Sleep and Aging - Research on Aging

The Sam and Rose Stein Institute for Aging Research is committed to promoting health and well-being across the lifespan through

research

, professional training, patient care, and community service as a nonprofit organization. At the University of California, San Diego School of Medicine our

research

and educational outreach activities are made possible through the generosity of private donors. Our vision is that successful

aging

is an achievable goal for everyone. For more information, visit our website at

aging

.ucsd.edu. Tonight we will talk about

sleep

and aging. I'm going to ask you a favor, don't put me to

sleep

. We'll try to get through all of this and hopefully share some of the knowledge we've gained about sleep and what it turns out to be.

It's not all we want to know, but let's investigate what happens to sleep as we age. Everything that has life sleeps in one way or another and some of these creatures and organisms have ingenious ways of sleeping, for example, the dolphin. There, a dolphin breathes air like you and I have lungs, but he lives in the water and has to sleep. When you sleep, you slow down and stop swimming, so what is it going to do for the dolphin to have this ingenious way of half of the brain sleeping at the same time and half with the other, so you can still run and sleep at one time or another, you have fish, birds sleep and this here represents a bacteria, even bacteria sleep now, they don't sleep like you and Duermo but they have a rest time in their daily, annual or monthly cycle, whatever whatever bacteria it is, you can consider this as possible sleep, even viruses remain inactive to a certain extent, so everything that has life, that is the point of this slide, sleeps. therefore, sleep must be important.

It turns out that about a third of our lives are spent sleeping, now some of us maybe a quarter of our lives and we'll talk about that too because it's important for health, but for a long time. We never paid attention to sleep, we all took it for granted that we went to sleep and we took, um, we pay attention to the moment when we are awake, but it turns out that sleep instead of just a moment when the brain turns off, let's say a computer. turn it off, it actually doesn't just turn off some aspects of sleep, the brain is extremely active, in fact, the brain actually heats up and some of what we call stages of sleep and it turns out that sleep is a very dynamic behavior that has specific categories of sleep we call stages of sleep, I try to put them here as stage 1, stage 2, stage 3. now they call them n1 and 2 and m3 and rem sleep, everyone remembers rem sleep, this is a very sexy word, right, rem sleep , quick eye. movement and it turns out to be very important for health and we will also talk a little bit about rem sleep if all of you are sitting here now and I ask you to look ahead quietly and close your eyes just for a second. you can open it now well if you had electricity EEG in your brain your your brain would do exactly this you would do it right now when your eyes are open your brain looks like this your EEG your electroencephalogram as soon as you close it you get what are called alpha waves, just rhythm pure alpha and 90 of you will have this, some of you don't have this, but 90 of us will have this alpha rhythm and if your eyes slowly start doing a slow eye movement like this, don't do it.

Don't do that because that means you're about to fall asleep, you're getting groggy, that's why I only had you for two seconds with your eyes closed and then you go into alpha dropout, you go into stage one of sleep and then you have these same specific packets. very fast frequency of the brain called sleep spindles and there are other big waves called k complexes and that makes it stage two of sleep and you can actually rest in stage two of sleep, stage one of sleep is like a transition, still we can hear some things maybe 50 of us can still hear sweet things in our ears others are already out for the count and then you go into a deep sleep when you get these big high waves and that is a very deep restful sleep where the body basically breathes the breath.

The mechanism is now being guided by our very stable, very stable metabolic rate and then you enter the chaotic part of rem sleep. Rem sleep is when the brain really warms up, we tend to cool down as we go to sleep, but it warms up and the body cools down and you have these rabbit eye movements, it's very interesting, they were discovered for the first time in children, it was actually a medical colleague who was just looking at his little sun and the little eyes kept moving and they did an EEG and you have these quick eyes. movements during sleep and that is rem sleep, so they are precise, elaborate and very controlled mechanisms and we have discovered that each of these stages has a physiological meaning and that is more than we need to address right now, there is a range in terms of what people think about sleep now, this lady, some of you may know Ethel pf, a famous French singer and actress, and this is what she said about sleeping to me, sleeping is a waste of time, I am afraid to sleep, now it is a form of death, yes Look at the scriptures of various religions and you will see that death is equated or is an allegory of sleep because it is something similar when you are unconscious when you sleep very well and you wake up in the morning of one day to the next.

Suddenly you wake up, eight hours have passed, it's like you are dead, you have no sense of time, but in reality you are not dead, as I already mentioned, sleep is a very, very active process in which we perform certain physiological functions that then I'll tell you what they do, but that's how I see sleep, a good laugh, a long sleep are the two best cures for anything. There is an Irish proverb and it is true. If you don't sleep well, nothing works well, your brain doesn't. works well your heart does not work well your veins do not work well your arteries you do not feel well your muscles your skin deteriorates that's why people talk about their restful sleep so sleep is very important that's why a third of our lives is We spend sleeping that's it what we have discovered so far so um it's important now the question always arises why we sleep.

I remember in medical school I had a professor who was looking for substances and cerebrospinal fluid somewhere trying to see, you know? If he could do a good job and eight hours a day, what if he could be awake 24 hours a day and not have to sleep? I could do a lot more work. I like to sleep. I don't like being awake all day. but we found some things that sleep does and one of the things we know for sure is that sleep has physically and mentally restorative properties, literally when we go to sleep the brain repairs itself and that means when we're awake this lecture here what you're learning you're putting in information but it literally exhausts your brain it uses atp energy which we need and it can even have some structural damage that when we go to sleep it repairs itself there's good evidence on this um there's something called adenosine like a medication that we actually use in the intensive care unit, but it is an ATP product, as you know, it is the high energy compound that we have and that is what makes our muscles move and that is the energy that We have in our bodies is actually a chemical and when it is metabolized you get adenosine and adenosine builds up in the brain as we go through the day and at night when we go to sleep it is the highest and by Tomorrow when we wake up it is the lowest.

