Healthier Sleep Magazine Sleep Apnea Issue Jan/Feb 2021

healthiersleepmag.com January/February 2021 | Sleep Apnea Issue

Sleep in the

Dental Chair

Sleep Apnea

Sleep Apnea 101

What Everyone Should Know about this Common Sleep Disorder

Improve Your Sleep

by Changing Your Eating & Drinking Habits

Happy New Year!

PSYCHIATRIC DISORDERS insomnia Restless Sleep Disorder Excessive Daytime Sleepiness HYPERSOMNIA Narcolepsy

2021

Neural Plasticity

Sleep Breathing Disorders

PHARMACOLOGY

Basic Research

PARASOMNIA

AGING & DEVELOPMENTAL ISSUES

Chronobiology/Circadian Disorders MEMORY MOVEMENT DISORDERS NEUROLOGICAL SLEEP DISORDERS

Technology/Technical RLS

REM Behavior Disorders

Behavior Cognition & Dreaming

Healthier Sleep A publication of World Sleep Society Your Trusted Source for Improving Sleep Publisher World Sleep Society Editor Gina Dewink dewink@worldsleepsociety.org Issue Reviewers Lourdes DelRosso, MD Melissa C. Lipford, MD Robert J. Thomas, MD Rochelle Zak, MD Sales Manager healthiersleep@worldsleepsociety.org Designer Brook Lanz Copy Editor Wendi Kitsteiner Contributing Writers Shanti Argue CĂŠlyne H. Bastien, PhD Diego Z. Carvalho, MD Peter Cistulli, MD, PhD Lourdes DelRosso, MD Gina Dewink Wendi Kitsteiner Kali Patrick

ABOUT For advertising or editorial contact information, email healthiersleep@worldsleepsociety.org or visit healthiersleepmag.com for current rates.

Healthier Sleep is published up to six times per year by World Sleep Society, 3270 19th Street NW, Suite 109, Rochester, MN 55901 and distributed to sleep medicine and research professionals throughout the United States. No part of this publication may be reprinted or reproduced without written permission.

Healthier Sleep does not necessarily endorse the claims or content of advertising or editorial materials. All advertisements and editorial material included represents the opinions of the respective authors.

World Sleep Society/Healthier Sleep Magazine does not provide or offer medical advice. All content within the magazine, such as text, graphics, information obtained from sleep experts, and other material, is for informational purposes only. The content is not intended to be a substitute for medical diagnosis, advice or treatment. Relying on information provided by World Sleep Society and/or any of its employees, experts within the material, or other writers is solely at your own risk.

Š2020 World Sleep Society. All rights reserved.

Printed in the U.S.A.

CONTENTS

January/February 2021 | Sleep Apnea Issue

|4| Sleep in the Dental Chair

| 11 | Sleep Apnea 101 What Everyone Should Know about this Common Sleep Disorder

| 15 | Improve Your Sleep

by Changing Your Eating & Drinking Habits

2 6 9 10

About Healthier Sleep Magazine Yes, Children Can Have Sleep Apnea Too Snoring is Common but Not Always Normal 5 Ways to Prioritize Your Sleep

11 15 19 20

Sleep Apnea 101 Nutrition & Sleep 2021-2022 Editorial Calendar Patient Organization Highlight

22 23 25 31

World Sleep Society Programs Bedtime Reads Sundowning Advertising Rates

IN EVERY ISSUE The BuZZZ about Sleep

Right Now in Sleep Science

Bedtime Reads

Ask the Sleep Doc

PAGE 14

PAGE 26

PAGE 23

PAGE 27

Your latest buzzword is OMT

New Research on sleep and unwanted thoughts

Sleep-Wrecked Kids: Helping Parents Raise Happy, Healthy Kids, One Sleep at a Time

Your questions answered by sleep professionals 3 | healthiersleepmag.com

DENTAL

Sleep in the Dental Chair Stacey Quo, DDS, MS has made it her passion to help patients who might never know they have a sleep disorder, find rest.

By Wendi Kitsteiner

S

ometimes you discover sleep disorders in the most unlikely of places.

Like the orthodontist’s office.

Dr. Stacey Quo began her orthodontic career in 1994 in Palo Alto, California. She found herself interested in sleep medicine after a chance encounter with a patient who had undiagnosed severe obstructive sleep apnea (OSA). That encounter—just four years into her career as an orthodontist—was an adult male patient who was falling asleep during his short, ten-minute appointments.

When Dr. Quo inquired about his sleeping habits, the patient 4 | healthiersleepmag.com

mentioned he was a college professor and would need to nap between his lectures. She referred him to a sleep study and was blown away by the results. “His case is so vivid in my memory because his oxygen saturation dropped to 54% and his Apnea Hypopnea Index (AHI) was 59.6.” AHI refers to the number of abnormal breathing events per hour of sleep. Mild levels are 5 to 14; 15 to 30 is moderate; greater than 30 is severe and this patient was experiencing nearly 60. Because of his dangerously low oxygen level, they stopped the study and placed a CPAP on him for the rest of the night.

MEETING A SLEEP PIONEER As Dr. Quo moved forward with this patient’s treatment plan, she was fortunate enough to meet Dr. Christian Guilleminault, a French physician and a pioneer in the field of sleep medicine at the Stanford Sleep Clinic. Dr. Guilleminault, who passed away in 2019, is known for coining the term obstructive sleep apnea.

Under Dr. Guilleminault’s mentorship, Dr. Quo learned about sleep physiology. She also began recognizing sleep disorders in her own family. “I am so very grateful for his education, as it allowed me to better help care for my family to improve their longevity and

quality of life. As I treated more cases implementing what I learned, I saw profound changes in patients, and realized another impact the orthodontist has in the patient’s well-being, other than treating their oral health.”

Dr. Quo says that this is a common among professionals. While they are initially seeking help for their patients when they sit through one of her lectures, a secondary benefit is that their own family members are also helped. “Some of their questions relate to things they’ve noticed in their patients, but mostly it’s concerning symptoms or associations they’ve seen in their family.”

TREATING THE CHILD Dr. Guilleminault was the first physician-scientist to describe pediatric sleep disordered breathing (SDB) back in 1976. “He felt that OSA was a disorder that began in childhood and approached OSA through the lens of early intervention in children to prevent the symptoms and manifestation seen in adults,” Dr. Quo relayed.

Recognizing that these children had certain oral and facial features, Dr. Guilleminault became aware that an orthodontist might be able to help. “He was acutely aware of the orthodontist’s ability to modify facial growth in treating bite problems,” Dr. Quo explained. An orthodontist can help with sleep disorders by expanding skeletal structures to improve airflow during the day and night. Recognizing how valuable the orthodontist is in helping treat SBD, Dr. Guilleminault became the world’s advocate for team collaboration between orthodontists, ENT

surgeons, dentists, allergists, myofunctional therapists and oral surgeons.

lower jaws form one of the walls of the throat (pharyngeal airway). The pharynx or throat is a susceptible site for airway collapse during sleep.

The upper airway is a complex of three distinct but contiguous structures: the nose, the mouth and the throat, separated anatomically by the upper jaw/maxilla.”

It was actually at Dr. Guilleminault’s urging that Dr. Quo began treating young children in her office. Her first was a fouryear-old patient. “I cautiously and perhaps reluctantly started upper jaw expansion and was surprised She goes on to explain, “When to see a dramatic improvement the nose is congested and nasal in daytime school engagement, breathing is blocked, the mouth acts irritability, as a respiratory anxiety and organ. This temperament. bimodal switching Then I started between nose to widening the mouth breathing lower teeth and and the amount found more of time spent in improvement. each mode affects Now this is the development a therapy of the lower part we routinely of the face: the utilize. And this jaws, the teeth and brought us to the airway. It’s an implementing integrated space, other strategies where chewing, to enlarge the swallowing, Stacey Quo, DDS, MS upper airway by breathing and improving the mode of breathing, speaking are executed. The developing the upper jaw forward musculature governs these functions and improving the performance as directed by voluntary and of the upper airway musculature. involuntary signals from the brain.”

