Sleep disruptions have unexpected and serious impacts on the health of your brain. Dr. Ana Krieger, Chief of Sleep Neurology at Weill Cornell Medicine, explains why snoring is a danger sign for sleep apnea affecting 40 million Americans -- and why "getting by" on 6 hours of sleep a night is a risk you probably shouldn't take.
Dr. Stieg: Welcome. I'm with Dr. Ana Krieger, the Medical Director of the Weill Cornell Center for Sleep Medicine and Associate Professor of Clinical Medicine in the Departments of Medicine, Neurology, and Genetic Medicine. Over the past 20 years, Dr. Krieger has been actively involved in patient care, training of sleep specialists, sleep disorders, education and scientific research. Dr. Krieger is a regular contributor in the media to increase public awareness of obstructive sleep apnea and other sleep problems as well as the latest treatment alternatives. We are also joined by one of Ana's patients, Stephen Allen. Stephen is in senior management at Ralph Pucci Furniture and Design Showroom in Manhattan, specializing in high end French and other modernist design. Welcome to both of you. Sleep apnea is a huge problem throughout the world, but a lot of people don't really want to admit it. They don't want to talk about it. How prevalent is it?
Dr. Krieger: Sleep apnea is quite prevalent. It seems interesting because for many years we've felt that snoring was very common and we took for granted and accepted it as potentially normal and now that we have tools for diagnosing it, we believe that over 40 million people in this country are suffering from sleep apnea. What are the biggest factors that led to increase diagnoses of sleep apnea was this obesity epidemic and that is what actually triggered a lot of programs like ours and we are able to find out through this program is that a lot of people don't actually have a sleep apnea just because of obesity. They may just have sleep apnea because of their own anatomy. There are groups of course, men over 50 if they have high blood pressure, we know that they have higher chance of having sleep apnea. If people are overweight and have diabetes for instance, is another group of patients that we know have high rates of sleep apnea. We have children with sleep apnea. We have patients as old as a hundred that get the initial diagnosis sleep apnea close to their a hundredth birthday. Yeah, it's fascinating and it's interesting because in women we get to see that as sleep apnea sometimes develop after menopause.
Dr. Stieg: Are there specific risk factors for developing? Can I do something that would induce me to develop sleep apnea?
Dr. Krieger: Definitely gaining weight increases the chance of people developing apnea and moreso in men than women, but other factors are not necessarily is it to change. As you get older you have perhaps the hypertension, so there are some intrinsic risk factors that are really hard to modify and that's why we're very concerned about properly diagnosing people because you can't necessarily make the apnea go away.
Dr. Stieg: I'm a little bit perplexed by, even in my patient population, when someone comes in, they get an operation and postoperatively while they're in the ICU we find out, gosh, they've got sleep apnea or they've got obstructive sleep apnea and we have to start treating them. What, what is this lack of understanding? Is it denial or is it a lack of understanding? What process do you find going on with your patients?
Dr. Krieger: I think sometimes people are not aware of their disease, similar to having high blood pressure, high cholesterol, and as that gets checked, people really don't know that that's an issue that we are so sleep deprived nowadays that it's hard for people to really say, Oh, something medically is going on besides the sleep deprivation, how many hours should I be sleeping every night? Well, that's very interesting because probably between seven and eight but that changes depending on your activities, on your age, on your health and your genetics, but that's what typically we recommend for people, between seven and eight hours.
Dr. Stieg: What are some of the greatest myths that you see out there about obstructive sleep apnea patients come to you and they have this misunderstanding? What are those?
Dr. Krieger: Well, I think one of the biggest myths is that snoring is normal just because it was socially acceptable before. I think somehow it isn't anymore.
Dr. Stieg: So I'm going to be a little bit personal here and we always used to tease my dad. He was 95 years old and he'd sit in the chair and his head would fall back and we would tease him because he had, we'd call it pooing and gooing. Is that snoring?
Dr. Krieger: Yeah. Then probably a little more than that. It's probably the airway is closed and he might be choking. Right?
Dr. Stieg: He always woke up fresh.