So it turns out that the tight blood-brain barrier that we have, which keeps certain medications out of our brain and protects our brain during the day and at night, loosens up a little bit and is able to get rid of some of these chemicals and byproducts and waste that are accumulate in the brain there are also certain genes that are activated only when we sleep, not when we are awake, and these genes have been described very well in animals. They repair Schwann cells, our cells are a type of brain cells that cover the axons, think of them as the wires that run through our body and the myelin membrane, which is the insulation, it repairs it, when you don't have insulation you get into trouble, that's what multiple sclerosis does, the myelin membrane breaks down and now you have short circuits everywhere and you have multiple sclerosis so the brain literally repairs itself when we sleep therefore sleep is important and if nothing works at least when we get up in the morning we no longer feel sleepy cure drowsiness, that is one of the good things about sleeping now, why do we sleep?

Sleep is also a state of cardiovascular relaxation. Even when you take a nap, even those 20 minutes, you know, an hour and a half, 15 minutes, 30 minutes, your heart rate, your blood pressure, your metabolism. the rate drops between 10 and 20 percent, that's for everyone, and literature is called immersion. 85 of us are immersed, when we go to sleep, our blood pressure goes down and we feel that that is important for cardiovascular health, even that little break. 15 to 20 minutes can be beneficial for the heart to rest, the blood vessels to rest from the high blood pressure that we have and we believe that it is a good prevention of cardiovascular diseases and, in fact, a sleep disorder that we suffer .

Tonight we're going to talk about obstructive sleep apnea, those people tend to become hypertensive and hypertension is one of the first steps in developing cardiovascular disease, atherosclerosis and then heart attacks, strokes and things of that nature, so that's another reason to know if at least that is a reason. Why we sleep besides repairing the brain and this is very intriguing. I don't want to call it a reason to sleep, but it is something that happens during sleep and has to do with the processing of information that Now that you are accomplishing what you have accomplished throughout the day and consolidating memory, it turns out that the 80 percent of what you will remember tomorrow or what you learned tonight will depend on how well you sleep that night. having 80 tonight that's quite a lot and it turns out that when you sleep after studying you are able to remember things and you do well on an exam, I'm not talking about 30 40 up to 50 70 percent improvement in your ability to remember things and it turns out that rem sleep is good for things so you will do very well on a multiple choice question you may not be able to write the answer but if I give you options you say that is the answer and yes and deep sleep the one that has big waves and high I saw you called delta waves delta dream that is very good for a type of spatial learning for example a surgeon learning a procedure a pianist learning a piece a gymnast learning a routine that will consolidate that memory of that exercise that that person was doing and for the Tomorrow you will be able to perform even better, so to learn you must rest well, but to remember things to consolidate your memory you must also sleep well after learning.

It is better to study and sleep and then take the test than to study and take the test. You'll do much better if you do it by just sleeping those hours and getting some patchy sleep and deep sleep in those cases when I do it for the first time. I learned about this, you know, and the people who are doing this kind of work, it's amazing and how many hours we wasted, studying all night, and there comes a time when the returns are diminishing, you just have to go to bed and have Confidence in what you do.

What you learned will be there and, in fact, sleeping will help you do it. There are some forces that drive us to sleep and the one that everyone knows is the circadian force, but we are going to talk about the circadian homeostatic force, those two in red. the hormonal neural forces not so much, but you know there is a hormone that comes out, it's called melatonin, when we go to sleep for the first time, you turn off the lights, the melatonin turns on if you turn on the lights, the melatonin disappears, so the melatonin is quite weak, but it helps us sleep it helps us we use it in the clinic to move sleep around the sleep phase someone's sleep is delayed or advanced we use melatonin sometimes to help them that and social cultural forces there are some some some um some countries or people who have the habit of taking a nap at night, if you care, I go visit my parents in Mexico and they take a nap even if they are in the field working, you go under a tree and take a nap and that can It would also be good for someone's health to take a nap, but circadian forces have to do with a suprachiasmatic nucleus.

This is a core. It is a small ball of cells found in the anterior hypothalamus, which is located in the middle front under the brain. and it is directly attached to the optic nerves and the eyes and what governs this nucleus is bright light, real light and every cell in your body has a clock, a circadian clock, so if you take a cell and make it alive to stay alive In a Petri dish, that cell will maintain a certain rhythm,it may not be 24 hours, but it has its rhythmicity, but the clock that governs them all is the suprachiasmatic nucleus and this is an important clock because you probably noticed this clock when you go to Europe or Asia, not South America or North America, but you travel east or west, you are not in sync, even your bathroom needs say it is very annoying, you are trying to have a good time and you know where you used to go.

The morning is now noon and it is very difficult, very annoying and that is the super cosmetic thing, eventually you become like the natives, as long as you stick to the sun and go out and act with nothing, very soon you do. In fact, you can move this clock about an hour a day just by performing with the natives, so if you are eight hours away, it will take you about a week to become like a native. I have here, again, talking about a super super charismatic core, this is more. or less the propensity to fall asleep this is falling asleep and getting up is waking up or being more aroused more awake to wake up and this is our circadian rhythm throughout the day and someone who is well rested and sleeping well on a regular waking sleep schedule we We are most awake around nine in the morning, we wake up again around nine at night and we are most sleepy around one or two in the afternoon, this is after eating, you sit down and take a nap and then your drowsiness is around each other.