We’re using these therapies in adults too.” Dr. Quo is careful to note that Characterizing the face is a routine part of an orthodontist’s job during multiple therapies may be needed and there still may be residual OSA an exam on a patient. The dentist and orthodontist therefore play after treatments. a vital role in helping patients who might not think they have a THE SLEEP DISORDER problem and would never consider CONNECTION TO THE going to a sleep clinic. “SDB/OSA DENTAL CHAIR prevalence studies suggest a large Dr. Quo explains how dental work percentage of mild to moderate can walk hand-in-hand with SBD adult sleep apnea is undiagnosed and OSA. “Structurally, the upper as patients may not be aware of the airway comprises the nose and the spectrum of associated symptoms.” throat (pharynx). There is a shared anatomy as the nose sits inside of the upper jaw and the upper and Dental Chair continued on page 9 5 | January/February 2021

PEDIATRIC

Yes, Children Can Have Sleep Apnea Too Understand the rates, risks and treatments for your little one.

A

By Gina Dewink

ll around the world, parents worry about their children’s health. And while there is plenty of talk around how much sleep children should get, there is not always talk about what quality of sleep children should get. Aroonwan Preutthipan, MD, FCCP of Thailand has been working in the field of pediatric sleep medicine since 1992. She offers advice and insight into pediatric obstructive sleep apnea (OSA).

When parents tell me their child has been naughty or hyper or attention-seeking, I know those are symptoms of lack of quality sleep.

SYMPTOMS & RISKS Risk factors for children and OSA differ from adults.

In children, some of the risks include enlarged tonsils and/or adenoids, allergies or sinusitis and—the same as in adults—obesity. “Internationally,” Dr. Preutthipan begins, “the prevalence of OSA in children is reported at 2-5%. Primary snoring with no obstruction, is reported at 10-15%. This is much lower than the prevalence for adults, but parents should be aware of the symptoms.” The youngest child Dr. Preutthipan has ever diagnosed with OSA was less than one year old. She defines pediatric as younger than 18-years-old.

RISK FACTORS FOR OSA IN CHILDREN • Enlarged tonsils and/or adenoids • Allergies or sinusitis • Congenital abnormalities • Obesity • Craniofacial narrow airways • Hypothyroidism

6 | healthiersleepmag.com

In Dr. Preutthipan’s experience, snoring is usually the first symptom noticed by parents.

“Some parents come to me and explain they’ve noticed the child’s snoring leads to gasping or pauses in breathing.

Others tell me about changes Aroonwan Preutthipan, in behavior.” By definition, MD, FCCP OSA means to stop or pause breathing. If you notice your child’s breathing is abnormal, consulting a physician is advised.

For children, sleep deprivation often presents differently from adults. When an adult lacks sleep, physical fatigue and excessive daytime sleepiness are often reported. In children, Dr. Preutthipan explains how symptoms do not look the same. “When parents tell me their child has been naughty or hyper or attention-seeking, I know those are symptoms of lack of quality sleep. I want more people to be aware that children do not always act sleepy when they are tired. There can be differences in emotions, learning difficulties and loss of concentration.”

SIGNS OF SLEEP DEPRIVATION IN CHILDREN • Hyperactivity • Attention-seeking or "naughty" behavior • Changes in emotions • Learning difficulties • Lack or loss of concentration

WHEN SHOULD PARENTS CONSULT A PHYSICIAN “Snoring is a danger sign,” Dr. Preutthipan explains.

“Some studies show snoring without obstruction may have negative consequences to development. Report to the doctor at your routine wellness check any snoring sounds you may have noticed. If significant—meaning you have observed your child snoring three nights per week—we call it habitual snoring. Our guidelines recommend action be taken if habitualsnoring is present.” Dr. Preutthipan also recommends asking questions about OSA at your child’s visit.

DIAGNOSES & TREATMENT So how does a child get officially diagnosed with OSA? The gold standard, as Dr. Preutthipan states, is a sleep study. But that’s not always an option.

“Polysomnography, or a sleep study, is recommended, but patients have told me they believe they are too complicated or expensive. So before setting one up, I ask them: How well does your child sleep? Have you observed labored breathing? Does your child gasp for air while asleep? Have you seen their chest indrawing?

Have you noticed daytime symptoms?

A primary care physician can look for complications of OSA Pediatric patient wearing OSA mask symptoms.” When asked if she recommends using any sleep trackers or apps to record a child’s sleep habits, Dr. Preutthipan suggested video recording a night’s sleep instead.

When treating a child with OSA, special considerations need to be taken. For example, while CPAP masks may be the first line of treatment for adults, that may be a difficult-to-enforce option for young children. Dr. Preutthipan often prescribes the drug with the generic name montelukast (brand name Singulair) and also intranasal corticosteroids (such as Nasonex, Avamys) as both of them make breathing easier by reducing swelling and/or inflammation of the upper airways.

When that doesn’t have an affect on OSA symptoms, Dr. Preutthipan explains that in Thailand, the next course of treatment is surgery. “There is a classic study of OSA in children from The New England Journal of Medicine that found administering a tonsillectomy and adenoidectomy (T&A) cured OSA 79% of the time conducted by Professor Carole Marcus, my dear mentor.

For our ENT surgeons, this is a routine and low-risk surgery. I believe in the US, it is an out-patient procedure.” But if enlarged tonsils or adenoids aren’t the cause of the OSA and the child cannot tolerate CPAP, Dr. Preutthipan suggests looking into 7 | January/February 2021

Peds continued from page 7 orthodontic devices. “A narrow palate can cause OSA so another line of treatment is to visit an orthodontist.

Orthodontic devices are available to widen and enlarge the palate. One is called rapid maxillary expansion.

And there are myofunctional therapy exercises that can relieve symptoms. All of these options should be considered with the patient.”

WARNINGS FOR LEAVING UNTREATED In serious cases of OSA, leaving the symptoms untreated can have dire consequences.

“Unfortunately, the list of consequences of leaving OSA untreated is long. There could be growth failure, hypertension, behavior and learning problems, aggressiveness or increased pressure in the lungs. I think if parents knew the association between OSA and any of these things, they would be more careful is looking for obstructions. My hope is that parents realize this is much more than a snore.”

Example of young child doing myofunctional therapy exercises that can help relieve symptoms of OSA.

PRESENTS

Am I sleep deprived?

How much sleep do I need?

ADVANCING PUBLIC SLEEP HEALTH

Why won’t my child sleep?

Does exercise really help sleep?

What is the impact of pregnancy & menopause in women?

What are the consequences of poor sleep?

Do women need more sleep than men?

How do I sleep better?

DO I HAVE SLEEP APNEA?

bit.ly/WSSyoutube

HAVE SLEEP QUESTIONS?

VISIT THE WORLD SLEEP SOCIETY YOUTUBE CHANNEL TO GET THE ANSWERS FROM SLEEP EXPERTS IN A SERIES OF LECTURE-BASED PRESENTATIONS

Dental Chair continued from page 5 Because sleep disorders are so detrimental to a person’s health, these yearly appointments with their dentist or orthodontist can be incredibly helpful to identify facial and oral risk factors. They are becoming “standards of care” in dentistry.

“It’s always surprising and humbling when parents mention that treating the SDB/ OSA has given them their child back, or when adult patients report The dentist and that treatment has been life changing orthodontist play or that they can a vital role in now breathe, and that they didn’t helping patients know they couldn’t who might not breathe–until consider going to they could!”

a sleep clinic.

There are other options besides CPAP and pharmacotherapy, and it is Dr. Quo’s hope that she can continue to help people who didn’t even know there was a problem, finally benefit from much-deserved rest.

Snoring is Common But Not Always Normal

By Peter Cistulli, MD, PhD

S

noring is extremely common— one of the most common presenting symptoms to a sleep clinic.

I had the good fortune to work with Professor Colin Sullivan, a pioneer of the sleep field and inventor of CPAP for the treatment of obstructive sleep Peter Cistulli, MD, PhD apnea. I have dedicated my career to finding patient-friendly solutions for snoring and sleep apnea.

Snoring is the audible component of tissue vibrations occurring in the throat passage as air passes through it.

Most commonly it occurs while breathing in, but it can also occur while breathing out. The tissue vibrations originate around the soft palate or tongue area, and these produce qualitatively different types of sounds.

.....................................................................

