Sleep Smart: How Sleep Impacts Your Health

Episode Transcript

Dr. Daniel Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa. This is The Brain & Life podcast.
We mentioned before that we're going to be talking some more about sleep with Dr. Jennifer Molano. I wanted to touch on a few of the things that we all might be encountering right now that I work on in terms of my own sleep schedule. If you're having a tough time falling asleep, it's better to sit up, do something outside of bed. Maybe read a magazine, not with a screen for a few minutes and do a little walk around and then try lying back down and settling back into bed. Another thing that may help is a breathing and relaxation exercise, so stay tuned to the end. After our discussion with Dr. Jennifer Molano, we wanted also to offer you an example of a breathing and relaxation exercise that I have found helpful and in our upcoming weeks. Make sure that you have subscribed so you don't miss our discussion with John Stein, a jazz musician who lives with myasthenia gravis.
And we'll also be talking with John Hendrickson, a journalist and writer who talks about his own experience with stuttering or childhood onset fluency disorder. Make sure that you subscribe and if you have 90 seconds now or at another time, make sure to get to Spotify or Apple and leave us a review that will really help other people find the podcast and share it with your friends.
Welcome back to the Brain & Life podcast. This week I'm really excited to have one of our fellow members of the Brain & Life editorial board, Dr. Jennifer Molano. So she's associate professor of neurology and a specialist in sleep neurology at University of Cincinnati, and I'm excited to have her here so that we can talk a little bit more in detail about our health and sleep, and brain health. We started that discussion initially with a discussion between Audrey and I about the importance of sleep, but I'm glad to have the specialist here with us today. Jen, thank you so much for joining us.

Dr. Jennifer Molano:
Thank you so much for having me. It's a pleasure.

Dr. Daniel Correa:
We highlighted some of the recommendations that have been out there about sleep, but when you're explaining to your patients, but also even just to your family members, what is the ideal sleep recommendations for all of us?

Dr. Jennifer Molano:
I think in terms of sleep duration, what I tell people is I base it off of the National Sleep Foundation recommendations. So for adults between the ages of 18 and 65, seven to nine hours of sleep is considered to be normal or recommended, and then for those over the age of 65, seven to eight hours of sleep is what's recommended for folks. And I tell people that in order to feel well rested and ready for the day and able to do what you are intending to do during the waking hours, ideally we want an adequate duration of sleep. So again, that seven to nine hours of sleep or seven to eight hours of sleep depending on your age range and also good quality of sleep as well. So the combination of the two is very important for us to feel well rested when we wake up in the morning.

Dr. Daniel Correa:
You were talking about age ranges, but we seem to leave off the little kiddos. So how are the sleep recommendations different for kids and other younger age groups than for adults?

Dr. Jennifer Molano:
As we are younger, we need more sleep, and so that tends to decrease when we're adults where that seven to nine hours of sleep tends to happen. The National Sleep Foundation has recommendations for infants, for toddlers, for school-aged kids as well, and so looking at those resources can be helpful

Dr. Daniel Correa:
For our listeners we'll include a link to the National Sleep Foundation's website also in the show notes, so make sure to check that out. But Jen, we all know someone who says they're a short sleeper, they're fine sleeping five hours. How do we really know, I mean you talked about ranges of seven to nine or seven to eight. How do we know if we're a seven-hour sleeper or a nine-hour sleeper or if we're okay with six?

Dr. Jennifer Molano:
Well, I think a lot of it depends on how you feel during the day and throughout the day. So some people do say that I only need about five to six hours of sleep. I think some celebrities say that they're definitely short sleepers and there are some people who have a more genetic predisposition to being a short sleeper, but at the same time, I think the one thing to determine that is how you feel. So if you feel like you are able to stay awake and be proactive and doing the things that you want to do and function during the day up until the time you're about to go to sleep, then you may be getting an adequate amount of sleep. I think part of the thing to also consider is that it's the consistency of sleep as well.
A lot of times people say, well, I get on average about seven hours of sleep, but then when we have them track their data, they may be getting five hours of sleep on one night, nine hours of sleep the next night, and then the challenge is that the brain likes consistency and so I think it's the consistent piece of it that's important. So if someone's getting six hours of sleep consistently, they're feeling like they're really refreshed throughout the day and able to do their work, then they just may need six hours of sleep. But for the most part, the vast majority of folks will need that seven to nine hours of sleep.

Dr. Daniel Correa:
And this is in the morning feeling refreshed and ready to work before caffeine and any of these other stimulants. Or is it okay to feel tired starting off your day and have a difficult start but better after caffeine?