Three in the morning or so and that's why you can get up and go to the bathroom and go back to bed and fall asleep again unless you have insomnia. Everyone can do this if you get up to go to the bathroom, you know, before. You may not be able to fall asleep or after that you may not be able to fall asleep as easily. This propensity to fall asleep is closely associated with our body's core temperature, which is warmest when we are awake and where cold is when we are very sleepy and we wake up while warming up and fall asleep while cooling down so when uh your doctor tells you well that you have insomnia take a hot shower and then go to bed well So that warms you up, you said well, it will wake me up, but now, after you get out of the shower, you start to get cold and that's what supposedly It does promote sleep, so that's a little trick that we use, but this is the circadian rhythm.

It's about 24 hours a day, in fact, the suprachiasmatic nucleus, the rhythm is not 24 hours a day, it's closer to 25 hours a day, if I put you in a dark cave, there is no light, nothing at all, you will sleep and you will be awake at a rate that is about 25 hours a day, but we live in a world that has 24 hours a day, therefore, we need it. I'm going to show it again, we need the sun, we need to be out there to get into a 24 hour day and stuff. By the way, it synchronizes our clock with our world.

What planet in our solar system has a 25-hour day? It's a question that nobody knows. I guess Mars actually has a 24 hour day or close to it compared to Earth having 24 hour days. all the others are too fast or too slow and some of them don't even spin they just sit there like quicksilver but that's why some people say we come from Mars, at least men came from Mars that's what I say. It's called a hypnogram, if we do a sleep study on you, you go to the lab, we put the electrodes on the EEG and we plot here the time you were in the lab sleeping and then your stages of sleep, you'll see a very nice pattern here every 90 minutes or so. minutes you enter a rem period and you notice that the edge periods are getting longer and longer and in fact when we look at the rem, let's call it deeper or the rem density increases, you are reminding your brain that it is you.

You're moving your eyes faster and faster as you go and the last rem period can be half an hour, it can be 45 minutes and rem sleep. 80 of our dreams are done in rem sleep and that's why most of us do it. you wake up from a dream in the morning and they are interesting when you wake up from rem sleep you are wide awake you know exactly where you are you know exactly what you need to do when you wake up in a deep sleep you have a headache and you wonder what is happening, what time it is, what day it is and finally it takes you a few minutes to get your bearings and luckily most of the time we wake up from remote sleep and notice that deep sleep occurs. mainly in the first half, first third of the night and rem sleep, most of it occurs in the last half, last third of the night, so we have some rem cycles and contrary to what people think they should We sleep like logs, we wake up. about 10 times an hour, that's normal, pretty normal, you don't realize they're waking up, they're small and last 15 seconds or less, but that's enough to keep the muscle tone moving a little and prevent thrombosis deep vein, clots in the legs.

The design is pretty good, if you sit there without moving you will suffer muscle and skin damage in the ICU. When we sedate someone, we don't turn them over for a day or two, they develop a pressure sore, so it's important to us. to maintain that muscle tone those wake ups and every 90 minutes when you get to a hoop period we tend to wake up completely, we'll wake up maybe a minute or so, you might not even remember that you woke up, but you can roll over and take a big sigh and we go back to sleep or in some cases, like men, when we get older, we get up and go to the restaurant because our prostate is killing us and there are a few more changes that are normal during sleep that I just need mention them. before entering as we age, but the temperature when we enter rem sleep we become poi kilothermal, meaning we tend to reach room temperature we cannot control our temperature when we are in rem sleep we become colder we do not sweat we do not shiver when we are in rem sleep and we become like amphibians you know they need to be in the sun to warm up fortunately we don't stay there that long we can't move when we are in rem sleep this is why when you have that nightmare and the lion is chasing you don't you run away from the room and then you crash into the window or something?

We just don't move, although I will show you that there is the last if. um hopefully we'll get to the whole final sleep disorder thing that has to do with people being able to move during remote sleep, blood pressure, we talked about immersion and hypoventilation, we don't breathe as deeply when we're asleep and that's good for most. of us, you know, if I do an oximetry, look at how much oxygen you have in your blood, most of us will be 97 98 99, the youngest ones will be 99 100, okay and when we go to sleep, it will go down to 96 95 Who cares? , it's perfectly normal, but if someone has COPD, interstitial lung disease, or pulmonary hypertension, going to sleep can be harmful or dangerous because their oxygen saturation can drop enough to cause other problems, so that's normal sleep and?

What happening when? you have an abnormal dream, this is a survival limit where you show here years, they follow these patients for 10 years and they are all alive at the beginning, you know people die, so even the normal ones, these are normal people when 10 years pass , you know very well what. I don't know? 15 died or something, but compared to people who had sleep apnea, this is severe, this is moderate, and this is mild sleep apnea. The point of this slide is that when you have an abnormal dream in this case. People with obstructive sleep apnea snore, choke, and gasp throughout the night.

After 10 years, there is a significant difference between those with normal, mild sleep apnea and those with severe sleep apnea in terms of their survival, so sleep and good quality of sleep appear to be important for our health. survival as we have gone through the years over the last 50 years, as a group we have slept less and less and there are people who have discussed why, you know, there are various reasons, but I can tell you that there are devices in our house that we look for . all the time and um we've been sleeping less and less and it turns out that the amount of time you sleep is emerging as a very important health factor in their study.