Although snoring is generally considered a social problem through disturbance to the bed partner, it can be a marker of an underlying medical disorder called obstructive sleep apnea, a condition where breathing pauses occur during sleep. There are multiple factors that can trigger snoring, including nasal obstruction (eg. deviated nasal septum or hayfever), being overweight, smoking and excessive alcohol consumption.

Wendi Kitsteiner is a former high school English and Journalism teacher who has worked as a writer/editor for the RLS Foundation and as an editorial assistant for a cardiovascular researcher at Mayo Clinic. She has written for many magazines and websites and is currently homeschooling her four children on a farm in East Tennessee.

IDENTIFYING WORRISOME SYMPTOMS A key trigger for seeking medical attention is if the partner witnesses breathing pauses or stoppages during sleep, or if the person themselves wakes up choking or gasping. Also, in individuals with chronic medical conditions such as high blood pressure, diabetes, heart disease and strokes, the presence of snoring may be a strong indicator of obstructive sleep apnea.

Snoring is never normal, and many treatments exist. So early discussion of the problem with your family doctor is highly advisable to prevent it from worsening over time. .............................................................................................

Dr. Cistulli of the Charles Perkins Centre, University of Sydney and Department of Respiratory and Sleep Medicine, Royal North Shore Hospital in Sydney, Australia has been working in the field of sleep for 30 years.

9 | January/February 2021

LIFESTYLE

5 Ways to Prioritize Your Sleep (Even When You’re Busy)

By Kali Patrick, MS

W

kyphotic posture caused by too much computer use, which restricts full breathing and can result in tiredness.

1.) Start each new day brightly.

Even if you didn’t get quality sleep that night, get out of bed at the same time daily, and find some light. Notice and counter any Automatic Negative Thoughts (ANTs) about what your day might bring with an opposite (or neutral) statement. Energize your body and clear out any morning brain fog with some gentle movement.

4.) Have a(ny) ritual that clearly demarcates the end of your workday. This is especially important if you work from home or have too fluid a boundary between your roles in life. Select a time to power down your workstation or close your office door. One client of mine who works from home cleverly places different figurines on her table: one represents working, the other personal business and fun so she put out different ones at different times.

hen there are so many people and activities competing for your attention, prioritizing sleep can feel impossible. Here are 5 tips that can help. Even if you’re busy, you can…

2.) Have a macronutrientbalanced meal mid-day. Eat it away from your workspace, ideally in nature or with a nature view. Even 20 minutes (without multitasking) can help you feel nourished and rejuvenated.

3.) Counter mid-afternoon energy slumps with an energizing practice. Need to release stress? Try 2-3 rounds of healthy breathing techniques that open your chest and/or create energy. They also combat the 10 | January/February 2021

5.) Create a supportive, daily rhythm for yourself. The mindbody system is soothed by rhythm.

It likes to anticipate what’s going to happen and have that expectation met. (This is why uncertainty often produces anxiety, and why upended plans can feel stressful.)

Rhythms can be set by time, light, food/drink, or movement.

They reinforce circadian rhythm, and may result in deeper, less fragmented, and more refreshing sleep at night.

Start by selecting one from the list above—ideally the one that’s most feasible for your busy life and feels most enjoyable. Do it consistently for at least a month and notice its impact on your sleep and energy. .......................................................

Kali Patrick, MS is a Sleep Wellness Coach, therapeutic yoga & meditation teacher, and speaker who helps stressed-out, busy professionals learn to sleep better and improve their energy. She also supports corporate wellness programs with 1-1 coaching, classes, and presentations.

Sleep Apnea 101

What everyone should know about this common sleep disorder.

By Shanti Argue

S

leep apnea is a pervasive, potentially dangerous disorder that deserves wider public awareness and understanding. An estimated 80% of moderate to severe cases go undiagnosed, and this sleep disorder can wreak havoc on longevity and quality of life.

Thomas Penzel, PhD of Charité Interdisciplinary Center of Sleep Medicine in Berlin, defines sleep apnea as “respiratory cessations during sleep,” meaning breathing actually stops for 10 seconds or more. As a prominent sleep researcher, physician and author, Dr. Penzel points out that people are not consciously aware of these pauses, but they can happen hundreds of times a night leading to fragmented sleep.

Thomas Penzel, PhD PERSISTENT, UNEXPLAINED FATIGUE If sleep apnea is present, a full night’s sleep is rarely restorative.

Dr. Penzel says patients might see “no improvement, even when taking naps in the daytime.”

Untreated sleep apnea can sap the energy and enjoyment from daily life through mood swings, daytime sleepiness and loss of libido.

DAILY DANGERS Dr. Penzel warns drowsiness can lead to work and traffic accidents, poor job performance and cardiovascular complications.

Unchecked, sleep apnea can lead to diabetes, obesity and depression.

HEART DISEASE Dr. Penzel has investigated the cardiovascular risks associated with untreated sleep apnea. He cites high blood pressure, the potential for stroke and even myocardial infarction (heart attack) as compelling reasons to take sleep apnea seriously. Long term, overlooked sleep apnea can cause premature death.

UNDERSTANDING APNEA TYPES The most common, Obstructive Sleep Apnea (OSA) occurs when structures in the mouth or throat— such as the tongue or tonsils—relax during sleep and block the airway.

In other words, something is physically in the way of breathing.

Less commonly, Central Sleep Apnea (CSA) happens when the brain sends insufficient breathing signals to the body. Simply put, this type originates in the brain, rather than the airway.

SEVERITY While apnea means “stop breathing,” hypopnea means “reduction in airflow.” Doctors analyze patient data into an Apnea Hypopnea Index (AHI). A patient’s AHI is the number of events (apnea or hypopnea) per hour of sleep.

Adult AHI Ranges • Mild: AHI between 5-15 events per hour • Moderate: AHI between 15-30 events per hour • Severe: AHI greater than 30 events per hour 11 | January/February 2021

Apnea continued from page 11 RISK FACTORS While anyone can develop sleep apnea, certain risk factors can increase your odds: • Obesity or being overweight • Family history of OSA or snoring • More common in men over 40

TALK TO YOUR DOCTOR If you have concerning symptoms, Dr. Penzel recommends beginning with your primary care physician.

If they suspect you might have sleep apnea, they will likely refer you to a sleep specialist, cardiologist or pulmonologist who will determine the necessary tests.

obtain results with a Mandibular Advancement Device (MAD), which looks like a mouth guard and moves the jaw forward, keeping tongue away from the airway.

The best therapy for sleep apnea will depend on the patient, type and severity of apnea, and what might be its cause. From lifestyle changes to surgery, doctors have a variety of options at their disposal.

TREATMENT Dr. Penzel finds Continuous Positive Airway Pressure (CPAP) helps most patients with OSA, while others

Dr. Thomas Penzel says many patients benefit from a Continuous Positive Airway Pressure (CPAP) device. Most CPAP machines are small (about the size of a bulky alarm clock) and portable. They are surprisingly quiet. A mask worn over the nose and/or mouth is attached by a flexible tube and delivers a steady pressure of warm, humid air.

What if I snore?

Snoring is not a reliable indicator for apnea in adults.

While many patients with apnea do snore, many others do not. And just because you snore, that doesn’t mean you have sleep apnea either.

DIAGNOSIS FROM HOME Dr. Penzel says many patients are able to receive an accurate diagnosis through a home sleep study. Their doctor outfits them with “a device recording respiration, oxygen saturation, snoring, and heartbeat.” When the study is complete, the patient returns the equipment, and the doctors analyze the data.

POLYSOMNOGRAPHY Sometimes, physicians need more information. Patients may need Polysomnography, which is a sleep study conducted in a lab.

In addition to monitoring the heart, movement and breathing, brain waves are recorded through electrodes attached to the scalp.

WHAT IS CPAP?

The only way to get treatment for sleep apnea is to talk to your doctor, but the solution might be easier than you think. Don’t ignore symptoms, such as drowsiness, fatigue, headaches, irritability, high blood pressure or weight gain.

What about my weight?

Sleep apnea and weight gain often go hand and hand, but it can be difficult to determine causation or correlation in a particular individual. The repeated stopping and starting of breathing during sleep raises blood sugar and stress hormones, which can lead to weight gain. Being tired can make exercise a challenge.

Additionally, excess fat in the neck and throat can collapse a relaxed airway.

