Online Health Chat with Laurence Smolley, MD and Ketan Deoras, MD
Tuesday, March 8, 2016
Getting a good night's sleep is an essential part of good health and wellness. Sleep disorders are changes in sleeping patterns or habits that can negatively affect health. Many factors play a part in the quality of sleep. Our experts specialize in the diagnosis and treatment of a broad range of sleep disorders, using a variety of advanced techniques; such as, polysomnograms (PSG), video electroencephalography-PSG, multiple sleep latency tests (MSLT) and positive airway pressure (PAP). There are more than 80 sleep disorders, most of which fall within six main categories:
- Sleep-related breathing disorders
- Circadian rhythm disorders
- Sleep-related movement disorders
About the Speakers
Laurence Smolley, MD, is chair of the Department of Pulmonary Medicine and medical director of the Sleep Disorders Center at Cleveland Clinic Florida in Weston. Dr. Smolley received his medical degree from Yale University and his Master’s from the New York University School of Medicine. He completed his residency at King County Hospital Center and his fellowship training at University of Miami School of Medicine. Dr. Smolley is board certified and specializes in critical care medicine, granulomatous lung diseases and sleep disorders.
Ketan Deoras, MD, is a psychiatrist. Dr. Deoras received his medical degree from The Ohio State University and his Master’s from The University of Toledo College of Medicine. He completed his residency at University of Arizona Medical Center and his fellowship training at the Cleveland Clinic Sleep Medicine Center. Dr. Deoras is board certified and specializes in sleep medicine and psychiatry.
Let’s Chat About Daytime Sleepiness
Moderator: Welcome to our chat about Daytime Sleepiness with Cleveland Clinic pulmonologist Laurence Smolley, MD, and psychiatrist Ketan Deoras, MD. Doctors, thank you for taking the time to be with us and share your expertise.
bergem: I have had a hypoactive thyroid for 15 years as a side effect of Amiodarone, which I had stopped in 2011. I follow my TSH and other levels regularly and am on 100 mcg of Synthroid daily. However, I am tired in the morning and get more energy in the afternoon. I stay in bed for eight hours, sleep well for the first six hours, measuring my sleep level at six to eight overall. I take an herbal sleep aid called "Calms Forte," three tablets. Thank you.
Ketan_Deoras,_MD: Unrefreshing sleep can be attributed to a variety of sleep disorders, including but not limited to sleep apnea and insomnia. You would likely benefit from a comprehensive sleep evaluation to further assess your sleep pattern and see what else might be contributing to your sleep issue.
sbdavisrn: Can you address sleep inertia and how to combat it?
Laurence_Smolley,_MD: If you are aware of having a lot of inertia upon arousing from sleep and needing to be functional, it is important to plan some time to get activated in the morning or whenever you're awakened. Sleep inertia may be particularly concerning in people who have professions that require that they be "on-call" and have to respond to telephones, for example, in the middle the night. We all have some element of sleep inertia and an extent may be related to the sleep stage during which we are awakened, for example.
annacolm: This is for the daytime sleepiness clinic. I won't be able to attend live. I almost always get very sleepy between 1:30 p.m. to 2:30 p.m. and have a lot of trouble concentrating on work. I regularly get about seven and a half hours of sleep at night and otherwise feel fine throughout the day. I intentionally tend to eat light, low carb lunches (like a salad with grilled chicken or fish) and sometimes also go to the gym at lunch. Both of those things help the sleepiness a little, but not enough. Often, I want a snack like chocolate to fight the sleepy feeling. Eating a bigger lunch does not help and just makes me sleepier. What else can I do, short of moving to Spain so I can take a siesta?
Laurence_Smolley,_MD: I would suggest a comprehensive evaluation with an experienced, certified sleep disorders physician. And take note, you may need specific sleep studies to confirm a diagnosis. Possibilities include narcolepsy, idiopathic hypersomnia and obstructive sleep apnea.
Sleep Aid Sense
rachelepappas: What is the most effective natural/non-drug sleep aide to help with staying asleep throughout the night, in your opinion?
Ketan_Deoras,_MD: Most often, we will start with melatonin. You could try an extended-release version to see if this may help more with staying asleep.