Dr. Jennifer Molano:
It's a very interesting thing. So how it works from a more physiologic perspective is again, assuming that you have an adequate amount of sleep and adequate quality of sleep the night before. You wake up in the morning and then you have our homeostatic sleep drive or that drive to go to sleep is lowest when we first wake up in the morning. And so when you are working throughout the day, that sleep drive builds up and builds up and builds up and builds up until our internal body clock tells us to go to sleep at night. Caffeine directly weakens that signal to go to sleep at night. So there's a direct effect with caffeine and that homeostatic sleep drive. So if you're waking up in the morning and you're feeling tired and sluggish and you feel like you need that burst of caffeine to kind of get you going, it may indicate that you probably didn't get as much sleep the night before as you need.

Dr. Daniel Correa:
Now we've been talking about these numbers or hours as if when you go into your bedroom or lie down in your bed, you fall right asleep and then you wake up and hop out. You're like, "What about that reality of the time it takes to fall asleep or to wake up?" How do we actually estimate for ourselves what is our sleep time without having a big device on us?

Dr. Jennifer Molano:
I think it's an estimate. A lot of times when patients come in to see me sometimes they say, well, it's hard for me to determine how long it takes for me to fall asleep. Ideally, I think if you can fall asleep within 30 minutes, then you're able to fall asleep pretty well and when you wake up in the morning, we tend to recommend actually getting out of bed at that time. That gives you a better sense of how much time you're actually sleeping in bed. So a lot of times what we see is that people are going into bed, they might be looking at their devices or watching TV or reading. In that case, it's challenging to estimate how long it's actually taking them to fall asleep. So in an ideal world, I think in terms of that consistency, one of the reasons that we recommend keeping the bedroom for sleep only is this idea that the brain likes to know what it's supposed to do at specific times.
And so especially if people are having problems falling asleep or staying asleep, I tell people, if you're staying in bed for a prolonged period of time, you are actually training your brain that that's okay. It becomes a learned behavior and then it can actually contribute to issues falling asleep and staying asleep. So I think if we're looking at what we like to call sleep efficiency, that's basically talking about the total amount of sleep divided by the total time in bed. We want that to be at least 85% or higher. So trying, again, emphasizing the fact that the bedroom tends to be more for sleep only. And if you're doing that, then I think it's easier to estimate how long it's taking you to fall asleep and how long it's taking you to wake up in the morning.

Dr. Daniel Correa:
For many people it might not just be simply as getting into a pattern of good sleep. There may be other medical issues or neurologic issues that may be affecting their sleep patterns. What are some of the most common sleep disorders and conditions that people may have and should discuss if they're having any of these symptoms with their primary care doctor or another specialist?

Dr. Jennifer Molano:
I think one of the main things that we see that can interfere with sleep is pain. A lot of times people can have arthritis or they've had previous hip surgery or something like that, that may hinder them from sleeping at night just due to the discomfort. Some people too have said that they may have headaches and things like that that may contribute to having issues staying asleep. One of the common medical conditions that can occur during sleep is asthma. So asthma tends to be a little bit more prominent when someone is sleeping at night as well.
So certainly we know that medical conditions may contribute to sleep issues. On the other hand, I think sometimes what I've heard with some folks in the clinic is that if they're having a headache as an example during the day, what they do to try and escape the pain is they sleep during the day to try and escape that pain. And the downstream effect of that or the night-stream effect of that is the fact that if they're sleeping during the day, they're stealing from their sleep at night. And so it makes it more challenging for them to sleep at night, which then makes it more challenging for them to deal with the pain during the day and puts people in a vicious cycle.

Dr. Daniel Correa:
Generally in those more common situations, whether it's asthma or pain issues affecting someone's sleep onset and their sleep overall. What do you usually recommend to people to try and manage those symptoms as they're getting ready or going to sleep?

Dr. Jennifer Molano:
I tend to focus more on the non-medication approaches as much as possible, and one of my go-to techniques is the deep breathing exercise. Trying to take a deep breath in, take a deep breath out and really try to think of it as trying to release some of the anxiety and the pain that might be contributing to that. I think for some people, if they're anxious about it, what they're dealing with, and that might be a contributing factor as well. Sometimes journaling, writing down those thoughts and then trying to let go of those thoughts in written form can be helpful as well. The other piece of it too is that I know here at the University of Cincinnati we have a chronic pain group that they emphasize some of those other strategies as well. Mindfulness meditation as another example can be helpful.