In some of these studies, I'm talking about thousands of people. It's around 7000 people, this is around 73,000 people, this was around a million, it was from the ucsd right here, obviously, when you talk about these types of studies that are huge, we are talking about a questionnaire and we ask the people how long they sleep. and then correlating that with your health status, it turns out that if you sleep less than six hours in this study, less than five hours in this study you have a higher risk of high blood pressure, coronary artery events, heart attacks and in this one here, if Could you graph that?

It would be like a U shape where if you sleep less than seven or eight hours your health is worse. If you sleep more than seven or eight hours your health is also worse, and including death, you can put anything there to make it U-shaped. theme or brake, so sleep becomes very important, it seems that there is a specific amount of hours that are best for adults, seven to eight, that is the recommended sleep for adults, which puts you on a plane where you are most likely to be in better health. It turns out that those who sleep a lot are probably already sick but the Those who sleep little sleep eh, those are still healthy and can get sick or have more problems because they don't sleep enough, so getting older and sleeping what bothers us.

From this to that, okay, that's what we're going to talk a little bit about today and um, and the three factors that for a good night's sleep are actually three is the length of the schedule and the quality of the sleep, no. we have a There is a lot of control over our sleep quality. Some already know, for example, if you drink three beers and then go to sleep, the quality of your sleep will not be as good. It's okay if you drink a lot of water and then go to sleep. We are going to wake up a lot to go to the bathroom, so there is some control, but other than that not much, but the timing and duration we do have control over those aspects of our lives.

Sometimes you know we have we're ruled by the clock sometimes we're actually ruled by the late night show we have to watch Stephen Colbert or whoever these guys are okay but you know what I'll tell you a secret these guys are on YouTube and just go there, you can. Watch them there anytime you want, so instead of in the middle of the night, um and um, we're creatures to have it, we need to be able to have a specific time to go to sleep, especially as we get older because there's so many things they want. do.

How many of you are retired? Most of you, well, most of you are fine, so you have the whole world and you have time on your hands and, hopefully, money, so you can go wherever you want, you can think. of all kinds of things, but you still need your sleeping habits because what we call sleep hygiene does not mean that you don't bathe before going to sleep, it means that you have good rules for sleeping and therefore going to bed at the time at the same time and getting up at the same time as a habit sometimes you are going to stay late because or whatever but that is very important for our health getting ready for bed making it auspicious so that you can sleep you know what it is someone with insomnia ends up watching i don't know csi or something like that you can't sleep after watching it especially you have insomnia you see a couple of murders you can't sleep that so you have to get ready to go to sleep and wake up at the same time morning time um and uh and of course something that you may not have here but that can spread everywhere if you have at least 30 minutes to half an hour of bright light in the morning outdoors without sunglasses in the morning the sun won It won't give you cancer okay , it won't give you cataracts either.

It comes from one side, but it's brilliant, it's beautiful, it's the strongest, one of the strongest natural antidepressants that we have, it gives you energy, it gives you strength and you don't go in. the midday sun only mad dogs and the English do that don't do that but in the morning it's beautiful do that and I'll probably be out of a job you do it right so the national sleep foundation has some recommendations on how long should we be sleeping and, as you will notice here, the tendency when we are young we need to sleep a lot, from 14 to 17 years old for a newborn, but the way their sleep is not like ours, it only has two stages when they are newborns? now they're six months old, they're going through their four stages like all of us and then the sleep duration decreases and for us older adults, seven to eight hours of sleep a night, pretty similar to the i'm still a young adult Oh my gosh, okay, or am I just an adult, sorry, I'm not a young adult, but what is recommended is to sleep seven to eight hours a night, so it's time to go home and do a health assessment. his dream.

Adopt sleep hygiene habits and make some healthy changes and I think it will reward you greatly.Now that as we age, we look at the eggs, our sleep pattern, what we call sleep architecture, also changes and there are some changes that every study has shown. which are pretty much set in stone, one is the decrease in total sleep time. Notice how when someone is less than five years old or so, this is the total amount of sleep they get during the night and minutes, and as we get older we sleep less. also the wazo the wazo is the awakening after the onset of sleep, how consolidated the sleep is, which also increases, so there are more aches and pains, prostates, hot flashes and things like that that wake us up and we end up more awake during the night . it doesn't really suffer much, it holds up pretty well, but deep sleep, slow wave sleep, this one really drops off and by the way, I'm sorry to say this, but most of the drop off has to do with men, we sleep soundly. between 20 and 25 times. where I'm younger as an adult, but as we age, men when they're 85 will probably have less than 5 percent deep sleep compared to women, they still maintain probably between 15 and 18, they decrease, but not as much as men , we still do it.

I don't know why I blame the testosterone. I don't know, we still don't know why that happens because our brains atrophy as we age and that may have something to do with it, but I don't think brain atrophy in men. more than that of women, but we lose it a lot. There are also some things that we lose, but that's one of the most important ones for sleep now as well, um, the others. Stage one may go up a bit. Stage two, a little bit, but others. Besides that, those are the biggest changes we see as we age with sleep, so if we can't change some of these things, we can do other things related to sleep , like hygiene, if you have a sleep disorder, take care of it and to improve the quality of our sleep as best we can and therefore improve our health now these are some common sleep disorders that we like to overcome, but we will talk about apnea obstructive sleep disorder, insomnia, advanced renal facial disorder, and rem sleep behavior disorder.

