Early to bed and early to rise makes a man healthy, wealthy and wise – or at least it would, if so many of us weren’t suffering from sleeping disorders. In their follow-up from last week’s conversation on the effects of sleep on mental health, host Rick Hoaglund and Dr. Rajesh Balagani dig into sleeping disorders – why they happen, how they affect us, and what we can do to curb the trend – before diving into REM cycles, therapeutic remedies, and how you can optimize your resting hours to get the maximum benefit from a good night’s rest.
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00;00;09;02 – 00;01;56;12
Rick Hoaglund
Welcome to OnTopic with Empathia! I’m your host, Rick Hoaglund. Today on the show we’re continuing our conversation started in the last episode with Dr. Balagani. We discussed the types and the signs of sleep disorders. Today we’ll discuss what we should do if we recognized that we have a sleep disorder or that we know someone with a disorder. How do we treat it? Do we need a physician? You can find part one of this conversation on our website, www.Empathia.com. Early to bed and early to rise makes a man healthy, wealthy and wise. This is one of Benjamin Franklin’s most well-known sayings. Franklin had a very strict routine when it came to his sleeping schedule. He would sleep 7 hours per night, wake up at five in the morning and go to bed at ten at night. It’s also common knowledge that sleep is good for your brain. Einstein took this advice more seriously than most. He reportedly slept for at least 10 hours per day, nearly one and a half times as much as the average American. The average American sleeps 6.8 hours per night. But is that enough? It depends on your age. According to the American Academy of Sleep Medicine. The younger the person, the more sleep they require. Babies under 12 months need 12 to 16 hours per day. Children 1 to 2 years old need 11 to 14 hours per day. 3 to 5 year olds need 11 to 14 hours per day. And children from 6 to 12 years old need 9 to 12 hours per day. Teens need 8 to 10 hours per day and adults 7 to 8 hours per day. Hello, Dr. Balagani! Thanks for sitting down with us again!
00;01;56;15 – 00;01;59;10
Dr. Rajesh Balagani
Good, Rick! How are you? Thanks for having me on!
00;01;59;13 – 00;02;09;22
Rick Hoaglund
So let’s say that I have now had a sleep disorder. I know I have one. I’ve gone to- What happens at that point? I mean, I need to tell my physician, I’m guessing. Right?
00;02;09;25 – 00;04;53;24
Dr. Rajesh Balagani
Right! Right. So either your primary care physician will be the first person is probably going to be the quarterback that kind of picks up on anything that you say. And sometimes they may even look at certain parameters. They’re looking at your blood pressure. They’re looking at your cardiovascular risks and saying, well, how does this tie in to any kind of sleep disorder? A lot of times what we get from primary care or even cardiology nowadays is that if someone has blood pressure that’s elevated out of proportion to what you’d expect more difficult control with medication, that might be enough for them to prompt. Well, it is there. They’ll go on a line of questions that may unmask the other sleep things. Are you snoring? Are you finding that anyone’s told you that you have pauses in your breathing from a sleep apnea standpoint? Or they may go down the line of question of how you know, how long are you sleeping? Are you finding that you’re only sleeping less than that time? That would be thought up as being necessary. So less than 5 hours and those kind of things. So on that questioning, they may decide, okay, from that standpoint, one of two ways that that can go. One, they may put in for what we call a sleep study at that time, or they may actually send you to a someone who specializes in sleep. So that might be one of the two avenues that they take at that point in neither of them, you know, I think both of them have their purposes. I think that one of the things that someone who practices in specializing in sleep may be able to do if they see that person before the sleep study is get more of a global finding of, well, which one of these disorders? Remember we talked about four or five different classes of disorders. So where does this person potentially fall? So you’re not going to treat someone who has insomnia the same as someone who has hypersomnia or someone who has sleep apnea. So you you want to then at least try and say, well, which one to be primarily falling into because, you know, some people are going to fall into more than one anyway, The ones where you kind of gather that, then we can kind of decide on treatment based on what we think. So I’ll take the example of sleep apnea because again, this has become such a common thing that we’re sending patients receive study. So let’s say your primary care physicians find that you have high blood pressure and said, well, let’s have you give a sleep specialist. We go through with questions. There’s a lot of risk to sleep apnea. So snoring there, BMI is high. They’ve got high blood pressure. Their neck size is large. So they’ve got all the characteristics that might increase the risk of sleep apnea. So from there, they will then either one or two things. They can either be at home sleep test or they can be a in lab polysomnography. So those are the two potential avenues. If you’re trying to find someone sleep apnea more so than anything else.