CCF: Sometimes, it may take me up to two hours before I fall asleep. Is that normal? Should I use some sort of sleep aromatherapy body wash or Epsom salt bath before going to bed?
Ketan_Deoras,_MD: Ideally, mostly people fall asleep within 30 minutes. When it becomes longer than that, it is typically defined as insomnia. There’s certainly no harm in trying things like aromatherapy or Epsom bath salts. You could also consider other relaxation methods such as meditation or yoga. However, if sleep difficulties persist despite these measures, you might need further evaluation to discuss alternative measures to deal with the difficulty falling asleep.
rieglerm: What do you think about Calms Forte?
Ketan_Deoras,_MD: Unfortunately, since Calms Forte is prepared with homeopathic ingredients, there isn't much in terms of evidence through studies. I haven't had any specific experience with this supplement though in my patients.
Simply_Tired: Does melatonin have any side effects? Will I feel groggy using it?
Ketan_Deoras,_MD: Typically, melatonin is tolerated well without significant side effects at low doses. Sometimes, patients taking it will complain of nightmares or headaches and occasionally grogginess. In terms of the grogginess itself, typically, there isn't any way to know without trying it. Since melatonin is an over-the-counter supplement and isn't standardized, there can be widely varying differences in side effects depending on the manufacturer and preparation.
Meg_N_Ohio: Thank you for talking about this subject. I could fill this whole chat with questions, so please filter and answer what you think would help most people. Most of my issues with sleep stem from working rotating shifts. I have to use Benadryl to help relax, as well as black-out curtains, white noise and cool temperatures in the bedroom. Even doing that, I average three to five hours of sleep a day, and that sleep is broken. I sleep two hours then wake up for an hour, go back to sleep for an hour, etc. The last time I slept eight hours straight was at least a month ago. I'm tired all the time, but can't sleep, even on my days off. Other issues include being menopausal (I’m 57 years old) and show low T4 and low vitamin D in blood tests. I am taking supplements but have yet to really notice any difference. Is there a way of testing for adrenal fatigue or is that determined by looking at the different numbers in the blood work? That was mentioned by the doctor, but I forgot to ask what that really meant. Thank you.
Laurence_Smolley,_MD: I have seen a number of patients who have issues with sleep stemming from working rotating shifts. Shift work disorder is extremely stressful. In order to best address all the issues, a detailed analysis of your sleep-wake schedule, rotating shift schedule and other information must be done in a face-to-face consultation with an experienced expert certified in sleep disorders medicine.
LucyintheSkies: I am going to be traveling to Europe for two weeks. What do you suggest to help me deal with the time zone changes?
Ketan_Deoras,_MD: Some people will begin gradually adjusting their sleep schedules in advance of their trip, in order to acclimate more easily (this depends on how big of a time difference there is as well). There are various online sleep calculators that you can search for into which you can input your schedule and destination and they will provide a proposed schedule. In addition, taking melatonin up until you leave and after you arrive can also be helpful. In cases where it is still not possible to adjust easily, you could consider the use of a prescription sedative hypnotic aid short-term during your travel.
Specifically Sleep Apnea
bergem: I can fall asleep easy, but I wake up frequently after three hours or so. Because of my insomnia, I feel tired and weak in the morning. I had a sleep study performed, which showed apnea about six times an hour with short duration. Would a CPAP machine help to improve my sleep?
Laurence_Smolley,_MD: Six apneas per hour is considered abnormal, as the normal cutoff is less than five. If a person has other types of sleep-related breathing disorders, such as hypopneas, that also contributes to the severity. There are various treatment alternatives to the gold standard of therapy, the CPAP machine. These include an oral appliance or mandibular advancement device, something called nasal EPAP, something called oral pressure therapy, etc. Making a true commitment to losing weight should be considered for those who are overweight and have no significant symptoms getting in the way of daytime functioning and no high blood pressure or atrial fibrillation. For very mild sleep apnea, back positional therapy, which is associated with utilizing the device or tennis balls in a sock sewn to the back of the night shirt to condition the person not to sleep on the back may be an alternative. Various very well designed surgeries might be considered. I feel these are last resorts for very specifically selected patients.
softballmom: I haven't slept through the night in years. First, my husband snores, so now we don't sleep together. Now, I am going through menopause and have hot flashes. They are getting better, but I still thrash around the bed all night. We got a new mattress, pillows, etc. I've tried natural supplements, and prescription Ambien didn't even help. Now, I am catching myself snoring a little when my head falls forward and blocks my airway, but I usually sleep on my side.
