Sleep Patterns and Disorders with Dr. Nancy Foldvary-Schaefer

Podcast Transcript

Nada Youssef:   Hi, and thank you for joining us. I'm your Host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic Main Campus here in Cleveland, Ohio. And today, we'll be chatting about the different sleep disorders and how to identify them.

Our sleep expert today is an acknowledged leader in the field, she's the Director of the Sleep Disorder Center here at Cleveland Clinic, Dr. Nancy Foldvary-Schaefer. Happy to have you.

Dr. Foldvary-Schaefer:   Thank you.

Nada Youssef:   Before we get started, please remember this is for informational purposes only, and it's not intended to replace your own physician's advice.

So before we jump into the topic, I'm going to go ahead and ask you some questions, just so the audience and I can get to know you better.

Dr. Foldvary-Schaefer:   Okay.

Nada Youssef:   So first of all, food. What is your favorite food?

Dr. Foldvary-Schaefer:   Pizza.

Nada Youssef:   Pizza.

Dr. Foldvary-Schaefer:   I love all kinds of pizza.

Nada Youssef:   What's your favorite topping?

Dr. Foldvary-Schaefer:   Probably sausage.

Nada Youssef:   Sausage.

Dr. Foldvary-Schaefer:   Just plain old cheesy sausage.

Nada Youssef:   Not cauliflower crust, you're talking about like a pizza.

Dr. Foldvary-Schaefer:   No, I'm talking about a real Chicago-style pizza.

Nada Youssef:   Good. Okay, and since we're talking about sleep, what is your bedtime and what do you do to fall asleep?

Dr. Foldvary-Schaefer:   Well, my bedtime's probably around 10 o'clock.

Nada Youssef:   Wow.

Dr. Foldvary-Schaefer:   And I read in a bed. I read books, like real books.

Nada Youssef:   Actual books, yeah.

Dr. Foldvary-Schaefer:   No electronics. So I keep electronics out of the bedroom for about an hour before I go to bed, because the light keeps you awake at night and I read just old fashioned things like classic novels and fun stuff that I don't get to read at work.

Nada Youssef:   Okay. Well, what's your favorite book? That was my next question.

Dr. Foldvary-Schaefer:   Oh my gosh.

Nada Youssef:   Do you have a favorite?

Dr. Foldvary-Schaefer:   I love Jane Eyre. I've read that many, many times. I've read, I've read a lot of the old classics, you know Dickinson and Hemingway and stuff like that.

Nada Youssef:   A lot of fiction classics. Okay, good. Great, well going back to sleep, so changes in sleep patterns or habits can negatively affect our health big time. I think a lot of people underestimate that. So I want to talk about it, because it could be, sleep deprivations can cause car accidents, relationship troubles, job performance, all kinds of stuff. So before anything, I want to talk about what is considered a sleep disorder?

Dr. Foldvary-Schaefer:   Sleep disorders, actually sleep experts will call these sleep and awake disorders, because these are a collection of disorders that either are associated with some type of abnormality in sleep or an inability to maintain wakefulness. So for example in sleep apnea, which is a very common sleep disorder, there's repeated episodes of inability to breathe during sleep and so that leads to fragmentation of sleep and therefore people don't get into deep sleep. On the other hand, a wake disorder like narcolepsy is a disorder where nighttime sleep is a little bit more normal, there's no problem breathing, but there's a difficulty maintaining wakefulness. So there's a huge spectrum of these disorders.

Nada Youssef:   Of these sleep disorders. So okay, so what happens to your body when you're not getting enough sleep, when you have a sleep disorder? What is physically happening to our brains, to our bodies?

Dr. Foldvary-Schaefer:   Yeah, so that's a great question, and to kind of flip it backwards, I like to start by just talking about the function of sleep. So for centuries people didn't really understand the function of sleep until in the 1920s for the first time a scientist recorded brainwaves and we began to learn that sleep is not the passive process, like Dracula laying in a coffin, that mankind thought it was for years. Sleep is actually an active process. There are different stages of sleep and they function to restore the brain and every cell in our bodies differently. So during sleep, every cell in our body is repairing, our body is clearing toxins from it so that we can function optimally the next day. So when we don't get sleep, chronic sleep deficiency or sleep deprivation therefore is associated with a host of medical disorders that have a common theme of inflammation, diabetes, heart disease, stroke, things like that.

Nada Youssef:   From lack of sleep?

Dr. Foldvary-Schaefer:   From lack of sleep and dysfunction of immunity for example, because again sleep functions by repairing the body. Now dementing disorders and cognitive impairment has been associated with inadequate sleep.

Nada Youssef:   Can you explain that? Is that like Alzheimer's or?

Dr. Foldvary-Schaefer:   It is Alzheimer's. So very recent, in the last five to ten years, there's been a lot of effort, research dedicated, time invested in this area and what we're learning is that people with dementing disorders like Alzheimer's have very abnormal sleep and circadian rhythms, and it may be that you can even predict who is going to have a neurodegenerative problem based on an earlier presentation of sleep disruption. The classic example of this is REM sleep behavior disorder, which is a parasomnia disorder where people, during REM sleep, lack the normal muscle paralysis of REM sleep. So they can act out very vivid dreams, which can lead to serious sleep related injuries. This has been discovered now going back over a decade ago to be a precursor to neuro degeneration. Not Alzheimer's, but Parkinson's disease and the neurological disorders that are close to Parkinson's disease. So just identifying a sleep disorder turns out to be something that can be very predictive of something serious.

