STORY BYFinal segment of the three-part series, “Sleepless”
Chocolate was my obsession before I had kids. Now long, languid naps and uninterrupted slumbers fill my fantasies. But like many parents of young children, my sleep reality is far from peaceful. Nights in my bed often include a snoring husband, restless baby and thrashing 4-year-old, all jockeying for space. And judging from talk around preschool and recent sleep polls, I know we are not the only family struggling to get a good night’s sleep—or any sleep at all.
Lack of sleep is a growing problem for individuals and society, says pulmonologist and sleep expert Richard Castriotta, MD, director of the Division of Pulmonary, Critical Care and Sleep Medicine at The University of Texas Medical School at Houston and medical director of the Sleep Disorders Center at Memorial Hermann Hospital -Texas Medical Center.
Dr. Castriotta provides insight into the environmental and physical factors causing us to lose sleep, and offers some proven alternatives to counting sheep.
Q. It seems like a new study comes out every day about the negative effects of not getting enough sleep. What do we now know about sleep that we didn't 10 or 20 years ago?
A. We know that we need more sleep than what we are getting. Adolescents and teenagers need nine and a quarter hours of sleep. If you take the average teenager now and add on all the activities and homework he or she has to do when home from school, and very early morning start times for school, you have a chronically sleep-deprived child. Most teenagers will be in first period when they should be in their deepest REM (Rapid Eye Movement) sleep.
Adults need seven or eight hours of sleep. Younger children need 10 or more. We are getting much less sleep than we used to get. The average amount of sleep over the past few decades has decreased by almost two hours.
What specialties have been practicing sleep medicine up to this point? I always associate it with pulmonologists like yourself.
Sleep medicine has been under the surveillance of many specialties including pulmonary, neurology, psychiatry and psychology. It turns out that there are more people involved in sleep medicine with a pulmonary background than any other subspecialty. The reason is most of the serious causes of daytime sleepiness are related to an abnormality such as sleep apnea (the cessation of breathing during sleep) that involves the pulmonary system. In our program, for example, we have a sleep fellowship for physicians who wish to study sleep medicine. Pulmonologists, neurologists, internists, psychiatrists and pediatricians are all involved in this training program.
What research are you working on?
We are studying sleep disorders after traumatic brain injury. We also are involved in developing new technologies on infrared monitoring of airflow and blood pressure during sleep.
Judging from recent laws for later school start times and against driving while sleepy, do you think that the public is becoming more aware of the importance of sleep?
There is indeed a growing awareness about sleep. In general, the whole phenomenon of sleep has come to the forefront everywhere. It still is underrepresented in the medical school curriculum and postgraduate physician training. But actions are being taken to change that. The American College of Chest Physicians Sleep Institute is organizing a group of training sessions across the United States educating primary care physicians and caregivers (including nurse practitioners) about sleep medicine. The National Sleep Foundation has done national sleep polls to publicize sleep problems. There also has been an introduction into the medical school curriculum and postgraduate education dealing with sleep and the changes to the entire body.
Such as...
During sleep, everything in the body changes, its whole physiology. Making it more complicated, there are two physiologic states the body is in when sleeping: REM sleep (Rapid Eye Movement) and non-REM sleep, which are as different from each other as sleep and wakefulness. Nobody has really paid much attention to these states of sleep until very recently.
The American Board of Medical Specialties (ABMS) recently recognized sleep medicine as a distinct specialty with the first examination in sleep medicine given this past November. This has replaced the American Board of Sleep Medicine examination, which has been the defining credential in sleep medicine up until now, but it had not been recognized by the ABMS. Now the specialty of sleep medicine is finally being recognized as a legitimate specialty off on its own with ABMS-sanctioned certification.
Q. Why do you think we are getting less sleep now?
A. Certain phenomena have occurred that have changed our sleep/wake cycles.
First, of course, was electricity, which extended our functioning into the night.
Second was television, which resulted in our staying up later at night.
Third was the computer and Internet, which represent a qualitative change from just television and electric light because online activities presented an opportunity for active engagement. Everyone has had that experience when you have been busy at the computer, you look up and it’s 3 a.m. and you didn’t even realize it. All these phenomena have contributed to the decreasing amount of sleep in our society in general.