Dr. Krieger: Right? It is interesting because I had, one of the most interesting cases I ever treated was an elderly woman in her mid eighties that the son was an EMS provider and he would resuscitate her because she arrested at home and they always believed it was a cardiac arrest, was that it made it multiple times. Had pacemaker implanted was in and out of the hospital up to one time and one of her primary care providers sad. You know Ana, "I don't know what else to do. Can you just do a sleep study on her?" And she had, she would be choking to the point that her heart would stop.
Dr. Stieg: So as you said, many patients don't even know that they have sleep apnea. I would
presume then it's important for our partners to say, you know, we need to go get a doctor. Right? Is that hard for them to do?
Dr. Krieger: Well, I think it's harder for people to accept, you know, I think the partners sometimes are pretty vocal. They record, you know, we have tape recording nowadays and then people say, Oh no, no, no, that's really not a big deal. Or maybe that day I drank too much or maybe I ate too late so they blaming other factors that may actually worse than apnea but may not necessarily be the only cause
Dr. Stieg: Given one of my main tenets is brain health. What is the advantage to early detection? Why should either, I admit I've got it, or my mates say, listen, you need to go get help.
Dr. Krieger: Well one of the biggest issues is that for people that have sleep apnea, there are two major factors that happen during the night. One is that intermittently their oxygen levels drop. So we know for brain health that is really not desirable, in the second aspect is in order to improve their breathing. So they, when they are choking and making big, loud efforts to breathe, they wake themselves up from sleep even if they are not aware of. And that leads to sleep fragmentation, which is also not good for brain health.
Dr. Stieg: So I want to bring Steven into this since he lives with it, lived it. Stephen, tell us a little bit about what were your symptoms? Why did you go see Dr. Krieger?
Stephen Allen: I wasn't at all aware of my snoring as you were just saying. And my wife would wake me up in the middle of the night and say, you know you're snoring.
Dr. Stieg: So was that a gentle nudge? Was it a kick? Was it a punch? Thrown out of bed?
Stephen Allen: It didn't start off to be gentle. I can't blame her. I spoke to her about it. I said, "I'm not snoring." And she said, "Yes you are." And I said, "Would you be a little kinder when you wake me up?" So then it was a soft touch, and "Honey, you're snoring." So I appreciated that, but then it was back to the shaking me awake again and I said, what are you doing? And she goes, you're gasping for air. And she said, promise me you'll get this checked out.
Dr. Stieg: As an aside, Ana, how common is it for sleep apnea to cause marital difficulties?
Dr. Krieger: Well, it's actually very common. Not necessarily difficulties, but people move to different
bedrooms often, and a different bed, you know, it's very, very common because of that.
Dr. Stieg: Is that good for a marriage or bad? Don't answer that.
Stephen Allen: If I could add to that, that was an option, but I didn't want that to happen. So I kept my promise because I didn't want a separate bedroom just because I snore. I felt like an outcast or something was wrong with me and it was causing a problem in the marriage. So I was in denial. As you mentioned earlier, my father snored, my sister snores, snoring was a part of growing up in my household.
Dr. Stieg: So it seems to me that even I, not a sleep expert could probably make your diagnosis. You know, your wife's waking you up, you're snoring. That's pretty straight forward that it need to be tested. And I'm presuming the first thing you did was a sleep study. What's that like?
Stephen Allen: It's unusual where you're being hooked up to a little electrode wires all over your body. As a with an echocardiogram, the little electrical pod, things that stick to you everywhere. It takes about 45 minutes to get all hooked up before you actually get in bed and the study begins.
Dr. Stieg: Ana, is this covered by insurance?
Dr. Krieger: Yes, overnight sleep studies and mostly covered although over the past five to seven years, regulations have changed. The insurances are trying to cut costs so they are trying to move the bulk of those statuses back to the home environment.
Dr. Stieg: The bulk of the tests in the home environment? But it's not as though patients have to come in and pay for this stuff.
Dr. Krieger: Yes, no — it has always been covered to some degree. At least, again, policies are constantly changing, but it is a covered evaluation.