Nada Youssef:   Sure. So a lot of us feel like we don't always sleep well. I was tossing and turning last night as like a one thing that happens-

Dr. Foldvary-Schaefer:   Nervous about today?

Nada Youssef:   I'm not really sure. I was like, "Why am I not sleeping?" But here is my question. What is a healthy pattern? What is healthy sleep? How many hours, and especially at what ages, because ages differ right?

Dr. Foldvary-Schaefer:   Yeah. It varies by age. I mean babies when they're born sleep 50% of their hours. Then rapidly during early development, wake time becomes longer and sleep time shortens. The average adult should be sleeping seven to nine hours. Older adults, over 60, 65, seven to eight hours. Teens in the nine to ten, eleven hour range. Littler ones even longer. So I mean the average teenager going to school, doing sports and stuff, is sleeping six and a half, seven hours. They're really sleep deprived, and sleep deprivation in that age leads to learning problems. When you're sleep deprived your brain is not working properly, attention is impaired, memory is impaired, and there are studies showing that it's better on test scores if you sleep the night before instead of pulling an all nighter.

Nada Youssef:   And studying, yeah.

Dr. Foldvary-Schaefer:   Yeah, because when you're sleep deprived, during sleep our brains lay down the memory of what we read the night before.

Nada Youssef:   Sometimes I wake up and I remember something that I was completely forgetting the night before and I was trying to remember, but I swear it's like sleeping regenerated my brain cells.

Dr. Foldvary-Schaefer:   Sleep literally lays, during sleep literally our brains, the memory circuit of our brains, work to lay down the memory and embed it in our brains as real memory. So this is one of the areas that we could be doing a lot more in, in terms of public awareness and public health, educating students and young people about how critically important it is to sleep in order to succeed in school.

Nada Youssef:   And maybe moms, because I have two little kids, five and eight, and I have to put them to bed by eight o'clock, and I wake them up at six a.m., but it's very hard to put two kids to bed in the same room and it happens. Electronics, you got TV, you got so much going on. So sleep deprivation is very important, because it also impairs alertness, just being awake, your judgments. I mean there's a lot of things that it does when you're awake, just like you mentioned. So, I've read about a study that driving while sleep deprived is more dangerous than driving after a few drinks. Is that true?

Dr. Foldvary-Schaefer:   Yeah, so there's a long body of literature on this, and some very early studies that showed that being awake for sustained number of hours, 17 or 18 hours, which is most of us in the evening right, if we're getting up at five and six o'clock in the morning, that people who are awake that long perform about the same on cognitive tests as if you were legally intoxicated. So it's dangerous driving. Now, this is a very common thing to be concerned about in the transportation industry. There are lots of regulations now for pilots and railroad drivers and-

Nada Youssef:   Truck drivers, yeah.

Dr. Foldvary-Schaefer:   Truck drivers, about the need to have rest periods in between shifts, because of the high rate of sleepiness and fatigue causing accidents.

Nada Youssef:   Right, right. Okay and then I also read that it kills sex drive.

Dr. Foldvary-Schaefer:   Yeah, so this probably relates to the fact that sleep disorders lead to inflammatory conditions in the brain that lead to vascular disease that could affect all of our organ systems.

Nada Youssef:   Everything. Right, right. So a lot of health issues will come out from this.

Dr. Foldvary-Schaefer:   Absolutely. Mm-hmm (affirmative).

Nada Youssef:   So you always hear about, "Get your beauty sleep," and then I read that it does really age your skin if you're sleep deprived. Is that also true?

Dr. Foldvary-Schaefer:   Yes, that's true too. There's much less literature on that, but that's absolutely true. Again, because when we're sleeping our cells are repairing, dead cells are getting cleared from the system, toxins are getting cleared from our body. There was a study a few years ago that was really pivotal in the neurosciences that demonstrated that when mice slept, that's when their brains cleared neurotoxins that otherwise would build up and cause Alzheimer's disease. So the idea is that sleep is really an active process. So it's not elective, it's not something that we do just because there's nothing else to do today kind of thing.

Nada Youssef:   So you were mentioning testing brainwaves, and brainwaves, is it true that it's most active when you're sleeping?

Dr. Foldvary-Schaefer:   So during stages of sleep our brainwaves are actually very active, and in REM sleep, when we dream, our brainwaves look a whole lot like when we're awake.

Nada Youssef:   Wow. Fascinating, some interesting stuff. All right. So let's talk about some sleep disorders. First of all, what common symptoms are related to sleep disorders?

Dr. Foldvary-Schaefer:   Well probably the most common ones are difficulty falling asleep, staying asleep, so nighttime awakenings, and then on the flip side, not feeling refreshed in the morning, or feeling fatigued during the day, or sleepy during the day.

Nada Youssef:   Okay. So looking at both awake and sleep, something like insomnia, could that be something that is related to poor sleep hygiene, like eating before you go to bed or the iPad or just like what you explained earlier?

Dr. Foldvary-Schaefer:   Yep. Yeah, so there's a sleep disorder that we just simply call poor sleep hygiene. These are seen in people who sort of adopt bad sleep habits and therefore it leads to secondary sleep impairment. So yeah, like having bright electronics in the room at night, having a bedroom that's just not conducive to sleep, drinking coffee and alcohol at night, which disrupt sleep. But people with insomnia also have difficulty, it's defined by difficulty initiating and maintaining sleep, and some of those folks will have very good sleep hygiene and do all the right things, but they still have an insomnia disorder.