These are sleep disorders that are quite common as we age and that's why I brought them up. What is obstructive sleep apnea? It is an intermittent repetitive obstruction or collapse of the upper airways. It is a mechanical process in most cases, although there are other reasons besides mechanical ones. associated with a drop in blood pressure because you're not breathing you're completely drowning you're not breathing in drops of oxygen and I'm telling you some of these highs can last two and a half minutes and a long time you sit there when it's This guy's going to breathe, you know?

Should I go in and shake it? And that's what happens. The bedmate ends up shaking them because he bothers them. They're trying to breathe with their throat closed that activity makes them sweat, they sweat, they usually wet the pillow and then it wakes them up and luckily that's what saves them uh because when they wake up they snore and they choke and they gasp and they carry Do that four or five times, breathes and then falls back and falls asleep, do it again, repeat everything again. The heart rate also goes down because you have to have apnea and it's like stepping on the brakes and the accelerator. at the same time in a car because your heart rate goes down but your blood pressure starts to go up and when you start breathing again you're not hitting the brakes anymore, not just the accelerator, and then your heart rate really shoots up and your blood pressure really goes up . and that's a huge amount of stress on the cardiovascular system.

In fact, I have a chart here from one of our patients. This was about 10 years ago here at UCSD. This person has severe objective sleep apnea. We will focus on this for the moment. way this patient is in rem sleep rem sleep gets worse when he urinates and the apnea gets worse when you're on ramps because you're paralyzed totally asphyxiated and there are two channels for air flow, two channels for respiratory effort and this channel is for for saturation, how much oxygen do you have in your blood? Notice that there is a lack of air movement here for almost a minute.

In this case, notice how the effort goes in crescendo and the patient is also paradoxical, meaning that the chest goes in the belly because there is no air movement. and the abdomen has to move somehow, the abdomen is stronger than the chest when we breathe and we notice the saturation of 95, 94 to 66 percent, an enormous amount of stress on the cardiovascular system, so this patient has apnea severe sleep obstruction. especially in this case during remote sleep and you can't see the heart rate here, but here it speeds up and then slows down. There are other cases that are more prominent than this one.

So how many of us have obstructive sleep apnea? I just highlighted two here and this graph of the prevalence of specific populations, older veterans. I am the chief of sleep medicine at the VA hospital. If I walk among warts or in the hallways, anyone I see eighty percent of the time will be right in saying that this has sleep apnea has sleep apnea sleep apnea because they are older they are overweight blood pressure hypertension diabetes among other factors risk, so eighty percent will have significant obstacles that need to be addressed and the elderly between fifty and seventy percent just in This is the fact that we are getting older, we tend to have obstructed sleep apnea as we get older, things get bigger, you know, the ears get bigger, the nose gets bigger, things start to sink in, okay, UV leather, the soft palate is flexible and it's very easy.

Choking, the tongue gets bigger and if you are overweight it is even worse, so older people also tend to have obstructive sleep apnea, as you can see, the risk factor is also for women and men and I did not put the reference here. but it just goes to show that aging has a lot to do with the prevalence of sleep apnea. It tends to stabilize around age 65 or 70. And that's probably just a survival effect because people have died and now it's only the strongest that survive and don't change, so who gets obstructive sleep apnea? It is really a public health problem because in epidemic proportions it was seen that 80 and 70 percent of us, when we get older, suffer from it, young people suffer from it.

I think there are two types. of sleep apnea, which I call malignant sleep apnea, has not yet been detected in the literature; those who are between 30 and 60 years old are strongly associated with obesity and who have very prominent or very important cardiovascular complications, at some point they will suffer a heart attack or stroke. the younger, and then you have sleep apnea, it happens only because we get older, you know, the sagging that I described is exactly like that and so that one is not so bad, but when someone is sleepy we treat it, but you know people who are like that .

This gentleman actually gave us permission to use this photo and he has a short thick neck um trunk obesity thin arm thin legs maybe hypertensive diabetes and but what about her do you think she would have sleep apnea? Well, most people say no, she is young, she is thin and but I tell you that up to 25 or 30 of the patients who have sleep apnea are thin. I have patients who look like her and it is a social problem, they cannot maintain a boyfriend or family goes on a trip with their girlfriends and they have to rent a room alone because they snore too much and they say you go out and then it can become a social problem, including this, the consequences you can dress them, comb their hair, bathe them , but you can not. take them anywhere because they fall asleep and even in the days of the flintstones uh this guy you know got in trouble because he fell asleep at the wheel save Tooth Tyler and up to 20 percent of car accidents um drowsiness had to see with that the police don't ask about it but investigations have shown that 20 25 these people fell asleep and just didn't tell anyone and how many of you had crashed under the car because he fell asleep so he fell with me all. right, I didn't do any harm, okay and the consequences, other consequences, lack of concentration, you crash your car because he wasn't paying attention, personality changes in men, not just sleep apnea, yes men have lack of dream, we tend to be bad, we were angry, we.

We're impatient, we rip people's heads off, and when we treat them, they're like little lambs and women, and on the other hand, they tend to be more like lack of energy, they just don't feel like doing anything. Tired men just get angry and upset and erectile dysfunction depression fatigue family discord usually it is the man who hits, but here is the woman who got angry and someone had them on the Internet, do you know the various characteristics of sleep apnea dream, so I picked them up there. but the consequence that we fear most because it takes time and is very insidious is cardiovascular disease, so, whatever you want, you know, obesity, hypertension, hypersonic stroke, metabolic syndrome, insulin resistance, activated chemorectal dysfunction, angina, hypercoagulability and you fall asleep, well, that's the point.

