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Johns Hopkins Health - Losing Sleep

Spring 2009
Issue No. 4

Losing Sleep

Date: April 24, 2009

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Stop counting sheep. Let the experts uncover what’s keeping you up at night

In the 1800s, the average adult American slept more than nine hours a night. Since then, we’ve been steadily losing sleep, and in the last decade we’ve given up yet another half-hour of it a night.

If you conducted a person-on-the-street poll, you’d likely find many respondents admitting that the quantity and quality, or both, is lacking in their sleep. In fact, it’s estimated that around 70 million Americans have some type of sleep-related complaint.

That’s a big problem, says Johns Hopkins sleep specialist David Neubauer, M.D. “Sleep has been maintained throughout evolution because it is so important.”

It’s easy to see just how important sleep is when you look at some of the daunting results of not getting enough of it, including drowsy-driving auto accidents; poor decision making; and learning, memory and concentration problems. On the other side are the health issues such as hypertension, obesity, diabetes and depression that either exacerbate or cause certain types of sleep disorders. Then there are the newer studies that prove the correlation of stroke, heart attack and even death to chronic, untreated sleep problems.

Put it all together and it’s clear that the costs of losing sleep are too plentiful to ignore. At least part of the problem is that sleep is undervalued, Neubauer says. Witness the peculiar machismo that often accompanies people who voluntarily get away with four or five hours of sleep at night—until fatigue sends them crashing.

Sleep—like Rodney Dangerfield—just doesn’t get any respect.

Johns Hopkins clinical psychologist and behavioral sleep specialist Michael Smith, Ph.D., sees that a lot. Smith’s patients are among the 10 to 15 percent of the overall population with chronic insomnia (this doesn’t include the undiagnosed).

“Most people don’t want to talk to their doctors about sleep problems,” he says. “It’s like a badge of honor to not need as much sleep as the rest of us.”

What happens, though, is that people develop ways to adapt to their insomnia or go the over-the-counter route, Smith says. So, what could have been a short-term, acute situation becomes chronic, taking longer and costing more to treat. And getting to the root of the problem in the first place also has been lost.

“When you know if there’s a medical or psychological issue causing the insomnia, then you’re going to know better how to treat it,” Smith says. “People aren’t going to be able to figure that out on their own.”

Addressing the Problem Head-On
That’s where Neubauer, Smith and other colleagues like pulmonologist and sleep specialist Philip Smith, M.D., come in. The three are part of the Johns Hopkins Sleep Disorders Center, a program that tackles the complexities of sleep problems from all angles, biologically and behaviorally.

To get an idea of just how complicated sleep is, you might start with why people end up in sleep centers to begin with. Most patients show up because of excessive daytime sleepiness. But there’s a long list of possible reasons for why that’s happening, Philip Smith says.

“Insomnia is one, but is it primary or secondary?” he says. “What are you eating or drinking? Are you taking any medications? Are you under stress? How long has it been happening? These are some of the things to consider.”

Then there’s sleep apnea. Neubauer calls it insidious because most people are unaware that they have it. The condition, most often associated with loud snoring and halted breathing while sleeping, may affect up to 18 million people in the United States. About 5 million of those are undiagnosed. Like insomnia, its symptoms could include daytime sleepiness and fatigue.

“Obstructive sleep apnea evolves over a long period of time,” Philip Smith says. “Unfortunately, you don’t really become symptomatic until you’re having 15 to 20 episodes of [apnea] an hour.” The downside is that the longer sleep apnea is untreated, the more likely the chance for developing hypertension and cardiovascular disease.

The upside is that risk factors for sleep apnea are a lot clearer than they were just a decade ago. If a bed partner complains that you’re consistently a loud snorer, you’re about 50 percent likely to have some degree of sleep apnea, Philip Smith says. If he or she has to leave the room because of the noise, that likelihood jumps to 90 percent. Obesity is a major risk factor for sleep apnea, and if you have diabetes, that increases your risk, too. And in one of those chicken-or-egg twists, while sleep apnea increases the likelihood for developing hypertension, the reverse is also true.

“If you already have hypertension and are obese, you should be checked for sleep apnea,” Neubauer says.

What Tomorrow Brings
Although sleep problems and disorders seem rampant, the ability to diagnose and treat them successfully is better than it’s ever been. Systematic testing and evaluation can identify root causes, making it easier to target and individualize treatment. CPAP (continuous positive airway pressure) devices—still the primary treatment for sleep apnea—are now more comfortable so patients are more likely to use them. Most important, mild to moderate weight loss can cure sleep apnea. And other treatments, including lifestyle changes, behavioral therapy, a new generation of prescription sleep medications, and minimally invasive surgeries, all are helping millions to sleep easier and better.

This is all good, Neubauer says. “Sleep should be automatic,” he adds. “It’s a wonderful thing.”

Women: Take Note
Sleep apnea research has been mostly focused on men. The commonly cited symptoms such as excessive snoring at night and daytime sleepiness may not hold true for women, who are more likely to complain about trouble falling and staying asleep.

“That means that these women are frequently misdiagnosed and their sleep complaints often blamed on anxiety or insomnia,” says Johns Hopkins sleep specialist Charlene Gamaldo, M.D.

If you experience insomnia-like symptoms, feel irritable during the day and have trouble concentrating, it’s worth seeing your doctor to ask about a sleep study, Gamaldo says.

Not Just for the Grown-Ups
Insomnia and sleep apnea are not just adult problems, says Johns Hopkins Children’s Center pediatric sleep specialist Brian McGinley, M.D.

Up to 4 percent of children have sleep apnea, he explains. Kids also are more likely than adults to experience parasomnia events—such as recurring nightmares, night terrors and sleepwalking.

Parents should talk to their children’s doctors if they suspect anything, and be on the lookout for symptoms such as snoring and stopped breathing at night, as well as these symptoms:

  • Difficulty breathing
  • Restlessness or frequent changing of position at night
  • Night sweats
  • Grunting or gasping during sleep
  • Bed-wetting
  • Daytime sleepiness or behavioral difficulties
  • Learning problems

Tips for Sleeplessness
Sleep specialist Michael Smith, Ph.D., says insomnia is part of life. About 30 percent of us at any one time will have some experience with not being able to sleep.

If you’re having episodes more than three nights a week for longer than a month, you should see a doctor. If the occasional sleepless night is your problem, Smith recommends these tips:

  • Back off the caffeine. Especially watch for the hidden caffeine in so-called energy drinks.
  • Avoid alcohol before bedtime. Even though it’s a sedative, alcohol may make it difficult to stay asleep.
  • Stay away from over-the-counter sleep aids. They’re counterproductive and can lead to a habit.
  • Stick to an exercise routine. But not within an hour or two before bedtime.

Go to and search “insomnia” to learn more.

Interested in a Sleep Trial?
Johns Hopkins is currently recruiting for several sleep-related clinical trials. You or someone you know may be eligible. Call 877-546-1872 to learn more.

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