That's sort of a mystery, but we believe there are probably inheritable tendencies for that and there may be, there are associated medical and neurological and psychiatric conditions that can lead to insomnia and perpetuate insomnia. The classic one being mental health disorders, so sometimes it's like the chicken and the egg, you have a depressed patient who can't sleep, and it's hard to know which is exacerbating the other, and the truth is that it's probably bidirectional. So when you treat depression disorders with medication, some people have improvements in their sleep, but conversely if you treat insomnia disorders in people with depression, their mood improves.

Nada Youssef:   I see. It's a vicious cycle.

Dr. Foldvary-Schaefer:   It is.

Nada Youssef:   So something like PTSD, patients would have a lot of nightmares. You're saying if you treat PTSD, their sleep will get better, which will make their PTSD better? Is that what you mean?

Dr. Foldvary-Schaefer:   There are ways to treat PTSD that in turn improve nighttime sleep. So for example there are psychotherapy mechanisms that are used in people with PTSD that allow people to work on their nightmares by sort of replaying the dream and changing the course of the dream.

Nada Youssef:   Are you talking about like a VR thing?

Dr. Foldvary-Schaefer:   Yeah.

Nada Youssef:   Yeah, I read about that as well.

Dr. Foldvary-Schaefer:   Yeah, and then in turn there are people with disorders like PTSD who have co-morbid sleep disorders like sleep apnea, and simply treating the sleep apnea helps to keep them asleep, which can help prevent their sleep disruption and improve their mental health.

Nada Youssef:   So when it comes with something like anxiety or depression, there are medications for these diseases that can cause insomnia. Isn't that correct?

Dr. Foldvary-Schaefer:   Yes. There are many medications that can cause insomnia and there are actually some medications that are used for anxiety and depression that can improve sleep as well. Sometimes people with anxiety and depression who have severe insomnia need a sleeping aid, like a sleeping pill on top of any medication you might use for anxiety or depression.

Nada Youssef:   Okay. I'm going to go down to sleep aids and treatment in a bit, but I'm going to keep going through the sleep disorders. Sleep apnea is huge. First of all what is sleep apnea and who gets sleep apnea?

Dr. Foldvary-Schaefer:   So sleep apnea is actually a generic term for a number of different disorders, but the most common of those disorders is obstructive sleep apnea. This is a disorder where during sleep the upper airway muscles are floppy such that they lose their muscle tone, such that the airway becomes collapsible in sleep. When the airway collapses on itself completely it's called an apnea. Then what happens is that when there's an apnea, oxygen levels go down, the heart rate will change, eventually the person is going to wake up and that's going to lead to a lot of what we call autonomic instability, so instability of the heart rate and oxygen levels and sleep fragmentation. So when that airway obstruction happens many times per night, sometimes hundreds of times per night, that leads to a condition where people aren't getting deep, good sleep, so they're not getting the benefits of good sleep, and they're very sleepy during the day. So the classic type of person with sleep apnea of that type is an overweight person with a larger neck, men more than women, but there's lots of interesting features about this. After menopause, women have the same rate of sleep apnea as men, regardless of how heavy their necks might be, because female sex steroids have input to the upper airway. So in the post menopausal state, without estrogen and progesterone, sleep apnea becomes more prevalent.

Sleep apnea of that obstructive type is also not uncommon in babies and kids. It's just that it can be missed because in the typical presentation, a middle aged male comes in snoring, making big sounds at night, choking in sleep, and sleepy during the day, but post menopausal women tend to not have that typical manifestation. They tend to be more tired, fatigued, may not snore that much, and so they can get misdiagnosed very easily as having a psychiatric condition when they really have sleep apnea. Similarly, the pediatric presentation of sleep apnea may be snoring, but it's not usually big choking sounds in sleep and daytime sleepiness, it's often attention deficit disorders and behavioral disorders. There's a body of literature that shows us that when you treat sleep apnea in children, you can reverse attention deficit disorder. So really attention deficit in some children may simply be a manifestation of a missed diagnosed or undiagnosed sleep disorder.

Nada Youssef:   Sleep disorder, not sleep apnea, sleep apnea being the main one?

Dr. Foldvary-Schaefer:   Sleep apnea being the prime.

Nada Youssef:   So are you telling me that some people may have sleep apnea and not know it?

Dr. Foldvary-Schaefer:   Yes.

Nada Youssef:   You're not waking up choking or gasping for air?

Dr. Foldvary-Schaefer:   Yes. In fact, studies have demonstrated that 80 to 85% of people in the U.S. in estimate with sleep apnea are undiagnosed.

Nada Youssef:   Wow. So you're looking at the symptoms that you would get from it, like ADHD for children, so then you would do a sleep test or what would you do?

Dr. Foldvary-Schaefer:   You would do a sleep test. After you took a sleep history, if you were really suspicious, looked in the airway, you might do a sleep study and you might then have that child have their tonsils removed, because tonsil or hypertrophy, big tonsils, is the main cause of sleep apnea in children.

Nada Youssef:   It's swollen?

Dr. Foldvary-Schaefer:   Yep.

Nada Youssef:   Oh wow, okay.

Dr. Foldvary-Schaefer:   And that may then reverse all the symptoms of attention deficit disorder. There's many examples of this in the sleep literature. I saw a patient the other day who had what we call refractory hypertension, so on hypertension medicines, on multiple medications and still hypertensive, with severe sleep apnea who over time came off three out of four blood pressure medicines, because we identified the sleep apnea, which was really exacerbating the condition, and treated it. So he didn't need all that blood pressure medication.

Nada Youssef:   Wow. Could it be fatal? Can you not wake up from the obstruction?