Now, how do you know if you have sleep apnea? There should be a high index of suspicion. One time, I think I landed in Boston somewhere like two in the morning and I was walking, it was empty and they were trying to find my bags and there was this worker the guy who cleans the place but I sleep and a bench like this is chokes I woke him up and I gave him a card and that's because I had a high level of suspicion that this man probably had obstructive sleep apnea and So in that case we sent them to the lab and today we do sleep studies at home in the laboratory.

It is a very good study, but it is expensive, it is cumbersome like a funnel. You know, you know, the bottleneck of going to the lab and nowadays to sleep. apnea we can do a study at home. We have been pioneers in home sleep studies for the last 25 years and now everyone agrees with us that yes, home sleep studies can diagnose sleep apnea and we have used all of these except for this one device is made into a sleeve, so it's not important to know what they are, other than you can diagnose sleep apnea at home.

Now how do you treat it well? There are some things, obviously, weight loss, because six and seventy percent of patients are overweight. or obese, so losing weight is important, exercise is important, in fact, aerobic exercise 12 weeks in a study, some muscle exercise and aerobic exercise decrease the severity of attractiveness by 25 percent and also good sleeping habits avoiding certain things like alcohol to go to bed. Alcohol very specifically relaxes the muscles of the throat, what we call pharyngeal dilators, and you will snore if you don't have apnea or you snore and you drink and go to sleep, you will snore that night and if you snore but you don't have apnea, baby you will have acne at night If you have apnea it will be more serious, it is just that way, so avoid drinking alcohol before going to bed.

Here you have the dreaded cpap continuous positive airway pressure, but it is the best therapy we have. So far there are all kinds of other things that you may have some questions about inspire or some other things available right now, but this is still the gold standard that we have, it's effective 100 of the time if you're capable and you're willing to use it. We rarely have to do anything else and that has to do with people who are extremely large, otherwise it's quite effective but cumbersome, it opens your throat, that's all it does, it's not a ventilator, it doesn't give you oxygen, it just keeps the throat open. and you do the rest there are other treatment options this is called a mandibular repositioning device or mrd or mandibular advancement device or jaw advancement whatever you want to call it it goes inside the teeth and pulls the jaw forward , must have good teeth.

Good for people who have mild, maybe moderate apnea, and good young teeth, otherwise you will knock out your teeth and have TMJ problems. It's definitely a second after sleep apnea and cpap, but probably a distant second, some people use it widely, but when we take it to the lab and see how effective it is, it's not that effective, at least in the hospital. VA, it's not very good because of the population that we have and there are other therapies that I mentioned, inspirational therapies, it's actually surgery, it's a pacemaker that you put in. goes into your a wire goes to your tongue a wire goes to your ribs there are these little pieces of plastic that you put in your throat and they are basically for snoring it doesn't work very well this one you stick a needle in the back of your tongue and You cook it with a microwave and then as it cures it decreases in volume, it becomes rigid because that is the part of the tongue that blocks you again due to snoring, it is not much use for apnea.of sleep and this you put these plugs in your nose, it's a one-way valve when you inhale, it's open when you exhale, it's partially closed, so put on the back pressure.

I haven't gotten it to work on anyone who's tried it and some people say it works, but I'm telling you. You, my patients, can't even stay awake with that thing on and it turns out that exercising your tongue is important I don't mean speaking well I don't mean speaking I mean exercising your tongue uh it decreases the severity of the apnea if you do it correctly up to 50 percent, so 20 or 20 minutes a day of didgeridoo keeps the sleep doctor away, so this gentleman is a middle-aged adult man probably needs it, probably has sleep apnea nicole kidman does not have sleep apnea sleep this guy definitely needs it and by the way, when you do this exercise you don't have to dress like you're wearing it like this and you'll be fine, uh, but I'd be surprised to have a patient, maybe four, that's using it. this and one is very cute because he lost weight and I thought yeah he actually cured his sleep apnea he lost weight and used the didgeridoo so the studio knows about apnea but now the wife is upset because it makes noise all day and then he goes, he goes on vacation with the wife and forgets how blessed you are two weeks later he starts snoring the wife said when we get home you better start that again so it works insomnia what is insomnia is difficulty starting sleep difficulty staying asleep and waking up too early and not being able to go back to sleep, that's insomnia.

We are all going to have insomnia at some point. Almost 100 of us, but only 15 percent will have it, so it affects our daily living activities. and I tell people with insomnia, I have compared it to a person, a man or a woman, who is drowning in the middle of, what is that drowning person doing, still alive? He screams and screams and kicks, asking for help and the more they move. the more they sink they don't realize that if you just stop I know it's easier said than done for what happens when you're in the water you float and if you get up the water is just to level your navel that's insomnia you have the ability, you have the brain, the brain works and I have adopted this this philosophy, get out of the way and let the brain do what it is supposed to do, but insomniacs are so upset, so angry and so nervous about it that they are looking at all the days the whole day is spent thinking what am I going to do so I can sleep well at night and guess what happens that night they try something else and it works no it doesn't work you have to get out of the way and give it time and the brain will eventually recover there are some tricks that we use but eventually we will recover and the goal of until my insomniacs are these is that I will be able to help you have the perfect sleep and not compare yourself to your spouse or your bed partner, whoever you are.