Q. OK, so how does not getting enough sleep affect us personally, and as a society?
A. We have a serious problem with chronic sleep deprivation. What sleep deprivation does is reduce your efficiency, your mental capacity, your vigilance and your ability to act quickly and make decisions.
We also are imposing an extra burden on our children, who are learning while under sub-optimal conditions for memory retention.
For adults in the workplace, we put them in a position that leads to chronic sleep deprivation. We get up early in the morning for long commutes and then arrive home late. We then stay up late watching television or working on the computer. That sleep deprivation translates into judgment problems at work and can cause accidents.
All of the major manmade catastrophes that have occurred in our lifetimes have been results of sleep deprivation: Chernobyl, Three Mile Island, The Exxon Valdez and the (Space Shuttle) Challenger. A whole list of problems has ensued because of multiple wrong decisions on the part of people who were overly sleepy, and as a result, made wrong decisions.
Right now, nearly a third of adults in the United States sleep less than six hours a night. Less than six hours a night over a long period of time may have consequences with the immune system, and with judgment and activity.
Q. So, a lack of sleep affects your health in a measurable way...
A. Yes. Lack of sleep has been linked to an increase in appetite and obesity. There also is a relationship to life expectancy. There is a U-shaped curve with sleep that shows that the optimum amount of sleep is seven or eight hours. People who get less than that have an increased mortality. Below six hours of sleep, there are pathological consequences in your ability to make decisions and do things over a long period of time, increased risk of gaining weight, and increased risk of developing diabetes and coronary artery disease, a decrease in immune function—all of which increases your risk for mortality.
Q. What can the average American family do to get more—and better sleep?
A. Implement a regular sleep schedule, which would include more regular sleep times and wake times. Put restrictions on nighttime entertainment. Reduce the amount of stimulants. The available caffeinated and super-caffeinated beverages on the market have increased hugely. It’s no coincidence that our increased use of mega-caffeinated drinks is occurring at the same time we are becoming increasingly sleep deprived.
Q. How about using alcohol to help you sleep, or cough and cold medicine?
A. Alcohol is very disturbing to sleep in many ways. It has a biphasic metabolism, which results first, in early sleepiness, followed by the reverse effect later in the night. So, alcohol causes one to go to sleep and then wake up and not be able to get back to sleep again.
Alcohol (like most hypnotic medications: “sleeping pills” or sedatives) also can worsen sleep apnea and all breathing problems. We never recommend cold medicine as “sleeping pills” because these are usually sedating antihistamines with many side effects, which include sleepiness, dry mouth, etc. These can be taken to help relieve symptoms of an upper respiratory tract infection or allergies, but not primarily to induce sleep.
Q. What about using medications to help you sleep (like the sedative zolpidem, sold as Ambien) or to stay awake (like modafinal, sold as Provigil)? When should people use them and when should they not?
A. At the Sleep Disorders Center, we rely on cognitive behavioral therapy, sleep health counseling and common sense to manage most chronic insomnia, rather than hypnotics. These are still OK for short-term use in many stressful situations and their judicious use can help prevent transition from acute to chronic insomnia. We do use hypnotics as an adjunct to treatment in some people with chronic insomnia.
Hypnotics vary in potential for addiction, depending on the precise one. Some are addictive and some aren't, so they should be taken under a physician’s careful supervision.
We use modafinil frequently to treat narcolepsy, posttraumatic hypersomnia (excessive sleepiness that develops as the result of physical injury or disease in the central nervous system) and idiopathic hypersomnia (also called non-REM narcolepsy).
In some situations we may also use it in shift work sleep disorders and rarely as an adjunct to nasal continuous positive airway pressure (CPAP) in a few patients with obstructive sleep apnea and refractory hypersomnia despite faithful use of CPAP.
It is a helpful medication because unlike traditional stimulants, it doesn’t give you an uncomfortable jittery feeling, like drinking too much coffee. You also don’t crash when the effects wear off, like you would on amphetamines. Also, it is not physically addictive. That said, like hypnotics, modafinil should be taken while under the care of a physician.