*Citations available on healthiersleepmag.com

12 | January/February 2021

Risk of Sleep Apnea I am over age 40. ⃝ Yes ⃝ No .......................................................

I snore. ⃝ Yes ⃝ No .......................................................

I am overweight. ⃝ Yes ⃝ No .......................................................

SAVE THE DATE

I often awake with a morning headache. ⃝ Yes ⃝ No .......................................................

Guatemala

Q

I have woken up gasping or choking in the night. ⃝ Yes ⃝ No ......................................................

I have been told I stop breathing at night. ⃝ Yes ⃝ No ......................................................

I often awake feeling tired and unrefreshed. ⃝ Yes ⃝ No ......................................................

I take naps to try and refresh my daytime sleepiness. ⃝ Yes ⃝ No ......................................................

Portugal

z ui I have depression and/or diabetes. ⃝ Yes ⃝ No .......................................................

I awaken with a dry and/or uncomfortable throat. ⃝ Yes ⃝ No .......................................................

If you answered ‘Yes’ to four or more of these questions, you are at risk of living with sleep apnea.

The next step toward healthy sleep is to contact your primary care physician to talk about your concerns.

India

Hungary

United Kingdom

World Sleep Day is an annual event, intended to be a celebration of sleep and a call to action on important issues related to sleep. Hosted by World Sleep Society, it is a data-driven opportunity for sleep experts to inform the public about the importance of sleep in all aspects of health.

Become one of the hundreds of delegates representing over 88 countries by visiting worldsleepsociety.org/WSD.

worldsleepday.org

twitter.com/_WorldSleep

facebook.com/wasmf

The BuZZZ about Sleep Your Latest Buzzword is OMT. Orofacial Myofunctional Therapy, or OMT as it’s regularly referred to, is a therapy of exercises for the face and tongue that can improve or even eliminate causes of snoring and obstructive sleep apnea. The muscles of the tongue, throat and face can improve function and use through OMT and reduce obstruction to the airway.

OMT is painless and relatively simple. For success, consistent exercise every day is necessary until the patient has corrected their improper muscle pattern.

Treatment usually consists of a regular program of exercises over a 6–12 month period. OMT is best done under supervision, and if sleep symptoms are bothersome, through a sleep medicine professional.

14 | January/February 2021

HEALTH

Nutrition & Sleep

How to improve your sleep by changing your eating & drinking habits.

By Diego Z. Carvalho, MD

T

he relationship between nutrition and sleep is far from being completely clarified. However, the available scientific evidence supports a few tips that can improve your sleep: 1.) Cut down on coffee and caffeinated products (soft drinks, tea, chocolate); and restrict them to the morning.1 Caffeine has stimulating effects and can make it difficult to fall asleep.

For those who can sleep after Diego Z. Carvalho, MD a cup of coffee, it can lead to reduced sleep duration, more awakenings, reduced deep sleep, and worsened subjective sleep quality. Caffeine doses equivalent to two 8oz cups of coffee in the morning have been shown to reduce deep sleep at night.

2.) Reduce or eliminate alcoholic beverages before bedtime.2-3 Although alcohol has sedative properties and can make you sleep more quickly, it comes at a high cost. In the second half of the night, you are more likely to experience increased sleep disruption with more awakenings and less deep sleep, which can make you feel less refreshed in the morning. Alcohol can also give rise to or worsen obstructive sleep apnea and reduce your oxygen levels at night.

3.) Swap out sugary and starchy foods, for vegetables and fruits.4-5 A high glycemic index diet, which is associated with foods with high amount of simple carbohydrates such as potatoes, white rice

and white bread, can quickly increase blood sugar. Although high glycemic meals were shown to help healthy volunteers fall asleep in experimental conditions higher intakes of dietary added sugars, starch, and nonwhole/ refined grains have been associated with a higher risk of developing insomnia over time. By contrast, higher nonjuice fruit and vegetable intakes were significantly associated with lower chances of developing insomnia.

4.) Eat more fiber and less saturated fats.5 Avoid food choices with high amount of saturated fat (butter, red meat, chicken skin, whole dairy products) and focus on eating more fibers. An experimental study has found that higher percentage of energy from saturated fat was associated with more arousals and less deep sleep, while greater fiber intake was associated with more deep sleep.

5.) Avoid heavy meals prior to bedtime.6 Eating a large amount before bed can delay your sleep onset time and cause more awakenings. On the other hand, significant food restriction can cause more difficulty falling asleep and reduce the amount of deep sleep. .....................................................................

Dr. Carvalho is with the Center for Sleep Medicine at Mayo Clinic in Rochester, MN. References Clark I, Landolt HP. “Coffee, caffeine, and sleep: A systematic review of

epidemiological studies and randomized controlled trials,” Sleep Med Rev.

Feb;31 (2017):70-78. PMID: 26899133 Colrain IM, Nicholas CL, Baker FC. “Alcohol and the sleeping brain,”

Handb Clin Neurol. 12 (2014) 5:415-31. PMID: 25307588 Kolla BP, Foroughi M, Saeidifard F, Chakravorty S, Wang Z, Mansukhani MP.

“The impact of alcohol on breathing parameters during sleep: A systematic

review and meta-analysis,” Sleep Med Rev. Dec;42 (2018):59-67. PMID: 30017492 Afaghi A, O'Connor H, Chow CM. “High-glycemic-index carbohydrate meals

shorten sleep onset,” Am J Clin Nutr. Feb;85(2) (2007):426-30. doi:

10.1093/ajcn/85.2.426. Erratum in: Am J Clin Nutr. Sep;86(3)

(2007):809. PMID: 17284739 Gangwisch JE, Hale L, St-Onge MP, Choi L, LeBlanc ES, Malaspina D, Opler

MG, Shadyab AH, Shikany JM, Snetselaar L, Zaslavsky O, Lane D.

“High glycemic index and glycemic load diets as risk factors for insomnia:

Analyses from the Women's Health Initiative,” Am J Clin Nutr. Feb

1;111(2) (2020):429-439. PMCID: PMC6997082 Karklin A, Driver HS, Buffenstein R. “Restricted energy intake affects nocturnal

body temperature and sleep patterns,” Am J Clin Nutr. Feb;59(2)

(1994):346-9. doi: 10.1093/ajcn/59.2.346. PMID: 8310984

15 | January/February 2021

YOUR TRUSTED SOURCE FOR IMPROVING SLEEP A MAGAZINE FROM WORLD SLEEP SOCIETY Join the 1,350 individuals & sleep clinics, hospitals, & other professional sleep businesses adding Healthier Sleep Magazine to waiting rooms.

• Instant online access available • Complimentary print subscriptions are available in the US • Up to six issues per year, each issue highlighting a different subtopic in sleep We are a trusted source within the sleep community, now bringing our worldwide expertise to the patient level.

Welcome to Healthier Sleep.

IN EVERY ISSUE

UPCOMING ISSUE TOPICS • HEALTHY SLEEP • SLEEP DISORDERS • INSOMNIA

• HYPERSOMNIA & NARCOLEPSY • RESTLESS LEGS SYNDROME • SNORING & OSA

Healthier Sleep is published up to six times per year

by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide.

CONTACT US For more information or to subscribe, visit Healthiersleepmag.com.

For questions, contact healthiersleep@worldsleepsociety.org.

Danger on the Road Watch out for drowsy driving.

By Shanti Argue

H

igh speed. No skid marks.

A serious accident. These hallmarks often indicate to crash scene investigators that a driver nodded off at the wheel.

MICROSLEEP We’ve all seen someone do it: in a meeting, in a church pew or on the couch after dinner. Their eyelids droop, their head nods as they try to keep their chin up. Though they fight to remain alert, they cannot contend with their body’s overwhelming urge to sleep.

A microsleep can last just seconds and people are often unaware that it occurred. It happens most often due to fatigue and strikes during monotonous tasks like driving, especially long stretches of highway.

Unfortunately, that means these collisions tend to involve high rates

of speed. And because the driver is momentarily unaware, they fail to brake or make any attempt to avoid the accident.

A chemical in our brains called adenosine builds up gradually during wakefulness, compelling the brain to sleep. The only way to decrease adenosine is with rest, so no matter how strong-willed a driver is, they cannot stop this biological process.