You are a different person, but the goal is for you to be satisfied with what you have, that is the beginning of healing, even if it is four hours a night, being satisfied eventually turns into five hours, eventually six and maybe that will be it. whatever you do, but that's enough. the way we need four hours a day of long-term sleep to stay alive and insomnia doesn't kill anyone and there's one called lethal familial insomnia, but none of you have that here, it's very rare and but um, if you just do it You allow it, you get out of the way and you start to relax, and that's hard to do, stop drinking that caffeine and eventually sleep will come, even if it's not perfect, but sleep will come.

We use the Spilman model. Spillman's model for observing insomnia. something I teach to my residents and medical students and even other doctors because I tell you that some of you have probably gone to the doctor to get treatment for insomnia and this is what happens in most cases, I hope your doctor be a great guy, but uh, you said I have insomnia, what do they do, they get the prescription pads, okay, ambien zolpidem, here's a soapy mass, here it goes, go home, you're ready, that's not the answer, the answer you need to find out why you have insomnia, so we have the predisposition to three-piece insomnia we can't change this much, maybe we can advise you not to worry too much, but there are precipitating factors, sometimes we can intervene here, usually there are some kind of stress for example I had a colleague come and see me at ucsd I called him from va because I work at both places and he told me he had insomnia for a year.

I have tried everything, ah, they work, but I am not satisfied. I want to leave these things. I want to stop, so next time. The question is, do you know in the year what happened a year ago and you start to think that you got promoted now that you are the boss of something or another? He has a lot of lazy doctors under his belt and they push him around. He is under a lot of stress. So, I said, you know, I think that's the cause, um and um, so we can work together, you can either ride it out or you can quit.

He went home and thought about it and guess what he decided to stop the insomnia from him. We just asked him about his old job. when he got it the insomnia went away and I lost a client so the factors that perpetuate here is where we do more of our intervention here we are more effective here and we use something called cognitive behavioral therapy uh cbti for insomnia that that therapy can be use it for pain for various things, but we use it for insomnia and trying to change maladaptive behavior, like, for example, I don't get enough sleep, so I go to bed and I'll stay there longer.

They still have insomnia and now it is worse because now they are in bed for 10 hours they are sleeping so it feels worse or the television that told you that the television was a hypnotic television set is designed to keep you awake they sell you the hamburgers and then they sell you las and rolaids or something you know to take care of the heartburn you have and then look at the clock, you know what's the point of looking at every hour, it's just frustration and anger, so the first thing we do is get rid of the clock and the la television by the way the bedroom is only for two things and we are talking about sleeping uh misfit thinking that I should sleep eight hours because Laredo said that what I need is seven to eight hours and if I don't get it I'm going to die and then we try to get this thought and these behaviors of the path.

We go out, we just let the brain do what it's supposed to do and eventually they start to sleep. It takes a good eight hours just to try to get them to understand that, so there's that. that's how we look at insomnia, there are drugs and things that we use outside that can cause insomnia, alcohol alone, caffeine, by the way, caffeine and someone who is sensitive to it, even if you can fall asleep, your sleep won't. It's so good when you have caffeine on board. So for insomnia, it behooves us to stop any stimulant we take, even if it's in the morning, why don't they drink it in the morning?

It doesn't matter, diet pills, stimulants, things we find in cold medicines, nicotine, sometimes our patients just wake up. They smoke because they're going to quit smoking, so they wake up two hours later, they smoke and then they go to sleep and then you know that nicotine helps them sleep in a sense because they go through withdrawals and therefore a kind of behavioral therapy just sleeps too fast. hygiene, we just talked about good sleep habits, relaxation, if you're tense, of course, prepare to sleep, relax, control stimuli, it's something that teaches you that when you're in bed you're supposed to be asleep, That is a technique used by many. other things and it's hard because sometimes we think of the bedroom as the war room, we go in there to do all kinds of things, don't do your financial stuff in the bedroom because you'll never sleep, whether you have too much money or it's not enough money You will never sleep and sometimes we use something called the sleeping circus.

This is the strong one. This is the best intervention we have, which is called behavioral. If you only sleep four hours and you are staying in bed for 10 hours, I tell you that you will only be in bed for five hours and very soon your sleep efficiency looks good and you feel good so we trick them into doing that and little by little we lengthen the time in bed and they will sleep and then cognitive behavioral therapy talked about changing their mind just by saying oh , you're thinking, is getting them to accept that the thought is wrong and change their way of thinking, so if you compare, you'll notice that I didn't mention any medications other than a few that I mentioned. but no drug slides because I don't think medications are the key or the answer to insomnia um they're all coming out there are new ones that are coming out there's one called bill shadow who in a sense took advantage of narcolepsy so it makes your brain like a narcoleptic brain and hopefully you will sleep with narcoleptics.

You're very sleepy and it doesn't work because the dose they're using is too low anyway, so it doesn't seem to work very well, but when we compare the medications to cognitive behavioral therapy, the effect size is about the same, around of 50, so if it took you an hour to fall asleep now it will be 30 minutes with both, but the important thing here is that at the end of six months of both therapies you will have 30 40 percent of patients who use cpti sleep well and zero drugs because everyone depends on drugs, they call me in the middle and I tell them that I ran out of medication.