Dr. Foldvary-Schaefer:   So as humans, our anatomy and physiology is such that when our oxygen levels drop really low, there is signals in the brain to wake us up, but there are certainly situations, including some famous people like Carrie Fisher, there was a question of whether she had sleep apnea. So there are people who either die in their sleep or die suddenly and the pathology suggests that it might have been due or exacerbated by sleep apnea.

Nada Youssef:   So there are new implants out there, correct, for sleep apnea?

Dr. Foldvary-Schaefer:   Yes. So there is an FDA approved implant that came out a couple of years ago that's still gaining a lot of momentum. It's called hypoglossal nerve stimulation and the hypoglossal nerve is one of our cranial nerves, so it comes out of the brainstem and innervates the tongue. Some of the branches of this nerve allow the tongue to protrude sort of out of the mouth. So this stimulator is implanted like a pacemaker would be, under the clavicle, and there is a sensor that goes in between the two ribs on the chest wall that senses an obstructive apnea and then will stimulate the nerve during sleep-

Nada Youssef:   That will make your tongue move.

Dr. Foldvary-Schaefer:   Make the tongue advance forward a little bit, creating space in the back of the airway. So our center has done many of these now and almost everybody that's had an implantation with this device has a significant improvement or complete resolution of their obstructive sleep apnea.

Nada Youssef:   Amazing, and we actually have a podcast and a Facebook Live for our audience if they want to hear about more, about adult sleep apnea. We have another podcast for that as well. So restless leg syndrome, can you explain what that is? I mean it sounds kind of to the point, but why is that a disorder?

Dr. Foldvary-Schaefer:   Well this is a disorder that has what we call a circadian pattern. So restless legs is condition where people will get an irresistible need to move the legs at night and being circadian, it tends to come up in the evening time, seven, eight, nine, ten o'clock at night. That urge to move the legs is intense. It is associated with movement, so people need to move to make the symptom improve. It tends to happen at night, so it tends to happen in bed. So people will get into bed and suddenly their legs start getting feeling irritated and they have to move, many people will have to get out of bed and walk. Once people fall asleep, it can be associated with periodic movements of the limbs that we measure in the sleep laboratory during sleep tests, and this can lead to difficulty falling asleep or difficulty maintaining sleep. It's important because 15% of adults get restless legs and it increases as we get older. So many older people, we believe, who have sleep problems, or just tend to be poor sleepers, probably have restless legs. Very treatable condition almost all the time.

Nada Youssef:   Oh good. So you get an urge from both legs that they need to move, to get up and move.

Dr. Foldvary-Schaefer:   Mm-hmm (affirmative).

Nada Youssef:   Is there a reason? Is there a certain risk factors?

Dr. Foldvary-Schaefer:   Yes. Yeah so there's primary restless legs and there are many secondary causes of restless legs. So for example restless legs is sort of classically seen in people with kidney disease, in pregnant women, in people with iron deficiency, and iron turns out to be part of the pathway in the brain that leads to restless legs. So people with iron deficiency and who are low on an iron transport molecule that enhances dopamine in the brain tend to be prone to restless legs and restless legs can be inherited. So it can run in families, and when it runs in families it can present earlier and earlier. So there are young people in their teens and 20s that can present with restless legs too. In its severest form, it's a horrible condition. It really drives people.

Nada Youssef:   It sounds unusual that you feel like you want to get up when you're sleeping. I mean I can imagine.

Dr. Foldvary-Schaefer:   I mean, imagine if you just want to stretch your legs and your legs are like strapped in bed or something and you can't move, but you just need to move. It's like that irritating, irresistible need to move.

Nada Youssef:   Yeah. Okay I'm going to jump to sleep paralysis, because I've had it a few times when I first had my kids, and I was exactly what you just said, I felt like I can't move though. You know, you just feel kind of still like your brain is awake, your eyes a little bit awake, but everything is stuck. So can you talk about sleep paralysis, is there a demon in the room, what's happening? I read weird stuff about it.

Dr. Foldvary-Schaefer:   Yeah. So there are people who have what we call isolated sleep paralysis, and these are probably normal people who occasionally will wake up abruptly out of REM sleep, and in REM sleep our bodies are paralyzed. So the physiology of REM sleep, dream sleep, is such that our brains are active, there tends to be a lot of dream imagery. A part of normal REM, which is a protective mechanism, is that the muscles are paralyzed so we cannot act out dreams.

Nada Youssef:   So you don't get up and so, yeah.

Dr. Foldvary-Schaefer:   Yeah and so in isolated sleep paralysis, or sleep paralysis that can happen in people who are very sleep deprived, or maybe in the setting of alcohol ingestion and you wake up suddenly during the night and you're in REM, your brain feels like you're awake, but you can't move. It's usually a very terrifying experience and it usually feels, most people will describe a sense of suffocation, because they actually feel like they can't fill their lungs with air and sometimes associated with it can be a hallucination, like if somebody's watching in the distance or something's crawling on me, and a feeling.

Nada Youssef:   You see a shadow, and yeah, yeah.

Dr. Foldvary-Schaefer:   Yeah.

Nada Youssef:   Okay, so with sleep paralysis, if someone is going through it, how are you supposed to wake yourself up if you're in this terrifying state of I want to freak out, to wake up?