Laurence_Smolley,_MD: Your story is quite suspicious for obstructive sleep apnea. There is good treatment for this after a specific diagnosis is confirmed. I would recommend you have a consultation with a qualified sleep specialist.
tabialex: Is the sleep apnea appliance made to fit your mouth just as effective as the CPAP machine? Thank you for your help.
Laurence_Smolley,_MD: If you have healthy teeth, gums and temporal mandibular joint, you can try an oral appliance or mandibular advancement device worn during sleep. If you have less than severe obstructive sleep apnea, then this appliance is considered a reasonable alternative. It may take some getting used to, and it has to be adjusted by the special dentist who creates/fits it for you. Once subjective improvement is obtained, such as significant reduction in snoring, trouble staying asleep and daytime sleepiness, then objective proof of efficacy is necessary by way of a home sleep study or in-laboratory sleep study.
Edwinjcb: I've had severe sleep apnea for about five years. I use a BIPAP machine, which helps, but I've noticed in the last couple of years I'm not feeling as refreshed in the morning as I used to. In fact, I often start feeling sleepy by 9 or 10 a.m. I've seen my sleep specialist doctor, who reads my memory chip from my machine and says it's keeping my apnea events per hour to an acceptably low number, so that appears to be working. I'm unsure what, if anything, more I can do so I'm not so sleepy.
Laurence_Smolley,_MD: A detailed history would be required to understand what is going on with you at night. You may be having more sleep-related breathing disorder events than the Pap device is actually able to detect. This is because some of the significant sleep-related breathing disorder events require an oximeter to check oxygen levels or electroencephalography, electrodes on the scalp, to see if there are arousals affecting your sleep. Even though the "apnea events per hour" are at an "acceptably low number," this may be a very grave underestimate of what is really going on. Sometimes, a full sleep study in an accredited laboratory is necessary. Also, you may have acquired another sleep disorder such as periodic limb movements during sleep, for example, brought on by various reasons such as the utilization of an antihistamine or other medication that can precipitate this movement disorder and ruin sleep. A sleep study in the laboratory would be required to detect this.
Dealing with Disorders
loveitaly: My daughter is 34-years-old and has a developmental disability. Her disability includes seizure disorder, cerebral palsy and several other associated conditions. She is nonverbal and non-ambulatory. She has always suffered from insomnia, especially when her seizure medications are adjusted (even more if they are sedatives like phenobarbital and clonazepan). She had a sleep disorder study done two years ago to see if she had sleep apnea. Thank God she didn't. When her physicians adjust her sedatives, far from sleeping all night, (that is what they expected she would do), she is awake long hours. We change her position in bed, and sometimes she falls asleep, but many times won't. Frequently, the moment we sit her early in the morning to begin breakfast, she falls asleep almost instantly. Can position changes make a person fall asleep so quickly? This doesn't happen every day, because if she slept during the night, it won't. Thanks for your time and input.
Ketan_Deoras,_MD: Typically, I wouldn't expect a positional change to impact sleepiness to this effect. Most often, positional changes would be involved in cases of sleep apnea, where sleeping in a certain position makes the sleep apnea worse. Your daughter's sleepiness may be related more to the quantity and quality of her sleep the night before manifesting when she is out of bed in the morning rather than the position itself. In addition, sometimes insomniacs also become conditioned to be less sleepy in bed than in other places, which may be playing a role with her as well.
rjb112: I have a delayed sleep phase where I only feel tired and able to sleep at about 3 or 4 a.m. Melatonin has not helped, nor has bright light when I wake up. My sleep study didn't show anything useful. What else do you recommend that I try?