MORE COMMON THAN YOU THINK Even if a drowsy driver manages to avoid falling asleep, their driving can be equivalent to that of a drunk driver. Sleepiness diminishes reaction times, memory and coordination, making drivers slow to respond, even when quick thinking might be the only way to

avoid a crash.

Reasons for drowsiness are familiar: lack of sleep from a new baby, long hours of studying or a late night with friends, shift workers exhausted on their way home from a night on the job and people whose jobs involve driving. All of these routine reasons for sleepiness can endanger drivers, passengers and those on the streets around them.

An in-depth 2018 study found that as many as 10.8% of all policereportable crashes and a substantial number of fatal accidents are because of sleepy drivers.

Additionally, an astounding 1 in 25 adults surveyed admitted they had fallen asleep at the wheel within the last 30 days.

Drowsy driving is most likely to be a factor during the body’s habitual sleep periods through the night and early morning hours.

Some people also experience an afternoon dip in alertness, and older drivers are especially prone to accidents at this time of day.

Untreated sleep disorders, such as narcolepsy and sleep apnea, prevent people from getting the good-quality, restorative sleep necessary to prevent drowsiness behind the wheel.

Drowsy driving continued on page 18 17 | January/February 2021

Creating Your Optimal Sleep Environment

By Jodi Mindell, PhD

T

here are many things that affect sleep, including physical health, mental health, sleep habits and the physical environment. The physical environment is generally defined as all the things in a person’s sleeping space that are either conducive to sleep or interfere with sleep.

Drowsy Driving from page 17 SAFETY FIRST Drowsy driving kills and disables, but the good news is that these accidents are largely preventable.

Make lifestyle changes that allow at least 7 hours of quality sleep, including addressing any sleep issues with your doctor. In special circumstances, take a short nap in a safe spot to prevent accidentally succumbing to sleep. The only way to avoid microsleep sneaking up on you is by getting enough healthy sleep.

Although there has been little research conducted in this area, we typically recommend that the sleep space is cool, dark, quiet and comfortable. If it’s too hot, too noisy, too light or uncomfortable, it may be hard to fall asleep or stay asleep. A few recent studies have found that sleep is negatively impacted in areas where there is increased light pollution, as well as traffic noise (from nearby trains or airports). The sleep environment is important at all ages, from infancy through old age.

Jodi Mindell, PhD

Any temptation to engage with the world when you should be sleeping should be avoided. This means, the television and electronics from the bedroom. Also consider other elements that may have a negative affect your sleep, such as late afternoon/evening caffeine, pets that may disturb your sleep and alcohol near bedtime. Some couples even find that sleeping in separate spaces improves sleep.

STAY ALERT WHILE DRIVING

Individuals should consider the bedrooms of everyone in their family and ensure that they are sleep-conducive. Your checklist could include:

● Always start out well-rested

● Be sure the bed, bedding and sleep clothes are comfortable.

● On long trips, stop for a few minutes of exercise and stretching every hour or two

● Be sure that the room temperature is comfortable, prioritizing being cool rather than too warm.

● Keep your brain engaged: Scan the road and scenery, don’t use cruise control ● Engage in lively conversation with a passenger or via hands-free call ● Do not drive for long periods at night (or day for shift workers) ● Keep the vehicle cool

● Consider adding a noisy fan or sound machine to drown out household and outside noise. ● Add room-darkening shades if the bedroom is too light at night. ● Remove all electronic screens to eliminate the temptation to go online, scroll through social media or check texts throughout the night. ● Set a morning alarm with an old-fashioned alarm clock instead of relying on a cell phone.

If someone in your household is having a difficult time sleeping, consider the bedroom environment and ensure healthy sleep habits are in place.

If the problem persists, be sure to talk to your primary care provider or a sleep specialist in your area. ................................................................................................................

*Citations available on healthiersleepmag.com

18 | January/February 2021

Dr. Mindell is the Associate Director of the Sleep Center at the Children’s Hospital of Philadelphia and Professor of Psychology at Saint Joseph’s University who’s been working in the field of sleep medicine and research for over 30 years. She is also the chair of the Pediatric Sleep Council (www.babysleep.com).

2021-2022 EDITORIAL CALENDAR MARCH/APRIL 2021

• • • • •

HEALTHY SLEEP

SLEEP DISORDERS

MAY/JUNE 2021

JULY/AUGUST 2021

Ads Due: 12/23/20

Ads Due: 2/25/21

Ads Due: 4/28/21

COVID-19 & sleep World Sleep Day Autism & sleep Mental health & sleep Aging & sleep

• Insomnia • Pediatric sleep disorders • Chronic lack of sleep/effects of sleep deprivation • Anxiety • Insomnia & mental health

SEPTEMBER/OCTOBER 2021

NOVEMBER/DECEMBER 2021

JANUARY/FEBRUARY 2022

Ads Due: 6/30/21

Ads Due: 8/26/21

Ads Due: 10/25/21

HYPERSOMNIA & NARCOLEPSY

• • • • •

• Night Terrors • Circadian Rhythm Sleep Disorders • Sleepwalking • Nightmare disorder • Sleep Related Hypoventilation/Hypoxemia

INSOMNIA

Narcolepsy Hypersomnia Parasomnias Depression Non 24 Sleep Wake Disorder

ABOUT HEALTHIER SLEEP MAGAZINE

RLS

• Restless Legs Syndrome • Periodic limb movement disorder • Alzheimer’s disease • Parkinson’s disease • Sleep & sports performance & injury

IN EVERY ISSUE

Healthier Sleep is published six times per year by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide.

Welcome to Healthier Sleep.

CONTACT US For more information, visit healthiersleepmag.com.

For a custom quote, contact healthiersleep@worldsleepsociety.org.

SNORING & OSA

• • • • •

Sleep Breathing Disorder Bruxism or teeth grinding Sleep & Memory CPAP Sleep & women (pregnancy to menopause)

PATIENT ORGANIZATION HIGHLIGHT

Alliance of Sleep Apnea Partners (ASAP) ASAP is an organization for patients with sleep

apnea created by patients with sleep apnea. Kathy Page, Past President of the ASAP Board of Directors explains, “Everything we do, everything we create or try to build, is based around one question: will it help those who have sleep apnea?

As patients and members of the board, each one of us comes with a different perspective.

Differences in how and when we were diagnosed, how we manage our sleep apnea, problems with mask fittings, insurance issues, finding quality medical help and more. We wanted to create a place where patients could easily find answers.”

Page believes getting diagnosed and adhering to a treatment option are not easy things, so it is paramount to educate oneself about sleep apnea. “Know what kind of sleep apnea you have, the probable cause, the best treatment therapy for you, find a doctor who will help, learn how to tolerate the treatment and where to look for quality, reliable information,” Page reiterates.

ASAP is a nonprofit founded by a multi-stakeholder group of patients, researchers and healthcare providers.

ASAP is an affiliate partner of the Sleep Apnea PatientCentered Outcomes Network (myapnea.org), a virtual community of over 20,000 patients. Patients can learn about sleep apnea definitions, types, who is at risk, symptoms and more through their patient website.

20 | January/February 2021

“Personally,” Page begins, “I had no idea that sleep apnea was so common! When I was diagnosed, I had heard of sleep apnea, but all I really knew was that you had to wear a horrible-looking mask. I had no idea how much harm could be done to your body by leaving sleep apnea untreated.

I want people to know it can affect your blood pressure, heart, lungs, brain, and of course—cause daytime sleepiness. I learned there were other treatment options besides the dreaded mask. But the most important thing I learned was that others struggle just like me.”

ASAP plans to raise awareness about apneapartners.org through social media efforts and a direct outreach to providers. The site was developed collaboratively by patients and clinicians. It is designed to be a vital sleep apnea resource for individuals, families, caregivers, communities and schools.

—apneapartners.org

WELL-BEING

4 Things to Know about Sleep & Stress

By Célyne H. Bastien, PhD

T

he topic of stress and sleep is of the outmost importance as we head into 2021. The unprecedent times we have been living in since March 2020 have had a devastating effect on sleep, especially because of the stress caused by different situations linked to the pandemic such as financial hardship, isolation/confinement, loneliness, fear of catching or seeing a close one catching and dying of COVID-19; working from home, having kids home, etc.

2.) Sleep can help stress. By sleeping, your body is relaxing, and your mind is at peace (besides the occasional bad dreams which could be punctually disturbing).