Dr. Daniel Correa:
Recently I myself was diagnosed with mild sleep apnea. So can you explain for our listeners what is sleep apnea? The different types?

Dr. Jennifer Molano:
Sleep apnea tends to be associated when you've had either a decrease of your breathing or a stoppage of your breathing when you're sleeping at night, and it tends to occur multiple times throughout the night so that people can feel sleepy during the day or they might have headaches or they might even have issues with their memory and their thinking as well. There are two main types of sleep apnea. The first type is the obstructive sleep apnea where there's an actual blockage of the airway. As a result of that, your oxygen levels may drop and it can cause disruption in your sleep. There's another type of sleep apnea called central sleep apnea where what happens is that unlike an obstructive apnea where your airways close up and your chest and your belly are trying to compensate for that obstruction. Someone with central sleep apnea may stop breathing or have a decrease of their breathing, but their chest and their belly may not try to compensate for that and that central sleep apnea may be due to heart issues.
Sometimes it can be due to neurological conditions, especially if there's something affecting the brainstem, the back of the base of the brain, which houses our breathing apparatus so to speak, or helps to control our breathing apparatus and sometimes it could be due to medications like opioids or narcotics. So those are some of the things that we see how we classify mild, moderate, or severe sleep apnea. The degree of sleep apnea basically is associated with the number of abnormal breathing events per hour. So if you have a sleep study and you were diagnosed with mild sleep apnea, that tends to be due to having five to 15 abnormal breathing events per hour. Moderate is 15 to 30 events per hour, and then severe sleep apnea is greater than 30 abnormal breathing events per hour.

Dr. Daniel Correa:
What are typical symptoms that someone themself might notice or someone maybe in their family or in their household may notice about their breathing or the way their breathing or waking up in the morning that might give them a clue towards having sleep apnea? It probably won't help them figure out obstructive versus central, but at least giving them the clue that this is something to discuss more with their doctor.

Dr. Jennifer Molano:
Absolutely. So I think snoring is one of the most common things that we hear about and a lot of times I have folks who come in. And I said, "Why are you coming in today? How can I help you?" And they said, "Well, I eventually want to get back to sleeping in the same bedroom as my spouse because their snoring is so loud." So that's one of them. Having headaches in the morning or waking up with headaches in the morning may be a factor. In addition to that, people may be sleepy during the day as well where they're able to stay alert when they're actively doing something, but then if they have that opportunity to just relax or if they're reading or in a movie theater or something like that, they tend to be a little bit more sleepy. Sometimes even people come in and they say, "Well, I'm just waking up multiple times throughout the night." So we know that sleep apnea can be a contributing factor to waking up to urinate multiple times throughout the night as an example. So those are some of the things that we tend to look for.

Dr. Daniel Correa:
Why is it important to actually start working on it other than just sleeping better? Is there a general understanding if you can explain for the impact of sleep or this disordered sleeping on other medical conditions in our overall health?

Dr. Jennifer Molano:
I think one of the things that we tell people is that it can increase the risk for strokes and heart disease. If you have untreated sleep apnea, it may contribute to high blood pressure. So as an example, if someone is more of a normal sleeper. What happens during normal sleep is that our blood pressure tends to dip a little bit just as a part of the normal rejuvenation process of the body. And so if someone has obstructive sleep apnea, the body's ability to have a decrease of that blood pressure is dampened. They're at a higher risk for having high blood pressure. In addition to that, studies have shown that sleep apnea may affect memory and thinking. So you may not be able to make decisions as quickly or may not be able to multitask or may even have difficulty paying attention to things. So that has lots of different consequences if you have untreated sleep apnea.

Dr. Daniel Correa:
I know in my clinical practice and seeing patients both in the hospital, both with our epilepsy program and stroke patients. Sometimes we have people who have poorly controlled epilepsy, but it seems like everything else is where it should be and sometimes we will screen them with questions and then maybe even send them to the sleep clinic to see if maybe they're having sleep apnea or another disordered sleeping pattern that might be contributing to increased seizures or poorly controlled seizures. And we often try to get at least some screening done for people if they have an early morning or a wake-up stroke because we're concerned that the sleep apnea may be contributing to their risk factors.

Dr. Jennifer Molano:
Absolutely, and there definitely has been an association with sleep apnea and people with epilepsy and those who are having difficulty with their seizure control even despite multiple medications. So I'm glad to hear that you are all screening for that in your clinic as well.