Dr. Stieg: Steven, it's obvious that you find out that you had sleep apnea. Where do you go? You go to a shop and they got 20 different little devices that you can pick from. How do you go about?
Stephen Allen: Well actually, Dr. Krieger has a very thorough office and she had several machines to pick from. I chose the mask that was as simple as possible, the newest technology, which Dr. Krieger also was able to supply for me, and I tried the mask and the machine. I fell in love.
Dr. Stieg: Is it like the Rolls-Royce version, the Chevy version, and the Mercedes version, or are they all the same price and you just got to pick one that fits your face?
Dr. Krieger: I think choosing what works best for you is the most important because it's very hard for us. We could say this is the latest model and the best technology, but if it doesn't fit to our patient, it's really not going to work.
Dr. Stieg: Every time I think about the patient or I have my patients sitting in the ICU with one of these CPAP machines on, you know, I think, gosh, what's that like to live with at home? What kind of fears did you have when you're thinking about now? I gotta take this thing home. And you wear it all night?
Stephen Allen: Absolutely. When I don't wear it I snore.
Dr. Stieg: Pre-use did you go through any anxiety and thought process about, gosh, how's this going to change my life?
Stephen Allen: I wasn't so concerned about me, but I was more concerned about when my wife looks over at me in bed with this mask on, what is she going to think? So I found myself trying not to put the mask on until I knew my wife was asleep.
Dr. Stieg: But what would happen is I would go to sleep first and she would end up nudging me, say, put your mask on. So I got over that because she was getting a good night's sleep. I was getting a good night's sleep. So the fear of, "Did she marry a Frankenstein" now passed quickly after the results were evident.
Dr. Stieg: So you have the Mother Teresa award in your household for your wife I gather?
Stephen Allen: Absolutely.
Dr. Stieg: Does the machine or the process make noise?
Stephen Allen: It's a very low hum.
Dr. Stieg: So it's white noise.
Stephen Allen: It's a white noise.
Dr. Stieg: And when you're wrong through the mask, it's not as though you still sound like Darth Vader.
Stephen Allen: No, no. If it's an improper fit, absolutely.
Dr. Stieg: So it doesn't disturb the person with you?
Stephen Allen: No, it doesn't.
Dr. Stieg: Is this machine you just put the mask on and flip it on or is it complex to use?
Stephen Allen: Once you put the mask on, it senses that you have it on and it will start off slowly and build up to full speed as your breathing becomes more normal. It was easy for me to adjust to the mask because I breathe in and out of my nose. Unlike some people that are mouth breathers, years of yoga helped me train myself to breathe in, and breathe out through my nose and sometimes if I am a little anxious, I start the breathing techniques from yoga classes and the machine just accelerates that to help me really relax and I'm getting a very restful sleep.
Dr. Stieg: Stephen, this is, I presume, been transformative for you. How has it changed your life?
Stephen Allen: I feel much better. My wife feels much better.
Dr. Stieg: What advice would you give to somebody about this? How are you going to help us motivate people to get help?
Stephen Allen: Looking at my experience and the way I have improved my health, it's a life changing experience for both your partner and yourself.
Dr. Stieg: Before we get into insomnia, can you describe the physiology of the normal sleep cycle? What language do you use to explain to your patients?
Dr. Krieger: One of the most important things about sleep is that sleep is necessary, right? Sometimes people will say, can I get by without sleeping? We can't. So it's part of a physiological process. Any follows a rhythm. Every 24 hours we have a rhythm that closes off. In part of that 24 hours over a seven or eight hour period is where we should be sleeping. Not everybody needs the same amount of sleep and not all the time. We need the same amount. If you're more stressed, if you do more physical or cognitive activity, you may need more or less sleep. So there's always a variation.
Dr. Stieg: But never less than seven? Our current president says that he only needs three hours of sleep. And, and I have a lot of friends that say that. Is that real?