Thus, if you get a good night’s Célyne H. Bastien, PhD sleep, your body and your mind is more ‘equipped’ to face stressing situations: your stress coping mechanisms are more effective.

1.) It is normal during periods of stress to feel that our sleep is not of good quality or has deteriorated. We can take longer to fall asleep, wake up more often during the night or even wake up in the wee hours of the morning without being able to go back to sleep. When we experience sleep difficulties, we may start to worry about our sleep and then get anxious about the fact that we are not getting enough sleep. From there, our health might deteriorate because of the lack of sleep.

3.) Lighten the mood to lessen the stress. There are many things you can do and they relate mostly to sleep hygiene and general health hygiene: have a nice sleeping environment, make sure you have plenty of time to recuperate, learn something new (cooking, language, etc), talk to family members and friends to release some of the stress, exercise (but no later than four hours before going to bed), watch funny movies, do not use any electronics in your bedroom, attend some relaxation/ meditation/mindfulness/yoga classes and eat well to lighten your mental load and mindset.

We can get ourselves into a kind of vicious circle where stress induces sleep difficulties and sleep difficulties increase stress. And being sleep deprived is associated with emotion dysregulation. Feeling irritated, more depressed, more anxious, lacking concentration and attention are common consequences of sleep deprivation.

4.) Stress during the day, instead of at night. One other recommendation would be to reserve a time during the day (30-60 minutes) during the day to sit down and take the time to write what stresses you. It will not only give you the opportunity to find solutions to what is stressing you, it will

Stress continued on page 24 21 | January/February 2021

ASSOCIATE SOCIETY MEMBERS

MISSION

In an effort to increase global awareness of sleep issues, World Sleep Society has formed a relationship with the following national sleep societies or regional federations.

The fundamental mission of the World Sleep Society is to advance sleep health worldwide. World Sleep Society will fulfill this mission by promoting and encouraging education, research and patient care throughout the World, particularly in those parts of the world where the practice of sleep medicine is less developed.

The goal and purpose of World Sleep Society is to advance knowledge about sleep, circadian rhythms, sleep health, and sleep disorders worldwide, especially in those parts of the world where this knowledge has not advanced sufficiently.

World Sleep Society developed the following programs that consist of promoting sleep education, awareness, and member services and include World Sleep Congress and World Sleep Day.

WSS

CONGRESS

THE BEST OF SLEEP MEDICINE & RESEARCH BIENNIAL MEETING

International Sleep Disorder Specialist

EXAMINATION PROVIDING SLEEP MEDICINE COMPETANCE

ANNUAL AWARENESS EVENT WITH CALL TO ACTION

ENDORSED SOCIETY

PROMOTING SLEEP MEDICINE & RESEARCH WORLDWIDE

ONLINE LIBRARY OF EDUCATIONAL CONTENT

OFFICIAL JOURNAL OF WORLD SLEEP SOCIETY

HEALTHIER SLEEP PATIENT SLEEP MAGAZINE

INTERNATIONAL SLEEP

GUIDELINES RECOMMENDATIONS FOR DIAGNOSIS & TREATMENT

Official journal of World Sleep Society & International Pediatric Sleep Association

• • • • •

• Asian Society of Sleep Medicine • Japanese Society of Sleep Research • South East Asian Academy of Sleep Medicine • Australia and New Zealand Sleep Science Association • Integrated Sleep Medicine Society Japan • International Restless Legs Syndrome Study Group MEMBERS SINCE 2018

MEMBERS SINCE 2015 • Taiwan Society of Sleep Medicine • Czech Sleep Research and Sleep Medicine Society • German Sleep Society • Russian Society of Somnologists • Serbian Sleep Society • Turkish Sleep Medicine Society • British Sleep Society • French Society for Sleep Research and Sleep Medicine • Finnish Sleep Research Society MEMBERS SINCE 2016

MEETINGS MENTORING & TRAINING SLEEP RESEARCH LEADERS

MEMBERS SINCE 2017

Asian Sleep Research Society Australasian Sleep Association Canadian Sleep Society European Sleep Research Society Federation of Latin American Sleep Societies • Sleep Research Society

GOAL & PURPOSE

OPERATING PROGRAMS

FOUNDING MEMBERS

• Israel Sleep Society • Peruvian Association of Sleep Medicine • Romanian Association for Pediatric Sleep Disorders • Sleep and Wakefulness Medicine Moroccan Federation • Bulgarian Association of Obstructive Sleep Apnea & Snoring • Indian Society for Sleep Research

• Georgian Sleep Research and Sleep Medicine Society • International Pediatric Sleep Association • Indian Association of Surgeons for Sleep Apnoea • Austrian Sleep Research Association • Brazilian Sleep Society • European Academy of Dental Sleep Medicine • Hong Kong Society of Sleep Medicine MEMBERS SINCE 2019 • • • • • •

ASEAN Sleep Federation European Restless Legs Syndrome Minnesota Sleep Society American Academy of Sleep Medicine Chinese Sleep Research Society CMDASM -Chinese Medical Doctor Association sleep medicine Specialized Committee • Canadian Sleep and Circadian Network MEMBERS SINCE 2020

UPCOMING WORLD SLEEP MEETINGS

VIRTUAL MEETING 2021

CONNECT WITH US

IN PERSON MEETING 2022

• Portuguese Sleep Association • Indian Sleep Disorders Association • Italian Association of Sleep Medicine

IN PERSON MEETING 2023

The Discovery of a New Pediatric Sleep Disorder

By Lourdes DelRosso, MD

R

frequent movements during sleep and daytime symptoms as a consequence of this poor sleep. Restless legs syndrome (RLS) for instance, manifests at bedtime with symptoms of leg discomfort, but children with RSD go to sleep well, without any problems. It’s just that once they are asleep, they move more than children without RSD and these movements interfere with sleep quality and contribute to daytime symptoms.

Lourdes DelRosso, MD

ecently, I was a member of a group of international sleep researchers who developed consensus diagnostic criteria detailing a new sleep disorder in children called Restless Sleep Disorder or RSD. With this new discovery, we intend to improve clinical practice and promote further research.

For years, sleep experts have identified ‘restless sleep’ as part of other sleep conditions that can cause sleep disruption or nocturnal awakenings like obstructive sleep apnea or restless legs syndrome. However, recent research in children has shown that restless sleep can also be a primary disorder, not always associated with another condition.

Adequate sleep is important for growth, memory, mental and physical health, social interactions, safe alertness during the day and many other functions. We, as sleep physicians, recommend and have guidelines on how much sleep should someone get. But we do not only need an adequate amount of sleep. We also need good quality of sleep. This is the main significance of RSD. It identifies children with poor sleep quality,

RSD has been studied in comparison with other sleep disorders showing individual and particular characteristics. Initially, research on children with RSD was started due to the need to better understand how these children slept. Dr. Judith Owens, an author on the journal article, as well as the current President of the International Pediatric Sleep Association (IPSA) explains, “Parents were concerned that children did not get enough sleep at night because they were “moving all night,” “trashing the bed,” or “sleeping like a helicopter”—various terms used by parents to characterize the sleep patterns of their children. Parents also noticed undereye dark circles, nextday fatigue, inability to concentrate

Bedtime Reads Looking to learn even more? Each issue, we highlight one book about sleep.

In Sleep-Wrecked Kids: Helping Parents Raise Happy, Healthy Kids, One Sleep at a Time,

author and speech pathologist/myofunctional practitioner with 38 years of clinical experience, Sharon Moore will explain: • The importance of sleep for kids • The good sleep formula • 7 tailored assessments to target sleep red flags • Simple environment and routine changes • How to address sleep disordered breathing, even before your kids are born • 20+ specialists who can help your kids sleep —sleepwreckedkids.com 23 | January/February 2021

RSD continued from page 23 and sleepiness. We identified that there was no other explanation for the symptoms.”

Using sleep studies and other advanced technology, we on the research team were able to understand that children with RSD were moving a lot more than their counterparts. The movements occurred through the night, and were associated with other findings of sleep disruption. Prior to this team discovery, the International Restless Legs Syndrome Study Group assigned nine experts in sleep medicine to develop a pediatric consensus. The taskforce was chaired by Drs. Dan Picchietti and myself. Later, the taskforce invited another expert for a consensus of ten sleep physicians form various parts of the world.

