Sleeping Well and Staying in Rhythm

Implications for Health and Performance

Hrayr Attarian MD

Introduction. Why we sleep?

How we sleep?

Rhythms

Hormones

Age changes

Age related illnesses

Why we sleep? Other than the fact that we get sleepy if we

don’t there is no conclusive data regarding the function of sleep.

Memory consolidation, learning, tissue repair are some of the suggested functions.

How We Sleep?

Circadian Rhythms

Terminology Non Rapid Eye Movement Sleep: 70-80% of the night

divided into N1 =drowsiness, N2 = light sleep and N3 =deep sleep.

Rapid Eye Movement Sleep: 20-30% of the night. Dream sleep. There is paralysis of all muscles except eyes and breathing muscles. There is poor body temperature control.

Sleep Efficiency: Time spent asleep over time spent in bed times 100. Reported as a %.

WASO = Wake after sleep onset. Time spent awake after initially falling asleep.

SL = sleep latency, time it takes from laying down and turning off lights to fall asleep

Arousal = 2-3 second change in brain waves to a lighter stage of sleep or more often to wakefulness. Too short for the sleeper to recognize it.

Arousal index =♯of arousals/hour of sleep

Ultradian Rhythms Cyclic alteration of wake, REM sleep and NREM

sleep during the sleep period

Three important hormones.

Growth hormone: helps children grow and helps adults and children utilize sugar better.

Three important hormones.

Interleukin 6: one of the hormones that increase inflammation to combat insults to the body

Three important hormones

Cortisol: is important in preparing the body to deal with stress.

Younger vs. Older

Changes in Sleep With Age

12 Ohayon et al Sleep 2004

Changes in Sleep With Age

13 Ohayon et al Sleep 2004WASO consistently increases by about 10 minutes per night per decade of age after age 30.

Changes in Sleep With Age

14 Ohayon et al Sleep 2004

Vertical axis shows min of sleep and horizontal axis age.Caution! This does not mean we need less sleep it means we are getting less sleep

Changes in Sleep With Age

15

Ohayon et al Sleep 2004Vertical axis time to fall asleep in minutes. Horizontal axis age of subjets

Changes in Sleep With Age

16

Ohayon et al Sleep 2004

Time in bed Sleep time at night Sleep efficiency

Sleep Efficiency

Bonnet and Arand JCSM 2006

Age Group Sleep Efficiency

18-30 95%

31-40 88%

41-50 85%

51-70 80%

Arousal Index (AI)Norms

Upper limit of AI in 18-30 years of age 11/hour.

In 31-50 years of age 14/hour In 51-70 years of age 20/hour Arousal increased with age because sleep

becomes more disrupted among other things by age related comorbidities i.e. arthritis, pain etc in addition to higher prevalence of sleep disorders such as periodic limb movements and sleep related breathing disorders

Bonnet and Arand JCSM 2006

Sleep Stage Changes

N3

N2

N1

Age and Sex N 1 N 2 N 3 R

Age M F M F M F M F

37-54 5.8% 4.6% 61.4% 58.5% 11.2% 14.2% 19.5% 20.9%

55-60 6.3% 5% 64.5% 56.2% 8.2% 17% 19.1% 20.2%

61-70 7.1% 5% 65.2% 57.3% 6.7% 16. 7% 18.4% 19.3%

>70 7.6% 4.9% 66.5% 57.1% 5.5% 17.2% 17.8% 18.8%

Redline et al Arch Intern Med. 2004

Hormonal Correlates

PM Cortisol = REM (2-3%)

Interleukin 6 = Sleep efficiency

Growth Hormone = N3 (deep, slow wave sleep)

Van Cauter et al JAMA 2000Printz et al Chronobiol Int 2000

Napping and Age. Napping increases with age past 70

Controversial as to whether napping impacts night time sleep

Vitelo Sleep Med Clin (2006)Yoon et al J Sleep Res (2003}

Circadian Rhythm Changes with Age

Advance of sleep wake cycle.

Decreased light sensitivity.

Decreased exposure to light due to yellowing of cornea and environmental changes.

Decreased melatonin levels.