Q. What else can we tweak to help us sleep?
A. Change the time of your workout: Exercise should be done earlier in the day, not at night. And, temperature control is important. Having the temperature too high will interfere with sleep and result in very poor quality sleep.
Q. What can we do when we wake up and can’t get back to sleep?
A. When you are up, keep lights down low, do whatever you have to do in semi-darkness. Normally, the reason you can’t get back to sleep is that something has happened to turn on your hormones, the ones that are normally only activated when you wake up in the morning after sunrise.
Before you go to bed, think about what you want to focus on, in case you wake up and can’t get back to sleep. Think of five or six different scenarios that you can rotate so you don’t get bored. The ones that work best are real life memories, but movies or books can be substituted. The memories should be pleasant but not overly stimulating, like a recent beach trip. Then just replay it in your mind in vivid detail, like walking down the beach, the smells, the texture of the sand, everything that happened, and how pleasant it was. Focus on real details. You can’t make yourself go back to sleep, but this allows you to avoid becoming overly aroused by thinking of other things.
Q. One last question: Can some people really get by on just a few hours of sleep a night?
A. Some people can. Like everything else, there are extremes from the norm. There can be extremely long sleepers and real short sleepers. True short sleepers just don't have a need for much sleep. As a result, they are much more productive people than the rest of us.
If you would like to make an appointment at the UT Sleep Disorders Center, please call 832-325-7222.
Comments do not necessarily reflect the opinion or approval of HealthLeader or The University of Texas Health Science Center at Houston.
A reader writes:
Date: August 26, 2008
Q. I have been taking 1 tablet of Benadryl (generic) every night to help me fall asleep and stay asleep. It usually helps quite a bit. I asked my family practitioner about it and he did not feel there were any bad side effects to taking that and agreed that I could continue. This article mentions that it isn’t good to take, so can you tell me what the bad side effects would be. Dry mouth is a small price to pay for a good night’s sleep.
A. The active ingredient in Benadryl is diphenhydramine, which is an antihistamine with sedation as a side effect. Over time tolerance may develop and it may decrease REM sleep time. A study of its use in the hospitalized elderly by Agostini in 2001 found the following documented effects: delirium symptoms, inattention, disorganized speech, altered consciousness, abnormal psychomotor activity, altered sleep/wake cycle and behavioral disturbance. It also has a drying effect that is part of its pharmacology.
It is certainly not the same as the more dangerous sedative hypnotics being used, but as an OTC sleep aid it is not entirely benign, especially in older folks. If someone can derive benefit from it without untoward effects, that's great... but what may be good for this goose may be a problem for the next gander, so we do not give it universal sanction.
The other reason for not using it long term (aside from its expected decreased real effectiveness) is that we try to address the causes of insomnia and attempt to resolve those problems without drugs if possible. There will be some people with severe chronic insomnia who will require medication over the long term, but usually they do not find resolution with such drugs as diphenhydramine.
— Richard J. Castriotta, MD, FCCP
Last Updated: 08-20-2008Editorial Board | Legal Disclaimer | Privacy & Security | Contact Us
©2000-2009 Office of Institutional Advancement, UT-Houston
Follow us on:
Dr. Richard Castriotta is director of the Division of Pulmonary, Critical Care and Sleep Medicine at UT Medical School.
See Dr. Castriotta also at:
Packing Bag Lunches Safely
If you pack lunches for your child to take to school, be careful that you do not accidentally expose them to foodborne illness.
Bagged lunches, especially those containing perishable foods, need to be packed and handled properly in order to keep the food safe. In general, perishable foods should not be left at room temperature for more than two hours. If left out too long, the temperature of the food can enter the danger zone where bacteria grow most rapidly, which is between 40 and 140 degrees Fahrenheit.
Below are some tips to help families pack bagged lunches safely:
Before eating lunch or snacks at school, make sure your child washes his or her hands with soap and warm water for at least 20 seconds. If your child's school does not have a handwashing program in place, encourage them to adopt a such a program, as handwashing is one of the best ways kids and parents can protect health and stop the spread of germs.