Dr. Krieger: Well there is a curve. So at the same time we have people that need 10 hours of sleep. We do have people that need five or six hours of sleep. Sometimes if you look at very successful people, maybe they did have a lot more hours during the day to work. So maybe that was a factor, but sometimes, or more often than anything else, that people sleep deprive themselves. So it's not necessarily what they actually need is what they get by with in the bodies in the brain is very resilient. So we're able to cope sleeping last and what we actually physiologically would need the same way they may be. We don't nourish our body exactly the way we should. We get by, you know, you know, doing reasonably well with that.
Dr. Stieg: is it a myth that I didn't get enough sleep this week, I'm going to crash and make up for it on the weekend. You can compensate for sleep deprivation.
Dr. Krieger: Well many people do that. It's better than not compensating to be honest.
Dr. Stieg: So there is an advantage?
Dr. Krieger: There is. The major concern is that people need to look back into the reason for this. Is there really a necessity for them to be sleep deprived during the week? And if there is not, people need to be a little more mindful. So we always focus on trying to get people to understand this 24 hour rhythm and try to see how can you make each day more predictable in terms of sleep.
Dr. Stieg: So let's get back to that sleep cycle. Out of that eight hours, do you go through multiple sleep cycles and what constitutes one full sleep cycle?
Dr. Krieger: So we go through the night over about four or five cycles of sleep. Each cycle lasts about 90-120 minutes. As the night progressed, as we have more and more dream sleep, which comes at the end of each cycle and we have less and less of what actually is deep sleep is when the brain functions very slowly and very regularly. And this actually is a period of the night where we also synchronize some hormonal release. And we've been, even with little kids, we used to say, "If you don't to bed early, you're not going to grow," because growth hormone is actually released during that first third of the night, more or less around the same time where do we go into this deeper stage of sleep.
Dr. Stieg: And what about anti-inflammatory effects of sleep on the brain?
Dr. Krieger: This is beautiful. I love this question because the effect of sleep is really amazing because the brain gets you to sleep but also benefits itself from sleep. No other organ can do that at the same level as brain does, so that's beautiful.
Dr. Stieg: I have this discussion all the time with the heart specialist — that the brain is the diamond organ.
Dr. Krieger: And it is unbelievable and not only anti-inflammatory for the brain, but for the whole body. The rhythm of our sleep is actually measured in the rest of the body as well. We can do biopsies on your skin cells and see if they follow a rhythm. Biopsy your liver, the liver function follows a rhythm and that's all regularized by the sleep cycle.
Dr. Stieg: There's a lot of conversation about REM sleep. Does that occur during a particular portion of the cycle? And how long is that? How important is that?
Dr. Krieger: So REM sleep comes at the end of each cycle. Let's say we go into the more superficial stages of sleep. Then stage two is one of the bulk of our non-REM stages of sleep. Then typically we go into delta, sleep, and slow wave sleep, in then into REM sleep.
Dr. Krieger: So REM sleep doesn't come in one cluster, it comes in little clusters. The first one is very small and it could be, you know, just 10 seconds. And then over cycles and cycles towards the end of the night period, we have more and more REM sleep. So just before waking up is when we get the bulk of our REM sleep.
Dr. Stieg: And is it a myth or a reality about the importance of REM sleep? If you block pupils, you let them sleep through all the other portions of the cycle, but you block their REM sleep. Are there any ramifications for the result?
Dr. Krieger: Well, animal studies have shown that if you deprive rats from REM sleep specifically after two weeks, they die. We haven't tried that in humans, of course, right? But we know that we have to be very mindful because there is probably a very good link between memory consolidation that happens during REM sleep.
Dr. Stieg: People that have sleep apnea, do they have less REM sleep?
Dr. Krieger: They tend to do because what happens in REM sleep is that in order for the brain to be very active, we actually paralyze your muscles. Then imagine the airway that is already compromised. Now, if you paralyze those muscles fully collapses the airway. So patients who have obstructive sleep apnea often have a state of deprivation or REM sleep.
Dr. Stieg: But we never take it away completely. So we wouldn't know whether the rat studies apply to the human.
Dr. Stieg: Right. But it's definitely a major concern.
Dr. Stieg: To hear more about this important topic. Please join us on our next episode.