00;04;53;27 – 00;04;56;26
Rick Hoaglund
Tell me about the home sleep test. How does that work?
00;04;56;29 – 00;06;11;01
Dr. Rajesh Balagani
Well, at home sleep test is more of the bare bones skeleton of a test, but it’s really device so that, you know, it was device more one because you can’t send everyone that has a sleep disorder or a sleep apnea into a lab. There’s not enough lab. There’s not enough technicians. Just, you know, from a standpoint of just numbers, it doesn’t work. So it also can be somewhat cost prohibitive. So what we’ve got is more of a bare bones where you look at their oxygenation, you look at their airflow. So seeing if they do have that apnea expel, which is a stop or a decrease in breathing or hypoxia, which is a decrease but not a stop. So we look at how many of those events they’re having, and that’s really all it’s geared to do. It doesn’t tell you if they’re in deep sleep. It doesn’t tell you if they’re, you know, about their sleep itself. It really tells us their oxygen level, heart rate and those events. So this is not a study that you’re going to get for someone who you’re looking for, a periodic limb, movements, a restless leg. This is not a study that you’re going to get for someone who you think has a parasomnia because you’re not going to get any of those. It really is dictated for that sleep apnea patient if you get a home study.
00;06;11;03 – 00;06;13;10
Rick Hoaglund
So is there equipment involved in that?
00;06;13;13 – 00;07;15;21
Dr. Rajesh Balagani
Yeah, very simple. So you got four or five leads and what usually happens is the patient will go into the sleep lab, they’ll be shown how to wear this, that kit or device during the night. Well, it usually is just a probe that goes onto their finger, fingertip that looks at their heart rate and oxygen level. There might be a lead across their chest that looks at their chest excursion to say that there is a stop or decrease in airflow and they may be wanting their nose just looking at the same kind of thing. So there’s very few leads that go on to it. And it’s very easy to do cost wise. It’s- it’s much more in line with what someone would be able to get covered pretty easily. So it’s much cheaper. And as far as effectiveness for the right kind of setting, which is in there someone who has a lot of risk of sleep apnea. This is a test that you can do and still get accurate information.
00;07;15;23 – 00;07;31;06
Rick Hoaglund
So tell me about the, someone that now has either, is not- doesn’t have sleep apnea or has one of the other symptoms or their sleep apnea has- is very large. And now they need to go to a sleep clinic. At what point, how does that work?