Dr. Foldvary-Schaefer:   So if you're awake, it's a matter of really trying to stay calm and most people with sleep paralysis, and this is actually mostly in narcolepsy patients who get sleep paralysis, will find that they slowly start to move muscles and intentionally move muscles. So they're laying there unable to move, but they'll often tell themselves, "Okay, I'm going to try to move my right thumb right now." And sort of work through it. Then now I can move my right hand and now I can move my right arm, and it does take a few minutes to resolve. People with narcolepsy get sleep paralysis as part of their syndrome, because people with narcolepsy have a dysfunction in the chemistry, the neural chemistry of the brain, that doesn't allow them to maintain sleep or maintain wake. So they flip flop a lot from lighter stages of sleep and wakefulness to REM. So as they're flipping a lot, they can wake from REM and have something like sleep paralysis.

Nada Youssef:   It sounds like a limbo state almost. You're not fully awake, you're not fully asleep.

Dr. Foldvary-Schaefer:   Yes, exactly.

Nada Youssef:   Let's talk about narcolepsy. Warning signs, because I mean you get tired during the day, but you're absolutely falling asleep during a drive, during work, what is narcolepsy?

Dr. Foldvary-Schaefer:   Yeah, so narcolepsy can present with a broad spectrum. So most people, when we see them in the clinic and we tell them that we suspect narcolepsy, most are really surprised and they'll say, "Well I don't just fall asleep in my food. I don't just collapse." Very few people just abruptly collapse in their food or behind the wheel. Most people struggle to stay awake during the day and have difficulty functioning simply because they're so sleepy, more than fatigued, but very sleepy. They take naps that are refreshing for short periods of time, but not for long. At night they tend to have very fragmented sleep. They're not like you think the textbook person would be, a deep sleeper, a person that craves sleep all the time and sleep beautifully.

Narcoleptic people actually have very dysfunctional sleep and they don't sleep solidly at night, but they also, their brains crave REM sleep and their brains want them to be in REM sleep during the day. That's where some of the co-morbidities come into play, because they have a high rate of accidents, they have trouble performing academically, they have trouble performing occupationally. Yet because many people don't talk to their doctors about my trouble staying awake during the day, and don't recognize that it could be a serious condition, most people go for ten, fifteen years without a diagnosis.

Nada Youssef:   Wow. So I wanted to jump back to the naps. You talked about the nap really fast. People with narcolepsy, are they taking long naps? You said short naps are kind of powerful. What is a good nap?

Dr. Foldvary-Schaefer:   Yeah, so short naps for narcolepsy, some narcolepsy patients are sleeping one, two, three hours during the day, but really many of them will tell us that a 20, 30 minutes nap if very refreshing. Sometimes a five minutes nap can be very refreshing.

Nada Youssef:   For a narcoleptic.

Dr. Foldvary-Schaefer:   Yes, yes. So in general, napping is okay, but when we let ourselves nap longer, probably 20 minutes is a good cut off.

Nada Youssef:   20 minutes?

Dr. Foldvary-Schaefer:   When we let ourselves sleep longer, we risk going into deep delta sleep, slow wave sleep. When we go into slow wave sleep during the day, we can wake up and have what's called sleep inertia, that groggy brain where you wish you didn't nap because you feel worse now. So for people who work and are in school and stuff, it's probably best to limit naps, like set a timer and limit naps to 20 minutes so that one is not waking up from slow wave sleep.

Nada Youssef:   Okay. I want to go back to what you said about the textbook sleep cycle. I've read that, I don't even know how long ago, the sleep cycle was, but was it completely cut up where people used to sleep at like nine or ten, wake up at one or two, maybe have something to eat and go back to bed?

Dr. Foldvary-Schaefer:   Yeah so this is the two sleeps. The first sleep and the second sleep. Yeah.

Nada Youssef:   Yeah, is that normal? Should we go back to that?

Dr. Foldvary-Schaefer:   Well yeah. So this is fun. It's fun to think about this. So before the invention of the light bulb people slept longer, so in America adults slept probably nine hours on average before the 24/7 world we live in now. Historically people used to have two sleeps. The first sleep and then there'd be a period of activity, getting things done for a couple of hours, and then the second sleep period. So there are some insomnia researchers and experts who really feel that some people with insomnia, we've sort of created this insomnia disorder by having this high expectation that we're going to sleep eight hours and we're going to be sound asleep for eight hours. So biologically it might not be that we were really born to sleep that way.

Nada Youssef:   So we should probably start work at ten or eleven, because we won't be up by eight.

Dr. Foldvary-Schaefer:   Yes.

Nada Youssef:   Yeah, that makes sense. So let's go back to that, a little bit about oversleeping. Is oversleeping as bad as sleep deprived?

Dr. Foldvary-Schaefer:   Probably not. There's much less literature and research on oversleeping. So really, I think what we know is that chronic over sleepers, people who are sleeping nine, ten hours, eleven hours, tend to have medical issues and psychiatric issues. So chronic oversleeping is not uncommon in people with significant mental health problems like depression or really chronic diseases.

Nada Youssef:   So is nine hours, for me, oversleeping? Are we talking about twelve hours?

Dr. Foldvary-Schaefer:   Probably we're talking about over nine hours regularly.

Nada Youssef:   Over nine hours?

Dr. Foldvary-Schaefer:   Because seven to nine hours would be considered normal.

Nada Youssef:   Okay, okay.

Dr. Foldvary-Schaefer:   Now having said that, our sleep needs are genetically wired. So there are normal people who are genetically wired to be ten hour sleepers. They function beautifully during the day, but ten hours is about what they need. That's probably one percent of the adult population though. The vast majority of us as adults probably need somewhere in the range of seven to nine hours.