Sleep Disturbances 50% have disrupted sleep

20-30% have undiagnosed sleep disorders

A number of sleep disorder associated problem have their start in mid-life.

Sleep Disorders with Age.

Vitelo Sleep Med Clin (2006)

Sleep Disordered Breathing.

Obstructive Sleep Apnea

Central Sleep Apnea (much less common)

Prevalence is 31% in over 65 year olds vs. 4% in younger age groups.

Treatment: Continuous Positive Airway Pressure (CPAP) or related devices.

High success rate compliance in >65 is 70% vs 50% in younger groups.

Obstructive Sleep Apnea.

The muscles of the soft palate at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether.

Unknown to the person, this results in heavy snoring, periods of not breathing, and frequent arousals..

Consequences of OSAS

Excessive Sleepiness due to poor sleep quality.

High Blood Pressure.

Heart disease.

Stroke.

Frequent bathroom visits at night.

Insomnia.

Sexual dysfunction

Memory problems

Depression

OSAS: Diagnosis Formal sleep studies (polysomnograms) are

mandatory in suspected cases The polysomnogram records brain waves, eye

movements, muscle activity, blood oxygen, limb movements, airflow, heart rate, body position, snoring sound and chest and abdominal movements during sleep, usually for the entire night.

Home studies may be recommended in some cases.

Insomnia

Ancoli-Israel Sleep Med (2009)

Insomnia Treatment depends on targeting underlying causes in

addition to specific insomnia related therapies.

Behavioral therapy is the best treatment option.

Medications are best avoided but if absolutely necessary the ones that are less risky include Lunesta® at 1-2 mg dose, Sonata® 5-10 mg dose, Rozerem® at 8 mg and Ambien® at 5 mg.

Doxepin and trazodone may also be helpful.

Antipsychotics, OTC medicines should be avoided

Melatonin role is controversial.

Advanced Sleep Phase

Early morning awakenings.

Long naps lead to less quality sleep at night which lead to daytime sleepiness and unintentional napping.

Difficulty staying awake in early evening may lead to further social isolation.

Treatment: bright light exposure in the early afternoon

Structured day

Irregular Sleep Phase Disorder

More common in those with dementia than healthy elderly.

Sleep occurs in 3-4 periods through out the day and leads to night time insomnia.

Treatment: bright light in the first half of the day and structured daytime activities.

Bright Light Either outside sunlight without sunglasses

on.

10,000 lux full spectrum light box

Blue Light box at 100% intensity.

Restless Legs Syndrome.

Very common in older people; 10% in >65 and 19%>80.

Diagnosis made by history in the clinic not with a sleep study.

Iron levels must be checked as low iron can lead to RLS and replacing it will solve the problem.

Medications are available for those who have normal iron levels.

Restless Legs Syndrome.

Symptoms:

An urge to move the legs, often accompanied by uncomfortable sensations in the legs. (The arms may also be affected, but that's much less common.)

The need to move the legs to relieve the discomfort. Moving usually offers some temporary relief of symptoms.

A definite worsening when lying down, especially when trying to fall asleep at night, or during other forms of inactivity.

A tendency to experience the most discomfort late in the day and at night.

May need to more napping and more disrupted sleep at night as RLS tends to be better in the early afternoon in most people.

Association with heart disease?

Periodic Limb Movement Disorder.

PLMD is the most common movement disorder in older persons, with a prevalence of 34%.

Brief movements of ankle or toe rarely the entire leg lead to disruption in sleep 15 or more times and hour.

Although there is considerable overlap with RLS, PLMD and RLS are not the same.

PLMD most often is secondary to medications, iron deficiency, sleep apnea, poor kidney function.

Rarely it occurs without a known cause.

Treatment should target the underlying problem first and meds should be used only if there is no underlying problem.

Finally Everything is interconnected.

Example 1: sleep is disturbed because of frequent bathroom visits which leads to poor sleep quality which leads to weight changes that can worsen sleep apnea which makes night time urination worse etc.

Example 2:Insomnia leads to depression which leads to antidepressants which make sleep poorer quality which in turn worsen depression etc.

Very important to have a comprehensive evaluation.

Questions.