00;07;31;09 – 00;10;32;07
Dr. Rajesh Balagani
Yeah. So all the type of test that we have is the polysomnograph. This is now, this is that really the gold standard from a sleep standpoint. In the past it was really encountered for sleep apnea and there’s insurance issues and all those kind of things that came into play as well. But this is a test that truly tell someone how they’re sleeping. We talked about the different stages of sleep. So what happens is that the first thing that they’ll have is the sleep technologist will actually put a sleep EEG. So they’re looking at brainwaves, so they put them in different points of their skull just on the exterior. They attaching with just a glue and paste. And just like any other EEG, it’s going to give them brainwaves during Wake, it’s going to show if there’s a change in those waveforms. As we talked about, there’ll be different waveforms from different stages. And so we’re looking at that. And what we’re correlating along with that is they also have leads that go across their chest and abdomen. Again, still looking at the movement in air flow. Now, there’s still is that oxygen level. There still is the heart rate. And there’s also going to be some leads on the the patient’s legs looking at any kind of limb movements that are occurring during the course of – the course of the night. So now that you’ve got this whole setup going, let’s say, again, it’s for simple sleep apnea. Well, you’re going to get that same information that you got from the home study, just that a much more accurate representation of it, because you now know well, this person, when they went into REM, they had more sleep apnea, which is something that does happen. Or this person when they were in and pre, they had more stable sleep. Along with that, you’re also going to see any kind of parasomnias. So parasomnias, it might be that we witness them on a EEG itself. So we see that this person has- has gone into REM, but during REM, they actually have some degree of leg movement, so they’re having their leg movements. Then we know that they may have potential for REM behavior disorder, because remember, again, the premise is that during REM, you shouldn’t have much in the way of limb or significant movement occurring. Other parasomnias we see sometimes if a child is having any night terrors, it might have- might happen during their sleep. If they’re having nightmares, it occurs during REM. So you can differentiate to some degree between those two. So those are some of the things that you see in a full polysomnogram. You know, I tell most of my patients take the amount of each of those stages that they have on that one night with some grain of salt, just because this is one night that you had in a strange place with someone looking at you and, you know, measuring your, you know, your amount of N2 or N3 may not be the most accurate thing for that one night itself.
00;10;32;10 – 00;10;51;14
Rick Hoaglund
So I would imagine that people are a little anxious going to a sleep clinic where they’re- you’re right, you’re in a strange place. You have all kinds of strange wires attached to you. What do you tell your patients? Like, will they be able to sleep there? I mean, I would think about that and think, oh, my gosh, I probably won’t be able to go to sleep at all. How do you prep for that?
00;10;51;17 – 00;12;07;02
Dr. Rajesh Balagani
Right! I mean, so the thing that you find is that, you know, people are able to at least for the most part, I mean, there’s always going to be people that I find it difficult to sleep. But for the most part, most people that we have sleep studies on are able to accommodate for those settings. And again, the main thing to keep in mind is that you want, at least on the outside, one of the things is most of these sleep labs, so if you go into the room itself, it doesn’t look like a hospital room. It’s really kind of decorated as though you’re in a hotel room. So it kind of hopefully makes them feel that that way rather than they’re in a hotel- in a hospital room setting. So there’s that part of it. But yeah, you do have a lot of wires and those kind of things that can lessen sleep. Usually we do take you to a fact called the First Night Effect, which is that the first night that you’re in a sleep, like maybe you have a decrease in sleep efficiency due to that factor. I’ve heard of stories where back in the day they used to do three or four day sleep studies. I don’t know how they got insurance to go along with that, but you know, but now it’s that it’s been tailored down to just one day at this point.
00;12;07;04 – 00;12;20;19
Rick Hoaglund
What is the treatment like following that? So you get your results, and I’m sure some of this is going to depend on what what is in these results, but what can the average person expect as a treatment going forward? What do you what are you telling them?
00;12;20;21 – 00;14;22;19
Dr. Rajesh Balagani
The most common reason that you’re still going to have a sleep study, either an in lab or a home study still in, you know, in most places still ends up being sleep apnea. So let’s say from that standpoint, they do have sleep apnea. One of the things that will happen at that point is depending on the severity of the sleep apnea, we dictate as far as would dictate, as far as treatment options. Now, people get a tendency to think that the only way that we treat sleep apnea is with the CPAP. And there are other options at this point. You know, one of which is really dependent on severity. But if it’s a mild the severity, there’s more options. Now, there are things that there are oral appliances or mandibular advancement devices that they can place in their mouth just as a kind of a mouth guard and it moves their lower jaw forward and those kind of things. So there are more than one treatment option which can happen in the setting of sleep apnea. Now, let’s say they have a REM behavior disorder. So we did see that this person had a lot of movement in REM. And not only did they have just leg movement, but they were acting out dreams. So then we made that diagnosis. And then from there we decide on, well, is this connected to anything yet? Is it connected to medications that they have potentially on there? Could it be potentially from a neurological or neurodegenerative disorder? Those kind of things also fall into place when we see those if they come back with one of the other parasomina’s, you’ve got a child who’s having a lot of nightmares. So night terrors. Is this related to any kind of behavioral aspect? I mean, which came first? You know, is it that they’re having these behavioral issues leading to some of this or, you know, or is that a behavioral issue from the disruption in their sleep that is happening because of the nightmares or night terrors? It gives us information to be able to go back to the patient and say, okay, this is what we think is going on based on the sleep study and this is where we should start from a further diagnostic again or treatment.