Dr. Daniel Correa:
I mean, you mentioned before some of the non-medication approaches to managing our sleep and improving sleep, but when there are medicines or devices or procedures needed, how do you know and what are some of the different things that are used in the management of sleep conditions?

Dr. Jennifer Molano:
There are FDA approved medications to help with sleep, and it tends to be more for short-term use only in an ideal setting as much as possible and trying to introduce more of the non-medication strategies if you can. So I know that I think in terms of gold standard treatment, the cognitive behavioral techniques for insomnia tends to be what's recommended. So cognitive meaning trying to identify the thoughts that might be contributing to your sleep issues and trying to reframe them the behavior. So making sure that you're not drinking caffeine after two o'clock in the afternoon as an example, or not staying in bed for a prolonged period of time if you're having difficulty falling asleep. So that can be helpful. In some cases, medications can be helpful, and so talking with your physician about that and seeing what might be appropriate is important. Now in terms of supplements, because one of the questions that I often get is about melatonin as an example.
I think the challenge with melatonin and just supplements in general is that it's not as regulated compared to medications that have been FDA approved. There was one study that came up recently and they looked at melatonin supplements and compared the amount of melatonin that was actually in the supplement compared to what was actually on the label, and the variation ranged from 74% to 347% of the labeled quantities. In terms of other devices and things like that. Well, CPAP or Continuous Positive Airway Pressure, that's something that can be appropriate for sleep apnea, and there's a lot of different technologies that are out and being researched in terms of being studied right now that might help with other sleep conditions down the road. And I think definitely this is where you talk to your physician to see what might be appropriate for you.

Dr. Daniel Correa:
And if there were three steps that you would really recommend people start working on in terms of their own behavior change, just for all of us to start getting better sleep in addition to that tracking. Where should we start so we can start building a more consistent and long-lasting good sleep hygiene.

Dr. Jennifer Molano:
I think the other one piece of it is trying to anchor your sleep-wake cycle, so having number one, a consistent wake-up time. And then going back in terms of when you should actually go to bed, in terms of how many hours you may sleep, because some people may vary from that seven to nine hour recommendation. I think the other thing too is really watch the caffeine intake and the energy drink intake as well. We tend to recommend no caffeine after 2:00 in the afternoon because caffeine has what we call a half-life of about three to five hours.
So as an example, if someone consumes a caffeinated beverage, half of the caffeine that's still in that beverage is still in the body three to five hours later, and so it can take some time to wear off. And then I think the third thing is trying to at least monitor whether or not you are keeping your bedroom for sleep only. Because a lot of times people are reading in bed or watching TV or looking in devices, and so if you are going into bed, be mindful if you are wanting to pick up that phone or look at the computer or look at the TV and be mindful and say why? Why am I actually doing this?

Dr. Daniel Correa:
What kinds of recommendations do you give to people to wind down because they may not necessarily be able to limit the bedroom or their traditional bed space as being only for sleep.

Dr. Jennifer Molano:
We have patients who live in a one bedroom apartment or they live in a studio apartment and we see students as well. So I think it's a matter of trying to find that pocket where you can intentionally put yourself in a space that will help you to fall asleep. If you have a small space in the apartment where this is my space where I try to wind down before I go to bed or one patient was saying, "I have my earplugs and my eye mask that I use, and those are the triggers for me as a notification to my brain that it's time for me to go to sleep." So even with smaller spaces, I think there is an opportunity and a way to figure out, "Okay, what is that trigger for me to go to sleep?" And I think that's the main thing. So with any habit change, you need that cue. Then it triggers that behavior and then if you're able to do it, you celebrate at some point in time that you're able to do it, and that helps to contribute that behavioral change.

Dr. Daniel Correa:
Jen, thank you so much for taking the time to join us to share this information with us and our listeners. I really appreciate it. It's such a great time spending with you.

Dr. Jennifer Molano:
It was a pleasure and an honor. Thank you for having me.