Laurence_Smolley,_MD: Delayed sleep phase syndrome may be difficult to treat. Sometimes, specific behavioral modifications may be helpful and perhaps even more important than melatonin or light therapy. A so-called "chronobiological" approach may involve gradually advancing sleep-wake times until the desired time is reached. This may be done in conjunction with light therapy.
lightning#: I have a collagen/connective tissue disorder (Ehlers-Danlos Syndrome). Even when I'm getting more sleep, I fall asleep at inappropriate times. I don't like taking sleeping pills because they take so long to get out of my body and I feel sedated for the next day or so. I've tried most of them. I understand that the weight I've gained and the difficulty with mental confusion at times can be the result of insomnia. How do I get restorative sleep, and what medications could I take if needed?
Laurence_Smolley,_MD: Falling asleep at inappropriate times suggest that the quality and/or duration of your sleep is abnormal or not adequate. You may have obstructive sleep apnea. Repeat a comprehensive evaluation by qualified sleep disorders expert.
mhcvol84: Why do I feel worse when I get more sleep (say eight hours or more) than when I have approximately seven or seven and a half hours? There are very few mornings that I feel refreshed and feel good. It takes a good hour for me to "function."
Laurence_Smolley,_MD: Certain details to your situation are missing. “There are very few mornings that I feel refreshed and feel good" suggests that the quality of your sleep is not good. You may have a sleep disorder such as obstructive sleep apnea, which is quite common. A comprehensive history and physical exam and perhaps a sleep study would be beneficial in guiding your therapy.
rachelepappas: Is one type of mattress better than another to prevent tossing and turning from minor aches and pains and diffuse discomfort throughout the night?
Laurence_Smolley,_MD: It is very worthwhile investing in a high quality mattress. I think of most importance is dealing specifically with the underlying cause of these aches and pains and discomfort. Consultation with a physician may be very helpful, and then appropriate therapy to ameliorate these aches and pains can be applied.
Francesca: My teenager uses the weekends to “catch up” on sleep. Can you really catch up?
Laurence_Smolley,_MD: You can catch up, but it is extremely important to maintain a consistent, regular sleep-wake schedule. The most important set point for your internal clock is when you start your day in the morning. That is getting out of bed, being vertical and being exposed to light. If your teen sleeps too late on weekends, Saturday and Sunday mornings, then he may have trouble falling asleep at his usual time Sunday night. I would suggest not staying in bed more than about one hour on Saturday and Sunday mornings to avoid this problem. Teenagers are particularly susceptible to delaying their sleep phase or staying up too late and consequently sleeping too late. This can be avoided with consistent, regular sleep-wake schedule with not too much divergence therefrom.
Diet and Your Day
Red38: Are there any particular foods that are good to eat in the morning to help with energy throughout the day? And what should be avoided? Does it matter throughout the day when vitamins are taken?
Laurence_Smolley,_MD: Breakfast is definitely the most important meal and should be eating at around the same time each day after awakening/getting out of bed at about the same time each day. Quality protein such as egg whites, nuts you are not allergic to, oatmeal or whole wheat such as wheat germ (be aware those who are gluten sensitive), high-quality Greek yogurt, ideally herbal tea without caffeine and fresh fruit are probably ideal. As with any diet, careful individual consideration for diet must be applied in each case. Carbohydrates, especially sweetened ones such as bread, bagels and doughnuts, should be avoided for many reasons. (It’s good to know the effects of carbohydrates, especially sweets, on the pancreas, liver and brain.) Each person ideally should take responsibility for his or her diet, which includes becoming knowledgeable about the quality of foods and mindful of what is ingested into the body. Each person needs to take responsibility for his or her diet and understand his or her specific needs and goals. It doesn't really matter what time of day the vitamin is taken, but perhaps it is best taken with meals.
Diagnosis and Evaluation
Bebop: I've recently started to have difficulty sleeping through the night. I exercise daily, eat fairly healthy and try to get at least six to seven hours of sleep. For example, I go to bed at 10 p.m., wake up at 1 a.m. thinking it should be close to my wake up time of 5 a.m. How would I know if I have a sleep disorder?