00;14;22;22 – 00;14;38;22
Rick Hoaglund
When someone is undergoing treatment for sleep disorder, I guess my question is, what can they expect on the other side? Like, they start taking their medication – do they feel different? Do they look different? Do they? I mean, what is the difference between before and after? How will they know if it’s working?
00;14;38;25 – 00;16;35;15
Dr. Rajesh Balagani
The first thing we’ll talk about is actually, again, you know, alluding back to sleep apnea. So let’s say this is someone who had significant sleep apnea. They came in because they do have cardiovascular risk. They do have difficult to treat hypertension. If you’ve got some of those parameters and then you get placed on CPAP, the first thing that that patient will encounter is really hopefully that their sleep has gotten better, right? I mean, the two things that they’ll get, actually there’s two things. One, the bed partner is much happier because this person is not snoring next to them. Right? So that happens first. And then along with that, hopefully because they’re regulating their sleep better at night, they’re waking up with more energy. I’ve got patients within a week of CPAP or even a couple of days of CPAP where even actually I’ve had some anecdotally you get patients right after the sleep study where half of their night was actually a diagnostic and the other half of it was that with sleep apnea, they’ll say this is the best night of sleep I’ve had with that half night of feedback. And that’s what we want to see. They’re not going to know that there are cardiovascular risk lessened because they’ve been using sleep apnea, all those kind of things. But they’ll see that they’re feeling more refreshed when they wake up. They’re not taking daytime naps. They’re not falling, you know, worst cases, they’re not falling asleep behind the wheel driving and those kind of things. So that might be the things that they notice. Now, let’s say again, go to something that’s easier to look at, which is the REM behavior disorders. So let’s say once we know that they do have REM behavior disorder and it’s significant, they are acting out dreams and those kind of things. So we may put them on pharmacological treatment at that point and see if we can extinguish some of these behaviors. So they may notice that they’re not having these or these periods where they wake up and or they’re in this kind of dream state that they’re acting out.
00;16;35;17 – 00;16;58;21
Rick Hoaglund
What are some of the factors that you’re looking at following a sleep study? Are you- is part of the sleep study looking at, say, lifestyle and you know, what medications they’re taking, which you alluded to a little bit ago? And then what do they do going forward? Like how should they be changing certain things? Like should I be getting more exercise? What makes for a good night’s sleep for someone that’s undergone a sleep study?
00;16;58;23 – 00;18;27;20
Dr. Rajesh Balagani
Yeah, no, I think it’s helpful as far as looking at medications and seeing how many of these medications could be playing some impact on sleep, there’s probably going to be a significant amount of medications that we take and things that seem relatively innocuous that can cause some degree of changes. Sleep Apnea doesn’t have to be always a insomnia, but it also could be hypersomnia. Some of the medications that we take without knowing, let’s say someone’s on any kind of opiates or pain and those kind of things or gabapentin for pain and those kind of things. They can affect their sleep to a point where it’s not so much that it’s actually causing a decrease, but it’s actually causing them to have a increase in their sleep aspect. So if we let’s say if one of those medications was on board during the sleep test and we find that there was significant excessive sleep or there were certain apnea. So now this can be either what we call obstructive, which is obstructive sleep apnea, and that’s the airway kind of collapsing. And that can be other type of abuse called central, which are being regulated by the brain. And certain medications can actually bring that on. And we may see that and then decide, well, you know, maybe the dose of these medications that you’re on is not is not helping your sleep situation. Any reason for your excessive sleepiness could be this. Are we able to safely come down to a lower dose? Is there an alternative? All those kind of things can be discussed at that point.