The current “consensus criteria for the diagnosis” was completed in June 2020. It published in Sleep Medicine journal on August 17, 2020. The world had a name for this sleep disorder in children.

TREATMENT Current treatment for RSD is iron supplementation— both oral or IV—as we identified that iron supplementation improves sleep quality in children with RSD during our research. More studies continue to be done on children with RSD to help understand the syndrome better.

COMMON SYMPTOMS OF RSD IN CHILDREN (AGED 6-18) • Ability to fall asleep is not usually compromised

Sleep & Stress continued from page 21 also allow you to say "this is my time to worry and to think about all my problems." This reserved time to "worry" is the time to worry so when you get to bed, you can recognize that it is not the time to worry as you already had your reserved time to that during the day.

Many resources are now available online to help you and offer sleep tips for sleeping better. For example, you can visit sleeponitcanada.ca to find some of these tips. ..................................................................................

Dr. Bastien of the School of Psychology at Laval University in Quebec City, Canada has been working in the field of sleep for more than 30 years.

=

Less Sleep More Negative Behaviors Studies and surveys of American adults have made a clear pattern connecting sleep and symptoms of stress.

Less than 8 hours of quality sleep means…

More likely to feel overwhelmed

• During sleep, frequent movements can be observed • Frequent movements during sleep include repositioning of arms, legs or full body • Next day indications of lack of healthy sleep such as sleepiness, undereye dark circles, fatigue, inability to concentrate

If you suspect that your child has RSD, please consult your physician or request a referral to a sleep expert.

More likely to lose patience and/or yell

More feelings of irritability

.................................................................................

Dr. DelRosso is an Associate Professor of Pediatrics and Associate Sleep Medicine Fellowship director at the University of Washington. She co-chairs the 2021 World Sleep Day.

24 | January/February 2021

More likely to forgo exercising

More likely to report high levels of stress

Sundowning

A sleep disorder may be affecting your loved one with dementia.

By Antonio Culebras MD, FAAN, FAHA, FAASM

A

ntonio Culebras MD, FAAN, FAHA, FAASM is a Professor of Neurology at SUNY Upstate Medical University in Syracuse, NY. His research has led him to study a sleep disorder you may not have heard Antonio Culebras MD, of: SunFAAN, FAHA, FAASM downing.

A sleep disorder usually reserved for those living with dementia or Alzheimer’s, it is characterized by the confusion of when sleep should occur.

If you know of someone experiencing a state of confusion in late afternoons or nights accompanied with wandering, pacing or being stuck in a confused state, they may have sundowning. Dr. Culebras was interviewed about the specifics on this circadian disorder.

Q: In your own words, what

is sundowning?

Sundowning is a circadian dysrhythmia characterized by reversal of the sleep-wake rhythm, confusion, occasional agitation and nocturnal wandering.

Q: Who suffers from

sundowning?

It occurs generally in older people with poor brain reserve particularly if they suffer delirium, dementia or encephalopathy, which is damage or disease that affects the brain.

Q: What are signs a loved

one may be dealing with sundowning?

The chief characteristic is the tendency to wander at night in a confused state. This creates risk of accidents and is very disturbing to family members. Sundowning at home is the most important reason for requesting institutionalization of the patient.

In the hospital, sundowning represents one of the main factors that delays placement, since nursing homes dislike accepting patients who wander at night.

Q: Do you have any tips on

how to sleep better if living with sundowning?

Sundowning is challenging and resistant to management.

Caregivers may want to discourage daytime napping and try turning

on floodlights in the bedroom during the night. Soft floodlights are turned on at night to provide some visibility in case the patient gets out of bed. This visibility dispels some of the confusion.

Otherwise, total darkness seems to add to the confusion. Lack of light seems to play an important part in sundowning. The bedroom should also be reviewed for safety and dangerous items removed while windows and doors secured.

Q: What led you to study

sundowning?

My activities in the Stroke Unit expose me frequently to the challenge of sundowning in patients convalescent from stroke or patients who have been mistakenly admitted because Sundowning continued on page 26 25 | January/February 2021

Sundowning continued from page 25 of encephalopathy and have no stroke. Generally, these are patients with baseline cognitive deficits who become decompensated because of the stroke or the encephalopathy.

Sundowning delays discharge from the unit, sometimes for many days or weeks.

Q: Can you highlight current

research on this topic for those who would like to learn more?

We are exploring best management of sundowning. In addition to removing causes of cognitive decompensation, we add mild tranquilizers at night, leave floodlights on at night and discourage napping during the day. Most importantly, we are

exploring the use of bright light during daytime hours, starting at 9:00AM. Our current protocol is to expose patients for 20 minutes to bright light (5,000 to 10,000 lux) and to open window shades.

Exposure is continued for at least three sequential hours in the morning. Bright light boxes are available commercially and are not expensive. Melatonin is very popular, but has little to no effect.

Currently, there is no treatment for sundowning other than adjusting light levels, but by diagnosing the disorder, caregivers are able to better understand and prepare for disruptions in sleep.

If you suspect your loved one is living with sundowning, contact his/her primary physician with your concerns.

Right Now in Sleep Science A new study reveals that sleep deprivation and/or lack of sleep impairs the ability to stop and block unwanted thoughts. Intrusive, negative or unwanted thoughts tend to be a complaint of those living with depression, post-traumatic stress disorder and other psychiatric conditions. Sleep deprived participants reported an increase of nearly 50% in unwanted thoughts compared to those who had a good night’s sleep. This data suggest that sleep loss could contribute to mental illness by developing symptoms and obstructing thought suppression mechanisms.

Clinical Psychological Science. October 2020.

26 | January/February 2021

doi.org/10.1177/2167702620951511

Ask the Sleep Doc As answered by our issue reviewers.

Lourdes DelRosso, MD

Q: Is it normal to awaken to use the bathroom several times per night?

Dr. Thomas No. This reflects either fragmented sleep, resulting in periods of wake after each sleep cycle, bladder irritability or increased urine formation. Knowing if the amount of urine is large or small is useful.

Melissa C. Lipford, MD

Robert J. Thomas, MD

Rochelle Zak, MD

Dr. Zak If one awakens for any reason during the night, one will feel that one’s bladder is full. Thus, some people awaken because of disturbing environmental stimuli or other reasons and think they were awakened to urinate when it was the other way around.

That being said, awakening several times during the night to urinate raises the following possibilities: untreated obstructive sleep apnea, prostate enlargement, diuretic substances (such as tea, coffee, or alcohol) taken prior to bedtime or increased evening fluid intake.

Dr. DelRosso Although it is common to get up at least once to use the bathroom at night (also called nocturia), it should not be considered normal. Nocturia can disrupt sleep, contribute to daytime sleepiness and increase the risk of falls or injuries.

Nocturia can have many causes; among them, caffeine ingestion, medications, increased fluid intake before bedtime, urinary tract infection and obstructive sleep apnea.

Q: As I age, I find I’m waking up earlier and earlier, but too tired to get out of bed. How can I curb this?

Dr. DelRosso As we age, our internal clock (circadian rhythm) undergoes changes that favors early awakenings and early bedtimes. This is called advanced circadian cycle. It is considered a disorder if it causes significant symptoms. One treatment option is to allow yourself to sleep in accordance with 27 | January/February 2021

Ask the doc continued from page 27

Q: I fall asleep with the TV on, but I’ve read that’s bad for me. Why?

your own clock. Try to go to bed earlier if you feel sleepy and wake up naturally.

Dr. Lipford It might be tempting to unwind by watching TV or other electronic devices in bed, but as you become engrossed in the content, it will be harder to fall asleep and you may end up staying up later than you anticipated. Coming up with a relaxing bedtime routine that doesn’t involve electronics can help the body and mind prepare for sleep and may result in a more restful and restorative night.

Dr. Thomas An advance of the internal clock in the brain is often seen with aging. The best way to counter this is to ensure bright evening light until about 8PM, then minimizing the light. Avoid light before 6AM in the morning. Evening darkness and light too early in the morning will make this pattern worse. Sometimes, use of a light box in the evening is necessary.