Ketan_Deoras,_MD: There are several questionnaires that you can take that can give you a better indication of a possible sleep disorder and indicate the need for further evaluation. The STOP-BANG and insomnia severity index are two examples. In general, if you feel the quantity or quality of your sleep is interfering with or affecting your ability to function the next day (be it at work, within the family or socially), it's probably a good idea to get evaluated by a sleep specialist. Here are links to our Cleveland Clinic Sleep Quizzes: my.clevelandclinic.org/services/neurological_institute/sleep-disorders-center/patient-education/sleep-quizzes or clevelandclinic.org/sleepquiz.
nelene: My husband has developed a really bad snoring issue, almost like he’s going to suck the whole house in when he breathes. Is this sleep apnea? He’s 5’9” and weighs 170 pounds, not a heavy guy. Do we start with our primary care physician or see a sleep specialist?
Laurence_Smolley,_MD: Two thirds of patients with sleep apnea are overweight, but the other one third of patients with sleep apnea are not overweight. They may have other problems such as an overbite or a nasal obstruction that predisposes them to snoring and sleep apnea. By the way, not everyone who snores has sleep apnea. If you can see one as per your insurance coverage and a sleep disorder specialist is available, that would be the most efficient first step for dealing with the problem.
Sybil: I fall asleep many times a day. How is it determined if this is narcolepsy?
Ketan_Deoras,_MD: After performing a comprehensive sleep evaluation, if there is strong suspicion that you have narcolepsy, we will typically do a two-part study to determine this. The first part involves an overnight sleep study in a sleep lab. This is done to rule out sleep apnea as a cause/contributor to the sleepiness, and also to ensure that you have had enough sleep the night before the second part of the test. The second part of the study continues the next morning after the sleep study (as long as significant sleep apnea wasn't observed overnight), and consists of five opportunities to take a nap throughout the day. Based on how quickly you fall asleep and how quickly you go into dream sleep, we can get an idea if you fulfill the objective criteria for narcolepsy.
Grumpy: My doctor feels that I need a sleep study, but I really do not want to go into a lab to have one done. I think that would make me nervous trying to sleep. Are there any programs that can be used at home?
Ketan_Deoras,_MD: We do have the ability to perform home sleep studies as well, from the comfort of your own bedroom. Certain medical conditions preclude the ability to do a home sleep test, or would be better served by doing an in-laboratory sleep study. You would need to further discuss this with your sleep specialist to see if a home sleep test would be appropriate for you.
sbdavisrn: Are you aware of any connection between taking Imdur and nightmares?
Laurence_Smolley,_MD: Nightmares would be a very unusual side effect of the Imdur, a nitrate-containing medication, although emotional lability has been reported. There is such a thing as an idiosyncratic reaction to a drug if there is a very clear-cut association between the onset of nightmares and the taking of this specific drug and there is no other reason for the nightmares such as stress or some other medication such as a beta blocker. Then, with the careful consideration of the doctor who prescribed the nitrate in the first place, another drug might be considered, if feasible, to treat the particular condition for which the nitrate was given in the first place.
That is all the time we have for questions today. Thank you, Dr. Smolley and Dr. Deoras, for taking time to educate us about daytime sleepiness and sleep disorders.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
To make an appointment with Dr. Smolley in the Sleep Disorders Center at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at www.clevelandclinicflorida.org.
To make an appointment with any of the other specialists in Cleveland Clinic’s Sleep Disorder Center, please call 866.588.2264. You can also visit us online at clevelandclinic.org/sleep.
For More Information
Established in 1978, Cleveland Clinic's Sleep Disorders Center was among the first in the nation dedicated to the diagnosis and treatment of sleep disorders in people of all ages. Accredited by the American Academy of Sleep Medicine, Cleveland Clinic's Sleep Disorders Center is staffed by physicians specializing in sleep disorders from a variety of disciplines, including adult and child neurology, pulmonary and critical care medicine, psychology, psychiatry and otolaryngology.
Cleveland Clinic Florida
Cleveland Clinic Florida’s Sleep Disorder Center, a part of the Neurological Institute, is a multispecialty comprehensive program dedicated to the treatment of sleep and wake disorders in adults. The center, which is accredited by the American Academy of Sleep Medicine, comprises specialists in neurology, pulmonary medicine, psychiatry and critical care medicine. More than 1,500 sleep studies are performed in our laboratories each year.
Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments for sleep disorders:
Cleveland Clinic Treatment Guide
Download our Understanding Sleep Disorders treatment guide to learn more
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