Oversleeping done, oversleeping chronically seems to not be considered a good thing, because it tends to be associated with other health conditions and shorter lifespan, and it's probably because the long sleeping just becomes a lifestyle of having chronic conditions and perhaps being awake and exercising and being more mobile, these are things that are associated with better quality of life and longer longevity. But oversleeping once in a while, like oversleeping on a Saturday because we get sleep deprived-

Nada Youssef:   Catch up?

Dr. Foldvary-Schaefer:   Yeah, there's some literature suggesting that that's okay and that's probably good. The problem comes in if we oversleep every Saturday and every Sunday and then you can't get to sleep on Sunday night and so then you're starting your week off poorly. So I think it's really important to just pay attention to that, because we can never make up all the sleep we lose.

Nada Youssef:   But we might be able to make up a little bit.

Dr. Foldvary-Schaefer:   We might be able to make up a little bit.

Nada Youssef:   Okay, so take your naps and sleep in on the weekends. Do you deal with any pediatric patients?

Dr. Foldvary-Schaefer:   Well we do in our center. I don't personally do pediatric, but we do treat pediatric sleep disorders.

Nada Youssef:   I wanted to talk a little bit about sleepwalking and especially night terrors for kids, because my oldest went through both. It was only the one child and it's terrifying as a mom. You're like do I wake her up, do I soothe her back to bed? What is going on in their brains, especially with sleepwalking, even with adults? Sleep eating, there's all kinds of stuff.

Dr. Foldvary-Schaefer:   Yes, yes. So these are called disorders of arousal. They're called parasomnias. Abnormal behaviors and emotional experiences that happen surrounding sleep and awake. So classically these present in young children, but adults can present with night terrors, for the first time in their life as well, and sleepwalking. These disorders tend to present in younger ages. They are probably genetically inherited and what's happening is that there is a disordered arousal. So this is where the brain waves wake up and behaviors emerge when normally they wouldn't. So people will night terrors will wake up and not really be awake. They will look behaviorally awake, but not be conscious, and they're truly terrified. So most of these children cannot be consoled and you really just have to wait it out, which is probably very scary as a parent.

Nada Youssef:   It's terrifying, yeah. You want to wake them up, but you feel like exactly what you said, it's a state that they're already really shook up.

Dr. Foldvary-Schaefer:   Yes and when you do try to shake someone out of it, and this happens with sleepwalkers, like you'll try to shake someone awake, the brain that's really still asleep is going to respond in a defensive way. It's going to feel threatened. So it's much more dangerous to really interact and shake someone awake. Much better to just allow the episode to go, sort of pass on its own. Make sure the person is safe, but not get too close and not really scream at them or shake them, because people can get hurt.

Nada Youssef:   That's very good to know. I know you were mentioning night terrors in adults, is that the same thing as a nightmare then? Or what is a night terror for an adult?

Dr. Foldvary-Schaefer:   No. So night terrors and confusional arousal's and sleepwalking are all occurring during non-REM sleep, deep non-REM or what we call delta sleep, also known as slow wave sleep. So these are disorders where the brain is waking up and acting out during non-REM sleep. A nightmare comes from REM sleep.

Nada Youssef:   I see, because it's easy to wake up from it, right?

Dr. Foldvary-Schaefer:   Yes and people with nightmares therefore remember that imagery, whereas people who have night terrors and sleepwalking tend to have little if any recollection of what happened the night before.

Nada Youssef:   Oh wow.

Dr. Foldvary-Schaefer:   So people with nightmares, because of the way dreaming happens in such an elaborate way in REM, when they do wake up from a nightmare, they remember a lot of it.

Nada Youssef:   Yeah. Now I know there's not a lot of research about dreams, but I'm wondering, I want to pick your brain. Is dreaming, does it have something to do with the whole sleep, is it just an insignificant thing that we do in REM or what do you think about dreaming?

Dr. Foldvary-Schaefer:   Yeah, well dreaming is part and parcel of REM sleep and it has to do with the physiology of the way REM sleep is constructed with a lot of brain activity that is very close to wakefulness and a lot of emotional component to it as well. So dreaming is something that is still very poorly understood and it's a manifestation of the memory sort of consolidation that happens primarily during REM sleep.

Nada Youssef:   Very, very interesting. I want to go back and talk about circadian rhythm disorder. So people that have maybe jet lag, the time change, or shift work, something like that, is that a disorder that you can get just from that?

Dr. Foldvary-Schaefer:   Yes. So circadian rhythm disorders, again there's a group of them, these are disorders where the timing of sleep is abnormal. So jet lag is sort of a transient example of that. When we travel across multiple time zones and the timing of sleep therefore has to be adjusted, but our brains work on a circadian rhythm, our brains and bodies have multiple clocks in our bodies and our brains that regulate processes. So traveling across multiple time zones makes it really challenging to acclimate quickly and adopt the new time zone. So that's really what jet lag is. Shift work also is a circadian rhythm disorder. When people are chronically working a night shift and really our brains should be sleeping on nights, that can pose problems with performance, because people don't sleep as well during the daytime hours as they would during the night.

The other circadian rhythm disorders, one is called advanced sleep phase and delayed sleep phase. So delayed sleep phase is sort of the night owl, this presents in usually teens and young adults. These are people who probably have some genetic tendency to have altered timing of sleep, which can become a huge problem. If you are 25 years old, you graduate from college, get your first job, but your brain will not let you fall asleep before three in the morning and it wants to sleep until eleven o'clock the next day. So these are disorders that have to do with the timing of sleep more so than the quality of sleep, like sleep apnea.

Nada Youssef:   Okay and their brains are actually shutting off. So I've read that if it takes you less than ten to fifteen minutes to fall asleep when you put your head on the pillow, you're sleep deprived.