Dr. Daniel Correa:
Welcome back. We're going to go through together a simple breathing exercise that you can try out and learn from and do on your own on the evenings or whenever you need to. Just bring your attention back to yourself and calm down and go into a new activity or start to fall asleep. A colleague of mine brought my attention to this simple exercise. Let's start by settling into a comfortable position. If you're planning on going to sleep, then go ahead, adjust yourself in your preferred sleeping position. If you'll be staying awake, then sit up tall, find a comfortable position for your back.
Slowly shift front and back, little side to side until you feel that the top of your head sits directly over your hips, all just comfortably balanced and let your chin come down to wherever your head is in a balanced position. And if you're lying down, don't have to do anything. Now allow your eyes to close or keep them open if you'd like. And begin by taking several long, slow, deep breaths, breathing in fully and exhaling fully. Breathe in through your nose and out through your mouth. Allow your breath to find a natural rhythm. Don't have to really do any effort or force anything. Bring your full attention to noticing each in breath.
As it enters your nostrils travels down into your lungs and causes your belly to expand. Notice as each out breath goes out, your belly contracts, the air is moving up through your lungs and chest and out through your nostrils or mouth. Bring your attention to the full breath cycle. Notice how that inhale feels a little different from your exhale. You might notice that as that cool air enters your nose a little warmer as you breathe out. As you turn your attention more deeply, begin to notice and let go of any of those noises around you. If they distract you for a moment, just notice them and see if you can let it go, again. Simply breathe and as you breathe, don't strive to change anything. Just notice your breath. You don't have to try to control your breath in any way. Just bring your attention and accept your own experience and how your breath feels something is tight. Just try to relax that area and bring your attention back to your breath. If your mind wanders to thoughts, plans, problems, the next day, the next activity, just notice that.
Maybe make a quick note of it for later and try to work your attention back to your breathing. Watch as that thought enters your awareness, just neutrally let it go. Practicing letting go of the thought as if it were a leaf or a fish moving down the stream and going away. In your mind, place each thought that arises on a leaf and watch it as it floats out of sight down the stream. Then bring your attention back to your breath. Your breath can be an anchor. You can return over and over when you become distracted by thoughts or tension to the sensations in the feeling and the movement of your breath. Notice when your mind has wandered. You can observe the type of thoughts and how they feel. Why is it maybe that it distracts you? You might notice that aspect as being one of the most important things you can learn about those thoughts and how you're feeling.
With that knowledge, you can strengthen your ability to detach and have some control and power of those thoughts, but always bringing your attention back to those breaths. Practice coming home to the breath with your full attention. Observing the gentle rise of your stomach on the in breath and relaxing, letting go on the out breath. Allow yourself to be completely with your breath as it flows in and out. You might become distracted by pain or discomfort in your body, a little twitch or some itching sensations, and they can take you away from the breath. Just notice those feelings. They might come up and see if you can observe them and let them go. Bring your attention back to the breathing. Simply notice where your mind went without making a judgment and let it move away.
Put it back on that leaf and let it go down the stream. Clinging to it or wishing it were different is not necessary. Simply refocus your mind, guide your attention back to your breath. Breathe in and breathe out. Follow the air all the way in and all the way out mindfully trying to be present moment by moment with your breath and the sensations of your breathing. If your mind wanders away from your breath, just notice it. Let it be a thought, an emotion, a sensation, but don't let it hook you. Your attention to your breath can gently guide your awareness back. If you're going to sleep, try to keep bringing your attention back to your breath and releasing tension and any hook of those thoughts.
If you're getting back to your day, then as this relaxation exercise comes to an end, slowly allow your attention to expand beyond the breathing. Noticing your entire body and the position you're in. How your body and limbs feel, and then beyond your body to where you are in the room and the sounds around you. And when you're ready, open your eyes. Come back to a fully alert and awake state. The breath is always with you as a refocusing tool to bring you back to the present moment, and you can practice this exercise to bring your attention back to the breath and relaxation for your sleep or throughout the day. You can set an intention to your practice in some thought or just relaxing. I hope that helps.
Thank you again for joining us today on the Brain & Life podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life magazine for free at brainandlife.org and even get the Espanol version for each episode. You can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in by email to BLpodcast@brainandlife.org and leave us a message at 612-928-6206. You can also follow the Brain & Life magazine and me on any of your preferred social media channels.
These episodes would not be possible without the Brain & Life podcast team, including Nicole Lussier, our Public Engagement Program Manager, Rachel Coleman, our Public Engagement Coordinator and Twin Cities Sound, our audio editing partner. I'm your host, Dr. Daniel Correa, connecting with you from New York City and online @NeuroDrCorrea. Most importantly, thanks to our community members that trust us with their health and everyone living with neurologic conditions. We hope together we can take steps to better brain health and each thrive with our own abilities every day. Before you start the next episode, we would appreciate it if you could give us five stars and leave a review. This helps others find The Brain and Life Podcast. See you next week.

Sleep Smart: How Sleep Impacts Your Health

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