00;18;27;23 – 00;18;38;07
Rick Hoaglund
How about things like your diet? Like, I’m going to be honest, the whole idea of, you know, don’t drink coffee before you go to bed type of thing, your weight, does that have any effect on this at all?
00;18;38;09 – 00;20;40;22
Dr. Rajesh Balagani
Yeah. So coffee, you know, I always find it interesting because, you know, and you probably heard this where you’ll have someone who says, Yeah, you know, if I drink coffee late at night, then I can’t sleep at all. But then you’ll have that dear friend who says, well I can drink, you know, a pot of coffee and then still fall asleep. And I thought that that was very interesting. And I think one of the things is that you have to remember that sleep and wake. Yeah. From a brain standpoint are, are so complex that there’s multiple neurotransmitters that are being driven, either decrease or increase production and how they interact with something else. And that leads to this kind of dance of sleep and wakefulness. So when we have that, I think caffeine is actually a direct antagonist. Adenosine! Adenosine is very interesting in that if one of these neurotransmitters and hormones that or neurotransmitter that ATP, which is adenosine triphosphate is you know we think of it as a building block of energy, right? So as we use up energy during the course of the day, we’re using up ATP and is being converted to ATP and then adenosine. Adenosine, which when it builds up, makes you sleepy, which makes sense, right? When you work out a lot or when you work a lot and you’re using up that building block of energy and is breaking down into it- to its end point, which is adenosine, you feel tired? Well, that’s where coffee actually comes in is because it actually disrupts or antagonizes that identity. So it keeps you wakeful right. But remember that sleep itself and wakefulness is made up of so many of these different neurotransmitters that maybe in that person who says, I can drink a pot of coffee and still go to sleep, well, maybe adenosine is only a small portion of it. So the coffee is doing what it’s supposed to do, but it can’t regulate the rest of those neurotransmitters to lessen their wakefulness or with the coffee at that point.
00;20;40;24 – 00;20;55;19
Rick Hoaglund
Is there any technology out there that can help us? Like there are sleep trackers, there’s, you know, smart beds and there’s all kinds of stuff out there, including, I guess, if you want to talk about technology being really all just sleep masks, does any any of that help?
00;20;55;22 – 00;23;33;05
Dr. Rajesh Balagani
Yeah, no, I think that I think technology is great. You know, as we found today, you know, it’s a double edged sword, right? I mean, you know, it’s like we keep hearing about this with A.I., you know, we could do a whole guide. You know, it’s like A.I, yeah I’m a believer in A.I., but you see how many people have talked about their concerns about A.I. Now, similarly, one of the things that, you know, you’ve got to take with a grain of salt is relying too much on your Fitbit or your Apple Watch to tell you how you’re sleeping. There’s certain algorithms that these devices will run. The Fitbit usually runs on two or three different things. One of them is actually a accelerometer, which if you’re moving and you’re moving, a lot, it tells you you’re awake. I mean, so if someone is lashing out, you know, in their sleep itself, that their accelerometer might be changing and saying that you were actually sleeping or actually you’re awake while you’re sleeping. The other thing that it also uses is that it uses a technology which is heart rate variability. So certain stages of sleep, you have less or more heart rate variability. And it’s looking at that and saying, well, you must be in this stage of sleep because you had this much heart rate variability. And so it’s making a- it’s calculating all those algorithms and coming up with, yes, you only had a 5% in stage N2 or 5% in stage N3. So that’s good or not good, but they’re getting better. I mean, they’re relatively accurate, especially the Fitbit and the Apple Watch. They’re relatively good if it’s a normal sleeper. They’re not as good when you’ve got someone with a significant amount of sleep stage disruptions, meaning that this person is going promptly from N1 to N2 and then N3 and then back to N1, if they have a lot of shifting in their staging of sleep, it doesn’t seem to allow for the device to pick up well. So again, if you feel like you’re sleeping well and you’re not having any manifestation of anything, you’re not waking up tired, your bed partner is not complaining about you kicking you or your snoring. You are able to do your activity over the course of the day and not have to take naps. And then your Apple Watch says while you didn’t sleep well, well, who are you going to believe? Right? I mean, you’ve got to kind of take that along with the actual, you know, the clinical aspect of it at this point.