Dr. Foldvary-Schaefer:   That's probably true most of the time. In normal sleep pattern studies, it takes ten or fifteen minutes usually for an adult to fall asleep. So if you're hitting the pillow and you're out like a light on a regular basis, you are probably sleep deprived.

Nada Youssef:   Okay so if I feel like I may have something wrong with my sleep, but you can't really remember, you're always in the limbo stage of sleeping anyways, is a sleep diary a smart thing to do? If you can explain what a sleep diary is and how it should be used.

Dr. Foldvary-Schaefer:   Yeah. So there's many ways to log sleep. Traditionally we've used diaries, people will keep a journal and make notes. So write down when I went to bed last night, when I woke up, did I take a nap, how many times did I wake up? That kind of chronic journaling is very useful when we have trouble diagnosing disorders like circadian rhythm disorders, that ten to be disorders that need to be diagnosed by understanding sleep over a long period of time, as opposed to doing a sleep study one night and diagnosing sleep apnea for example. Now with sleep trackers and Fitbits and all kinds of ways to track sleep.

Nada Youssef:   I was just going to say, it tells you how long you've been on REM, if you've been deep, it's insane.

Dr. Foldvary-Schaefer:   Yeah, so now people are using these to help track their sleep. There are some studies that are suggesting a reasonable correlation between data on a Fitbit for example compared to a sleep lab study, but not really great correlations yet. So I think this is an early area of sleep research. We need to do a lot more work on this, but what's great about tracking is that more and more people are doing it because they're recognizing that sleep is as important as diet and exercise. It's a triad and you really can't have-

Nada Youssef:   One without the other?

Dr. Foldvary-Schaefer:   wellness without all three.

Nada Youssef:   I agree.

Dr. Foldvary-Schaefer:   And you really can't have good nutrition without sleep, because sleep actually regulates a lot of aspects of the microbiome and our dietary choices and our digestion. So they are really connected and so it's great to see that people are watching their data. We don't always have good answers for them when they bring their Fitbit data to the sleep clinic, but still it's important that it's becoming on the radar screen for good health.

Nada Youssef:   Right, right. That's good and sleep deprivation can cause weight gain as well and can cause you to crave junk food, which we already crave all the time.

Dr. Foldvary-Schaefer:   Yes, so you're becoming a sleep expert.

Nada Youssef:   Yes a little bit. Okay so how to get a diagnosis. Take my sleep diary, go see a specialist, and get a sleep test? Is that how?

Dr. Foldvary-Schaefer:   It depends on the disorder. So for insomnia there's no need for a sleep test. It's a clinical diagnosis, we love sleep diaries to compliment, and we can make that diagnosis in the sleep clinic with an interview, like we're talking right now. For sleep apnea, you need a sleep test. For other disorders like narcolepsy you need more than a simple sleep test. You need an overnight study with a daytime study that monitors nighttime sleep and then tendency to fall asleep during the day. So what's really important I think about this question is that there are many different types of sleep disorders and there's not one size fits all for a test. When people come to sleep disorder centers, they should expect to really have their testing tailored to their problem.

Nada Youssef:   Sure, and we do that here at the Cleveland Clinic, correct?

Dr. Foldvary-Schaefer:   Yes, we do.

Nada Youssef:   Okay, great. Now I want to talk about medical treatments. I've read quite a bit about melatonin, you know it's right off the counter, you can just get it from CVS, but before you go snatching up Ambiens and things like that, I've heard really scary side effects. What do you think about that, because it kind of sounds counterintuitive for a sleeping pill?

Dr. Foldvary-Schaefer:   Yes. So insomnia effects 30% of the population. So at any given time in ones life, the majority of people have had some sleepless nights and reached for Benadryl over the counter, and Unisom, and all of these products that are over the counter, melatonin, and asked their doctors for sleep aids. Several big studies and meta analyses have shown that behavioral therapy, what we call cognitive behavioral therapy, works better or as well as sleeping pills, but works better and longer, and of course without the side effects.

Nada Youssef:   Okay go ahead and tell us what it is. What is cognitive therapy?

Dr. Foldvary-Schaefer:   So this is CBTI, Cognitive Behavioral Therapy for Insomnia, is essentially a form of behavioral therapy for sleep disorders. So there are behavioral sleep medicine specialists, we've got one in our group who's a psychologist and she specializes in this, and behavioral sleep medicine experts use behavioral strategies, psychological treatments, to treat sleep disorders. So for example the insomniac who lays in bed until they get so frustrated that they're crying because they're so frustrated by not being able to sleep, there's a simple therapy called sleep restriction therapy.

We ask people to not lay in bed awake, because the bed should be a pleasant place to be. When we get into bed at night and crawl under the covers, we should be feeling happy and sleepy, right, like sleep is coming. If, when that happens, the brain is wide awake worrying and ruminating and wondering, "When am I going to go to sleep?", and counting sheep and being very active and frustrated, it's not the place to be. You need to get out of bed, wind down, and get back into bed. So that's just one example of a behavioral strategy that works very, very well for chronic insomniacs, that probably works better than Ambien.

Nada Youssef:   Good, good. That's excellent. So how about something like meditation? How about pink noise? Any of that stuff you think would help as well? Is that a form of therapy?

Dr. Foldvary-Schaefer:   Yes and that's part of the therapy. So another example is progressive muscle relaxation, teaching people to meditate and relax their muscles at night, that's another therapy. Another part of cognitive behavioral therapy is making sure that your bedroom is conducive to sleep. So whether it's the noise, the temperature, the bedding, the pillow, the bed partner-

Nada Youssef:   The baby sleeping next to you in the bed.