When I die, I need one, so it had to be dry medications at night, so dependence on medications is actually one of the most distressing things for our patients. Other age-related changes in the circadian rhythm and something that happens to the elderly. Advanced sleep faces everyone. Okay, so the guy comes out and they don't care, so what happens, what happens as we get older, the circadian rhythm, as you remember, that leads us to sleep, it doesn't work very well and literally, because the brain doesn't. It doesn't work as well when we get older, the older brain compared to the younger brain we don't learn as much, it's actually smaller, it's shrunken and that's why I never have an act in my head because I'm afraid it will look like that . like Homer's symptoms, but you can see that the brain goes from a younger brain to an older brain, there are many spaces there, in fact, when we fall, it is easy to bleed in the brain because the brain shrinks and the veins that join the skull. a little tight and you fall there and they close the shear and now you have to bleed, so the weaker synchronization is weaker as a suprachiasmatic nucleus reduces the amplitude.

Melatonin production is not as good as it used to be. We have the pineal gland if you do something. scans of people the pineal gland calcifies now it's a fossil it doesn't work it doesn't produce melatonin that's where melatonins are produced and also the weaker or nonexistent zeitgebers zeitgeist is time giver it's a german word i'm not sure i pronounce it correctly, but the sun is the main one and the elderly people in nursing homes live in the dark, some of them never go out in the bright sunlight so it is important to get them out to synchronize their day, that is why they have a lot of sunsets and this advanced phase they fall asleep at seven in the afternoon and then wake up at three in the morning they disturb everyone else in the house the young people are the complete opposite they fall asleep at four in the morning they wake up at noon you can You don't lift them quite right and then um, but that's what happens as we get older.

The last one here is rem sleep behavior disorder. This disorder occurs almost strictly in older men. It has been described in women. It's been described to children, but the vast majority of the 99 percent are older men and these people remember that I told them that in remote sleep they lose muscle tone and are paralyzed, except for our breathing process, well, these people don't they lose muscle tone, they gain it and they have Dreams and remote sleep are very active dreams, uh, they're full of action, violent dreams, I found this nice little cartoon here, this drawing of this, this old gentleman is fighting, but He is dreaming that he is boxing and many times he beats his wives.

I just saw a patient, a couple today, a patient and his wife, and when he came three years ago and I diagnosed him with this, the lady said she had to do something, she had done a test on me. headlock this morning and now I had him. in a headlock and I had an uncle who passed away a few years ago, but I treated him for this for the last 20 years and he fought dirty, bit his wife in the middle of the night, he's a street fighter. So, violent dreams can cause injury to themselves and others.

Some people jump out of bed because they're trying to get out of the way of any oncoming truck and they hit something sharp and now they're hurt and it's important. The fact is that 85 of them already have or will develop some type of neurodegenerative disorder, the most common is Parkinson's disease and that is why we look very carefully because not much can be done about Parkinson's when it arrives, but at least we can talk with them and consult with them andtell you what to expect some of them don't have it at all my uncle didn't have it at all this gentleman i have doesn't have any signs of parkinson's disease but those are the possible problems with rem sleep behavior disorder now how to get diagnosed with the medical history you already know headlock you know if you have your wife in a headlock that is a telltale sign we do a polysomnogram remember when you are in rem sleep no, there is no muscle tone, well, these guys, suddenly, they They recover and you can see well, even if they don't represent their sleep, you can see the rem sleep and the muscle tone returns and that is a sign.

Also that they may have rbd or rem sleep behavior disorder. We have a questionnaire that asks: Do you know if you move while you sleep? How many things are out? that and you get a score and we have to rule out obstructive sleep apnea sleep apnea is the 800 pound gorilla and sleep medicine can mask so many things like insomnia like baby rem sleep disorder like leg movements during sleep and uh because there's a syndrome where they just have severe sleep apnea, they're not in the brain, but they act like a baby rem sleep disorder and we treat the sleep apnea and it goes away, so they'll respond very well to cpap, so the treatment makes the bedroom safe sometimes works like in terms of making them sleep late on the floor, putting the mattress on the floor because if they fall out of bed they won't hurt themselves as much, removing any sharp objects around of the bed, you know, they make the nightstands brown so they don't burn. a big hole would just take them out and the windows can't really get up and walk.

You know there have been murders that have been attributed to RBD, but if the man goes into the kitchen, grabs a knife, and stabs his wife, it's allowed. Until murder, these people can roll and hit, but they can't really walk. Some of them practice karate very well, they can't do it and when they are awake but when they are asleep they are very good at kicking therapy. It's actually quite good a little bit of clonopin clonazepam, which is one of the benzodiazepines, just a little bit, there's a quarter of a milligram, sometimes half a milligram will solve the problem.

We typically start with melatonin at higher doses because klonopin can cause drowsiness. in the morning because the half-life is 42 hours in certain people and that's why it lasts a long time, so you don't want the older person to pee in bed or do something else in bed because you know it will suppress you. by doing that you just can't wake up and they seem to work very, very well, so it's very rewarding to treat them. They are very happy to overwinter if it doesn't work out. If these medications don't work, we have to start thinking there's something to it.

Otherwise, it is not a rem sleep behavior disorder, so in conclusion, aging does not really decrease the need for sleep, we still need seven to eight hours of sleep a night. The problem is that aging can worsen our ability to fall asleep, prostate and menopause aches and pains that come into our lives and there are certain disorders as I mentioned that are more prevalent in older people or as we age, obstructive sleep apnea, insomnia in advanced stages. I face a circadian rhythm disorder or rem sleep behavior disorder and the point is that good sleep habits are still important.

Exposure to bright light in the morning will help me retire early and maintaining good health can significantly improve the quality of your sleep as we both age. You are very much you