorphins in the body to circulate which can have a stimulant effect, and keep you awake longer at night.
• Stay away from caffeine at night. The effects of caffeine are different from person to person, and may last hours after your last cup of coffee, so make your last cup of coffee, regular tea or soda earlier in the day.
• Avoid alcohol and medicines that make you drowsy. Even if you think it is helping you fall asleep initially, alcohol and medicines that makes you drowsy may affect your sleep throughout the night.

Remember, people need an average of 7-8 hours of restful sleep to fully take advantage of its restorative power and avoid daytime symptoms of fatigue. If a regular, peaceful routine incorporating the tips above doesn’t help you start sleeping peacefully throughout the night, contact your doctor. You may have a more serious cause of sleeplessness such as snoring, sleep apnea or chronic insomnia. Getting treated could prevent heart disease, hypertension and stroke.

Snoring a Top Predictor of Heart Attacks and Strokes

By Dr. David O. Volpi

I read a study recently that I immediately knew I had to make you aware of.

Researchers at Henry Ford Hospital in Detroit found that snoring is a bigger risk factor for heart disease, including stroke and heart attacks, than being overweight, having high cholesterol, and even smoking! Yes, you read that right—snoring is an even bigger risk factor for heart disease.

The study, which was submitted to The Laryngoscope journal, is the first of its kind to show a link between snoring and heart disease, similar to other risk factors, such as sleep apnea, obesity, smoking and high cholesterol are also linked to heart disease.

Snorers showed arterial damage

For the study, Dr. Robert Deeb, MD, and senior study author Karen Yaremchuk, MD, reviewed the data of 913 patients, all between the ages of 18 and 40, who had been evaluated by the Henry Ford sleep center between December 2006 and January 2012.

The researchers noticed that the carotid arteries—the arteries that supply oxygen-rich blood to the brain—had thickened among the snorers, indicating that arterial damage had occurred due to snoring.

The researchers hypothesized that the thickening of the artery walls could have been due to the trauma and inflammation caused by snoring. But previous research on sleep apnea and artery disease has found the opposite: arterial damage comes first, reducing the oxygen level in the blood, leading to interruptions in breathing. The thickening of the arteries may also be contributing to the snoring in the patients.

Even more interesting: The snorers’ arterial walls had thickened, even though none of the patients had been diagnosed with obstructive sleep apnea (OSA). While OSA often develops from snoring and has been known as an indicator of cardiovascular disease, there’s been little evidence until now to prove that arterial damage can actually begin with snoring.

What these results mean

So what are the medical implications of the Henry Ford study? Let’s review coronary artery disease for a moment. Coronary artery disease (CAD), also known as atherosclerosis, occurs when waxy plaque builds up on the inner walls of the arteries.

Over time, the arterial walls thicken and stiffen, restricting blood flow to the heart and/or brain. It is commonly know that CAD is a precursor to conditions such as heart attack, stroke, and heart failure.

The results of the Henry Ford study—that the carotid arteries had thickened among the snorers, is important to pay attention to because it means that snoring, not just OSA, is a high risk factor for coronary artery disease, heart disease, and other related conditions.

Drs. Deeb and Yaremchuk’s research is groundbreaking because arterial blockage and other forms of heart disease are usually detected only after significant permanent damage has been done.

This new research should encourage snorers—and those who love them—to visit a doctor to discuss cardiovascular health and stroke prevention, and get properly diagnosed and treated.

The research is clear that doctors should add snoring to the list of coronary artery disease risk factors, along with high blood pressure, high cholesterol, diabetes, smoking and family history. Perhaps if patients and their doctors considered snoring a serious health threat and treated it accordingly, there would be a great reduction in heart disease.

Women with Sleep Apnea Show Higher Brain Damage, Anxiety than Men

An estimated 18 million Americans have obstructive sleep apnea (OSA), including one in four women over 65, according to the National Sleep Foundation.

And several recent studies have linked OSA to health disorders specifically in women. Sleep apnea has been linked to dementia in older women,  and another observational study found that women with untreated severe OSA are 3.5 times more likely to die from cardiovascular disease than women without OSA.

Here’s another reason for women to take sleep apnea seriously: A first-of-its-kind study out of the UCLA School of Nursing discovered that women with sleep apnea are more likely to suffer a higher degree of brain damage than men with sleep apnea.

What is obstructive sleep apnea? OSA is a disorder that occurs when a person's breathing is repeatedly interrupted during sleep, sometimes hundreds of times a night. During each obstruction, the oxygen level in the blood drops, which over time, causes myriad health problems. For people with sleep apnea, the combination of disturbed sleep and oxygen starvation may lead to hypertension, heart disease and mood and memory problems, among other disorders.

The new UCLA study

UCLA has been on the cutting edge of sleep apnea research. About 10 years ago, the same UCLA research team that conducted the new study was the first to show that men with OSA have damage to their brain cells.

For the latest multi-year study, entitled "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea,” the researchers studied patients diagnosed with OSA at the UCLA Sleep Laboratory. They compared the nerve fibers in the patients' brains, known as “white matter,” to the nerve fibers of people without OSA or other sleep problems. The goal was to find the differences in brain damage, if any, between men and women with OSA.

Results of the study

The researchers found that women are actually more affected by sleep apnea than men. Additionally, women with OSA have more severe brain damage than men suffering from a similar condition. The women with sleep apnea also showed higher levels of depression and anxiety symptoms.

Specifically, the study found that women were impacted in the cingulum bundle and the anterior cingulate cortex areas in the front of the brain involved in decision-making and mood regulation.

Based on the results, chief investigator Paul Macey said, “Doctors should consider that OSA in women may be more problematic and therefore need earlier treatment in women than men.”

With the results of this study as a foundation, the next step is for the researchers to find out if treating sleep apnea can help the brain.

In a “chicken or egg” scenario, did the OSA cause the brain damage, or did the brain damage cause the OSA?  Or did the common conditions, such as depression, dementia or cardiovascular issues cause the brain damage, which in turn leads to sleep apnea?

The study and resulting questions are fascinating, and one thing is for sure: both men and women who are having trouble sleeping should get checked for obstructive sleep apnea and other sleep disorders.

Researchers estimate that up to 85 percent of people with severe sleep apnea have not been diagnosed yet.

Many times, sleep apnea can be misdiagnosed as chronic fatigue, insomnia, depression, or some other non-specific condition, so be specific about the symptoms you are experiencing.

Don't wait to get checked—it could save your life, or someone you love.

For more information, read the article, “Women with sleep apnea have higher degree of brain damage than men, UCLA study shows.”