Dr. Foldvary-Schaefer:   The baby, the dog in the bed, I mean all of these, the coffee cup or whatever, the diet coke at the bedside, all of these things are things that promote bad sleep hygiene and some of us can get away with it. I mean some of us are good sleepers and we can sleep through a lot, but people who are insomniacs cannot. So they really have to pay attention to the bedroom environment and that's what sleep hygiene is.

Nada Youssef:   Okay so light sleeper versus deep sleeper. If I'm a light sleeper, does that mean something is wrong with me or is this how I'm wired?

Dr. Foldvary-Schaefer:   It may simply be that that's how you're wired. It may be though that you have a mild form of insomnia and it really hasn't been diagnosed. Light sleepers are going to be more likely to be disrupted by things in the environment and have to pay more attention to that.

Nada Youssef:   I think also having little kids at home, I hear. If there's any movement I tend to wake up more. I think it's since I've been a mother that's happened.

Dr. Foldvary-Schaefer:   Yes.

Nada Youssef:   Let's talk about the importance of diet and exercise for sleep.

Dr. Foldvary-Schaefer:   Yes, yes. So again, these things are sort of intimately connected and we're just now learning about how nutrition and digestion relates with sleep. So that's another area of sleep research that's in its infancy, but there's no doubt about it that when we eat too late and when we exercise too late, close to bedtime, those things will disrupt sleep. So eating healthy is important and not eating after probably eight o'clock at night. Some people actually do those twelve hour fasts now, which are healthy. In terms of exercise, exercise is really good to promote good sleep for insomniacs, but it needs to be done early in the day. It can't be that you're on your treadmill at seven, eight, nine o'clock. It gets you going.

Nada Youssef:   So with diet, and obviously avoid caffeine, maybe like spicy food, things that are heavy, alcohol, is there anything-

Dr. Foldvary-Schaefer:   High carbs.

Nada Youssef:   High carbs? Okay. So is there any kind of food that you should go for that makes you sleepier or puts you to bed? I heard seafood or some kind of fish can make you more sleepier.

Dr. Foldvary-Schaefer:   Yeah, I'm not sure there's any research. I'm not sure there's any research on that, but I think nowadays people are going toward chamomile and teas that are non-caffeinated, that are soothing, and that's all part of sort of the building a sleep ritual. So if you have trouble sleeping, it's really important to give yourself that wind down time. So I used to sit in bed on my laptop, like up to the very minute I wanted to go to sleep. As you get older, you find that you can't do that as readily. Some people can, but anyway it's healthy to stop what we're doing, let our work day end a couple hours before bedtime, and give ourselves the luxury of having some wind down time. That might be having tea, a hot bath, getting into your favorite pajamas, getting your good book going. These things are not important or necessary for some people who are great sleepers, but invariably as we get older, all of our sleep rhythms tend to get a little bit more fragile, and so it really becomes important to have sort of a ritual around falling asleep.

Nada Youssef:   Okay one last question for you before you leave. How long should the wind down time be? If you're going to go read a book, you're going to meditate, you're going to take a warm bath, how long should you give yourself before you sleep?

Dr. Foldvary-Schaefer:   You know for me it's ten, fifteen minutes.

Nada Youssef:   Oh, okay.

Dr. Foldvary-Schaefer:   For me it's not long.

Nada Youssef:   I see.

Dr. Foldvary-Schaefer:   But there are insomniacs who really have to work hard at this and to decide I'm going to do my worry journal, this is another good one for insomniacs.

Nada Youssef:   A worry journal?

Dr. Foldvary-Schaefer:   Yeah. So insomniacs tend to, when they're awake at night, they tend to ruminate and start thinking about, "I'm awake, so what's going to happen tomorrow? What do I have to do tomorrow? How am I going to feel? I'm going to feel so bad tomorrow." So one of the other strategies of cognitive behavioral therapy is to, if you're a worrier at night and it's affecting your sleep, is to work on that during the day. So we used to call it a worry journal.

Nada Youssef:   You write it out?

Dr. Foldvary-Schaefer:   Yeah, write it out. Make notes.

Nada Youssef:   The middle of the night, you wake up, you're worried about something, write it out and you'll read it in the morning?

Dr. Foldvary-Schaefer:   This is something better to do during the day.

Nada Youssef:   Oh, okay.

Dr. Foldvary-Schaefer:   So it's like planning your next day. You don't plan your next day in bed at ten o'clock at night. Better to plan it a few hours earlier. If you need to write down some things that are bothering you or make your list of things to do, don't do that right before bedtime.

Nada Youssef:   Okay, great. All right. Well we're out of time. Thank you so much for coming back and speaking to us.

Dr. Foldvary-Schaefer:   Oh, you're welcome.

Nada Youssef:   This is very, very important information.

Dr. Foldvary-Schaefer:   It was fun.

Nada Youssef:   I'm sure we'll do it again.

Dr. Foldvary-Schaefer:   Thank you. It was fun.

Nada Youssef:   Thank you. For more information or to make an appointment, call 866-588-2264 or you can visit www.Clevelandclinic.org/sleep and to listen to more of our health essentials podcast from our Cleveland Clinic experts, make sure you go to Clevelandclinic.org/HEPodcast or you can subscribe on iTunes or Spotify. For more health tips, news and information, don't forget to follow us on Facebook, Twitter, Snapchat, and Instagram, @ClevelandClinic, just one word. Thank you, we'll see you again next time.