Dr. Zak It is normal to have one’s biological clock move earlier (phase advance) with aging, but usually both the wake and sleep onset times move earlier. My first suggestion would be to move the bedtime earlier to correspond with the earlier wake time and avoid activities (put down the iPad) such as using personal screens in bed that may delay sleep onset. However, what the writer may be complaining of is not the normal phase advancement with aging but, rather, he/she is experiencing early morning awakening.

Causes of early morning awakening include stress and depression, which can increase in prevalence with age (and certainly have increased with the pandemic), but also disturbing environmental stimuli, evening consumption of alcohol and sleep disruption from medical disorders (e.g., heart failure or emphysema) that may be more common with aging. In summary, this is a complicated question and seeing your primary care physician and/or a sleep specialist may be in order.

28 | January/February 2021

Dr. Thomas Habituation to noise is possible, but fluctuating noise and light can cause arousals. Light exposure, if you are close to the TV, can disrupt sleep even if eyes are closed. Needing a TV to fall asleep also may suggest the development of an “association disorder” or inability to fall asleep in any other circumstance. If you wake up, the temptation to channel surf may further disrupt sleep. If you also have a snack, that is the end of undisturbed sleep.

Dr. DelRosso Electronics emit blue light that can interfere with the signals that tell the brain to produce melatonin, a sleep promoting substance. Furthermore, falling asleep with the TV on can be restless as the volume fluctuates and disrupts what would otherwise be a restful sleep.

Watching TV also promotes bad “sleep hygiene” as the brain can start identifying the bedroom as a place to watch TV instead of a place to sleep, so the habit could contribute to symptoms of insomnia.

Dr. Zak Everything is relative. Some people find falling asleep to TV helpful for them and do not have insomnia.

Even if you are using a sleep timer, the noise of the TV turning off can cause an arousal.

Ask the doc continued from page 28

Q: I live alone. How can I find out if my snoring is a concern?

Dr. Zak There are many symptoms of sleep apnea, of which snoring is just one, so not knowing whether or not you snore should not prevent you from seeking evaluation for possible sleep apnea (with other prominent symptoms being awakening gasping for air, unrefreshed or awakening with a dry mouth). That being said, there are apps that will record your snoring and, in pre-pandemic times, individuals without regular bed partners would often have friends or family report on snoring or, at times, symptoms would be reported during a medical procedure, such as colonoscopy or surgery.

Dr. Lipford There are several smartphone apps that can monitor for snoring and provide you with trackable information.

Some people are aware of waking up with a gasp, choke or snort that could indicate concerning snoring.

But snoring isn’t the only indicator of a potential sleep problem. If you don’t feel rested by your sleep, mention it to your doctor. They may recommend further testing, which can now often be done in the comfort and convenience of your own bed.

World Sleep Society has created a list of healthy habits for healthy sleep Establish regular sleep & wake times.

Avoid light from smartphones & tablets near bedtime.

Reserve the bedroom environment for sleep & sex only, avoiding work or study.

If you do not fall asleep in 20 minutes, leave the bedroom and return to bed when tired so your body will begin to associate the bedroom environment with sleep only.

Dr. Thomas If you live alone, then snoring is not always a concern (who are you disturbing?). If you are curious, recordings can be done with a cell phone and played back, several applications can enable this. If you are concerned about sleep apnea, then direct measurement is best. Go through an MD and perhaps take a home sleep apnea test. In the near future, I expect that over-the-counter, medical-grade apnea diagnostics will be available.

Exercise regularly.

...............................................

Avoid caffeine six hours before bedtime.

HAVE A QUESTION FOR THE SLEEP DOCS?

Avoid heavy, spicy, or sugary foods four hours before bedtime.

Submit your questions by email to healthiersleep@worldsleepsociety.org.

Questions are selected based on space & applicability.

Do not exceed 30 minutes of daytime sleep or napping.

Avoid excessive alcohol ingestion four hours before bedtime.

Do not smoke.

A light healthy snack before bed is acceptable.

29 | January/February 2021

GET ACCESS TO THE LATEST IN SLEEP MEDICINE & RESEARCH WITH ON DEMAND SESSIONS FROM OUR DECEMBER 2020 VIRTUAL MEETING PLUS NEW CONTENT ARRIVING IN FEBRUARY 2021 AND CONTINUING THROUGH THE END OF THE YEAR FOR JUST $29

Program Topics • MENTAL HEALTH

• OSA DIAGNOSIS & MANAGEMENT

• FATIGUE & ALERTNESS

• CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS

• RLS DEVELOPMENTS & TREATMENTS

• HEALTHIER SLEEP

For more information visit worldsleepsociety.org/2021-virtual-meeting

RATES & REQUIREMENTS ADVERTISING RATES B&W RATE

COLOR RATE FREQUENCY

FULL PAGE

1/2 PAGE

1/4 PAGE

1x

$1,080

$630

$360

$640

2x

$1,728

$1,008

$576

$1,680

$960

3x

$2,592

$1,512

$864

$3,600

$2,100

$1,200

4x

$3,240

$1,890

$1,080

$4,200

$2,450

$1,400

5x

$3,780

$2,205

$1,260

$5,040

$2,940

$1,680

6x

$4,536

$2,646

$1,512

FULL PAGE

1/2 PAGE

1/4 PAGE

1x

$1,200

$700

$400

2x

$1,920

$1,120

3x

$2,880

4x 5x 6x

FREQUENCY

Full page

1/4 page Horizontal

COVER & PREMIUM PLACEMENT

AD SIZES

INSIDE FRONT COVER

$1,800 per page

TABLE OF CONTENTS PAGE

$1,800

CENTER SPREAD (1-2 PAGES)

$1,800 per page

INSIDE BACK COVER

$1,800

BACK COVER

$2,400

COVER TIP PER ISSUE * NOT FULL PAGE

$600 add on (must purchase additional interior pages)

7.375” wide x 9.833” high

FULL PAGE WITH BLEED

Image area: 7.875” wide x 10.375” wide Trim area: 8.375” wide x 10.875” high Bleed: 8.625” wide x 11.125” high

1/2 PAGE HORZ

7.375” wide x 4.833” high

1/2 PAGE VERT

3.604” wide x 9.833” high

1/4 PAGE HORZ

7.375” wide x 2.333” high

1/4 PAGE VERT

3.604” wide x 4.833” high

1/2 page horizontal

1/4 page Vertical

1/2 page Vertical

FILE SPECIFICATIONS

INSERT RATES FREQUENCY

FULL PAGE NO BLEED

2-PAGE

4-PAGE

8-PAGE

1x

$1,920

$2,400

$4,800

2x

$3,072

$3,840

$7,680

3x

$4,608

$5,760

$11,520

4x

$5,760

$7,200

$14,400

5x

$6,720

$8,400

$16,800

6x

$8,064

$10,080

$20,160

ABOUT HEALTHIER SLEEP MAGAZINE

Healthier Sleep is published six times per year by World Sleep Society. World Sleep Society is a membership organization for professionals working in the field of sleep medicine and research with a mission to advance sleep health worldwide.

DIGITAL ADVERTISING AVAILABLE

• The preferred file format is PDF, set to Print Quality • All 4-color files must be in CMYK; Black and white files must be in grayscale • All files must be the correct size as listed above • Additional bleed is required for all bleed ads • All files submitted must be final artwork • Fonts and images must be embedded and/or converted to outlines • All files and images must be at least 300 dpi

CONTACT US For more information, visit Healthiersleepmag.com.

For a custom quote, contact healthiersleep@worldsleepsociety.org.

Email healthiersleep@worldsleepsociety.org for details.

HEALTHIER SLEEP MAGAZINE 3270 19th Street NW, Suite 109 Rochester, MN 55901 USA

ROAD TO BETTER SLEEP 3 ELEMENTS OF HEALTHY SLEEP DEPTH

DURATION

DURATION

The length of sleep should be sufficient for the sleeper to be rested & alert the following day.

CONTINUITY

DEPTH

Sleep should be deep enough to be restorative.

CONTINUITY

Sleep periods should be seamless without fragmentation.

3270 19th Street NW, Suite 109 Rochester, MN 55901 USA

+1-507-316-0084

worldsleepsociety.org

facebook.com/wasmf

twitter.com/_WorldSleep

Created by World Sleep Society’s committee of internationally-renowned experts in the field of Sleep Medicine and Research.