00;23;33;07 – 00;23;51;28
Rick Hoaglund
What about the, I would call them soothing sounds? Like people that get – you can get, that you can get apps. You can- you can play it yourself. I guess there’s machines that do this that put like the sound of the rainforest or sound a bird calling. Does any of that work? Is it- or is it up to the individual?
00;23;52;00 – 00;24;41;29
Dr. Rajesh Balagani
I think, you know, I think it’s useful. I think that all of these are going to be adjunct to just the things that we talked about, which is, you know, maintain and regular time, all those kind of things. But I think that, you know, the white noise machine and those kind of things can be helpful to maybe put your mind at ease or you’ve got something to focus on, which is very kind of, you know, drones out your thinking and that- that can be helpful. But again, I think overly reliant on any of these then still doing all the bad activities. So, you know, you can’t you can’t drink a pot of coffee and watch TV and then put the white noise machine and expect it to, you know, do something miraculous. So I think that you’ve got to put that into the context of everything else. Then if it’s used as an adjunct, I think it can be very helpful.
00;24;42;02 – 00;24;59;21
Rick Hoaglund
One of the last questions, and I know it’s a little bit repetitive from our first section, but I’m going to I’m going to sort of ask it in a new way. If you were building a toolbox for someone to say, okay, this is the best way for you to get a good night’s sleep, what would that toolbox look like? What would you- what would you tell them?
00;24;59;23 – 00;26;34;11
Dr. Rajesh Balagani
The biggest thing is, keep at it on a regular basis. So I think that repetition really does make things better. And that’s one of the things that even when we see patients that do have insomnia and we have to change any of these behaviors, it’s you have to keep on going with a behavioral measure. So wait time, sleep time being very regulated, make sure that you’re comfortable from a physical standpoint, physical, you know, discomfort, pain and those kind of things can be also detrimental. So you’ve got to take care of the things that you can’t avoid. The other thing we actually didn’t touch much on and, you know, is alcohol. We think that alcohol is something that can help with sleep, but it is- it’s a sedative, but it actually wears off in the the metabolites that you get from alcohol actually have a tendency to cause more wakefulness than they do actually sleep. So the initial impact might be, yes, you fall asleep, but then you wake up much earlier than you would and you’re not able to fall back to sleep because of those things. So avoid any kind of significant alcohol late at night. The other thing is from a brain being somewhat quiet, avoid having anything that engaging or excessively engaging late at night that’s going to be detrimental. And the thing with technology is, yeah, I know that they’ve got all these, you know, blue light blocking and things like that. Well, if you can do without your phone for the last hour of the night and then that might be one other thing that you want to be able to do.
00;26;34;13 – 00;26;38;04
Rick Hoaglund
Is there anything you’d like to add for our listeners?
00;26;38;06 – 00;27;21;11
Dr. Rajesh Balagani
No, it’s practice makes perfect in sleep! And I think that, you know, there’s very few of us nowadays that have a tendency to be able to, you know, put our heads on the pillow and fall asleep. And I, I find that to be a, you know, more of a boon than anything else. But most of us have to work at it. And I think that, you know, we keep- keep at it, keep all the good behaviors. Helping mental standpoint really is very important from a sleep anxiety and depression, those kind of things, which we have a tendency to unfortunately underestimate, have a really significant impact on excessive sleepiness and also a decrease in overall sleep.
00;27;21;14 – 00;27;48;05
Rick Hoaglund
Dr. Balagani, thank you for joining us today! You’ll find more information about overcoming challenges on all of our podcasts. To hear more episodes of OnTopic with Empathia, visit our website, www.Empathia.com. Follow us on social media @Empathia, and subscribe to OnTopic with Empathia to hear new episodes as soon as they go live. I’m Rick Hoaglund – Thanks for listening to OnTopic with Empathia!
